Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00161647 Renewal 08/21/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.182(c)Individual #1's Assessment, dated 9/7/18, states "it's unclear if Individual #1 knows to avoid poisonous materials;" however, the assessment indicates "Yes" that the individual can safely use or avoid poisonous materials. Individual #1's ISP, last updated 6/5/19, states that Individual #1 "does not understand safety precautions including handling or storage of poisonous substances, danger signs, or warning labels."The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.Individual # 1 was reassessed on 8/29/19 and she is not able to understand safety precautions handling of storage of poisonous substances, danger signs, or warning labels. The Program Specialist will follow regulation 182(c) to fulfill the role as the PlanLead. A training was held on 8/28/19 with Kelly Stillwell, Director of IDD Services and Program Specialists, Kristy Weaver and Anthony Bradley. [As per CEO, the Director of IDD Services trained the PS(s) on the reviewing the assessments quarterly to ensure assessments are revised and updated as needed based on the individuals' current needs and the individual plans are revised based on the current assessments. Documentation of the training shall be kept. At least quarterly 1 year, the CEO or designee shall audit a 10% sample of individuals' assessments and Individuals' plans to ensure individuals' plans are initially developed, revised annually and revised when an individual's needs change based upon a current assessment. Documentations of the audits shall be kept. (DPOC by AES,HSLS on 9/24/19)] 09/11/2019 Implemented
SIN-00100989 Renewal 09/07/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)The physical examination completed on 8/4/16 for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Emmaus has changed their Physician's Medical Form as of 09/27/2016 to include a line that states, "Please list Medical information pertinent to diagnosis and treatment in case of an emergency:" A line is also provided for comment by the Physician. This statement is on page 2 of 2 of the document. However, for the record, Emmaus feels that our form has been utilized since 2011 and previous BHSL Inspectors did not comment on this absence. The entire form encompasses medical information that is pertinent to diagnosis and treatement in case of an emergency. This new Physician's Medical Form will be utilized throughout the agency for all of our individuals under the 6400 Regulations. [Individual #1 (AS 11/1/16)] will take this new form with her to her Annual Physical exam in August of 2017. [Individual #1's (AS 11/1/16)] Residential Advisor, Keiona Allen, will ensure that the new updated Physician's Medical Form, revised 09/27/2016, will be used.[Individual #1's medical information was updated on 10/28/16 to included medical information pertinent to diagnosis and treatment in case of an emergency. Immediately and upon completion, the Director of IDD services shall review all individuals' physical examinations to ensure all required information is included and there are not areas of required information left blank. Designated staff persons shall immediately obtain missing information from the completing physician. Documentation of reviews shall be kept. (AS 11/1/16)] 09/27/2016 Implemented
SIN-00213158 Renewal 10/12/2022 Compliant - Finalized
SIN-00180268 Renewal 12/08/2020 Compliant - Finalized
SIN-00140770 Renewal 08/28/2018 Compliant - Finalized