Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00232793 Renewal 09/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)On 4.7.23 there was a fire record which reflects a fire drill was completed at 3:03pm and there was a 4 second evacuation. However, the comment section reports that one individual refused to evacuate the home. The agency did not complete a follow up drill for the month of April 2023. This results in the agency not having completed a successful fire drill for the month of April 2023. Also on 2.27.23 an individual refused to evacuate the home during the fire drill and again there was not follow up fire drill for that month. Also on 11.19.22 an individual refused to evacuate the home during the drill and there was no follow up drill was conducted. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Program Manager of the home will review fire safety concerns with all individuals and provide schedule a time for the fire chief to give additional training to consumers. All team members will be made aware of concerns regarding previously failed fire drills will be discussed so that actionable plans can be implemented to prevent reoccurrence. Fire Chief will be scheduled to assess whether or not the home requires an extended evacuation time. 12/31/2023 Implemented
6400.141(a)An individual shall have a physical exam 12 months prior to admission and annually thereafter. There was a physical dated on 4.27.22, however this physical was partially filled out and missing most of the regulatory items. This resulted in not having a physical prior to the admission date.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. IHRS will contact the PCP to determine if any additional information can be added or if another appointment is necessary. Documentation will be attached to the physical in question. Program Manager and DSP's will be retrained on the responsibility of getting the physical completed and the responsibility of advocating for clients during medical appointments. IHRS will review all client physicals to ensure that they meet regulatory compliance 12/31/2023 Implemented
6400.144This individual is prescribed Hydroxyzine as needed for anxiety or to assist with sleep. There was no protocol describing the exhibited symptoms of anxiety that would require staff to administer the medication. Pharmaceutical services were not provided as necessary.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. IHRS contacted prescriber to discuss PRN policy. IHRS has PRN policy in place. Program Manager was trained on PRN policy as well as all DSP's administering medications. 12/31/2023 Implemented
6400.34(a)The home shall inform the individual of their rights upon admission and annually thereafter. The individual was informed of her rights on 6/22/22. The annual rights were not updated to reflect the current regulation.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.Program Manager will be retrained on the above cited regulation. Quality Assurance and Regulatory Compliance Manager will review current Individual Rights to ensure that all required information is present. All old forms will be removed from offices and electronic storage to ensure they are no longer used. Program Manager will meet with Individual #1 to review updated forms. 12/31/2023 Implemented
SIN-00178651 Unannounced Monitoring 10/29/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.52(c)(5)The records provided for Staff #1, Staff #2, Staff #4, Staff#5 and Staff #6 did not contain documentation of training on the behavioral support plans for Individual #1. Individual #1 plan date 10/21/20-4/20/21. The records for Staff #1 and Staff #2 did not contain documentation of training on the behavioral supports plan for Individual #2 plan date 3/25/20-3/25/21.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.Program Specialist in conjunction with the Behavior Specialist will make sure all staff working in the home are trained properly on the implementation of the Behavior Plan. Staff are being trained by the Program Specialist and/or the Behavior Specialist but proper documentation is not being kept to indicate this is being done. Compliance department and training department will assist in the tracking of employee training. 11/30/2020 Implemented
SIN-00173791 Unannounced Monitoring 06/23/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(f)One of the trash receptacles located outside of the home was open and did not have a cover.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The garbage can was missing a lid. A new garbage can has been purchased with a lid. Staff will routinely check to make sure the lid is present. This is part of the monthly Physical site checklist. 07/31/2020 Implemented
6400.83(a)Individuals do not have access to necessary equipment to prepare appropriate meals. All utensils and knives were locked in a kitchen drawer which denies the individuals living in the home access to equipment necessary to prepare and consume meals and snacks. A home shall have a kitchen area with a refrigerator, sink, cooking equipment and cabinets for storage. All knives and utensils have been unlocked. Lock has been removed from drawer. All clients have access. 07/31/2020 Implemented
SIN-00171818 Unannounced Monitoring 02/26/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Institute for Human Resources and Services failed to provide health services to Individual #1. The prescription Loxapine was not administered on the following dates due to the medication not being refilled: at 8pm on 2/12/2020 and at 8AM on 2/13/2020. The prescription Polyethylene Glycol (17gm BID) was not administered on the following dates due to the medication not being refilled: at 8AM on 1/11/2020 and 1/12/2020, at 8PM on 1/10/2020 and 1/11/2020, at 8AM 2/3-2/6/2020, and at 8PM 2/2-2/6/2020. The prescription for Propanolol (80mg TID) was not administered on the following dates due to the medication not being refilled: 2/9/2020 at 2PM, 2/9/2020 at 8PM and 2/10/2020 at 8AM.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. All medication errors reported during the unannounced visit will be verified and filed in the EIM system. Medication error follow-up will be provided with each employee as per the agency's medication error policy. PCP was contacted and agency is attempting to get documentation on directive for medication errors. IHRS will review with employees that at least a 10 day supply of medications should be on site at all times. Efforts to obtain medications running low will begin early to avoid missed medications and medication errors. IHRS has discussed with agency pharmacy ways to remedy issues moving forward. 04/30/2020 Implemented
6400.18(b)(2)Medication Errors are incidents required to be reported in EIM within 72 hours. The following medication errors occurred for Individual #1: Polyethylene Glycol (17gm) at 8AM on 1/11/2020 and 1/12/2020, at 8PM on 1/10/2020 and 1/11/2020, at 8AM 2/3-2/6/2020, and at 8PM 2/2-2/6/2020; Propranolol HCL (80mg) at 2PM and 8PM on 2/9/2020, and at 8AM on 2/10/2020; Loxapine (100mg) at 8pm on 2/12/2020, Loxapine (50mg) at 8AM on 2/13/2020. These medication errors were not reported in EIM.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person: A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner.All medication errors reported during the unannounced visit will be verified and filed in the EIM system. Medication error follow-up will be provided with each employee as per the agency's medication error policy. PCP was contacted and agency is attempting to get documentation on directive for medication errors. 04/30/2020 Implemented
6400.32(c)Individual #1's health needs were neglected on 2/9/2020 and 2/10/2020. The prescription for Propanolol (80mg TID) ran out and the following doses were not administered: 2/9/2020 at 2PM, 2/9/2020 at 8PM and 2/10/2020 at 8AM. On the morning of 2/11/2020, her blood pressure was high (160/106). She was taken to the Emergency Room where she had to be treated with IV medication to get her blood pressure back to normal. Individual #1's health needs were neglected as the provider agency failed to obtain blood pressure medication once the prescription has run out.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.IHRS will review with employees that at least a 10 day supply of medications should be on site at all times. Efforts to obtain medications running low will begin early to avoid missed medications and medication errors. IHRS has discussed with agency pharmacy ways to remedy issues moving forward. 04/10/2020 Implemented
6400.165(c)The following medications were not administered to Individual #1 as prescribed: Polyethylene Glycol (17gm) at 8AM on 1/11/2020 and 1/12/2020, at 8PM on 1/10/2020 and 1/11/2020, at 8AM 2/2-2/6/2020, and at 8PM 2/2-2/6/2020; Propranolol HCL (80mg) at 2PM and 8PM on 2/9/2020, and at 8AM on 2/10/2020; Loxapine (100mg) at 8pm on 2/12/2020, Loxapine (50mg) at 8AM on 2/12/2020 and 2/13/2020.A prescription medication shall be administered as prescribed.IHRS will review with employees that at least a 10 day supply of medications should be on site at all times. Efforts to obtain medications running low will begin early to avoid missed medications and medication errors. IHRS has discussed with agency pharmacy ways to remedy issues moving forward. 04/10/2020 Implemented
6400.166(b)The following medications were not initialed as administered to Individual #1: Polyethylene Glycol (17gm) and Ocusoft Foaming Lid Scrub at 8AM on 2/21/2020.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.IHRS will review missing information with employee who passed 8am medications on 2/21/20. Employee will be issued training and disciplinary action under IHRS's Medication Documentation Policy. 04/30/2020 Implemented
6400.167(b)The following medication errors occurred for Individual #1: Polyethylene Glycol (17gm) at 8AM on 1/11/2020 and 1/12/2020, at 8PM on 1/10/2020 and 1/11/2020, at 8AM 2/3-2/6/2020, and at 8PM 2/2-2/6/2020; Propranolol HCL (80mg) at 2PM and 8PM on 2/9/2020, and at 8AM on 2/10/2020; Loxapine (100mg) at 8pm on 2/12/2020, Loxapine (50mg) at 8AM on 2/13/2020. There is no documentation of these medication errors or follow-up action taken by the agency.Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record.All medication errors reported during the unannounced visit will be verified and filed in the EIM system. Medication error follow-up will be provided with each employee as per the agency's medication error policy. PCP was contacted and agency is attempting to get documentation on directive for medication errors. 04/30/2020 Implemented
SIN-00138092 Renewal 08/16/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The baseboard heater in the bathroom had a significant amount of rust on it. The front panel was coming forward and there was debris that appeared to be toilet paper shreds inside of it.Floors, walls, ceilings and other surfaces shall be in good repair. The baseboard will be fixed, sanded and repainted or it will be replaced, pending on the recommendation of IHRS's contractor. Site employees and Program Specialists complete monthly site checklists. Checking baseboard heaters for rust/repair is going to be added as a specific item to check-off on the monthly checklist. The Residential Programs Manager has requested a work order for the baseboard heater. The Residential Programs Manager will update the monthly site checklists. The new checklists will be reviewed with the Program department and direct care staff. 09/30/2018 Implemented
SIN-00072789 Change in Location Capacity 12/22/2014 Compliant - Finalized
SIN-00071150 Change in Location Capacity 11/05/2014 Compliant - Finalized