Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00248126 Renewal 07/22/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)Fire drill conducted on 10/3/2023 at 11:50pm does not record the amount of time it took for evacuation. Fire drill conducted on 12/29/2023 recorded two different times that the drill was conducted. Documentation states that the drill was conducted at 12:30pm and 12:26pm. The recoded amount of time to evacuate was 15 seconds.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. Residential Program Specialist will correct the October 2023 fire drill to include the amount of time it took to evacuate. Residential Program Specialist will correct the December 2023 fire drill to include the time the drill was conducted and the amount of time it took to evacuate. Documentation will be maintained and available for on-site review. Residential Program Specialists will inspect every licensed 6400 facility home¿s fire drills to ensure all times are accurately documented. Program Specialists will immediately correct any discrepancies identified during the inspection. Documentation will be maintained and available for on-site review. Manager of Compliance and Training will retrain Residential Employees on policy #5.21 Water, Heating, Fire Safety & Emergency Evacuation Standards Policy and Procedure and revised Fire Drill form to ensure written fire drill records shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered, and whether the fire alarm or smoke detector was operative. Documentation will be maintained and available for on-site review. 09/30/2024 Implemented
SIN-00172416 Unannounced Monitoring 03/10/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(r)Lock bedroom door- Individual #1 does not have a locking mechanism on the bedroom door for privacy.An individual has the right to lock the individual's bedroom door.Hope will discuss if the individuals want a lock on their bedroom door. If they do then it will be installed with their input. Hope will review the Individuals in their care to make sure this has been address agency wide. 04/10/2020 Implemented
SIN-00146852 Unannounced Monitoring 12/13/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The inside of the dishwasher appeared to have rust stains. There was a black substance on the inside of the dishwasher door.Clean and sanitary conditions shall be maintained in the home. Hope will complete a walkthrough of the facility monthly and then a higher level supervisor will conduct a walkthrough of the facility quarterly. All staff in the agency will be trained on this regulation and how to correct it in the future. Hope will sign off on a form that all three steps of this process have been completed. A walkthrough of each home for hope will be completed to make sure this regulation is in compliance agency wide. 12/21/2018 Implemented
SIN-00071785 Renewal 11/03/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(i)Staff #4 completed first aid training on 1/26/11 and not again until 3/26/13.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. Staff #4 is currently certified and will complete first aid training by January 31, 2015. In conjunction with the LCN Region Directed Corrective Action Plan Hope Training Department will be tracking all staff training in a computer database. Memorandums will be sent to staff as reminders of upcoming training. Memorandums will also be sent to Directors of their staffs' training dates and attendance at the training. CMSU Region currently has a procedure for tracking training in place and will maintain the current practice. 02/28/2015 Implemented
6400.72(b)The patio screen door had a tear in the screen near the bottom left-hand corner (looking at the screen from the outside of the house). Screens, windows and doors shall be in good repair. The screen in the patio door was repaired. See attachments #2, #3, #4. In conjunction with the LCN Region Directed Corrective Action Plan to assure continued compliance, Hope has hired a Residential Support Specialist that will oversee the maintenance department. The RSS will inspect each community home once a month, using a checklist of all physical site regulations to assure the homes are properly maintained. The checklist will be reviewed by the Residential Coordinator each month. The RSS will assign maintenance issues to be completed by maintenance staff within two weeks. Directors will also visit other Director's home once a month and complete a physical site checklist. All issues will be referred to the RSS for assignment. CMSU Region currently has a process for repairs in place and will maintain the current practice. 11/14/2014 Implemented
6400.103There was not an emergency evactuation procedure for this location. There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. An emergency evacuation procedure was written for 1609 Northway Apt. 2 which includes individual and staff responsibilities, means of transportation, and emergency shelter location. See attachment #1. Residential staff will review the evacuation plan with the program director at the bi-weekly staff meeting. The emergency evacuation procedure will be maintained in the control log in each home. The emergency evacuation procedure will be updated as changes occur and annually during fire safety by the program director and submitted to RSS for review. CMSU Region currently has an emergency evacuation procedure process in place and will maintain the current practice. 02/28/2015 Implemented
SIN-00214538 Renewal 11/14/2022 Compliant - Finalized
SIN-00189094 Unannounced Monitoring 06/16/2021 Compliant - Finalized
SIN-00186246 Unannounced Monitoring 04/13/2021 Compliant - Finalized
SIN-00181781 Unannounced Monitoring 01/12/2021 Compliant - Finalized
SIN-00175044 Unannounced Monitoring 08/13/2020 Compliant - Finalized
SIN-00173253 Unannounced Monitoring 06/03/2020 Compliant - Finalized
SIN-00170367 Unannounced Monitoring 01/16/2020 Compliant - Finalized
SIN-00168065 Unannounced Monitoring 12/06/2019 Compliant - Finalized
SIN-00160021 Unannounced Monitoring 07/15/2019 Compliant - Finalized
SIN-00120703 Unannounced Monitoring 08/28/2017 Compliant - Finalized