Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00249587 Renewal 08/08/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)Five of the fire drill reports for the year do not include information regarding whether there were any problems encountered during the drill. Agency staff utilize a comments box on the monthly fire drill forms to indicate whether the drill was successful. The comments box on the fire drill forms indicated the following on the months where information is missing: 9/8/23: comments were "N/A" 10/2/23: comments indicated one individual living in the home was away visiting home. While this is important information, it does not indicate whether their were issues with the drill that occurred. 2/5/24: comments were "N/A" 4/3/24: comments box was left blank 7/4/24: comments were "N/A"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. On 8/9/2024 all staff was retrained on the correct way to complete a fire drill form. Please see attachment A1 and A2. 08/09/2024 Implemented
6400.34(a)The individual rights form for Individual #2 was signed on 6/4/24 by the individual's grandmother as legal guardian. There is no official documentation in the record indicating the grandmother is legal guardian. Other documents in the record are signed by the individual and the individual has the ability to sign/make a mark.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.On 8/12/2024 the Individual rights and the process to report rights violation was explained to Individual #2 and then was signed by Individual #2 using hand over hand assistance. Please see documentation labeled B1, B2 and B3. 08/12/2024 Implemented
6400.181(f)There was no documentation in the record that the 12/8/23 annual assessment for individual #2 was sent out to the team at least 30 days prior to the 1/29/24 ISP meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.A schedule was made to track the due dates of all Assessments. 08/15/2024 Implemented
SIN-00209011 Renewal 07/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)Bleach was stored in a clear spray bottle instead of its original container. Agency staff disposed of the bottle immediately upon discovery.Poisonous materials shall be stored in their original, labeled containers. A staff was held on August 11 where they were all informed that poisonous materials should always be kept in their original containers. 08/11/2022 Implemented
6400.144There are two as needed orders for individual 4, Lorazepam 1 MG tab (one every 4 hours as needed for agitation and one hour before medical or dental appointment). Neither Lorazepam order was present during the time of inspection. A protocol was not established dictating the specific use of order for agitation.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. Individual #4 doctor was contacted and after review of Individual #4's medication the doctor decided to discontinue Lorazepam 1mg every 4 hours for agitation. The doctor also discontinued PRN Ativan 1mg one hour prior to appointment. A copy of the discontinuation paperwork and MAR reflecting the discontinuation is attached. 08/01/2022 Implemented
6400.165(b)Triamcinolon Cream .1% medication prescribed to individual 4 is listed on the medication record (MAR), but a different mediation, Triple Antibiotic Ointment, was present. Also, the instructions are different on the label and MAR. The MAR stated to apply to the affected areas of body twice a day as needed. The Medication label stated to apply topically to affected area twice a day for 7 days).A prescription order shall be kept current.At the time the mediation was ordered the pharmacy did not have the Triamcinolon Cream .1% medication and replaced it with the Triple Antibiotic Ointment. The Pharmacy did not change the MAR to reflect the change. The information was communicated to the pharmacy about the discrepancy, but the replacement medication was not delivered in a timely manner. 08/15/2022 Implemented
SIN-00190537 Renewal 07/21/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The sunken patio accessible through the basement screen porch did not have an operational light at time of inspection.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The light for the patio accessible through the basement screen porch was repaired on 7/26/2021. A photo of said light is attached, please see photo labeled Item #1. 07/26/2021 Implemented
6400.72(b)Not all windows were found to be operable or in good repair; including two windows in the living room, in Individual #2's bedroom and Individual #3's bedroom. Screens, windows and doors shall be in good repair. The windows in Individual #2 bedroom and the living room was repaired on 07/26/2021. Please see photo attached labeled Item #2. Parts for the window in the individual # 3 bedroom is on back order as soon as it comes in the window will be repaired. 10/30/2021 Implemented
6400.80(b)Exterior conditions were not found to be in good repair. The first post on the right walking up the ramp to the main entrance had a jagged plastic fixture on its top, a cup-shaped planter or lamp post that was broken and sharp to the touch. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The plastic fixture on the first post on the right walking up the ramp to the main entrance was removed on 7/26/2021. Please see photo attached labeled Item#3 07/26/2021 Implemented
6400.81(k)(6)Individual # 1 was not found to have a mirror in their bedroom at time of inspection.In bedrooms, each individual shall have the following: A mirror. A mirror was installed in Individual #1 bedroom on 7/30/2021. Please see attached photo labeled Item #4. 09/21/2021 Implemented
SIN-00169735 Renewal 01/22/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The seats of the dining table chairs were worn and tornFloors, walls, ceilings and other surfaces shall be in good repair. New chairs were purchased to replaced the worn and torn chairs. A copy of the receipt of purchase labeled Item #5 is submitted with this report. 03/13/2020 Implemented
6400.82(f)There was No soap and no towels found in Individual #1's master 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. To make sure that Individual # 1's bathroom always have soap and toilet paper, the Program Supervisor will do a walk through of the house each morning to make sure that all the bathrooms have the necessary supplies. Also as part of staff responsibility each shift is required to make sure that all supplies are available to all residents. If running low on supplies the supervisor is notified immediately. 03/09/2020 Implemented
6400.141(a)Individual #1 physical examination was not completed timely. The last physical examination was completed 04/17/19, prior examination was completed 03/01/2018.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. There was a turnover in Supervisor for the program where Individual # 1 lives. The incoming supervisor did not use the appointment tracking sheet which led to the appointment being missed. To make sure that Individual #1 physical examination is completed in a timely fashion in the future the Program Supervisor will use a Medical appointment checklist to keep track of all medical appointments. This checklist will be reviewed monthly at the monthly Supervisors meeting. A copy of this form labeled Item # 4 is submitted with this report. 03/09/2020 Implemented
6400.141(c)(6)On Individual #1 physical form dated 04/17/19 the (TB) Tuberculin skin testing was omitted.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. The (TB) Tuberculin skin test was not done by the PCP, it was done by the Royer Greaves School Nurse. The nurse at Royer Greave have made the corrections to the annual physical. Going forward the Nurse at Royer Greaves will check all Physicals to make sure that all physical forms are completely filled out with the Tuberculin skin test, the date of testing and the date the results were read and whether its positive or negative. A copy of the corrected section of the Physical along with a copy of the Tuberculin Testing signed by Royer Greaves Nurse labeled Item #3 is attached. 03/09/2020 Implemented
6400.181(a)Individual #1 does not have an assessment annually, no assessment could be located for 2018. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The Program Supervisor removed Individual #1 2018 Assessment from his binder and archived it when she filed the 2019 Assessment in the binder. The 2018 Assessment was returned to Individual #1 binder. And the Deputy Executive Director met with the Program Supervisor and explained to her that the two most current years Assessment must always be available in Individual #1 binder. A copy of the 2018 Assessment labeled Item 2 is submitted with this report. 03/09/2020 Implemented
6400.168(a)Lorazepam .5mg (Ativan brand name) tablet, was a possible chemical restraint for individual #1. It was to be taken as needed for anxiety and behavior (PRN) was prescribed without a protocol in place.If an individual has a suspected adverse reaction to a medication, the home shall immediately consult a health care practitioner or seek emergency medical treatment.Royer Greaves School Nurse spoke with the doctor that prescribed the Lorazapam .5mg. The doctor has written a new script that states that the medication should be taken once a day as needed for anxiety prior to medical appointments. Protocol were also written and placed in Individual #1 Medical book stating that Lorazepam .5mg should be administered only for anxiety before medical appointments. Staff will notify the Supervisor prior to administering the Lorazepam 0.5mg. If Individual #1 should have an adverse reaction to the medication the staff shall immediately call the doctor, if Staff is unable to reach the doctor staff should call 911. A copy of the new script and protocol Labeled Item 1 is submitted with this report. 03/11/2020 Implemented
SIN-00118437 Renewal 06/28/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(c)THERE WAS NO DOCUMENTATION IN STAFF #1'S FILE THAT INDICATED THEY WERE QUALIFIED TO BE A PROGRAM SPECIALIST. A program specialist shall have one of the following groups of qualifications: (1) A master's degree or above from an accredited college or university and 1 year work experience working directly with persons with Intellectual Disability. (2) A bachelor's degree from an accredited college or university and 2 years work experience working directly with persons with Intellectual Disability. (3) An associate's degree or 60 credit hours from an accredited college or university and 4 years work experience working directly with persons with Intellectual Disability.Staff #1 was removed from the Program Specialist position effective July 5. 2017. The current Program Specialist is The Assistant Executive Director. In the future the HR department will review the 6400 regulations to make sure that all applicants are qualified for the position. 07/05/2017 Implemented
6400.181(e)(14)THE ANNUAL ASSESSMENT FOR INDIVIDUAL #1 DATED 08/01/2016 DID NOT DOCUMENT THE INDIVIDUAL'S KNOWLEDGE OF WATER SAFETY OR 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. A current Assessment was completed for Individual on 8/4/17. This Assessment includes the Individual's knowledge of water safety and ability to swim. In the future the Program Specialist and the Asst. Executive Director will review all Assessments to make sure that they include all the necessary information before approving them for distribution. 08/04/2017 Implemented
6400.213(1)(i)INDIVIDUAL #1'S RECORD DID NOT INCLUDE IDENTIFYING MARKS. Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.The plan was updated on 7/5/2017 to reflect that the Individual had no identifying marks. Going forward the Nursing Department and the Program Directors will review the Personal Data Summary Sheet Annually, to make sure that it includes (I) the Individual's name, sex, admission, date, birthdate and social security number. (ii) Race, Height, weight, color of hair, color of eyes and Identifying marks. (iii) Language used in Individual's natural home if other than English. (iv) The religious affiliation. (v) The next of Kin. (vi) A current dated photograph. 07/05/2017 Implemented
SIN-00088303 Renewal 03/14/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)Self-inspections were not done 3 to 6 months prior to the expiration of the license.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. A Self-Inspection was completed on September 22, 2016. The Assistant Executive Director will be responsible for making sure that the Self-assessment will be completed annually within 3 to 6 months prior to the expiration date of the agency's certificate of compliance. 09/22/2016 Implemented
6400.110(b)There was not a smoke detector within 15 ft. of the bedrooms.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. Smoke detector was placed on the ceiling in the hallway outside the bedroom on July 26, 2016. The maintenance Supervisor is now responsible for making sure that smoke detectors are located within 15ft of each individual and staff bedroom door. 07/26/2016 Implemented
SIN-00229694 Renewal 08/16/2023 Compliant - Finalized
SIN-00144250 Renewal 10/23/2018 Compliant - Finalized