Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00264340 Renewal 03/24/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)On 08/18/24, Individual #1 purchased a rocking chair for $186.55; this item was not on Individual #1 property record.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. This occurred due to a lack of a formalized process in place to update client inventory (personal property inventory). Program Manager completed an updated client inventory (personal property inventory) on 3/26/2025 indicating the purchase of a rocking chair on 8/18/24 (see attached "22d1 Client Inventory"). 04/30/2025 Implemented
6400.144Individual #1's annual physical from 10/12/23 ordered that cholesterol and blood sugar levels are to be tested annually. No documentation was provided verifying that this occurred. The annual physical completed on 10/15/24 recommended lab work be completed every six months. Lab work is not being completed every six months. Additionally, it was recommended that Individual #1 have labs drawn a few weeks prior to their 03/14/25 Primary Care Provider appointment. This did not occur. Individual #1 had a podiatry appointment on 04/29/24. There was to be follow-up in three to four months. The follow-up appointment did not take place until December 2024. (Repeat from 04/03/24 Inspection)Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. This occurred due to a lack of process being in place to alert management when individuals are due for recommended lab work that should take place on a regular basis. Individual #1 had lab work completed on 04/02/2025 (see attached "144 Lab work from 04 02 2025"). Director of Service Impact and Director of Nursing are meeting with Program Specialists on 4/16/2025 to train on the roll out a new module in the EHR (Therap) to automate health recommendations including lab work, physicals, specialist appointments, etc. This module allows for Program Specialists to record at what frequency health screenings should occur and schedule alerts as they approach their due date to avoid missed follow ups. This new module will be active in Therap by 5/30/2025. 04/30/2025 Implemented
6400.181(e)(13)(i)Individual #1's most recent Annual Assessment completed on 08/09/24 does not adequately and thoroughly document the individual's health and how their health status progressed through the year.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. This occurred due to lack of training on the necessity to provide detailed progress when completing annual assessments. An addendum to the 8/9/24 annual assessment was completed on 4/11/2025 and shared with the individual's team. See attached "181 Addendum 04 11 2025". 04/30/2025 Implemented
6400.181(e)(13)(vi)Individual #1's most recent Annual Assessment completed on 08/09/24 does not adequately and thoroughly document the individual's recreation preferences and how they progressed through the year in this category.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. This occurred due to lack of training on the necessity to provide detailed progress when completing annual assessments. An addendum to the 8/9/24 annual assessment was completed on 4/11/2025 and shared with the individual's team. See attached "181 Addendum 04 11 2025". 04/30/2025 Implemented
6400.211(b)(2)Individual #1's demographic information does not include the name, address, or phone number of their physician. Emergency information for each individual shall include the following: The name, address and telephone number of the individual's physician or source of health care.This occurred due to an error in inputting physician's name, address, and phone number for the physician. Immediately upon discovery, this was resolved. See "Active Contacts section of attached 211b2 Demographic Information." 04/30/2025 Implemented
6400.32(c)Individual #1 has a bowel movement protocol that their bowel movements are to be tracked daily. If they go 48 hours with no bowel movement, they are to receive an additional dose of Senna. They are to receive the medication daily until they have a bowel movement. If Individual #1 goes four days with no bowel movement, their Primary Care Provider (PCP) is to be called. From April 2024 through March 2025, Individual #1 went without a bowel movement for 48 hours a total of 12 times. Individual #1 went without a bowel movement a total of three days five times. They went without a bowel movement four or more days a total of 7 times. The longest stretch without a bowel movement was five days. No PRN Senna was given, and the individual's PCP was not contacted as per the protocol. During the review period, there were 16 days without documentation regarding if the individual had a bowel movement.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.This occurred due to failure of direct care staff to document bowel movements and of management to monitor tracking to ensure protocols were being followed as prescribed. A bowel protocol audit to ensure present protocols align with doctor recommendations and prescribed medications was completed by Program Specialists on 3/28/2025. 05/30/2025 Implemented
6400.165(c)The requirements of this will be trained on during TLC's Plan of Correction Training with TLC Leadership, Program Specialists, Program Managers, and Incident Management Coordinators on April 30, 2025.A prescription medication shall be administered as prescribed.This occurred due to lack of training on adding end dates to Carasolva (eMAR) for short-term medications. The medication was started on a paper MAR prior to being added to the eMAR; subsequently the proper end date was not added so staff created a documentation error by signing off on 6/22's 8AM administration time. EIM #9600875 was input to account for the error. 05/30/2025 Implemented
6400.166(b)Individual #1 had medication administrations that were not logged immediately on 06/24/24, 7/26/24, 11/01/24, 11/16/24, 01/04/24, 01/11/24, 01/26/24, 02/07/24, 02/13/24, 02/19/24, 02/22/24, 02/23/24, 03/06/24, and 03/19/24.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.This occurred due to lack of training on the necessity of completing paper MARs in the event of Carasolva downtime and/or being in the community during medication administration. DSPs will be retrained on the importance of completing paper MARs for late administration in addition to later documenting the late administration in Carasolva by Program Managers during house meetings in the month of May during the DSP Plan of Correction Training. 05/30/2025 Implemented
6400.167(a)(1)Individual #1 did not receive their 8:00pm doses of Docusate Sodium, Perphenazine, or Risperidone on 10/28/24. They did not receive any of their 8:00am medications on 12/28/24.Medication errors include the following: Failure to administer a medication.This occurred due to DSP staff failing to adhere to Medication Administration guidelines and administer medication in the required timeframe. In addition, the Program Manager failed to catch this error when completing their Weekly Medication Audit. EIM #s: 9594130 and 9594156 were input to account for omissions of medication. 05/30/2025 Implemented
6400.183(a)(2)Individual #1's mother did not attend the January 2025 Individual Support Plan team meeting.The individual plan shall be developed by an interdisciplinary team, including the following: Persons designated by the individual.This occurred due to Individual #1's mother choosing not to participate in the annual ISP meeting and the team failing to document. In the future, if an individual's designated person chooses not to participate, the Program Specialist will document on ISP signature sheet provided from the SC that the designated person chose not to attend. 04/30/2025 Implemented
SIN-00198454 Renewal 01/03/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)(Repeat from inspection dated 1/11/21) The Self-Assessment that was completed was not dated; not able to verify that it was completed during the correct time frame.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. This occurred due to Self-Assessments not being collected and reviewed for completion. Staff will be trained on how to complete the Self-Assessment form thoroughly. Quality department will monitor for completion.Staff will be trained on how to complete the Self-Assessment form thoroughly on 2/22/22. 02/22/2022 Implemented
SIN-00181478 Renewal 01/11/2021 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)REPEAT VIOLATIONS FROM 12/10/19: The self-assessment for this home is dated 8/3/20, which is outside of the required time frame. The self-assessment is also incomplete.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. A self-assessment is necessary to understand any deficiencies within a residence, be able to correct them in a timely manner, identify safety hazards for the supported people and provide guidance to the staff in areas necessary for regulatory compliance. Violations occurred because the self assessments were not completed nor submitted within the allowed 3-6 month window before license expiration A lack of complete understanding by new staff, including ADOS, Directors and Quality about when the 3-6 month window opens and closes for submittal of the document Within the months of February and March each ADOS, Directors of Residential Services, Quality Staff, including the Director of Compliance, the Quality Coordinator and Quality Assistant will receive trainiing in the completion of the self assessments. In addition, the Program Managers will participate in the trainings. A training log of participants will be kept and maintained by the Quality Department. 1. TLC commits to one timely self assessment in each calendar year. The self assessment will be done in May beginning in 2021 and will continue in 2022 and each succeeding year 2. The May self assessment will be submitted for each location in accordance with the regulation. 3. The Quality Department, specifically the Quality Assistant will maintain a paper copy as well as a folder in Sharepoint where each assessment will be electronically filed in a folder titled Self Assessments-Residential. 4. Each Service Area's ADOS staff will review within 4 weeks with the Director of Compliance, Quality Coordinator, Quality Assistant and appropriate Director of Services. 5. The assessment identification of deficiencies will be used to develop an in-house correction plan. 6. The Quality Coordinator and Quality Assistant will monitor the correction plan, report to the monthly quality meeting the status of the POCs and the Compliance Director will report at a quarterly meeting in of the Directors in writing the data/finidings regarding compliance with this POC and the status of each location's assessment. 7. All assessments will be reviewed and completed with Plans of Correction by June 20th. 8. All new leadership staff will complete a training during their orientation on self assessments and their importance to each location within the company. 03/05/2021 Implemented
6400.103There are no written emergency evacuation procedures for the home.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. "Ensure a calm transition and the safety of people in care in an emergency situation Plans used in the past were found to be inadequate The current evacuation plan did not have a current address for the evacuation location with did not identify the staff responsibilites, means of transportation, and there was no explanation of the provision of services at the evacuation site. Directors reviewed the regulation and developed a template for a new evauation form that will be used in each residential location and for each resident. The Program Managers will complete the new form ensuring it is tailored to the unique needs of the residents they support. The Operational Associate Director responsible for the program will monitor that the form is completed corectly. 1) By 2/15/2021, the Directors will train each ADOS. 2) By 2/21/2021, each PM will be trained on how to create the plan and how to train thier staff on the plan. 3) Each Program Manager is responsible to complete the plan by 2/28/2021. Training logs will be maintained to indicate the completion of the training. 1. The Directors of residential will develop a checklist that encompasses the required docuentation for a new admission. An element of the checklist will be to ensure that evacuation plans are completed. 2. The checklist will be used by each PM at the time a person is admitted in the residence. 3. The ADOS will be responsible to reveiew the checklist for completness.4. The completion of the checklist will also be monitored by the Director of Services and reported. " 03/05/2021 Implemented
6400.112(a)There were no fire drills conducted in the following months: 7/2020 and 8/2020. An unannounced fire drill shall be held at least once a month. Consistently completing fire drills ensures that staff and persons in care understand how to respond in the event of a fire emergency. There was no documentation that the fire drills were conducted Documentation was not adequately maintained Fire Drills are now input and montiored into the Fire Drill log monthly by Program Specialist/Associate Director of Services/Program Manager. The Listed supervisiors were retrained on the fire drill regulations to ensure understanding of all requirements. 1) All staff will be training in the regulation and its importance. A training log will be maintained of this training. 2) The PM of each house will monitor the completion of the fire drill. 3) In addition the Quality Coordinator and the Quality Assistant will monitor each house and their performance along on at least a monthly basis. A notification will be sent to any home on the nearest business day to the 15th of the month if a fire drill entry has not happened at a home. This will be done with a review of an MS FORMS document that will mirror the old Google form no longer available to staff. 4) A report will be made to the ADOS-Operational Group and the Quality Meeting monthly and to the Director's meeting quarterly. The Quality Meeting Group, consisting of the HR Director, the three Directors of Services, the Training and Development Coordinator, the Director of Compliance and the Quality Coordinator and Assistant will report monthly at those meetings. Minutes of these meetings will be maintained. 03/12/2021 Not Implemented
6400.144Individual #1 was a no-show for her blood draw to be completed on 6/22/20. There is no indication why she missed this appointment.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Ensuring health services are received protects the health and safety of the people we support by making sure they receive appropriate healthcare services. The person supported scheduled the appointment and did not inform the staff. The appointment was missed because staff were unaware the person supported made the appointment. The Program Manager will collaborate with the person supported to ensure they are aware of appointments that are scheduled by the person in supports. The Directors of Residential will monitor the completion of this task during monthly supervisions with the Clinical Directors. 03/19/2021 Not Implemented
6400.181(a)Individual #1's date of admission is 12/16/19. Her initial assessment was not completed until 2/20/2020. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The initial assessment indicates functional strengths and needs, preferences and current levels of performance in areas such as communication and the levels of assistance needed. The Clinical Associate Director did not remember to complete the assessment on time. The initial assessment was completed on 2/20/2020. The Associate Directors will use the Outlook calendar app to enter due dates to ensure the timely completion of assessments. The Directors of Residential will review the as needed completion of this task during monthly supervisions. 03/19/2021 Not Implemented
6400.32(r)Individuals #1, #2, and #3 do not have locks on their bedroom doors and were not asked if they wanted locks.An individual has the right to lock the individual's bedroom door.Individuals have the right to have locks on their bedroom doors to protect their belongings. Individuals were not offered the opportunity to have locks placed on their bedroom doors. The choice to have a lock on a bedroom door was not discussed during team meetings. The residential provider will contact the individual's team to schedule a meeting to discuss the person's choice for a lock on the bedroom door. If the person wants a lock, the residential provider will ensure a lock is installed. The meetings will take place by 4/30/2021 and be scheduled by the Clinical ADOS before March 10 During the annual ISP meeting, or when the person requests, the residential provider will ensure the subject of securing the bedroom is discussed. The Directors of Residential will monitor the completion of this task during monthly supervisions with the residential Clinical and Operational Associate Directors. 03/15/2021 Implemented
6400.165(c)Individual #1's prescription for potassium was discontinued on 6/24/20. On the following dates, the medication was signed as administered to individual: 6/25/20, 7/1/20, 7/13/20, 7/27/20, and 8/23/20.A prescription medication shall be administered as prescribed.Providing a discontinued medication can be dangerous to the recipient and depending on the medication and other changes made to the regimen may lead to health complications The paper records did not allow for the proper paperwork to always be as up-to date as the orders provided by the physicians The violation occurred because the discontinuation of the medication order was not properly noted by the staff member the current methodology and the use of an electronic Medication Administration Record allows for real time changes and discontinuations to take place immediately. In addition only Program Managers and ADOS personnel receive, add and delete meds. The advent of the eMAR within the organization, allows for immediate discontinuation of medications and visual cues that don't allow someone to incorrectly continue to deliver medications without permissions. When there is a medication error, an incident report will be entered into the AWARDS system by the Program Manager and the EIM entry will be done by the LPN or RN in the Quality Department. 03/12/2021 Not Implemented
6400.166(a)(2)Individual #1's Medication Administration Record does not include the name of the prescriber for the following medications: Amlodipine, Paricalcitol, Potassium ER, Acetominophen.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.The prescriber is important to know so that if questions about the medications, dosage or reactions can be imperative to the health of the persons supported by TLC The name of the prescriber is not included in the MAR for this individual The Program Manager did not review the labels on the medication after delivery. And the medication administration certified staff did not complete the 6 rights of medication administration, which includes ensuring the right documentation. There was a lack of supervision and follow through. The current Program Manager will routinely review the labels on medication after delivery. 03/12/2021 Implemented
6400.166(a)(11)Individual #1's Medication Administration Record does not include the diagnosis or purpose for the following medications: Amlodipine, Folic Acid, Levetiracetam, Oxcarbazepine, Paricalcitol, Potassium ER, Vitamin B12, Warfarin.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.Knowing the diagnosis and purpose are important because the same medications could be used to treat a variety of different conditions. The Program Manager did not review the labels on the medication after delivery. The change in leadership and turnover in staff resulted in an oversight of this requirement. The current Program Manager will routinely review the labels on medication after delivery. The staff trained in medication administration will complete a weekly audit of medications and labels. The checklist will then be submitted to the Program Manager and the Program Manager will review the checklist. The checklist will be submitted to the Associate Director who will review and submit to the Directors of Residential. 03/12/2021 Not Implemented
SIN-00261727 Renewal 03/24/2025 Compliant - Finalized
SIN-00241351 Renewal 04/01/2024 Compliant - Finalized
SIN-00086415 Renewal 10/20/2015 Compliant - Finalized
SIN-00068642 Renewal 08/04/2014 Compliant - Finalized
SIN-00066403 Renewal 08/04/2014 Compliant - Finalized