Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00211283 Unannounced Monitoring 09/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(f)During this inspection, the bed shaker equipped to alert Individual #1 of a fire, didn't operate on the initial testing of the fire system. During the second attempt, the bed shaker had a 20 second delayed start from the time the smoke detector was set off to when it began working. This home utilizes strobe lights to alert Individual #1 of a fire when they are in other areas of the home besides their bedroom. When Individual #1 is in the living room, there is no system to alert them of a fire. 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. On 9/15/22, a strobe fixture was installed in the living room. The bed shaker was assessed for compliance to ensure that individual #1 is able to be alerted to respond, in the event of a fire, in an appropriate timeframe. 10/31/2022 Implemented
6400.214(b)During this inspection, the annual assessment available in the home for Individual #2 was dated 8/21/21. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. On 9/13/22, the most current assessment, for individual #2 was made available in the home. By 10/1/22, all programs will be checked to ensure that the most recent copies of the assessments are present in the homes. The Director of Residential will keep records of this check. 11/01/2022 Implemented
SIN-00210420 Unannounced Monitoring 08/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #1's fall plan dated 5/9/22 states that EMS is to be called for all falls. If Individual #1 refuses to go to the ER, then their PCP is to be contacted as soon as possible (preferably the same day or the next day) to schedule an appointment. Additionally, if Individual #1 refuses to go to the ER and there is an orthopedic injury, Individual #1 is to be taken to OSS Urgent Care, which is open from 8am to 8pm on weekdays and 9am to 6pm on weekends. Individual #1 fell in their home at 3:19pm on 4/26/22. EMS was contacted and Individual #1 refused to go to the ER, and Individual #1's PCP was not contacted. Individual #1 was not taken to an Urgent Care facility until the following day. Individual #1 fell in their home at 11:10am on 7/24/22. EMS was contacted and Individual #1 refused to go to the ER. Individual #1's PCP was not contacted. Individual #1 was not taken to an Urgent Care facility until the following morning.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. On 9/1/22, the Fall plan was rewritten to clarify more specific time frames and medical professionals to be contacted. All staff will be retrained on this update to the fall plan, prior to working with the individual. All fall plans will be reviewed by 11/1/22 to ensure that there is no ambiguous language related to time frames and people to contact. This will be completed during the biweekly (PLAN) meetings that consist of the LPN, PS, Lead, and AD. This review will be noted on the meeting agenda. 11/01/2022 Implemented
6400.167(a)(1)Individual #1 was not administered their daily dose of Ferrous Sulfate on 4/4/22.Medication errors include the following: Failure to administer a medication.On 4/5/2022, EIM #9004528 was submitted after the identification of this error. One of The target staff resigned 4/5/2022. All programs are being reviewed to identify if med errors are present. This is being completed by the LPN position in each program. This will be completed by 10/1/22 and documentation of this process will be kept by the Director of Nursing. 11/01/2022 Implemented
SIN-00200292 Unannounced Monitoring 02/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)There was two ceiling tiles in the basement sensory room with a large amount of water damage due to a recent leak.Floors, walls, ceilings and other surfaces shall be in good repair. On 2/16/22, the ceiling tile in the basement sensory room was replaced. All homes will be assessed for current compliance with this regulation by 3/1/22. All staff working in this home will be re-trained on this regulation by 3/1/22. Documentation of this training will be kept 03/01/2022 Implemented
SIN-00195599 Unannounced Monitoring 11/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.217There is no record of a Release of Information for Individual #1 in the record.Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. An Authorization for Release of Information (ROI) will be completed for Individual #1 for all applicable persons, organizations, or agencies (see addendum ***). All individuals receiving residential services from Shadowfax will have their files assessed for current and appropriate ROIs by 12/31/21. 01/01/2022 Implemented
6400.34(a)The Department issued updated regulatory rights, effective 2/3/2020, stating that individuals have additional rights they need to be informed of. At the time of this inspection, Individual #1 was never informed of the individual rights as described in 6400.32.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.The current Individual Rights have been acquired and every individual receiving residential services from Shadowfax are being informed of the individual rights as described in 6400.32. The Program Specialists will confirm that these have been reviewed and signed by the individuals by 12/31/21. 01/01/2022 Implemented
SIN-00187227 Unannounced Monitoring 04/21/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.52(c)(6)Individual #2's choking protocol was developed 6/25/20. Individual #1's choking protocol was developed 8/17/20. The following staff worked in the home prior to being trained on the choking protocols for both individuals: Staff person #1, #2, and #3.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.All staff must be trained in an individual's specific dietary needs before working in a home to ensure the health and safety of all individuals. All staff who are currently not trained will be trained by 5/11/21 or will not work with that individual until training is complete. Beginning immediately, ALL staff will be trained in individual dietary needs prior to their first shift in a new home or where a new protocol is implemented. If new dietary restrictions or choking protocols are recommended by a medical professional, the agency nurse will review orders and the program specialist will update all required documents within 24 hours of receipt. Staff will be trained on updates/changes prior to working their first shift with individual. 05/11/2021 Implemented
SIN-00255933 Renewal 11/18/2024 Compliant - Finalized
SIN-00236062 Renewal 12/12/2023 Compliant - Finalized
SIN-00224671 Unannounced Monitoring 04/25/2023 Compliant - Finalized
SIN-00220297 Unannounced Monitoring 03/03/2023 Compliant - Finalized
SIN-00215772 Unannounced Monitoring 12/05/2022 Compliant - Finalized
SIN-00192069 Unannounced Monitoring 08/30/2021 Compliant - Finalized
SIN-00189497 Unannounced Monitoring 06/29/2021 Compliant - Finalized
SIN-00183886 Unannounced Monitoring 02/25/2021 Compliant - Finalized
SIN-00174682 Unannounced Monitoring 08/04/2020 Compliant - Finalized
SIN-00159635 Initial review 07/23/2019 Compliant - Finalized