Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00230574 Renewal 10/03/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Per agency staff during the 10/4/23 inspection, Individual #1 is not safe with poisonous materials. During the inspection there were multiple items unlocked and accessible in the home that contained the label to contact poison control center if ingest or to contact a physician. The items found were a tube of caulk and Kwik fabric protectant spray, approximately 2 gallons of bleach, laundry detergent, odoban detergent, and fabric softener beads in upper cabinets in the staff office, within reach to the those in the home. According to Individual #1's individual support plan they have no awareness of the dangers of poisonous/toxic substances, poisonous materials such as cleaning supplies are kept locked at the residence, some things don't need locked but kept out of reach would be laundry detergent, deodorant, shampoo and body wash, dish soap and dishwashing detergent. Bleach is a cleaning substance and still unlocked and accessible, and the other items were in cabinets were in reachable locations in the staff office. In the bathroom, all shampoos, soap, toothpaste, and mouthwash with labels to contact poison control centers were accessible at chest level in the bathroom closet.Poisonous materials shall be kept locked or made inaccessible to individuals. 10/9/23 A maintenance request was sent to the SFI maintenance department to put locks on the bathroom closet door and laundry room cabinets where poisonous materials are kept. (Attachment #2) 10/10/23 All locks were installed in bathroom and laundry rooms per the request. (Attachment #2) 10/13/23 Program specialists and working managers were trained on their responsibilities including: Poisonous materials shall be kept locked or made inaccessible to individuals. 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 poisonous materials shall be kept locked or made inaccessible to individuals. (Attachment #1) 10/13/2023 The SFI Safety Inspection Checklist was updated to include a review that all poisons are stored properly and locked if needed. This includes anything that has Poison Control info or "Keep out of reach of children" on it. (Attachment #3) 10/18/23 Assessments and individual plans were updated appropriately to reflect safe use of poisonous materials. (Attachment #4) 10/18/2023 Implemented
6400.72(b)At the time of the inspection, the rear sliding screen door would not open easily. The tracks of the door had dirt and debris and the door was hard to slide open. Screens, windows and doors shall be in good repair. 10/5/23 A maintenance request was submitted to have the screen door repaired as it doesn't open and close easily. (Attachment #5) 10/5/23 The screen door track was cleaned of debris and the door and track repaired. (Attachment #6) 10/13/23 Program specialists and working managers were trained on their responsibilities including: screens, windows and doors 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 screens, windows and doors shall be in good repair. (Attachment #1) 10/13/2023 The SFI Safety Inspection Checklist was updated to include a review of all screens, windows and doors are in good repair, including screen doors. (Attachment #3) 10/17/2023 Implemented
6400.208(a)Individual #2 has bedrails and the agency needs to produce all documents that this is approved. Our records show the agency needs a plan developed identifying how often the individual will be checked on while the bedrails are in use. During the 10/3/23 inspection the home has not produced a plan in place for how often the individual will be checked on while the bedrails are in use.A physical restraint, defined as a manual method that restricts, immobilizes or reduces an individual's ability to move the individual's arms, legs, head or other body parts freely, may only be used in the case of an emergency to prevent an individual from immediate physical harm to the individual or others.10/13/23 Program specialists, working managers and nurses were trained on their responsibilities including: a physical restraint, defined as a manual method that restricts, immobilizes or reduces an individual's ability to move the individual's arms, legs, head, or other body parts freely, may only be used in the case of an emergency to prevent an individual from immediate physical harm to the individual or others. 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 physical restraint follows the guidelines of the 6400 regulations. A physical restraint, defined as a manual method that restricts, immobilizes or reduces an individual's ability to move the individual's arms, legs, head or other body parts freely, may only be used in the case of an emergency to prevent an individual from immediate physical harm to the individual or others. (Attachment #1) 10/18/23 Individual #2's individual plan was updated to include the use of bedrails on the bed. The plan includes a signed statement from Individual #2 stating they agree with the plan and wants the bedrails on their bed, when the bedrails will be up and how often staff will check on Individual #2 when the bedrails are up on the bed. (Attachment #7) 10/17/23 A tracking form was developed for staff to track when they are checking on Individual #2 during the times the bedrails are up on the bed. (Attachment #8) 11/12/2023 Implemented
SIN-00213395 Renewal 10/17/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The self-assessment that was completed on 3/16/22 identified the following violations: 62b. There was no written summary of corrections.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. 10/26/2022- All program specialists and working managers were trained on their responsibility that self-assessment results and a written summary of corrections made shall be complete and kept by the agency for at least one year. 10/26/2022- A training record was signed indicating their attendance and understanding. (Attachment #1) All program specialists and working managers will continue to complete self-assessments per the regulations and regulatory compliance guide to ensure all regulations are answered and a written summary of corrections is completed if a regulation is in violation. 10/25/2022- The Self-Assessment front page was updated to include the program specialist and program director signatures to indicate the self-assessment was completed correctly. The signatures verify all regulations were reviewed and documented. They also verify a written summary of corrections were completed for all regulatory violations (if applicable). 10/26/2022 Implemented
6400.22(d)(1)Individual #1 receives Snap Benefits. There is not current and up to date financial record verifying the amount of Snap Benefits the individual has nor the amount of Snap Benefits that were spent for the Individual each month.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. 10/26/2022- All program specialists and working managers were trained on their responsibility that the home shall keep up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. 10/26/2022- A training record was signed indicating their attendance and understanding. (Attachment #1) All program specialists and working managers will continue to review and assure the home shall keep an up-to-date financial record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. 10/25/2022- A new Food Stamp/EBT cash card Ledger form was created to document each individual's monthly Food Stamp/EBT cash transactions. 10/25/2022- The Residential Bill of Rights form was updated to include the following statement: Individuals have the right to access and choose food/items bought with their Food Stamp/EBT cash card. Individuals understand their card can be utilized for personal use and/or household purchases at their discretion. 11/01/2022 Implemented
6400.141(c)(9)At the time of the inspection, no documentation was provided verifying that Individual #1 had a prostate exam completed annually.The physical examination shall include: A prostate examination for men 40 years of age or older. 10/26/2022- All program specialists, working managers, and LPNs were trained on their responsibility that the physical examination shall include: A prostate examination for men 40 years of age or older. 10/26/2022- A training record was signed indicating their attendance and understanding. (Attachment #1) Program specialists, working managers, and LPNs will continue to review physical examinations to assure all information is complete, including a prostate examination for men 40 years of age or older. All program specialists, working managers, and LPNs have verified physical examinations shall include: A prostate examination for men 40 years of age or older. 10/26/2022- The individual physical form was updated to include medical reasons, specific testing such as the prostate examination, is to be deferred (if applicable). 11/1/22 Individual #1 received clarification from their primary care physician as to the specific medical reason a prostate examination was not needed at this time. (Attachment #2) 12/09/2022 Implemented
6400.144(Repeat from Inspection Completed 12/13/21) On 5/18/22, Individual #1 saw an Ear, Nose, Throat Doctor. The doctor recommended that Individual #1 have an Auditory Brainstem Response test to get a more accurate hearing test. At the time of the inspection, the test was not scheduled nor was the test discussed with the Individual's parents, who are the legal guardians.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. 10/26/2022- All program specialists, working managers, and LPNs were trained on their responsibility that 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. 10/26/2022- A training record was signed indicating their attendance and understanding. (Attachment #1) Program specialists, working managers, and LPNs will continue to ensure 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. All program specialists, working managers, and LPNs have verified all Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for all individuals are completed. 10/18/2022- Information received from individual #1's Ear, Nose, Throat doctor indicated they had not heard from Strawberry Fields regarding scheduling the Auditory Brainstem Response test, therefore, the test was not scheduled. (Attachment #2) 10/18/2022- Individual #1's parents and legal guardians were contacted to find out if they were notified of the testing and to also find out if they wanted the test to be scheduled. (Attachment #2) 10/18/2022- Individual #1's parents indicated they were not notified of the recommended Auditory Brainstem Response test. Individual #1's parents and legal guardians also indicated at that time they did not want individual #1 to have the Auditory Brainstem Response test done. (Attachment #2) 10/26/2022- Individual #1's Ear, Nose, and Throat doctor was notified the Auditory Brainstem Response test was declined by individual #1's parents (legal guardians). (Attachment #3) 10/26/2022- The Medical Visits form was updated to include a section documenting correspondence with legal guardians regarding appointments (if applicable). 10/28/2022 Implemented
6400.214(b)Individual #2 did not have a current copy of their ISP available at the home at the time of the inspection. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. 10/26/2022- All program specialists and working managers were trained on their responsibility that the most current copies of record information required in 6400.213(2)-(14) shall be kept in the residential home. 10/26/2022- A training record was signed indicating their attendance and understanding. (Attachment #1) Program specialists and working managers will continue to review and assure that the most current copies of record information required in 6400.213(2)-(14) are in the residential homes. All program specialists and working managers have reviewed and verified that the most current copies of record information required in 6400.213(2)-(14) are in the residential homes. 10/25/2022- Individual #2's most current ISP was printed from HCSIS and placed in the ISP section of the individual's programming binder at the residential home. (Attachment #2) 11/01/2022 Implemented
SIN-00160807 Renewal 10/16/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)- Over the last year, individuals have been unable to evacuate the home in under 2 minutes and 30 seconds on 7 out of the last 11 monthly fire drills. According to the 10/25/18 extended evacuation letter, the fire safety expert did not include a signed statement that due to the structure of the home, the evacuation time could extend passed 2 minutes and 30 seconds. The letter states: "there is always a trained staff member present whenever individuals are at the home and all occupants are evacuated upon the sounding of the alarm and not after the alarm is investigated." Then goes on to list what each home is made out of and where the smoke detectors are located. 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. November 7, 2019-The extended evacuation letter was revised to include the statement ¿The evacuation time is based on the design and construction of the home and not the needs of the individuals served at each location.¿ The letter will be reviewed and signed by the local fire department representative. November 7, 2019-All agency programs were reviewed and evaluated to ensure each home is within the approved evacuation time and meets all guidelines for each program. All agency programs are correct and within compliance. November 8, 2019-All Program Specialists were trained on their responsibilities that 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 ½ 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 employee 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. A monthly review will be done by the Program Specialists to ensure all programs are evacuating within the specified evacuation time. A training record was signed indicating their attendance and understanding. (Attachment #1) November 12, 2019-An annual review of the fire safety evacuation letter by a fire safety expert will be approved and signed to ensure the programs are in compliance of this regulation. 11/12/2019 Implemented
SIN-00118882 Renewal 09/27/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)The two bathrooms in this home did not contain hand soap. Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle.All Program Specialists were trained on their responsibilities concerning regulation (82) (f). Each bathroom and toilet area that is used shall have a sink, wall mirror,soap, toilet paper, individual clean paper towel or cloth towels and trash receptacle. ( See Attachment #1 ) Softsoap was purchased and put in each of the two bathrooms at this location. (See Attachment #2 ) The Monthly Safety Inspection Checklist was updated to include the confirmation that pump hand soap is in all bathrooms. (See Attachment #3 ) A review of bathrooms in each home was conducted to ensure there was pump hand soap in each of them. 10/26/2017 Implemented
SIN-00081852 Renewal 05/18/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103The evacuation procedures were missing what the individuals responsibilites 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-00048015 Renewal 05/30/2013 Compliant - Finalized