Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00104630 Renewal 12/07/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There was a 3' by 7' dark grey stain on Individual #1's bedroom carpet.Clean and sanitary conditions shall be maintained in the home. The flooring in the bedroom of Individual #1 will be replaced by BCI flooring the week of January 9,2017 (Attachment #22). To prevent a recurrence, Team supervisors were retrained on the responsibility to ensure the physical site of the home is in compliances with all regulatory requirements to include a clean and sanitary home. Any violation that cannot be corrected onsite by the Team Supervisor will be immediately reported to the maintenance department through the Skyline Database and handled with priority (Team Supervisors Training Attachment #9). To ensure compliance to this requirement, the Team Supervisors are responsible to do bi-weekly physical site reviews using a Quality Review Form documenting a physical site check. This review process will be monitored by the assigned Program Specialist, who signs off on the Quality Review form (Completed Sample Attachment #13). 01/13/2017 Implemented
6400.112(d)The 6/11/16 fire drill log had an evacuation time of 2 minutes and 49 seconds. 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. The specific issue around the 6/11/16 fire drill was that the time indicated 2.4.9 seconds, which was interpreted as over the 2 ½ minute allowance for safe evacuation. NHS Cambrian Hills acknowledges that the documentation was confusing and could not be corrected or validated in any other way. To prevent a recurrence of this violation, Team Supervisors have been retrained in the responsibility to assure that all monthly fire drills are completed and that the documentation is clear and meets regulation, to include the ability 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. (Team Supervisor Training Attachment #9 ) The Regional IDD Director monitors compliance by completing an audit of drills for each home, and addressing any identified issues with the support of the team Supervisor. (Audit Tool attachment #21) 01/06/2017 Implemented
6400.151(a)Staff #1's 10/19/16 physical exam was completed late. The previous physical exam was completed on 9/16/14. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. NHS Cambrian Hills Center acknowledges that this non compliance cannot be corrected. To ensure that all employees are notified and receive their physical with TB in the required timeframes, NHS Cambrian Hills utilizes a data base across this region that identifies and notifies employees of their expected examination date. A reminder through Microsoft Outlook is automatically forwarded 2 months prior to the expiration date with reminders at one month, 15 days and the due date. This process has been in place and has been generally effective in meeting compliance to this regulation. (Copy of recent employee physical that is within compliance attached #18) To enhance the compliance of all employees, the notifications will additionally be forwarded to the assigned Team Supervisors as well as the Cambrian Hills Administrative Assistant for follow up and support. Both the Administrative Assistant and the Team Supervisors have been trained on the responsibility to facilitate compliance for employee physicals. (Team Supervisor Training Attached #, Administrative Assistant Training attached #19 ) To monitor compliance the NHS Administrative Assistant is responsible to support the staff through this process, verify completion of the physical and input the updated physical date in the electronic system. The Administrative Assistant was additionally trained in these responsibilities (Administrative Assistant Training attached #20). 01/06/2017 Implemented
6400.151(c)(2)Staff #1's 10/21/16 tuberculin test was completed late. The previous tuberculin testing was completed on 9/17/14. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. NHS Cambrian Hills Center acknowledges that this non compliance cannot be corrected. To ensure that all employees are notified and receive their physical with TB in the required timeframes, NHS Cambrian Hills utilizes a data base across this region that identifies and notifies employees of their expected examination date. A reminder through Microsoft Outlook is automatically forwarded 2 months prior to the expiration date with reminders at one month, 15 days and the due date. This process has been in place and has been generally effective in meeting compliance to this regulation. (Copy of recent employee physical that is within compliance attached #18) To enhance the compliance of all employees, the notifications will additionally be forwarded to the assigned Team Supervisors as well as the Cambrian Hills Administrative Assistant for follow up and support. Both the Administrative Assistant and the Team Supervisors have been trained on the responsibility to facilitate compliance for employee physicals. (Team Supervisor Training Attached #, Administrative Assistant Training attached #19 ) To monitor compliance the NHS Administrative Assistant is responsible to support the staff through this process, verify completion of the physical and input the updated physical date in the electronic system. The Administrative Assistant was additionally trained in these responsibilities (Administrative Assistant Training attached #20). 01/06/2017 Implemented
SIN-00067301 Renewal 08/06/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)Individual #1's date of admission was 3/1/14. Fire department notification letter was not completed until 4/28/14. 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. NHS Cambrian Hills Center cannot correct the failure to notify the fire department prior to individual #1 moving to this home. NHS has edited the Consumer Admission Checklist to reflect the need for prior notification to the local Fire Department to be submitted by the assigned Program Specialist prior to admission (Copy Attachment #15). The Program Specialist has been retrained on this responsibility (Attachment #16). 09/15/2014 Implemented
6400.164(a)Individual #1 was to start Ortho TM Cyclen on 7/15/14 but the med log did not note the medication starting as prescribed. 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. Medication Ortho TM Cyclen for Individual #1 was prescribed on 7/15/2014. The Team Supervisor who accompanied individual #1 to the appointment was verbally directed by the prescribing physician to complete the current cycle of previously prescribed Orsythia /Alesse, and therefore begin the newly prescribed Ortho TM Cyclen on 8/3/2014. NHS received signed verification from prescribing physician that the start date of 8/3/2014 was appropriate (Documentation attached #17). To appropriately document medication change effective dates in the future, staff will utilize the Physician/Consult/Communication Form at every medical appointment (Completed sample attached #18). Attending staff will assure that when the effective/start date is not within the next 24 hours, the physician must document on the case note the expected start date. All team members were trained in this process (Attached Verification #19). It is the responsibility of the Medical Coordinator to verify all medication or treatment changes are implemented as prescribed with a final sign off on the Physician/Consult/Communication Form. When a new medication or new diagnosis is present, the employee immediately calls the Medical Coordinator or designee, who will be responsible for necessary follow up. Both forms are to be delivered or faxed to the Medical Coordinator within 24 hours. The Medical Coordinator has been trained in this responsibility (Training verification attached#20). 09/15/2014 Implemented
6400.167(b)On 7/15/14, physician ordered Individual #1's Omeprazole to be changed to twice per day. This was not completed as prescribed until 7/19/14. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.NHS recognizes that the medication for individual #1 Omeprazole was not started as prescribed on 7/15/2014, and this cannot be corrected. To appropriately document medication change effective dates in the future, staff will utilize the Physician/Consult/Communication Form at every medical appointment (completed sample attached #18), as well as the standard case note. Attending staff will assure that when the effective/start date is not within the next 24 hours, the physician must document on the case note the expected start date. When a new medication or new diagnosis is present, the employee immediately calls the Medical Coordinator or designee, who will be responsible for necessary follow up. Both forms are to be delivered or faxed to the Medical Coordinator within 24 hours. All team members were trained in this process (Attached Verification# 19). It is the responsibility of the Medical Coordinator to verify all medication or treatment changes are implemented as prescribed with a final sign off on the Physician/Consult/Communication Form. The Medical Coordinator has been trained in this responsibility (Training verification attached # 20). 09/15/2014 Implemented
6400.186(a)ISP reviews on 7/11/14 and 4/8/14 for Individual #1 were not completed in a timely manner. There was no indication that the reviews were sent to team members and both reviews were date stamped 8/1/14. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. NHS recognizes that the ISP reviews for Individual #1 were time stamped well past the required due date. In an effort to avoid this in future reviews all Program Specialists were trained in the responsibility to complete and print each review within 15 days of the end of the 3 month period. This revised process is also to include an immediate, documented and dated review with the individual and mailing to the support team with a Plan verification Sheet, with a copy placed in the Program Record (Sample of 3 Month review with all requirements met attached #21 ) (Training verification attached #22). Additionally, records will be randomly audited by the management team for compliance to this process on a monthly basis (Audit tool attached #23). 09/08/2014 Implemented
6400.186(e)There was not documentation that the option to decline ISP reviews was given to team members for Individual #1. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. NHS recognizes that the option to decline ISP reviews for individual #1 was missing from the record. All Program Specialists have been retrained in the expectation to use the NHS form at planning meetings that provides the team members the option to decline ISP reviews. Any team member not in attendance will be provided the option to decline via email or regular mail, when the NHS Plan is sent (Training verification attached #24, and Completed sample attached #25). Additionally, records will be randomly audited by the management team for compliance to this process on a monthly basis (Audit tool attached#23). 09/14/2014 Implemented
6400.213(11)The ISP for individual #1 does not include that sharp objects need to be locked in her home. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. The team that supports individual #1, as well the individual agrees that sharp objects need to be locked in her home as a personal safety measure. Requested changes in the ISP to reflect this consensus have been sent to the Supports Coordinator on 9/15/2014 (Attached #26). All Program Specialists have been retrained in their responsibility to identify any content discrepancy or necessary revision in the ISP and send effective communication to the Supports Coordinator to correct the noted discrepancy (Training verification attached #27). Records will be randomly audited by the management team for compliance to this process on a monthly basis (Audit tool attached#23). 09/15/2014 Implemented
SIN-00242161 Renewal 03/19/2024 Compliant - Finalized
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SIN-00151500 Renewal 04/17/2019 Compliant - Finalized
SIN-00129396 Renewal 04/05/2018 Compliant - Finalized