Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00250002 Renewal 09/09/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)At the time for the 09/10/24 inspection., the exterior door leading to the outside from the kitchen had chipping and peeling paint on the exterior side. Screens, windows and doors shall be in good repair. 9/11/24 A maintenance request was initiated to fix the back exterior door-patch and paint. (Attachment # 2) 9/12/24 Maintenance staff fixed the exterior door by wire brushing rust and painting. (Attachment #2) 9/13/24 The Safety Inspection Checklist was updated to include a review of all doors to confirm they are in good repair, including interior and exterior doors. (Attachment #3) 9/18/24 Program specialists and working managers were trained on their responsibilities including screens, windows and doors shall be in good repair. (Attachment #1) 9/18/24 A training record was signed indicating their attendance and understanding. All program specialists and working managers will continue to verify all screens, windows and doors are in good repair. (Attachment #1) 09/19/2024 Implemented
6400.80(a)At the time of the 09/10/24 inspection, there were cracks in the concrete near the asphalt driveway deep enough to be a tripping hazard. Outside walkways shall be free from ice, snow, obstructions and other hazards. 9/11/24 A maintenance request was initiated to fix cracks in the concrete on the walkways to the side and front doors. (Attachment #2) 9/12/24 Maintenance staff fixed the cracks in the concrete on the walkways to the side and front doors. (Attachment #2) 9/13/24 The Safety Inspection Checklist was updated to include a review of outside walkways to ensure they are free of ice, snow and other hazards. (Attachment #3) 9/18/24 Program specialists and working managers were trained on their responsibilities including: Outside walkways shall be free of ice, snow, obstructions and other hazards. (Attachment #1) 9/18/24 A training record was signed indicating their attendance and understanding. All program specialists and working managers will continue to verify all outside walkways shall be free of ice, snow, obstructions and other hazards.(Attachment #1) 09/19/2024 Implemented
6400.145(1)The Emergency Medical Plans for the Individuals in the home do not document the hospital of choice for each individual.The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. 9/11/2024 The Emergency removal plan form was updated to include the following information: In the event of an emergency, (Individuals name), will be transported to the individual's preferred hospital/source of healthcare, which is (Name of hospital) or nearest appropriate medical center as applicable. (Attachment #4) 9/11/24 Emergency Removal plans were updated for each individual in the home to include the individual's preferred hospital/source of health care that will be used in an emergency. (Attachment #4) 9/16/24 The Monthly Supervisory Documentation form was updated to include a monthly review of the emergency medical plan to confirm the preferred hospital/source of health care is documented correctly. (Attachment #5) 9/18/24 Program specialists and working managers were trained on their responsibilities including: The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. (Attachment #1) 9/18/24 A training record was signed indicating their attendance and understanding. All program specialists and working managers will continue to verify all individuals in the home will have a written emergency medical plan listing the following: the hospital or source of health care that will be used in an emergency. (Attachment #1) 09/18/2024 Implemented
SIN-00230571 Renewal 10/03/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)At the time of inspection on 10/5/23, there was a can of artificial snow in a cabinet in the dining room. This was labeled keep out of reach of children and had a medical emergency info phone # listed. Per individual #3's ISP, poisonous substances must be locked in the home.Poisonous materials shall be kept locked or made inaccessible to individuals. 10/13/2023 Program specialists, working managers, and nurses were trained on their responsibilities including Poisonous materials shall be kept locked or made inaccessible to individuals. 10/13/2023 A training record was signed indicating their attendance, understanding and knowledge of future procedures to ensure poisonous materials are kept locked. All program specialists, working managers and nurses will continue to review and ensure poisonous materials are kept locked or made inaccessible to individuals. (Attachment #1) 10/13/2023 The SFI Safety Inspection Checklist was updated to include a review that all poisons are stored properly and locked if needed. This includes anything that has Poison Control info or "Keep out of reach of children" on it. (Attachment #2) 10/17/2023 Implemented
6400.110(f)At the time of the inspection on 10/5/23, individual #2's, bed alarm/shaker was not operative. If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. 10/5/2023- A maintenance request was completed to include the purchase and installation of a bed alarm for Individual #2's bed. (Attachment #3) 10/6/2023- A new SafeAwake Smoke Alarm Aid with Bed Shaker was purchased online from Hear it Better for Individual #2's bed. (Attachment #4) 10/6/2023 The Health Safety Inspection form that is completely monthly with the fire drill was updated to include checking equipment for hearing impaired, if applicable, to ensure it was working during the drill. (Attachment #5) 10/13/2023 Program specialists and working managers were trained on their responsibilities including: if one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. 10/13/2023 A training record was signed indicating their attendance, understanding, and knowledge of future procedures to ensure smoke detectors, fire alarms and equipment is in working order for individuals or staff persons who are not able to hear the smoke detector or fire alarm system. All program specialists and working managers will continue to verify that smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. (Attachment #1) 10/18/23 A new SafeAwake Smoke Alarm Aid with Bed Shaker had to be ordered when it was determined the original order on 10/6/23 was canceled by the company (Hear it Better) without notification to Strawberry Fields. (Attachment #6) 11/12/2023 Implemented
6400.144(Repeat from 10/2022 inspection) - Also, on the date of the home inspection, 10/5/23, the PRN medication MUCINEX COLD LIQ FLU & SORE was not available in the home for individual #1.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. 10/6/2023-The Monthly Supervisory Documentation form was updated to include a review and verification that all prescription and PRN medications are present at the home and documented correctly on the MAR. (Attachment #7) 10/9/2023 Mucinex was purchased for Individual #1 and put in their medication area. (Attachment #8) 10/13/2023 Program specialists, working managers and nurses were trained on their responsibilities including 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. 10/13/2023 A training record was signed indicating their attendance, understanding and knowledge regarding all medications being present at the home. All program specialists, working managers and nurses will continue to review all health services such as medical, nursing, pharmaceutical, dental, dietary and psychological that are planned or prescribed to ensure they are arranged and provided. (Attachment #1) 10/13/2023 Program specialists and working managers were trained on correctly utilizing the Monthly Supervisory documentation form, which includes a review of medications and MARs. Prescription and PRN meds are present at the home and documented correctly on the MAR. (Attachment #1) 10/19/2023 Implemented
6400.166(a)(11)On the MAR reviewed at the home inspection on 10/5/23 for individual #1, the following medications did not have diagnoses listed on the MAR: Topiramate 50mg, Trintellix 5mg, and Vit D3. All of these medication boxes state diagnosis as See ISP. This is also the case for PRN medications Banophen and Robitussin.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.10/6/2023 The Monthly Supervisory Documentation form was updated to include verification each medication has a diagnosis or purpose listed on the medication record including pro re nata. (Attachment #7) 10/9/23 Individual #1's MAR was updated to include the diagnosis/purpose of medication for each medication. (Attachment #9) 10/13/2023 Program specialists, working managers, and nurses were trained on their responsibilities including: a medication record shall be kept, including the following for each individual with whom a prescription medication is administered: diagnosis or purpose for the medication, including pro re nata. 10/13/2023 A training record was signed indicating their attendance, understanding and knowledge of future procedures to ensure all medication records have a diagnosis or purpose of medication for all prescription medication, including pro re nata. All program specialists, working managers and nurses will continue to review all medication records to verify and ensure all prescription medication include a diagnosis or purpose for the medication, including pro re nata. (Attachment #1) 10/19/2023 Implemented
SIN-00213392 Renewal 10/17/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment completed on 2/21/22 did not review for all the regulations. The following regulations were not reviewed: 163a and 163b.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.10/26/2022- All program specialists and working managers were trained on their responsibility that 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. 10/26/2022- A training record was signed indicating their attendance and understanding. (Attachment #1). All program specialists and working managers will continue to 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. 10/25/2022- The self-assessment front page was updated to include the program specialist and program director signatures to indicate the self-assessment was completed correctly. The signatures verify all regulations were reviewed and documented. They also verify a written summary of corrections were completed for all regulatory violations (if applicable. 10/26/2022 Implemented
SIN-00141412 Renewal 10/24/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103The written emergency evacuation plan did not include the means of transportation. The plan indicated staff were going to transport the individual but did not explain how; i.e. staff vehicle, personal vehicle, company vehicle, etc.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. November 8, 2018- All Program Specialists were trained on their responsibilities that there shall be written emergency evacuation procedures that include individual and staff responsibilities, mean of transportation, and an emergency shelter location. A training record was signed indicating their attendance and understanding. The agency Emergency and Removal Transfer Plan template has been revised to include means of transportation. This new form is a template and is prepopulated to ensure compliance when referencing means of transportation. November 12, 2018- In all agency homes the Program Specialist updated all Emergency and Removal Transfer plans. They have been verified by the ID Director to be correct and in compliance. 11/12/2018 Implemented
6400.112(h)Previous individual, 1 did not evacuate the residence during the 8/23/18 fire drill. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.November 8, 2018- All Program Specialists were trained on their responsibilities that all individuals should evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. A training record was signed indicating their attendance and understanding. The agency fire drill record has been revised with the addition of instructions that if an individual refuses and/or they do not evacuate within the specified time, the fire drill needs to be done again within the month with documentation. November 13, 2018- A fire drill was conducted and all individuals evacuated to the designated meeting place outside the building. All fire drill records were reviewed by the ID Director to verify that all individuals have evacuated to a designated meeting place outside the building with the only exception being on 8/23/18 as cited. All agency homes have been reviewed to ensure compliance is being met agency wide. The ID Director will review all agency homes to ensure compliance on a quarterly basis. 11/13/2018 Implemented
SIN-00081850 Renewal 05/18/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103The evacuation procedures for the home was missing the evacuation responsibilities for Individual #1.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. Program Specialists were trained on their responsibilities on 7/28/15. See Attachment #1. The Emergency Removal and Transfer Plan has been revised to include individual responsibilities during an evacuation. All current forms have been updated and verified by the Program Specialists to be corrected and in compliance. See Attachment #2. This updated form will be part of all New Admission Paperwork and updated as needed. 06/18/2015 Implemented
6400.186(c)(1)Individual #1's ISP reviews on 4/17/15 and 1/15/15 did not review the outcome. Morning routine was the outcome but the review stated he had this outcome but didnt list the progres that was made on this outcome. 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. Program Specialists were trained on their responsibilities on 7/28/15. See Attachment #1. This outcome was discontinued effective 6/12/15. See Attachment #3. The quarterly review form has been updated to reflect participation and progress during the prior three months towards ISP outcomes. See Attachment #4. All quarterly records for all individuals have been reviewed for compliance and updated by reviewing quarterly documentation of an ISP outcome. 08/07/2015 Implemented
6400.186(c)(2)Individuals #1's ISP review on 4/17/15, 1/15/15, and 10/15/14 did not review the supervision plan. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. Program Specialists were trained on their responsibilities on 7/28/15. See Attachment #1. The supervison plan for individual #1 will be reviewed quarterly as stated in his ISP. See attachment #5. The quarterly review form has been updated to reflect these reviews. All quarterly records for all individuals have been reviewed for compliance and updated by reviewing each section of the ISP including the supervison plans. See Attachment #6. 08/07/2015 Implemented
SIN-00198056 Renewal 12/13/2021 Compliant - Finalized
SIN-00118879 Renewal 09/27/2017 Compliant - Finalized
SIN-00048012 Renewal 05/30/2013 Compliant - Finalized