Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00256477 Renewal 12/26/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(11)Individual #1's physical dated 11/8/2024 did not include information for health Maintenace.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. This regulation is important because maintaining the individual's health is of the utmost importance. This regulation reminds staff to keep this information up to date so that we can better understand the individual's needs. What happened in this situation was that the doctor did not address this need during the annual physical, and staff also did not follow up with the area of concern. This part of the form was therefore left blank. This happened because staff were not paying adequate attention to the annual physical form, which is set up to address all the necessary areas of health information for the individual. Management staff also missed that the form had blanks, and therefore did not follow up after the appointment. Moving forward, both DSP staff and management must review forms more thoroughly to ensure that the physician has reviewed all necessary parts of the annual physical, and answered them accordingly. Staff will immediately follow up with the doctor if there is any unclear information written. Staff will also pre-populate all appropriate areas of the form prior to the appointment to better assist the physician in completing the form effectively and providing necessary information to the medical team. The doctor will be able to review this information and make any changes prior to them signing the form. 01/14/2025 Implemented
6400.141(c)(12)Individual #1's physical dated 11/8/2024 did not include information for physical limitations.The physical examination shall include: Physical limitations of the individual. This regulation is important because staff providing care to the individual must know her physical limitations in order to best provide her care. Additionally, staff must relay any observed physical limitations to the individual¿s doctor so that they can offer any medical interventions necessary. What happened in this case is that the Physician did not document this area on the annual physical, and staff also did address her physical limitations with the doctor. This part of the form was therefore left blank. This happened because staff were not paying enough attention to what the annual physical form was requesting. Management staff also missed that the physical limitations portion of the form was blank, and therefore did not follow up with the doctor after the appointment to request this information. Moving forward, both DSP staff and management must review forms more thoroughly to ensure that the physician has reviewed all necessary parts of the annual physical, and answered them accordingly. Staff will immediately follow up with the doctor if there is any unclear information written. Staff will also pre-populate all appropriate areas of the form prior to the appointment to better assist the physician in completing the form effectively. The doctor will be able to review this information and make any changes prior to them signing the form. Eagle Valley CHS management team will review all documents to ensure the proper information has been obtained and will request additional information from the doctor if necessary. 01/14/2025 Implemented
6400.141(c)(15)Individual #1's physical dated 11/8/2024 did not include information for special diets.The physical examination shall include:Special instructions for the individual's diet. This regulation is important because we as providers must know the residents dietary needs so that we are providing them an appropriate diet in the appropriate manner for their health needs. What happened in this situation is that the ¿special dietary instructions¿ section of the annual physical form was left blank. This happened because the doctor did not address this individual's dietary needs during this appointment, and staff also did not address it with the physician. This part of the form was left blank. Staff relaying observed information about the individual's diet to the Doctor is very important as the doctor cannot make medical recommendations for the individual's health without knowing this information. This happened because staff were not paying sufficient attention to the annual physical form, which is set up to address all the necessary areas of health information for the individual. Management staff also missed that the form had blanks, and therefore did not follow up after the appointment either. Moving forward, both DSP staff and management must review forms more thoroughly to ensure that the physician has reviewed all necessary parts of the annual physical, and answered them accordingly. Staff will immediately follow up with the doctor if there is any unclear information written. Staff will also pre-populate appropriate areas of the form prior to the appointment to better assist the physician in completing the form effectively and relaying all important information regarding the residents needs. The doctor will be able to review this information and make any changes prior to them signing the form. Eagle Valley CHS management team will review all documents to ensure the proper information has been obtained and will request additional information from the doctor if necessary. 01/14/2025 Implemented
6400.143(a)Individual #1 had several refusals of medications and medical equipment in December. There was no refusal plan in the record.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. This regulation is important because we as providers must ensure that the individual understands their right to refuse and outcome possibilities related to the refusals. What happened in this situation is that the individual had multiple refusals for treatments prescribed by doctors. Staff did not document communication with Doctors about the refusals or education to the individual. This has happened due to the individual being inconsistent with her use of the treatment and staff not appropriately documenting her refusals with a refusal plan. A protocol has been written to cover refusals. Staff are being educated on the protocol. ¿In the event that an individual refuses to go to an appointment, take medications, treatment, or perform hygiene tasks¿Refused Appointments will be canceled and rescheduled. After 24 hours of refusing ALL medications, the doctor will be notified. When she picks out only one medication and refuses that for 3 med passes, the doctor will be notified And Education about the importance of each task (Hygiene, Medications, treatment, appointments) will occur. Eagle Valley CHS treatments that are often refused include Oxygen, C-PAP, and Dental Care. Staff must communicate to the Doctor that resident refused treatment and medication through the patient Portal and make a note about the communication on Tabula.¿ To prevent this violation from occurring again Program Specialist and/or Program Manager will check MAR and portal weekly. 12/31/2024 A message was sent to the doctor's office making the prescribing doctor aware that she has refused 18 out of 31 nights. Staff also requested if her O2 could be a PRN due to chronic refusals. As of 1/14/2025 no definite answer has been given by her doctor, but has an appointment scheduled with her doctor on 1/23/25 where it can be discussed further. 01/14/2025 Implemented
SIN-00164788 Renewal 01/22/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(c)The kitchen of the home was not equipped with a fire extinguisher with a 2A-10BC fire rating. The extinguisher found in the home had a 1A-10BC rating. A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). Maintenance picked up and installed appropriate fire extinguishers on final date of inspection. Maintenance Supervisor sulted with fire extinguisher supplier, Swartz Fire Safety to ensure that they had the appropriate extinguishers in stock, which they did. Maintenance crew member ws asent to Swartz to pick up extinguishers at retail location and proceeded to install new fire extinguishers at all locations in violation. Swartz is now aware of the regulatory needs as they relate to extinguishers for our Residential locations. They will continue to inspect and service annually and Maintenance will continue to ensure they are inspected monthly. Swartz will replace as needed with regulation-compliant extinguishers moving forward. See attachment #19 for photographic evidence of all program extinguishers being in compliance. 01/24/2020 Implemented
6400.141(c)(12)Individual #1's 4/1/19 physical examination form did not include their physical limitations. The field on the physical form was left blank.The physical examination shall include: Physical limitations of the individual. Human Resources Director, Program Manager, Program Specialist What: Updated existing Policy When: 3/20/2020 How: Reviewed current policy to determine how blanks were missed. Determined that there was no official review procedure that would provide a checks/balance system to ensure that forms are appropriately filled out by the physicians. Included a Form Review Procedure for the Staff Health and Individual Physical Exam policies. Additionally, reviewed form for Staff physicals and adjusted to ensure that Date of Exam is clearly documented to ensure that the exam was performed within the 1-year time frame. Included is the first Resident Physical form completed and reviewed per the updated policy (Attachment #15) and the policies updated in response (Attachments #16-18). In response to the COVID-19 pandemic, there were no recent staff physicals to review in conjunction with the new review policy. Plan to prevent future occurrences: Policy was updated and were educated in the double-review process of all physical forms being submitted for regulatory purposes. Attachments 15-18 03/20/2020 Implemented
6400.141(c)(14)Individual #1's 4/1/19 physical examination form did not include medical information pertinent to diagnosis and treatment in case of an emergency. The field on the physical form was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Human Resources Director, Program Manager, Program Specialist What: Updated existing Policy When: 3/20/2020 How: Reviewed current policy to determine how blanks were missed. Determined that there was no official review procedure that would provide a checks/balance system to ensure that forms are appropriately filled out by the physicians. Included a Form Review Procedure for the Staff Health and Individual Physical Exam policies. Additionally, reviewed form for Staff physicals and adjusted to ensure that Date of Exam is clearly documented to ensure that the exam was performed within the 1-year time frame. Included is the first Resident Physical form completed and reviewed per the updated policy (Attachment #15) and the policies updated in response (Attachments #16-18). In response to the COVID-19 pandemic, there were no recent staff physicals to review in conjunction with the new review policy. Plan to prevent future occurrences: Policy was updated and PS and PM were educated in the double-review process of all physical forms being submitted for regulatory purposes. Attachments 15-18 03/20/2020 Implemented
6400.165According to Individual #1's 12/1/19 and 12/19/19 medication administration records (mars) a few of the individual's prescribed medications were not administered as evidences by blank spots on the individual's mar and no explanation of why the individual did not receive their medications. The following are the examples of the medications missed on 12/1/19 and 12/19/19: -The individual's 4PM doses of Carbidopa, Levo 25/100, and Docusate Sod were not administered. -The individual's 8Pm doses of Lorazepam, Benzotropine Mes, Chlorpromazine, Clozapine, Gabapentin, and Thera-Gesic Analgesic cream were not administered.Documentation of medication errors and follow-up action taken shall be kept. Program Manager/Program Specialist What: PM Reviewed MARS weekly following inspection through the months of February and March, 2020 (Attachment #14) while Program Specialist worked with documentation system to get EMAR up and running for the facility. Slated to start on April 1, 2020. When: Feb 1-Mar 31, 2020 How: Beginning Feb 1, 2020, Program Manager was tasked with Weekly MAR checks (Attachments #14) to oversee the MARs during transition from a paper MAR system to a digital EMAR system. This was decided based on the illegibility of MARs reviewed upon inspection and administration felt that EMAR would be a cleaner, more governable format for maintaining the MARs. Program Specialist formatted all medications in the current documentation system to be compatible with the EMAR program offered by the current documentation system. A pilot date was set for 2/27/2020, which allowed paper MARs to be maintained through the month of March while allowing Team Leaders, initially, to be inputting medication administration into EMAR using the EMAR system. After a 2-week trial period involving only Team Leaders, all remaining staff were instructed to utilize the EMAR system as well, while maintaining formal paper MARs. During the pilot period, a number of issues were noted, and Program Specialist worked with documentation system programmers to rectify issues and ensure that the EMAR system was going to be a satisfactory replacement for current paper MAR system. By March 20, 2020, it seemed that all issues with the programming related to EMAR had been resolved, which allowed all staff 11 more days in the pilot period before completing the full transition on April 1, 2020. Plan to prevent future occurrences: Transitioning to EMAR will alleviate many of the issues with the current MAR system, specifically illegibility on the MAR, passing and documenting meds passed at time of admission, master log signatures with appropriate initials, recording date and time of all medications, and indicating dosage for medications that allow flexibility of dose dependent upon severity of symptoms. EMAR prints neatly and legibly, requires that medications are passed and confirmed within the time frame set by the provider (2 hour window per Medication administration course), maintains master signature log based on current staff list at the bottom of each MAR, records date and time of administration of meds in real time as meds are passed, and prompts for units for any medication with flexibility of administration such as novolog, decongestants and pain relievers. As administration can review all MARs at any time in real time, EMARs allow more managerial oversight, which will reduce or eliminate issues with the presentation of the MAR when completed. (Attachment 9,10) March 20, 2020 PS confirmed that EMAR was running smoothly. EMAR will officially replace paper MARS on April 1, 2020 Attachments: 7-10, 14, 20-22 03/20/2020 Implemented
6400.167(b)Documentation of the medication errors, follow up action taken and the prescriber's response was not kept for the individual's medication errors described under 6400.165(c) of this report.Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record.Program Specialist What: Reviewed dates suspected of medication errors due to blanks on MARs When: Reviewed following inspection between 1/24/2020 and 1/29/2020 How: Medications are routinely and systematically monitored for accuracy of administration via single dose packs, prepared by the pharmacy. Medication errors are most often recognized in this manner (med not popped from appropriate date). All medication passes in question can be verified as being appropriately administered via recognizing the dot placed in each box (placed when medication is poured into the medication cup) as well as the confirmation of count of medications being appropriate, with the exception of 8pm medications on 1/19/2020. This was an error of omission and was recognized promptly at 7:30am on 1/20/2020 during routine daily review of MARs by the Team Leader at the home when blanks were noted in the MAR. Eagle Valley staff are trained to dot each med as they are popped into the cup. This had not been done on the evening of 1/19/2020 and no initials were present. This prompted an investigation of the medication packs by the Team Leader, who noted that all medications dated for 1/19/2020 had remained in the dose packs. Narcotic record was reviewed as well and indicated that narcotic medication for 8pm was also omitted. Immediately upon report to PS, administering staff from the previous evening was contacted and returned into work to review with PS and determined that she must have forgotton to pass meds, though she thought she had. Following confirmation of medication error of omission, and EIM report was filed (Incident #8645603). Appropriate follow-up was completed and Staff in question was pulled from medications, retrained and counseled until 4 observations deemed her to be in compliance with medication administration procedures. She was also instructed to set an alarm on her phone to ensure that she was reminded to administer medications at the appropriate time. Observations were completed on 2/7/2020. Plan to prevent future occurrence: Eagle Valley is transitioning to an EMAR system to ensure more oversight by administration. Program Specialist has marshalled the transition for all staff and has communicated with Tabula (documentation system currently in place) to ensure a smooth transition. The additional layer of administrative oversight will allow closer review of MARs on a real-time basis which will enable recognition of blank MAR spaces in a more timely manner, therefore alleviating the likelihood of blanks being misinterpreted as Medication errors. As of March 20, 2020, EMAR system in place is effective. Paper MARS were maintained for the duration of the month of March and April 1 will be transition date for EMAR system to replace paper MAR system. (See attachments #11-13) 03/20/2020 Implemented
SIN-00126231 Renewal 01/03/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Staff member #1's hire date was 7/24/2017. The physical examination was completed on 7/25/2017. 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 regulation pertaining to staff physicals and TB tests to be completed prior to the date of hire (151 a,c2) serves to protect individuals from communicable diseases and ensures the overall health of each direct care staff member to ensure their ability to provide adequate care for all individuals. The violation resulted from an insufficient policy pertaining to the timeline of events prior to hire. Staff #1 was permitted to complete paperwork on 7/24/17 following report of a scheduled doctor's appointment the following day to have required TB test and physical completed. Date of paperwork sets the date of hire, which led to a violation of 151a and 151c2. Staff #1 only completed paperwork and completed necessary training prior to working with the individual prior to receipt of completed physical and TB. Individuals were not endangered. The policy was reviewed as a result of violation (See attachment #5, F37 original) and was determined to be too broad in regards to timeline. The policy subsequently was amended to include more specific and stringent timeline requirements (See attachment #6, F37 revised) and stipulates that a scheduled appointment for TB and Physical is not sufficient to begin new hire paperwork. Lastly, administrative staff responsible for any part of the hiring process was trained on the updated procedure (attachment #7, training sheet). It is expected that following more regimented and clear policy will prevent violations pertaining to new hire requirements from occurring in the future. Program Specialist was tasked with updating policy F37 as well as completing training for administrative staff involved with the new hire process. 01/09/2018 Implemented
6400.151(c)(2)Staff member #1's hire date was 7/24/2017. Mantoux test was read on 7/28/2017. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. The regulation pertaining to staff physicals and TB tests to be completed prior to the date of hire (151 a,c2) serves to protect individuals from communicable diseases and ensures the overall health of each direct care staff member to ensure their ability to provide adequate care for all individuals. The violation resulted from an insufficient policy pertaining to the timeline of events prior to hire. Staff #1 was permitted to complete paperwork on 7/24/17 following report of a scheduled doctor's appointment the following day to have required TB test and physical completed. Date of paperwork sets the date of hire, which led to a violation of 151a and 151c2. Staff #1 only completed paperwork and completed necessary training prior to working with the individual prior to receipt of completed physical and TB. Individuals were not endangered. The policy was reviewed as a result of violation (See attachment #5, F37 original) and was determined to be too broad in regards to timeline. The policy subsequently was amended to include more specific and stringent timeline requirements (See attachment #6, F37 revised) and stipulates that a scheduled appointment for TB and Physical is not sufficient to begin new hire paperwork. Lastly, administrative staff responsible for any part of the hiring process was trained on the updated procedure (attachment #7, training sheet). It is expected that following more regimented and clear policy will prevent violations pertaining to new hire requirements from occurring in the future. Program Specialist was tasked with updating policy F37 as well as completing training for administrative staff involved with the new hire process. 01/09/2018 Implemented
6400.213(1)(i)Individual #1's record did not include information regarding (v) The next of kin.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. The regulation regarding next of kin as part of the individual's record (213 (1) (i) ) serves to ensure a complete and accurate account of the individual's natural supports and acts as a directory for staff to adequately notify relevant person(s) in the event of an emergency or alternative unusual event. The violation resulted from an oversight of this portion of the regulation pertaining to Individual records and misinterpretation of how best to indicate "next of kin." Initially, "Emergency Contact #1" was presumed to indicate a person's next of kin. In the event of Individual 1, no next of kin exists and the individual's Emergency Contact #1 is not a suitable next of kin due to having no familial relationship. As documented in attachment #1 (page 2), Emergency Contact #1 now also contains the phrase "NO NEXT OF KIN" as individual 1 does not maintain contact with any family. Policy A4 (Attachment #2, Original Version) has been reviewed and adapted to more specifically address the issue of indicating next of kin (See attachment #3, A4, revised). All individual records have been subsequently reviewed and corrected to accurately and specifically indicate next of kin. Additionally, administrative staff responsible for inputting individual records data into documentation system have been trained regarding appropriate documentation and documentation location of next of kin for all individuals (See attachment #4). It is intended that these efforts to clarify policy and more specifically train administrative staff will prevent further violations pertaining to individual records from occurring in the future. Program Specialist was specifically tasked with completion of updating policy, correcting face sheets, and training administrative staff. 01/09/2018 Implemented
SIN-00101810 Renewal 11/21/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The agency's completed self-assessment did not contain a summary of corrections made. A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. The Program Specialist corrected the "Self-Inspection Tool" to include the score and the summary, see attachment #20. Policy on the Self Assessment was developed, describing in detail the procedure for self-inspection and follow-up plan, attachment # 21. Training conducted by the Program Specialist is documented on Attachment #22. 01/06/2017 Implemented
6400.71The telephone number to the poison control center was not posted on or near any of the telephones in the home. 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. The Program Specialist posted the Police-Fire-Ambulance: 911, emergency phone number poster in the kitchen near the telephone, see attachment #14. Program Specialist educated staff on "Emergency Telephone Number" policy, see attachment #15. Attachment #16 is the documentation of the staff retraining. 01/06/2017 Implemented
6400.103The written emergency evacuation procedure did not include individual responsibilities. There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. The program specialist updated the "Evacuation Plan" to include the distribution of duties, see attachment #12. Staff were re-educated on the "Emergency Procedure Plan" attachment #11 and the "Evacuation Plan" attachment #12. Documentation of retraining is Attachment #13. Ongoing training will be conducted on hire and annually thereafter at mandatory in-service 01/06/2017 Implemented
6400.112(h)The fire drill logs did not indicate if the individuals evacuated 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 program specialist revised the policy "Fire Drills" see Attachment #5. The fire drill log was updated to include the meeting place, see Attachment #8. The fire drill was completed on 12/9/2016 using the revised form. 01/06/2017 Implemented
6400.113(a)The home was licensed starting 12/1/15. Individual #1 was living in the home since 12/1/15 and not instructed in general fire safety until 9/1/16. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. Who: The program specialist and director of human resources updated the policy on Fire Safety Training, Attachment #4, to include " Upon admission and annually every January". What: Policy was revised. When: Current resident was re-educated on fire safety training program. The training is documented in attachment #4. The information presented to each resident is documented on Attachments #3 & 5. Staff retrained on the resident fire safety training plan as documented on Attachment #6. 01/06/2017 Implemented
6400.145(3)The written emergency medical plan did not include an emergency staffing plan. The home shall have a written emergency medical plan listing the following: An emergency staffing plan.WHO: The program specialist and director of human resources updated the policy on the emergency medical plan, attachment #1. What: The emergency medical plan was revised to include the link between the supervisor and the team leader. The team leader is now directed to call the supervisor on call in the event of a medical emergency When and How: All staff were retrained on the revisions of the policy, see Attachment #2. Moving forward the emergency medical plan with new provision will be addressed in new employee orientation and part of our annual mandatory in-service training. Dates: 1/3/2017 01/06/2017 Implemented
SIN-00237247 Renewal 01/23/2024 Compliant - Finalized
SIN-00219715 Renewal 01/31/2023 Compliant - Finalized
SIN-00199696 Renewal 02/08/2022 Compliant - Finalized
SIN-00184029 Renewal 01/19/2021 Compliant - Finalized
SIN-00146181 Renewal 01/03/2019 Compliant - Finalized
SIN-00086641 Initial review 11/25/2015 Compliant - Finalized