Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00262573 Unannounced Monitoring 03/07/2025 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34On 3/7/2025 at 2:37pm, licensing personnel were not provided access to inspect the locked closet located inside the staff office. According to Chief Executive Officer #1, the keys to the closet were taken to Individual #1's home mistakenly after Individual #1 stayed at this home while work was completed at their primary residence. Chief Executive Officer did not have a spare key to unlock this closet; therefore, it could not be inspected while licensing personnel were on-site. [Repeated violation: 8/13/2024 et al and 9/16/2024 et al]The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients.Ceo immediately obtained the key, unlocked it and placed the key in the staff office. 04/04/2025 Implemented
6400.64(a)On 3/7/2025 at 2:25pm, the inside of the oven was observed with burn food particles built up on the bottom inside the appliance.Clean and sanitary conditions shall be maintained in the home. Ceo immediately cleaned the oven. 04/04/2025 Not Implemented
SIN-00256535 Renewal 11/19/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)On 11/19/2024 at 1:56pm, a significant amount of dirt, hair, and debris was observed behind the toilet, inside the bathroom closet, and to the right of the vanity on the main level bathroom floor. On 11/19/2024 at 1:57pm, a significant amount of dirt, dust, and debris was observed on the floor inside the main level hallway closet. On 11/19/2024 at 2:07pm, a significant amount of dust was observed on the blades and light shades of the ceiling fan in the vacant individual bedroom located closest to the living room. On 11/19/2024 at 2:10pm, the washtub in the basement of the home was observed with dirt and debris in the sink basin. On 11/19/2024 at 2:15pm, dirt, dust, debris, and hair were observed on the floors and windowsills in the basement and garage. On 11/19/2024 at 2:17pm, cobwebs were observed suspended from the ceiling and in the corners throughout the basement and garage. On 11/19/2024 at 2:18pm, the inside walls and doors of the microwave and oven were observed with a thick layer of built-up food and grease. On 11/19/2024 at 2:20pm, a thick layer of sticky grease and splattered food particles were observed on the walls, cabinet doors, counters, floors, and appliance in the kitchen. All of the surfaces in the kitchen were tacky from the splattered grease. On 11/19/2024 at 2:21pm, a thick layer of dust was observed on the blades of the ceiling fan in the dining room. Additionally, cobwebs were observed suspended between the canopy and motor of the dining room ceiling fan.Clean and sanitary conditions shall be maintained in the home. CEO has contracted with a cleaning company to complete a deep cleaning of the entire home. 12/20/2024 Not Implemented
6400.64(b)On 11/19/2024 at 2:12pm, dirt and wood particles, that appeared to be from possible termites or other tunneling pests, were observed suspended from the rafters and on the water filtration system in the basement of the home. [Repeated violation: 9/16/2024, et al]There may not be evidence of infestation of insects or rodents in the home. CEO has contacted the landlord and maintenance team to assess the situation. The area will be tested and treated for any possible infestation. 12/20/2024 Not Implemented
6400.66On 11/19/2024 at 2:13pm, there was no light source observed in the room in the basement located directly across from the garage door. [Repeated violation: 9/16/2024, et al]Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. CEO has had maintenance team installed a wall light in the room in addition to the cieling light. 12/20/2024 Implemented
6400.67(b)On 11/19/2024 at 1:57pm, 4 small shards of wood, each measuring approximately two to three inches in length, were observed on the floor and shelf in the main level hallway closet. Floors, walls, ceilings and other surfaces shall be free of hazards.CEO has scheduled a deep cleaning on this site to ensure all debris and dust is removed. 12/20/2024 Not Implemented
6400.76(a)On 11/19/2024 at 2:09pm, the drain in shower in the basement of the home was observed without a cover. Furniture and equipment shall be nonhazardous, clean and sturdy. CEO has contacted the landlord and maintenance team and has the repair scheduled. Home is vacant and shower is not being used. 12/20/2024 Not Implemented
6400.82(f)On 11/19/2024 at 1:55pm, the main level bathroom was observed without a trash receptacle. [Repeated violation: 4/9/2024, et al]Each 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. CEO will place proper trash receptacle in the bathroom. 12/20/2024 Not Implemented
6400.104The fire department notification letter for this home was not kept current. The most recent version of the fire department notification, which was provided to licensing personnel on 11/5/2024, indicated that "the home services 1 individual with a mental disability". The home has been vacant since individual #1 was discharged from the agency on 7/5/2024.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. CEO has sent out an updated notification to the local fire department. CEO will continue to update this notification when new client is admit into the program/home. 12/20/2024 Implemented
6400.105On 11/19/2024 at 2:10pm, the lint trap in the dryer was observed plugged with approximately one-quarter of an inch of dryer lint. [Repeated violation: 4/9/2024, et al]Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. CEO has removed the lint from dryer. 12/20/2024 Implemented
6400.112(c)The fire drill logs for the drills occurring from 6/10/2023 through 6/18/2024 did not include a space for staff to document problems that were encountered during the fire drills. [Repeated violation: 4/9/2024, et al]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. CEO has updated the fire drill log and has placed new copies in the home. New fire drill log has area for staff to document problems encountered during the drill. 12/20/2024 Not Implemented
6400.112(e)The fire drill logs for the drills occurring from 6/10/2023 through 6/18/2024 did not indicate if the individual was awake or sleeping at the time of the fire drill. The fire drill logs did not include documentation that any drills were conducted during normal sleeping hours. [Repeated violation: 4/9/2024, et al]A fire drill shall be held during sleeping hours at least every 6 months. CEO has updated fire drill log to give staff an area to document if the drill was conducted during awake or sleep hours. 12/20/2024 Not Implemented
6400.112(f)The front door of the home was utilized for the exit route for all drills occurring from 6/10/2023 through 6/18/2024. [Repeated violation: 4/9/2024, et al]Alternate exit routes shall be used during fire drills. CEO will train new staff upon hire for this home of the need to use both the primary and secondary exists within the home. 12/20/2024 Not Implemented
6400.216(a)On 11/19/2024 at 2:00pm, the following documentation containing identifying information for individual #1 was observed in the unlocked closet in the unlocked staff office: approximately 40 controlled medication count sheets containing individual #1's name and prescribed medications; 1 ledger from March and April 2024 containing individual #1's name and petty cash balance; multiple body assessments ranging from December 2023 through July 2024 containing individual #1 name, physical concerns, and hygiene routine; individual #1's Function Behavior Assessment completed in March of 2014 containing individual #1's name and date of birth. [Repeated violation: 8/13/2024, et al] An individual's records shall be kept locked when unattended. CEO has removed all documents from the home pertaining to the previous client. 12/20/2024 Implemented
SIN-00249889 Unannounced Monitoring 08/13/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34On 8/13/2024 at approximately 12:35pm, Program Specialist #2 was made aware that licensing staff would need to be given access to this home as part of the unannounced inspection. Program Specialist #2 stated that Chief Executive Officer #1 had the key for the home and that licensing would be unable to inspect the home. At the time of the inspection, Chief Executive Officer #1 was reportedly out of town. Program Specialist #2 contacted Chief Executive Officer #1 via phone and confirmed that there was not a spare key for the home at the agency office and that the only key was with Chief Executive Officer #1. The agency was unable to provide licensing personnel with access to the home and the home could not be inspected to measure compliance with the §6400 regulations.The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients.CEO has placed a spare key at the home to ensure all avaliable staff have access to the home. 09/23/2024 Not Implemented
SIN-00246098 Unannounced Monitoring 05/23/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101On 5/23/2024 at approximately 2:40pm, a sliding lock was observed on the doorknob on the dining room side of the basement door. On the basement side of the door, there was no release mechanism for the lock. This door is the only means of egress from the basement of the home.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. CEO immediately contacted the maintenance man. He arrived 2 days after and disabled the lock from the door. CEO check the door knob and it is functional and cannot be locked. 06/21/2024 Implemented
6400.181(c)Individual #1's assessment, completed on 5/8/2024 by Program Specialist #1, has sections to include individual's functional strengths, individual's needs, individual's preferences, individual's dislikes, individual's interests, acquisition of functional skills, and recommendations that have been copied verbatim from the individual's ISPs that were last updated 8/11/2023 and 5/14/2024. The assessment was not based on the results of assessment instruments, interviews, progress notes and observations.The assessment shall be based on assessment instruments, interviews, progress notes and observations. CEO has personally updated all sections of the assessment. All new assessments are in the home and accessible to staff. 06/21/2024 Implemented
SIN-00242666 Renewal 04/09/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)On 4/9/2024 at 2:32pm, poisonous substances to include an 80-count container of Lysol disinfectant wipes, a 16 fluid ounce bottle of Finish Jet Dry rinse aid, and a 9.7 ounce bag of Finish Powerball Quantum dishwasher tabs were observed in the cabinet below the television in the living room. On 4/9/2024 at 2:35pm, poisonous substances to include 160-count container of McKesson Instant Hand Sanitizing Wipes was observed in the bottom drawer of the end table in the living, adjacent to the front door. Individual #1 is not assessed safe with poisonous materials.Poisonous materials shall be kept locked or made inaccessible to individuals. CEO placed all poisonous material in the identified lock cabinet. House Manager and DSP staff have been trained on the individuals RPP. House Manager and DSP staff have been trained on the identified locking cabinets in the home to store these poisonous materials. 04/22/2024 Not Implemented
6400.64(a)On 4/9/2024 at 2:20pm, the microwave located above the stove was observed with a thick layer of dirt and grease built up on the front, the kitchen range was observed with a thick layer of dirt and grease built up on the front, and the inside of the oven was observed with built up grease and food particles on the inside of the oven door and throughout the inside of the oven. On 4/9/2023 at 2:20pm, the walls and floors throughout the kitchen and dining room was observed with food crumbs and splatters. On 4/9/2024 at 2:21pm, the inside of the freezer was observed with spilled food and crumbs throughout the inside.Clean and sanitary conditions shall be maintained in the home. The CEO has scheduled a maintenance/cleaning service to be completed in the home. During that time the Kitchen and the appliances will be cleaned and replaced if needed. 05/01/2024 Not Implemented
6400.64(d)On 4/9/2024 at 2:31pm, a large black trash bag was found on the basement floor adjacent to the dryer. The bag was open and not secured in a trash receptacle to prevent penetration by insects and rodents.Trash in the bathroom, dining and kitchen areas shall be kept in cleanable receptacles that prevent the penetration of insects and rodents. CEO immediately removed the trash bag and placed it outside for disposal. CEO trained the House Manager and DSP staff on the requirement for daily trash removal. 05/01/2024 Implemented
6400.65On 4/9/2024 at 2:36pm, the furnace vent located in the living room to the left of the sofa was observed clogged with dirt and debris and was not allowing for proper airflow. On 4/9/2023 at 2:40pm, the cold air return located on the floor in the hallway adjacent to the bathroom was observed clogged with dirt and debris and was not allowing for proper airflow.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. CEO has scheduled a maintenance/cleaning service for the home. During this time all vents will be cleaned and replaced if needed. CEO has trained the House Manager and DSP staff on the requirements for clean ventilation. CEO has explained what is acceptable quality. 05/01/2024 Not Implemented
6400.67(b)On 4/9/2024 at 2:28pm, a puddle of water measuring approximately 12 inches wide by 18 inches long was observed on the basement floor in the storage room located across from the entrance to the garage. On 4/9/2024 at 2:28pm, approximately 4 puddles of water ranging from approximately 10 inches in diameter to 18 inches in diameter were observed on the floor in the garage. On 4/9/2024 at 2:30pm, a puddle of water measuring approximately 12 inches wide by 8 inches long was observed on the floor near the drain. The puddles posed potential slipping hazards for staff and individuals. Floors, walls, ceilings and other surfaces shall be free of hazards.CEO has spoken with the landlord/property manager about the flooding of the home during heavy rain. The property manager has scheduled and completed a maintenance service on the basement in which all areas of the basement were cleaned and dried. Property manager is looking into additional drain options to ensure the basement stays dry. 05/01/2024 Not Implemented
6400.76(a)On 4/9/2024 at 2:26pm one of the three benches located at the outdoor table on the back deck was observed with a chunk of wood missing from the corner. The missing piece of wood had exposed a sharp corner at the end of the bench and a rusty screw that could potentially injure staff or and individual. Furniture and equipment shall be nonhazardous, clean and sturdy. CEO has placed the damaged bench outside for disposal. 05/01/2024 Not Implemented
6400.105On 4/9/2024 at 2:30pm, the dryer lint filter was observed packed with approximately one quarter of an inch of lint and debris, posing a potential fire hazard. [Repeat violation: 5/23/2023]Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. CEO has cleaned the lint filter in the dryer and disposed of the excess lint. 05/01/2024 Not Implemented
6400.112(c)For all fire drills completed from 4/14/2023 through 3/18/2024, the fire drill record did not include the time the fire drills were conducted nor did it include whether or not problems were encountered during the drill.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. CEO has created a new document that fire drills will be recorded on. CEO has reviewed and trained himself on the regulations prior to developing the form. The CEO will train the DSP, House manager and Program Specialist on the new form and how to properly complete the form. 05/01/2024 Not Implemented
6400.112(e)For all fire drills completed from 4/14/2023 through 3/18/2024, the fire drill record did not indicate which drills, if any, were held during sleeping hours.A fire drill shall be held during sleeping hours at least every 6 months. CEO has created a new document that fire drills will be recorded on. CEO has reviewed and trained himself on the regulations prior to developing the form. The CEO will train the DSP, House manager and Program Specialist on the new form and how to properly complete the form. 05/01/2024 Implemented
6400.112(f)The fire drills conducted from 4/14/2023 through 3/18/2023 did not utilize alternating exit routes. All drills conducted during this time period utilized the front door for the means of egress.Alternate exit routes shall be used during fire drills. CEO has created a new document that fire drills will be recorded on. CEO has reviewed and trained himself on the regulations prior to developing the form. The CEO will train the DSP, House manager and Program Specialist on the new form and how to properly complete the form. 05/01/2024 Implemented
6400.141(c)(14)Individual #1's annual physical examination, completed on 6/22/2023, does not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. CEO has trained the program specialist on what is required for the individuals physical. The Program specialist has scheduled the individual to have another physical completed in July. During which time the doctor will fill out a new physical form. Once this form is received by the program specialist. They will review the form to ensure it is completed in its entirety. If not completed entirely the doctor will be contacted immediately and the form will be faxed for completion. 05/01/2024 Implemented
6400.145(1)The emergency medical plan for individual #1 does not include the hospital or source of healthcare to be used in the event of an emergency.The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. The CEO has taken the individuals preference for emergency medical treatment center and updated the emergency binder within the home. All will be trained on the updates in the individuals emergency binder. 05/01/2024 Implemented
6400.171On 4/9/2024 at 2:12pm, a 30 fluid ounce jar of Miracle Whip that expired on 12/5/2023 was observed in the refrigerator. On 4/9/2024 at 2:16pm, an 8.5 fluid ounce bottle of Premium Blend Soybean and Extra Virgin Olive Oil that expired on 10/31/2022 was observed in the kitchen cupboard to the left of the sink. On 4/9/2024 at 2:17pm, a 20 ounce loaf of classic white bread that expired on 4/3/2024 and a partial 20 ounce loaf of L'oven fresh wheat bread that expired on 4/4/2024 were observed in the kitchen drawer to the right of the stove. On 4/9/2024 at 2:18pm, a 40 ounce bag of frozen chicken tenderloins that expired on 1/15/2024 was observed in the freezer. On 4/9/2024 at 2:12pm, a plastic Country Crock butter container was observed in the kitchen cupboard with what appeared to be dried out raisins. The container was not labeled or dated. On 4/9/2024 at 2:13pm, a plastic Philadelphia Cream Cheese container that contained an unidentified white powder. The container was not labeled or dated. On 4/9/2024 at 2:14pm, a small clear jar that contained an unidentified light brown colored power. The jar was not labeled or dated. On 4/9/2024 at 2:18pm, an empty mayonnaise jar that contained an unidentified frozen clear substance. The jar was not labeled or dated. On 4/9/2024 at 2:21pm, a small pot that contained, what appeared to be, cooking oil. The pot did not have a lid and the oil was not label or dated. On 4/9/2024 at 2:22pm, a 6 ounce bottle of Old Bay Seasoning was observed in the kitchen cupboard adjacent to the fridge. The bottle was open and unprotected from contamination. On 4/9/2024 at 2:22pm, a 12 fluid ounce bottle of Burman's Hot Sauce was observed in the kitchen cupboard adjacent to the refrigerator. The bottle was open and the label stated to refrigerate after opening. On 4/9/2024 at 2:24pm, three 52 fluid ounce bottles of Nature's Nectar Homestyle Lemonade were observed on the kitchen counter. The labels indicated to keep the item refrigerated. [Repeat violation: 5/23/2023 and 6/29/2023]Food shall be protected from contamination while being stored, prepared, transported and served. CEO immediately removed all the expired and unlabeled food from the home. 05/01/2024 Not Implemented
6400.181(e)(1)Individual #1's assessment completed on 1/17/2024 did not include the strengths, needs, and preferences of the individual. This section was left blank. The assessment must include the following information: Functional strengths, needs and preferences of the individual. CEO has trained the program specialist on the regulations and the agencies form for assessing the individuals we serve. The Program specialist will be completing a completely new assessment. 05/01/2024 Not Implemented
6400.181(e)(2)Individual #1's assessment completed on 1/17/2024 did not include the likes, dislikes, and interests of the individual. This section was left blank.The assessment must include the following information: The likes, dislikes and interest of the individual. CEO has trained the program specialist on the regulations and the agencies form for assessing the individuals we serve. The Program specialist will be completing a completely new assessment. 05/01/2024 Not Implemented
6400.181(e)(3)(i)Individual #1's assessment completed on 1/17/2024 did not include the current level of performance and progress in the acquisition of functional skills. This section was left blank.The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. CEO has trained the program specialist on the regulations and the agencies form for assessing the individuals we serve. The Program specialist will be completing a completely new assessment. 05/01/2024 Implemented
6400.181(e)(3)(ii)Individual #1's assessment completed on 1/17/2024 did not include the current level of performance and progress in communication. This section was left blank. The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. CEO has trained the program specialist on the regulations and the agencies form for assessing the individuals we serve. The Program specialist will be completing a completely new assessment. 05/01/2024 Implemented
6400.181(e)(3)(iii)Individual #1's assessment completed on 1/17/2024 did not include the current level of performance and progress in personal adjustment. This section was left blank.The individual's current level of performance and progress in the following areas: Personal adjustment. CEO has trained the program specialist on the regulations and the agencies form for assessing the individuals we serve. The Program specialist will be completing a completely new assessment. 05/01/2024 Implemented
6400.181(e)(3)(iv)Individual #1's assessment completed on 1/17/2024 did not include the current level of performance and progress in personal needs without assistance from others. This section was left blank.The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others. CEO has trained the program specialist on the regulations and the agencies form for assessing the individuals we serve. The Program specialist will be completing a completely new assessment. 05/01/2024 Implemented
6400.181(e)(12)Individual #1's assessment completed on 1/17/2024 did not include recommendations for specific areas of training, programming and services. This section was left blank.The assessment must include the following information: Recommendations for specific areas of training, programming and services. CEO has trained the program specialist on the regulations and the agencies form for assessing the individuals we serve. The Program specialist will be completing a completely new assessment. 05/01/2024 Not Implemented
6400.18(i)Incident #9351761, had a due date of 2/23/2024 for the Provider's Administrative Review Section. The Administrative Review was entered into the Department's Enterprise Incident Management System on 2/27/2024 at 12:04:55 PM. Incident #9387761, had a due date of 3/14/2024 for the First Section of the report. The First section was entered into the Department's Enterprise Incident Management System on 3/26/2024 at 2:31:28 PM. Extensions for the incidents were not requested.The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension.CEO and Program Specialist (CI) have reviewed the EIM bulletin and familiarized themselves with the regulations and timelines for reporting incidents. 05/01/2024 Not Implemented
6400.34(a)Individual #1 was informed of their individual rights on 1/12/2023 and again on 1/23/2024.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.CEO has trained the program specialist on the client file regulations which include the notification/training deadlines for the individuals rights policies. 05/01/2024 Implemented
6400.163(h)On 4/9/2024 at 2:04pm, the following PRN medications prescribed to Individual #1 had expired on 4/23/2023 and had not been properly disposed of: Ibuprofen Tab 200mg, Acetamin Tab 500mg, Acetaminophe Tab 325mg, Loratadine 10mg Tabs, Stool Softener Tab 8.6-50mg. [Repeat violation: 5/23/2023]Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.CEO removed and disposed of the medications per agency policy and procedure. 05/09/2024 Implemented
6400.165(g)Individual #1's psychiatric medication reviews were completed on 5/9/2023, 10/31/2023, and 2/12/2024.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.The CEO has trained the Program Specialists on the required quarterly psych medications review regulations. The CEO has trained the Program specialist on the proper documentation required for each of these reviews (Agency form and consult forms). The CEO has trained the Program Specialist on the proper way to document if there are any unavoidable delays in these medications reviews. 04/25/2024 Not Implemented
6400.194(c)The human rights committee members that approved Individual #1's restrictive procedure plan at the meetings held on 8/15/2023, 11/1/2023, and 2/1/2024 included of Program Specialist #1, Chief Executive Officer #2, and House Manager #3. All of the committee members provide direct services to the individual.The human rights team shall include a majority of persons who do not provide direct services to the individual.The CEO will identify and add a member from outside the agency who is not affiliated with the client. 05/01/2024 Not Implemented
SIN-00231972 Unannounced Monitoring 09/25/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)At the time of inspection, the kitchen sink had a significant leak, from a gray tube under the sink. The leak has gone through the kitchen floor to the ceiling of the basement. The leak is dripping onto the washer and an electrical outlet. [Repeat violation-5/23/23, 6/29/23 and 7/25/23] Floors, walls, ceilings and other surfaces shall be free of hazards.The homes rental manager was immediately notified of the Maintenace request. The CEO was informed that the maintenance man would be coming to the home on multiple different dates. The maintenance man did arrive on 9/27/23 and the leak was repaired again. 10/19/2023 Implemented
6400.69(b)The digital thermostat, located in the livingroom of the home, reflects the temperature is set at 50 degrees Fahrenheit during sleeping hours.The indoor temperature may not be less than 58°F during sleeping hours. The educated the staff within the home and the house manager that the house cannot be kept a temperature less than 58 degrees. The House Lead adjusted the thermostat. 10/19/2023 Implemented
6400.165(b)At the time of inspection, Pseudoephedrine, 120mg ER, take 1 tablet by mouth every 12 hours only as needed for congestion was listed on Individual #1's September 2023 Medication Administration Record, but was not in the home. [Repeat violation-5/23/23]A prescription order shall be kept current.The agency submit and EIM for this missing medication but was later informed it was not a reportable incident. The Program specialist contacted the pharmacy and the medications was overnighted to the home. 10/19/2023 Implemented
SIN-00228231 Unannounced Monitoring 07/25/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone number of the poison control center was not located on or by the telephones in the living room and staff office. [Repeat Violation-2/14/23, 5/23/23 and 6/29/23]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 home laptop has the emergency phone numbers document saved to the computer. The Home has labels that the emergency numbers can be printed on and placed on the back the phone. New label has been placed on the back of the phone picture confirmation has been sent to the CEO and the CEO will check during his weekly house checks and unannounced visits. 08/02/2023 Implemented
6400.77(b)The first aid kit did not contain a thermometer. [Repeat Violation-3/17/23, 5/23/23 and 6/29/23] A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. The CEO has purchased 2 thermometers for the home to be placed in each first aid kit. 08/02/2023 Implemented
SIN-00226914 Unannounced Monitoring 06/29/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The first aid kit did not contain scissors or tweezers. [Repeat Violation: 3/17/23 and 5/23/23] A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. The house lead located the missing tweezers and placed them in the first aid kit. The CEO purchased a back up first aid kit for the home in the event that an item is missing from the initial first aid kit the back up first aid kit will be accessible for staff. 07/17/2023 Implemented
6400.171During inspection the following items were not properly sealed to prevent contamination: an open Ziploc bag filled, approximately ¼ of the way full of flour was being stored in the refrigerator and an open box of Idahoan Instant Mashed Potatoes 13.75-ounce box was being stored on top of the refrigerator. [Repeat Violation: 2/14/23, 3/17/23 and 5/23/23]Food shall be protected from contamination while being stored, prepared, transported and served. The House Manager and House lead the identified open containers of food. The house was accessed for any additional open containers of food. The CEO has purchased multiple storage containers for the home to have on hand for there use as needed. All staff have been trained on what the food storage regulations are and how the agency complies with these regulations. 07/17/2023 Implemented
SIN-00225319 Unannounced Monitoring 05/23/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(b)At 10:50AM on 5/23/2023, there were an inordinate amount of small black insects on the floor along the walls in the basement of the home.There may not be evidence of infestation of insects or rodents in the home. The CEO purchased ant killer from Home Depot and sprayed the exterior walls of the basement. During his treatment there were no ants present. The House Manager is making spot checks of the home to ensure all trash is taken out daily. 06/22/2023 Implemented
6400.64(e)At 10:53AM on 5/23/2023, a trash receptacle over 18 inches, overflowing with trash, was in the basement of the home near the washer and dryer.Trash receptacles over 18 inches high shall have lids. the CEO purchased a new trash can from amazon which is scheduled to be delivered on 6/24/23. This new trash can lid is connected and cannot be removed. The previous trash can lid was removed and not replaced. The House Manager and DSP staff have been trained on the regulations surrounding the trash receptacles and the requirements for having a lid. 06/24/2023 Implemented
6400.68(b)At 10:57 AM the hot water measured 126.5 degrees Fahrenheit in the only bathtub in the home. [Repeat Violation: 3/17/23] Hot water temperatures in bathtubs and showers may not exceed 120°F. The House Manager has turned down the temperature on the hot water tank. The House Manager checked the temperature after the water was temp as adjusted. The Water temp after adjusted was within regulatory range. The DSP staff have been trained on where the hot water thermostat is located and what the sign posted saying DO NOT TOUCH means. 06/24/2023 Implemented
6400.71Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by the telephone in the living room. [Repeat Violation: 2/14/23]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 CEO and the House Manager reviewed the staff office and house phone. The Emergency numbers were placed under the phone jack in the office. The emergency numbers have been adhered to the back of the house phone. 06/24/2023 Not Implemented
6400.77(b)The first aid kit did not contain scissors. [Repeat Violation: 3/17/23] A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. The House Manager completed a audit of the first aid kit and located scissors within the kit at the time of the audit. It is unknown if the scissors were removed for use during the time of the inspection. The House Manager trained the DSP staff that all supplies need to be returned to the first aid kit immediately after use. 06/20/2023 Not Implemented
6400.81(k)(6)Individual #1's bedroom did not have a mirror.In bedrooms, each individual shall have the following: A mirror. The CEO has purchased a free standing mirror on 6/21/23 via amazon to be delivered to the individual hom on 6/24/23. Once the mirror is delivered the House Manager will ensure it is assembled and installed in the individuals bedroom where the individual chooses. 06/24/2023 Implemented
6400.105At 10:52AM on 5/23/2023, there was approximately a ¼ inch thick accumulation of lint in the dryer lint trap causing a fire hazard. [Repeat Violation: 2/14/23 and 3/17/23]Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. The House Manager disposed of the excess lint in the dryer. The House Manager trained the DSP staff on where the lint catcher is located in the dryer. The House Manager has made periodic checks to ensure the lint catcher is emptied on a regular basis. 06/22/2023 Implemented
6400.171At 10:16AM on 5/23/2023, a package of lunchmeat with a best by date of 5/8/2023 was in the drawer inside the refrigerator. [Repeat Violation 2/14/23 and 3/17/23]Food shall be protected from contamination while being stored, prepared, transported and served. The House Manager has completed a thorough inspection of the food items in the home. All outdated food items have been disposed of. The CEO has purchased labels for the DSP staff and House Manager to use to label food items that the expiration dates are difficult to read. Labels were ordered via amazon on 6/21/23. 06/24/2023 Not Implemented
6400.18(a)(1)Incident #9201138 was discovered 4/10/23 and reported in EIM 4/18/23.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Death.The incident was reported to the county IM rep and there was not sufficient information to complete and EIM. The IM rep stated they needed to get back to us with further information prior to entering the EIM. Once we received the needed information the EIM was entered. All email documentation on this delay is kept in the office. 06/20/2023 Implemented
6400.163(h)Individual #1's May 2023 Medication Administration Record states "Medroxypr AC inj, 1ml, IM, every 12 weeks". Through interviews it was disclosed this medication was discontinued prior to Individual #1's date of admission 1/5/23. [Repeat Violation: 2/21/23 and 3/17/23]Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The CEO reviewed the MAR with the Program Specialist and the RN and it was determined that this medication was discontinued in February. This medication was not on the MAR in March, April, May, nor is it present on Junes MAR. 06/20/2023 Implemented
6400.166(a)(3)Individual #1's May 2023 Medication Administration Record did not include drug allergies.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Drug allergies.The CEO spoke with the program specialist whom stated the individuals list of medications and allergies are in Therap and all staff have been trained and have access to them. The Program Specialist has sent the list of allergies to the agency's RN whom is updating the MAR. 06/25/2023 Implemented
6400.166(a)(4)The following as needed medications were located in the home but are not listed on Individual #1's May 2023 medication administration record: Acetaminophen 500 mg, Stool softener 8.6mg-50mg, Loratadine 10 mg, Acetaminophen 325mg, Stimulant 8.6mg-50mg.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.The CEO worked with the Program Specialist and the RN to review the MAR and the medications in the home. All medications listed in this violation are on the MAR and have been on the MAR other than the stimulant 8.6mg-50mg. The prescribing physician was contacted, and the prescription is no longer active. That stimulant was removed and disposed of per agency procedure. 06/20/2023 Implemented
6400.166(a)(5)The following as needed medications were located in the home but are not listed on Individual #1's May 2023 medication administration record: Acetaminophen 500 mg, Stool softener 8.6mg-50mg, Loratadine 10 mg, Acetaminophen 325mg, Stimulant 8.6mg-50mg.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.The CEO worked with the Program Specialist and the RN to review the MAR and the medications in the home. All medications listed in this violation are on the MAR and have been on the MAR other than the stimulant 8.6mg-50mg. The prescribing physician was contacted, and the prescription is no longer active. That stimulant was removed and disposed of per agency procedure. 06/20/2023 Implemented
6400.166(a)(6)The following as needed medications were located in the home but are not listed on Individual #1's May 2023 medication administration record: Acetaminophen 500 mg, Stool softener 8.6mg-50mg, Loratadine 10 mg, Acetaminophen 325mg, Stimulant 8.6mg-50mg.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form.The CEO worked with the Program Specialist and the RN to review the MAR and the medications in the home. All medications listed in this violation are on the MAR and have been on the MAR other than the stimulant 8.6mg-50mg. The prescribing physician was contacted, and the prescription is no longer active. That stimulant was removed and disposed of per agency procedure. 06/20/2023 Implemented
6400.166(a)(7)Individual #1's prescribed Melatonin medication label states, "Take 2 Tablets (6MG) by mouth at bedtime." The May 2023 paper Medication Administration Record states, "Take one tablet by mouth at bedtime."A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.The CEO worked with the Program Specialist and the RN to review the MAR. Upon review of the MAR the correct dosage of the medication was determined to be in the MAR. The medication was increased by the physician on 5/9/23. Once the orders were received the Program specialist forwarded those orders to the RN and the RN updated the MAR accordingly. The program specialist has documentation all communication and MAR update. 06/24/2023 Implemented
6400.166(a)(7)The following as needed medications were located in the home but are not listed on Individual #1's May 2023 medication administration record: Acetaminophen 500 mg, Stool softener 8.6mg-50mg, Loratadine 10 mg, Acetaminophen 325mg, Stimulant 8.6mg-50mg.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.The CEO worked with the Program Specialist and the RN to review the MAR and the medications in the home. All medications listed in this violation are on the MAR and have been on the MAR other than the stimulant 8.6mg-50mg. The prescribing physician was contacted, and the prescription is no longer active. That stimulant was removed and disposed of per agency procedure. 06/20/2023 Implemented
6400.166(a)(8)The following as needed medications were located in the home but are not listed on Individual #1's May 2023 medication administration record: Acetaminophen 500 mg, Stool softener 8.6mg-50mg, Loratadine 10 mg, Acetaminophen 325mg, Stimulant 8.6mg-50mg.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.The CEO worked with the Program Specialist and the RN to review the MAR and the medications in the home. All medications listed in this violation are on the MAR and have been on the MAR other than the stimulant 8.6mg-50mg. The prescribing physician was contacted, and the prescription is no longer active. That stimulant was removed and disposed of per agency procedure. 06/20/2023 Implemented
6400.166(a)(9)The following as needed medications were located in the home but are not listed on Individual #1's May 2023 medication administration record: Acetaminophen 500 mg, Stool softener 8.6mg-50mg, Loratadine 10 mg, Acetaminophen 325mg, Stimulant 8.6mg-50mg.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.The CEO worked with the Program Specialist and the RN to review the MAR and the medications in the home. All medications listed in this violation are on the MAR and have been on the MAR other than the stimulant 8.6mg-50mg. The prescribing physician was contacted, and the prescription is no longer active. That stimulant was removed and disposed of per agency procedure. 06/20/2023 Implemented
6400.166(b)Individual #1's is prescribed Lorazepam as needed. The medication has been administered 4 times; 1/24/23, 2/8/23 and 4/5/23. A third pill was popped from the blister pack; however, it was not dated or initialed by the staff who administered the medication. Through interviews, staff disclosed they are not initialing Individual #1's Medication Administration Record when administering medications. The staff administering the medications calls the House Manager, who then enters the staff's initials into Therap.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The agency's electronic MAR system, Therap, was down for 3 days and there was a paper MAR in place. The CEO has trained the Program Specialist, The House Manager and the DSP staff that in the event the electronic MAR is down. The staff are to document on the paper MAR then once the electronic MAR is up and running again. Those staff whom passed meds are to log in and document again on the electronic MAR. 06/20/2023 Implemented
6400.208(a)Individual #1 wears a leotard, daily, in an effort to avoid behaviors. There is no restrictive procedure documentation provided.A physical restraint, defined as a manual method that restricts, immobilizes or reduces an individual's ability to move the individual's arms, legs, head or other body parts freely, may only be used in the case of an emergency to prevent an individual from immediate physical harm to the individual or others.The CEO and Program Specialist scheduled a team meeting with the individuals Guardian, SC, BSP, and SWAP admin. The meeting was held on 6/8/23 at 10am. During the meeting it was decided to write an RPP for the individuals leotard as well as locking the kitchen cabinets. The BSP has written the RPP and has submit the plan to her supervisor for approval. SWAP is currently waiting on the approved plan to be provided. Once we receive the RPP we will train all staff on the RPP and make the modifications to the home as needed. 06/08/2023 Implemented
SIN-00221199 Unannounced Monitoring 03/17/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(b)(3)On 3/17/2023, interviews revealed that Chief Executive Officer#1 had trained staff to manipulate the Therap computer software allowing them to falsify information on the medication administration record by entering or changing staff's initials to reflect medications had been administered to Individual #1. It was also revealed that there is a direct support staff with the agency who cannot use the Therap system, so someone else enters their initials on the medication administration record. This presents the possibility of the medication administration record being initialed without the medications being administered.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. The DSP were immediately spoken with and educated on therap and they confirmed that they were not trained on how to manipulate therap. The staff were trained on the agency uses Therap for the individuals MAR and daily note. All staff have confirmed they understand how to properly use therap. 03/31/2023 Not Implemented
6400.101At 8:30 AM, on 3/17/23, staff had placed the round, wooden dining table against the entry way into the kitchen blocking entry to the kitchen and also blocking the sliding glass door in the dining room preventing egress from the home.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The CEO has educated staff on the regulations regarding means of egress and what is considered restrictive to the individual. The dinning room table is in its proper position. A meeting was held regarding the individuals supervision and safety. Motion sensors were installed in the entry way into the kitchen and are operable. 03/31/2023 Not Implemented
6400.18(a)(5)Incident# 9178730 For Individual #1 for Neglect, Failure to provide needed care regarding Individual #1's personal care, was discovered 3/2/2023 and reported 3/7/2023. Incident #9178759 for Individual #1 for Neglect, Failure to provide needed supervision regarding staff not being present at the home at appointed times, was discovered 3/2/2023, and reported 3/7/2023. Incident #9178786 for Individual #1 for Neglect, Failure to provide protection from hazards regarding window coverings, furniture/appliances in disrepair and alarms on door and cabinets was discovered 3/2/2023 and reported 3/7/2023. Incident #9172481 for Individual #1 for Neglect, Failure to Provide Needed care regarding feces under Individual #1's fingernails was discovered 2/10/2023 and reported 2/22/2023. Incident #9178708 for Individual #1 for Neglect, Failure to Provide medication management regarding neglectful interruption of refills resulting in going without Clonazepam, was discovered 1/31/2023 and reported 3/7/2023. As of 3/16/2023 at 4:56pm an investigation for incident #9178708 had not been started.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Neglect. The agency Program Specialist has completed the CI training and is now a certified CI. The agency has a contract with a back up CI in the event the Program Specialist is not avaliable. All incidents and APS reports have been reviewed and entered into the EIM system. 03/20/2023 Not Implemented
6400.18(a)(6)Incident #9178744 for Individual #1 for Exploitation, Misuse/Theft of Medications regarding theft of $100 from resident's personal cash on hand, was discovered 3/2/2023 and reported 3/7/2023.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Exploitation .The agency Program Specialist has completed the CI training and is now a certified CI. The agency has a contract with a back up CI in the event the Program Specialist is not avaliable. All incidents and APS reports have been reviewed and entered into the EIM system. 03/20/2023 Not Implemented
6400.18(a)(13)Incident #9188766 for Individual #1 for Rights Violation, Services regarding Individual #1 being unavailable/not prepared for psychiatric telemedicine appointment was discovered 3/2/2023 and reported 3/7/2023.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: A violation of individual rights.The agency Program Specialist has completed the CI training and is now a certified CI. The agency has a contract with a back up CI in the event the Program Specialist is not avaliable. All incidents and APS reports have been reviewed and entered into the EIM system. 03/20/2023 Not Implemented
6400.32(t)At 8:30 AM, on 3/17/23, staff had placed the round, wooden dining table against the entry way into the kitchen blocking entry to the kitchen, prohibiting the Individual access to food.An individual has the right to access food at any time.The CEO has educated staff on the regulations regarding means of egress and what is considered restrictive to the individual. The dinning room table is in its proper position. A meeting was held regarding the individuals supervision and safety. Motion sensors were installed in the entry way into the kitchen and are operable. 03/31/2023 Not Implemented
6400.207(1)As directed by Individual #1's 3/7/2023 Temporary Safety Plan, "·In the event staff need to utilize the bathroom, staff will place Individual #1 into her bedroom to confirm a safe location and will be able to hear & view Individual #1 from the bathroom."The following procedures are prohibited: Seclusion, defined as involuntary confinement of an individual in a room or area from which the individual is physically prevented or verbally directed from leaving. Seclusion includes physically holding a door shut or using a foot pressure lock.The safety plan was never implemented it was only in draft form staff were not trained on it prior to the inspection. The finale safety plan has been approved and updated in the ISP. The installation and use of video monitors were approved and installed in the home. 03/31/2023 Not Implemented
SIN-00219557 Unannounced Monitoring 02/21/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)Individual #1, date of admission 1/5/23, had initial fire safety training 1/12/23. 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. what specific change will be made: Fire safety training paperwork and training be presented and completed on date of admission who will make the change: Program Specialist and Program Director when will the change be made: 3/1/2023 how will the change be made: Fire safety action will be added to the admission packet list system that has been implemented to make sure that the same violation will not occur again: Fire safety action will be added to the admission packet list training that will be provided to staff: Staff will be trained on updated admission packet list and all annual trainings 03/01/2023 Not Implemented
6400.141(a)Individual #1, date of admission 1/5/23, did not have a physical examination prior to admission. The documentation provided, dated 6/6/22 was a printout from a doctor's office but did not appear to be a physical examination and did not meet regulations, therefore, compliance could not be measured.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. what specific change will be made: Agency made physical examination form will be sent to PCP prior to admission date and this procedure will be added to pre admission protocol. who will make the change: Program Specialist and Program Director when will the change be made: 3/1/2023 how will the change be made: Admission protocol will be altered so as to ensure proper documentation for physical examination is obtained system that has been implemented to make sure that the same violation will not occur again: Sending physical examination form will be permanently apart of pre-admission procedure for all clients training that will be provided to staff: Staff will be trained on updated admission packet list and all annual trainings 03/01/2023 Not Implemented
6400.34(a)Individual #1, date of admission 1/5/23, was informed and explained individual rights 1/12/23.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.what specific change will be made: Individual Rights paperwork and training be presented and completed on date of admission who will make the change: Program Specialist and Program Director when will the change be made: 3/1/2023 how will the change be made: Individual rights will be added to the admission packet list system that has been implemented to make sure that the same violation will not occur again: Individual Rights document will be added to the admission packet list, explained to client/guardian, and signed upon admission date training that will be provided to staff: Staff will be trained on updated admission packet list 03/01/2023 Not Implemented
6400.52(c)(6)The Direct Service Workers at the home did not receive individual specific trainings, as stated in the ISP last updated 2/8/23, prior to working with Individual #1. The trainings include "behavior plan, restrictive plan, PICA diagnosis, chocking risk, incident reporting, emergency PRN medication and process for approval and how to support Individual #1due to elopement concerns."The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.what specific change will be made: Staff will complete the following trainings once hiring paperwork and working schedule assigned : Behavior plan restrictive plan, PICA diagnosis, chocking risk, incident reporting, emergency PRN medication and process for approval and how to support client. who will make the change: Program Specialist and Program Director when will the change be made: 3/1/2023 how will the change be made: Staff onboarding will alter to adhere to all required client specific training. system that has been implemented to make sure that the same violation will not occur again: Staff will not be able to work in the home in specific client training is not completed with onboarding and orientation. training that will be provided to staff: Staff will be trained on client specific trainings upon hiring and home assignment 03/01/2023 Not Implemented
6400.163(h)Individual #1's February 2023 medication administration record lists Medroxy PR AC injection, 150mg/ml, inject 1 ml intramuscular every 12 weeks for birth control. The Program Specialist and Direct Support Worker present during this investigation reported the medication had been discontinued. However, there was no discontinue order for the medication.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.what specific change will be made: Discontinue order for medication in question will be obtained by individual's PCP and recorded in medication records. who will make the change: Program Specialist and Program Director when will the change be made: 3/10/2023 how will the change be made: PCP office will be contacted and order will be emailed or faxed to program specialist for documentation system that has been implemented to make sure that the same violation will not occur again: Program specialist, Agency nurse and house managers will audit medication administration record list on a monthly basis to assure accurate and updated information. training that will be provided to staff: Program specialist will obtain records and engage with nurse on changes in medication administration records. 03/02/2023 Implemented
6400.165(c)Individual #1's February 2023 medication administration record lists Pseudoephedrine, 120mg tablet, take 1 tablet by mouth every 12 hours 8am/8pm for congestion. The Program Specialist and Direct Service worker present during this investigation reported this medication is an as needed medication. The medication was not located at the home and the order did not indicate it was an as needed medication.A prescription medication shall be administered as prescribed.what specific change will be made: PRN order for medication in question will be obtained by individual's PCP and recorded in medication records. who will make the change: Program Specialist and Program Director when will the change be made: 3/10/2023 how will the change be made: PCP office will be contacted and PRN order will be emailed or faxed to program specialist for documentation system that has been implemented to make sure that the same violation will not occur again: Program specialist, Agency nurse and house managers will audit medication administration record list on a monthly basis to assure accurate and updated information. training that will be provided to staff: Program specialist will obtain records and engage with nurse on changes in medication administration records. 03/02/2023 Implemented
6400.166(a)(11)Individual #1's medication administration record did not include a diagnosis or purpose for the medication Divalproex, 250mg tab.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.what specific change will be made: medication administration record will be changed to add purpose of diagnosis for medication in question. Agency nurse will alter this who will make the change: Program Specialist and Agency RN when will the change be made: 3/3/2023 how will the change be made: Correct change will be made in medication administration record system that has been implemented to make sure that the same violation will not occur again: Program specialist, Agency nurse and house managers will audit medication administration record list on a monthly basis to assure accurate and updated information. training that will be provided to staff: Agency nurse will be trained on policy and information input into medication system 03/02/2023 Implemented
6400.186Individual #1's ISP, last updated 2/8/23, states the home shall have ALARMS ON THE KITCHEN CABINETS AND CAMERAS BOTH IN AND OUTSIDE OF THE HOME, A SENSORY ROOM, a PECS COMMUNICATION SYSTEM and that STAFF NEEDS TO DOCUMENT INJURIES AT LEAST ONCE PER BLOCK OR SHIFT. The home did not have alarms on the kitchen cabinets or cameras in and outside of the home, a sensory room or a PECS communication system at the time of this investigation. The Direct Support Worker present during this investigation reported and provided documentation for Individual #1's injuries being documented when Individual is bathed 4 times per week.The home shall implement the individual plan, including revisions.what specific change will be made: Program Specialist will contact Support's Coordinator in order to obtain accurate changes to ISP which reflect client's way of living. Client and guardian of client do not require sensory room or cameras, per guardian and treatment team who will make the change: Program Specialist and Supports Coordinator when will the change be made: 3/10/2023 how will the change be made: Program Specialist will discuss alterations of ISP with treatment team system that has been implemented to make sure that the same violation will not occur again: Program Director and Specialist will meet on a monthly basis to audit ISP training that will be provided to staff: Staff to be trained on new ISP after changes 03/10/2023 Not Implemented
6400.207(4)(I)Individual #1 is prescribed Lorazepam, 1mg every 6 hours, as needed, for behaviors.A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition.what specific change will be made: Program Director will create and initiate new policy on this medication and procedures on how to administer medication who will make the change: Program Director when will the change be made: 3/10/2023 how will the change be made: Program Director to administer new agency policy immediately and train staff on appropriate protocol system that has been implemented to make sure that the same violation will not occur again: Program Director and Specialist will meet on a monthly basis to discuss medication policies training that will be provided to staff: Staff to be trained on new medication policy 03/10/2023 Not Implemented
SIN-00215212 Add an Addendum 11/22/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The hot water temperature measured 127.7 degrees Fahrenheit at 10:45 AM, at the only bathtub, in the bathroom near the bedrooms. Hot water temperatures in bathtubs and showers may not exceed 120°F. SWAP house manager and direct care staff have been trained on the regulations surrounding the water temperature in the homes. CEO trained the management team on 11/29/22 has adjusted the temperature thermostat on the hot water tank. House Manager has placed a sign on the hot water tank to direct all staff to not touch nor adjust the hot water tank temperature. When licensing any new site house managers will check the hot water temperature to ensure it does not exceed 120 degrees. House managers will also place signs on the hot water tanks that direct all employees to not adjust the thermostat. 11/29/2022 Implemented
SIN-00264964 Unannounced Monitoring 04/22/2025 Compliant - Finalized