Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00272417 Unannounced Monitoring 08/12/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(d)Individual #1's current assessment was not dated by the program specialist.The program specialist shall sign and date the assessment. Assessment was dated in a different area and program specialist was under the belief that that was sufficient. Assessment updated, dated and signed by Program specialist on 8.28.25 to reflect appropriate compliance. Moving forward assessments will be reviewed by Assistant director or Director prior to final submission in order to maintain compliance by 9.12.25 09/12/2025 Implemented
6400.34(a)Individual #1's Rights were signed by the Program Specialist but not dated at the time of inspection 8/12/25.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.Program Specialist missed adding the date to the form due to it being present elsewhere on the document. Program specialist was retrained Individual Rights were updated and signed on 8.13.25 by guardian to reflect appropriately. 09/11/2025 Implemented
6400.166(a)(4)The following PRN medications where not on the Aug 2025 medication administration record for Individual #1- Aleve 220mg PRN for pain, Acetaminophen every 4 hours PRN.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.Individual had recently had a medical appointment where the medication was added on medical summary, however, as no script was given and the medication was not pointed out at the visit accompanying staff did not relay the information that PRN medication was needed. Later it was discovered during a medication review and promptly ordered, delivered and added to the MAR and will reflect fully by 9.11.25. 09/11/2025 Implemented
6400.213(1)(i)Individual #1's record contained a photo, but it was not dated.6400.213(1)i-vi - Each individual's record must include the following personal information, including-A current, dated photographProgram Specialist missed adding the date to the form due to it being present elsewhere on the document. Also prior the program books had single pictures which were dated which was changed recently and caused some confusion, which has been cleared up and rectified. Program specialist and Director reviewed 6400.21 regulations to understand the date is a compliance feature. Program Specialist also updated the face sheet to reflect the correct date the picture was actually taken. Also highlighted the form to ensure any updates and changes will be reflected better in real time with accurate information and current pictures. Updates are made and are electronic and will be in program books no later than 9.11.25. 09/11/2025 Implemented
SIN-00266456 Unannounced Monitoring 05/13/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104A letter to the fire department has not been updated to notify them that Individual #1 had moved out of this residence on 5/7/25.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. During a recent discharge administrative staff including Assistant Director and Program specialists who were currently in process of reviewing all documentation in homes did not update fire letters to ensure accuracy. Assistant Director of community homes stated they thought they had updated the record, and must have just missed it. Current Director of community homes and Assistant Director of community homes Updated all fire letters and resent to fire departments. Updated fire letters will be put into new binders ordered by Director of community homes, and implemented fully by target date of 6.20.25. 06/20/2025 Implemented
6400.216(a)(Repeat 2/3/25 and 3/31/25) At the time of the inspection, on 5/15/25, Individual #2's ISP and assessment were not kept locked and were located in an unlocked cabinet in the living room. An individual's records shall be kept locked when unattended. Staff in home were aware, but stated they didn't understand the importance of books being locked away. The current director of community homes explaining the HIPPA violations they signed off on and the fact that there may be people like contractors, who come into the home and can access records that could compromise the individuals we serve. Also showed them the regulator compliance guide which outlined the citation. Current director of community homes started removing unnecessary books, binders and paperwork in the home and merge them to be more efficient. And designated a locked space for the books to go in what will become an office space with a lock and key that only can be accessed by lead directs service professional or residential coordinator with direct service professionals needing permission to access and remove binders when needed. 06/20/2025 Implemented
SIN-00260425 Unannounced Monitoring 02/03/2025 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(b)(1)Individual #2 had a fall on 10/24/24 in which the individual hit their head. While staff did transport the individual to the Emergency Room for medical attention, 911 was not called immediately per the provider agency's "Individual Fall Protocol."The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. Individual fall protocol (attachment 10) has been updated to reflect the ODP regulation 6400.43.b.1. 02/28/2025 Not Accepted
6400.43(b)(3)Apex Healthcare Services has an "Unexplained Bruise/Injury Policy" in place if staff are to find an injury of unknown origin present on an individual. This policy instructs staff to contact management, then complete body chart documentation until the injury is gone. The only time staff are advised to seek medical attention is if there are signs of infection present. There are no policies in place to ensure that medical attention is promptly sought or that the origin of the injury is investigated to ensure the safety of the individuals.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. The Unexplained Bruise/Injury Policy will be updated to ensure all bruising of unknown origin should be examined by a medical professional (attachment 11). 02/28/2025 Not Accepted
6400.141(c)(1)Individual #1's most recent physical does not include a review of their lifetime medical history.The physical examination shall include: A review of previous medical history. The physical has been sent out to be corrected and filled out by the physician. As of this plan of correction, it has not been returned to the organization, but the physician's office stated it will take 7-10 business days to return (attachment 24). 02/28/2025 Not Accepted
6400.141(c)(4)Individual #1 has not had a vision/hearing screening. On 8/2/24, the individual's PCP attempted a hearing test, but it was indicated that the test was not successful due to "cognitive abilities." Another hearing test was attempted on 9/13/24 with no success. There have been no further attempts to get a completed hearing test, or a plan put into place to prepare Individual #2 to complete a hearing test.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The individual's vision records have been requested from the guardian (attachment 42). A hearing exam has been scheduled for 3/6/2025 (attachment 43). 02/28/2025 Not Accepted
6400.18(a)(4)Individual #2 had bruising and swelling of injuries of unknown origin on the following dates that were not entered as a potential physical abuse incident: 9/1/24, 10/4/24, 10/14/24, 10/18/24, 11/15/24, 12/31/24, 1/6/25 and 1/28/25.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 24 hours of discovery by a staff person: Abuse, including abuse to a individual by another client. An incident has been entered for potential physical abuse on 2/12/2025 (attachment 45). 02/28/2025 Not Accepted
6400.18(a)(9)Individual #2 had a fall in which they hit their head and required an emergency room visit on 10/24/24. Individual #2 required a CT scan which diagnosed a facial contusion and a possible fractured nasal bone. This serious injury was not reported in the department's incident management system.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 24 hours of discovery by a staff person: Injury requiring treatment beyond first aid. An incident has been filed under serious injury (attachment 47). 02/28/2025 Not Accepted
6400.18(f)Individual #2 had bruising and swelling of injuries of unknown origin on the following dates that were potential physical abuse, and no medical care was sought, or medical care was delayed: 9/1/24, 10/4/24 10/14/24, 10/18/24, 11/15/24, 12/31/24, 1/6/25 and 1/28/25.The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident.An incident has been entered for potential physical abuse on 2/12/2025 (attachment 45). 02/28/2025 Not Accepted
6400.18(g)Individual #2 had bruising and swelling of injuries of unknown origin on the following dates that were potential physical abuse incidents, and a certified investigation was not completed: 9/1/24, 10/4/24, 10/14/24, 10/18/24, 11/15/24, 12/31/24, 1/6/25 and 1/28/25.The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person.An incident has been entered for potential physical abuse on 2/12/2025 (attachment 45). 02/28/2025 Not Accepted
6400.18(b)(2)The medication errors described in 6400.167a1 were not reported in the department's incident management system.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.Multiple medication error incidents were filed for these med errors: 9568491, 9568595, 9568608 (attachment 48-48.2) 02/28/2025 Not Accepted
6400.18(i)A potential neglect incident, EIM #9540497, was discovered on 12/24/24. An investigator was assigned, however, the certified investigation was not completed and entered in EIM until 2/4/25.The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension.The administrative review and final section will be completed by 2/28/2025. The certified investigator was terminated while this investigation was completed but not fully entered. 02/28/2025 Not Accepted
6400.32(c)On 9/1/24, Individual #2 was taken to urgent care for left hand pain and a blister on their palm. The physician diagnosed cellulitis and ordered an X-ray to be completed of the Individual's left hand. The provider agency did not take Individual #1 to get this x-ray completed until 9/3/24. On 10/4/24, staff noted a bruise on Individual #2's right buttocks and left thigh. On 10/14/24, 10/15/24, and 10/16/24, staff noted that Individual #1 had right and left leg bruises. On 10/18/24 through 10/21/24, it was noted that Individual #1 had a red spot on the right side of their back. No medical attention was sought for any of these instances On 11/15/24, staff noted on Individual #2's body chart that the individual's left foot was swollen. This was again noted on 11/18/24. The individual was not taken for medical attention until 11/18/24, when an x-ray was ordered and a podiatry referral completed. The individual was also diagnosed with cellulitis and an antibiotic prescribed. Additionally, staff noted that bruises were discovered on the Individual's right buttocks and upper left thigh, but no medical care was sought for these injuries. On 1/6/25, staff noted on Individual #1's body chart that Individual #2's finger was swollen and there was a scratch behind their ear. On 1/7/25, staff noted the finger was "even bigger," and Individual #2 was taken to urgent care for a right foot bruise and left-hand swelling and bruise. The physician ordered rest, ice, and elevation for both extremities and for the individual to wear supportive shoes. Neither of these recommendations were completed. An orthopedic follow up was ordered but was not scheduled until after the start of the inspection. X-rays were also ordered on 1/7/25, but the provider agency did not take the individual to have these scans completed until 1/8/25. On 1/16/25, staff noted that Individual #2 had a bruise on their right hand and a swollen right foot. No medical attention was sought for these injuries. On 1/28/25, staff noted that after returning from a doctor appointment, Individual #2's right pinky finger was bruised and swollen. The bruising had worsened and spread on 1/29/25, but no medical attention was sought. As described above, there were 9 occasions between 8/15/24 and 1/31/25 where individual #2 had unexplained bruising and swelling, and medical care was not sought or was delayed. These injuries were of unknown origin, and no effort was made to determine the origin of the injuries to ensure they were not potential physical abuse. Additionally, the individual had 2 head injuries during this time period that medical care was not sought or was delayed. The failure to seek timely medical care and the failure to investigate the origin of unexplained injuries in many instances created conditions conductive to serious harm for Individual #2.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.A new appointment-timing policy "Emergent, urgent, certain time" has been created (attachment 8). 02/28/2025 Not Accepted
6400.166(a)(2)Individual #2's September 2024 Medication Administration Record does not include the prescriber's name for Orajel.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.The prescribers name and the diagnosis has been added to the PRN MAR for orajel (attachment 50) 02/28/2025 Not Accepted
6400.167(a)(1)Individual #2 was not administered the following medications: · 10/31/24 -- 6pm metformin and all 8pm medications · 1/10/25 -- 6pm metforminMedication errors include the following: Failure to administer a medication.Multiple medication error incidents were filed for these med errors: 9568491, 9568595, 9568608 (attachment 48-48.2) . 02/28/2025 Not Accepted
6400.195(a)Individual #2's 11/6/24 Behavior Support Plan indicates that one of the individual's goals to target boundary invasion is to, "Give staff space alone for 5 minutes using a set timer 80% of [their] opportunities for 3 consecutive months." Utilizing a timer can be considered restrictive and has not been approved by a human rights team.For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures.The BSP has been updated to remove restrictive wording as well as update goals and behaviors (attachment 18). 02/28/2025 Not Accepted
SIN-00256406 Renewal 12/10/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)REPEAT from 10/8/24 inspection-At the times of the inspection on 12/11/24, the mechanical vent in Individual #1's bathroom was covered in a thick layer of dust.Clean and sanitary conditions shall be maintained in the home. The vent in Individual #1's bathroom was cleaned on 12/18/24. (Attachment #32). All vents in all the homes were inspected and cleaned if needed by 12/26/24. 01/09/2024 Not Implemented
6400.141(c)(10)Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. This section was missing from Individual #1's 6/20/24 physical exam.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. The physical form for Individual #1 was returned to the PCP to complete the section on communicable disease. (Attachment #33) - to be submitted upon receipt from the PCP. Program Specialists were trained on 12/17/24 on the physical form and which questions on the form pertain to regulations. They reviewed 6400.141 in entirety and specifically 6400.141c10 and 6400.141c12. (Attachment #27) The current physical form includes this question on which the PCP is to document. The incorrect form was used. All outdated forms will be purged by 1/9/25. 01/09/2025 Implemented
6400.141(c)(12)The physical limitations section was missing from Individual #1's 6/20/24 physical exam.The physical examination shall include: Physical limitations of the individual. Individual #1's physical form was returned to the PCP for documentation of physical limitations. (Attachment #33). This will be submitted upon it's receipt. Program Specialists were trained on 12/17/24 on the physical form and which questions on the form pertain to regulations. They reviewed 6400.141 in its entirety and specifically 6400.141c10 and 6400.141c12. (Attachment #27) All outdated forms will be purged by 1/9/25. 01/09/2025 Implemented
6400.141(c)(14)The medical information pertinent to diagnosis and treatment in case of an emergency section was missing from Individual #1's 6/20/24 physical exam.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The information pertinent to diagnosis and treatment in case of emergency for Individual #1 was added to the physical form and returned to the PCP for review and signature on 12/26/24 (Attachment # 33). When it is received from the physician with signature, it will be submitted. The information pertinent to diagnosis and treatment is being added to the physical form. It will no longer be a separate document. 01/09/2025 Not Implemented
6400.181(e)(6)Individual #1's annual assessment 7/9/24 does not clearly state the ability in all sections indicating the knowledge for poisonous materials. The assessment in the section- awareness of danger/safety indicates a #5- constantly completes task/activity independent. In the annual summary of progress in the assessment- it states that Individual #1 needs assistance from staff to recognize poisonous materials. Most poisons are kept in a locked cabinet in the home with exceptions of hand/dish/ hand sanitizer & disinfecting wipes. The 10/17/24 ISP indicates that Individual #1 has no awareness of the dangers of handling poisonous substances. These materials must be kept out of reach at all times and have complete supervision is necessary around hazardous substances. All hazardous substances are store in a secured location.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. Individual #1's Assessment was revised to more clearly state Individual #1's need for supervision around poisonous materials and the discrepancies were resolved on 12/31/24. (Attachment #35) These revisions were sent to Individual #1's team on 1/2/25. (Attachment #36). 01/09/2025 Implemented
6400.181(e)(10)The assessment dated 7/9/24 for Individual #1 did not contain a lifetime medical history.The assessment must include the following information: A lifetime medical history. The Lifetime Medical History Form was added to the Assessment form for individual #1 on 12/26/24 and sent to the team. (Attachment #35) 01/09/2025 Implemented
6400.166(a)(4)Individual #1's Medication administration record did not include the following PRN medications prescribed by the doctor- Clear Lax- polyethylene Glycol 179gm by mouth in 4- 8 ounces of a beverage as needed. Aleve 220mg 1 tab every 8 hrs as needed for pain, acetaminophen 325 mg -- 2 tabs every 4 hrs as needed for pain.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.Individual '#1's PRN medication was added to the MAR on 12/13/24 . (Attachment # 38) 01/09/2025 Implemented
6400.182(a)The assessment 7/9/24 for Individual #1 was not updated to include financial information. Individual #1 carries a debit card, not cash in their wallet. This information is not in the assessment or ISP. The assessment 7/9/24 indicates that Individual requires staff to check on Individual #1 every 30 minutes overnight. There is no documentation this is completed and there is no medical professional indicating this is necessary. This is not indicated in the ISP.The program specialist shall coordinate the development of the individual plan, including revisions with the individual and the individual plan team.Individual #1's Assessment was revised to clearly state Individual #1's financial information. (Attachment #35) The revised assessment was sent to the team (Attachment #36). Individual #1's SC was contacted to revise the ISP to match the assessment (Attachment #36.1) 01/09/2025 Implemented
6400.213(1)(i)The inspection held on 12/11/24 Individual #1's record did not contain a dated photo. Individual #1's date of admission was 1/17/24. There was no photo taken of Individual #1 as of 12/11/2024.6400.213(1)i-vi - Each individual's record must include the following personal information, including: A current, dated photograph.New photos of all individual's were taken and dated. They were placed in the home binders on 12/16/24. (Attachments # 12-12.6) 01/09/2025 Implemented
SIN-00254901 Unannounced Monitoring 10/17/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(c)Individual #1 has received residential habilitation services through Apex Healthcare Services since 1/31/23. They have Moderate ID, sleep issues, anxiety managed with multiple medications, and are semi-verbal, able to complete short sentences but often repeat phrases. Their Individual Support Plan (ISP) highlights the need for frequent community outings to reduce anxiety. They enjoy van rides and social interactions. If anxious in the community, they should be encouraged to find a quiet space with staff to talk, addressing their emotional needs. Due to anxiety-related behaviors, a Behavior Support Plan (BSP) was updated on 1/8/24, focusing on "perseveration" (repeated questions/statements for attention) and "boundary invasion" (following staff, throwing others' belongings, invading personal space). Prevention strategies include the following: · When [Individual #1] desires to converse, be aware [they] will ask repeated questions. · Only respond to questions or converse when needed. · Set a timer for 5 minutes and pair with a red/green card to indicate when [they] will be given attention. · When the green stimulus is presented, give [them] attention/conversation for 5 minutes with the timer set. Attempt this 3x/shift to produce a routine to the stimulus cues. · When the red stimulus is presented, do not give [the individual] attention. Response strategies include the following: · When [Individual #1] is perseverating, decrease verbal responses and go to non-verbal gestures. · Utilize red/green stimulus cues to help [them] know when they will be provided attention. In Boundary invasion, the BSP indicates that Individual #1 will follow staff within 10 seconds, throw other's personal property away and invade other's personal space to gain access. One of the response strategies staff has if Individual #1 is invading boundaries is, "set a timer for 5 minutes, and pair with red/green stimulus cards, so [the individual] can be aware when they will receive attention again." The BSP culminates in a "skill development plan." Staff are to do the following when in Individual #1's presence: · At home, keep the red and green stimulus cards on you so they are visible to [Individual #1] · Show and explain that green card means you are available to talk and red card means you cannot talk · Show [the individual] when the card is on red, "[Individual #1] the card is on red, that means I can't talk right now." · If [they] make their generalized statements when the card is on red, do not respond, and point to the red card. · If [Individual #1] requests something [they] need during that time, you can get it for [them] and not engage in small talk conversation. · Turn the card to green then tell [them] you can talk and engage with them. · Do not leave it on red for more than 5 minutes (when trials first begin). Set a timer. · When there are opportunities where [they] are quiet (eating) keep the card on red to help [them] keep learning the routine consistently. · If [the individual] continuously interrupts during red card times, shorten the time you are showing the red card (i.e. 5 minutes to 2 minutes) · As [the individual] becomes familiar with the cards, you can increase the time of the red card showing (i.e. 5 minutes to 10 minutes) This plan as written does not help Individual #1 learn to manage and handle anxiety appropriately. Implementing this behavior support system within a home allows for the possibility of staff to mistreat and neglect Individual #1 under the guise of "following the behavior support plan," and depriving Individual #1 of their emotional needs that social interaction and attention provides.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.Apex immediately stopped the use of the red card/green card task and requested to collaborate with behavior supports to come up with a replacement strategy to mitigate the individuals perseveration and teach non-verbal cues. 11/06/2024 Implemented
6400.32(d)Individual #1 has a Behavior Support Plan (BSP) dated 1/8/24 in place that utilizes red and green stimulus cards and a timer to give Individual #1 permission to interact with staff. Individual #1 requires social interaction with staff as part of their emotional needs. Limiting Individual #1's interaction with staff is undignified and disrespectful.An individual shall be treated with dignity and respect.Apex immediately stopped the use of the red card/green card task and requested to collaborate with behavior supports to replace this task to ensure dignity and respect is upheld at all times. An updated BSP has been created and will be followed by staff. 11/06/2024 Implemented
SIN-00253488 Unannounced Monitoring 10/08/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At the time of the inspection on 10/8/24, the ceiling vent in the hall bathroom was dirty and covered in thick layer of dust. The bathtub in this same bathroom also appeared in need of cleaning with a noticeable reddish stain around the drain area.Clean and sanitary conditions shall be maintained in the home. The ceiling vent in hall bathroom was cleaned. (Attachment #9) The tub was cleaned. Since then the tub was removed and a shower was installed. (Attachment # 10) 11/07/2024 Not Implemented
6400.82(f)At the time of the inspection on 10/8/24, there were no hand towels or paper towels in the in the hall bathroom.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Paper towels were replaced in the hall bathroom. (Attachment 9.5) 10/12/2024 Implemented
6400.112(c)The 9/2/24 fire drill does not include the time the fire drill occurred.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. The staff who ran the drill was contacted for the time of the 9/2/24 fire drill. Time was added to the form. (Attachment #12) 11/07/2024 Not Implemented
6400.214(b)At the time of the inspection on 10/8/24, there was no ISP or assessment in the home for individual #1. The ISP on site for individual #2 was dated 12/22/23. The ISP was last updated 8/15/24 per HCSIS. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The binder for individual # 1 was located. The most recent ISP (Attachment # 14) and assessment (Attachment #15) for Individual # 1 were brought to the home. The binder for the other individual was located and checked for compliance. 11/07/2024 Not Implemented
SIN-00245569 Unannounced Monitoring 04/24/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(4)Individual #1's date of admission is 1/31/23. Individual #1 has not had a hearing or vision screening since their date of admission.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Individual #1's vision screening was completed on 5/16/24. (Attachment # 118). Individual # 1's PCP stated that a hearing screening was not needed. However, hearing screening is scheduled for 7/17/24 with Miracle Ear. (Attachment #119) The Program Specialist created a preventative screening tracking tool to maintain compliance with all preventative medical service appointments. (Attachment # 120). 07/17/2024 Not Implemented
6400.141(c)(15)Individual #1's Individual Support Plan indicates they require a low cholesterol, diabetic diet. This is not included on Individual #1's 8/24/23 annual physical examination.The physical examination shall include:Special instructions for the individual's diet. The PCP has reflected the Annual Physical form to reflect the ISP. Individual #1's Annual Physical form was amended to indicate the low cholesterol, diabetic diet. (Attachment #121) 09/30/2024 Implemented
6400.142(a)Individual #1's date of admission is 1/31/23. The only dental examination that has been attempted was on 9/20/23, however, this examination was not completed and an examination under sedation was recommended. Individual #1 has not yet had a full dental examination, nor has one been scheduled.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Individual # 1 was scheduled for a consult for dentistry under sedation on 7/16/24 (Attachment #122). All other dental providers in the area were researched but they either did not accept the insurance or refused to treat the individual under sedation due to their special needs. The Program Specialist created a preventative screening tracking tool on an Excel spreadsheet to maintain compliance with preventative dental appointments. (Attachment # 120). 09/30/2024 Implemented
6400.144Individual #1's Individual Support Plan indicates that they are to have bloodwork completed for their liver and thyroid every 3 months. The only times that bloodwork has been completed since 3/1/23 are on the following dates: 3/9/23, 11/28/23, and 5/9/24. Individual #1's Risperidone was increased on 1/17/24 with a "return to clinic in 1 month" order. This follow up appointment was not completed until 3/13/24.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. The Program Specialist sent a request to Individual #1's PCP for Bloodwork orders (Attachment #123). The Program Specialist created a preventative screening tracking tool to maintain compliance with all preventative medical serve appointments. (Attachment # 120). 08/16/2024 Not Implemented
6400.181(e)(10)There is no lifetime medical history included with Individual #1's 8/25/23 assessment.The assessment must include the following information: A lifetime medical history. The Lifetime Medical History was added to Individual #1's Assessment (Attachment #135). Program Specialist will be retrained on the updated assessment requirements in 6400.181. by 7/14/24. Confirmation of this training will be sent upon completion. 08/16/2024 Not Implemented
6400.18(b)(2)The medication errors described in 6400.167a1 were not reported in the department's incident management system.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.Individual #1 was not administered their 6pm dose of Metformin and 8pm dose of Trazodone on 2/26/24. - A medication error was entered into EIM. 08/16/2024 Implemented
6400.162(b)(2)(ii)Staff persons #1, 2, 3, 4, 5, 9, and 13 have not been trained to administer topical medications. All listed staff persons have administered topical medication to Individual #1.A prescription medication that is not self-administered shall be administered by one of the following: A person who has completed the medication administration course requirements as specified in § 6400.168 (relating to medication administration training) for the administration of the following: Topical medications.The RN trained the Director of Community Homes, who is the Medication Administration trainer, on using Ear drops, Eye Drops, Topicals and Patches on 6/10/24. The Director of Community Homes/Medication Administration Trainer trained all staff who are Med Trained to use Ear Drops, Eye Drops, Topicals and Patches in Annual Trainings from 6/10/24-6/18/24. Staff #1 - 6/12/24 Staff # 2 - 6/11/24 Staff #3 - no longer employed so could not participate in plan of correction Staff # 4 - 6/11/24 Staff # 5 - 6/18/24 Staff # 9 - 5/4/24 Staff # 13 - 6/12/24 06/18/2024 Implemented
6400.165(c)Individual #1's Risperidone was increased from .25mg twice daily to .5mg twice daily on 1/17/24. This medication increase was not administered to Individual #1 until the evening of 1/24/24.A prescription medication shall be administered as prescribed.Medication Error entered into EIM. - 9443724 Staff will be retrained on proper MAR documentation by 7/31/24. The focus will be on start and stop of a medication. All staff will be retrained on proper MAR documentation by 8/2/24. Staff will be retrained by 7/31/24 on reporting medication errors immediately to their supervisor. MARs will be checked by the Lead DSP each day that they work. The House Supervisor will check the MARs at least 2x/week and the Program Specialist will check the MARs 1x/week for the next 90 days. A new MAR tracking system for Lead DSP's, House Supervisors, and the Program Specialist will be put into place. (Attachment # 54) The Director of Community Homes will train the Lead DSP's, House Supervisors, and the PS on using the tracking system by 7/31/24. Results will be reported to the Medication Administration Trainer and the EIM Representatives immediately so the errors can be entered into EIM within 72 hours. For the next 90 days, if there is a change to the MAR, the RN or the Medication Administration Trainer will be called to enter it on the MAR. 10/01/2024 Implemented
6400.166(a)(2)Individual #1 has 3 PRN medications, Anti-Diarrheal, Acetaminophen, and Proctofoam, listed on their January 2024 Medication Administration Records. These PRN medications are not included on the individual's February, March, and April 2024 Medication Administration Records, nor are there discontinue orders for these medications. There was no prescriber listed for Anti-Diarrheal on Individual #1's January 2024 Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.Individual #1's staff who are med trained will receive remediation training consisting of documentation practice and a review of what needs to be done when PRN or time limited medications are ordered by 7/31/24. In addition what documentation is needed for a PRN or time limited medication to be administered will be reviewed as well. A record of the training will be sent after completion. The Program Specialist sent new PRN sheets to all individuals' PCPs for authorization. These will be sent upon receipt from the PCP. Any PRN medications that are in addition to regular PCP's orders, or any time limited medications that will be added to the MAR will be done so under observation by the Medication Administration Trainer or the RN. This compliance plan will be distributed to all staff by 7/14/24. All staff will be retrained on reporting medication errors immediately to their supervisor. MARs will be checked by the Lead DSP each day that they work. The House Supervisor will check the MARs at least 2x/week and the Program Specialist will check the MARs 1x/week. 10/09/2024 Implemented
6400.166(a)(6)There was no dosage form listed for Anti-Diarrheal on Individual #1's January 2024 Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form.Individual #1's staff who are med trained will receive remediation training consisting of documentation practice and a review of what needs to be done when PRN or time limited medications are ordered by 7/31/24. In addition what documentation is needed for a PRN or time limited medication to be administered will be reviewed as well. A record of the training will be sent after completion. The Program Specialist sent new PRN sheets to all individuals' PCPs for authorization. These will be sent upon receipt from the PCP. Any PRN medications that are in addition to regular PCP's orders, or any time limited medications that will be added to the MAR will be done so under observation by the Medication Administration Trainer or the RN. This compliance plan will be distributed to all staff by 7/14/24. All staff will be retrained on reporting medication errors immediately to their supervisor. MARs will be checked by the Lead DSP each day that they work. The House Supervisor will check the MARs at least 2x/week and the Program Specialist will check the MARs 1x/week. 09/30/2024 Implemented
6400.166(a)(7)There was no dose listed for Anti-Diarrheal on Individual #1's January 2024 Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.Individual #1's staff who are med trained will receive remediation training consisting of documentation practice and a review of what needs to be done when PRN or time limited medications are ordered by 7/31/24. In addition what documentation is needed for a PRN or time limited medication to be administered will be reviewed as well. A record of the training will be sent after completion. The Program Specialist sent new PRN sheets to all individuals' PCPs for authorization. These will be sent upon receipt from the PCP. Any PRN medications that are in addition to regular PCP's orders, or any time limited medications that will be added to the MAR will be done so under observation by the Medication Administration Trainer or the RN. This compliance plan will be distributed to all staff by 7/14/24. All staff will be retrained on reporting medication errors immediately to their supervisor. MARs will be checked by the Lead DSP each day that they work. The House Supervisor will check the MARs at least 2x/week and the Program Specialist will check the MARs 1x/week. 09/30/2024 Implemented
6400.166(a)(8)There was no route of administration listed for Anti-Diarrheal on Individual #1's January 2024 Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.Individual #1's staff who are med trained will receive remediation training consisting of documentation practice and a review of what needs to be done when PRN or time limited medications are ordered by 7/31/24. In addition what documentation is needed for a PRN or time limited medication to be administered will be reviewed as well. A record of the training will be sent after completion. The Program Specialist sent new PRN sheets to all individuals' PCPs for authorization. These will be sent upon receipt from the PCP. Any PRN medications that are in addition to regular PCP's orders, or any time limited medications that will be added to the MAR will be done so under observation by the Medication Administration Trainer or the RN. This compliance plan will be distributed to all staff by 7/14/24. All staff will be retrained on reporting medication errors immediately to their supervisor. MARs will be checked by the Lead DSP each day that they work. The House Supervisor will check the MARs at least 2x/week and the Program Specialist will check the MARs 1x/week. 09/30/2024 Implemented
6400.166(a)(9)There was no frequency of administration listed for Anti-Diarrheal on Individual #1's January 2024 Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.Individual #1's staff who are med trained will receive remediation training consisting of documentation practice and a review of what needs to be done when PRN or time limited medications are ordered by 7/31/24. In addition what documentation is needed for a PRN or time limited medication to be administered will be reviewed as well. A record of the training will be sent after completion. The Program Specialist sent new PRN sheets to all individuals' PCPs for authorization. These will be sent upon receipt from the PCP. Any PRN medications that are in addition to regular PCP's orders, or any time limited medications that will be added to the MAR will be done so under observation by the Medication Administration Trainer or the RN. This compliance plan will be distributed to all staff by 7/14/24. All staff will be retrained on reporting medication errors immediately to their supervisor. MARs will be checked by the Lead DSP each day that they work. The House Supervisor will check the MARs at least 2x/week and the Program Specialist will check the MARs 1x/week. 09/30/2024 Implemented
6400.167(a)(1)Individual #1 was not administered their 6pm dose of Metformin and 8pm dose of Trazodone on 2/26/24.Medication errors include the following: Failure to administer a medication.A medication Error was entered into EIM. Individual #1's staff will be given 2 supervised medication observations over the next 90 days. The documentation will be sent upon completion. Individual #1's staff who are med trained will receive remediation training consisting of documentation practice and a review of what needs to be done when PRN or time limited medications are ordered by 7/31/24. In addition what documentation is needed for a PRN or time limited medication to be administered will be reviewed as well. A record of the training will be sent after completion. All staff who are med trained will receive remediation training consisting of documentation practice and a review of what needs to be done when PRN or time limited medications are ordered by 7/31/24. In addition, what documentation is needed for a PRN or time limited medication to be administered will be reviewed as well. A record of the training will be sent after completion. All staff will be retrained on reporting medication errors immediately to their supervisor. MARs will be checked by the Lead DSP each day that they work. The House Supervisor will check the MARs at least 2x/week and the Program Specialist will check the MARs 1x/week. 10/01/2024 Implemented
6400.181(f)Individual #1's 8/25/23 assessment was not sent to the team.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.The Program Specialist will be retrained on the requirements of the assessment according to 6400.181 by 7/14/24. 07/14/2024 Not Implemented
SIN-00229358 Renewal 08/30/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(2)(Repeated Violation -- 9/20/22) Individual #1's April and May 2023 financial ledgers indicates on 4/30/23, Individual #1 had $225.78 and on 5/1/23, they had $225.87. This $.09 difference continued through at least 7/31/23.(2) Disbursements made to or for the individual. 8/31/23 - The math error for Individual # 1's financial ledger (of $0.09) was corrected by the house supervisor and subsequent financial ledgers were adjusted. (attachment # 14a,b,c,d) (5/1/23-7/31/23) 09/11/2023 Implemented
6400.77(b)At the time of the 8/31/23 inspection, the thermometer was not present in the first aid kit. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. 9/1/23 - The house supervisor placed a thermometer inside the first aid kit of the home. (attachment #15a) 09/21/2023 Implemented
6400.111(f)There is no documentation provided verifying the fire extinguishers in the home were inspected before 9/30/22. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The CEO of Apex Healthcare Services, LLC reviewed the company's bank statements to determine the dates for the fire extinguisher inspection for 2022 (attachment #1 & 2). however, the receipts were for multiple homes on one payment. The receipts are also for the date of payment not the date of inspection. The CEO also said that they paid in cash for some of the inspections and did not get a receipt. The plan of correction is maintaining compliance with this regulation from this point forward by retaining actual receipts as well as keeping a Fire Extinguisher inspection Compliance Tracker. This will be kept in the Fire Safety Binder of the home. (attachment # 6) receipt. 09/21/2023 Implemented
6400.144Individual #1 had a colonoscopy on 5/11/23, with prep completed on 5/10/23. Individual #1's Metformin was to be held both days, however, the Medication Administration Records indicate that the medication was administered to Individual #1 on 5/10/23.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. 9/21/23 - All staff will be re-trained on the importance of following doctor's instructions and what is required for an order to hold a medication (attachment #7). Documentation will be sent after the completion of this training. 09/21/2023 Implemented
6400.151(c)(3)Staff person # 3- 2/17/23 physical examination does not include a signed statement regarding the staff person's communicable disease status. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. 9/13/23-The provider of Staff person #3's physical was contacted by Apex to request that the doctor check the box on the physical form that was left unchecked (even though the negative PPD result was included with the physical). The provider of the physical requested that Staff # 3 be present. Staff member #3 is on personal leave due to a death in the family. When they return to work, they will have until 9/30/23 to complete this request. This documentation will be sent, once it is completed. 09/30/2023 Implemented
6400.181(e)(10)Individual #1's 2/14/23 initial assessment did not include a lifetime medical history. It did include 3 of the individual's diagnoses, but not a complete history.The assessment must include the following information: A lifetime medical history. 9/1/23 - The Program Specialist added the Lifetime Medical History to the initial assessment. (attachment # 18.1-6) 09/11/2023 Implemented
6400.214(b)(Repeated Violation -- 9/20/22) The most recent Individual Support Plan at the home for Individual #1 was dated 6/5/23. Individual #1 had a plan update completed on 8/17/23. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. 9/1/23 - The Program Specialist printed the most current version of individual # 1's ISP and placed it in the individual records. On 9/13/23, the Program Specialist printed another revision. (attachment # 20) 09/01/2023 Implemented
6400.24Staff person #3 and staff person #5 both had criminal records discovered upon hire, however documentation was not kept in the staff's records that the following case-by-case reviews were completed before hire: · The nature of the crime, · Facts surrounding the conviction, · Time elapsed since the conviction, · The evidence of the individual's rehabilitation; and · The nature and requirements of the job.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.9/15/2023: Apex reviewed the nature of the crimes on staff #3 and #5 and documented the nature, facts, time elapsed, rehabilitation, and job requirements (attachment # 22a &22b). 09/11/2023 Implemented
6400.46(c)Staff person #2 was hired on 4/25/23. This staff person did not have training on general first aid before working with individuals. Staff person # 3 was hired on 2/20/23. This staff person did not have training on general first aid before working with individuals.Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques.Staff person #2 who was hired on 4/25/23 completed CPR and First Aid training on 6/5/23. Staff member # 3 who was hired on 2/20/23 completed CPR and First Aid Training on 4/18/23. 9/1/23 - The Director of Community Homes added First Aid Basics to the Orientation Checklist. (attachment # 23) 09/11/2023 Implemented
6400.165(b)Individual #1 was prescribed Trazodone 50mg on 3/29/23. This medication was not administered to Individual #1 until 4/4/23. This medication was then increased to 100mg on 5/24/23. The 50mg dose was discontinued on 5/25/23, however, the new 100mg dose was not administered until 6/1/23.A prescription order shall be kept current.9/1/23 - The Program Specialist and the House Supervisor were re-trained on obtaining new medications in a timely manner to ensure meds are given as soon as prescribed. They were also retrained on running an appointment, double checking scripts were sent from the medical professional to the pharmacy, ensuring pick up of medications, what to do if the pharmacy is closed and communication of new medications to DSP's in the home. (attachment #25 ) 09/21/2023 Implemented
6400.165(c)Individual #1 was taken to the emergency room on 5/20/23 for an anal fissure and external hemorrhoid. Individual #1 was prescribed PRN Protofoam and Docusate to help alleviate their current discomfort and help any future discomfort. Individual #1 was not administered either of these medications before 6/12/23. Individual #1 was taken to urgent care on 5/9/23 for a possible UTI and was prescribed Nystatin and Bactrim. These medications were not administered to Individual #1 on 5/11/23.A prescription medication shall be administered as prescribed.9/1/23 - The Program Specialist and House Supervisor were re-trained on obtaining new medications in a timely manner to ensure meds are given as soon as prescribed. They were also trained on running appointments, checking scripts were sent from medical professional to the pharmacy, ensuring the pick up of medications in a timely manner, what to do if the pharmacy is closed, and communication to the DSP of the home. (attachment #25) 09/21/2023 Implemented
6400.166(a)(4)Individual #1 had to complete a colonoscopy prep on 5/10/23, which included administrations of Miralax. None of the medication administrations for the prep were documented on Individual #1's Medication Administration Record (MAR). Individual #1 has the following PRN medications: Protofoam, Acetaminophen, and DG Anti-diarrheal. None of these medications are listed on the August 2023 MAR. Additionally, DG Anti-diarrheal is a standing OTC order and this order was not kept with the MAR. Individual #1's PRN Acetaminophen was refilled on 7/20/23. At the time of the 8/31/23 inspection, 9 doses of the medication were documented as administered in August 2023, however, 17 doses have been administered. The other 8 administered doses were not recorded on the July or August 2023 MAR.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.9/1/23 - A PRN medication administrative record was created for all individuals by the program specialist. It was placed in their medication records. (attachment # 26a,b,c,d,e) 09/21/2023 Implemented
Article X.1007Staff person #2 was hired on 4/25/23. A Pennsylvania State Police Criminal Background check was not completed before this staff person's date of hire.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.9/13/23 - A PA State Criminal Check was completed. It is currently under review for control. (attachment #21) 09/13/2023 Implemented
SIN-00211172 Renewal 09/19/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)Hand soap was in a condiment bottle in the laundry room and was not in original labeled container.Poisonous materials shall be stored in their original, labeled containers. 9/21/2022: The condiment bottle containing soap was immediately removed and replaced with a new hand soap dispenser in its original packaging/container by the program supervisor. Attachment #15 10/20/2022: All staff will be trained on the plan of correction at their all staff meeting on 10/20/2022.This roster will be sent as evidence on 10/21/22. 09/21/2022 Implemented
6400.112(c)Fire Drills on 02/22/22, 02/28/22, 03/10/22, 04/24/22, 05/10/22, 07/15/22, 07/20/22, 08/07/22, 09/11/22 do not indicate problems encountered. The spaces were left blank.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. 9/22/2022: All fire drill forms were edited to include a check box for "no problems encountered" within the section problems encountered. This was completed by the Program Specialist. Attachment #16 10/20/2022: All staff will be trained on this edited fire drill during their All Staff Meeting. This roster will be sent as evidence on 10/21/22. 09/22/2022 Implemented
6400.141(c)(3)Individual # 1's physical exam dated 02/24/22 does not include immunizations.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. 9/22/2022: Individual #1's immunization record was added to the physical document. - Attachment #17b.1 - 7 10/20/2022: All staff will be trained on the plan of correction at their all staff meeting on 10/20/2022. This roster will be sent as evidence on 10/21/22. 10/28/2022: Evidence of new form usage will be sent following the next scheduled physical. 10/28/2022 Implemented
6400.141(c)(14)Individual # 1's physical exam dated 02/24/22 does not include information pertinent to an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. 9/22/2022: Individual #1 was not in the care of Apex Healthcare Services, LLC during the time of his physical. The Information pertinent to diagnosis in case of emergency document was signed 8/11/2022 by his PCP. This document has been attached to individual #1s physical by the Program Specialist. Attachment #17b.1 -7 10/6/2022: All physical forms have been modified to include the Information pertinent to diagnosis and treatment in case of emergency document for each individual and include a signature line for the physician to sign at the time of the physical. These documents have been prepared by the Program Specialist. - Attachment #17b.1 -7 10/20/2022: All staff will be trained on the plan of correction at their all staff meeting on 10/20/2022. This roster will be sent as evidence on 10/21/22. 10/28/2022: Evidence of new form usage will be sent following the next scheduled physical. 10/28/2022 Implemented
6400.181(e)(14)Individual # 1's assessment dated 07/02/22 does not include an assessment of individual #1'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. 9/22/2022: The Program Specialist has revised the assessment to include the individuals ability to swim. - Attachment #19a-f 10/20/2022: All staff will be trained on the plan of correction at their all staff meeting on 10/20/2022.This roster will be sent as evidence on 10/21/22. 09/22/2022 Implemented
6400.32(p)Individual # 1's rights statement signed on 02/28/22 does not include the right to choose persons with whom to share a bedroom.An individual has the right to choose persons with whom to share a bedroom.9/22/2022 - The Program Specialist created a revised Rights Statement that includes the right to choose persons with whom to share a bedroom. Attachment #8b 9/23/2022 - The rights statement was reviewed with individual #1 as well as his guardian by the Program Specialist. The individual signed the statement on the same day. Attachment #8a-e 9/28/2022 - The new Rights Statement was reviewed with all individuals receiving services through Apex Healthcare Services, LLC Community Homes and copies have been sent to their guardians. 10/20/2022: All staff will be trained on the plan of correction at their all staff meeting on 10/20/2022. This roster will be sent as evidence on 10/21/22. 09/28/2022 Implemented
6400.32(q)Individual # 1's rights statement signed on 02/28/22 does not include the right to furnish and decorate their bedroom.An individual has the right to furnish and decorate the individual's bedroom and the common areas of the home in accordance with § 6400.33 (relating to negotiation of choices).9/22/2022 - The Program Specialist created a revised Rights Statement that includes the right to furnish and decorate their bedroom. Attachment #8b 9/23/2022 - The rights statement was reviewed with individual #1 as well as his guardian by the Program Specialist. The individual signed the statement on the same day. Attachment #8a-e 9/28/2022 - The new Rights Statement was reviewed with all individuals receiving services through Apex Healthcare Services, LLC Community Homes and copies have been sent to their guardians. 10/20/2022: All staff will be trained on the plan of correction at their all staff meeting on 10/20/2022. This roster will be sent as evidence on 10/21/22. 09/28/2022 Implemented
6400.32(r)Individual # 1's rights statement signed on 02/28/22 does not include the right to lock their bedroom door.An individual has the right to lock the individual's bedroom door.9/22/2022 - The Program Specialist created a revised Rights Statement that includes the right to lock their bedroom door. Attachment #8b 9/23/2022 - The rights statement was reviewed with individual #1 as well as his guardian by the Program Specialist. The individual signed the statement on the same day. Attachment #8a-e 9/28/2022 - The new Rights Statement was reviewed with all individuals receiving services through Apex Healthcare Services, LLC Community Homes and copies have been sent to their guardians. 10/20/2022: All staff will be trained on the plan of correction at their all staff meeting on 10/20/2022. This roster will be sent as evidence on 10/21/22. 09/28/2022 Implemented
6400.32(s)Individual # 1's rights statement signed on 02/28/22 does not include the right to have a key or access to lock and unlock the entrance door of the home.An individual has the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home.9/22/2022 -The Program Specialist created a revised Rights Statement that includes the right to have a key or access to lock and unlock the entrance door of the home. Attachment #8b 9/23/2022 - The rights statement was reviewed with individual #1 as well as his guardian by the Program Specialist. The individual signed the statement on the same day. Attachment #8a-e 9/28/2022 - The new Rights Statement was reviewed with all individuals receiving services through Apex Healthcare Services, LLC Community Homes and copies have been sent to their guardians. 10/20/2022: All staff will be trained on the plan of correction at their all staff meeting on 10/20/2022. This roster will be sent as evidence on 10/21/22. 09/28/2022 Implemented
6400.32(t)Individual # 1's rights statement signed on 02/28/22 does not include the right to access food at any time.An individual has the right to access food at any time.9/22/2022 - The Program Specialist created a revised Rights Statement that includes the right to access food at any time. - Attachment #8b 9/23/2022 - The rights statement was reviewed with individual #1 as well as his guardian by the Program Specialist. The individual signed the statement on the same day. Attachment #8a-e 9/28/2022 -The new Rights Statement was reviewed with all individuals receiving services through Apex Healthcare Services, LLC Community Homes and copies have been sent to their guardians. 10/20/2022: All staff will be trained on the plan of correction at their all staff meeting on 10/20/2022. This roster will be sent as evidence on 10/21/22. 09/28/2022 Implemented
6400.166(a)(11)Individual # 1's August MAR lists Atorvastatin, Meta-Mucil Fiber, Spectravite-Multivitamin, Divalproex, Trazodone and Risperidone as medications but does not include the purpose for each medication.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.9/22/2022: The Program Specialist has added the purpose of the medication for each medication on the MAR. Attachment #18a-b 9/22/2022: All individual's MARs were reviewed by the Program Specialist and Director of Community Homes to ensure that all components of the MAR were present. 10/20/2022: All staff will be trained on the plan of correction at their all staff meeting on 10/20/2022. This roster will be sent as evidence on 10/21/22. 09/22/2022 Implemented
SIN-00277664 Unannounced Monitoring 11/06/2025 Compliant - Finalized
SIN-00275299 Unannounced Monitoring 09/30/2025 Compliant - Finalized
SIN-00270625 Unannounced Monitoring 07/23/2025 Compliant - Finalized