Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00264913 Unannounced Monitoring 04/21/2025 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)At the time of the inspection, there were no scissors available in the first aid kit. Corrected on site. 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. Director of Programs and/or QA Coordinator will review the daily house checklist to ensure that the first aid kits are listed in order for them to be checked daily to ensure that all items are in the kit. Director of Programs will meet with the Residential Managers to review the importance of checking specific items when performing the daily checklist. This was completed on 4.29.25. 05/09/2025 Accepted
6400.81(i)At the time of the inspection, the privacy paper on Individual #1's bedroom window was peeling.Bedroom windows shall have drapes, curtains, shades, blinds or shutters. Director of Programs created a work order for Facility Manager to address the privacy paper on the bedroom window. This was completed on 4.22.25. Director of Programs and/or QA Coordinator will review the monthly house checklist to ensure that specific items in each area of the home/yard is listed on the house checklist. Director of Programs will meet with the Residential Managers to review the importance of checking specific items when performing the monthly house checklist. This was completed on 4.29.25. 05/09/2025 Accepted
SIN-00258628 Unannounced Monitoring 12/06/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16Individual #1 requires periodic line of sight supervision. Staff must be sitting with Individual #1 while they are eating due to choking hazards. The individual requires physical assistance bathing and after a bowel movement. Individual #2 requires periodic line of sight supervision when in the home. Individual #3 requires periodic line of sight supervision in the home and staff in line of sight while eating due to choking hazards. Individual #3 also requires physical assistance while bathing. All 3 individuals require awake overnight staff and there are to be 2 staff always present in the home for the safety of the individuals. On November 22, 2024, this home was reopened after a temporary closure. Individuals #1 and #2 moved back into the home at this time. Individual #3 had out of the home medical care until they returned to the home on 12/8/24. Between 11/22/24 and 12/14/24, there were a total of 58 time periods where the proper staff ratio was not maintained. On 12 of these occurrences, the only staff in the home was a "sleep" overnight staff. 3 times, no staff were present in the home with individuals. The other 43 occurrences, there was only 1 staff present in the home. Failure to adequately staff the home creates conditions conducive to serious harm for all 3 individuals in the home.Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.A mandatory on-call system will be put into place to ensure immediate coverage when a staff shortage occurs. Administrative staff and available float staff will be assigned as emergency backup to meet staffing requirements. Daily staffing logs will be reviewed by the Program Manager/House Supervisor to ensure the correct staff ratio is maintained. Immediate corrective action will be taken if staffing levels drop below the required minimum. All staff will be trained on the importance of staffing ratios and supervision requirements for Individuals #1, #2, and #. Training will include emergency protocols when short staffing occurs. 02/17/2025 Implemented
SIN-00256639 Unannounced Monitoring 10/23/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16Individual #1 has Moderate ID, Down's Syndrome, Parkinson's Disease, and multilevel degenerative disc disease. They can perform most daily activities independently, but they need assistance with cooking, medication, and navigating stairs or uneven terrain due to tremors. Individual #2 has Mild ID, Autism, Seizure Disorder, Tic Disorder, PTSD, IED, and Psychosexual Disorder. They require verbal prompts for daily tasks and lack danger awareness. Two staff must always be available in the home. Individual #1 has multiple plans and protocols in place that staff are to be trained on before working in the home. These plans include an Individual Support Plan (ISP), SEEN plan, CPAP protocol, Fire Evacuation Support plan, Dental Hygiene plan, Blood Thinner Protocol, Fall Protocol, Apartment Alone Time and Stay Alone Protocol. Individual #2 also has multiple plans and protocols in place that staff are to be trained on before working in the home. These plans include an ISP, SEEN plan, Seizure protocol, Fire Evacuation protocol, and constipation protocol. There was a total of 18 staff who worked in Individual #1 and Individual #2's home between 7/1/24 and 10/23/24. None of these staff were trained in Individual #1 or Individual #2's plans and protocols. Both individuals require staff to administer medications to them and require numerous medications throughout the day. Between 7/1/24 and 10/23/24, there were 4 staff members who worked in Individual #1's home who were not properly trained in Medication Administration but administered medications to both individuals while not trained. Individual #1's 1/5/24 Individual Support Plan (ISP) indicates that the individual has a diagnosis of Parkinson's with tremors. Individual #1's gross and fine motor skills have declined due to their Parkinson's' diagnosis. The ISP states that Individual #1, "needs monitoring to ambulate." Additionally, Individual #1 must hold onto a railing when going up and down the stairs due to their decline in functioning. This is reinforced in a "Stair Plan" that was put into place for Individual #1 on 3/26/24. A SIS assessment was completed on 9/17/24 indicates that Individual #1's highest need area is now health and safety and that the individual needs physical guidance ambulating over uneven terrain and up and down stairs. Individual #1 currently lives in a basement apartment of their current home. Individual #1's 10/18/24 ISP states, "[They] have access to the upstairs via the staircase or by walking outside and going around to the upstairs door. [Individual #1] has fallen outside while going upstairs before, and [their] team has concerns about [them] using the stairs." As of the 10/23/24 inspection, Individual #1 is still residing in the basement apartment of this home, which does not provide accommodations to ensure the safety of the individual. Failure to properly train staff in individual plans and protocols, failure to ensure that staff are medication administration trained before administering medications, and failure to ensure that Individual #1 is living in a home that ensures their safety creates conditions conducive to serious harm or injury for Individuals #1 and #2.Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.By January 15, 2025, all current staff will be trained on the following plans for each individual: Individual #1: ISP, SEEN Plan, CPAP Protocol, Fire Evacuation Support Plan, Dental Hygiene Plan, Blood Thinner Protocol, Fall Protocol, Apartment Alone Time, and Stay Alone Protocol. Individual #2: ISP, SEEN Plan, Seizure Protocol, Fire Evacuation Protocol, and Constipation Protocol. -Document attendance, completion status, and staff competency evaluations. -New Hire Training Protocol-Establish a mandatory pre-service training program for all new hires. Staff must complete all individual-specific training prior to working in the home. -Quarterly Training Review-Implement quarterly refresher training on plans and protocols to ensure staff retain knowledge and stay updated on any changes. -Accountability Measures-Designate a Training Coordinator to oversee training compliance. Conduct random audits monthly to verify staff knowledge of individual specific plans. MEDICATION ADMINISTRATION COMPLIANCE -Prohibit any staff member from administering medications with proof of completion of the Medication Administration Training. -By 1/24/25, ensure that all staff complete Medication Administration Training. -Appoint a Medication Compliance Officer to verify med training before assigning medication responsibilities. -Until all staff are certified medication administrators, the Residential House Manager will ensure that a staff certified in medication administration is assigned to give meds when an untrained staff is scheduled to work. Additionally, we will maintain one backup staff member in case the initial staff member is unavailable. This backup plan is crucial to ensure the smooth continuation of medication administration. The untrained staff will receive contact information for those scheduled to administer medications. The Residential House Manager will ensure the Program Director knows the arrangements and the backup plan. -Individual #1 moved to a home without stairs on: November 1, 2024. The Residential Program Specialist (RPS) will schedule a Critical Revision to ensure the team agrees with the move and to follow up on other changes needed in the ISP. -Conduct a comprehensive environmental assessment of the current home by a physical therapist or an occupational therapist to identify additional safety concerns. Address all concerns promptly. -Include updates on Individual #1's living environment and ambulation needs during quarterly team reviews to ensure continued safety and accommodations. 01/24/2025 Implemented
6400.61(a)Individual #1's 1/5/24 Individual Support Plan (ISP) indicates that the individual has a diagnosis of Parkinson's with tremors. Individual #1's gross and fine motor skills have declined due to their Parkinson's' diagnosis. The ISP states that Individual #1, "needs monitoring to ambulate." Additionally, Individual #1 must hold onto a railing when going up and down the stairs due to their decline in functioning. This is reinforced in a "Stair Plan" that was put into place for Individual #1 on 3/26/24. A SIS assessment was completed on 9/17/24 indicates that Individual #1's highest need area is now health and safety and that the individual needs physical guidance ambulating over uneven terrain and up and down stairs. Individual #1 currently lives in a basement apartment of their current home. Individual #1's 10/18/24 ISP states, "[They] have access to the upstairs via the staircase or by walking outside and going around to the upstairs door. [Individual #1] has fallen outside while going upstairs before, and [their] team has concerns about [them] using the stairs." As of the 10/23/24 inspection, Individual #1 is still residing in the basement apartment of this home, which does not provide accommodations to ensure the safety of the individual.A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. Before moving the individual, the Residential program specialist and Residential Manager will assess the individual and their needs to ensure the living environment is safe and manageable. 01/02/2025 Not Implemented
6400.141(a)Individual #1 has not had an annual physical examination completed since 10/20/23. As of 11/5/24, this appointment was not scheduled.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The annual physical was completed on 11/19/2024. 01/02/2025 Implemented
6400.143(a)Individual #1 has a PRN prescription for Trienza Digestive Enzymes is to be taken with each snack. Staff report that Individual #1 chooses to not take this medication. Individual #2 frequently refuses to utilize their Ketoconazole shampoo, however, there is no documentation of refusals or the repeated attempts to education Individual #1 or Individual #2 on the importance of these medications.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. The provider has developed standard operating procedure which instructs medication administration-trained staff in ways to proactively prevent medication administration refusals. The new protocols provide instructions related to the management of both occasional, and consistent refusals, as well as when to direct concerns to the ordering physician. 01/24/2025 Not Implemented
6400.144Individual #2 had a constipation protocol implemented on 7/26/24. If Individual #2 does not have a bowel movement in 3 days, the individual's PCP is to be contacted. There was no tracked bowel movement on the following dates, and Individual #2's PCP was not contacted: · 7/25/24 pm -- 7/30/24 am · 7/30/24 pm -- 8/3/24 am · 8/4/24 am -- 8/9/24 pm · 8/15/24 pm -- 8/23/24 pm · 8/24/24 am -- 8/29/24 am · 9/3/24 am -- 9/7/24 am · 9/11/24 pm -- 9/26/24 pm · 9/27/24 am -- 10/5/24 pm · 10/8/24 pm -- 10/14/24 pmHealth 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. REVISED PROVIDER'S PLAN OF CORRECTION: The Residential House Manager will discuss the importance of the tracking protocol with the staff, explaining that early detection allows for prompt medical intervention, identifying triggers, and monitoring the effectiveness of the constipation treatment. The staff will be trained on using "CaraSolva's MedSupport" app extension to track bowel movements by January 01, 2025. 01/01/2025 Not Implemented
6400.18(c)A rights violation for Individual #1 was discovered on 11/20/24. This incident was not reported timely to Individual #1's legal guardian.The individual and persons designated by the individual shall be notified within 24 hours of discovery of an incident relating to the individual.-Issue a formal apology to the legal guardian acknowledging the delay and outlining steps being taken to prevent future occurrences. -Conduct a meeting with the involved staff to identify why the delay occurred. Document findings and contributing factors. -Review the current incident reporting policy to identify gaps or unclear procedures. -Ensure staff who failed to notify the family timely is retrained on Incident Management and Reporting Guidelines. Require staff acknowledgement of completed training. -Conduct mandatory training sessions for all staff on the importance of timely reporting of rights violations and specific guidelines for notifying guardians. -Provide a checklist to ensure compliance with policy. 01/24/2025 Implemented
6400.18(b)(2)The medication errors described in 6400.167a1 and 6400.167a4 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.: Monday-Friday, the Residential Manager (RM) will review the MARs daily by 10 a.m. for medication administration errors. The RM will email the Program Director by noon to report the findings. If there is a medication error, the Program Director will enter the error into EIM within 48 hours or no later than 72 hours. 10/23/2024 Implemented
6400.52(c)(6)Individual #1 has multiple plans and protocols in place that staff are to be trained on before working in the home. These plans include an Individual Support Plan (ISP), SEEN plan, CPAP protocol, Fire Evacuation Support plan, Dental Hygiene plan, Blood Thinner Protocol, Fall Protocol, Apartment Alone Time and Stay Alone Protocol. Individual #2 also has multiple plans and protocols in place that staff are to be trained on before working in the home. These plans include an ISP, SEEN plan, Seizure protocol, Fire Evacuation protocol, and constipation protocol. There were a total of 18 staff who worked in Individual #1 and Individual #2's home between 7/1/24 and 10/23/24. None of these staff were trained in Individual #1 or Individual #2's plans and protocols. The provider is utilizing a "read and acknowledge" style of training which is not appropriate for these plans and protocols. Individual plan and protocol training must be an in-person training with at least part of the training occurring with the individual physically present.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.The Residence Program Specialist & Residential Manager will ensure staff assigned to work in the home are trained before working alone. The training will be held in person, in the individual's home, with the individual present. 01/02/2025 Implemented
6400.162(b)(2)(ii)Staff persons #1 and #12 are not trained in topical medication administration. These staff persons administered topical medication to Individual #2.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.Staff #1 and #12 will be identified and trained by the agency nurse on topical medication administration. 01/02/2025 Not Implemented
6400.165(c)Individual #1 has a PRN prescription for Trienza Digestive Enzymes. The directions for this medication are to take, "one capsule by mouth with each snack." From 7/1/24 through 10/23/24, this medication was not administered to Individual #1, even when snacks were given.A prescription medication shall be administered as prescribed.Within the next 7 days, the Residential House Manager will follow up with the PCP to verify the physician's orders and ensure staff are aware of any changes. 12/25/2024 Not Implemented
6400.167(a)(1)Individual #1 was not administered the following medications: · 8/26/24 -- 12pm Carbidopa and 5pm Digestive Enzymes · 8/31/24 -- 12pm, 5pm, and 8pm medications · 9/1/24 -- 8am Ammonium Lactate · 10/27/24 -- 8pm vitamin E Individual #2 was not administered the following medications: · 7/26/24 -- 8pm meds · 7/27/24 -- 12pm quetiapine and 8pm meds · 7/28/24 -- 4pm meds · 8/10/24 -- 8pm melatonin · 8/31/24 -- 12pm, 4pm, and 8pm meds · 9/26/24 -- 8pm zolpidem · 10/5/24 -- 8pm melatonin · 10/8/24 -- 8pm Perphenazine · 10/20/24 -- 8pm zolpidem · 10/24/24 -- 4pm lorazepam · 10/26/24 -- 4pm lorazepam, oxcarbazepine, and quetiapine; 8pm melatonin and zolpidemMedication errors include the following: Failure to administer a medication.-Convene a team meeting with all staff involved in medication administration to identify why the errors occurred. -Document findings and share with leadership. -Update Agency Policy to include a standardized double-check system for medication administration. -Establish clear protocols for handling missed doses. -Develop defined timelines for notifying supervisors of any discrepancies. -Complete competency assessments to ensure staff understand the medication administration training. 01/24/2025 Not Implemented
6400.167(a)(4)Individual #1's neurologist changed the administration time of the individual's prescription for Ropinirole from dinner time to breakfast time on 9/13/24. This administration time change was not made in the home until 10/1/24. From 9/13/24 through 9/30/24, this medication was administered at 5pm instead of at breakfast time.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.-Convene a team meeting with all staff involved in medication administration to identify why the errors occurred. -Document findings and share with leadership. -Update Agency Policy to include a standardized double-check system for medication administration. -Establish clear protocols for handling missed doses. -Develop defined timelines for notifying supervisors of any discrepancies. -Complete competency assessments to ensure staff understand the medication administration training. 01/24/2025 Implemented
6400.169(a)Staff person #3 completed their 2023 Medication Administration Practicum observations on 5/16/23. This staff person did not have their required yearly observations and MAR reviews for 2024 done until 5/21/24. There was no remediation completed to ensure that the staff could continue administering medications. Staff person #3 has not been qualified to administer medications since 5/16/24 and must retake the entire Medication Administration Training initial course before administering medications to individuals. Staff person #3 has administered medications to Individual #1 and Individual #2 since 5/16/24. Staff persons #5 and #7 have not completed the department's Medication Administration Initial Training Course. These staff persons have administered medications to Individual #1 and Individual #2. Staff person #8's 2024 Medication Administration Practicum is not completed by the trainer indicating that Staff person #8 is requalified to administer medications. As of 10/12/24, staff person #8 was no longer qualified to give medications, but administered medications to Individual #1.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).-Staff #3, #5, #7, and #8 will immediately cease administering medications until they meet all training and qualification requirements. -Staff #3, #5, and #7 must enroll in and complete the initial Medication Administration Training course and the required practicum before resuming medication administration. -Staff #8 must complete their 2024 practicum and demonstrate competency through trainer observations. 01/24/2025 Implemented
6400.186Individual #1 had a "Apartment Time Alone Plan" implemented on 8/14/24 indicating that the individual could be alone in their apartment for up to 6 hours with staff on the premises if staff are periodically checking on the individual. The plan later states that staff only have to check on the Individual at least once every 6 hours. This directly contradicts Individual #1's Individual Support Plan, which states that staff are to be checking on Individual #1 every 2 hours while in their apartment unsupervised. There is no tracking in place to ensure these checks are completed, and staff is given conflicting information when working in the home, making it unclear how often Individual #1 is to be checked on.The home shall implement the individual plan, including revisions.-Convene a meeting with the interdisciplinary team, including Individual #1's guardian to review and reconcile the "Apartment Time Alone Plan" and the ISP. -Ensure all updates are approved by the Team and documented in the official records. -Inform all staff working with Individual #1 about the updated plan. -Train staff on how to document check-ins accurately. -Implement a system to record each check-in. -Logs should include the date, time, and staff member's initials for each check-in. 01/24/2025 Not Implemented
SIN-00244394 Renewal 05/15/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At the time of the 5/15/24 inspection, the bathroom in the downstairs apartment area had brown, black, and pink staining on the floor of the shower resembling mildew and/or mold. The sink also had multiple stains on the countertop. There was a brown ring in the toilet bowl as well as hair and dirt collected behind the toilet seat. There was a slight buildup of debris on the floor by the shower and around the toilet area.Clean and sanitary conditions shall be maintained in the home. Director of Programs will put in a maintenance request for the apartment bathroom to be thoroughly cleaned and if needed repairs made. Residential Manager will create a cleaning schedule with the individual to ensure that the bathroom is being cleaned and sanitized weekly. The cleaning schedule will include specific cleaning tasks to be completed (ie: bathroom floor mopped; toilet bowl cleaned with cleaner) Residential Manager will retrain the individual on the importance of keeping the bathroom clean and sanitized. 06/03/2024 Implemented
6400.144(Repeated Violation -- 3/21/24) Individual #1 has a PRN prescription for Senna due to a diagnosis of constipation. The PRN instructions indicate that the medication is to be taken, "Once daily as needed." Bowel movements are being tracked for the individual, and there have been 11 stretches of time ranging from 3 days to 11 days between 2/1/24 and 5/15/24 where the individual has not had a bowel movement tracked and there has been no PRN administered. There is no bowel protocol in place to ensure that PRN medications are given in a timely manner to address Individual #1's constipation.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. Residential Manager will contact the PCP requesting directions for the protocol and administration for the use of the PRN medication for this individual. Program Specialist will develop a bowel protocol for the individual following the PCP recommendations. J&FC Nurse will train the team on the new protocol having staff sign off that they have been trained and understand the new protocol and when to administer the PRN medication. 06/05/2024 Implemented
6400.217Individual #1's release of information is signed by their mother and not the individual. Individual #1's mother is not their legal guardian.Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. Program Specialist will have the individual sign the release of information form and file it in the individual's binder. Program Specialist will review each individual's binder to ensure that if there is a legal guardian that the appropriate paperwork is in their binder. Program Specialist will review each individuals binder to ensure that the release of information has been signed by each individual and not a parent unless they are the legal guardian. 06/03/2024 Implemented
6400.34(b)Individual #1's individual rights document review was signed by the individual's mother and not the individual. Individual #1's mother is not their legal guardian.The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights.Program Specialist will have the individual sign the individual rights document and file it in the individual's binder. Program Specialist will review each individual's binder to ensure that if there is a legal guardian that the appropriate paperwork is in their binder. Program Specialist will review each individual's binder to ensure that the individual rights document has been signed by each individual and not a parent unless they are the legal guardian. 06/03/2024 Implemented
6400.163(h)(Repeated Violation -- 3/21/24) At the time of the 5/15/24 inspection, Individual #1's PRN medication, Fluticasone prop 50mcg nasal spray had expired on 4/14/24.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Residential Manager will review all current PRN medications for the individual in the home to ensure that all PRN medications are not expired. The manager will remove any PRN medications that are expired and put it in the disposal box. The manager will contact the pharmacy to order a replacement PRN medication. Senior House Manager will develop a PRN form for all PRN medications to be listed with the expiration date and share it with the other Residential Managers to be completed for each individual in their home. Residential Manager will complete the form, print it out and put it with the PRN medication for each individual. 06/03/2024 Implemented
6400.165(g)(Repeated Violation -- 2/22/24) Individual #1's 2/16/24 psychiatric medication review does not include the reason for prescribing the medication and the necessary dosage.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Director of Programs will meet with the manager of this home to review the appropriate paperwork needed for quarterly medication reviews for individuals living in the home. Director of Programs will review the regulation with the manager to ensure it is understood that the required information - reason for the prescribed medication and dosage - must be on the form for each appointment. The manager will review the other binders to ensure that all quarterly medication reviews have the correct and completed forms filed. If a form is missing, the manager will reach out to the prescribing doctor, sending the form for review and approval. 06/03/2024 Implemented
SIN-00238379 Unannounced Monitoring 01/24/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16Individual #1 has a diagnosis of autism, adjustment disorder, intermittent explosive disorder, psychosexual disorder, disruptive behavior disorder, and PTSD. Individual #1 has deficient awareness of health and safety risks and limited self-preservation skills. Individual #2 has a diagnosis of autism and severe intellectual disability. Individual #2 is non-verbal and has a history of elopement. Individual #3 has a diagnosis of profound intellectual disabilities, cerebral palsy, anxiety disorder, and depression. Individual #3 is also a choking risk. Individuals #1 -- 3 have a supervision requirement that includes 2 staff at the home at all times. On the following dates, there was an open shift for a second staff that was not filled, and a single staff was working in the home: · January 4, 2024 -- 6:02am to 7:00am · January 11, 2024 -- 6:00am to 7:22am · January 18, 2024 -- 6:02am to 6:59am · January 21, 2024 -- 6:17am to 9:04am · January 23, 2024 -- 6:01am to 6:40am The only incidents of single staffing, which constitutes neglect, that have been entered into the Department's incident management system and a Certified Investigation assigned are the January 21 and January 23 incidents. Staff person #1 and Staff person #2 are listed as targets in these investigations, but they are still working with individuals, including in the home where these neglect incidents occurred. The failure to provide adequate staffing and ensure the immediate health and safety of the individuals residing at this home creates conditions conducive to serious harm for Individuals #1 - #3.Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.Upon notification of this, additional dates where the home was singled staff, the Director of Programs had them entered into EIM/HCSIS on 2.2.24. A certified investigator was assigned to complete the investigation. The targets that were identified were separated from all ODP individuals upon completion of the investigation. Director of Programs, Residential Manager & Program Specialist will review the supervision care need requirements for each individual in the home. Director of Programs will discuss with the CEO reinstating two staff on all shifts at the home until the team can meet to discuss the proper staffing for each individual's supervision care needs and to ensure that each ISP is revised if needed. 02/16/2024 Implemented
6400.18(a)(5)Individuals #1 - #3 require 2 staff to be present in the home at all times. On the following dates, only one staff was working in the home, creating a situation of neglect: · January 4, 2024 -- 6:02am to 7:00am · January 11, 2024 -- 6:00am to 7:22am · January 18, 2024 -- 6:02am to 6:59am These incidents were not entered into 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: Neglect. Upon notification of this, additional dates where the home was singled staff, the Director of Programs had them entered into EIM/HCSIS on 2.2.24. A certified investigator was assigned to complete the investigation. The targets that were identified were separated from all ODP individuals upon completion of the investigation. 02/16/2024 Implemented
6400.18(f)There were 5 times in the month of January 2024, noted in 6400.16, where there was only single staffing in a home that requires 2 staff at all times. There are currently 2 investigations ongoing for 2 of the dates, naming staff person #1 and staff person #2 as targets. These staff members are still working with individuals, including individuals in this home, while the investigation is ongoing. Immediate action was not taken to protect the health and safety of any individuals in this home for these 5 neglect incidents.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.Upon notification of the additional dates where the house was singled staffed the Director of Programs had them entered into EIM/HCSIS on 2.2.24. The targets that were identified were separated from all ODP individuals upon completion of the investigation. A certified investigator was assigned to complete the investigation. Upon completion of the admin review the corrective actions will be implemented and documented by the Director of Programs and/or designee as outlined in the plan. 02/16/2024 Implemented
6400.18(g)Individuals #1 - #3 require 2 staff to be present in the home at all times. On the following dates, only one staff was working in the home, creating a situation of neglect: · January 4, 2024 -- 6:02am to 7:00am · January 11, 2024 -- 6:00am to 7:22am · January 18, 2024 -- 6:02am to 6:59am There has not been a certified investigation initiated for these incidents.The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person.Upon notification of the additional dates where the house was singled staffed the Director of Programs had them entered into EIM/HCSIS on 2.2.24. The targets that were identified were separated from all ODP individuals upon completion of the investigation. A certified investigator was assigned to complete the investigation. Upon completion of the admin review the corrective actions will be implemented and documented by the Director of Programs and/or designee as outlined in the plan. 02/16/2024 Implemented
SIN-00230555 Renewal 09/26/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Individual #1's record does contain a personal property inventory record or a current list of their personal possessions within the home. The agency's financial policy indicates an up-to-date property record shall be kept.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. The Associate Director of Residential developed an electronic property inventory record form on 10/13/23. The house manager and/or designee will complete an inventory record for each individual in their program and keep it up to date. 11/17/2023 Implemented
6400.43(b)(1)The agency is not implementing their financial policy. According to the financial policy, the home shall keep an up-to-date personal property record for each individual residing in their homes. As referenced in 22(d)(1) of this report, the home is not doing this. According to the agency's financial policy, the home is to lock individual's monies deposited into the home in their locked money boxes in the staff office. On 9/3/23, Individual #1's family deposited two envelopes at the home, each envelope containing cash for Individual #1. Staff did not document on Individual #1's financial ledger when they received the two envelopes of cash from Individual #1's family on 9/3/23 or the amount the envelopes contained. Staff did not lock the envelopes with cash in them, in the lock box in the staff office as directed in the policy. The agency didn't follow or implement the Department's medication administration training course requirements. According to the Department's medication administration training course, staff who complete and pass the initial and annual medication administration training practicum observer course, are certified practicum observers and can completed some portions of staff's annual medication administration training requirements; the two medication administration reviews (mars) and two medication observations. Then a medication administration trainer must document if staff have passed or failed their initial or annual medication administration training to administer medications to individuals. During the 9/26/23 annual inspection, Staff #1's 5/15/23 annual medication administration training documents stated Staff #2 completed one of the two mars and one of the two medication observations as a certified practicum observer (PO) for Staff #1's 5/15/23 medication training. The agency did not have documentation that Staff #2 was a certified PO or had the credentials to complete these items for Staff #1's annual medication administration training. According to Staff #2's initial practicum observer medication training provided during the inspection, the following items that are required, per the initial practicum observer medication training course, were blank and not completed: multiple choice examination and the 3 mar review examinations. The agency's previous medication administration trainer, Staff #3, indicated that Staff #2 was a certified practicum observer on 11/2/22 but never provided or recorded examination documents and passing scores. Therefore, Staff #1 has been administering medications to individuals, but their annual medication administration training was never completed by the properly certified staff. Staff #5 completed 2 mars and 4 observations for Staff #4's 6/26/23 annual medication administration training. However, the agency does not have records that Staff #5 passed the initial or annual practicum observer course and tests to be a certified PO. The following items that are required, per the initial practicum observer medication training course, were blank and not completed for Staff #5's initial practicum observer medication administration training: multiple choice examination and the 3 mar review examinations. The agency's previous medication administration trainer, Staff #3, indicated that Staff #5 was a certified practicum observer on 11/2/22 but never provided or recorded examination documents and passing scores. Therefore, Staff #4 has been administering medications to individuals, but their 6/26/23 annual medication administration training was never completed by the properly certified staff.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. Moving forward the Director of Residential will be responsible for ensuring that policies and procedures are implemented as written throughout the residential programs. The Associate Director of Residential developed an electronic property inventory record form on 10/13/23. The house manager and/or designee will complete an inventory record for each individual in their program and keep it up to date. All Practicum Observer paperwork was immediately reviewed on 9/28/23 and all Practicum Observers at Jessica and Friends were removed from their role as a Practicum Observer. Certified Medication Administration Trainer completed a new annual practicum by 10/25/23 for all of the staff that had invalid observations. 11/14/2023 Not Implemented
6400.65At the time of the inspection, the entire mechanical venting system in Individual #2's bathroom was covered in a thick layer of dust, not allowing the ventilation system to function properly.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. Associate Director of Residential submitted a work order to clean the vent in individual #2's bathroom on 11/1/23. The maintenance coordinator will clean the vent to ensure the ventilation system is able to function properly. 11/15/2023 Implemented
6400.67(a)At the time of the inspection, in Individual #2's bathroom, above the shower stall, there is a section, approximately 5"x5", in the corner that the paint is peeling off the wall.Floors, walls, ceilings and other surfaces shall be in good repair. Associate Director of Residential submitted a work order to repaint the 5"x5" section in individual #2's bathroom on 11/1/23. The maintenance coordinator will repaint this 5"x5" section to ensure the surfaces are in good repair. 11/30/2023 Implemented
6400.112(c)The time of the fire drill was not recorded on the fire drill record for the drill conducted on 2/22/23. The record stated the drill was conducted at 8:18, but did not include AM or PM.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 Associate Director of Residential will retrain the house managers on ensuring that fire drill records are thoroughly completed, including the date, time, the amount of time it took for evacuating, the exit route used, problem encountered and whether the fire alarm or smoke detector was operative. 11/14/2023 Not Implemented
6400.141(c)(11)Individual #1's current, 9/29/22 physical examination record does not include a review of their current mediation regimen. The physical examination record stated to see the attached list of medications, however, nothing was attached to the physical examination record.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 Specialist immediately filed a copy of individual #1's current medication regimen behind the 2022 annual physical examination record. Moving forward, all current medication regimens will be reviewed and printed on the annual physical examination records. 11/14/2023 Implemented
6400.144REPEAT from 10/4/22 annual inspection: According to Individual #1's current, 9/29/22 physical examination record, they are ordered to be on an 1800 calorie per day diet. Staff are not calculating the individual's calorie intake or documenting the individual's calorie intake on the individual's daily food intake records.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 #1 was evaluated at his annual physical on 10/5/23, where the PCP discontinued the order for an 1800 calorie per day die and recommended to encourage healthy choices and proper portions with no special calorie limit. 10/05/2023 Not Implemented
6400.46(b)Staff #1 had fire safety training on 1/26/21 and not again until 12/27/22, outside of the annual timeframe. Additionally, the staff's 1/26/21 fire safety training produced states Staff #1 completed the training independently, and not by a fire safety expert. A manager signed this training form on 1/31/21 but doesn't indicate if they provided the training, or the date they, or a fire safety expert, provided the training.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Moving forward staff will be trained by a fire safety expert within the annual timeframe. The fire safety training form has been revised to have the fire safety expert sign and date the training immediately upon completion. All annual training forms will be forwarded to the Staffing Specialist by the House Manager. 11/01/2023 Not Implemented
6400.162(a)Staff person #1 received medication administration training on 3/12/22 and not again until 5/15/23, outside the annual time frame requirement. Staff person #1 did not receive additional remediation medication administration trainings due to their late annual medication administration training. Staff person #1 continued to administer medications to Individual #1 throughout all of March, April, and May 2023 when their medication training lapsed.A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication.The annual practicum was redone with a Certified Medication Administration Trainer, including two med passes and two MAR reviews. This was completed on 10/25/23. 10/25/2023 Implemented
6400.165(g)The review of Individual #1's psychotropic medications conducted by a physician on 8/24/23, 5/23/23, and 1/18/23 did not include the prescribed medications or the need to continue the medications.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The Associate Director of residential will retrain House Managers on completing quarterly psychotropic medication reviews to ensure that all prescribed medications and the need to continue are included. 11/14/2023 Not Implemented
6400.166(a)(12)Individual #1 is prescribed medicated, Nizoral 2% shampoo, apply daily, leave on for 5-10 minutes then rinse off. The following medication administration records (mars) were signed by staff, indicating administering the shampoo as prescribed, however, the time of administration wasn't recorded on the mars: November 1st-30, 2022, December 1st-31st, 2022, February 1st-28th, 2023, and April 1st-30th, 2023.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.The Medication Trainer retrained individual #1's staff that the time of administration must be recorded on the MAR. 10/01/2023 Not Implemented
6400.169(a)Staff #1's medication administration training documents state they passed the Department's annual medication administration training course and all requirements on 3/12/22 and not again until 5/15/23, outside the annual time frame requirement. At the time of the 9/26/23 inspection, additional medication administration trainings and remediation requirements, as required by the Department's medication administration training course for trainings completed outside the annual time frame, were never completed. As referenced in 6400.43(b)(1) of this report, their 2023 medication training requirements (1 of the 2 medication administration reviews and 1 of the 2 medication observations) were completed by a staff without the qualifications or certifications to do so. Staff #4's medication administration training documents state they passed the Department's annual medication administration training course and all requirements on 6/26/22 and 6/26/23. However, as referenced in 6400.43(b)(1) of this report, their 2023 medication training requirements (2 medication administration reviews and 4 medication observations) were completed by a staff without the qualifications or certifications to do so. Both staff have been administering medications without the proper qualifications to do so.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).These staff repeated their annual practicum requirements with a Certified Medication Administration Trainer by 10/25/23. All Practicum Observers who did not meet the proper training requirements were removed from their roles immediately on 9/28/23. 10/25/2023 Not Implemented
SIN-00212302 Renewal 10/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment dated 7/13/22 did not assess compliance for 6400.213(4).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. The Quality Assurance & Compliance Coordinator will ensure that self-assessments are completed accurately, to reflect the compliance within each location. 10/31/2022 Implemented
SIN-00196946 Renewal 11/29/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66There was no light outside the doorway leading off the deck to the stairs used as an exit.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. A work order has been put in to install a dusk to dawn light that will illuminate the back deck area. The maintenance supervisor will have the light installed by 12/31/2021. It is the responsibility of the house manager to ensure all rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes are well lit in order to assure the safety of the individuals and to avoid accidents. 12/14/2021 Implemented
SIN-00180252 Renewal 12/07/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Kitchen cabinets and kitchen drawers in the upstairs kitchen have sections in which the paint is peeling and wood is exposed underneath.Floors, walls, ceilings and other surfaces shall be in good repair. Kitchen cabinets will be repainted by 12/31/2020. A work order has been submitted to the maintenance supervisor by the director of programs on 12/15/2020. It is the responsibility of the house manager to ensure that the surfaces are in good condition. Please reference attachment #2. 12/31/2020 Implemented
6400.112(d)In the month of November 2019, individuals did not successfully evacuate the home in under 2 minutes and 30 seconds. Both fire drills held 11/22/19 and 11/26/19 took longer than 2 minutes and 30 seconds.Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home.The house manager has been retrained on the evacuation protocol and requirements by the director of programs on December 10th. It is the responsibility of the house manager to ensure that fire drills successfully meet the fire drill requirements. Please reference attachment #1. 12/10/2020 Implemented
6400.112(e)From 9/28/19 to 11/16/20, no fire drills were held during sleeping hours. Sleeping hours are considered to be from 11pm to 7am.A fire drill shall be held during sleeping hours at least every 6 months. The house manager has been retrained on the fire drill requirements for overnight drills by the director of programs on December 10th. It is the responsibility of the house manager to ensure that overnight fire drills are completed from 11PM-7AM. Please reference attachment #1. 12/10/2020 Implemented
6400.112(f)From 9/28/19 to 11/16/20, the front door was used as an exit during every fire drill. There were times the garage was also used as an exit; however the front door was used for every fire drill. Alternate exits must be usedAlternate exit routes shall be used during fire drills. The house manager has been retrained on the evacuation protocol and requirements by the director of programs on December 10th. It is the responsibility of the house manager to ensure that alternate exits are used for fire drills. Please reference attachment #1. 12/10/2020 Implemented
6400.18(b)(1)On 11/27/20, Individual #1 was not administered Famotidine. This medication error was not reported within 72 hours.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: Use of a restraint. Staff will be retrained on immediately reporting any med errors by the medication administration trainer by 12/23/2020. The agency nurse will continue to monitor MAR's on a weekly basis. It is the responsibility of the nurse and house manager to ensure medications are being administered. 12/23/2020 Implemented
6400.52(c)(6)Staff #4 and Staff #8 were not trained on Individual #1's SEEN plan. Staff #5 was not trained on Individual #1's dental hygiene plan. Staff #6 was not trained on Individual #1's choking protocol. Staff #7 and Staff #9 were not trained on Individual #1's fire evacuation plan or dental hygiene plan.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.The staff will be trained on the plans and protocol's by 12/31/2020. It is the responsibility of the house manager to ensure that these staff are retrained by this date and it is the responsibility of the house manager to ensure that all staff are trained in necessary plans and protocols in a timely fashion going forward. Staff will be trained upon initial hire and as plans and protocols are updated. 12/31/2020 Implemented
SIN-00146590 Renewal 12/10/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-inspection was completed on 10/24/18. The certificate of compliance expired 11/24/18.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. The manager of the house has placed reminders on the house calendar in advance of the due date of the self-assessment on a recurring basis to begin working on the self-assessment. The dates were also placed on the calendar of the Executive Director and Program Specialist to eliminate missing the due date. Assistant house managers will be trained on this as well. The Executive Director will ensure that there is follow through with completing these assessments and receipt of them in a timely manner. 12/27/2018 Implemented
6400.33(e)An audio monitor was present in the living room, kitchen and Individual #1's bedroom.An individual has the right to privacy in bedrooms, bathrooms and during personal care. The monitor has been removed from the bedroom. There were adjustments made to staffing to ensure that the safety needs of the resident are met. The manager removed the monitor and all managers and staff in all programs have been trained that these are not to be used. If there is a safety need related to an individual being unsupervised in the home, there will adjustments made to staffing and team meetings held to discuss this if necessary. 12/27/2018 Implemented
SIN-00126105 Renewal 12/27/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(e)The recycling bin was not covered with a lid.Trash receptacles over 18 inches high shall have lids. There was a work order submitted to maintenance for a recycling container with a lid. It has been placed in the home. 01/19/2018 Implemented
6400.67(a)Individual #1's bedroom carpet was ripped.Floors, walls, ceilings and other surfaces shall be in good repair. The house manager has submitted a work order for replacement of the carpet in the bedroom. This was done on 1/19/18. There will be a threshold strip placed over the seam by 2/1/18 until the new carpet can be installed. 01/19/2018 Implemented
6400.112(c)The 10/18/17 fire drill log did not include the evacuation time. All smoke detectors in the home were not checked monthly according to staff.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 fire drill log has been updated to include all regulatory required information. All staff have been trained on the proper way to document this information on the log. The log has been expanded to include a check of each smoke detector to ensure they are operating within a timely manner of the fire drill. The house manager will provide oversight to this following the drill and the senior house manager, program specialist, and executive director will oversee the documentation as well. 01/02/2018 Implemented
6400.141(c)(9)A prostate exam was not completed for Individual #1.The physical examination shall include: A prostate examination for men 40 years of age or older. The house manager will ensure that a refusal for treatment plan will be implemented for prostate examination. All staff will be trained on the plan. Additionally, a PSA testing will be added to the individual's blood work which will be done one week prior to his next follow up appointment. 01/09/2018 Implemented
6400.142(d)Individual #1 received a teeth cleaning from the dentist on 10/6/17, 3/10/17, and 9/9/16. A dental exam was not completed at any of the appointments.The dental examination shall include teeth cleaning or checking gums and dentures. House manager has implemented a refusal for treatment chart and plan. The house manager will ensure that dental examination appointments are completed thoroughly and followed through with as scheduled. The house manager will also ensure that necessary procedures are followed through with to complete the appointments. Oversight of this will be provided by the senior house manager and executive director. 01/21/2018 Implemented
6400.143(a)Individual #1 refused dental cleanings and prostate exams. A refusal of treatment plan was not in place and there were no documented attempts at training Individual #1 on the importance of health care.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. A refusal for treatment plan has been implemented by the house manager. All staff have been trained on the plan. Staff and manager will be working with Individual #1 to discuss the importance of health and dental care and to encourage cooperation with appointments. Staff will process with him what will happen prior to appointments. This plan will be reviewed by the program specialist, senior house manager, and executive director to provide oversight. 01/16/2018 Implemented
6400.144REPEATED VIOLATION - 10/6/16. On 6/9/17, Individual #1's physician recommended arranging the removal of a cyst on the right jaw when sedated for dental care. Individual #1 was seen by the dentist on 10/6/17 however, not under sedation. The provider indicated they wouldn't be scheduling the sedation until April of 2018, failing to seek treatment for the cyst.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 house manager contacted the PCP and dentist on 1/8/18. The PCP provided documentation in an attachment. The house manager will continue follow up with the PCP and dentist. at this time the PCP is stating to just monitor the size of the cyst and is not recommending removal. The dentist referred back to the PCP for any treatment of the cyst. The house manager will ensure that the 3/15/18 appointment is completed and proper documentation included regarding the cyst. 01/08/2018 Implemented
6400.163(c)Individual #1 had a psychiatric medication review on 9/22/16 with a two month recall. Individual #1 did not return for another medication review until 2/24/17. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The house manager has provided instruction to all staff on how to properly document and follow through with instructions on the medical appointment form. The staff were instructed to ensure this is done completely and accurately prior to leaving the appointment. The staff were further instructed to ensure that all follow up appointments are documented and provided to the house manager to make sure they are completed. The house manager is providing first line oversight to this by reviewing all medical appointment forms before they are filed and recording follow up appointments as well as reviewing all information on the form. The program specialist and senior house manager will provide oversight on a monthly basis while compiling information for monthly progress notes. 01/16/2018 Implemented
6400.164(a)On 10/21/16, Individual #1's physician decreased Sertraline from 100mg twice daily to 50mg once daily for one week, then 50mg every other day for one week, then 50mg every third day for one week, and then discontinue the medication. The October 2016 medication log stated Sertraline 50mg, take 1 tab daily for 1 week. The 50mg of Sertraline was administered from 10/22/16 to 10/28/16 and again on 10/30/16. The medication log did not indicate to give Sertraline every other day as per the physician order.A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication.The house manager will ensure that all medication changes or updated medication information is documented correctly and understood by the staff. The house manager reviewed proper documentation for medication on the MARs with all staff. 01/16/2018 Implemented
6400.164(b)Individual #1's medication logs were not signed off by the person administering the medications on the following dates: 12/26/17, 12/23/17, 11/27/17, 11/26/17, 11/23/17, 11/19/17, 10/31/17, 9/14/17 ,8/18/17, 7/12/17, 6/30/17, 5/31/17, 5/25/17, and 5/21/17. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. The house manager reviewed with all staff the proper steps for documentation on medication administration records. The manager reviewed the documentation error policy with all staff. It was emphasized during which step of the med administration process the staff initial and sign the MAR. The house manager will providing oversight to this process at least on a weekly basis. Additional oversight will be provided by senior house manager and program specialist monthly. 01/16/2018 Implemented
6400.167(b)On 10/21/16, Individual #1's physician decreased Sertraline from 100mg twice daily to 50mg once daily for one week, then 50mg every other day for one week, then 50mg every third day for one week, and then discontinue the medication. The third week of the Sertraline administration should have been administered on 11/7/16 and 11/10/16 and then discontinued. Sertraline was administered on 11/6/16, 11/9/16, and 11/12/16. On 3/7/17, the physician ordered Amphetamine-Dextroamphetamine to be discontinued however, the medication was administered on 3/8/17. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.The house manager reviewed with each staff the proper way to discontinue medications and to ensure that documentation is completed correctly in the MAR. The house manager has established a protocol to review MAR's at least weekly and more frequently if there is a medication change or discontinuation. The senior house manager and program specialist will provide oversight to this. 01/16/2018 Implemented
6400.181(e)(13)(ii)Individual #1's 12/5/17 assessment did not include progress or regression over the past year in communication skills. The 2017 and 2016 assessments were the same.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. Katrina Perry, Program Specialist, will be responsible for collecting, collaborating, and interviewing staff to find areas where Individual #1 has made progress in the area of communication. She will also look for times where Individual #1 has been given opportunity to participate in activities related to communication. An addendum related to progress in communication was completed on 1/1/18. An updated assessment form was completed and sent to the team so that progress will be fully documented throughout the assessment. Oversight will be given to this by the house manager by reviewing Individual #1's communication during house meetings with staff. There will be documentation provided to show how this is being completed. 01/01/2018 Implemented
6400.181(e)(13)(iii)Individual #1's 12/5/17 assessment did not include progress or regression over the past year in residential living. The 2017 and 2016 assessments were the same.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. Katrina Perry, Program Specialist, will be responsible for collecting, collaborating, and interviewing staff to find areas where Individual #1 has made progress in the area of residential living. She will also look for times where Individual #1 has been given opportunity to participate in activities related to residential living. An addendum related to progress in residential living was completed on 1/1/18. An updated assessment form was completed and sent to the team so that progress will be fully documented throughout the assessment. The house manager will provide oversight to this process to review Individual #1's residential living skills during house meetings and documentation provided to show this. 01/01/2018 Implemented
6400.181(e)(13)(iv)Individual #1's 12/5/17 assessment did not include progress or regression over the past year in personal adjustment. The 2017 and 2016 assessments were the same.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. Katrina Perry, Program Specialist, will be responsible for collecting, collaborating, and interviewing staff to find areas where Individual #1 has made progress in the area of personal adjustment. She will also look for times where Individual #1 has been given opportunity to participate in activities related to personal adjustment. An addendum related to progress in personal adjustment was completed on 1/1/18. An updated assessment form was completed and sent to the team so that progress will be fully documented throughout the assessment. The house manager will provide oversight to this process. This will be done through monthly team meetings to discuss Individual #1's progress in personal adjustment and through documentation kept by staff that the manager and senior house manager and program specialist will provide oversight to. 01/01/2018 Implemented
6400.181(e)(13)(vi)Individual #1's 12/5/17 assessment did not include progress or regression over the past year in recreation. The 2017 and 2016 assessments were the same.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. Katrina Perry, Program Specialist, will be responsible for collecting, collaborating, and interviewing staff to find areas where Individual #1 has made progress in the area of recreation. She will also look for times where Individual #1 has been given opportunity to participate in activities related to recreation. An addendum related to progress in recreation was completed on 1/1/18. An updated assessment form was completed and sent to the team so that progress will be fully documented throughout the assessment. The house manager will provide oversight to this by reviewing with staff at house meetings and documentation kept by the staff. This will also be reviewed by the senior house manager and program specialist. 01/01/2018 Implemented
6400.181(e)(14)Individual #1's 12/5/17 assessment did not include his/her ability to swim.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim.The program specialist, Katrina Perry, has provided an addendum to update Individual #1's assessment. This addendum addressed his ability to swim. Prior to his next annual assessment, oversight of this will be done by the house manager and senior house manager to ensure all regulatory required information is included in the assessment. 01/01/2018 Implemented
6400.186(c)(1)Individual #1's 1/6/17, 3/31/17, 7/7/17, and 10/4/17 Individual Support Plan (ISP) Reviews did not include progress toward the ISP outcomes of visiting the library and remembering a bible verse.The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. Katrina Perry, Program Specialist, will be responsible for making sure progress is being shown on quarterly ISP Reviews. She will show on Individual #1's most recent 12/31/17 ISP Review that progress was being made towards outcomes. She will meet with manager to revise goals if documentation shows progress is not being made. Oversight of this will be provided by the manager by reviewing goal documentation on a weekly basis and by the senior house manager and program specialist on a monthly basis. 12/31/2017 Implemented
6400.186(c)(2)Individual #1's 1/6/17, 3/31/17, 7/7/17, and 10/4/17 Individual Support Plan (ISP) Reviews did not include a review of his/her social, emotional, environmental needs plan or the behaviors/symptoms exhibited over the quarter. The 1/6/17 ISP review did not review the fall prevention plan. The report indicated 0 falls but incident reports indicated 1 fall. The 3/31/17 ISP review indicated 0 falls however, the incident reports indicated 2 falls. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. Katrina Perry, Program Specialist, will be responsible for making sure accurate documentation is reported on the ISP Review. Program Manager will ensure documentation is completed and sent to Program Specialist. Specific documentation and behavior support was completed on the most current ISP Review dated 12/31/17. An addendum to 1/17 and 3/17 ISP reviews are completed to report falls that happened that quarter. She will send the ISP Review to the team as well as the addendum and file it in the individual's¿ record on 1/19/18. A fall chart will be placed in the daily binder for staff to fill out immediately upon a fall as well as proper documentation. Oversight of this process will done by the house manager by reviewing fall charts on a weekly basis and by the senior house manager and program specialist on a monthly basis. 12/31/2017 Implemented
6400.213(11)REPEATED VIOLATION - 10/6/16. Individual #1's 11/21/17 physical exam indicated to cut good into dime sized pieces. The Individual Support Plan (SIP)indicated to cut food into finely chopped pieces. The 6/19/17 choking plan indicated all meats should be finely chopped and cut food into dime sized pieces. Individual #1's ISP indicated an allergy to Risperdal. The physical exam indicated allergies to Risperdal and Succiny Choline. The 3/31/17 ISP Review indicated an adverse reaction to adderal. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. Katrina Perry, Program Specialist, will be responsible for making sure Succinylcholine as a possible allergy is added to the ISP. She obtained a letter from Dr. Rogers. Program Specialist will communicate to SC changes needed for the ISP. Changes were emailed to SC. Katrina Perry, Program Specialist, will be responsible for making sure the plans are consistent and accurate. She and program manager will review and make corrections to the choking plan to reflect Individual #1's current need. Program Specialist will communicate to SC changes needed for the ISP. Changes recommended for the ISP and updated support plan were emailed to SC. Oversight of this will be provided by the senior house manager and executive director. 01/19/2018 Implemented
SIN-00090490 Unannounced Monitoring 01/22/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32On 1/10/16, Staff #2 made an entry into the staff communication log stating Individual #1 had a slight rage after he/she was denied a third cup of tea. Individual #1 is not on a fluid restriction. On 1/21/16, Staff #1 made an entry into the staff communication log stating Indivdiual #1 had a rage for approxiamatley 15 minutes and Staff #1 and Staff #2 decided Individual #1 was not attending an outing that night. An individual may not be deprived of rights. Individual #1 Support Plan updated to reflect behavior triggers (such as certain drinks) and staff response. Staff have been trained in the update to offer water to the individual.Josh Lindsey, Residential House Manager, has updated Individual #1 Support Plan to reflect his drive for certain drinks. The support plan was updated to reflect triggers for negative behaviors (certain drinks) and staff response. Staff were trained on the plan and the plan also includes offering water to Individual #1 when he is requesting extra drinks. Staff were also trained that if there are drinks available to Individual #1, he may have them. This was completed on 3/11/16. 03/11/2016 Implemented
6400.62(a)Disinfecting wipes, which stated to contact poison control if ingested, were unlocked in a kitchen cabinet. Individual #1's Individual Support Plan states he/she has inadequate knowledge of poisons. Poisonous materials shall be kept locked or made inaccessible to individuals.Staff checklist updated to reflect need to keep poisons locked or inaccessible.Josh Lindsey, Residential House Manager, will ensure that all poisons are locked in the proper cabinet designated for poisons. He has created a checklist for staff during their shift which has this included so that staff are also ensuring that poisons are locked up. Staff were reminded that per Individual #1 ISP which states that individual is not aware of poisons, they must be diligent in keeping them locked when not in use. This checklist was put into effect on 3/11/16. 03/11/2016 Implemented
6400.74The steps leading to the basement do not have a nonskid surface.Interior stairs and outside steps shall have a nonskid surface. Non-skid surface added to steps. Josh Lindsey, Residential House Manager, corrected the problem. The steps leading to the lower level are hardwood and did not have extra nonskid surface. Josh contacted our maintenance manager and had nonskid tape placed on the stairs. This was completed by 2/1/16. 03/11/2016 Implemented
6400.164(a)Individual #1's medication logs for January of 2016, December of 2015, and November of 2015, do not include a time of administration for Cetaphil.A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. Medication log has been updated to include the time of administration.Josh Lindsey, Residential House Manager, corrected the medication log that had times missing on it. The medication log will be reviewed to ensure that times are on it going forward. This was corrected as of 3/11/16. 03/11/2016 Implemented
6400.164(b)Individual #1 is prescribed Cetaphil every morning and evening. There were no initials of the person administering the medication on 1/8/16 and 1/24/16. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. These dates were documented on the med log as documentation errors. Josh Lindsey, Residential House Manager, reviews medication logs at the end of the month. The medication log cited had 2 documentation errors noted. The medication administration policy was distributed to all staff as well as copies of forms to be filled out for medication errors and documentation errors. In March, all staff who are trained in medication administration, were given refresher training. 03/11/2016 Implemented
6400.168(d)Staff #3 passed the medication administration training on 3/27/14 and not again until 4/24/15. Staff #3 passed medications on 4/18/15 without completing the annual medication administration practicum.Staff #2 passed the medication administration training on 4/14/14 and not again until 5/25/15. Staff #2 passed medications approxiately 12 days in April of 2015 and approximately 16 days in May of 2015 without completing the annual medication administration practicum. A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. Medication administration trainer has updated a checklist to include all due dates for med admin training.Jodi Bird, Medication Administration Trainer, has created an updated checklist for tracking staff due dates for Med Admin Practicums. The checklist will be organized by dates so the trainer is aware when staff are due to have their practicums completed. This will ensure they are completed on time. The checklist has been updated and staff practicums arranged by due date as of 3/11/16. 03/11/2016 Implemented
6400.171There was an open box of exposed waffles stored in the freezer. Food shall be protected from contamination while being stored, prepared, transported and served. Staff have received training information on the safe storage of food.Josh Lindsey, Residential House Manager, has created an updated training for safe food storage. He has reviewed this training with all staff in the home and emphasized the importance of safe food storage. Josh will be routinely checking food storage to prevent this from happening again. Any food in the home, whether in cabinets, refrigerator, or freezers, will be stored properly and safely. Food safety is typically an annual training at the agency. Staff were provided the training and completed by 3/11/16. 03/11/2016 Implemented
SIN-00070839 Renewal 09/25/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106Late furnace inspection for 2014. Furnace was inspected on 8/1/2013 and not again until 8/27/2014. Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. A system has been put in place where all residential furnace inspections will be coordinated during the same month each year. Each year they they will be scheduled for the following year one month prior to when they are due so they will actually be done every eleven months. 10/01/2014 Implemented
6400.167(a)Staff #1 continued to pass medications even though her medication administration certificate was out of compliance. Prescription medications and injections of a substance not self-administered by individuals shall be administered by one of the following: (1) A licensed physician, licensed dentist, licensed physician's assistant, registered nurse or licensed practical nurse. (2) A graduate of an approved nursing program functioning under the direct supervision of a professional nurse who is present in the home.(3) A student nurse of an approved nursing program functioning under the direct supervision of a member of the nursing school faculty who is present in the home. (4) A staff person who meets the criteria specified in § 6400.168 (relating to medications administration training) for the administration of oral, topical and eye and ear drop prescriptions and insulin injections. On the fifteenth of each month the Med Administrator will revew the med training records of all trained staff to assure they are current and that the staff can pass med in the upcoming month. Any staff that is not current in the certification will not administer meds in the upcoming month or until their certification is updated. 01/01/2015 Implemented
6400.168(a)Staff #1's Medication Administration Training was late for 2014. It was completed 4/2/2013 then not completed until 4/27/2014. In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. All med trained staff have been assigned to a certified med trainer or med proctor. The med trainer will on the fifteenth of each month assign med trainings for the upcoming month. 01/01/2015 Implemented
SIN-00040858 Renewal 08/30/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The October 2011 fire drill exceeded the two and a half minute time limit. Thsi is considered corrected during inspection because agency put a plan in place immediately after the untimely fire drill and there was not a repeat occurance of this issue(d) Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. See above 08/31/2012 Implemented
6400.181(e)(1)Individual #1's assessment did not include his preferences.(e) The assessment must include the following information: (1) Functional strengths, needs and preferences of the individual. Our assessment tool will be updated and modified to include and prompt inclusion of the additional narrative on preferences and progress. The revised assessment will be utilized on the next organizational assessment which is due in Novemeber 2012. Following its first use, house managers, the program specialist and the Executive Director will review against items cited in the POC. In addition, any protocols/plans identified in the assessment will be reviewed and updated at the time of the assessment and attached. On a quarterly basis, the program specialist, house manager(s) and the Executive Director will review the most recently completed assessment as part of a quality assurance process. 10/11/2012 Implemented
6400.181(e)(12)Individual #1's assessment did not include any recommendations for training, programming and services.(12) Recommendations for specific areas of training, programming and services. Our assessment tool will be updated and modified to include and prompt inclusion of the additional narrative on preferences and progress. The revised assessment will be utilized on the next organizational assessment which is due in Novemeber 2012. Following its first use, house managers, the program specialist and the Executive Director will review against items cited in the POC. In addition, any protocols/plans identified in the assessment will be reviewed and updated at the time of the assessment and attached. On a quarterly basis, the program specialist, house manager(s) and the Executive Director will review the most recently completed assessment as part of a quality assurance process. 10/11/2012 Implemented
6400.181(e)(13)(i)Individual #1's assessment did not include progress and growth in the 8 areas of 181(13)(13) The individual's progress over the last 365 calendar days and current level in the following areas: (i) Health. Our assessment tool will be updated and modified to include and prompt inclusion of the additional narrative on preferences and progress. The revised assessment will be utilized on the next organizational assessment which is due in Novemeber 2012. Following its first use, house managers, the program specialist and the Executive Director will review against items cited in the POC. In addition, any protocols/plans identified in the assessment will be reviewed and updated at the time of the assessment and attached. On a quarterly basis, the program specialist, house manager(s) and the Executive Director will review the most recently completed assessment as part of a quality assurance process. 10/12/2012 Implemented
6400.199(b)Individual #1 was given a PRN Lorazepam on April 2, 2012 for his behaivior. The home did not have a PRN protocol in place for the admistration of this PRN.(b) Administration of a chemical restraint is prohibited except for the administration of drugs ordered by a licensed physician on an emergency basis. PRN Medication Protocol has beeen created. We have identified a tool to use in conjunction with the protocol. Both are attached. 10/11/2012 Implemented