Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00238266 Renewal 09/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144For individual 5, Medication HYDROXYZINE HCI 50mg tablet is kept at the school as indicated on the Blister pack and MAR. However, this medication is not in the home if needed during the weekend times.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. ¿ Additional Medication for individual # 5 has been ordered for both day program and residential setting and the prescription updated to include the use of the medication both at day program and in the residential setting. (Attachment # 15). 03/09/2024 Implemented
SIN-00206916 Renewal 09/09/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)There were no screens in the windows located in the living room.Windows, including windows in doors, shall be securely screened when windows or doors are open. Our 6400.72(a) protocol has been updated and the following procedures have been instituted; ¿ A work order was completed and the screen has been installed. See attachment # 16. 07/13/2022 Implemented
6400.144The prescription medication EYE ITCH RELIEF .0025% SOLUTION was not present in individual #2 med box at time of inspection, medication must be kept current. Staff is signing off on the MAR as administered.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. The prescription medication EYE ITCH RELIEF .0025% SOLUTION was ordered and delivered to the home the same day as the day of the inspection. Staff were retrained immediately to notify a nurse when medications are running low to ensure they are refilled prior to running out. 07/13/2022 Implemented
6400.34(b)Individual #2 was not informed of his individual rights at the time of his 7/1/20 admission, as a signed copy of his rights was not included in the rights/consents package for 2020 that was given at the time of inspection.The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights.Our 6400.34(b) protocol has been updated and the following procedures have been instituted; ¿ The Rights package was reviewed and signed on by individual 2. See attachment # 15. 07/13/2022 Implemented
6400.165(g)Individual #2 takes at least one psychotropic medication (quetiapine 150 mg daily), has not had a medication review at least every three months. A telemedicine visit was conducted on 3/17/21 and 7/7/21. Documentation from the last visit does not indicate which medication was reviewed, nor the necessary dosage.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Our 6400.165(g) protocol has been updated and the following procedures have been instituted; ¿A medication review was conducted for individual # 2 and the documentation indicate which medications were reviewed including the dosage. ¿The Individual's Psychiatric appointment calendar has been updated to ensure individuals receiving a medication prescribed to treat symptoms of a psychiatric illness are seen by a licensed physician at least every 3 months, including individual #2. Next appointment date will be scheduled on the day of the appointment to ensure 3 months does not lapse. 07/13/2022 Implemented
6400.167(a)(1)Staff is signing off on Individual #2 MAR as administering medication EYE ITCH RELIEF SOLUTION, although this medication was not on site. Agency staff could not locate the empty bottle that was allegedly administered at 8am. It could not be determined if this medication was administered.Medication errors include the following: Failure to administer a medication.The staff were retrained to ensure accurate documentation when administering medication. If a medication is not available, it should be stated so and the appropriate Health Care Coordinator notified to ensure a new order is obtained. 07/13/2022 Implemented
SIN-00126643 Renewal 10/30/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(a)On 10/21/2017 it was documented that Individual #3 was not provided 2:1 staffing from approximately 7AM to approximately 11AM. The individual's level of supervision, per the ISP, is to be 2:1 during awake hours. Not providing the required level of staffing constitutes neglect.An individual may not be neglected, abused, mistreated or subjected to corporal punishment. a certified investigation was conducted for this incident and corrective actions developed. The investigation outcomes and associated corrective actions can be located in EIM. 03/16/2018 Implemented
6400.33(e)There was a video monitor in individual #2's bedroom which provides live feed (no sound, does not record) to a monitoring unit in the living room to monitor for seizure activity.An individual has the right to privacy in bedrooms, bathrooms and during personal care. The video monitor was removed from the premises. 03/16/2018 Implemented
6400.64(a)The carpet on the stairs to the second floor and the second floor hallway had numerous black stains and appeared very soiled.Clean and sanitary conditions shall be maintained in the home. this has been corrected. Carpet cleaning was ordered and carried out on March 12, 2018. 03/12/2018 Implemented
6400.67(a)A window pane in the living room was cracked.Floors, walls, ceilings and other surfaces shall be in good repair. See Appendix C-B. This has been corrected. 03/16/2018 Implemented
6400.101The doorknob on Individual #1's bedroom door was reversed, so that the locking mechanism was on the outside of the door, creating a potential delayed egress if the individual would be inadvertently locked in the bedroom.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. This has been corrected. See Appendix B-B 03/16/2018 Implemented
6400.142(g)Individual #3's current dental hygiene plan does not reflect the dentist's recommendations made on 10/09/2017.A dental hygiene plan shall be rewritten at least annually. Managers were retrained on this requirement and a dental plan was updated for individual #3. See Appendix A 03/16/2018 Implemented
6400.181(a)Individual #3 was admitted on 7/10/2017 and the initial assessment was not completed until 10/07/2017. 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. Managers were retrained on this requirement. See Appendix A 03/16/2018 Implemented
6400.185(b)On 10/21/2017 it was documented that Individual #3 was not provided 2:1 staffing from approximately 7AM to approximately 11AM. The individual's level of supervision, per the ISP, is to be 2:1 during awake hours.The ISP shall be implemented as written.A certified investigated was completed for this incident, and corrective actions were implemented per the certified investigation. The investigation outcomes and corrective actions are available in EIM. 03/16/2018 Implemented
SIN-00251607 Renewal 09/05/2024 Compliant - Finalized