Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00270410 Renewal 07/22/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)Individual #1 was placed with the agency for emergency respite care on 10/4/2024 and was provided fire safety training on 2/2/20205. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. Fire Safety was completed on 2/2/2025. 02/02/2025 Implemented
6400.141(c)(6)Individual #1 was placed with the agency on 10/4/2024 for emergency respite care. Individual #1, date of admission 11/5/2024, did not have a tuberculin skin test completed prior to admission. Individual #1's physical examination, completed 10/8/2024, indicated that the individual has a history of positive skin tests, and a chest x-ray was required to determine if the individual was negative for tuberculosis. Individual #1's chest x-ray was not completed until 3/18/2025.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. TB was completed on 3/18/2025 03/18/2025 Implemented
6400.181(a)Individual #1 was placed with the agency on 10/4/2024 for emergency respite care. Individual #1, date of admission 11/5/2024, had their initial residential assessment completed on 3/20/2025. Individual #1's initial residential assessment, completed 3/20/2025, indicates that the individual can be left alone at home for unlimited hours. Interviews with Program Specialist #1 revealed that Individual #1 typically requires 12 hours of staffing per day. Individual #1's 12 hours of staffing primarily occurs during sleeping hours. Program Specialist #1 also indicated that Individual #1 is not willing to cook for themself and that staff must complete cooking tasks on their behalf. Individual #1's assessment does not accurately reflect their current supervision needs. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Based on team discussion on the assessment of adapted behavior. Individual will need 12 hours of home supervision and will be added to assessment to reflect needed supervision. Assessment will be sent by 8/25/2025. 08/25/2025 Implemented
6400.181(c)Individual #1's annual assessment, which was completed on 3/20/2025 by Program Specialist #1, indicated that it was based on the Individual Support Plan.The assessment shall be based on assessment instruments, interviews, progress notes and observations. Individual #1's assessment will be updated by Residential Program Specialist to reflect that it is based on assessment instruments, interviews, progress notes and observations 08/25/2025 Implemented
6400.214(b)On 7/23/2025 at approximately 11:10am, the following documents from Individual #1's record were not accessible at the residential home: current assessment and psychological evaluation. The agency utilizes Therap to digitally store individual record information; however, these documents had not been uploaded to Individual #1's electronic record. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The most current copies of record information required in § 6400.213(2)(14) will be uploaded to an electronic file accessible to staff in all ResHab locations. 09/15/2025 Implemented
6400.34(a)Individual #1 was placed with the agency for emergency respite care on 10/4/2024 and was informed of their individual rights and the process to report a rights violation on 1/1/2025.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Individual Right were completed 1/1/2025 01/01/2025 Implemented
SIN-00211199 Renewal 09/07/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)Four minutes and zero seconds is the home's maximum evacuation time determined by a fire safety expert on 10/28/21. The home exceeded this time on the following fire drills: 10/26/21 at 12:00 a.m. with an evacuation time of 4 minutes and 56 seconds; 01/25/22 at 04:38 a.m. with an evacuation time of 10 minutes 15 seconds. 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 employe 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. All Fire Drills compliant at this time. Equipment for the individuals have been added to the home to ensure that Fire Drills can be completed in a more timely manner. Sit to stand lift and Gait belt can be used to encourage and assist individuals in getting up and exiting the home. 09/21/2022 Implemented
6400.141(c)(6)6400.141d states: "Immunizations, vision and hearing screening and tuberculin skin testing may be completed, signed and dated by a registered nurse or licensed practical nurse instead of a licensed physician, certified nurse practitioner or licensed physician's assistant. Individual #1 had a Tuberculin evaluation completed on 8/7/22 that was completed by a Certified Medical Assistant (CMA). There was no documentation that the CMA had been trained to complete the Tuberculin evaluation.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Credentials of staff completing the TB are being checked for compliance as results come in to this provider by Human Resources for staff physicals and by the Program Specialist for individual physicals. If PCP allows the TB will be read by MCAR LPN or RN to ensure that valid credentials are reading the TB. IF the PCP states they must read the TB they will be notified that an RN, LPN, licensed physician, certified nurse practitioner or Licensed physicians assistant must read the TB. 09/21/2022 Implemented
6400.181(e)(4)Individual #1's assessment, dated 10/4/21, states that individual requires 24-hour staff supervision; however, Individual's Individual Support Plan (IPS), last updated 7/29/22, states that the individual requires 24 supervision, the individual can never be left alone in the home, and that staff should remain within hearing distance with 15 minutes visual checks. The assessment must include the following information: The individual's need for supervision. All individual assessments will be check for accuracy on supervision levels to make sure there is consistency between the ISP. This will be completed by 12/19/22. Special attention will be paid to Assessment results, Progress over the last year, strengths and needs. These sections will be compared to MCAR individual demographics and details pages as well as the ISP to ensure that all information is synonymous. 12/19/2022 Implemented
6400.165(g)Individual #1 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness. Individual had a psychiatric medication review completed on 11/12/21, and then again on 2/18/22, exceeding the 3-month requirement.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Individual #1 had medication monitoring on 5/13/22 and 8/5/22. If the individual is unable to get in to see Psychiatrist for any reason for Medication monitoring and the medication has not been changed. Licensed physician will be contacted to confirm no changes in medication and this will be documented for the individual record. Individual will attend Psychiatric Clinic which occurs approximately every 90 days to ensure that they are on a proper medication monitoring schedule. 09/21/2022 Implemented
SIN-00157700 Renewal 06/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(c)The home had coliform water tests completed on 9/25/18 and then again on 5/8/19.A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept.MCAR POC is that Residential Director Heather H will schedule the water tests to be completed monthly rather than quarterly. Residential Director has scheduled the montly water tests in the outlook calendar which is shared with maintenance and group home staff. Maintenance and group home staff will gather the samples and bring them to be tested. Residential director will receive all documentation from testing and keep on file for review. [Immediately, the CEO or designee shall educate all staff persons responsible for ensuring that coliform water testing is completed timely of their responsibilities. Documentation of training shall be kept. (DPOC by AES,HSLS on 9/9/2019)] 07/19/2019 Implemented
6400.163(c)The review medications prescribed for treatment of symptoms of a diagnosed psychiatric illness for Individual #1 completed 05/31/19 did not include the need to continue the medication. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.MMI forms will be reviewed by MCAR Behavioral Health Specialist Gail M. Gail has been retrained on 7/4/19 of the requirements of these forms. Behavioral Health specialist will review the forms to ensure all requirements are being met. Nursing director Jessica B will review the MMI form after Gail. Jessica was trained on the regulation requirements on 7/4/19. Nursing Director will review the MMI form as a double check. If there are any discrepancies during the review the prescribing physician will be notified. In the case for this individual the prescribing physician has been contact and MCAR is waiting on an updated MMI form. Once MCAR has the updated form it will be emailed as supporting documentation. [The medication review completed 8/16/2019 for Individual #1 included required information. Documentation of aforementioned audits shall be kept. Immediately, the CEO or designee shall educate all staff persons responsible for ensuring that medication reviews are completed, reviewed and individual are administered medications as prescribed of their responsibilities to ensure there is review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage and individuals are administered medications as prescribed. Documentation of training shall be kept. (DPOC by AES,HSLS on 9/9/2019)] 07/11/2019 Implemented
SIN-00096252 Renewal 06/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)Fourteen fire drills were held between 5/25/15 and 5/25/16. The front door was used as the exit route for eleven of the fourteen fire drills.Alternate exit routes shall be used during fire drills. Staff will be retrained at In service training in September 2016, dates have yet to be identified. A Rolodex has been created for each home to ensure all exits used are alternating with the month. Residential Program Specialist will ensure that the alternate exits are used by initialing and dating the houses fire drill once received and reviewed.[Within 90 days of receipt of the plan of correction, the Administrator of Residential Services will develop and implement policy and procedures to ensure fire drills are unannounced and alternate exit routes are used during fire drill. Staff responsible for conducting fire drill and documenting and reviewing fire drill shall be trained in the policies and procedures. Documentation of reviews shall be kept. (AS 7/11/16)] 07/01/2016 Implemented
SIN-00046682 Renewal 02/07/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The carpet in the sunroom has a large black stain approximately 1 foot by 1 foot, a red stain approximately 4 feet by 6 inches and numerous dark spots throughout the carpet. (Partially Implemented. Adequate Progress. CHG 5/9/13)(a) Clean and sanitary conditions shall be maintained in the home. We have replaced the carpet with hardwood flooring. Staff will complete a work order that will be given to the Program Specialist. The Program Specialist will then give that work order to our maintenance department. The documentation on the work order explains if that job was done. The Program Specialist will follow up after all work was completed. [The Program Specialist will perform an audit weekly of the home's floors, walls and other surfaces to ensure that no unsanitary or unclean conditions exist. Documentation shall be kept. (CHG 5/9/13)] 04/07/2013 Implemented
6400.72(b)The closet doors in Individual #1 bedroom has a 2 inch hole in the middle close to the top on the right side of the door and the left side of the door is off the track. (Partially Implemented. Adequate Progress. CHG 5/9/13)(b) Screens, windows and doors shall be in good repair. Staff will complete a work order that will be given to the Program Specialist. THe Program Specialist will then give that work order to our maintenance department. The documentation on the work order explains if that job was done. The Program Specialist will follow up after all work was completed. [The Program Specialist will perform an audit weekly of the home's screens, windows and doors to ensure they are in good repair. Documentation shall be kept. (CHG 5/9/13)] 02/08/2013 Implemented
6400.76(a)The chest of drawer is missing a knob on the left side of the top drawer. The handle is missing from the bottom drawer. (Partially Implemented. Adequate Progress. CHG 5/9/13)(a) Furniture and equipment shall be nonhazardous, clean and sturdy. Staff will complete a work order that will be given to the Program Specialist. The Program Specialist will then give that work order to our maintenance department. The doucmentation on the work order explains if that job was done. The Program Specialist will follow up after all work was completed. [The Program Specialist will perform an audit weekly of the home's furniture and equipment to ensure they are in good nonhazardous, clean, and sturdy. Documentation shall be kept. (CHG 5/9/13)] 02/08/2013 Implemented