Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00252415 Renewal 09/25/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)A fire drill was held during sleeping hours on 10/06/23, and then again on 05/17/24. This exceeds the at least every 6-months requirement.A fire drill shall be held during sleeping hours at least every 6 months. On 10/4/24 a meeting was held with the Director and Assistant Director of IDD Services, and Residential Advisors where the violation was explained. The RA that works at this particular home was also present at the Exit meeting on 9/26/24, therefore, she is aware of this regulation. A new Unannounced Fire Drill form was created on 10/3/24. This new form was distributed to the RA's today, 10/4/24. On this form a line was created for person Reviewed signature along with the date. The RA's will complete overnight drills every 6 months regularly, per year. Unannounced overnight fire drills will be done by the 15th of the months designated by the RA/ Director of IDD and Assistant Director of IDD. This particular drill will be delivered shortly thereafter to the main office, so that it can be approved. If not approved by the Director of Assistant Director of IDD, it will be re-done by the corresponding RA of that location, for correct completion. 10/04/2024 Implemented
SIN-00196647 Renewal 11/22/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(11)The medication administration record for November 2021 for Individual #1 did not list the diagnosis or purpose for any prescribed medications.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.Immediately on 11/23/21, the Emmaus Healthcare and Quality Management Coordinator made the corrections to the current November MAR based on the recommendation from Licensing Representative. This was also so indicated onto the MAR for December 2021 as well. Quality Management Coordinator also talked to our Pharmacy, PDC on 12/3/21. Quality Management Coordinator is retrieving new medication for January on 12/27/21 and will reassure that all MARs have the corresponding diagnoses for all medications. Pharmacy also has a menu option when calling for MAR Corrections. This was discussed with all Emmaus RA's on 12/9/21, at a Program Meeting. All RA's are aware to communicate to Physicians about indicating the diagnosis onto prescription information for the corresponding medication label in the future. 12/23/2021 Implemented
SIN-00213160 Renewal 10/12/2022 Compliant - Finalized