Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00252772 Renewal 10/15/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66At the time of the 10/16/24 inspection, the front porch light did not illuminate.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The light above the front stairs only illuminates after dusk. Please see a picture of the light working in the Supporting documentation folder. 12/20/2024 Implemented
6400.80(a)At the time of the 10/16/24 inspection, there was a large crack in the concrete sidewalk, which is a tripping hazard. Outside walkways shall be free from ice, snow, obstructions and other hazards. At the time of the 10/16/24 inspection, there was a large crack in the concrete sidewalk, which is a tripping hazard. 12/20/2024 Implemented
6400.104The fire department notification letter dated 6/1/23 indicates that Individual #1 does not need any prompting to evacuate, however, Individual #1's Individual Support Plan indicates that the individual does need verbal prompts at times to evacuate.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. The team held a meeting on 11/13/24 to discuss Individual #1's responses to the fire alarm. Individual #1 has not had any issues in responding to the alarms and evacuates independently. The ISP and Assessment will be revised to show Individual #1 is independent in responding safely to the fire alarm. A copy of the email sent to the SC and the updated assessment can be found in the Wilson Supporting Documentation folder titled Assessment and Email to SC. 12/20/2024 Implemented
SIN-00182721 Renewal 02/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Individual #1 financial ledger had a balance of $149.44, there was $149.49 cash on hand.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. After each purchase, all receipt(s) will be documented in the electronic cash reimbursement distribution sheet. The Program Supervisor will complete daily funds audits and correct any errors discovered. The Program Manager will complete a weekly funds audit to ensure accuracy. 03/18/2021 Implemented
6400.80(a)There was snow and ice on the exterior stairs leading from the deck to the backyard. Outside walkways shall be free from ice, snow, obstructions and other hazards. On February 4, 2021 the snow and ice that had fallen from the roof was removed with shovels. Stairs are clear from hazards. See photo of cleared stairs in supporting information folder 03/18/2021 Implemented
6400.141(a)Individual #1 annual physical was performed 3/19/19 and not again until 1/15/21.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The Program Supervisor will utilize Google calendar to track all appointments as required of this regulation, and set reminders for upcoming events. The Program Manager will check all appointment forms and notes weekly with the Program Supervisor. All Supervisors, Managers and Specialists will be retrained in the requirement of this regulation by 5/31/2021. All records will be reviewed by Managers for the component of this regulation by 5/31/2021. 03/18/2021 Implemented
6400.141(c)(7)Individual #1 1/15/21 annual physical did not include a gynecological exam.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. Program Supervisor received an updated letter on 3/17/21 from PCP stating Gynecological exams are not needed for this individual. Individual physical exams will include the requirement in this regulation. The Supervisor is responsible for reviewing the physical exam to ensure all components of the physical are completed. The Supervisor will send the physical exam form to the Manager and they will review with the Supervisor to ensure the record is completed and meets the requirement of this regulation. All Supervisors, Managers and Specialists will be retrained in the requirement of this regulation by 5/31/2021. All records will be reviewed by Managers for the component of this regulation by 5/31/2021. 03/18/2021 Implemented
6400.144The dentist who performed the 10/24/19 exam on Individual #1 recommended an appointment in 04/30/20. The dentist who performed the 9/1/20 exam on Individual #1 recommended an appointment in January 2021. Neither of those appointments were made.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. A dental appointment was completed on 1/20/21 and not seen at the time of inspection. Documentation was obtained to record the appointment from the dentist office on 3/17/21. Individual dental exams will include the requirement in this regulation. The Supervisor is responsible for reviewing the dental exam to ensure all components are completed and all follow ups are scheduled and attended. The Program Supervisor will utilize Google calendar to track appointments and ensure they are completed within designated timeframes. The Supervisor will send the dental exam form to the Manager and they will review with the Supervisor to ensure the record is completed and meets the requirement of this regulation. All Supervisors, Managers and Specialists will be retrained in the requirement of this regulation by 5/31/2021. All records will be reviewed by Managers for the component of this regulation by 5/31/2021. 03/18/2021 Implemented
6400.181(e)(4)The 2/1/21 annual assessment lists Individual #1 supervision needs as "15 minutes alone time", "···does not have any alone time" and "···can be left alone for very short periods of time.". There is no consistency in the evaluation. The assessment must include the following information: The individual's need for supervision. The Program Specialist made revisions to the Assessment and ISP to ensure all documents read the same way for consistency throughout the documents on 2/15/21. Program Specialists will ensure each assessment is based on assessment instruments, interviews, and observations. The Program Specialist will review ISP, electronic health record, and Annual Assessment, to ensure all documentation on individual¿s supervision needs are clear and consistent. All Supervisors, Managers and Specialists will be retrained in the requirement of this regulation by 5/31/2021. All records will be reviewed by Managers for the component of this regulation by 5/31/2021. 03/18/2021 Implemented
SIN-00112228 Unannounced Monitoring 12/22/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16Individual #1 experienced a fall on 12/8/2016 which lead to a severe injury (5 broken ribs). Staff did not call 911. Individual #1 did not receive the services and supports necessary to meet her medical needs at the time of the fall. 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.Individuals will receive the services and supports necessary to meet their medical needs and will be protected from abuse and neglect. The situation involving the fall which led to severe injury was reported as a neglect incident due to the fact that the staff involved did not call 911. The primary target was suspended pending the results of an investigation, which was determined to be confirmed neglect. The primary target received corrective action and training on 12/20/16 prior to returning to work. In addition, the two secondary targets also received corrective action and training on 12/14/16 prior to being on-call again. The training included how to handle falls and other injuries, when to call 911, as well as abuse and neglect training. (Attachment #8, Pages 1-13). Training regarding when to call 911 was also provided for the remaining on-call staff responsible for Wilson Avenue who were not involved in this incident on 1/10/17 to ensure that on-call staff were aware of the importance of calling 911 and ensuring that the needs of individuals are met. (Attachment #9, Pages 1-4). All staff will be retrained in Regulation 16 to ensure that individuals receive the services and supports necessary to meet their medical needs and to be protected from abuse and neglect. This training will include review of the Abuse policy as well as a review of the ODP Health Alert regarding medical emergencies and when to call 911. 05/31/2017 Implemented
6400.62(a)Individual #2 is not safe with poisonous materials. Medline Micro-kill cleaner wipes were present in an unlocked downstairs cabinet, by the laundry room. Poisonous materials shall be kept locked or made inaccessible to individuals.Poisonous materials will be kept locked or made inaccessible to individuals. The Medline Micro-kill cleaner wipes were placed in the locked cabinet for cleaning supplies on the date of the inspection, 12/22/16 and have been kept locked since that time. (Attachment #7, Pages 1 & 2). All staff will be retrained in Regulation 62(a) to ensure that all poisonous materials will be kept locked or made inaccessible to individuals. 05/31/2017 Implemented
6400.64(a)Upstairs bathroom floor was dusty and hair was present alongside the showere/tub area, blood stain the size of a quarter was present on shower curtain, blood stains present on toilet seat of Individual #3's bathroom. Clean and sanitary conditions shall be maintained in the home. Clean and sanitary conditions will be maintained in the home. The upstairs bathroom was cleaned and the shower curtain was replaced on the date of the inspection, 12/22/16. (Attachment #6, Page 1). Individual #3's bathroom was also cleaned and blood stains were removed from the toilet seat on 12/22/16. (Attachment #6, Page 2). The Program Specialist implemented a daily cleaning checklist to maintain clean and sanitary conditions. (Attachment #6, Page 3). 12/22/2016 Implemented
6400.66Individual #2's bedroom was lit only using a small lamp on dresser. Very dim lighting in this bedroom. Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ranps and fire escapes will be lighted to assure safety and to avoid accidents. Two lamps were added to Individual #2's bedroom in order to provide adequate lighting. (Attachment #5, Pages 1-3). 12/27/2016 Implemented
6400.71Individual #1's portable telephone in downstairs living area did not have ER numbers posted on it, or near it. No ER numbers were posted on or near telephone in Individual #4's bedroom. Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center will be on or by each telephone in the home with an outside line. Emergency numbers have been posted on Individual #1's portable telephone in downstairs living area and on the telphone in Individual #4's bedroom. (Attachment #4, Pages 1 & 2). 12/27/2016 Implemented
6400.101Door leading to the back deck outside stairway could not be easlily opened. Locking mechanism is difficult to manipulate and casuses difficulty in quickly accessing the egress. Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Stairways, halls, doorways, passageways, and exits from rooms and from the building will be unobstructed. On the date of the inspection, the locking mechanism was removed from the door to enable the door to be easily opened to quickly access the egress. A new storm door has been installed and does not include any type of locking mechanism. (Attachment #3, Pages 1-3). 12/22/2016 Implemented
6400.162(a)Unable to read medication labels for Individual #1's PreviDent 5000 Plus 1.1% Cream, and Debrox 6.5% Solution. Printing on labels was worn off and difficult to read. The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. The original container for prescription medications will be labeled with a pharmaceutical label that includes the individual's name, name of medication, date prescription was issued, prescribed dose and name of prescribing physician. The medication labels for Individual #1's Prevident 5000 Plus 1.1% Cream and Debrox 6.5% solution have been replaced with clear pharmaceutical labels that include the individual's name, name of medication, date prescription was issued, prescribed dose and name of prescribing physician. (Attachment #1, Pages 1 & 2 and Attachment #2, Page 1). All Program Specialists and house supervisors will be retrained in Regulation 162(a) to ensure that all original containers for prescription medications will be clearly labeled with a pharmaceutical label that includes the individual's name, name of medication, date prescription was issued, prescribed dose and name of prescribing physician. 05/31/2017 Implemented
6400.164(a)Individual #1's Lidocaine Ointment 5% medication label read apply topically to affected area on right foot 3 times a day; instructions on MAR read apply topically to affected area 3 times per day. Instructions on label did not match MAR. 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. Medication logs will list the medication 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 medications. The specific medication listed in the citation was discontinued in Dec. 2016 while the individual was in the hospital. The medication labels match the instructions on the MAR for the individual's current medication. Examples of this include the Denta and the Debrox. The label on the Denta states "brush once daily in the morning", which matches the instructions on the MAR. (Attachment #1, Pages 1-3). the label on the Debrox states "instill 4 drops in each ear once weekly", which matches the instructions on the MAR. (Attachment #2, Pages 1 & 2). All Program Specialists and house supervisors will be retrained in Regulation 164(a) to ensure that the medication log lists the medications prescribed, dosage, time and date that prescription medications were adminisstered and the name of the person who administered the medication for each individual who does not self-administer medications. 05/31/2017 Implemented
SIN-00099203 Renewal 08/01/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment was completed 2/23/16 and was therefore late. The license expires 5/13/16.The 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. The agency will complete a self-assessment of each home within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with the regulations. Based upon the expiration date of 5/13/17, self-assessments will be completed between the dates of 11/13/16 and 2/13/17. All Program Specialists will be retrained on Regulation 15(a) to ensure that self-assessments are completed within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance. All Program Specialists will initiate the completion of the self-assessments after 11/13/16 and it will be the responsibility of all Program Directors to ensure their completion by 2/13/17. 11/30/2016 Implemented
6400.141(c)(4)Individual #23's physical dated 2/12/16 did not include a vision exam. The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Each physical examination will include vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Individual #23 had a pre-admission physical on 2/12/16, which did not include a vision exam. She did have a vision exam on 5/14/16. (Attachment #6) In the future, The Program Specialist will ensure that the physical includes the required vision exam prior to admission. All Program Specialists and house supervisors will be retrained in Regulation 141(c)(4) to ensure that each physical examination includes vision and hearing screening for individuals 18 years of age or older. 11/30/2016 Implemented
6400.141(c)(7)Individual #23's physical dated 2/12/16 did not include information regarding a comprehensive gynecological exam. The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. Each physical examination will include a gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. Individual #23 had a pre-admission physical on 2/12/16, which did not include a comprehensive gynecological examination. On 8/18/16, Individual #23's physician documented that she does not require this type of exam. (Attachment #7). A plan has been developed for the gynecological examination to be completed for Individual #23 during sedation that is planned for another procedure. (Attachment #7). In the future, the Program Specialist will ensure that the physical includes the required gynecological examination prior to admission. All Program Specialists and house supervisors will be retrained in Regulation 141 (c)(7) to ensure that each physical examination includes a comprehensive gynecological examination. 08/18/2016 Implemented
6400.144Individual #23¿s dental appointment on 4/18/16 indicated a change in her prescriptions for the medication Chlorhexidine to a brush-on. The agency never got the script and was not aware of this until recently. The individual is not using it yet.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. Health services such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual will be provided. The Chlorhexidine order has been entered in the medication administration record for Individual #23 and is being administered as a brush-on as prescribed. (Attachment #5). All Program Specialists and house supervisors will be retrained in Regulation 144 to ensure that all health services that are planned or prescribed for the individual are provided. 11/30/2016 Implemented
6400.164(a)On 7/1/16 the medication Trazadone 50 mg ½ tab QD for individual #23 started according to the MAR. On 8/2/16 it was administered as 50 mg ½ tab PRN. On 8/3/16 the medication was corrected to 50 mg ½ tab QD.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. There will be a medication log listing the medications prescribed, dosage, time and date that the prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin for each individual who does not self-administer medication. The medication log for Individual #23 was updated on 8/3/16 to clarify that the Trazodone was prescribed as 25 mg. once daily at bedtime rather than as a PRN medication. The Trazodone was then discontinued on 9/11/16. (Attachment #4) All Program Specialists and house supervisors will be retrained in Regulation 164(a) to ensure that the medication log lists the medications prescribed, dosage, time and date that prescription medications were administered and the name of the person who administered the medication for each individual who does not self-administer medication. 11/30/2016 Implemented
6400.186(a)Individual #23 did not have a quarterly review completed by 7/27/16. No quarterly reviews were found in her record. 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. Services and supports provided to the individual, relative to the ISP outcomes linked to services provided to the individual by the program will be reviewed at least every 3 months by the Program Specialist. Individual #23 did have a team meeting to decide upon outcomes within the first 3 months of her admission on 7/11/16. (Attachment #3). The quarterly review for Individual #23 was completed on 10/13/16. (Attachment #3) Another individual who was admitted on 5/23/16 had a quarterly review within the first 3 months of her admission, as required. (Attachment #3) All Program Specialists will be retrained in Regulation 186(a) to ensure that the services and supports provided to the individual, relative to the ISP outcomes linked to services provided to the individual by the program are reviewed at least every 3 months by the Program Specialist. 11/30/2016 Implemented
6400.211(b)(3)Individual #23's record did not contain information regarding emergency consent information.Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. Emergency information for each individual will include the name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. This information has been added to the screens in the electronic health record with other required demographic information. (Attachment #1 and Attachment #2) All Program Specialists will be retrained in Regulation 211(b)(1) to ensure that each individual record contains this information. Each individual record will be reviewed by the Program Specialist to ensure that it contains this information by 11/30/16. 11/30/2016 Implemented
6400.213(1)(i)Individual #23's record did not contain her weight, height, hair color, eye color or identifying marks. Individual #23's record did not contain a 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.Each individual's record will include personal information including: name, sex, admission date, birth date, social security number, race, height, weight, color of hair, color of eyes, identifying marks, language spoken or understood by individual, primary language if other than English, religious affiliation, next of kin and a current, dated photograph. Individual #23's record has been updated to include her weight, height, hair color, eye color, identifying marks and religious affiliation. (Attachment #1) All Program Specialists will be retrained in Regulation 213(1) to ensure that each individual record contains this information. Each individual record will be reviewed by the Program Specialist to ensure that it contains this information by 11/30/16. 11/30/2016 Implemented
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