Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00192689 Renewal 09/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment for the home did not include a date of completion; therefore, compliance could not be measured.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. All self-assessments, once completed annually, will be turned into the Quality and Compliance Department for review to ensure the assessment is completed in its entirety and within the required timeframe prior to being shared with Licensing Representatives each year. 09/15/2021 Implemented
6400.141(c)(14)Individual #1's physical examination completed 2/19/21 did include medical information pertinent to diagnosis and treatment in case of an emergency. This section was blankThe physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. This person's was corrected during exit interview when noted. CCI¿s Nursing Department will ensure all medical information on the individual¿s physical form is completed upon return from appointment. 09/10/2021 Implemented
6400.32(r)Individual #1's bedroom door did not have a lock. Individual #2's bedroom door did not have a lock. Individual #3's bedroom door did not have a lock. Individual #4's bedroom door did not have a lock.An individual has the right to lock the individual's bedroom door.CCI has implemented a Door Lock Declination Statement defining each person¿s request for a door lock, the type of door lock requested to suit their needs and any additional supports needed. The declination was implemented on 9/20, giving all Program Specialist until the end of October to complete the initial declination. All declinations for CCI were completed on 10/31 and placed on each individual¿s chart. Moving forward, the Declination will then be an addendum to the Rights Assessment, completed annually thereafter, along with as needed at the individual¿s request and upon admission. Currently, all door locks based on the individual¿s preference was to be installed in all homes and bedrooms by 10/31, however, CCI is working with Barrier Protection Services Inc, who informed us that a delay was possible due to supply and demand with ordering the locks in bulk given the pandemic. As of this writing, Barrier has confirmed the locks are in and will be installation on 11/17/21 to 11/24/21. People individually identified in the violation will be completed first, along with those residing in the home of the violation. All people will be completed before their last date scheduled of 11/24/21. 12/10/2021 Implemented
6400.166(a)(11)Individual #1's September 2021 Medication Administration Record did not include the diagnosis or purpose for the following prescribed medications: Levothyroxine, Florastor, Cyclobenzapine, Melatonin, and Polyethylene Glycol-Miralax.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Upon receiving feedback after virtual tours on the second day of inspection, the Director of Nursing contacted the Pharmacy to implement a plan on all MARS moving forward. With CCI currently in the middle of a month, all changes were reflected on the October MARS, however, the month of October was used as a learning month for both CCI and the Pharmacy, to ensure all information is correct once printed and distributed to the homes. All corrections to the October MARS were made final with implementation of November MARS moving forward. A review from the Director of Nursing and her nurses, note no errors with information on the November MARS. 10/31/2021 Implemented
SIN-00107428 Unannounced Monitoring 01/05/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(a)On 11/25/16, at approximately 8:15 AM, Direct Service Worker #1 overheard Direct Service Worker #2 tell Individual #1 to be quiet because Direct Service Worker #2 was busy. When Individual #1 asked Direct Service Worker #2 "what are you doing?" Direct Service Worker #2 replied "I told you not to fuck with me today." Individual #1 was upset and appeared to be afraid of Direct Service Worker #2. When Direct Service Worker #2 left the site, Individual #1 asked Direct Service Worker #1 "did you see what [Direct Service Worker #2] did to me?" Individual #1 asked Direct Service Worker #1 repeatedly throughout the day if Direct Service Worker #2 would be returning. Individual #1 is diagnosed with mild ID, dementia, glaucoma, bilateral severe to profound sensorineural hearing loss, anxiety disorder and depressive disorder. Individual #1's Behavioral Support Plan in the ISP, most recently updated 5/16/16, states Individual #1 becomes anxious when redirected or corrected...[Individual #1] requires much social praise and interaction throughout the day...Staff needs to reassure [Individual #1] that [s/he] has not done anything wrong and that [s/he] is not in trouble...Staff must assist [Individual #1] in a calm and neutral manner." An individual may not be neglected, abused, mistreated or subjected to corporal punishment. This violation of regulation CH 6400.33 (a) relates to an allegation of verbal abuse, which had been reported on 11/26/16 by a staff to a manager at CCI. The investigation was initiated the same day by a certified investigator. The target was suspended while the investigation was conducted. The victim was offered informal counseling and declined numerous offers of further assistance. She did not verify that she had been verbally abused. One of her roommates, who was in the same area also did not verify that the target was verbally abusive. The investigation was inconclusive, as the reporter of the incident and the target had opposing accounts of the incident. The target was transferred to a different site; will not work with the victim again and received additional training from Patty Taylor, the HR Director of Training, on 1/4/17 in regard to dealing with difficult situations. In any reported situation of abuse, CCI follows the above described process: immediate reporting to management; timely reporting in EIM and APS and other notifications as required; immediate assignment of an investigator; immediate suspension of the target; immediate offer of appropriate assistance to the victim. If the target is found to have been abusive, the target will be terminated, and depending on the situation, official charges would be filed. If the investigation shows an inconclusive result, to protect the victim, as well as, the target, the target will not work with the victim again. The target, if still employed, will receive additional appropriate training, as was done in this situation. In order to prevent such a violation in the future, all new employees during induction training are informed that no individual may ever be neglected, abused, mistreated or subjected to corporal punishment. This is the responsibility of the HR department. Additionally, Patty Taylor, the HR Director of Training will conduct the annual abuse and neglect training starting March 20th, 2017 and will be completed by April 30th, 2017. 03/07/2017 Implemented
SIN-00064732 Renewal 05/27/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.164(a)Individual #1 is ordered Medroxyprogesterone 150mg injection, inject 1ml (=150mg) intramuscularly every 3 months. A review of the medication log shows that the injection was administered on 2/25/14; however, according to staff interviews and a review of the nurse's calendar the injection was administered on 1/25/14. On 11/26/13, Individual #1 was ordered Lamotrigine tablet 100mg, take one tablet at bedtime (along with 200mg tablet). In addition, Individual #1 was ordered Lamotrigine tablet 200mg, take one tablet at bedtime (along with 100 mg tablet). However for the period of 11/26/13 through 11/30/13, the medication log only listed Lamotrigine tablet 100mg, take one tablet at bedtime. 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. 6/2/14, mandatory trainings were started during which all direct care staff, who work in the community living division, as well as, nursing and management staff were provided additional training in regard to the proper administration and documentation of medications. These trainings were completed on 6/30/2014. Training included a change of procedures in regard to documentation of medication on the medication administration record (MAR) when there is a medication implementation, change or discontinuation. All staff were informed that only the nurses, medication administration supervisors or observers will be permitted to document those medication changes (implementation, change or discontinuation) on the MAR. Only in those rare situations when a nurse or medication supervisor/observer is not available but the medication must be implemented immediately as per doctor¿s order, will a direct care staff document the medication (implementation, change or discontinuation) on the MAR. However, in that circumstance, a nurse, or medication supervisor/observer, will check on the accuracy of that documentation within 24 hours. During this training all staff was also reminded that any kind of errors involving medications, administration or documentation, must be reported to a medication supervisor immediately. Additionally, staff was reminded to document the administration of any medication as soon as the medication is administered. Staff is to double check the administration and documentation again before the end of the acceptable medication administration time frame. When there are 2 staff in the home, they were encouraged to remind each other of the administration times and the need for immediate documentation. Correction Plan, Part 2, completed in the Month of July, 2014: It is of utmost 07/18/2014 Implemented
SIN-00066063 Renewal 05/27/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.164(a)Individual #1 is ordered Medroxyprogesterone 150mg injection, inject 1ml (=150mg) intramuscularly every 3 months. A review of the medication log shows that the injection was administered on 2/25/14; however, according to staff interviews and a review of the nurse¿s calendar the injection was administered on 1/25/14. 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. 6/2/14, mandatory trainings were started during which all direct care staff, who work in the community living division, as well as, nursing and management staff were provided additional training in regard to the proper administration and documentation of medications. These trainings were completed on 6/30/2014. Training included a change of procedures in regard to documentation of medication on the medication administration record (MAR) when there is a medication implementation, change or discontinuation. All staff were informed that only the nurses, medication administration supervisors or observers will be permitted to document those medication changes (implementation, change or discontinuation) on the MAR. Only in those rare situations when a nurse or medication supervisor/observer is not available but the medication must be implemented immediately as per doctor¿s order, will a direct care staff document the medication (implementation, change or discontinuation) on the MAR. However, in that circumstance, a nurse, or medication supervisor/observer, will check on the accuracy of that documentation within 24 hours. 07/13/2014 Implemented
SIN-00177397 Renewal 10/05/2020 Compliant - Finalized
SIN-00115513 Renewal 06/07/2017 Compliant - Finalized
SIN-00106271 Unannounced Monitoring 01/05/2017 Compliant - Finalized