Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00214757 Renewal 11/14/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There were various cleaning chemicals left unlocked in kitchen accessible to the individuals who reside in the home.Poisonous materials shall be kept locked or made inaccessible to individuals. Provider locked all cleaning chemicals in locked area per the individuals ISPs. 11/15/2022 Implemented
6400.64(f)One of the outdoor trashcans did not have a lid.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.Provider purchased new trashcans with lids. New trash cans were placed outside the home with lids secure to prevent the penetration of insects and rodents. 11/16/2022 Implemented
6400.141(c)(6)Last tuberculin test with negative results was conducted on 10/7/2020 for individual 2. The test for 2022 was overdue and not yet completed.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Provider escorted individual to Urgent care to receive TB skin test on 11/14/2022. Test was read on 11/16/2022. Test had negative results. 11/16/2022 Implemented
6400.141(c)(7)Last exam annual Gyn exam was completed on 12/16/2020.The record did not include an updated annual GYN exam for individual 2.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. Site Manager received confirmation that Individual #2 completed her GYN 3/11/2022 and her last pap smear exam was completed 12/16/2020, and her pap smear exam is not medically necessary during 3/11/22, per American College of Obstetrics and Gynecology Guidelines. Documentation from physician will be provided. 11/18/2022 Implemented
6400.144The medications 4% Aspercreme, to be administered daily at 8am, and Motrin 600, to be administered as needed, to individual 2 was not present at the home available for the individual to use.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Provider ordered identified medication on 11/14/22, and it was delivered on 11/15/22. Motrin was discontinued on 3/30/22, and nursing made corrections on November 2022 MAR. Pharmacy will remove discontinued medication for December MAR. 11/14/2022 Implemented
6400.34(a)The individual rights statement signed by individual 2 on 2/17/2022 and all individuals reviewed by the agency was out dated. It did not include the most recent rights in adherence to chapter regulations.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.Provider has revised Individual Rights forms and all consumers have signed new revised form. 12/02/2022 Implemented
6400.207(4)(IV)Medication Ataxan 25mg tablet to be given twice daily as needed for anxiety did not specify in individual 2's record the specific and exclusive purpose or a specific time limited event or situation for administration. The most recent individual assessment, behavioral support plan and individual support plan did not notate that the individual is able to communicate the need for aforementioned medication or to express they have symptoms.A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: A specific, time-limited stressful event or situation to assist the individual to control the individual's own behavior.Program specialist reached out to Behavior specialist and SC to update the BSP and ISP for Individual #2 to reflect that the individual possesses the capacity to request identified PRN medication Ataxan, for prescribed reason. 12/07/2022 Implemented
SIN-00179262 Renewal 11/12/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(e)At inspection, there was no non-slip surface, or mat present in the basement bathroom. Bathtubs and showers shall have a nonslip surface or mat. On 11/19/2020, New bath mat placed in shower area according to 6400.82 (e), and the Assistant Site Manager was retrained. Evening/Weekend Site Coordinator will complete physical site visits monthly to assure non-slip surfaces are secured. 11/19/2020 Implemented
SIN-00155429 Renewal 03/06/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.213(1)(i)Individual #1's record did not include religious affiliation or a current dated photo.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. The religious affiliation for individual #1 was added to her record. A current and dated photo was added to individual #1's file. Staff was retrained on the importance of including the above information in the individual's file. 04/03/2019 Implemented
SIN-00103799 Renewal 09/26/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessments were dated with three different dates making it undeterminable when the self assessment was completed.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Assistant Residential Directors will complete the self-assessment required under regulation 6400.15(a) for each COMHAR site 3 to 6 months prior to the expiration date of COMHAR¿s certificate of compliance on February 4. They will list only one date on that self-assessment, the date of completion of the self-assessment. The Lead Assistant Residential Director will monitor process and timeliness of completion. 12/21/2016 Implemented
6400.67(a)The basement office area had a radiator partially detached from the wall.Floors, walls, ceilings and other surfaces shall be in good repair. The damaged wall which had caused the radiator to become partially detached was repaired and radiator reattached. This damage which was the result of an accident was in bid status at time of licensing. Concrete bumpers were installed to prevent further accidental vehicle strikes to the wall. Maintenance will continue to monitor and repair issues as discovered with site manager and assistant site manager assuring timely repairs. 12/21/2016 Implemented
6400.76(a)There were rust and bent drawers on a storage cabinet located in the 1st floor office. Furniture and equipment shall be nonhazardous, clean and sturdy. The file cabinet located in the staff office with rust and bent drawers was removed from the site and disposed of. It was replaced by a new cabinet from stock. Site Manager/Assistant Site Manager will ensure that furniture and equipment is in good repair during monthly site check using checklist. Training was provided on proper completion of monthly checklist. 12/21/2016 Implemented
6400.82(f)There were missing toilet paper rollers in the first and second floor bathrooms.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle.Toilet paper rollers were purchased and installed in first and second floor bathrooms. Assistant site managers during their monthly site check will ensure that rollers are present at all bathrooms requiring toilet paper. 12/21/2016 Implemented
6400.141(c)(14)Individual # 1¿s physical exam dated 6/8/16 did not document medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Individual #1 had her emergency information scattered throughout her physical exam form. Individual #1¿s PCP was contacted and an addendum to her physical exam was completed identifying medical information pertinent to diagnosis and treatment in case of an emergency. Going forward this information will be entered by the site manager/assistant site manager under that heading (medical information pertinent to diagnosis and treatment in case of an emergency) on the physical form and will be reviewed by nursing for completeness. Training was completed to assure same. 12/21/2016 Implemented
6400.181(e)(14)Individual # 1¿s assessment dated 10/24/15 did not document knowledge of water safety or the ability to swim.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. Individual #1¿s assessment dated for 10/24/2015 was revised to indicate her knowledge of water safety and the ability to swim. The Program Specialists were trained on the content of Assessments such as being clear on water safety and the ability to swim on 9/13/2016 and 9/29/2016 by Clinical Coordinator. The Assessment form was also revised to clarify the response to both knowledge of water safety and the ability to swim and the Program Specialists were trained on the new form on 10/25/2016 by Day Program Director and again by Clinical Coordinator on 12/15/2016. There will be ongoing monitoring by the Clinical Coordinator in order to review with the Program Specialist that the documentation is complete, meets licensure requirements and that the appropriate revised form is utilized. 12/21/2016 Implemented
SIN-00074303 Renewal 01/06/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)There was approximately one foot deep scratches on the floor throughout the dining room. There was rusted air vents in the upstairs and downstairs bathrooms. There was a rusted towel rack in the downstairs bathroom There was bleach stains on the carpeted steps leading to the 2nd floor. Floors, walls, ceilings and other surfaces shall be in good repair. The maintenance department staff repaired all of the rusted surfaces in the home. In the future, the maintenance department staff will conduct monthly checks of the home to ensure that all surfaces are in good repair. Staff of the home will be trained on the importance of timely reporting of needed repairs. 09/18/2015 Implemented
6400.76(a)A dresser drawer in the bedroom of Individual # 4 was screwed closed and another draw was unable to be opened. Furniture and equipment shall be nonhazardous, clean and sturdy. The dresser was discarded and was replaced by a new dresser. In the future, the maintenance department staff will conduct monthly checks of the home to ensure that all equipment is in good repair. Staff will be trained on the importance of timely reporting of needed repairs. 09/18/2015 Implemented
SIN-00078433 Renewal 01/06/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)There was approximately one foot deep scratches on the floor throughout the dining room. There was rusted air vents in the upstairs and downstairs bathrooms. There was a rusted towel rack in the downstairs bathroom There was bleach stains on the carpeted steps leading to the second floor. Floors, walls, ceilings and other surfaces shall be in good repair. Scratches on dining room floor were cleaned, sanded and stained. Plastic bumpers were placed on feet of chairs that originally caused the gouges and scrapes to prevent further damage. Rusted air vents in upstairs and downstairs bathrooms were painted. Rusted towelrack was replaced in downstairs bathroom. Bleach stained carpet was removed from stairs. Site Manager and Assistant Site Manager will review site issues on weekly basis and report on maintenace web system when discovered. Training for all Site Managers was conducted to increase their awareness of physical site issues and how to report. Floors throughout COMHAR CLA's will be checked at least quarterly for good repair by site and assistant site managers assigned to locations. 03/27/2015 Implemented
6400.76(a)A dresser drawer in the bedroom of Individual #4 was screwed closed and another draw was unable to be opened. Furniture and equipment shall be nonhazardous, clean and sturdy. Dresser in individual #4's bedroom was replaced with new dresser. Furniture throughout COMHAR will be checked at least quarterly for hazardous, clean and sturdy condition by site manager and assistant site managers assigned to the CLA locations. Any issues will be reported immediately by staff to maintenance for remedy. 04/27/2015 Implemented
SIN-00066951 Unannounced Monitoring 05/28/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The first floor shower/tub base has rust stains throughout the base of the tub and on the bathmat. In addition, the bathmat is shredding.Clean and sanitary conditions shall be maintained in the home. The first floor bathtub had the hard water stain removed. The bathmat was replaced. The Site Manager and Assistant Residential Director will monitor the bathtub to assure that any recurring hard water stains are removed and that the bathmat remains in acceptable condition or will be replaced as needed. 08/28/2014 Implemented
6400.67(a)The kitchen ceiling had a large patch (3 x 3 ft.) that was a repair, but now is crumbling.Floors, walls, ceilings and other surfaces shall be in good repair. COMHAR¿s maintenance department repaired the kitchen ceiling area that had been previously repaired but completed to an unacceptable finish using joint compound that was over applied and unfinished at the time of the inspection. The ceiling area is now smooth and finished. The department head will spot monitor repairs completed by the maintenance department to assure acceptable repairs. The site managers will report any sub-standard repairs to the department head. 08/28/2014 Implemented
SIN-00044549 Renewal 01/22/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)Only one exit route was used for monthly fire drills held November, 2011 to November, 2012. The home has three exits that can be used.(f) Alternate exit routes shall be used during fire drills. All staff in all ID residential programs were re-trained to alternate exits used during fire drills. Residential Administrative Assistant or designee will collect and review site fire drills. Site Managers will be advised of any issues observed and initiate appropriate actions. A new form was developed to track alternate exit use. 02/01/2013 Implemented
SIN-00057021 Renewal 12/09/2013 Compliant - Finalized