Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00266369 Renewal 06/09/2025 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)At the time of the inspection on 6/11/25 there was a golf ball sized amount of lint in the dryer. Floors, walls, ceilings and other surfaces shall be free of hazards.The lint was removed from the lint from the lint trap. Create a document that outlines the process of removing clothes and lint from dryer, with photos, to distribute to the team by 07/15/2025. 09/01/2025 Accepted
6400.68(b)At the time of the inspection on 6/11/25 the water temperature in the basement bathroom sink was 154.2 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. A mixing valve was installed to regulate temperature and was in range on 06/17/25. 07/31/2025 Accepted
6400.82(f)At the time of the inspection on 6/11/25 there was no soap in either of the bathrooms on the first floor of the home.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Home will make sure soap is non-toxic and take a picture of it at the sink by 07/07/2025 08/15/2025 Accepted
6400.112(d)The fire safety expert recommended an extended evacuation time of 10 minutes on 5/16/24 and not again until 6/10/25 which is outside the annual timeframe with allowable 15-day grace period. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Annual evaluation completed by 06/20/2025. Operations team will be retrained on the requirement for annual evaluation by 07/05/2025. 07/15/2025 Accepted
SIN-00256173 Unannounced Monitoring 09/23/2024 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #1's 6/7/24 Individual Support Plan indicates they are to be using a hand splint on their left hand; however, this has not been in use in the home. There was not a discontinue order on file from a medical provider for ceasing the use of this splint until 11/5/24. Individual #1 is incontinent and requires staff assistance to reposition to prevent skin breakdown. This is to be done every 2 hours. There is tracking to be completed, however, it is completed per shift as opposed to every 2 hours and is frequently not completed by staff.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. Discharge order for hand splint was obtained on 11/5/24. Team member who failed to obtain written instructions prior to 11/5/24 is no longer employed at Friendship Community. A system has been implemented where Residential Managers are now confirming in an electronic system that they have checked documentation for completion on a weekly basis. 01/31/2025 Accepted
6400.18(b)(2)A medication error occurred on 8/25/24, was discovered on 9/12/24, and was not entered into the department's incident management system until 9/18/24.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person: A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner.The Nursing team, including the nurse who discovered the error during a MAR Review but did not report it sufficiently which led to the late EIM report, was instructed to notify both the Residential Manager and Coordinator as soon as they discover a med error, since a Neglect report might need to be entered in addition to the Medication Error report. 01/01/2025 Accepted
6400.52(c)(6)Individual #1 has an Individual Support Plan (ISP), aspiration risk which requires Fatal Five training, and a hoyer lift for transfers that staff need to be trained in before working with Individual #1. Staff persons #10, 16, 17, 18, and 20 were not trained in Individual #1's ISP before working with Individual #1.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.Train staff persons #10, 16, 17 on Individual #1's most recent ISP and trainings required to work with Individual #1. Complete trainings with staff persons #18 and 20 if they return to Individual #1's home to complete cross-training process. 12/31/2024 Accepted
6400.166(a)(2)Individual #1's September 2024 Medication Administration Records do not include the prescriber for Doxycycline.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.Train eMAR Facilitators to check to ensure that all required details are present when verifying medication orders in the eMAR. 01/01/2025 Accepted
6400.166(a)(5)Individual #1's September 2024 Medication Administration Records do not include the strength for Doxycycline.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.Train eMAR Facilitators to check to ensure that all required details are present when verifying medication orders in the eMAR. 01/01/2025 Accepted
6400.166(a)(11)Individual #1's September 2024 Medication Administration Records do not include the diagnosis or purpose for Vitamin D2 and Doxycycline.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.Train eMAR Facilitators to check to ensure that all required details are present when verifying medication orders in the eMAR. 01/01/2025 Accepted
6400.166(a)(14)Individual #1's September 2024 Medication Administration Records do not include the duration of treatment for Doxycycline.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Duration of treatment, if applicable.Train eMAR Facilitators to check to ensure that all required details are present when verifying medication orders in the eMAR. 01/01/2025 Accepted
SIN-00245247 Renewal 06/11/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The most recent self-assessment completed on 11/14/23 identified the following violations: 152c2. No plan of correction was completed.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. Associate Directors of Operations shall gather all of the necessary supporting documentation of the corrective action plans by 7/12/24. 08/15/2024 Implemented
SIN-00226523 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 10/12/22 did not assess compliance with the following regulations: 6400.45a -- 6400.45e, 6400.52c5, 6400.52c6, 6400.181e13ix, and 6400.213(3) -- 6400.213(5).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
SIN-00207969 Renewal 07/11/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(4)Individual #1 had a vision screening on 4/14/21 and not again since, outside of the annual timeframe.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Individual #1's next Optometry appointment is scheduled for 08/08/2022. 09/01/2022 Implemented
6400.141(c)(7)Individual #1 had a gynecology exam on 1/29/21 and not again since, outside of the annual timeframe.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. Associate Director to work with Residential Coordinator and Manager to collect a letter from the physician with reason for deferment by 8/15/2022. 09/01/2022 Implemented
6400.141(c)(8)Individual #1 had a mammogram on 8/4/20 and not again until 9/1/21, outside of the annual timeframe.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. Individual #1's next mammogram is scheduled for 09/02/2022. 09/01/2022 Implemented
6400.142(e)At the dental appointment on 12/15/21, it was recommended Individual #1 have an OR Prophy with X-Rays. As of the time of the inspection, this has not occurred or been scheduled.Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed.Individual #1's next dental care appointment is scheduled for 08/31/2022. 08/31/2022 Implemented
6400.144On 9/14/21, it was recommended Individual #1 have a non-fasting lab scheduled in a week due to high Depakote levels. This lab was not scheduled and did not take place. Individual #1's next labs were not completed until 10/28/21.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. A retraining shall be completed with the Residential Manager, MSP, and Nursing Coordinator overseeing the home by the Associate Director overseeing Training by 08/23/2022. 08/23/2022 Implemented
SIN-00191551 Renewal 08/10/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(a)There was no smoke detector in the attic. There was a heat monitoring detector that did not activate during the inspection. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Installation of an audible smoke detector shall be facilitated by Friendship Community Maintenance Team by 9/23/21. Friendship Community Maintenance Team shall survey all homes by 10/31/21 to ensure there is a functioning, audible smoke detector in all accessible attic spaces. 09/23/2021 Implemented
SIN-00245380 Renewal 05/30/2024 Compliant - Finalized