Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00148674 Renewal 01/15/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)There was no thermometer in the first aid kit. The kit was also lacking an assortment of bandages. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Our 6400.77(b) protocol has been updated and the following procedures have been instituted; A check list for first aid kit has been formulated to include checking that a thermometer is in the first aid kit. See attachment A. The first aid kit in Widener House was replaced with all required materials and excludes Tylenol and Benadryl Cream (see attachment F) Program specialist will be trained on the check list. The checklist will be completed monthly by the Program specialist moving forward and reviewed by Assistant Directors/Directors. Target date 2/28/2019. All Program specialist will be trained on how to utilize and complete the first aid kit. Target date 2/28/2019. Person Responsible: Director and Assistant Director 02/28/2019 Implemented
6400.161(b)There were packets of Tylenol and Benadryl in the first aid kit which was in an unlocked cabinet in the kitchen.Prescription and potentially toxic nonprescription medications shall be kept in an area or container that is locked, unless it is documented in each individual's assessment that each individual in the home can safely use or avoid toxic materials. Our 6400.161(b) protocol has been updated and the following procedures have been instituted; A check list for first aid kit has been formulated to include checking for potentially toxic non-prescription medications and securing the medications if found. See attachment A Program specialist will be trained on the check list. The checklist will be completed monthly by the Program specialist moving forward and reviewed by Assistant Directors/Directors. Target date 2/28/2019. All Program specialist will be trained on how to utilize and complete the first aid kit. Target date 2/28/2019. Person Responsible; Program Specialist, Assistant Director and Director. 02/28/2019 Implemented
SIN-00077067 Renewal 05/27/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill records, dated 2/4/15 and 1/14/15, did not include the amount of time it took for evacuation.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. By 7/15/15, all Managers will be trained in fire drill reporting requirements including requirements to document evacuation time. In order to ensure the required items are preserved in a record, the completed drill record will be emailed to director and printed within 72 hours of completion of the drill. Status of completion of all drill records will be reviewed monthly as part of Melmark leadership scorecard which is submitted to VP of Adult Services. 07/15/2015 Implemented
SIN-00050758 Renewal 05/13/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(g)Staff #1 last fire safety training was 5/2/12. (g) Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). The staff person completed fire safety training on 5/15/13. All staff will receive messages to schedule and attend required training. The Staff Development Department will provide Program Directors with reports on the status of completion of training requirements for all staff. Program Directors will use reports to monitor completion of required training and, as appropriate, implement corrective action for any staff person who fails to attend required training. 08/31/2013 Implemented
6400.112(f)The front door was used for fire drills held 5/14/12, 6/24/12 and 7/4/12.(f) Alternate exit routes shall be used during fire drills. The Program Director will review requirements for drills with site supervisors and provide guidance, in the form of sample calendars, to assist in required variation. Drills will be monitored by Program Directors and Compliance to ensure requirements are met. When conducting drills staff will refer to records of previous drills to prevent patterns and ensure that drills are held at various times of day, on various days of the week and use varying exit routes. 07/09/2013 Implemented
6400.186(a)Individual #1 ISP review for quarter ending 3/24/13 and 12/24/12 did not include a review of ISP outcome to increase coping skills.(a) The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. The Program Specialist has included progress toward the coping skills outcome in updated monthly and quarterly reports. All Program Specialists will be trained in Melmark Documentation Standards including requirements to document progress on all outcomes in monthly and quarterly reviews of the ISP. Program Directors and Compliance will audit a sample of records on monthly basis to ensure that progress on all outcomes is included in monthly and quarterly reviews. 08/09/2013 Implemented
6400.186(c)(1)The monthly reviews for 6/12- 10/12, 12/12, 1/13 and 4/13 did not include progress and growth for ISP outcome to increase individual #1 coping skills.(c) The ISP review must include the following: (1) A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. The Program Specialist has included progress toward the coping skills outcome in updated monthly and quarterly reports. All Program Specialists will be trained in Melmark Documentation Standards including requirements to document progress on all outcomes in monthly and quarterly reviews of the ISP. Program Directors and Compliance will audit a sample of records on monthly basis to ensure that progress on all outcomes is included in monthly and quarterly reviews. 08/09/2013 Implemented
SIN-00110198 Renewal 09/07/2016 Compliant - Finalized
SIN-00066153 Renewal 04/29/2014 Compliant - Finalized