Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00232123 Renewal 09/26/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101During the inspection conducted 9/27/2023 there were turn locks on both doors inside the basement, leading to the garage, and no exit door from the garage to the outside posing a potential entrapment risk.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. 6400.101 No swing doors , or door with Chain locks/hotel type locks, etc. The garage is not considered an exit, as in the event of a fire, the power would be inoperable, therefore garage doors would not be able to open via an individual with IDD. Regulation 6400.101 was fixed upon Inspection completion on 9/28/23 by the Emmaus Facilities Manager. 10/20/2023 Implemented
SIN-00196646 Renewal 11/22/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(11)The medication administration record for November 2021 for Individual #1 did not list the diagnosis or purpose for the prescribed Phenobarb and Tamsulosin.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Immediately on 11/23/21, the Emmaus Healthcare and Quality Management Coordinator made the corrections to the current November MAR based on the recommendation from Licensing Representative. This was also so indicated onto the MAR for December 2021 as well. Quality Management Coordinator also talked to our Pharmacy, PDC on 12/3/21. Quality Management Coordinator is retrieving new medication for January on 12/27/21 and will reassure that all MARs have the corresponding diagnoses for all medications. Pharmacy also has a menu option when calling for MAR Corrections. This was discussed with all Emmaus RA's on 12/9/21, at a Program Meeting. All RA's are aware to communicate to Physicians about indicating the diagnosis onto prescription information for the corresponding medication label in the future. 12/23/2021 Implemented