Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00247052 Renewal 06/25/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.182(c)Individual #1's individual plan, last updated 5/06/2024, states "There is a shake awake attached to Individual #1's bed to wake them during fire drills when Individual #1 is lying in bed. Individual #1 needs the shake awake going off with fire drills as Individual #1 is deaf and may not be able to hear the fire alarm going off." On 6/26/2024 at 11:04pm, the shake awake device on individual #1's bed was not operable and did not vibrate when the fire alarms were tested.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.It was discovered that the shake awake was disconnected to the fire alarm. It was reconnected and video taken to verify that shake awake remains in working order ISP and Assessment were reviewed to ensure that the need for the bed shaker is documented in each 07/31/2024 Implemented
6400.207(5)(III)On 6/26/2024 at approximately 10:50 AM, Individual #1's hospital bed was observed with bilateral upper and lower bedrails that restrict the movement or function of Individual #1's body. On 6/26/2024 at approximately 10:58 AM, Individual #2's hospital bed was observed with bilateral upper and lower bedrails that restrict the movement or function of Individual #2's body. On 6/26/2024 at approximately 10:59 AM, Individual #3's hospital bed was observed with bilateral upper and lower bedrails that restrict the movement or function of Individual #3's body. On 6/26/2024 at approximately 11:00 AM, Individual #4's hospital bed was observed with bilateral upper and lower bedrails that restrict the movement or function of Individual #4's body.A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Protection from injury during a seizure or other medical condition, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement.Lakeshore will transition from the use of bed rails to alternative adaptive equipment to be used in beds to ensure consumer's health and safety 09/01/2024 Implemented
SIN-00209283 Renewal 07/28/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace was inspected 2/09/2021, 2/21/2021, 1/13/2022, and 6/29/2022 but there is no documentation it was cleaned by a professional cleaning company.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. Maintenance staff will be re-certified to inspect and clean the furnace. The Certification will be kept on file. A form will be developed to document the date the Maintenance staff will clean furnaces and inspect the furnace. The furnace will be re-inspected and re-cleaned by October 1, 2022. 10/01/2022 Implemented
6400.113(c)Individual #1's fire safety training did not include the content of the training. A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept.Descriptive content detailing what individuals are instructed on during monthly fire drills was developed and will be distributed to all homes as a resource for staff completing the drill and instructing consumers 09/15/2022 Implemented
6400.51(b)(5)Direct Service Worker #2's, date of hire 11/10/2021, orientation did not include job-related knowledge and skills.The orientation must encompass the following areas: Job-related knowledge and skills.Staff was originally hired on 10/12/2015. Staff resigned on 11/1/2019. Staff was rehired on 2/10/2020. Staff resigned on 10/11/2021. Staff was rehired on 11/10/2021. Staff¿s original orientation on 10/12/2015 included job-related knowledge and skills that were submitted during licensing 07/29/2022 Implemented
6400.52(c)(5)Program Specialist #1's annual training did not include the safe and appropriate use of behavior supports. Direct Service Worker #3's annual training did not include the safe and appropriate use of behavior supports.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.Behavioral Support Plan training records are maintained in the consumer's permanent file. Requested documentation of the training was submitted. 07/29/2022 Implemented
6400.52(c)(6)Program Specialist #1's annual training did not include implementation of the individual plan. Direct Service Worker #3's annual training did not include implementation of the individual plan.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.ISP training records are maintained in the consumer's permanent file. Requested documentation of the training was submitted. 07/29/2022 Implemented
6400.166(a)(11)Individual #1's July 2022 medication administration record did not include diagnosis or purpose for the following medications: Florajens Capsule, Fluticasone 50mcg spray, Terazosin 5mg capsule, Mineral Oil, Paroxetine 20mg tablet, and Risperidone 1mg tablet.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.Program Specialists and Directors will review all Medication Administration Records to ensure that all medications prescribed have a diagnosis and reason for medication. Any found missing this information will be remediated by contacting the prescribing physician 10/01/2022 Implemented
6400.195(b)Individual #1 had the behavior support component of the individual plan reviewed 12/17/2021 and then again 6/24/2022.The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews.Behavioral Support Plans will be reviewed not to exceed 180 days 09/05/2022 Implemented
6400.213(1)(i)213 (1)ii Individual #1's record did not include identifying marks.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.Error was found in electronic medical record that did not populate identifying marks to the emergency information. Error has been corrected 09/05/2022 Implemented
SIN-00153763 Renewal 04/16/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(d)Program Specialist #1, date of hire 1/12/08, completed his/her own Medication Administration Record reviews for the medication administration annual course practicum. Program Specialist #2, date of hire 10/13/14, completed his/her own Medication Administration Record reviews for the medication administration annual course practicum.A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. The issue is being immediately addressed by assigning all observer's to a different facility to conduct MAR reviews ensuring their MAR reviews are completed by another trained Practicum Observer. All Observer's will be scheduled once a month in a different facility to ensure that they have the time and availability to complete the MAR review for other Practicum Observers. No Observer will be permitted to perform/document their own MAR review form. Human Resources Department will be responsible for ensuring compliance with the plan. [Within 30 days of receipt of the plan of correction, the CEO or designee shall train all staff responsible for completing medication administration course annual practicum and the human resource department of each of their responsibilities and of the procedures to ensure that all staff person who administer prescription medications to the individual have passed the Medications Administration Course Practicum annually. (DPOC by AES,HSLS on 5/3/19)] 04/29/2019 Implemented
SIN-00093063 Unannounced Monitoring 03/02/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)Between the dates of 10/29/15 and 12/22/15, the Direct Service Worker #1 was responsible for the disbursement and documentation including reconciliation of spending money for Individual #1, Individual #2, Individual #3 and Individual #4. On 10/15/15, a check for $200.00 was issued to Direct Service Worker #1 to purchase clothing and other personal items for Individual #1. The check was cashed by Direct Service Worker #1 on 10/29/15. There were no receipts or other proof of purchases to account for the $200.00. On 12/21/15, during an account reconciliation, the program manager discovered $29.41 missing from Individual #2's account, $40.85 missing from Individual #3's account, and $42.13 missing from Individual #4's account. There were no receipts or ledger entries to account for the spending of these monies. Individual funds and property shall be used for the individual's benefit. Internal audits of all financial accounts present at every facility will be conducted by the House Manager on a weekly basis. They will document findings on the Ledger Audit Form and submit to the Program Manager weekly for review. Program Managers will conduct an unannounced physical financial audit of each facility under their charge every 6 months. Each financial account in the home will be reconciled. Program Managers' completed Ledger Audit Form will be turned into Program Directors for review every 6 months. A representative from the Fiscal Department will conduct unannounced audits of financial accounts at each facility once per year. [Within 5 months of the receipt of the plan of correction, all staff persons involved with assisting individuals with funds, auditing and reviewing financial records will be trained by CEO or designated fiscal staff person on policy and procedures for maintaining individuals' financial resources and accurately recording financial transactions. Documentation of trainings shall be kept. Within 5 months of receipt of the plan of correction, designated representative from the fiscal department will conduct an audit of all individuals' financial accounts to ensure all Individuals' funds are being used to the individuals' benefit. Documentation of all audits and reviews shall be kept and reviewed by the compliance officer or designated management staff person at least quarterly to ensure completion and the individual funds are being used for the individual's benefit. (AS 5/25/16)] 05/22/2016 Implemented
6400.22(e)(3)On 10/15/15, a check for $200.00 was issued to Direct Service Worker #1 to purchase clothing and other personal items for Individual #1. The check was cashed by Direct Service Worker #1 on 10/29/15. There were no receipts or other proof of purchases to account for the $200.00. On 12/21/15, during an account reconciliation, the program manager discovered $29.41 missing from Individual #2's account, $40.85 missing from Individual #3's account, and $42.13 missing from Individual #4's account. There were no receipts or ledger entries to account for the spending of these monies. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. Internal audits of all financial accounts present at every facility will be conducted by the House Manager on a weekly basis. They will document findings on the Ledger Audit Form and submit to the Program Manager weekly for review. Program Managers will conduct an unannounced physical financial audit of each facility under their charge every 6 months. Each financial account in the home will be reconciled. Program Managers' completed Ledger Audit Form will be turned into Program Directors for review every 6 months. A representative from the Fiscal Department will conduct unannounced audits of financial accounts at each facility once per year. [Within 5 months of the receipt of the plan of correction, all staff persons involved with assisting individuals with funds, auditing and reviewing financial records will be trained by CEO or designated fiscal staff person on policy and procedures for maintaining individuals' financial resources and accurately recording financial transactions. Documentation of trainings shall be kept. Within 5 months of receipt of the plan of correction, designated representative from the fiscal department will conduct an audit of all individuals' financial accounts to ensure documentation, by actual receipt or expense record, of each single purchase exceeding 15 dollars made on behalf of the individual carried out by or in conjunction with a staff person is being maintained. Documentation of all audits and reviews shall be kept and reviewed by the compliance officer or designated management staff person at least quarterly to ensure completion and documentation, by actual receipt or expense record, of each single purchase exceeding 15 dollars made on behalf of the individual carried out by or in conjunction with a staff person is being maintained. (AS 5/25/16)] 05/22/2016 Implemented
SIN-00091385 Renewal 03/02/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(b)The nearest smoke detector in a common area or hallway was 23 feet 7 inches from Bedroom #1, 31 feet 11 inches from Bedroom #2, 45 feet 10 inches from Bedroom #3 and 28 feet from Bedroom #4.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. On 3/4/2016, the Lakeshore Community Services' (LCS) Maintenance Supervisor and Program Directors were given a copy of Chapter 6400.110(b) Regulations to remind them aware of the requirement that smoke detectors be located within 15 feet of each individual and staff bedroom door. LCS Maintenance Staff installed a smoke detector in the hallway of the bedrooms within 15 feet of all four bedroom doors on 3/4/2016 at 906 E. Grandview. Placement of smoke detectors at all other group homes will be checked by 5/16/2016 by Program Managers. They will complete a report with the measurement to the nearest smoke detector. If there are any smoke detectors that are not installed in a common area within 15 feet of bedroom doors the Program Manager will notify LCS Maintenance Staff immediately to request they be installed. The Compliance Officer will review the reports by Program Managers. If a new smoke detector needed installed, the Compliance Officer will follow up with Maintenance Staff to obtain supporting documentation of installation. In the event a new group home is opened, the Maintenance Supervisor will ensure smoke detectors are located within 15 feet of each individual and staff bedroom door. Proper placement will be verified during pre-inspection by Program Directors. [Documentation of on site checks and reports and reviews of installation shall be kept. (AS 5/23/16)] 05/16/2016 Implemented