Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00235692 Renewal 12/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)Individual #1 and #2 did not have screens in their bedroom windows at the time of inspection. The bathroom window also did not have a screen at the time of inspection.Windows, including windows in doors, shall be securely screened when windows or doors are open. Screens were immediately installed in the bedroom windows. It was determined that they were removed when work was done on the windows and were not reinstalled, so they were present in the home. A third screen was put in the bathroom window on 12/16/23. 12/16/2023 Implemented
6400.77(b)The first aid kit did not have a thermometer at the time of inspection. 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. A thermometer was immediately placed in the First Aid Kit. 12/07/2023 Implemented
6400.141(c)(7)A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. Individual had a gyno exam on 3/2/21 and not again until 6/14/23. This exceeds the annual time frame for the gynecological exam.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. It was determined that individual #1 had a gynecological appointment and exam on 3/7/22 but the issue was agency documentation. The documentation was added to the medical binder for Individual #1 on 1/12/24 and she was scheduled for her annual appointment with the gynecologist on 4/9/2024. 01/12/2024 Implemented
6400.144Health services shall be provided for. Individual had a medication review on 10/9/23 with a follow up appointment on 12/7/23. There was no documentation to reflect the December appointment occurred.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 was scheduled for and completed a medication review on 1/4/24. 01/04/2024 Implemented
6400.151(a)A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Staff had a physical on 7/22/19 and not again until 11/17/21. This exceeds the time frame. This staff is also past due for this years annual physical. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Staff completed an annual physical on 12/15/23. 12/15/2023 Implemented
6400.152(c)The staff had a TB test completed on 7/22/19 and not again until 12/13/21. This exceeds the time frame. The physician's written instructions and precautions shall be followed.Staff completed an annual physical including TB test on 12/15/23. 12/15/2023 Implemented
6400.213(1)(i)The individual record did not list the individual's religious affiliation. The area was left blank on the document.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.Individual was asked for her religious affiliation and this information was added to her profile in Setworks on 1/12/24. 01/12/2024 Implemented
SIN-00219545 Renewal 12/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There was a black area, approximately the diameter of a CD disk, on the wall at the top of the basement stairs where floor mops were stored. The black area appeared to be mold or mildew, likely a result of a wet mop hanging from the wall hooks and in contact with the wall.Clean and sanitary conditions shall be maintained in the home. Area on stairwell cleaned and painted with Kilz paint. 01/13/2023 Implemented
6400.112(c)The fire drill record for the drill conducted on 4/02/2022 did not record the evacuation time. Staff had written on the record "under two minutes" which is not acceptable. Exact time of evacuation in minutes and/or seconds is required.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. Agency Fire Safety Policies were updated to include, updates to the policy itself, update to the fire drill form, creation of a fire drill tracking log, and updating fire safety binders for each residence. 01/04/2023 Implemented
SIN-00190461 Unannounced Monitoring 07/16/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Individual Support Plan (ISP) for Individual #1 with a plan last updated date of 5/27/21, indicates that Individual #1 is not safe with poisons. In the Safety Precaution section of the ISP it states "Has no poison awareness skills. All cleaning and poisonous substances are locked within her home and at program." All cleaning supplies and poisons within the home were unlocked and easily accessible at the time of inspection.Poisonous materials shall be kept locked or made inaccessible to individuals. ISP was updated to include the following statement: COLLEEN HAS POISON AWARENESS SKILLS. MOM FEELS SHE WOULD NOT INGEST POISONS. SHE IS ABLE TO USE CLEANING SUPPLIES SAFELY. ALL CLEANING AND POISONOUS SUBSTANCES ARE LOCKED AT HER COMMUNITY PARTICIPATION SUPPORTS PROGRAM DUE TO POLICY. POISONOUS SUBSTANCES DO NOT NEED TO BE LOCKED AT HER HOME. 08/30/2021 Implemented
6400.67(a)The handle water adjuster in the rear shower of the home was missing. Staff #1 reported that water was adjusted with a set of pliers. All surfaces shall be in good repair.Floors, walls, ceilings and other surfaces shall be in good repair. The handle for this shower has been replaced. 08/19/2021 Implemented
6400.82(f)The mirrored door on the medicine cabinet in the rear bathroom of the home was missing. Mirrors are required in bathrooms.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Mirror has been replaced in the bathroom. 07/20/2021 Implemented
6400.101The lock on the basement door had the keyed lock on the basement side of the door. Staff #1 reported that the basement area is accessed by individuals and is utilized as a laundry area. Egress from the basement is obstructed by the locked door.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The lock has been replaced with a non-locking doorknob. 07/20/2021 Implemented
6400.181(a)There was no assessment available for Individual #1 at the time of inspection or upon request. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. This assessment has been completed. 07/30/2021 Implemented
6400.166(a)(13)The July Medication Administration Record (MAR) for Individual #1 did not contain the initials of the staff administering the 8pm doses for Klonopin and SF 5000 Plus Cream on 7/15/21. (Repeat Violation 1/19/2021)A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.Documentation has been completed for this error. All staff will retake ODP modified medication training. 09/15/2021 Implemented
SIN-00186552 Unannounced Monitoring 03/22/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.18(b)(2)A medication error is an incident required to be reported in EIM within 72 hours. Individual #2 missed her 2pm dose of Clonazepam (0.5mg) on 2/9/2021 and 2/28/2021. These incidents weren't reported in the Enterprise Incident management (EIM) 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.The agency has filed a Medication Error Report to report the missed dose of medication on 2/9/21 and 2/28/21. The agency has recently developed a position, Medical Coordinator. The Medical Coordinator will be responsible to review health practices along with Medication Administration and MAR documentation. This will provide additional oversight and training to ensure that Medication Administration practices are followed and documented accordingly to the ODP curriculum. 06/15/2021 Implemented
6400.32(c)Individual #3's health and safety needs were neglected by this agency. On the overnight shift from 3/1-3/2/2021, the furnace went out due to a windstorm. When the power came back on, the furnace was still not working. Several texts and calls were made by the staff on duty to Eihab management along with the maintenance director over a period of approximately 7 hours. She didn't receive a text back until 6:24am. The lowest the temperature got was 47.2 degrees. Individual #1 was given extra blankets to sleep with throughout this. It was reported that the heat didn't come back on until approximately 10am. (Repeat Violation: 1/22/2021)An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.Since the time of survey, the Maintenance has provided the residence with training on show to reset the furnace in the event a windstorms interrupts the furnace. 06/15/2021 Implemented
SIN-00181629 Renewal 01/19/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(a)At time of inspection there was no fire extinguisher in the kitchen.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. After review, the fire extinguisher was discovered underneath the kitchen sink. Since the time of the survey, a sign has been posted to remind staff where the fire extinguisher was located. Fire Extinguished signage will be place near all fire extinguisher at all sites. On a monthly basis the Program Specialist will visit the residence and ensure the fire extinguisher is present on each floor and designated location as indicated by the sign. Staff will continue to receive training Fire Safety training, in addition to on site Fire Safety training that will include locations of fire extinguishers during initial and annual training. 02/10/2021 Implemented
6400.112(c)A fire drill was not completed in March 2020.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. After review, the March 2020 fire drill was located and currently on file. The Vice President has developed a Fire Drill Report Review Procedure which includes a Shared Fire Drill Annual Calendar amongst management and administration. On the shared calendar, drills will be scheduled to ensure various conditions with indicate alternate exits to be used. This shared calendar will be reviewed on a daily basis by the Program Specialist to ensure and verify that all scheduled drills have been completed. In addition, staff will upload the documented fire drill report for the Management and Program Specialist to review the drill report within 24-72 hours. Management and the Program Specialist will review the drill report to ensure that the scheduled drill was successful and documentation was complete and accurate. Training will be done with all Management and Administrative Staff on this procedure and implementation will be in effect by March 15, 2021. This procedure will be monitored on a daily basis by the Program Specialist for oversight and ensure that all drill reports completed as indicated. The Quality Assurance Department will be conducting quarterly reviews of all fire drills to ensure this procedure is followed and fire drills procedures are in compliance. 03/15/2021 Implemented
6400.112(f)Record of fire drills indicated that the back exit was only used for the 6/29/20 fire drill. All other drills conducted during 2020 used the front exit. Use of exits from the home must be varied throughout the year.Alternate exit routes shall be used during fire drills. The Vice President has developed a Fire Drill Report Review Procedure which includes a Shared Fire Drill Annual Calendar amongst management and administration. On the shared calendar, drills will be scheduled to ensure various conditions with indicate alternate exits to be used. This shared calendar will be reviewed on a daily basis by the Program Specialist to ensure and verify that all scheduled drills have been completed. Training will be done with all Management and Administrative Staff on this procedure and implementation will be in effect by March 15, 2021. This procedure will be monitored on a daily basis by the Program Specialist for oversight and ensure that all drill reports completed as indicated. The Quality Assurance Department will be conducting quarterly reviews of all fire drills to ensure this procedure is followed and fire drills procedures are in compliance. 03/15/2021 Implemented
6400.181(a)Admission date provided for Individual #9 was 4/6/20. The only assessment included for Individual #9 was dated 1/12/21 and was not completed Eihab. An assessment dated one year prior to or 60 days after her admission was not completed as required. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Since the time of the survey, Individual #9 has been discharged from EIHAB. The Vice President has developed a procedure to monitor the timeliness of the required skills assessment. Assessments will be completed within 30 days of admissions and quarterly reviews thereafter. Program Specialist will be trained to review skills assessment on a quarterly basis and to complete the assessment during the quarter prior the annual review date. The Program Specialist will review that the assessments on file are completed accurately. There will be shared calendar to provide oversight to indicate when each individual¿s skills quarterly review and annual assessment will be completed. Training will be done with all Management and Administrative Staff on this procedure and implementation will be in effect by March 15, 2021. 03/15/2021 Implemented
6400.32(r)During inspection of the home it was noted that Individual #10 does not have a key to the lock on her bedroom door.An individual has the right to lock the individual's bedroom door.Since the time of the survey, Individual #10 has been given a key to lock her bedroom door. Individual #10 key to obtain a key will be reviewed to monitor if she still wants a key, needs supports and that she is aware of her rights to lock her bedroom door. A Key Assessment will be completed by the Behavior Specialist. The completed the assessment will share with the team and forwarded to Service Coordinator. Moving forward, all individuals will be assessed including new admission. Staff, Behavior Specialist, Management and Administration will be trained on this procedure by March 15, 2021. 03/15/2021 Implemented
6400.166(a)(4)Individual medication entry on the December 2020 Medication Administration Record (MAR) for Individual #9 does not include the name of the medication. "Take 1 tablet by mouth at 8pm daily for 1 week. Take 2 tablets by mouth daily at 8pm for 1 week. Then 3 tabs by mouth daily at 8pm." The name of the medication was not included on the individual entry.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.Since the time of the survey, Individual #9¿s Medication Administration Record has been updated to include the name of medication. As a result of pharmacy not meeting the agencies needs and causing potential medication errors, in January 2021, administration has changed pharmacies. Prior to licensing, the new pharmacy has been notified of MAR requirements to meet the agency¿s medication administration practices and ODP regulations. Staff will be retrained on the Accountability Log Procedure to include each shift reviewing the MAR in preparation to administer medication. Residence management will be conducting weekly reviews to ensure that all medications are transcribed correctly to include the name of the medication. The Medication Trainer will conduct monthly reviews in addition to the Quality Assurance Department conducting quarterly reviews. Staff will be retrained to review the five rights when administering medication. Staff, Management and Administration will be trained on the oversight and monitoring procedure by March 15, 2021 03/15/2021 Implemented
6400.166(a)(5)Individual medication entry on the December 2020 Medication Administration Record (MAR) for Individual #9 does not include the name of the medication. "Take 1 tablet by mouth at 8pm daily for 1 week. Take 2 tablets by mouth daily at 8pm for 1 week. Then 3 tabs by mouth daily at 8pm." The strength of the medication was not included on the individual entry.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.Since the time of the survey, Individual #9¿s Medication Administration Record has been updated to include the name of medication. As a result of pharmacy not meeting the agencies needs and causing potential medication errors, in January 2021, administration has changed pharmacies. Prior to licensing, the new pharmacy has been notified of MAR requirements to meet the agency¿s medication administration practices and ODP regulations. Staff will be retrained on the Accountability Log Procedure to include each shift reviewing the MAR in preparation to administer medication. Residence management will be conducting weekly reviews to ensure that all medications are transcribed correctly to include the strength of medications. The Medication Trainer will conduct monthly reviews in addition to the Quality Assurance Department conducting quarterly reviews. Staff will be retrained to review the five rights when administering medication. Staff, Management and Administration will be trained on the oversight and monitoring procedure by March 15, 2021. 03/15/2021 Implemented
SIN-00162275 Renewal 09/25/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)There was no thermometer in the first aid kit at this 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. A thermometer was placed in the first aid kit on 09.26.19. First aid kits will be reviewed monthly. A checklist of necessary first aid items will be placed in the kit for review each time the first aid kit is checked. During monthly reviews, Quality Assurance Department will ensure the kit contains antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual is 4 years of age or younger or an individual likely to ingest poisons is served. 09/26/2019 Implemented