Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00225297 Renewal 05/04/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The first aid kit did not include a manual. 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. Division Manager will add First Aid manual to kit 05/05/2023 Implemented
6400.104Fire department notices were not provided for ALL SIX homes during the inspection, despite several requests for them.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. IDD Residential Director will send letters to local fire departments 05/05/2023 Implemented
SIN-00204486 Renewal 05/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The bathroom ceiling above the toilet is peeling, with an area of approximately 5 to 6 inches of paint/material peeled away, exposing a lightly brown-tinged surface beneath.Floors, walls, ceilings and other surfaces shall be in good repair. The bathroom ceiling will be repaired by maintenance by 07/01/2022 or by the time an individual is slated to move in as this site is not occupied. 07/01/2022 Implemented
6400.71Emergency numbers were not posted in the property.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Emergency numbers will be posted by the phone by 07/01/2022 or by the time another individual is slated to move in as the site is currently unoccupied. 07/01/2022 Implemented
SIN-00161677 Renewal 08/27/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)The shade in individual #2's bedroom was damaged. Furniture and equipment shall be nonhazardous, clean and sturdy. Individual #2 lives in a 1 bedroom semi-independent setting. He often times will not allow staff to come into his bedroom and inspect for items that may be damaged and need to be repaired or replaced. During the time of inspection it was found that the window shade in the bedroom was damaged. The window shade was repaired 8/29/19 by maintenance department. 08/29/2019 Implemented
6400.77(b)The first aid kit did not have 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. During time of inspection the first aid kit did have scissors. It was discovered that individual #2 removed the scissors from the kit to cut paper and the supervisor was not aware. Individual #2 was reminded about the purpose of the first aid kit and how important it was to have everything in there in case of an emergency. Separate scissors were purchased for him for cutting his papers so he wouldn't remove the scissors from the kit again. As ongoing monitoring, the first aid kit will checked monthly by the House Supervisor. As part of this monthly review, the House Supervisor will remove, add or replace anything needed in the first aid kit. To be certain all staff know what items are required in the kits and what items should be removed a checklist of required items is taped inside the kit. Additionally, checking the first aid kit is a part of the Environmental of Care Quarterly Checklist which is completed and submitted to the IDD Manager and is monitored by Committee for compliance. 08/30/2019 Implemented
6400.113(a)Individual #2 refused the fire safety training and there was not proper follow up for the refusal. They waited four months to give it again. Individual #2 had training on 12/20/17 and then again on 3/2019. 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. The previous IDD Manager would have the individuals trained by the fire marshal. Individual #2 would not attend the training with the Marshal in December 2018; which would have been 1 year from his previous training and been in compliance with the required timeframe. The IDD Manager told the staff that they needed a fire specialist so they waited until the next time the fire specialist came which was in March of 2019 which was 3 months late. At the time, the IDD coordinator was not aware that the training could be completed with the individual by an IDD Coordinator that was trained vs the fire marshal. This regulation was reviewed the IDD Coordinator as well as all coordinator. The individual already received his training and will receive training again in March of 2020. Ongoing training with the IDD coordinators on a quarterly basis on the Regulations. For ongoing compliance monthly chart audits are completed by the IDD coordinator. The IDD Manager audits the Program charts quarterly and submits the report to the IDD Director. Additionally the charts are audited using the Audit tool by the CPIC group annually 08/27/2019 Implemented
6400.141(c)(3)Individual #2's annual physical exam completed on 2/4/19 did not include immunizations.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. The immunizations were completed but was not attached to the annual physical, it was located in a separate section of the medical chart. The immunization log was located and placed on the chart in the along with the annual physical on the date on inspection. The charts have since been purged and reorganized to allow for items to be readily located. The House supervisor oversees medical appointments and documentation weekly. Monthly chart audits are conducted by the IDD Coordinator (PS role) to identify any missing, outdated, or misplaced paperwork. The IDD Manager audits the Program charts quarterly and submits the report to the IDD Director. Additionally the charts are audited using the Audit tool by the CPIC group annually. 08/27/2019 Implemented
6400.141(c)(4)Individual #2's annual physical exam completed on 2/4/19 did not indicate if a hearing test was administered.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The PCP typically has not in the past completed the annual hearing test noted on the annual physical form. An appointment was scheduled for the audiologist for the annual hearing exam and it was completed on 9/30/2019. Going forward, audiology will be scheduled separately and within the year to ensure that the annual hearing test is done timely. For ongoing compliance, Medical appointments are monitored by the House Supervisor weekly. Additionally, the IDD Coordinator reviews medical records on a monthly basis. As an additional level of compliance, the IDD Manager does quarterly chart audits 09/30/2019 Implemented
6400.143(a)Refusal plan for individual #2 is not adequate. Documentation of the refusal procedures is not being completed. There are notes that the individual refused but not the follow up to the refusal.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. Following the audit, the refusal plan was rewritten by the BSP to properly address medication and medical appointment refusals. Since implementation of the refusal plan, individual #2 has not refused any medication or medical appointments. In reviewing Individual #2's current program level and based on the team meetings and recommendations, the team recommended and Individual #1 agreed to a higher level of support within a licensed Community Home supported with 24 hours of supervision. This placement has been secured and he moved to another provider on Nov 14, 2019. 09/30/2019 Implemented
6400.144Individual #2's medication ketaconazole cream was not available at the time of inspection. Agency staff stated that the med was discontinued but remained on the medication administration record.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 #2 lives in a 1 bedroom semi-independent setting and administers his own medications. This medication was originally prescribed for antifungal/dry feet and he applies it himself. During the time of inspection, this medication was not available because the individual had finished using it and threw it away without informing staff members. This medication was prescribed by a doctor that individual #2 no longer see; this medication was subsequently discontinued on 10/7/19 and removed from the Medication Administration Record (MAR). He visited his current podiatrist on 10/10/19 and no further treatment was ordered for foot fungus or dry feet. Individual #2 was reminded that when he completes or stops using medication, he needs to inform staff so that they can contact the doctor. Staff will continually monitor Individual #2 medication to ensure his compliance and review his medications monthly. For on-going monitoring the House Supervisor will review the MAR weekly and the Program Coordinator will review the MAR monthly to be certain that all medications listed on the MAR are current. 10/10/2019 Implemented
6400.184(c)The sign in sheet for individual #2's ISP dated 2/24/19 was not available or in the file. A plan team member who attends a meeting under subsection (b) shall sign and date the signature sheet.The sign in sheet for Individual #2's ISP was not located on the chart during time of inspection due to the chart needing to be purged and organized. The sign in sheet was located and placed on the chart in the proper area on the date on inspection. The charts have since been purged and reorganized to allow for items to be readily located. To ensure ongoing compliance, monthly chart audits are conducted by the IDD Coordinator (PS role) to identify any missing, outdated, or misplaced paperwork. The IDD Manager audits the Program charts quarterly and submits the report to the IDD Director. Additionally the charts are audited using the Audit tool by the CPIC group annually. 08/27/2019 Implemented
6400.165(f)Individual #2 has not had psychotropic medication reviews even though he is prescribed psychotropic medications by his PCP.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.Individual #2 Individual chooses to receive his medication management from his PCP and does not want to see a psychiatrist. He failed to have a 90 day medication review. An appointment was scheduled with his PCP dated and he did receive the medication review on 9/18/19. To ensure on-going monitoring, the IDD Coordinator will review all medical files and medical compliance monthly. As another level of monitoring the IDD Manager will review all files quarterly. 09/18/2019 Implemented
SIN-00140980 Renewal 06/21/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water temperature in the bathtub was tested and found to be 127.4°F. Hot water temperatures in bathtubs and showers may not exceed 120°F. It is the responsibility of the program supervisor to be in compliance with this regulation. Water temperatures are checked on a daily basis by staff and temperatures exceeding 120 degrees F. are immediately reported to the coordinator to be addressed by the apartment maintenance. The staff at the apartment office was notified that the water temperature cannot exceed 120 degrees F. The apartment complex continues to work with the plumbers to adjust the water temperature and remain in compliance. 09/26/2018 Implemented
6400.110(e)The smoke detectors in the home were not audible throughout the home.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. This regulation was out of compliance due to a mechanical problem discovered during inspection. This issue was brought to the attention of the apartment complex on 6/22/18 and a new detector was installed. It is the responsibility of the supervisor and coordinator to ensure compliance to this regulation. The alarm will be checked weekly to ensure it is working properly. The program supervisor and coordinator will provide feedback to the manager to address any areas of non-compliance. The manager will follow up on a quarterly basis to ensure all fire safety equipment are in working order and work orders are submitted to complete any needed repairs. A review of this regulation and its' explanation was conducted with the program staff, supervisor and coordinator as shown in the supporting syllabus. This was completed on 6/25/18 06/25/2018 Implemented
SIN-00115551 Renewal 06/01/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(a)INDIVIDUAL #1 WAS LEFT UNSUPERVISED THE RESIDENCE ON 06/02/2017. THE INDIVIDUAL IS REQUIRED TO HAVE 8 HOURS OF SUPERVISION STARTING AT 9 AM AND ENDING AT 5 PM ON FRIDAYS. An individual may not be neglected, abused, mistreated or subjected to corporal punishment. It is the responsibility of the program supervisor/coordinator to ensure all supervision services are provided in accordance to the ISP. Individual #1 has been provided 44 hours of service on a weekly basis however it was not documented accurately by the neither supervisor and coordinator. The ISP for Individual #1 has been revised to show that services will be provided in accordance to the ISP based on the individual's acceptance to receive the services. Please see attached documentation. 06/05/2017 Implemented
6400.64(a)THERE WAS A PUNGENT ODOR THAT WAS CONSISTENT WITH THE SMELL OF URINE IN THE BATHROOM THAT REMAINED DURING THE INSPECTION OF THE HOME. THERE WERE ALSO TISSUE PAPERS ON THE BATHROOM FLOOR AND IN THE TUB. THERE WAS ALSO A DARK STAIN ON THE CARPET LEADING TO THE BATHROOM IN THE HALLWAY. Clean and sanitary conditions shall be maintained in the home. It is the responsibility of the program supervisor/coordinator to notify the facilities manager on any needed repairs that need to be addressed at the site. The apartment was contacted on 6/5/2017 to address the issue with the toilet in the bathroom. They were contacted several more times as well as follow up from Holcomb's compliance officer. The complex has acknowledged the issue. Please see the attaché documentation. 08/01/2017 Implemented
6400.67(a)THE FABRIC ON THE BROWN CHAIR IN THE LIVING ROOM WAS PEELING ON BOTH ARMS. Floors, walls, ceilings and other surfaces shall be in good repair. It is the responsibility of the program supervisor /coordinator to notify the facilities manager of any needed repairs to the site as well as any furniture that does not meet regulation standards. The chair was discarded on 6/21/2017. Please see attached documentation. 06/21/2017 Implemented
6400.188(c)BASED ON REVIEW OF STAFF TIME CARDS, INTERVIEWS WITH STAFF AND OBSERVATION 44 HOURS OF SUPERVISION SERVICES AS SPECIFIED IN INDIVIDUAL #1'S ISP WAS NOT PROVIDED. The residential home shall provide services to the individual as specified in the individual's ISP. It is the responsibility of the program supervisor/coordinator to ensure all supervision services are provided in accordance to the ISP. The ISP for Individual #1 has been revised to show that services will be provided in accordance to the ISP based on the individual's acceptance to receive the services. Please see attached documentation. 08/10/2017 Implemented
SIN-00090724 Renewal 01/26/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The license expired 12/29/15. The self-assessment was completed on 10/12/15 which was after the required 3-6 month period. 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. According to the license date of 12/29/15 staff should have submitted the self- assessment that was done in August 2015 instead of the one completed between October and November 2015. See supporting documentation of the requirement to complete assessments in August & February per Coordinator's/Supervisor's schedule and memo.The August date is within the required time frame. 02/17/2016 Implemented
SIN-00077830 Renewal 10/29/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(d)Soda and Iced Tea were stored in the hall closet with bleach, and Spic and Span. The cleaning idems labels documented to call Poison Control if accidentally swallowed. Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.Soda & iced tea were removed from the hall closet. All Staff will be trained in the importance of ensure that poisonous materials are kept separate from food and food preparation surfaces and dining surfaces. The training will take place on or before July 15. A memo was posted on the closet door to assure that all staff adhere to this requirement. 11/04/2014 Implemented
6400.64(a)There was a rusted personal hygiene rack in the shower area of the main bathroom. Clean and sanitary conditions shall be maintained in the home. A plastic shower caddy was purchased and installed on 11/4/14. Moving forward, the staff have been reminded to report necessary repairs or items that need to be replace. The house supervisor will do weekly checks to ensure all items are hazard free and in good repair. 11/04/2014 Implemented
6400.141(c)(6)Individual #1's most recent tuberculin screening was dated 1/7/11. 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. Individual # 1 had a TB Test on 1/7/11 & not again until March of 2014 that exceeded the required 2 year time frame. He is not due for a repeat TB Test until March of 2016. He had a chest X Ray on 1/23/15 at Fitzgerald Mercy Hospital ER for Upper Respiratory symptoms. Individual #1 is not a positive TB reactor. The program supervisor and coordinator will review individuals charts on a monthly basis to ensure all medical appointments and diagnostic tests are completed in a timely manner set forth in the 6400 regulations. Training will be conducted for staff, supervisor, and coordinator at the North Ave site prior to July 15, 2015 on the requested areas including poisonous materials, house repairs, Quarterly review of records, SEEP/Refusal Plans, self-medication procedures, and implementation of outcome measurements. Implemented
6400.143(a)Individual #1 refuses to take Fluticasone Propionate; Individual #1 refused a prostate exam on 12/10/13, 7/14/14 and 10/24/14. Individual #1 refused a dental exam on 12/25/13 and on 9/11/14; there was no refusal plan developed to address the Individuals consistant refusals.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. A refusal plan was developed for individual #1 on 12/18/14. The coordinator will assure that the refusal plan is current & updated. The coordinator and program specialist will be retrained to ensure that all necessary plans are developed for individuals. The training will occur on or before July 15 The program coordinator will review records quarterly. 12/18/2014 Implemented
6400.164(c)Individual #1 was prescribed Fluticasone Propionate on 9/25/14; it was not documented of the medication administration record. A list of prescription medications, the prescribed dosage and the name of the prescribing physician shall be kept for each individual who self-administers medication.Individual #1 did not want Fluticasone Propionate on his MAR as he is self-administering & he refused to take it. A refusal plan was developed on 12/18/14 to address this issue. See attached-the coordinator will assure that the refusal plan is current & updated. The coordinator and program specialist will be retrained to ensure that all necessary plans are developed for individuals. The training will occur on or before July 15 The program coordinator will review records quarterly. In addition a list of medications for Individual #1 and all self-medication individuals will be kept on site as required by regulation 164c. 12/18/2014 Implemented
6400.183(5)Individual #1 is prescribed Lorazepam 1.m three times a day for anxiety. There was no Social Emotional and Environmental Plan developed to address the anxiety. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. A SEEP Plan was developed for individual #1 on 12/18/14. The supervisor/coordinator is responsible to assure that this information is documented in his ISP/revisions. The program specialist and the coordinator will be trained by July 15 to ensure that all individual's who require a SEEP has one developed and that it the plan stays relevant. The program director¿s will review the Individual¿s record quarterly to ensure that the all plans are implemented and up to date. 12/18/2014 Implemented
6400.186(c)(2)Individual #1's ISP reviews dated 3/17/14, 6/17/14, and 9/17/14 identified that that this Individual either did not progress or regressed on the following outcomes: personal hygiene, exercising, volunteering, and relationship building; the program specialist did not recommend revisions to the 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. Individual #1 has a refusal plan in effect addressing his overall refusal at all attempts to deal with hygiene issues, exercising volunteering & or relationship building. A meeting was held with his team ( including him)on 4/24/15 again to discuss outcomes & as a result a 60 day discharge notice was written on 4/29/15 to assist him to find a provider who may be better able to meet his needs. All program specialist will be retrained regarding the regulation and the importance of modifying as required by the regulation 6400-186 (c)(4) (iii). 04/29/2015 Implemented
6400.188(a)Individual #1's ISP, dated 2/24/14, identified exercising, personal hygiene, volunteering, community integration, and relationship building as needs. There was no protocol developed to identify how there outcomes would be implemented and how progress would be measured.The residential home shall provide services including assistance, training and support for the acquisition, maintenance or improvement of functional skills, personal needs, communication and personal adjustment. The program specialist will be retained on or before July 15 regarding the development and implantation of program outcomes that include how outcomes will be measured. It is important to note that Individual #1 has a history of refusing to participate in outcomes. A refusal plan was developed on 12/18/14. A meeting was held with his team ( including him)on 4/24/15 again to discuss outcomes & as a result a 60 day discharge notice was written on 4/29/15 to assist him to find a provider who may be better able to meet his needs. 04/29/2015 Implemented
6400.213(1)(i)Individual #1's religious affiliation was not identified in the file. Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.Individual #1 's religious affiliation is documented on admission on Intake sheet. The face sheet was updated on 11/4/2014 It is the responsibility of supervisor/coordinator to make sure that this data is forwarded to current forms when files are purged and when forms are updated. The program director and or program coordination will review files quarterly to ensure that the file meets all regulatory requirements. 11/04/2014 Implemented
SIN-00053554 Renewal 10/11/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)The home did not conduct a fire drill during the month of June 2013. (a) An unannounced fire drill shall be held at least once a month. The Coordinator & Supervisor are responsible to assure that a fire drill occurs monthly.A system has been put in place to have the Environment of Care representative be dually responsible to see that monthly drills are held. SEE ATTACHED MEMO 10/25/2013 Implemented
SIN-00041052 Renewal 09/19/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(b)Home was infested with flying gnats.(b) There may not be evidence of infestation of insects or rodents in the home. The apartment complex maintenance staff was contacted on 9/17/12 in reference to the gnats.Staff was dispatched to the apartment on 9/19/12 to treat the gnats. It was found that more extensive treatment was required. Exterminator arrived on 10/3/12 to fog the apartment and the crawl space under the apartment.The complex now contracts with Pest Professionals to regularly service the complex. The Pest Professionals service invoice has been forwarded. 10/03/2012 Implemented
SIN-00244145 Renewal 05/02/2024 Compliant - Finalized