Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00243040 Renewal 04/09/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The toilet paper dispenser in the 2nd story bathroom was broken off of the wall.Floors, walls, ceilings and other surfaces shall be in good repair. On 4/12/24 a toilet paper dispenser was installed. The Residential Supervisor will conduct training with group home staff on the process for reporting maintenance issues. Training will be completed by 5/31/24. Documentation will be maintained in staff HR files. Beginning May 2024 the Residential Supervisor will complete a monthly site monitoring form. This form will be sent to the Associate Director for review. Issue noted will be sent to the Manager of Facilities for follow up. 05/31/2024 Implemented
6400.141(a)The annual physical exam for individual #2 dated 2/9/24 was incomplete. The provided document appeared to be missing the first two pages which contained documentation required to qualify the appointment as an annual physical exam.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. A complete copy of Individual #2¿s physical exam was obtained on 5/6/24. The Associate Director will conduct training with Nursing staff regarding the review of medical documentation and process for follow up if issues like missing pages are identified. Training will be completed by 5/17/24. Documentation will be maintained in staff HR files. 05/17/2024 Implemented
6400.34(a)The most recent signed individual rights statement for individual #2 was dated 03/03/2023.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.On 5/8/24 individual rights were reviewed with Individual #2 and a signed copy has been placed in the individual¿s record. The Associate Director will conduct training with Program Specialists regarding individual rights regulatory requirements. Training will be completed by 5/31/24. Documentation will be maintained in staff HR files. 05/31/2024 Implemented
6400.165(b)PRN Neosporin prescribed to individual #2 was not present in the medication box.A prescription order shall be kept current.On 4/12/24 the medication was delivered to the home. The Residential Supervisor will conduct training with group home staff regarding the medication reordering process and medication counts to ensure all medications, including PRNs, are present. Training will be completed by 5/31/24. Documentation will be maintained in staff HR files. 05/31/2024 Implemented
SIN-00134331 Renewal 04/24/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill on 2/12/18 did not list if problems occurred during the fire drill.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 fire alarm or smoke detector was operative. On 5/10/18 the Associate Director conducted training with Program Specialists and Residential Managers focused on ensuring the mandatory use of the electronic fire drill form, equipped with mandatory fields that ensure compliance to regulatory requirements, which includes whether the alarm systems are operable. The Residential Manager will ensure the completion of the fire drill form using the electronic record system each month and will document on the monthly checklist and submit to the program specialist for review. The Program specialist will review the electronic records system to ensure the utilization of the electronic form and will maintain a tracking chart for that purpose. The Associate Director will complete a quarterly review of the tracking charts with the program specialists and will initial each month checked. 05/10/2018 Implemented
6400.112(h)The fire drill on 3/7/18 did not list the designated meeting place. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.On 5/3/18 the Associate Director conducted training with Program Specialists and Residential Managers focused on ensuring the mandatory use of the electronic fire drill form, equipped with mandatory fields that ensure compliance to regulatory requirements, which includes identifying the designated meeting place outside the building. The Residential Manager will ensure the completion of the fire drill form using the electronic record system each month and will document on the monthly checklist and submit to the program specialist for review. The Program specialist will review the electronic records system to ensure the utilization of the electronic form and will maintain a tracking chart for that purpose. The Associate Director will complete a quarterly review of the tracking charts with the program specialists and will initial each month checked. 05/03/2018 Implemented
SIN-00067520 Renewal 09/22/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)The most recent sleeping hour fire drill was conducted on 9/7/14; the previous sleeping hour fire drill was held on 12/6/13.A fire drill shall be held during sleeping hours at least every 6 months. Staff were retrained on fire drills on 10/1/14 and 10/8/14 to ensure that a sleeping drill is held at least every 6 months and ensuring legible documentation on the fire drill form. See attached training sheet. The residential managers will monitor through a tracking chart to ensure that the drill times vary and include sleeping hour drill at last every 6 months. The Program Specialist will monitor through submitted drills and will ensure another drill is run if the times had not been varied or did not include sleeping hours. 10/08/2014 Implemented
SIN-00052235 Renewal 09/16/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.164(a)On 9-13-13, staff A did not sign the medication log indicating that the multivitamin was administered to Individual #1 Staff A did not sign their full name and initials on the medication log. (a) A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. The Manager of Residential Programs has retrained the Program Specialists regarding review of the medication log and ensuring that any errors are reported via a medication error form. The Program Specialist will ensure the review of the medication logs weekly and the Residential Managers three times per week to confirm that they are being documented according to the regulatory requirement and that the full name of the person who is administering the medication is on the medex as well as their initials in the administration box. The Program Specialist and Residential Manager will initial the medex to confirm their review. Should it be found that an error occurred the Program Specialist or Residential Manager will ensure that a medication error form is filed and that follow up action is taken and that the error is communicated to the Director. The Program Specialist identified will submit the medication log reviews to the Manager of Residential services via weekly PS checklist for a period of three months. Training was completed on 10/24/13. 10/24/2013 Implemented
6400.165On 9-13-13 staff A committed a medication error by not signing the medication log indicating the multivitamin was administered to Individual # 1 and there was no documentation of the medication error. Documentation of medication errors and follow-up action taken shall be kept. The Manager of Residential Programs has retrained the Program Specialists regarding review of the medication log and ensuring that any errors are reported via a medication error form. The Program Specialist will ensure the review of the medication logs weekly and the Residential Managers three times per week to confirm that they are being documented according to the regulatory requirement and that the full name of the person who is administering the medication is on the medex as well as their initials in the administration box. The Program Specialist and Residential Manager will initial the medex to confirm their review. Should it be found that an error occurred the Program Specialist or Residential Manager will ensure that a medication error form is filed and that follow up action is taken and that the error is communicated to the Director. The Program Specialist identified will submit the medication log reviews to the Manager of Residential services via weekly PS checklist for a period of three months. Training was completed on 10/24/13. 10/24/2013 Implemented
SIN-00158974 Renewal 07/18/2019 Compliant - Finalized