Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00249619 Unannounced Monitoring 06/07/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(b)(1)Individual #1 had a behavioral health crisis event on 2/15/24. This event was detailed in EIM #9367437. In response to the incident, all staff were to be retrained in Individual #1's Behavior Support Plan by 2/15/24. This retraining did not occur.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. All staff were retrained in individual #1's Behavior Support Plan by the Behavior Specialist on 7/26/24 (Attachment #7). 09/30/2024 Implemented
6400.141(c)(14)The "medical information pertinent to diagnosis and treatment in case of an emergency" section of Individual #1's 5/20/24 physical states, "does well for fire drills."The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Individual #1's physical form was updated on 9/5/24 under "medical information pertinent to diagnosis and treatment in case of an emergency" (Attachment #5). 09/30/2024 Implemented
6400.141(c)(15)The special diet instructions section of Individual #1's 5/20/24 physical is blank.The physical examination shall include:Special instructions for the individual's diet. Individual #1's physical form was updated to include special diet instructions on 9/5/24 (Attachment #5). 09/30/2024 Implemented
6400.18(a)(4)A potential physical abuse incident was discovered by Community Services Group on 5/20/24. This incident was not entered into EIM until 6/6/24.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 24 hours of discovery by a staff person: Abuse, including abuse to a individual by another client. All staff received additional training completed by the Program Specialist on the IM Bulletin regarding Recognition, Reporting, and Filing incidents in the required timeframe established in the 6400 Regulations on 6/18/24 (Attachment #1). 09/30/2024 Implemented
6400.18(b)(1)On 4/8/24, staff noted in daily logs that Individual #1 was having a behavior and staff had to utilize a "bear hug" to keep Individual #1 from assaulting their roommate and staff. This physical restraint was not reported in the department's incident management system.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: Use of a restraint. An incident was entered into EIM on 8/15/24 to look into the 4/8/24 incident and an investigator has been assigned (Attachment #2). Additionally, individual #1's team has been collaborating to address the current challenges and staff received training on appropriate de-escalation techniques to prevent potential crisis situations on 6/18/24 (Attachment #1). 09/30/2024 Implemented
6400.18(f)A potential physical abuse incident was discovered by Community Services Group on 5/20/24. Individual #1 had bruising of unknown origin on their arm and side. A medical appointment to ensure the health and safety of Individual #1 was not conducted until 6/5/24.The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident.Staff were trained on daily body charting and CSG's Who to Call for Help by the Program Nurse and Program Specialist on 8/23/2024 (Attachment #4). 09/30/2024 Implemented
6400.18(g)A potential physical abuse incident was discovered by Community Services Group on 5/20/24. A certified investigation was not initiated until 6/6/24.The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person.All staff received additional training completed by the Program Specialist on the IM Bulletin regarding Recognition, Reporting, and Filing incidents in the required timeframe established in the 6400 Regulations on 6/18/24 (Attachment #1). 09/30/2024 Implemented
6400.18(b)(2)The medication errors described in 6400.167a1 were not reported in the department's incident management system.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 medication errors described in 6400.167a1 were entered into EIM on 8/15/24 (Attachment #3) by the Program Manager. 09/30/2024 Implemented
6400.32(c)Individual #1 has a bowel protocol in place dated 3/10/2020 which indicates that if Individual #1 does not have a bowel movement within 72 hours, polyethylene glycol is to be administered. If no bowel movement within 24 hours of PRN Poly Glycol administration, Individual #1's PCP is to be contacted. Individual #1 does not currently have Polyethylene Glycol as one of their PRN medications. Sennosides are Individual #1's only PRN related to bowel movements. Additionally, PRN bowel medications are not given consistently. Individual #1 went the following dates without a bowel movement and no PRN medications were administered: · 3/5/24 8:15am through 3/13/24 at 12pm · 3/14/24 3:13pm through 3/20 12:53pm · 3/20/24 12:53pm through 3/26/24 12:50pm · 3/28/24 6:31pm through 4/1/24 12:33pm · 4/4/24 5:55pm through 4/9/24 7:44am · 4/11/24 12:40pm through 4/15/24 12:15pm · 4/15/24 12:15pm through 4/25/24 6:15pm · 4/25/24 6:15pm through 5/8/24 7:48am · 5/9/24 2:04pm through 5/17/24 8:46am · 5/17/24 8:46am through 5/22/24 8:05am · 5/29/24 8:10am through 6/11/24 There were 2 occasions where PRN Sennosides were also administered less than 72 hours after a bowel movement: · 3/22/24 7:54am (a bowel movement was recorded on 3/20/24 at 12:53pm) · 3/28/24 12:20pm (a bowel movement was recorded on 3/26/24 at 12:50pm) Failure to have a current bowel movement protocol in place creates conditions conductive to serious harm for Individual #1.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.Individual #1's bowel movement protocol was updated by the PCP on 9/5/24 (Attachment #5) and eMAR was updated (Attachment #6). Staff will be trained by the Program Specialist on the update by 9/13/24. 09/30/2024 Implemented
6400.166(a)(2)There was no prescriber name for the following medications on Individual #1's Medication Administration Record: Mucinex Fast Max Cold and Flu, Laxative Sennosides, Vitamin D, Sodium Fluoride, Prenatal vitamin, Pantoprazole, Magnesium Glycate, Loratadine, Lamotrigine, Ear Wax removal drops, Culturelle, and Vitamin B12.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.The prescribing physician was added by the Program Supervisor on 8/16/24 to individual #1's Medication Administration Record for the following medications: Mucinex Fast Max Cold and Flu, Laxative Sennosides, Vitamin D, Sodium Fluoride, Prenatal vitamin, Pantoprazole, Magnesium Glycate, Loratadine, Lamotrigine, Ear Wax removal drops, Culturelle, and Vitamin B12 (Attachment #6). 09/30/2024 Implemented
6400.166(a)(5)There was no strength of medication for the following medications on Individual #1's Medication Administration Record: Mucinex, Mirafiber Gummies, Magnesium Glycate.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.The strength of medication was added by the Program Supervisor on 8/16/24 to individual #1's Medication Administration Record for the following medications: Mucinex, Mirafiber Gummies, Magnesium Glycate (Attachment #6). 09/30/2024 Implemented
6400.167(a)(1)Individual #1 did not receive their 8am medications on 4/30/24. Individual #1 did not receive their 9pm dose of Benzotropine on 5/2/24.Medication errors include the following: Failure to administer a medication.The medication error individual #1's missed 9pm dose of Benztropine on 5/2/24 was entered into EIM on 8/15/24 by the Program Manager (Attachment #3). 09/30/2024 Implemented
6400.182(b)Individual #1 lived at home with their parents during the COVID-19 pandemic, extending from 2020 through 11/29/23, when Individual #1's transition back to the home resumed. Individual #1 should have been treated as a new admission with an updated Behavior Support Plan completed within 90 days of the individual's return to the home, addressing Individual #1's current behaviors with the transition. The most recent Behavior Support Plan was updated on 11/28/23, prior to Individual #1's return and has not been updated with behaviors that Individual #1 has had since return.The initial individual plan shall be developed based on the individual assessment within 90 days of the individual's date of admission to the home.Individual #1's behavior plan was updated by the Behavior Specialist on 7/19/24 (Attachment #8). The Behavior Specialist trained staff in this updated behavior plan on 7/26/24 (Attachment #7). 09/30/2024 Implemented
SIN-00217413 Renewal 01/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(c)At the time of the inspection the first aid kit in the home did not have a first aid manual. A first aid manual shall be kept with the first aid kit.A first aid manual was placed in the first aid kit on the day of inspection on 1/11/23. See picture of first aid manual in the first aid kit. 02/07/2023 Implemented
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SIN-00199538 Renewal 02/07/2022 Compliant - Finalized
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