Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00231006 Unannounced Monitoring 09/13/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34No access to the respite bedroom door. Staff did not have a key. Requested validation once access was acquired, this was not provided.The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients.Video was sent to the Licensing Inspector on 9/22/23 (see attachment 9). 09/26/2023 Implemented
6400.64(a)Windowsill leading to apt b needs to be cleaned to remove dead insects. There was a spider crawling on the bathroom ceiling during the inspection.Clean and sanitary conditions shall be maintained in the home. All windowsills were cleaned on 9/13/23 (see attachment 10). All spiders and insects that were discovered were disposed of as well. 09/13/2023 Implemented
6400.64(b)Windowsill leading to apt b needs to be cleaned to remove dead insects.There may not be evidence of infestation of insects or rodents in the home. All windowsills were cleaned on 9/13/23 (see attachment 10) 09/13/2023 Implemented
SIN-00118451 Renewal 07/06/2017 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(9)INDIVIDUAL #1'S PHYSICAL DATED 06/27/2017 DID NOT INCLUDE A PROSTATE EXAMINATION.The physical examination shall include: A prostate examination for men 40 years of age or older. Why is the regulation important? 141c9 -Annual prostate exams for males 40 years of age and older are important preventative screening tools. How was the regulation violated? Individual Nick Thompson did not have an annual prostate exam in the past year and is over the age of 40. What Caused the Violation? The gap in time between prostate exams was not identified on Nick's 2017 annual physical consultation form and not completed during his annual physical and not identified as missing upon review of physical form. What can be done right away to fix the violation? The individual has a prostate exam scheduled for 8/11/17. What can be done to prevent future violations? Specific instructions to check records regarding annual prostate exam prior to nurses meeting added to the nurses meeting guide. Manager of program was also retrained in requirements for annual physical completion and physical review check list to be completed after physical is completed. See attachment # 3 Who will be responsible for preventing future violations? Program Director- Brian Havlik Program Manager- Jeffery Davis Agency LPN- Kim McCarthy 08/01/2017 Accepted
6400.167(a)STAFF #1 DID NOT HAVE A CURRENT MEDICATION PRACTICUM BEYOND 05/28/2017 BUT ADMINISTERED MEDICATION DURING THE MONTH OF JUNE 2017. Prescription medications and injections of a substance not self-administered by individuals shall be administered by one of the following: (1) A licensed physician, licensed dentist, licensed physician's assistant, registered nurse or licensed practical nurse. (2) A graduate of an approved nursing program functioning under the direct supervision of a professional nurse who is present in the home.(3) A student nurse of an approved nursing program functioning under the direct supervision of a member of the nursing school faculty who is present in the home. (4) A staff person who meets the criteria specified in § 6400.168 (relating to medications administration training) for the administration of oral, topical and eye and ear drop prescriptions and insulin injections. Why is the regulation important? This regulation is important to ensure that individual staff are aware of how to accuratletly complete the medication adminstration process for the overall health and safety of the indivuduals we serve. How was the regulation violated? Only one medication observation was completed within the annual due date for staff #1. whom was due on 5/28, but still continued to give medication in June 2017. What Caused the Violation? The practicum observer who was assigned to completed the observation on staff #1, did not complete the assignment. The missing assigment was not noticed by adminstative staff. What can be done right away to fix the violation? Remedication chart was followed and staff #1 completed two addictional medication obseervations in July 2017. (see attached ) What can be done to prevent future violations? A new PDF tracking system has been updated to better track all staff's individual due dates and has been updated to fit the new regulations regarding medication assignment. The assignements for the praticum observers is now being sent out earlier than previous assignments to ensure that the assignments are completed the due date. At the end of each month Quality Assurance Director tracks completed assigments and follows up with individual staff is not completed. For future staff members that may be out of compliace proper remedication will be assigned. Who will be responsible for preventing future violations? Quality Assurance Director , Lisa McGough 08/01/2017 Accepted
SIN-00089949 Renewal 01/26/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(a)Individual #1's assessment completed after the 365 calendar days requirement (annually). Previous assessment was completed on 10/10/14 and the current assessment was completed on 10/30/15 Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential 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 residential home. Why is the regulation important? This regulation is important to ensure the timely assessment of individual¿s we serve. How was the regulation violated? Individual #1's assessment completed after the 365 calendar days requirement (annually). Previous assessment was completed on 10/10/14 and the current assessment was completed on 10/30/15 What caused the violation? In looking at when the Assessment needed to be completed the person completing the Assessment was going by the ISP Meeting date as opposed to when the last Assessment was completed. What can be done right away to fix the violation? The immediate violation cannot be corrected as the Assessment was completed late. What can be done to prevent future violations? An Assessment Tracking form (attachment #6) is sent out to personnel involved in completing the Assessment, this form has been updated to have the Assessment due date along with the date the previous Assessment was completed. Who will be responsible for preventing future violations? Clerical, Program Director, Medical Assistant, PSM/RM 08/22/2016 Implemented
6400.181(f)Individual #1's assessment, dated 10/30/15, was not sent to the Support Coordinator and Plan Team at least 30 calendar days prior to Individual Support Plan Meeting.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). Why is the regulation important? This regulation is important to ensure the team has had an opportunity to review/give feedback on the Assessment prior to the meeting to ensure all team members are involved with ensure accurate assessment of the individual. How was the regulation violated? Individual #1's assessment dated 10/30/15 was not sent to the Support Coordinator and Plan Team at least 30 calendar days prior to Individual Support Plan Meeting. What caused the violation? The person completing the Assessment did not ensure that documentation of sending the Assessment was kept. What can be done right away to fix the violation? The team was given a copy of the Assessment at the time of the meeting. What can be done to prevent future violations? The Assessment has been updated to provide cues for when and how the Assessment should be sent to the team, including how to preserve the documentation indicating that the Assessment was sent.(attachment #5) Who will be responsible for preventing future violations? Program Director 08/22/2016 Implemented
SIN-00055960 Renewal 10/01/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)The carpet outside of individual #1¿s bedroom was not held down by the metal strip thus causing a tripping hazard.(b) Floors, walls, ceilings and other surfaces shall be free of hazards.Why is the regulation important? Reg 67 b is important in order to help ensure staff and consumer safety by eliminating tripping/falling hazards. How was the regulation violated? There was a section of the flooring that wasn¿t secure, which created a tripping hazard. What Caused the Violation? There was a portion of carpet padding that was bunched up under the carpet creating a tripping hazard. What can be done right away to fix the violation? The maintenance coordinator pulled up the carpet and cut a portion of padding away on 10/4/13. He could't permanently repair the situation, so he contacted a contractor. The contractor assessed and presented a proposal to repair that section of the house and replace with vinyl flooring. This flooring was installed 11/1/13. (Please see attached documentation.) What can be done to prevent future violations? Our maintenance staff was retrained in the regulation and to be able know why it's important and how they'll identify, report, and/or resolve the issue. Who will be responsible for preventing future violations? Our maintenance coordinator 11/01/2013 Implemented
6400.112(f)The provider conducts joint fire drills at two locations (Merlin A and Merlin B) without indication that alternate exits were used during the drills.(f) Alternate exit routes shall be used during fire drills. Why is the regulation important? To ensure the safety of individuals during a fire drill and to familiarize each available exit in case of a fire. How was the regulation violated? Exit routes were not clearly labeled to differentiate which exit routes were being used on monthly fire drills and staff were unaware that alternate exit routes should be used. What Caused the Violation? Staff members were unaware to use alternate routes and labels for each exit were not documented satisfactorily. What can be done right away to fix the violation? A new fire drill form has been created for both Merlin A and Merlin B to separate information. Staff members were retrained to use alternate routes each month and clearly label exit route noted on fire drill form. (See attached fire drill forms.) What can be done to prevent future violations? Program Support Specialist and Quality Assurance director will check to ensure that when monthly fire drill forms are complete that staff have clearly labeled each exit route and ensure exits are being altered. Who will be responsible for preventing future violations? Quality Assurance Director and Program Support Specialist 10/18/2013 Implemented
SIN-00161422 Renewal 08/20/2019 Compliant - Finalized
SIN-00078113 Renewal 10/23/2014 Compliant - Finalized