Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00199893 Renewal 02/10/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(11)Individual #1's February 2022 Medication Administration Record did not include the diagnosis or purpose for the following medications: Cyanocobalamin 1000 mcg/ml Inject once a month, Acetaminophen 500mg tabs, Amlactin 12% lotion apply topically to arms and legs twice a day, and Ciclopirox 0.77% cream Apply topically to toenails 2 times a dayA medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The medication administration record for this individual has been corrected by writing in the diagnoses for each medication that did not include a diagnosis. A copy of these corrections has been sent to the pharmacy to be included on upcoming medication administration records. 03/04/2022 Implemented
SIN-00168309 Renewal 12/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The fire drill conducted on 5/27/19 at 4:15 PM had an evacuation time of 2 minutes 55 seconds. The fire drill conducted on 6/26/19 at 9:30 PM had an evacuation time of 2 minutes 55 seconds. The home does not have an extended evacuation time designated in writing by a fire safety expert. [Repeat violation 1/7/19 et. al.] 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. The fire drill procedure will be reviewed with the residential manager of the Locust residence, paying close attention to when the time is supposed to start and end during a drill. This will also be reviewed with the managers from the other sites. The Locust residence, and all other residences are to conduct their fire drills at varying times throughout the month but should leave time at the end of each month should the drill need to be repeated. For Locust and all other sites, the residential manager will review the drill evacuation times after conducting the drill. If the evacuation time exceeds 2.5 minutes then the drill will be repeated. If the drill continues to be an issue, the program director will be notified and a fire safety professional consulted for an evaluation of that site¿s fire drills and to make recommendations. If an extended time is needed the fire safety professional will submit a written letter including the reasons for the extended evacuation time and the length of time the fire safety professional is recommending for a safe evacuation. This letter will be reviewed and resubmitted annually if necessary. The administrative assistant will receive a copy of each site¿s fire drill and notify the program director of any drills that exceed the 2.5 minutes evacuation time. The program director will be responsible for this plan of correction and will monitor at least 25% of the fire drills each month. [Prior to completing any additional fire drill, the CEO or designee shall educate all staff persons responsible for conducting fire drill and reviewing fire drill records of the requirements and the aforementioned procedures to ensure fire drills are conducted and documented as required. Documentation of trainings shall be kept. (DPOC by AES,HSLS on 1/14/20)] 02/29/2020 Implemented
6400.151(c)(3)The Chief Executive Officer Designee #1, date of hire 11/25/03, had a physical examination, dated 5/13/19; however, the physical examination does not address communicable diseases. This form states that the employee is free from communicable TB. Program Specialist #2, date of hire 11/4/19 had a physical examination, dated 10/21/19; however, the physical examination does not address communicable diseases. This form states that the employee is free from communicable TB. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. The physicals for these staff will be reviewed by the administrative assistant and any staff that do not currently have a physical form which states they are free from communicable disease will have that part of the physical completed and placed in their file. The Occupational Medicine office which completes our staff physicals has been consulted and has agreed to revise their physical form to include ¿free from communicable disease¿ on the physical form. The administrative assistant will monitor the staff physicals once they are sent to the main office to determine that all areas are complete, including the ¿free from communicable disease¿. The administrative assistant will monitor at least 25% of the staff physicals each month to ensure that they are complete and have the ¿free from communicable disease¿ section on the form and completed. The administrative assistant will be responsible for this plan of correction. 02/29/2020 Implemented
SIN-00148613 Renewal 01/07/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(c)Individual #1's psychiatric medication review completed 11/29/18, did not include the need to continue the medications. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.For this individual the psychiatrist will be contacted for a review of prescribed psychiatric medications and then complete in its entirety the psychiatric medication review form. For this and all individuals, the psychiatric medication review form has been revised to include the required components (medication, dose, reason for the medication, and the need to continue). The residential managers were trained on 1/9/19 on how to assist the medical professional in completing this form. The residential managers will review the form prior to leaving the appointment to ensure that all necessary information has been included on the psychiatric medication review form. The Waiver Supervisor will be responsible for overseeing this plan of correction and will keep copies of all psychiatric medication review forms in a binder and sign each form once she has reviewed it. 02/22/2019 Implemented
SIN-00131458 Unannounced Monitoring 02/16/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)Between November 2017 and December 2017, House Manager #1 was responsible for management of Individual #1, Individual #2, Individual #3, and Individual #4 funds and purchasing Christmas gifts for each of the Individuals. On December 25, 2017, it was reported to President #2, by several direct service workers in the home that the individuals did not receive the Christmas gifts believed to have been purchased. Per agency policy revised December 1, 2016, The Manager is responsible for that money and will have two (2) days from the issue date of the check to return the receipt(s) and/or change. If the receipt(s) and/or change is not returned within two (2) days, the entire amount will be deducted from the Manager's next paycheck.' On December 28, 2017, President #2 requested via text message that House Manager #1 submit receipts to Fiscal Employee #3 to verify expenses. House Manager #1 provided incomplete receipts that were missing dates and details of the purchased items. On January 5, 2017, House Manager #1 reported to the agency office to discuss the incident and a request to the return of the missing items was made. House Manager #1 left the meeting and ceased communication with the agency. City of Washington Police report, #18000170, filed January 9, 2018 reads that charges to be filed' against House Manager #1. The following total amount of funds for the specified individuals were not accounted for and/or not used for the individuals: Individual #1, $496.94; Individual #2, $483.99; Individual #3, $2739.00 and Individual #4, $2091.97.Individual funds and property shall be used for the individual's benefit. On 1/31/18, the missing funds were returned to each of the four individuals: Individual #1 $496.94, Individual #2 $483.99, Individual #3 $2,739.00 and Individual #4 $2,091.97. The Residential Cash Procedure has been revised by Staff #2 to include the following: If there is a need for an individual greater than $100.00, the Manager will submit a purchase request to Administration Fiscal Employee for review and/or approval. Depending on the circumstances, the Administration Fiscal Employee may help with the purchase (i.e. on-line order) or a separate check may be issued. If a separate check is issued, the Manager will sign an Individual Funds Sign-out Sheet in order to receive the check. The Manager is responsible for that money and will have two (2) days from the issue date of the check to return the receipts and/or remaining money. If the receipt(s) and remaining money are not returned within (2) days, the entire amount of the check will be deducted from the Manager's next paycheck. All funds have been reviewed during the month of February, 2018, by the Fiscal Employee #3 and currently all records balance. The review is documented. All fiscal employees were trained on the policy and procedures on 2/26/18. All managers will be trained on the policy by 4/15/18. The Manager will train each employee on the Resident Cash Procedure and the reporting process for any violations of that policy during individual residential staff meetings during April, 2018. The Fiscal Employee will review all funds for each individual once per month to verify that funds, receipts, and money left are accounted for and that the records balance. The review will be documented including issues that may arise on the Resident Personal Account Audit Detail. The Director will review 25% of the individuals' funds each quarter for one year to verify that policies have been followed and records balance. The Director will document the review. The police case continues. WGARS, Inc. has not been advised of any dates for proceedings as of this time. [House Manager #1 as terminated effective 1/5/18. (AS 4/4/18)] 04/30/2018 Implemented
SIN-00088996 Renewal 01/07/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.74The first, sixth and seventh steps from the top of the outside fire escape did not have a nonskid surface. Interior stairs and outside steps shall have a nonskid surface. The missing non-skid strips were replaced on the fire escape January 15, 2016 (see attached picture). Safety Committee Inspections include checking all non-skid areas (see attached Residential Inspection Safety Checklist). During winter months, house managers will check non-skid areas weekly and report needed repairs to maintenance to be fixed immediately. [Within 60 days of receipt of the plan of correction all staff responsible for completing aforementioned physical site checks and completing checklists and reporting repair needs shall be trained in the policies and procedures to ensure all areas of all community homes including the interior stairs and outside steps having nonskid surface are maintained as required. Documentation of trainings and physical site checks shall be kept. (AS 7/28/16)] 01/15/2016 Implemented
SIN-00073435 Renewal 01/13/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.142(f)Individual #1's record did not include a written dental hygiene plan; Individual #1's dental exam, dated 7/16/14, indicated that "a plan must be put in place to assist patient with oral hygiene".An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. A dental procedure plan has been developed and all staff at that location has been trained (see attached). 01/25/2015 Implemented
SIN-00057494 Renewal 03/04/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(3)For the program specialist's job description, the items regarding the ISP were missing. (b) The program specialist shall be responsible for the following: (3) Participating in the development of the ISP, ISP annual update and ISP revision. Program Specialist's job description has been rewritten and Program Specialists have been trained. Quality Management Team will review job descriptions annually. 03/14/2014 Implemented
6400.74The outside steps at the side of the house do not have a non-skid surface, and the last back step -- leading up to the fire escape -- does not have a non-skid surface. Interior stairs and outside steps shall have a nonskid surface. Non-skid has been replaced (pictures will be mailed separately). Maintenance has been trained. 03/11/2014 Implemented
6400.112(a)There were no fire drills held in April or May of 2013.(a) An unannounced fire drill shall be held at least once a month. A memo regarding fire drills has been send to all sites. A copy of the memo will be mailed separately. We cannot go back and do the fire drills. New guidelines for fire drills has been developed. 03/05/2014 Implemented
6400.163(c)For Individual #1, there are no psychiatric consults beyond 9-16-2013. Also, on the psychiatric consult form for 8-26-2013, there are no dosages listed for the medications listed. (c) If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. We cannot go back to get this appointment. However, this individuals is now under Hospice and that physician will monitor his psych medications. Attached is a copy of the new form to be used to eliminate scheduled appointments not being done. All managers have been trained on this 03/11/2014 Implemented
SIN-00237596 Renewal 12/19/2023 Compliant - Finalized
SIN-00217754 Renewal 01/18/2023 Compliant - Finalized
SIN-00185560 Renewal 03/11/2021 Compliant - Finalized
SIN-00128210 Renewal 01/23/2018 Compliant - Finalized
SIN-00107480 Renewal 01/26/2017 Compliant - Finalized