Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00213400 Renewal 10/17/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Individual #1's financial record was not current and up to date. On 10/12/22, there was a receipt in the record showing Individual #1 spent $2.73. The petty cash log documented that $2.73 was spent. When the $2.73 was deducted from the balance, only $2 was deducted. The cash count corroborated that $2.73 should have been deducted on that date.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 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- A training record was signed indicating their attendance and understanding. (Attachment #1) All program specialists and working managers will continue to review and 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. All program specialists and working managers have reviewed and verified that all individuals have an up to date financial and property record. 10/20/2022- The current financial ledger for individual #1 was updated to clarify the math error on the ledger and to verify the current balance on the ledger with the petty cash. (Attachment #2) 11/01/2022 Implemented
6400.104Individual #1 moved into the home on 8/21/22. An updated letter was not sent to the fire department at that time. The last letter sent to the fire department was sent on 8/18/20. That letter sent on 8/18/20 was not clear as to how many individuals living in the home needed either physical or verbal assistance to evacuate. The letter was not clear as to which bedrooms the individuals who needed assistance were in.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. 10/26/2022- All program specialists and working managers were trained on their responsibility that the home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. 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 exact locations of bedrooms of individuals who need assistance evacuating in the event of an actual fire. All program specialists and working managers verified and confirmed the address of the home and the exact locations of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. 10/28/2022- The program director sent updated letters to the local fire department listing the following information: the address of the home and the exact locations of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. (Attachment #2) 10/28/2022 Implemented
6400.165(e)Individual #1 was being prescribed Fish Oil and Vitamin D3 that was to be taken in the morning. The doctor switched the morning dose to an evening dose. Staff had a phone consult with the doctor who determined that Staff should wait until the next cycle to start the evening dose. There was no written documentation verifying that Staff were to wait for the next cycle to start the evening dose. The Staff from Strawberry Fields who took the verbal order was not a medical professional.Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received.10/26/2022- All program specialists, working managers, and LPNs were trained on their responsibility that changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as written notice of the change is received. 10/26/2022- A training record was signed indicating their attendance and understanding. (Attachment #1) All program specialists, working managers, and LPNs will continue to review and assure that changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. All program specialists, working managers, and LPNs have reviewed and verified that all medications are correct and medications and MARS match exactly. 10/20/2022- SFI LPN, contacted the doctor to confirm medication information for individual #1, Fish Oil and Vitamin D3. LPN received a verbal order as follows: Fish Oil- 3 capsules one time a day at 8 am and Vitamin D3 1000U, 2 capsules one time a day at 8 pm. Verbal orders were given by the PA. (Attachment #2) 10/21/2022- Geisinger faxed written order confirming medication to be administered as follows: Fish Oil- take by mouth 3 capsules in the morning at 8 am and Vitamin D3- take 2 capsules by mouth at 8 pm. (Attachment #3) 11/01/2022 Implemented
6400.166(a)(3)Individual #1's MAR indicated they were allergic to Haloperidol and Tegretol. However, Individual #1 is not allergic to Tegretol. They are allergic to Trileptal.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Drug allergies.10/26/2022- All program specialists, working managers, and LPNs were trained on their responsibility that a medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Drug allergies. 10/26/2022- A training record was signed indicating their attendance and understanding. (Attachment #1) All program specialists, working managers, and LPNs will continue to review medication records, including the following for each individual for whom a prescription medication is administered: Drug allergies. All program specialists, working managers, and LPNs reviewed and verified that each individual for whom a prescription medication is administered has a current medication record with correct drug allergies. 11/1/2022- Individual #1's primary care doctor sent fax to SFI confirming current drug allergies. (Attachment #2) 11/1/2022- Individual #1's medication record (MAR) was updated to include all current drug allergies. (Attachment #3) 11/01/2022 Implemented
SIN-00180501 Renewal 12/15/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.216(a)Individual specific record information was found unlocked and accessible in the attic. During the 12/15/2020 inspection of the home, the attic door was unlocked and staff could not locate the key to lock the door. An individual's records shall be kept locked when unattended. January 8, 2021- A maintenance request was completed to have the individuals records removed and taken to a locked storage facility. (Attachment # 2) January 11, 2021- All program specialists were trained on their responsibilities that individuals records shall be kept locked when unattended. A training record was signed indicating their attendance and understanding. (Attachment # 1) Program specialists will continue to keep individual records locked when unattended. All program specialists have reviewed and verified that all individuals records are kept locked when unattended. January 14, 2021- A review was completed confirming that all individual records are kept locked when unattended. This will be completed monthly by a member of the safety committee. (Attachment # 3) 01/14/2021 Implemented
SIN-00160812 Renewal 10/16/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(h)Individual #1's bedroom has a monitoring devise sitting on the night stand beside the bed. It is a voice monitoring system. The speaker portion of the monitoring system can also be found in the staff office where the overnight sleep staff sleeps. Per staff, the individual cannot ambulate independently from the bed to the bathroom during the night and needs the assistance of staff. The monitor is so she/he can call for staff overnight sleep staff assistance should she/he need to get up at night. The family is the individual's legal guardian and is requesting the monitoring devise be in the bedroom. The agency needs to provide documentation to show that the individual is aware of the devise and is ok with it, any form of doctor's note, any information that is included in the individual's plans for the reasoning behind the devise requirementAn individual has the right to reasonable access to a telephone and the opportunity to receive and make private calls, with assistance when necessary. October 29, 2019-Individual #1¿s parents and legal guardians wrote a letter to Strawberry Fields documenting their request to have an audio monitor in Individual #1¿s bedroom. (Attachment #11) Individual #1 needs staff assistance when getting out of bed. The monitor is to alert staff when Individual #1 needs assistance. The request was made to support Individual #1¿s health safety and welfare. November 6, 2019-Program Specialist met with Individual #1 to discuss the audio monitor i.e. why it¿s in her bedroom and the process around the monitor. Individual #1 indicated she is aware and in agreement. Individual #1 signed an Audio Monitor Agreement indicating her knowledge and agreement. (Attachment #12) An email was sent to Individual #1's supports coordinator to update Individual #1's isp with all relevant information regarding the audio monitor. (Attachment #13) November 8, 2019-All Program Specialists were trained on their responsibilities that an individual has the right to reasonable access to a telephone and the opportunity to receive and make private calls, with assistance when necessary. A training record was signed indicating their attendance and understanding. (Attachment #1) In the future, an individual¿s right to privacy may be modified by use of an audio monitor to the extent necessary to mitigate a significant health and safety risk to the individual or others. Appropriate documentation will be acquired and added to an individuals¿ plan prior to the use of the audio monitor. 11/08/2019 Implemented
6400.73(a)- The 10+ attic steps are not equipped with a handrail Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. October 21, 2019-A maintenance request was sent to Strawberry Fields maintenance department to have the attic steps equipped with a handrail. (Attachment #8) October 25, 2019-A handrail was equipped by the attic steps. (Attachment #10) All agency homes have been reviewed and evaluated and are currently in compliance. November 8, 2019-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. (Attachment #1) In the future, a monthly review will be completed by a member of the safety committee evaluating homes ramps, and interior stairways and outside steps exceeding two steps have a well-secured handrail. 11/08/2019 Implemented
6400.74The top 5 steps leading into the attic, are not equipped with a non-skid surfaceInterior stairs and outside steps shall have a nonskid surface. October 21, 2019-A maintenance request was sent to Strawberry Fields maintenance department to have nonskid surface added to the attic steps. (Attachment #8) October 25, 2019-Nonskid surface was added to the attic steps. (Attachment #9) All agency homes have been reviewed and evaluated and are currently in compliance. November 7, 2019-The Strawberry Fields, Inc. Safety Inspection checklist was updated to include a monthly review of nonskid surfaces on interior stairs and outside steps. November 8, 2019-All Program Specialists were trained on their responsibilities that interior stairs and outside steps shall have a nonskid surface. A training record was signed indicating their attendance and understanding. (Attachment #1) In the future, a monthly review will be completed by a member of the safety committee evaluating homes interior stairs and outside steps have a nonskid surface. 11/08/2019 Implemented
SIN-00118887 Renewal 09/27/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(3)The physical exam for Individual #1 last Tentus immunization was given 9/7/07 and was due 9/7/17. Individual #1 did not receive the tentus immunization, making it late. The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. All Program Specialists were trained on their responsibilities concerning regulation 141(c)(3). The physical examination shall include immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta , Georgia.( See Attachment # 1 ) Individual #1 received a Tetanus immunization on 9/29/2017. (See Attachment #2 ) All Program Specialists reviewed individual records and a Tetanus immunization was given to an individual that had an immunization due on 10/31/2017. The Tetanus immunization was given on 10/11/2017. (See Attachment #3) All Program Specialists conducted a review of immunizations to ensure that all immunizations are current . 10/25/2017 Implemented
6400.141(c)(6)Individual #1 date of admission was 11/17/15, the TB was not admisinstered until 12/9/15. This is to be completed prior to the admission dateThe physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. All Program Specialists were trained in their responsibilities concerning regulation 141(c)(6). The physical examination shall include Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted.( See Attachment # 1 ) Individual #1 received a TB skin test by Mantoux method on and again on .(See Attachment #2) All Program Specialists conducted a review of individuals TB test due dates to ensure that all are current. 10/25/2017 Implemented
6400.163(c)REPEAT from the 2016 inspection- Individual #1 is prescribed a medication to treat symptoms of a diagnosed psychiatric illness, there was only 1 medication review held on 12/7/16, this is to be completed at least every 3 months. 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 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 ) This specific prescription for individual #1 was a PRN and has been discontinued as of 10/3/2017 (See Attachment #2) All Program Specialists will ensure that medications prescribed to treat symptoms of a diagnosed psychiatric illness will be reviewed with documentation by a licensed physician at least every 3 months with all regulatory information.(See Attachment #3) All Program Specialists reviewed individuals records to verify that medication reviews for all individuals taking psychiatric medications were reviewed by a licensed physician at least every 3 months. 10/25/2017 Implemented
6400.181(e)(13)(vi)REPEAT from 2016 inspection- Individual #1¿s 6/8/17 annual assessment did not include press and growth 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 181(13)(vi). The assessment must include the individuals progress over the last 365 calendar days and current level in the area of recreation.( See Attachment # 1 ) Individual #1 assessment has been updated to include progress and growth over the last 365 calendar days and current level in the area of recreation. (See Attachment #2 ) SFI Annual Assessment was revised to reflect each specific regulation and the information to be reviewed. All future assessments will have this information included.(See Attachment #3) A review of all individual assessments was completed to ensure they all included progress and growth over the last 365 calendar days and current level in the area of recreation. 10/25/2017 Implemented
6400.181(e)(13)(vii)REPEAT from the 2016 inspection- The 6/8/17 annual assessment for Individual #1 did not include progress and growth in financial independenceThe 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. All Program Specialists were trained on their responsibilities concerning regulation 181(13)(vii). The assessment must include the individuals progress over the last 365 calendar days and current level in the area of financial independence. (See Attachment # 1 ) Individual #1 assessment has been updated to include progress and growth over the last 365 calendar days and current level in the area of financial independence. (See Attachment #2) SFI Annual Assessment was revised to reflect each specific regulation and the information to be reviewed. All future assessments will have this information included. (See Attachment #3) A review of all individual assessments was completed to ensure they all included progress and growth over the last 365 calendar days and current level in the area of financial independence. 10/25/2017 Implemented
6400.186(a)Individual #1's ISP reviews where not completed within the 3 month time frame according to the dates of the program specialist and Individual #1. The 12/19/16 ISP review not signed until 3/13/17, the 3/19/17 ISP review not signed by PS until 6/16/17, the 6/19/17 ISP review not signed by the PS until 9/18/17. 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. All Program Specialists were trained on their responsibilities concerning regulation 186(a). 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 individuals every 3 months or more frequently if the individuals needs change which impacts the services as specified in the current ISP.(See Attachment # 1) The ISP review for Individual #1 ended on 9/19/2017.The report was reviewed and signed by individual #1 and the Program Specialist on 10/4/2017. (See Attachment #2 ). All Program Specialists will ensure that ISP reviews will be completed ,reviewed and signed by the individuals and Program Specialists within the 30 day time frame. All ISP reviews were checked to ensure that they were completed, reviewed and signed by all individuals and Program Specialists within the 30 day time frame .. 10/25/2017 Implemented
6400.186(d)Individual #1's ISP reviews where not sent to the team members within the 30 days after the ISP review meeting according to the dates of the program specialist and Individual #1. The 6/19/17 ISP review sent to team on 9/18/17, the 12/20/17 ISP review sent out to team on 6/16/17, the 9/20/16 ISP review sent out on 3/8/16, but this review was not signed by the program specialist until 3/13/16 as being completed.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. All Program Specialists were trained on their responsibilities concerning regulation 186(d). 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. (See Attachment # 1 ) The ISP review for individual #1 ended on 9/19/2017 , the report was sent out to all team members on 10/4/2017. (See Attachment #2) All Program Specialists will ensure that all ISP reviews will be sent out to all team members within the 30 day time frame. All ISP reviews were checked to ensure that they were sent out to all team members within the 30 day time frame. 10/25/2017 Implemented
SIN-00100042 Renewal 08/18/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water temperature in the bathroom was 124 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. All Program Specialists were trained on their responsibilities concerning regulation 6400.68(b)-Hot water temperatures in bathtubs and showers may not exceed 120 degrees. (See attachment #1). The Safety Inspection Checklist that is completed monthly was updated to include the documentation of the hot water temperature. If it reads over 120 degrees a request will be completed. This form will be completed monthly at all programs. (See attachment #8.) In addition, it will continue to be checked during monthly fire drill safety inspections. (See attachment #¬¬¬¬_9___). An email was sent to the landlord requesting that he evaluate and lower the hot water temperature (see attachment#__10____). 10/10/2016 Implemented
6400.72(b)The sliding screen door in the living room area had an approximate 4 inch tear along seam of the door. Screens, windows and doors shall be in good repair. All Program Specialists were trained on their responsibilities concerning regulation 6400.72(b)-concerning screens, windows and doors shall be in good repair (see attachment #1). A maintenance request was completed and the screen was repaired ( See attachments #5 and 6). In addition the specific regulation was added to our Monthly Safety Inspection Checklist. This means that all sites will have their screens checked monthly. (See Attachment #7) 10/10/2016 Implemented
6400.104The notification letter that was sent to the local fire department on 11/15/15 did not indicate which bedrooms contained individuals who required assistance to evacuate. Two individuals in the home required verbal prompts and one required physical assistance to evacuate during fire drills.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. The Program Specialists were trained in their responsibilities concerning regulation 6400.104-the home shall notify the local fire department in writing in the address of the home and the exact locations of the bedrooms of individuals who need assistance in evacuating in the event of an actual fire. The notification shall be kept current. (See Attachment #1) The letter to fire department has been updated indicating the address of the home and the exact locations of the bedrooms and individuals that need assistance. (See Attachment #5) In addition, all letters are current and state the address of the home and the exact locations of the bedrooms of individuals who need assistance in evacuating in the event of an actual fire. 10/10/2016 Implemented
6400.110(a)A smoke detector was not located in the attic. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. All Program Specialists were trained on their responsibilities concerning regulation 6400.110(a)-A home shall have a minimum of one operable automatic smoke detector on each floor including the basement and attic (see attachment #1) An automatic smoke detector was purchased and installed in the attic (see attachments #2 and 3). In addition the smoke detector location was added to the sites specific Fire Drill/Health Safety Inspection Record (see attachment #4). All sites have the location of smoke detectors listed on their site specific Fire Drill/ Health Safety Inspection Record and can be verified monthly (see attachment #4). 10/10/2016 Implemented