Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00243773 Renewal 04/23/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(11)Individual #3's current physical dated 8/1/23 did not indicate health maintenance needs.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 physical form was returned to the physician to have the missing information completed (Attachment #4). 06/06/2024 Implemented
6400.181(e)(13)(i)Individual #3's annual assessment dated 11/2/23 did not include progress and growth in the area of health.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. The assessment was revised ton ensure that the health changes for the past year were clearly highlighted so that anyone reading Individual #3's plan has a clear idea of her current health status (Attachment #5) 07/01/2024 Implemented
6400.34(a)Individual #3's rights were not provided annually. In 2023 they were given on 2/14/2023 and then in 2024 the rights document was signed on 4/1/24.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.Individual #3's rights were reviewed with them on 5/14/24 (Attachment #6). 07/31/2024 Implemented
6400.34(b)Individual #3's record contained a document that did not include many of the required individual rights. None of the rights under section R and S were provided.The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights.The Participant Rights form was revised to incorporate all rights as prescribed in §6400.32. Individual #3's rights were reviewed with them using the updated form on 5/14/24 (Attachment #6). 07/31/2024 Implemented
SIN-00187014 Renewal 04/21/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There was a Palmolive container left unlocked in the kitchen at the time of inspection.Poisonous materials shall be kept locked or made inaccessible to individuals. Program Managers and Program Specialist were trained on 5-26-21, that no chemical products can be used in the CLA without CADEs approval and Safety Data Sheet. The Management Team was trained on CADES Poisonous Materials Policy. See attached #97-98, 120. This policy includes : - Poisonous materials shall be kept locked or made inaccessible when not in use. The House Supervisor completes a Physical Plant Walk-Through and submits data to Program Manager by the 10th of each month. The Program Manager will complete a Physical Plant Walk-Through for all assigned locations. This report will be sent to the Program Coordinator by the 20th of each month. An additional layer of Physical Plant review will be conducted by Quality Assurance personnel. Six homes per month will be inspected by Quality Assurance. Results will be reviewed by the Program Coordinator, Facilities Director and the Senior Director of Adult Services. See attached procedure and sample of Physical Plant Walk- Through # 99-115. The Program Managers also completed a Residential Site Inspection of all assigned homes which included all violations reported by ODP , see attached # 31-96. The Palmolive dish soap was locked on 4-21-21. 05/26/2021 Implemented
6400.141(c)(6)Individual #3's last TB test was conducted on 3/27/19 which is more than two years since the last test.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. CADES Chief Clinical Officer reviewed all residential medical records to confirm any testing needs with regard to PPD. Several individuals were noted and appointments were scheduled See attached # 10-13. CADES is currently using Therap electronic record. This system will alert CADES nurses of any PPD that is due. The Chief Clinical Officer will run reports in order to monitor individual medical records and nurse actions. Med Meetings will begin in June 1, 2021. This meeting includes the primary nurse, Program Specialist and Program Manager. This meeting was not enforced during the pandemic. The three member team has the responsibility to report needed medical appointments, follow-up on recommendations and have an understanding of appointment completion which involves scheduling of vehicles and staffing. See attached example # 117-119. Training was held on 5-19-21. 06/25/2021 Implemented
SIN-00108159 Renewal 02/01/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.213(1)(i)Individual #1's record did not contain a current photograph. 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.Correction: Individual's photograph has been retaken and added to individuals file and electronic record on 3/28/17.The case record review has been revised and includes photograph within 5 years. Persons Responsible: Program Specialist are responsible to have current clear photograph of each resident (within 5 years) in the individual¿s record and electronic file. Re-training completed on 2/14/17. See attachment #5- photograph of Individual #1. Attachment #6 Program Specialist agenda and signatures. 03/28/2017 Implemented
SIN-00204600 Renewal 04/20/2022 Compliant - Finalized