Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00192690 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
6400.32(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
SIN-00134753 Renewal 05/22/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(g)Direct Service Worker #1 received annual fire safety training on 10/24/16 and again on 11/15/17.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). Fire safety and evacuation training will now be required twice a year for all residential staff to ensure that all staff have the training annually. The initial round of training will begin on June 25, 2018 and run through July 14, 2018. Another round of training will be scheduled for October of 2018. All staff will be mandated to attend both sessions. All new hires will continue to receive fire safety and evacuation training as part of their initial orientation. Director of Training notified Management staff of this change on 5/29/2018. [At least quarterly for 1 year, a designated staff person shall audit a 10% sample of staff person's fire safety training to ensure timely completion. Documentation of audits shall be kept. (AS 5/31/18)] 05/29/2018 Implemented
SIN-00106319 Unannounced Monitoring 01/05/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.164(a)On 6/9/16, Individual #1 was prescribed a Fentanyl 12 mcg/HR patch to be applied every 72 hours for 30 days. On 7/14/16, the orders were changed to Fentanyl 25 mcg/HR patch to be applied every 72 hours for 30 days. On 7/14/16, Program Specialist #1 revised the Medication Administration Record (MAR) to Fentanyl 25 mcg/HR patch apply two patches every 72 hours for 30 days. On 7/16/16 Individual #1 was administered two patches of Fentanyl 25 mcg/HR at 8:00 AM. Individual #1 became lethargic and had slurred speech and was taken to the emergency room for an accidental overdose. 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 staff will continue to receive medication administration and documentation training upon induction and annually thereafter, including the required number of observations. Remediation training will continue if errors are made. Additionally, we will review regulation 164 (a) in detail with direct care professionals, nurses, supervisors, managers and directors. In short, all personnel, who may implement and administer medications. As a general rule, whenever possible, it is only nurses, managers, coordinators, supervisors, senior supports assistants and directors, who implement new medications in order to avoid mistakes. When direct care staff are implementing medications, we will remind the manager or nurse to check asap that the implementation was done correctly. It will be my, Petra Mussi¿s, responsibility to review the regulation with nurses, supervisors, managers and directors. It will be the supervisors, medication trainer and observers responsibilities to review the regulation with the direct care professionals assigned to them. Additionally, we will remind the nightshift supervisors to remind and retrain the night shift staff to check all MARs against all blister packs for correctness nightly, as well as, verify that each staff who has administered a medication has signed the back of the MAR with their full name. We have designed and will place in each medication book or clip board with the MARs, new posters, which in an eye catching way will remind people to sign the backs of MARs. We have also assigned the nursing staff to compare all doctors¿ orders against MARs and blister pack labels within the next few weeks to ensure all medications are implemented correctly. This verification will continue every 6 month. Finally, we have revised our medication error remediation process to focus on re-training in various ways, by various trainers without the previously associated disciplinary action. We hope this will decrease fear of making mistakes and increase new ways and methods of learning. We have also included various positive consequences for people who do not make errors for certain timeframes; these include commendations, various gifts, monetary amounts depending on years of no errors, and a congratulatory mention in the CCI employee up-dater for recognition by all. This whole process will be completed by 3/3/2017. 01/27/2017 Implemented
SIN-00105955 Unannounced Monitoring 12/20/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.164(a)Baclofen 10 mg u/f Lioresal, take ½ tablet (5mg) orally 3 times a day at 8:00AM, 4:00PM and 8:00PM prescribed to Individual #1 was initialed by two different staff "AS" and "CR" for the 8:00AM dosage on 12/4/16. 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. CORRECTION PLAN for SIN # 00105955 All staff will continue to receive medication administration and documentation training upon induction and annually thereafter, including the required number of observations. Remediation training will continue if errors are made. Additionally, we will review regulation 164 (a) in detail with direct care professionals, nurses, supervisors, managers and directors. In short, all personnel, who may implement and administer medications. In this particular situation, staff will be retrained that, a medication is only to be administered by one person at a prescribed time. If 2 people document the medication, this is a medication administration error, which must be reported to a medication supervisor immediately. The medication supervisor must file an EIM and contact the pharmacy for further instructions should the medication have been administered twice. It will be my, Petra Mussi¿s, responsibility to review the regulation with nurses, supervisors, managers and directors. It will be the supervisors, medication trainer and observers responsibilities to review the regulation with the direct care professionals assigned to them. Additionally, we will remind the nightshift supervisors to remind and retrain the night shift staff to check all MARs against all blister packs for correctness nightly. When an error is detected, the medication supervisor needs to be consulted immediately for advice as to how to correct the situation. Here an EIM should have been filed, and the pharmacy should have been contacted for further instructions should the medication have been administered twice. Additionally, both staff, should have documented their initials on the back of the MAR. We have also assigned the nursing staff to compare all doctors¿ orders against MARs and blister pack labels within the next few weeks to ensure all medications are implemented correctly. This verification will continue every 6 month. Finally, we have revised our medication error remediation process to focus on re-training in various ways, by various trainers without the previously associated disciplinary action. We hope this will decrease fear of making mistakes and increase new ways and methods of learning. We have also included various positive consequences for people who do not make errors for certain timeframes; these include commendations, various gifts, monetary amounts depending on years of no errors, and a congratulatory mention in the CCI employee up-dater for recognition by all. This whole process will be completed by 3/24/2017. 02/25/2017 Implemented
SIN-00106272 Unannounced Monitoring 01/05/2017 Compliant - Finalized
SIN-00079534 Renewal 05/12/2015 Compliant - Finalized