| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
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SIN-00228662
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Renewal
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07/27/2023
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(1) | The staff in this home were not wearing face mask coverings while working with individuals, per this agency's policy. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | Program Director took immediate action was taken immediately. Staff put on face mask coverings. Mask coverings will be worn by staff in the site for entire shift. |
08/04/2023
| Implemented |
| 6400.65 | The bathroom skylight was not operational. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Program Director contacted the maintenance worker, to repair the bathroom skylight. |
08/18/2023
| Implemented |
| 6400.110(a) | The smoke detector on the first floor was not operational. Also, the smoke detectors were not interconnected in this three story home, but this requirement is exempt due to this home being licensed prior to 1991. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | Supervisor purchased a new smoke detector and installed on the first floor. |
07/28/2023
| Implemented |
| 6400.151(c)(3) | On staff physical it is indicated that staff has communicable disease. When completing the form, the physical placed one mark down the entire column checked off "yes'. This makes it appear that staff 2 in NOT free from communicable diseases for staff 2 | 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. | The Human Resources Administrator received a letter from the employee's physician, stating the employee is free of communicable disease. |
08/11/2023
| Implemented |
| 6400.165(b) | Individual 1 prescribed medication timolol melanate ophthalmic solution .5% with instructions to administer one drop in left eye at 8 am and 8 pm, was present in the medication box however not present on the medication administration record. | A prescription order shall be kept current. | Medical Coordinator is responsible for entering or updating all Medication Administration Records on a monthly basis. Site Supervisor is responsible for ensure MARs and medication labels match when they receive the MARs.
Program Director corrected the medication administration record.
Medical Coordinator corrected the information on the computer to match the label. |
08/25/2023
| Implemented |
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SIN-00209606
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Renewal
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07/21/2022
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | There is excessive residue of burnt food/grease on the oven door | Clean and sanitary conditions shall be maintained in the home. | Action was taken immediately. Site supervisor purchased Easy Off oven cleaner and Zep Grease remover and cleaned the oven. Site Supervisors/Program Managers will complete a weekly Physical Site Self-Assessment and develop resolutions to noncompliant areas with Program Coordinator/Program Director. |
07/27/2022
| Implemented |
| 6400.66 | There is no exterior light at the basement door | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Program Director contacted maintenance to install light at basement door exterior. Maintenance contacted on 9/27/22 and a work order was submitted . Maintenance will follow up by 10/7/22. |
10/07/2022
| Implemented |
| 6400.67(a) | A few of the upper kitchen cabinets are broken | Floors, walls, ceilings and other surfaces shall be in good repair. | Action was taken immediately; maintenance was contacted by Program Director, after visit and repaired cabinets. Service order attached. |
08/02/2022
| Implemented |
| 6400.77(b) | The first aid kit is missing tweezers. | 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. | Action was taken immediately by Site Supervisor and tweezers were replaced. |
08/02/2022
| Implemented |
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SIN-00075887
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Renewal
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03/19/2015
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) |
The surface of the bathtub in the second floor bathroom has a deep black tint that makes the tub appear dirty. The paint on the wall behind the bathtub is peeling; there is a gulf ball size hole in the wall where a shower head once was located. Many of the tiles on the back wall of the tub are missing caulking. The caulking around the tub is missing in several spots and other spots have a dark substance consistent with mold. The wall in the second floor bathroom is full of dust. The radiator cover is rusted over. The walk in shower, which is not in use, has rusted color caulking. The edges of the floor tile near the tub are lifting from the floor.
| Floors, walls, ceilings and other surfaces shall be in good repair. | The landlord will remodel the bathroom to include new floors, walls, ceilings, a tub within the next 30 days. The Site Supervisor will inspect the site to ensure the home is in compliance, at a minimum weekly. The site supervisor will report their findings to the Program Director weekly. As problems arise, repairs will be made in a timely fashion. |
06/30/2015
| Implemented |
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SIN-00057797
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Renewal
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02/26/2014
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment form was not dated. | (a) 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.
| In the future, when the Program Director completes the self-assessment of each home, within 3 to 6 months prior to the expiration date of the certificate of compliance (April 1), the document will be dated and submitted to the Program Administrator for review. |
01/01/2015
| Implemented |
| 6400.101 | The basement exit leading to the outside was blocked by snow and ice. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The basement exit leading to the outside was cleared of snow and ice. In the future, the clearing of snow and ice will occur with every storm. |
03/31/2014
| Implemented |
| 6400.164(a) | Staff # 1 did not sign full name and initial on the back of the medication log for the month of February. | (a) A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication.
| Staff #1 signed the February Medication Log and received a disciplinary for failure to complete documentation. |
03/13/2014
| Implemented |
| 6400.213(1)(i) | The client record for individual # 1 did not have a description or identifying marks for this individual. | Each individual's record must include the following information:
(1) Personal information including:
(i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.
| The individual's Emergency Medical Sheet (Face Sheet) for the individual's record was updated to include the required information. All individuals' records were updated to include the required information. |
03/31/2014
| Implemented |
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SIN-00049231
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Renewal
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03/14/2013
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(h) | Employee A was hired on 2/8/13, but did not have Initial First Aid Training. | (h) Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home, shall be trained before working with individuals in first aid techniques.
| The Pre-Service Orientation Training for new hires will include initial basic first aid techniques. This training will occur prior to the staff working with the individuals. |
03/31/2013
| Implemented |
| 6400.141(c)(4) | Individual #1 was admitted to the program on 1/4/13 but did not have hearing or vision screening upon admission. | (4) Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician.
| For future admission, the Medical Coordinator will be responsible to ensure all new admissions have vision and hearing screenings prior to admission.
Individual #1 had a vision and hearing schreening on 3/22/2013.
The Program Director will review all pre-admission documents to ensure all requirements are met.
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05/31/2013
| Implemented |
| 6400.141(c)(8) | Individual #1 was smitted to the program on 1/4/13, but did not have a prostate exam upon admission. | (8) A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older.
| For future admission, the Medical Coordinator will be responsible to ensure all new male admissions have a prostate screenings prior to admission.
The Program Director will review all pre-admission documents to ensure all requirements are met.
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05/31/2013
| Implemented |
| 6400.192 | The facility's Restrictive Procedure Policy ddi not include definitions of specific types- permitted or prohiited, did not include circumstances when it could e used, nor did it provide a process for individual's or family to review. | A written policy that defines the prohibition or use of specific types of restrictive procedures, describes the circumstances in which restrictive procedures may be used, the persons who may authorize the use of restrictive procedures, a mechanism to monitor and control the use of restrictive procedures and a process for the individual and family to review the use of restrictive procedures shall be kept at the home.
| The Restrictive Procedure Policy was revised to include definitions of specific types restrictive procedures that are prohibited, describes the circumstance in which restrictive procedures may be used, the persons who may authorize the use of restrictive procedures, a mechanism to monitor and control the use of restrictive procedures and a process for the individual and family to review the use of restrictive procedures at the home. |
03/31/2013
| Implemented |
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SIN-00121847
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Renewal
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09/22/2017
|
Compliant - Finalized
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