Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00251412 Renewal 09/12/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There was a large bottle of bleach and tide laundry detergent unlocked on a shelf over the washer and dryer, which was in the kitchen.Poisonous materials shall be kept locked or made inaccessible to individuals. Both the bleach and detergent were removed immediately and locked up the same day. Locking of poisonous materials was reviewed with managers on9/13/24, Attachment #2 and with Direct care staff on 9/15/24, Attachment #7 09/12/2024 Implemented
6400.64(a)There were two open pots in the refrigerator containing macaroni and cheese and mashed potatoes.Clean and sanitary conditions shall be maintained in the home. The two open pots of mashed potatoes and macaroni and cheese were discarded the same day. Proper food storage and labelling was reviewed with management on 9/13/24, Attachment #3 and with DSP's on 9/15/24, Attachment #7 09/12/2024 Implemented
6400.66There was no light in the kitchen bathroom.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The 2 light bulbs in the bathroom were replaced on 9/17/24, Attachments 19 and 20. Maintenance issues were reviewed with Management n 9/13/24, Attachment #3 and with Direct Care Staff on 9/15/24, Attachment #7 09/17/2024 Implemented
6400.76(a)The bathroom shelf behind the toilet was unsteady and was not connected to the wall. Furniture and equipment shall be nonhazardous, clean and sturdy. The bathroom shelf was secured properly on 9/17/24, See Attachment 21 Maintenance issues were reviewed with Management n 9/13/24, Attachment #3 and with Direct Care Staff on 9/15/24, Attachment #7 09/17/2024 Implemented
6400.80(b)There was a gate outside on the side of the home which could only be opened from the outside causing anyone attempting to exit from that direction to be stuck. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The gate was repaired on 9/17/24 and a handle added, see attachment #22 Maintenance issues were reviewed with Management n 9/13/24, Attachment #3 and with Direct Care Staff on 9/15/24, Attachment #7 09/17/2024 Implemented
6400.85(a)In the backyard where the in-ground pool is located, one section of fence had falling over leaving an opening of approximately six feet.An in-ground swimming pool shall be fenced with a gate that is locked when the pool is not in use. Staff were trained on 9/25(Attachment #27) and fence was repaired on 9/26/24(Attachments 25 & 26) Maintenance issues were rereviewed with Management on 9/13/24, Attachment #3 and direct care staff on 9/15/24, Attachment #7 09/26/2024 Implemented
6400.151(a)Most recent physical for Staff 1 was completed more than two years apart (8/13/22 to 9/6/24). 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. Staff 1 was trained on 9/16/24 on Staff Physical Requirements, Attachment #23 Office Manager was trained on 9/20/24 on compliance for staff physical requirements, Attachment #24 09/20/2024 Implemented
SIN-00217192 Unannounced Monitoring 01/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)The agency does not keep an up-to-date financial and property record for each individual that includes, disbursement made to or for the individuals, documentation utilizing a receipt or expense record that shows any purchase of $15.00 or more are not being kept or logged.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. It is the obligation of Shared Values to protect the rights and financial integrity of the individuals we support. An up-to-date financial and property record for each individual that includes personal possessions and funds received by or deposited with the home must be maintained for each individual served. Each individual must be encouraged to exercise his or her rights as they relate to budgeting and personal spending. In corrective action, development of new record-keeping procedures was completed 1/17/2023, wherein Client Funds Policy and Procedure was updated (see Attachment A1), and an Expense Record, as well as an Inventory Record have been templated for procedural use (see Attachment A2). Client Fund procedures were reviewed with all site staff during a mandatory staff meeting 1/19/2023 (see attachment A3). Shared Values will encourage the individuals we support to take an active role in the management of their personal funds to the best of their ability as we continue to assist the individual in development of this skill area. Updated procedures for record-keeping and oversight of Client Funds are effective 1/18/2023, wherein logging of financial and property will begin for the remainder of the current month and continue accordingly. 01/17/2023 Implemented
6400.64(a)There was a plate of food left in the microwave, that once opened it smelled. It could not be determined how long the food remained in the microwave. (Removed at time of inspection)Clean and sanitary conditions shall be maintained in the home. Upon inspection, Shared Values was non-compliant with code 6400.64a as there was a plate of food left in the microwave, that once opened it smelled, and it could not be determined how long the food remained in the microwave. Since the inspection, the items have been cleaned, and are now nonhazardous, and sanitized. The sanitization was completed by Shared Values Direct Care Staff 1/5/2023. Shared Values has also on-boarded an additional Support Manager. The Residential Managers will be responsible for ensuring ongoing cleanliness and residential site repairs are reported and repaired in a timely manner to maintain compliance. A mandatory staff meeting was held 1/19/2023 wherein cleaning responsibilities were reviewed with site staff (See Attachment A3) Staff will continue with protocols to contact a supervisor immediately in the event there is a residential repair needed or sanitization concerns arise. The Residential Mangers will complete scheduled residential site visits to follow-up on the status of all home's cleanliness. The Compliance Director will uphold compliance by completing site visits and completing the self-assessments of the homes and site inspection reports monthly. 2/15/2023. 01/05/2023 Implemented
6400.77(b)The first aid kit did not contain antiseptic, tweezers or thermometer. 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. Shared Values has re-purchased a first aid kit for the home. The first aid kits contain the following: a first aid manual, antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, and scissors (See Attachment B1). The new first aid kit was purchased 1/11/2023. The Residential Managers will monitor First aid kits weekly, and will check for restock needs monthly during site self-assessment completion. 01/11/2023 Implemented
6400.77(c)The first aid manual was not kept with the first aid kit, staff could not locate one. A first aid manual shall be kept with the first aid kit.Shared Values has re-purchased a first aid kit for the home. The first aid kits contain the following: a first aid manual, antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, and scissors. The new first aid kit was purchased 1/11/2023 (See Attachment B1). The Residential Managers will monitor First aid kits weekly, and will check for restock needs monthly during site self-assessment completion. 01/11/2023 Implemented
6400.111(f)The fire extinguisher located in the dining room was not inspected, not date or tag was present. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. Shared Values was non-compliant in regulatory code 6400.111(f), the fire extinguisher located in the dining room was not inspected as no date nor tag was present. Shapiro Fire Protection Company was contacted and dispatched to the home 1/6/2023 wherein successful inspection and tagging of the fire extinguisher was completed (See Attachment C1) 01/06/2023 Implemented
6400.144Several medications for Ind. #2 were not on site at time of inspection but being signed on the MAR as administered. Medication(s): FLUTICASONE SPRAY 50mg, BACITRACIN 500gm oint, AZELASTINE 0.1% SPRAY.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 employees of Shared Values that work in the 6400-residential program as a Direct Support Professional (DSP) are required to take and pass the Department of Human Services (DHS) Medication Administration Training program. Only staff that have been certified can administer prescription and non-prescription medications to the clients we support. Shared Values policy requires that employees who administer prescription and non-prescription medications to the clients we support review the Medication. The Community Manager has reviewed all medication onsite for individuals 1 and 2. A review of medication was completed 1/6/2023. Individual FLUTICASONE SPRAY 50mg, BACITRACIN 500gm ointment, and AZELASTINE 0.1% SPRAY. was ordered and delivered by the affiliate pharmacy 1/5/2023 (See Attachment E1). In response to the licensing inspection, Shared Values has implemented an internal corrective action to staff who incurred the documentation error in medication administration and entered the Medication Error into EIM accordingly (1/11/2023). Due to the medication discrepancies and errors, a Med Administration Trainer has been contracted to complete practicum observations on med certified staff to ensure compliance in med administration practices 1/17/2023. A mandatory staff meeting was held 1/19/2023 wherein medication administration procedures were reviewed with site staff (See Attachment A3). Shared Values has hired a nurse 1/9/2023 to monitor and reconcile medication errors and documentation errors related to med administration. The Nurse will complete weekly med reviews. An Overnight Audit of medications has been developed procedurally 1/11/2023 (See Attachment E2). All employees who administer medication must be certified with valid up to date training and successfully completed practicum observations with documentation in their file reviewed routinely. Staff are required to initial the MAR accordingly when medication has been given. The community managers have been retrained in medication documentation practices for strengthened operational oversight 1/18/2023. The community managers will be required to review medication and MARS during each site visit. The community mangers are required to have a minimum of three site visits a week. The Nurse will be required to review medication at all homes at least once a week. The Nurse completed an initial medication audit for both individuals in the home 1/12/2023 (See Attachment E3). The Program Specialist will be required to conduct random reviews of MARs at all homes. Upon notification of any medication errors, progressive disciplinary action will be implemented and retraining of staff will be considered as necessary. All Shared Values DSP are expected to be trained and observed in medication administration by February 15, 2023 01/05/2023 Implemented
6400.144Individual #2's Medication TRIAMCINOLON 0.1 ointment was delivered to the facility (per the sealed package dated 01/03/2023) and has not been administered to the individual. The MAR indicated the medication is being given.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 employees of Shared Values that work in the 6400-residential program as a Direct Support Professional (DSP) are required to take and pass the Department of Human Services (DHS) Medication Administration Training program. Only staff that have been certified can administer prescription and non-prescription medications to the clients we support. Shared Values policy requires that employees who administer prescription and non-prescription medications to the clients we support review the Medication. In response to the licensing inspection, Shared Values has implemented an internal corrective action to staff who incurred the medication and documentation error in medication administration and entered the Medication Error into EIM accordingly (1/11/2023). Due to the medication discrepancies and errors, a Med Administration Trainer has been contracted to complete practicum observations on med certified staff to ensure compliance in med administration practices 1/17/2023. Shared Values has hired a nurse 1/9/2023 to monitor and reconcile medication errors and documentation errors related to med administration. An Overnight Audit of medications has been developed procedurally 1/11/2023 (See Attachment E2). All employees who administer medication must be certified with valid up to date training and successfully completed practicum observations with documentation in their file reviewed routinely. Staff are required to initial the MAR accordingly when medication has been given. A mandatory staff meeting was held 1/19/2023 wherein medication administration procedures were reviewed with site staff (See Attachment A3). The community managers have been retrained in medication documentation practices for strengthened operational oversight 1/18/2023. The community managers will be required to review medication and MARS during each site visit. The community mangers are required to have a minimum of three site visits a week. The Nurse will be required to review medication at all homes at least once a week. The Nurse completed an initial medication audit for both individuals in the home 1/12/2023 (See Attachment E3). The Program Specialist will be required to conduct random reviews of MARs at all homes. Upon notification of any medication errors, progressive disciplinary action will be implemented and retraining of staff will be considered as necessary. All Shared Values DSP are expected to be trained and observed in medication administration by February 15, 2023 01/11/2023 Implemented
6400.144The staff person who administered medication to Ind. #1 and Ind.#2 was not qualified to administer medication based on not completing the required Department-approved medication administration course.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 employees of Shared Values that work in the 6400-residential program as a Direct Support Professional (DSP) are required to take and pass the Department of Human Services (DHS) Medication Administration Training program. Only staff that have been certified can administer prescription and non-prescription medications to the clients we support. Shared Values policy requires that employees who administer prescription and non-prescription medications to the clients we support review the Medication Administration Record (MAR) daily to make sure there are no errors. Medication labels should also be compared to the MAR during this period of review. In response to the licensing inspection, Shared Values has implemented an internal corrective action to staff who incurred the documentation error in medication administration and entered the Medication Error into EIM accordingly (1/11/2023). Due to the medication discrepancies and errors, a Med Administration Trainer has been contracted to complete practicum observations on med certified staff to ensure compliance in med administration practices 1/17/2023. A mandatory staff meeting was held 1/19/2023 wherein medication administration procedures were reviewed with site staff (See Attachment A3). Shared Values has hired a nurse 1/9/2023 to monitor and reconcile medication errors and documentation errors related to med administration. The Nurse will complete weekly med reviews. An Overnight Audit of medications has been developed procedurally 1/11/2023 (See Attachment E2). All employees who administer medication must be certified with valid up to date training and successfully completed practicum observations with documentation in their file reviewed routinely. Staff are required to initial the MAR accordingly when medication has been given. The community managers have been retrained in medication documentation practices for strengthened operational oversight 1/18/2023. The community managers will be required to review medication and MARS during each site visit. The community mangers are required to have a minimum of three site visits a week. The Nurse will be required to review medication at all homes at least once a week. The Nurse completed an initial medication audit for both individuals in the home 1/12/2023 (See Attachment E3). The Program Specialist will be required to conduct random reviews of MARs at all homes. Upon notification of any medication errors, progressive disciplinary action will be implemented and retraining of staff will be considered as necessary. All Shared Values DSP are expected to be trained and observed in medication administration by February 15, 2023 01/11/2023 Implemented
6400.190(c)There is little to no documentation of recreational and social activities in either Individual #1 or individual #2's records. There is no record that clearly show when or how often the individuals #1 and #2 are on any scheduled outings outside the home.Documentation of recreational and social activities shall be kept in the individual¿s record. Shared Values is responsible and accountable for meeting the needs of each individual we support. Shared Values commits to making every effort to help the individuals we serve to participate in a system which allows the individual's personal choice to be respected, and their community integration be adapted to their preference. In response to non-compliance in area 6400.190(c). a Community Activity Log has been developed to log and monitor the social and recreational activities, as well as their frequency, for each individual 1/17/2023 (See Attachment F1). An Activities Calendar has been implemented for way of proper planning and integrating personal choice (Attachment F1) 1/17/2023. Documentation of recreational activities shall be kept in the respective individual's record. 01/17/2023 Implemented
6400.163(d)Prescription medications were not kept locked, the closet where the medication was stored had the key in the lock and the door left unlooked. (This was not during med administration times)Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.Shared Values will ensure all homes contain Prescription medications and syringes in an area that is kept locked. Since inspection, direct support staff have monitored the medication closet to ensure it remains locked when not accessing medications 1/6/2023. A staff meeting was conducted 1/19/2023 to address and reiterate procedures of securing prescription medications (See Attachment A3). A Community manager has been onboarded for the home. The community manager will be responsible for ensuring all staff are equipped with operable keys that lock and unlock the medication closet, and that the key is kept on the staff's person. This shall be monitored on a regular ongoing basis. Direct support staff will still be responsible to ensure medication cabinets and closets are kept locked at all times 9/13/2022. Shared Values conducted a mandatory full staff meeting for direct support staff at the home on 1/19/2023. During this time, all employees revisited the process on securing medications in locked areas. The facilitators will keep a sign-in sheet of all attendees for all staff meetings. Employees who miss the meeting will be required to attend a follow-up meeting with their direct supervisor. On 1/23/2023 the community mangers will complete scheduled residential site visits to follow-up on the status of secured medications and locked areas of all homes. The compliance director will uphold compliance by completing site visits and completing the self-assessments of the homes and site inspection reports monthly. 2/15/2023 01/06/2023 Implemented
6400.165(c)Medication CLONIDINE 0.2mg was not administered on 01/05/2023 for 8am dosage. Medication was still in blister pack and signed as given.A prescription medication shall be administered as prescribed.All employees of Shared Values that work in the 6400-residential program as a Direct Support Professional (DSP) are required to take and pass the Department of Human Services (DHS) Medication Administration Training program. Only staff that have been certified can administer prescription and non-prescription medications to the clients we support. Shared Values policy requires that employees who administer prescription and non-prescription medications to the clients we support review the Medication. In response to the licensing inspection, Shared Values has implemented an internal corrective action to staff who incurred the medication error in medication administration and entered the Medication Error into EIM accordingly (1/11/2023). Due to the medication discrepancies and errors, a Med Administration Trainer has been contracted to complete practicum observations on med certified staff to ensure compliance in med administration practices 1/17/2023. Shared Values has hired a nurse 1/9/2023 to monitor and reconcile medication errors and documentation errors related to med administration. The Nurse will complete weekly med reviews. An Overnight Audit of medications has been developed procedurally 1/11/2023 (See Attachment E2). All employees who administer medication must be certified with valid up to date training and successfully completed practicum observations with documentation in their file reviewed routinely. Staff are required to initial the MAR accordingly when medication has been given. A mandatory staff meeting was held 1/19/2023 wherein medication administration procedures were reviewed with site staff (See Attachment A3). The community managers have been retrained in medication documentation practices for strengthened operational oversight 1/18/2023. The community managers will be required to review medication and MARS during each site visit. The community mangers are required to have a minimum of three site visits a week. The Nurse will be required to review medication at all homes at least once a week. The Nurse completed an initial medication audit for both individuals in the home 1/12/2023 (See Attachment E3). The Program Specialist will be required to conduct random reviews of MARs at all homes. Upon notification of any medication errors, progressive disciplinary action will be implemented and retraining of staff will be considered as necessary. All Shared Values DSP are expected to be trained and observed in medication administration by February 15, 2023 01/11/2023 Implemented
6400.166(a)(13)Medication was not administered to Ind. #1 on 01/04/2023 for the 8am dosage, the MAR was left blank. The individuals record must indicate the reason the medication was not given as the agencies MAR specifies.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.All employees of Shared Values that work in the 6400-residential program as a Direct Support Professional (DSP) are required to take and pass the Department of Human Services (DHS) Medication Administration Training program. Only staff that have been certified can administer prescription and non-prescription medications to the clients we support. Shared Values policy requires that employees who administer prescription and non-prescription medications to the clients we support review the Medication. In response to the licensing inspection, Shared Values has implemented an internal corrective action to staff who incurred the medication error in medication administration and entered the Medication Error into EIM accordingly (1/11/2023). Due to the medication discrepancies and errors, a Med Administration Trainer has been contracted to complete practicum observations on med certified staff to ensure compliance in med administration practices 1/17/2023. Shared Values has hired a nurse 1/9/2023 to monitor and reconcile medication errors and documentation errors related to med administration. An Overnight Audit of medications has been developed procedurally 1/11/2023 (See Attachment E2). All employees who administer medication must be certified with valid up to date training and successfully completed practicum observations with documentation in their file reviewed routinely. Staff are required to initial the MAR accordingly when medication has been given. The community managers have been retrained in medication documentation practices for strengthened operational oversight 1/18/2023. The community managers will be required to review medication and MARS during each site visit. The community mangers are required to have a minimum of three site visits a week. The Nurse will be required to review medication at all homes at least once a week. The Nurse completed an initial medication audit for both individuals in the home 1/12/2023 (See Attachment E3). The Program Specialist will be required to conduct random reviews of MARs at all homes. Upon notification of any medication errors, progressive disciplinary action will be implemented and retraining of staff will be considered as necessary. All Shared Values DSP are expected to be trained and observed in medication administration by February 15, 2023 01/11/2023 Implemented
6400.166(a)(13)All of Ind. #1 medications was administered for the 8PM dosage on 01/04/2023 but not initialed by the staff who administered the medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.All employees of Shared Values that work in the 6400-residential program as a Direct Support Professional (DSP) are required to take and pass the Department of Human Services (DHS) Medication Administration Training program. Only staff that have been certified can administer prescription and non-prescription medications to the clients we support. Shared Values policy requires that employees who administer prescription and non-prescription medications to the clients we support review the Medication. In response to the licensing inspection, Shared Values has implemented an internal corrective action to staff who incurred the documentation error in medication administration. Due to the medication discrepancies and errors, a Med Administration Trainer has been contracted to complete practicum observations on med certified staff to ensure compliance in med administration practices 1/17/2023. Shared Values has hired a nurse 1/9/2023 to monitor and reconcile medication errors and documentation errors related to med administration. An Overnight Audit of medications has been developed procedurally 1/11/2023 (See Attachment E2). All employees who administer medication must be certified with valid up to date training and successfully completed practicum observations with documentation in their file reviewed routinely. Staff are required to initial the MAR accordingly when medication has been given. The community managers have been retrained in medication documentation practices for strengthened operational oversight 1/18/2023. The community managers will be required to review medication and MARS during each site visit. The community mangers are required to have a minimum of three site visits a week. The Nurse will be required to review medication at all homes at least once a week. The Nurse completed an initial medication audit for both individuals in the home 1/12/2023 (See Attachment E3). The Program Specialist will be required to conduct random reviews of MARs at all homes. Upon notification of any medication errors, progressive disciplinary action will be implemented and retraining of staff will be considered as necessary. All Shared Values DSP are expected to be trained and observed in medication administration by February 15, 2023 01/11/2023 Implemented
6400.166(b)All of Ind. #2 medication(s) was administered and not recorded as given on the MAR for AM and PM dosage on 01/03/2023 and 01/04/2023. The individual's MAR is not being documented and utilized correctly.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.All employees of Shared Values that work in the 6400-residential program as a Direct Support Professional (DSP) are required to take and pass the Department of Human Services (DHS) Medication Administration Training program. Only staff that have been certified can administer prescription and non-prescription medications to the clients we support. Shared Values policy requires that employees who administer prescription and non-prescription medications to the clients we support review the Medication. In response to the licensing inspection, Shared Values has implemented an internal corrective action to staff who incurred the documentation error in medication administration. Due to the medication discrepancies and errors, a Med Administration Trainer has been contracted to complete practicum observations on med certified staff to ensure compliance in med administration practices 1/17/2023. Shared Values has hired a nurse 1/9/2023 to monitor and reconcile medication errors and documentation errors related to med administration. An Overnight Audit of medications has been developed procedurally 1/11/2023 (See Attachment E2). All employees who administer medication must be certified with valid up to date training and successfully completed practicum observations with documentation in their file reviewed routinely. Staff are required to initial the MAR accordingly when medication has been given. The community managers have been retrained in medication documentation practices for strengthened operational oversight 1/18/2023. The community managers will be required to review medication and MARS during each site visit. The community mangers are required to have a minimum of three site visits a week. The Nurse will be required to review medication at all homes at least once a week. The Nurse completed an initial medication audit for both individuals in the home 1/12/2023 (See Attachment E3). The Program Specialist will be required to conduct random reviews of MARs at all homes. Upon notification of any medication errors, progressive disciplinary action will be implemented and retraining of staff will be considered as necessary. All Shared Values DSP are expected to be trained and observed in medication administration by February 15, 2023 01/11/2023 Implemented
6400.166(b)Medication of Ind. #1, VITAMIN D3 1000-unit tab, was not initialed by the staff administering the medication on 01/04/2023 for 8am dosage. The medication was not in the blister pack.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.All employees of Shared Values that work in the 6400-residential program as a Direct Support Professional (DSP) are required to take and pass the Department of Human Services (DHS) Medication Administration Training program. Only staff that have been certified can administer prescription and non-prescription medications to the clients we support. Shared Values policy requires that employees who administer prescription and non-prescription medications to the clients we support review the Medication. In response to the licensing inspection, Shared Values has implemented an internal corrective action to staff who incurred the documentation error in medication administration. Due to the medication discrepancies and errors, a Med Administration Trainer has been contracted to complete practicum observations on med certified staff to ensure compliance in med administration practices 1/17/2023. Shared Values has hired a nurse 1/9/2023 to monitor and reconcile medication errors and documentation errors related to med administration. An Overnight Audit of medications has been developed procedurally 1/11/2023 (See Attachment E2). All employees who administer medication must be certified with valid up to date training and successfully completed practicum observations with documentation in their file reviewed routinely. Staff are required to initial the MAR accordingly when medication has been given. The community managers have been retrained in medication documentation practices for strengthened operational oversight 1/18/2023. The community managers will be required to review medication and MARS during each site visit. The community mangers are required to have a minimum of three site visits a week. The Nurse will be required to review medication at all homes at least once a week. The Nurse completed an initial medication audit for both individuals in the home 1/12/2023 (See Attachment E3). The Program Specialist will be required to conduct random reviews of MARs at all homes. Upon notification of any medication errors, progressive disciplinary action will be implemented and retraining of staff will be considered as necessary. All Shared Values DSP are expected to be trained and observed in medication administration by February 15, 2023 01/11/2023 Implemented
6400.186The agency is not implementing the individual plan (ISP), including revisions as documented. No current ISP was provided for Individual.The home shall implement the individual plan, including revisions.Shared Values was not compliant with 6400.186. In efforts to ensure compliance, all staff will be trained on Indivduals' support plans during mandatory staff meeting 1/19/2023 (See Attachment A4). During this time, managerial facilitators will ensure staff are educated on the importance of reading and understand the ISP when working with any individual served. Managers also discussed requirements for maintaining an updated ISP on-site with all staff and replaced missing copies of the ISP for staff's access in the home 1/19/2023. 01/19/2023 Implemented
SIN-00215063 Unannounced Monitoring 11/18/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Individual #1 ISP indicates poisons must be locked up; poisons were found unlocked in various points around the house. Lysol toilet cleaner, Ajax, and Scrubbing Bubbles cleaner were found in an unlocked cabinet under the sink in the first floor half bath; antibacterial soap was found on the sink. Laundry detergent and fabric softener were found in the unlocked laundry area. Antibacterial soap was also found on the kitchen sink. Poisonous materials were locked up at point of inspection.Poisonous materials shall be kept locked or made inaccessible to individuals. Poisonous substances, including Lysol toilet cleaner, Ajax, and Scrubbing Bubbles cleaner were found in an unlocked cabinet under the sink in the first floor half bath; antibacterial soap was found on the sink. Laundry detergent and fabric softener were found in the unlocked laundry area; Antibacterial soap was also found on the kitchen sink, accessible at the time of inspection. The community manager has been retrained in identification and secured storage of poisonous materials to ensure oversight of staff practices with hazardous chemicals in the residential homes 11/19/2022. A full site visit will be completed by the program director and the community manager on 11/25/2022 to ensure compliance has continued. Since the inspection, all hazardous supplies have been locked accordingly. The supplies will remain locked at all times when items are not being retrieved, with 24-hour supervision of the substances inside. The compliance director will ensure and maintain compliance moving forward. The compliance director will uphold compliance by completing site visits and completing the self-assessments of the homes with site inspection reports monthly 12/1/2022. The community manager will uphold compliance by completing site visits and completing the compliance checklists of the homes weekly 12/5/2022 11/19/2022 Implemented
6400.64(a)There is a thick build-up of food waste or grease on the interior of the oven door, in the broiler, and on the broiler door. There was also a smear of indeterminate brown material on the trim between the bathroom and closet doors in the bedroom hallway.Clean and sanitary conditions shall be maintained in the home. Upon inspection, Shared Values was non-compliant with code 6400.64a and there was a thick build-up of food waste or grease on the interior of the oven door, in the broiler, and on the broiler door. There was also a smear of indeterminate brown material on the trim between the bathroom and closet doors in the bedroom hallway. Since the inspection, the items have been cleaned, and are now nonhazardous, and sanitized. The sanitization was completed by Shared Values maintenance 11/19/2022. Shared Values has also taken corrective disciplinary action including termination of the manager whom continually neglected oversight of the home. The acting community managers will be responsible for ensuring ongoing cleanliness and residential site repairs are reported and repaired in a timely manner to avoid any injuries and maintain compliance. Our community managers will be trained in utilization of the provider self-assessment to check for regulatory issues 12/5/2022. Staff will continue with protocols to contact a supervisor immediately in the event there is a residential repair needed or sanitization concerns arise. The program director and community mangers will complete scheduled residential site visits to follow-up on the status of all home's cleanliness. The compliance director will uphold compliance by completing site visits and completing the self-assessments of the homes and site inspection reports monthly. 12/1/2022 11/19/2022 Implemented
6400.67(a)Blinds on the front-facing window in the living room were inoperative; they could not be lifted using the string. Also, the duct work in the laundry area above the washer and dryer is starting to significantly rust up and corrode, with a build-up of dripped white, streaky material running from the ceiling down the exterior of the duct.Floors, walls, ceilings and other surfaces shall be in good repair. Shared Values will ensure all homes are in good repair. Upon inspection the blinds on the front-facing window in the living room were inoperative; they could not be lifted using the string. Also, the duct work in the laundry area above the washer and dryer is starting to significantly rust up and corrode, with a build-up of dripped white, streaky material running from the ceiling down the exterior of the duct. On December 23, 2022, Shared Values will be conducting a mandatory full staff meeting for all direct support staff. During this time, all employees will revisit the process on submitting work orders for residential repairs. The facilitators will keep a sign-in sheet of all attendees. Employees who miss the meeting will be required to attend a follow-up meeting with their direct supervisor. Maintenance has been tasked to complete a residential corrective action as a result of licensing inspection. All items needing repair must be completed by 12/9/2022. On 12/19/2022 the program director and community mangers will complete scheduled residential site visits to follow-up on the status of all aging repairs. The compliance director will uphold compliance by completing site visits and completing the self-assessments of the homes and site inspection reports monthly. 12/1/2022 12/09/2022 Implemented
6400.67(b)Individual #2 ISP indicates they have vision concerns; the home has several significant tripping hazards. A decorative stove in the kitchen sits on a stone dais a few inches off the ground with no safety barrier around it. The decorative fireplace in the living room also has a raised step extending out from its base, also with no safety barrier. Agency staff indicated Individual #2 has repeatedly tripped over both the decorative kitchen stove and fireplace platforms/bases. In the living room, a few feet of wiring was found partially curled up, still connected to the wall; the wiring was in the middle of the pathway that leads around the living room furniture toward the hallway where the individuals' bedrooms and bathroom are. There was also a thick build-up of lint in the dryer lint trap, about the size of a golf ball when removed. Floors, walls, ceilings and other surfaces shall be free of hazards.Shared Values will ensure all homes are in free of hazards. Upon inspection the home had several significant tripping hazards. Maintenance has been tasked to complete a residential corrective action as a result of licensing inspection, by 12/9/2022. On December 23, 2022, Shared Values will be conducting a mandatory full staff meeting for all direct support staff. During this time, all employees will revisit the process on maintaining a hazard free residential program site. The facilitators will keep a sign-in sheet of all attendees. Employees who miss the meeting will be required to attend a follow-up meeting with their direct supervisor. On 12/19/2022 the program director and community mangers will complete scheduled residential site visits to follow-up on the status of hazard-free residential conditions. The compliance director will uphold compliance by completing site visits and completing the self-assessments of the homes and site inspection reports monthly. 12/1/2022. 12/09/2022 Implemented
6400.77(b)The first aid kit did not have a thermometer, or tweezers. 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. Shared Values will re-purchase a first aid kit for the home. The first aid kit will contain the following antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, and scissors. New first aid kits will be purchased for all homes by 12/09/2022. Upon inspection, the first aid kit did not contain tweezers, or thermometer as required per regulation code 6400.77b. The community managers will monitor First aid kits weekly, and will check for restock needs monthly during site self-assessment completion. 12/09/2022 Implemented
6400.77(c)The first aid kit did not have a first aid manual. A first aid manual shall be kept with the first aid kit.Shared Values will re-purchase a first aid kit for the home. The first aid kit will contain the following antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, and scissors. New first aid kits will be purchased for all homes by 12/09/2022. Upon inspection, the first aid kit did not contain a manual as required per regulation code 6400.77c. The community managers will monitor First aid kits weekly, and will check for restock needs monthly during site self-assessment completion. 12/09/2022 Implemented
6400.81(k)(6)Individuals #2 and Ind. #1 do not have mirrors in their bedrooms.In bedrooms, each individual shall have the following: A mirror. Mirrors were fixtured in both bedrooms of the home, upon completion of inspection. 11/18/2022 11/18/2022 Implemented
6400.82(f)The first floor half and full bathrooms had no paper towels. The first floor half bath had no mirror.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. Paper towels were purchased and replenished in all bathrooms of the home. A mirror has been fixtured to the first floor half bath upon completion of inspection. 11/18/2022 11/18/2022 Implemented
6400.110(c)While there are working smoke detectors inside the individuals' bedrooms, there is no smoke detector in a common area within 15 feet of the bedrooms.The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. Shared Values will ensure all homes have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Since inspection, Maintenance has placed a smoke detector in the common area within 15 feet of bedrooms 12/2/2022. A test of the smoke detector's operability was completed. The community manager will be responsible for ensuring each level of the home maintains an operable smoke detector. This shall be monitored on a regular ongoing basis. Direct support staff will still be responsible to ensure smoke detectors are operable during monthly fire drill completion. Shared Values will be conducting a mandatory full staff meeting for all direct support staff 12/23/2022. During this time, all employees will revisit the process on maintaining hazard-free residential conditions. The facilitators will keep a sign-in sheet of all attendees. Employees who miss the meeting will be required to attend a follow-up meeting with their direct supervisor. Maintenance has been tasked to complete a residential corrective action as a result of licensing inspection. All items needing repair or purchase must be completed by 12/09/2022. On 12/19/2022 the program director and community mangers will complete scheduled residential site visits to follow-up on the status of all housing needs. The compliance director will uphold compliance by completing site visits and completing the self assessments of the homes and site inspection reports monthly. 12/1/2022 12/02/2022 Implemented
6400.144Prescription Medication ACIDOPHILUS PROBIOTIC CAPS was administered from 11/01/2022 through 11/18/2022 and was not signed for as given and the medication was not listed on the individuals November MAR.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 employees of Shared Values that work in the 6400-residential program as a Direct Support Professional (DSP) are required to take and pass the Department of Human Services (DHS) Medication Administration Training program. Only staff that have been certified can administer prescription and non-prescription medications to the clients we support. Shared Values policy requires that employees who administer prescription and non-prescription medications to the clients we support review the Medication Administration Record (MAR) daily to make sure there are no errors. Medication labels should also be compared to the MAR during this period of review. Shared Values will ensure all participants receive medication as prescribed by a physician 12/09/2022. In response to the licensing inspection, Shared Values has implemented an internal corrective action to staff who incurred the documentation error in medication administration 11/19/2022. Shared Values will hire a nurse to monitor and reconcile medication errors and documentation errors related to med administration by 1/7/2023. All employees who administer medication must be certified with valid up to date training, documentation in their file reviewed by human resources. Staff are required to initial the MAR accordingly when medication has been given. The community managers have been retrained in medication documentation practices for strengthened operational oversight 11/19/2022. The community managers will be required to review medication and MARS during each site visit. The community mangers are required to have a minimum of three site visits a week. The program specialist will be required to review medication at all homes at least once a week. The program director will be required to conduct random reviews of MARs at all homes. The program director has reviewed job descriptions and completed internal training with the community managers with medication oversight of all the residential homes. Shared Values will hire a nurse by 1/7/2022.The nurse will be responsible for reviewing the MARs, blood sugar logs and additional medical documentation. Upon notification of any medication errors, progressive disciplinary action will be implemented and retraining of staff will be considered as necessary. All medications have been notated on the individual's MAR accordingly 11/19/2022. 11/19/2022 Implemented
6400.163(h)Medication VALTOCO 10mg Spray was located in IND.#1 medication box and not listed on the MAR.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The community managers will be required to review medication and MARS during each site visit. The community mangers are required to have a minimum of three site visits a week. The program specialist will be required to review medication at all homes at least once a week. The program director will be required to conduct random reviews of MARs at all homes. The program director has reviewed job descriptions and completed internal training with the community managers with medication oversight of all the residential homes. Shared Values will hire a nurse by 1/7/2022.The nurse will be responsible for reviewing the MARs, blood sugar logs and additional medical documentation. Upon notification of any medication errors, progressive disciplinary action will be implemented and retraining of staff will be considered as necessary. All medications have been notated on the individual's MAR accordingly 11/19/2022. 11/19/2022 Implemented
6400.165(b)Medication CHLORHEX GLO SOL, is listed on Ind. #1 MAR and medication is not on site as required (not refilled)A prescription order shall be kept current.The community managers will be required to review medication and MARS during each site visit. The community mangers are required to have a minimum of three site visits a week. The program specialist will be required to review medication at all homes at least once a week. The program director will be required to conduct random reviews of MARs at all homes. The program director has reviewed job descriptions and completed internal training with the community managers with medication oversight of all the residential homes. Shared Values will hire a nurse by 1/7/2022.The nurse will be responsible for reviewing the MARs, blood sugar logs and additional medical documentation. Upon notification of any medication errors, progressive disciplinary action will be implemented and retraining of staff will be considered as necessary. All medications have been notated on the individual's MAR accordingly 11/19/2022. Medication CHLORHEX GLO SOL, as listed on Ind. #1 MAR will be refilled by the pharmacy 12/5/2022 and delivered to the home. 12/05/2022 Implemented
6400.166(a)(13)Prescription Medication(s): Record was not kept on Ind. #2 MAR, the Date and the Initials of the person that administered the medication was not logged as required. 8am doses- not signed when administered on 11/18/2022- CALCIUM 600mg, LOCOSAMIDE 100mg, NALTREXONE 50mg, OLANZAPINE 10mg, VITAMIN D3 1000mg, CLONAZEPAN 1mg 8pm doses- not signed when administered on 11/17/2022- CLONAZEPAM 1mg, LOCOSAMIDE 100mg, MELATONIN 3mg, OLANZAPINE 20mg, CETIRIZINE 10mg, GUANFACINE 1mgA medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.All employees of Shared Values that work in the 6400-residential program as a Direct Support Professional (DSP) are required to take and pass the Department of Human Services (DHS) Medication Administration Training program. Only staff that have been certified can administer prescription and non-prescription medications to the clients we support. Shared Values policy requires that employees who administer prescription and non-prescription medications to the clients we support review the Medication Administration Record (MAR) daily to make sure there are no errors. Medication labels should also be compared to the MAR during this period of review. Shared Values will ensure all participants receive medication as prescribed by a physician 12/09/2022. In response to the licensing inspection, Shared Values has implemented an internal corrective action to staff who incurred the documentation error in medication administration 11/19/2022. Shared Values will hire a nurse to monitor and reconcile medication errors and documentation errors related to med administration by 1/7/2023. All employees who administer medication must be certified with valid up to date training, documentation in their file reviewed by human resources. Staff are required to initial the MAR accordingly when medication has been given. The community managers have been retrained in medication documentation practices for strengthened operational oversight 11/19/2022. The community managers will be required to review medication and MARS during each site visit. The community mangers are required to have a minimum of three site visits a week. The program specialist will be required to review medication at all homes at least once a week. The program director will be required to conduct random reviews of MARs at all homes. The program director has reviewed job descriptions and completed internal training with the community managers with medication oversight of all the residential homes. Shared Values will hire a nurse by 1/7/2022.The nurse will be responsible for reviewing the MARs, blood sugar logs and additional medical documentation. Upon notification of any medication errors, progressive disciplinary action will be implemented and retraining of staff will be considered as necessary. 11/19/2022 Implemented
6400.166(a)(13)Prescription Medication(s): Record was not kept on Ind. #1 MAR, the Date and the Initials of the person that administered the medication was not logged as required. 8am doses- not recorded as administered on 11/17/2022- CLONAZEPAM 0.5mg, RISPERIDONE 0.5mg. ARIPRAZOLE 2mg, NALTREXONE 50mg, CLONIDINE 0.2mg, FEXOFENADINE 60mg. 4pm dose- not recorded as administered on 11/17/2022- FEXOFENADINE 60mg 8pm doses- not recorded as administered on 11/17/2022- MONTELUKAST 10mg, RISPERIDONE 2mg, DIPHENHYDRAM 25mg, FLUVOXAMINE 25mg, TRAZODONE 0.2mgA medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.All employees of Shared Values that work in the 6400-residential program as a Direct Support Professional (DSP) are required to take and pass the Department of Human Services (DHS) Medication Administration Training program. Only staff that have been certified can administer prescription and non-prescription medications to the clients we support. Shared Values policy requires that employees who administer prescription and non-prescription medications to the clients we support review the Medication Administration Record (MAR) daily to make sure there are no errors. Medication labels should also be compared to the MAR during this period of review. Shared Values will ensure all participants receive medication as prescribed by a physician 12/09/2022. In response to the licensing inspection, Shared Values has implemented an internal corrective action to staff who incurred the documentation error in medication administration 11/19/2022. Shared Values will hire a nurse to monitor and reconcile medication errors and documentation errors related to med administration by 1/7/2023. All employees who administer medication must be certified with valid up to date training, documentation in their file reviewed by human resources. Staff are required to initial the MAR accordingly when medication has been given. The community managers have been retrained in medication documentation practices for strengthened operational oversight 11/19/2022. The community managers will be required to review medication and MARS during each site visit. The community mangers are required to have a minimum of three site visits a week. The program specialist will be required to review medication at all homes at least once a week. The program director will be required to conduct random reviews of MARs at all homes. The program director has reviewed job descriptions and completed internal training with the community managers with medication oversight of all the residential homes. Shared Values will hire a nurse by 1/7/2022.The nurse will be responsible for reviewing the MARs, blood sugar logs and additional medical documentation. Upon notification of any medication errors, progressive disciplinary action will be implemented and retraining of staff will be considered as necessary. 11/19/2022 Implemented
SIN-00211063 Renewal 09/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)No self-assessments were completed for this agency.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. Shared Values was non-compliant in regulatory code 6400.15 wherein self-assessments for the agency were not 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. The Compliance Director will be trained in the completion of Self-Assessments and use of the Self-Assessment tools by 11/18/2022. The Compliance Director will monitor routine completion of all compliance related assessments by managers and supervisory level staff. 11/18/2022 Implemented
6400.64(b)There were a large number of bugs in attic area, largely swarming around the window and light sources.There may not be evidence of infestation of insects or rodents in the home. Shared Values was non-compliant in regulatory code 6400.51 wherein the CEO did not complete orientation within 30 days of hire. All direct care employees and supervisory staff will be trained on the ISP and Behavior Support Plan (BSP ¿ if applicable) before having direct contact with a client. In addition, employees working in the 6400 homes are required to complete an on-site orientation with their direct supervisor or designee prior to their first shift. Supervisory staff and Direct Care workers must also be trained in the following prior to working with individuals: General Fire Safety Evacuation procedures Responsibilities during fire drills Smoking Safety procedures Supervisory staff and Direct Care workers must complete 24 hours of training related to job skills and knowledge each year. Administrative and Fiscal staff persons must complete 12 hours of training annually. The annual training hours must encompass the following areas: Person-Centered Practices Prevention, Detection, and Reporting of Abuse Individual Rights Recognizing and Reporting Incidents The Behavior Support Plan (BSP) of all individuals worked with The Individual Support Plan (ISP) of all individuals worked with All staff are responsible for tracking and completing annual training hour requirements. Supervisory staff will issue notice to staff who have not met training hour requirements at the approach of the training year¿s end. Staff who fail to complete the necessary training hours by the ascribed deadline will be subject to removal from the staffing schedule, and cannot return to a working shift until the training requirements have been met. The Human Resources/Office Management department has been tasked to ensure and review compliance for all employees. An internal corrective action date of October 30, 2022 has been given to the department. All employees out of compliance will be scheduled to complete appropriate and credible [orientation] Training by 11/18/2022. If the employee does not complete the required training, the employee will be removed from schedule. 11/18/2022 Implemented
6400.73(a)There are 3 stairs which lead from the side doors up to the pool area which requires the installation of a hand rail. {Repeated Non-Compliance 9/15/2021} Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Shared Values will ensure all homes are in good repair, free of hazard, with well-secured handrails. Upon inspection there are 3 stairs which lead from the side doors up to the pool area that required the installation of a hand rail. Maintenance was tasked to complete a residential corrective action as a result of licensing inspection. All items needing repair must be completed by 10/16/2022. On September 22, 2022 Maintenance installed a safe and appropriate hand rail along the 3 stairs leading from the side doors up to the pool area. On 10/17/2022 the program director and community mangers will complete scheduled residential site visits to follow-up on the status of all aging repairs. The compliance director will uphold compliance by completing site visits and completing the self-assessments of the homes and site inspection reports monthly. 10/16/2022. SEE ATTACHMENT Rail.JPG 09/22/2022 Implemented
6400.85(a)There is no lockable fence around the above ground pool.An in-ground swimming pool shall be fenced with a gate that is locked when the pool is not in use. Shared Values will ensure all homes are in good repair, free of hazard, with well-secured fencing in all areas where appropriate. Upon inspection there is no lockable fence around the above ground pool. Maintenance was tasked to complete a residential corrective action as a result of licensing inspection. All items needing repair must be completed by 10/16/2022. On September 27, 2022 Maintenance installed a safe and appropriate fence prohibiting access to the above ground pool. On 10/17/2022 the program director and community mangers will complete scheduled residential site visits to follow-up on the status of all aging repairs. The compliance director will uphold compliance by completing site visits and completing the self-assessments of the homes and site inspection reports monthly. 10/16/2022. SEE ATTACHMENT Fence.JPG 09/27/2022 Implemented
6400.101There is a door in one of the bedrooms which leads to a patio area which is unopenable and has no knob. This would need to be replaced with either a wall or a functional lockable door.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Shared Values will ensure all homes are in good repair, free of hazard, and that doorways will be unobstructed. Upon inspection there was a door in one of the bedrooms which leads to a patio area which is unopenable and has no knob. This would need to be replaced with either a wall or a functional lockable door. Maintenance was tasked to complete a residential corrective action as a result of licensing inspection. All items needing repair must be completed by 10/16/2022. On October 3, 2022 Maintenance installed a safe and appropriate wall in the bedroom. On 10/17/2022 the program director and community mangers will complete scheduled residential site visits to follow-up on the status of all aging repairs. The compliance director will uphold compliance by completing site visits and completing the self-assessments of the homes and site inspection reports monthly. 10/16/2022. SEE ATTACHMENT Wall.JPG 10/03/2022 Implemented
6400.106There was no furnace inspection for this location over the past year.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. Shared Values was non-compliant in regulatory code 6400.106, there was no furnace inspection on file for the home over the past year. Shared Values residential properties are rented, not owned. The furnace inspections have been maintained by the property owners/landlords of the residential sites and newly transitioned administrative staff were unable to locate copies of completed inspections. All property managers for all residential homes were contacted 10/10/2022 in request of completed furnace inspections. Property Managers were given 10 days to produce documentation of completed furnace inspections. If a completed furnace inspection is not produced for any home by 10/20/2022, Shared Values will schedule and have completed all necessary inspections in all applicable residential programs. 10/20/2022 10/20/2022 Implemented
6400.51(a)(1)The CEO did not complete orientation within 30 days of hire. The CEO started on 8/1/22, but agency records do not contain documentation showing orientation was completed.{Repeated Non-Compliance 9/15/2021}Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons.Shared Values was non-compliant in regulatory code 6400.51 wherein the CEO did not complete orientation within 30 days of hire. All direct care employees and supervisory staff will be trained on the ISP and Behavior Support Plan (BSP ¿ if applicable) before having direct contact with a client. In addition, employees working in the 6400 homes are required to complete an on-site orientation with their direct supervisor or designee prior to their first shift. Supervisory staff and Direct Care workers must also be trained in the following prior to working with individuals: General Fire Safety Evacuation procedures Responsibilities during fire drills Smoking Safety procedures Supervisory staff and Direct Care workers must complete 24 hours of training related to job skills and knowledge each year. Administrative and Fiscal staff persons must complete 12 hours of training annually. The annual training hours must encompass the following areas: Person-Centered Practices Prevention, Detection, and Reporting of Abuse Individual Rights Recognizing and Reporting Incidents The Behavior Support Plan (BSP) of all individuals worked with The Individual Support Plan (ISP) of all individuals worked with All staff are responsible for tracking and completing annual training hour requirements. Supervisory staff will issue notice to staff who have not met training hour requirements at the approach of the training year¿s end. Staff who fail to complete the necessary training hours by the ascribed deadline will be subject to removal from the staffing schedule, and cannot return to a working shift until the training requirements have been met. The Human Resources/Office Management department has been tasked to ensure and review compliance for all employees. An internal corrective action date of October 30, 2022 has been given to the department. All employees out of compliance will be scheduled to complete appropriate and credible [orientation] Training by 11/18/2022. If the employee does not complete the required training, the employee will be removed from schedule. 11/18/2022 Implemented
6400.52(a)(3)Staff Member 1 did not have 24 hours of training in 2021. Records provided show 12.5 hours.The following shall complete 24 hours of training related to job skills and knowledge each year: Program specialists.Shared Values was non-compliant in regulatory code 6400.51 wherein Staff 1 did not complete 24 hours of training in 2021. All direct care employees and supervisory staff will be trained on the ISP and Behavior Support Plan (BSP ¿ if applicable) before having direct contact with a client. In addition, employees working in the 6400 homes are required to complete an on-site orientation with their direct supervisor or designee prior to their first shift. Supervisory staff and Direct Care workers must also be trained in the following prior to working with individuals: General Fire Safety Evacuation procedures Responsibilities during fire drills Smoking Safety procedures Supervisory staff and Direct Care workers must complete 24 hours of training related to job skills and knowledge each year. Administrative and Fiscal staff persons must complete 12 hours of training annually. The annual training hours must encompass the following areas: Person-Centered Practices Prevention, Detection, and Reporting of Abuse Individual Rights Recognizing and Reporting Incidents The Behavior Support Plan (BSP) of all individuals worked with The Individual Support Plan (ISP) of all individuals worked with All staff are responsible for tracking and completing annual training hour requirements. Supervisory staff will issue notice to staff who have not met training hour requirements at the approach of the training year¿s end. Staff who fail to complete the necessary training hours by the ascribed deadline will be subject to removal from the staffing schedule, and cannot return to a working shift until the training requirements have been met. The Human Resources/Office Management department has been tasked to ensure and review compliance for all employees. An internal corrective action date of October 30, 2022 has been given to the department. All employees out of compliance will be scheduled to complete appropriate and credible [orientation] Training by 11/18/2022. If the employee does not complete the required training, the employee will be removed from schedule. 11/18/2022 Implemented
SIN-00230708 Renewal 09/12/2023 Compliant - Finalized