Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00243025 Renewal 04/18/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The exhaust fan in the ceiling of bedroom #1 has significant dirt buildup and requires cleaning.Clean and sanitary conditions shall be maintained in the home. The exhaust fan was cleaned immediately after the licensing inspection on 4/19/2024. 05/15/2024 Implemented
SIN-00224036 Renewal 04/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)There were two items behind the dryer, a towel and a sock which could lead to a potential fire hazard Floors, walls, ceilings and other surfaces shall be free of hazards.This was a health and safety problem that was addressed during the walk thru inspection when it was immediately removed. 05/01/2023 Implemented
6400.106Documentation that a furnace inspection was completed annually was not provided.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. To ensure health and safety these inspections need to be completed annually. This inspection had been completed annually; however, we did not have the report available upon inspection. 05/01/2023 Implemented
SIN-00203987 Renewal 04/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)Individual #1 went out to a dinner at the crafty crab on 1/21/22. At this dinner he spent $241.52 on several people. His ISP states that he will provide for staff accommodations and activities on vacations but Merakey will be responsible for staff food.Individual funds and property shall be used for the individual's benefit. This was Bruce¿s Birthday Party, his birthday is 1/21/1950. 05/04/2022 Implemented
6400.67(b)The bathroom cabinet was coming apart at the front of the cabinet and could fall off and cause injury. Floors, walls, ceilings and other surfaces shall be free of hazards.Work order was submitted, a new vanity was ordered 2 weeks ago and is expected to arrive by the week of 5/16/22. It will be replaced as soon as we receive. 05/26/2022 Implemented
6400.141(c)(14)The annual physical for individual #1 dated 10/19/21 did not have the section on information pertinent to diagnosis and treatment in case of an emergency filled out.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Paperwork will be completed at next scheduled PCP appointment. 06/30/2022 Implemented
6400.142(g)There was no current dental plan on file for individual #2A dental hygiene plan shall be rewritten at least annually. Dental plan was completed by Program Specialist on 5/2/2022 and reviewed with the individual. 05/02/2022 Implemented
6400.181(f)Individual #1's Individual Assessment was not sent to the to the individual's Plan Team members by the program specialist at least 30 calendar days prior to an individual plan meeting, which took place on 11/15/2021. Documentation within the Individual Record indicates that the Individual Assessment was not sent to Individual Plan Team members until 12/15/2021.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Program Specialist will send Assessment 30 days prior to the Annual Review meeting. Unfortunately, and in this case, supports coordinators give us so little time to prep for the ISP that we do not have the option to send 30 days in advance. 05/04/2022 Implemented
SIN-00187191 Renewal 04/22/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)Assessments for agency's locations were not completed 3-6 months prior to the expiration of the license date of 2/1/2021, the range of 9/2020-2/2021, or 3-6 months after licensing's last visit of August 2019.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 provider failed to show all inspections that had been completed in the 2020 and 2021 years during this annual inspection. Attached is the inspection/self-survey that was completed January 2021 at 426 Stanford Rd. An inspection was also held at the nearby 8 Beechwood Lane site on the same date. January 24th was the on-site portion of the inspection with environmental checks. The full inspection is dated 1/26/21, because that is the final date every item in the self- survey was responded to. 08/01/2021 Implemented
6400.67(a)There was a missing knob on Individual 1's dresser drawer at time of inspection.Floors, walls, ceilings and other surfaces shall be in good repair. A knob had fallen off the dresser for individual 1. It is essential that all items be in good condition and that any damage, uncleanliness, or untidy conditions be immediately resolved. A photograph is attached that show that knob has since been added and the furniture is in good repair. Plan to maintain compliance: Staff will be re-trained on the work order process and will be reminded during monthly staff meetings to call in any environmental issues noticed on site so they can quickly be remedied. Managers will do weekly walk-throughs of the home to ensure tidy, hygienic conditions. Correction date: This is completed. 06/23/2021 Implemented
SIN-00142669 Renewal 06/18/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)The bathroom located next to the 2nd bedroom has a switch cover made of steel and has rust around the cover. Floors, walls, ceilings and other surfaces shall be free of hazards.On 6/21/18, House Manager, Nathan Walusimbi, entered a work order in our system to have the switch cover replaced in the bathroom located next to the second bedroom, by 7/1/18. The importance of this requirement was reviewed with staff and the need for floors, walls, ceilings, and other surfaces to be free of hazards is understood. Nathan will monitor the home and continue to strive to meet this necessary requirement to assure the Individuals are receiving the highest quality of care. Implemented
6400.76(a)The dining room chairs have scrapped surfaces in need of repainting. Furniture and equipment shall be nonhazardous, clean and sturdy. On 6/21/18, House Manager, Nathan Walusimbi, entered a work in our system to have Dining room chairs repainted by 7/1/18. The importance of this requirement was reviewed with staff and the need for all furniture and equipment to be non-hazardous, clean, and sturdy is understood. Nathan will monitor the home and continue to strive to meet this necessary requirement to assure the Individuals are receiving the highest quality of care. Implemented
SIN-00115294 Renewal 05/26/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment was completed in January 2017 and the license expired on 2/01/2017.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 agency should complete a self assessment of each home within 3-6 months prior to the expiration date of the agency's certificate of compliance. The assessment was completed on January 2017, 1 month before the license expired on 2/1/17. The provider will continue to strive to meet this necessary requirement. [Going forward, a Program Designee will monitor to ensure compliance with meeting the required deadline. JG 11/28/17]. 03/01/2017 Implemented
6400.71The emergency telephone numbers posted in the home did not include the local fire department, police or ambulance.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. There were no emergency telephone numbers posted in the home. Telephone numbers for the nearest hospital, police department, fire department, ambulance, and poison control center were posted on or near the house phone with an outside line. 09/05/2017 Implemented
SIN-00095009 Renewal 02/02/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.164(b)Citalopram 40 mg was administered to individual # 1 but was not logged on the Medication Administration Record immediatly on 2/2/16.The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. Staff was counseled on this, by manager Nate Walusimbi. Management (Nate Walusimbi) and regional nursing check the MAR and compares to blister packs weekly to ensure that meds are being given as prescribed and signed off on. All staff also receive observations during med passes to ensure they are following medication admin protocol. 02/05/2016 Implemented
6400.181(e)(12)The assessment for individual #1 dated 4/12/15 did not include recommendations for specific areas of training, progamming and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. Please see attached assessment- this information was included in the addended assessment and lists recommended areas for training and programming. This addendum was completed by program specialist Laura Winchester following the violation.[Quality manager/Program Designee will review the assessments of all individuals served to ensure that the assessment includes recommendations for specific areas of training, programming and services. If there is anyone found to not have that information included in their assessment the addendum will be completed within 30 days of receipt of this plan of correction DD 6.10.16] 02/05/2016 Implemented
6400.186(a)Individual #1's three month ISP reviews dated, 6/20/15,9/20/15 and 12/20/2015 do not document any information around the medication reviews of the psychotropic medication prescribed.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. Laura Winchester, program specialist made the update to Bruce's ISP review per licensing violation and also reviewed other individuals on her caseload to ensure this information is captured in every quarterly ISP review. Program books and quarterly ISP reports are audited at least every 6 months (more if there is a change to goals or status) Please see attached documentation- with the reviews in question addended to reflect changes in the psych medications. Also please see current Bruce's 3 month review to ensure that we are continuing to follow the practice of documenting psychotropic medication reviews in quarterly reports. Quality Manager or Program Designee will develop a checklist to ensure that all program specialists are addressing the required areas of the ISP 3 month review. Quality manager or Program Designee will complete quarterly audits of all 3 month ISP reviews to ensure compliance with all regulations DD 6.10.16] 02/05/2016 Implemented