Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00149058 Renewal 01/07/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)A blue spray bottle, not equipped with a label, contained a clear substance that smelled like rubbing alcohol. The words "rubbing alcohol" was written on the bottle.Poisonous materials shall be stored in their original, labeled containers. The blue spray bottle, not equipped with a label which contained a clear substance that smelled like rubbing alcohol was discarded on 1/11/19. All poisons are in their original, labeled containers. The Program Supervisor will provide ongoing coaching to staff surrounding the need to ensure that all poisonous materials are stored in their original, labeled containers. If it is noticed that poisonous materials are not stored and labeled properly, staff will fix the issue immediately. The Program Manager will be responsible to complete a quarterly inspection of the home to insure compliance with all physical site and safety requirements. A checklist for all physical site and safety requirements will be developed by 5/15/19 and all Program Managers will be trained on the use of the checklist and the quarterly inspection requirements by 5/31/19. The first quarterly inspection review by the Program Manager will be completed by 7/31/19. Program Directors in coordination with CSG¿s Facility Maintenance Team will complete a walkthrough of each home in CSG to insure agency-wide compliance with all physical site and safety requirements utilizing CSG¿s Risk Management Checklist. All walkthroughs will be completed by 7/31/19. All staff, Supervisors, Managers and Specialists will be retrained on the requirements for regulation 62(c) by 5/31/19. See photos of shelf without the unlabeled container, shelf with properly labeled poisonous materials and locked cabinet where poisonous materials are stored. 07/31/2019 Implemented
6400.64(f)There were two large recycling bins outside of the home not equipped with a lid to prevent the penetration of insects and rodents. The recycling bins contained recycling materials.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The recycling container was replaced with one that has a lid on 1/30/19. The Program Supervisor will provide ongoing coaching to staff surrounding the need to ensure that trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. If it is noticed that trash is not in a closed receptacle, staff will fix the issue immediately. If the issue cannot be resolved immediately, all DSP staff and Program Supervisors will be required to report any physical site or safety concerns directly to the Program Manager via the home webex room. The Program Manager will be responsible to complete a quarterly inspection of the home to insure compliance with all physical site and safety requirements. A checklist for all physical site and safety requirements will be developed by 5/15/19 and all Program Managers will be trained on the use of the checklist and the quarterly inspection requirements by 5/31/19. The first quarterly inspection review by the Program Manager will be completed by 7/31/19. Program Directors in coordination with CSG¿s Facility Maintenance Team will complete a walkthrough of each home in CSG to insure agency-wide compliance with all physical site and safety requirements utilizing CSG¿s Risk Management Checklist. All walkthroughs will be completed by 7/31/19. All staff, Supervisors, Managers and Specialists will be retrained on the requirements for regulation 64 (f) by 5/31/19. See picture of the outdoor recycling receptacle with a lid. 07/31/2019 Implemented
6400.72(b)REPEAT from 9/18/17 annual inspection: The back screen door contained multiple long scratches and holes in the screen door. Screens, windows and doors shall be in good repair. The back screen door was replaced on 01/30/19. The Program Supervisor will provide ongoing coaching to staff surrounding the need to ensure that screens, windows and doors are in good repair. If it is noticed that screens are ripped or not secured properly, staff will fix the issue immediately. If the issue cannot be resolved immediately, all DSP staff and Program Supervisors will be required to report any physical site or safety concerns directly to the Program Manager via the home webex room. The Program Manager will be responsible to complete a quarterly inspection of the home to insure compliance with all physical site and safety requirements. A checklist for all physical site and safety requirements will be developed by 5/15/19 and all Program Managers will be trained on the use of the checklist and the quarterly inspection requirements by 5/31/19. The first quarterly inspection review by the Program Manager will be completed by 7/31/19. Program Directors in coordination with CSG¿s Facility Maintenance Team will complete a walkthrough of each home in CSG to insure agency-wide compliance with all physical site and safety requirements utilizing CSG¿s Risk Management Checklist. All walkthroughs will be completed by 7/31/19. All staff, Supervisors, Managers and Specialists will be retrained on the requirements for regulation 72 (b) by 5/31/19. See picture of the repaired screen door. 07/31/2019 Implemented
6400.101A wheelchair was positioned directly in front of the back, sliding glass door egress.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The wheelchair which was positioned directly in front of the back, sliding glass door egress has been moved on 1/31/19. A smaller table has been ordered for this area. The Program Supervisor will provide ongoing coaching to staff surrounding the need to ensure that stairways, halls, doorways, passageways and exits from rooms and from the building are unobstructed. If it is noticed that there are obstructions to stairways, doorways, passageways and exits, staff will fix the issue(s) immediately. If the issue cannot be resolved immediately, all DSP staff and Program Supervisors will be required to report any physical site or safety concerns directly to the Program Manager via the home webex room. The Program Manager will be responsible to complete a quarterly inspection of the home to insure compliance with all physical site and safety requirements. A checklist for all physical site and safety requirements will be developed by 5/15/19 and all Program Managers will be trained on the use of the checklist and the quarterly inspection requirements by 5/31/19. The first quarterly inspection review by the Program Manager will be completed by 7/31/19. Program Directors in coordination with CSG¿s Facility Maintenance Team will complete a walkthrough of each home in CSG to insure agency-wide compliance with all physical site and safety requirements utilizing CSG¿s Risk Management Checklist. All walkthroughs will be completed by 7/31/19. All staff, Supervisors, Managers and Specialists will be retrained on the requirements for Program Managers and Supervisors will be retrained on the regulation 101 by 5/31/19. See copy of purchase order for a smaller table dated 2/26/19. 07/31/2019 Implemented
6400.161(b)REPEAT from 9/18/17 annual inspection: Individual specific record information was found unlocked, accessible and unattended in the staff office. The staff office is not kept locked at all times when the individuals and staff are present in the home.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. Medications locked in a cabinet in a locked closet in the staff office on 1/31/19. The Program Supervisor will continue to coach staff surrounding the need to keep prescription and potentially toxic nonprescription medications locked when unattended. If staff find that medication has been left unattended, the staff will secure the medication, immediately. The Program Manager will be responsible to complete a quarterly inspection of the home to insure all medications are kept secure. A checklist for securing all medications will be developed by 5/15/19 and all Program Managers will be trained on the use of the checklist and the quarterly inspection requirements by 5/31/19. The first quarterly inspection review by the Program Manager will be completed by July 31, 2019. All Program Supervisors, Program Managers and Program Specialists will be trained in regulation 161 (b) by 5/31/2019. See pictures of the locked closet in the staff room and file cabinets in the locked closet where medications are kept. 07/31/2019 Implemented
6400.216(a)REPEAT from 9/18/17 annual inspection: Individual specific record information was found unlocked, accessible and unattended in the staff office. The staff office is not kept locked at all times when the individuals and staff are present in the home. -Additional individuals' assessments, notes, Individual Support Plans (ISPs), and other record information was found unlocked and unattended in the basement. An individual's records shall be kept locked when unattended. Staff secured all individual records on 1/31/19 in a locked closet in the staff room. The Program Supervisor will continue to coach staff surrounding the need to keep individual records locked when unattended. If staff find that a record has been left unattended, the staff will secure the record, immediately. The Program Manager will be responsible to complete a quarterly inspection of the home to insure all individual records are kept secure. A checklist for all individual record requirements will be developed by 5/15/19 and all Program Managers will be trained on the use of the checklist and the quarterly inspection requirements by 5/31/19. The first quarterly inspection review by the Program Manager will be completed by July 31, 2019. All Program Supervisors, Program Managers and Program Specialists will be trained in regulation 216(a) by 5/31/2019. See pictures of the locked closet in the staff room and the locked file cabinets in the basement where the records are kept. 07/31/2019 Implemented
SIN-00079112 Renewal 04/27/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103The written emergency evacuation procedure plan did not include the individual and staff responsibilities in the event of an emergency.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. The written evacuation procedure plan will include individual and staff responsibilities, means of transportation and an emergency shelter location. The emergency evacuation procedure plan has been revised to include individual and staff responsibilities in the event of an emergency. (Attachment #6). In addition, a standard format will be developed and implemented across all IDD residential programs. All Program Specialists will be retrained in Reg. 6400.103 to ensure that the written evacuation procedure plan includes individual and staff responsibilities. 08/31/2015 Implemented
6400.164(a)Individual #1 is prescribed Gold Bond Powder. On 4/14/15, according to staff, thie powder was applied to the individual's foot however, there was no indication on the electronic medication log that this medication was given. The powder wasn't listed on the medication log at all. Staff relayed to the inspector that it was possible the medication wasn't taken off hold from when the individual was away. 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. 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 will be kept for each individual who does not self-administer medication. The Gold Bond Powder was dropped from the electronic system and needed to be re-entered. As soon as this was discovered, the medication was re-entered and has been properly administered and documented since that time. (Attachment #5, Pg.1-6). All Program Specialists and house supervisors will be retrained in Reg. 6400.164(a) to ensure that medication logs list the medications prescribed, dosage, time and date that prescription medications were administered and the name of the person who administered the prescription medication for each individual who does not self-administer medication. In addition, Medication Administration Trainers will emphasize the importance of this information with all staff trained to administer medications. 08/31/2015 Implemented
6400.181(e)(6)The assessment for Individual #1 did not address her ability to safely use or avoid poisonous materials. The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. The assessment will include the individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. The Program Specialist has revised the assessment for Individual #1 on 6/8/15 to include her ability to safely use or avoid poisonous materials. (Attachment #4, Pg.2). All Program Specialists will be retrained in Reg. 6400.181(6) to ensure that assessments include the ability to safely use or avoid poisonous materials. Each individual record will be reviewed by 9/30/15 to ensure that the assessment includes this information. 08/31/2015 Implemented
6400.181(e)(7)The assessment for Individual #1 did not address her knowledge of heat sources and her ability to sense and move away quickly. The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. The assessment will include the individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120 degrees F and are not insulated. The Program Specialist has revised the assessment for Individual #1 on 6/8/15 to include her knowledge of heat sources and ability to sense and move away quickly. (Attachment #4, Pg.2). All Program Specialists will be retrained in Reg. 6400.181(7) to ensure that assessments include knowledge of heat sources and the ability to sense and move away quickly. Each individual record will be reviewed by 9/30/15 to ensure that the assessment includes this information. 08/31/2015 Implemented
6400.181(e)(8)The assessment for Individual #1 did not address her ability to evacuate in the event of a fire. The assessment stated she knew the emergency procedures and the meeting place but not her actual ability to evacuate. The assessment must include the following information: The individual's ability to evacuate in the event of a fire. The assessment will include the individual's ability to evacuate in the event of a fire. The Program Specialist has revised the assessment for Individual #1 on 6/8/15 to include her ability to evacuate in the event of a fire. (Attachment #4, Pg.1). All Program Specialists will be retrained in Reg. 6400.181(8) to ensure that assessments include the ability to evacuate in the event of a fire. Each individual record will be reviewed by 9/30/15 to ensure that the assessment includes this information. 08/31/2015 Implemented
6400.181(e)(14)The assessment for Individual #1 did not address the individual's knowledge of water safety. The assessment must include the following information: The individual's knowledge of water safety and ability to swim. The assessment will include the individual's knowledge of water safety and ability to swim. The Program Specialist has revised the assessment for Individual #1 to include her knowledge of water safety. (Attachment #4, Pg. 2 and 3). All Program Specialists will be retrained in Reg. 6400.181(14) to ensure that assessments include knowledge of water safety and ability to swim. Each individual record will be reviewed by 9/30/15 to ensure that the assessment includes this information. 08/31/2015 Implemented
6400.186(d)The ISP reviews for Individual #1 were not sent to all plan team members. The ISP reviews were not sent to the day program that she attends. The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. The Program Specialist will provide the ISP review documentation, including recommendations, if applicable, to the SC and plan team members within 30 calendar days after the ISP review meeting. For Individual #1, the Program Specialist has sent the ISP review dated 5/4/15 to all plan team members on 5/8/15, including the day program. (Attachment #1, Pg.3). The ISP review dated 11/3/14 actually was sent to the day program and was documented in a communication note in the record. (Attachment #2). All Program Specialists will be retrained in Reg. 6400.186(d) to ensure that ISP reviews are sent to all plan team members within 30 calendar days of the meeting. Each individual record will be reviewed by 9/30/15 to ensure that ISP reviews have been sent to all plan team members within 30 calendar days of the meeting. 08/31/2015 Implemented
6400.186(e)The program specialist did not notify all plan team members of the option to decline the ISP review documentation. The day program is part of her ISP plan team and was not given the option to decline the review documentation. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. The Program Specialist will notify the plan team members of the option to decline the ISP review documentation. For Individual #1, the Program Specialist notified the day program of the option to decline the ISP review documentation on 5/4/15. (Attachment #3). All Program Specialists will be retrained in Reg. 6400.186(e) to ensure that the plan team members will be notified of the option to decline the ISP review documentation. Each individual record will be reviewed by 9/30/15 to ensure that plan team members have been notified of the option to decline the ISP review documentation. 08/31/2015 Implemented
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