Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00179477 Renewal 11/17/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(g)Individual #1 is prescribed medications to treat symptoms of the psychiatric illness, obsessive compulsive disorder. The reviews of medications conducted 11/9/20, 9/10/20, 6/11/20 and 10/30/19 did not include the need to continue the medications.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.On 11/24/2020, the program managers and program coordinators have been retrained on the 6400.165.g regulation if a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage. A new psychiatric medication review form was created and effective immediately, will be used in addition to the appointment consultation form. All forms will be uploaded to the ECR. The program manager and program coordinator will review the appointment documentation to ensure that the scheduled appointment is within the 3-month time frame, includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. An additional review will be completed by utilizing a monthly clinician report in the ECR and ongoing audits will be conducted by the quality team. Supporting documentation of the retraining of the program managers and program coordinators, the new psychiatric medication review form and the example of the ECR monthly clinician report will be submitted. 11/25/2020 Implemented
SIN-00119666 Renewal 08/14/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(a)Individual #1 was informed of the individual's rights on 12/30/15 and 1/24/17.Each individual, or the individual's parent, guardian or advocate, if appropriate, shall be informed of the individual's rights upon admission and annually thereafter. Mainstay Life Services Policy and Procedure Manual was revised to reflect the annual date requirement. Each individual shall be informed of their rights upon admission and annually thereafter. Program Managers, Program Coordinators and Administrative Staff were retrained to ensure that the annual date requirement of 365 day plus 15 for individual rights will be met. Going forward, documentation will be signed annually within the first 10 days of each January. Supporting documentation will be submitted. [Aforementioned trainings occurred on 8/28-30/17 for 20 staff persons. Within 30 days of receive of the plan of correction, the CEO or designee shall develop and implement a tracking system and process to ensure individuals are informed of the individual's rights upon admission and annually thereafter. Within 60 days of receipt of the plan of correction, the CEO or designee shall train all staff person responsible for implementation of the tracking and process to ensure individuals are informed of the individual's rights upon admission and annually thereafter. Documentation of tracking system and trainings shall be kept. (AS 9/1/17)] 08/31/2017 Implemented
SIN-00069649 Renewal 09/10/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)Individual #1 used the front door for all fire drills conducted October 2013 through September 2014.Alternate exit routes shall be used during fire drills. The policy has been amended to include the statement "All individuals in the home must use every exit that they are physically able to use". Forms have been developed to make it apparent which exits have been used as the year progresses. All staff will be retrained on the new policy by their manager during the December and January staff meetings. The individuals currently living in this home use wheelchairs and are unable to evacuate using alternate exits. 11/07/2014 Implemented
SIN-00194858 Renewal 10/20/2021 Compliant - Finalized