Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00252018 Renewal 09/30/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.61(a)At the time of the inspection Individual #1's bed shaker was not operable when the fire alarm was set off.A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. The Director of Residential Services provided written education/retraining to all staff including Program Specialists, Program Managers, Program Supervisors and Direct Care Professionals on 10-11-24 regarding regulation 61(a) that specifies that a home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. The Director of Residential services provided verbal retraining to all Program Specialists, Program Managers and Program Supervisors on 10-9-24 in an in-person department management meeting regarding regulation 61(a) that specifies that a home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. 10/17/2024 Implemented
6400.64(a)At the time of the inspection the fridge and stove were found to be unsanitary and needed cleaned. Additionally, there was cauliflower found in the refrigerator with mold on it.Clean and sanitary conditions shall be maintained in the home. The refrigerator and stove were cleaned by Program Manager of the home on 10-3-24. The Director of Residential Services provided written education/retraining to all staff including Program Specialists, Program Managers, Program Supervisors and Direct Care Professionals on 10-11-24 regarding regulation 64(a) that specifies clean and sanitary conditions shall be maintained in the home. The Director of Residential services provided verbal retraining to all Program Specialists, Program Managers and Program Supervisors on 10-9-24 in an in-person department management meeting regarding regulation 64(a) that specifies clean and sanitary conditions shall be maintained in the home. 10/17/2024 Implemented
SIN-00176488 Renewal 09/22/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(r)Individuals #1 and #2 did not have a lock on their bedroom doors, and they were not assessed if they wanted a lock or not.An individual has the right to lock the individual's bedroom door.Individual #1 and #2 were assessed if they wanted a lock on their bedroom doors. This information was added as an addendum to the Annual Assessment and sent to their ISP team to be added to the ISP on 10/7/2020. A work order was placed on 10/1/2020 to remove door locks on both individuals bedroom doors and completed on 10/2/2020. Excentia's annual Assessment form has been changed to include information regarding assessing a persons desire to lock their bedroom door as well as assessing the type to locking mechanism to be used. 10/08/2020 Implemented
6400.32(r)(5)Individual #3 has a lock on their bedroom door, but staff in the home did not have the key in case of an emergency.Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.Program Specialist, had extra keys placed in the desk drawer of the locked staff office for the bedroom door lock for Individual #3. All keys were labeled. A document explaining the need for staff to carry a key on them while on duty in the home for emergencies was created and staff are to sign acknowledgement that they have read this requirement. Information about staff carrying the key for the door and Individual #3 carrying his bedroom door key was added as an addendum to the Annual Assessment and sent to his ISP team to be added to the ISP on 10/1/2020. 10/08/2020 Implemented
SIN-00105086 Renewal 02/07/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(c)Individual #3 had no psychiatric medication review in the record for the quarter 09/16-12/16. The most recent psychiatric review was dated 06/02/16. Individual #3 is prescribed Aripiprazole (Abilify) 10 mg 1 tab 1 x/day @ 8 am for Paranoia, delusions. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.163(c)- If a medication is prescribed to treat a psychiatric illness, is there a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage? Individual #3 is seen every 3 months by a licensed physician due to him taking Aripiprazole (Abilify) for Paranoia, Delusions. On 11/9/16 and 8/16/16, the medication review form was not taken to these appointments so it was attempted to have the physician sign off on a health service record stating these appointments occurred. In the future, the Supervisor as well as the Associate Director/Program Specialist will assure that the appropriate 3 month medication review form is brought to all Medication Reviews. If a form is forgotten, it will be up to the Supervisor and Associate Director/Program Specialist to return to the physician¿s office to have the appropriate forms signed off on that confirm the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Attached you will also find the 3 month medication review forms for Individual # 3 and Individual A to show we have come into compliance with this regulation. 03/01/2017 Implemented
6400.164(b)On June 24, 2016, the medication Phenobarb 32.4 mg tab take 1 tab 2x/day for seizures was not documented on the 8 AM med log. No initials on the record nor documentation on the back of the medication log that the medication was given to Individual # 3. On June 30, 2016 the medication Pilocarpine sol 4% op - Instill 1 drop in left eye 4x daily for glaucoma was not documented on the medication log. The 06/30/16, 9 pm drops were not signed/initialed as given. The medication log was blank and not documentation on the back of the medication log. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. 164(b)- Is the information specified in 164(a) logged immediately after each individual¿s dose of medication is administered? On June 24th, 2016, the medication Phenobarb 32.4 mg was not documented on the 8 am med log. The June 30th, 2016, the medication Pilocarpine sol 4% was not documented on the medication log. Also on that same date, the 9pm drops were not recorded as well. In the future, the Supervisor as well as the Associate Director/Program Specialist will assure that immediate documentation of medications is taking place. Failure to do so will result in disciplinary action for not only the person who missed documenting, but also each person who administered medication after the missed initial. The Supervisor as well as the Associate Director/Program Specialist will continue to review each med log to assure all time slots are properly filled out. Attached you will also find Medication Logs for Individual A, Individual B and Individual #3 to show we have come into compliance with this regulation. 03/01/2017 Implemented
6400.186(c)(2)Individual # 3 has a seizure protocol in the Individual Support Plan but the seizure protocol was not reviewed in the following quarterly reviews dated 12/2/16, 09/12/16, 06/08/16 and 03/10/16. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. 186(c)(2)- Does each review include a review of each section of the ISP specific to the facility licensed under this chapter? Individual #3 has a seizure protocol in his Individual Support Plan but the seizure protocol was not reviewed in the quarterly reviews. In the future, the Program Specialist will assure that seizure protocols are clearly stated and reviewed with all the quarterly reviews sent to the team. Appropriate documentation will occur under the update section. Attached you will also find the quarterly ISP review for Individual #3 and for Individual A to show we have come into compliance with this regulation. 03/01/2017 Implemented
SIN-00047010 Renewal 04/01/2013 Compliant - Finalized