Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00263127 Renewal 03/11/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Clean and sanitary conditions shall be maintained in the home. At the time of the inspection, there were 2 heads of lettuce located in the refrigerator in the garage and both heads of lettuce had multiple sections varying in sizes on them that were brown. Agency threw both heads of lettuce away during the inspection.Clean and sanitary conditions shall be maintained in the home. The lettuce was thrown away while the inspector was on site. The refrigerator was cleaned and sanitized on 3/13/25. The photo is attached. 03/13/2025 Implemented
6400.112(c)The fire drill conducted on 1/4/25 at 11:45 did not indicate the time the drill was conducted by indicated AM/PM this was left blank on the form.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. A copy of the fire drill from 1/4/25 was cross checked with the staff schedule to determine if the drill was completed in am or pm. The Assistant Manager verified that the drill was completed at 11:45am and initialed the original copy. Revised copy attached. 04/11/2025 Implemented
6400.195(a)At the time of the inspection, there was a locked cabinet in the kitchen next to the refrigerator. Inside the locked cabinet it contained various items to include the following items: various canned pantry items, pasta sauce, boxes of Macaroni and Cheese, approximately 6 applesauce cups, container of raisins, a single container of Sour Cream & onion pringles chips, 2 container of juice mix, a jar of peanut butter, and condiments. The refrigerator contained 4 heads of lettuce, 2 jugs of juice, and lunch meat. Agency staff reported that the cardboard box located under the desk in the kitchen is where snacks are kept upstairs for individuals, and the box only contained 5 packets of salted whole peanuts. The rest of the snacks were being stored/kept the garage where you had to go down a flight of steps to the basement and open a door to the garage area. There was a plastic tote/bin on top of the refrigerator labeled in black marker "Program Only" that had various bags of what appeared to be Frito lays snack bags, and then on a plastic shelf in the garage in a plastic tote were approximately 4 boxes of cookies. There is no Restrictive Procedures in place for any of the individuals residing in the home related to accessing foFor each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures.A variety of snacks are available for individuals in the kitchen. Completed 4/18/25. Photo attached. The clinical department will evaluate the need for a restrictive procedure plan for individual B.G. 04/18/2025 Implemented
SIN-00242455 Renewal 04/02/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(r)The door locking mechanism on Individual #1's bedroom was a "privacy lock". This type of lock can be opened with a tool or device that is not specific to the door or lock, such as, a screwdriver or coin. These types of locks do not provide the level of privacy and security of person and possessions as expected by this regulation.An individual has the right to lock the individual's bedroom door.The locking mechanism for Individual #1¿s bedroom was changed to a passage doorknob. (Attachment 1: New Knob) (Individual does not wish to have a bedroom door lock. -CH 5/17/24) 04/03/2024 Implemented
SIN-00222521 Renewal 03/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104The notification to the local fire department dated 1/18/23 listed the addresses of four 6400 community homes and stated that "we currently have individuals with developmental disabilities residing at the homes located at." Further noted was "Attached are updated floor plans indicating the location of bedrooms of any individual who requires assistance evacuating in the event of a fire." The referenced floor plans were requested for review. A floor plan submitted to the local fire department for the home was not included. As presented the notification to the local fire department for the home did not include the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire, the body of the letter also did not address the number of individuals who reside in the home, nor a general description of the mobility needs of the individuals served.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 center¿s QI, Operations, and Facilities Maintenance team has revised its fire safety letter to include needs identified within the citation, but also the updated needs noted in the 03/15/2023 6400 RCG update. (Attachment: Updated fire safety letter with attachments) 05/01/2023 Implemented
SIN-00203490 Renewal 04/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment is to completed within 3 to 6 months prior to the expiration of the expiration of the certificate of compliance. The expiration date for the certificate of compliance was 3/31/2022 and the Self-Assessment was completed on 2/01/2022.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. 2022-2023 self-assessment was completed on 02/01/2022. 01/01/2023 Implemented
6400.80(b)The exterior stairs leading from the back deck to the ground level were obstructed by several large branches from a thorn bush. Staff cut the branches at the time of inspection after learning of the obstruction from the licensing representative. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.Branches and growth were removed immediately on 04/13/2022 at the time of inspection to ensure safety and available means of egress from the home. 04/03/2022 Implemented
SIN-00172821 Renewal 03/02/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(b)There were no smoke detectors located within 15 feet of the bedrooms (2) located off of the kitchen and living room.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. The facilities maintenance team immediately installed the required smoke detector within 15 feet of the resident¿s bedroom on 3/3/2020 (Attachment #7). On-going the facility will conduct monthly quality audits (Attachment #1) on the home to assist in identifying the needs of the homes. The audit tool will consist of not only physical site needs, but also ensuring all homes are in compliance with ODP regulations. All audits will be completed by individuals well versed in ODP regulations, Devereux policies & procedures, and local township requirements. All audits will be collected by the facilities Quality Improvement Manager for review and secure document storage. All needs identified during the audits will immediately be disseminated to the proper department by the individual completing the audit in accordance with Devereux policy. Smoke detectors will also be monitored during monthly unannounced fire drills to ensure all smoke detectors are functioning properly. If a smoke detector is not functioning properly staff will contact the facilities maintenance team immediately via phone to report the issue to ensure rapid response to the safety need of the home. 03/03/2020 Implemented
6400.144The medication Tylenol, prescribed to be administered PRN to Individual #3, was not on site.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. The facility immediately ordered the Tylenol to comply with the individual¿s PRN order. The Tylenol blister pack delivered by the contracted pharmacy on 3/3/20 during the 3-11p shift. To ensure all medications are in stock and available in the home ODP Medication Administration certified staff members will complete a medication audit once monthly. Furthermore, staff will continue to follow current medical protocols that call for a review of prescribed medications during administration to ensure proper amounts are available for administration. All needs during the two modes of audit mentioned above will immediately be reported to the facilities nursing department, and notation of request will be placed in the homes shift binder to notify fellow staff of the order submission and upcoming delivery. 03/03/2020 Implemented
SIN-00111926 Renewal 05/02/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)The soap in the dispenser in the bathroom was poisonous. It directed that a physician should be contacted if the soap is ingested.Poisonous materials shall be kept locked or made inaccessible to individuals.The soap in the dispenser was removed immediately and replaced with non-toxic soap on 5/4/17. The Maintenance Manager will research non-toxic soap that can be purchased in bulk and used across all programs. This was completed 6/15/17. 06/15/2017 Implemented
SIN-00091012 Renewal 04/04/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(3)Staff #1's physical exam doesn't state that she is free from communicable diseases. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Staff #1 contacted her physician and the appropriate information was faxed back to Human Resources and reviewed by inspectors during inspection. (No attachment will be included unless requested since this was already provided). The statement that a staff is free of communicable disease is already part of the staff physical but was not checked in this case. HR staff will review all staff physicals as they are received to ensure all information is completely filled out, and will return the form to staff for any information that is lacking. 04/05/2016 Implemented
SIN-00079307 Renewal 03/26/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104refer to SIN-00070722The 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.   01/01/1900 Implemented
SIN-00070722 Renewal 03/25/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104Individual #2's ISP states: Leo would not be able to react independently during a fire;and his Annual assessment states, that he requires verbal and gestural prompting to evacuate when the fire alarm sounds. However, the fire letter to the local fire department states that the bedroom of individual requiring assistance is shown on the map. However, the map attached has a note written at the top stating that no clients need assistance. 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. Due to discrepanices between the individual¿s ISP, assessment and the letter sent to the fire chief regarding his evacuation status, an additional fire drill was conducted. All staff were instructed not to offer any physical, verbal or gestural prompting or assistance during this drill to determine the individual¿s correct evacuation status. The individual was able to evacuate independently. The assessment is being revised and a request to have the ISP revised will be made by the Program Specialist to the Supports Coordinator. Please see attachment 2 Target Date: Request for revision by 5/8/15 05/08/2015 Implemented
SIN-00279743 Renewal 12/09/2025 Compliant - Finalized
SIN-00190150 Renewal 04/20/2021 Compliant - Finalized
SIN-00152343 Renewal 03/18/2019 Compliant - Finalized
SIN-00130483 Renewal 03/20/2018 Compliant - Finalized
SIN-00136793 Renewal 03/20/2018 Compliant - Finalized