Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00264191 Renewal 04/14/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)At the time of the inspection, the first aid kit did not include an assortment of bandages. The kit only contained 5 Band-Aids, and they were all the same size. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. An assortment of band aids was purchased and placed in the first aid kit of the home by the Program Lead on 4/17/25. See attachment # 1. 05/30/2025 Implemented
6400.182(a)Individual #1's most recent ISP dated 4/2/2025 states under section "Medical Information" that the individual has an eye allergy and is prescribed "Olopatadine sol 0.2% (Pataday) to be used PRN, however the MARS do not have this PRN medication listed for more than the past 3 months, and staff stated the individual does not use this PRN script/medication. The ISP has not been updated to reflect these changes.The program specialist shall coordinate the development of the individual plan, including revisions with the individual and the individual plan team.The Program Specialist completed and sent an ISP General Update Form to individual #1¿s Supports Coordinator to have this medication removed from the medications listed in the ISP on 4/25/25, see attachment # 4. 04/30/2025 Implemented
SIN-00168377 Renewal 03/04/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)The was no fire drill for the month of January 2020. An unannounced fire drill shall be held at least once a month. Merakey recognizes that this violation cannot be corrected. To prevent a recurrence of this violation, the IDD Director conducted a training for all the Team Supervisors and Program Specialists on 3/24/2020 on regulation 6400.112(a) including the Team Supervisors and Program Specialists responsibility to ensure that an unannounced fire drill is held at least once a month. See attached sign in sheet (attachment #1). It is the Team Supervisors responsibility to ensure a drill is conducted monthly. In the absence of a Team Supervisor it will be the reasonability of the Program Specialist or a designee. All drills must be completed by the 21st of the month and must be faxed to the office after completion. The original drill must be handed in to the office to the IDD Residential Director so that it can be accounted for on the Fire Drill Check Sheet. A drill is not considered completed until the original drill is received at the office. See attached Fire Drill Check Sheet for the month of March 2020 (attachment # 2). 03/24/2020 Implemented
SIN-00127786 Renewal 02/13/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(a)The smoke detector in the attic and upstairs storage room were not operative. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. An operable smoke detector was placed in the attic and the upstairs storage room on 2/14/18 (Photo of installed smoke detectors attachment #1). These detectors were added to the Fire Equipment Monthly Monitoring Form which is completed with the monthly fire drill. Each smoke detector is tested each month and documented on the form. This form is handed in after the fire drill and reviewed by the Administrator. It indicates on the form that if any alarms are inoperable to contact the supervisor or on-call immediately (completed Fire Equipment Monthly monitoring form attachment # 2). The team supervisors were retrained on this responsibility at the Team Supervisor meeting on 2/27/18 (copy of agenda and sign in sheet attachment #3). A memo outlining the expectations was distributed on 2/27/18 and in addition the team supervisors will review the memo at their staff meeting in March 2018 (copy of memo attachment #4). 03/08/2018 Implemented
SIN-00104611 Renewal 11/21/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.61(b)Individual #2's bedshaker was not operable during the fire drill at the time of the inspection. A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have adaptive equipment necessary for the individuals to move about and function at the home.Individual #2¿s bed shaker has been replaced and is now operable, see photo attachment #2. To prevent a recurrence of this violation, all team supervisors will be retrained in the responsibility to test the bed shaker monthly after each fire drill and document on the Fire Equipment Monthly Monitoring Form, which is page two of the fire drill form. This will occur at the next team supervisor meeting 1/24/17 and will be forwarded to the licensing representative by 1/28/17. The Fire Drill Equipment Monthly Monitoring Form was modified to include the testing of the Bed Shakers under the smoke detector section. See a completed fire drill including the Fire Equipment Monthly Monitoring Form attachment #3. NHS Capital Region maintains an extra bed shaker at the local office so that an inoperable bed shaker can immediately be replaced. Compliance to this correction will be monitored by the program administrator who has been trained on his responsibility to audit all fire drill documentation, administrator training document #4. 01/24/2017 Implemented
6400.113(c)Individual # 2 received fire safety training on 06/06/14 and 04/28/16. Individual #2 did not receive annual fire safety training in 2015. A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept.NHS Capital Region acknowledges that we cannot correct the fire safety training that was not completed in 2015. To prevent a reoccurrence of this violation, all residential program specialists were retrained and all team supervisors will be retrained in their responsibility to complete the annual fire safety training for all individuals receiving residential services. Program Specialist training occurred 1/10/17, see attachment #1. All Team Supervisors will be trained at their next meeting on January 24, 2017, a copy of the training topics and sign in sheet will be forwarded to licensing representative by 1/28/17. The completion of the fire safety training for individuals occurs on an 11 month cycle to assure compliance with the annual requirement; the program specialist prepares the training material and delivers the information to the team supervisor to complete the training. The 2017 completion is scheduled for March 2017. Compliance will be monitored during supervision by the IDD Director with the program specialists in April 2017 and noted on the monthly monitoring form. 01/24/2017 Implemented
SIN-00053075 Renewal 07/16/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(g)Fire safety training was completed late for Staff #4. Staff #4 had fire safety training on 10/4/11, but then not again until 11/15/12. This exceeds the annual regulatory requirement. (g) Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). FULLY IMPLEMENTED. JW NHS Capital Region acknowledges that this item cannot be corrected. A training tracking system has been put in place to routinely inform staff in advance of due dates. The tracker is color coded for upcoming due dates up to 3 months out and stored on a shared drive so that the information is readily accessible. Each home¿s Supervisor reviews the training due dates monthly, and is responsible to inform individual staff of all trainings due in the next 3 months, which allows adequate time to register for and receive the training. All trainings appear on the staff¿s work schedule. See attached sample of an employee¿s schedule with fire safety training scheduled on it (Attachment #1). The LPQI (Local Performance Quality Improvement) Coordinator also reviews fire safety trainings monthly, identifying staff coming due for training within 30 days and reports those findings to the Administrator for immediate follow up. See Monthly Training Report (Attachment #2). Additionally, all homes will be providing fire safety training to the staff every 6 months. Attached are copies of fire safety trainings for four staff at different residential sites that took place after 7/19/2013, which are in compliance with the annual training year. Both the current and previous year training records are included to demonstrate compliance (Attachment #3). This process was reviewed with the Supervisors at the Team Supervisor meeting on 8/27/2013. Attached are copies of the sign in sheet from the meeting and the agenda topics (Attachment #4). 09/17/2013 Implemented
6400.164(a)On 2/4/13 and 6/24/13, the medication log did not include the time Lorezapam was administered to Individual #1.(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. PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW NHS Capital Region acknowledges that the missing time for medication administered to Individual #1 on 2/4/13 and 6/24/13 cannot be corrected. All staff working in the homes are medication administration certified and receive training on how to complete medication logs, with sample books at the home to guide appropriate documentation. To further aid in proper documentation, a buddy system has been implemented in homes with double staffing. The non- medication dispensing staff will review the MAR (Medication Administration Record) for completeness. Where homes are single staffed, this review will occur at shift change. The incoming staff person will complete the attached check sheet (Attachment #5) indicating the review was completed. The Supervisors were trained on this process and their responsibility to train the staff at the house during a Supervisor¿s Meeting on 8/27/2013. Staff have been reminded/ retrained on the complete documentation requirements for Medication Administration. Attached are minutes from the house staff meeting completed on 8/29/2013 (Attachment # 6). The attached August MAR for individual #1 reflects compliance to this requirement (Attachment #7). The Team Supervisor is responsible to monitor appropriate completion of the MARs weekly. There are also monthly audits completed by the Medical Assistant. New staff are trained on the buddy system during medication administration training. 08/29/2013 Implemented
6400.186(e)There was no option to decline receiving ISP reviews sent to plan team members for Individual #1.(e) The program specialist shall notify the plan team members of the option to decline the ISP review documentation. FULLY IMPLEMENTED. JW Individual #1¿s team was notified of their option to decline the ISP review documentation on 8/2/13; this was documented on the Individual Support Plan development sign in sheet (Attachment #8). The Individual Support Plan signature sheet that contains the option to decline is used annually at the individuals¿ ISP planning meeting and is kept in the individuals¿ record. Attached are two additional documents indicating option to decline completed after 7/19/2013 (Attachment #9). The Program Specialists are responsible for assuring the opportunity to decline is completed at every planning meeting and have been trained on this responsibility (Attachment #10). Compliance is also monitored during the NHS PQI Residential Audit process, which is completed annually for each person. The IDD Director will forward the Licensing Representative two completed audits by 10/7/2013. 10/07/2013 Implemented
SIN-00185378 Renewal 03/22/2021 Compliant - Finalized