Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00241458 Renewal 04/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(d)Poisonous materials are not kept separate from food. Four bottles of juice were stored in the closet in the living room on a shelf with cleaning supplies.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.Staff was retrained on 4/5/24 on the utmost importance of storing food items separately from poisons. There will also be ongoing training.to ensure there is not a reoccurrence. 04/05/2024 Implemented
6400.144Health services including pharmaceutical are not provided. Individual #1 is prescribed over the counter, pro nata medications including Tylenol, Robitussin, Alegra, Tums, Colace, Imodium, Preparation H, Hydrocortisone cream, and Neosporin. These medications are not available in the home.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. Updated OTC, pro nata list is with the PCP for reviewing and approval. This will be forwarded to the pharmacy by 4/22/24. The Pharmacy will provide the medications and create a medication record. Medication record will be utilized to record administrations.. 04/18/2024 Implemented
6400.165(c)Prescription medications are not administered as prescribed. Individual #1 is prescribed Melatonin 5mg and Lamictal 25mg at 8PM. Medications packets dated 4/2/24 containing medications for this date were located in Individual #1's medication box. The Medication Administration Record initialed indicating that the medications were administered on 4/2/24. Individual #1 is prescribed Escitalopram 10mg at 8am. A medication packet dated 4/4/24 containing medications for this date were located in Individual #1's medication box. The Medication Administration Record initialed indicating that the medications were administered on 4/4/24. Individual #1 is prescribed Mirtazapine 15mg and Perphenazine 8mg at 8PM. A medication packet dated 3/20/24 containing medications for this date were located in Individual #1's medication box. The Medication Administration Record initialed indicating that the medications were administered on 3/20/24.A prescription medication shall be administered as prescribed.On 4/6/24 staff was retrained on proper medication administration procedures as per DHS guidelines 04/06/2024 Implemented
6400.166(b)Individual #1 is prescribed over the counter, pro nata medications including Tylenol, Robitussin, Alegra, Tums, Colace, Imodium, Preparation H, Hydrocortisone cream, and Neosporin. These medications and dosing instructions are not recorded on the medication administration record.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Updated OTC, pro nata list is with the PCP for reviewing and approval. This will be forwarded to the pharmacy by 4/22/24. The Pharmacy will provide the medications and create a medication record. Medication record will be utilized to record administrations.. 04/18/2024 Implemented
6400.185(1)Individual #1's Individual Service Plan (ISP) does not contain revisions including the Individuals ability to manage money. Individual #1's annual assessment dated 3/8/24 states "Individual #1 recognizes money as a medium exchange and has cash in the individual's possession without losing it." Individual #1's ISP states "Individual #1 is unable to complete transactions without supervision and does not possess any concept of money thus would be easily exploited without someone to assist with money management. Wakefield currently serves as rep payee." Individual #1 is provided between $10-50 in spending money that the individual maintains on their person. The information contained in Individual #1's ISP indicates that Individual #1 is unable to maintain any amount of money.The individual plan, including revisions, must include the following: The individual's strengths, functional abilities and service needs.The ISP has been revised to include the individuals' strengths functional ability and service needs as illustrated below. The Individual understands money as a medium of exchange. She is also able to identify one dollar, five-dollar, ten dollar and twenty-dollar bills. Individual is unable to complete transactions on her own and requires supervision due to limited concept of money. While she is able to identify money , the team believes that individual would be at risk of financial exploitation thus she is always supervised when making purchases up to $50 to eliminate risk. Individual will stand in line with staff and wait for her receipts. Individual is able to carry up to $20 in her possession without losing it. Wakefield Cottage currently serves as her Rep payee. 04/22/2024 Implemented
SIN-00170286 Renewal 02/27/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill record for fire drill that was held on 1/26/20 did not document 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. On 2/27/20, the Program Specialist contacted the House Supervisor who conducted the Fire Drill. House Supervisor, Kavel Thompson reported that the evacuation time should have been recorded as 1 minute and 17 seconds, she failed to carry over that time from the initial documentation. Program Specialist, Patricia Richardson reminded the House Supervisor as to the importance of filling out every piece of information on every document. Moving forward we will review the monthly Fire Drills at the time of our weekly Administrative Review Meetings to prevent recurrence of this incident. 02/27/2020 Implemented
SIN-00130811 Renewal 03/06/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(c)The well water was tested on 10/19/2017. It wasn't tested again until 1/29/2018, which exceeds the 3 month 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.Water tests performed on January 29, 2018 were not conducted in a timely fashion due to winter weather conditions causing numerous power failures in our area. These power failures affected our electronic reminders including water testing. This was noticed when we checked our physical documentation on January 29, 2018 and noted that the electronic reminder was off. The tests were immediately carried out. Going forward in addition to the electronic reminder a hard copy calendar has been implemented. 03/06/2018 Implemented
SIN-00089390 Renewal 03/02/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(c)Water testing was performed on 1/20/2015. Water wasn't tested again until5/7/2015, which supassed the 3 month 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.The manual calendar has been modified. In addition, an electronic calendar has been created and will be maintained to identify tests and provide alerts prior to the test due dates to foster timely completion. The water test wll be completed and recorded by the Program Manager prior to the due date. The Deputy Director of Operations will check for compliance including results and date. 04/13/2016 Implemented
SIN-00071137 Renewal 02/19/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.186(a)Individual #3 did not have a review of her ISP every 3 months. The following reviews occurred for individual #3: annual on 3/4/2014, a Quarterly review on 9/3/2014, and 12/2/2014. 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. Wakefield Cottage's Program Specialist will complete an ISP review of service and the expected outcomes in the ISP for the individual every 3 months. The individual's next 3 month review was conducted on March 4, 2015 03/04/2015 Implemented
SIN-00218655 Renewal 03/28/2023 Compliant - Finalized
SIN-00201450 Renewal 04/14/2022 Compliant - Finalized