Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00250828 Renewal 09/04/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.49(b)Family Living Provider #1 completed the modified medication training on 6/16/2023; however, documentation of the training was not kept by the agency.A training record for each person trained shall be kept.¿ Family Living Provider #1 completed modified medication administration training on 9/12/24 (copy of cert included) ¿ Family Living Program Specialist was trained on regulation 6500.49b by program director on 9/9/24 (training doc attached) ¿ Printed documentation of completion for training is filed in a binder created by Family Living Program Specialist, under the Modified Medication Training tab. ¿ An electronic copy is also retained in a Training folder, which is stored on the Pressley Ridge mainframe, and placed in the sub-folder labeled Modified Medication Administration Training. 09/24/2024 Implemented
6500.136(a)(2)Individual #1's September 2024 medication record did not include the name of the prescriber.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.¿ All Medication Administration Records (MARs) were reviewed and revised as of 9/10/24 to include prescriber (see revised MARS) ¿ Family Living Program Specialist was trained by program director on reg 6500 136a2 on 9/9/24 (see attached training doc) ¿ Family Living Providers will notify Family Living Program Specialist of any changes to medications or prescribers within 24 hours. ¿ Family Living Providers will document on MAR in Notes/Concerns box of any changes to medications or any changes in prescribers. ¿ Updated MARs will be completed and sent to family within 48 hours of notification of needed changes. 09/24/2024 Implemented
6500.136(a)(3)Individual #1's September 2024 medication record did not include drug allergies.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Drug allergies.¿ All Medication Administration Records (MARs) were reviewed and revised as of 9/10/24 to include list of allergies (see revised MARS) ¿ Family Living Program Specialist was trained by program director on reg 6500 136a3 on 9/9/24 (see attached training doc) ¿ Family Living Providers will notify Family Living Program Specialist of any changes to allergies within 24 hours. ¿ Family Living Providers will document on MAR in Notes/Concerns box of any changes to allergies. ¿ Updated MARs will be completed and sent to family within 48 hours of notification of needed changes. 09/24/2024 Implemented
SIN-00233473 Renewal 09/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.121(c)(8)Individual #1, date of birth 5/13/82, did not have a mammogram.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older.A mammogram will be completed every two years or provider will get documentation from doctor saying that this is not required. FLP will schedule appointments at time of current appointment to ensure they are on time. We are going to request an ultrasound for mammogram instead of routine mammogram procedure as it is not felt that individual will be able to tolerate it. provider will assist individual with being comfortable with any procedures. 11/02/2023 Implemented
6500.45(a)Life Sharing Provider #1 completed general training in first aid and Heimlich techniques on 9/28/21 and did not complete first aid and Heimlich techniques training by a certified trainer until 8/28/23.The primary caregiver shall be trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid and Heimlich techniques prior to an individual living in the home and annually thereafter.All FLPs will be trained annually or certified biannually in first aid/cpr/Heimlich techniques. 11/02/2023 Implemented
6500.135(g)Individual #1 is prescribed psychotropic medication. Individual #1 has 3-month medication reviews on 10/19/22 and then again on 2/1/23.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review by a licensed physician at least every 3 months to document the r reason for prescribing the medication, the need to continue the medication and the necessary dosage.Psychotropic med reviews will be completed every 3 months. FLP and individual will be encouraged to schedule at time of current appointments to ensure they are within the required timeline. Families and individual will be reminded that if they need to change or reschedule due to illness that they should get documentation for this. 11/02/2023 Implemented
SIN-00195482 Renewal 10/21/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.24(f)Individual #1's October 2021 financial record showed the individual had a negative 4.99 balance. Life Sharing Provider #1 stated that she will give the individual money when she runs out, and will be reimbursed by the individual's funds the following month.There may not be commingling of the individual's personal funds with agency or household funds.Cash on hand was adjusted and log was corrected. family will not add extra expenses spent on individual to ledger and only spend cash on hand family trained on reg 24f. See attached documentation. FLS will monitor financial log at end of every month to ensure receipts are separate and that transactions are entered correctly on the ledger. 11/08/2021 Implemented
6500.122(a)The most recent dental examination for Individual #1 was completed 2/14/2020An individual 17 years of age or younger, shall have a dental examination performed by a licensed dentist semiannually. Each individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually.Due to covid the dental appointment scheduled for 2/2021 was cancelled. JD needs sedation to have dental work completed. We have not been able to get JD in for sedation as they have no appoints available. We continue to call dentist for cancelled appointments and will take her for sedated dental work as soon as appointment opens up. 11/09/2021 Implemented
6500.136(a)(8)Individual #1 is prescribed Melatonin 3mg, with instructions to take 1 tablet at bedtime. The October 2021 medication administration record did not include route of administration.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.All med logs were updated to include route of administration. See attached med log. FLS will review med log and medication labels at the beginning and end of month to ensure that labels and logs match and include the route of administration. FLS and family trained in accurate med documentation including the right route on log. 11/01/2021 Implemented
6500.136(a)(11)Individual # 1 is prescribed the following medications: Fluoxetine HCL 10mg, Risperidone 3mg tabs, Levothyroxine Sod 50mgs, Dok 100mg- soft gel, Senna 8.6mg tabs, and Melatonin 3mg,. The October 2021 medication administration record did not include diagnosis or purpose for the medications.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.All med logs were updated to include diagnosis. See attached med log. FLS will review med log and medication labels monthly to ensure that labels and logs match and include the diagnosis. FLS and family trained in accurate med documentation including the diagnosis for each medication. 11/01/2021 Implemented
6500.136(b)Individual #1 is prescribed the following medications: Dok 100mg- soft gel, with instructions to take 1 capsule by mouth two times a day, Senna 8.6mg tabs with instructions to take 2 tablets by mouth daily at bedtime, and Melatonin 3mg, take 1 tablet at bedtime. During the inspection on 10/21/21 at 1:50pm the October 2021 medication administration record had initials for the 10/21/21 9pm doses, but the medications were not yet administered.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Family inadvertently signed off on the wrong block. Error was corrected during licensing review. Family retrained in medication administration and documentation. 11/01/2021 Implemented
SIN-00178423 Renewal 10/27/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.121(c)(14)Individual #1's physical examination, completed 12/26/19 did not include medical information pertinent to diagnosis and treatment in case of an emergency. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.new FLS used physical from 3800 regulations. Staff were trained and given physical to be used for individuals licensed under 6500 regulations. All supervisors and family living providers were given physical for 6500 regulations. Director will review quarterly to ensure accurate documentation is used for physicals. Documentation and forms are on the agency idrive for each specific programs regulations. Office manager will ensure documentation and forms are removed and updaed when needed. [Upon competition, those supporting the individuals in obtaining current physical examinations shall audit the documentation to ensure all required information is completed and there are no areas left blank and health services are arranged and provided. (DPOC by AES,HSLS on 11/17/20)] 11/03/2020 Implemented
SIN-00137352 Renewal 06/20/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.17(a)The self assessment completed on 12/14/17 did not measure compliance in regulations 6500.75(b) through 6500.80(a), 6500.142 through 6500.144, 6500.155 (a), 6500.155(b), and 6500.162 through 6500.176.If an agency is the legal entity for the family living home, the agency shall complete a self-assessment of each home the agency is licensed to operate 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 self assessment will be completed 3-6 months prior to expiration of certificate of compliance. director and coordinator will review each assessment once completed by the FLS to ensure each assessment is accurately completed in its entirety. training docs for all staff included for reg 6500.1717a [Documentation of aforementioned audits of each assessment by the Director and the Coordinator shall be kept. (DPOC by AES,HSLS on 8/14/18)] 07/27/2018 Implemented
SIN-00117830 Renewal 07/05/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.68(b)At 2:45PM, the hot water temperature at the bathtub in the bathroom in the hallway of the first floor measured was 126.3°F. Individual #1 is not assessed to understand the danger of hot water and have the ability to sense and move away from hot water quickly. Hot water temperatures in bathtubs and showers that are accessible to individuals may not exceed 120°F.hot water tank was adjusted on 7/5 by family. when checked again on following day temperature read at 119 degrees . Family living providers complete monthly safety checks and water temp will be checked by family then. New thermometers were purchased that have better accuracy with readings. family living specialist will oversee safety checks to ensure monthly water temperatures occur and that they read under 120 degrees . Family trained on 6500.68(b) and to lower water temp if ever over 120 degrees. [At least quarterly for 1 year, the family living specialist shall measure the hot water temperatures at all bathtubs and showers in the family living homes where individuals are assessed to understand the danger of hot water and have the ability to sense and move away from hot water quickly that are accessible to individuals to ensure the hot water temperature does not exceed 120°F. Documentation of all checks shall be kept.(AS 8/11/17)] 08/03/2017 Implemented
SIN-00096240 Renewal 06/08/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.182(c)(8)Individual #1's record did not include a copy of the current ISP; the ISP that was in the record was for fiscal year 2014/2015 with all services ending on 6/30/15. Each individual's record must include the following information: A copy of the current ISP.current ISP was in HCSIS and was printed at put in file at time of licensing review. FLS and clinical coordinator were trained on regulation and procedure to check files quarterly on 6/28/16 by director kutz. Director will check HCSIS alerts monthly to ensure all current ISP are printed and files. All other files had current ISP in them. Files continue to be reviewed quarterly [to ensure all required information including a copy of current ISP is present in all individuals' records. Documentation of record reviews shall be kept. (AS 8/9/16)] 07/28/2016 Implemented
SIN-00077793 Renewal 06/11/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.43(d)(7)Individual #1's most recent ISP, 03/01/2015, reads "poisons are kept locked" and "Individual #1 would ingest substances if s/he thought it was food or drink". Individual #1's assessment, completed 10/30/2014, reads "poisons do not have to be locked" and "Individual #1 is able to identify things that are dangerous and knows not to ingest". The family living specialist did not report the content discrepancy to the SC and plan team members. The family living specialist shall be responsible for the following: Reporting content discrepancy to the SC, as applicable, and plan team members.PS contacted SC and had her change information in ISP in regards to individual¿s ability to manage poisons and whether they need to be locked. SC responded and did change info in ISP. Receipt of this is in an email and will be filed in individuals file. PS trained in 6500.43(d)(7)[Training attendance documentation for was submitted to the department. (AS 7/14/15)] 07/10/2015 Implemented
6500.121(c)(14)The physical examination, completed 12/22/2014, for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of an emergency. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Physical exam was updated/revised to include medical information pertinent to diagnosis and treatment in case of emergency. PS and FLP were trained in regulation 6500.121 (c)(14))[Blank annual physical examination form and training attendance documentation for was submitted to the department.(AS 7/14/15)] 07/10/2015 Implemented
6500.151(f)The program specialist did not provide the assessment, completed on 10/30/14, for Individual #1 to the plan team members for an ISP meeting on 12/01/2014.The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development of the ISP, the annual update, and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).Assessment was sent but there was no written verification of doing so. PS will email copy and save receipt of doing so and file. Form was also updated/revised to add a line stating when and who it was mailed out to. PS was trained in regulation 6500.151(f)) [Training attendance documentation was submitted to the department.(AS 7/14/15)] 07/10/2015 Implemented
6500.182(c)(6)(ii)Individual #1's record did not include the invitation letter to the annual update meeting held on 12/01/2014. Each individual's record must include the following information: A copy of the invitation to: The annual update meeting.Individual file had invite from meeting but one from Pressley ridge. Program specialist will be responsible to ensure that state invite is in the file. If not received by supports coordinator he will document attempts to get this from them and file that. Program specialist was trained on regulation 6500.182(c) (6)(ii)[Training attendance documentation was submitted to the department.(AS 7/14/15)] 07/10/2015 Implemented
6500.182(c)(7)(ii)Individual #1's record did not include a copy of the signature sheet for the annual update meeting completed on 12/1/2014.Each individual's record must include the following information: A copy of the signature sheet for: The annual update meeting.Individual file had signature page from meeting but one from Pressley ridge. Program specialist will be responsible to ensure that state invite is in the file. If not received by supports coordinator he will document attempts to get this from them and file that. Program specialist was trained on regulation 6500.182(c) (7)(ii[Training attendance documentation was submitted to the department.(AS 7/14/15)] 07/10/2015 Implemented
SIN-00065819 Renewal 06/24/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.109(d)The fire drill record for the the drill conducted on 12/5/13 did not include the time.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the smoke detector was operative.FLP was trained in 6500.109d in regards to completing safety/fire drill checklist form in full this includes the time that drill was implemented. FLPspecialist will review and oversee that the fire drill is comopleted in full on a monthly basis 08/02/2014 Implemented
6500.151(e)(12)The assessment, dated 11/4/13, for Individual # 1 does not include recommendations for areas of training, programming and services. The assessment must include the following information: Recommendations for specific areas of training, programming and services.FLP specialist was trained in regulation 6500.151e12. Clinical coordinator is reviewing current assessments and assessing what new one will encompass what is required in the regulation. FLPspecialist will add a line to his current assessment sumary that will add Recommendations for specific areas of training, programming and services. 08/02/2014 Implemented
6500.151(e)(13)(i)The assessment, dated 11/4/13, for Individual #1 does not include any information on the individual's progress over the last 365 caledar days and current level in the area of health. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.FLP specialist was trained in regulation 6500.151e13(i). Health intake form was revised and has addition of individual's progress over the last 365 calendar days and current level in the following areas: Health. Agency is moving to electronic health system that will have this added to it as well. 08/02/2014 Implemented
SIN-00047638 Renewal 02/28/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.151(f)The annual assessment for Individual #1, dated 10/1/12, was not sent to the supports coordinator and plan team members. The meeting was held on 11/19/2012. The assessment was sent on 11/16/12. (Partially Implemented-Adequate Progress; 5/21/13; CEM)The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development of the ISP, the annual update, and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).A line has been added to the bottom of the assessment that will be signed off by the FLS to show that the assessment was sent and dated when it was sent. FLS was trained on regulation 6500.151(f(send doc) FLs will ensure that the assessment is sent and that documentation of it is in the individual file. Clinical coordinator has this added to her monthly supervision note with FLS to review that he has completed this. 04/15/2013 Implemented
6500.156(c)(2)Individual Support Plan review documentation for Individual #1, dated 3/1/12, 6/1/12, 9/1/12, 11/19/12, and 2/19/13, do not include a review of each section of the Individual Support Plan specific to the family living home. Only the signature sheets were in the individual record. The content of the reviews was not available in the record. (Partially Implemented-Adequate Progress; 5/21/13; CEM)(c) The ISP review must include the following: (2) A review of each section of the ISP specific to the family living home licensed under this chapter.All sections within the ISP will be added to quarterly progress reviews. FLS was trained on regulation 6500.156 (c)(2)(sent doc)FLS is responsible for ensuring this is completed quarterly. 04/15/2013 Implemented
6500.156(d)Individual Support Plan review documentation for Individual #1, dated 3/1/12, 6/1/12, 9/1/12, 11/19/12, and 2/9/13, was not sent to the supports coordinator and plan team members. (Partially Implemented-Adequate Progress; 5/21/13; CEM)The family living specialist shall provide the ISP review documentation, including recommendations if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting.A line was added to ISP to indicate that the ISP was sent to supports coordinator and all team members and when it was sent. FLS was trained on 6500.156(d)(send doc) FLS is responsible to ensure all team members and SC receive ISP plans for all meetings. 04/15/2013 Implemented
6500.156(e)The family living specialist did not notify plan team members of the option to decline Individual Support Plan review documentation for Individual #1. Reviews for Individual #1 were conducted on 3/1/12, 6/1/12, 9/1/12, 11/19/12, and 2/9/13. (Partially Implemented-Adequate Progress; 5/21/13; CEM)The family living specialist shall notify the plan team members of the option to decline the ISP review documentation.Declination form was created. (send doc) FLS was trained on regulation 6500.156(e)FLS has sent Declination option to all team members. FLS will be responsible for sending out option for team members to decline receiving ISP review documentation. 04/15/2013 Implemented
6500.182(c)(1)(ii)The record for Individual #1 does not address identifying marks of the individual. (Partially Implemented-Adequate Progress; 5/21/13; CEM)(c ) Each individual's record must include the following information: (1.)Personal information, including: (ii)The race, height, weight, color of hair, color of eyes and identifying marks.FLS filled in identifying marks on the individual¿s record fact sheet. (send doc)FLS was trained on reg6500.182(c)(1)(ii)(send doc)Individual record fact sheet will have all personal information filled out. If any information is unknown N/A will be documented. All status changes will be updated on this sheet as they occur. FLS is responsible for completing and updating this sheet accurately. 04/15/2013 Implemented
6500.182(c)(1)(iv)The record for Individual #1 does not address the religious affiliation of the individual. (Partially Implemented-Adequate Progress; 5/21/13; CEM) (c ) Each individual's record must include the following information:( 1.)Personal information, including: (iv)The religious affiliation.FLS filled in religious affiliation on the individual¿s record fact sheet. (send doc)FLS was trained on reg6500.182(c)(1)(iv)(send doc)Individual record fact sheet will have all personal information filled out. If any information is unknown N/A will be documented. All status changes will be updated on this sheet as they occur. FLS is responsible for completing and updating this sheet accurately. 04/15/2013 Implemented
6500.182(c)(6)(ii)The record for Individual #1 does not include a copy of the invitation letter to the annual update meeting held on 11/19/12. (Partially Implemented-Adequate Progress; 5/21/13; CEM)( c) Each individual's record must include the following information: (6) A copy of the invitation to: (ii) The annual update meeting.Invitations to all meetings will be sent and a record of it will be kept in individuals file. FLS was trained on regulation 6500 182(c)(6)(ii)(send doc) FLS is responsible to ensure all invites are sent to all team members for all annual update meetings. 04/15/2013 Implemented
SIN-00211825 Renewal 09/14/2022 Compliant - Finalized
SIN-00157707 Renewal 06/20/2019 Compliant - Finalized
SIN-00065442 Renewal 06/23/2014 Compliant - Finalized