Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00250830 Renewal 09/04/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.34(a)Individual #1 was informed of Individual rights and the process to report a rights violation on 4/4/23 then again 4/24/24.Individual rights and the process to report a rights violation shall be explained to the individual, and persons designated by the individual prior to moving into the home and annually thereafter.¿ Family Living Program Specialist were trained by program director on 9/9/24 on 6500-34a.(see attached training doc) ¿ Current Clients Rights and Consent documents for all clients were reviewed and are scheduled to be completed before 365 days of the last one. ¿ A spreadsheet will be kept listing Annual Consent Packet completion dates, including Client Rights, to ensure annual completion within regulation timelines. (see attached checklist) 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
6500.139(a)Family Living Provider #1 has not completed the medication administration training. Family Living Provider #1 administered Loratadine 10MG, take one tablet daily as needed for allergies and Fluticasone Propionate 50mcg, instill one spray in each nostril daily as needed for allergies, to Individual #1 from September 1, 2024, to September 4, 2024 at 8:00AM.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6500.132 (relating to medication administration).¿ Family Living Provider #1 completed modified medication administration training on 9/6/24 (copy of cert included) ¿ 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. ¿ A monthly training schedule will be created and distributed to each Family Living Provider to ensure they know the month the training is to be completed. 09/24/2024 Implemented
6500.152(c)Individual #1's assessment, completed 2/23/24 indicated that Individual #1 has up to 3 hours alone time at home and 15 minutes unsupervised time in the community. Individual #1's ISP updated, 6/20/2024 reads, "[Individual #1] IS SUPERVISED AT HOME AND REQUIRES SOMEONE ON SITE TO ENSURE HIS HEALTH AND SAFETY. HE IS ABLE TO HAVE UP TO 15 MINS OF ALONE TIME IN THE HOME" and Individual #1 "REQUIRES SUPERVISION AND GUIDANCE TO HELP MAINTAIN AND LEARN APPROPRIATE SOCIAL AND COMMUNITY SKILLS, AS WELL AS PROTECT HIM FROM POTENTIALLY HARMFUL SITUATIONS AND PEOPLE." Individual #1's assessment, completed 2/23/24 indicated that Individual #1 is safe around poisons. Individual #1's ISP updated, 6/20/2024 reads, "[Individual #1] WOULD NOT GENERALLY INGEST POISONS BUT SHOULD USE CLEANING PRODUCTS WHEN ACCOMPANIED BY STAFF."The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.Assessment was reviewed and revised to match the ISP wording on 9/15/24. Family Living Program Specialist will review assessment and ISP at next quarterly meeting with supports coordinator in November 2024.¿ Family Living Program Specialist was trained by program director on reg 6500 152 c on 9/9/24 (see attached training doc) ¿ Each quarter, assessment packet dues dates will be determined and discussed during supervision with Clinical Coordinator/Program Director and Family Living Program Specialist. (see supervision form) 09/24/2024 Implemented
SIN-00211827 Renewal 09/14/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.71The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the telephone in the basement of the home.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.Telephone numbers were posted by the phone in basement. FLP and FLS was trained in regulation 6500.71 10/05/2022 Implemented
SIN-00137354 Renewal 06/20/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.17(a)The self assessment completed on 12/18/17 did not measure compliance with regulations 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 6500.17 [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-00117832 Renewal 07/05/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.31(b)A statement acknowledging receipt of the information on individual rights was signed by Individual #1 on 3/17/16 and then again 4/13/17.A statement signed and dated by the individual, or the individual's parent, guardian or advocate if appropriate, acknowledging receipt of the information on individual rights upon admission and annually thereafter, shall be kept.FLS was trained on 7/20/17 on reg 6500.31(b). all consents will be reviewed and signed within 1 year of prior consents. Clinical coordinator will review files quarterly to ensure all documents including consents are signed off on annually. [Within 30 days of receipt of the plan of correction, the Program Manager shall develop and implement a tracking system to ensure individuals are informed of the individuals' rights, timely. Within 45 days of receipt of the plan of correction, the program specialist shall be trained on the tracking system. At least quarterly, for 1 year the Program Manager shall review the tracking system to ensure individuals are informed of the individuals' rights, timely. (AS 8/10/17)] 08/03/2017 Implemented
6500.121(a)Individual #1 had a physical examination completed on 5/18/16 and then again on 6/7/17.An individual shall have a physical examination within 12 months prior to living in the home and annually thereafter.FLS was trained on 7/20/17 on reg 6500.121(a). all physicals will be completed within 1 year of prior exam. Clinical coordinator will review files quarterly to ensure all medical appointments occur annually[Within 30 days of receipt of the plan of correction, the Program Manager shall develop and implement a tracking system to ensure individuals have a physical examination, timely. Within 45 days of receipt of the plan of correction, the program specialist shall be trained on the tracking system. At least quarterly, for 1 year the Program Manager shall review the tracking system to ensure individuals have a physical examination, timely. (AS 8/10/17)] 08/03/2017 Implemented
6500.156(a)Individual #1's most recent ISP review was completed 4/1/16. The family living specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the family living 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.Family living specialist held quarterly ISP reviews but did not file appropriate supporting documents, signature pages. FLS was trained on 6500.156(a) Clinical coordinator will review all files quarterly to ensure proper documentation is maintained for quarterly ISP reviews. [Documentation of reviews shall be kept. (AS 8/11/17)] 08/03/2017 Implemented
SIN-00233475 Renewal 09/12/2023 Compliant - Finalized
SIN-00195484 Renewal 10/21/2021 Compliant - Finalized
SIN-00178424 Renewal 10/27/2020 Compliant - Finalized
SIN-00157709 Renewal 06/20/2019 Compliant - Finalized