Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00260559 Renewal 02/04/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(6)On 2/5/25 at 11:45am, Individual's bedroom, located off the kitchen on the right-hand side, did not have a mirror.In bedrooms, each individual shall have the following: A mirror. The mirror that belonged in the room was taken down for painting purposed. The mirror will be hung back up on the wall. PS will ask maintenance to hang the mirror on the wall. The mirror has been hung back up on the wall, in the bedroom, on 2/6/25. PS will be retrained on regulation 6400.81(k)(6). 02/06/2025 Implemented
6400.110(a)On 2/5/25 at 11:38am the attic, accessed by using the dropped down ladder in the hallway, did not have an operable automatic smoke detector. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. An operable automatic smoke detector will be placed in the attic. PS has purchased the automatic smoke detector and placed it in the attic. The change has been made on 2/17/25. PS will be retrained on regulation 6400.100(a). 02/17/2025 Implemented
6400.111(a)On 2/5/25 at 11:38am the attic, accessed by using the dropped down ladder located in the hallway, did not have a fire extinguisher with a minimum 2-A rating.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. Fire extinguisher with 2-A rating will be added to the attic space of the home. PS has purchased and placed the fire extinguisher to the attic space. The fire extinguisher has been placed in the attic space. PS have been retrained on regulation 6400.111a 02/17/2025 Implemented
6400.141(c)(3)Individual 1's most recent diphtheria vaccine was administered on 11/26/232. This exceeds every 10-year recommendation provided by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.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. Individual received diphtheria vaccine on 2/4/25. Change was immediately made by the provider by having the individual obtain the diphtheria vaccine. The correction was made on 2/4/25. Electronic health record implemented to keep track of immunizations. PS retrained on regulation 6400.141(c)(3) 02/04/2025 Implemented
6400.141(c)(12)Individual #1's physical examination, dated 9/18/24, did not address the physical limitations of the individual.The physical examination shall include: Physical limitations of the individual. Individual's record will be updated to include physical limitations. PS will have PCP update the individual's record. Individual has a PCP appointment on 2/27/25. Provide will have PCP document physical limitations on the coordination of care form. 02/27/2025 Implemented
6400.141(c)(15)Individual #1's physical examination, dated 9/18/24, did not address any special instructions for the individual's diet.The physical examination shall include:Special instructions for the individual's diet. Special instructions for the individual's diet will be documented. PS will have PCP update the individual's record. Individual has a PCP appointment on 2/27/25. Provide will have PCP document any special instructions for the individual's diet on the coordination of care form. 02/27/2025 Implemented
SIN-00238945 Renewal 02/06/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(11)Individual #1's February 2024 Medication Administration Record (MAR) did not include a diagnosis or purpose for the following medications: Aspirin Low Tab 81 MG EC Sub for: Aspirin tab delayed release Take 1 Tablet by mouth once daily and Clarus Apply to toenails once daily. Individual #2's February 2024 MAR did not include a diagnosis or purpose for the following medications: Atorvastatin Tab 40MG Take 1 Tab by mouth at bedtime, Bumetanide Tab 2MG Take 1 Tablet by mouth twice a day, Chlonidine DIS 0.1/24HR Apply 1 patch on the skin once a week, Ferrous Sulfate 325 MG TABS Take 1 Tablet by mouth three times daily with meals, Hydralazine HCL 100MG TAB Take 1 tablet by mouth three times daily, Losartan POT TAB 100MG Takew 1 tablet by mouth once daily, Nifedipine TAB 60MG ER Take 1 tablet by mouth twice daily, Pantoprazole TAB 40 MG Take 1 tablet (40mg) by mouth every morning before breakfast, Polyeth GLYC POW 3350 NF Mix 17GM (one capful) in 8 ounces liquid and drink once daily.Quetiapine TAB 50 MG Take 1 Tablet by mouth at bedtime, Senna TAB 8.6 MG Take 2 Tablets (17.2MG) by mouth at bedtime, Sertraline TAB 100 MG Take 1 Tablet by mouth once daily, and SOD POY SUL POW Take 15 grams (4 teaspoons) by mouth once daily on non-dialysis days.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.MARs are moving to an electronic format as of March 4th and diagnoses will be connected to each medication. The Program Specialists are in the process of uploading medications into the eMAR with diagnoses attached to the medications. The eMAR system wil be going live March 4th organization-wide. The format will be transitioning to an electronic process. We have transitioned from paper MAR records to an eMAR system. All employees have been trained on eMARs so the sytem will be rolled out and going live March 4, 2024. 03/04/2024 Implemented
6400.167(a)(2)Individual #1 is prescribed Debrox Sol 6.5% OT Instill 1-2 drops in each ear for wax build up. Individual #1 was administered Med Ear Drops for Swimmers Isopropyl Alcohol 95% Anhydrous Glycerin 55.Medication errors include the following: Administration of the wrong medication.The individual will no longer receive the medication for swimmers. The staff at the individuals' home have properly disposed of the previous medication and ensured the correct medication was ordered and is being administered. The change has already been made as of Thursday, February 8th. The Awake Overnight staff is checking in all medications and the Home Leader is serving as a double check and auditing. On February 22nd, a Team Meeting was held to discuss the new procedure for double checking all medications to prevent future errors. The process was shared with all team members. 02/22/2024 Implemented
SIN-00220390 Renewal 02/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(f)Program Specialist #1 sent Individual #1's assessment, completed on 07/07/22, to the plan team members on 08/02/22 for an annual ISP meeting held on 08/23/22.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Specific change: Core Member's assessment will be sent to plan team members within 30 days prior to the individual ISP meeting. Who will make the change: Assigned Program Specialist When will the change be made: This change went into effect immediately as of today, April 3rd, 2023. How will the change be made: Dates will be monitored by the assigned PS, and Outlook reminders have been put in place as a method of tracking. To ensure the violation does not occur again, the assigned PS will utilize Outlook calendar reminders in addition to their existing methods as duplicate means of tracking to ensure dates are not missed moving forward. Training: Program Specialists reviewed regulation 6400.181(f) and an in-service / retraining form has been signed and dated by our PSs as of April 3, 2023. The in-service record will be maintained in the employees file. [Documentation of training, dated 4/3/23, related to 6400.181f was received on 4/4/23 and reviewed 4/5/23. DPOC by HDKPO, HSLS, on 4/5/23]. 04/03/2023 Implemented
SIN-00082104 Renewal 08/06/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(6)Individual #1 admitted on 1/28/15 had Tuberculin skin testing by Mantoux completed on 5/8/15.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. The program specialist and healthcare coordinator were trained on 9/29/2015 on the requirements of 6400.141(c)(6) regarding the inclusion of Tuberculin skin testing in the physical examination prior to admission to services. [As per conversation with CEO on 10/23/15, the healthcare coordinator will review physical examination documentation for completion prior to admission; as well as, the ongoing required physical examination to include all required information and follow up as needed. Healthcare coordinator will review all current physical examinations for all individual for required information and follow up as needed. PS will review individual records including the physical examinations at least quarterly. (AS 10/23/15)] 09/29/2015 Implemented
6400.141(c)(7)Individual# 1 admitted on 1/28/15 had gynecological examination completed on 3/4/15.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. The program specialist and healthcare coordinator were trained on 9/29/2015 on the requirements of 6400.141(c)(7) regarding the inclusion of a gynecological exam in the physical examination prior to admission to services. [As per conversation with CEO on 10/23/15, the healthcare coordinator will review physical examination documentation for completion prior to admission; as well as, the ongoing required physical examination to include all required information and follow up as needed. Healthcare coordinator will review all current physical examinations for all individual for required information and follow up as needed. PS will review individual records including the physical examinations at least quarterly. (AS 10/23/15)] 09/29/2015 Implemented
SIN-00201928 Renewal 03/16/2022 Compliant - Finalized
SIN-00160062 Renewal 08/01/2019 Compliant - Finalized
SIN-00120722 Renewal 08/31/2017 Compliant - Finalized
SIN-00099471 Renewal 08/17/2016 Compliant - Finalized
SIN-00066965 Renewal 07/29/2014 Compliant - Finalized
SIN-00049332 Renewal 04/24/2013 Compliant - Finalized