Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00261876 Unannounced Monitoring 03/04/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(e)At the time of the 03/04/25 inspection, the smoke detector in the accessible attic had been removed and did not sound when the other interconnected smoke alarms were activated.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. Director of Programs created a work order for Facility Manager to address the connection of the smoke detector in the attic of the home. Facility Manager replaced and connected the smoke detector. Smoke detector was tested and in working condition. This was completed on 3.7.25 03/07/2025 Implemented
SIN-00244395 Renewal 05/15/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71At the time of the 5/15/24 inspection, the phone in the upstairs office did not have emergency telephone numbers on it or posted nearby.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Director of Programs will revise the monthly house checklist by adding that all phones are checked specifically for the emergency numbers are posted on the phone. Emergency numbers were added to the phone. 06/03/2024 Implemented
6400.104The most recent fire department notification letter, dated 1/19/19, indicates that there are 4 individuals in the home. On 2/21/24, an individual in the home passed away, and the fire department was not notified that there are now 3 individuals residing in the home.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Residential Manager and/or Program Specialist for the home will send an updated notification letter to the local fire department notifying them that there are now only 3 individuals living at that address. New letter will be printed and placed in the fire book for that home. 06/03/2024 Implemented
6400.112(c)The 5/13/24 fire drill log did not indicate if the smoke detectors were operative.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. Director of Programs will review with the Residential Managers at the next Manager meeting this regulation that the fire drill record must be completed in its entirety at the time of the drill including that all smoke detectors were checked and are operable. Director of Programs will revise the fire drill form by removing that the smoke detectors are checked within 72 hours of the fire drill and add that smoke detectors must be checked at the time of the fire drill. 06/05/2024 Implemented
6400.151(a)Staff person #1 had a physical on 2/11/22 and not again until 4/1/24. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Director of Programs will review the regulation with the Director of Human Resources specifically that there is only a 15-day grace period for physicals to be completed to ensure we are giving enough notification to employees in order for the physicals to be scheduled within the required timeframe. 06/03/2024 Implemented
6400.151(c)(2)Staff person #1 had a tuberculin test on 2/11/22 and not again until 4/10/24. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Director of Programs will review the regulation with the Director of Human Resources specifically that there is only a 15-day grace period for tuberculin test to be completed to ensure we are giving enough notification to employees in order for the test to be scheduled within the required timeframe. 06/03/2024 Implemented
6400.46(b)Staff person #1 had fire safety training on 3/29/23 and not again until 4/11/24.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Director of Human Resources and Director of Programs have developed a spreadsheet for each employee within J&FC in order to track that the required training hours are completed within the required timeframe. Director of Programs and the Facilities Coordinator have developed an annual training calendar for fire safety training. 06/03/2024 Implemented
6400.166(a)(2)Individual #1 has a PRN prescription for Acetaminophen 325mg. This medication was in the home at the time of the 5/15/24 inspection but was not on the individual's Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.Residential Manager will update the May MARS adding the following PRN medication "Acetaminophen". Residential Manager will review with the team at the next house meeting the steps to take when a medication is delivered specifically the importance of adding it to the MAR by end of shift. When a new medication is delivered the lead staff of that shift will notify the Residential Manager that a new medication was delivered. 06/03/2024 Implemented
6400.166(a)(10)There is no administration time for the 2/25/24 administration of Individual #1's PRN medication Cerave Daily Moisturizing Lotion.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.J&FC Nurse will review with the managers the correct process for documenting when a PRN medication is administered and how it must be documented including the time. The managers will review this process with their team at the next house meeting. 06/03/2024 Implemented
SIN-00241223 Unannounced Monitoring 02/22/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.143(a)Individual #1 was to be completing leg exercises at home at least twice per week per their physician in order to build leg strength. These exercises were rarely completed, and, when refused, there was no documentation of the attempts to educate Individual #1 on the importance of these exercises.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. Residential program specialists will review all forms/charts used for individuals in the home to ensure that the forms/charts are comprehensive, covering all information needing to be documented. Residential managers and/or program specialists will revise the forms/charts to include space to document attempts made to educate the individual about the need for health care and include the proper charting key code to document completed, not completed and/or refusals. Residential managers will communicate to the team any changes made on the forms/charts at their house meeting and train staff on the expectations of the documentation required on the forms/charts. 04/05/2024 Implemented
6400.18(g)Individual #1's date of death was 2/21/24. The first witness statement for the assigned certified investigation was not collected until 2/25/24.The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person.The Director of Programs will train the certified investigator on the requirements of p. 16 of the 2021 Version of the ODP Certified Investigator Manual. 04/05/2024 Implemented
6400.32(c)Individual #1's Polyethylene Glycol was increased from once daily to twice daily on 1/25/24 due to issues with constipation. This increase was never administered to Individual #1. The failure to administer this increased dose of medication created conditions conducive to serious harm for Individual #1.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.Director of Programs will train residence managers in their post medical appointment roles and the steps they are required to take to ensure all recommendations from the individual's appointments are being implemented. Director of Programs will review with the residence managers on the steps to take and the importance of documentation if/when something arises that does not allow the recommendations to be implemented within the timeframe written by the prescribing physician. 04/05/2024 Implemented
6400.52(c)(6)Individual #1 had an Individual Support Plan (ISP), choking plan, SEEN plan, and seizure plan. There were a total of 14 staff who worked in Individual #1's home from 11/1/23 through 2/21/24. No staff were trained in Individual #1's ISP. Staff persons #1, 2, 11, 12, and 14 were not trained in Individual #1's choking plan, SEEN plan, or seizure plan.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Director of Programs will implement a new training process and checklist to ensure that all staff have been trained on each individual's ISP and specialized plans (choking, seizure, SEEN, fall, etc). Director of Programs will train the residential managers and program specialists on this new process and checklist to ensure all new employees are trained thoroughly on each ISP and specialized plan. 04/05/2024 Implemented
6400.165(g)Individual #1's 1/3/24 quarterly medication review did not include the dosage or the reason for prescribing the medication.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Director of Programs will meet with the current residential manager of this home to review the appropriate paperwork needed for quarterly medication reviews for individuals living in J&FC home. Director of Programs will review this regulation with the current manager so they are aware of what is expected per the regulations. The residential manager will review the other binders to ensure that all quarterly medication reviews have the correct and completed forms filed. 03/27/2024 Implemented
6400.167(a)(1)Individual #1's physician increased their Polyethylene Glycol prescription from 1 capful mixed in 8 ounces of water once daily to twice daily on 1/25/24. This change was never made in the home before Individual #1's death on 2/21/24. Individual #1 only received 1 dose per day from 1/26/24 through 2/20/24.Medication errors include the following: Failure to administer a medication.Director of Programs will review with the residential managers their role after appointments and the steps they are required to take to ensure that all recommendations from the individual's appointments are being implemented. Director of Programs will also review with the residential managers the steps to take and the importance of documentation if/when something arises that does not allow the recommendations to be implemented within the timeframe written by the prescribing physician. 04/05/2024 Implemented
6400.167(a)(3)On 12/20/23, Individual #1's physician increased the individual's daily dose of Vitamin D3 from 1 tab by mouth daily to 2 tabs by mouth daily, and Individual #1 was to start this increase at their next dose. Individual #1 was only administered 1 tab of Vitamin D3 on 12/21/23.Medication errors include the following: Administration of the wrong dose of medication.Director of Programs will review with the residential managers their role after appointments and the steps they are required to take to ensure that all recommendations from the individual's appointments are being implemented. Director of Programs will also review with the residential managers the steps to take and the importance of documentation if/when something arises that does not allow the recommendations to be implemented within the timeframe written by the prescribing physician. 04/05/2024 Implemented
6400.167(c)The medication errors described in 6400.167a1 and 6400.167a3 were not reported in the department's incident management system.A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation).Director of Programs had the two medication incidents entered in EIM/HCSIS on 3.25.24. A certified investigator will be assigned if needed. Director of Programs will review with residential managers the importance of ensuring that all MARs have the correct prescribed medications listed. Director of Programs will review with the managers the incident management guidelines around medication errors and the timeframe in which these incidents need to be reported. 04/05/2024 Implemented
SIN-00233411 Unannounced Monitoring 09/26/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.13The maximum capacity on the licensed certificate is 4. The home had 5 parties residing in the licensed residential home from October 2022 to August 1, 2023.The maximum capacity specified on the certificate of compliance may not be exceeded.The 2nd fl. apartment is currently vacant and will remain so until the organization obtains a separate address and separate utilities. The Director of Residential will begin the process of obtaining separate utilities and address. 10/30/2023 Implemented
6400.14(a)The home had 4 individuals with intellectual disabilities residing in the home and 1 tenant from October 2022 through August 1, 2023. There isn't a fire safety occupancy permit from the department of labor documenting this approval.If the home is located outside Philadelphia, Scranton or Pittsburgh and serves four or more individuals or if the home is located in a multiple family dwelling, the home shall have a valid fire safety occupancy permit listing the appropriate type of occupancy from the Department of Labor and Industry or the Department of Health. If the home is located in Philadelphia, Scranton or Pittsburgh, the home shall have a valid fire safety occupancy permit from the Department of Health or the Department of Public Safety of the city of Pittsburgh, the Department of Licensing and Inspection of the city of Philadelphia or the Department of Community Development of the city of Scranton, if required by State law or regulation or local codes. Source: Records.Jessica & Friends Community is in the process of pursuing licensure for the 2nd fl. apartment. The apartment has been vacant since 8/1/23 and will remain so until the organization obtains a fire safety occupancy permit from the department of labor documenting approval for multiple family dwelling. Once obtained, the original will be kept by the Maintenance Coordinator and a copy will be filed in the fire safety book at the residence. 01/01/2024 Not Implemented
6400.22(c)From October 2022 through August 1, 2023, there was a tenant living in a licensed residential home. Individual's room and board was used to pay for utilities of the home. The home does not have separate electric, water, sewer, etc. for the home and the apartment, therefore individuals' room and board was being used for the other tenant's benefit.Individual funds and property shall be used for the individual's benefit. The individuals living in the home were reimbursed for 1/5 of the total cost of utilities from October 2022 through August 1, 2023. An incident was entered into EIM of exploitation and an investigation was initiated. 10/06/2023 Implemented
SIN-00212303 Renewal 10/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)At the time of the 10/4/22 inspection, the metal corner bead was exposed in Individual #1's bedroom, the paint was peeling off of the door frame outside Individual #2's bedroom, and the paint was peeling off the wall at the top of the shower stall.Floors, walls, ceilings and other surfaces shall be in good repair. A work order will be completed and sent to the maintenance department for repair by 10/13/2022, by the Executive Director of Operations. The request will be dated for repair to be addressed by 10/31/2022. 10/31/2022 Implemented
6400.72(b)At the time of the 10/4/22 inspection, the window screens in the screened in porch were torn in 3 areas. Screens, windows and doors shall be in good repair. A work order will be completed and sent to the maintenance department for repair by 10/13/2022, by the Executive Director of Operations. The request will be dated for repair to be addressed by 10/31/2022. 10/31/2022 Implemented
6400.111(f)The fire extinguishers in the home were inspected 7/8/21 and not again until 7/21/22. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The Executive Director of Operations will meet with the Maintenance Director to review the regulation above to ensure that all fire extinguishers are inspected within 364 days of the previous year's inspection. 10/31/2022 Implemented
SIN-00196947 Renewal 11/29/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The 6/21, 9/21, 10/21, and 11/21 fire drill records do not indicate if the fire alarms functioned.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The house managers have been provided feedback on completing the fire drill forms in their entirety, which includes indicating if the fire alarms are functioning. It is the responsibility of the house managers to ensure the forms are completed in their entirety to meet regulatory requirements. 12/06/2021 Implemented
SIN-00164949 Renewal 12/11/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(f)Individual # 1's bedroom exits into the staff office and not into a corridor, living area, dining area or outdoors.Each bedroom shall have direct access to a corridor, living area, dining area or outdoors. The office will be moved downstairs and the current space will be transformed into a common area for all residents. Assistant director of programs will be responsible for ensuring this is done. Target date for completion is 1/10/20. Please see attachment 2 for reference. 01/03/2020 Implemented
SIN-00146591 Renewal 12/10/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace cleaning was completed on 7/11/17 and not again until 7/27/18.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The agency maintenance department has the date of the furnace inspection on his work calendar and has also set up with the provider who does the cleaning to return annually before this date. The date of the inspections are also on the house manager, program specialist, and executive director calendars to ensure that it is not missed. Staff in the home were also trained to review due dates in the fire safety book (where the furnace inspection is recorded) to help ensure this does not occur again. 12/27/2018 Implemented
SIN-00126106 Renewal 12/27/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32The garage area and walkway to the front door of the home are monitored and recorded by a camera installed on the garage. Individuals residing in the home were not made aware of the camera and were not notified by the provider of the possibility of being recorded while on the grounds of the home.An individual may not be deprived of rights. All residents were informed of the camera that is recording in front of the garage. Each signed a notification form to show this. 01/19/2018 Implemented
6400.46(e)Staff #1 received fire safety training on 4/27/16 and not again until 8/18/17.Program specialists and direct service workers shall have training in the areas of intellectual disability, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. House Manager had the staff review the fire safety procedures and watch the video as soon as this was discovered. The house manager reminded the staff of the months that fire safety training takes place. The house manager has a training chart available to staff to assist with follow through on training to ensure compliance. 12/28/2018 Implemented
6400.104REPEATED VIOLATION - 10/6/16. The 9/1/17 fire notification letter indicated Individual #1 was independent with evacuating the home in an emergency. According to the fire drill logs, he/she required physical assistance to evacuate. He/she refused to evacuate during two drills.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. An updated notification letter was sent to the fire department. This letter has the addition of verbal prompts and possible physical assistance that is needed for the residents for their evacuation process. 01/19/2018 Implemented
6400.110(g)On 9/13/17, the fire department completed an inspection of the home and recommended all smoke detectors be replaced. Smoke detectors were not purchased until 9/20/17. There is no documentation of when the smoke detectors were installed in the home. If a smoke detector or fire alarm is inoperative, notification for repair shall be made within 24 hours and repairs completed within 48 hours of the time the detector or alarm was found to be inoperative. The fire company had ensured that all smoke detectors were operable before they vacated the premises. All staff have been trained on the inoperable alarm policy. Work orders have been updated to include time frame of repair (48 hours) for inoperable alarms. 01/04/2018 Implemented
6400.112(a)REPEATED VIOLATION - 10/6/16. A fire drill was not conducted in June of 2017 or November of 2016. An unannounced fire drill shall be held at least once a month. The house manager has completed and implemented an annual fire drill schedule with dates for the fire drills for the upcoming year. This schedule has an alternate date in case the fire drill is postponed due to weather conditions or other circumstances. This plan was updated on 12/28/17. The staff in the residence were all trained on the fire drill process and importance of the required monthly fire drills. The house manager, senior house manager, program specialist, and executive director of operations will be providing oversight of this process. 12/28/2017 Implemented
6400.112(c)The 5/31/17 fire drill log did not indicate of all smoke detectors were operative. All smoke detectors in the home are not checked monthly according to staff members in the home.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. There will now be documentation along with the fire drill log that all smoke detectors are being checked monthly for proper operation. The documentation will include that each smoke detector was tested individually in a timely manner before or after the fire drill. This will show that each was tested and whether it was working along with the date of the test. The fire drill log has been revised and staff have been trained on documentation on the log. Oversight is given to this by the house manager, senior house manager, and executive director. New logs are being implemented January 1, 2018. 01/01/2018 Implemented
SIN-00101814 Renewal 10/06/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Dog waste was located in the screened off porch. Clean and sanitary conditions shall be maintained in the home. Elizabeth Jones, House Manager will be responsible for maintaining a clean and sanitary living environment for the residents of the home. The dog waste that was on the porch area was cleaned up on 10/7/16 by Elizabeth Jones. The dog has been relocated and the policy is now that permission must be granted from the CEO for any animal to be in a home unless it is a therapy animal there for the purpose of providing therapy animal services. 10/15/2016 Implemented
6400.103The written emergency evaction procedures missing individual and staff responsibilties and emergecy shelter location. Staff #1 indicated on 10/6/16 at 11am that the location listed for individuals were family members but the addresses were not listed on as the emergency shelter location. There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. Katrina Perry, Program Specialist, will be responsible for creating an emergency evacuation procedure for each residential home. The emergency evacuation procedures will be kept in each individual¿s record. Staff will be informed where the document is kept and what information it contains. The program specialist will review and update the document as needed. A completed copy of the emergency evacuation procedures was completed on 10/7/16. The CEO will provide periodic oversight of the individual files to maintain compliance with the documentation that is entered in the files. 10/07/2016 Implemented
6400.104The fire letter was sent to the fire department on 6/6/16 stated that the individual #1 uses a walker sometimes. However individual #1 moved out of the home August 2015. Individual #2 moved in 8/2015 but letter was not updated. The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Elizabeth Jones, House Manager, will be responsible for updating and sending correct information to the fire department regarding the individuals living in the home. The letter that was in the fire safety book had incorrect information on it. This letter was updated on 10/10/16 by the house manager to include updated information about the resident who moved into the home. If it any time this letter will need to be updated again, the house manager will share the letter with either the program specialist or CEO to review the information in it. 10/07/2016 Implemented
6400.112(a)The fire drill was not held in December 2015. Staff #2 stated on 10/6/16 that the fire drill was missed. An unannounced fire drill shall be held at least once a month. Elizabeth Jones, House Manager, will be responsible for conducting monthly fire drills in the home. The manager has added to her calendar the dates for the upcoming months fire drills. This will be rechecked with end of month paperwork is collected. Ongoing the manager will ensure that a fire drill is completed each month. This was corrected on October 10, 2016 by scheduling the fire drills for October, November, and December on the manager¿s calendar. The manager has also spoken with staff about the role they play in maintaining the safety of the home and encouraged them to speak up if they notice it is getting late in the month and there has not been a fire drill conducted. 10/07/2016 Implemented
6400.145(1)Emergency medical plan was not included in the indiivduals record. The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. Katrina Perry, Program Specialist, will be responsible for creating an emergency medical procedure document for each individual. The emergency medical procedure document will be kept in each individual¿s record. Staff will be informed where the document is kept and what information it contains. The program specialist will review and update the document as needed. A completed copy of the emergency medical procedure document was completed on 10/7/16. The CEO will provide periodic oversight of the individual files to maintain compliance with the documentation that is entered in the files. 10/07/2016 Implemented
6400.145(2)Emergency medical plan was not included in the indiivduals record. The home shall have a written emergency medical plan listing the following: The method of transportation to be used. Katrina Perry, Program Specialist, will be responsible for creating an emergency medical procedure document for each individual. The emergency medical procedure document will be kept in each individual¿s record. Staff will be informed where the document is kept and what information it contains. The program specialist will review and update the document as needed. A completed copy of the emergency medical procedure document was completed on 10/7/16. The CEO will provide periodic oversight of the individual files to maintain compliance with the documentation that is entered in the files. 10/07/2016 Implemented
6400.145(3)Emergency medical plan was not included in the indiivduals record. The home shall have a written emergency medical plan listing the following: An emergency staffing plan.Katrina Perry, Program Specialist, will be responsible for creating an emergency medical procedure document for each individual. The emergency medical procedure document will be kept in each individual¿s record. Staff will be informed where the document is kept and what information it contains. The program specialist will review and update the document as needed. A completed copy of the emergency medical procedure document was completed on 10/7/16. The CEO will provide periodic oversight of the individual files to maintain compliance with the documentation that is entered in the files. 10/07/2016 Implemented
SIN-00070840 Renewal 09/25/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106Furnance Inspection was late. Completed on 8/27/2014. It was completed last year on 7/31/2013. Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. A system has been put in place where all residential furnace inspections will be coordinated during the same month each year. Each year they they will be scheduled for the following year one month prior to when they are due so they will actually be done every eleven months. 10/01/2014 Implemented
6400.213(11)ISP does not list all of Indiv. #1's allergies. It only stated pencillin and any other drugs with "cillin". Allergies should also include Cephalusporins, Bataloctams, and Carbapenem. Also there was a discrepancy regarding supervision. ISP states line of site; in psychosocial section for supervision states occassional line of sight. In the safety precausion section it states line of sight when around others. Behavioral Supports Plan section states occasional line of site needed. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. 400.213(11) - Provider's Plan of Correction: The allergy information and discrepancies regarding supervision of Individual #1 were addressed with SC at Bi-Annual ISP meeting on 1/13/15. Going forward, all changes to ISPs will be documented via email to the SC, and the email will be printed out and stored in the Individual's record book. 02/01/2015 Implemented
SIN-00040870 Renewal 08/30/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(13)Program Specialist did not complete ISP reviews for Individual #2.(b) The program specialist shall be responsible for the following: (13) Documenting the review of the ISP as required under § 6400.186. Program Specialist has created a master calendar which includes an ISP Review Date, Assessment Dates, and ISP Meeting Dates. The calendar will also note dates that letters are to be sent to all team members. Monthly, at House Manager Meetings, the Program Specialist will review the upcoming month and all due dates. Additional items will be added to the calendar to help assure compliance with differing due dates. DD-1 Fully Implemented 09/15/2012 Implemented
6400.112(i)None of the homes fire drill form indicate which smoke detector was set off during the fire drill(i)  A fire alarm or smoke detector shall be set off during each fire drill.A fire drill was held on 9/24/12 and recorded on new tool. Copy attached. DD-2 Fully Implemented 09/14/2012 Implemented
6400.141(c)(9)Indivdiual #2's prostate examination was documented as deferred on the annual physical examination form. However there was no documentation from the doctor of why it was deferred.(9) A prostate examination for men 40 years of age or older. Primary Care Physician was consulted and the attached letter was received. DD-3 Fully Implemented 09/25/2012 Implemented
6400.144Individual #2's primary care physician recommended on April 26, 2012 that Individual #2 see an eye doctor. Individual #2 still had not seen an eye doctor as of the date of survey.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. All appointments are added to the House Mangaer Master Calendar with a reminder set. Copy attached. Fully Implemented 10/25/2012 Implemented
6400.163(b)Individual #2 takes medication to treat a psychiatric illness; however he has no protocol to meet his social, emotional, and enviromental needs in place.(b) If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the ISP to address the social, emotional and environmental needs of the individual related to the symptoms of the diagnosed psychiatric illness. The Plan has been updated with the requested changes/additions. It is attached. Fully Implemented 10/25/2012 Implemented
6400.165Individual #2's January 2012 medication administration record for Prevident 5000 was not signed by the staff who administered medications on January22, 2012. There was no explanation of the medication error.Documentation of medication errors and follow-up action taken shall be kept. Med Error - Our home¿s daily checklists have been updated to include an additional check on items like med administration. House Managers will do staff re-training at October and March House Meetings on how to use and the importance of the checklist. Documentation will be a focus at annual medication administration certification. Fully Implemented 10/08/2012 Implemented
6400.181(e)(1)Individual #2's assessment did not include his preferences.(e) The assessment must include the following information: (1) Functional strengths, needs and preferences of the individual. Our Assessment Tool will be updated and modified to include and prompt inclusion of the additional narrative on preferences and progress. The revised assessment will be utilized on the next organizational assessment which is due in November 2012. Following its first use, house managers, the program specialist, and the Executive Director will review against items cited in the POC. In addition, any protocols/plans identified in the assessment will be reviewed and updated at the time of the assessment and attached. On a quarterly basis, the program specialist, house manager(s), and the Executive Director will review the most recently completed assessment as part of a quality assurance process. 11/15/2012 Implemented
6400.181(e)(13)(vi)Individual #2's assessment did not include progress and growth in the area of recreation.(13) The individual's progress over the last 365 calendar days and current level in the following areas: (vi) Recreation. Our Assessment Tool will be updated and modified to include and prompt inclusion of the additional narrative on preferences and progress. The revised assessment will be utilized on the next organizational assessment which is due in November 2012. Following its first use, house managers, the program specialist, and the Executive Director will review against items cited in the POC. In addition, any protocols/plans identified in the assessment will be reviewed and updated at the time of the assessment and attached. On a quarterly basis, the program specialist, house manager(s), and the Executive Director will review the most recently completed assessment as part of a quality assurance process. 11/15/2012 Implemented
6400.181(f)There was no documentation that Individual #2's assessment was sent to the SC and the Plan Team members.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). ISP Review - Our ISP Review template will be updated and modified so that all protocols/plans are identified. The tool will require that progress or any updates are captured in the review. The most recent completed ISP Review is attached. POC-2. 10/04/2012 Implemented
6400.186(a)Individual #2 had no ISP reviews completed for the past inspection year.(a) The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. ISP Review - Our ISP Review template will be updated and modified so that all protocols/plans are identified. The tool will require that progress or any updates are captured in the review. The most recent completed ISP Review is attached. POC-2. 10/04/2012 Implemented
6400.186(d)Individual#2's SC and Plan Team did not receive ISP reviews.(d) The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. ISP Review - Our ISP Review template will be updated and modified so that all protocols/plans are identified. The tool will require that progress or any updates are captured in the review. The most recent completed ISP Review is attached. POC-2. 10/04/2012 Implemented
SIN-00267705 Unannounced Monitoring 06/03/2025 Compliant - Finalized
SIN-00264906 Unannounced Monitoring 04/21/2025 Compliant - Finalized