Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00289139 Unannounced Monitoring 05/04/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)On 5/4/2026 at 10:12 AM, the hot water temperature at the kitchen sink measured 126.8°F. On 5/4/2026 at 10:19 AM, the hot water temperature at the sink in the full bathroom adjacent to the kitchen measured 129.5°F.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. CLASS immediately corrected by adjusting the water temperature on hot water tank. This correction was in place on 5/4/2026. 06/16/2026 Implemented
6400.67(b)On 5/4/2026 at 10:35 AM, the door to the full bathroom adjacent to the kitchen had been removed; however, the three hinge pins were observed in the corresponding knuckles of the hinge mechanisms. The hinge pins were severely rusted and had the potential to cause injury or infection. Floors, walls, ceilings and other surfaces shall be free of hazards.CLASS immediately corrected by removing the hinge pins and hinge mechanisms. This correction was in place on 5/4/2026. 06/16/2026 Implemented
6400.110(a)On 5/4/2026 at 10:25 AM, the empty attic space measuring approximately 4-feet in height, which is accessible via a retractable ladder in the attached garage, was observed without an automatic smoke detector. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. CLASS corrected by installing an operable automatic smoke detector in the attic of this home. This fix was in place on 5/19/2026. 06/16/2026 Implemented
6400.111(a)On 5/4/2026 at 10:25 AM, the attic space measuring approximately 4-feet in height, which is accessible via a retractable ladder in the attached garage, was observed without a fire extinguisher with a minimum 2-A rating.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. CLASS corrected by installing an operable fire extinguisher with a minimum 2-A in the attic of the home. This fix was in place on 6/9/2026. 06/16/2026 Implemented
6400.141(c)(4)Individual #2 last had a vision screening or examination completed on 4/2/2025. This exceeds teh annual requirement.[Repeat violation 09/24/25, et. al.]The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. CLASS recognizes that we cannot correct this violation. 06/16/2026 Implemented
6400.142(g)Individual #1's most recent written dental hygiene plan was completed on 9/18/24. This exceeds the annual requirement.A dental hygiene plan shall be rewritten at least annually. CLASS understands this cannot be corrected in the required time frame. A dental hygiene plan was written and signed after 5/4/2026. 06/16/2026 Implemented
6400.144Individual #1 was seen for a routine vision screening on 3/26/2024 where the physician indicated the need for a twelve-month follow-up appointment, which was completed on 5/21/2025. The agency failed to ensure such prescribed health services were arranged for and provided in a timely manner. Individual #1 was seen for a routine dental examination on 6/17/2024 where the physician indicated the need for a six-month follow-up appointment; however, the agency failed to ensure that such health services were arranged for or provided, as follow-up appointment documentation was not provided. Individual #1 was seen for a routine podiatry examination on 7/31/2024 where the physician indicated the need for a three-month follow-up appointment; however, the agency failed to ensure such health services were arranged for or provided as prescribed, as follow-up appointment documentation was not provided. Individual #2 had a vision examination conducted on 4/2/2025 where the physician indicated the need for an annual follow-up examination; however, the agency failed to ensure such health services were arranged for and provided as prescribed, as follow-up appointment documentation was not provided. Individual #2 was discharged from the hospital on 4/3/2025 where the aftercare instructions indicated the need for a follow-up with their Primary Care Practitioner within three to five days; however, the agency failed to ensure such health services were arranged for and provided as prescribed, as follow-up appointment documentation was not provided. Individual #2 was seen for a sleep consultation on 5/13/2025 where the physician indicated the need for a follow-up with a BiPAP Specialist; however, the agency failed to ensure such health services were arranged for and provided as prescribed, as follow-up appointment documentation was not provided. Individual #2 was seen for a routine dental examination on 6/23/2025 where the physician indicated the need for a follow-up on 1/26/2026. Agency staff indicated that the appointment on 1/26/2026 was cancelled and was rescheduled for 2/23/2026; however, no documentation or explanation for the cancellation could be provided, as the agency failed to ensure Individual #2's dental services were completed as prescribed. Individual #2 was seen for a routine wound care appointment on 8/27/2025 where the physician indicated the need for a one-month follow-up; however, the agency failed to ensure such health services were arranged for and provided as prescribed, as follow-up appointment documentation was not provided. Individual #2 was seen for routine nail care at the podiatrist on 11/20/2025 where the physician indicated the need for a return visit on 3/12/2026; however, the agency failed to ensure such health services were arranged for and provided, as follow-up appointment documentation was not provided. [Repeat violation 09/24/25, et. al.]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. CLASS recognizes that we cannot correct this violation. 06/16/2026 Implemented
6400.171On 5/4/2026 at 10:23 AM, a pot of, what appeared to be, tomato soup was observed uncovered on the rear left burner of the stove. The stovetop burner was neither on nor warm. It was unknown how long the soup had been left unprotected on the stove; however, it appeared to be old, as there were dried streaks of soup stained along the sides of the pot as well as a layer of biofilm on top of the soup. [Repeat violation 09/24/25, et. al.]Food shall be protected from contamination while being stored, prepared, transported and served. CLASS corrected this immediately citation by disposing of the soup sitting on the stove on 5/4/2026. 06/16/2026 Implemented
6400.163(a)On 5/4/2026 at 12:21 PM, the following medications that were previously and exclusively prescribed to Individual #3 were observed in the staff office without a pharmacy issued medication label: three 24-capsule boxes of Anti-Diarrheal Loperamide HCL Tablets 2mg, two 100-softgel bottles of Vitamin D3 5000 IU (125mcg), and one 30-tablet bottle of Non-Drowsy 24-hour Allergy Relief Antihistamine 10mg. Individual #3, has been deceased since 2/28/2026. Repeat violation 09/24/25, et. al.]Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.CLASS immediately removed medications of deceased individual from the home. This was completed on 5/4/26. Medications were disposed of on 5/5/26 (SB Med Disposal Form Attachment #6). 06/16/2026 Implemented
6400.163(h)Individual #1 is prescribed, Acetamin Tab 325mg, with instructions to "Take 2 tablets (650mg) by mouth every four hours as needed for pain/fever." On 5/4/2026 at 12:17 PM, this medication was observed with an expiration date of 3/25/2026. Individual #2 is prescribed, Calc Antacid Chw 750mg, with instructions to "Chew 2 tablets (1500mg) by mouth as needed for dyspepsia *NTE 15 tablets per 24 hours." At 12:10 PM, this medication was observed with an expiration date of 4/27/2026. At 12:21 PM, three 24-capsule boxes of Anti-Diarrheal Loperamide HCL Tablets 2mg that had previously been prescribed to Individual #3 were observed in the staff office with an expiration date of 4/2026. Additionally, at 12:21 PM, two 100-softgel bottles of Vitamin D3 5000 IU (125mcg) and one 30-tablet bottle of Non-Drowsy 24-hour Allergy Relief Antihistamine 10mg that had previously been prescribed to Individual #3 were observed in the staff office. Individual #3 has been deceased since 2/28/2026. [Repeat violation 09/24/25, et. al.]Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.CLASS immediately removed expired and/or discontinued medications from the home. This was completed on 5/4/26. 06/16/2026 Implemented
6400.166(a)(5)Individual #2 is prescribed, Budesonide Sus 0.5mg/2mL, with instructions to "Use 1 vial (2mL) via nebulizer twice a day for asthma/wheezing." On 5/4/2026, Individual #1's May 2026 Medication Administration Record did not include the strength of this medication. [Repeat violation 09/24/25, et. al.]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.CLASS corrected this by updating the medication record. 06/16/2026 Implemented
6400.166(b)On 5/4/2026, Individual #2's prescribed medications including, but not limited to the following, were not initialed by staff as having been administered as reflected on Individual #2's April 2026 Medication Administration Record for the corresponding times and dates: Baclofen Tab. 10 MG with instructions to "Take 1 tablet by mouth four times a day (In addition to 20 MG dose) for muscle spasm" at 4 PM on 4/18/2026 and at 8 PM on 4/23/2026; Famotidine Tab. 20 MG with instructions to "Take 1 tablet by mouth twice a day at 12 PM and 8 PM for antacid" at 12 PM on 4/13/2026 and at 8 PM on 4/23/2026; and Pot Citra ER Tab. 1080 MG with instructions to "Take 1 tablet by mouth three times a day with meals for kidney stones" at 12 PM on 4/13/2026 and at 8 PM on 4/23/2026. [Repeat violation 09/24/25, et. al.]The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.CLASS recognizes that we cannot correct this violation 06/16/2026 Implemented
6400.167(a)(1)Individual #2 is prescribed, Budesonide Sus 0.5mg/2mL, with instructions to "Use 1 vial (2mL) via nebulizer twice a day for asthma/wheezing." This medication was not initialed by Direct Service Worker #1 as having been given on 5/1/2026 at 8:00 AM as reflected on Individual #2's May 2026 Medication Administration Record. Furthermore, Direct Service Worker #1 was unavailable to interview on 5/4/2026, and Individual #2's prescribed, Budesonide Sus 0.5mg/2ml, is in liquid form. Therefore, verification that this medication had been administered on 5/1/2026 at 8:00 AM could not be measured. [Repeat violation 09/24/25, et. al.]Medication errors include the following: Failure to administer a medication.CLASS recognizes that we cannot correct this violation 06/16/2026 Implemented
6400.207(5)(III)On 5/4/2026 at 12:39 PM, Individual #2's bed contained bilateral upper-half bedrails that restricted the movement or function of the individual's body. The agency obtained a prescription on 10/7/2024, indicating that the bedrails are medically necessary; however, the order did not include the diagnosis for which the device was intended to treat or a statement of direct correlation between the diagnosis and the behavior of concern. In addition, Individual #2's current physical examination, completed on 1/9/2026, did not contain such information. Although the bed rails are prescribed by the medical practitioner, Individual #2's assessment, last updated 9/8/2025, did not indicate if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual. Individual #2's Support Plan, last updated 10/17/2025, did not include periodic relief of the device to allow freedom of movement. [Repeat violation 09/24/25, et. al.]A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Protection from injury during a seizure or other medical condition, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement.CLASS recognizes that we cannot correct this violation. 06/16/2026 Implemented
SIN-00253366 Renewal 09/25/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency's self-assessment windows of completion are the following: 5/23/24 to 8/3/24 and/or 3/28/24 to 6/28/24. The home's self-assessment was completed from 9/12-13/24.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. CLASS Quality and Compliance Coordinator (QCC) will complete quarterly self-assessments of houses. Residential house managers (RHM) will complete monthly house inspections. The self-assessment windows will be placed on the corporate calendar for continuity of completion and to ensure that dates are being met. 12/31/2024 Implemented
6400.15(c)The agency completed the home's self-assessment from 9/12-13/2024. The following violations were identified with no written summary of corrections: .20b, .34a, .112a, .112b, .112c, .112d, .112e, .112f, .112g, .112h, .112i, .141a, .141c4, .141d, .142a, .142b, .142c, .142d, .213(3) and .213(4).A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. CLASS Quality and Compliance Coordinator (QCC) will complete quarterly self-assessments of houses. Any identified violations will be corrected and a new self-assessment will be completed showing compliance. 12/31/2024 Implemented
6400.112(c)The written record of the fire drills conducted on 5/17/24, 6/20/24, 7/18/24, and 8/6/24, did not document the exit route used.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. Residential homes managers were all retrained on the regulations pertaining to fire drills. Fire drill log forms were updated with exit route used and reviewed with all residential homes managers on 10/3/2024. 12/31/2024 Implemented
6400.32(r)(1)At 12:21 PM on 9/26/24, Individual #1's bedroom door was equipped with a thumb- turn lock. Interviews revealed that Individual #1 did not have a designated mechanism to lock and unlock the door. At 12:23 PM on 9/26/2024, Individual #2's bedroom door was equipped with a thumb-turn lock. Interviews revealed that Individual #2 did not have a designated mechanism to lock and unlock the door. At 12:24 PM on 9/26/24, Individual #3's bedroom door was equipped with a thumb-turn lock. Interviews revealed that Individual #3 did not have a designated mechanism to lock and unlock the door.Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.Locks were changed to straight locks on bedroom doors 12/31/2024 Implemented
6400.32(r)(5)At 12:21 PM on 9/26/2024, Individual #1's bedroom door was equipped with a thumb- turn lock. Interviews revealed that staff did not have a designated mechanism to lock and unlock the door. At 12:23 PM on 9/26/24, Individual #2's bedroom door was equipped with a thumb-turn lock. Interviews revealed that staff did not have a designated mechanism to lock and unlock the door. At 12:24 PM on 9/26/24, Individual #3's bedroom door was equipped with a thumb-turn lock. Interviews revealed that staff did not have a designated mechanism to lock and unlock the door.Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.Locks were changed to straight locks on bedroom doors 12/31/2024 Implemented
6400.163(d)At 12:16 PM on 9/26/24, the key to the staff office where medications are kept was stored in plain sight, hanging from a thumb tack on the wall directly outside the office, rendering the medication accessible.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.Keys were removed from the current location and are now kept on the staff on duty's person at all times. Staff will hand off keys during shift changes. 12/31/2024 Implemented
6400.166(a)(4)Individual #1's September 2024 Medication Administration Record did not include the medication's name for the prescribed, Scopolamine.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.Program Specialists reviewed all medications, medication labels, and medication administration records to ensure that all medications were properly documented. 12/31/2024 Implemented
6400.166(a)(5)Individual #1's September 2024 Medication Administration Record did not include the strength of the prescribed, Scopolamine.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.Program Specialists reviewed all medications, medication labels, and medication administration records to ensure that all medications were properly documented. 12/31/2024 Implemented
6400.166(a)(6)Individual #1's September 2024 Medication Administration Record did not include the dosage form of the prescribed, Scopolamine.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form.Program Specialists reviewed all medications, medication labels, and medication administration records to ensure that all medications were properly documented. 12/31/2024 Implemented
6400.166(a)(7)Individual #1's September 2024 Medication Administration Record did not include the dose of the prescribed, Scopolamine.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.Program Specialists reviewed all medications, medication labels, and medication administration records to ensure that all medications were properly documented. 12/31/2024 Implemented
6400.166(a)(8)Individual #1's September 2024 Medication Administration Record did not include the route of administration for the prescribed, Scopolamine.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.Program Specialists reviewed all medications, medication labels, and medication administration records to ensure that all medications were properly documented. 12/31/2024 Implemented
6400.166(a)(9)Individual #1's September 2024 Medication Administration Record did not include the frequency of administration for the prescribed, Scopolamine.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.Program Specialists reviewed all medications, medication labels, and medication administration records to ensure that all medications were properly documented. 12/31/2024 Implemented
6400.166(a)(10)Individual #1's September 2024 Medication Administration Record did not include the administration times for the prescribed, Scopolamine.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.Program Specialists reviewed all medications, medication labels, and medication administration records to ensure that all medications were properly documented. 12/31/2024 Implemented
6400.166(a)(11)Individual #1's September 2024 Medication Administration Record did not include the diagnosis or purpose for the prescribed, Scopolamine.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.Program Specialists reviewed all medications, medication labels, and medication administration records to ensure that all medications were properly documented. 12/31/2024 Implemented
6400.207(5)(III)On 9/26/24 at 11:58 AM, Individual #1's bed contained half bed rails that restrict the movement or function of the individual's body. The agency did not obtain a prescription from a medical practitioner for the bedrails. The most current assessment, dated 8/30/24, does not address if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual. The individual plan, most recently updated 9/4/24, does not include periodic relief of the device to allow freedom of movement. On 9/26/24 at 12:00 PM, Individual #2's bed contained a half bed rail on the right side against the wall that restricted the movement or function of the individual's body. The agency did not obtain a prescription from a medical practitioner for the bedrail. The individual plan, last updated 8/13/24, does not include periodic relief of the device to allow freedom of movement. On 9/26/24 at 12:36 PM, Individual #3's bed contained full bed rails that restricted the movement or function of the individual's body. The agency did not obtain a prescription from a medical practitioner for the bedrails. Interviews revealed that Individual #3 did not need the bed rails and only had them because the bed had belonged to a previous individual who occupied the bedroom.A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Protection from injury during a seizure or other medical condition, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement.Residential homes manager is working with the primary care doctor to get a copy of orders for the bed rails. Assessments will be completed to assess the needs for bed rails. Individual #3 bed rails have been removed. 12/31/2024 Implemented
SIN-00213560 Renewal 10/19/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101There is a turn lock on the basement side of the door leading to the garage posing an obstructed egress from the garage when engaged. There is not a "man door" from the garage.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The Residential House Manager has submitted a maintenance request for the locks to be taken off this obstructed egress. The work order has been submitted and has been completed. Residential House Manager will complete a walk through of their home to ensure compliance to the regulation. § 6400.101. Unobstructed egress. Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. 12/01/2022 Implemented
6400.110(b)The closest smoke detector outside of Individual #1's bedroom is 27 feet away.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. Residential House Manager, Maintenance Professionals, Program Specialist, and direct care staff will review 6400.101 (a) A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. (b) There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. (c) The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. (d) Smoke detectors and fire alarms shall be of a type approved by the Department of Labor and Industry or listed by Underwriters Laboratories. (e) 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. (f) If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. (g) If a smoke detector or fire alarm is inoperative, notification for repair shall be made within 24 hours and repairs completed within 48 hours of the time the detector or alarm was found to be inoperative. (h) There shall be a written procedure for fire safety monitoring in the event the smoke detector or fire alarm is inoperative. they will read, sign and date. A maintenance request was placed by the Residential House manager to correct the violation. The work order was completed by the Maintenance professional. 11/22/2022 Implemented
6400.114(b)At 11:11AM on 10/20/2022, a small, unsecured ashtray with cigarette butts and ashes was on a ledge next to the front door of the home. The provider's undated written smoking policy states, "Smokers should discard all cigarette butts in the ash tray provided by CLASS. The ash tray should be a fixed object."Written smoking safety procedures shall be followed.Fixed ashtrays were ordered for the site by Program Director. A maintenance request was placed for the fixed ashtray to be installed. All staff working at this site will be presented with the agency smoking policy at the site house meeting on 11/22/2022 at 10:00am, they will read, review, sign and date. 12/02/2022 Implemented
6400.181(e)(12)Individual #1's assessment, completed 6/21/2022 did not include recommendations.The assessment must include the following information: Recommendations for specific areas of training, programming and services. Program Director and Assistant will assist the Program Specialists in completing an addendum to the initial Assessment by 12/1/2022 this Program Specialists will be retrained on Assessments on 11/9/2022. The assessment training will cover the following.... PROGRAM SPECIALIST ASSESSMENT MEETING AGENDA DATE OF MEETING: 11/9/22 ¿ BIG IDEA BEHIND THE ASSESSMENTS o WHO THEY ARE FOR: ¿ PARTICIPANTS ¿ STAFF ¿ SC ¿ FAMILIES AND OTHER TEAM MEMBERS o WHY THEY ARE DONE ¿ GOALS ¿ SUPPORTS THAT ARE REQUIRED/ RECOMMENDED o WHEN THEY ARE DONE ¿ WHO SHOULD BE INVOLVED ¿ PROVIDING COPIES o RECOMMENDATIONS ¿ AUDITS o CHECKING FOR ACCURACY 12/01/2022 Implemented
6400.15(b)The agency completed a self-assessment of the home on 5/6/2022; however, the agency did not use the Department's most current licensing inspection instrument (reflecting regulatory changes promulgated in February 2020) to measure and record compliance for this chapter.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.Old versions of the self-assessment tool were shredded and discarded. Staff were asked to complete the self-assessment on the correct version this will be completed by 11/22/2022 The correct version of the Self Assessment Tool was sought out by new Quality and Compliance Coordinator and supplied by inspector. All expired versions of the Self Assessment Tools were erased off the internal databases by Quality and Compliance Coordinator. Updated version was placed on internal site by direction of IT 11/22/2022 Implemented
6400.165(c)Individual #1's October 2022 Medication Administration Record states, "Milk of Magnesia, take 1 tablespoonfuls by mouth every 24 hours as needed for constipation." The medication label states, "Milk of Magnesia, take 2 tablespoonfuls by mouth every 24 hours as needed for constipation."A prescription medication shall be administered as prescribed.The MAR has been corrected by the Residential Program Manager to match the label on the medication. All MAR's will be reviewed by the Residential House Manager. 12/19/2022 Implemented
SIN-00196561 Renewal 11/18/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self assessment of the home.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. The Senior Residential Homes Managers will complete the self-assessment of their assigned homes by December 20, 2021. The Residential Director will review each plan prior to submission. 12/20/2021 Implemented