Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00257172 Renewal 12/09/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.132(9)The freezer temperature log for 2024 maintained on the freezer door by the provider indicates that of the 143 daily temperature checks the temperature was maintained at or below zero 40 of those days as of 12/9/24. Frozen food shall be kept at or below 0°F.If the facility provides or arranges for meals for individuals, the following requirements apply: Cold food shall be kept at or below 45°F. Hot food shall be kept at or above 140°F. Frozen food shall be kept at or below 0°F.Staff will check the temperature of the freezer first thing in the morning to make sure it is accurate. 12/10/2024 Implemented
2380.36(b)Documentation indicates that Staff #2 had annual fire safety training on 7/19/23 then not again until 8/9/24. This is beyond the regulatory allowed time frames.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Staff will complete Fire Safety Training every 6 months to ensure the training is being completed. 12/10/2024 Implemented
2380.126(a)(2)The December 2024 Medication Administration Record in use for Individual #1 did not contain the name of the provider as required.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.MAR sheet was corrected to include the name of the prescriber 12/10/2024 Implemented
2380.126(a)(3)The December 2024 Medication Administration Record in use for Individual #1 did not contain the drug allergies or absence of as required.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Drug allergies.Changes were made to the MAR sheet to make sure Drug allergies were listed 12/10/2024 Implemented
2380.126(a)(8)The December 2024 Medication Administration Record for Individual #1 contained and entry for Clonidine written as "Clonidine 0.2mg Tablet take ½ tab @ 12pm mood stabilizer." The route of administration was not recorded on the December 2024 Medication Administration Record for Individual #1.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.MAR sheet was corrected to include the Route of administration 12/10/2024 Implemented
2380.181(f)There was no documentation to support that the assessments for Individual #1 and Individual #2 had been provided to the individual plan team members at least 30 calendar days prior to the individual plan meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.Letters were sent to individual plan team members after inspection 12/10/2024 Implemented
SIN-00235620 Renewal 12/20/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(e)Alternate exit routes shall be used during fire drills. All of the fire drills conducted from 12/30/2022 through 11/28/23 utilized the front door exit.Alternate exit routes shall be used during fire drills.Staff and individuals were all trained on the exits that need to be used during a fire drill. 01/16/2024 Implemented
SIN-00216041 Renewal 12/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)Poisonous materials are not kept locked or made inaccessible to individuals when not in use. There was a Bona mop with cleaning solution in the mop located in the Lilac room.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Upon discovery, poisonous material was immediately locked up and all other areas were checked to be sure there was not any poisonous material not locked up. 12/12/2022 Implemented
2380.55(a)Clean and sanitary conditions are maintained in the facility. The vent in the bathrooms were covered in significant amounts of dust.Clean and sanitary conditions shall be maintained in the facility.The 2 vents were cleaned immediately upon discovery of the dust. All vents in other areas were checked as well to be sure they were free of dust. 12/12/2022 Implemented
SIN-00197045 Renewal 12/07/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.70(a)The facility does not have a first aid area. The facility utilizes an area in a separate building on the grounds.The facility shall have a first aid area that is separated by partition or privacy screen from program areas.A privacy screen has been placed in the building to separate the first aid area from the rest of the room. Staff have been informed regarding using the privacy area. 12/14/2021 Implemented
2380.70(b)The facility does not have a bed or cot, blanket and pillow.The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit.A cot has been purchased (scheduled to arrive 7-14 January) and pillows and blankets provided. There is a recliner in the building that the privacy screen can be used with until the cot arrives. 12/13/2021 Implemented
SIN-00160752 Renewal 08/20/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(f)The annual assessment for Individual #1 was not provided to the individual plan team members at least 30 calendar days prior to the individual plan meeting. The assessment was completed on 2/22/19 and the individual plan meeting was held on 3/14/19.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.A chart has been developed to list the following; ISP dates, the date that is 30 days before the ISP, and a check off that the assessment has been sent. The program specialist will be responsible to make sure this is completed. Day Supervisor will check the list periodically to make sure it is being completed. 08/22/2019 Implemented
SIN-00138105 Renewal 07/25/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(a)Individual #1's date of admission to Martha Lloyd MacNett was 09-12-17. She did not come into the program with a previous assessment and one was not completed for her until 90 days after admission.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.A checklist for new admissions has been completed which indicates that assessments must be completed within 60 days of admission. All Program Specialists have been reminded of this requirement. 07/26/2018 Implemented
SIN-00119831 Renewal 09/05/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(7)Health maintenance needs was not on the physical exams for Individual #1 (1/25/2017), Individual #2 (10/4/2016), and Individual #3 (4/21/2017).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 for Individual 1 & 3 was from a residential provider other than Martha Lloyd. The CEO of the organizations was made aware and an e-mail was sent to the ID Director of the organization requesting that the information be added to their form or a Martha Lloyd Physical form also be completed by the physician at the time of their annual physical. Individual #2 does have a Martha Lloyd Physical form dated 10.04.2016 which contains this information. This physical form has been placed in the individual's file rather than the other form. A checklist has been completed and all physical forms will be reviewed by the Program Specialist to ensure it is complete. There will also be random quarterly checks of physical forms completed by the Program Supervisor to check for accurate information. The Program Specislit is responsible for ensuring the physical is complete and contains the necessary information. 09/22/2017 Implemented
2380.111(c)(10)This section wasn't on the physical exam for Individual #2 (10/4/2016). This section was left blank on the physical exam for Individual #3 (4/21/2017). The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The physical form for individual #3 was from a residential provider other than Martha Lloyd. The CEO of the organizations was made aware and an e-mail was sent to the ID Director of the organization requesting that all information on the form be completed and nothing left blank by the physician at the time of their annual physical. Individual#2 has a Martha Lloyd physical that was completed on 10.04.2016 and it contains this information. This physical form has been put in the file to replace the other physical. A checklist has been completed and all physical forms will be reviewed by the Program Specialist to ensure it is complete. There will also be random quarterly checks of physical forms completed by the Program Supervisor to check for accurate information. The Program Specislit is responsible for ensuring the physical is complete and contains the necessary information. 09/22/2017 Implemented
2380.186(a)Individual #1 and Individual #2 were both admitted to this program on 5/30/2017. As of the date of this inspection, ISP Reviews have not been completed for either individuals.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impact the services as specified in the current ISP.ISP reviews for both of these individuals were completed on 09.07.2017. All future reviews will be completed based on the admission date. ISP reviews for other individuals were reviewed to be sure that were completed in the proper time frame. The Program Specialists are responsible for ensuring SP reviews are completed quarterly. 09/15/2017 Implemented
SIN-00100786 Renewal 08/16/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.173(1)(ii)Identifying marks are not listed in the records for Individual #1 and Individual #3.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.The information regarding identifying marks has been added to the Individual Personal Information document for Individuals #1 and #3. All Individual records have been reviewed by the Program Specialist to ensure that all personal information required is included on this document. Program Specialist are responsible for ensuring this information remains up to date. 09/23/2016 Implemented
2380.173(1)(iv)Religious Affiliation is not listed in the records for Individual #1, Individual #2, and Individual #3.Each individual¿s record must include the following information: Personal information including: Religious affiliation.The information regarding Religious Affiliation has been added to the Individual Personal Information document for Individuals #1, #2, and #3. All Individual records have been reviewed by the Program Specialist to ensure that all personal information required is included on this document. Program Specialist are responsible for ensuring this information remains up to date. 09/23/2016 Implemented
2380.186(c)(2)Reviews of ISP areas such as health and safety are not being completed in the ISP Reviews for Individual #1, Individual #2 and Individual #3.The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.A Heath and Safety section has been added to the day program quarterly review form . Program Specialists will document and Health and Safety information pertinent to day program in this section. Program Specialists are responsible for this correction and have been trained in the requirement. 09/23/2016 Implemented
SIN-00095437 Initial review 06/01/2016 Compliant - Finalized