Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00244487 Unannounced Monitoring 04/29/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(d)Because the provider is not staffing the lower-level apartment correctly, the individuals in the upper-level apartment cannot leave their home for activities as they choose. Their assigned DSP is also being used as a DSP for the lower-level apartment for the convenience of the agency. They cannot just choose to go out independent of the needs of the individuals in the lower-level apartment.An individual shall be treated with dignity and respect.Currently, the individuals in the upper level apartment go into the community 2-3x per week with the use of our hired driver and/or the CEO transporting them. In addition, the individuals in both the upper level and lower level are taken to their medical appointments by both the driver and/or the CEO, ensuring that there are always 2 DSP working in the house. The individuals in the lower level require 1 DSP for feeding and personal hygiene. Both individuals are incontinent and require the use of diapers. The DSP assigned to the lower level is capable of changing the diaper without assistance. If a transfer is necessary to either the wheelchair or shower chair, the hoyer lift is used. All staff have been trained on the use of the hoyer lift at this time. At the time of this violation, the ISPs for both individuals had not been updated to reflect the current staffing needs, diets and other incidental items. The CEO has been in contact with both supports coordinators to make the necessary changes to the respective ISPs. The CEO has been able to meet in person with the SC for 1 individual (AP) on 5/28/24. At this meeting the current staffing levels were discussed. It was agreed upon that AP requires 1 DSP for changing her diaper and personal hygiene activities. Also, 1 DSP is capable of using the hoyer lift to transfer AP to the shower chair or wheelchair. The SC advised the CEO that these changes will be made to the ISP, although no timeframe was given. The CEO had a phone meeting with the SC for the 2nd individual, (TB), on 5/31/24. During this phone call it was agreed upon that TB requires 1 DSP for changing her diaper and personal hygiene activities. Also, 1 DSP is capable of using the hoyer lift to transfer TB to the shower chair or wheelchair. The SC advised the CEO that these changes will be made to the ISP, although no timeframe was given. 06/01/2024 Implemented
SIN-00235177 Unannounced Monitoring 11/27/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144All MAR's present and previous (09/2023 -- 11/2023) indicate that the individuals self-medicate, both individual's medication administration record show that the individuals are initialing and not by the person(s) administering the medication. (Individual 1 was interviewed and stated they does not know their medication(s)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. it is apparent that individual 1's skills may need to be reevaluated. We will discuss with the team in regard to changing the ISP to better reflect individual 1's current capabilities. This discussion occurred on 12/11/23 with individual 1's SC and it was determined by the team to change the ISP to reflect that they need meds to be administered by trained staff. When new admissions occur with self-administering individuals the agency will complete a self-administering competence and assessment to ensure they can complete self-administration. This will be reviewed by management when doing onsite visits. [DIRECTED PLAN 2/26/2024] 03/18/2024 Not Implemented
6400.190(c)There is no documentation of recreational and social activities for all individuals housed in the residential homes Apt. A and Apt. B. (It was disclosed that individuals are not being taken out on any outings)Documentation of recreational and social activities shall be kept in the individual¿s record. A record to document activities will be created. 2 activities will be scheduled immediately. 12/16/2023 Not Implemented
6400.214(b)The records in the home were outdated for individuals 1 and 2. ISPs and physicals were outdated. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. Prior management was unaware of the location of the physicals. The physicals are current and in compliance and are now located in the home. Current ISPs will be placed in the home as soon as current CEO regains access to HCSIS. 12/04/2023 Not Implemented
6400.216(a)Records for all individuals were unlocked in the home. An individual's records shall be kept locked when unattended. Individual records were replaced to their normal location which is the locked medicine cabinet. 12/31/2023 Not Implemented
6400.162(a)Both units Apt. A and Apt B staff are administering medications. No verification was provided (staff stated no training was given) that medication administration training was completed or trained by a trainer.A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication.Previous management was allowing non-trained staff to deliver medications occasionally. On the date of the unannounced visit, there was a medication trained staff member, but his credentials could not be verified by licensing because management did not know where they were physically located. Once the current CEO resumed his role, these documents were provided to licensing and the county and were verified, so that this staff member is now providing meds for both A/B. 12/31/2023 Not Implemented
6400.163(f)Prescription medications that were stored in the refrigerator was kept in an unlocked container.Prescription medications stored in a refrigerator shall be kept in an area or container that is locked.Upon review of the container, it was found to be not functioning properly, therefore a new container was purchased and put in its place. Medication will be stored in the new locked container. 12/04/2023 Not Implemented
6400.182(c)The ISP is not being revised annually and revised as needed when changes are made to the assessments for individuals 1 and 2.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.While the ISP is updated in the annual meetings, an outdated ISP was on the premises at the time of inspection. This will be fixed by the CEO placing a current ISP in the home. 12/05/2023 Not Implemented
SIN-00228498 Renewal 07/20/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)Information pertinent to diagnosis and treatment in case of emergency was not present on the most recent annual physical exam of individual #1The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Moving forward, the program specialist will pre-fill the annual physical form for the "information pertinent to diagnosis and treatment in case of emergency" section prior to the individual going to the appointment. 08/03/2023 Implemented
SIN-00208331 Renewal 07/22/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessments shall be completed for each of the licensed programs. A single self-assessment was submitted for the entirety of 1000 gum place however given that they are licensed as separate programs, a self-assessment would need to be completed for each one individually.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 provider will complete a separate self assessment for each licensed program at 1000 Gum Place. This will occur 3-6 months prior to the expiration date of the certificate of compliance. 09/16/2022 Implemented
6400.112(c)The fire drills were being documented as if the two apartments were one. Given that they are two separately licensed locations, each would need the have the fire drill documented independent of one another.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 provider will complete fire drills separately at 1000 Gum Place for each licensed apartment. This will occur monthly and be filed on different forms. 09/16/2022 Implemented
6400.151(a)Staff Members 1, 2, and 3's most recent two physicals were greater than two years apart. Staff Member 1's were dated 1/3/19 and 2/26/21, Staff Member 2's were dated 1/23/20 and 7/11/22, and Staff Member 3's were dated 2/1/20 and 7/9/22. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. The provider will have each staff member complete a physical every 2 years during their employment. 09/16/2022 Implemented
6400.52(c)(1)Staff Members 2, 3, and the CEO did not receive training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships during the 2021/2022 training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The provider will ensure that all employees will receive training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships during the 2022/2023 training year. 09/16/2022 Implemented
6400.181(f)The Program Specialist did not send an invite for individuals 1, 2, and 3 30 days prior to ISP meeting date.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.The program specialist will send the annual residential assessment for each individual to the team 30 days prior to the ISP meeting date. 09/16/2022 Implemented
SIN-00190642 Renewal 07/26/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(5)On Individual 1's assessment dated 4/13/2021, self-administration of medications was not adequately discussed; the assessment stated that the individual is "capable" of self-administering medications, but did not notate the level of assistance the staff provides during administration.The assessment must include the following information:  The individual's ability to self-administer medications.The CEO will update the assessment with a more detailed description of the individual's capabilities with self administration of medication. 07/27/2021 Implemented
SIN-00170097 Renewal 02/03/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(b)Individual 2's annual physical exam dated 10/25/19 was completed by a clinic due to the fact that the PCP could not provide a date within the regulatory confines. The form was not completed in several areas the clinic and was stamped not signed.The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. Moving forward, whoever is accompanying the individual to the physician's office for the physcial, will ensure that the physician signs and dates the physical in the appropriate areas. In addition, that person will ask the physician to complete the physical in its entirety. The program specialist will enure compliance in this area. 02/24/2020 Implemented
6400.142(f)Individual 2's record did not contain a dental hygiene planAn individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. Considering the need for a dental hygiene plan for individual 2, the program specialist has created a plan and inservice the staff on this plan. The plan was based on safe dental care outlined by the American Dental Association. The CEO will the ensure compliance with enacting this plan. 02/24/2020 Implemented
6400.181(d)Individual 2's annual assessment dated 5/16/19 was not signed and dated by the program specialist.The program specialist shall sign and date the assessment. After being brought to our attention that the annual assessment has to be signed by the program specialist, the CEO created a template on the annual assessment with a signature and date line for the program specialist to sign. Moving forward, the program specialist will sign and date the annual assessment and the CEO will ensure compliance. 02/24/2020 Implemented
6400.32(h)Cameras were installed in the living and dining area throughout home. Consents were signed when they were installed, however, agency did not have a policy explaining control and management of the devices. Also, there was no documentation of a person centered plan for individual 2.An individual has the right to privacy of person and possessions.The CEO will create a policy explaining the control and management of the video cameras at the home. This policy will comply with the 6400 regulations. The cameras will be turned off until team meetings are held and a person centered plan is put in place and the location of the cameras reviewed. 02/24/2020 Implemented
SIN-00248258 Renewal 08/12/2024 Compliant - Finalized
SIN-00245979 Unannounced Monitoring 06/06/2024 Compliant - Finalized