Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00266375 Renewal 05/15/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(f)Fire extinguisher in the pull-down attic had not been inspected in greater than 1 year. Documentation has been provided that the particular extinguisher has been replaced with a recently inspected extinguisher. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. Fire extinguisher was replaced on May 16, 2025. Evidence of updated extinguisher submitted to lead inspector (attachment #9). 05/16/2025 Implemented
6400.144Individual #3 is prescribed the medication Metoprol Tab 25mg -- Give 1 tablet by mouth twice a day if systolic BP is 120 or greater. On 5/6/25 the medication was administered when systolic was 119. The medication was administered every day in May, however there were only documented blood pressure readings on 5/5, 5/6, 5/7, 5/10, and 5/12. The blood pressure needs to be taken and documented prior to administering the medication in order to verify proper administration and compliance.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. New blood pressure medication book was created by Delta LPN (attachment #8) with AM and PM blood pressure readings and staff were educated to follow directions on pharmacy label and document blood pressure (attachment #10) 05/16/2025 Implemented
6400.165(b)Three medications prescribed to Individual #3 were not present at site: Alubterol Nebulizer - PRN Acetaminophen 325 - PRN NYStatin Cream 100000 - PRNA prescription order shall be kept current.Tylenol was delivered to the home on 5/16/25. 05/16/2025 Implemented
SIN-00091507 Renewal 05/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(a)Staff # 13's initial medication administration training was invalid as the trainer did not completed the paperwork. 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. After the follow up licensing visit, a medication administration plan of correction was developed and implemented immediately. Attachment # 1 . All staff who were not properly certified to administer medications ceased administering medications that same day. Delta continued to implement the steps of the plan of correction until all homes had staff certified to administer medications. The plan of correction was updated and submitted to BHSL on a weekly basis . Adjustment was made to accommodate medication administration training changes that came into effect on 7/1/16. The final plan of correction was revised and submitted 8/8/16 Attachment # 2. Ongoing, the Regional Director and the lead medication administration trainer reviews all training materials and documentation to ensure staff are properly trained and certified prior to administering medications. The lead trainer is responsible for maintaining documentation and records on an ongoing basis. 05/16/2016 Implemented
6400.168(d)Staff # 14's annual medication administration training dated 11/03/2015 was invalid as the fourth MAR review was completed on 12/08/2015.A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. After the follow up licensing visit, a medication administration plan of correction was developed and implemented immediately. Attachment # 1. All staff who were not properly certified to administer medications ceased administering medications that same day. Delta continued to implement the steps of the plan of correction until all homes had staff certified to administer medications. The plan of correction was updated and submitted to BHSL on a weekly basis . Adjustment was made to accommodate medication administration training changes that came into effect on 7/1/16. The final plan of correction was revised and submitted 8/8/16 Attachment # 2. Ongoing, the Regional Director and the lead medication administration trainer reviews all training materials and documentation to ensure staff are properly trained and certified prior to administering medications. The lead trainer is responsible for maintaining documentation and records on an ongoing basis. 05/16/2016 Implemented
SIN-00075961 Renewal 02/25/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The first floor laundry room has a water damaged ceiling with loose tape and plaster debris. Floors, walls, ceilings and other surfaces shall be in good repair. The ceiling was repaired on 3/9/15. Our internal process is to complete work orders for facility maintenance concerns. We will continue to follow our process. The Program Specialist will check the home on a monthly basis to ensure that the home is in good repair. 03/09/2015 Implemented