Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00252253 Unannounced Monitoring 09/23/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65The fan which provides mechanical ventilation in the upstairs bathroom was inoperable.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. A work order to have ventilation fan was submitted on 9/23/24. This was completed on 9/26/24. 10/05/2024 Implemented
SIN-00233126 Unannounced Monitoring 10/13/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16The incident (Incident ID: 9278681) that occurred on 09/10/2023 was an act that willfully deprived the individual #1 of her rights and dignity which caused actual physical unwanted touch and emotional harm. The staff #1 did not monitor the situation which caused the horrific event.Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.The staff who failed to monitor the situation was given corrective action on November 6, 2023 and retrained on supervision needs of individuals he is assigned to. The target individual involved with this was relocated on November 27, 2023 to another 1 person home that is not in close proximity to where individual #1 currently lives. 11/27/2023 Not Accepted
6400.43(b)(3)The CEO did not ensure the safety and protection of individual #1 in the incident (Incident ID: 9278681) that occurred on 09/10/2023 was an act that willfully deprived the individual #1 of her rights and dignity which caused actual physical unwanted touch and emotional harm. The staff #1 did not monitor the situation which caused the horrific event.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. The staff who did not monitor the situation was given corrective action on November 6, 2023. The target individual was relocated to another location that is not in close proximity to individual #1 on November 27, 2023 - see attachment 16 ISP cheat sheet was distributed to each home in each individual's ISP binder on November 6, 2023. 11/06/2023 Not Accepted
6400.45(e)Staffing: It was demonstrated that the agency put the individuals in harm way by not having staff coverage needed to address the individual's needs (Ind.#1 and Ind. #3. An individual may not be left unsupervised solely for the convenience of the home or the direct service worker.An individual may not be left unsupervised solely for the convenience of the home or the direct service worker.A contingency plan was implemented to ensure that home managers and upper management secure coverage for all homes according to supervision needs outlined in individual's ISPs. 11/09/2023 Not Accepted
6400.186The ISP for individual #3 states "AT MINIMUM, HAS WITHIN LINE-OF-SIGHT SUPERVISION DURING AWAKE HOURS." Through interview with staff, this level of supervision did not occur on 9/10/23 when an incident occurred between Ind. #3 and Ind. #1, with Ind. #3 named as the alleged perpetrator. Staff are not implementing the plan as written for Ind. #3.The home shall implement the individual plan, including revisions.The staff in question was given corrective action on November 6, 2023 and retrained on the individual's staffing and supervision needs. 11/06/2023 Not Implemented
SIN-00211251 Unannounced Monitoring 09/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The bedroom of Individual 1 has a damaged dresser and the bedrooms of the home were unclean. There were clothes and discarded food items scattered.Clean and sanitary conditions shall be maintained in the home. The damaged dresser has been discarded from the bedroom. The individual who lived in that bedroom has voluntarily discharged from PAHrtners. House manager has ensured the bedroom has been thoroughly clean and ready for new future admission. 10/25/2022 Implemented
6400.77(b)The first aid kit in the home did not contain tape 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. The first aid kit was restocked immediately. 10/25/2022 Implemented
6400.77(c)The first aid kit in the home did not contain a manual A first aid manual shall be kept with the first aid kit.First aid manual was added to the toolbox. The manual also has a label that states "do not remove" as a reminder to those using the toolbox to always put the manual back. 10/25/2022 Implemented
6400.163(a)Prescribed medication to be taken as needed to individual 1 was not labeled with a pharmaceutical label. Medications included a VAPORIZING RUB and CHLORASEPTIC.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.Medication with no pharmaceutical label was removed. Unable to support the individual in obtaining a new refill with matching RX due to individual voluntarily discharged from program. 10/25/2022 Implemented
6400.165(b)Medication NAPROXEN SODIUM 550mg Tab prescribed to individual 1 was not located in the individuals' medication box.A prescription order shall be kept current.Unable to support the individual in obtaining a new refill to keep medication box current due to individual voluntarily discharged from program. 10/25/2022 Implemented
SIN-00207338 Renewal 04/13/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)10 of the 11 self-assessments completed were not completed 3-6 months prior to the license expiration date or 3-6 months after the last inspection 4/21The 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. Provider created a self inspection spreadsheet with due dates in the folder with the spreadsheet includes completed self inspection form with the right form to us. 07/15/2022 Implemented
6400.65The fan in the bathroom was not operational, no ventilation.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. Provider reivewed work order system with maintenance and maintenance was able to repair the bathroom fan. 05/17/2022 Implemented
6400.52(a)(1)Staff #2 had only 18 hours of training during the past training year, fewer than the 24 hours of training required for Direct Service Workers each year.The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.Provider developed online trainings with videos that have caption/signing along with quizzes for all employees. Employees have more access to training modules if not able to attend in person. 06/20/2022 Implemented
SIN-00158885 Renewal 07/11/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)There is a damaged floor tile in the kitchen and another damaged floor tile in the laundry area by the dryer.Floors, walls, ceilings and other surfaces shall be in good repair. A work order was submitted on July 9,2019 and is currently a work in progress. Anticipated completion date is October 31, 2019. 10/31/2019 Implemented
6400.77(b)The first aid kit was missing the thermometer and scissors. 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. Thermometer will be purchased for the first aid kit in the home and all other CLA homes have been inspected to ensure that they have the required items. A monthly checklist will be procured by each house manager indicating that the first aid kits are up to par. 09/27/2019 Implemented
6400.80(b)On the outside of the kitchen door there are loose cables. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.Maintenance was contacted to have the loose cable secured. This was repaired on 7/17/19 07/17/2019 Implemented
6400.112(a)There was no fire drill for this location during the month of December in 2018. An unannounced fire drill shall be held at least once a month. A designated person (Denise D'Antonio) will audit every month during the week of 15th to ensure fire drill forms are turned in, and completed. In the event fire drills were not completed, Denise will inform the Operations Director who in turn will ensure fire drills are completed by the team. 08/31/2019 Implemented