Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00227984 Renewal 07/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101There is a sliding latch lock on the inside of the door in the basement leading to the back exit of the home, posing an obstructed egress when engaged. [Repeat Violation, 11/18/2022]Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The sliding latch has been removed from the door. All doors have been checked to ensure that there are no obstructed egress route such as chained, padlocked exit doors or as subtle as furniture or any other objects that would create a ¿choke point¿ if multiple individuals were attempting to escape at the same time. 08/01/2023 Implemented
6400.151(b)Direct Service Worker #3 had a physical examination dated, 1/4/2023, that was not signed by a physician. The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. Reviewed above regulation with Residential Manager to ensure the understanding of the regulation and to clarify that the regulation includes contracted/temp staff. Direct Service Worker #3 is from a Temp Staff Agency. Also had a phone meeting with Temp Staff Agency on 8/2/2023 to clarify the staff training requirements. Sent documentation, to include the 6400 regulations, along with a list of orientation & annual trainings required to stay in compliance. 08/02/2023 Implemented
6400.34(a)Individual #1 was informed and explained individual rights on 4/6/2022 and then again on 7/11/2023.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Reviewed above violation with Program Specialist, to ensure the understanding of the regulation and to understand that each individual must be informed and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter and that grace periods for this regulations are not permitted. 08/11/2023 Implemented
6400.46(a)Direct Service Worker #2 began working with individuals on 11/11/2022 and has not completed fire safety training. Direct Service Worker #3 began working with individuals on 1/28/2023 and has not completed fire safety training.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.Reviewed above regulation with Residential Manager to ensure the understanding of the regulation and to clarify that the regulation includes contracted staff. Direct Service Worker #2 & #3 are both from a Temp Staff Agency. 08/11/2023 Implemented
6400.51(b)(1)Direct Service Worker #2 began working with individuals on 11/11/2022 and completed initial training on person centered practices on 5/30/2023. Direct Service Worker #1 began working with individuals on 1/28/2023 and completed initial training on person centered practices on 4/12/2023.The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Reviewed above regulation with Residential Manager to ensure the understanding of the regulation and to clarify that the regulation includes contracted/temp staff. Direct Service Worker #2 & #3 are both from a Temp Staff Agency. Also had a phone meeting with Temp Staff Agency on 8/2/2023 to clarify the staff training requirements. Sent documentation, to include the 6400 regulations, along with a list of orientation & annual trainings required to stay in compliance. 08/02/2023 Implemented
6400.51(b)(3)Direct Service Worker #2 began working with individuals on 11/11/2022 and completed initial training on individual rights on 5/29/2023. Direct Service Worker #3 began working with individuals on 1/28/2023 and completed initial training on individual rights on 4/6/2023.The orientation must encompass the following areas: Individual rights.Reviewed above regulation with Residential Manager to ensure the understanding of the regulation and to clarify that the regulation includes contracted/temp staff. Direct Service Worker #2 & #3 are both from a Temp Staff Agency. Also had a phone meeting with Temp Staff Agency on 8/2/2023 to clarify the staff training requirements. Sent documentation, to include the 6400 regulations, along with a list of orientation & annual trainings required to stay in compliance 08/02/2023 Implemented
6400.51(b)(4)Direct Service Worker #2 began working with individuals on 11/11/2022 and completed initial training on recognizing and reporting incidents on 5/29/2023. Direct Service Worker #3 began working with individuals on 1/28/2023 and completed initial training on recognizing and reporting incidents on 4/6/2023.The orientation must encompass the following areas: recognizing and reporting incidents.Reviewed above regulation with Residential Manager to ensure the understanding of the regulation and to clarify that the regulation includes contracted/temp staff. Direct Service Worker #2 & #3 are both from a Temp Staff Agency. Also had a phone meeting with Temp Staff Agency on 8/2/2023 to clarify the staff training requirements. Sent documentation, to include the 6400 regulations, along with a list of orientation & annual trainings required to stay in compliance. 08/02/2023 Implemented
6400.166(b)At 12:30PM on 7/19/2023, Individual #1's 5:30PM dose of Insulin Aspa Inj Flexpen and 7:30PM dose of Lantus Solos Inj were initialed as administered.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Residential Manager spoke with the staff that initialed as administered for the above times, it was confirmed that the medication was not given, that the the MAR was marked incorrectly. Staff was on site the date of the inspection on 7/19/2023. 08/31/2023 Implemented
6400.169(a)Direct Service Worker #1, date of hire 8/26/2022, has not completed the Department approved Medication Administration Course. Direct Service Worker #1 complete Modified Medication Administration Training on 9/1/2022. Direct Service Worker #1 administered Individual #1's medications on 7/18/2023 at 7:30AM.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).All staff person's that have not completed the Department-approved medication course, including renewal requirements have been informed that they are not permitted to administer medications, including injections, procedures and treatments as specified in 6400.162. 08/05/2023 Implemented
SIN-00215611 Renewal 11/17/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At 1:25PM on 11/18/2022, there were splatters and particles of food throughout the inside of the microwave and the kitchen sink. There was a bowl of mashed potatoes with a fork on the nightstand in Individual #1's bedroom. There was a multitude of tissues soiled with what appeared to be feces in an uncovered trash receptacle in the bathroom on the first floor of the home.Clean and sanitary conditions shall be maintained in the home. Residential Manager removed and disposed of all expired food. All refrigerators were checked and all expired food was removed and disposed of as needed. 12/16/2022 Not Implemented
6400.66The light outside the basement exit is inoperable.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The light outside the basement exit was repaired. All rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes lights were repaired as needed. to assure safety and to avoid accidents. 12/16/2022 Not Implemented
6400.74The outside steps on the side exit of the home do not have a nonskid surface.Interior stairs and outside steps shall have a nonskid surface. Nonskid material was placed on outside steps on the side exit of the home. 12/16/2022 Not Implemented
6400.83(c)At 1:26PM on 11/18/2022, there was a soiled plate, silverware, serving spoon and a glass in sink in the kitchen of the home.Utensils used for eating, drinking and preparation of food or drink shall be washed and rinsed after each use.Soiled plate, silverware, serving spoon and a glass in sink in the kitchen of the home was immediately placed in the dishwasher. 12/16/2022 Not Implemented
6400.214(b)The most current copy of Individual #1's assessment was not kept at the home. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. Copies of all assessments were placed in the homes to ensure that all staff can view the assessments and accurately know the abilities of the individuals. 12/12/2022 Not Implemented
6400.163(d)At 1:39PM on 11/18/2022, there was a bottle of Acetaminophen on the end table in the living room. [Repeat Violation, 12/2/2021]Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.Individual #1's prescription medication Polyethylene Glycol 3350, & Olopatadine Sol 0.2% was immediately placed in the locked area with the rest of the medications. The blister packs containing expired prescription medications belonging to another individual, along with the medication dispenser were immediately removed from Individual #1's home, and disposed of according to KZL Agency's policy. 12/16/2022 Not Implemented
SIN-00198876 Renewal 12/02/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65During the on-site inspection conducted 12/03/2021 there was no ventilation in the bathroom located in the basement of the home.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. A ventilation fan was placed in the bathroom located in the basement of the home on 12/06/2021. A house-checklist was put into place to ensure that all mechanical ventilation systems in the home are in operable condition. 12/06/2021 Implemented
6400.110(f)During the on-site inspection conducted 12/03/2021 the smoke detectors were not equipped so that Individual #1 would be alerted in the event of a fire. Individual #1's individual service plan updated 11/28/2021 states the individual has congenital hearing loss in both ears and has two hearing aids. If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. Individual #1 had an audiology appointment on 01/12/2022. Smoke detectors and fire alarms equipped so that a person with a hearing impairment can be alerted in the event of a fire was discussed. Two fire alarms with strobe lights were ordered on 02/04/2022 and are scheduled to be delivered February 9th-11th. They will be installed immediately upon arrival. 02/04/2022 Implemented
6400.142(c)The agency did not provide documentation of Individual #1's dental examination completed 2/22/2021 including the date of the examination, procedures completed and follow-up treatment recommended.A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. Residential Manager has been instructed to contact Individual #1's Dentist to get documentation including the date of the examination, procedures completed and follow-up treatment recommended. for the appointment that was completed on 2/22/2021. Director of Operations has reviewed Regulation 6400.142(c) - A written record of the dental examination, including the date of the examination, dentist¿s name, procedures completed and follow-up treatment recommended shall be kept. with the Residential Manager and the importance of Compliance. 02/04/2021 Implemented
6400.144Documentation was provided from a licensed physician that Individual #1 "had a Pap test completed in 2017 and she does not require annual screenings. Her next Pap test would be due in July 2020." Individual #1's following Pap test was completed on 1/26/2021.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. Residential Manager has been instructed to contact Individual #1's PCP to get information her Pap test that was completed on 1/26/2021. Director of Operations has reviewed Regulation 6400.144 - 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, with the Residential Manager and the importance of Compliance. 02/04/2022 Implemented
6400.181(e)(12)Individual #1's assessment completed 2/10/2021 did not include: Recommendations for specific areas of training, programming and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. KZL Agency has revised and updated Residential Annual Assessment to ensure all information as noted in Chapter 6440.181(e) is reflected, including specific recommendations for specific areas of training, programming, and services. KZL Agency Residential Program Specialist will begin using this revised assessment immediately, replacing the old assessment. 01/26/2022 Implemented
6400.195(c)Individual #1 had a restrictive procedure plan implemented on 1/22/2021 stating that the individual's razors are to be kept locked in a cabinet and items such as sewing needles and scissors need to be locked, and while in use, the individual will be in visual sight. The only human rights committee review was conducted on 8/02/2021 and documents the plan remains in place. The 9/28/2021 T-Log note by Behavior Specialist #2 states the individual was going to get her stuff back. During the on-site inspection conducted 12/03/2021, the individual's razor was located unlocked in the main floor bathroom, above the sink in a cabinet behind a mirror.The restrictive procedure plan shall be reviewed, and revised, if necessary, according to the time frame established by the restrictive procedure review committee, not to exceed 6 months. KZL Agency has revised and updated Restrictive Procedures/Human Rights Team policy to ensure all mandatory Chapter 6400 and 6100 Regulatory guidance is included. KZL Agency Director of Operations has reviewed this updated policy and procedure with all members of the Human Rights Team, as well as the behavior support team. KZL Agency will ensure going forward that a Human Rights Team meeting with a restrictive procedure review is conducted prior to discontinuing any restrictive procedure plan which has been put in place by the team. 12/28/2021 Implemented
6400.18(a)(9)During the on-site inspection conducted 12/03/2021, Director of Operations #1 stated Individual #1 had ingested a battery and a necklace charm on 11/01/2021. Individual #1 was seen by a medical professional on 11/04/2021. The agency did not report the incident to the Department.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Injury requiring treatment beyond first aid. KZL Agency failed to report the aforementioned incident to the Department when Individual #1 ingested the battery and necklace charm due to an error on the part of the provider. As Individual #1 was not taken to the hospital for this incident, KZL Agency management mis-understood the need to report the incident as an "Injury requiring treatment beyond first aid." Incident was input into HCSIS albeit late. KZL Agency Incident Manager has ensured all KZL Agency employees are aware of the changes to the Incident Management bulletin to ensure timely and accurate reporting of all reportable incidents in the future. 02/03/2022 Implemented
6400.34(a)Individual #1's most recent signed copy of rights completed 3/10/2021, did not include the following rights: 6400.32e through 6400.32g, to choose, accept risks, refusal and control the individual's schedule, activities and services; 6400.32j to voice concerns and 6400.32k to participation in the development and implementation of the individual plan; 6400.32r and 6400.32s relating to locking doors in bedrooms and in the home.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.KZL Agency has revised and updated our agency Individual Rights policy to include all rights as noted in Chapter 6400 and Chapter 6100 regulations. KZL Agency has already been following the guidelines in the residential homes but had not updated written policy to reflect these guidelines. KZL Agency will ensure that this updated policy is what is shared with individuals going forward. 12/03/2021 Implemented
6400.181(f)Individual #1's assessment completed 2/10/2021, was sent to the individual plan team members on 2/10/2021, for the individual service plan meeting that occurred 3/10/2021.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.KZL Agency residential Program Specialist inaccurately counted 30 days prior to ISP meeting scheduled for 3/10/2021 resulting in the residential assessment being sent to team members late. KZL Agency residential Program Specialist will ensure that due dates for assessments are recorded on the calendar and will be sent to ISP team members at least 30 days prior to the scheduled ISP meeting. 02/03/2022 Implemented
SIN-00247814 Renewal 07/11/2024 Compliant - Finalized
SIN-00222786 Unannounced Monitoring 04/17/2023 Compliant - Finalized