Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00244147 Renewal 05/02/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)There was a spray bottle with the word "pine" written on it that did not list the ingredients of the contents inside the bottle.Poisonous materials shall be stored in their original, labeled containers. The item was discarded immediately. All staff will be retrained on regulation 6400.62c and the importance of implementing this practice for the safety of the individuals served. 06/01/2024 Implemented
6400.81(k)(6)There was no mirror in Individual 1's bedroom.In bedrooms, each individual shall have the following: A mirror. Maintenance replaced the original mirror that was mounted in the individual's bedroom. 05/03/2024 Implemented
6400.24New hires-non-compliant-no fbi background checks or residency waivers found in record at inspection. Staff Member 3 -11/20/23 Staff Member 4 -12/4/23The home shall comply with applicable Federal and State statutes and regulations and local ordinances.HR will obtain appropriate documentation for non compliant staff. Additionally, HR will perform quarterly self-audits on all staff for compliance. 07/01/2024 Implemented
6400.52(a)(3)P.S.- Staff Member 1 2/27/23-19.75 hours of training completed. It should be 24 hours of training related to job skills and knowledge completed annually. DSP-Staff Member 2 -10/17/22-21.75 hours of trainings provided (2) did not include the length of the trainings on the training certificates. The required 24 hours of training was not completed for the training year reviewed.The following shall complete 24 hours of training related to job skills and knowledge each year: Program specialists.The training department will update certificates to include the length of time for trainings and create an inspection checklist for annual inspections. 05/20/2024 Implemented
SIN-00225300 Renewal 05/04/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)For individual 4, the most recent physical does not answer the question regarding information pertinent to diagnosis in the event of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Program Nurse will inspect physical forms for completion as they are completed for the individual 08/11/2023 Implemented
6400.181(e)(13)(i)For individual 4, the assessment does not include his progress over the last 365 days.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. Division Manager updated the Biopsychosocial to reflect health information. 08/09/2023 Implemented
6400.167(a)(4)Individual 4's MAR had a medication error for Chlorpromazine 100mg on 5/4/23. Staff initialed the medication was given to individual at 8am, which should have been given to the individual at 8pm. Staff administered medication at the wrong time, which exceeds more than 1 hour before or after the prescribed time.Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time.Staff will be retrained in medication administration by Program Nurse 08/11/2023 Implemented
SIN-00204489 Renewal 05/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)A bottle of blue liquid was found under the locked kitchen sink labeled, "21". This bottle was not the original container; therefore, the contents and its poison safety status were unknowable.Poisonous materials shall be kept locked or made inaccessible to individuals. The blue liquid was removed from the home on 05/04/2022. Staff will be reminded all cleaning products need to remain in their original containers by 07/01/2022. 07/01/2022 Implemented
6400.64(a)There was significant soap residue and build up in the dishwasher, both on the door and the interior chamber. This was to such a degree that a cleaning should be completed prior to its use again.Clean and sanitary conditions shall be maintained in the home. The dishwasher was replaced by Holcomb maintenance on 05/14/2022. 05/14/2022 Implemented
6400.66The front door's exterior light was not functional.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The light was repaired by Holcomb maintenance on 05/04/2022. 05/04/2022 Implemented
SIN-00187582 Renewal 05/06/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(f)Trash cans observed alongside the house were overfilled, their lids unable to be placed on top of them, and a bag of trash was observed on the ground between them outside of the cans.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The Division Manager provided an additional trash can in the refuse area to accommodate the overflow of trash. 06/30/2021 Implemented
6400.67(a)The Jack and Jill bathroom shared between two bedrooms was observed to have large areas of incomplete or unpainted patch work on the ceiling and wall above the shower.Floors, walls, ceilings and other surfaces shall be in good repair. A work order was submitted for the area to be completed with a paint job. 05/07/2021 Implemented
SIN-00161680 Renewal 08/27/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(3)Individual #1's annual physical exam completed on 9/27/18, documented diphtheria/tetanus shot as given on 6/22/2009.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. At the time of inspection, the individual last documented diphtheria/tetanus shot was over the 10 year time frame. The individual did have his booster shot within the allotted timeframe but record of this was not noted on the chart. Individual #1 had an annual physical done on 10/8/19 that had the corrected date for the diphtheria/tetanus shot noted by the doctor on the physical. The corrected date is 6/19/19 which is within the 10 year timeframe. The supervisor and program IDD Coordinator are responsible for ensuring that all documentation on the file is up to date and current. At this time, this location was without an IDD Coordinator and was overseen by the IDD Manager. This IDD Manager is no longer with the organization. There is a new IDD Coordinator and a new IDD Manager in place overseeing this location. Both of them are trained and familiar with the requirements of an assessment and the role of the program specialist. For ongoing compliance, Medical appointments are monitored by the House Supervisor weekly. Additionally, the IDD Coordinator reviews medical records on a monthly basis. As an additional level of compliance, the IDD Manager does quarterly chart audits. 10/08/2019 Implemented
6400.142(g)The dental hygiene plan for individual #1 was last updated on 3/29/18.A dental hygiene plan shall be rewritten at least annually. Individual #1 had seen the dentist for his routine visits but there was no documented dental hygiene plan for Individual #1 on the chart at the time of inspection. It is the role of the IDD Coordinator to ensure that all plans are on the chart and current. At the time, the IDD Coordinator position was vacant and it was being managed by the IDD Manager who failed to ensure a dental plan was on the chart. Since the time of inspection the dental plan has been updated (10/7/19) and implemented. There is a new IDD Coordinator and a new IDD Manager in place overseeing this location. Both of them are trained and familiar with the requirements of an assessment and the role of the program specialist. The IDD Manager audits the Program charts quarterly and submits the report to the IDD Director. Additionally the charts are audited using the Audit tool by the CPIC group annually. 10/07/2019 Implemented
6400.181(d)Individual #1's annual assessment dated 1/10/19 was not signed/dated by program specialistThe program specialist shall sign and date the assessment. At the time of inspection this program did not have an IDD Coordinator who would have been responsible for completing the assessment. The assessment was completed by the previous IDD Manager and she failed to sign the assessment and have the individual sign the assessment. This staff person is no longer employed by the organization. There is a new IDD Coordinator and a new IDD Manager in place overseeing this location. Both of them are trained and familiar with the requirements of an assessment and the role of the program specialist. An updated assessment was completed on 10/7/19 by the new IDD coordinator and annual assessment was reviewed with Individual #1 and was signed and dated by both Program Specialist and the individual. The IDD Manager audits the Program charts quarterly and submits the report to the IDD Director. Additionally the charts are audited using the Audit tool by the CPIC group annually. 10/07/2019 Implemented
6400.181(e)(13)(ix)Individual #1's annual assessment dated 1/10/19 did not include community integration.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.At the time of inspection this program did not have an IDD Coordinator who would have been responsible for completing the assessment. The assessment was completed by the previous IDD Manager and she failed to include Community Integration into the assessment. This staff person is no longer employed by the organization. There is a new IDD Coordinator and a new IDD Manager in place overseeing this location. Both of them are trained and familiar with the requirements of an assessment and the role of the program specialist. An updated assessment was completed on 10/7/19 by the new IDD coordinator and does include this information. The IDD Manager audits the Program charts quarterly and submits the report to the IDD Director. Additionally the charts are audited using the Audit tool by the CPIC group annually 10/07/2019 Implemented
6400.46(d)Staff #1 had 21 hours of training over the last training year.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.Staff #1 is had completed all of the required 24 hours of training, but there was not a comprehensive training record to demonstrate this. At the time of inspection, there was not an IDD Coordinator in place which is who would typically tabulate and track the training hours. The IDD Manager at the time failed to ensure the training hours were together and tracked as well. There is a new IDD Coordinator and a new IDD Manager in place over this location. Going forward, Holcomb has been switched to both live and online training to make it easier for staff to take training and for Holcomb to track the training. Staff training is tracked monthly via the quarter training log and it submitted to the IDD Manager for review. Any areas of concern are reported to the IDD Director so that corrections can be made before the close of the training year 09/01/2019 Implemented
SIN-00140983 Renewal 06/21/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(b)The railing leading from the back deck to the second floor was loose and unstable.Each porch that has over an 18-inch drop shall have a well-secured railing.The program supervisor is responsible to assure compliance to this regulation. The residential coordinator will complete monthly and quarterly checks of the physical site and submit work orders to address the repairs needed in any area of non-compliance. This regulations was out of compliance due to a missed inspection by program supervisor and manager. A work order was placed and the required repairs were completed. It is the responsibility of the program manager for follow up on a quarterly basis to ensure all submitted work orders have been completed and all railing leading from the back deck to the second floor are secure. A review of this regulation and its' explanation was conducted with the program specialists and coordinators shown in the supporting syllabus. 07/23/2018 Implemented
SIN-00090727 Renewal 01/26/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The license expired 12/29/15. The self-assessment was completed on 10/12/15-10/15/15 which was after the required 3-6 month period. 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. According to the license date of 12/29/15 staff should have submitted the self assessment that was done in August instead of the one completed between October and November 2015. See supporting document of the assessment done in February 2016. See attached 02/29/2016 Implemented
6400.110(e)The three story home did not have interconnected smoke detectors.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. The 110 Delaware Avenue Ridley Park site does have a working interconnected smoke detector. The inspector returned to the site during the exit interview to confirm the alarm was in working order.[The Program Specialist will conduct monthly checks of all homes to ensure the smoke detectors are operable, starting immediately. SW 3.8.17] 01/27/2016 Implemented
6400.112(a)Staffs in the home are aware of fire drills and therefore, the drills are announced. An unannounced fire drill shall be held at least once a month. The supervisor and program coordinator are responsible for each monthly fire drill to be conducted unannounced. An unannounced fire drill was held on 2/29/16 and 3/16/16. See attached documentation. 02/29/2016 Implemented
6400.141(c)(4)Individual #1's annual physical dated 8-3-15 did not indicate that a hearing screen was conducted. The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The individual physicals will be reviewed by the program coordinator, and site supervisor to assure compliance with 6400 regulations. If boxes are not checked as required it will be brought to the PCP's attention to clarify. Individual #1 does not have a hearing deficit, however, the PCP did not check off that his hearing was checked. 04/22/2016 Implemented
6400.151(c)(1)Staff 26's physical dated 1/28/15 did not indicate that a general physical was conducted. The physical examination shall include: A general physical examination. To be in compliance with state regulation 151 (c)1, the staff physicals will be reviewed by the program coordinator, site supervisor and double checked with the Director of HR. A memo was sent to the Human resources dept. requesting this information is clearly marked as being complete. 02/15/2016 Implemented
6400.151(c)(3)Staff 26's physical dated 1/28/15 did not indicate she was free from communicable disease. 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. To be in compliance with state regulation 151 (c)1, the staff physicals will be reviewed by the program coordinator, site supervisor and double checked with the Director of HR. A memo was sent to the Human resources dept. requesting this information is clearly marked as being complete. 02/15/2016 Implemented
6400.168(d)Staff 21's previous medication training was completed on 12/30/14 and the most recent was completed on 1/1/16. Staff 22's previous medication training was completed on 11/20/14 and the most recent was completed on 12/17/15. "Repeated Violation-10/30/14 et al" A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. Per instructions from state inspectors, remediation would need to occur for staff 21 to give meds. On 1/27/ 16-- 4 MAR Reviews were completed with passing results. On 1/27/16 (2 )practicum observations were completed for this individual with passing results. See supporting documents. 01/27/2016 Implemented
6400.181(a)Individual #1's last assessment was dated 1-6-15 and there was not one for the current period (due 1-6-16). 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. Individual # 1's assessment that due on 1/6/16 was completed on 1/29/16. The assessment was supposed to be completed on a timely basis per the attached Coordinator's/Supervisors schedule. A memo dated 2/17/16- reinforces that the assessment be completed as required by 6400 regulations- attached 02/17/2016 Implemented
6400.185(a)Individual #1's ISP quarterly review for the period from 3/11/15 through 6/11/15. The ISP shall be implemented by the ISP's start date. All Program Specialists will use the quarterly chart to ensure they are in compliance with ISP start date for a residential clients. The supervisor and the site coordinator will be responsible for ensuring compliance. A copy of the Quarterly chart will be submitted with supporting documents.[The Program Director will conduct quarterly reviews of the documentation to ensure compliance, starting immediately. SW 3.8.17] 02/16/2016 Implemented
SIN-00077835 Renewal 10/29/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(g)Staff C had fire safety training during the previous full training year, but was not trained by a fire safety expert. Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). Staff C attended fire safety training at Ridley Park Fire Dept. on 12/16/2014. All staff will receive annual fire safety training through the local fire department or fire marshall office. The program coordinator will ensure that all annual fire safety training is conducted by a fire safety expert and the training coordinator will review of all staff training records quarterly to ensure that trainings are up-to-date and meet the regulatory guidelines. 12/16/2014 Implemented
6400.168(a)Staff C administers medication, but has not completed medication administration training. Staff I administers medication, but has not completed medication administration training. 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. Staff C attended & passed the Medication Course on 11/-13-14/2014. A Policy has been developed and put in effect that requires require Medication Administration Trainers to train all staff prior to that staff administering medications. The Medication Administration Policy also outlines that all medication administrators are to ensure that each staff who administers medication will be monitored as outline in the Medication Administration Course. All Practicums will be completed in the required time frame. Documentation to support this ongoing training is to be submitted quarterly. Staff not in compliance will not be permitted to administer medications. The Training Coordinator will review of all staff training records quarterly to ensure that trainings are up-to-date. 11/14/2014 Implemented
6400.181(e)(12)Individual #3's annual assessment dated 3/15/14 did not include recommendations for areas of training, programming and services. The assessment must include the following information: Recommendations for specific areas of training, programming and services. Individual #3's assessment now includes the following recommendations: That he will receive training on anxiety releiving techniques from behavior support services. he will also participate in monthly fire drills as part of ongoing fire safety training. He will benefit from taking cooking & exercise classes through Community Hab services. The supervisor/coordinator are responsible to ensure that these recommendations are implemented & note progress through quarterly reports. See attached 12/02/2014 Implemented
SIN-00053559 Renewal 10/11/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.164(a)Individual #1's medication log did not list full instructions for the administration of Humalog. The instructions were that 6 units at lunch be held if blood glucose is below 100 and this was not on the medication log.(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. Humalog, at any time it is given, is held if blood glucose is below 100.This order is not only for lunch time. SEE ATTACHED DR.'s order & MAR The Program Specialist will review the MAR's on a monthly basis by the 1st of every month to ensure that all physician orders are clearly written for all individuals that receive medications administered by unlicensed medical professionals starting 3/1/14. 10/11/2013 Implemented
SIN-00115554 Renewal 06/01/2017 Compliant - Finalized
SIN-00050663 Initial review 06/13/2013 Compliant - Finalized