Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00241525 Renewal 03/26/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The fire drill held on 1/29/24 does not indicate the amount of time it took to evacuate the home. Staff wrote in the time slot designated for the "exit time" the actual time of the drill occurring. *Staff wrote that the time of the drill was at "8:15pm" and then in the exit time "8:17pm" which may indicate that it took 2 minutes, however this is an unacceptable way to record this information because that is based off an assumption··· they could have actually just recorded the time of the drill twice but didn't get the time right··· we need actual min./sec. for accuracy of documentation. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Provider will offer retraining to all staff on fire drill regulations including overnight fire drills to occur at least every six months. Training will also include evacuation time, problems encountered, documentation and explanation needed when problems are encountered. A call to the supervisor will occur when evacuation time exceeds 2.5 minutes. Documentation on fire drill logs has been updated to include signatures required from Site Coordinators, Program Specialists, Compliance Officer and Program Director to ensure all documentation is complete on each fire drill log. Fire drills will be repeated when problems occur. 05/31/2024 Implemented
6400.112(e)A sleep fire drill was conducted on 6/25/23 and not again until 3/20/24 (8 months apart), which exceeds the every 6 months requirement of this regulation.A fire drill shall be held during sleeping hours at least every 6 months. Provider will offer retraining to all staff on the regulations for fire drills with specifics on overnight drills. The provider Compliance Officer will send reminder emails to Site Coordinators and provider management team prior to an overnight fire drill month which should occur in the months March, June, October. These reminder emails will go out to the team late February, May, and September. The Site Coordinator is responsible to ensure the overnight drill has been complete with follow up from the Program Specialist at site house meetings that held at least twice a month. The Compliance Officer will review the fire drill log for completion of the overnight fire drill. If the overnight drill is missed in the months of March, June, and October, the Program Specialist will assist staff with completion the following month. 05/31/2024 Implemented
6400.112(i)The fire drill held on 12/16/23 did not indicate which smoke detector was used in the fire drill. A fire alarm or smoke detector shall be set off during each fire drill.Provider will offer retraining to all staff on fire drill regulations. Training will also include detector used, problems encountered, documentation and explanation needed when problems are encountered. Documentation on fire drill logs has been updated to include signatures required from Site Coordinators, Program Specialists, Compliance Officer and Program Director to ensure all documentation is complete on each fire drill log. 05/31/2024 Implemented
SIN-00184934 Renewal 03/15/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(e)The trashcan next to the garage, closest to the road, did not have a lid during the 03/16/21 inspection.Trash receptacles over 18 inches high shall have lids. The trash can was replaced on 3/27/2021. On 3/18/2021, an email from the Director of Operations was sent to the entire agency reminding of the process for Maintenance Requests. On 3/18/21 and 3/22/21, all ID Management was retrained on the Maintenance Request Procedure. Retraining of the Maintenance Request Procedure will be reviewed by staff at all sites by 4/16/2021. 04/12/2021 Implemented
6400.113(a)Individual #1 was not trained in fire safety upon initial admission. Individual #1 DOA is 01/28/21, the training did not happen until 02/12/21. 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 FSI ID Moving Procedure was updated on 3/18/2021 to include that Fire Safety is to be completed prior to or on the date of move in. On 3/18/21 and 3/22/21, all ID Management was trained on the updates to the Moving Procedure. Training of the Moving Procedure will be completed by staff at all sites by 4/16/2021. 04/16/2021 Implemented
6400.141(c)(11)Individual #1 health maintenance needs were not evaluated at the 11/16/20 annual physical.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The FSI ID Moving Procedure was updated on 3/18/2021 to include that the individual's Annual Physical must be received prior to the move, updated with required information and signed by a medical professional prior to move in date. On 3/18/21 and 3/22/21, all ID Management was trained on the updates to the FSI Moving Procedure. Training of the FSI Moving Procedure will be completed by staff at all sites by 4/16/2021. 04/16/2021 Implemented
6400.141(c)(13)The 11/16/20 annual physical document does not list the individuals needs in case of an emergency.The physical examination shall include: Allergies or contraindicated medications.The FSI Moving Procedure was updated on 3/18/2021 to include that the individual's Annual Physical must be received prior to the move, updated with required information and signed by a medical professional prior to move in date. On 3/18/21 and 3/22/21, all ID Management was trained on the updates to the Moving Procedure. Training of the Moving Procedure will be reviewed by staff at all sites by 4/16/2021. 04/16/2021 Implemented
6400.34(a)The Department issued updated regulatory rights, effective 2/3/2020, stating that individuals have additional rights they need to be informed of. At the time of the 03/15/2020 annual inspection, Individual #1 was never informed of the individuals rights as described in 6400.32.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.FSI Individual Consents/Rights were updated on 3/18/2021. On 3/18/21 and 3/22/2021, all ID Management was trained on the updates to the form. Training of the updates will be completed by staff at all sites by 4/16/2021. The updated Individual Consent/Rights will be reviewed with and signed by individuals and mailed out for guardians review and signatures by 4/16/2021. 04/16/2021 Implemented
6400.166(a)(2)The name of the prescriber of the medication is not listed on the MAR for Individual #1 Lorazepam and multiple other current medications.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.All physician names were added to the electronic MAR after communication with FSI's Long Term Care Pharmacy on 4/7/2021. The FSI Moving Procedure was updated on 3/18/2021 to include that there will be communication with the current pharmacy and FSI's Long Term Care pharmacy to ensure all medications are transferred correctly, including the prescriber name being entered onto the electronic MAR originating at the pharmacy. On 3/18/21 and 3/22/21, all ID Management was trained on the updates to the Moving Procedure. Training of the Moving Procedure will completed by staff at all sites by 4/16/21. 04/16/2021 Implemented
SIN-00167852 Renewal 02/25/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The self-inspection was completed on 2/3/20, but does not contain a written summary of corrections made. The violations are written out, but there is no POC indicated.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. 1. Between January 14- February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 3-10, 2020, 3 new Program Specialists have joined the ID managment team. 2. A Self-Assessment binder was assembled and each site has it's own section. 3. All Program specialists were trained/retrained on the purpose of the self-assessment, how to complete and where they will be kept on 3/12/2020. 4. Self-assessments will be completed in January and July of every year. This will be scheduled by the Compliance Officer (hired 7/28/19) and completed as a group with assistance. 03/12/2020 Implemented
SIN-00128612 Renewal 02/13/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)No date on self inspection when it was completed.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Program Specialists training will be held to review how to complete the self-assessment. 04/30/2018 Implemented
6400.46(f)Staff #1 had fire safety training on 6/1/16 and not again until 6/2/17.Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. Training and Compliance officer was made aware that there is no leeway in staff training records. Will hold training's a month earlier, if possible. 02/16/2018 Implemented
6400.112(c)The fire drill record for drill held on 11/30/17 did not include problems encountered during the drill.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. Site Coordinators will be tasked with this over sight. Site coordinators will be trained by 4/30/18. 04/30/2018 Implemented
6400.112(d)Individuals did not evacuate the building within 2 1/2 minutes during the drill held on 11/30/17. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Letter to fire chief requesting site evaluation whether additional time could be added to the evacuation. 04/06/2018 Implemented
SIN-00104667 Renewal 12/19/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)Individual #1 was using his/her funds to pay for staff meals. There was no documentation in Individual #1's Individual Support Plan (ISP) or in a service note from his/her supports coordinator indicating that Individual #1 agreed to pay for staff meals when on an outing. Individual funds and property shall be used for the individual's benefit. Person Responsible: Christina Tickerhoof (Program Specialist), Elizabeth Hogue (Training and Compliance Officer), Program Specialists Individuals ISP will not be updated to reflect this, although the team did meet and discuss on 12/28/2016. Although she indicated that she wanted to pay for staff meals, Program Specialists have been instructed that this is not appropriate in this case. Review of All records will take place no later than February 10, 2017 to ensure compliance in this chapter for all people served. Conversation with Program Specialists to ensure this has not happened with any other individual occurred on January 25, 2017. Plan to Prevent Future Occurrence: All Program Specialists were retrained January 25, 2017 on what is required for individuals to pay for staff expenses. This included conversation around clarification on listserv published in December of 2015. (Attachment #2). 01/31/2017 Implemented
6400.67(a)Aproximately a 4 foot long stream of water and soap was witnessed on the basement floor near the washing machine. The washing machine was running and the water appeared to be dripping from a pipe connected to the washing machine. Floors, walls, ceilings and other surfaces shall be in good repair. Person Responsible: Christina Tickerhoof (Program Specialist), Elizabeth Hogue (Training and Compliance Officer), Program Specialists, Jeff Snyder (Maintenance Supervisor) Maintenance Request was completed immediately upon discovery on 12/20/2017. A new PVC pipe and reducer were purchased to fix the leak in the washer. It was fixed on 1/3/2017 and the Email to show the maintenance request and Purchase Request for these items to correct the issue is attached. (Attachment #15) Plan to Prevent Future Occurrence: All Program Specialists were retrained on this requirement on January 25, 2017 (Attachment #2) 01/03/2017 Implemented
6400.80(b)Part of a tree, approximately 20 foot in length with numerous branches extending from the tree, had severed from the trunk and fallen over in the backyard. The tree was laying on the ground approximately 15 feet from the house. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.Person Responsible: Christina Tickerhoof (Program Specialist), Elizabeth Hogue (Training and Compliance Officer), Program Specialists, Jeff Snyder (Maintenance Supervisor) The tree was removed. Attachments with photographs before and after are attached. (Attachment #14). Plan to Prevent Future Occurrence: All Program Specialists were retrained on this requirement on January 25, 2017 (Attachment #2) 01/25/2017 Implemented
6400.141(c)(14)The physical exam form completed for Individual #1 on 12/20/16, did not include medical information pertinent to diagnosis and treatment in case of an emergency. The field was left blank. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Person Responsible: Christina Tickerhoof (Program Specialist), Elizabeth Hogue (Training and Compliance Officer), Program Specialists The physical form was updated and sent to individuals PCP on 1/25/2017 for review (attachment #13-Fax with updated physical to PCP). Review of All records will take place no later than February 10, 2017 to ensure compliance in this chapter for all people served. Plan to Prevent Future Occurrence: All Program Specialists were retrained on this requirement on January 25, 2017 (Attachment #2) 01/31/2017 Implemented
6400.142(f)Indvidual #1's record did not include a written plan for dental hygiene. Individual #1 often refuses daily dental hygiene along with dental visits. An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. Person Responsible: Christina Tickerhoof (Program Specialist), Elizabeth Hogue (Training and Compliance Officer), Program Specialists A written plan for dental hygiene was added to individual #1¿s plan on 1/24/2017 in the form of track changes that were sent to the individuals Support¿s Coordinator on 1/25/2017 (attachment #4-Track changes including Dental Hygiene Health Promotion). Review of All records will take place no later than February 10, 2017 to ensure compliance in this chapter for all people served. Plan to Prevent Future Occurrence: All Program Specialists were retrained on the requirements of this chapter on January 25, 2017 (Attachment #2). 01/31/2017 Implemented
6400.143(a)Individual #1 refused multiple medical and dental examinations and treatments. The refusals and continued attempts to train the individual about the need for health care was not documented in the Individual's record. 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. Person Responsible: Christina Tickerhoof (Program Specialist), Elizabeth Hogue (Training and Compliance Officer), Program Specialists Individual #1¿s team met on 12/28/2017 and developed a desensitization plan which includes that 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 (Attachment #12- Desensitization Plan and Team Meeting Info) . The plan addresses all areas and allows for documentation of refusals and attempts to train. The desensitization will be implemented with individual and staff who support her when she is released from her current hospitalization. Review of All records will take place no later than February 10, 2017 to ensure compliance in this chapter for all people served. Plan to Prevent Future Occurrence: All Program Specialists were retrained on this requirement on January 25, 2017 (Attachment #2). 01/31/2017 Implemented
6400.163(c)REPEAT from 5/6/15 renewal inspection: Individual #1 is was prescribed Hydroxyzine 25mg twice per day for anxiety. His/Her 12/5/16 and 10/3/16 medication review documentation did not include a review of the reason for prescribing this medication. He/She was prescribed Geodon 40mg twice per day for Bi-Polar Disorder at the time of his/her 12/5/16 medication review with his/her psychiatrist. The 12/5/16 medication review documentation only included a review of Geodon being prescribed 20mg twice per day. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Person Responsible: Christina Tickerhoof (Program Specialist), Elizabeth Hogue (Training and Compliance Officer), Program Specialists Program Specialist will begin taking Family Services Psych Visit Form (Attachment #7) to all appointments, this document is attached and includes all areas within this regulation (reason for prescribing medication, need to continue medication and necessary dosage) as well as other things. The Program Specialist understands that they should complete the documentation on this form and encourage the Psych doctor to sign, if the doctor refuses to sign that will be documented and their documentation will be kept as well as FSI documentation. Ongoing compliance could not be shown because this person does not return to psych doctor until March 2017. Review of All records will take place no later than February 10, 2017 to ensure compliance in this chapter for all people served. Plan to Prevent Future Occurrence: All Program Specialists were retrained on this requirement on January 25, 2017 (attachment #2). 01/25/2017 Implemented
6400.164(a)Individual #1 was prescribed SF 1.1% toothpaste, apply this layer of gel to teeth once per day with toothbrush for 1 minute, don't eat, drink, or rinse for 30 minutes. Individual #1's December 2016 medication administration record (MAR) did not include "with toothbrush for 1 minute, don't eat, drink, or rinse for 30 minutes." His/Her December 2016 MAR did not include a time of administration for Hydrocodone on 12/12/16 and 12/11/16. The only information recorded was "10" and "4:35" respectively, not indicating a morning or evening administration. A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. Responsible Person: Elizabeth Hogue, Training and Compliance Officer Christina Tickerhoof, Program Specialist Regarding the SF 1/1% toothpaste, he MAR¿s for individual #1 were updated upon discovery of non-compliance on 12/19/2016 and current MAR¿s have all information included for this particular medication. (attachment #9 December MARS and Attachment #10-January MARs). Review of All records will take place no later than February 10, 2017 to ensure compliance in this chapter for all people served. Plan to Prevent Future Occurrence: Reminders surrounding documentation on Medication Administration Records were sent via email to all Family Services staff on 1/20/2017. This included the responsibility around PRN medications and documentation of everything on the MAR. This also included the responsibility to include AM/PM when documenting administration of PRN medications. Email was signed by all staff to indicate understanding and copies are attached for review (Attachment #11). MAR Reviews continue to be completed by Med Admin Trainers and Practicum observers on a quarterly basis. 01/31/2017 Implemented
6400.167(b)According to Individual #1's 9/12/16 medication review, he/she was prescribed Divalproex ER 250mg, 1 tablet at night. Individual #1's medication administration record (MAR) indicated that Divalproex ER 250mg 1 tablet at night was discontinued by his/her psychiatrist on 9/12/16. Divalproex ER 250mg tablet at night was not signed as administered after 9/12/16. The 9/12/16 medication review indicated that Individual #1 was to discontinue Risperdal 1mg twice a day and start Geodon 20mg twice a day. According to his/her Septermber 2016 MAR, Risperdal continued to be administered until 9/18/16 and Geodon was not administered until 9/19/16. According to the 12/5/16 medication review, Individual #1's psychiatrist increased his/her Geodon from 20mg twice a day to 60mg twice per day. According to his/her December 2016 MAR, Geodon was initialed after administration of 40mg twice per day until 12/10/16. From 12/10/16 until 12/14/16 Geodon 20mg twice a day was initialed as being administered to Individual #1. Then after 12/14/16, Geodon 40mg twice per day was initialed as administered for Individual #1 on his/her MAR. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.Plan of Correction: At the 9/12/16 Med review there was a verbal order given to discontinue Divalproex ER due to high Depakote levels. This information was communicated verbally but not on paper. Moving forward, Family Services Inc. Psychiatric Medical Visit Forms (Attachment #7) will be utilized at all medication review appointments, regardless of the doctors refusal to complete/sign. Dr. Vanacore was contacted on 1/25/2017 requesting clarification by Behavior Support Specialist. At this time no response has been received. Once that is received this order will be placed with medication records. Regarding the Risperdal being discontinued, staff were under the impression that the medication needed to be discontinued immediately, and they did not need to wait for the replacement medication. Therefore, that is why the medication was documented as it was. Documentation for this will be kept on the FSI Psych Visit form so that all medication changes are documented correctly. The Geodon as noted for 12/6/16 medication review this was an error in notes from the Behavior Specialist were incorrect, noting it as being 20 mg instead. The Geodon was increased to 40 mg after correspondence with the Behavior Specialist on 12/13/16, correspondence with Behavior Specialist including this information is attached (attachment #8). All Program Specialist were retrained around the requirements of this chapter on 1/25/2017. This included the requirement to take Family Services Psych Visit forms to all Medication Review/Psych appointments regardless of their willingness to complete (attachment #2). 01/31/2017 Implemented
6400.181(b)Individual #1 required an increase in his/her staffing from 1:1 staff to individual ratio to a 2:1 staff to individual ratio on 12/11/16. Individual #1's assessment was not updated to reflect the recommendation of an increase in staffing services. If the program specialist is making a recommendation to revise a service or outcome in the ISP as provided under § 6400.186(c)(4) (relating to ISP review and revision), the individual shall have an assessment completed as required under this section. Person responsible: Christina Tickerhoof (Program Specialist), Elizabeth Hogue (Training and Compliance Officer), Program Specialists. Individual #1's Assessment was updated and sent to team to reflect the additional staffing ratio on January 27, 2017 and now reflects the recommendation of an increase in staffing services (Attachment #5). Review of all records will take place no later than February 28, 2017 to ensure compliance in this chapter for all people served. Plan to Prevent Future Occurrence: On January 25, 2017 all Program Specialists were retrained on the requirement that if the program specialist is making a recommendation to revise a service or outcome in the ISP as provided under 6400.186(c)(4) (relating to ISP review and revision), the individual shall have an assessment completed as required under this section (Attachment #2). 01/31/2017 Implemented
6400.181(e)(7)REPEAT from 5/6/15 renewal inspection: Individual #1's 4/21/16 assessment did not include his/her ability to sense and move away quickly from heat sources. The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. Person Responsible: Christina Tickerhoof (Program Specialist), Elizabeth Hogue (Training and Compliance Officer), Program Specialists Assessment for individual #1 was updated on 1/27/2017 to includes her ability to sense and move away quickly from heat sources (Attachment #5). Assessment templates agency wide were updated and implemented January 1, 2017. Upon receipt of non-compliant areas this assessment template was updated again. The new assessment template is included and includes individual¿s ability to sense and move quickly away from heat sources (attachment #6). Review of All records will take place no later than February 10, 2017 to ensure compliance in this chapter for all people served. Plan to Prevent Future Occurrence: Program Specialists were retrained around the requirements of this chapter on January 25, 2017, this included retraining on the updates to the Annual Assessment Template (Attachment #2). 01/31/2017 Implemented
6400.181(e)(8)Individual #1's 4/21/16 assessment did not include his/her ability to evacuate in the event of a fire. His/Her assessment only indicated that he/she "understood what to do in case of a fire" not what their ability was. The assessment must include the following information: The individual's ability to evacuate in the event of a fire. Christina Tickerhoof (Program Specialist), Elizabeth Hogue (Training and Compliance Officer), Program Specialists Assessment for individual #1 was updated on 1/27/2017 to include her ability to evacuate in the event of a fire (Attachment #5). Assessment templates agency wide were updated and implemented January 1, 2017. The new assessment template is included and includes individual¿s ability to evacuate in the event of a fire (attachment #6). Review of All records will take place no later than February 10, 2017 to ensure compliance in this chapter for all people served. Plan to Prevent Future Occurrence: All Program Specialists were retrained around the requirements of this chapter on January 25, 2017 (Attachment #2). 01/27/2017 Implemented
6400.181(e)(12)Individual #1's 4/21/16 assessment did not include recommendations for specific areas of training, programming and services. His/Her assessment only indicated what activities he/she enjoys doing and how staff are going to help him/her through any behaviors related to his/her mental health diagnosis. The assessment must include the following information: Recommendations for specific areas of training, programming and services. Person Responsible: Christina Tickerhoof (Program Specialist), Elizabeth Hogue (Training and Compliance Officer), Program Specialists Assessment for individual #1 was updated on 1/27/2017 to include Recommendations for specific areas of training, programming and services specific to the individual, not just what supports will do in the next year (Attachment #5). Assessment templates agency wide were updated and implemented January 1, 2017. The new assessment template is included and includes the need to have a variety of recommendations for training, programming and services for supports as well as person served (Attachment #6). Review of All records will take place no later than February 10, 2017 to ensure compliance in this chapter for all people served. Plan to Prevent Future Occurrence: Program Specialists were retrained around the requirements of this chapter on January 25, 2017 (Attachment #2) 01/31/2017 Implemented
6400.183(4)The Individual Support Plan (ISP) in Individual #1's record did not include a protocol and schedule outlining specific periods of time he/she could be without direct eye sigh supervision or his/her current level of supervision needs. Individual #1 currently requires 2 staff to 1 individual ratio however his/her ISP indicated he/she only required a 1:1 staff to individual ratio. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. Person Responsible: Christina Tickerhoof (Program Specialist), Elizabeth Hogue (Training and Compliance Officer), Program Specialists. Track changes to the ISP and AIS request for 2:1 supports was completed on 12/12/2016 (attachment #3). Additional track changes were completed on 1/25/2017 to include the protocol and schedule outlining specified periods of time for the individual to be without direct supervision (attachment #4). Review of all house records will take place no later than February 28, 2017 to ensure compliance in this chapter for all people served. Plan to Prevent Future Occurrence: Program Specialists were retrained on this requirement on January 25, 2017 (Attachment #2). 02/10/2017 Implemented
6400.183(7)(iii)Individual #1's Individual Support Plan (ISP) in his/her record did not include an assessment of their potential to advance in vocational programming. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. Person responsible: Christina Tickerhoof (Program Specialist), Elizabeth Hogue (Training and Compliance Officer), Program Specialists. Updates to assessment were completed and sent on 1/27/2017 to include individual's potential to advance in Vocational programming (Attachment #5). Review of all house records will take place no later than February 28, 2017 to ensure compliance in this chapter for all people served. Plan to prevent future occurrence: All Program Specialists were retrained on January 25, 2017 around the requirements of this chapter (Attachment #2). 01/27/2017 Implemented
6400.213(1)(i)Individual #1's record did not include his/her religious affiliation. The field was blank on his/her identification sheet and the information was not located anywhere else in his/her record. Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.Individual's record was updated by Christina Tickerhoof, Program Specialist, on 1/19/2017 to include religious affiliation; this included updating identification sheet (Attachment #1). Review od all house records will take place no later than February 28, 2017 to ensure compliance in this chapter for all people served. Plan to prevent future Occurrence: All program specialist's were retrained on the requirements of this chapter on January 25, 2017. Person responsible: Christina Tickerhoof (Program Specialist), Elizabeth Hogue (Training and Compliance Officer), Program Specialists. 01/31/2017 Implemented
SIN-00076845 Renewal 05/06/2015 Compliant - Finalized
SIN-00048635 Renewal 05/21/2013 Compliant - Finalized