Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00230572 Renewal 10/03/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)At the time of the inspection, Individual #1's drain in their shower/bathtub combination drained slow. The bathtub filled up with water when using the waterspout to test the water temperature and took a few minutes after the water was shut off to completely drain out of the bathtub.Floors, walls, ceilings and other surfaces shall be in good repair. 10/9/23 A maintenance request was submitted to the maintenance department to fix the drain in the shower/tub. (Attachment #7) 10/9/23 Drain O was added to the drain, and it was plunged. No further issues were noted, and water drained freely when water was added to the shower/tub. The program specialist verified the work was complete. (Attachment #7) 10/13/23 Program specialists and working managers were trained on their responsibilities including floors, walls, ceilings and other surfaces shall be in good repair. 10/13/23 A training record was signed indicating their attendance and understanding. All program specialists and working managers will continue to verify and ensure all floors, walls, ceilings and other surfaces are in good repair. (Attachment #1) 10/13/2023 The SFI Safety Inspection Checklist was updated to include the following inspection: Bathtub floors clean, without stains and working properly (draining well). (Attachment #8) 10/17/2023 Implemented
6400.141(c)(11)Individual #1's current, 6/28/23 physical examination record did not include a review of their prescribed medications. The examination record stated their medication record was attached but only a general as needed list of over-the-counter medications the individual could take was attached. According to the individual's records they take approximately 11 daily medications for various diagnosis. The individual's medical record included another copy of their 6/28/23 physical examination with a list of medication attached. However, this medication list wasn't completed until 8/17/23 and only included six psychotropic medications.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. 10/13/23 Program specialists, working managers, and nurses were trained on their responsibilities including: the physical exam shall include: an assessment of the individual's health maintenance needs, medication regimen, and the need for blood work at recommended intervals. 10/13/23 A training record was signed indicating their attendance and understanding. All program specialists, working managers and nurses will continue to verify and ensure physical exams will include: an assessment of the individual's health maintenance needs, medication regimen, and the need for blood work at recommended intervals. (Attachment #1) 10/14/23 Program specialist reviewed medical appointment section of Individual #1¿s binder and found the original physical with correct and current medication list attached (from 6/2/23). Program Specialist attached the correct medication list from the appointment to the copies of the physical for Individual #1 at the program. (Attachment #11) 10/16/23 The SFI physical form was updated to include a verification from staff that current medications are listed on the form or attached with the physical form. (Attachment #9) 10/17/23 The medical visit record form was updated to include a verification from staff, the program specialist or working manager and nurse that current medications were listed on the form or attached with the visit record. (Attachment #10) 10/26/2023 Implemented
6400.142(e)On 12/21/22, Individual #1's dentist stated that the individual had two broken teeth that need extracted by an oral surgeon and provided the caretaker with the referral. The agency, Strawberry Fields Inc., did not provide information about Individual #1's referral to an oral surgeon until 2/17/23. At the time of the 10/3/23 inspection, the agency has not followed the dentist recommendations for completing the extraction, or had the individual indicate if they wish to have the procedure or not.Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed.10/13/23 Program specialists, working managers, and nurses were trained on their responsibilities including follow up dental work indicated by the examination, such as treatment of cavities, shall be completed. 10/13/23 A training record was signed indicating their attendance and understanding. All program specialists, working managers, and nurses will continue to verify and ensure follow up dental work indicated by the examination, such as treatment of cavities, will be completed. 10/17/23 The oral surgeon was contacted by Strawberry Fields nurse to schedule an appointment. SFI nurse was told the scheduling secretary was out of the office this week and an appointment could not be scheduled at the time of the call. SFI nurse will call the week of 10/23/23. (Attachment #12) 10/17/23 The Monthly Health Assessment form was updated in Carelogic. A section was added to the form to review appointment information. If a follow up appointment needs to be scheduled by the doctor's office, the nurse will contact the office to get an update regarding the appointment. (Attachment #13) 10/19/2023 Implemented
6400.144(REPEAT from 10/2022 inspection) -Individual #1 needs a referral to psychologist for behavioral issues listed. At the time of the 10/3/23 inspection there are no records that a referral is completed for a psychologist for behavioral issues listed at the medical appointment. During the months of August and September Individual #1's counselor recommended the following techniques for Individual #1 to cope with stress and anxiety: Deep Breathing, Progressive Muscle Relaxation, Counting Down, Grounding and Using Visual Reminders of Daily Tasks. It was also recommended that the Individual refer to staff for Problem-Solving & Coping with frustration. Staff are to encourage the individual to use words to express themselves. Staff should adjust the Lighting & Discontinuing TV Loudness at bedtime and Individual #1 was recommended to complete calm acts before bedtime. Staff are to encourage Individual #1 to verbalize their feelings with matching facial expressions and body language. Individual #1 is to use cold water and exercise to manage stress. It was recommended that Individual #1 assess their feelings and intensity daily on a scale of 1-5. It was recommended that they give themselves a butterfly hug to self-soothe. There are no records that home staff are attempting to work on the therapist's recommendations with the individual or if the individual is refusing. On 9/29/23 the individual's physical therapist recommended the individual consider the addition of an electric heating pad for use at home. Staff administered over the counter medication to the individual 28 times for back and leg pain. For approximately half of the administration, the home documented that the medication administration wasn't effective at handling the pain. The home has not reported the amount of back pain the individual was expressing to a medical professional to have them evaluated.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. 10/9/23 Program Specialist contacted Individual #1's PCP to clarify a referral to a psychologist from 5/2/23 appointment. The PCP documents in the note since Individual #1 is seeing a counselor, that should be good for behavioral support plan. The PCP also wrote "You can also discuss with the psychiatrist." Staff will follow up with the psychiatrist to get their recommendation. (Attachment #15) 10/9/23 Program specialist contacted behavior support specialist and counselor to discuss tracking behaviors, ways staff can help Individual #1 and the outcome. Staff will track Individual #1's behaviors and staff's response on this form. The form and tracking information was reviewed by the counselor and behavior specialist and both agreed it is a good tool to use. (Attachment #16) 10/13/23 Program specialists, working managers and nurses were trained on their responsibilities including: health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged or provided. 10/13/23 A training record was signed indicating their attendance and understanding. All program specialists, working managers and nurses will continue to verify and ensure all health services, such as medical, nursing, pharmaceutical, dental, dietary, and psychological services that are planned or prescribed for the individual are arranged or provided. (Attachment #1) 10/16/23 The Monthly Supervisory Documentation form was updated to include a review of appointments, follow-up and recommendations needed. Verification is documented that all appointments, follow-up, and recommendations are completed as prescribed. (Attachment #20) 10/19/23 Individual #1 purchased a heating pad to use when needed per the PT recommendations on 9/29/23 (Attachment #17) 10/19/23 SFI's nurse completed a Health Assessment on Individual #1 due to consistent reported back and leg pain in September. Over the counter medication was administered 28 times in September for back and leg pain. (Attachment #18) 10/19/23 Individual #1 had a doctor appointment and the issue of the consistent back and leg pain in September was addressed. (Attachment #19) 10/31/2023 Implemented
6400.181(e)(14)Individual #1's current, 8/23/23 assessment doesn't include their ability to swim. The assessment states the individual enjoys going to the swimming pool but would require a lifeguard when swimming and staff supervision, they are frightened of deep water, and very uncomfortable in deep water. None of the descriptions state if the individual can or can't swim.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. 10/9/23 Program Specialist reviewed and updated Individual #1's assessment to include accurate information regarding knowledge of water safety and ability to swim. (Attachment #24) 10/13/23 Program specialists and working managers were trained on their responsibilities including: the assessment must include the following information: the individual's knowledge of water safety and ability to swim. 10/13/23 A training record was signed indicating their attendance and understanding. All program specialists and working managers will continue to verity assessments include the following information: the individual's knowledge of water safety and ability to swim, including specifically if individuals can swim or not. (Attachment #1) 10/17/23 Individual #1's isp was updated to include accurate information regarding knowledge of water safety and ability to swim. (Attachment #25) 10/19/2023 Implemented
6400.18(a)(4)The following information and incident was produced during the 10/5/23 inspection due to an emergency room visit for Individual #1 on 4/2/23. According to Individual #1's current behavior support plan it lists different prevention and intervention strategies to use in the event the individual is exhibiting the target behaviors identified within the plan. Prevention and intervention strategies stated staff should praise the individual when noticing they are doing a good job. They are to keep the approach positive. They are to communicate boundaries and pick their battles. When the individual appears overwhelmed, they are to offer a break. If threats of physical aggression are made staff are to reflect and empathize how the individual is feeling. They are to redirect them and demonstrate understanding of how upset the individual is. They are always to attempt to deescalate and praise. On 4/2/23 individual #1 was taken to the emergency room for a fall and altercation with staff. According to staff #1's incident report, "Individual #1 got back in staff's face this time with their bodies up against staff's body. Staff asked the individual again repeatedly to step back, the individual refused. The staff lightly nudged the individual and the individual lost their balance and knocked over the chair and fell on their butt." The staff continued to state that the individual was asking for help up off the ground and Staff #1 reported they told the individual they couldn't help them up. There wasn't a physician's note that staff #1 was on any job duty restrictions due to a medical concern they reported as the reason for not helping the individual up after they fell. The behavior support plan was not implemented, and staff used physical contact that resulted in the individual falling. The home never investigated the incident.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 24 hours of discovery by a staff person: Abuse, including abuse to a individual by another client. 0/9/2023-An incident (#9293809) of suspected physical abuse was reported into the Enterprise. Management System regarding an altercation between an SFI staff and Individual #1 on 4/1/2023. An investigation was initiated and SFI staff was identified as a potential target in the incident. (Attachment #2) 10/11/2023 An administrative review of the investigation took place for incident #9293809. A determination of the investigation was made based on the evidence and documentation presented by the Certified Investigator and appropriate corrective actions were identified. (Attachment #3) 10/13/2023 Program specialists, working managers, nurses, IM Representative, and ID Director were trained on their responsibilities including: 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 with 24 hours of discovery by a staff person: abuse, including individual by another client. 10/13/2023 A training record was signed indicating their attendance and understanding. All program specialists, working managers, IM Representative, and ID Director will continue to verify and confirm the homes 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 with 24 hours of discovery by a staff person: abuse, including individual by another client. (Attachment #1) 10/13/23 Program specialists, working managers, nurses, IM representative, and ID Director were trained on Incident management and reporting guidelines per the Incident Management bulletin, 0221-02. Specific details regarding appropriate reporting guidelines (24 and 72 hours) and the categories of incidents were included in the training. (Attachment #4) 10/16/23 The initial incident report was updated to include a review of the incident by the Program Specialist, IM representative, ID Director, and Quality and Compliance Director for Strawberry Fields. The review will ensure incidents are reported correctly and/or initiate further incidents/investigations if necessary. (Attachment #5) 10/17/2023 Implemented
6400.32(c)On 4/2/23 individual #1 was taken to the emergency room for a fall and altercation with staff. According to staff #1's incident report (the staff working with individual at the time of the fall and altercation) "Individual #1 got back in staff's face this time with their bodies up against staff's body. Staff asked the individual again repeatedly to step back, the individual refused. The staff lightly nudged the individual and the individual lost their balance and knocked over the chair and fell on their butt." The staff continued to state that the individual was asking for help up off the ground and Staff #1 reported they told the individual they couldn't help them up. There wasn't a physician's note that staff #1 was on any job duty restrictions due to a medical concern they reported as the reason for not helping the individual up after they fell. The behavior support plan was not implemented, and staff used physical altercation that resulted in the individual falling.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.10/9/2023-An incident (#9293809) of suspected physical abuse was reported into the Enterprise Management System regarding an altercation between an SFI staff and Individual #1 on 4/1/2023. An investigation was initiated and SFI staff was identified as a potential target in the incident. (Attachment #2) 10/11/2023 An administrative review of the investigation took place for incident #9293809. A determination of the investigation was made based on the evidence and documentation presented by the Certified Investigator and appropriate corrective actions were identified. (Attachment #3) 10/13/2023 Program specialists, working managers, nurses, IM Representative and ID Director were trained on their responsibilities including: An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. 10/13/2023 A training record was signed indicating their attendance and understanding. All program specialists, working managers, nurses, IM Representative and ID Director will continue to verify and confirm an individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. (Attachment #1) 10/13/23 Program specialists, working managers, nurses, IM representative and ID Director were trained on Incident management and reporting guidelines per the Incident Management bulletin, 0221-02. Specific details regarding appropriate reporting guidelines (24 and 72 hours) and the categories of incidents were included in the training. (Attachment #4) 10/16/23 The initial incident report was updated to include a review of the incident by the Program Specialist, IM representative, ID Director and Quality and Compliance Director for Strawberry Fields. The review will ensure incidents are reported correctly and/or initiate further incidents/investigations if necessary. (Attachment #5) 10/17/2023 Implemented
6400.165(g)Individual #1 is prescribed psychotropic medications for psychiatric diagnoses. Their monthly medication reviews do not clarify the specific reason for haloperidol. There are two forms attached to the appointment records, one identifying the medication is prescribed for auditory hallucinations and the other medication record states its for mood disorder. Additionally, one of the medication lists state 20mg of haloperidol is prescribed but the other medication list states 20mg twice a day is what is prescribed. This 20mg dosage then decreased throughout the year and on a few monthly reviews, 20mg was recorded, then crossed off and 15mg added to the form. The name of the person making this change and when wasn't recorded on the record to know what dosage the physician reviewed during the appointments.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.10/9/23 Program specialist contacted Individual #1'spsychiatrist to confirm reason for medication (haloperidol) was for mood (per medication label prescribed by the psychiatrist) and not auditory hallucinations as was written by SFI staff on the appointment form. 10/12/23 Individual #1 had a psychiatric medication review and medication name, dosage, and reason for medication was documented correctly on the form and signed by the psychiatrist. (Attachment #21) 10/10/23 Program specialist contacted Individual #1's psychiatrist to confirm the dosage of the Haloperidol as it was different on several medication lists. Current medication list was sent through the portal. (Attachment #29) 10/13/23 Program specialists, working managers and nurses were trained on their responsibilities including: 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 the reason for prescribing the medication, the need to continue the medication and the necessary dosage. 10/13/23 A training record was signed indicating their attendance and understanding. All program specialists, working managers, and nurses will continue to verify and ensure a medication prescribed to treat symptoms of a psychiatric illness there shall be a review by a licensed physician at least every 3 months and includes the reason for prescribing the medication, the need to continue the medication, and the necessary dosage. (Attachment #1) 10/16/23 The Psychiatric Consult/Medication Review form was updated to include verification of medication, dosage, and reason for med/diagnosis by the program specialist or working manager. There is also a verification that the medications prescribed for psychiatric illness match the current med list. (Attachment #22) 10/16/23 The Monthly Supervisory Documentation form was updated to include a review of Psychiatric appointments to verify medication, dosage and reason for medication is documented correctly and matched med list. (Attachment #20) 10/27/2023 Implemented
6400.166(a)(2)Individual #1's September 2023 medication administration record (mar) didn't include the name of the prescriber for some of their Austedo medications (there were multiple lines for administration of this medication and not all contained the prescriber), or their as needed medications Advil, Benadryl, or Mucinex. Their October 2023 mar was also missing the name of the prescriber for the same medications listed above.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.10/6/2023 The Monthly Supervisory Documentation form was updated to include a verification of general information on the medication record, including the name of the prescriber for each prescription medication. 10/13/23 Program specialists, working managers, and nurses were trained on their responsibilities including: a medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of prescriber. 10/13/23 A training record was signed indicating their attendance and understanding. All program specialists, working managers, and nurses will continue to verity a medication record is kept, including the following for each individual for whom a prescription medication is administered: Name of prescriber. (Attachment #1) 10/17/23 Individual #1's medication record was updated to include a prescriber for each prescribed medication on the medication administration record. (Attachment #23) 10/19/2023 Implemented
6400.186Individual #1's current, 3/16/23 assessment states they can handle up to $30 independently and will be provided $15 twice weekly. According to financial transaction record for September 2023, Individual #1 was provided $57 on 9/14/23 to handle independently. Individual #1's current behavior support lists target behaviors: physical aggression, threats of physical aggression, adopting an intimate posture, deliberate initiate of conflict with staff, resistance to staff prompts of de-escalation and coping, bids to have contact with emergency services, hiding food, hiding/hoarding valueless items, saying things that are untrue, selective reporting to staff in order to gain a particular outcome. Per agency program specialist on 10/5/23 the home doesn't have tracking records for any of the behaviors or what was done to help the individual through these behaviors. According to the program specialist, staff are to record items on daily notes, but they have difficulty getting staff to record daily notes so the number of target behaviors in the home is unknown and its unknown what staff are doing to help the individual through incidents identified within the plan. For example, Individual #1 was taken to the emergency room on 4/26/23 for anxiety. There are no records around this event, what occurred, and how staff assisted the individual through this event.The home shall implement the individual plan, including revisions.10/10/23 Program specialist contacted Individual #1's Counselor and Behavior Support Specialist to discuss behaviors, staff support, and creating a tracking form for them. A tracking form was created to include the following information: date/time, what happened prior to the incident, what was individual #1 experiencing/what was the incident, which recommendation was used to help individual #1 and what was the outcome. The counselor behavior support specialist approved the use of the tracking form. (Attachment #16) 10/13/23 Program specialists and working managers were trained on their responsibilities including: the home shall implement the individual plan, including revisions. 10/13/23 A training record was signed indicating their attendance and understanding. All program specialists and working managers will continue to verity the home will implement the individual plan, including revisions. (Attachment #1) 10/17/23 Program specialist contacted Individual #1's representative payee to discuss dispensing spending money as written in the individual's plan. The plan indicates Individual #1 can handle up to $30 independently and will be provided $15 twice weekly. (Attachment #27) 10/17/23 Strawberry Fields Petty Cash Transfer form was updated to include the total amount an Individual can handle independently each day/week/month. Staff will then know the maximum allowed to give to an individual for petty cash. (Attachment #28) 10/31/2023 Implemented
SIN-00141413 Renewal 10/24/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The basement door did not shut completely unless force was used to slam it shut.Floors, walls, ceilings and other surfaces shall be in good repair. November 8, 2018- All Program Specialists were trained on their responsibilities that floors, walls, ceilings and other surfaces shall be in good repair. A training record was signed indicating their attendance and understanding. November 20, 2018- A maintenance request was completed to install a handle on the middle of the basement door to facilitate the ease of closing it. The handle has been installed. All agency homes have been reviewed and evaluated and are currently in compliance. November 20, 2018- A monthly review will be completed by a member of the safety committee evaluating the homes floors, walls, ceilings, and other surfaces to ensure they are all in good repair. The process is completed at each home on a monthly basis. 11/20/2018 Implemented
6400.73(a)The steps leading to the basement on the outside of the home were not equipped with a handrail on the top 5 steps. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. November 8, 2018- All Program Specialists were trained on their responsibilities that each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. A training record was signed indicating their attendance and understanding. November 20, 2018- A maintenance request was completed to install a handrail to the steps leading to the basement. The handrail has been installed. All agency homes have been reviewed and evaluated and are currently are in compliance. November 20, 2018- A monthly review will be completed by a member of the safety committee evaluating the homes ramps, interior stairways, and outside steps exceeding two steps needed for a well secured handrail. The process is completed at each home on a monthly basis. 11/20/2018 Implemented
6400.103The written emergency evacuation plan did not include the means of transportation. The plan indicated staff were going to transport the individual but did not explain how; i.e. staff vehicle, personal vehicle, company vehicle, etc.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. November 8, 2018- All Program Specialists were trained on their responsibilities that there shall be written emergency evacuation procedures that include individual and staff responsibilities, mean of transportation, and an emergency shelter location. A training record was signed indicating their attendance and understanding. The agency Emergency and Removal Transfer Plan template has been revised to include means of transportation. This new form is a template and is prepopulated to ensure compliance when referencing means of transportation. November 12, 2018- In all agency homes the Program Specialist updated all Emergency and Removal Transfer plans. They have been verified by the ID Director to be correct and in compliance. 11/12/2018 Implemented
6400.112(i)A smoke detector wasn't sent off for every fire drill. Sometimes the smoke detector was set off in 311 Fry Drive home that is attached to 309 Fry Drive (a separate licensed home) and the smoke detectors are inner connected. A fire alarm or smoke detector shall be set off during each fire drill.All Program Specialists were trained on their responsibilities that a fire alarm or smoke detector shall be set off during each fire drill. A training record was signed indicating their attendance and understanding. The agency fire drill record has been revised with instructions stating that ¿Interconnected detectors at 309/311 Fry Drive and 1259 A/B Old Boalsburg Road must have a smoke detector set off at each home during each fire drill.¿ November 13, 2018- A fire drill was conducted at 309 and 311 Fry Drive with a smoke detector being set off at each location during the fire drill. All fire drill records were reviewed to verify that a fire alarm or smoke detector was set off during each fire drill. All agency fire drill records have been reviewed by the ID Director to verify that a fire alarm or smoke detector is set off during each fire drill at each home. The ID Director will review all fire drill records at each home to ensure compliance on a quarterly basis. 11/13/2018 Implemented
6400.113(a)Individual #1 moved into the residential home located at 309 Fry Drive on 7/18/18 but did not receive fire safety training for this home location upon moving into the home. The individual last received fire safety training at Old Boalsburg Rd on 3/29/18. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. November 8, 2018- All Program Specialists were trained on their responsibilities that an individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. A training record was signed indicating their attendance and understanding. October 29, 2018- Individual #1 last received fire safety training on 3/29/18 at her prior home. She moved into her new home on 7/18/18 and did not receive fire safety training until 10/29/18. In addition, a client site safety inspection has been developed and will be used for all new admissions. All Program Specialists have verified that all individuals are up to date with fire safety. November 20, 2018- All Program Specialists will coordinate/review fire safety training at least annually for all individuals, including new admissions and/or individuals who transfer within the agency. 12/05/2018 Implemented
6400.141(c)(11)Individual #1's 4/30/18 physical examination form did not include health maintanence needs. The field was left blank. The department clarified that blanks of regulatory requirements on the physical form would result in a violation.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. November 8, 2018- All Program Specialists were trained on their responsibilities that the physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. A training record was signed indicating their attendance and understanding. November 6, 2018- Individual #1¿s physical exam was returned to the physician to complete the health maintenance needs, the medication review, and the need for bloodwork at recommended intervals, which was left blank. The required info was completed by the physician. All physicals have been reviewed by the Program Specialists and verified to be completed correctly and in compliance. November 20, 2018- All Program Specialists will review all completed physicals when returned to ensure that all spaces on the physical are completed/responded to. 12/26/2018 Implemented
6400.142(f)According to Individual #1's medication lists, they have been prescribed Prevident Dental Rinse to use on Sundays before bed since 3/16/16. The individual's dentist also included on their 5/17/18 dental examination form, to brush 2x/day, floss 1x/day with manual floss followed by water pik at night. The individual was not independent with dental hygiene and there wasn't a written plan for dental 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. November 8, 2018- All Program Specialists were trained on their responsibilities that 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 training record was signed indicating their attendance and understanding. November 15, 2018- Individual #1 had their ISP updated to reflect current levels of assistance needed, including the use of a dental rinse and the process. The use of Prevident Dental Rinse on Sundays before bed has been added, including brushing 2x/day, floss 1x/day with manual floss, followed by water pik at night. The plan was also updated to include Individual #1 is independent in dental hygiene. All current dental hygiene plans have been reviewed by the Program Specialists and are currently in compliance. November 2, 2018- The quarterly review form has been revised to include a ¿Dental Hygiene Plan Review¿ section of the quarterly report. All ISP¿s have been verified by the Program Specialists to be in compliance. Program Specialists will review all sections of the ISP in each quarterly report which includes dental hygiene plan review. 11/15/2018 Implemented
6400.144Individual #1's therapy note indicated the visit scheduled for 3/21/18 was canceled due to inclement weather and the next appointment was scheduled for 3/28/18. The individual was not seen again until 4/4/18 with no indication of why the appointment on 3/28/18 was missed. The individual's therapy appointment on 6/20/18 indicated he/she was to be seen again on 6/27/18. The individual did not return to his/her therapist until 7/11/18 with no indication of why the appointment was late. ---Individual #1 was seen by their dentist on 8/8/18 for a cleaning and the dentist indicated "regular 6 month recall visits, #5 root canal - see if ma covers it, if not we will do it here." There was no documentation that this was addressed with insurance or the dentist for a follow up root canal at the time of licensing on 10/24/18.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. November 8, 2018- All Program Specialists were trained on their responsibilities that all 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. A training record was signed indicating their attendance and understanding. November 14, 2018- Individual #1 had a therapy note indicating a visit scheduled for 3/21/18 was cancelled due to inclement weather and the next appointment was scheduled for 3/28/18. She was not seen on 3/28/18 due to the counselor being out of the office. The counselor sent a letter to SFI stating that they were cancelling the appointment. Individual #1 had a therapy appointment scheduled for 6/20/18 and was to be seen again on 6/27/18. This appointment did take place as scheduled on 6/27/18 and a counseling form was completed at the appointment for verification. Individual #1 was scheduled for and received a root canal on 11/5/18 and a dental form was completed at the appointment for verification. Program Specialists will continue to arrange for and provide all health services that are planned or prescribed for individuals. All Program Specialists have reviewed and verified that all health services are currently in compliance. 11/14/2018 Implemented
6400.164(a)Individual #1's physician indicated that over the counter Ibuprofen or equal medication can be used for pain. The over the counter medication label for Ibuprofen indicated "if pain or fever doesn't respond to 1 tablet, 2 caplets may be used" but this wasn't indicated on the medication log. --The individual's over the counter approved Pepto-Bismol indicated to "shake well, 1 dose (30ml or 2 tbsp.) every half to one hour as needed, don't exceed 8 doses in 24 hours use until diarrhea stops but no more than 2 days." The medication logs for the year only indicated to administer "1 dose (30ml or 2 tbsp) every ½ hour to 1 hour as needed by mouth." --Ibuprofen was administered on 4/4/18 and only "10" was indicated on the medication log; No AM or PM indicated for the actual time of administration. --Saline nasal spray was administered on 1/29/18 but no time of administration was recorded. Only "245" was indicated on the medication log; no AM or PM was included to indicate time of administration. --The Individual's Sudafed over the county medication label indicated to administer "1 tab ever 12 hours, don't take more than 2 tabs in 24 hours, tabs=120mg." The medication log indicated to "take 1 tablet every 12 hours don't take more than 2 in 24 hrs." --Clear eyes maximum itchy eye relief over the counter medication label indicated to "instill 1 to 2 drops in affected eyes up to 4x daily." The corresponding medication logs indicated "clear eyes instill 2 drops into affected eyes up to 4x daily." --Saline Nasal Spray over the counter medication label indicated to "squeeze twice in each nostril as needed." The medication log indicated to "use one spray in each nostril as needed for nose bleeds and dryness."A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. November 8, 2018- All Program Specialists were trained on their responsibilities that a medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. A training record was signed indicating their attendance and understanding. November 20, 2018- Individual #1¿s over the counter medication administration record was corrected to include all instructions for the following OTC medications: Ibuprofen, Pepto Bismol, Sudafed, and saline nasal spray. All OTC medications and medication administration logs have been reviewed and verified by the Program Specialists to be correct and in compliance. All Program Specialists will review over the counter medications and medication administration records monthly to ensure all instructions are written correctly on the medication administration record. 11/20/2018 Implemented
6400.167(b)Individual #1 was prescribed Naproxen 250mg twice a day for 5 days then as needed. The medication was initialed as administered for 5.5 days from 8pm on 11/16/17 to 8pm on 11/21/17. --The individual did not have a doctor's order or approved over the counter order for clear eyes maximum itch relief and it was administered on 8/26/18, 2/17/18, and 1/8/18. --The individual did not have a doctor's order or approved over the counter order for saline nasal spray and it was administered on 2/7/18, 2/20/18,1/29/18, 12/1/17, 12/4/17, 12/10/17 and 12/29/17. --The individual did not have a doctor's order or approved over the counter order for fluticasone prop 50mcg spray. The medication was administered once daily up until 1/31/18. The medication wasn't administered daily after 1/31/18. There is no original order or a discontinue order in the individual's record. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.November 8, 2018- All Program Specialists were trained on their responsibilities that prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician¿s assistant. A training record was signed indicating their attendance and understanding. November 17, 2018- Individual #1 obtained approval to use Clear Eyes and saline nasal spray as an OTC. This is documented June 19, 2017. Individual #1 does have an original order for Fluticasone Prop 50mcg spray from Dr. Victoria Devan. There is not a discontinuation order because they still receive it daily. The Fluticasone Prop 50mcg spray is documented on Individual #1¿s medication administration record from 2/1/18-present. The medication is administered daily as prescribed. 11/20/2018 Implemented
6400.181(e)(3)(i)Individual #1's 4/16/18 assessment did not include the individual's current level of performance in functional skills. This section was blank on the assessment.The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. November 8, 2018- All Program Specialists were trained on their responsibilities that the assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. A training record was signed indicating their attendance and understanding. November 15, 2018- The agency assessment template was revised to allow a place to respond to ¿Acquisition of Functional Skills.¿ The revision and addition of this expanded space will help to make it more clear that it is a section to be addressed. Individual #1¿s assessment has been updated to include information on their current level of performance and progress in the area of ¿Acquisition of Functional Skills.¿ All assessments agency wide have been reviewed by the Program Specialists to ensure compliance. Program Specialists will review assessment content in the quarterly reports. 11/15/2018 Implemented
6400.181(e)(13)(vii)REPEAT from 9/27/17 annual inspection and 2016 annual inspection: Individual #1's 4/16/18 assessment indicated they could not handle any amounts of money. However according to the agency, the individual handles $20 independently.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. November 8, 2018- All Program Specialists were trained on their responsibilities that the assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. A training record was signed indicating their attendance and understanding. November 14, 2018- Individual #1 had their assessment updated to reflect their progress over the last 365 calendar days to include their current level in the financial independence area. All assessments have been reviewed and verified by the Program Specialists to be correct and in compliance. SFI¿s annual assessment form has been updated to include any changes made in the areas of progress and growth should be verified for accuracy in the individual¿s current ISP. All Program Specialists will review assessments and ISP for content accuracy. 11/14/2018 Implemented
6400.181(f)Individual #1's team members that were not sent a copy of the individual's 4/6/18 assessment were their father and CSG day program.(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). November 8, 2018- All Program Specialists were trained on their responsibilities that 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 (relating to development, annual update and revision of the ISP). A training record was signed indicating their attendance and understanding. November 14, 2018- Individual #1¿s assessment was sent to all plan team members. November 8, 2018- The annual assessment cover letter has been revised to include a CC that references all team members. This revision will help alert the Program Specialists to include all team members to receive the assessment at 30 days prior to the ISP meeting. All assessment dates have been reviewed and verified to have been sent to all plan team members at least 30 calendar days prior to the ISP meeting by the Program Specialist. All Program Specialists will review and ensure team members receive the assessment as appropriate. 01/20/2019 Implemented
6400.183(5)The protocol to address Individual #1's social, emotional and environmental needs in relation to the symptoms of his/her diagnosed psychiatric illness that was included in their Individual Support Plan (ISP) didn't include the individual's recommendations they made throughout the year. Those recommendation were to practice deep breathing with staff, having staff check on the individual at night to make sure he's/she's ok, asking the individual if he/she is ok throughout the day, and seeing if his/her nails are clipped so he/she won't scratch himself/herself.The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. November 8, 2018- All Program Specialists were trained on their responsibilities that the ISP, including annual updates and revisions (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. A training record was signed indicating their attendance and understanding. November 2, 2018- Individual #1¿s quarterly report ending on 10/9/18 and sent out to all team members on 11/2/18, included a revision to the protocol to address the social, emotional, and environmental needs of the individual (SEEP). The revision included recommendations Individual #1 and their therapist had discussed throughout the year. November 9, 2018- The ISP of Individual #1 was revised in the Behavior Support Plan section under the protocol to address the social, emotional, and emotional needs of Individual #1. The plan includes recommendations they made throughout the year. All ISP¿s have been reviewed and verified by the Program Specialist to be in compliance. November 2, 2018- The quarterly review form has been revised to include any recommendations made by the individual in addition to the therapist notes. Program Specialists will review all sections of the ISP for accuracy. 11/09/2018 Implemented
6400.185(b)--Individual #1's Individual Support Plan (ISP) indicates knives and scissors need locked up due to the individuals threats of self-harm. There were 5 scissors unlocked and easily accessible in the staff office. Staff indicated that the staff office isn't locked when the individual is home. --The Individual's ISP also indicates that they can carry out small financial transactions at stores, needs help with budgeting, and she/he and staff have to go cash a weekly check for $20. It doesn't indicate the individual can handle up to $20 and the individual is given the $20 to spend independently currently.The ISP shall be implemented as written.November 8, 2018- All Program Specialists were trained on their responsibilities that the ISP shall be implemented as written. A training record was signed indicating their attendance and understanding. November 15, 2018- A new locking file cabinet was purchased to ensure that knives and scissors are locked up due to Individual #1¿s threats of self-harm. All knives and scissors were moved to this locking file cabinet and a memo went out to all current staff instructing them of this procedure. Individual #1¿s ISP Financial Management section has been revised to reflect that she can handle up to $20 independently. All ISP¿s have been verified by the Program Specialists to be in compliance. November 15, 2018- All staff will be trained on implementing the ISP as written. This training will be completed during a staff members on site training and will be verified by the Program Specialists. 11/15/2018 Implemented
6400.186(a)REPEAT from 9/27/17 annual inspection: Individual #1's Individual Support Plan (ISP) reviews covering the quarterly period from 1/20/18-4/19/18 wasn't completed (signed/dated) until 5/8/18, late. The individual's 2/8/18 ISP review reviewed the period from 10/20/17 to 1/19/18, therefore completed late.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. November 8, 2018- All Program Specialists were trained on their responsibilities that the Program Specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. A training record was signed indicating their attendance and understanding. November 2, 2018- A three month review was completed for the review period 7/20/18 to 10/19/18. The three month review was also signed/dated and sent to the team on 11/2/18, which is within the required 15 days. All Program Specialists have reviewed and verified that all quarterly reviews are currently in compliance. November 2, 2018- A new process has been instituted and all Program Specialists must send all quarterly reports to the Assistant Director of ID for verification of completion and distribution within 15 days after the three month review period ends, allowing time for a reminder notification to be sent to the Program Specialists. 11/08/2018 Implemented
6400.186(c)(2)Individual #1's 10/23/18, 8/3/18, 5/8/18 and 2/8/18 Individual Support Plan (ISP) reviews didn't review if the individual used any of his/her unsupervised time in the community. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. November 8, 2018- All Program Specialists were trained on their responsibilities that the ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. A training record was signed indicating their attendance and understanding. November 2, 2018- The quarterly review form has been revised to include ¿Supervision Plan Review¿ in the ¿Review of all Sections of the ISP¿ section of the quarterly report. All ISP reviews have been verified by the Program Specialists to be in compliance. Program Specialists will review all sections of the ISP in each quarterly report which includes Supervision Plan Review. November 2, 2018- A new process has been instituted and all Program Specialists must send all quarterly reports to the Assistant Director of ID for verification of completion and distribution within 15 days after the three month review period ends, allowing time for a reminder notification to be sent to the Program Specialists. 11/08/2018 Implemented
6400.186(d)REPEAT from 9/27/17 annual inspection: Individual #1's 10/23/18, 8/3/18 and 5/8/18 Individual Support Plan (ISP) reviews were not sent to day program, job coach and the individual's father whom are all team members. The individual's 2/8/18 ISP review was only sent to the supports coordinator and not to the individual or any other team member.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. November 8, 2018- All Program Specialists were trained on their responsibilities that the program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. A training record was signed indicating their attendance and understanding. November 2, 2018- Individual #1 had an ISP review on 10/19/18 and it was sent out to all team members on 11/2/18. November 2, 2018- A new process has been instituted and all Program Specialists must send all quarterly reports and cover letters to the Assistant Director of ID for verification of completion and distribution to all team members within 30 days after the ISP review meeting. All ISP¿s have been verified by the Program Specialists to be in compliance. 11/08/2018 Implemented
6400.186(e)The individual's program specialist did not offer the individual's father, supports coordinator, day program or job coach the option to decline the individual's Individual Support Plan (ISP) review documentation. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. November 8, 2018- All Program Specialists were trained on their responsibilities that the program specialist shall notify the plan team members of the option to decline the ISP review documentation. A training record was signed indicating their attendance and understanding. November 2, 2018- The Program Specialist has notified all plan team members of the option to decline the ISP review documentation via the quarterly ISP review cover letter when it was sent out. Individual #1 had an ISP review ending 10/19/18 and it was sent out to all team members on 11/2/18. All ISP reviews have been verified by the Program Specialists to be in compliance. November 2, 2018- A new process has been instituted and all Program Specialists must send all quarterly reports and cover letters to the Assistant Director of ID for verification of completion and distribution to all team members. The cover letter includes the following statement, ¿As a member of _______¿s team, you have the right to decline receiving the ISP review documentation.¿ 11/08/2018 Implemented
6400.216(a)The individual's records were kept in unlocked and accessible I'm the staff office. According to staff, the staff office isn't locked when the individual is home. An individual's records shall be kept locked when unattended. November 8, 2018- All Program Specialists were trained on their responsibilities that all individuals records shall be kept locked when unattended. A training record was signed indicating their attendance and understanding. November 15, 2018- A new locking file cabinet was purchased to ensure that the individual¿s records are kept locked when unattended. All records were moved into this locking file cabinet and a memo went to all current staff instructing them of this procedure. All Program Specialists have reviewed and verified that individuals records are kept locked when unattended and are in compliance. November 15, 2018- All staff will be trained on keeping all individuals records locked when unattended. This training will be completed during a staff member¿s on-site training and will be verified by the Program Specialists. 11/20/2018 Implemented
SIN-00081851 Renewal 05/18/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103The evacuation procedures was missing what the individual responsibilties are. There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. Program Specialists were trained on their responsibilities on 7/28/15. See Attachment #1. The Emergency Removal and Transfer Plan has been revised to include individual responsibilities during an evacuation. All current forms have been updated and verified by the Program Specialists to be corrected and in compliance. See Attachment #2. This updated form will be part of all New Admission Paperwork and updated as needed. 06/18/2015 Implemented
SIN-00180494 Renewal 12/15/2020 Compliant - Finalized
SIN-00048013 Renewal 05/30/2013 Compliant - Finalized