Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00253139 Unannounced Monitoring 09/25/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Individual #1's financial ledger did not list how much money the individual had prior to or after the transactions that took place during the months of August and September 2024.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 Financial Director is responsible for fixing this. The agency shall ensure that every home keeps an up to date financial and property record for each individual that includes personal procession and funds received. This violation has been implemented on the 14th of October 2024 10/14/2024 Implemented
6400.22(d)(2)Individual #1's financial ledger did not list how much money the individual had prior to or after the transactions took place during the months of August and September 2024.The home shall keep an up-to-date financial and property record for each individual that includes the following: (2) Disbursements made to or for the individual.The Financial Director is responsible for fixing this. The agency shall ensure that every home keeps an up to date financial and property record for each individual that includes personal procession and funds received. This violation has been implemented on the 14th of October 2024 10/14/2024 Implemented
6400.166(a)(11)Individual #1's MAR did not include the diagnosis and or purpose for the medications.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The Agency nurse/Medical director/Program specialist is responsible for this The agency shall ensure all Medication records reflect the diagnosis or purpose of the medication. The agency has completed updates to medication in MARs that do not reflect the purpose of the medication. 10/15/2024 Implemented
SIN-00222403 Renewal 05/10/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The shower mat in the bathroom had substances consistent with dirt and mildew around the edges.Clean and sanitary conditions shall be maintained in the home. WHO: The Residential supervisor is responsible for implementing this fix. WHAT: The residential supervisor would ensure that the residents are clean and sanitary conditions shall be maintained in the homes. The mat would be washed and put to dry frequently. The agency did replace the current mat See emailed Picture labeled "Teresa bath mat 6400.64a" 03/31/2023 Implemented
6400.181(e)(14)The assessment does not indicate Individual #4's ability to swim.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. WHO: Program specialist would be responsible for fixing this WHAT: The assessment would be updated to indicate individuals ability to swim WHEN: Issue has been fixed. See emailed correction labeled "TM Individual assessment 6400.181e14" 04/15/2023 Implemented
6400.24The individual's room and board contract is blank.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.WHO: Program Specialist is responsible for implementing this POC WHAT:Ensure that comply with applicable Federal and State statutes and regulations and local ordinances are complied with and the room and board document must contain all pertinent information. WHEN: With immediate effect. Room and board contract has been updated to include required details. See emailed document titled "Teresa room and brd 6400.24" 04/15/2022 Implemented
6400.207(4)(I)Lorazapam 2mg tablets was prescribed to individual #4 to be taken as needed every 8 hours. There was no clarification of a specific event notated on the medication administration. It was not found on location.A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition.WHO: Program specialist in partnership with agency Nurse WHAT: Ensure that any chemical restraint prescribed must include specific details and purpose for administration WHEN: With immediate effect. Medication was discontinued by psychiatrist. See email doc labelled "TM Lorazepam DC 6400.207" 05/01/2023 Implemented