Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00259833 Renewal 02/19/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(e)The home consists of two floors and a basement. As defined by regulation, a total of three stories. One individual resides in the home. When tested the smoke detector on the second floor did not sound and was not interconnected with the first floor and basement that were interconnected. A lone working smoke detector was on the second floor but not interconnected as required.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. On 2/27/25 staff were retrained on the importance of ensuring that the If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. A mock drill was conducted on 2/19/25, by the program specialist and direct care staff after the licensing inspector left and the alarms were reconnected and tested, they worked and were interconnected. 03/20/2025 Implemented
SIN-00240486 Renewal 03/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)Base of the toilet seat triangular crack approximately 6 inches long that was misaligned with the base. Metal baseboard heat behind the toilet and sink was bent, rusted and chipping paint. Repeat violation 2/6/23 Floors, walls, ceilings and other surfaces shall be free of hazards.On 3/14/24 - all staff were retrained on the importance of ensuring that floors, walls, ceilings and other surfaces shall be free of hazards as well as how to submit maintenance concerns in ta timely manner in order to correct the issue. The Director of Residential was able to contact Essig plumbing to evaluate the toilet on3/12/24 and once evaluated they were able to order the toilet and it was replaced on 3/26/24 and it is functioning and in good repair. 04/05/2024 Implemented
SIN-00217272 Renewal 02/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Located in Individual #2's shower were several areas of a black like substance resembling mold/mildew. Located on the corner tile where you step into Individual #2's shower was an area of a black like substance resembling mold/mildew. (REPEAT VIOLATION)Clean and sanitary conditions shall be maintained in the home. On 2/17/2023 all staff were retrained on the importance of Clean and sanitary conditions shall be maintained in the home as well as tier responsibility while on the shift which includes cleaning assignments. The bathroom had a deep cleaning in the shower completed on 2/10/2023 and no longer reflects any mold and or mildew substance. 02/17/2023 Implemented
6400.66Rooms shall be lighted to assure safety and to avoid accidents The light fixture on the ceiling located in the basement was inoperative at the time of the inspection.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. On 2/17/2023 all staff were trained on the importance of ensuing that Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. On 2/15/2023 -An electrician was able to check and fix all the light fixtures i the basement and they are all now in working order effective 2/15/2023. 02/17/2023 Implemented
6400.67(b)Surfaces shall be free of hazards. When opening the basement door which leads to the outside a green garden house was on the ground in front of it and coiled behind the door posing a tripping hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.the hose was removed on 2/10/2023 and ease of access to get outside and no hazards while exiting the basement door was checked and confirmed. On 2/17/2023 -all staff were trained on the importance of having Floors, walls, ceilings and other surfaces shall be free of hazards. 02/17/2023 Implemented
6400.77(b)At the time of inspection the first aid kit did not contain antiseptic. The tube of Neosporin that was in the first aid kit expired on 11/2019. 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. On 2/17/2023- all staff trained on the importance of having 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. A new first aid kit was ordered on 3/1/2023 and will be delivered to the home on 3/3/2023- the kit includes up to date Neosporin. 03/03/2023 Implemented
6400.101Stairways, halls, doorways and exits from rooms and from the building shall be unobstructed. The basement door leading outside would only open approximately ¾ of the way open as the green garden house was on the ground in front of it and coiled behind the door blocking it from opening all of the way.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. the hose was removed on 2/10/2023 and ease of access to get outside and no hazards while exiting the basement door was checked and confirmed that is was unobstructed. On 2/17/2023 -all staff were trained on the importance of having Floors, walls, ceilings and other surfaces shall be free of hazards as well as Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. 02/10/2023 Implemented
6400.213(1)(i)Citation given is 213(1)(ii): Individual #2's record did not include identifying marks.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.On 2/17/2023 all staff including management were retrained on the importance of having documentation Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number and identifying marks listed on the Face sheet/Demographic sheet for the individuals. on 2/17/2023 the demographic sheet was updated for individual #1 to reflect identifying marks. On 2/17/2023 -The program specialist and coordinator were also trained on the importance of completing book checks and updating the face sheet on a regular basis 02/17/2023 Implemented
SIN-00200557 Renewal 03/31/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Individual #5 is not safe around poisons. There were several poisons that were no locked and accessible in the home. Dial antibacterial soap located in the second-floor bathroom, Swiffer cleaning pads, located in the closet in the kitchen, 2 garbage bags with paint cans stored in them in the garage and ice melt stored in the garage. All of these product's state to seek medical attention and/or contact poison control if ingested.Poisonous materials shall be kept locked or made inaccessible to individuals. direct care staff were retrained on the safety hazards as related to poisons being kept in the home as well as the individuals required level of safety as it relates to poisons. staff were trained on the importance of keeping poisonous items locked when not in use. 05/27/2022 Implemented
6400.64(a)Clean and sanitary conditions were not maintained in the home. There were approximately 7 mouse droppings on the molding above the door to the crawl space in the upstairs front bedroom to the left of the steps.Clean and sanitary conditions shall be maintained in the home. direct care staff were retrained on how to maintain and the importance of clean and sanitary conditions that need to be kept to a higher standard within the home on an ongoing basis. All rooms were cleaned and surfaces sanitized within the home and while individual was on a home visit a non chemical bug spray was used in the areas that were identified as a problem zone . 05/27/2022 Implemented
6400.67(a)The back of the sink in the bathroom on the second floor of the home was not in good repair as it was covered in rust.Floors, walls, ceilings and other surfaces shall be in good repair. Direct care staff were retrained on recognizing and reporting any floors, walls and ceiling that are not in good repair and next steps in the follow up including reporting to the leads staff and or program coordinator . Per the handyman's schedule of availability - the Sink area is scheduled to be reglazed 6/8/22 06/08/2022 Implemented
6400.72(b)The front screen door and screen door out of the basement door were not in good repair as there were not handles on the doors. The screen door out off the basement was not in good repair as it had a screen that was ripped. Screens, windows and doors shall be in good repair. Direct care staff were retrained on recognizing and reporting any floors, walls and ceiling that are not in good repair and next steps in the follow up including reporting to the leads staff and or program coordinator. Per the handyman's schedule of availability - the door will be replaced/updated on 6/8/22 06/08/2022 Implemented
6400.106The furnace in the home is not inspected and cleaned annually. The most recent inspection and cleaning was completed on 3/18/21.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The program coordinator was retrained on the annual requirements of furnace inspections. Calendar reminders were created for the furnace inspections for the next year for all home in the reading area. the calendar appointment is reflected on the program coordinator calendar but also the entire team. 05/30/2022 Implemented
6400.110(e)The home consists of three stories including a basement. The smoke detectors in the home are not interconnected throughout the home.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. Staff were retrained on the importance of smoke detectors in the home and staff were retrained on the value/requirement of having interconnected smoke detectors in the home that has three or more stories . The smoke detector was actually onsite but needed a battery . the battery was installed and the smoke detector was rehung and tested and drill completed. 05/30/2022 Implemented
6400.110(f)Individual #5 is hearing and visually impaired. Individual #5 had a bed shaker on the individual's bed, however the shaker was not connected to the smoke detectors in the home and would not alert the individual to a fire if the alarms were so sound. 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. direct care staff were retrained on the process of completing firedriills while using the interconnected safety aid bed shaker. a new bed shaker was ordered and staff increase overnight checks until the new bed shaker was in place . 05/30/2022 Implemented
6400.15(b)The self-assessment of the home was completed on 9/2/21. This assessment was not completed on the appropriate licensing inspection instrument.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.program coordinator was retrained on the updated self-assessments and due dates and proper form. 05/30/2022 Implemented
6400.52(a)(1)Staff #1 did not complete 24 hours of training related to job skills and knowledge. Staff #1 only completed 21.75 hours of training.The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.the program coordinator was re-trained by the Director of operations on the requirement of the 24hrs training and came up with a plan to implement additional trainings monthly for staff via staff meetings, ODP and or PCHC site. 05/30/2022 Implemented
6400.169(a)Staff #1 did not receive annual training in medication administration. Staff #1 was last certified in medication administration on 1/31/20.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).Staff #1 was retrained and is currently in compliance for medication administration . 05/30/2022 Implemented
SIN-00183560 Renewal 03/30/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Antimicrobial Lotion soap was located next to the kitchen sink. The label indicated to call poison control if ingested. Dial soap was located next to the upstairs bathroom sink. Label indicated that poison control should be contacted if ingested.Poisonous materials shall be kept locked or made inaccessible to individuals. The soap was replaced by the kitchen sink with Lifebouy handwash, which is not listed as a poisonous. staff was retrained on poisons and safety awareness as it pertains to keeping poisons locked . 04/02/2021 Implemented
6400.71There were no emergency telephone numbers located next to the phone in the living room. *REPEAT VIOLATIONTelephone 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 reposted by the phone in the the living room . staff was retrained on the important of the phone list especially during an emergency . 04/02/2021 Implemented
6400.77(b)There was no antiseptic located in the first aid box at the time of inspection. 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. First aid kit was updated and antiseptic replaced. Lead Staff was retrained on what to check for monthly in a first aid kit 04/02/2021 Implemented
6400.82(f)There was no soap in the downstairs small bathroom. There were no individual clean paper or cloth towels in the upstairs bathroom.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. The soap was replaced by the downstairs bathroom sink with Lifebouy handwash, which is not listed as a poison. Papertowels was also replenished in the bathroom. staff was retrained on poisons and safety awareness as it pertains to keeping poisons locked and the importance of having specific things in the bathroom and toilet area in order to create a safe and sanitary environment. 04/02/2021 Implemented
6400.110(f)Individual #1 is documented to be deaf and blind. At the time of inspection, the bed shaker to alert Individual #1 in the event of a fire was inoperable. There were no other devices in the home to alert Individual #1 of a fire. *REPEAT VIOLATION-Fairmont 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. At the time of the drill the bed shaker for Individual #1 was not located by staff that was completing the inspection . After the inspection ended the regular staff was able to locate the drill onsite. The lead staff was retraining on the importance of the bed shaker for individual who is documented to be blind and deaf. 04/02/2021 Implemented
6400.112(c)The fire drill conducted on 11/7/20 did not have a time of drill entered. The space for time of drill was empty.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. The drill for November 2020 were completed but when exported out of the online system , some of the data was transposed/lost on the document. Staff updated the fire drills with the corrected information and JJ, the assistant operations director was retrained on the monthly fire drill process and its requirements. 04/02/2021 Implemented
6400.151(c)(3)Staff #1 physical dated 11/25/20 did not contain a statement that Staff #1 is free of communicable diseases. * REPEAT VIOLATION-Olive The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Although staff #1 has a Tb test that was negative she did not have a updated physical that reflects this ¿ staff has requested her doctor( PCP) fill out the missing portions of her physical including any medical problems .The Program coordinator who currently does the hiring for that region was retrained on staff intake documents for hiring and reviewed all the aspects that need to be completed on a staff physical. 04/30/2021 Implemented
6400.151(c)(4)Staff #1 physical dated 11/25/20 did not contain information of medical problems which might interfere with the health of the individuals.The physical examination shall include: Information of medical problems which might interfere with the health of the individuals.Although staff #1 has a Tb test that was negative she did not have a updated physical that reflects this ¿ staff has requested her doctor fill out the missing portions of her physical including any medical problems .The Program coordinator who currently does the hiring for that region was retraining on staff intake documents for hiring and reviewed all the aspects that need to be completed on a staff physical. 04/02/2021 Implemented
6400.51(b)(1)Staff #1 training record provided did not include documentation of training completed for supporting individuals to develop and maintain relationships.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.Staff #1 was trained on supporting individuals to develop and maintain relationships during his training but the actual documentation does not have everything reviewed listed, so the document did not reflect full compliance. Assistant director was retrained on requirements of the trainings. 04/23/2021 Implemented
SIN-00167273 Renewal 12/17/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71There were no emergency telephone numbers posted near the telephone in the living room.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. Staff ( SS) was retrained on the requirement of having emergency telephone numbers in each home by the telephones. A new emergency sheet was created and posted on 12/17/2019. In order to prevent this oversight from occurring again staff will be retrained on how to complete a biweekly home checklist , so that he/she can recognize necessary items needed in the home such as emergency telephone list (12/24/2020). 12/24/2019 Implemented
6400.151(a)Staff person #1's most recent physical examination occurred on 9/25/17. Physical examinations are required every two years and Staff #1 was due for a physical examination on 9/25/19.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.Administrative staff (SM and JJ) were trained on the requirements of physical for staff including time frames for when annual physical should occur was conducted 12/24/2019. Staff ( YM ) did her physical on 12/18/19. In order to avoid this error again, A new training tracking system via Kaleidacare was implemented 1/1/2020 , which now tracks all staff training, physical due dates and tuberculin test due dates and sends reminder via email to staff and or administrative personnel , about upcoming training requirements. 01/01/2020 Implemented
6400.151(c)(2)Staff #1's most recent tuberculin skin testing by Mantoux method occurred on 5/06/17. Tuberculin skin testing by Mantoux method with negative results is required every two years. Staff #1 was due for Tuberculin skin testing by 5/06/19.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner.Administrative staff (SM and JJ) were trained on the requirements of physical for staff including time frames for when tuberculin skin test should be conducted training 12/24/2019). Staff ( YM ) took her tb test on 12/18/19, which came back negative results. In order to avoid this error again, A new training tracking system via Kaleidacare was implemented 1/1/2020 , which now tracks all staff training, physical due dates and tuberculin test due dates and sends reminder via email to staff and or administrative personnel , about upcoming training requirements. 01/01/2020 Implemented
6400.52(a)(1)Staff #1 did not complete the required 24 hours of training in training year 2018. There was no documentation of training hours completed in 2018 by Staff #1.The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.Administrative staff (SM and JJ) were trained on the required mandatory 24 hours of training that should be completed by all staff (12/24/2019). In order to avoid this error again, A new staff training tracking system via Kaleidacare was implemented 1/1/2020 , which now tracks all staff training and sends reminder via email to staff and or administrative personnel , about upcoming training requirements. 01/01/2020 Implemented
SIN-00203789 Unannounced Monitoring 03/14/2022 Compliant - Finalized