Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00262157 Renewal 03/13/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)The kitchen cabinet sink underneath base worn due to water damage. Floors, walls, ceilings and other surfaces shall be free of hazards.Description: Plan to fix the immediate problem: House manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the appearance of water damage to ensure good repair. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to water damage . The owner will have cabinets repaired or replaced to ensure the home is in good standing. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes the water damage being replaced in the homes to ensure the home is presented in good repair. When and How: House Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance and will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the appearance of water damage, to ensure the home is free of hazards. - House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the appearance of water damage, to ensure the home is free of hazards. - House manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or, by 06/01/2025 06/01/2025 Implemented
6400.77(b)There was no thermometer in the first aid kit 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. Plan to fix the immediate problem: House Manager will walk through the sites and review all First aid kits to make sure all components are on site as listed in the 6400 regulations, such as the Manual. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: House Manager will replace all first aid kits , at all sites, to ensure all first aid kits are equipped with all components are on site as listed in the 6400 regulations, such as the thermometer, we located and ensure one was onsite 03/13/2025 . What will be corrected: House Manager will replace all first aid kits, at all sites, to ensure all first aid kits are equipped with all components are on site as listed in the 6400 regulations, such as the thermometer. When and How: House Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance. House Manager will replace all first aid kits , at all sites, to ensure all first aid kits are equipped with all components are on site as listed in the 6400 regulations, such as the thermometer . - House Manager will walk through the sites monthly to ensure all first aid kits , at all sites, are equipped with all components are on site as listed in the 6400 regulations, such as the thermometer. - House Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance: House Manager will replace all first aid kits , at all sites, to ensure all first aid kits are equipped with all components are on site as listed in the 6400 regulations, such as the thermometer, by 03/13/2025 -C.E. O will oversee that House Manger via a monthly meeting to ensure walk throughs are being done and to ensure all first aid kits are equipped with all components are on site as listed in the 6400 regulations, such as the Manual. Meetings will continue and will meet monthly before or around the 5th of the month, starting May of 2025. 03/13/2025 Implemented
6400.81(k)(2)Individual #2 has a bed on the floor and not on a bed frame or any solid foundation.In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. Plan to fix the immediate problem: House manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure all beds are on a solid foundation. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: house manager will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure all beds are on a solid foundation. The broke items will be removed or replaced correctly. The owner will ensure replacement items are purchased and the site is in good standing. What will be corrected: bed wasn¿t on a solid foundation in one individual¿s room. When and How: Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance. Manager will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings ensure all beds are on a solid foundation in all individuals walls in their rooms. - House manger will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure all beds are on a solid foundation in all individuals rooms. - House Manger will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure all beds are on a solid foundation in all individual¿s rooms, by 06/01/2025 -C.E. O will oversee the house manger via a monthly meeting to ensure walk throughs are being done, to ensure items such as mirrors are on all individuals walls in their rooms. Meetings will continue on a monthly basis and we will meet monthly before or around the 5th of the month. 06/01/2025 Implemented
6400.81(k)(4)Individual #2 has no dresser in his bedroom. The individual's clothes are being stored in the basement area per the provider.In bedrooms, each individual shall have the following: A chest of drawers. Plan to fix the immediate problem: House manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure a dresser is all participates rooms. Its documented in ISP and Assessment that participants hygiene practices has a direct effect on their health and safety. They will defecate, and vomit in clothing and store in drawers and clothing. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: house manager will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings, to ensure to ensure a dresser is all participates rooms. Its documented in ISP and Assessment that participants hygiene practices has a direct effect on their health and safety. They will defecate, and vomit in clothing and store in drawers and clothing. What will be corrected: A dresser wasn¿t in the individual¿s room. When and How: Its documented in ISP and Assessment that participants hygiene practices has a direct effect on their health and safety. They will defecate, and vomit in clothing and store in drawers and clothing. - House Manger will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure dressers are in all individual¿s rooms, by 06/01/2025 -C.E. O will oversee the house manger via a monthly meeting to ensure walk throughs are being done, to proper document is being done. Meetings will continue on a monthly basis and we will meet monthly before or around the 5th of the month. 06/01/2025 Implemented
6400.112(e)Only one sleep drill conducted during the past year which was 4/3/2024 at 2am.A fire drill shall be held during sleeping hours at least every 6 months. Plan to fix the immediate problem: Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period. Who (job title) will be responsible for correcting the problem (each step in the process) in the future Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period, monthly. What will be corrected: Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period. When and How: Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance. Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period. - Program specialist will walk through the sites monthly to ensure fire drills are conducted in accordance to the 6400 regulations. Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period. - Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance: Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period, by 04/01/2025 -C.E. O will oversee that program specialist via a monthly meeting to ensure walk throughs are being done and to ensure all sleep fire drills are done at least every six months or repeat of drill if exceeds that time period. Meetings will continue and will meet monthly before or around the 5th of the month, starting May of 2025 03/13/2025 Implemented
6400.181(a)Initial assessment completed 3/29/2024. Individual #3 moved into the home on 1/3/2024. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Plan to fix the immediate problem: Program specialist will review all individuals¿ assessment to make sure an initial assessment is written within 60 days of admission and sent to support coordinator prior to isp date. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will review all individuals¿ assessment to make sure an initial assessment is written within 60 days of admission and sent to support coordinator prior to isp date. What will be corrected: Program specialist will create a spreadsheet with all individuals¿ initial assessment date is within 60 days of admission and evaluated and updated annually to ensure that the assessment is written and to make sure all upcoming assessments have progress and growth in the areas and sent to support coordinator prior to isp date. When and How: program specialist will review the components of the 6400 and how it should be applied to the areas of non-compliance Program specialist will create a spreadsheet that will be used to verify that an initial assessment is written within 60 days of admission and sent to support coordinator prior to isp date.. -Program specialist will ensure an initial assessment is written within 60 days of admission to and sent to support coordinator prior to isp date.. `Program specialist will create a spreadsheet with all individuals¿ assessment date and assessment due date, by 05/01/2025 -C.E. O will oversee that program specialist via a monthly meeting to review paperwork according to due dates. Meetings will be started 05/05/2025 and will meet monthly before or around the 5th of the month. 06/01/2025 Implemented
6400.32(r)There are no locking mechanisms on any of the individual's bedroom doors.An individual has the right to lock the individual's bedroom door.Individual#1's bedroom door did not lock. The plans and assessments provided concerning Individual#1, did not discuss whether the individual wanted to be able to lock their bedroom door for privacy. Plan to fix the immediate problem: Compliance Manager will work with house staff and upper management team to establish the best strategy to ensure An individual has the right of privacy, to assure safety and to avoid any violations of rights. We will work with support coordinator to update ISP to discuss the inability of safety when dangerous occurs with locked door. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Compliance Manager will work with house staff and upper management team to establish the best strategy to ensure An individual has the right of privacy, to assure safety and to avoid any violations of rights. Compliance Manager will work with the support coordinator and behavior specialist to advise a plan to maintain possessions outside of direct possession, in order to accommodate avoiding rights violate and decreasing behaviors. What will be corrected: Compliance Manager will work with house staff and upper management team to establish the best strategy to An individual has the right of privacy. When and How: Compliance Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance. Compliance Manager will work with house staff and upper management team to establish the best strategy to ensure An individual has the right of privacy, to assure safety and to avoid any violations of rights. Compliance Manager will work with the support coordinator and behavior specialist to advise a plan to maintain possessions outside of direct possession, in order to accommodate avoiding rights violate and decreasing behaviors. . - Compliance Manager will work with house staff and upper management team to establish the best strategy to An individual has the right of privacy, to assure safety and to avoid any violations of rights. Compliance Manager will work with the support coordinator and behavior specialist to advise a plan to maintain possessions outside of direct possession, in order to accommodate avoiding rights violate and decreasing behaviors. - Compliance Manager will work with house staff and upper management team to establish the best strategy to ensure An individual has the right of privacy, to assure safety and to avoid any violations of rights. Compliance Manager will work with the support coordinator and behavior specialist to advise a plan to maintain possessions outside of direct possession, in order to accommodate avoiding rights violate and decreasing behaviors, by 06/01/2025 06/01/2025 Implemented
SIN-00221551 Renewal 03/15/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)The upper-level bathroom was missing soap, toilet paper and a hand towel.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. Plan to fix the immediate problem: Compliance Manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings, as well outdoor areas to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes hand towels in the bathrooms, to assure safety and proper disposal. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Compliance will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings as well outdoor areas, to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes hand towels in the bathrooms, to assure safety and proper disposal. What will be corrected: Make sure are sites are on clean and sanitary conditions especially when it comes hand towels in the bathrooms, to assure safety and proper disposal. When and How: Compliance Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance and will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings, as well outdoor areas to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes hand towels in the bathrooms, to assure safety and proper disposal. - Compliance Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings, as well outdoor areas to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes hand towels in the bathrooms, to assure safety and proper disposal. - Compliance manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings, as well outdoor areas, to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes hand towels in the bathrooms, to assure safety and proper disposal, As of 04/01/2023. 05/01/2023 Implemented
6400.32(r)None of the bedroom doors were equipped with locks to ensure privacy. There was no indication in assessments or ISPs that the right to lock their bedroom doors was discussed with the individuals living in the home.An individual has the right to lock the individual's bedroom door.Plan to fix the immediate problem: Compliance Manager will work with house staff and upper management team to establish the best strategy to ensure An individual has the right of privacy, to assure safety and to avoid any violations of rights. We will work with support coordinator to update ISP to discuss the inability of safety when dangerous occurs with locked door. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Compliance Manager will work with house staff and upper management team to establish the best strategy to ensure An individual has the right of privacy, to assure safety and to avoid any violations of rights. Compliance Manager will work with the support coordinator and behavior specialist to advise a plan to maintain possessions outside of direct possession, in order to accommodate avoiding rights violate and decreasing behaviors. What will be corrected: Compliance Manager will work with house staff and upper management team to establish the best strategy to An individual has the right of privacy. When and How: Compliance Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance. Compliance Manager will work with house staff and upper management team to establish the best strategy to ensure An individual has the right of privacy, to assure safety and to avoid any violations of rights. Compliance Manager will work with the support coordinator and behavior specialist to advise a plan to maintain possessions outside of direct possession, in order to accommodate avoiding rights violate and decreasing behaviors. . - Compliance Manager will work with house staff and upper management team to establish the best strategy to An individual has the right of privacy, to assure safety and to avoid any violations of rights. Compliance Manager will work with the support coordinator and behavior specialist to advise a plan to maintain possessions outside of direct possession, in order to accommodate avoiding rights violate and decreasing behaviors. 05/01/2023 Implemented
6400.186The plan addressing canvas covering the walls of individual#1's bedroom and the removal of bathroom items such as soap, towels and toilet papers from the upper bathroom only was not provided. Bathroom and other hygiene item storage was not discussed in other roommate's individual plans. The agency stated hygiene items and soaps are stored in individual bedrooms as a safety precaution in the home.The home shall implement the individual plan, including revisions.Plan to fix the immediate problem: Compliance Manager will work with house staff and upper management team to establish the best strategy to assure safety of the individual and to avoid any violations of rights. We will work with the support coordinator to update ISP to discuss the inability of safety when dangerous occurs with locked door. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Compliance Manager will work with house staff and upper management team to establish the best strategy to assure safety of the individual to avoid any violations of rights. Compliance Manager will work with the support coordinator and behavior specialist to advise a plan to maintain possessions outside of direct possession, in order to accommodate avoiding rights violate and decreasing behaviors. What will be corrected: Compliance Manager will work with house staff and upper management team to establish the best strategy to assure safety of the individual. When and How: Compliance Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance. Compliance Manager will work with house staff and upper management team to establish the best strategy to assure safety of the individual, and to avoid any violations of rights. Compliance Manager will work with the support coordinator and behavior specialist to advise a plan to maintain possessions outside of direct possession, in order to accommodate avoiding rights violate and decreasing behaviors. - Compliance Manager will work with house staff and upper management team to establish the best strategy to assure safety of the individual and to avoid any violations of rights. Compliance Manager will work with the support coordinator and behavior specialist to advise a plan to maintain possessions outside of direct possession, in order to accommodate avoiding rights violate and decreasing behaviors. 05/01/2023 Implemented
SIN-00184593 Renewal 03/09/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)There were items stored on the stairs leading down to the basement, including a blanket, bundles of reusable plastic shopping bags, and an empty paint mixing bucket. These items partially blocked the stairway, constituting a tripping hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.Plan to fix the immediate problem: Compliance Manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to stairways be free of items, to assure safety and to avoid accidents. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Compliance will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, , especially when it comes to stairways be free of items, to assure safety and to avoid accidents. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to stairways be free of items, to assure safety and to avoid accidents. When and How: Compliance Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance and will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to stairways be free of items, to assure safety and to avoid accidents. - Compliance Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to stairways be free of items, to assure safety and to avoid accidents. - Compliance manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes to stairways be free of items, to assure safety and to avoid accidents. 05/01/2021 Implemented
6400.71There were no emergency contact numbers found on or near the telephone in the first floor living room area.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Plan to fix the immediate problem: House manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to posting emergence numbers by telephone. This was corrected day of inspection on 03/09/2021 Who (job title) will be responsible for correcting the problem (each step in the process) in the future: House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to posting emergence numbers by telephone. This was corrected day of inspection on 03/09/2021. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to posting emergence numbers by telephone. This was corrected day of inspection on 03/09/2021. When and How: House Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance and will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, comes to posting emergence numbers by telephone. This was corrected day of inspection on 03/09/2021. - House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to posting emergence numbers by telephone but was corrected day of inspection on 03/09/2021. - House manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes to the proper posting of the emergence numbers by the telephone, by 03/09/2021 03/09/2021 Implemented
6400.112(d)The fire drill record on 10/15/2020 indicated that it took 3 minutes to evacuate. 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. Plan to fix the immediate problem: Program specialist will walk through the sites and review all fire drills to make sure the evacuation is done within 2 ½ minutes or explain and repeat of drill if exceeds this time. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will walk through the sites and review all fire drills to make sure the evacuation is done within 2 ½ minutes or explain and repeat of drill if exceeds this time, monthly. What will be corrected: Program specialist will walk through the sites and review all fire drills to make sure the evacuation is done within 2 ½ minutes or explain and repeat of drill if exceeds this time. When and How: Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance. Program specialist will walk through the sites and review all fire drills to make sure the evacuation is done within 2 ½ minutes or explain and repeat of drill if exceeds this time. - Program specialist will walk through the sites monthly to ensure fire drills are conducted in accordance to the 6400 regulations. Program specialist will walk through the sites and review all fire drills to make sure the evacuation is done within 2 ½ minutes or explain and repeat of drill if exceeds this time. - Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance: Program specialist will walk through the sites and review all fire drills to make sure the evacuation is done within 2 ½ minutes or explain and repeat of drill if exceeds this time, by 04/01/2021 04/01/2021 Implemented
6400.112(e)There was no sleep drill held between 4/20/2020 and February of 2021.A fire drill shall be held during sleeping hours at least every 6 months. Plan to fix the immediate problem: Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period. Who (job title) will be responsible for correcting the problem (each step in the process) in the future Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period, monthly. What will be corrected: Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period. When and How: Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance. Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period. - Program specialist will walk through the sites monthly to ensure fire drills are conducted in accordance to the 6400 regulations. Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period. - Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance: Program specialist will walk through the sites and review all fire drills to make sure the sleep fire drills are done at least every six months or a repeat of drill if exceeds that time period, by 05/01/2021 05/01/2021 Implemented
6400.32(i)Individual #5 did not have a dresser in the bedroom. Staff on site directed this inspector to a dresser in an unoccupied bedroom within the residence, stating that Individual #5's dresser and clothing were kept in this location because, if the dresser were in the other room, access to clothing and throw it around the room and floor. When asked if this intervention was part of a Behavioral Support Plan (BSP) or within the Individual Support Plan (ISP), staff on site stated that it was not. The staff on site were asked whether or not Individual #5's ISP Team had met to discuss these concerns, and they indicated that the team had not. This Inspector accessed Individual #5's ISP through Home and Community Services Information System (HCSIS) and confirmed that information on this restriction was not in the individual #5's ated 02/02/2021. Individual #5 did not have access to clothing.An individual has the right of access to and security of the individual's possessions.Plan to fix the immediate problem: Compliance Manager will work with house staff and upper management team to establish the best strategy to ensure An individual has the right of access to and security of the individual¿s possessions, to assure safety and to avoid any violations of rights. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Compliance Manager will work with house staff and upper management team to establish the best strategy to ensure An individual has the right of access to and security of the individual¿s possessions, to assure safety and to avoid any violations of rights. Compliance Manager will work with the support coordinator and behavior specialist to advise a plan to maintain possessions outside of direct possession, in order to accommodate avoiding rights violate and decreasing behaviors. What will be corrected: Compliance Manager will work with house staff and upper management team to establish the best strategy to ensure An individual has the right of access to and security of the individual¿s possessions. When and How: Compliance Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance. Compliance Manager will work with house staff and upper management team to establish the best strategy to ensure An individual has the right of access to and security of the individual¿s possessions, to assure safety and to avoid any violations of rights. Compliance Manager will work with the support coordinator and behavior specialist to advise a plan to maintain possessions outside of direct possession, in order to accommodate avoiding rights violate and decreasing behaviors. - Compliance Manager will work with house staff and upper management team to establish the best strategy to ensure An individual has the right of access to and security of the individual¿s possessions, to assure safety and to avoid any violations of rights. Compliance Manager will work with the support coordinator and behavior specialist to advise a plan to maintain possessions outside of direct possession, in order to accommodate avoiding rights violate and decreasing behaviors. - Compliance Manager will work with house staff and upper management team to establish the best strategy to ensure An individual has the right of access to and security of the individual¿s possessions, to assure safety and to avoid any violations of rights. Compliance Manager will work with the support coordinator and behavior specialist to advise a plan to maintain possessions outside of direct possession, in order to accommodate avoiding rights violate and decreasing behaviors, by 06/01/2021 06/01/2021 Implemented
SIN-00156858 Renewal 06/05/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Emergency numbers were not posted on or by the telephone. Agency posted phone numbers after physical site inspection.Floors, walls, ceilings and other surfaces shall be in good repair. Plan to fix the immediate problem: House manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to posting emergence numbers by telephone. This was corrected day of inspection on 06/06/2019. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to posting emergence numbers by telephone. This was corrected day of inspection on 06/06/2019. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to posting emergence numbers by telephone. This was corrected day of inspection on 06/06/2019. When and How: House Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance and will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, comes to posting emergence numbers by telephone. This was corrected day of inspection on 06/06/2019. - House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to posting emergence numbers by telephone, but was corrected day of inspection on 06/06/2019. - House manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes to the proper posting of the emergence numbers by the telephone, by 06/06/2019 -C.E. O will oversee that House Manager via a monthly meeting to ensure walk throughs are being done and that items are being removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to posting emergence numbers by telephone. This was corrected day of inspection on 06/06/2019. Meetings will continue monthly and we will meet before or around the 5th of the month Starting in July of 2019. 07/15/2019 Implemented
6400.67(a)The upper right stove burner in the kitchen is missing the control dial.Floors, walls, ceilings and other surfaces shall be in good repair. Plan to fix the immediate problem: House manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the stove have all knobs to ensure good repair. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the stove have all knobs to ensure good repair. The owner will purchase knob ensure the stove is in good standing. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to the stove have all knobs be present to ensure good repair. When and How: House Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance and will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the stove have all knobs to ensure good repair. - House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the stove have all knobs to ensure good repair. - House manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes to the stove have all knobs to ensure good repair, by 08/01/2019 -C.E. O will oversee that House Manager via a monthly meeting to ensure walk throughs are being done and that items are being removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the stove have all knobs to ensure good repair. Meetings will continue monthly and we will meet before or around the 5th of the month Starting in August of 2019. 08/01/2019 Implemented
SIN-00131531 Renewal 04/03/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The kitchen floor was to be buckled due to some previous water damage.Floors, walls, ceilings and other surfaces shall be in good repair. Plan to fix the immediate problem: House manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. The dryer hose was replaced and walls surrounding the area was cleaned and repaired on April 03, 2018. State licensing inspector verified repaired was done on 04/04/2018 Who (job title) will be responsible for correcting the problem (each step in the process) in the future: House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. The program specialist will purchase ensure that replacement items are purchased, and the site is in good standing. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. When and How: House Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. - House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the lint trap of the dryer. - House manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor, by 04/03/2018 -C.E. O will oversee that House Manager via a monthly meeting to ensure walk throughs are being done and that items are being removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. Meetings will continue monthly and we will meet before or around the 5th of the month Starting in May of 2018. Implemented
6400.76(a)The living room coffee table was found scratched. Furniture and equipment shall be nonhazardous, clean and sturdy. Plan to fix the immediate problem: House manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. The dryer hose was replaced and walls surrounding the area was cleaned and repaired on April 03, 2018. State licensing inspector verified repaired was done on 04/04/2018 Who (job title) will be responsible for correcting the problem (each step in the process) in the future: House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. The program specialist will purchase ensure that replacement items are purchased, and the site is in good standing. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. When and How: House Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. - House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the lint trap of the dryer. - House manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor, by 04/03/2018 -C.E. O will oversee that House Manager via a monthly meeting to ensure walk throughs are being done and that items are being removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. Meetings will continue monthly and we will meet before or around the 5th of the month Starting in May of 2018. Implemented
6400.82(f)The wall toilet paper was no longer attached and missing.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. Plan to fix the immediate problem: House manager will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. The dryer hose was replaced and walls surrounding the area was cleaned and repaired on April 03, 2018. State licensing inspector verified repaired was done on 04/04/2018 Who (job title) will be responsible for correcting the problem (each step in the process) in the future: House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. The program specialist will purchase ensure that replacement items are purchased, and the site is in good standing. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. When and How: House Manager will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. - House Manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the lint trap of the dryer. - House manager will walk through the sites weekly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor, by 04/03/2018 -C.E. O will oversee that House Manager via a monthly meeting to ensure walk throughs are being done and that items are being removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to the dryer and hose to ensure the lint is discharging on to the walls and floor. Meetings will continue monthly and we will meet before or around the 5th of the month Starting in May of 2018. Implemented
6400.141(c)(14)Individual #2's annual physical dated 9/19/17 did not record information pertinent to diagnosis in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Plan to fix the immediate problem: Program specialist will send out a written request to ensure service address is accurate in the person being served ISP. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will review the ISP in detail upon receipt to verify the service address is correct. Program specialist will send out a written request to ensure service address is accurate in the person being served ISP. What will be corrected: Program specialist will send out a written request to ensure service address is accurate in the person being served ISP. When and How: Program Specialist will review the components of the 6400 and how it should be applied to the areas of non-compliance Program specialist will review the ISP in detail upon receipt to verify the service address is correct. Program specialist will send out a written request to ensure service address is accurate in the person being served to SC or plan lead, as applicable, and plan team member when address in not current. -A written request will be made - Program specialist will review the ISP in detail upon receipt to verify the service address is correct. Program specialist will send out a written request to ensure service address is accurate in the person being served ISP, by 04/04/2018 -C.E.O will oversee that program specialist via a monthly meeting to review paperwork according to due dates. Meetings will be started 05/05/2018 and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. Implemented
SIN-00113349 Renewal 04/10/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)"Source" brand antibacterial hand soap was found unlocked on the sink vanity in the 2nd floor bathroom.Poisonous materials shall be kept locked or made inaccessible to individuals.The Program specialist will walk through the sites and will all poisonous materials is kept locked up, such as "Source" brand antibacterial hand soap was found unlocked on the sink vanity. The Program specialist will walk through the sites and will all poisonous materials is kept locked up, such as "Source" brand antibacterial hand soap, monthly. The Program specialist will walk through the sites and will all poisonous materials is kept locked up, such as "Source" brand antibacterial hand soap, monthly. The Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance. Program specialist will walk through the sites and will all make sure all poisonous materials be kept locked up, such as "Source" brand antibacterial hand soap. - Program specialist will walk through the sites monthly to ensure that poisonous materials, if ingested are being kept locked away until use. Program specialist will walk through the sites and will all poisonous materials be kept locked up, such as "Source" brand antibacterial hand soap. - Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance: Program specialist will walk through the sites and will all poisonous materials is kept locked up, such as "Source" brand antibacterial hand soap, by 07/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to ensure walk throughs are being done and to ensure Poisonous materials, if ingested will be kept in a locked cabinet, in order to prevent an emergence, where individual could have ingested poisonous materials. Meetings will continue and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 07/03/2017 Implemented
6400.64(a)In the 2nd floor bathroom, a black substance consistent with mildew was found on the caulking around the bathtub and tile wall. Clean and sanitary conditions shall be maintained in the home. The Program specialist will walk through the sites to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes a black substance consistent with mildew was found on the caulking around the bathtub and tile wall. The Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to a black substance consistent with mildew was found on the caulking around the bathtub and tile wall. The program specialist will ensure that replacement items are purchased and the site is in good standing. What will be corrected: Make sure are sites are on clean and sanitary conditions, especially when it comes to a black substance consistent with mildew was found on the caulking around the bathtub and tile wall. The Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to a black substance consistent with mildew was found on the caulking around the bathtub and tile wall. - program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to a black substance consistent with mildew was found on the caulking around the bathtub and tile wall. - Program specialist will walk through the sites monthly to examine all furniture, surfaces, floors, walls and ceilings to ensure they are in good repair. The broke items will be removed or replaced correctly, and to make sure are sites are on clean and sanitary conditions, especially when it comes to a black substance consistent with mildew was found on the caulking around the bathtub and tile wall, by 07/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to ensure walk throughs are being done and that items are being removed or replaced correctly and to make sure are sites are on clean and sanitary conditions, especially when it comes to a black substance consistent with mildew was found on the caulking around the bathtub and tile wall. Meetings will continue monthly and we will meet before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 07/03/2017 Implemented
6400.68(b)The hot water temperature in the 2nd floor bathtub was 132° Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. The hot water temperature in the 2nd floor bathtub was 132° Fahrenheit. Plan to fix the immediate problem: Program specialist will go to all the sites and check the water temperature to ensure the hot water does not exceed 120 f. The temperature will be adjusted if the water temperature is above the 120 f. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Program specialist will go to all the sites and check the water temperature to ensure the hot water does not exceed 120 f. The temperature will be adjusted if the water temperature is above the 120 f, if noncompliance is discovered on a monthly basis. What will be corrected: The hot water temperature was 132° Fahrenheit. When and How: Program specialist will go to all the sites and check the water temperature to ensure the hot water does not exceed 120 f. The temperature will be adjusted if the water temperature is above the 120 f, if noncompliance is discovered on a monthly basis. - Program specialist will walk through the site monthly to check hot water temperature to ensure hot water doesn¿t exceed 120 f. - Program specialist will review the components of the 6400 regulations and how it should be applied to the areas of non-compliance Program specialist will walk through the site monthly to check hot water temperature to ensure hot water doesn¿t exceed 120 f, by 07/03/2017 -C.E. O will oversee that program specialist via a monthly meeting to ensure Program specialist will walk through the site monthly to check hot water temperature to ensure hot water doesn¿t exceed 120 f. Meetings will be continued and will meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with Program specialist monthly. 07/03/2017 Implemented
6400.141(c)(14)Individual #1's physical examination dated 1/17/17 did not list information pertinent to diagnosis in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Individual #1's physical examination dated 1/17/17 did not list information pertinent to diagnosis in case of an emergency. Plan to fix the immediate problem: staff will review all Individuals files and to ensure all individuals have proper documentation that lists information pertinent to diagnosis in case of an emergency, when they have their yearly physical and as needed in accordance to the 6400 regulations. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Staff will review all individual¿s files and to ensure all individuals have proper documentation that lists information pertinent to diagnosis in case of an emergency, when they have their yearly physical and as needed in accordance to the 6400 regulations. In order for individual to get the services they or may not require. What will be corrected: Staff will review all Individuals files and to ensure all individuals have proper documentation that lists information pertinent to diagnosis in case of an emergency, when they have their yearly physical and as needed in accordance to the 6400 regulations. When and How: Staff will review the components of the 6400 and how it should be applied to the areas of non-compliance. Staff will review all Individuals files and to ensure all individuals have proper documentation that lists information pertinent to diagnosis in case of an emergency, when they have their yearly physical and as needed in accordance to the 6400 regulations. - No Documentation that lists information pertinent to diagnosis in case of an emergency on yearly physical - Staff will review all Individuals files and to ensure all individuals have proper documentation that lists information pertinent to diagnosis in case of an emergency, when they have their yearly physical and as needed in accordance to the 6400 regulations, by 07/03/2017. -C.E. O will oversee staff¿s practices via a monthly meeting to review paperwork of all Individuals files and to ensure all individuals have proper documentation that lists information pertinent to diagnosis in case of an emergency, when they have their yearly physical and as needed in accordance to the 6400 regulations. Meetings will continue monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with staff monthly to review all Individuals files and to ensure all individuals have proper documentation that lists information pertinent to diagnosis in case of an emergency, when they have their yearly physical and as needed in accordance to the 6400 regulations. 07/03/2017 Implemented
6400.164(b)Individual #1's 7am medication on 4/11/17 were not initialed as given. Individual #1's Benzoyl peroxide 5% gel on 4/10/17 and 4/9/17 at 7pm were not initialed as given. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. Plan to fix the immediate problem: Staff will remind individuals of their inability to self-medicate according to individual service plan, while adhering to their rights. Who (job title) will be responsible for correcting the problem (each step in the process) in the future: Staff will remind individuals of their inability to self-medicate according to individual service plan, while adhering to their rights in accordance to the 6400 regulations, that entitles individuals to have the right to refuse the assist of the staff to administrator medications such as their Benzoyl peroxide 5% gel for acne. What will be corrected: Staff will continue to give reminders to individuals of their inability to self-medicate according to individual service plan when it comes to their Benzoyl peroxide 5% gel for acne. When and How: Staff will review the components of the 6400 and how it should be applied to the areas of non-compliance. Program specialist will be retraining all staff on individual service plans, focusing on an individual¿s inability or ability to self-medicate. - individual does not self-medicate, such as Benzoyl peroxide 5% gel for acne. - program will be retraining all staff on individual service plans, focusing on an individual¿s inability or ability to self-medicate such as Benzoyl peroxide 5% gel for acne, by 07/03/2017. -C.E. O will oversee staff¿s practices via a monthly meeting to review trainings of all employees and paperwork according to due dates. Meetings will be continuing to meet monthly before or around the 5th of the month. A plan to prevent future occurrence: C.E.O will continue to meet with staff monthly and review all training to ensure all employees remain trained on individual service plans, focusing on an individual¿s inability or ability to self-medicate, such as Benzoyl peroxide 5% gel for acne. 07/03/2017 Implemented
SIN-00042564 Initial review 10/26/2012 Compliant - Finalized