Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00259320 Unannounced Monitoring 01/23/2025 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)At 2:15PM, the hot water temperature measured 126.5F at the kitchen sink. [Repeated Violation-10/7/24]Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. The hot water temperature at the kitchen sink was immediately adjusted to ensure it does not exceed 120°F. Direct Support Professionals (DSPs) have been reminded of their responsibility to conduct and document daily water temperature checks, and the maintenance team has been notified to promptly address any irregularities. The Directors of Residential Facilities and Compliance will oversee the effectiveness of these measures to prevent recurrence. 03/07/2025 Not Implemented
6400.80(a)At 2:22PM, the outside walkway, leading from the basement to the rear of the home, was covered in snow. [Repeated Violation-11/21/24] Outside walkways shall be free from ice, snow, obstructions and other hazards. The snow-covered walkway leading from the basement to the rear of the home was immediately cleared to ensure safe passage. Staff have been reminded of their responsibility to keep all walkways free from snow, ice, and other hazards in accordance with ODP 6400 regulations. 03/07/2025 Not Implemented
6400.163(a)Individual #1 is prescribed Olanzapine 20mg Tab. At 2:00PM, there was one loose tablet out of the medication blister back in the bottom of Individual #1's medication storage container.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.The loose Olanzapine 20mg tablet found in Individual #1¿s medication storage container was immediately discarded. Staff were reminded and retrained on proper medication handling and the requirement that all medications remain in their original labeled containers at all times. 03/07/2025 Not Implemented
6400.166(a)(6)Individual #1 is prescribed Olanzapine 20mg Tab with instructions to dissolve one tablet by mouth every night at bedtime for mood. Individual #1's January 2025 medication record has instructions for Olanzapine 20mg Tab to take one tablet by mouth every night at bedtime for mood.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form.The medication record for Individual #1 has been updated in Therap to accurately reflect the correct dosage form of Olanzapine 20mg Tab as ¿dissolve one tablet by mouth every night at bedtime¿ instead of just ¿take one tablet by mouth.¿ Staff have been reminded and retrained on the importance of ensuring that all medication records reflect the exact prescribed dosage form as issued by the pharmacy. 03/07/2025 Implemented
6400.166(a)(11)Individual #1 is prescribed Asenapine Sub 5mg with instructions to place one tablet beneath the tongue twice a day and let dissolve for mood. Individual #1's January 2025 electronic medication record for Asenapine Sub 5mg has instructions to take one tablet under the tongue twice a day for Bipolar Disorder, allow to dissolve completely.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 medication record for Individual #1 in Therap has been updated to reflect the correct diagnosis/purpose for Asenapine Sub 5mg as ¿mood¿ to match the prescriber¿s instructions. Staff have been reminded and retrained on the importance of ensuring that all medication records accurately document the prescribed diagnosis or purpose for each medication. 03/07/2025 Not Implemented
6400.166(b)Asenapine Sub 5mg, Multivitamin, Olanzapine 5mg tab prescribed to Individual #1 were not initialed as administered on 1/4/25,1/6/25, 1/11/25, and 1/19/25 at 8:00AM. Olanzapine 20mg, Sodium Fluoride Gel prescribed to Individual #1 were not initialed as administered on 1/11/25 at 8:00PM. [Repeated Violation- 10/7/24 and 11/21/24]The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The missed initials for Asenapine Sub 5mg, Multivitamin, Olanzapine 5mg Tab, Olanzapine 20mg, and Sodium Fluoride Gel in Therap have been reviewed, and staff responsible have been retrained on proper medication documentation procedures. Staff have been reminded that all medication administration must be recorded in Therap at the time of administration to ensure compliance with ODP 6400 regulations. 03/07/2025 Not Implemented
6400.167(a)(1)On 1/9/25 at 8:00PM, Individual #1 was not administered Asenapine, Olanzapine 5mg tab & Sodium Fluoride Gel. The following comment was in Individual #1's record: "[Individual #1] did not have her meds this evening due to lost med key." [Repeated Violation- 11/21/24]Medication errors include the following: Failure to administer a medication.On 1/9/25 at 8:00PM, Individual #1 was not administered Asenapine, Olanzapine 5mg Tab, and Sodium Fluoride Gel due to a lost medication key. To prevent recurrence, an emergency backup key system has been implemented, ensuring that a second set of medication keys is securely stored and accessible to authorized personnel at all times. Staff have been retrained on proper key management protocols to prevent medication access issues. 03/07/2025 Not Implemented
6400.207(4)(III)A blister package of Hydroxyz Pam Cap 25mg, take one capsule by mouth daily as needed for moderate anxiety was dispensed for Individual #1 on 7/12/2024. "Take 30 minutes before any outings" was hand-written without a date or signature in black marker on the blister pack. This medication was administered to Individual #1 fourteen times including on 1/9/25. There is not documentation on Individual #1's medication administration record of the administration of this medication on 1/9/25. There is no PRN protocol to include a very clear description of the explicit symptoms of the psychiatric diagnosis in the prescription and pharmacy label, authorization by the CEO or CEO's designee for each instance of administration and documentation of monitoring of the actual response to the medication of each administration.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: An ongoing program of medication.The handwritten note on the blister pack of Hydroxyz Pam Cap 25mg has been removed, and staff have been instructed not to alter medication packaging in any way. The medication administration record (MAR) in Therap has been updated to ensure proper documentation of all PRN (as-needed) medication use, including clear descriptions of symptoms leading to administration. Additionally, a PRN protocol has been created that includes: 1) A clear description of symptoms requiring administration. 2) Authorization by the CEO or designee for each instance of administration. 3) Documentation of the individual¿s response to the medication after each administration. 03/07/2025 Implemented
SIN-00256069 Unannounced Monitoring 11/21/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)At 1:47PM, the two windows in Individual #1's bedroom did not contain the cranks that are needed to open the windows. Screens, windows and doors shall be in good repair. To address the violation, immediate corrective actions will be taken to ensure that the windows in Individual #1's bedroom are in good repair. The missing cranks for the two windows will be replaced by the maintenance team by the end of the month December 2024 to restore their functionality. Once the cranks have been installed, the windows will be tested by the maintenance team to confirm they can be opened and closed properly. Devon Baskin, the Director of Compliance and Residential, will review the completed work to ensure compliance with regulatory standards. Additionally, the Site Coordinator will inspect all other windows in the home to identify and address any additional repair needs, ensuring compliance throughout the residence. 01/03/2025 Not Implemented
6400.80(a)At 1:41PM, the exterior walkway and steps, along the side of the home, were covered in dried leaves and twigs. Outside walkways shall be free from ice, snow, obstructions and other hazards. Immediate action was taken to address the violation by ensuring the exterior walkway and steps along the side of the home were cleaned and made free from obstructions and hazards. The dried leaves and twigs covering the walkway and steps were promptly removed by the maintenance team, ensuring a clear and safe pathway. Following the cleanup, the Site Coordinator inspected the area to confirm the walkway was free of debris and compliant with safety standards. 01/03/2025 Not Implemented
6400.171On 11/21/24, Individual #1 was not at the home. Staff interview revealed that Individual #1 has not been at the home since 11/19/24. At 12:36PM, the microwave contained a bowl partially eaten chicken and asparagus and metal fork. When the microwave was opened a pungent smell of spoiled food emanated from within that encompassed the entire kitchen area. At 1:07PM, an opened package of frozen bread sticks was unsealed in the freezer in the kitchen of the home.Food shall be protected from contamination while being stored, prepared, transported and served. Immediate corrective actions were taken shortly after the violation to ensure all food is properly stored and labeled with the current date of storage, preventing contamination and spoilage. The partially eaten bowl of chicken and asparagus, along with the metal fork, were removed, and the microwave was cleaned thoroughly to eliminate the pungent smell of spoiled food. Additionally, the unsealed package of frozen breadsticks in the freezer was discarded to prevent potential contamination. Staff have been retrained on food storage protocols, emphasizing the importance of promptly discarding leftover food, sealing all food items appropriately, and maintaining clean and sanitary conditions in the kitchen. The Site Coordinator oversaw the cleaning of all kitchen appliances, including the microwave, to restore them to a sanitary condition. 01/03/2025 Not Implemented
6400.167(a)(1)Asenapine sublingual 5mg, Olanzapine Tab 20mg, Sodium Fluoride Gel 1.1% prescribed to Individual #1 were not administered on 11/3/24 at 8:00PM.Medication errors include the following: Failure to administer a medication.To address the violation, corrective actions will be taken to ensure that all medications are administered as prescribed. The missed administration of Asenapine sublingual 5mg, Olanzapine Tab 20mg, and Sodium Fluoride Gel 1.1% on 11/3/24 at 8:00 PM will be investigated immediately. The staff responsible for administering medications during this time will be interviewed to determine the cause of the error and held accountable if necessary. Staff will be retrained on medication administration protocols by the end of December 2024, with an emphasis on the importance of following prescribed schedules and documenting administration accurately in the medication administration record (MAR). The retraining will include step-by-step instructions on cross-checking the MAR during and after medication rounds to ensure no doses are missed. Additionally, the MAR will be reviewed by the Site Coordinator/Program Specialist to confirm the documentation reflects proper administration moving forward. Any discrepancies will be addressed immediately, with corrective actions taken as needed. 01/03/2025 Not Implemented
6400.182(c)Individual #1 assessment, completed 12/23/23, indicates that Individual #1 is not capable of self-administering medications. In the general health and safety section of Individual #1's individual plan, last updated 11/13/24 reads, " [Individual #1] is considered self-medicating. [Individual #1] does know how to open/close containers, dispense the correct amount, identify the correct medication, and sign the MAR."The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.Immediate corrective actions will be taken to ensure that Individual #1's Individual Plan (IP) accurately reflects their current needs and abilities based on their most recent assessment. The inconsistency between the 12/23/23 assessment, which indicates Individual #1 is not capable of self-administering medications, and the general health and safety section of the IP, updated on 11/13/24, will be corrected immediately. The Program Specialist will review both documents to identify all discrepancies and update the IP to align with the most recent assessment. The updated IP will clearly state that Individual #1 is not capable of self-administering medications and will include any necessary supports or protocols to ensure safe medication administration. 01/03/2025 Not Implemented
SIN-00252203 Unannounced Monitoring 09/20/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16On 9/18/24, Individual #1 was left unsupervised for approximately eight hours when Direct Service Worker #1 left the home at approximately 3:00 PM until Direct Service Worker #2 arrived at the home at 11:00 PM. In the home supervision section of Individual #1's individual plan, last updated on 8/19/24 reads, "[Individual #1] requires 24-hour supervision in the home. She requires supervision to ensure she is taking her medications. She requires assistance with meal preparation and to ensure she is eating meals and snacks daily. " [Repeated Violation- 7/23/24 et al]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.To address the violation where Individual #1 was left unsupervised for approximately eight hours, immediate corrective actions have been taken. Direct Service Worker #1, who was responsible for the lapse, was suspended by HR following the incident and is no longer employed with the agency as of today. A comprehensive internal review was conducted to identify and address any gaps in oversight. The Residential Site Supervisor convened a mandatory meeting with all staff to review Individual #1¿s Individual Plan (IP), emphasizing the critical requirement for 24-hour supervision and the severe consequences of neglect. This review also reinforced the necessity of ensuring individuals receive proper medication management, meal preparation, and daily care as outlined in their plans. 12/02/2024 Not Implemented
6400.144Olanzapine Tab 20 mg., take 1 tablet by mouth every night at bedtime, prescribed to Individual #1 was not administered at 8:00PM on 9/17/24, 9/18/24, and 9/19/24. On 9/20/24, at 11:16AM, the blister pack for the Olanzapine Tab 20 mg. was empty. On 9/20/24, at 11:55AM, Individual #1's Supports Coordinator spoke with Individual #1's Pharmacy which confirmed the most recent delivery of Individual #1's Olanzapine Tab. 20 mg was on 8/22/24. In addition, the Pharmacy informed Individual #1's Supports Coordinator that the refill request made by the agency on 9/13/24 was denied due to the lack of a current physician's order.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 lapse in medication administration was primarily due to Individual #1 refusing a previous psychiatrist appointment, which delayed the renewal of the prescription. The Support Coordinator was notified promptly to arrange a telehealth appointment, but no response was received in time to prevent the gap in medication refills. Individual #1 has since attended her psychiatrist appointment, and the medication is now being administered as prescribed. 12/02/2024 Not Implemented
6400.45(e)Due to the agency not having enough staff to cover shifts, Individual #1 was taken to one of the agency's other licensed homes at 4:36PM on 9/15/24. This home is occupied by Individual #2. In the home supervision section of Individual #2's individual plan last updated on 9/23/24 reads, "1:1 supervision is necessary to ensure [Individual #2]'s safety. She requires extensive support and one-on-one encouragement to engage in almost all activities. In the home supervision section of Individual #1's individual plan last updated on 8/19/24 reads, "[Individual #1] requires 24-hour supervision in the home. She requires supervision to ensure she is taking her medications. She requires assistance with meal preparation and to ensure she is eating meals and snacks daily. " Direct Service Worker #3 was the only staff supporting both individuals on 9/15/24.An individual may not be left unsupervised solely for the convenience of the home or the direct service worker.Staff was suspended for taking individual to another site and leaving the individual. Site Supervisor had team meeting to review Individual Plans (IP) for individual and requirement for 24-hour supervision, to ensure staff are fully aware of client's needs. Site Supervisor will reinforce the importance of adhering strictly to IPs, with special attention to the consequences of unsupervised care and the importance of contacting logistic coordinator for assistance. 12/02/2024 Not Implemented
6400.166(d)Olanzapine Tab 20 mg., take 1 tablet by mouth every night at bedtime, prescribed to Individual #1 was not administered at 8:00PM on 9/17/24, 9/18/24, and 9/19/24.The directions of the prescriber shall be followed.To address this violation, staff will be retrained on the critical importance of administering medications at the prescribed times and properly documenting each administration. Medications will be securely stored in a utility box with a proper locking mechanism to prevent unauthorized access. The staff office will be locked when not in use to ensure medications are safeguarded. Additionally, any missed doses will be immediately reported, and corrective actions will be taken to ensure compliance. 12/02/2024 Not Implemented
6400.167(c)Olanzapine Tab 20 mg., take 1 tablet by mouth every night at bedtime, prescribed to Individual #1 was not administered at 8:00PM on 9/17/24, 9/18/24, and 9/19/24. As of 9/23/24, these medication errors have not been reported into the Enterprise Incident Management, the Department's Incident Management System.A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation).The missed doses of Olanzapine were reported in the Enterprise Incident Management (EIM) system, albeit later than required. To address this lapse, all staff involved in the oversight have undergone re-training focused on the critical importance of timely and accurate incident reporting, with a specific emphasis on medication errors. This re-training ensures that all staff understand their responsibilities in promptly reporting incidents to prevent future delays and maintain compliance with regulatory standards. 12/02/2024 Not Implemented
SIN-00248521 Renewal 07/23/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(e)On 7/24/24 at 10:24AM, a 24 inch high trash receptacle in the laundry room in the basement of the home did not have a lid.Trash receptacles over 18 inches high shall have lids. Site Supervisor removed the trash receptacle that had no lid 7/24/24. 08/26/2024 Not Implemented
6400.68(b)On 7/24/24 at 10:26AM, the hot water temperature at the bathtub in the only bathroom in the home measured 127 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. Temperature was adjusted by maintenance the day before inspection because it was a few degrees under 120; however, it got too hot. 7/24/24 Maintenance came to site to address the hot water temperature to ensure water temperature in bathroom and kitchen area were within range of required temperature. Maintenance revisited the site 2 days later to ensure water temperature was still within range.(68b) 08/05/2024 Not Implemented
6400.72(a)On 7/24/24 at 10:15AM, the open windows in the home's living room did not have screens. At 10:27 AM, the two open windows in Individual #1's bedroom did not have screens. At 10:28AM the window in the vacant bedroom did not have a screen.Windows, including windows in doors, shall be securely screened when windows or doors are open. 8/5/24 Maintenance has ordered screens for the second floor bathroom. 08/05/2024 Not Implemented
6400.101On 7/24/24 at 10:22AM, there was a sliding latch lock on the top right corner of the door in the basement of the home leading to the outside of the home posing a "choke point" during an emergency evacuation. At 10:27 AM, the door between the basement and the garage has a key locking mechanism on the garage side of the door posing an obstructed egress from the garage when engaged without access to a key.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. 8/16/24 Maintenance has addressed the locked door to ensure a key is provided to staff and accessible to the individual. 08/16/2024 Not Implemented
6400.105On 7/24/24 at 10:23AM, the outside dryer exhaust vent was clogged with thick pieces of lint preventing the flow of hot air from the dryer.Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.7/24/24 Site supervisor remove lint from outside dryer exhaust vent to prevent clogging. 08/26/2024 Implemented
6400.113(a)Individual #1 date of admission 10/30/23 had fire safety training on 10/31/23. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. 8/6/24 Program Director has updated checklist for individual's being admitted to ensure fire safety training is listed as day of action item. 08/06/2024 Implemented
6400.141(c)(3)Individual #1's physical examination, completed 7/22/24 does not include immunizations.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. 8/7/24 Program Director requested immunization from physician. 08/05/2024 Not Implemented
6400.141(c)(6)Individual #1, date of admission 10/30/23, does not have Tuberculin testing.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. 8/6/24 Program Director has updated checklist for individual's being admitted to ensure all necessary documentation is collected before transitioning from another provider. 08/06/2024 Not Implemented
6400.143(a)Individual #1 refused a routine dental appointment on 6/7/24. The continued attempts to educate Individual #1 about the need for health care was not documented in Individual #1's record. The agency form," Refusal of Medical/Dental Examination/Treatment" was left blank in the area to record the date and technique used in training the individual about the need for 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. The individual was educated on the importance of medical appointments; however this education was not documented. The program specialist updated the documentation of the refusal and training 7/30/24 . 07/30/2024 Not Implemented
6400.181(e)(12)Individual #1's assessment, completed 12/23/23 did not address recommendations for specific areas of training, programming, and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. The program specialist will update the individual's assessment during the next annual assessment review to ensure the assessment includes recommendations for specific areas of training, programming and services. 08/27/2024 Not Implemented
6400.18(i)Enterprise Incident Management Incident # 9330638 for an allegation of abuse had a finalization due date of 6/8/24. As of 7/30/24, the incident has not been finalized or an extension has not been requested. Enterprise Incident Management Incident #9384894 for an allegation of neglect had a finalization due date of 4/19/24. As of 7/30/24, the incident has not been finalized or an extension has not been requested. Enterprise Incident Management incident #9384910 for an allegation of neglect with a finalization due date of 4/19/24; however, the incident was not finalized until 4/25/24.The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension.Individual was no longer in our care for year and a half when AE requested entry of Incident # 9330638. Several attempts to visit the individual in the hospital were unsuccessful. CI will complete CIR by 8/30/34. Incident #9384894 finalized 5/4/24. 08/30/2024 Not Implemented
6400.165(g)Individual #1, date of admission 10/30/23 is prescribed medications to treat symptoms of a psychiatric illness. Individual #1 has not had a review of medications by a licensed physician. [Repeated Violation- 8/7/23 et al]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 individual has had a review of medication every 3 months as required. This is how the agency is able to renew prescriptions. The psychiatrist has not completed the documentation to show medication reviews have been completed. Program Director and Program Specialist have been contacting the psychiatrist to obtain information needed for medication review documentation. 08/05/2024 Not Implemented
6400.182(c)Individual #1's assessment, completed 12/23/23, indicates Individual #1 requires a 1:1 staffing to individual ratio at home and in the community and can be left alone when at home. Individual #1's individual plan, last updated 7/11/24, states that they require 24/7 supervision at home and in the community.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The individual previously was allowed to have alone time at home; however, due behaviors that put the individual at risk recently, the team and the individual decided it was best to remove the alone time until further notice. 12/23/24 The program specialist will update the individual's assessment during the next annual assessment review to remove a line that states the individual can be left alone when at home. 08/27/2024 Not Implemented
SIN-00194381 Renewal 09/28/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The home was added to the agency's Certificate of Compliance, effective 3/5/21; however, the initial furnace inspection was completed on 9/24/21.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. The management team has been retrained on the self assessment tool. This training included properly inspecting the furnace "prior to" an individual transitioning into the home. 09/30/2021 Implemented
6400.166(a)(11)There was no purpose or diagnosis Listed on Individual #1's September 2021 Medication Administration Record for any of Invidiuall#1's medications, including, but not limited to: Celecoxib Cap 200 mg for Celebrex with instructions to take 1 capsule by mouth twice a day; Gabapentin Cap 200 mg with instructions take 1 capsule three times a day.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.Diagnosis or purpose for the medication was written on the MAR. 10/01/2021 Implemented