Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00255913 Renewal 11/22/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)The legs at the foot of Individual #1's bedframe are broken and the built-in drawers are inaccessible due to the damaged furniture. Furniture and equipment shall be nonhazardous, clean and sturdy. Program Director sent email to OPS listing areas of non compliance. Ops repaired the leg of the bed so the drawers are now accessible. Please see attachment# 6. 11/27/2024 Implemented
6400.111(a)Basement fire extinguisher was last serviced in June 2023 and was past-due for servicing. The extinguisher was removed and replaced while the inspector was still on-site.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. Immediate Action: The fire extinguisher was put in basement while inspection was conducted and remains there. See attachment # 7 11/22/2024 Implemented
6400.24The 1970 Controlled Substances Act requires accurate counts be kept for controlled medications. Controlled medication counts for Individual #2's Clobazam 10mg Tablets was inaccurate. The count read 10 tablets remained, however only 9 tablets were in the blister pack.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.Controlled Medication Utilization Record reviewed with all medication trained staff within the home. Count will be done at the end of the each shift and should match the number on the sheet attached. Please see attached training sheet. See attachment # 8. 12/02/2024 Implemented
6400.166(b)Medication administrations for the following medicines and times were not marked as administered or refused on 11/21/2024 for Individual #2 -- Lamictal XR 300mg tablet (8 PM), Luvox 100mg tablet (8 PM), Clobazam 10mg tablet (8 PM), Clobazam 20mg tablet (8 PM), Phenobarbital 16.2mg tabet (8 PM), Risperdol 3mg tablet (8 PM), Simbrinza 1% eye drops (4 pm & 8 pm), Topamax 100mg tablet (8 PM), Xalatan 0.005% eye drops (8 PM).The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.This area of non compliance was immediately addressed with the staff who was responsible for not following the guidelines given for medication administration. These guidelines include signing for medication when it is administered. The Program Manager who is also a med trainer reviewed the medication administration procedure will all staff including the staff who administered the medication without signing. Please see attached sign in sheet for training (see attachment # 8). 12/03/2024 Implemented
SIN-00235219 Renewal 11/29/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The drop ceiling and floor in the former basement contain hazards and are in poor repair. The ceiling tiles that was present and not being held stable and are at peril of falling from the drop ceiling and were blocking the door from opening all the way.Floors, walls, ceilings and other surfaces shall be in good repair. Program Director sent request to Ops reporting area of non compliance needing repair. The drop ceiling tiles were removed entirely. See Attachment #12 12/05/2023 Implemented
6400.76(a)The floor where the toilet was removed has the flange protruding from the floor can cause a hazard. Furniture and equipment shall be nonhazardous, clean and sturdy. Program Director sent request to Ops reporting area of non compliance needing repair. The flange protruding from the floor was removed and the hole was covered. see Attachment #13 12/05/2023 Implemented
SIN-00152966 Renewal 03/27/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #1's medication, Lotrimin AF was not available at the time of the inspection.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. Program manager immediately contacted med certified staff who had worked the am shift and documented that the medication had been administered as prescribed. Staff stated that he administered the last of the cream in the morning and then disposed of the empty tube. Household trash had been collected and disposed of prior to inspection. MAR had been documented that medication was administered. Program manager contacted program nurse who telephoned prescribing doctor to order replacement tube. Medication was delivered and administered at prescribed time (attachments #50 and 51). Memo was given to staff as follow up, due to him not contacting program manager and/or nurse, providing notification that medication needed refill (attachment #52). To ensure that health services, including pharmaceutical are arranged for or provided, CHS directors provided a memo to all staff, reminding them of the requirement to immediately contact program manager and/or nurse whenever a medication needs a refill, so that the medication is always on site and available to be administered (attachment #53). To ensure ongoing compliance with the regulation, program managers will check medication at least once weekly and indicate issues on Community Home Review sheet (attachment #3). In addition, CHS Co Directors, Assistant CHS Director, and Quality Assurance Assistant will randomly audit medication boxes during weekly visits to the homes (attachment #4). 03/29/2019 Implemented
SIN-00110899 Renewal 11/16/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The hot water temperature measured in the first floor bathroom was 136.0 degrees Fahrenheit.Hot water temperatures in bathtubs and showers may not exceed 120°F. Interact maintenance department was immediately called to the site to lower the temperature on the hot water heater. Water temperature was retaken after 2 hours to allow for the existing water in the tank to cool. Temperature was measured at 114.3 degrees Fahrenheit (attachment #23 ). Instant read thermometer was purchased for the home (attachment # 24) to be used every time the water temperature is tested. To ensure compliance that hot water temperatures in bathtubs and showers may not exceed 120°F, digital thermometers were purchased and equipped in the homes that did not have them (attachment #24). In addition, Program managers will visit all their sites at least weekly and document water temperature on a CHS site review checklist, which will be submitted to Co-Directors biweekly. Any/all issues identified with water temperature exceeding the allowable limit will be immediately addressed with the program manager and/or Operations as needed. 11/21/2016 Implemented
6400.105A 5-gallon bucket of enamel house paint was found stored within two feet of the furnace in the basement.Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. 5 gallon bucket of enamel house paint was immediately removed from next to the furnace (attachment # 25). To ensure compliance that flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources, all homes will be visited by Program managers at least weekly and inspected fully and visits will be documented on a CHS site review checklist, which will be submitted to co-directors biweekly. In addition, reminder email was sent to Interact maintenance department re: being mindful to not store any flammable or combustible supplies near any heat sources (attachment # 26). Any/all issues identified with this issue will be immediately addressed with the program manager and/or Operations as needed. 11/18/2016 Implemented
6400.110(g)The smoke detector located in the basement was not operable.If a smoke detector or fire alarm is inoperative, notification for repair shall be made within 24 hours and repairs completed within 48 hours of the time the detector or alarm was found to be inoperative. Fidelity Burglar and Alarm Company were immediately contacted and brought to the site to repair the basement smoke detector as needed. Repair was completed 11/18/2016 (attachments #27). To ensure compliance that If a smoke detector or fire alarm is inoperative, notification for repair shall be made within 24 hours and repairs completed within 48 hours of the time the detector or alarm was found to be inoperative, monthly fire drills will continue to be run and all detectors will be monitored to ensure that they are operating as needed. The smoke detector/fire system being operative is indicated on the form (attachment #28). If a repair cannot be made within 48 hours of the time the detector or alarm is found to be inoperative, emergency relocation of individuals will occur. 11/18/2016 Implemented
SIN-00128046 Renewal 12/18/2017 Compliant - Finalized