Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00255698 Unannounced Monitoring 11/15/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There were several areas in the residence where there were cleanliness issues. Those areas are as follows: -The door for Individual 1's bedroom has dried blood streaks on it. -The bathroom located in the basement was unclean and had dirt on the floor and sink. The toilet was dirty with apparent signs of urine and fecal stains on the seat and toilet basin. - The floor was dirty and dusty. - The walls in the upstairs kitchen, and individual 1's bedroom were generally dirty and marked with stains/debris. - In individual 1's bedroom, the lone bed pillow had blood stains on it.Clean and sanitary conditions shall be maintained in the home. The Organization will ensure there are clean and sanitary conditions maintained in the home. All Areas mentioned in the description have been addressed and are now compliant. The individual does not always allow staff into clean his room and this has been discussed with the SC during a team meeting. 12/13/2024 Implemented
6400.67(a)There were areas of disrepair throughout the residence. Those areas are as follows: -The wall leading to the 3rd floor had peeled paint and showed signs of potential moisture damage. -The closet door in Individual 1's room was completely off its hinges and leaning against the wall.Floors, walls, ceilings and other surfaces shall be in good repair. The organization will ensure the walls, ceilings and other surfaces will be in good repair. Maintenance requests have been submitted for the closet door to be repaired and repainting the wall leading to the 3rd floor due to peeled paint. 11/27/2024 Implemented
6400.70There is no easily accessible phone in the residence. Individual 2 says that they have a habit of swallowing things (including batteries), their BSP confirms the same. There was a landline in the office on the third floor, though that office remains behind two locked doors. Site manager said that a standard (corded) phone was being installed in the unit, but this wasn't done while the inspectors were on site.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. The Organization will ensure operable phones with an outside line are easily accessible to the individuals and staff persons. The cordless phone base was found in the basement, disconnected and new phones were able to connect to the phone system and are operable. 11/15/2024 Implemented
6400.72(a)On the first floor, there are no screens in the front bedroom window (not covered by the security bars).Windows, including windows in doors, shall be securely screened when windows or doors are open. The organization will ensure the windows will be securely screened when windows are open. Maintenace will install screens in the front bedroom windows. 12/06/2024 Implemented
6400.72(b)The screen in the window of Individual 1's bedroom had a hole in it. The entryway door had a broken glass pane at the top. The screen to the entryway door is tattered and ripped from the door at the bottom. There were broken blinds in the bedroom of the first-floor bedroom. Screens, windows and doors shall be in good repair. The organization will ensure all screen, windows and doors will be in good repair. The screen in individuals #1's room will be replaced. Th screen door was removed so that it can be repaired. 12/06/2024 Implemented
6400.76(a)On the first floor, the dryer door was difficult to close, requiring significant force to do so. Furniture and equipment shall be nonhazardous, clean and sturdy. The organization will ensure the furniture and equipment are nonhazardous, clean and sturdy. The dryer door will be repaired by maintenance 12/06/2024 Implemented
6400.76(a)The mattress in individual 1's bedroom has ripped seams, and is broken with an obvious collapse through the middle, at one side. [REPEAT VIOLATION - 3/5/24] Furniture and equipment shall be nonhazardous, clean and sturdy. The organization will ensure furniture and equipment will be nonhazardous, clean and sturdy. A new mattress will be ordered to replace the old one. The organization will seek out more durable mattress pad in efforts to slow down wear and tear of the mattress because the individual has incontinent issues that can contribute to deterioration of the mattress. 12/13/2024 Implemented
6400.81(k)(3)In Individual 1's bedroom, the bed had no sheets on it, and one pillow that was without a case.In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season.The organization will ensure all beds have pillows, linens and blankets appropriate for the season. Individual's #1 bed was dressed in linens a pillow and a comforter. The individual does not always comply with having his bed made daily. The individual has been reminded to keep the linens on the bed until it's time to change the bed. 11/25/2024 Implemented
6400.81(k)(6)In individual 1's bedroom, there was no mirror.In bedrooms, each individual shall have the following: A mirror. The organization will ensure that there is a mirror in each bedroom. A mirror has been placed in the room for the individual to use as needed. 11/22/2024 Implemented
6400.82(f)The bathroom located in the basement did not have toilet paper or a trash receptacle. The bathroom located on the second floor did not have trash receptacle.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. The organization will ensure that all bathrooms are clean, have a trash can, toilet paper, soap and paper towels. A trash can was placed in the basement bathroom. 11/24/2024 Implemented
6400.84(b)There are trash bags of clothing and linen in the hallway, individual 1's bedroom, and in their bedroom closet.Clean laundry shall be stored in an area separate from soiled laundry.The organization will ensure that clean laundry is stored in an area separate from soiled clothes. The clothes and linen in the plastic bags have been washed and stored with in the closet. 11/16/2024 Implemented
6400.144Medication review for Individual 1: MAR indicates that the Individual has Nicotine patches that are applied to the skin daily for nicotine cravings, but medicine lockbox did not contain any patches. Upon questioning Staff Member for the whereabouts of the patches, it was stated that Individual no longer requires them, but MAR shows daily signatures (up to and including current day) indicating that they are/were applied. Previous pages of MAR indicates that they were discontinued effective 9/17/24. Ibuprofen is listed as a PRN on MAR, but was not found. Staff Member could not locate this medication. Medication review for Individual 2: The glucose test log showed that the 8AM test was not completed, and their PRN Docusate Sodium 100mg soft gel was not found in the med box. The script label for PRN Anbesol 20 maximum strength gel is cut off, making it impossible to know the discard date.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. The organization will ensure that all services will be provided for including medication management. The individual is no longer on the nicotine patches and the MAR has been adjusted to reflect that the medication has been discontinued. 11/15/2024 Implemented
6400.171A bottle of open mustard was found in an upper cabinet in the kitchen of the 1st floor unit. A bottle of open hot sauce was found in an upper cabinet in the kitchen of the 2nd floor unit.Food shall be protected from contamination while being stored, prepared, transported and served. The organization will ensure that food will be protected from contamination while being stored, prepared, transported and served. Both items were discarded. Moving forward these items will be stored in the refrigerator once opened. 11/15/2024 Implemented
6400.166(a)(2)For Individual 2: The following medications had discrepancies in the prescribing authority between the MAR and script label: Pantoprazole Sod Dr 40mg tab, Levothyroxine 25mcg tab, and Divalproex Sod Dr 250mg tab (morning and night dose blister packs). In all cases, the prescribing doctor on the prescription label did not match the prescribing doctor listed on the MAR.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.The organization will ensure that the medication will includes the prescriber of the medication. We are currently working with the pharmacy to rectify the situation and to ensure all future Mars reflect the correct prescribing Doctor. on the pharmacy label and the MAR 11/29/2024 Implemented
6400.166(a)(4)For individual 1- Dulera was found in the medicine lockbox to be administered every 12 hours for COPD, but was not listed on the MAR.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.The organization will ensure that a medication record will be kept up to date and the MAR matches all medications on site. Dulera was added to the MAR so proper documentation can occur on the MAR for administration 11/15/2024 Implemented
6400.166(a)(12)For individual 2- PRN Acetaminophen 500mg tab (prescribed 11/23)- blister pack has 13 or 24 doses empty; MAR review back to November 2023 shows doses given seven times, twice in 2/23, 11/23, twice in 2/24, 3/24, and 7/24. Leaving six unaccounted for. PRN Acetaminophen 500mg tab (prescribed 6/24)- shows three doses administered given, there are no administrations logged on the MARs.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration.The organization will ensure the medications and MAR documentation matches up to ensure the documentation matches the medication that has been administered. A training is planned to review proper documentation of the PRN medication. 12/06/2024 Implemented
SIN-00252372 Unannounced Monitoring 09/24/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The bedroom on the second floor belonging to individual number 1 continues to smell of urine. (REPEAT NON-COMPLIANCE 3/5/2024, 4/12/24.)Clean and sanitary conditions shall be maintained in the home. The Life Group Will ensure clean and sanitary conditions will remain in the home at all times. The plan of correction for this citation is listed below: . 1. Another waterproof mattress was purchased with a delivery date of 10/14/24. 2. Staff assisted the individual with cleaning, sanitizing and deodorizing his entire room on the day of the inspection. 3. A team meeting with the SC will be scheduled to discuss the issue of the consumer adamantly refusing to have staff in his room for cleaning. 4.BSS will assist team with 10/18/2024 Not Accepted
SIN-00245297 Unannounced Monitoring 05/29/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)Standing water found in the basement. The standing water in the basement was nesting mosquitoes. The amount of water is at least 1.5 inches high at the highest point. This poses a hazard as if not corrected will begin to cause mold due to the moisture. Floors, walls, ceilings and other surfaces shall be free of hazards.The L.I.F.E GROUP will ensure all floors, walls, ceilings and other surfaces are free of hazards. The water was removed, and the area was sanitized. A plumber has been contracted to find the source of the standing water leak. 06/26/2024 Implemented
6400.163(g)For individual 1 the blister pack for the 2-tablet dosage of Medication Divalproex SOD Dr 500 mg Tab was incorrectly labeled "Morning" instead of "Night".Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions.The L.I.F.E. GROUP will ensure Medication will be stored and organized according to the manufacturer's instructions. An incident report was submitted for the medication error. The blister packs were corrected to correspond with the label and MAR. The Indvidual's PCP was notified of the error 05/29/2024 Implemented
6400.166(a)(12)Medication review for individual 1 was done on 05/29/24 at 10:45 AM and medication Bd Ultra-fine Pen Ndl 4mmx3 was incorrectly signed off on on the MAR for the 05/29/24 dosages at 12 PM, 5 PM and 8 PM. Medication review for individual 1 was done on 05/29/24 at 10:50 AM and medication Buspirone Hcl 5mg tablet was incorrectly signed off on on the MAR for the 05/29/24 dosage at 8 PM. Melatonin 5 mg tablet was taken on 05/29/24 but was not signed off on the MAR.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration.The L.I.FE. GROUP will ensure proper documentation of medication administration is occurring at the time of medication administration and not signed in advanced. The DSP was identified, and the PM reviewed the MAR with the DSP and issued a written warning. 05/30/2024 Implemented
6400.167(a)(3)For individual 1 the medication Divalproex SOD Dr 500 mg Tab was prescribed for 1 tablet to be taken at 8 AM and 2 tablets to be taken at 8 PM. However, the MAR shows that 2 tablets were taken at 8 AM on 05/29/24.Medication errors include the following: Administration of the wrong dose of medication.The L.I.F.E. GROUP will ensure Medication will be stored and organized according to the manufacturer's instructions. An incident report was submitted for the medication error. The blister packs were corrected to correspond with the label and MAR. The Indvidual's PCP was notified of the error 05/29/2024 Implemented
SIN-00242762 Unannounced Monitoring 04/12/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)Lint filter in the dryer was not clear of lint which could cause a fire hazard.. Floors, walls, ceilings and other surfaces shall be free of hazards.The L.I.F.E. GROUP will ensure all area and surfaces are free of hazards. The lint trap was cleaned while the inspector was on site. 04/24/2024 Implemented
6400.144Staff is logging in the MAR that medication (GNP Nicotine Patch 21 mg) for Ind. #1 is being administered daily, this medication was not administered to the individual on 04/12/2024 and logged on the MAR as administered.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. The L.I.F.E. GROUP will ensure that all health services are provided. The staff who signed the MAR on the day of the inspection instead of indicating that the individual refused the patch received a counseling. and the MAR was updated to reflect a refusal instead of an administration. A training was conducted with all staff members of the site to review documenting refusals. 04/22/2024 Implemented
6400.32(d)Individual #1 bedroom still has a smell strongly of urine. {REPEAT NON-COMPLIANCE 3/5/2024}An individual shall be treated with dignity and respect.The L.I.F.E. GROUP will ensure that all individuals will be treated with dignity and respect. The origin of the smell appeared to be coming from the flooring per the inspector. The flooring was replaced with vinyl for a seep proof and easier to clean surface. 04/19/2024 Not Implemented
SIN-00240311 Unannounced Monitoring 03/05/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16Individual #1 reports of being teased about their enuresis by staff and one staff person in particular that they do not want in their home. The staff do not interaction with him in any meaningful ways. They are persistently on their phones.Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.The LIFEGROUP will ensure that all individuals are free from abuse. Such abuse is deprivation of rights or human dignity, physical, emotional, sexual, neglect, exploitation, sexual harassment, molestation, financial, restraints, withholding meals, sexual harassment, withholding care as specified in the ISP, and support. Staff provided emotional support to the Individual #1. Staff training has been planned to be conducted by the end of the month. The Program Specialist scheduled a team meeting to discuss the issues and provide support to the individual. 03/15/2024 Not Accepted
6400.64(a)Individual #1's bedroom is thoroughly dirty and there is a distinct and pungent urine smell. The floors and surfaces are dirty with debris, and dust accumulation. There is soiled bedding and clothing in the closet.Clean and sanitary conditions shall be maintained in the home. The LIFEGROUP will ensure it maintains clean and sanitary conditions in all sites. The LIFEGROUP Will contract a secure a professional cleaning service to clean and disinfect all surfaces. The soiled bedding has been replaced with new bedding. A professional cleaning has been scheduled. to clean and sanitize the room. Staff will be retrained on the Cleaning Protocol for Individual's# 1 room 03/29/2024 Not Accepted
6400.72(a)Individual # 2's bedroom on the first-floor middle window on the long wall, has broken blinds and no screen in it. The blinds need to be replaced and a screen installed. Additionally, the third-floor rec room (the room with tan sheer curtains, and a red/black dotted carpet) has a window with a missing screen. This window needs to have a screen installed.Windows, including windows in doors, shall be securely screened when windows or doors are open. The LIFEGROUP will ensure that all windows and doors will be secure with a screen when the window or door is open. A screen has been ordered and will be installed in the window. Broken blinds will be replaced with a new one. 03/11/2024 Not Accepted
6400.76(a)The furniture on the second floor of the home is damaged with the upholstery severely deteriorated. These items all have slip covers on them which are stained. This furniture needs to be replaced. Additionally, Individual #1's bed appears to have a section that is broken. The mattress has sunk below its frame in one area. The mattress, box spring and frame need to be replaced. Furniture and equipment shall be nonhazardous, clean and sturdy. The LIFEGROUP will ensure that furniture and equipment will be nonhazardous, clean and sturdy. The current furniture will be replaced with faux leather furniture that is easy to wipe down and sanitize. 03/11/2024 Not Accepted
6400.81(k)(3)Individual #1 had no bedding on his bed, no sheets, pillowcases, blankets, etc.In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season.The LIFEGFROUP will ensure that each individual have clean bedding, pillows, linens and blankets appropriate for the season. Bed linens including pillows, sheets, and blankets will be purchased to replace the old linens. 03/11/2024 Not Accepted
6400.82(e)The basement bathroom shower has no door or shower curtain, or non-slip mat, and is not appropriate for use. Bathtubs and showers shall have a nonslip surface or mat. The LIFEGROUP will ensure all bathtubs and showers have nonslip surface or mat. A bathmat was purchased for the basement bathroom. 03/11/2024 Not Accepted
6400.144Individual #1 had a urology appointment which occurred on 6/21/23. The MD stated that a follow-up appointment is needed in 6 months, however there is no documentation that this follow-up appointment occurred.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. The LIFEGROUP will ensure that all health services for the individual are arranged and provided for. the Urology appointment for individual #2 has been scheduled for 3/13@10:30am 03/13/2024 Not Accepted
6400.171There was an uncovered bowl of food in the first-floor kitchen refrigerator.Food shall be protected from contamination while being stored, prepared, transported and served. The LIFEGROUP will ensure that all food be protected from contamination while stored, prepared, transported and served. Food storage containers have been purchased to store food. Staff will be retrained on the proper storage of food. 03/11/2024 Not Accepted
6400.32(d)Individual # 1's bed is soiled and smells strongly of urine which has not be addressed. Individual #1 is embarrassed by the odor which permeates throughout the entire home.An individual shall be treated with dignity and respect.The LIFEGROUP will ensure all individuals are treated with dignity and respect. A new waterproof bed has been ordered to replace the old bed. A waterproof mattress pad will also be purchased. Air freshener spray and gel air freshener will be purchased to use in the room. 03/08/2024 Not Accepted
6400.32(g)Individual #1 does not have regular access to transportation and is unable to attend all the outings desired. The van for the home has a flat tire and is currently inoperable and transportation via staff vehicles or by other means is inconsistent. Individual #1 cannot create or control their own schedule.An individual has the right to control the individual's own schedule and activities.The LIFEGROUP will ensure that all individuals have the right to control their own schedule and activities. The Program Specialist will work with the individual to develop a calendar each month to plan activities that the individual chooses his own activities. Transportation will be provided for the individual by either Uber/Lyft, public trasportation or agency vehicle. 03/20/2024 Not Accepted
SIN-00239012 Renewal 01/29/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)it could not be determined if the fire safety trainer received training to train individuals on fire safety. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. The LIFE Group will ensure that leadership has completed the "train the trainer" course. A training with an Expert Fire Safety trainer has been scheduled. 08/01/2024 Not Implemented
6400.141(c)(10)The physical exam for individual#1 did not indicate if the individual was free of communicable diseases.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. The LIFE Group will ensure all physical exams will identify if individuals are free from communicable disease. Documentation from the PCP has been obtained. 08/01/2024 Not Implemented
6400.142(a)There was no annual dental exam found in the record for individual#1 at inspection.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. The LIFE GROUP will ensure that all individuals have a dental examination performed by a licensed dentist annually. The dental exam for individual #1 has been schedule for 3/15/24 08/01/2024 Not Implemented
6400.151(c)(3)Staff member#2's physical exam dated 9/14/22 does not include if the staff member is free of communicable diseases. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. The LIFE GROUP will ensure that all staff are free from communicable disease. Staff # 2 provided documentation that the staff member is free from communicable disease. 08/01/2024 Not Implemented
6400.181(a)The individual file did not contain an initial assessment upon admission. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The LIFEGROUP will ensure that each individual will have an initial assessment completed within 60days of admission. 08/01/2024 Not Implemented
6400.18(i)Incident#9247603-extension date passed 1/11/24 no further documentation found in record. Incident #9215085-extension date passed 10/29/23-no further documentation found in record.The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension.The LIFEGROUP will ensure that all incidents in EIM will be finalized in 30days. The incidents have been finalized and waiting for County review. 03/08/2024 Not Implemented
6400.24There were no criminal or FBI background checks found in record during inspection for staff member#3.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.The LIFEGROUP will ensure to comply with the Federal and State statutes and regulations and local ordinances. A background check was obtained. 08/01/2024 Not Implemented
6400.32(r)Individual rights were not updated to reflect the individual has the right to lock or unlock their bedroom door.An individual has the right to lock the individual's bedroom door.The LIFE GROUP will ensure that an individual has the right to lock their bedroom door. The Resident Rights document was revised to include the "right to lock the individual's door", reviewed and signed by the resident. The agency will complete an assessment of each individual's desire to have a bedroom lock and/or their safety concerns around locks and will submit documentation of these assessments along with records of team meetings in cases where it is determined that a rights modification is necessary. These assessments will be completed for all current individuals in the agency as well as at admission for new individuals and retained for licensing review. 08/01/2024 Not Implemented
6400.46(b)The credentials for the fire safety expert were requested, however, not provided.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).The LIFE GROUP will schedule fire safety training for all staff with a fire safety expert or using a curriculum reviewed, created, and/or approved by a fire safety expert, whose credentials they will provide to ODP prior to the training(s). If approved, the fire safety expert's credentials shall be retained by the agency and made available to licensing staff on future inspections along with the training curriculum. These steps shall be completed by 8/1/24. 08/01/2024 Not Implemented
6400.52(b)(1)Staff member#1-did not have the required annual training for the training year in record at inspection.The following shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons.The LIFEGROUP will ensure that Leadership members complete 12hrs of training each year. Trainings have been completed. 08/01/2024 Not Implemented
6400.165(g)The individual did not have psych review every 90 days as mandated to ensure compliance.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.The LIFEGROUP will ensure that individuals who are on psychiatric medication will have a medication review with a licensed physician every 3 months. On March 1st the individual went to the appointment but would not cooperate. The appointment was rescheduled for 4/1/24. the BSS will attend for support.. 04/01/2024 Not Implemented
6400.181(f)The invite letter for ISP was not sent out 30days prior to ISP meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.The LIFE GROUP will establish or revise their procedure regarding periodic reviews of individual files. This will include setting a calendar for time-sensitive items, such as assessment documentation being provided to the team within 30 days of the individual's ISP. 08/01/2024 Not Implemented
SIN-00227836 Unannounced Monitoring 07/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The floor and shower of the bathroom in the basement is completely covered with dark stains that appear mold-like and render the bathroom unusable. This needs to be addressed/repaired. There is also unknown material in the toilet. Staff indicated these issues are from water damage in the basement.Clean and sanitary conditions shall be maintained in the home. The LIFEGROUP will ensure clean and sanity conditions will be maintained in the home. Maintenance has been called in to clean up the mold like substances on the floor and shower. The toilet was cleaned. 08/11/2023 Implemented
6400.64(b)There were multiple ants observed in the drawer of the 2nd floor kitchen (the kitchen used to prepare meals and store food for individual #1).There may not be evidence of infestation of insects or rodents in the home. The LIFEGROUP will ensure that there is no evidence of insect or rodent infestation in the home. An exterminator contracted to sole the ant problem. 08/04/2023 Implemented
6400.65No working fan in 1st floor bathroom. There was no working fan in basement bathroom. There was no working fan in 3rd floor bathroom. No other ventilation source exists for these rooms.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. The LIFEGROUP will ensure all areas that require ventilation will be ventilated by at least one operable window or mechanical ventilation. A contractor has been employed to assess the areas and address the ventilation issue. 08/11/2023 Implemented
6400.67(b)There was a large accumulation of lint in the dryer lint trap. Floors, walls, ceilings and other surfaces shall be free of hazards.The LIFEGROUP will ensure the residential site is free from Hazards. The lint was immediately was removed from the lint trap. 08/04/2023 Implemented
6400.73(a)There is no handrail secured to the wall for the top half of the interior basement stairs. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The LIFEGROUP will ensure ramps, interior stairways and outside steps exceeding 2 steps will have a well secured handrail. The LIFEGROUP has contacted a contractor to install a handrail in the designated area. 08/16/2023 Implemented
6400.81(k)(6)The bedroom for individual #1 did not have a mirror.In bedrooms, each individual shall have the following: A mirror. The LIFEGROUP will ensure each bedroom has a mirror. The PM put a mirror in the bedroom. 08/11/2023 Implemented
6400.82(f)There were no paper towels or soap in the first-floor bathroom. There was no toilet tissue available, nor was there paper towels available for use in the second-floor bathroom (the floor where individual #1's bedroom and kitchen area are located). There were no paper towels or soap available in the third- floor bathroom. There was no soap, toilet tissue or paper towels available in the basement bathroom.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. The LIFEGROUP will ensure all site bathrooms are supplied with paper towels, toilet paper and soap. The PM supplied all bathrooms at this site with toilet paper, paper towel and soap. 07/18/2023 Implemented
6400.144Medication prescribed for individual #1, Atorvastatin (generic Lipitor) 20mg, 8pm daily dosage, was not administered at on 7/8/23 and remains in the blister pack with no explanation on the medication administration record. [REPEATED VIOLATION 4/5/23]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. The staff was identified, and the PM performed a counseling with the identified staff. 07/21/2023 Implemented
6400.214(b)There was no copy of the behavior support plan for individual #1 available for review at the home. Staff interviewed were not knowledgeable about the plan. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The LIFEGROUP will ensure the current behavior support plan for individual#1 is in the residential home. 08/11/2023 Implemented
6400.166(b)On 7/8/23, staff initials on the MAR indicate that individual #1's prescribed medication Atorvastatin (Lipitor) 20mg 8pm dosage was administered, however this dosage is still in the blister pack. There is an "x" indicating that another prescribed medication Aripiprazole 10mg 8pm dosage was not administered, however this dosage was not present in the blister pack. There was no information on the medication administration record which explains this discrepancy. [REPEATED VIOLATION 4/5/23]The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Medication error was entered in EIM. The med errors were addressed with staff on duty. 07/18/2023 Implemented
6400.167(c)Individual #1 prescribed medication Atorvastatin (Lipitor) 20mg 8pm dosage was not administered at 8:00pm on 7/8/23 and was not reported via an incident report in HCSIS.A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation).The LIFEGROUP will ensure that all medication errors will be identified and entered into HCSIS in a timely manner. The medication error was entered into HCSIS on 7/18/23. 07/18/2023 Implemented
6400.182(a)The behavior plan provided for individual #1 utilizes different pronouns to refer to this individual throughout the plan. This is noted in the reports from the behavior specialist that were available at the home as well. This behavior plan is not individualized and shows that portions of the plan were cut and pasted from another individuals plan.The program specialist shall coordinate the development of the individual plan, including revisions with the individual and the individual plan team.The LIFEGROUP will ensure that the entire BSP will reflect the named individual throughout the plan. The Program Specialist will meet with the team and the individual to review revisions and corrections . 08/18/2023 Implemented
6400.182(c)The individual plan for individual #1 states that the behavior plan is restrictive. However, the written behavior plan provided does not contain a restrictive component. This information needs to be updated to reflect accurate information.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The SC will be notified of the error in the plan by the Program Specialist. The plan will be updated by the SC 08/31/2023 Implemented
SIN-00222347 Unannounced Monitoring 04/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Pungent odor coming from Individual 1's bedroom on the second floor. This odor was extremely strong even with facial masks worn by inspector.Clean and sanitary conditions shall be maintained in the home. The Life Group will ensure that clean and sanitary conditions will be maintained in the home. The soiled mattress was removed from the home and discarded. a new mattress was brought and a waterproof mattress pad was purchased to use on the bed. The room was thoroughly cleaned and room deodorizer was purchased to use in the room. 04/10/2023 Implemented
6400.64(a)There is an unidentifiable brown stain on second floor couch.Clean and sanitary conditions shall be maintained in the home. The LIFE Group will ensure clean and sanitary conditions will be maintained in the home. On the day of inspection, the couch slipcover was washed to eliminate the stain. 04/05/2023 Implemented
6400.67(a)The floor planks on second floor hallway are tearing and coming up from the surface.Floors, walls, ceilings and other surfaces shall be in good repair. The Life Group will ensure that the floors, walls, ceilings and other surfaces are in good repair. The floor planks were repaired by the contractor to ensure the planks are even and sturdy. 04/14/2023 Implemented
6400.67(b)The shower knob on third floor bathroom fell off when attempted to turn water on/ Floors, walls, ceilings and other surfaces shall be free of hazards.The LIFE Group will ensure that all surfaces will be free of hazard. The plumber repaired the shower knob to ensure it does not fall off when the water is turned on or off. 04/21/2023 Implemented
6400.72(a)There is no screen in second floor hall window.Windows, including windows in doors, shall be securely screened when windows or doors are open. The LIFE Group will ensure all windows will be securely screened. A screen was purchased for the 2nd floor window and inserted in the 2nd floor window. 04/06/2023 Implemented
6400.77(b)There were no scissors in first aid kit at the time of inspection. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. The LIFE Group will ensure that all First Aide kits contain all items per the 6400 regulations. The original pair of scissors was replaced with a new pair of scissors to make the First Aide kit complete. 04/05/2023 Implemented
6400.81(k)(2)Individual 2's bed was covered with clothes and other materials, making it impossible to lay comfortably in bed.In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. The LIFE Group will ensure all bedrooms have a clean, comfortable and solid foundation. The consumer prefers to have his personal items on the bed at all times. .The Program Specialist and the Program Manager will work with the consumer to get him to understand that by removing items from his bed, he will have a more comfortable surface to sleep on. 04/08/2023 Implemented
6400.81(k)(3)There are no bed linens on Individual 2's bed.In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season.The Life Group will ensure that each bed has bedding, pillows, linens and blankets that are appropriate for the season. On the day of inspection the individual had soiled the bed the night before and the the staff took off the bedding to let it air out. The soiled mattress was replaced and bedding as per 6400 regulations was put on the bed. 04/10/2023 Implemented
6400.82(e)The bathroom in basement does not have a nonslip mat. Bathtubs and showers shall have a nonslip surface or mat. The Life Group will ensure that bathtubs and showers have a non-slip surface or mat. Although the basement bathroom is not used by consumer or staff, a bathmat was purchased and put in place to remain in compliance with the 6400 regulations. 04/10/2023 Implemented
6400.144The following medications were not present during the medication review for Individual #2: Ensure (to be taken daily), Total block SPF 65.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. The LIFE Group will ensure that prescribed medication and supplements be provided as ordered. The Director contacted the Pharmacy and doctor to get a supplement that was more readily available than the one originally ordered or discontinued. The sunblock was changed to SPF 50. A new MAR was sent to reflect the change. 04/06/2023 Implemented
6400.216(a)Individual program books with confidential information were stored in an unlocked hall closet on the second floor. An individual's records shall be kept locked when unattended. The Life Group will ensure that all individuals records be kept locked when unattended. The Service notes book was relocated to the site office. A sign is posted for all staff to remind them to lock up the books after use. This office is kept locked when not in sure. 04/05/2023 Implemented
6400.163(a)Loose unidentified medications were stored inside clear non latex gloves.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.The Life Group will ensure that all medications be kept in their original containers. The medication found on the day of the inspection was medication that the individual refused. The medication was properly discarded. 05/12/2023 Implemented
6400.163(h)Old medications were stored in a closet in one medication bin and not disposed properly.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The Life Group will ensure that discontinued or expired medication will be destroyed in a safe manner according to Federal and State Statues and regulations. On the day of the inspection the old medication was taken to Walgreens and put in the receptacle for discarded medications by the Director. 04/05/2023 Implemented
6400.165(b)Regarding the medication review for Individual #2: The MAR states to take two tablets of Therems Multivitamin at 8 AM, however, the blister pack states to take one tablet at 8 AM.A prescription order shall be kept current.The Life Group will ensure that all Prescription orders are kept current. On the day of the inspection the Pharmacy was called for clarity of the order and a new MAR and blister pack was sent to the home to reflect the correct order of Therems Multivitamin take 1 tablet at 8am. 04/24/2023 Implemented
6400.165(b)Regarding Medication review for Individual #2: The MAR states to take two Topiramate 200 mg at bedtime, however the blister back states to take one at bedtime.A prescription order shall be kept current.The Life Group will ensure that a prescription order will be kept current. on the day of the inspection the Director called the pharmacy and the ordering physician to get clarification of the order. The Pharmacy sent an amended MAR to match the Pharmacy label. 04/05/2023 Implemented
6400.166(b)Regarding the medication review for Individual #2: Ziprasidone 80 MG was not signed off as administered on 4/1/23 at 8 PM, 4/2/23 at 8 PM, 4/3/23 at 8 AM, 4/4/23 at 8 AM, and 4/5/23 at 8 AM.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The Life Group will ensure that all medication administration signatures are completed at the time of administration. The Program Manager reviewed the documentation errors with the staff involved to resolve the error. 04/06/2023 Implemented
SIN-00212346 Unannounced Monitoring 09/23/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(b)(4)On July 24, 2022, The LIFE Group's ("LIFE") Chief Executive Officer submitted a "Self-Inspection and Declaration Tool" to the Department for 318 Parker St., Unit A, Chester, PA 19013 for purposes of adding the location to LIFE's existing license. On August 4, 2022, the Chief Executive Officer submitted a second "Self-Inspection and Declaration Tool" for 318 Parker St., Unit B, Chester, PA 19013, also for purposes of adding the location to LIFE's existing license. During the Department's September 23, 2022, inspection, it was discovered that Units A and B were not separate and distinct locations, but rather structured and operated as a single, 3-floor Community Home as follows: · There was only one entrance door to access the home. · There was a single stairway to access all floors in the home. · There was only one washer and only one dryer in the home. · LIFE staff were moving from floor to floor to perform their duties. · All individuals' medications were stored together on the third floor. · There was only one first aid kit for the entire home. Additionally, the Department identified violations of the following regulations (specific details about the violations are provided elsewhere in this inspection summary): 55 Pa.Code: · § 6400.64(a) (relating to Sanitation) · § 6400.67(a),(b) (relating to Surfaces) · § 6400.71 (relating to Emergency telephone numbers) · § 6400.80(b) (relating to Exterior conditions) · § 6400.81(k)(5) (relating to Individual bedrooms) · § 6400.111(f) (relating to Fire extinguishers) The Chief Executive Officer documented on the Self-Inspection and Declaration Tools for both Unit A and Unit B that LIFE was in compliance with all of the above regulations. The Self-Inspection and Declaration Tool reads "By signing below, I swear that the above information is true and correct, that the agency is responsible for compliance with all applicable statues and regulations, including but not limited to Article X of the Public Welfare Code, 62 P.S. § 1001 et seq. and 55 Pa. Code § 20.1 et seq., and that knowingly providing inaccurate information may lead to enforcement action up to and including revocation of the agency's license to operate." Both tools were signed by the Chief Executive Officer. The Chief Executive Officer knowingly providing inaccurate information to the Department about the number of homes to be operated and the compliance status of each unit for purposes of adding the "homes" to LIFE's existing license.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Compliance with this chapter. DIRECTED PLAN OF CORRECTION: The CEO or designee will close the home in CLS listed as "318 Parker Street Unit B" immediately upon receipt of this Directed Plan of Correction. The CEO or designee will submit an "increase in capacity" self-inspection form to increase licensed capacity from 2 to 4 at "Unit A" to the Department immediately upon receipt of this DPOC. Immediately upon receipt of this DPOC, "Unit A" will operate as 1 community home with a maximum licensed capacity of 4. Immediately upon receipt of this DPOC, CEO will ensure staffing coverage is such that supervision needs of the individuals residing in the home are met. Within 48 hours, CEO will submit a staffing schedule to the SE regional office for the month of November 2022. 11/08/2022 Not Implemented
6400.64(a)Outdoor trash and trash cans were located in the living room space and the can holding the trash was overflowing. The kitchen had a trash bag tied and not in the can or discarded.Clean and sanitary conditions shall be maintained in the home. Due to construction in the backyard staff put the trash cans in the home. The trash cans were immediately removed while the inspector was on site. 09/23/2022 Implemented
6400.67(b)There were various light switches without protective plates. The locations missing protective platers were the entrance of the home, in the individual #1's bedroom and the switch at the top of the stairs leading to the basement. Floors, walls, ceilings and other surfaces shall be free of hazards.Protective light covering were replaced while the inspector was on site. 09/23/2022 Implemented
6400.71There were no emergency telephone numbers located nearby the telephones on all three levels.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. The list for emergency numbers has been placed nearby all phones on all 3 levels in plain sight for all staff and consumers to utilize as needed. 10/06/2022 Implemented
6400.80(b)The exit in the rear of the home was not able to be accessed due to pending construction work. There was no precaution in place to caution the hazard if the rear exit was used. Signage was placed on door after discovery. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.DIRECTED PLAN OF CORRECTION: While the construction in the back was being completed a sign to not use that door as an exit was put up for everyone's safety while the inspectors were onsite. 11/08/2022 Implemented
6400.81(k)(5)Individual #1s bedroom did not contain a closet or wardrobe.In bedrooms, each individual shall have the following: Closet or wardrobe space with clothing racks and shelves accessible to the individual. DIRECTED PLAN OF CORRECTION: A wardrobe for the bedroom was purchased and assembled for the individual to use. 11/08/2022 Implemented
6400.111(f)The fire extinguisher in the basement was dated 2021 with no annual inspection tag. The extinguisher was replaced with a new extinguisher during monitoring. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. DIRECTED PLANOF CORRECTION: The Life Group purchased a new fire extinguisher while licensing inspectors were onsite. 11/08/2022 Implemented
6400.165(c)Individual #1's prescribed Calcium/ Vit D3 600-400 medication to be taken twice daily at 8am and 8pm was logged as given on 9/23/2022 but not administered per the pill count on the blister pack. The medication was located in the as needed (PRN) medication boxA prescription medication shall be administered as prescribed.DIRECTED PLAN OF CORRECTION: An EIM report was submitted in HCSIS. The Life Group will train the staff on ensuring proper medication administration. 11/15/2022 Implemented
6400.166(b)Individual #1's Ozempic 1mg injections to begiven once weekly at 8am on Thursdays was not logged immediately after administration on 9/22/2022, the log was left blank on the aforementioned date.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.DIRECTED PLAN OF CORRECTION: The staff was identified and completed the documentation on the medication record. The Life Group retrained this staff on documenting after administration of medication. 11/08/2022 Implemented