Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00175943 Renewal 09/08/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The curtains in individual #1, bedroom were stained and had residue similar to paint on them.Clean and sanitary conditions shall be maintained in the home. The curtains in individual #1¿s bedroom have been removed, and an order for new curtains has been placed (see Appendix A). To prevent future occurrence program managers will be trained on regulation 6400.64 (a) pertaining to clean and sanitary conditions in the home, and minimum of one safety round (see Appendix B) will be completed for each program area every two weeks. Any area in a home that is identified on the safety round form as not meeting clean or sanitary conditions will be corrected immediately. Person Responsible for carrying out and oversight: Program manager, Assist. Director and Director of Programs. 11/11/2020 Implemented
6400.142(a)The dental exam for individual #2 was not completed annually. The last dental exam was completed October 2018. There was an attempt to schedule an appointment on 10/21/2019. No subsequent follow up documentation was provided.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. Individual #2 had a dental appointment and procedure completed on 10/7/2020 (see Appendix C) Actions taken to prevent future recurrence: all individuals will have dentist appointments scheduled annually by their primary care nurse/healthcare coordinator. This will be reviewed and retrained with the healthcare team, and will be documented on the team meeting minutes Person responsible: primary care nurse, healthcare coordinator, nurse manager 11/11/2020 Implemented
6400.144The Medication administration record (MAR) for individual #1 weight check was not logged weekly per September 2020 physicians order. The Vitals report did not obtain weight tracking for the week of 8/24/2020 and 9/7/2020. The health service prescribed by the physician was not being provided as orderd. The MAR was also left blank.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. The prescribed weight check for individual #1 was completed on the day of the survey. Actions taken to prevent future recurrence: all healthcare professionals responsible for documenting weight checks as prescribed by a physician in iMAR were retrained on this expectations (see appendix D) Person responsible: primary care nurse, healthcare coordinator, nurse manager 11/11/2020 Implemented
SIN-00148663 Renewal 01/15/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The ceiling above individual #6's bed was peiling paint and the vent seemed to be coming away from the ceiling.Floors, walls, ceilings and other surfaces shall be in good repair. Our 6400.67 (a) protocol has been updated and the following procedures have been instituted; Work order has been placed and both the ceiling peel and vent have been repaired. Ceiling and vent checks have been added to our environmental check list. All Program Specialists will be trained on how to utilize the environmental check list. The environmental check list will be completed monthly and any concerns noted will be reported to facilities within 24 hours. Target Date 4/30/2019. Person Responsible: Program Specialist. 04/30/2019 Implemented
6400.76(a)Individual #7 has bedrails in their room to help them avoid falls out of bed. This is in their annual plans. However, the rails during inspection were flimsy and the brackets did not hold the rails in place. The brackets for the rails have been compromised and need to be replaced. Furniture and equipment shall be nonhazardous, clean and sturdy. Our 6400.76 protocol has been updated and the following procedures have been instituted; Work order was completed and both the bedrails and brackets have been replaced. A check of bedrails, brackets and other parts of furniture and equipment utilized by individuals supported have been added to our environmental check list. All Program Specialists will be trained on how to utilize the environmental check list. The environmental check list will be completed monthly and any concerns noted will be reported to facilities within 24 hours. Target Date 4/30/2019. Person Responsible: Program Specialist. 04/30/2019 Implemented
6400.161(b)There was a packet of Motrin IB found in the first aid kit which was unlocked in a cabinet above the refrigerator in the kitchen.Prescription and potentially toxic nonprescription medications shall be kept in an area or container that is locked, unless it is documented in each individual's assessment that each individual in the home can safely use or avoid toxic materials. Our 6400.161(b) protocol has been updated and the following procedures have been instituted; A check list for first aid kit has been formulated to include checking for potentially toxic non-prescription medications and securing the medications if found. See attachment A. Program specialist will be trained on the check list. The checklist will be completed monthly by the Program specialist moving forward and reviewed by Assistant Directors/Directors. Target date 2/28/2019. All Program specialist will be trained on how to utilize and complete the first aid kit. Target date 2/28/2019. Person Responsible; Program Specialist, Assistant Director and Director. 02/28/2019 Implemented
SIN-00110179 Renewal 09/07/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(b)Individual #1's previous individual rights statement was signed on 4/6/15 and the most recent individual rights statement was signed on 7/28/16.Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. Program Specialists/managers have been retrained on their responsibilities, including the responsibility to have all rights forms and consent forms completed annually for each individual. see attachment 1_MB_PS. The assistant director or director will complete chart audits as needed, and will ensure correction of any identified missing documents upon discovery. 04/07/2017 Implemented
6400.112(d)The fire drill on 11/25/15 was 3 minutes and 14 seconds, which exceeded the 2 minutes and 30 second limit. 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. all managers have been retrained on the requirement for the fire drill to be completed within 2 minutes and 30 seconds, or the fire drill will be re-run. See attachment 2_MB_Fire for training documentation. the assistant director or director will review the fire drill each month upon completion to ensure fire drills were run correctly. Any drill identified by the assistant director or director as not having been run correctly will be re-run, and the responsible manager will be retrained. 04/07/2017 Implemented
6400.141(c)(9)Individual #2's annual physical, dated 6/2/16, did not document a prostate exam. The physical examination shall include: A prostate examination for men 40 years of age or older. Individual #2 had a prostate exam completed. see attachment MB_P_Exam. Chart audits will be completed by the responsible nurse and any missing or lapsed exams will be corrected upon discovery. 07/01/2017 Implemented
6400.181(d)Individual #1's assessment, dated 7/28/16, was not signed and dated by the program specialist. Individual #2's assessment, dated 6/16/16, was not signed and dated by the program specialist. The program specialist shall sign and date the assessment. Program specialists have been retrained on the responsibility of completing assessments, which including signing and dating all assessments. See attachment 1_MB_PS for training documentation. The assistant director and director of the home will complete chart audits to ensure that all assessments are signed and dated when completed. 04/07/2017 Implemented
6400.181(f)Individual #1's assessment, dated 7/28/16, did not have documentation that it was sent to the team members. (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). Program Specialists were retrained on their responsibilities, including the responsibility of sending the assessment and assessment letters to the team 30 days prior to the ISP. See attachment 1_MB_PS for training documentation. The assistant director or director will complete chart audits as needed to ensure assessments have been completed and sent to the team 30 days prior to the ISP meeting. 04/07/2017 Implemented
SIN-00095236 Unannounced Monitoring 01/12/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Individual # 1 and # 2 cannot safely use or avoid poisonous materials and Lysol Antibacterial Spray, Cascade Dish detergent Powder, Cascade Dishwashing Liquid, Lysol Disinfecting Spray, Equate Ultra Sun Protection, Oven and Grill Cleaner, Pro Clean Power Temp Liquid mechanical Detergent, and Hibiclens Chlorhexidine Gluconate Solution which indicated to contact poison control if ingested, were found unlocked in various cabinets in the kitchen. Two bottles of Lysol disinfectant spray which indicated to contact poison control if ingest was found unlocked in Individual # 1's bedroom. Lysol Antibacterial Kitchen cleaner which indicated to contact poison control if ingested was found unlocked in the bathroom used by the individuals residing in the home. Lysol Antibacterial Kitchen cleaner, which indicated to contact poison control if ingested, was found unlocked in the staff bathroom. Listerine Total care, Speed Stick Men¿s deodorant and roll on med spa deodorant which indicated to contact poison control if ingested was found unlocked in an individual¿s room. Wet ones antibacterial wipes which indicated to contact poison control if ingested was found unlocked in the TV room.Poisonous materials shall be kept locked or made inaccessible to individuals. 1. Plan to fix the immediate problem a. Program Manager, Assistant Director, Director or designees will be responsible for ensuring that all homes keep poisonous chemicals locked up when not in use. b. The problem was corrected immediately and all chemicals required to be stored in a locked location were moved to a lock location. New locks were purchased for cabinets containing hygiene items (see attachment 5) c. WHEN and HOW ¿ See attachment 2 for the full process of inspecting the homes ¿ All items were moved to a locked location (see attachment 5) ¿ All other 6400 homes are inspected regularly to ensure all poisonous materials remain locked (see attachment 3) ¿ All homes will continue to be monitored with the facility¿s updated safety round process (see attachment 2) 2. A plan to prevent future occurrences ¿ See attachment 2 for the facility¿s updated process to monitor and correct future occurrences. 3. Facility staff training: ¿ All staff responsible for carrying out the facility¿s new process (attachment 2) will be trained on this process no later than 7/15/2016. 4. Send documents that will enable us to validate that the new plan is up and running. ¿ See attachment 3 (Program staff will conduct safety rounds by using a checklist to ensure all areas are in compliance at the end of the shift including the proper storage of poisonous substances, the removal of lint from dryers and environmental concerns. Program Managers or designated Lead Staff member will conduct rounds twice per month using the safety round checklist as well as The Facilities Department will conduct monthly safety rounds using the safety round checklist. Assistant Directors and Directors are responsible for conducting spot checks to ensure any area of deficiency has been reported and corrected. DS 07.05/.16) 07/15/2016 Implemented
6400.64(b)There was an infestation of ants located on the floor near the trash receptacle in the kitchen.There may not be evidence of infestation of insects or rodents in the home. 64 (b) 1. Plan to fix the immediate problem a. Program Manager, Assistant Director, Director or designees will be responsible for ensuring that all homes remain free of any insect infestations. If any infestations are discovered, they will reported and treated immediately. b. The infestation was treated and the problem resolved (see attachment 4) c. WHEN and HOW ¿ See attachment 2 for the full process of inspecting the homes ¿ The infestation was treated a resolved (see attachment 4) ¿ All other 6400 homes on campus have been inspected and no other infestations have been noted. ¿ All homes will continue to be monitored with the facility¿s updated safety round process (see attachment 2) 2. A plan to prevent future occurrences ¿ See attachment 2 for the facility¿s updated process to monitor and correct future occurrences. 3. Facility staff training: ¿ All staff responsible for carrying out the facility¿s new process (attachment 2) will be trained on this process no later than 7/15/2016. 4. Send documents that will enable us to validate that the new plan is up and running. ¿ See attachment 3 (Program staff will conduct safety rounds by using a checklist to ensure all areas are in compliance at the end of the shift including the proper storage of poisonous substances, the removal of lint from dryers and environmental concerns. Program Managers or designated Lead Staff member will conduct rounds twice per month using the safety round checklist as well as The Facilities Department will conduct monthly safety rounds using the safety round checklist. Assistant Directors and Directors are responsible for conducting spot checks to ensure any area of deficiency has been reported and corrected. DS 07.05/.16) 07/15/2016 Implemented
6400.64(e)The lid was missing from the trash receptacle located in the kitchen.Trash receptacles over 18 inches high shall have lids. 64 (e) 1. Plan to fix the immediate problem a. Program Manager, Assistant Director, Director or designees will be responsible for ensuring that all trash cans 2 feet tall or higher have lids. If a trash can that requires a lid is observed to not have one, a new can or lid will be purchased at the next immediate available opportunity. b. A new trash can with a lid was purchased for the home and is currently in use (see attachment 1). c. WHEN and HOW ¿ See attachment 2 for the full process of inspecting the homes ¿ A trash can with a lid has already been purchased and is in use in the home (see attachment 1) ¿ All other 6400 homes on campus have been inspected and all have trash cans with lids if the they meet the criteria to require a lid ¿ All homes will continue to be monitored with the facility¿s updated safety round process (see attachment 2) 2. A plan to prevent future occurrences ¿ See attachment 2 for the facility¿s updated process to monitor and correct future occurrences. 3. Facility staff training: ¿ All staff responsible for carrying out the facility¿s new process (attachment 2) will be trained on this process no later than 7/15/2016. 4. Send documents that will enable us to validate that the new plan is up and running. ¿ See attachment 3 (Program staff will conduct safety rounds by using a checklist to ensure all areas are in compliance at the end of the shift including the proper storage of poisonous substances, the removal of lint from dryers and environmental concerns. Program Managers or designated Lead Staff member will conduct rounds twice per month using the safety round checklist as well as The Facilities Department will conduct monthly safety rounds using the safety round checklist. Assistant Directors and Directors are responsible for conducting spot checks to ensure any area of deficiency has been reported and corrected. DS 07.05/.16) 07/15/2016 Implemented
SIN-00077719 Renewal 05/27/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Individual #2's bedroom closet had Dove men's deodorant unlocked.Poisonous materials shall be kept locked or made inaccessible to individuals.Locked bins have been obtained for any personal care products deemed potentially poisonous and dangerous to individuals. By 7/15/15, managers will be trained on requirements to keep all poisonous materials locked or inaccessible. Rounds will be completed by house managers on a weekly basis to verify that poisonous materials are locked or inaccessible. Results of rounds will be reported to the Program Director. The Program Director will complete monthly physical site checks to ensure poisonous materials are inaccessible to individuals. AH 07/15/2015 Implemented
6400.68(b)The hot water temperature in the bathtub was 126.8° Fahrenheit.Hot water temperatures in bathtubs and showers may not exceed 120°F. Temperature of hot water in Miller B was adjusted to 115 degrees. Hot water temperature will be monitored on a weekly basis by the house manager and documented. Should the water temperature exceed 120 degrees Fahrenheit, the house manager will immediately notify management. (AH) The hot water temperature will be monitored on a monthly basis by the Melmark plumber who will complete a summary every month verifying temperatures at various locations in the home are under 120 degrees. A report of temperature checks will be submitted monthly to the safety committee. 07/15/2015 Implemented
6400.112(c)The fire drill records dated 11/13/14 and 9/13/14 did not include the amount of time it took for evacuation.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. By 7/15/15, all Managers will be trained in fire drill reporting requirements including requirements to document evacuation time. In order to ensure the required items are preserved in a record, the completed drill record will be emailed to director and printed within 72 hours of completion of the drill. Status of completion of all drill records will be reviewed monthly as part of Melmark leadership scorecard which is submitted to the Program Director and Executive Director of Children's Services. 07/15/2015 Implemented
6400.141(a)Individual #1 had a physical exam completed on 9/10/13 and did not have another physical exam completed until 12/5/14.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Melmark management tracks completion of annual physicals so that Melmark primary care can complete them on time. In this instance, the parent chose an outside healthcare provider who failed to comply with our request to complete the physical on time. Melmark will request authorization from the family to have Melmark PCP complete physical at the next annual due date to maintain compliance. 06/25/2015 Implemented
6400.161(e)Individual #1 was prescribed Guaifensin 100mg/5ml, give 30ml via J-Tube. The medication was discontinued in March of 2015 and continued to be stored in the medication box. Discontinued prescription medications shall be disposed of in a safe manner.Individual # 1's discontinued medication was disposed of in a safe manner. All discontinued medications will be disposed of according to Melmark Medication safety policy. By 7/15/15 Managers will be trained on the medication safety policy and audit medication storage areas to ensure disposal procedures are followed. The program specialist will complete a monthly check of all medications to ensure that expired and discontinued medications are disposed of safely and in a timely manner. The monthly audit will be documented and kept on file.(AH) 07/15/2015 Implemented
6400.181(d)(3)The Individual Support Plan (ISP) for Individual #1, dated 11/1/14, was not on the Department-designated form.The plan lead shall develop, update and revise the ISP according to the following: The ISP, annual updates and revisions shall be documented on the Department-designated form located in the Home and Community Services Information System (HCSIS) and also on the Department's web site. Melmark has included all elements of the department designated form as an electronic document so that all ISPs are documented with department required content. Melmark will use ODPconsulting.net to locate the Department-designated form. Melmark Management is responsible to conduct a record review of all individuals in the agency by August 22, 2015 to ensure that all individuals have an ISP on the designated form. Staff will be re-trained on the regulations regarding Plan Leads and their responsibilities by August 22, 2015. (AH) 07/15/2015 Implemented
SIN-00212199 Renewal 09/06/2022 Compliant - Finalized