Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00230509 Renewal 09/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.34(a)Individual #1 was informed and explained their individual rights on 01/08/22, and then again on 02/07/23. This exceeds the annual requirement. [Repeat violation 09/21/22 et. al]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.Mainstay will reinstate a process of distributing individual rights information to residential supervisors at the beginning of each calendar year so that the rights will be explained to all individuals receiving services on an annual basis. [Additional information received from the agency via email on 10/4/23: Training related to informing and explaining Individual Rights to individuals on an annual basis is scheduled to occur on or about 10/10/23. DPOC by HDKP, HSLS on 11/1/23]. 09/26/2023 Implemented
SIN-00212511 Renewal 09/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment for the home is dated 8/30/22; however, the agency's Certificate of Compliance expired on 7/1/2022. Therefore, the self-assessment was not completed 3-6 months prior to the expiration of the Certificate of Compliance.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The agency will ensure that all licensed homes listed on the Certificate of Compliance (whether new or undergoing renovation) will comply with the self-assessment standards under 6400.15(a). All self-assessment documents will use the standard LII tool provided by the department and will be completed within 3 to 6 months of the expiration of the certificate of compliance. [Documentation of the Compliance Committee meeting, dated 1/25/23, was received on 2/6/23 and reviewed 3/1/23. DPOC by HDKP, HSLS, on 3/8/23]. 10/23/2022 Implemented
6400.110(b)On 9/22/22, the smoke detector was 25 feet from Individual #1's bedroom door, exceeding the requirement that the detector be within 15 feet.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. Maintenance staff placed the smoke detector within the required 15 feet of the bedroom door,.and submitted a photo to show the move was completed. [Documentation of smoke detector placed, via photograph, was received on 2/14/23 and reviewed 3/1/23. DPOC by HDKP, HSLS, on 3/8/23]. 09/23/2022 Implemented
6400.181(b)Individual #1's assessment, dated 2/24/22, states that the individual can be unsupervised in the home and in the community for up to 24 hours; however, Individual #1's Individual Support Plan, last updated 8/23/22, states that the individual can be unsupervised for up to 3 hours.If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have an assessment completed as required under this section.The Program Specialist will review the individual's assessment during the month leading up to the ISP meeting to ensure assessments are accurately reflected in the individual's ISP at the ISP meeting. [Documentation of notification to the Support Coordinator of discrepancies between the Assessment and ISP, dated 2/1/23, was received on 2/6/23 and reviewed 3/1/23. DPOC by HDKP, HSLS, on 3/8/23]. 09/26/2022 Implemented
SIN-00179474 Renewal 11/17/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill record for the fire drill conducted 9/2/20 did not include if the smoke detector was operative. This section was blank on the form.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The fire drill record for the fire drill conducted on 9/2/2020 did not include if the smoke detector was operative. The section on the form was blank. A written fire drill record shall include whether the fire alarm or smoke detector was operative. On November 23, 2020, the fire system was checked and was recorded as operative. The fire drill form was initialed and dated on November 23, 2020 by the Director of Residential Operations. The fire drill conducted on October 10, 2020 also noted that the smoke/fire detector and fire alarm system was operative. Program coordinators and program managers were retrained on regulation 112.c on November 24, 2020 and the procedure to include that the fire alarm and smoke detectors were operative. Going forward, all staff will be retrained on the regulation 112.c and the procedure for completing the written fire drill record during December site staff meetings. Program manager, Program Coordinator and the administrative assistant will continue to review each fire drill record for completeness and accuracy. Supporting documentation will include the program manager and program coordinator retraining on November 24, 2020 and the completed signature sheet, the corrected fire drill showing the system was operative on November 23, 2020 and the subsequent fire drill dated October 10, 2020 showing that the fire alarm system was operative. 11/25/2020 Implemented
6400.165(g)Individual #1 is prescribed medications to treat symptoms of the psychiatric illness, obsessive compulsive disorder. The review of medications conducted 7/13/20 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-00119662 Renewal 08/14/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.161(e)Orabase PST 20%, apply topically to lip or mouth ulcers 3 times per day until healed prescribed to Individual #1 was discontinued on 2/27/17 and remained in Individual #1's medication box on 8/15/17. Discontinued prescription medications shall be disposed of in a safe manner.The discontinued medication was disposed of on 8/15/17 and documented on the MAR. Staff has been re-trained by a medication supervisor on the proper medication administration procedures for disposing of discontinued medications. Medication supervisors have been instructed to make sure all discontinued medications are disposed of according to procedures when the meds are reviewed bi weekly, and documented on the back of the MAR. Supporting documentation will be submitted. [4 staff persons signed as trained as stated above on 8/28/17 or 8/29/17. (AS 9/7/17)] 08/31/2017 Implemented
SIN-00069644 Renewal 09/10/2014 Compliant - Finalized