Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00216157 Renewal 11/22/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.103The furnace was cleaned 8/03/2021 and then again on 11/17/2022. This exceeds the annual requirement.Furnaces shall be cleaned at least annually. Written documentation of the cleaning shall be kept.Furnace at this location will be cleaned on or before November 7, 2023. The assigned Program specialist will make this change. The change will be that the furnace cleaning date and time has been pre-scheduled with contracted company on a recurring annual basis. The Assigned Program Specialist will reach out to the contracted company to ensure appointments are set prior to the last completed date. Pre-scheduled appointments are confirmed by the Assigned Program Specialist and the contracted company has been made aware of our regulation requirements and the parameters/timeframes in which cleanings should occur. The furnace cleaning has also been added to Relias as a requirement for the assigned Program Specialist as another means of double check. Training: Code 6500.103 was reviewed with the 2 Program Specialists regarding annual training requirements: Furnaces shall be completed at least annually. Written documentation of the cleaning shall be kept. [Training documentation related to regulation 6500.103, dated 12/27/2022, was received on 2/15/23 and reviewed 2/27/23. Contractual agreement between agency and professional furnace cleaning company, which is not dated, was received on 2/15/23 and reviewed 2/27/23. DPOC by HDKP, HSLS, on 2/27/23.] 12/27/2022 Implemented
6500.110(c)Individual #1, date of admission 3/28/2020, was trained in fire safety on 3/09/2021 and then again on 11/01/2022. This exceeds the annual requirement.Family members and individuals, including children, shall be trained within 31 calendar days of an individual living in the home and retrained annually, in accordance with the training plan specified in subsection (a).Fire Safety training will be completed within 365 days from the last completed date. The assigned Program Specialist will make the change. This change has been made immediately. The next training for individual #1 will occur on or before March 9, 2023. Fire Safety has been added to Relias Online Learning System. The training dates are monitored by the Assigned Program Specialist, as well as the HR Assistant. Reminders for Relias are provided by the HR Assistant to providers and employees. We will utilize Relias, and the Program Specialist will utilize recurring calendar reminders and spreadsheets as duplicate means of tracking to ensure dates are not missed moving forward. The Assigned Program Specialist will be retrained on 6500.110 (c), which states Family members and individual, including children, shall be trained within 31 calendar days of an individual living in the home and retrained annually, in accordance with the training plan specified. An in-service / retraining form has been signed and dated by the Program Specialist. [Training documentation related to regulation 6500.110c, dated 12/27/2022, was received on 2/15/23 and reviewed 2/27/23. Documentation that the topic of fire safety was added to the Relias Training program, dated 2/14/23, was received on 2/15/23 and reviewed 2/27/23. DPOC by HDKP, HSLS, on 2/27/23.] 12/27/2022 Implemented
6500.182(b)The most current assessment for Individual #1 did not include the full date. It was documented as being completed "November 2022."Entries in an individual's record must be legible, dated and signed by the person making the entry.The Program Specialists are to provide all completed assessments to the Executive Director, who will double check that entries are legible, dated and signed. The assigned Program Specialist and Executive Director will make the change. Change is to be made immediately as all assessments on and after 12/27/2022, must go to the Executive Director for approval. The Program Specialist will provide completed documentation to the Executive Director within 5 business days after the assessment completion date. Once the documentation is received, the Executive Director will double check all documentation to ensure we are in compliance with 6500.182(b). We have implemented an approval process. All completed assessment paperwork must be approved by the Executive Director prior to uploading to the Core Member's chart. The Assigned Program Specialist has been trained on 6500.182(b) and documentation of training in-service / retraining will be kept in the employee's personnel file. [Training documentation related to regulation 6500.182b, dated 12/27/2022, was received on 2/15/23 and reviewed 2/27/23. DPOC by HDKP, HSLS, on 2/27/23.] 12/27/2022 Implemented
6500.151(a)Individual #1 had an assessment completed on 2/01/2021 and then again in "November 2022." This exceeds the annual requirement.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the home.Core Member Assessment will be completed within 365 days from the last completed date. The Assigned Program Specialist will be responsible for the change. This change has been made immediately. The next training for individual #1 will occur on or before November 30, 2023. External Course, Core Member Assessment, has been added to Relias Online Learning System. The training dates are monitored by the Assigned Program Specialist, as well as the HR Assistant. Reminders for Relias are provided by the HR Assistant to providers and employees. We will utilize Relias, and the Program Specialist will utilize recurring calendar reminders and spreadsheets as duplicate means of tracking to ensure dates are not missed moving forward. The Assigned Program Specialist will be retrained on 6500.151(a), which states each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the home and an updated assessment annually therafter in accordance with the training plan specified. An in-service / retraining form has been signed and dated by the Program Specialist. [Training documentation related to regulation 6500.151a, dated 12/27/2022, was received on 2/15/23 and reviewed 2/27/23. Documentation that the topic of "Core Member Assessment" was added to the Relias Training program, dated 2/14/23, was received on 2/15/23 and reviewed 2/27/23. DPOC by HDKP, HSLS, on 2/27/23.] 12/27/2022 Implemented
SIN-00197730 Renewal 12/14/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.107(a)The basement of the home did not have a smoke detector.A home shall have a minimum of one operable automatic smoke detector provided on each floor, including the basement and attic.Life Sharing home owner purchased a new smoke detector on 12/15/2021 and installed the new smoke detector on the same date. 12/21/2021 Implemented
SIN-00181818 Renewal 01/22/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.121(c)(3)Individual #1, date of admission 3-27-20, does not have immunizations.Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.The Program Specialist is working with the individual and the Life Sharing Family to obtain a scheduled visit for updated immunizations. However, due to the individual needing kidney testing conducted (per the request of the individual's family), the individual is unable to have her immunizations updated immediately. The Program Specialist will work with the Life Sharing Family and the individual's natural family to ensure scheduling happens within the next 30 days. 03/05/2021 Implemented
6500.121(c)(7)Individual #1, date of admission 3-27-20, has not had a gynecological examination. 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.At the time of admission, the individual was refusing to have a gynecological examination conducted. The Program Specialist educated the individual of the importance of such routine visits. After the educational session the individual had the gynecological examination completed. Provider will continue to education the individual on the importance of said routine visits and will proceed with yearly gynecological exams for the individual, so far that the individual is in agreement. [Individual #1 had a gynecological examination on 11/17/20. Prior to admission and at least annually, the CEO or designee shall audit physical examination documentation to ensure all required examinations and information is included. Missing information, examinations or testing shall be immediately obtained. (DPOC by AES,HSLS on 2/17/20)] 02/05/2021 Implemented
6500.121(c)(8)Individual #1, date of admission 3-27-20 does not have a mammogram. Individual #1's date of birth is 5-6-55. The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older.At the time of admission, the individual was refusing to have a mammogram examination conducted. The Program Specialist educated the individual of the importance of such routine visits. After the educational session the individual had the mammogram examination completed. Provider will continue to education the individual on the importance of said routine visits and will proceed with regularly scheduled mammogram exams for the individual, so far that the individual is in agreement.[Individual #1 had a gynecological examination on 11/17/20. Prior to admission and at least annually, the CEO or designee shall audit physical examination documentation to ensure all required examinations and information is included. Missing information, examinations or testing shall be immediately obtained. (DPOC by AES,HSLS on 2/17/20)] 02/05/2021 Implemented
SIN-00102989 Renewal 10/27/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.43(d)(1)Individual #1's assessment was completed by the family living provider and reviewed by the family living specialist on 12/7/16.The family living specialist shall be responsible for the following: Coordinating and completing assessments.1. The Family Living Specialist, M. Walker will interview the Life Sharing provider and individual #1 in order to accurately complete the Functional Skills Assessment tool. The FL Specialist will complete the assessment for individual #1 by December 6, 2016. 2. FL Specialist, M. Walker will be trained on 6500.43(d)(1) by CEO, V. Washek by December 2, 2016. 11/28/2016 Implemented
6500.109(e)The two most recent fire drill held during sleeping hours were conducted on 8/2/15 and 10/5/16.A fire drill shall be held during sleeping hours at least every 12 months.1. By December 16, 2016, the Family Living Specialist, M. Walker will train the Life Sharing Family on 6500.109(e) and the expectation of a fire drill during sleeping hours to be held at least every 12 months. 2. The FL Specialist, M. Walker will prepare a fire drill form on a "blue" paper indicating it is to be held during sleeping hours and will provide it to the Life Sharing provider 10 months after the previous sleeping hours drill was completed with a deadline for completion of a sleeping hours drill. The Life Sharing provider will submit the completed drill form to the FL Specialist the day after the drill. 11/28/2016 Implemented
6500.123(a)Individual #1 refused the prostate examination on 8/31/16. There was no documentation of continued attempts to train the individual on the need for health care. [Repeated violation 10/22/16, et al]If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record.1. Beginning on November 28, 2016, the Healthcare Coordinator, C. Smith will provide a prostate exam training sheet to the Life Sharing provider each month at the time MAR sheets are distributed. The Life Sharing provider will review the training sheet with individual #1, document the training on the form, and return the completed sheet to the Family Living Specialist before the end of the month. 2. The FL Specialist, M. Walker will train the Life Sharing provider on 6500.123(a) and the above procedure by December 16, 2016. 3. The annual physical exam form will be revised by December 2, 2016 to include the following questions for the physician regarding the prostate exam for male individuals: whether the exam is indicated for the individual and reasons why if it is not indicated; and if the individual refuses an indicated prostate exam, what are the physician's recommendations per the refusal.[At least quarterly for 1 year, the Executive Director will review the training document to ensure the individuals who refuel medical or dental examinations are educated about the need for health care and documented in the individual's record. Documentation of the education shall be kept. (AS 12/7/16)] 11/28/2016 Implemented
SIN-00085702 Renewal 10/22/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.123(a)Individual #1 refused a prostate examination on 10/9/15. Individual #1's record does not include documented attempts to educate Individual #1 about the need for this health care.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record.Records of all other individuals were reviewed on October 26, 2015 to verify that no other individual was out of compliance. Carrie Smith, LPN prepared a documentation and training sheet on November 20, 2015 to be used during the annual physical examination that will go to the PCP of individual #1 and other male individuals for the doctor to document if an individual refuses a prostate examination. The sheet includes a diagram and information for the PCP to educate any male that refuses the prostate exam and document that education was given. [LPN will continue to provide education to Individual #1 about the need for a prostate examination; as well as, work with Individual's physician to ensure the health and well being of Individual #1. Documentation will be maintained of education etc. will be maintained. (AS 12/22/15)] 11/20/2015 Implemented
6500.131(e)Risperidone 1 mg, 1 tablet by mouth twice a day for paranoia prescribed for Individual #1 was discontinued on 11/20/14. The medication was still in Individual #1's medication box with current medications.Discontinued prescription medications of individuals shall be disposed of in a safe manner.The Risperidone 1 mg medication was removed from the medication box of individual #1 immediately by Marge Walker, FL Specialist. Medications for all individuals were reviewed during the week of October 26, 2015 by each Family Living provider to verify that all discontinued medications had been disposed of; Marge Walker verified this during her November monitoring visit to each home. Marge Walker reviewed the process of disposing of discontinued medications with the Family Living provider of individual #1 on October 26, 2015. Marge Walker, Family Living Specialist, will verify that discontinued medications have been disposed of and are no longer present on site at each regular home visit to all FL homes. She will assist the provider in modifying processes to dispose of discontinued medications as needed. 11/30/2015 Implemented
SIN-00233112 Renewal 10/17/2023 Compliant - Finalized
SIN-00163229 Renewal 09/26/2019 Compliant - Finalized
SIN-00142782 Renewal 10/04/2018 Compliant - Finalized
SIN-00123260 Renewal 10/18/2017 Compliant - Finalized
SIN-00070604 Renewal 10/29/2014 Compliant - Finalized
SIN-00054056 Renewal 09/16/2013 Compliant - Finalized