Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00265460 Renewal 04/16/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The upper interior surface of the home's kitchen microwave was covered with small brownish discolorations in a spatter pattern consistent with food material spatter. The lower surface of the microwave's interior was brown and discolored. The surfaces of this microwave were not clean and sanitary.Clean and sanitary conditions shall be maintained in the home. the staff had a meeting to review the new chore list that has been implemented for compliance with appliances being clean and sanitary. 05/16/2025 Implemented
6400.64(c)At the time of inspection, there were two plastic recycling bins filled with deconstructed cardboard located in the side yard of the home. The pieces of cardboard were water-damaged, torn, dissolved, and distressed in a way that suggested that they had been there for a long period of time. When asked how long the cardboard had been located there, provider staff were unable to supply a clear answer. This trash was not removed from the premises at least once per week as required.Trash shall be removed from the premises at least once per week. the staff removed the cardboard the next day with the weekly trash removal. 05/16/2025 Implemented
6400.66At the time of inspection, there was no lightbulb screwed into the only lighting fixture found in the rear of the home, which was located outside of the home's back door on the rear deck. There was no other lighting in the rear of the home that could provide illumination for the home's backyard.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. a light bulb was put into the light fixture as soon as the inspector left. 05/16/2025 Implemented
6400.67(b)The home's dryer lint trap was overflowing with dryer lint at the time of inspection. Once collected and condensed, this thick, dense dryer lint was as large as a softball. The dryer lint trap being filled in this manner increased the risk of a fire occurring within the home and, therefore, constituted a fire hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.after each use of the dryer staff will be cleaning the lint trap to avoid any fire hazards, this will be documented on the chore list for staff to complete daily. 05/16/2025 Implemented
6400.72(a)At the time of inspection, one of the windows in the home's attic was missing a window screen. As there was no window screen that could be fit into this window's frame if it were to be opened, this window was incapable of being securely screened.Windows, including windows in doors, shall be securely screened when windows or doors are open. the window screen has been replaced at this time. 05/16/2025 Implemented
6400.72(c)The home's basement had a wooden door that led to an exit stairway then up to Bilco-style hatch doors that opened into the home's backyard. Neither the Bilco-style hatch doors nor the wooden door had an operable locking mechanism, leaving this area of the home susceptible to intrusion. Outside doors shall have operable locks.the landlord is replacing the door for a more sturdy door for the basement coal ben. the door has a lock on it. 05/16/2025 Implemented
6400.73(a)The home's basement had a wooden door that led to an exit stairway then up to Bilco-style hatch doors that opened into the home's backyard. The stairway leading out of this egress, which exceeded two steps, was not equipped with a handrail. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. the landlord has added a hand rail to the one side of the stairs to maintain compliance. 05/16/2025 Implemented
6400.82(f)At the time of inspection, the home's bathroom lacked individual clean paper or cloth towels and a trash receptacleEach bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. a chore list has been implemented to make sure that each bathroom and kitchen has paper towels and a garbage receptacle. 05/16/2025 Implemented
6400.112(c)The written Fire Drill Record for this location was missing the Evacuation Time of the fire drill that occurred on 12/16/2024. The area of the "Fire Drill and Safety System" form designated for this information was blank.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. the fire drills have been added to our electronic records and it will not save unless each section has been filled in for compliance. 05/01/2025 Implemented
6400.141(c)(1)The Physical Form associated with Individual #2's 09/20/2024 Annual Physical Examination was missing the following information: a review of the individual's previous medical history. This Physical Form listed only one of the individual's medical diagnoses in the designated section of the form. Per other medical documentation in the Individual Record, the individual does have additional health diagnoses. As information on the individual's other established diagnoses was not found elsewhere on the Physical Form or accompanying documentation, there was no evidence that this information was reviewed by the medical professional during the visit.The physical examination shall include: A review of previous medical history. the director will verify all forms are accurately and complexly completed prior to excepting a new individual into ARS. 05/16/2025 Implemented
6400.141(c)(3)The Physical Form associated with Individual #2's 09/20/2024 Annual Physical Examination was missing the following information: the individual's immunization history. The area of the Physical Form designated for this information was left blank, stating "See Attached." Information related to the individual's immunization history was not found elsewhere on the Physical Form or attached to it.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. the director will verify all forms are accurately and complexly completed prior to excepting a new individual into ARS. 05/16/2025 Implemented
6400.141(c)(11)The Physical Form associated with Individual #2's 09/20/2024 Annual Physical Examination was missing the following information: the individual's medication regimen. The area of the Physical Form designated for this information was left blank, stating "See Attached." Information related to the individual's medications was not found elsewhere on the Physical Form or attached to it.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. all "see attached" will be checked by the program specialist prior to them being uploaded into the electronic health record. 05/16/2025 Implemented
6400.141(c)(15)Individual #1's most recent Physical Examination, dated 02/07/2025, did not include special instructions for the individual's diet. This area of the physical form was left blank by the medical professional completing the form.The physical examination shall include:Special instructions for the individual's diet. the program specialist will check all forms prior to them being uploaded into the electronic health record for accuracy and completions of the forms. 05/16/2025 Implemented
6400.144Per Individual #1's April 2025 Medication Administration Record (MAR), Individual #1 is prescribed Trulicity 3MG/0.5ML SOPN, "Inject 3mg (0.5ml) subcutaneously once a week (DX: Diabetes)." At the time of inspection, this medication could not be located within the home. Provider staff reported that the medication had not been filled due to issues with the pharmacy accepting the individual's insurance coverage. At the time of inspection, no alternative arrangements had been made by the provider to ensure that this medication prescribed for the individual was obtained for the individual. The provider failed to secure pharmaceutical services for the individual as required.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. approval of the medication was given and the doctor gave a 5 day window to ARS for the medication to be given to this individual prior to it becoming a medication error. 05/16/2025 Implemented
6400.32(c)Per Individual #1's April 2025 Medication Administration Record (MAR), Individual #1 is prescribed Trulicity 3MG/0.5ML SOPN, "Inject 3mg (0.5ml) subcutaneously once a week (DX: Diabetes)." At the time of inspection, this medication could not be located within the home. Provider staff reported that the medication had not been filled due to issues with the pharmacy accepting the individual's insurance coverage. At the time of inspection, no alternative arrangements had been made by the provider to ensure that this medication prescribed for the individual was obtained for the individual. By failing to ensure that the individual had access to the individual's medically necessary Diabetes medication to use as directed by the individual's physician, the Provider Agency neglected the individual and put the individual's health and safety at risk.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.approval of the medication was given and the doctor gave a 5 day window to ARS for the medication to be given to this individual prior to it becoming a medication error. 05/16/2025 Implemented
6400.46(b)Per the Staff Record, Staff #1's most recent Fire Safety training was completed on 09/23/2023. As there was no record of a more recent training, Staff #1 did not complete Fire Safety training annually as required.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).a fire safety test was completed for all staff to complete at time of orientation and annually thereafter to stay in compliance with the regulations. 05/16/2025 Implemented
6400.165(c)Per Individual #1's April 2025 Medication Administration Record (MAR), Individual #1 is prescribed Trulicity 3MG/0.5ML SOPN, "Inject 3mg (0.5ml) subcutaneously once a week (DX: Diabetes)." At the time of inspection, this medication could not be located within the home. Provider staff reported that the medication had not been filled due to issues with the pharmacy accepting the individual's insurance coverage. At the time of inspection, no alternative arrangements had been made by the provider to ensure that this medication prescribed for the individual was obtained for the individual. The staff initial box associated with the 8:00am administration time for this medication on 04/10/2025 was left blank. Provider staff confirmed that this administration of the medication to the individual was missed due to the medication being absent from the home at the time of administration. This medication was not administered to the individual as prescribed.A prescription medication shall be administered as prescribed.approval of the medication was given and the doctor gave a 5 day window to ARS for the medication to be given to this individual prior to it becoming a medication error. 05/16/2025 Implemented
6400.166(a)(11)The following prescription medication entries on Individual #1's April 2025 Medication Administration Record (MAR) were missing a diagnosis or reason for prescribing the medication: 1. Daysee 0.15-0.03-0.01 MG TA -- "Take 1 tablet by mouth every morning" 2. Benzoyl Peroxide Wash 5% L -- "Leave on for 5 minutes then rinse affected area every evening rinse thoroughly-product will bleach" The following prescription medication entries on Individual #2's April 2025 MAR were missing a diagnosis or reason for prescribing the medication: 1. Estarylla 0.25-35 MG-MCG Tab -- "Take 1 tablet by mouth every morning" 2. Ammonium Lactate 12% Cream -- "Apply to feet twice a day *Avoid applying between the toes*" 3. Clotrimazole 1% Cream -- "Apply Topically to affected area on the skin daily"A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.the med trainer at the end of the month will look at each individual's medications and the new packs being sent form the pharmacy and the trainer will make sure that all entries on the MAR are accurate and have a diagnosis for the medication listed for each medication. 04/28/2025 Implemented
6400.167(b)Per Individual #1's April 2025 Medication Administration Record (MAR), Individual #1 is prescribed Trulicity 3MG/0.5ML SOPN, "Inject 3mg (0.5ml) subcutaneously once a week (DX: Diabetes)." At the time of inspection, this medication could not be located within the home. Provider staff reported that the medication had not been filled due to issues with the pharmacy accepting the individual's insurance coverage. At the time of inspection, no alternative arrangements had been made by the provider to ensure that this medication prescribed for the individual was obtained for the individual. The staff initial box associated with the 8:00am administration time for this medication on 04/10/2025 was left blank. Provider staff confirmed that this administration of the medication to the individual was missed due to the medication being absent from the home at the time of administration. There was no notation on the MAR or documentation found within the Individual Record to record that the medication was omitted, held, or otherwise missed, nor was it noted that the provider had followed up with the individual's prescribing physician for this medication when the dose was missed. There was no documentation of follow-up by the provider. This medication administration error was not recorded in the individual's Individual Record by the Provider in the manner required.Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record.one of the med trainers will be reviewing the MAR's for compliance throughout the month to make sure that all documentation is being documented accurately. 05/16/2025 Implemented
6400.167(c)Per Individual #1's April 2025 Medication Administration Record (MAR), Individual #1 is prescribed Trulicity 3MG/0.5ML SOPN, "Inject 3mg (0.5ml) subcutaneously once a week (DX: Diabetes)." At the time of inspection, this medication could not be located within the home. Provider staff reported that the medication had not been filled due to issues with the pharmacy accepting the individual's insurance coverage. At the time of inspection, no alternative arrangements had been made by the provider to ensure that this medication prescribed for the individual was obtained for the individual. The staff initial box associated with the 8:00am administration time for this medication on 04/10/2025 was left blank. Provider staff confirmed that this administration of the medication to the individual was missed due to the medication being absent from the home at the time of administration. Per Provider staff, the Provider Agency was taking steps to secure the medication for the individual since the missed dose; in other words, the medication error had been known by the provider since at least the time of the missed medication administration on 04/10/2025 at 8:00am. At the time of inspection, there was no entry for this medication error in the Enterprise Incident Management (EIM) system, exceeding the 72-hour time frame that began with the discovery of the incident by a Provider staff person on 04/10/2025 at 8:00am.A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation).the EIM was completed immediately when it was brought to the directors attention. 05/16/2025 Implemented
SIN-00240655 Renewal 04/09/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101At time of inspection there was a keyed padlock on the door leading to the exterior bilco doors in the basement. The padlock obstructed egress from the basement to the outside of the home.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. the landlord has removed the lock from the bilco doors. 05/03/2024 Implemented
6400.110(f)As documented in the Individual Support Plan (ISP) last updated on 3/7/24 for Individual #2, Individual #2 is diagnosed with hearing loss and "has hearing aids and glasses ([Individual #2] chooses not to wear the hearing aids and glasses). The home is equipped with strobe lights and a bed shaker. At time of inspection the bed shaker was not functional. A new bed shaker was ordered on 4/16/24 and in place as of 4/17/24. The strobe lights were functional at time of inspection. If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. the new bed shaker was placed in the home on 4-17-24 and a picture of it will be sent in with the POC. 04/17/2024 Implemented
6400.112(h)Fire drills reviewed for the location did not include documentation that the individuals evacuated to a designated meeting place outside the building or within the fire safe area during each fire drill. The meeting place was recorded on the fire drill forms but the form lacked documentation that all individuals made it to the designated meeting place. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.the fire drills have been redone, so that when staff are completing the fire drill they will be documenting that each individual did or did not make it to the meeting place during the fire drills. 04/19/2024 Implemented
6400.141(c)(11)The physical dated 1/30/24 for Individual #1 did not contain an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The assigned section on the physical form was blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. When the physicals are due, the program specialist will verify that each section of the physical has been completed by the doctor or the doctors nursing staff prior to leaving the appointment. 05/02/2024 Implemented
6400.144At time of inspection on 4/16/24 the April Medication Administration Record (MAR) in use for Individual #1 contained an entry for "Humalog 100 units/ML Kwikpe Administer before meals per sliding scale. TDD 80 units." The handwritten sliding scale filed with the MAR noted "[Individual #1] 71-99 Give 0 units, 100-119 give 2 units, 120-150 Give 4 units, 151-200 Give 6 units, 201-250 Give 8 units, 251-300 give 10 units, 301-350, Give 12 units." The document was not dated and lacked any additional information. A current order for the sliding scale was requested and produced on 4/17/24. The sliding scale produced on 4/17/24 was clearly identified as an "After Visit Summary" from Geisinger. The sliding scale document was dated 3/28/24 and instructed "Administer 10-15 minutes before meals per sliding scale. TDD 80 units E11.9 <70- correct, recheck glucose and then dose if eating based on scale below 71-99 Give 0 units, 100-119 give 2 units, 120-150 Give 4 units, 151-200 Give 6 units, 201-250 Give 8 units, 251-300 give 10 units, 301-350, Give 12 units." This was not the order being followed and contained on the April MARs at the time of 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. the correct order has been written on the MAR's for each sliding scale, staff will sign off on the amount each day that they are giving in accordance to her blood sugar level. A picture of the MAR will be sent with the POC. 05/02/2024 Implemented
6400.46(b)The fire safety training presented as being conducted in 2022 did not have a date of completion listed on the form. Documentation of 2023 fire safety training was conducted on 8/10/23 for Staff #2. Due to the lack of date on the presented as 2022 training record, it could not be determined that the 2023 fire safety training had been completed in the year time frame as required.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).All forms for the staff #2 will be reviewed and will look at the HR persons notes to verify the date of each section on the form that was missing the date. Also the employee files will be separated for easier access of information as discussed during the inspection visit. 05/02/2024 Implemented
6400.163(a)At time of inspection the Humalog pen for Individual #1 was in a bin in the locked medication area used for the home. The Humalog pen was not in the original labeled container. The original labeled container was locked and properly stored in the refrigerator, storing additional pens for future use. Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. A labeled bag/container was issued by the pharmacy and given to the provider on 4/17/24.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.the director called the pharmacy and had a bag with the label for the individual and their insulin delivered on 4/17/24. they will be able to keep the pen that can't go back into the frig in this labeled bag in the locked medication cabinet. 05/02/2024 Implemented
6400.163(h)At time of inspection a single pill was found laying on the bottom a basket containing the medication blister packs for Individual #1. The pill was handed to staff #3 who determined it to be Gabapentin. It could not be determined which Individual the medication was prescribed to, how long it had been laying in the basket or if the pill was expired. Staff #3 disposed of the pill in the kitchen garbage can while Licensing Representative reviewed the remaining medications.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.during the staff meeting on 5/1/24 it was discussed with all staff that when they are passing medications, they are to look inside the med box containers for cleanliness and to make sure that no pills came out of the blister packs without anyone knowing, They will look each med pass to verify that there are no lose pills laying in the boxes. 05/02/2024 Implemented
6400.165(b)Individual #1 is prescribed Humalog KwikPen. At the time of inspection, the sliding scale was not defined on the pharmacy label or Medication Administration Record (MAR) for Individual #1. The sliding scale was on a plain piece of paper, handwritten with no information identifying the author or date. It is unknown who wrote the sliding scale or when. A current order for the sliding scale was requested and produced on 4/17/24. The sliding scale produced on 4/17/24 was clearly identified as an "After Visit Summary" from Geisinger. The sliding scale document was dated 3/28/24 and instructed " Administer 10-15 minutes before meals per sliding scale. TDD 80 units E11.9 <70- correct, recheck glucose and then dose if eating based on scale below 71-99 Give 0 units, 100-119 give 2 units, 120-150 Give 4 units, 151-200 Give 6 units, 201-250 Give 8 units, 251-300 give 10 units, 301-350, Give 12 units." This was not the order being followed and contained on the April MARs at the time of inspection. The information followed was not updated to reflect the sliding scale documented on 3/28/24. Prescription orders shall be kept current.A prescription order shall be kept current.the correct order has been written on the MAR's for each sliding scale, staff will sign off on the amount each day that they are giving in accordance to her blood sugar level. A picture of the MAR will be sent with the POC. 05/02/2024 Implemented
6400.165(g)The 2/19/24 and 1/5/24 medication reviews did not include the reason the medications were prescribed nor the dose of medication to be administered. The reason for prescribing the medication, and the necessary dosage information are required to be documented to fulfill the regulation.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Each psych review will be looked at by the director to verify compliance with regulations and that all sections have been filled in by the doctor or their nursing staff. 05/02/2024 Implemented
6400.166(a)(7)The Medication Administration Record (MAR) dated April 2024 and in use at the time of inspection did not include the dose of Humalog administered to Individual #1 from 4/1/24 to 4/16/24. The MAR entry for the medication noted "Humalog 100 units/ML Kwikpe Administer before meals per sliding scale. TDD 80 units." Each day and administration time was initialed as administered or marked with a O to indicate that there was no administration. The dose of the medication administered according to the sliding scale was not recorded on the April 2024 MAR for Individual #1.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.the correct order has been written on the MAR's for each sliding scale, staff will sign off on the amount each day that they are giving in accordance to her blood sugar level. A picture of the MAR will be sent with the POC. 05/02/2024 Implemented
SIN-00223694 Renewal 04/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Clean and sanitary conditions are not maintained in the home. The ceiling fan located in the living room was covered in dust.Clean and sanitary conditions shall be maintained in the home. the lead staff of the site cleaned the ceiling fan on 4-19-23 and will maintain it every week of dust. 04/19/2023 Implemented
6400.67(b)The home is not free of hazards. There is a sewer drainpipe sticking up out of the sidewalk in the front of the home, creating a tripping hazard. There is a piece of wood on the back deck of the home that is rotted and sagging, creating a hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.the landlord was contacted about the hazardous areas and he contracted with a construction company to come out and fix the boards on the deck and the front sidewalk with the sewer pipe. the contractors came out on 5-4-23 and it was raining they were unable to fix the areas. they are scheduled to come back out on 5-31-23 to fix all items. 04/20/2023 Implemented
6400.106The furnace inspection in the home was completed late. The furnace was inspected on March 18, 2022, and not again until April 14, 2023.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. a tracking compliance record has been created to monitor compliance in all inspections. 04/20/2023 Implemented
6400.141(c)(8)Individual #2 had a late mammogram. Individual #1 has a mammogram completed on 3/14/22 with instructions to schedule the next mammogram after March 15, 2022. Individual #1's annual mammogram was not scheduled until May 26, 2023. There is no documentation indicating when the appointment was scheduled for May 26, 2023.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. the lead staff will keep track of all appointments and annuals and will schedule appointments as needed. documentation will be kept if the office is unable to get the individual in within the grace period of the last annual. 04/20/2023 Implemented
6400.181(e)(12)Individual #1's annual assessment dated 9/27/22 does not include recommendations for specific areas of training, programming and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. Section 4 of the assessment has the recommendations for specific areas of training, appointments and services; however, we will make it more prominent in the assessment the areas and elaborate on each section more. 04/28/2023 Implemented
6400.181(e)(13)(i)Individual #2's annual assessment dated 9/27/22 does not address progress and growth over the past 365 days in Health.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.an additional section of the plan has been added to address the progress that was made from the last assessment to the current one in the area of Health. the progress will be labeled separately in the assessment. 04/28/2023 Implemented
6400.181(e)(13)(ii)Individual #2's annual assessment dated 9/27/22 does not address progress and growth over the past 365 days in motor and communication skills.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. an additional section of the plan has been added to address the progress that was made from the last assessment to the current one in the area of motor and communication skills. the progress will be labeled separately in the assessment. 04/28/2023 Implemented
6400.181(e)(13)(iii)Individual #2's annual assessment dated 9/27/22 does not address progress and growth over the past 365 days in activities of daily living.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. an additional section of the plan has been added to address the progress that was made from the last assessment to the current one in the area of activities of daily living. the progress will be labeled separately in the assessment. 04/28/2023 Implemented
6400.181(e)(13)(iv)Individual #2's annual assessment dated 9/27/22 does not address progress and growth over the past 365 days personal adjustment.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. an additional section of the plan has been added to address the progress that was made from the last assessment to the current one in the area of personal adjustment. the progress will be labeled separately in the assessment. 04/28/2023 Implemented
6400.181(e)(13)(v)Individual #2's annual assessment dated 9/27/22 does not address progress and growth over the past 365 days in socialization.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. an additional section of the plan has been added to address the progress that was made from the last assessment to the current one in the area of socialization. the progress will be labeled separately in the assessment. 04/28/2023 Implemented
6400.181(e)(13)(vi)Individual #2's annual assessment dated 9/27/22 does not address progress and growth over the past 365 days in recreation.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. an additional section of the plan has been added to address the progress that was made from the last assessment to the current one in the area of recreation. the progress will be labeled separately in the assessment. 04/28/2023 Implemented
6400.181(e)(13)(vii)Individual #2's annual assessment dated 9/27/22 does not address progress and growth over the past 365 days in financial independence.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. an additional section of the plan has been added to address the progress that was made from the last assessment to the current one in the area of financial independence. the progress will be labeled separately in the assessment. 04/28/2023 Implemented
6400.181(e)(13)(viii)Individual #2's annual assessment dated 9/27/22 does not address progress and growth over the past 365 days in manage personal property.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. an additional section of the plan has been added to address the progress that was made from the last assessment to the current one in the area of managing personal property. the progress will be labeled separately in the assessment. 04/28/2023 Implemented
6400.181(e)(13)(ix)Individual #2's annual assessment dated 9/27/22 does not address progress and growth over the past 365 days in community integration.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.an additional section of the plan has been added to address the progress that was made from the last assessment to the current one in the area of community integration. the progress will be labeled separately in the assessment. 04/28/2023 Implemented
6400.46(d)Staff #2 was hired on 1/20/21. Staff #2 did not receive annual training 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.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 training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.the staff is scheduled to have CPR and First Aide training on May 26, 2023 by a trained professional with the American Red Cross. 05/18/2023 Implemented
6400.165(a)Individual #2 is prescribed Levothyroxine 50mcg, take 1 tablet by mouth daily at least 30 minutes prior to breakfast or other meds for thyroid. This medication was administered on April 1 and April 2, 2023, however it was not documented as administered at the time of administration.A prescription medication shall be prescribed in writing by an authorized prescriber.the staff that actually gave that medication had to retake the medication class over so that they were trained in the new medication administration course thru university of Mass. 04/23/2023 Implemented
SIN-00206847 Renewal 07/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(11)The medication administration record for Individual #1 did not contain a diagnosis or purpose for each prescribed medication listed on the record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.On July 15, 2022, Director called each doctor and pharmacist to speak to them about correcting the labels and the MAR. Each doctor was able to call in to the pharmacy to have the orders changed to add the diagnosis or the purpose for the medication, including the pro re nata's for individual #1. This was completed by 3:30 pm on 7-15-22 for each of the labels. The MAR's were also corrected, reprinted and staff were retrained and started a new MAR for individual #1 for the rest of the month. 07/20/2022 Implemented
SIN-00188226 Initial review 05/21/2021 Compliant - Finalized