Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00261874 Unannounced Monitoring 03/04/2025 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At the time of the 03/04/25 inspection, there was a black mold-like substance on the ceiling in the bedroom with the attached bathroom shower stall.Clean and sanitary conditions shall be maintained in the home. Director of Programs created a work order for Facility Manager to address the mold like substance at the home. Facility Manager cleaned and sanitized the walls and ceiling of the affected area using bathroom cleaner and mildewcide. Cleaned out mildewed caulk and recaulked. Cleaned shower ceiling and painted. This was completed on 3.7.25 Director of Programs will review the monthly house checklist to ensure that the bathrooms are checked specifically for any issues that could lead to moldlike substances appearing is on the monthly house checklist. This will be completed by 3.13.25 Director of Programs will meet with the Residential Managers to implement weekly proper cleaning of bathrooms specifically showers and ensure it is on the daily/weekly house chore chart and team members are retrained on the importance of this task. This will be completed by 3.13.25. 03/07/2025 Implemented
6400.166(a)(13)There are two marks on the February 23rd, 2025, Medication Administration Record (MAR) for Individual #1, that appear to state either "GO" or "OO". These initials do not correspond to a staff name or signature on the MAR.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.Director of Programs will review with the Residential Managers the appropriate signature and initials that are to be used by all medication certified staff. Residential Managers will need to check all signatures and initials of team members to ensure they match as shown on the signature sheet. Director of Programs will meet with the Residential Manager of the home to address the issue of staff person whose initials do not match the signature form. Residential Manager will meet with this specific staff member to establish proper initials that will be used on the eMARs. 03/11/2025 Implemented
SIN-00238354 Unannounced Monitoring 01/24/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(b)(1)On December 28, 2023, staff person #1 found a lighter and 2 burnt spoons, which is potential drug paraphernalia, among staff person #2's desk items while cleaning. Staff person #1 reported this to HR at 10:49am, who reported it to staff person #3 on that same date. Staff person #3 advised staff person #1 to not contact law enforcement, which is Jessica & Friends Community's policy, and that staff person #3 would discuss the situation with staff person #2 and staff person #4. Staff person #3 advised staff person #1 to lock up the lighters and spoon where no one could find it. No further action was taken until 1/3/24, when staff person #1 discovered that staff person #4 had never been advised of the incident. There was not an investigation completed, nor was drug testing completed, as per company policy. Additionally, there was no counseling or disciplinary action taken as a result of this incident.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. Upon notification of this incident on January 3, 2024, the CEO contacted the Director of Human Resources to receive clarification on the situation. Once receiving all the information, the CEO contacted the Executive Committee of the Board of Directors as well as the Human Resource Committee members. The CEO will implement the Board approved drug and alcohol policy which will include the steps for random drug testing of employees. Once it is approved, the Director of Human Resources along with the CEO will begin the implementation of drug testing on March 1, 2024 for those employees who currently work and those who transferred from the Old Colony home. Then from this point on, random drug testing will be conducted with the Director of Human Resources overseeing this process. 02/16/2024 Implemented
6400.18(a)(5)On December 28, 2023, Staff Person #1 found a lighter and 2 burnt spoons, which is potential drug paraphernalia, among Staff Person #2's desk items while cleaning. Staff person #1 reported this to HR at 10:49am, who reported it to staff person #3 on that same date. This incident has never been entered into the department's incident management system.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: Neglect. Upon notification of this situation, the Director of Programs had it entered into EIM/HCSIS on 2.2.24. A certified investigator was assigned to complete the investigation. The targets that were identified were separated from all ODP individuals upon completion of the investigation. Upon completion of the admin review the corrective actions will be implemented and documented by the Director of Programs and/or designee as outlined in the plan. Director of Programs will notify the targets of this incident that they will need take ODP's Abuse and Incident Management training. The Director of Programs will ensure the trainings are completed and certificates received. 02/16/2024 Implemented
6400.18(f)On December 28, 2023, staff person #1 reported potential drug paraphernalia in the home office, potentially accessible to individuals in the home. There were no actions taken to protect the health and safety of the individuals in the home.The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident.Upon notification of this incident the Director of Programs had it entered into EIM/HCSIS on 2.2.24. The targets that were identified were separated from all ODP individuals upon completion of the investigation. A certified investigator was assigned to complete the investigation. The items that were found were removed from the home by the manager and taken to the main office the day they were found. Upon completion of the admin review the corrective actions will be implemented and documented by the Director of Programs and/or designee as outlined in the plan. The Director of Programs and the Director of Human Resources will contact the York County D&A office to schedule trainings for all J&FC employees. The administrative trainings will be completed within 30 days (March 8, 2024). All employee trainings will be completed within three months (May 1, 2024) 02/16/2024 Implemented
6400.18(g)On December 28, 2023, staff person #1 reported a neglect incident to staff person #3. There was never a certified investigation completed for this incident.The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person.Upon notification of this incident the Director of Programs had it entered into EIM/HCSIS on 2.2.24. The targets that were identified were separated from all ODP individuals upon completion of the investigation. A certified investigator was assigned to complete the investigation. Upon completion of the admin review the corrective actions will be implemented and documented by the Director of Programs and/or designee as outlined in the plan. Director of Programs will notify the targets of this incident that they will need take ODP's Abuse and Incident Management training. The Director of Programs will ensure the trainings are completed and certificates received. 02/16/2024 Implemented
SIN-00230560 Renewal 09/26/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Individual #1 is assessed to be unsafe around poisonous items. At the time of the 9/27/23 onsite inspection, there was carpet cleaner accessible in the individual's bathroom in an unlocked cabinet. The carpet cleaner did indicate to call poison control if ingested.Poisonous materials shall be kept locked or made inaccessible to individuals. The Director of Quality Assurance & Compliance placed the carpet cleaner in a locked cabinet immediately, upon finding it in an unlocked cabinet. The house manager and staff will ensure that all poisons in the home are locked at all times when they are not in use daily. 09/27/2023 Implemented
6400.67(a)At the time of the 9/27/23 onsite inspection, the sink in the half-bathroom was draining extremely slowly.Floors, walls, ceilings and other surfaces shall be in good repair. Associate Director of Residential submitted a work order to fix the sink on 9/27/23. The maintenance coordinator fixed the slow draining sink on 9/27/23. 09/27/2023 Implemented
6400.101At the time of the 9/27/23 onsite inspection, the door leading from the garage to the outside of the home was obstructed by a ladder.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Associate Director of Residential submitted a work order to move the ladder on 9/29/23. The maintenance coordinator moved the ladder from the door leading from the garage to the outside of the home on 9/29/23. 09/29/2023 Implemented
6400.110(a)At the time of the 9/27/23 onsite inspection, a smoke detector was not located in the accessible attic of the home. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Associate Director of Residential submitted a work order to bolt the attic door shut so that it is no longer accessible to anyone in the organization on 9/29/23. The maintenance coordinator bolted the attic door shut on 9/29/23. 09/29/2023 Implemented
6400.111(a)At the time of the 9/27/23 onsite inspection, a fire extinguisher was not located in the accessible attic of the home.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. Associate Director of Residential submitted a work order to bolt the attic door shut so that it is no longer accessible to anyone in the organization on 9/29/23. The maintenance coordinator bolted the attic door shut on 9/29/23. 09/29/2023 Implemented
6400.171At the time of the 9/27/23 onsite inspection, there was a container of sour cream in the refrigerator that had expired on 7/28/23.Food shall be protected from contamination while being stored, prepared, transported and served. The Director of Quality Assurance & Compliance placed the sour cream in the trash can immediately, upon finding it expired in the refrigerator. The house manager and staff will ensure that all food in the home is not out of date/expired. 09/27/2023 Implemented
SIN-00212307 Renewal 10/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)At the time of the 10/4/22 inspection, the kitchen table had an approximately 3" x3" wooden section missing from the center area.Floors, walls, ceilings and other surfaces shall be in good repair. A work order will be completed and sent to the maintenance department for repair or replacement by 10/13/2022, by the Executive Director of Operations. The request will be dated for repair or replacement to be addressed by 10/31/2022. If replacement is needed, the House Manager will begin the process of shopping for a new dining room set. The House Manager will send options to the Executive Director of Operations for approval to purchase, to ensure it's within the home's budget. 10/31/2022 Implemented
6400.111(f)The fire extinguishers in the home were inspected 3/23/21 and not again until 3/30/22. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The Executive Director of Operations will meet with the Maintenance Director to review the regulation above to ensure that all fire extinguishers are inspected within 364 days of the previous year's inspection. 10/31/2022 Implemented
SIN-00196952 Renewal 11/29/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(2)On 2/25/21, Individual #1's mother wrote a check for $100 for Individual #1. That check was not cashed or accounted for in the record.(2) Disbursements made to or for the individual. The mother of the individual was notified about the check that was not cashed. The check was voided as per the mother's wishes. A copy of the voided check was made and will be given to the mother. It is the manager's responsibility to ensure all future checks are cashed within 48 hours of receiving them. 12/14/2021 Implemented
6400.71Emergency numbers were not on nor posted near the cordless telephone on the kitchen counter.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The emergency numbers were printed off and attached to the phone. It is the responsibility of all house managers to ensure all phones have emergency numbers posted on or near them. 12/02/2021 Implemented
6400.112(h)During the 9/27/21 fire drill Individual #2 did not reach the meeting place. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.The house managers have been provided feedback on the need for individuals to reach the meeting place safely during fire drills. It is the manager's responsibility to ensure this happens, and if it does not, it is their responsibility to ensure the fire drill is re-attempted prior to the end of the month. 12/06/2021 Implemented
SIN-00180258 Renewal 12/07/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #1's doctor had recommended follow up blood work be completed two weeks after 11/6/20 due to Individual #1's WBC being low. As of 12/9/20, this has not yet occurred. The PCP had also recommended that Fluvoxamine be discussed with Individual #1's psychiatrist as a possible cause of unexplained weight loss to see if this medication should be adjusted. As of 12/9/20, this has not yet occurred.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The individual had blood work completed on 12/11/2020. By December 31st, 2020, a doctor's visit/telemed appointment will be held to discuss the medication and the unexplained weight loss. It is the responsibility of the house manager to ensure recommended follow up appointments are completed. 12/31/2020 Implemented
6400.165(b)The current order for each prescribed medication must match the medication listed on the MAR. The MAR indicates Individual #1 takes Flonase and Doxycycline Hyclate. The current orders for these two medications are for Fluticasone and Doxycycline monohydrate.A prescription order shall be kept current.The staff will be retrained on the importance of the MAR's matching the orders of the prescribed medication by 12/31/2020 by a medication administration trainer. It is the responsibility of the house manager to ensure the MAR's match the orders. 12/31/2020 Implemented
SIN-00164955 Renewal 12/11/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(6)Individual # 1 doesn't have a mirror in his bedroomIn bedrooms, each individual shall have the following: A mirror. A mirror was placed in the individuals bedroom. All other rooms in the agency were checked to ensure each individual has a mirror in their bedroom. Going forward, program managers will be responsible for ensuring all residents have a mirror in the bedrooms. 01/03/2020 Implemented
SIN-00244399 Renewal 05/15/2024 Compliant - Finalized
SIN-00238958 Unannounced Monitoring 01/31/2024 Compliant - Finalized