Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00250216 Renewal 09/03/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.107(a)During the walk-through inspection of the home, the smoke detector on the 2nd floor did not operate properly. The smoke detector when activated only produced a sound that was barely audible and would not alert someone in case of a fire. The smoke detectors in this home appeared to be old and discolored and not working properly. These smoke detectors should be replaced.A home shall have a minimum of one operable automatic smoke detector provided on each floor, including the basement and attic.A new smoke detector was installed on the second and third floors (Attachment #7) to ensure that all smoke detectors were audible and would alert someone in the event of an emergency. 09/18/2024 Implemented
SIN-00230588 Renewal 10/02/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.24(d)(1)(Repeat from Inspection completed on 11/28/22) According to Individual #1's most recent assessment and ISP, Individual #1 needs constant help with their finances. No petty cash logs are being kept. An up-to-date financial and property record shall be kept for each indivudal that includes the personal possessions and funds received by or deposited with the family or agency.On 10/05/2023, Individual #1's annual assessment was updated to include their ability to independently manage their finances (Attachment #4). Track changes were completed on 10/06/2023 to reflect these changes as well (Attachment #5). The updated assessment and track changes were sent to the team on 10/09/2023 (Attachment #6). 10/09/2023 Implemented
6500.110(b)Individual #1's fire safety training completed on 6/1/23 did not include responsibilities during fire drills, the designated meeting place, or notification of the fire department.The training plan shall include training in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the home, smoking safety procedures if any individuals or family members smoke in the home, the use of fire extinguishers and smoke detectors and notification of the local fire department as soon as possible after a fire is discovered.At the next monthly home visit (currently scheduled for November 1, 2023 at 3:30pm), a Fire Safety Training will review the updated fire safety training signature form (Attachment #3) with Individual #1 and Staff/Facility Person/Household Member #3. 10/04/2023 Implemented
6500.151(e)(13)(iii)Individual #1's most recent Assessment does not document their Activities of Daily Living. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living.On 10/05/2023 Individual #1's annual assessment was updated to include their activities of residential living (Attachment #4). The updated assessment was sent to the team on 10/09/2023 (Attachment #6). 10/09/2023 Implemented
6500.182(c)(1)(ii)Individual #1's demographic information does not include information on their identifying marks or hair color. Each individual's record must include the following information: Personal information, including: The race, height, weight, color of hair, color of eyes and identifying marks.On 10/05/2023, Individual #1's fact sheet was updated to include their hair color and identifying marks (Attachment #8). The updated fact sheet was sent to the team on 10/09/2023 (Attachment #6). 10/09/2023 Implemented
SIN-00215416 Renewal 11/28/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.24(d)(1)Individual #1's financial record is not current and up to date. The ending balance in June 2022 should have been $8.51 and was documented as $10.51. The mathematical error was not corrected and as of the current date, the balance is still documented as $10.51. An up-to-date financial and property record shall be kept for each indivudal that includes the personal possessions and funds received by or deposited with the family or agency.The Residential Program Specialist will ensure that all ledgers are mathematically correct when they are handed in monthly and will sign off on the reconciled ledgers. 12/09/2022 Implemented
6500.121(c)(3)Individual #1's most recent physical completed on 1/27/22 does not document that Individual #1 is current and up to date with their immunizations.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.Provider obtained a list of all immunizations for Individual #1. 12/09/2022 Implemented
6500.124According to a cover letter dated 11/18/22, in Individual #1's record, Individual #1 had medical appointments on 3/18/22, 4/4/22, 4/25/22, 5/23/22, and 8/10/22. At the time of the inspection, there was no medical documentation for any of these appointments.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.All medical appointment forms for individual #1 were obtained and placed in the book. 12/09/2022 Implemented
6500.20(b)(2)Individual #1 did not receive their Doxepin on 4/27/22. This medication error was not reported to EIM. They did not receive their Vyvanse on 9/30/22. This medication error was not reported to EIM.The agency and 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 § 6500.136 (relating to medication errors), if the medication was ordered by a health care practitioner.There was an EIM filed for the missed Doxepin dose on 4/27/2022 EIM# 9134131, and EIM #9134143 was filed for the missed Vyvanse dose on 9/30/2022. 12/09/2022 Implemented
6500.135(g)Individual #1's date of admission was 2/7/22. Individual #1's first quarterly medication review was not until 8/5/22. There was no documentation that Individual #1 had a quarterly medication review prior to that date.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review by a licensed physician at least every 3 months to document the r reason for prescribing the medication, the need to continue the medication and the necessary dosage.All Individual #1's quarterly medications reviews prior to 8/5/22 and after 8/5/2022 have been obtained and filed in Individual # 1's book. 12/09/2022 Implemented
6500.137(a)(1)Individual #1 did not receive their Doxepin on 4/27/22 and they did not receive their Vyvanse on 9/30/22.Medication errors include the following: Failure to administer a medication.There was an EIM filed for the missed Doxepin dose on 4/27/2022 EIM# 9134131, and EIM #9134143 was filed for the missed Vyvanse dose on 9/30/2022 12/09/2022 Implemented