Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00247132 Renewal 06/12/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(9)111(c)(9). Individual number 1 physical examination. The 03/27/24 assessment's lifetime medical history states that the individual has seasonal allergies but the 10/10/23 annual physical exam states no allergies.The physical examination shall include: Allergies or contraindicated medication.We reached out to clients residential provider and learned that she received the allergy diagnosis after her annual physical was completed and that is why it wasn't included on the forms. The residential provider sent us documentation from her doctor that they are treating her for seasonal allergies. We will make sure that the next physical does include the documentation of her allergies. 08/30/2024 Implemented
2380.173(1)(iv)173(1)(iv). Content of records. The individual's number 1 religious affiliation was not included in the individual's record.Each individual's record must include the following information: Personal information including: Religious affiliation.The client had two pages in their application that covered the religious affiliation. When the staff member reviewed individual 1 file prior to client starting at the center, the form that included the religious affiliation should have been selected for the application instead of the form that wasn't fully completed. The procedure on how to review the client file for completeness was reviewed with the RN's and Director and they are aware every question must be completed prior to individual attending the program. All client files will be reviewed for completeness by 9/30/2024. 09/30/2024 Implemented
2380.177177 Individual 2 Consent for information released form is missing from the fileWritten consent of the individual, or the individual's parent or guardian if the individual is incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.We reached out to the caregiver and had her sign Individual 2's information release form. Our procedure was reviewed with each RN and Director that completes the application with the caregiver to insure that every form is reviewed and signed. Client files will be reviewed for completeness by the RN's or Director by 9/30/2024. 09/30/2024 Implemented
2380.21(a)21. Individual rights. Rights statement was not signed off on by individual's number 1 and 2 or representative.An individual may not be deprived of rights as provided under subsections (b) - (q).A client signature and date was added to the bottom of the client rights form to insure the rights has been reviewed and signed off. Individual number 1 and 2 also signed a client rights form. All clients will sign off on a new client rights form to insure we are meeting this regulation, this will be completed by 9/30/24. 09/30/2024 Implemented
SIN-00226709 Renewal 06/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(10)The current physical for individual#4 does not answer the "info pertinent to diagnosis in the event of an emergency" section.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Individual number 4's physical now has a completed "info pertinent to diagnosis in the event of an emergency" section in her 2022 physical and was initialled by our staff nurse. 07/06/2023 Implemented
2380.113(c)(2)Last Tuberculin skin test completed for staff member #1 was 1/6/20, then 3/30/23 Which was not within regulatory guidelines.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the 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, certified nurse practitioner or certified physician's assistant.Staff member number 1 had another ppd completed on 6/21/21 in addition to those on 1/6/20 and 3/30/23. The form was missing from her file and has now been added to her staff file. 07/07/2023 Implemented
2380.173(1)(iv)None of the individual's #1-4 face sheets included or identified their religious preference.Each individual¿s record must include the following information: Personal information including: Religious affiliation.Religious preference was added to each individuals face sheet and a new copy with the religious preference added was placed in their file. 07/06/2023 Implemented
SIN-00207073 Renewal 06/24/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.91(c)The fire safety training document provided for individual 1 did not include the content of the training, and did not specify the trainer.A written record of firesafety training, including the content of the training and individuals attending, shall be kept.Bon Homie conducts a fire drill and fire safety review monthly. The drill and training are both held on the same day each month. Our currect form that we use documents the drill and review, the date they were conducted, the time of day they were conducted on, the clients that were present for the training and review as well as the staff who were present. We do have the training review for the fire evacuation drill for April 4, 2022 that describes the content of the training. The trainer also signed the form above where the time of the review is documented. We have updated our form to include a formal signature line for the trainer that completes the fire drill and fre safety reivew. Please see the submitted forms that include the reivew for the April drill and the new, revised form for the reivew. Staff will receive training of the revised form by July 31, 2022. The staff nurse in charge of training will be responsible for making sure these documents are completed correcting and include all the necessary information to be in compliance. 07/07/2022 Implemented
SIN-00154226 Renewal 04/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(g)On 10/23/18 Individual #1 did not evacuate the building due to illnessIndividuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Every individual in attendance will evacuate the center during a fire drill. If a client is sick or having a seizure during the fire drill and is unable to participate in the drill, we will repeat the drill within the same month. 04/30/2019 Implemented
2380.111(a)Individual #2's most current Physical exam was dated 3/8/18, past annual date from calendar year 2017.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Each client/caregiver will need to submit their physical forms for it to meet the physical examination requirement yearly. (we will no longer accept that the physical was completed without the actual documentation). If the actual form is not submitted on time, services to the individual will be suspended until the physical forms are submitted to the nurse and accepted. 04/26/2019 Implemented
SIN-00129093 Renewal 01/24/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(h)The fire drills held over the annual review year do not state the alarm detector/pull station that was set off.A fire alarm shall be set off during each fire drill.The fire drill documentation form now contains a section where staff will document the alarm detector/pull station that was set off for that particular drill. 02/22/2018 Implemented
2380.111(c)(7)Individual #1 8/10/17 physical did not include the complete assessment of health maintenance needs, medication regimen, and blood work.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.The director and/or nurses will review the physical forms to make sure that each area is fully completed including an assessment of the individuals health maintenance needs, medication regimen and the need for blood work at recommended intervals. 02/22/2018 Implemented
2380.111(c)(8)Individual #4 8/12/17 physical the physical limitations was blank.The physical examination shall include: Physical limitations of the individual.The director and/or nurses will review the physical forms to make sure that each area is fully completed including information on physical limitations of the individual. 02/22/2018 Implemented
2380.113(c)(4)Staff #1 5/2/17 physical and staff #2 11/29/17 physical did not document information of medical problems which might interfere with the safety or health of the individuals.The physical examination shall include: Information of medical problems which might interfere with the safety or health of the individuals.The director and/or nurses will review the physical forms to make sure that each area is fully completed including information of medical problems which might interfere with the safety or health of the individuals. 02/22/2018 Implemented
2380.173(9)Individual #2 ISP updated 9/25/17 states she has a prescription for the medication Diazepam 1 tab PRN rectally as needed for seizures. This medication has never been at the program and staff are unsure if this medication is active. Following up asap per licensing direction.Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.All Program Specialist are aware that each individuals ISP must contain discrepensies if protocals are different in various environments. Individual #2 has diazepam as part of their seizure protocal but it is not given or kept at the day program. That difference needs to be stated in the ISP. 02/22/2018 Implemented
2380.177There was no consent for information released for individuals #1, #2, #3, #4, and #5.Written consent of the individual, or the individual's parent or guardian if the individual is incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.A written consent form was developed that authorizes the release of information, including photographs, to persons not otherwise authorized to receive it by the individual, parents or guardian. 02/22/2018 Implemented
2380.181(d)Individual #1 Program Sprcialist did not sign and date individual #1 2/6/17 assessment.The program specialist shall sign and date the assessment.The program specialist will sign and date each assessment; a computerized signature will not count as a acceptable signature. 02/22/2018 Implemented
2380.181(e)(1)Individual #1 2/6/17 assessment and individual #2 3/5/17 assessment do not include their preferences.The assessment must include the following information: Functional strengths, needs and preferences of the individual.The Program specialist will make sure that the assessment addresses current updates and revisions including functional strengths, needs and preferences of the individual. 02/22/2018 Implemented
2380.181(e)(6)The ability to use poisonous substances safely was not documented in #1, #2, #3, #4, and #5 all current assessments.The assessment must include the following information: The individual¿s ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.The Program specialist will make sure that the assessment addresses current updates and revisions including the individuals ability to safely use or avoid poisonous materials. when in the presence of poisonous materials. 02/22/2018 Implemented
2380.181(e)(7)The ability to sense and move away from heat sources was not documented in #1, #2, #3, #4, and #5 all current assessments.The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.The Program specialist will make sure that the assessment addresses current updates and revisions including the individuals knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120 degrees and are not insulated. 02/22/2018 Implemented
2380.181(e)(13)(i)No progress and growth in the area of Health for individual #3 5/15/17 assessment.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health.The Program specialist will make sure that the assessment addresses current updates and revisions including the individuals progress in the area of health over the last 365 calendar days and their current level. 03/01/2018 Implemented
2380.181(e)(13)(iii)No progress and growth in the area of personal adjustment noted for individual #1 2/6/17 assessment and individual #4 10/2/17 assessment.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment.The Program specialist will make sure that the assessment addresses current updates and revisions including the individuals progress in the area of personal adjustment over the last 365 calendar days and their current level. 02/22/2018 Implemented
2380.181(e)(13)(iv)No progress and growth in the area of socialization for individual #1 2/6/17 assessment, individual #2 3/5/17 assessment, individual #3 5/15/17 assessment, and individual #4 10/2/17 assessment.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.The Program specialist will make sure that the assessment addresses current updates and revisions including the individuals progress in the area of socialization over the last 365 calendar days and their current level. 02/22/2018 Implemented
2380.181(e)(13)(v)No progress and growth in the area of recreation for individual #1 2/6/17 assessment, individual #2 3/5/17 assessment, individual #3 5/15/17 assessment, and individual #4 10/2/17 assessment.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.The Program specialist will make sure that the assessment addresses current updates and revisions including the individuals progress in the area of recreation over the last 365 calendar days and their current level. 02/22/2018 Implemented
2380.181(e)(13)(vi)No progress and growth in the area of community integration for individual #1 2/6/17 assessment, individual #2 3/5/17 assessment, individual #3 5/15/17 assessment, and individual #4 assessment.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration.The Program specialist will make sure that the assessment addresses current updates and revisions including the individuals progress in the area of community-integration over the last 365 calendar days and their current level. 02/22/2018 Implemented
2380.183(3)Individual #2 ISP updated 9/25/17 does not explain the method of evaluation to determine progress towards her goal routine'. It only states she will maintain her routine and interact with peers. Individual #4 updated ISP 2/10/17 states he will participate in daily living, personal care and downtime activities for increasing periods of time.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome.Program specialists received direction that the ISP, including annual updates and revisions must include the current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome. 02/21/2018 Implemented
2380.183(5)Individual #2 takes psychotropic medications. She did have a behavioral plan in place; however that has since ended 8/2/17. Currently there is no SEEN plan in place.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.The Program specialist will make sure that the ISP contains current updates and revisions including protocols to address the social, emotional and environmental needs of the individual. If the individual takes psychotropic medications that will also be listed in the ISP as well as a current SEEN plan. 02/22/2018 Implemented
2380.183(7)(iii)Individuals #1, #2, #4, and #5 current ISP's do not include their potential to advance in competitive community integrated employment.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following:  Competitive community-integrated employment.The Program specialist will make sure that the Assessment and ISP contains current updates and revisions including the potential to advance in community integrated employment. 02/22/2018 Implemented
2380.184(a)There was no DSP at individual #1 3/28/17 ISP meeting.The plan team shall participate in the development of the ISP, including the annual updates and revisions under §  2380.186 (relating to ISP review and revision).A form was created and given to staff to complete regarding the individuals progress, wants, likes, needs progress on goals, etc. when an individuals ISP is taking place. This form will be utilized by the program specialists when a DSW cannot attend the ISP meeting. 02/21/2018 Implemented
2380.186(a)Individual #3 12/4/17 ISP review was late. It should have been completed no later than 11/30/17. Her Annual review update date is 11/15/17. Individual #4 1/2/18 ISP review was late. His annual review update date 3/15/17. It needed to be completed by 12/30/17.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.The program specialist has been informed that an ISP review of the services and expected outcomes in the ISP need to take place with the individual every 3 months or more frequently if the individuals needs change which impact the services as specified in the current ISP. 02/21/2018 Implemented
2380.186(c)(2)Individuals #2, #4, and #5 have a seizure protocol in place. These protocols were not reviewed during each ISP review over the annual review year.The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.The program specialists were informed that an ISP review must include a review of the seizure protocol that is in place over the annual review year. 02/21/2018 Implemented
2380.186(d)There was no documentation that individual #4 ISP reviews over the annual review year were sent to his family living provider.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.A form was developed that shows that all team members were sent the ISP reviews throughout the year. This form includes recommendations. 02/21/2018 Implemented
2380.186(e)No option to decline ISP reviews for all records reviewed; individuals' #1, #2, #3, #4, and #5.The program specialist shall notify the plan team members of the option to decline the ISP review documentation.A form was developed and will be distributed at each annual ISP meeting that will give plan team members the option to decline the ISP documentation. 02/21/2018 Implemented
SIN-00109524 Renewal 02/14/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.33(b)The monthly Individual Support Plan review documentations dated 3/20/16, 4/20/14, 5/20/16 and 6/20/16 were not signed by the Program Specialist.This section is being used to define the responsibilities for the program specialistThe program specialist will sign and date each monthly progress note once they are printed and prior to them being filed. See attachment #1 and signed progress notes. 03/30/2017 Implemented
2380.53(b) Dishwashing liquid was found near the kitchen sink and was not in its original container. Hand soap was found on the kitchen sink in an unlabelled container.Poisonous materials shall be stored in their original, labeled containers.Dish washing liquid is now in its original container as well as the hand soap. Kitchen staff and staff that is responsible for purchasing soap have been informed of the regulations and their requirements. See attachment #5. 03/30/2017 Implemented
2380.62There were no emergency numbers posted by the telephone in the main progrm room.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line.There are now emergency numbers posted by the telephone in the main program room. Staff when reviewing fire drill procedures each month will verify that their is a list of emergency numbers by each phone in the center. This procedure has been reviewed with staff, see attachment #4, 03/30/2017 Implemented
2380.91(a)There was no documentation that Individual #5 received initial fire safety training upon admission on 7/25/16.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, 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 facility.Individual #5 has received fire safety training monthly and once to cover the initial training since the documentation could not be found for the initial fire safety training that was held when she was admitted to our center. Client files contain a check list of documents that are required to attend Bon Homie and two staff members will review the file when a new clients starts to attend the program to insure all paperwork is complete and in the file. See attachment #3 for staff review and fire safety training. 03/30/2017 Implemented
2380.111(c)(5)Individual #2's date of admission was 8/15/16 and the Individual's TB test was completed on 9/22/16.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.Perspective clients will have a physical examination including a completed Tuberculin skin testing with negative results prior to starting the program. Submission of the application and physical examination will be required prior to the client start date. This will allow us the time to review all information and make sure that it is completed and meets licensing standards. Attachment #3 includes the review with staff. 03/30/2017 Implemented
2380.111(c)(8)Individual #5's physical examination, dated 4/11/16, did not include information relating to the Individual's physical limitations.The physical examination shall include: Physical limitations of the individual.Individual #5's physical examination, dated 4/11/16 now includes information relating to the individuals physical limitations. Submission of the application and physical examination will be required prior to the client start date. This will allow us the time to review all information and make sure that it is completed and meets licensing standards. See attachment #3 for staff review and for Individual #5's physical. 03/30/2017 Implemented
2380.173(1)(ii)Individual # 3's record did not document the Individual's eye color and identifying marks.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.Individual #3's record has been corrected to include race, height, weight, color of eyes and identifying marks. Staff will make sure that each part of the application is filled in and complete prior to accepting the application for admission. See attachment #3 and individual's updated record. 03/30/2017 Implemented
2380.173(1)(iv)Individual # 4's record did not document the Individual's religious affiliation.Each individual¿s record must include the following information: Personal information including: Religious affiliation.Individual #4's record now includes religious affiliation. Staff will make sure that religious affiliation is complete on all current applications and is filled in and complete prior to accepting any new applications for admission. See attachment #3 for review with staff and copy of individual #4's updated record. 03/30/2017 Implemented
2380.181(d)Individual #1's assessment, dated 6/6.16, and Individual #2's assessment, dated 9/6/16, were not signed by the program specialistThe program specialist shall sign and date the assessment.The program specialist will sign and date each assessment once they print them prior to filing them. Attachment #1 is a record of staff review and training regarding signatures on assessments and individual #1 and #2's assessments with signatures. 03/30/2017 Implemented
2380.181(e)(7)Individual #2 's assessment, dated 9/6/16, did not assess the Individual's ability to recognize and move away from heat source.The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.Individual #2's assessment dated 9/6/2016 does now include the individuals knowledge of the danger of heat sources and ability to sense and move away quickly from the heat sources which exceeds 120 F and are not insulated. This requirement has been reviewed with all program specialist, see training Attachment #2 and individual #2's updated assessment. 03/30/2017 Implemented
SIN-00081809 Renewal 07/09/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(b)The Chief Executive Officer (CEO) did not complete 24 hours of training for the training year January 1 through December 31, 2014.The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually.The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually. Ann Short, Director is responsible for the training for the CEO. See attachment for CEO trainings completed to this point. (The Director will keep a spreadsheet tracking the trainings and hours of all staff members to ensure 24 hours of training is received. 2 months prior to the end of the agency's training year, if 24 hours of training have not been completed for all staff, the director will notify the staff member, verbally and in writing, of the remaining hours needed. A record review of all staff in the agency will be completed within 30 days of receipt of this plan to identify any other records out of compliance. AH 10.20.2015) 10/02/2015 Implemented
2380.36(f)Staff #1, #2, #3, #4, and #5's previous fire safety training was completed on 2/22/14. The most recent fire saftery training was completed on 2/9/15. The fire safety training was not conducted by a fire safety expert. Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f).The staff viewed a video produced by the NFPA - National Fire Protection Association (NFPA writes code and trainings for fire fighters and instructors.) on 2/9/2015 which we believe NFPA falls under a fire safety expert. Ann Short, Director and Cyndi Bickings RN, BSN are responsible for making sure the training is conducted by a fire safety expert. See attachment for fire training expert information. (The director is responsible to ensure that the staff member presenting the fire safety video has been trained by a fire safety expert. The credentials of the fire safety expert that has trained the staff member presenting the video, will be kept on file at the agency. The staff person trained by the fire safety expert will keep all information provided at the training including content of the training and certificates from the fire safety expert. This information will be kept on file at the agency office. A record review will be completed within 30 days of receipt of this plan to identify any other staff not trained by a fire safety expert. All staff not trained by a fire safety expert will be re-trained within 2 months of receipt of this plan. AH 10.20.2015) 08/26/2015 Implemented
2380.53(b)Clorox Bleach was stored in a container without a label.Poisonous materials shall be stored in their original, labeled containers.Clorox bleach has been purchased and is stored in their original, labeled containers. See attachment for receipt of bleach and MSDS Sheet. Ann Short, Director is responsible for purchasing and storing poisonous materials in their original, labeled containers. (The supervisor will conduct monthly physical site inspections using a checklist created by the program specialist to ensure all physical site regulations are being followed. The checklist will include all physical site regulations. The checklist will be reviewed and signed by the program specialist monthly. The monthly checklists will be kept at the agency office. The program specialist will conduct a monthly physical inspection to ensure all poisons are safely stored in the original container. All staff working in the program will be re-trained on the physical site regulations within 30 days of receipt of this plan. Training content and signature pages will be sent to BHSL. AH 10.20.2015.) 08/28/2015 Implemented
2380.111(a)A 2015 physical examination was not completed for Individual #1. The most recent physical examination was dated 6/16/14. Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Individual #1 had a physical dated 6/16/14 and 6/23/15. Ann Short, Director and Cyndi Bickings RN, BSN are responsible for making sure the application includes all required information prior to client starting to attend the program. Please see attachment for copies of physicals. (The program specialist will utilize a tracking system for all individual's physical exam due dates. 3 months prior to the expiration of the physical exam, the program specialist will notify, verbally and in writing, the community home supervisor/direct care staff of the impending expiration and request an appointment be scheduled, if not already done. A copy of that written notification will be kept in the individual's record. A record review of all individuals in the agency will be completed within 30 days of receipt of this plan to identify any other records out of compliance. AH 10.20.2015) 08/26/2015 Implemented
2380.111(c)(3)Individual #1's physical examination, dated 6/16/14, did not include immunizations. The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Individual #1's physical examination dated 6/16/14 did include a PPD completed prior to her starting to attend the program on 7/9/2014. Please see attached. Ann Short, Director and Cyndi Bickings RN, BSN are responsible for making sure the physical examination form includes all required information prior to client starting to attend the program. Adaler she received on 9/2/2014. See attachment for copy of script. (A record review of all individuals in the agency will be completed within 30 days of receipt of this plan to identify any other records out of compliance. The program specialist is responsible to review the physical exams upon receipt to ensure all information is contained on the physical exam. The program specialist will pass the physical exam to the nursing staff who will review it to ensure all required information is contained on the exam. If information is missing, the exam will be returned to the physician's office for completion. AH 10.20.2015) 08/26/2015 Implemented
2380.113(a)Staff #5 did not have a physical examination completed in the regulatory timeframe. A physical was completed on 4/3/12 and not again until 5/16/14.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 persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.It is our policy that staff do not work from the time their physical is out dated until it is updated again. In the future staff #5 will not be able to work her shifts if her physical is outdated. Cyndi Bickings, RN, BSN will be responsible for making sure that all medical evaluations are completed to meet our regulations or will suspend the staff member until the physical is completed. Please see attachment for copy of the policy. (Cyndi Bickings will utilize a tracking system for all staff physical exam due dates. 3 months prior to the expiration of the physical exam, Cyndi Bickings will notify the staff member, verbally and in writing, of the impending expiration and request an appointment be scheduled, if not already done. A copy of that written notification will be kept in the staff's record. A record review of all staff in the agency will be completed within 30 days of receipt of this plan to identify any other staff physical exams that are out of compliance. AH 10.20.2015) 08/28/2015 Implemented
2380.171(b)(1)The record for Individual #2 did not include the required emergecy information. Emergency information for each individual shall include: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergencyEach clients record will include their name, address, telephone number and relationship of the designated person to be contacted in case of an emergency. Ann Short, Director and Cyndi Bickings RN, BSN will be responsible for making sure the application includes all required information prior to client starting to attend the program. Please see individual #2's record for completed information. Staff will also review each clients personal records to insure they are also completed; relationship of a designated person to be contacted in case of an emergency was added under the weather and emergency closing contact information but it was already listed under the emergency medical care authorization. All other clients files will be reviewed for completion and updated. (A record review of all individuals in the agency will be completed within 30 days of receipt of this plan, if not already done, to identify any other records out of compliance. Should other records be out of compliance, emergency information will be immediately added to their file. All files will contain emergency information within 30 days of receipt of this plan. All management staff will be re-trained on the regulations surrounding records (2380.171-177) by 11/20/2015. AH 10.20.2015) 10/02/2015 Implemented
2380.173(1)(i)The record for Individual #3 did not include personal information. Each individual's record must include the following information: Personal information including: The name, sex, admission date, birthdate and social security number.Each clients record will include their name, sex, admission date, birthdate and social security number. Ann Short, Director and Cyndi Bickings, RN, BSN will be responsible for making sure the application includes all required information prior to client starting to attend the program. Please see individual #3's record for completed information; Identifying marks was completed on the application. All other clients files will reviewed and updated. ((A record review of all individuals in the agency will be completed within 30 days of receipt of this plan, if not already done, to identify any other records out of compliance. Should other records be out of compliance, all personal information will be immediately added to their file. All files will contain personal information within 30 days of receipt of this plan. All management staff will be re-trained on the regulations surrounding records (2380.171-177) by 11/20/2015. AH 10.20.2015) 10/02/2015 Implemented
2380.173(1)(iii)The record for Individual #3 did not include the primary language spoken. Each individual¿s record must include the following information: Personal information including: 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.Each clients record will include the language or means of communication spoken by the individual and the primary language spoken in the home. Ann Short, Director and Cyndi Bickings, RN, BSN will be responsible for making sure the application includes all required information prior to client starting to attend the program. Please see individual #3's record for completed information. Primary language spoken was added to the application. All other client files will be reviewed and updated. (A record review of all individuals in the agency will be completed within 30 days of receipt of this plan, if not already done, to identify any other records out of compliance. Should other records be out of compliance, all personal information will be immediately added to their file. All files will contain personal information within 30 days of receipt of this plan. All management staff will be re-trained on the regulations surrounding records (2380.171-177) by 11/20/2015. AH 10.20.2015) 10/02/2015 Implemented
2380.181(e)(10)Individual #1's assessment, dated 8/5/14, did not include a lifetime medical history. The assessment must include the following information: A lifetime medical history.Individual #1's assessment did include a lifetime medical history which was taken from the clients ISP. In the future Bon Homie staff and caregivers will develop our own lifetime medical history for our assessments. Ann Short - Director, Janet Jones - RN and Cyndi Bickings RN, BSN will be responsible for making sure the assessment includes a lifetime medical developed by the Bon Homie Staff. See attachment for the Individual #1's assessment for completed changes. See attachment for policy on and training. (A record review of all individuals will be completed within 30 days of receipt of this plan to identify any other records out of compliance. The director and nursing staff will meet and/or discuss with the residential provider/family/individuals the lifetime medical history of the individual. A comprehensive medical history will be composed and kept in the individual's record as part of the assessment and physical exam. AH 10.20.2015) 08/28/2015 Implemented
2380.181(e)(13)(i)Individual #1's assessment, dated 8/5/14, did not include progress and growth in the areas of health and motor and commuication skills. Individual #2's assessment, dated 2/27/15, did not include progress and growth in the areas of health and motor and communication skills. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas:  Motor and communication skills.Assessments will now include progress and growth in the areas of health, motor and communication skills over the last 365 calendar days. The clients current level in health, motor and communication skills will also be included. Ann Short - Director, Janet Jones - RN and Cyndi Bickings RN, BSN will be responsible for making sure the assessment includes the information required. See attachment for updated changes on Individual #1's assessment. See attachment for Policy on completing assessments and training. (A record review of all individuals in the agency will be completed within 30 days of receipt of this plan to identify any other records out of compliance. The program specialist will be re-trained by 11/20/2015 on the regulations surrounding the assessment. Upon completion of the assessment, the director will review the assessments for any missing information. AH 10.20.2015) 08/28/2015 Implemented
2380.181(e)(13)(iii)Individual #1's assessment, dated 8/5/14, did not include progress and growth in the areas of personal adjustment and socilization. Individual #2's assessment, dated 2/27/14, did not include progress and growth in the areas of personal adjustment and socialization. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization.Individual #1's assessment will now include progress and growth in the areas of personal adjustment and socialization over the last 365 days. Ann Short - Director, Janet Jones - RN and Cyndi Bickings RN, BSN will be responsible for making sure the assessment includes the information required. See attachment for updated changes on Individual #1's assessment.The clients current level in socialization will be included in the assessment. See attachment for policy on completing assessments and training. (A record review of all individuals in the agency will be completed within 30 days of receipt of this plan to identify any other records out of compliance. The program specialist will be re-trained by 11/20/2015 on the regulations surrounding the assessment. Upon completion of the assessment, the director will review the assessments for any missing information. AH 10.20.2015) 08/28/2015 Implemented
2380.181(e)(13)(v)Individual #1's assessment, dated 8/5/14, did not include progress and growth in the areas of recreation and community integration. Individual #2's assessment, dated 2/27/15, did not include progress and growth in the areas of recreation and community integration. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.Individual #1's assessment will now include progress and growth in the areas of recreation - Community integration over the last 365 days. The clients current level in the areas of recreation and community integration will also be included. Ann Short - Director, Janet Jones - RN and Cyndi Bickings RN, BSN will be responsible for making sure the assessment includes the information required.. See attachment for updated changes on Individual #1's assessment. See attachment for policy on completing assessment and training. ((A record review of all individuals in the agency will be completed within 30 days of receipt of this plan to identify any other records out of compliance. The program specialist will be re-trained by 11/20/2015 on the regulations surrounding the assessment. Upon completion of the assessment, the director will review the assessments for any missing information. AH 10.20.2015) 08/28/2015 Implemented
SIN-00073660 Renewal 01/30/2015 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.16Staff #1, touched inappropriately, Individual #1's pubic region of the body, just above the genetalia, to stiumulate urination for four weeks from approximately 12/28/14 through 1/28/15. This applies to abuse occurring at the facility. Actions of one individual to another individual including rape, sexual molestation, sexual exploitation, and intentional actions causing physical injury that require medical attention by medical personnel at a medical facility are considered abuse. Relating to improper use of restraints, this regulation should be cited if there is serious or widespread use of restraints without following the requirements of this chapter. Otherwise, the specific section(s) of 151-165 should be cited. Record as non-compliance if there is any founded evidence of abuse since the previous annual licensing inspection for which appropriate corrective action was not taken. If appropriate corrective action was taken, non compliance should not be cited. If a report of abuse is investigated and determined to be unfounded, record as compliance. If a report of abuse is still under investigation at the time of the inspection, record as noncompliance on the LIS and score sheet. At the conclusion of the investigation, withdraw the non-compliance if the abuse is determined to be unfounded or if appropriate corrective action was taken. Source: Site Records Interview Once the staff member reported to the director there concerns regarding staff #1;the three staff that were aware of this incident were interviewed immediately. Staff # 1 was supervised on the floor and not left alone until she was interviewed within that hour. After staff #1 was interviewed she was asked to leave the premises until our investigation was complete. During staff #1's interview she admitted to touching individual #1's pubic area to stimulate urination for four weeks. Our Incident Investigator was called immediately and she conducted an investigation. She found that Staff #1 did touch inappropriately, individual #1's pubic region of the body, just above the genetalia, to stimulate urination for four weeks from approximately 12/28/14 through 1/28/15. Staff #1 did complete a written and signed document supporting this information. There is also a monthly background check conducted on every employee through OIG Compliance Now. Orientation and annual trainings include our incident management policy - which includes each type of abuse including sexual abuse. We now have a training on "Appropriate Touch of a client" that staff will receive during orientation and annually. We also have a behaviorist from Ken Crest scheduled to come into the center on April 3, 2015 to conduct a training on appropriate and inappropriate touch of clients. Current staff will receive this training on April 3, 2015 or will view the taped training within two weeks of the training taking place. New staff will view the taped DVD on the training prior to working with the clients. A copy of the incident report and all policies related to the incident have been forwarded to our licensing agency.All staff will be retrained on incontinence care and will meet with the Director or designee on a monthly basis to review all training conducted in response to this violation over the next three months starting within 15 days of receipt of this plan of correction. [per A.S. 4.17.15] 04/20/2015 Not Implemented
2380.173(1)(ii)Individual #2's record did not include identifying marks.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.Race, height, weight, color of hair, color of eyes and identifying marks has all been added to the client enrollment form. This information will be filled out completely prior to the client attending the program. 03/27/2015 Not Implemented
SIN-00056610 Renewal 01/27/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(4)Individual #2's annual physical examination dated 2-11-13 did not include the results of a hearing screening. Individual #3's annual physical examination dated 4-22-13 did not include the results of a vision and hearing screening.(c)  The physical examination shall include:(4)  Vision and hearing screening, as recommended by the physician.Bon Homie has received the results for Individual #2 hearing screening and Individual #3's hearing and vision screening. Supporting documentation was submitted to the licensing representative. 03/13/2014 Implemented
2380.111(c)(11)Individual #1's annual physical examination dated 2-6-13 did not include directions for a special diet. The record indicates a chopped diet is prescribed however that information was not included on the physical form.(c)  The physical examination shall include:(11)  Special instructions for an individual's diet.It has been documented by Individual #1's physican on the physical that a fine chopped diet should be served. In the future all incoming physical examinations will include current diet instructions. 02/21/2014 Implemented
SIN-00042914 Renewal 02/15/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(f)The facility sent 11 fire drills, which 7 of them were done during the 11 am hour; 1/30/12, 3/30/12, 4/30/12, 5/31/12, 7/301/12, 9/25/12, 10/31/12, 12/26/12. (f)  Fire drills shall be held on different days of the week and at different times of the day.Fire drills will be held on different days of the week and we will conduct drills at one of the following times each month: 9:15 AM, 10:15 AM, 11:30 AM, 1 PM, 1:45 PM or 2:15 PM. Staff running the drill will make sure that the drills are held at different times of the day each month. A fire drill was held on 2/27/2013 at 9:22 AM. 02/27/2013 Implemented