Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00247899 Renewal 08/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #1 is prescribed Chlorpromazine 50 mg tab, pro re nata (PRN) for aggression, can take with Lorazepam PRN. The prescription does not include symptoms of the specific mental, emotional, or behavioral condition which would require administration of this as needed medication such as the specific symptoms of aggression displayed by Individual #1 that would then indicate there is a need for the staff to administer the medication. In addition, there is no protocol or specific directions in their record for the administration of this medication. Individual #1 is prescribed Lorazepam 2 mg tab, PRN for anxiety *may take w/ Thorazine. The PRN psychiatric medication protocol form dated 7/31/24 for Individual #1's medication Lorazepam includes the specific symptoms of anxiety/aggression was completed by the agency nurse. The agency stated that the prescribing physician supported the agency nurse on the protocol however there was no documentation in the file to substantiate that the physician stated the specific symptoms of anxiety displayed by Individual #1 for staff to administer the PRN medication.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. Program Specialist contacted practitioner and obtained a PRN protocol for both medications which indluded the symptoms and the need to occassionally administer medications together. 08/19/2024 Implemented
6400.165(g)Individual #1 is prescribed medication to treat symptoms of a diagnosed psychiatric illness. Individual #1 had 3-month medication appointment on 9/9/23 and the next one on didn't occur until 1/11/24. This exceeds the requirement.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.Residential Manager will monitor medical appointment calendar to ensure appointments are in compliance and completed timely. 08/22/2024 Implemented
SIN-00191815 Renewal 08/10/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)Financial statements provided for review indicate that two comforter sets in the amount of $44.99 each were purchased. One sheet set in the amount of $22.99 and one sheet set in the amount of $23.95 were purchased using Individual #1's funds. Standard bedding is to be purchased by the agency.Individual funds and property shall be used for the individual's benefit. Fitzmaurice will immediately reimburse this individual for the purchase of the bedding. Copy of the check will be sent to licensing. 09/09/2021 Implemented
SIN-00094187 Renewal 05/03/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(b)Individual #2 was admitted on 3/10/2016. She wasn't informed of her Individual Rights until 4/19/2016.Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. The Intake Process has been revised and the ID Intake Form will assist in having the Resident Rights reviewed on the move in day. See attached ID Intake Form 05/16/2016 Implemented
6400.113(a)Individual #2 was admitted on 3/10/2016. She didn't have her initial fire safety training until 3/16/2016. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. The Intake Process has been revised and the ID Intake Form will assist in tracking fire safety training for all new residents. See attached 05/16/2016 Implemented
6400.213(1)(i)There is no eye color listed in Individual #2's record. Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.The Intake Process has been revised and demographic information will be compiled prior to the individual moving into the CLA. See Attached demographic listing eye color and the ID Intake Form 05/16/2016 Implemented
SIN-00154067 Renewal 05/01/2019 Compliant - Finalized