Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00170551 Unannounced Monitoring 02/04/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Individual #2's bedroom floor had a cracked tile in the middle of the floor.Floors, walls, ceilings and other surfaces shall be in good repair. The tiles on the floor were replaced on 2/12/2020 (see attachment 13) . These items are checked during site checks and if an issue is found, it is documented on the site Review Checklist, which will be submitted to co-directors biweekly. Additionally, the CHS Co-Directors, the Assistant Director, and will do random checks to inspect all homes to make sure cleanliness is maintained, and conditions meet regulations. The IDD Compliance Officer also completes random physical site inspections on sample of homes monthly. The visits she completes will be documented. Any/all issues identified with any physical site requirements will be immediately addressed with the program manager and/or Operations as needed. 02/12/2020 Implemented
6400.68(b)The water temperature in the bathtub and in the kitchen was 123.4°Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. Program director notified maintenance department of issue. Plumber arrived to the home on 2/7/2020. he made temporary repairs to hot water main in ceiling. He returned on 2/10/2020 and supplied and installed new 1/4 copper hot water supply piping in attic from laundry room across bedroom ceiling to hallway access panel. Temperature was measured at 117.2 degrees Fahrenheit (attachment #12, 12a, and 12b). To ensure compliance that hot water temperatures in bathtubs and showers may not exceed 120°F, Program managers will visit all their sites at least weekly to test and subsequently document water temperature on a CHS site review checklist, which will be submitted to Co-Directors biweekly (attachment #17). Any/all issues identified with water temperature exceeding the allowable limit will be immediately addressed with the program manager and/or Operations as needed. 02/10/2020 Implemented
6400.101The passageway exiting the escape route was obstructed by a food grill.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The grill was immediately removed from the passageway during licensing(see attachment 11) . To ensure compliance that stairway, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed, the homes will be inspected on a regular basis. Program managers will visit all their sites at least weekly and document such on CHS reveiw. Checklist, which will be submitted to co-directors biweekly. Additionally, the CHS Co-Director, the Assistant Director, will do site checks on a rotating basis, will inspect all homes to makes sure no egresses are blocked, and conditions meet regulations. Any all issues identified with any physical site issues will be immediately reported to maintenance. 02/04/2020 Implemented
6400.110(b)The smoke detector was not operational in the main hallway.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. The smoke detector battery was replaced immediately on 2/4/2020 and the alarm is working again. (See attachment 10). The Program Manager will check the detector during biweekly site checks. If there are any issues that the Program Manager cannot resolve, she will contact Maintenance. The staff are aware if they hear the alarm beeping to change the battery and if there is an issue, contact the Program Manager. 02/04/2020 Implemented
6400.181(d)The Program Specialist failed to sign or dated the Individual #1's assessment dated 3/13/19.The program specialist shall sign and date the assessment. The assessment was updated and signed on 2/14/2020 (see attachment 7). A biannual chart training will be completed in 3/2020. The importance of the Program Specialist signing and dating the assessment will be reviewed during this training. The Program Manager will also receive a memo of the importance of signing and dating the individuals assessment, monthlies, and quarterlies. Chart audits are also completed to ensure paperwork is completed randomly by Directors, Assistant Director, and Quality Assurance Department to ensure it is in compliance with the regulations. 02/14/2020 Implemented
6400.32(h)The home had cameras in the main living areas, and no team meeting and approval of the individual, and no real policy on the use, and who has access to the cameras.An individual has the right to privacy of person and possessions.RCG's were released on 2/3/2020. After reviewing the evaluation and individual rights, the agency decided to remove all indoor cameras. This was completed on 2/20/2020 for all CHS homes. 02/20/2020 Implemented
6400.195(b)The individual #1's Social Emotional Environmental Plan that was completed on 11/22/18 describing individual #1's Behavior, Psychiatry and Plan of Action was reviewed and revised on 11/22/19, but no changes were made and it was a duplicate of the previous year.The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews.The individuals Social Emotional Environmental Plan was updated on 2/18/2020 (attachment 7) with current medications and most recent information. In order to ensure compliance that each Social Emotional Environmental Plan is updated, the Interact Chart Audit form has been updated which is completed by the compliance officer, CHS Co-Directors and and Assistant Director. These chart audits are done semi annual to ensure the program paperwork is in compliance with regulations. 02/18/2020 Implemented
SIN-00152962 Renewal 03/27/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There was debris on the exit door consistent with dust and spider webs.Clean and sanitary conditions shall be maintained in the home. Door was immediately cleaned and cleared of dust and spider webs at the time of inspection (attachment #36). Program manager instituted cleaning schedule at the home, including cleaning between cracks and crevices (attachment #37). To ensure compliance that all conditions in the home are clean and sanitary, the homes will be inspected on a regular basis and cleanliness will be assessed. Program managers will visit all their sites at least weekly and document such on CHS Review Checklist, which will be submitted to co-directors biweekly (attachment #3). Additionally, the CHS Co-Directors, the Assistant Director, and the Quality Assurance Specialist, on a weekly rotating schedule, will inspect all homes to make sure cleanliness is maintained, and conditions meet regulations (attachment #4). Visits will be documented. Any/all issues identified with any physical site cleanliness will be immediately addressed with the program manager and/or residential staff as needed. 03/29/2019 Implemented
6400.68(b)The water temperature in the home was tested and found to be 128.6 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. Program director notified maintenance department of issue (attachment #33 b). Plumber was called to the home and discovered bad domestic hot water return pump. Taco stainless circulator was installed to address issue and allow for the correct temperature to flow through all faucets in the home (attachment #34 b). Temperature was measured at 118.2 degrees Fahrenheit (attachment #35). To ensure compliance that hot water temperatures in bathtubs and showers may not exceed 120°F, Program managers will visit all their sites at least weekly to test and subsequently document water temperature on a CHS site review checklist, which will be submitted to Co-Directors biweekly (attachment #3). Any/all issues identified with water temperature exceeding the allowable limit will be immediately addressed with the program manager and/or Operations as needed. 03/29/2019 Implemented
6400.72(a)There was no screen on the window of the exit door.Windows, including windows in doors, shall be securely screened when windows or doors are open. Exterior door does not have a screen ¿ the entire window was missing. Program director contacted maintenance about the issue (attachment #33). Maintenance came to site and found the window by the shed; window was replaced in the door (attachment #34). To ensure compliance that windows, including windows in doors, shall be securely screened when windows or doors are open, the homes will be inspected on a regular basis. Program managers will visit all their sites at least weekly and document windows in good repair on CHS Review Checklist, which will be submitted to co-directors biweekly (attachment #3). Additionally, the CHS Co-Directors, the Assistant Director, and the Quality Assurance Specialist, on a weekly rotating schedule, will inspect all homes to make sure conditions meet regulations (attachment #4). Visits will be documented. Any/all issues identified with any physical site requirements will be immediately addressed with the program manager and/or Operations as needed 03/29/2019 Implemented
6400.141(c)(11)Individual #3's annual physical completed on 2/21/19 did not include assessment of health maintenance. It was left blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Program nurse called Individual #3¿s PCP and faxed annual physical to doctor so that assessment of individual¿s health maintenance needs could be completed. PCP updated physical as required (attachment #31). In order to ensure compliance that annual physical will include assessment of individual¿s health maintenance needs, Compliance Officer audited individuals¿ annual physicals and found no others to be noncompliant. Going forward, semiannual medical chart training will be conducted with program specialists and nurses to review licensing regulations (attachment # 32). All annual physicals will be reviewed by both program specialist and program nurse, to ensure that all information is completed as needed. Physicals will be returned to PCP for completion of missed information as needed. 04/02/2019 Implemented
SIN-00130687 Renewal 12/18/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Food supplement/weight gainer was stored together with Listerine Mouth wash that contain instruction to contact poison control immediately if ingestedPoisonous materials shall be kept locked or made inaccessible to individuals. Listerine was immediately separated from medication area. (See attachment #2) Memo issued and staff retrained reminding them of the importance to keep poisons separate from items that can be ingested such as foods/medication (see attachment #3). Compliance will be monitored by PMs, CHS Co-Directors, Asst CHS Co-Director, QA Asst, and IDD C/O during their weekly visits to sites. Visits will be documented and any issues will be immediately addressed with staff and the program manager. Implemented
6400.80(b)There was a build up of dried leaves on the outside of the back escape walk way. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.There was a build up of dried leaves on the outside of the back escape walkway. This was immediately addressed; leaves were removed from path of 12/19/2018. (See attachment #1). To ensure compliance, Interact will assure that clean and sanitary conditions, as well as unobstructed exits are maintained in the home by inspecting on a regular basis. Program managers will visit all their sites at least weekly and document such on CHS Review Checklist which will be submitted to co-directors biweekly. Additionally, the CHS Co-Directors, the Assistant Director and the Quality Assurance Specialist, on a weekly rotating schedule, will inspect all homes to make sure homes are in good repair and free of unsafe conditions which includes making sure the back/escape egress is clear. The IDD Compliance Officer also does random site checks and ensures any/all issues identified with any physical site requirements will be immediately addressed with the program manager and/or Operations as needed. Implemented
6400.144Individual #1 was prescribed Preduisone 50 mg tab to be administered at 8:00pm for five days. This medication was not administered for all five days as the Medication Administration record was initial for all five days but there was yet one pill remaining in the pill cup.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. Incident was immediately filed with state upon discovery. Staff responsible for failing to administer medication as prescribed was given individual feedback and retrained on (12/21/2018) (discipline on file with HR). MAR and medications will be monitored by Program Manager on at least a weekly basis and documented on CHS Review Checklist, which will be submitted to co-directors biweekly. Additionally, the CHS Co-Directors, the Assistant Director, and the Quality Assurance Specialist, on a weekly rotating schedule, will inspect all homes, including random medication checks, to ensure compliance to regulations. Our CHS nurse also visits the homes randomly and completes medication checks .The IDD Compliance Officer also does random physical site inspections on a sample of homes and these monthly visits will be documented. Any/all issues identified with medications will be immediately addressed with the staff and reported as needed. Implemented
6400.165Individual #1 was prescribed Preduisone 50 mg tab to be administered at 8:00pm for five days. This medication was not administered for all five days as the Medication Administration record was initial for all five days but there was yet one pill remaining in the pill cup. There was no documentation of a medication administration error, and any follow up action.Documentation of medication errors and follow-up action taken shall be kept. Incident was immediately filed with state upon discovery. Staff responsible for failing to administer medication as prescribed was given individual feedback and retrained on (12/21/2018) (discipline on file with HR). MAR and medications will be monitored by Program Manager on at least a weekly basis and documented on site review checklist, which will be submitted to co-directors biweekly. Additionally, the CHS Co-Directors, the Assistant Director, and the Quality Assurance Specialist, on a weekly rotating schedule, will inspect all homes, including random medication checks, to ensure compliance to regulations. The IDD Compliance Officer also does random physical site inspections on sample of homes monthly Visits will be documented. Any/all issues identified with medications will be immediately addressed with the staff and reported as needed. Implemented
SIN-00110894 Renewal 11/16/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.213(1)(i)Individual #1's record did not indicate religious affiliation.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.Individual #1's face sheet was updated to indicate religious affiliation (attachment #22). To ensure compliance that each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph, program managers will participate in quarterly chart training and will receive re-training every 3 months on an ongoing basis to ensure full understanding of regulations and requirements in an effort to ensure future compliance with all aspects of record requirements. Furthermore, IDD Compliance Officer will complete monthly audit of a sample of client charts, as assigned to ensure compliance. Full client chart audits will also be completed at management level by co-directors, assistant director, and quality assurance specialist on a semi-annual basis as further assurance to licensing compliance. 11/21/2016 Implemented
SIN-00070253 Renewal 06/12/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(3)The agency did not maintain documentation on each single purchase item made on behalf of Individual #3. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. Individual financial monthly ledgers that are prepared by Fiscal and shared with Program Mgt did not contain the supporting documentation/receipt/invoice regarding cable bills, medical co-pays, and the like that are automatically paid by Fiscal through deductions to the individual¿s rep payee account. Although these expenditures are identified on the financial ledger for each individual, the actual supporting documentation was not attached. As a result, the CFO was contacted and has adjusted Fiscal's Procedure so that effective 7/1/2014, all supporting documentation will be attached to the individual's ledger and shared with Program Mgt as part of the resident's financial record on site. These records will be reviewed monthly by Program Mgrs and the Quality Assurance Specialist to ensure compliance by Fiscal dept. 07/01/2014 Implemented
SIN-00235216 Renewal 11/29/2023 Compliant - Finalized
SIN-00128040 Renewal 12/18/2017 Compliant - Finalized