Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00091514 Renewal 05/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(d)Staff # 19's annual medication administration training dated 11/30/2015 was invalid as the fourth MAR review was completed on 12/07/2015.A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. After the follow up licensing visit, a medication administration plan of correction was developed and implemented immediately. Attachment # 1. All staff who were not properly certified to administer medications ceased administering medications that same day. Delta continued to implement the steps of the plan of correction until all homes had staff certified to administer medications. The plan of correction was updated and submitted to BHSL on a weekly basis . Adjustment was made to accommodate medication administration training changes that came into effect on 7/1/16. The final plan of correction was revised and submitted 8/8/16 Attachment # 2. Ongoing, the Regional Director and the lead medication administration trainer reviews all training materials and documentation to ensure staff are properly trained and certified prior to administering medications. The lead trainer is responsible for maintaining documentation and records on an ongoing basis. 05/16/2016 Implemented
SIN-00047521 Renewal 03/27/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)On 4/4/12 and 5/10/12 the back door was used during the monthly fire drills and on 8/5/12, 9/3/12 and 11/7/12, 12/6/12, and 1/13/13 the front door was used during the monthly fire drills.(f) Alternate exit routes shall be used during fire drills. We have revised fire drills forms to note alternate exits used. Staff training was held on 4/5/2013. PD will monitor monthly use of alternate exits. 04/22/2013 Implemented
SIN-00075968 Renewal 02/25/2015 Compliant - Finalized