Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00227054 Renewal 08/15/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Poisonous materials shall be kept locked or made inaccessible to individuals. According to Individual #1's Individual Support Plan (ISP) poisonous substances are kept locked away or out of reach as a safety precaution. At the time of inspection, the right-hand kitchen sink cabinet was unlocked. Poisons are stored in this kitchen sink cabinet and the following poisons were located in the unlocked cabinet: a spray Clorox bathroom disinfecting cleaner spray bottle, Lysol disinfecting spray can, Lysol Power toilet bowel cleaner, a container of Lysol disinfecting wipes, and a 100 FL oz of Original Pin Sol Multi-surface cleaner. The labels on all of these items states to contact Poison Control Center.Poisonous materials shall be kept locked or made inaccessible to individuals. Provider ensured that all poisons in the home were locked and inaccessible to the individual. Program staff were retrained on regulation 62a and individual #1's ISP guidelines regarding the storage or poisonous material. 08/17/2023 Implemented
6400.64(a)Clean and sanitary conditions shall be maintained in the home. The bathtub/shower floor located in the bathtub/shower on the left in the main bathroom had 4 substantial areas of rust on it.Clean and sanitary conditions shall be maintained in the home. Provider thoroughly cleaned shower area, removing areas of rust from the shower surface. Program Directors have checked all areas to ensure clean and sanitary conditions. 08/21/2023 Implemented
6400.67(a)Floors, walls, ceilings, and other surfaces shall be in good repair. The plastic hot water cap indicator was missing from the bathroom sink knob in Individual #1's bathroom.Floors, walls, ceilings and other surfaces shall be in good repair. The hot water cap was replaced on faucet immediately indicating which knob is for hot water. All other knobs were checked to ensure compliance. 08/25/2023 Implemented
6400.68(c)A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources' certified laboratory stating that the water is safe for drinking purposes at least every 3 months. A coliform test was completed on 2/16/23 and then not again until 6/6/23. This exceeds the requirement.A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept.Provider's water testing laboratory went out of business with little notice. The provider established accounts with a new water testing laboratory and testing was done as quickly as possible but exceeded the quarterly requirement, resulting in a late water test. 08/23/2023 Implemented
6400.151(c)(3)A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Staff #1's physical examination dated 12/15/22 did not include that the staff person is free of communicable diseases. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Director of Human Resources, obtained a physical examination including a signed statement, confirming that staff #1 is free from communicable disease. 08/23/2023 Implemented
SIN-00191808 Renewal 08/10/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(h)During the fire drill conducted on 9/14/20 at 4:30am, Individual #1 refused to evacuate to the designated meeting place. As documented on the fire drill form "(Individual #1) refused to walk and only made it to her housemates bedroom/bathroom before sitting on the floor." Individual #1 shall evacuate to the designated meeting place in order to ensure compliance. A successful repeat drill was then conducted on 9/14/20 at 10:00pm with an evacuation time of 49.54 seconds. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.After fire drills house managers will have a discussion with all participants on the importance of evacuating quickly, safely and meeting at the designated areas. Discussions will also be had at house meetings on the importance of fire safety. 09/08/2021 Implemented
SIN-00134381 Renewal 05/01/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)The magnetic locking mechanism on the cabinet under the sink in the hall bathroom was not working properly, making poisons such as Secret Solid Antiperspirant and Crest Fluoride toothpaste (both items were labeled "contact Poison Control if ingested") accessible to individuals.Poisonous materials shall be kept locked or made inaccessible to individuals. The magnetic locks were tightened by the Facility Management Department that day. We are looking into other types of locks so that poisons are not accessible to individuals 05/02/2018 Implemented
6400.143(a)Individual #1 had documentation in the record to indicate that the individual had refused PAP smears at Gynecological appointments but does not have documented attempts at training.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. FCS has created a form that any medical appointment refusal will be reviewed quarterly with the hope tht the individual changes their mind and attends the appointment 07/18/2018 Implemented
SIN-00075055 Renewal 04/08/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.142(a)Individual #1 had a dental exam on 9/9/2013 and again on 1/8/2015. An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. The individual's next scheduled apt is 7/13/15 and future appointments are made at the end of each appointment. All doctor appointments are tracked to ensure compliance. The Program Director will monitor and ensure that Program Managers schedule medical appointments appropriately. 04/13/2015 Implemented
6400.161(e)Individual #2 had the following discontinued prescription that was not disposed of: polyethylene Glycol 3350 Nf Substitute for Miralax 3350 OTC (dissolve 1 teaspoon in 8oz of water/juice once daily as needed for Severe Constipation) with a fill date of 9/18/14. This medication is not listed on individual #2¿s MAR and according to agency staff it has been discontinued. Discontinued prescription medications shall be disposed of in a safe manner.The discontinued medication was properly destroyed. Manager was retrained on Agency Medication Disposal Policy 04/14/2015 Implemented
SIN-00060240 Renewal 02/28/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)There was no fire drill held during the month of November 2013(a) An unannounced fire drill shall be held at least once a month. To ensure that an unannounced fire drill is held once a month the program director will plan unannounced monthly drills 6 months in advance of when the drill is going to be held. They will keep a record of this date in their desktop calendar. Fire drill paperwork will be given to the house manager the day of the fire drill. The program director and house manager will review the paperwork the following business day after the fire drill is conducted 03/14/2014 Implemented
6400.112(e)There was no sleep fire drill held during the month of November 2013. The previous sleep fire drill was held 5-9-2013(e) A fire drill shall be held during sleeping hours at least every 6 months. To ensure that an unannounced fire drill is held once a month the program director will plan unannounced monthly drills 6 months in advance of when the drill is going to be held. They will keep a record of this date in their desktop calendar. Fire drill paperwork will be given to the house manager the day of the fire drill. The program director and the house manager will review the paperwork the following business day after the fire drill is conducted. A Sleep fire drill will be held every 6months. 03/21/2014 Implemented
SIN-00057859 Unannounced Monitoring 11/08/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.18(c)On 11-8-13, BHSL Inspector found that, on 10-18-13 Staff #1 reported a large bruise, of unknown origin, located on the left buttock of Individual #1, to her supervisor, Staff #2. Agency staff failed to file an incident report per regulation. On 12-11-13, BHSL found that on 11-17-13 Individual #1 struck Individual #2 on three separate occasions throughout the day, and that on 12-4-13 Individual #1 struck Individual #3. Agency staff failed to file an incident report per regulatory requirements on all four of these incidents. (c) The home shall orally notify the county mental retardation program of the county in which the home is located, the funding agency and the appropriate regional office of mental retardation, within 24 hours after abuse or suspected abuse of an individual or an incident requiring the services of a fire department or law enforcement agency occurs. A. Agency nurse creased a bruise tracking form that is being utilized by staff and was implemented 12/06/13. B. Staffing in the program has been customized to better suit our consumers' needs and will continued to be evaluated: 11/29/13 C. Staff have been retrained on recognizing and reporting incident or suspected incidents of abuse. We have also implemented a mandatory training made available to all staff through our Relias Training System that focuses on Abuse. D. Moving forward staff are required to participate in the course "Writing an Effective Incident Report" made available through Relias Training System. E. Once an incident has happened it shall be entered into HCSIS within a 24 hour period and the appropriate measures will be taken to ensure the safety of our consumers. And, notification will be made to the Supports Coordinator 01/31/2014 Implemented
6400.33(e)) On 10-18-13, Staff #1 violated Individual # 1¿s right to privacy in the bathroom during personal care, by taking a photograph of a bruise on her left buttock. This was done with Staff # 1¿s personal cell phone.(e) An individual has the right to privacy in bedrooms, bathrooms and during personal care. A. Staff #1 and #2 are no longer employed by FCS. B. There is a standard FCS policy that prohibits employees from using cameras at work, this includes camera phones. This policy will be reviewed at monthly house meetings to ensure that staff comprehend the policy. C. Staff are required to participate in a HIPAA and Confidentiality Training available through our online learning program, Relias. This is a mandatory annual training but will be reviewed at monthly staff meetings. 01/31/2014 Implemented
6400.183(5)On 11-8-13 and 11-14-13, the agency did not have a program in place at the home to address Individual #1¿s social, emotional or environmental needs. On 12-11-13, the agency did not have a program in place at the home to address Individual #1¿s social, emotional or environmental needs. Individual is prescribed Clonidine, for Impulse Control Disorder; Quetiapine Fumerate, for Mood Stabilizer; Guanfacine,for ADHD; and Loxitane. for Anxiety.(5) A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. A. The Behavior Support Plan for the individual was last updated 12/29/2013. B. All residents of the home have their ISP's and Behavior Support Plans located in the house ISP binder and consumer file. It is a FCS standard practice for all staff to read and individual's ISP and Behavior Support Plan when working in a program. The Program Director for the program is responsible to ensure that this is done. C. A program Director will communicate with a Supports Coordinator when a psychiatric medication has been prescribed or there has been a change in the medication order. This communication will be done orally and/or by email. 01/31/2014 Implemented
SIN-00178327 Renewal 10/20/2020 Compliant - Finalized