Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00225299 Renewal 05/04/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)The window in individual 3's room was inoperable. The windows are difficult to open. Screens, windows and doors shall be in good repair. Maintenance department will fix window so that it is operable, able to open and close 05/04/2023 Implemented
SIN-00204488 Renewal 05/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessments for Lincoln Green, Putnam, and Wallingford are not dated, so it can't be determined that they were completed within the allotted time frame.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. A management meeting will be held in July 2022 during which the Division Managers and House Managers will be retrained on the appropriate way to complete the Provider Self Assessment. 07/31/2022 Implemented
6400.65The bathroom has a vent that is connected to a heating lamp set into the bathroom's ceiling. The vent is not fully operational: while it can power on, it is very weak, and it does not provide adequate ventilation.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. The maintenance department for the complex was called on 05/04/2022 and determined the vent is in working order and is not broken. 05/04/2022 Implemented
6400.67(b)Wiring was ran in front of the sliding porch door, and had to be stepped over to exit onto the porch; the wiring was unsecured, fraying, and positioned in a way so that parts of it bunched up and raised off of the floor, posing a fall hazard. The shelf that the apartment's dryer is held on is very unsecure, wobbling severely when even lightly pressed. Floors, walls, ceilings and other surfaces shall be free of hazards.Wire was removed by maintenance on 05/09/2022. Management secured the wire so it was no longer a hazard until maintenance arrived. 05/04/2022 Implemented
6400.112(c)The fire drill held in December 2021 indicated the evacuation time for the drill was 1.2 seconds.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. Fire drill form was filled out incorrectly by staff. The fire drill form is being updated to ensure that minutes and seconds are clearly indicated by 07/01/2022. 07/01/2022 Implemented
6400.112(c)None of the fire drills for any of the homes indicate whether the smoke detector was operable.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. Fire drill form is being updated to capture the missing information and will begin to be used on July 1, 2022. 07/01/2022 Implemented
SIN-00187581 Renewal 05/06/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101The wooden walkway leading from the apartment unit's patio, through the yard of the apartment, and to the common sidewalk of the complex was partially obstructed by overgrown foliage and a gutter drainage pipe. Individual 1 is wheelchair-bound and independently uses an electric wheelchair for mobility; therefore, they must utilize this walkway to evacuate the apartment through the patio exit during a fire emergency. Due to Individual 1's mobility needs, the gutter drainage pipe and foliage pose a potential barrier to a safe and timely evacuation. As Individual 1 could not physically traverse the grass in their wheelchair as an alternative to using the wooden path, their only available mode of egress from the patio exit is obstructed.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The overgrown foliage has been trimmed and the drainage pipe has been retracted to be off of the walkway that the individual uses to exit from the apartment in the event of a fire. 06/03/2021 Implemented
SIN-00140982 Renewal 06/21/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)On 8/21/17, the fire drill record did not indicate the exit that was utilized. The time of the drill was put in that spot instead.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. This regulation was out of compliance due to improper documentation. The program supervisor is responsible to assure compliance to this regulation. The residential coordinator will review all fire drill logs and provide feedback to the program manager in any area of non-compliance. It is the responsibility of the program coordinator and program manager to follow up on a quarterly basis to assure proper documentation of time of day, exact time, and exit used during a drill was conducted and documented properly. Proper documentation of drills, , a review of this regulation and its' explanation was conducted with the program staff, supervisor, and coordinator. This was completed on 7/13/2018 07/13/2018 Implemented
SIN-00090726 Renewal 01/26/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The Self-assessment was completed 10/25/15 which is after the regulatory period.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. According to the license date of 12/29/15 staff should have submitted the self assessment that was done in August instead of the one completed between October and November 2015. See supporting document of the assessment done in February 2016 02/29/2016 Implemented
SIN-00077834 Renewal 10/29/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(g)Staff D received fire safety training on 10/13/13, but was not trained by a fire safety expert. Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). Staff D attended fire safety training at Ridley Park Fire Dept. on 2/10/15. All staff will receive annual fire safety training through the local fire department or fire marshall office. The program coordinator will ensure that all annual fire safety training is conducted by a fire safety expert and the training coordinator will review of all staff training records quarterly to ensure that trainings are up-to-date and meet the regulatory guidelines. 02/10/2015 Implemented
6400.64(a)There was an accumulation of dirt and debris under the kitchen sink.Clean and sanitary conditions shall be maintained in the home. It is the responsibility of all staff to assure the cleanliness of the residential sites. Supervisor/coordinator are responsible to assure these duties are performed. The debris under sink was removed the day of the inspection. 10/30/2014 Implemented
6400.112(f)Alternate exits were not used during monthly fire drills from November,2013 through October,2014. Alternate exit routes shall be used during fire drills. Effective 11/4/2014, a fire safety schedule was developed which identifies the location of the hypothetical fire . The house supervisor will train all Staff in the following areas ¿ A review of the regulations as they relate to fire safety including fire drill report documentation (including the use of alternate exit routes ¿ How to block off the hypothetical fire location ¿ How to train the Individuals to avoid the hypothetical fire and use the nearest exit away from the fire The house supervisor will monitor fire drills for 3 consecutive months to ensure that Staff are able to apply the information from the training . The house supervisor/coordinator will review fire drills reports on the 25th day of each much to ensure that the drill meets the regulator requirements including alternating exits. The program director will review fire dill reports quarterly. All staff will be trained in the requirements by 6/30/2014. 11/04/2014 Implemented
6400.168(a)Staff D's administers medication, but has not completed medication administration training. In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. Staff D attended & passed the Medication Course and Practicum on 11/13/14. A Policy has been put in effect to require all staff & medication Administration Trainer to complete required practicum & MAR reviews in a timely manner. Documentation to support this ongoing training is to be submitted quarterly. Staff not in compliance will not be permitted to administer medications. See Attached documentation 11/13/2014 Implemented
6400.181(a)Individual #2's previous annual assessment was dated 8/12/13 and the most resent assessment was dated 9/7/14. 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. The Supervisor is required to complete an annual biopsychosocial assessment in a timely manner. The Coordiator is responsible to review all assessments to assure required documentation per 6400 regs are completed annually. All files will be reviewed quarterly to identify individuals annual due dates. See attached 12/02/2014 Implemented
SIN-00041055 Renewal 09/19/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(f)Fire extinguisher was last inspected 7/11.(f) 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 fire extinguisher was inspected on 10/3/12. Holcomb has a contract with Kistler O'Brien for annual inspections & this site was inadvertently missed. Additional columns were added to the agency fire drill form to ensure that fire extinguishers are checked. The inspections will be monitored more closely by the Coordinator.Attached is the Kistler O'Brien inspection as well as the revised fire drill form. 10/03/2012 Implemented
SIN-00161679 Renewal 08/27/2019 Compliant - Finalized
SIN-00115553 Renewal 06/01/2017 Compliant - Finalized
SIN-00053558 Renewal 10/11/2013 Compliant - Finalized