Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00256552 Renewal 11/13/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)On 11/14/24, at 10:49 AM, there was no secured screen in the window in the middle of the staircase.Windows, including windows in doors, shall be securely screened when windows or doors are open. The maintenance department replaced the missing screen in the window in the middle of the staircase on 11/15/24. 01/15/2025 Implemented
6400.80(b)On 11/14/24, at 9:30 AM, the exterior of the home was found not in good repair. There was significant paint loss to the front door, door surroundings, front window, and corner trim of the home. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The Facility¿s Director has been in touch with our contractor for painting services and a quote has been requested. As soon as the weather breaks in the spring, the painting will be completed to the front door, door surroundings, front window, and corner trim of the home. A more firm date of the paining is to be announced. 01/15/2025 Implemented
6400.141(c)(3)Individual 1's most recent diphtheria vaccine was administered on 11/17/10. This exceeds the every 10-year recommendation provided by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. On Individual #2's did not have documentation of a current diphtheria vaccination. [Repeat violation 11/28/23, et. al.]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. The BLARS nursing staff contacted individual #1 and #2¿s PCP and requested and appointment for those individuals to get their diphtheria vaccines. These appointments have been scheduled for 12/17/24. 01/31/2025 Implemented
6400.181(d)Individual 1's assessment was not signed or dated by the Program Specialist.The program specialist shall sign and date the assessment. The assessment for individual #1 was actually completed on 3/7/24, however it was not signed or dated by the Program Specialist at that time. The Program Specialist did sign and date that assessment upon discovery of the issue on 11/14/24. 01/15/2025 Implemented
6400.163(h)Individual #2 was prescribed Albuterol MEB 0.083% for Proventil NEB use, contents of 1 AMP VIA Nebulizer, every four hours as needed for shortness of breath. The medication that was present had an expiration date of 10/29/24.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Individual #2¿s Albuterol that was discontinued (expiration date of 10/29/24) was destroyed on 11/14/24. 01/31/2025 Implemented
6400.165(d)Individual 1 and Individual 2 are prescribed Ibuprofen tablet 200 MG for Advil every 6 hours as needed for pain. Individual 1 and Individual 2 are prescribed Milk of Magnesia 30 ML by mouth at bedtime as needed for up to 2 nights if no bowel movement in 3 days. On 11/14/24 a bottles of ibuprofen and Milk of Magnesia in the home were labeled as "Waiver Floor Stock." Individual #1 and Individual #2 were sharing the medications.A prescription medication shall be used only by the individual for whom the prescription was prescribed.The BLARS nursing staff ordered and received individual stock meds for all of the individuals in care on 11/22/24. That same day (11/22/24) all of the previously, shared, stock medications were destroyed. 01/15/2025 Implemented
SIN-00235329 Renewal 11/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill records for the drills conducted on 12/20/2022 at 5:00pm and 2/8/2023 at 4:09pm did not indicate the total time it took for evacuation. These records indicated the time the fire drill concluded but they did not indicate the exact number of minutes and seconds it took to evacuate. [Repeat violation: 12/7/2022, et al.]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. The fire drill records for the drills conducted on 12/20/2022 at 5:00pm and 2/8/2023 at 4:09pm did not indicate the total time it took for evacuation. These records indicated the time the fire drill concluded but they did not indicate the exact number of minutes and seconds it took to evacuate. 12/31/2023 Implemented
6400.141(c)(1)Individual #2's annual physical examination, completed on 9/28/2023, does not include a review of the individual's previous medical history. This section was left blank on the physical examination form.The physical examination shall include: A review of previous medical history. The BLARS nursing staff will reach out to individual #2¿s PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (previous medical history). The second option will be that the BLARS Lead Nurse populate the ¿previous medical history¿ section and have the PCP review and sign off and date the physical form (as an addendum). 12/31/2023 Implemented
6400.141(c)(4)Individual #1's physical examination, completed on 5/16/2023, does not include a hearing screening. This section was omitted on the physical examination form. Individual #2's annual physical examination, completed on 9/28/2023, does not include vision and hearing screening. These sections were left blank on the physical examination form.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The BLARS nursing staff will reach out to individual #1¿s and #2¿s PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (hearing screening). The second option will be that the BLARS Lead Nurse populate the ¿hearing screening¿ section and have the PCP review and sign off and date the physical form (as an addendum). 12/31/2023 Implemented
6400.141(c)(6)Individual #1's physical examination, completed on 5/16/2023 does not include a tuberculin skin test by Mantoux method. This section was omitted on the physical examination form.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 BLARS nursing staff will reach out to individual #1¿s PCP and request that a Mantoux be completed as soon as possible; the target date is 12/31/23. 12/31/2023 Implemented
6400.141(c)(7)Individual #1's physical examination, completed on 5/16/2023, does not include a gynecological examination, breast examination, or Pap test. Documentation of this most recent examination was not obtained by the provider prior to Individual #1's admission.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 BLARS nursing staff will reach out to individual #1¿s PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (gynecological examination, breast examination, or Pap test). 12/31/2023 Implemented
6400.141(c)(10)Individual #1's physical examination, completed on 5/162023, does not indicate if the individual is free of all communicable disease or specific precautions that must be taken to prevent spread of the disease to other individuals. This section was omitted from the physical examination form. Individual #2's annual physical examination, completed on 9/28/2023, does not indicate if the individual is free of all communicable disease or specific precautions that must be taken to prevent spread of the disease to other individuals. This section was left blank on the physical examination form.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. The BLARS nursing staff will reach out to individual #1 and #2¿s PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (free of all communicable diseases). The second option will be that the BLARS Lead Nurse populate this section and have the PCP review and sign off and date the physical form (as an addendum). 12/31/2023 Implemented
6400.141(c)(11)Individual #2's annual physical examination, completed on 9/28/2023, does not include an assessment of the individual's health maintenance needs. This section was left blank on the physical examination form.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The BLARS nursing staff will reach out to individual #2¿s PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (assessment of the individual¿s health maintenance needs). The second option will be that the BLARS Lead Nurse populate this section and have the PCP review and sign off and date the physical form (as an addendum). 12/31/2023 Implemented
6400.141(c)(12)Individual #2's annual physical examination, completed on 9/28/2023, does not include the physical limitations of the individual. This section was left blank on the physical examination form. [Repeat violation: 12/7/2022, et al.]The physical examination shall include: Physical limitations of the individual. The BLARS nursing staff will reach out to individual #2¿s PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (physical limitations of the individual). The second option will be that the BLARS Lead Nurse populate this section and have the PCP review and sign off and date the physical form (as an addendum). 12/31/2023 Implemented
6400.141(c)(14)Individual #1's physical examination, completed on 5/16/2023, does not include medical information pertinent to diagnosis and treatment in case on an emergency. This section was omitted from the physical examination form. [Repeat violation: 12/7/2022, et al.]The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The BLARS nursing staff will reach out to individual #1¿s PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (medical information pertinent to diagnosis and treatment in case of an emergency). The second option will be that the BLARS Lead Nurse populate this section and have the PCP review and sign off and date the physical form (as an addendum). 12/31/2023 Implemented
6400.141(c)(15)Individual #1's physical examination, completed on 5/16/2023, does not include special instructions for the individual's diet. This section was omitted from the physical examination form. Individual #2's annual physical examination, completed on 9/28/2023, does not include special instructions for the individual's diet. This section was left blank on the physical examination form.The physical examination shall include:Special instructions for the individual's diet. The BLARS nursing staff will reach out to individual #1¿s and #2¿s PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (special instructions for the individual¿s diet). The second option will be that the BLARS Lead Nurse populate this section and have the PCP review and sign off and date the physical form (as an addendum). 12/31/2023 Implemented
6400.166(a)(4)On 11/29/2023 at 10:45am, it was discovered that Hydroxyz Pam Cap 25mg, take 1 capsule daily as needed for anxiety, prescribed to Individual #2, did not include the name of the medication on the November 2023 medication administration record. This medication was omitted entirely from the November 2023 medication administration record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.Regarding individual #2, a new MAR will be made which will separate his daily dose of the medication from the PRN order that was prescribed. On 12/5/23, the BLARS Nurse Lead communicated with the pharmacy; moving forward a new MAR will be received every month for the PRN dose of this medication. 12/31/2023 Implemented
6400.166(a)(5)On 11/29/2023 at 10:46am, it was discovered that Hydroxyz Pam Cap 25mg, take 1 capsule daily as needed for anxiety, prescribed to Individual #2, did not include the strength of the medication on the November 2023 medication administration record. This medication was omitted entirely from the November 2023 medication administration record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.Regarding individual #2, a new MAR will be made which will indicate the name and strength of medication. On 12/5/23, the BLARS Nurse Lead communicated with the pharmacy; moving forward a new MAR will be received every month for the PRN dose of this medication; the name and strength of the medication will obviously be listed on the MAR. 12/31/2023 Implemented
6400.166(a)(6)On 11/29/2023 at 10:47am, it was discovered that Hydroxyz Pam Cap 25mg, take 1 capsule daily as needed for anxiety, prescribed to Individual #2, did not include the dosage form of the medication on the November 2023 medication administration record. This medication was omitted entirely from the November 2023 medication administration record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form.Regarding individual #2, a new MAR will be made which will indicate the name and dosage form of the medication. On 12/5/23, the BLARS Nurse Lead communicated with the pharmacy; moving forward a new MAR will be received every month for the PRN dose of this medication; the name and dosage form of the medication will obviously be listed on the MAR. 12/31/2023 Implemented
6400.166(a)(7)On 11/29/2023 at 10:48am, it was discovered that Hydroxyz Pam Cap 25mg, take 1 capsule daily as needed for anxiety, prescribed to Individual #2, did not include the dosage of the medication on the November 2023 medication administration record. This medication was omitted entirely from the November 2023 medication administration record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.Regarding individual #2, a new MAR will be made which will indicate the name and dosage of medication. On 12/5/23, the BLARS Nurse Lead communicated with the pharmacy; moving forward a new MAR will be received every month for the PRN dose of this medication; the name and dosage of the medication will obviously be listed on the MAR. 12/31/2023 Implemented
6400.166(a)(8)On 11/29/2023 at 10:49am, it was discovered that Hydroxyz Pam Cap 25mg, take 1 capsule daily as needed for anxiety, prescribed to Individual #2, did not include the route of administration on the November 2023 medication administration record. This medication was omitted entirely from the November 2023 medication administration record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.Regarding individual #2, a new MAR will be made which will indicate the name and route of medication. On 12/5/23, the BLARS Nurse Lead communicated with the pharmacy; moving forward a new MAR will be received every month for the PRN dose of this medication; the name and route of medication will obviously be listed on the MAR. 12/31/2023 Implemented
6400.166(a)(9)On 11/29/2023 at 10:50am, it was discovered that Hydroxyz Pam Cap 25mg, take 1 capsule daily as needed for anxiety, prescribed to Individual #2, did not include the frequency of administration on the November 2023 medication administration record. This medication was omitted entirely from the November 2023 medication administration record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.Regarding individual #2, a new MAR will be made which will indicate the name and frequency of medication. On 12/5/23, the BLARS Nurse Lead communicated with the pharmacy; moving forward a new MAR will be received every month for the PRN dose of this medication; the name and frequency of medication will obviously be listed on the MAR. 12/31/2023 Implemented
6400.166(a)(10)On 11/29/2023 at 10:51am, it was discovered that Hydroxyz Pam Cap 25mg, take 1 capsule daily as needed for anxiety, prescribed to Individual #2, did not include the administration time on the November 2023 medication administration record. This medication was omitted entirely from the November 2023 medication administration record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.Regarding individual #2, a new MAR will be made which will indicate the name and administration times of medication. On 12/5/23, the BLARS Nurse Lead communicated with the pharmacy; moving forward a new MAR will be received every month for the PRN dose of this medication; the name and administration times of medication will obviously be listed on the MAR. 12/31/2023 Implemented
6400.166(a)(11)On 11/29/2023 at 10:52am, it was discovered that Hydroxyz Pam Cap 25mg, take 1 capsule daily as needed for anxiety, prescribed to Individual #2, did not include the diagnosis or purpose of the medication on the November 2023 medication administration record. This medication was omitted entirely from the November 2023 medication administration record. [Repeat violation: 12/7/2022, et al.]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.Regarding individual #2, a new MAR will be made which will indicate the name and diagnosis or purpose for the medication, including pro re nata of medication. On 12/5/23, the BLARS Nurse Lead communicated with the pharmacy; moving forward a new MAR will be received every month for the PRN dose of this medication; the name and diagnosis or purpose for the medication, including pro re nata of medication will obviously be listed on the MAR. 12/31/2023 Implemented
SIN-00216226 Renewal 12/07/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)On 12/08/2022, the first aid kit located in the home did not contain scissors. 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. Scissors were purchased for the first aid kit on 12/8/22; the first aid kit currently has all of its required contents. 01/11/2023 Implemented
6400.113(a)Individual #2, date of admission 8/20/2022, was trained 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 on 8/13/2021, and then again on 9/13/2022. This exceeds the annual requirement. 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. Individual #2¿s annual fire safety training which was completed late was conducted (caught up) on 1/10/23. 01/10/2023 Implemented
6400.141(a)Individual #2 had a physical examination completed on 8/26/2021, and then again on 10/04/2022. This exceeds the annual requirement.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual #2 had a physical on 10/4/22, which was late inasmuch as his previous one was completed on 8/26/21. His next scheduled physical is set for 9/28/23 which is within the regulatory time frame. 01/10/2023 Implemented
6400.142(a)Individual #1's most recent dental examination was completed on 9/21/2021. Individual #2's most recent dental examination was completed on 7/08/2021. This exceeds the annual requirement.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Individual #1 and Individual #2 both were late for annual dental appointments. Individual #1 next dental appointment is scheduled for 3/28/23 and individual #2 next appointment is scheduled for 6/13/23. 01/10/2023 Implemented
6400.181(e)(12)Individual #1's assessment completed on 12/01/2022 does not include the following information: Recommendations for specific areas of training, programming and services [Repeat violation 1/04/22, et. al.].The assessment must include the following information: Recommendations for specific areas of training, programming and services. Individual #1¿s assessment did include a paragraph at the end of the assessment to address the assessments however the recommendations for specific areas of training, programming and services was not included. There will now be a separate area after the paragraph to address the aforementioned areas. In addressing individual #1, this will be reassessed by 1/20/23 and with recommendations for specific areas of training, programming and services. 01/20/2023 Implemented
6400.165(c)The following medication for Individual #1 has not been administered since 12/01/2022 at 7:00 AM: D3 Tab 2000 unit - take one tablet by mouth daily.A prescription medication shall be administered as prescribed.Individual #1 was in another facility and was transferred back to our care and this medication was ordered by nursing but this did not reach the pharmacy for unknown reasons. After researching this issue it was found that the prescriber inadvertently failed to sign the physicians order. On 12/9/23 the order was signed and the medication was subsequently sent to us to begin administration. 02/01/2022 Implemented
6400.165(g)Individual #1 is prescribed a medication to treat symptoms of a psychiatric illness. The most recent review by a licensed physician was completed on 5/04/2022. This exceeds the 3-month requirement.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.Individual #1 was missing the Psychiatric review that should have been completed between 1/1/22 and 6/2/22. 01/11/2023 Implemented
6400.166(a)(11)Individual #1's December of 2022 Medication Administration Record did not include the diagnosis or purpose for the medication for the following medications: Propranolol 80 MG - Take one tablet by mouth three times daily, Quetiapine 200 MG - Take one tablet by mouth three times daily, and Simvastatin Tab 20 MG - Take one tablet by mouth once daily [Repeat violation 1/04/22, et. al.].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.Individual #1 was transferred back to our program from another facility and his MAR did not include the reason or need for the medication on the MAR. The pharmacy creates the paper MARS from the orders received through the order connect system. Nursing has sent this information to the pharmacy and this will be added to MARs for February and moving forward. 02/01/2023 Implemented
6400.166(b)The following medications for individual #1 were not initialed as administered on 12/04/2022 at 7:00 AM: Simvastatin Tab 20 MG - Take one tablet by mouth once daily and Famotidine tab 20 MG - take one tablet by mouth every morning.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Individual #1 had two medications that were administered on 12/4/22 that were not initialed by staff on the MAR. The medications were given, however as the staff also initial the medication card on the date that it was given. This was a double check we put into place to insure all medications were given correctly. 02/01/2023 Implemented
SIN-00198429 Renewal 01/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.142(g)Individual #1 is not independent in the area of dental hygiene. Their record includes a dental hygiene plan from 2/25/21 but no plan completion from 2020 to show demonstrate annual compliance.A dental hygiene plan shall be rewritten at least annually. The dental plans have been updated for individuals #1 and #2 and they been added to their records. This update took place on 1/19/22. These records were also sent to the group home for the staff to review and sign off on as well. A copy of the dental plans will be kept at the group home for the staff to refer to when needed. Moving forward, these plans will be reviewed and updated as needed during the annual assessment process. The Program Specialist and/or the Director of IDD will be responsible for monitoring this area for compliance annually. This process will be fully implemented by 2/21/22. 02/21/2022 Implemented
6400.181(e)(1)Individual #1's 8/17/21 assessment does not address their preferences. Individual #2's 12/7/21 assessment does not address their strengths, needs, and preferences. The assessment must include the following information: Functional strengths, needs and preferences of the individual. Individual¿s #1 and #2 strength and needs assessments have had preferences added to the assessment. These assessment will be updated by 2/21/22 and then will be completed annually prior to their ISP. 02/21/2022 Implemented
6400.181(e)(2)Individual #1's 8/17/21 assessment does not address their dislikes. Individual #2's 12/7/21 assessment does not address their dislikes.The assessment must include the following information: The likes, dislikes and interest of the individual. Individual #1 and #2 likes and dislikes will be re-evaluated to look at the individual¿s dislikes and to address those needs. These will be re-evaluated by 2/21/22 and then will done annually prior to their ISP. 02/21/2022 Implemented
6400.181(e)(12)Individual #1's 8/17/21 assessment does not address recommendations for specific areas of training, programming, and services. Individual #2's 12/7/21 assessment does 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. Individual #1 and #2 assessment will now include a paragraph at the end of the assessment to address recommendations for specific areas of training, programming and services. These will be re-evaluated by 2/21/22 and then will done annually prior to their ISP. 02/21/2022 Implemented
6400.34(a)Individual #1 was informed and explained individual rights on 6/26/21. Individual #2 was informed and explained individual rights on 8/12/21. The rights document did not include the following rights: .32m through .32n, to share contact information with whom the individual chooses and to unrestricted and private access to telecommunications; .32r1 through .32r5, to bedroom door locking provided by a key, access card, keypad code or other entry mechanism made accessible to permit them in locking and unlocking the door, to limiting access to their bedroom except in a life-safety emergency or with their expressed permission, to providing assistive technology as needed in allowing them to lock and unlock the door without assistance, to allowing easy and immediate access to their bedroom by themselves and staff persons in the event of an emergency, and to providing the primary caregiver with the key or entry device to lock and unlock the individual's bedroom door; and .32v, to right modifications limited only to the extent necessary to mitigate a significant health and safety risk to the individual or others. [Repeat violation from 2021.]The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.The Bill of Rights and Responsibilities was updated by the Program Specialist on 1/12/22 to include .32m through .32n; .32r1 through .32r5; and .32v. The revised Rights and Responsibilities was sent to the guardians for their review and signature and was also sent to the group home for review and signature of the clients who are their own guardian. 02/21/2022 Implemented
6400.46(a)Direct Service Worker #2, date of hire 10/19/21, did not have fire safety training [Repeat violation from 2021.]Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.The Direct Service Worker #2 completed her fire safety training on 1/12/22. 02/21/2022 Implemented
6400.46(b)Direct Service Worker #4's most recent fire safety training was completed 10/13/20.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Direct Service Worker #4 did not complete her annual fire safety training. She no longer works for us at this time. 02/21/2022 Implemented
6400.46(d)Program Specialist #1, date of hire 10/1/11, did not have a record of training in first aid, Heimlich techniques, and cardio-pulmonary resuscitation. Direct Service Worker #4, date of hire 11/16/17, did not have a record of training in cardio-pulmonary resuscitation.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.The Program Specialist did not have his first aid training completed in a timely manner. He has now completed the on line portion of the class and is awaiting a trainer to become available to finish the skills section of the class. This has been delayed by COVID issues but will be completed by 2/21/21. 02/21/2022 Implemented
6400.51(a)(3)Direct Service Worker #2, date of hire 10/19/21, completed orientation training 1/5/22. Direct Service Worker #3, date of hire 6/4/21, completed orientation training 8/30/21.Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons.The Program Specialist has been in communication with the Human Resources department and has requested that the orientation period for all waiver workers for the required training be changed from 90 days to 30 days. This change will be reflected in the HR data base and training module. 02/21/2022 Implemented
6400.51(b)(1)The orientation record for Direct Service Worker #2 is missing the following content areas: community integration, individual choice, and supporting individuals to develop and maintain relationships.The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Direct Service Worker #2 did not have the training in Community Integration, Individual Choice, Supporting individuals to develop and maintain relationships. Direct Service Worker #2 and all of the waiver staff will be trained on the following topics by 1/26/22: community integration, individual choice, and supporting individuals to develop and maintain relationships. 02/21/2022 Implemented
6400.51(b)(4)The orientation record for Direct Service Worker #2 is missing the following content area: recognizing and reporting incidents.The orientation must encompass the following areas: recognizing and reporting incidents.Direct Service Worker #2 did not have recognizing and reporting incidents training. Training on this topic for Direct Service Worker #2 will be completed by 1/26/22. Direct Service Worker #2 and all of the waiver staff will be trained on a variety of topics including recognizing and reporting incidents by 1/26/22. Recognizing and reporting incidents is already included in the annual training matrix. 02/21/2022 Implemented
6400.52(c)(1)The 2021 annual training record for Program Specialist #1 is missing the following content areas: community integration, individual choice, and supporting individuals to develop and maintain relationships. The 2021 annual training record for Direct Service Worker #4 is missing the following content areas: community integration, individual choice, and supporting individuals to develop and maintain relationships. The 2021 annual training record for Direct Service Worker #5 is missing the following content areas: community integration, individual choice, and supporting individuals to develop and maintain relationships.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The annual training record for Program Specialist #1 and Direct Service worker #4 as well as Direct Service Worker #5 were missing training for Community Integration, Individual Choice, Supporting individuals to develop and maintain relationships. The Program Specialist, Direct Service Worker #4 and $5 and all of the waiver staff will be trained on the following topics by 1/26/22: community integration, individual choice, and supporting individuals to develop and maintain relationships. 02/21/2022 Implemented
6400.52(c)(3)The 2021 annual training record for Program Specialist #1 is missing the following content area: individual rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.The program Specialist was missing the training for individual rights. The program Specialist will receive training on individual rights on 1/26/22. 02/21/2022 Implemented
6400.52(c)(5)The 2021 annual training record for Direct Service Worker #4 is missing the following content area: the safe and appropriate use of behavior supports.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.The training record for Direct Service Worker #4 was missing the training for safe an appropriate use of behavior supports. Direct Service worker #4 no longer works for the agency. 02/21/2022 Implemented
6400.52(c)(6)The 2021 annual training record for Direct Service Worker #4 is missing the following content area: implementation of the individual plan.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.The training record for Direct Service Worker #4 was missing the training for implementation of the individual plan. Direct Service worker #4 no longer works for the agency. 02/21/2022 Implemented
6400.166(a)(11)Individual #2's January 2022 Medication Administration Record does not list the diagnosis or purpose for the prescribed Risperidone and Concerta.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.Effective immediately, when verbal orders are placed in the Order Connect system by the nurse or prescriber the diagnosis will be added to the order description. This will then transfer to the eMAR in the electronic medical record. The pharmacy creates the paper MARS from the orders received through the order connect system so this correction will allow the paper MARs to include the reason and or diagnoses for the prescribed medication. Nursing will inspect the paper MARS before distributing to the programs to ensure all reasons and or diagnosis are listed on the paper MAR to utilize when the computers are down. The lead nurse with the director of nursing¿s guidance will be responsible for monitoring this area and will do monthly checks of the eMAR and paper MAR to ensure these changes are being completed and all required information is documented. This will be fully implemented by 2/21/22. 02/21/2022 Implemented
6400.169(a)Direct Service Worker #4 completed the Department-approved medication administration course on 12/4/20. Program Specialist #1 indicted that Direct Service Worker #4 has administered medications to individuals since 12/4/21, no annual practicum has been completed.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).Direct Service Worker #4 was missing the annual practicum for their medication administration training. Direct Service Worker #4 is no longer employed with the agency. 02/21/2022 Implemented
SIN-00183716 Renewal 02/23/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The home's first aid kit did not contain tweezers. 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. Immediately following the survey, tweezers were purchased for the first aid kit at 23 Williams Street. This was also doubled checked for 102 Williams Street. Effective 3/8/21, the Shift Manager (or her designee) will check the first aid kit every other week for all content items that are mandated per regulations and note this on the previously formulated ¿Monthly Program Check Sheet¿. At the end of every month, this check sheet will be turned in to the Program Specialist for his review. The Monthly Program Check Sheets will be stored in the Program Specialist¿s office. Should anything be missing or in disrepair, that item will be re-stocked in the first aid kit. 03/08/2021 Implemented
6400.81(k)(6)There is not a mirror in Individual #1's bedroom.In bedrooms, each individual shall have the following: A mirror. A mirror was put in individual #1¿s room on 2/24/21. The group home Shift Manager installed the mirror. All other waiver client¿s in both group homes have a mirror in their bedroom. Effective 3/8/21, the Shift Manager (or her designee) will check all the bedrooms to assure the mirrors are evident in all bedrooms and in good repair. This check will occur every other week and will be documented on the group home¿s ¿Monthly Program Check Sheet¿. At the end of every month, this check sheet will be turned in to the Program Specialist for his review. The Monthly Program Check Sheets will be stored in the Program Specialist¿s office. 03/08/2021 Implemented
6400.112(c)The written fire drill record for the fire drill completed on 3/21/2020 did not include the exit route used.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. The group homes protocol has historically been to label the exit route used during fire drills. The staff obviously failed to document the exit route on the 3/21/20 drill. Effective 3/5/21 all fire drill reports will be turned in to the Program Specialist for his review and approval of the fire drill report. If the report is documented thoroughly and accurately, the fire drill will be forwarded to the Director of IDD for his review and filing. Any reports with errors or discrepancies will be returned to the group home to clarify. If the situation warrants, a new fire drill will be conducted. Additionally, all of the staff at 23 Williams Street group home will be re-trained on appropriate procedures for running a file drill and the corresponding documentation. This training will be complete by 3/12/21. All staff will sign off on an ¿on-campus training record¿ to authenticate their attendance at the training. 03/15/2021 Implemented
6400.141(c)(5)Individual #1's most recent Tetanus immunization was on 11/17/2010.The physical examination shall include: Immunizations and screening tests for individuals 17 years of age or younger, as recommended by the Standards of Child Health Care of the American Academy of Pediatrics, Post Office Box 1034, Evanston, Illinois 60204. Individual #1 received his Tetanus shot on 3/1/21. All other clients were checked and are currently in compliance. Moving forward (effective 3/8/21), all of the waiver clients from both group homes will have their Tetanus shot status reviewed as part of the quarterly nursing assessment process. Well prior to their Tetanus date of expiration occurring they will be scheduled to receive their Tetanus by their PCP. The Beacon Light Adult Residential Services Health Services Department will be responsible for monitoring this area for compliance. 03/15/2021 Implemented
6400.34(a)Individual #1 was informed and explained individual rights on 10/13/2020. The rights document did not include the following rights: 6400.32e, the right to make choices and accept risks; 6400.32f, to refuse to participate in activities and services; 6400.32g, to control his own schedule and activities; 6400.32h, to control his own schedule and activities; 6400.32j, to voice concerns about the services the individual receives; 6400.32p, the right to choose persons with whom to share a bedroom; 6400.32q, to furnish and decorate the Individual's bedroom and the common areas of the home; 6400.32r, to lock the Individual's bedroom door; 6400.32s, to have a key, access card, key code or other entry mechanism to lock and unlock an entrance door of the home; 6400.32t, to access food at any time; 6400.32u, to make health care decisions; 6400.32v, right may only be modified accordance with 6400.185.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.The ¿Client Bill of Rights¿ will be revised to add all of the deficient areas as depicted in 6400.34 (a). This revision will be completed and finalized by 3/12/21. During the week of 3/15/21, this newly revised ¿Bill of Rights¿ will be thoroughly explained to all the clients in both group homes; a detailed progress note will be written for each individual once this is completed. The clients will also sign off that this information has been reviewed with them. Additionally, the revised ¿Bill of Rights¿ will be mailed to all the guardians for their review. They will also sign off to authenticate they have received and understand the new Bill of Rights. In order to track compliance in this area, the ¿Bill of Rights¿ will be reviewed during the quarterly record review process that is a standing meeting. Checking annual review of ¿Bill of Rights¿ will now be a part of this process. The Program Specialist will be responsible for monitoring this process for compliance.[A copy of the signed, 3/10/21 rights document was provided to the Department on 3/10/21. (AES,HSLS on 3/10/21)] 03/22/2021 Implemented
6400.165(g)Individual #1, date of admission 8/20/2020 had an initial review of medications prescribed to treat symptoms of a psychiatric illness completed on 12/22/2020.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.All waiver group home clients who are on psychiatric medications will be reviewed to assure they are in compliance with the required 3 month medication checks. This will be completed by 3/8/21. Moving forward, the Beacon Light Adult Residential Services Lead Nurse and the Program Specialist will meet monthly to review medications and to assure that scheduled appointments are in place for individuals in need of a medication check due to being on a psychotropic medication. The monthly checks completed by the Lead Nurse and the Program Specialist will be documented on a ¿Medication Check Compliance Form¿ and will be stored in the Executive Director¿s office. 03/15/2021 Implemented
SIN-00165522 Renewal 11/06/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)An unannounced fire drill was not held in September 2019. An unannounced fire drill shall be held at least once a month. Inasmuch as both 6400 group homes normally have only one staff working each shift, a fire drill schedule was developed by the Director of IDD and given to the Program Specialist for his viewing only. This schedule was developed to ensure all shifts (1st, 2nd, and 3rd )are represented on the schedule. The new process will involve the Program Specialist calling the group home at the scheduled time and directing the staff working the shift to run a fire drill, using the primary or alternative exit route (the group home staff will not have prior knowledge of when the drill will occur) The staff will be required to complete and submit a copy of the completed fire drill reports to the program specialist for his review to insure compliance with the schedule and exiting protocols. The program specialist will then submit all fire drill documentation to the Director of IDD who verifies that the schedule is followed and that the drills are completed appropriately and timely. This process will begin 1/1/20. The Program Specialist will be responsible for monitoring this area for ongoing compliance; fire drills will be reviewed as part of the weekly manager¿s meeting with the staff of both group homes. All group home staff will be trained by the Program Specialist on the various evacuation routes that will be directed in the unannounced drills, fire system protocols, and documentation procedures. For additional monitoring and oversight, all fire drill reports are submitted and reviewed during monthly safety committee meetings. [Documentation of trainings and review of records shall be kept. (DPOC by AES,HSLS on 12/2/19)] 01/01/2020 Implemented