Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00213396 Renewal 10/17/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The self-assessment completed on 3/3/22 identified the following violations: 61a, 61b, 72a, 80b, 81k6, 82e, 101, 141c3, 141c4,142a, 142c, 142d, 142e, and 213(4). 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
SIN-00198060 Renewal 12/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.61(a)Individual #2 always requires the use of a wheelchair to move within the home and for safe entrance and exit of the home. Currently the rear, and second exit from the home, does not provide Individual #2 with safe accommodations to exit the home, or move from the rear of the home to the front of the home. The current ramp locations off the back deck barely allow for movement in a wheelchair from one ramp to the other and the second ramp leads to a dirt flower bed with a rock boarder and large flowering tree extending over the ramp. Additionally, the back yard includes uneven, grassy, rocky, and occasionally muddy/snowy terrain. There isn't a safe, flaty, wooden or paved pathway to maneuver the individual's wheelchair safely around to the front of the home. The individuals need to move from the rear of the house to the front of the house to meet emergency personnel in the event of a fire or other emergency.A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. 1/3/22 All program specialists were trained on their responsibility that a home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual¿s needs. A training record was signed indicating their attendance and understanding (Attachment #1). Program specialists will continue to review and assure that all homes serving individuals shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual¿s needs. All program specialists have reviewed and verified that all homes have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual¿s needs. 03/31/2022 Implemented
6400.70The telephone in the home was not easily accessible to Individual #2. The house telephone was located within the staff office that is always locked, and the individual did not possess a key for access.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. 1/3/22 All program specialists were trained on their responsibility that homes shall have an operable, non-coin operated telephone with an outside line that is easily accessible to individuals and staff persons. A training record was signed indicating their attendance and understanding (Attachment #1). Program specialists will continue to review and assure that homes have an operable, non-coin operated telephone with an outside line that is easily accessible to individuals and staff persons. All program specialists have reviewed and verified that all homes have an operable, non-coin operated telephone with an outside line that is easily accessible to individuals and staff persons. 1/4/22 The Safety Inspection Checklist Review form was revised to include a review that all homes have an operable non-coin operated telephone with an outside line that is easily accessible to individual and staff persons (Attachment #2). 01/05/2022 Implemented
6400.143(a)Per audiologist's reports, Individual #1 has hearing loss, is to wear hearing aids daily, and individual's usage of the hearing aids shows 0%. There are no records maintained of the individual's refusals to comply with all audiologist recommendations, orders and treatments, or the continued attempts to train the individual on the need to follow the audiologist's health recommendations and orders for every refusal to comply with the audiologist's orders and recommendations.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. 1/3/20 All program specialists were trained on their responsibility that if an individual refuses routine medical or dental examinations or treatments, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individuals record. A training record was signed indicating their attendance and understanding (Attachment #1). Program specialists will continue to review and assure that if an individual refuses routine medical or dental examinations or treatment, the refusal or continued attempts to train the individual about the need for health care is documented in the record. All program specialists reviewed and verified that if an individual refuses routine medical or dental examinations or treatment, the refusal or continued attempts to train the individual about the need for health care is documented in the individual¿s record. 1/4/22 Monthly Health Assessment that is completed by the LPN has been updated to include refusals and education provided. 01/05/2022 Implemented
6400.144REPEAT from 12/14/2020 annual inspection: There were multiple occasions throughout the year where Individual #1's physicians recommended and ordered medications and various treatments that were not provided to the individual, or documentation of the individual's refusal. The agency failed to provide the following health services to Individual #1 as ordered. · The individual is to see their podiatrist every 9 weeks for a routine visit and nail trimming. They were seen on 2/26/21 and not again until 6/21/21. · Individual #1 was seen on 3/2/21 for left-side abdominal pain and ordered Advil three times a day for two days and apply 10 minutes of heat with Advil dosing. There are no records maintained all orders were followed or encouraged. The individual continued to experience left sided abdominal pain on 3/26/21 and 5/10/21. · On 3/15/21 the individual's physician stated the individual will start a sleep log due to reports of interrupted sleep, sleeping during the day and being awake at night, having increased anxiety around job situations, and the individual requesting medication to help them sleep. Sleep logs weren't produced during the inspection. · On 6/2/21 received diagnosis of Conjuctivitis, had redness in right eye, and was ordered Tobradex suspension four times a day for 7-10 days, cold compress, and lid hygiene; no records any orders were followed or encouraged. · On 6/15/21 their audiologist noted the individual does not wear their hearing aids, has decreased speech understanding in left ear, encouraged daily use of hearing aids to keep their speech understanding from decrease, and the domes and wax guards on the hearing aids need changed approximately every 6-8 weeks; no records any orders were followed or encouraged. · On 10/11/21 their audiologist noted batteries in both Individual #1's hearing aids were not operable, recommended putting a sticker on the calendar for reminders and to changing every 7 days, reported cerumen impaction in left ear that needs removed with Debrox or family doctor, and that the individual is to open the battery doors on their hearing aids every night; no records any orders were followed or encouraged. *all refusals not documented and all training not documented. On a 6/2/21 daily note it said did individual wear adaptive equipt, answered no, but never recorded training. All notes provided ask did he use adaptive equipment and was it charged. Most of the time no or n/a is answered for these sectionsHealth 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. 1/3/22 All program specialists 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 for or provided. A training record was signed indicating their attendance and understanding (Attachment #1). Program specialists will continue to review and assure 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. Since 6/21/21, individual #1 attended scheduled appointments on 9/24/21 and 12/1/21. The next scheduled appointment is on February 2, 2022 at 1pm (Attachment #2). A new process has been instituted that all medical visits will be reviewed by the program specialist to ensure recommendations, follow up and ordered medications and treatments were provided to the individual (Attachment #3). An overnight log was instituted to document when Individual #1 is sleeping and awake throughout the night (Attachment #4). A new process has been instituted that all medical visits will be reviewed by the program specialists to ensure recommendations, follow up, and ordered medications and treatments were provided to the individual. Individual #1 will have staff assist w/ eye drops and ear drops when prescribed. This information was updated in the individuals support plan. Staff will assist individual #1 in administering eye and ear drops when prescribed (Attachment #5). Individual #1 is encouraged to wear hearing aids daily. 1/1/22 A Hearing Aid Care Checklist was instituted to document changing domes and wax guards every 6-8 weeks (Attachment #6). 1/1/22 A Hearing Aid Care Checklist was instituted to document changing batteries every 7 days, leaving battery doors open at night and administering weekly ear wax drops (Attachment #6). 1/4/22 Monthly Health Assessment that is completed by the LPN has been updated to include refusals and education provided. Individual education and/or refusals will be documented in the electronic client record. 1/5/22 Individual #1s assessment and ISP were updated to reflect hearing aid care and procedures (Attachment #6). 01/06/2022 Implemented
6400.32(s)Individual #1's record does not indicate if they wished to have access via an entry mechanism (key, keypad, card swipe, etc) to an entry door of their home or if it would be unsafe for the individual to have access to an entry device to an entry door of their home.An individual has the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home.1/3/22 All program specialists were trained on their responsibility that an individual has the right to have access via an entry mechanism (key, keypad, card swipe, etc.) to lock and unlock an entrance door of the home. A training record was signed indicating their attendance and understanding (Attachment #1). Program specialists will continue to review and assure that individuals have the right to have access via a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home. All program specialists have reviewed and verified that individuals have the right to have access via a key, access card, keypad code, or other entry mechanism to lock and unlock an entrance door of the home. 1/5/22 Program specialist has updated the Annual Assessment to include wishes to have access via an entry mechanism for the entry door of the home. The info was requested to be added to the ISP (Attachment #2). 01/05/2022 Implemented
6400.165(g)Individual #1's 1/21/21 medication review record does not include the reason for prescribing Paroxetine HCL. Individual #1's 3/15/21, 5/15/21, 7/19/21, 9/27/21, and 11/4/21 medication review records do not include clarification of the reason for prescribing the medication. The agency medication form attached to this appointment states the medication is prescribed for Depression. However, the physician summary lists the individual is diagnosed with Anxiety disorder and Impulse disorder but does not define the reason for prescribing the medication. This appointment was completed virtually.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.1/3/22 All program specialists were trained on their responsibility that if a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes documentation of the reason for prescribing the medication, the need to continue the medication, and the necessary dosage. A training record was signed indicating their attendance and understanding (Attachment #1). Program specialists will continue to review and assure that if a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes documentation of the reason for prescribing the medication, the need to continue the medication, and the necessary dosage. All program specialists reviewed and verified that if a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes documentation of the reason for prescribing the medication, the need to continue the medication, and the necessary dosage. 1/3/22 Program specialist clarified with (psychiatrist) that the Paroxetine HCL was prescribed for anxiety, not depression (Attachment #2). 01/05/2022 Implemented
6400.166(a)(1)Staff recorded on 6/2/21, 6/7/21, 8/14/21, 8/15/21, 8/17-20/21, 8/22/21, and 8/24-26/21 that they helped administer or administered eye drops to Individual #1. There are no medication administration records kept for Individual #1 that included requirements defined in 6400.166(a)(1)-(16).A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Individual's name.1/3/22 All program specialists were trained in their responsibility that a medication record shall be kept for each individual for when a prescription medication is administered- including the individuals name. A training record was signed indicating their attendance and understanding (Attachment #1). Program specialists will continue to review and assure that the medication record shall be kept for each individual for whom a prescription medication is administered- including the individuals name. All program specialists have reviewed and verified that a medication record is kept for each individual for when a prescription medication is administered- including individuals name. 12/23/21 Individual #1s ability to self-medicate was updated in the assessment (Attachment #2). Staff will follow administration procedures for self-administering individuals as directed. 1/1/22 Medication Admin Record was utilized for Individual #1 (Attachment #3). 1/4/22 Individual #1s support plan was updated to include his current self-administration plan (Attachment #4). 01/06/2022 Implemented
6400.185(5)Individual #1's audiologist stated multiple times in 2021 that the individual refuses to wear their hearing aids, is suffering from decreased speech understanding in the left ear and encouraged the individual to use their hearing aids daily to prevent further loss of hearing and speech understanding. The individual's plan does not include their audiologist's concerns, or any risks provided for management and risk mitigation strategies identified by the audiologist or team members to prevent further hearing loss and maintenance of the individual's hearing aids. Individual #1 reported to their counselor on 10/26/21 concerns about potential unsafe conditions or behaviors happening in the bathroom at their day program. The reports from the therapist state that there is a plan set up for the individual and others to be safe in the bathroom. Individual #1's individual plan and behavior support plans do not include the specific plans for day program and community bathroom usage, risks to the individual and other's safety in that environment, behaviors likely to cause harm, or risk mitigation strategies for those specific situations. The individual's counselor reviewed breathing exercises the individual is to use when feeling frustrated. The exercises and situations to use them in are not include in the individual's individual and behavior support plans. Individual #1's behavior support plan states that the individual will identify language to use and practice to signal to staff that the individual is experiencing unsafe or sexual thoughts. Then states that all staff will be trained to understand these signals and that it signals the individual needs to speak in private about the unsafe thoughts. The individual's plans do not include the language and signals that identifies the individual is experiencing unsafe or sexual thoughts.The individual plan, including revisions, must include the following: Risks to the individual's health, safety or well-being, behaviors likely to result in immediate physical harm to the individual or others and risk mitigation strategies, if applicable.1/3/22 All program specialists were trained on their responsibilities that the individual plan, including revisions, must include the following: Risks to the individuals health, safety or well-being, behaviors likely to result in immediate physical harm to the individual or others and risk mitigation strategies, if applicable. A training record was signed indicating their attendance and understanding (Attachment #1). Program specialists will continue to review and assure that the individual plan, including revisions, must include the following: Risks to the individuals health, safety or well-being, behaviors likely to result in immediate physical harm to the individual or others and risk mitigation strategies, if applicable. All program specialists reviewed and verified that the individual plan, including revisions, must include the following: Risks to the individuals health, safety or well-bring, behaviors likely to result in immediate physical harm to the individual or others and risk mitigation strategies, if applicable. 1/5/22 Individual #1s assessment and ISP were updated to include hearing aid usage, procedures and care (Attachment #2). 1/5/22 Individual #1s assessment and ISP were updated to define a bathroom safety plan in the community and day program to decrease risks to the individual and others (Attachment #3). 1/5/22 Breathing exercises have been added to individual #1s ISP and behavior support plans (Attachment #4). 1/5/22 Individual #1s behavior support plan was updated to include the following: Individual #1 currently practices the signals and language to use with his counselor to identify that he is experiencing unsafe or sexual thoughts. This is being done at therapy sessions. 01/06/2022 Implemented
SIN-00141416 Renewal 10/24/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
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(f)According to the fire drill log, from September 2017 until October 2018, the back door was only used once as an egress route. All other times the front door was used as the evacuation route.Alternate exit routes shall be used during fire drills. November 8, 2018- All Program Specialists were trained on their responsibilities that alternate exit routes shall be used during fire drills. A training record was signed indicating their attendance and understanding. The agency fire drill record now includes a statement ¿alternate exit routes must be used.¿ The November 2018 fire drill uses the front door as an egress. We will continue to alternate exit routes throughout the year and at all programs. December 1, 2018- A fire drill was conducted using alternate exit routes- the backdoor was used. All agency homes fire drill records were reviewed by the ID Director to verify that alternate exit routes are used during the fire drills. The ID Director will review all fire drill records to ensure compliance on a quarterly basis. 12/01/2018 Implemented
6400.168(a)Staff #1 is passing medications and he has not completed the Department's Medication Administration Training in it's entirety since 2/13/17. Licensing was conducted on 10/24/18. In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. November 8, 2018- All Program Specialists have been trained on their responsibilities that in a home serving eight or fewer individuals, a staff person who has completed and passed the Department¿s Medication Administration Course is permitted to administer oral, topical, and eye and ear drop prescription medications. A training record was signed indicating their attendance and understanding. November 12, 2018- Staff #1 completed the Department¿s Medication Administration Course successfully and is certified to pass medications. This training included successful completion of online trainings, face to face interaction, a final exam, and successful medication administration observations. This was conducted by a certified med. trainer. A new process was instituted and the Assistant ID Director will review annual med. practicum dates to ensure practicums are completed in a timely manner. This will be communicated consistently to the Program Specialists via meetings and/or emails. All agency staff records have been reviewed to ensure that they are all currently up to date with the Department¿s Medication Administration. The Assistant ID Director will review all medication administration practicum due dates to ensure compliance on a quarterly basis. 11/12/2018 Implemented
6400.168(d)Staff #1 completed the Department's medication administration course on 2/13/17 and at the time of licensing, on 10/24/18, still hasn't completed the annual practicum or its required additional activities due to the length of time the annual practicum has lapsed.A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. November 8, 2018- All Program Specialists have been trained on their responsibilities that in a home serving eight or fewer individuals, a staff person who has completed and passed the Department¿s Medication Administration Course is permitted to administer oral, topical, and eye and ear drop prescription medications. A training record was signed indicating their attendance and understanding. November 12, 2018- Staff #1 completed the Department¿s Medication Administration Course successfully and is certified to pass medications. This training included successful completion of online trainings, face to face interaction, a final exam, and successful medication administration observations. This was conducted by a certified medication trainer. A new process was instituted and the Director of ID will review annual med. practicum dates to ensure practicums are completed in a timely manner. This will be communicated consistently to the Program Specialists via meetings and/or emails. All agency staff medication administration records have been reviewed to ensure that they are all up to date with the Department¿s Medication Administration currently. The ID Director will review all medication administration practicum due dates to ensure compliance on a quarterly basis. 11/12/2018 Implemented
SIN-00100039 Renewal 08/18/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(2)Staff #1 became a program specialist on 6/15/2015 and did not review program specialist job description/responsibilities until 9/3/2015. The program specialist shall be responsible for the following: Providing the assessment as required under § 6400.181(f) (relating to assessment). The Director of ID Services was trained in her responsibilities concerning regulation 6400.44(b)(2)-Program Specialist counted in the ratio in 44(a) responsible for providing the assessment for the development of the ISP, ISP Annual Update and all ISP revisions as required under Chapter 6400.181(f). (See Attachment #1) Director of ID Services updated the Employee handbook to include a procedure for all employees to review and sign a job description/responsibilities upon hire. (See Attachment #21). 10/10/2016 Implemented
6400.64(b)Multiple containers of food were found in the basement that contained hundreds of animal droppings. Examples being two boxes of Old El Paso taco shells and a box of rice. There may not be evidence of infestation of insects or rodents in the home. All Program Specialists were trained on their responsibilities concerning regulation 6400.64(b): There may not be evidence of infestation of insects or rodents in the home. (See Attachment #1) The Safety Inspection Checklist that is completed monthly was updated to include the documentation of the check for evidence of infestation of insects and rodents in the home. This form will be completed monthly by all programs. (See Attachment #19) All contaminated food at the home of individual #1 was disposed of and food stored properly. The updated Safety Inspection Checklist was completed at this program on 8/30/16. (See Attachment #20) 10/10/2016 Implemented
6400.144Individual #1's 5/9/2016 assessment indicated that meats needed to be cut into bite sized pieces. His/her 2/2/2016 physical indicated he/she was on a finely chopped diet. On 6/12/2015 and 12/21/2015 he/she choked on hot dog and corn dog that were not cut into bite sized pieces. Both choking incidents required Individual #1 to be seen at the emergency room for intervention. 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. All Program Specialists were trained on their responsibilities concerning regulation 6400.144: 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. (See Attachment #1) The Program Specialist has updated/ revised the ISP to reflect the correct diet as noted on the 2/2/16 physical for Individual #1. (See Attachment # 18) All individual records were reviewed to ensure that all dietary needs are being followed as per doctor recommendations. 10/10/2016 Implemented
6400.163(c)Individual #1 was prescribed Ambien and Valium for anxiety with dental appointments. This medication was not reviewed on his/her 3/1/16 and 4/26/16 psychiatric medication review appointments. 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.All Program Specialists were trained on their responsibilities concerning regulation 6400.163(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. (See Attachment #1) The Psychiatric Consult/ Medication Review form was updated to include a review of medication prescribed prior to any medical and/ or dental appointments. (See Attachment #17) This form will be used for all psychiatric medication reviews. 10/10/2016 Implemented
6400.164(a)The August 2016 medication administration record for Individual #1 did not include a time of administration for his/her Ammonium Lactate Lotion. Individual #1 was prescribed Pepto-Bismol "one dose (2 TBSP) every half to one hour as needed, don't exceed eight doses in 24 hours." Individual #1's August 2016 medication administration record for Pepto-Bismal only indicated "2 TBSP by mouth as needed."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. All Program Specialists were trained on their responsibilities concerning regulation 6400.164(a): 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. (See Attachment #1) The specific medication administration time of 9 AM was documented for Ammonium Lactate Lotion for Individual #1 effective 8/22/16. (See Attachment #13) In addition, Pepto Bismol for Individual #1 was correctly documented on the medication log beginning with the next dose which was given/ documented on 8/22/16. (See Attachment #14) All individual records were reviewed to ensure that medication logs include the time of administration for any PRN medication. (See Attachment #15) The Medication Administration Sign Off Sheet was updated to include a monthly review with signature required by the Program Manager or Lead Direct Support Professional to ensure that "All records are complete and/or documented correctly on the Medication Log Explanation Sheet (if needed)." (See Attachment #16) 10/10/2016 Implemented
6400.167(b)Individual #1 was prescribed Ammonium Lactate Lotion to be applied daily as needed. The medication is being applied as an as needed medication and not as an as needed medication as prescribed. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.All Program Specialists were trained on their responsibilities concerning regulation 6400.167(b): Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. (See Attachment #1) The prescribing physician for Individual #1 was contacted and they made the decision to discontinue the Ammonium Lactate Lotion on 8/23/16. (The order was dated 8/22/16 and was faxed to the Program Specialist on 8/23/16 at 12:09 PM.) (See Attachment #11) All individual records were reviewed to ensure prescription medications are administered according to the directions specified. (See Attachment #12) 10/10/2016 Implemented
6400.171Multiple containers of food were not protected from contamination while being stored in the basement. Two boxes of Old El Paso taco shells, one container of spaghetti noodles, one box of white rice, one box of wild grain rice and one bag of powdered sugar were found opened and not sealed properly. Food shall be protected from contamination while being stored, prepared, transported and served. All Program Specialists were trained on their responsibilities concerning regulation 6400.171: Food shall be protected from contamination while being stored, prepared, transported and served. (See Attachment #1) The Safety Inspection Checklist that is completed monthly was updated to include the documentation of food being protected from contamination while being stored including open food being protected in sealed containers. This form will be completed monthly by all programs. (See Attachment #9) All open food at the home of individual #1 was either disposed of or stored properly. The updated Safety Inspection Checklist was completed at this program on 8/30/16. (See Attachment #10) 10/10/2016 Implemented
6400.181(e)(13)(iii)The assessment completed on 5/9/2016 for Individual #1 did not contain progress in acitivities of residential living. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. All Program Specialists were trained on their responsibilities concerning regulation 6400.181(13)iii: The individual's progress over the last 365 calendar days and current level in the following areas: (iii) Activities of residential living. (See Attachment #1) The Annual Assessment form was revised to reflect progress in the area of Activities of Residential Living. (See Attachment # 8) All Assessments will be updated as required per regulation time-frames by the Program Specialist . 10/10/2016 Implemented
6400.181(e)(13)(v)The assessment completed on 5/9/2016 for Individual #1 did not contain progress in socialization.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. All Program Specialists were trained on their responsibilities concerning regulation 6400.181(13)v: The individual's progress over the last 365 calendar days and current level in the following areas: (v) Socialization (See Attachment #1) The Annual Assessment form was revised to reflect progress in the area of Socialization. (See Attachment # 8) All Assessments will be updated as required per regulation time-frames by the Program Specialist. 10/10/2016 Implemented
6400.181(e)(13)(vi)The assessment completed on 5/9/2016 for Individual #1 did not contain progress in recreation.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. All Program Specialists were trained on their responsibilities concerning regulation 6400.181(13)vi: The individual's progress over the last 365 calendar days and current level in the following areas: (vi) Recreation. (See Attachment #1) The Annual Assessment form was revised to reflect progress in the area of Recreation. (See Attachment # 8) All Assessments will be updated as required per regulation time-frames by the Program Specialist. 10/10/2016 Implemented
6400.181(e)(13)(viii)The assessment completed on 5/9/2016 for Individual #1 did not contain progress in managing personal property.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. All Program Specialists were trained on their responsibilities concerning regulation 6400.181(13)viii: The individual's progress over the last 365 calendar days and current level in the following areas: (viii) Managing personal property. (See Attachment #1) The Annual Assessment form was revised to reflect progress in the area of Managing personal property. (See Attachment # 8) All Assessments will be updated as required per regulation time-frames by the Program Specialist. 10/10/2016 Implemented
6400.181(e)(13)(ix)The assessment completed on 5/9/2016 for Individual #1 did not contain progress in community- integration.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.All Program Specialists were trained on their responsibilities concerning regulation 6400.181(13)ix: The individual's progress over the last 365 calendar days and current level in the following areas: (ix) Community-integration. (See Attachment #1) The Annual Assessment form was revised to reflect progress in the area of Community-integration. (See Attachment # 8) All Assessments will be updated as required per regulation time-frames by the Program Specialist. 10/10/2016 Implemented
6400.185(b)Individual #1's Individual Support Plan (ISP) indicated that sharps needed to be locked due to self injurious behaviors. A pizza cutter and cheese cutter were unlocked and accessible in a kitchen cabinet drawer. Four shaving razors were unlocked and accessible in the bathroom located off of the kitchen. A pair of scissors was unlocked and accessible in the first aid kit in the hallway closet.The ISP shall be implemented as written.6400.185(b) All Program Specialists were trained on their responsibilities concerning regulation 6400.185(b): The ISP shall be implemented as written. (See Attachment #1) The Program Specialist updated the ISP/Behavior Support Plan for Individual #1 to reflect that there were some exceptions to sharps being locked up. The team and Behavior Support Specialist agree that there are exceptions to this and changes have been noted. (See Attachment #7). A review of all individual records indicate that all other plans are in compliance. 10/10/2016 Implemented
6400.194(d)Individual #1 had many incident reports where restrictions were utilized on him/her. The restraints were not reviewed at the restrictive procedure review committee meetings. A body slide and turn around restriction was used on 11/30/15 and a "come along" was used on 12/9/15 and 12/14/15 but not reviewed at the restrictive review committee meetings. A written record of the meetings and activities of the restrictive procedure review committee shall be kept. 6400.194(d) All Program Specialists were trained on their responsibilities concerning regulation 6400.194(d): A written record of the meetings and activities of the restrictive procedure review committee shall be kept. (See Attachment #1) Individual #1's Restrictive Plan Data Collection Review Form was updated and revised to foster the complete collection of information including restrictions and physical interventions to be submitted to the Behavior Support Specialist for compilation and presentation to the Restrictive Procedure Review Committee. This form will now be used for all individuals' data collection prior to submission to Behavioral Support Specialists. In addition, there is a notation and review of restrictions previously omitted to include: 11/30/15, Body Slide and turn around; 12/9/15, Come Along; 12/14/15, Come Along. This new form was completed and submitted to the Behavior Support Specialist on 10/4/16 to prepare data for the Restrictive Procedure Review Committee to review on 10/5/16 (See Attachment #6). A review of all individual records indicate that others are in compliance with this regulation and this updated form will be used as appropriate for all individuals who have plans monitored by Behavioral Support Specialists. 10/10/2016 Implemented
6400.195(a)The restrictive procedure plan for Individual #1 did not include a restriction of food or restriction of access to the basement. At the time of inspection, Individual #1 was being restricted from having access to the basement. Staff were locking the basement door. The agency was also storing left over food from meals and food to be prepared, in the locked basement. For each individual for whom restrictive procedures may be used, a restrictive procedure plan shall be written prior to use of restrictive procedures. 6400.195(a) All Program Specialists were trained on their responsibilities concerning regulation 6400.195(a): For each individual for whom restrictive procedures may be used, a restrictive procedure plan shall be written prior to use of restrictive procedures. (See Attachment #1) In addition, the ISP for individual #1 was updated to indicate that staff no longer store leftover food from meals and food to be prepared locked in the basement. (See Attachment #4) Also, a notation was made in the monthly report for individual #1 that the basement door was not to be locked to restrict access to the basement. (See Attachment #5) A review of all individual records indicate that all others are in compliance with this regulation. 10/10/2016 Implemented
6400.205On many occasions the date for when a restraint was used on Individual #1 was not recorded on the restrictive procedure incident reports. The incident reports completed on 7/28/16, 6/29/16, 6/17/16, 6/3/16, 6/1/16, 4/10/16, 3/19/16, 2/8/16, 1/10/16, 11/30/15, 11/29/15 were left blank in the field titled "date of incident." The restrictive procedure review committee reviewed multiple restraints that were used on Individual #1, however there wasn't a record of the restrictive procedure used, methods of intervention, date and time of restraint, procedures followed, duration of restraint, who used the restrictive procedure, or staff that observed the restrictive procedure if applicable. The restraints reviewed at the committee meetings were 2/16/16 a clothing release restraint, 11/29/15 wrist control restraint, 11/8/15 come along restraint, and 11/3/15 blody slide restraint. A record of each use of a restrictive procedure documenting the specific behavior addressed, methods of intervention used to address the behavior, the date and time the restrictive procedure was used, the specific procedures followed, the staff person who used the restrictive procedure, the duration of the restrictive procedure, the staff person who observed the individual if exclusion was used and the individual's condition following the removal of the restrictive procedure shall be kept in the individual's record. 6400.205 All Program Specialists were trained on their responsibilities concerning regulation 6400.205: A record of each use of a restrictive procedure documenting the specific behavior addressed, methods of intervention used to address the behavior, the date and time the restrictive procedure was used, the specific procedures followed, the staff person who used the restrictive procedure, the duration of the restrictive procedure, the staff person who observed the individual if exclusion was used and the individual's condition following the removal of the restrictive procedure shall be kept in the individual's record. (See Attachment #1) The Program Specialist revised the Physical Intervention form to clarify "Date of Incident" making it more prominent and visible (see Attachment #3). In addition, incident reports for individual #1 where "Date of Incident" was left blank on the following dates: 7/28/16, 6/29/16, 6/17/16, 6/3/16; 6/1/16, 4/10/16, 3/19/16, 2/8/16, 1/10/16, 11/30/15, and 11/29/15 were reviewed and the date of incident was entered and dated and signed by the Program Specialist to meet this regulation. This revised form will be used for all physical interventions to ensure proper documentation. All individuals who have a restrictive procedure plan are in compliance with this regulation and will use the new form as needed. 10/10/2016 Implemented
6400.213(11)The Individual Support Plan (ISP) for Individual #1 indicated that on 5/5/2016 sedation for dental appointments ended. However the 5/5/2016 dental exam for Individual #1 indicated that his/her next visit under general anesthesia following cleanings only give 10 mg of Valium and 10 mg of Ambien. His/her 5/9/2016 assessment and ISP indicated their diet was calorie restricted, with reduced portion size, limited after meal snacks and heart healthy diet. Individual #1's 2/2/2016 phsyical indicated they were to follow a finely chopped diet. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. 6400.213(11) All Program Specialists were trained on their responsibilities concerning regulation 6400.213(11): Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. (See Attachment #1) The Program Specialist has updated/ revised the ISP of Individual #1 to reflect the corrected information to resolve all occurrences of content discrepancy and documentation of these discrepancies has been entered into the record for individual #1. (See Attachment #2) All individual records were reviewed to ensure that all others are in compliance with this regulation. 10/10/2016 Implemented
SIN-00065880 Renewal 06/03/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(i)Staff #1 did not have CPR training in the regulatory timeframe. He had training on 1/18/2011 and not again until 7/24/2013.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. Staff, Fran McDermid, the training coordinator was trained in her responsibilities (see attachment #1). As a result, staff will be notified via "Flyers" that are given to them in addition to being reminded via email. See attachment #2 for documentation of staff notification (flyer/email) in addition to initial training and annual required training. Note: Staff hire date 7/19/13, she came to us with CPR valid from 11/7/12-11/14; she recieved first aid training from SFI on 8/7/13, she then again received re-certification in both CPR/first aid on 7/16/14 07/01/2014 Implemented
6400.81(k)(6)Individual #1's bedroom did not have a mirror. In bedrooms, each individual shall have the following: A mirror. Staff, Matt Reynolds, Program Specialist was trained in his responsibilities (see attachment #1). On Wednesday June 4, 2014 Matt Reynolds sent an email to Laureen Knepp, the S.C. to request an addition to M.L ISP that due to safety concerns that he does not have a mirror in his room. This has been completed (see attachment #3) 06/06/2014 Implemented
6400.151(a)The physical for Staff #1 was not completed in the regulatory timeframe. The current physical was completed on 5/5/14. The past physical was completed on 4/19/2012. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Staff, Cindy Polinski, HR Director has been trained in her responsibilities (see attachment #1). As a result, staff will be notified of upcoming required physicals by informing them with a letter 30 days in advance sent to their home. See attachment #4 for staff notification of physical due date. 08/15/2014 Implemented
SIN-00072897 Renewal 06/03/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(i)Staff #1 did not have CPR training in the regulatory time frame. He had training on 1-18-11 and not again until 7-24-13.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. See POC by provider in original inspection Implemented
6400.81(k)(6)Individual's bedroom did not have a mirror.In bedrooms, each individual shall have the following: A mirror. See POC by provider in original inspection Implemented
6400.151(a)The physical for Staff #1 was not completed in the regulatory time frame. The current physical was completed on 5-5-14. The past physical was completed on 4-19-12. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. See POC by provider in original inspection Implemented
SIN-00160808 Renewal 10/16/2019 Compliant - Finalized
SIN-00048016 Renewal 05/30/2013 Compliant - Finalized