Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00234635 Renewal 12/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.52(c)(1)Provider training year reviewed was July 1, 2022, to June 30, 2023. It was documented that training on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships was completed on 6/3/22 and again on 10/4/23. There was no documentation that training was completed in the 7/1/22 to 6/30/23 training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The Staff is retrained. 12/14/2023 Implemented
6400.52(c)(3)Provider training year reviewed was July 1, 2022, to June 30, 2023. Documentation that training on rights was completed on 6/1/22 and again on 11/3/23. There was no documentation that training on rights was completed in the 7/1/22 to 6/30/23 training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.The Staff is Retrained. 12/15/2023 Implemented
6400.52(c)(4)Provider training year reviewed was July 1, 2022, to June 30, 2023. Documentation that training on recognizing and reporting incidents was completed on 5/6/22 and again on 10/19/23. There was no documentation that training on recognizing and reporting incidents was completed in the 7/22 to 6/23 training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.The staff is Retrained. 12/15/2023 Implemented
SIN-00196133 Renewal 02/24/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Individual #1's ISP indicates that the individual needs more assistance when it comes to money. Individual #1 receives $20 a week in spending money and does not need to turn in receipts. Individual #1's ISP does not indicate that the individual is able to manage this or any other amount of money. Individual #1's assessment does not indicate that the individual is able to manage any amount of money.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. on 3/1/22 Staff was trained on how to keep an up to date financial and property record for the individual in the home. And financial policy for the individual was implemented. ( see attached training record and policy emailed to Kristen) 03/01/2022 Implemented
6400.22(f)On February 21, 2021, staff members loaned Individual #1 $25.98 to purchase cigarettes as Individual #1 did not have any funds available. Individual #1 repaid the staff member on 2/27/21 after receiving $100 on 2/26/21.There may be no commingling of the individual's personal funds with the home or staff person's funds. on 3/1/22 staff was re-trained not to lend money to individual. ( see attached training sign in emailed to Kristen) 03/01/2022 Implemented
6400.64(a)The shower head in Individual #1's bathroom was covered with a significant layer of limescale and mildew.Clean and sanitary conditions shall be maintained in the home. on 3/7/22 staff was trained on how to clean the shower head and the shower head was clean. ( see attached clean shower head emailed to Kristen) 03/07/2022 Implemented
6400.181(e)(14)Individual #1's annual assessment dated 4/19/21 does not address the individual's ability to swim.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. The assessment was re-done and the individual ability to swim was addressed and the individual is able to swim in shallow area only. ( see attached addressing the individual ability to swim emailed to Kristen) 03/01/2022 Implemented
6400.165(g)Individual #1 is prescribed psychotropic medications and had three-month medication reviews completed on 4/13/21, 7/6/21 and 12/18/21. The medication review documentation did not include the reason for prescribing the medication and the necessary dosage of the medication.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.On 3/1/22 The program Director wrote a letter to the physician. Explaining to him to document the medication dosage and reason for prescribing the medication to the individual. (see a copy of letter to the Physician attached emailed to Kristen) 03/01/2022 Implemented
6400.166(a)(13)Individual #1 is prescribed Clindamycin HCL 300mg 1 Cap by mouth 4x daily at 8AM-12PM-4PM-8PM x 5 days *beg 2/23 and Sulfamethoxazole TMP 1 tab by mouth 2x daily @ 8AM and 8PM x 5 days begin 2/23. Individual #1 received this medication n 2/23/22, however the name and initials of the person administering the medication were not maintained on the Medication Administration Record (MAR).A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.on 3/2/22 staff re-trained on medication documentation. (see attached sign-in sheet emailed to Kristen) 03/02/2022 Implemented
SIN-00181897 Renewal 01/12/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(3)Individual #3 did not have immunizations documented in her file or on her physical examination.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. Individual #1's medical records were located. Her TDaP was on there from 2010. Due to the fact that it was expired, she received a new TDaP immunization on 03-16-2021. (See attached document in email to Kristen.) 02/04/2021 Implemented
6400.181(e)(10)Individual #3 did not have a lifetime medical history documented in her files.The assessment must include the following information: A lifetime medical history. The medical records and history were eventually obtained for Individual #1 and a lifetime medical history was developed from it and added into the assessment. 02/04/2021 Implemented
6400.34(a)Individual rights signed by Individual #3 and additional rights provided to licensing representatives as part of the annual inspection do not reflect changes to individual rights included in the updated 6100 regulations.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.Updated individual's rights is now on file. The updated individual rights was explained to the individual and she signed it. Moving forward agency will check on 6100 Regulation regularly. See attached updated individual's rights emailed to Kristen. 02/04/2021 Implemented
6400.165(c)Individual # 3 is prescribed a PRN for Ibuprophen 200mg tab directed to take 3 tabs every 8 hours as needed for pain or headache was on the Medication Administration Record but was not in the home. Due to the medication not being in the home, it is unclear if the medication has been administered as prescribed.A prescription medication shall be administered as prescribed.Staff was retrained. Site Supervisor has obtained Ibuprohen script and Ibuprophen was delivered to the home. Moving Forward quality assurance will audit PRN medication weekly. See attached picture of ibuprohen medication that was delivered. 01/13/2021 Implemented
6400.165(g)Individual # 3 is prescribed medication to treat psychiatric illness, review of documentation indicates individual did not see a licensed physician to review the medications and treatments during the time period reviewed.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.Staff was retrained. Moving forward it was implemented that every three months that Pshychiatry medication review is due, site supervisor will take the psychiatry review forms to the doctor's office for proper review. See attached Psych meds review form. 01/19/2021 Implemented
6400.186Individual # 3's ISP reflects that the individuals needs assistance with budgeting and paying bills on time and they are in the process of discussing a rep payee with her. No financial records or documentation of assistance with budgeting or bill pay were provided at the time of inspection.The home shall implement the individual plan, including revisions.It was implemented that, Conference of churches will be the individual's Rep payee. Moving forward the agency has started a ledger to track and account for the individual's finances . A financial policy has been implemented for staff to read, sign, and follow it when caring for the individuals. staff has been retrained on how to assist the individual with budgeting. Quality assurance will conduct an audit twice a month. See attached copy of money ledger developed and staff training signed off emailed to Kristen. 02/05/2021 Implemented
SIN-00162278 Renewal 09/27/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The evacuation time was not recorded for the fire drill conducted on 7/16/19.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. Staff was retrained . Moving forward it is implemented that the site supervisor will be present during fire drills to double check on staff. 10/02/2019 Implemented
6400.141(c)(9)Individual #3 is over the age of 40 years and a prostate exam was not included with the current physical examination.The physical examination shall include: A prostate examination for men 40 years of age or older. Prostate examination is now completed. Attached to Chris email is a copy of the examination paper. Moving Forward Prostate examination is now added to the new pre- admission check list created. it was also be part of the annual physical. 10/23/2019 Implemented
6400.181(a)Individual #3 was admitted on 6/28/19 and an initial assessment was not completed. 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. An assessment is now completed. attached to Chris email is a copy of the assessment. Moving Forward initial assessment completion is added to the pre- admission check list. which is also attached to chris's email. 10/01/2019 Implemented
SIN-00157907 Initial review 06/27/2019 Compliant - Finalized