Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00209287 Renewal 07/28/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace was inspected 2/04/2021, 7/21/2021, 1/13/2022, and 6/16/2022 but there is no documentation it was cleaned by a professional cleaning companyFurnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. Maintenance staff will be re-certified to inspect and clean the furnace. The Certification will be kept on file. A form will be developed to document the date the Maintenance staff will clean furnaces and inspect the furnace. The furnace will be re-inspected and re-cleaned by October 1, 2022. 10/01/2022 Implemented
6400.113(c)Individual #1's fire safety training did not include the content of the training. A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept.Descriptive content detailing what individuals are instructed on during monthly fire drills was developed and will be distributed to all homes as a resource for staff completing the drill and instructing consumers 09/05/2022 Implemented
SIN-00154242 Renewal 04/16/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)Individual #1 had a physical examination on 2/16/18 and then again on 3/4/19.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The issue is being immediately addressed by identifying all individual's annual physical exam date and their due date for completion of next exam.Physical exams will be completed in their entirety and staff responsible for scheduling, accompanying, and reviewing will be retrained by the Program Directors following written procedures provided by the VP of ID Services on the timely and proper completion of the appointment and documentation. Tracking of individual due dates will be scheduled utilizing the agency's electronic medical record which will alert the assigned person responsible of upcoming due dates and appointments. [At least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking system and a 10% sample of individuals' physical examinations to ensure completion, timely. Documentation of audits shall be kept. (DPOC by AES,HSLS on 5/3/19)] 05/17/2019 Implemented
6400.163(c)Individual #1 had a review of medications prescribed to treat symptoms of a diagnosed psychiatric illness on 6/27/18 and then again on 1/22/19. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The issue is being immediately addressed by identifying all individuals who are required to have a psychiatric review of medications completed and identifying their due dates.Psychiatric review of medications will be completed in their entirety and staff responsible for scheduling, accompanying, and reviewing will be retrained by the Program Directors following written procedures provided by the VP of ID Services on the timely and proper completion of the appointment and documentation. Tracking of individual due dates will be scheduled utilizing the agency's electronic medical record which will alert the assigned person responsible of upcoming due dates and appointments.[At least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking system and a 10% sample of individuals' psychiatric medication review documentation to ensure completion, timely. Documentation of audits shall be kept. (DPOC by AES,HSLS on 5/3/19)] 05/17/2019 Implemented
SIN-00091393 Renewal 03/02/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill record for the fire drill held on 6/5/15 did not include an evacuation time. Another fire drill record that did not include the date or the evacuation time for the fire drill. The fire drill record for the fire drill held on 1/20/15 and 8/13/15 did not indicate if the smoke detector or fire alarm was operative.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. Program Managers and House Supervisors in Erie were retrained by Program Director on 04/04/2016 on completing fire drill forms and reviewing fire drill forms for completeness. Emphasis was placed on including the date of the drill, evacuation time and the smoke detector used. The Compliance Officer will reveiw March and April 2016 fire drill records from 5071 Crane Road to verify proper procedures were followed and the forms were fully completed. A process to check fire drill records to ensure all necessary sections are complete will be developed by Program Directors by 06/01/2016. [Within 90 days of receipt of the plan of correction, all staff responsible for conducting and documenting fire drills will be trained by the program director or designated supervisory staff person to ensure fire drills are conducted and documented as required. At least quarterly for 1 year the compliance officer or designated supervisory staff person will review all fire drill records to ensure fire drill are conducted and documented as required. Documentation of reviews shall be kept. (AS 5/25/26)] 05/02/2016 Implemented