Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00266177 Renewal 05/15/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)At time of inspection a large red plastic Folgers coffee container was found locked under the kitchen sink. There was no coffee in the container. The container was approximately ¼ full of an unidentified white partially solid substance. Staff at the home identified it as cleaner used to clean the grease. Poisonous materials must be stored in their original labeled containers.Poisonous materials shall be stored in their original, labeled containers. The large red plastic Folgers coffee container that was found with the white partially solid substance was disposed of immediately upon discovery by the Site Supervisor of the home. 05/15/2025 Implemented
6400.64(a)Clean and sanitary conditions were not maintained in the home. The kitchen cabinet doors were sticky to the touch with what appeared to be a layer of grease. The doors in the upstairs hallway were covered in a layer of dust that could be wiped away. The upstairs bathroom window blinds had a layer of dust and a sticky substance on the surface. There were multiple cobwebs above the inside of the bathroom door.Clean and sanitary conditions shall be maintained in the home. To address the noted cleanliness concerns within the home, Independent Living LLC has taken corrective actions as follows: The kitchen cabinets were thoroughly cleaned to remove the layer of grease that had accumulated on their surfaces. The doors upstairs were wiped down and cleared of dust to improve overall cleanliness. The window blinds upstairs were replaced with new blinds to ensure functionality and appearance. Multiple cobwebs were removed from the inside of the bathroom door, restoring a sanitary and well-maintained environment. 05/29/2025 Implemented
6400.112(h)Documentation of fire drills completed on 11/5/24 and 1/30/25 did not record that all individuals evacuated the home to the designated meeting place as required. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.To address the documentation concern related to fire drills, Independent Living LLC has reviewed and corrected the fire drill records for the following dates: November 5, 2024; and January 30, 2025. The updated documentation now accurately reflects that all individuals residing in the home successfully evacuated to the designated meeting place during each of these drills. 05/29/2025 Implemented
6400.113(a)Individual #2 transferred from one provider operated home into their current provider operated home on 8/21/24. Per the Regulatory Compliance Guide "If an individual moves from one home to another within the same agency, this training must be completed prior to or on the same day the individual moves into the new location, as this training is specific to each home." There was no documentation to support that fire safety training had been completed at the new location as required. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. To ensure compliance with fire safety training requirements, Individual #2 was asked to complete a new fire safety training which was done. Documentation of the completed training has been added to his record. 05/30/2025 Implemented
6400.141(c)(3)There was no documentation that Individual #2 received a Tdap booster as recommended by the Center for Disease Control (CDC) every ten years. The last documented Tdap was noted as 3/11/91. Recent medical reports note that the Tdap was "not covered by insurance." No further explanation or documentation of the booster being administered as required was available.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. An appointment was made for Individual #2 to receive a Tdap Booster on 6/3/25 at 9:40 AM. 05/30/2025 Implemented
6400.143(a)Individual #2 has multiple medication refusals documented on the Medication Administration Records (MARs) over the last year. There was no documentation to indicate that staff and management developed a plan to address the refusals nor a process to train the individual about the need for health care and how to then document the refusals and training as required.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. To address the ongoing concern regarding multiple medication refusals by Individual #2, the Program Specialist developed a Desensitization Plan tailored to the individual's needs and support preferences. This plan was created to help reduce anxiety and resistance related to medication administration through gradual exposure, positive reinforcement, and individualized support strategies. The desensitization plan has been implemented and is being monitored by the residential team, with progress documented and reviewed regularly. Staff have been trained on the implementation of the plan, and adjustments will be made as needed based on Individual #2¿s response. The Program Specialist will oversee the plan¿s effectiveness and provide ongoing support to ensure improved medication compliance. 05/29/2025 Implemented
6400.144Records indicate that Individual #2 was seen on 12/19/24 for "Hospital follow up." Recommendations at that appointment included "Labile pulse-check pulse at home." There was no documentation that checks were completed as directed prior to the next appointment on 1/8/25. At the 1/8/25 appointment it was again recommended to "check pulse at home." Documentation of pulse checks were provided indicating that they were completed in January of 2025 on 9,10,11,12,15,19 and 26. A progress note from the physician dated 1/29/25 notes that numbers were shared with the health care provider. On 1/29/25 it was recommended by the reviewing physician to "continue to monitor pulse sporadically." Documentation of checks was requested for the period of January-May 2025. Documentation of additional checks was not provided. It could not be determined that additional checks were completed between 1/29/25 and time of inspection on 5/15/25. Individual #2 received treatment for dehydration on 12/5/24. Summary instructions from the visit indicated that follow up was needed within 2-3 days. A medical services report from 12/19/24 was provided as follow up for the 12/5/24 treatment. Follow up was not completed within 2-3 days as recommended. There was no additional documentation to illustrate the reason for the delay. 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.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. A follow up appointment was completed on 5/21/25 to get further clarification from the doctor about Individual # 2 pulse checks. The doctor recommended that he no longer needs pulse checks since Individual # 2 pulse reading was within normal limits. 05/21/2025 Implemented
SIN-00224622 Unannounced Monitoring 05/11/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At time of inspection the freezer door on the refrigerator was stuck shut. Slight force was needed to open the door. Once opened it was noted that a brown sticky substance covered areas of the door and rubber seal causing the door and seal to stick firmly to the surface of the refrigerator and inhibiting normal opening of the door.Clean and sanitary conditions shall be maintained in the home. The refrigerator and freezer was cleaned and the doors are able to be opened and shut easily now that it has been cleaned. 05/26/2023 Implemented
6400.67(a)The exposed pipe for the heating system in the home located between the open dining and living room areas was wrapped in a paperback fiberglass insulation. A section of the insulation approximately twelve inches in length was ripped open exposing the fiberglass insulation. An additional area of approximately two feet in length was ripped open but wrapped with a blue tape. Pipes, faucet, and knobs in the shower of the second-floor bathroom were not properly secured. When attempting to turn on water the pipes, faucet and knobs would move within the wall and visibly in and out of the surface of the shower.Floors, walls, ceilings and other surfaces shall be in good repair. The insulation for the exposed pipes will be replaced and will be completely covered to ensure safety. The faucet knobs were tightened and secured so that they do not move upon usage. 06/02/2023 Implemented
6400.67(b)At time of inspection the ceiling fan above the bed of Individual #3 was not in proper working order. The pull chain to turn on the lights was not working. Individual #3 was screwing the light bulbs in and out of the sockets to turn the lights on and off. While in the bedroom of Individual #3 with a provider staff present, one of the lightbulbs began to flicker on and off. The lightbulb was adjusted by provider staff but again flickered. Improperly working electrical fixtures present hazards. Floors, walls, ceilings and other surfaces shall be free of hazards.The ceiling fan is being replaced by the Property Manager. 06/09/2023 Implemented
6400.72(b)The screen in the front door screen door had an area of approximately eight inches in length that was pulled out of the metal screen door frame. Screens, windows and doors shall be in good repair. The Property Manager fixed the screen for the front door. 05/26/2023 Implemented
6400.165(c)Individual #2 is prescribed Chlorhexidine 0.12% rinse. Pharmacy label notes "Use 3 times a week. Use ½ oz after brushing and flossing. Swish for 30 seconds and spit." The May 2023 Medication Administration Record (MAR) for Individual #2 correctly records the pharmacy label instructions. However, the MAR notes an "8am" slot that was initialed by provider staff each day to indicate that the medication was given daily from 5/1/23-5/11/23. The Chlorhexidine 0.12% rinse 1 pint/473ml bottle in use on 5/11/23 and filled on 11/23/22 was found to be over ¾ full at the time of inspection. If administered as prescribed a refill would have been required by 2/5/23. (REPEAT VIOLATION 10/22, 1/23)A prescription medication shall be administered as prescribed.A medication error and neglect incident was entered to determine what occurred with the Chlorexidine 0.12% rinse. 06/30/2023 Implemented
6400.166(c)At time of inspection on 5/11/23 Individual #2 was asked by Licensing Representative if they had refused medications due to the amount remaining in each container filled in November 2022. Individual #2 stated that they had refused the medications in the past including the current month of May 2023. Individual #2 further stated that the Supervisor of the home instructed the staff to just put their initials on the log even if the medications had been refused. Individual #2 is prescribed Chlorhexidine 0.12% rinse. Pharmacy label notes "Use 3 times a week. Use ½ oz after brushing and flossing. Swish for 30 seconds and spit." Pharmacy label indicates the order was given on 11/22/22 and last filled on 11/23/22. The May 2023 Medication Administration Record (MAR) for Individual #2 correctly records the pharmacy label instructions. However, the MAR notes an "8am" slot that was initialed each day by provider staff to indicate that the medication was given daily from 5/1/23-5/11/23. There are no refusals noted on the May 2023 MAR. Individual #2 is prescribed Sodium Floride 5000 plus crm. Pharmacy label notes "Use pea size amount twice daily as toothpaste." Pharmacy label indicates the order was given on 11/23/22 and last filled on 11/25/22. The tube in use was mostly empty, with little appearing to be remaining in the tube. May 2023 administrations were initialed by staff indicating that the medication had been administered as prescribed. There were no refusals noted on the May 2023 MAR. (REPEAT VIOLATION 10/22)If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual.A medication error and neglect incident was entered to determine what occurred with the Chlorexidine 0.12% rinse. 06/30/2023 Implemented
SIN-00222341 Unannounced Monitoring 04/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)An unlabeled spray bottle containing an unknown cleaning solution was found in Individual #2's bedroom.Poisonous materials shall be stored in their original, labeled containers. The unlabeled spray bottle was disposed of after discovery that it was in Individual #2's bedroom by the Program Supervisor of the home. 04/17/2023 Implemented
6400.72(a)The back room located on the 3rd floor had two windows and the screens in both windows were ripped along the bottom edge.Windows, including windows in doors, shall be securely screened when windows or doors are open. The screens on the two windows that were ripped along the bottom edge were repaired by the Property manager. 04/17/2023 Implemented
6400.165(b)A prescription order shall be kept current. Artificial Tears eye drops, to be administered 2 drops in each eye every 2 hours as needed, was listed on the April 2023 medication administration record (MAR) for Individual #1 but was not found in the home. Staff indicated that they thought the medication was no longer needed but there was no documentation that it had been discontinued by the prescribing physician and it has not been removed from the MAR.A prescription order shall be kept current.The Program Supervisor obtained a discontinuation notice for the Artificial Tears from individual #1's doctor that prescribed the medication. The medication was also discontinued on the Medication Administration Record. 04/17/2023 Implemented
SIN-00217606 Unannounced Monitoring 01/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.18(b)(2)Individual #1 is prescribed Oxcarbazepine 300mg, 1 tablet twice daily. The January 2023 Medication Administration Record (MAR) for Individual #1 recorded a "O" for the 8pm administration with notation on the back of the MAR indicating that "Omission- Med not received from pharmacy." Individual #1 is prescribed Sertraline 50mg, 1 tablet once daily. The January 2023 Medication Administration Record (MAR) for Individual #1 recorded a "O" for the 8pm administration with notation on the back of the MAR indicating that "Med not received from pharmacy." As of inspection on 1/6/2023 at approximately 11:45am the medication errors had not been entered/reported into the Enterprise Incident Management (EIM) system within 72 hours as required.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person: A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner.A medication error incident report was submitted by administrative employee after discovery that there was an omission that was not logged on the enterprise incident management system for individual #1. The individual did not receive as prescribed his 8 pm doses of Oxcarbazepine 300 mg and Setraline 50 mg, 01/26/2023 Implemented
6400.165(c)Individual #1 is prescribed Oxcarbazepine 300mg, 1 tablet twice daily. The January 2023 Medication Administration Record (MAR) for Individual #1 recorded a "O" for the 8pm administration with notation on the back of the MAR indicating that "Omission- Med not received from pharmacy." Individual #1 is prescribed Sertraline 50mg, 1 tablet once daily. The January 2023 Medication Administration Record (MAR) for Individual #1 recorded a "O" for the 8pm administration with notation on the back of the MAR indicating that "Med not received from pharmacy." The 8pm doses of the Oxcarbazepine and Sertraline were not administered as prescribed to Individual #1 on 1/1/23.A prescription medication shall be administered as prescribed.After discovering that an 8 pm dose of the Oxcarbazepine and Sertraline was not administered as prescribed to individual # 1 on 1/1/23, administrative staff contacted individual #1's prescribing doctor to discuss the missed dose and receive guidance on continuing administration. The prescribing doctor said to continue to administer the medication as prescribed. 01/26/2023 Implemented
SIN-00214660 Unannounced Monitoring 10/28/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Clean and sanitary conditions are not being maintained in the home. There was a pile of dirt located under the electrical box in the basement. The ceiling and ceiling fan in Individual #6's bedroom was covered with a significant amount of dust, including dust balls. (Repeat Violation 6/7/22 and 9/16/22.)Clean and sanitary conditions shall be maintained in the home. The dirt in the basement, the ceiling and ceiling fan in Individual # 6's bedroom was cleaned by the direct support professionals. The Program Supervisor also helped to ensure cleanliness. 10/31/2022 Implemented
6400.67(a)Surfaces are not in good repair. The freezer in the kitchen of the home did not have a handle. There were holes located on the freezer door where the handle should have been located. (Repeat Violation 6/7/22 and 9/16/22)Floors, walls, ceilings and other surfaces shall be in good repair. The freezer handle was affixed back on to the freezer by the property manager. 11/17/2022 Implemented
6400.165(c)Individual #6 is prescribed Spironelactone 100mg tabs, give two tablets by mouth in the morning for high blood pressure. The medication administration record and the label both indicated that the medication was to be administered in the morning. This medication was administered at 4PM until 10/11/22. On 10/12/22, the medication administration time on the medication administration record was changed to 9AMA prescription medication shall be administered as prescribed.The Program Supervisor contacted the prescribing doctor to retrieve documentation showing that the medication time of administration has been changed. 10/31/2022 Implemented
6400.166(c)Individual #6 is prescribed Melatonin 5mg tablet, five 1 tablet by mouth at bedtime. This medication is documented to be administered at 11PM on the Medication Administration Record. The medication is documented as refused on 10/1/22 and sleeping on 10/15/22. Staff indicated that the individual is occasionally sleeping at the time of administration and does not want to wake in order to take the medication. There is no additional documentation of the refusal or that the refusal was reported to the prescriber.If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual.The Program Supervisor contacted the prescribing doctor to retrieve a refusal protcol for Individual # 6. The MAR was corrected to reflect the refusal. 11/17/2022 Implemented
SIN-00211525 Unannounced Monitoring 09/16/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The top of the microwave in the kitchen had a splatter of a yellow substance on top. The cabinet doors and doors of the refrigerator and freezer were soiled with fingerprints and a sticky film. Expired food items were located in the kitchen cabinets; Quaker Oats- Best before date 7/16/22, Instant mashed potatoes -Best by date 2/26/22 and a variety pack of oatmeal- Best by 4/19/22.Clean and sanitary conditions shall be maintained in the home. After discovery, the Program Supervisor along with Direct Support Professionals (DSPs) cleaned the microwave, the kitchen cabinets, refrigerator, and freezer doors. The Program Supervisor along with DSPs also went through all the cabinets & refrigerator and disposed of any expired food items on 9/16/22. 09/16/2022 Implemented
6400.67(a)The caulk surrounding the upstairs tub was peeling away from the surface and spotted with what appeared to be a black mold like substance.Floors, walls, ceilings and other surfaces shall be in good repair. The bathtub was stripped from the old caulking and recaulked by the Property Manager on 9/18/22. 09/18/2022 Implemented
6400.171An open and partially used package of hard taco shells were found on the top shelf of the upper cabinet to the right of the stove. Food shall be protected from contamination while being stored.Food shall be protected from contamination while being stored, prepared, transported and served. The opened package of taco shells that were left on the shelf were disposed of after discovery by the Executive Director during the licensing inspection on 9/16/22. 09/16/2022 Implemented
6400.166(b)At time of inspection, 10:50am on 9/16/22, the noon dose of Clonazepam had been initialed as being administered on the September 2022 Medication Administration Record (MAR) for Individual #3. The medication had not been administered. The initials of the person administering the medication should be recorded at the time the medication is administered.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The documentation error was corrected by the Program Supervisor on 09-16-22 after discovery during the licensing inspection. It was discovered that Individual # 3 was participating in his Community Support service. The Community Support Provider¿s staff administered his afternoon medication to him at the appropriate time, but Independent Living LLC Direct Support Professional (DSP) documented the administration in the Medication Administration Record incorrectly. The DSP wrote her initials in the Medication Administration Record instead of documenting it as away and explaining that Individual # 3 was absent at the time of medication administration. 09/16/2022 Implemented
SIN-00189357 Renewal 06/29/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The fronts of the cabinets and the handles on the cabinets in the kitchen were sticky and greasy to the touch. The caulking around the tub in the second floor bathroom had a black substance resembling mold or mildew. The basement area was extremely dirty with dirt on the floor and surfaces in the area utilized by at least two of the individuals.Clean and sanitary conditions shall be maintained in the home. Staff cleaned the kitchen, including the greasy cabinets and handles. The bathtub was recalked and cleaned. Staff also cleaned the basement. Administrative staff followed up to ensure cleanliness on 07/15/21. 07/15/2021 Implemented
6400.67(a)There were approximately three floor tiles around the bathroom sink that were cracked and broken.Floors, walls, ceilings and other surfaces shall be in good repair. The cracked and broken tiles were all replaced in the bathroom on 07/15/21. 07/15/2021 Implemented
6400.141(c)(11)The physical examination dated 10/29/2020 for individual #1 did not include health maintenance needs, medication regimen or need for bloodwork.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 Program Supervisor called on 7/15/21 to schedule a new physical for Individual # 1 for July 21st at 8:40 am so that the doctor can assess Individual # 1¿s health maintenance needs, medication regimen, and the need for bloodwork at recommended intervals. 07/15/2021 Implemented
6400.141(c)(12)The physical examination dated 10/29/2020 for individual #1 did not include physical limitations.The physical examination shall include: Physical limitations of the individual. The Program Supervisor called on 7/15/21 to schedule a new physical for Individual # 1 for July 21st at 8:40 am so that the doctor can assess Individual # 1 for physical limitations. 07/15/2021 Implemented
6400.141(c)(14)The physical examination dated 10/29/2020 for individual #1 did not include information pertinent to diagnosis in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The Program Supervisor called on 7/15/21 to schedule a new physical for Individual # 1 for July 21st at 8:40 am so that the doctor can assess Individual # 1 and include information pertinent to diagnoses in case of emergency. 07/15/2021 Implemented
SIN-00177104 Renewal 09/29/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)In the upstairs bathroom, there were 2 used & uncovered toothbrushes sitting on top of the dusty radiator cover.Clean and sanitary conditions shall be maintained in the home. A shelf for the bathroom was purchased on 10/2/20 and will be affixed to the wall on 10/7/20 to place the toothbursh holders on. The toothbrushes that were found on the radiator were tossed out. New toothbrushes were purchased for each individual and placed in new toothbrush holders for each individual. Also, toothbursh covers were purchased for each individual. 10/07/2020 Implemented
6400.141(a)Individual #1 was admitted on 9/1/2020. She does not have a complete regulated physical exam in her record. The missing items include: Immunizations, Vision & hearing, Gynecological exam, Communicable disease/precautions, Health maintenance needs, Physical limitations, Information pertinent to diagnosis, and Special diet instructions.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual # 1 has an appointment for a complete physical on October 12, 2020. Independent Living LLC's physical form, which includes the missing items that are immunizations, vision & hearing, gynecological exam, communicable disease/precautions, health maintenance needs, physical limitations, information pertinent to diagnosis, and special diet instructions will be completed at the physical appointment by the physician. The Program Specialist will check to ensure that all items were completed as well. 10/12/2020 Implemented
6400.211(b)(3)There was no name, address and telephone number of the person able to give consent for emergency medical treatment in Individual #1's record.Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. The Program Specialist is updating Individual # 1's records, including the Demographic form and the Emergency Medical Treatment Plan to include the person's contact information, including the name, address, and telephone number, to be able to give consent for emergency medical treatment. Individual # 1's ISP will be updated as well to include this information. 10/16/2020 Implemented
6400.46(d)Staff #1's CPR certification expired on 4/24/18. Staff #1 has not been recertified since then.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.Staff # 1 will be attending CPR/First Aid class which is scheduled for the agency by an American Red Cross instructor on 10/22/20. The Vice President/Program Specialist will be monitoring trainings monthly and ensuring that all staff that are coming due for their recertifications of CPR/First Aid get certified before the CPR/First Aid certification expires. 10/22/2020 Implemented
6400.166(a)(2)Individual #1's Medication Administration Record (MAR) does not list the name of the prescribing doctor.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.The Medication Administration Record was corrected to include the Name of the Prescriber by the Program Specialist/Medication Administration Instructor on 10/1/20 for Individual # 1. Also, the Program Supervisor will be monitoring the Medication Administration Log monthly to ensure that the name of the prescriber is listed. 10/01/2020 Implemented
6400.166(a)(10)The Medication Administration Record(MAR) does not list what times medications are to be administered for Individual #1. Individual #1 is prescribed the following medications with no specific time of administration: Fluoxetine HCL 20mg (1 tablet) every day; Aripiprazole 20mg (1 tablet) every day; Mirtazapine 15mg (1 tablet) every day at bedtime; and Famotidine 200mg (1 tablet) twice a day.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.The Program Specialist received written clarification of times to administer Individual # 1's medication by her prescribing doctor on 10/1/20. The Medication Administration Record was corrected on 10/1/20 by the Program Specialist. The Program Supervisor will monitor the Medication Administration Logs monthly upon delivery of her medications to ensure that they are correct. 10/01/2020 Implemented
6400.166(a)(12)Individual #1 was administered Mirtazapine 15mg and Famotidine 20mg on 9/9/2020; no times of administration were documented on her Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration.An EIM was submitted by the CEO. All of the Direct Support Staff that work with Individual # 1 are being trained by the HCQU on 10/21/20 on proper medication administration protocols. Direct Support Staff that administered the medication on the 09/09/2020 added the time that he administered the medication to Individual # 1. The Program Specialist/Medication Instructor ensured that the Medication Administration Record was properly set up for October, 2020. The Program Supervisor will monitor the Medication Administration Record monthly to ensure that proper Medication Administration protocols are followed. 10/21/2020 Implemented
6400.167(a)(4)Medication errors are occurring due to staff administering medications outside of the 1-hour window before or after the administration time. Individual #1 receives Fluoxetine and Aripiprazole at 10am. Both of these medications were administered outside the 1-hour window on the following dates: 9/3/2020 (8am), 9/5/2020 (8:30am), 9/6-9/11/2020 (8am), 9/14/2020 (7:30am), 9/15/2020 (8am), 9/16/2020 (7am), 9/17-9/19/2020 (8am), 9/20/2020 (8:30am), 9/21-9/22/2020 (8am), 9/24-9/26/2020 (8am), and 9/28-9/29/2020 (8am). Individual #1 receives Famotidine 8am and 8:30 pm. This medication was administered outside the 1-hour window on the following dates: 9/10-9/11/2020 (10pm), 9/18/2020 (10pm), 9/23/2020 (10am) and 9/27/2020 (10am).Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time.An EIM was submitted by the CEO on 10/01/2020 regarding all of the medication errors. The HCQU will be training all Direct Support Staff that work with Individual # 1 on 10/21/20 on proper medication administration techniques and protocols. Also, the doctor that prescribes Individual # 1's medications sent the Program Specialist written protocols which includes times of when the medication should be administered. 10/21/2020 Implemented
6400.169(a)Even though staff are trained to pass medications, they are not administering medications to Individual #1 per the department approved Medication Training Course. Individual #1 is prescribed the following medications with no specific time of administration: Fluoxetine HCL 20mg (1 tablet) every day; Aripiprazole 20mg (1 tablet) every day; Mirtazapine 15mg (1 tablet) every day at bedtime; and Famotidine 200mg (1 tablet) twice a day. None of these medications have a specific time for them to be administered. Medications are being administered at various times from day to day which is not in accordance with the Department's Medication Administration Training course.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).All staff members that administer medication to Individual # 1 will be participating in a training session with the HCQU on proper medication administration techniques including times of administration on 10/21/20. The Program Supervisor will monitor monthly that staff are following all of the protocols relating to Medication Administration. 10/21/2020 Implemented
6400.186This home is not implementing Individual #3's Individual Support Plan (ISP). According to the ISP, sharps are kept locked at this residence. During the home inspection, licensing representatives found knives and a metal grater in an unlocked kitchen drawer and in the upstairs bathroom, 2 shaving razors were onto of the radiator cover.The home shall implement the individual plan, including revisions.All sharps were locked immediately following discovery of unlocked sharps. The Program Supervisor continuously monitored that they were being locked. On 10/5/20, individual # 3 chose to terminate services with Independent Living LLC and moved out of the Carey Ave home, and no other individuals in the home have a sharp restriction so the sharps are no longer kept locked at that home. On 10/09/2020, individual # 3 chose to move into another home that Independent Living LLC operates, and all sharps are kept locked at that home. The Direct Support Staff as well as the Program Specialist are continuously monitoring that the sharps are kept locked at his new home. 09/29/2020 Implemented
SIN-00154035 Renewal 04/05/2019 Compliant - Finalized
SIN-00147474 Initial review 01/04/2019 Compliant - Finalized