Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00245246 Renewal 06/11/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)(Repeat from 7/5/23) Individual #1's finances were used to purchase incontinence products on 2/28/24 and 3/22/24.Individual funds and property shall be used for the individual's benefit. Friendship Community started a certified investigation of exploitation for individual #1 on 7/10/24. Friendship Community reimbursed individual #1 funds on 6/18/24. 08/30/2024 Implemented
6400.141(a)Individual #1's most recent physical completed on 8/2/23 was completely blank and indicated to "see attached." The attached did not document the following information: information pertinent to treat diagnose in the event of an emergency, Diet, Physical Limitations, Health Maintenance Needs, and immunizations.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual #1 has a physical examination scheduled for 7/30/24. 08/30/2024 Implemented
SIN-00234713 Unannounced Monitoring 10/24/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(15)Individual #1's 9/26/23 annual physical examination indicates that the individual required nectar-thickened liquids, however, Individual #1 required honey-thickened liquids. This recommendation did not change.The physical examination shall include:Special instructions for the individual's diet. Individual passed away so we are unable to have the physical examination corrected for correcting the initial findings. 11/30/2023 Implemented
6400.143(a)Individual #1 was to be completing 2 different physical therapy exercises 20 times each twice daily. Individual #1 frequently refused this physical therapy. From 8/1/23 through 10/22/23, this therapy was only completed twice in a day for 10 total days. Physical therapy was completely refused for a total of 33 days. Individual #1 was not trained in the importance of completing this exercise after refusals.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. DSP, RM's and RC's will be trained on the importance of routine medical appointments/treatment plans and how to inform the individual about the refusals and informing the individuals support team about the refusal (RC, RC, nurse, Behavorial support and Program Specialist). 12/04/2023 Implemented
6400.144Individual #1 required complete ostomy bag changes every 4th day or as needed. Individual #1's ostomy bag was not changed following the every 4th day requirement on the following dates: · Changed on 8/18/23 and not again until 8/26/23 · Changed on 9/21/23 and not again until 9/29/23 · Changed on 10/4/23 and not again until 10/12/23 Individual #1 required ostomy bag checks every 2 hours. Additionally, their output was to be tracked in order to administer a PRN medication if required. Bag check tracking was in place every 2 hours, however, the following dates and times were blank. · 8/5/23 10pm · 8/7/23 10am, 12pm · 8/8/23, 10am, 6pm · 8/9/23 8pm · 8/14/23 12pm · 8/26/23 6pm, 6am · 8/27/23 4am, 6am · 8/29/23 10am, 12pm · 9/5/23 12pm, 2pm · 9/22/23 10am · 10/1/23 10am · 10/2/23 10am · 10/5/23 12am, 2pm, 8pm · 10/7/23 8am, 12pm, 2pm · 10/8/23 10am · 10/9/23 10am, 12pm · 10/10/23 10am, 2pm · 10/19/23 12pm, 2pm Individual #1 had a nutritional supplement plan in place updated on 4/28/23 that indicated that Individual #1 was to receive nutrition supplements 3 times per day between meals. Individual #1 was to be offered a high protein supplement shake or a Gelatein high protein jello snack. Additionally, Gelatein was only to be offered once/day. On 9/26/23, Individual #1's PCP changed the recommendation to one high protein shake daily and they discontinued the Gelatein high protein jello snack. On the following dates, Individual #1 was not documented as receiving their high protein supplement: · 8/4/23 in the morning · 8/14/23 in the morning · 8/18/23 in the morning · 8/25/23 in the morning and evening · 8/26/23 in the evening · 8/29/23 in the morning · 9/8/23 -- All supplements · 9/14/23 in the afternoon · 9/15/23 in the morning · 9/22/23 in evening Additionally, on 21 days in August and September 2023, Individual #1 was given Gelatein more than the once daily order. Yogurt, which is not a part of the plan, was also given on 20 different occasions instead of the high protein shake or Gelatein. Pudding was also given once. Once the change to once daily shakes started on 10/1/23, Gelatein was given 7 times. Yogurt was given 4 times. Individual #1 is to be offered Pedialyte or sugar-free Gatorade on the dates that they are administered their PRN Diphenoxylate-Atrop. There is no tracking in place to ensure that this is being offered.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. Retraining shall be completed for direct support professional and manager of the home on the importance of proper documentation for all health services by 1/16/24. 11/30/2023 Implemented
6400.52(c)(6)Individual #1 had the following plans in place before they passed away on 10/23/23: · Individual Support Plan (ISP) · Nutrition Supplement (an additional update was completed on 9/26/23) · Ileostomy Diet · Chopped Foods · Thickened Liquids · Gait impairment and Assistive Devices · Use of Alarms/Fall Prevention · Emptying the Ileostomy Bag · Troubleshooting Ileostomy · Procedure for changing Ileostomy Bag · Parkinsonism Individual #1 moved into their most recent home on 7/17/23. Between 7/17/23 and 10/23/23, a total of 15 staff worked in Individual #1's home. None of those staff received training on all of Individual #1's plans and protocols before working with Individual #1. · Staff persons #5, 6, 7, 9, 10, and 15 did not receive any training on Individual #1's plans and protocols. · Staff persons #1, 2, and 12 did not receive training on Individual #1's Individual Support Plan or Nutrition Supplement plan. · Staff persons #3, 4, 8, 11, and 13 received training on Individual #1's Individual Support Plan, but not until after working with Individual #1. · Staff persons #2, 4, and 11 did not receive training on Individual #1's Ileostomy Diet, Chopped Foods, Thickened Liquids, Gait impairment and Assistive Devices, Use of Alarms/Fall Prevention, Emptying the Ileostomy Bag, Troubleshooting Ileostomy, and Procedure for Changing Ileostomy Bag until after they started working with Individual #1. · Staff person #14 did not receive any training on Individual #1's Ileostomy and related care.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Assoicate Director of Operations shall train DSPs, RMs, and RC on the importance of individual specific plans/protocols by 1/16/24. Program Specialist and nursing consultants shall audit all individuals plans/protocols to ensure compliance by 1/16/24. 12/04/2023 Implemented
6400.167(a)(1)Individual #1 had a PRN prescription for Diphenoxylate-Atrop which is to be administered if Individual #1's ostomy bag output is greater than 1500cc in 24 hours. On 8/31/23, Individual #1's output was 1550cc, and Individual #1's PRN was not administered.Medication errors include the following: Failure to administer a medication.Medication error was entered in to the EIM system on 11/13/23. 11/30/2023 Implemented
6400.167(c)The medication error described in 6400.167a1 was not reported as an incident in the Department's incident management system.A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation).Medication error was entered in to the EIM system on 11/13/23. 11/30/2023 Implemented
6400.186Individual #1's Individual Support Plan (ISP) indicates that Individual #1 is to receive at least hourly checks overnight because of their risk of seizures. While checks were being completed every 2 hours for Individual #1's ostomy bag, there were not hourly checks being tracked to ensure the plan is being followed.The home shall implement the individual plan, including revisions.Retraining shall be completed with the direct care professionals of the home about prior implementation of individuals plan and how to document once completed. Training shall be completed by 12/30/23. 11/30/2023 Implemented
SIN-00226522 Renewal 07/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment for the home completed on 12/1/22 did not assess compliance with the following regulations: 6400.50a, 6400.51b5, 6400.68a, 6400.213(3) -- 6400.213(5), and 6400.217.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. Associate Directors of Operations and the Director of Operations shall standardize the annual self-assessment process, including assigning point people to ensure that all self-assessment items are marked appropriately. 10/01/2023 Implemented
6400.15(c)(Repeated Violation -- 7/11/22) The self-assessment for the home completed on 12/1/22 did not include a written summary of corrections for the following violations: 6400.104, 6400.141c7, 6400.141c13, 6400.142b, 6400.144, 6400.165b, and 6400.171.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. Director of Operations and Associate Directors of Operations will model after RCG guide to follow the five steps and instruct point people to write an effective Plan of Correction and focus on prevention of citations by 9/1/23. 10/01/2023 Implemented
6400.62(a)Individual #1's 6/14/23 assessment includes contradictory information regarding their ability to safely use and avoid poisonous materials. The assessment states the individual has been evaluated to not be able to safely use or avoid poisonous materials due to their visual impairment and dementia, and it was noted they were having trouble with the following materials: milk, mouthwash, hand sanitizer, and disinfectant. The assessment also states they have been safe with hand sanitizer, hand soap, and dish soap. During the 7/6/23 inspection, multiple items that contained a label to contact poison control if ingested were found unlocked and accessible to Individual #1. These items included: mouthwash, toothpaste, sunscreen, and personal care items in the bathroom by the garage, hand sanitizer gel on a shelf in the kitchen and on the hallway bathroom counter, and Pine Sol, Multipurpose cleaner, Microban disinfectant and hand sanitizer in the hallway closet.Poisonous materials shall be kept locked or made inaccessible to individuals. Program Specialist will write an assessment addendum to reflect poisonous materials that do not need to be locked based on an updated evaluation tool by 8.11.23. 10/01/2023 Implemented
6400.110(a)During the 7/6/23 inspection, a smoke detector was not located in the basement or on the basement level of the home. A smoke detector was located on the ceiling at the top of the basement steps, however, this was the same level as the first floor of the home. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Associate Director of Facility Services moved smoke detector in the residential home to the ceiling of the basement on 7/26/2023. 10/01/2023 Implemented
6400.110(b)The smoke detector in the common area of the hallway is more than 15 feet from Individual #1's bedroom door.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. Associate Director of Facility Services moved the smoke detector to be within 15 feet of the bedrooms on 7/26/2023. 10/01/2023 Implemented
6400.111(f)The fire extinguishers for the home were inspected on 3/14/22 and not again until 3/16/23, outside of the 1-year time frame required by regulation. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. Director of Operations will train the Associate Director of Facility Services on the expectation of all fire extinguishers needed to be approved annually by a fire safety expert. 10/01/2023 Implemented
SIN-00157466 Renewal 08/13/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone number to the nearest hospital was not located on or near the telephone in the kitchen. This was rectified onsite during the inspection.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. Immediate: Emergency Numbers, including the nearest hospital, were immediately placed on the phone in all locations where a phone is present within the home on 8/15/19 by the Program Manager. Global Immediate: Program Managers and Program Coordinators received retraining by the Director of Operations on 8/15/19 regarding the necessity to have all emergency numbers, including the nearest hospital, located on or near each phone in the home. Program Managers shall verify all required Emergency Numbers are located either on or near every phone within their program. Verification of this review shall be sent to the Associate Directors of Operations by 8/31/19. Any occurrences of phones missing any of the Emergency Numbers shall be rectified immediately upon discovery. Global Preventative: A standardized template for each program shall be developed that contains all necessary information/phone numbers by Operations Leadership. This shall be developed by 8/31/19 and distributed to every 6400 program. Program Coordinators shall receive retraining on the necessity to verify during their monthly monitoring that all emergency numbers are present on or by every phone within the program. This retraining shall be provided by the Associate Directors of Operations on or before 8/31/19. All training/retraining documentation shall be kept on file. 08/31/2019 Implemented
6400.110(f)During the 8/15/19 onsite inspection, the home manager stated that Individual #1 recently attended an audiologist appointment. During that appointment, the individual's physician stated that Individual Individual #1 would not be able to hear the smoke detectors should Individual#1 not be wearing his hearing aids. According to the home manager, Individual #1 often chooses not to wear his hearing aids during the day. According to the individual's current, 8/14/19, Individual Support Plan review created by Friendship Community Services, "Individual #1's audiologist does not believe that he can hear the smoke detectors or hear the smoke detectors at a volume loud enough to alarm him to exit when he is not wearing his hearing aids." This audiologist appointment was held on 7/2/19 with Audiologist Bethany Noll. The home was not equipped with strobe lights to alert the individual if he was using the bathroom, living room, kitchen, dining, laundry, garage, sun room, or basement. The strobe light in his bedroom was not operable during the time of the inspection. The bed shaker did not activate when the smoke detectors in his bedroom or the hallway entrance was set off. If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. Immediate: An interconnected strobe light system has been purchased by Facility Services and shall be installed immediately upon the system¿s hardware arrival to the organization. Global Immediate: Retraining was provided to all Program Managers and Program Coordinators on 8/15/19 by the Director of Operations regarding the requirement to ensure that all smoke detectors and fire alarms are equipped so that each person with a hearing impairment can recognize the need to evacuate in the event of a fire. A list shall be compiled of all Individuals and Team Members who may require or benefit from interconnected strobe lights to provide a visual cue during the event of a fire drill and/or actual fire event by Associate Directors of Operations and/or Program Specialist Team on or before 8/31/19. Each situation shall be reviewed by the Associate Director of Facility Services and installation of strobes and/or interconnected detectors in homes where required will occur within 2 weeks following discovery of the need. Team Members trained in the various 6400 locations where Individuals and/or Team Members have been diagnosed with hearing impairments shall be notified of the need to have heightened awareness throughout this period of evaluation and installation of interconnected strobe lights, with the expectation of immediate support given to those with hearing impairments during the event of an actual fire. Global Preventative: An assessment and prompting system shall be developed and trained on by 10/31/19 to ensure that timely installation of interconnected strobe lights occurs when an Individual is admitted to Friendship Community¿s programs, as applicable, and/or upon new diagnosis of a hearing impairment where it has been determined that the Individual may have difficulty recognizing an audible only alarm. Assessment shall occur without the Individual using a hearing aid to determine the greatest need of the Individual. This shall be developed by the Support Services Team and implemented by 11/1/19. Assessment shall include overnight responses with environmental modifications in place. The admission and transfer checklists shall be updated by Operations Generalist on or before 8/31/19 to include a prompt to immediately address the installation of an interconnected strobe light alarm system at a home prior to the admission and/or transfer of an Individual to a new home. A specific Audiology form shall be developed, trained on and implemented, on or before 9/30/19 by the Support Services Team to address audiology needs including the need for environmental modifications related to fire evacuation based on a new or existing hearing impairment diagnosis. This form shall be used for all Audiology appointments and at the time of admission physicals for all Individuals who intend to receive services. Each completed form where an environmental modification is recommended by an Audiologist shall be addressed with Facility Services within 24 hours after receipt. The fire drill record template for all programs shall be adjusted to reflect the home¿s review of all adaptive equipment related to fire egress (i.e. strobe lights, interconnected system, bed shaker, etc.) at the time of each drill, which is intended to bring immediate awareness to the person completing the drill if any needed equipment is absent or non-operational. The form will also provide a prompt to submit an immediate request to the Maintenance Team if any equipment is needed for the purposes of fire egress safety. This template shall be updated by the Operations Generalist and/or Associate Director of Operations on or before 8/31/19 for implementation by all programs in the month of September. Beginning in September 2019, Associate Directors of Operations shall review each Programs¿ Monthly Fire Drill records for 6 months, to end February 2020, to ensure all fire drills have been successfully completed within the designated evacuation time frame, and that 11/01/2019 Implemented
6400.188(a)Individual # 2 and Individual # 1 have dietary needs and restrictions that require the individual's food to be pureed and liquids to be thickened. According to the provider, there are health and safety concerns for the individual's choking if the food is not locked. On 3/14/18, the agency reached out to ODP licensing supervisor, who directed the agency to include the restrictions in both individual's assessments and Individual Support Plans (ISP) which will suffice for documentation needed to provide support to the individuals. During the onsite inspection, it was found that Individual #2's assessment was never updated to include this restriction until 8/12/19 and the restriction is not included in her ISP yet.The home shall provide services, including assistance, training and support for the acquisition, maintenance or improvement of functional skills, personal needs, communication and personal adjustment.Immediate: Retraining occurred with the Program Manager and Program Coordinator on 8/15/19 regarding the requirement to update plans accordingly within a timely manner to ensure provision of all services and supports according to each person¿s needs and in adherence with regulatory guidelines. Training included, in particular, if a person transfers from one home to another, there must be a review of each housemate¿s paperwork to ensure that all applicable information regarding restrictions of a housemate are included in each person¿s ISP and Assessment. Global Immediate: Retraining occurred with Program Specialist Team, in addition to Program Managers and Program Coordinators, on 8/15/19 regarding the requirement to update plans within a timely manner to ensure provision of all services and supports according to each person¿s needs and in adherence with regulatory guidelines. Training included, in particular, if a person transfers from one home to another, there must be a review of each housemate¿s paperwork to ensure that all applicable information regarding restrictions of a housemate are included in each person¿s ISP and Assessment. Associate Director of Support Services or designee shall review each Individual¿s dietary restrictions on or before 8/31/19 to determine if these restrictions may have an impact on others who reside within the home. As applicable, the Associate Director of Support Services or designee shall ensure that each Individual¿s ISPs and Assessments contain consistent information and address each Individual¿s needs in the least restrictive way possible. Global Preventative: The admission, discharge and transfer checklists utilized for Individual¿s moves to a new location shall be adjusted by Operations Generalist on or before 8/31/19 to ensure that each Individual¿s ISPs and Assessments contain consistent information and address each Individual¿s needs in the least restrictive way possible. 08/31/2019 Implemented
SIN-00245379 Renewal 05/30/2024 Compliant - Finalized