Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00192992 Renewal 09/15/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment dated 01/29/21 did not include indications of compliance or non-compliance for regulations 6400.104-106, 111f-112h, 113a-114b, or 161a-167d1.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. Self Assessments will be reviewed by Residential Administrator once completed . Self Assessments will be completed Prior to 12/31/21 so that they can be thoroughly checked over. 12/31/2021 Implemented
SIN-00157698 Renewal 06/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The evacuation time for the fire drill held on 4/27/19 was 2 minutes and 40 seconds. The home does not have an extended time evacuation time.Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home.MCAR POC is as follows. Case Managers have reviewed all fire drill documentation required for each home. This home in question is the only home with an extended evacuation time. The extended evacuation documentation that was on file during inspection was outdated. The Case Manager for the home in question has had the local fire department inspect the home on 7/11/19 and has extended the evacuation time to 6 minutes. The Residential Director retrained case managers on 7/4/19 and the fire chief has been rescheduled to to inspect and approve the extended evacuation time next on 7/11/2020. [On August 20, 2019, extended evacuation time of 6 minutes was completed in writing by a fire safety expert (fire chief of City of Farrell Fire Department). Prior to conducting fire drill or other aforementioned responsibilities or within one month of receipt of the plan of correction/LIS, the CEO or designee shall educate all staff persons responsible for conducting and documenting fire drills and reviewing written fire drill records and aforementioned quarterly reports; of the requirements of conducting and documenting fire drills and their responsibilities to ensure fire drills are conducted and documented as required including procedures when a fire drill does not meet the requirements. Documentation of trainings shall be kept. (DPOC by AES,HSLS on 9/9/19)] 07/11/2019 Implemented
SIN-00117450 Renewal 07/13/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.164(a)On 10/25/16, Individual #1 was prescribed Docusate Sodium 100 MG twice daily; the Medication Administration Records for Individual #1 from October 2016 through July 2017 did not include the dosage of the Docusate Sodium.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. A medication retraining will be completed with all agency staff at in-service on the following dates due to scheduling issues with the HCQU trainer, 9/22,10/4,1/11,10/11,11/22,11/29 of 2017 documentation to be kept. LPN¿s and PS will continue to review medications and MAR¿s when in Group homes weekly documentation is kept by both (attachments)[On 7/24/17, Registered Nurse updated Individual #1's medication administration record to included the prescribed dosage of Docusate Sodium. On 7/25/17, RN reviewed all individuals' MARs and continuing at monthly for 3 months and then continuing at least quarterly a designated nursing staff person shall review all individuals' medications, medication administration records and physician's orders to ensure all individuals are administered medications as prescribed and documented as required. Documentation of reviews shall be kept. (AS 7/27/17)] 07/27/2017 Implemented
SIN-00060170 Renewal 06/17/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)The dryer vent inside the basement of the home was duct-taped in one section, and was not attached to the dryer for proper ventilation. In addition, the vent attached to the wall contained a 1/2 inch build up of dryer lint around the circumference of the duct which presented a fire hazard. Furniture and equipment shall be nonhazardous, clean and sturdy. maintenance department installed a new dryer vent hose from the dryer to the outside vent on 6-17-14, removing all fired hazardous material out of it, residential program directors will on a weekly basis check on the dryer vent/ duct and clean out to ensure that there is no buildup. That documentation will be on Weekly RPD Checklist and kept filed in Residential Director Office each week. 07/15/2014 Implemented
SIN-00249279 Renewal 08/06/2024 Compliant - Finalized