Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00243234 Unannounced Monitoring 03/27/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(f)On 3/27/2024 at 9:57am, 2 trash receptacles were observed in front of the home with so much trash the lids could not be closed. There was also a mattress, a few boxes, and trash bags on the grass.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The supervisor onsite immediately discussed proper trash disposal with the DSPs on 3/27 and altered the take out schedule to the night before to be onsite when garbage is being taken out. On 5/9, the regulations surrounding outdoor trash receptacles was discussed at the Thursday leadership meeting including the regulation, how to properly place out trash, and when to contact a director for large or bulky items that need special handling. Supervisors were instructed to have a list of all outdoor trashcan order requests for the following meeting on 5/16. 05/09/2024 Implemented
6400.18(b)(2)Individual #1 had 4 medications that were not administered as prescribed, as reported by the agency via Enterprise Incident Management (EIM) #9385778. The incident was discovered on 3/7/2024 at approximately 8:00 AM, but was not reported to the Department's information management system until 3/22/2024 at approximately 12:22 PM. This exceeds the 72-hour reporting requirement. Individual #2 was not administered their prescribed Aviane tablet birth control on 3/9/2024, 3/10/2024, and 3/11/2024. The failure to administer this prescribed medication was not reported to the Department's information management system as of 3/27/24. Individual #3 was not administered a dose of Alendronate tablet 70mg on 3/9/2024 at 8:00am. The failure to administer this prescribed medication was not reported to the Department's information management system as of 3/27/24.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person: A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner.The MARs of the site were reviewed by a Med Trainer on 4/9/24 and no medication errors were discovered. A monthly MAR and medication review checklist will be developed for the Med Trainers and Nurse who do onsite reviews no later than 5/10/24 to be implemented immediately in order to standardize the review process. Supervisors will be trained on the medication review checklist and proper reporting of med errors on 5/16/24. 05/10/2024 Implemented
6400.163(h)On 3/27/2024, Individual #1's medication Acetic Acid solution 2% was expired as of 12/2023 and not disposed in accordance with Federal and state statutes and regulations. The agency's disposal policy does not indicate the specific procedures staff are to use when disposing of expired medications. On 3/27/24 Individual #2 had the following expired medications on site and not disposed in accordance with Federal and state statutes and regulations.: Mupirocin Ointment USP 2% expired 8/2023 and Hydrocortisone Cream 2.5% expired 10/2023. There was also an OtiCare kit (hearing aid cleaning kit) expired 8/2009. The agency's disposal policy does not indicate the specific procedures staff are to use when disposing of expired medications.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The clients medications onsite were reviewed on 4/9/24 by a Med Trainer. On 5/6/24, medications that were expired were discarded and documented on the individuals monthly MAR record. A monthly MAR and medication review checklist will be developed for the Med Trainers and Nurse who do onsite reviews no later than 5/10/24 to be implemented immediately in order to standardize the review process. Supervisors will be trained on the medication review checklist and proper reporting of med errors on 5/16/24. 05/06/2024 Implemented
6400.165(e)On 3/27/2024, Acetic Acid solution 2% was still on site but noted in the site communication log as being discontinued on 2/23/2024. The order received from the physician on 4/17/2024 noted the medication was discontinued on 2/5/2024.Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received.On 4/9/24, a med trainer review all MARs at the site. Discontinued medications were noted and added to a spreadsheet for the agency nurse to contact the pharmacy. A monthly MAR and medication review checklist will be developed for the Med Trainers and Nurse who do onsite reviews no later than 5/10/24 to be implemented immediately in order to standardize the review process. 04/09/2024 Implemented
6400.166(a)(4)On 3/27/2024, Individual #1's March 2024 Medication Administration Record (MAR) did not include the prescribed medication Fiber Therapy Powder.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.On 4/9/24, a med trainer reviewed all MARs and medications onsite. All medications onsite were included in the MAR. A monthly MAR and medication review checklist will be developed for the Med Trainers and Nurse who do onsite reviews no later than 5/10/24 to be implemented immediately in order to standardize the review process. 05/10/2024 Implemented
6400.166(a)(5)On 3/27/2024, Individual #1's March 2024 Medication Administration Record (MAR) did not include the strength of the following medication: Fiber Therapy Powder.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.On 4/9/24, a med trainer reviewed all MARs and medications onsite. All medications onsite were included in the MAR. A monthly MAR and medication review checklist will be developed for the Med Trainers and Nurse who do onsite reviews no later than 5/10/24 to be implemented immediately in order to standardize the review process. 05/10/2024 Implemented
6400.166(a)(7)On 3/27/2024, Individual #1's March 2024 Medication Administration Record (MAR) did not include the dose of the following prescribed medication: Fiber Therapy Powder.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.On 4/9/24, a med trainer reviewed all MARs and medications onsite. All medications onsite were included in the MAR. A monthly MAR and medication review checklist will be developed for the Med Trainers and Nurse who do onsite reviews no later than 5/10/24 to be implemented immediately in order to standardize the review process. 05/10/2024 Implemented
6400.166(a)(8)On 3/27/2024, Individual #1's March 2024 Medication Administration Record (MAR) did not include the route of administration for the following prescribed medication: Fiber Therapy Powder.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.On 4/9/24, a med trainer reviewed all MARs and medications onsite. All medications onsite were included in the MAR. A monthly MAR and medication review checklist will be developed for the Med Trainers and Nurse who do onsite reviews no later than 5/10/24 to be implemented immediately in order to standardize the review process. 05/10/2024 Implemented
6400.166(a)(9)On 3/27/2024, Individual #1's March 2024 Medication Administration Record (MAR) did not include the frequency of administration for the following prescribed medication: Fiber Therapy Powder.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.On 4/9/24, a med trainer reviewed all MARs and medications onsite. All medications onsite were included in the MAR. A monthly MAR and medication review checklist will be developed for the Med Trainers and Nurse who do onsite reviews no later than 5/10/24 to be implemented immediately in order to standardize the review process. 05/10/2024 Implemented
6400.166(d)Individual #2 did not receive Aviane tablet birth control on 3/9/2024, 3/10/2024, and 3/11/2024, therefore this medication was not administered as prescribed. Individual #3 did not receive Alendronate tab 70mg 3/9/2024 at 8:00 AM, therefore this medication was not administered as prescribed.The directions of the prescriber shall be followed.On 4/9/24, a med trainer reviewed all MARs and medications onsite. All medications onsite were included in the MAR. A monthly MAR and medication review checklist will be developed for the Med Trainers and Nurse who do onsite reviews no later than 5/10/24 to be implemented immediately in order to standardize the review process. 05/10/2024 Implemented
6400.167(a)(1)Individual #1 had 4 medications that were not administered on 3/7/2024 at 8:00am: Atomoxetine, calcium, Lavetalol and multivitamin. Individual #2 was not administered Aviane tablet birth control on 3/9/2024, 3/10/2024, and 3/11/2024. Individual #3 was not administered Alendronate tablet 70mg on 3/9/2024 at 8:00am.Medication errors include the following: Failure to administer a medication.The MARs of the site were reviewed by a Med Trainer on 4/9/24 and no medication errors were discovered. A monthly MAR and medication review checklist will be developed for the Med Trainers and Nurse who do onsite reviews no later than 5/10/24 to be implemented immediately in order to standardize the review process. Supervisors will be trained on the medication review checklist and proper reporting of med errors on 5/16/24. 04/09/2024 Implemented
SIN-00220422 Renewal 02/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.18(a)(4)EIM Incident # 9082418 for Abuse was discovered on 8/25/22 at 9:30 AM and reported on 8/31/22 at 5:40 PM.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Abuse, including abuse to a individual by another client. The Director of Risk Management has set a recurring meeting every Friday morning with Residential Management to discuss the IM process including recognizing incidents and reporting. Res Management meets with the Supervisory team weekly to relay information and continue discussions on the foundation of recognizing and reporting incidents. 03/17/2023 Implemented
6400.18(i)EIM Incident # 9078426 for Serious Injury has a discovery date of 8/23/22 with a final report due date of 9/22/22. A final report was submitted on 12/8/22. No extensions had been requested.The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension.All open incidents that were near or over 30 days were reviewed and had an extension filed or were finalized on 3/17/23. On Monday mornings, the Director of Risk Management will provide a report of all open incidents to Residential Management. The incidents will be discussed every Friday morning with the Risk Dir and Residential Management. Quarterly, the Risk Manager will meet with the interagency Risk Management team to discuss incidents and trends. Documentation of all provided reports and meetings will be kept by the assisgned manager. 03/17/2023 Implemented
SIN-00203052 Renewal 03/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.74The four outside steps leading from the deck to the yard in the back of the home do not have a nonskid surface.Interior stairs and outside steps shall have a nonskid surface. The maintenance department placed non-skid material on the outside stairs at Harborview on 4/27/22. All supervisors will be trained on 4/25/22 on how to properly complete monthly site inspections. Monthly site inspections will be reported to the ADs no later than 10 days after completion if there are no issues found. Any site issues that require repair will be reported to the ADs within 24 hours. 04/25/2022 Implemented
6400.101The sliding glass door in the dining room of the home has a metal bar installed on the right side to block the door from opening causing an obstructed egress.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Immediately after the onsite licensing inspection, the metal bars on sliding doors were disengaged per instruction given to all Site Supervisors. The maintenance department will fully remove all metal bars by 4/29/22. All supervisors will be trained on 4/25/22 on how to properly complete monthly site inspections. Monthly site inspections will be reported to the ADs no later than 10 days after completion if there are no issues found. Any site issues that require repair will be reported to the ADs within 24 hours. 04/25/2022 Implemented
6400.141(c)(15)Individual #1's physical examination, completed on 3/3/2022, does not address special instructions for the individual's diet.The physical examination shall include:Special instructions for the individual's diet. The Site Supervisors will be trained on proper completion of all medical documentation on 5/2/22. They will be asked to review all physicals and report any missing areas of information to the ADs no later than 5/6/22. Any incomplete physicals will be submitted to the individual¿s PCP for additional information. 05/02/2022 Implemented
6400.142(a)Individual #1, date of admission 3/15/2021, has not had a dental examination.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. The ADs will review the medical paperwork for recent admissions no later than 5/6/22. Any necessary appointments will be scheduled, if not already completed. The Systems Director will provide a timeline for all required appointments for all new admissions moving forward. 05/06/2022 Implemented
6400.142(f)Individual #1, date of admission 3/15/2021, does not have a written plan for dental hygiene.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. The Dental Hygiene plan was completed for the individual on 4/22/22. The Site Supervisors were informed of the need for a dental hygiene plan on 3/31/22. The ADs will review all records no later than 7/31/22. 04/22/2022 Implemented
SIN-00184010 Renewal 02/23/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace inspection was completed on 9/27/19 and then again 12/01/20.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The Director of Res spoke to the Maintenance Director regarding time frames for annual furnance inspections. A tentative date was scheduled for furnace inspections for 2021 in September. Furnance inspections will be added for discussion to the Health and Safety agenda for the September and October meetings as a reminder for upcoming inspections and subsequent review of completed inspections by the Health and Safety Committee.[Documentation of all audits and trainings shall be kept (DPOC by RM, HSLS on 3/25/2021)] 03/10/2021 Implemented
SIN-00145458 Renewal 11/19/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(a)Direct Service Worker #1, date of hire 2/15/18 did not have orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals. Direct Service Worker #3, date of hire 10/4/18 did not have orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals.The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. Temp. records will be reviewed to ensure that all current temp employees have received required trainings by 12/31/18. The on-site binders for temp. staff that include ISP and pertinent medical information trainings will be expanded to include site orientation and fire safety training. Weekly, the DSPs will turn in all new orientation trainings to the Office Manager. The Office Manager will document all completed trainings and maintain a training binder for all temp. staff. Quarterly, the IDD Systems Director will audit 10% of temp. staff to ensure that all employees who have worked at a site have received orientation for the next calendar year. 12/31/2018 Implemented
6400.46(d)Direct Service Worker #2, date of hire 7/13/16, did not have 24 hours of training for training year 1/1/17-12/31/17.Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. Temp. records will be reviewed to ensure that all current temp employees have received required trainings by 12/31/18. The Director of IDD Services will draft and send a letter to all temp. agencies by 12/31/18 stating the training requirements for all employees who work directly with individuals. Monthly, the Office Manager and Assistant Directors will compare the active temp. staff list with the temp. staff who are actively working at the site. All temp. staff who are working at the sites for 40 hours or more monthly will be included in the agency training curriculum to accrue 24 training hours. The Office Manager will maintain all training records for temp. staff. 12/31/2018 Implemented
6400.46(f)Direct Service Worker #1, date of hire 2/15/18 did not have training in general fire safety. Direct Service Worker #3, date of hire 10/4/18 did not have training in general fire safety. Direct Service Worker #2, date of hire 7/13/16 was most recently trained on general fire safety training on 7/13/16.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. Temp. records will be reviewed to ensure that all current temp employees have received required annual trainings by 12/31/18. The on-site binders for temp. staff that include ISP and pertinent medical information trainings will be expanded to include site orientation and fire safety training. Weekly, the DSPs will turn in all new orientation trainings to the Office Manager. The Office Manager will document all completed trainings and maintain a training binder for all temp. staff. Quarterly, the IDD Systems Director will audit 10% of temp. staff to ensure that all employees who have worked at a site have received orientation for the next calendar year. 12/31/2018 Implemented
6400.46(i)Program Specialist #1, date of hire 4/10/17, has not been trained in first aid, Heimlich techniques and 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 trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. The Program Specialist received CPR training on 12/11/18. The Program Specialists were added to the due date tracking spreadsheet that is currently used for DSPs. The spreadsheet will be reviewed at least monthly by the Program Specialists for due dates and quarterly by the Assistant Residential Directors. 12/11/2018 Implemented
6400.71The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the telephone in the living room of the home.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. An emergency phone number sticker was placed on the phone the following day by a DSP. All phones at all sites will be checked for the presence of the emergency stickers by 12/31/18 by the Site Supervisors. Quarterly, the phones will be checked by the Health and Safety Committee and stickers will be placed on any phones on-site. Documentation of on-site visits will be maintained by the Health and Safety Committee. 12/31/2018 Implemented
6400.151(a)Direct Service Worker #3, date of hire 10/4/18, did not have a physical examination. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Temp. records will be reviewed to ensure that all current temp employees have a current physical in their record by 12/31/18. The Director of IDD Services will draft a letter by 12/31/18 to send to all temp. staff agencies that an employee physical is required prior to any of the temp staff being scheduled at any of the sites. The letter will also state that the physical needs to be sent via fax or email to the Office Manager to keep in an employee file. Quarterly, the Director of IDD Systems will review 10% of temp. staff files to ensure that the employee¿s physical is present for the next calendar year. 12/31/2018 Implemented
SIN-00086536 Renewal 11/10/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(a)Individual #1, admitted on 12/1/14 was informed of his/her rights on 1/9/15.Each individual, or the individual's parent, guardian or advocate, if appropriate, shall be informed of the individual's rights upon admission and annually thereafter. At the next monthly meeting, Site Supervisors will be retrained about informing new individuals of their rights upon admission. Site Supervisors will be instructed to have the individuals sign their rights at their Annual ISP meeting.[CEO or designee will review the required documents for new admissions for the next 5 newly admitted individual to ensure all required documents including the document of "rights" to ensure individuals have been informed of their rights upon admission. (AS 12/30/15)] 11/28/2015 Implemented
6400.44(b)(10)The program specialist did not sign the monthly documentation for July 2015 and August 2015 of Individual #1's participation and progress toward outcomes.The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of an individual's participation and progress toward outcomes.Program Specialist will check alerts daily in the electronic health record for individuals to ensure all documentation is signed in a timely manner. Asst. Director will be notified by the Program Specialist on the 15th of every month if monthly documentation is missing or incomplete from the Site Supervisor. 11/28/2015 Implemented
6400.161(e)The medication Citalopram (Celexa) 10 mg tablet, take 1 tablet by mouth, daily was discontinued on 8/19/15 was still in Individual #1's medication box on 11/10/15.Discontinued prescription medications shall be disposed of in a safe manner.At the next Site Supervisors, the Medication Administration Trainer will review the appropriate protocol to discontinue and remove medications. The Site Supervisors will do monthly reviews of MAR and medications at the home and the Asst. Residential Director will review at least quarterly. [Documentation of all reviews will be maintained.(AS 12/30/15)] 11/28/2015 Implemented
6400.163(c)The medication reviews dated 5/6/15 and 7/15/15 for medication prescribed to treat symptoms of a diagnosed psychiatric illness did not include the reason for prescribing Strattera 80 mg daily to Individual #1. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The supervisor of the home will receive individualized medication training in this area. The Site Supervisors, as a whole, will receive training at the next Site Supervisors meeting. The training will include monthly protocol for reviewing medication documentation. The Asst. Residential Director will do quarterly audits of all documentation related to medication administration. 11/28/2015 Implemented
6400.181(f)The assessment for Individual #1 completed on 1/29/15 was not sent to the entire plan team members.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). The Program Specialist met with the Office Manager. The office manager presented a list of team members for each residential client. This list corresponds with the invitation, therefore guaranteeing that all members will receive copies.[PS will also review ISP, invitation letters and other documents to ensure all team members receive the assessments as required for all individuals. At least quarterly for the next 6 months, CEO or designee will review the correspondence showing that all team members are provided the assessments for all individuals. (12/30/15)] 11/28/2015 Implemented
6400.186(d)The ISP review documentation for Individual #1 completed on the following dates was not sent to the entire team: 10/1/14 to 1/1/15; 1/1/15 to 4/1/15; 4/1/15 to 7/1/15 and 7/1/15-10/1/15.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. The Program Specialist met with the Office Manager. The office manager presented a list of team members for each residential client. This list corresponds with the invitation, therefore guaranteeing that all members will receive copies.[PS will also review ISP, invitation letters and other documents to ensure all team members receive the ISP review documentation as required for all individuals. At least quarterly for the next 6 months, CEO or designee will review the correspondence showing that all team members are provided the ISP review documentation for all individuals. (12/30/15)] 11/28/2015 Implemented