Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00259599 Unannounced Monitoring 01/02/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(c)On 12/18/24, Individual #1's day program, SERVE, documented, and recorded on Individual #1's daily communication log that goes back and forth from day program to the agency that "Individual #1 had a rough day. Lots of hard SIBS (self-injurious behaviors) to the face with the following possible marks: goose egg on his forehead from him slamming his head off a table." The agency staff, which included Staff #1, Staff #2, Staff #3, and Staff #4 , who worked with Individual #1 on 12/18/24, were unable to confirm reading Individual #1's daily communication log from Serve on 12/18/24, that documented the hard SIBS from slamming his head off a table that day, and that a possible goose egg to his forehead could result from this incident. On 12/19/24, Individual #1 was taken to the Emergency Room by the agency due to the discovery of the goose egg on Individual #1's forehead and they were diagnosed with a hematoma. The agency staff neglected to read Individual #1 daily communication log on 12/18/14 from Serve. If the agency staff had read Individual #1's daily communication log from Serve on 12/18/24, Individual #1 could have received medical treatment on 12/18 rather than on 12/19.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.On days that the individual, JB, attend SERVE Futures' staff working in his home will review the communication log. Staff will initial the communication after they have read it. 01/09/2025 Implemented
SIN-00249366 Renewal 08/14/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(g)Sleep drills were not held at different times of the night. Sleep drills were held on 2/20/24 and 8/12/24. Both drills were held at 1:30AM. Fire drills shall be held on different days of the week and at different times of the day and night. Additional Sleep Fire drill was completed 8/23/24 at 3:15 am . Program Managers and Program Specialist were retrained on Regulation 6400.112 (g) 09/17/2024 Implemented
SIN-00228779 Renewal 08/22/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(a)An initial assessment was not completed for Individual #1 within 1 year prior to date of admission or within 60 calendar days after the date of admission to the home. There was an initial assessment in the record for individual #1 that was labeled as the initial assessment for Individual #1, but all of the information contained in the assessment was written for a different individual who is a different gender. The body of the assessment repeatedly refers to a subject that is clearly not Individual #1. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Director or Programs will create a task within Microsoft outlook upon admission to remind the assigned program specialist of the due date for the initial assessment. Implemented
6400.32(r)An individual has the right to lock the individual's bedroom door. Individual #2 and Individual #3's bedroom doors have a lock that is a "privacy lock," aka coin-lock or any key lock. This type of lock can be opened with a tool or device that is not specific to the particular door or lock such as a screwdriver or coin. These types of locks do not provide the level of privacy and security of person and possessions as expected by this regulation.An individual has the right to lock the individual's bedroom door.Futures will communicate with all individuals and guardians who have opted to not have locks on their bedroom doors in an effort to help them make informed decisions. Futures will recommend all doors have locks on them and ensure all parties that staff will have a key on their person in case of emergency. If the person or guardian are adamant, they do not want a lock then the program specialist will request the ISP be updated. 10/18/2023 Implemented
6400.195(a)For each individual for whom restrictive procedures may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team prior to the use of restrictive procedures. At the time of the inspection, there was a locked closet located in a common area of the house that was used to store extra household supplies and cleaning products. Staff stated that the closet also contained personal items belonging to Individual #1 that the individual could potentially harm themself with. Those items included yarn and scarves. Staff stated that the items were kept out of reach but could be accessed by the individual if the individual requested so. The Individual's behavior support plan does not include a component addressing the locking of these possessions.For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures.If an individual without a restrictive procedure plan requests items to be locked up because they don't feel safe staff will honor the request. Staff will inform the individual that when they want their items back they can make the request and they will be returned. In addition, the program specialist will schedule a team meeting to include behavior support in order to discuss how the individual will be supported moving forward, this could result in a restrictive procedure plan or the development or update to a social emotional environmental plan. 12/19/2023 Implemented
SIN-00191303 Renewal 08/18/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water temperature at the time of this inspection read 122.7 degrees, which exceeds the requirement. Hot water temperatures in bathtubs and showers may not exceed 120°F. Water temperature was tested daily until it was safe and under 120 degrees. The water heather was adjusted to decrease the temperature. 08/27/2021 Implemented
6400.104Individual #1 was admitted on 12/1/2020 and requires physical assistance to evacuation. Notification to the fire department was not sent until 1/21/2021.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Regulation 6400.104 will be discussed at Futures Joint Meting which includes managers and program specialist. The requirement will be outlined for all parties. 09/14/2021 Implemented
6400.112(a)There were no fire drill records for October 2020, January 2021 and June 2021. An unannounced fire drill shall be held at least once a month. A monthly safety checklist has been developed and is required to be completed each month at all community homes. The checklists requires the reviewer to review fire drills to ensure they were completed and done properly. 09/01/2021 Implemented
6400.181(a)Individual #1 had an initial assessment completed on 2/1/2021 and a revised assessment completed on 5/1/2021. The following areas were not assessed on either of his assessments: Health, motor/communication, daily living, personal adjustment, socialization, recreation, financial independence, managing personal property and community integration. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Program specialist and ID director discussed this at a staff meeting directly following inspection. Program specialist are aware that even though this part of the assessment is to assess the last 365 days that you need a base in order to assess 365 days. 08/24/2021 Implemented
6400.34(a)Individual #1 was informed of his rights on 12/1/2020. The right to manage finances and the right to voice concerns were not included on the list of individual rights.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.Futures has updated their individual rights to include the individual's right to manage their own finances. The updated individual rights will be reviewed with individual #1. Upon review the individual will sign an acknowledgement form. 10/01/2021 Implemented
6400.166(a)(11)Individual #1 is prescribed the following medications: Tamulosin 0.4mg QD, Keppra 250mg BID, Multivitamin QD and Cranberry Fruit 4200mg QD. The diagnosis/purpose for these medications are not on his Medication Administration Record.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.Frontline supervisor will add the diagnosis to the instruction for each medication of the MARs for October. Futures MAR template will be updated to prompt for a diagnosis for each medication. The updated MAR will be available by November 1, 2021. 10/01/2021 Implemented
6400.213(1)(i)Identifying marks were not listed in Individual #1's record.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate, identifying marks and Social Security number.The facesheet has been updated to say no marks. 08/23/2021 Implemented
SIN-00178124 Renewal 10/06/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The bathroom located off of Individual #2's bedroom had a black substance resembling mold or mildew located along the caulking in the tub beneath the faucet.Clean and sanitary conditions shall be maintained in the home. The bath mat has been replaced and the tub was scrubbed thoroughly. At the time of the thorough cleaning mold was not present not has mold been present during daily cleaning. 11/10/2020 Implemented
6400.67(a)The ceiling in the dining room above the closet door had a large water stain from a leak. Inspectors were unable to determine if the area was still wet due to the inspection being virtual.Floors, walls, ceilings and other surfaces shall be in good repair. The section of the ceiling will be repaired by maintenance. Please note the due date could be exceeded due to COVID. 12/30/2020 Implemented
6400.112(e)Fire drills reviewed from August 2019 through September 2020. First sleep drill was recorded in March of 2020 and again in September of 2020. A sleep drill was not recorded 6 months or sooner from the sleep drill in March of 2020A fire drill shall be held during sleeping hours at least every 6 months. The sleep fire drill was completed in September but not filed. The frontline supervisor and program specialist will ensure fire drills are filed upon completion. 10/14/2020 Implemented
6400.32(r)(5)The device used to unlock the individual's bedroom door was located in an envelope in the office, and not on the staff's personDirect service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.Keys to the individuals locks on their bedroom doors have been added to the staff keychain which is kept on a staff person while working at the CLA. 10/08/2020 Implemented
6400.183(c)There is not a current ISP sign in sheet, showing the list of people that participated in the plan meeting located in Individual #2's record.The list of persons who participated in the individual plan meeting shall be kept.Program Specialist will obtain from individuals' Supports Coordinator and the program specialist will work with supports coordinator to ensure we have on file moving forward. 11/30/2020 Implemented
SIN-00156769 Renewal 06/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(6)There was no mirror in Individual #2's bedroom.In bedrooms, each individual shall have the following: A mirror. On 6/19/19 Program Specialist requested SC add information to individual ISP explaining why he does not have a mirror in his room as this had previously been in his ISP. The SC added this information on 7/9/19. 07/09/2019 Implemented
SIN-00117553 Renewal 07/05/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(2)Staff #1 had a TB test on 4/2/2014. She didn't have another TB test until 5/25/2016, which exceeds the requirement. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Human Resources has developed and implemented a list of employees that includes due dates Tuberculin Skin Testing. Two weeks prior to the following month Human Resources notifies the immediate supervisor of the staff person who needs to schedule Tuberculin Skin Testing. The staff is given a telephone number of the approved locations. Human Resources monitors this daily and maintains communication with the immediate supervisor. If an employee does not obtain their Tuberculin Skin Testing they will receive a letter from their immediate supervisor informing them that they are not able to work until Tuberculin Skin Testing results are received. 08/01/2017 Implemented
SIN-00081561 Renewal 06/17/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The foyer area had four ceiling water stains ranging from 1 inch by 12 inches ( which was wet) to 6 inches by 10 inches. Also the window pane in Individual #2's bedroom had been smashed out.Floors, walls, ceilings and other surfaces shall be in good repair. Provider has secured a repair person to determine the source of the water stains on ceiling and to make necessary repairs. The window pane in individual#2 bedroom has been replaced.The site manager will continue to submit work order forms as situations occur that need repair and/or replacement to ensure floors, walls and ceilings, and other surfaces are in good repair. The Program Specialist will ensure completion of maintenance issues have occurred. 08/31/2015 Implemented
6400.80(b)The rear deck had several rotted boards plus other boards that were very worn and in poor condition. The entire deck was not well maintained and may be unsafe for consumers to use. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.Provider is currently seeking estimates and permit to replace the rear deck. Site manager will continue to fill out work order forms as situations occur that need repair and/or replacement of maintenance issues to ensure the building, yard, and grounds are well maintained , in good repair and free from unsafe conditions. The Program Specialist will ensure completion. 12/31/2015 Implemented
6400.163(c)Individual #1 did not have medication reviews that addressed the reason for prescribing the medication, the need to continue the medication and the necessary dosage. 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.Individual #1 will have all medications being prescribed to treat symptoms of a diagnosed psychiatric illness, reviewed and documented by a licensed physician at least every 3 months. This will include the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Program Specialist and House Manager will be re-trained on regulation 6400.163.(c) to ensure future compliance. Program Specialist for individual #1 will ensure compliance by reviewing quarterly that the necessary documentation is in place in the individual's file. 08/10/2015 Implemented