Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00233472 Renewal 09/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.135(g)Individual #1 is prescribed psychotropic medication. Individual #1 has 3-month medication reviews on 04/04/23, and then again on 07/25/23.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review by a licensed physician at least every 3 months to document the r reason for prescribing the medication, the need to continue the medication and the necessary dosage.Psychotropic med reviews will be completed every 3 months. FLP and individual will be encouraged to schedule at time of current appointments to ensure they are within the required timeline. Families and individual will be reminded that if they need to change or reschedule due to illness that they should get documentation for this. 11/02/2023 Implemented
SIN-00211824 Renewal 09/14/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.136(a)(7)Individual #1 is prescribed Fluticasone Spray. The medication label states, "use two sprays in each nostril daily." Individual #1's September 2022 Medication Administration Record for the Fluticasone Spray reads, "Instill one spray in each nostril once daily for Asthma." Individual #1 is prescribed Azelastine 0.1%. The medication label states, "Instill two sprays in each nostril two times a day." Individual #1's September 2022 Medication Administration Record for the Azelastine 0.1% reads, "use one to two puffs in each nostril twice daily for Asthma."A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.All med logs and medication labels were reviewed and changed so that they match. FLP called PCP and pharmacy to ensure correct dosage was documented on both MAR and medication label 10/05/2022 Implemented
SIN-00195481 Renewal 10/21/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.24(e)(1)Individual #1's October 2021 financial record did not include dates of purchases and the ledger did not match the receipts provided.If the agency or family assumes the responsibility for an individual's financial resources, the following shall be maintained: a separate record of financial resources including the dates and amounts of deposits and withdrawals.Financial log was corrected to show dates of transactions. Financial ledger and amount of cash on hand was adjusted to show receipts that were purchased, and any wrong documentation was corrected. ( See doc of log and cash on hand.) Family was trained to have separate receipts for individual on all transactions, and to record all transactions by including dates and amount withdrawn.(see training doc) FLS will monitor financial logs monthly and ensure that all receipts are separate and entered accurately with dates and correct amounts to reflect what was spent by the individual. 10/29/2021 Implemented
6500.24(f)Individual #1's October 2021 financial record included a Dollar General receipt from 10/12/21 in the amount of $41.14 and an Apple Bees receipt from 10/17/21 in the amount of $26.31. Items on the receipt were crossed out and the amounts on the receipts were changed. Life Sharing Provider #1 stated she pays for the entire purchase, and the individual pays her back their share of the expenses.There may not be commingling of the individual's personal funds with agency or household funds.Cash on hand was adjusted and log was corrected. Family was trained to have separate receipts and to not share transaction with individual. See attached documentation. FLS will monitor financial log at end of every month to ensure receipts are separate and that transactions are entered correctly on the ledger. 11/08/2021 Implemented
6500.136(a)(5)Individual #1 is prescribed Potassium Citrate 10 MEQ, with instructions to take 3 tablets by mouth three times a day at 9a, 5pm, and 9pm. The October 2021 medication administration record documents the strength as 1080mgs. Individual #1 is prescribed Robitussin, 1 ½ teaspoons by mouth as needed. The October 2021 medication administration record did not include the strength of medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.All medication logs were adjusted and edited to reflect exactly what the medication label states. Strength of medication was edited on all med logs. See doc. Family and FLS were trained in having med logs and medication labels match exactly as written and prescribed. See doc. FLS will review med logs and labels at the beginning and end of the month to ensure the logs match labels. If any changes are made during the month family will notify FLS of changes and revisions will be made accordingly. Blank logs will be left in home for when changes occur. 11/01/2021 Implemented
6500.136(a)(7)Individual #1 is prescribed Sodium Bicarbonate 650 mg, with instructions to take 2 tablets by mouth every morning, 3 tablets every evening, and 3 tablets at bedtime. The October 2021 medication administration record states Sodium Bicar-650mgs, with instructions to take 3 tablets in the morning, 3 tabs in the evening, and 3 tabs at bedtime. Individual #1 is prescribed Ravicti Oral Liquid 1.1 Grams/MI, with instructions to take 5ml three times daily for a total daily dose of 15ml. The October 2021 medication administration record states Ravicti oral Liquid 25MI-1.1G/ML, with instructions to take 4.5ml, three times daily. Individual #1 is prescribed Albuterol Sulfate Inhalation Solution 0.083% 2.5mg/3ml, with instructions to use 3ml via nebulizer every 4 hours as needed for trouble breathing. The October 2021 medication administration record states Albuterol 0.083%, with instructions to use 1 neble via nebulizer every 4 hours as needed for trouble breathing.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.All medication logs were updated to reflect the accurate dosage of medication to be the same as the label on the medication. Family retrained in medication documentation . 11/01/2021 Implemented
6500.136(a)(8)Individual #1 is prescribed the following medications: Sodium Bicarbonate 650 mg , Potassium Citrate 10 MEQ, Cyclinex 2, Clonozapam 0.5mgs, Risperidone 1 mg, Topiramate 50mgs, Methlphenid 5mg , and Robitussin. The October 2021 medication administration record did not include route of administration for the medications.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.All med logs were updated to include route of administration. See attached med log. FLS will review med log and medication labels at the beginning and end of month to ensure that labels and logs match and include the route of administration. FLS and family trained in accurate med documentation including the right route on log. 11/01/2021 Implemented
6500.136(a)(9)Individual #1 is prescribed prescribed L-Arginine Base Powder, with instructions to give 14 grams by mouth every day.. The October 2021 medication administration record states Argenine Base Powder 2000gms Take 14 grams by mouth as directed divided into 3 doses: 7.3 grams at 9am, 12:30pm, & 5pm. Individual #1 is prescribed Albuterol Sulfate HFA 108, with instructions to inhale 2 puffs by mouth every 4 hours as needed. The October 2021 medication administration record states Ventolin HFA, with instructions to inhale 2 puffs 4 times a day, as needed.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.All medication logs were updated to reflect the accurate frequency of the medication to be the same as the label on the medication. Family retrained in medication documentation. 11/01/2021 Implemented
6500.136(a)(11)Individual #1 is prescribed the following medications: L-Arginine Base Powder, Albuterol Sulfate HFA 108 , Sodium Bicarbonate 650 mg, Ravicti Oral Liquid 1.1 Grams/MI, Potassium Citrate 10 MEQ, Montelukast 10mg, Cyclinex 2, Calcium D- 600mg, Lamotrigine 100mg, Lamotrigine 25mg, Clonazepam 0.5mgs, Risperidone 1 mg, Topiramate 200mgs, Topiramate 50mgs, Methlphenid E-54mg, Methlphenid 5mg, Azelastine 0.1%, Robitussin, and Fluticasone 50mcg. The October 2021 medication administration record did not include diagnosis or purpose for any of the medications.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.All med logs were updated to include diagnosis. See attached med log. FLS will review med log and medication labels monthly to ensure that labels and logs match and include the diagnosis. FLS and family trained in accurate med documentation including the diagnosis for each medication. 11/01/2021 Implemented
6500.136(b)Individual #1 is prescribed Sodium Bicarbonate 650 mg, with instructions to take 2 tablets by mouth every morning, 3 tablets every evening, and 3 tablets at bedtime. The 10/20/21 9am dose was not initialed at the time of the medication being administered. Individual #1 is prescribed Ravicti Oral Liquid 1.1 Grams/MI, with instructions to take 5ml three times daily for a total daily dose of 15ml. The 10/20/21 9pm dose was not initialed at the time of the medication being administered.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Family inadvertently signed off in between the block for 21st and 22nd block. Error was corrected during licensing review. Family retrained in medication administration and documentation. 11/01/2021 Implemented
SIN-00137351 Renewal 06/20/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.17(a)The self assessment completed on 12/16/17 did not measure compliance with regulations 6500.162 through 6500.176.If an agency is the legal entity for the family living home, the agency shall complete a self-assessment of each home the agency is licensed to operate 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.the self assessment will be completed 3-6 months prior to expiration of certificate of compliance. director and coordinator will review each assessment once completed by the FLS to ensure each assessment is accurately completed in its entirety. training docs for all staff included for reg 6500.17 [Documentation of aforementioned audits of each assessment by the Director and the Coordinator shall be kept. (DPOC by AES,HSLS on 8/14/18)] 07/27/2018 Implemented
6500.24(f)A receipt dated 5/9/18 included purchases for Individual #1 and Family Living Provider #1 totaling $271.64. Individual #1 paid Family Living Provider #1 $130.00 of the 271.64. A receipt dated 5/15/18 included purchases for Individual #1 and Family Living Provider #1 totaling $111.49. Individual #1 paid Family Living Provider #1 $62.19 of the $111.49.There may not be commingling of the individual's personal funds with agency or household funds.individuals funds will not be comingled with flp funds. flp and fls were trained on regulation 6500.24f. accounts are reviewed and balanced monthly. [Immediately, the CEO shall review and revise and train all staff persons and family living providers on the written policy that establishes procedures for the protection and adequate accounting of individuals' funds and property and for advising the individual concerning the use of funds and property as per 6500.24(a)-(d). Documentation of trainings shall be kept. At least monthly for 1 year, the CEO or designee and a designated management staff person shall review all individuals financial and property record to ensure policies are followed as per 6500.24(d)-(g) are implemented. Documentation of audits shall be kept. (DPOC by AES,HSLS on 8/14/18)] 07/12/2018 Implemented
6500.43(d)(6)The following discrepancies were noted in Individual #1's ISP, updated 6/1/18, and Individual #1's assessment, completed 10/27/17. In the ISP, the Psychosocial and General Health and Safety Risks sections indicate that Individual #1 requires assistance to ambulate steps safely due to an unsteady gait and assistance to transfer into a chair lift and that s/he requires continuous care as his/her medical needs have increased. Per the assessment, Individual #1 is independent in the areas of self-mobility and motor skills. In the Water Safety section of the ISP, it is indicated that Individual #1 requires supervision to regulate water temperature as well as safety due to seizure activity and can never be left unsupervised around water. Per the assessment, Individual #1 is independent in the area of showering/bathing including regulating water temperature. This section of the ISP also indicates that Individual #1 uses grab bars, a chair lift, rails in the bathtub, a shower bench and bars by the toilet as well as having a toilet seat by her bed side. It is also indicated that Individual #1 requires support, supervision and physical support, every time s/he transfers. Per the assessment, Individual #1 does not use any adaptive equipment nor does Individual #1 require support to transfer. Per the Know and Do section of the ISP, Individual #1 "has a protein deficiency disorder that requires a very strict and carefully regulated diet" which "involves monitoring ammonia levels. [Individual #1] also has frequent seizures." Per the assessment, Individual #1 "does not [have] medical needs that require special care. [Individual #1] does not have functional disabilities."The family living specialist shall be responsible for the following: Reviewing the ISP, annual updates and revisions for content accuracy.the assessment will be completed accurately to reflect current functioning and capabilities of individual annually by fls and revised as needed. coordinator will review accuracy prior to mailing out assessment. coordinator and director will ensure that assessment and ISP are congruent with assessment. if discrepancies are found, written communication will be sent to SC for revisions. individual one uses chairlift only when extremely ill which is noted in ISP. documentation is included notifying sc of revisions needing made. training for FLS is included. revised assessment is included.[Discrepancies in the ISP were sent on 7/23/18. At least quarterly, the family living program specialist shall review all individuals' assessments and current ISPs to ensure individuals are accurately assessed.(DPOC by AES,HSLS on 8/23/18)] 07/27/2018 Implemented
6500.121(c)(7)Individual #1's most recent gynecological examination was 5/11/17. The physical examination shall include: A gynecological examination, including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations.gynecological exam will completed annually for all female over 18. doctors office did not schedule enough time at the appointment as they assumed it was a routine depo provera shot appointment. Family living provider and FLS were trained on ensuring that gynecological exam is done annually. FLS will develop calendar so all medical appointments are visual to assist with all required medical appointments. gynecological exam is scheduled for next depo-provera injection which is 9/12/18. training doc included. [Immediately, a designate management staff person shall develop and implement a tracking system to ensure timely completion of gynecological examinations and train all responsible persons on the tracking system. Documentation of the training shall be kept. Immediately and upon completion, a designated management staff person shall audit all individuals' current physical examinations to ensure all required information is included as per 6500.121(c)(1)-(15) and health services are provided. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 8/23/18)] 09/12/2018 Implemented
SIN-00096238 Renewal 06/08/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.133(c)Individual #1's medication review documentation completed on 6/12/15, 9/4/15, 11/20/15, 2/10/16, and 5/3/16, did not include the reason for prescribing the medication and the necessary dosage.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.form was revised to include the reason for prescribing, need to continue, and doseage of medication. Flp and clinical coordinator were trained on regulation requirement and on procedure to check files and review forms quarterly, to ensure it is completed. training was 6/29/16. all other clients have used new form already. family and aide will be responsible to take new form to psychiatrist at next appointment [Within 1 week of the appointment and completion of documentation by the physician from the 3 month medication reviews for all individuals residing in family living homes, the family living specialist will review to ensure all required information is present and will obtain missing information if needed. Documentation of reviews shall be kept. (AS 8/9/16)] 07/28/2016 Implemented
SIN-00065817 Renewal 06/24/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.68(b)The hot water temperature at the bathtub was 137.6 degrees Fahrenheit. Individual #1 needs assistance to regulate water temperature. Hot water temperatures in bathtubs and showers that are accessible to individuals may not exceed 120°F.FLP was trained in procedure of checking H2O temp. She will check bi monthly for the next 3 months. FLPsecialist will oversee that this completed.documentaion will be added to the safetu checklist that is already completed monthly. If water is ever found to be over 120 degrees the heater will be adjusted and individual will be monitored to ensure safety until water is at appropriate degrreees [The hot water temperature was turned down in this house. (CHG 8/11/14)] 08/02/2014 Implemented
6500.108(a)The fire extinguisher in the kitchen is not fully charged. There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic.Home had back up extinguisher that was replaced that day. FLP will ensure that fire extiunguisher is fully charged. This will be checked bi monthly and is on the fire safety checklist. FLP specialist will oversee that process is completed. If extinguisher is not fully charged it will be replaces immediately. 08/02/2014 Implemented
6500.151(a)The most recent assessement for Individual #1 were 10/1/12 and 11/1/13.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the family living home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the family living home.FLP specialist was trained in completing assessments annually. All assessment will be done on annual basis. Program director will monitor that assessment are not over 365 days. 08/02/2014 Implemented
6500.151(e)(12)The assessment, dated 11/1/13, for Individual #1 does not include recommendations for areas of training, programming and services. The assessment must include the following information: Recommendations for specific areas of training, programming and services.FLP specialist was trained in regulation 6500.151e12. Clinical coordinator is reviewing current assessments and assessing what new one will encompass what is required in the regulation. FLPspecialist will add a line to his current assessment sumary that will add Recommendations for specific areas of training, programming and services. 08/02/2014 Implemented
6500.151(e)(13)(i)The assessment, dated 11/1/13, for Individual #1 does not include the individual's progress over the last 365 calendar days and current level in the area of health. The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: Health.FLP specialist was trained in regulation 6500.151e13(i). Health intake form was revised and has addition of individual's progress over the last 365 calendar days and current level in the following areas: Health. Agency is moving to electronic health system that will have this added to it as well. 08/02/2014 Implemented
SIN-00047636 Renewal 02/28/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.47Record of preservice training and annual training for the family living provider (Staff #1) does not include the exact dates of training. All training for the calendar year was documented with month and year only. (Partially Implemented-Adequate Progress; 5/21/13; CEM)Records of preservice and annual training, including the training source, content, dates, length of training, copies of certificates received and persons attending shall be kept.As of 4/1/13, month, day, and year has been added to all FLP training documentation records. Family Living Specialist was trained on 6500.47. (doc to be sent) FLS will be responsible to ensure that this is on all training documentation records for Family Living providers. 04/15/2013 Implemented
6500.109(d)The fire drill record, dated 10/16/12, does not include the time the drill was conducted. (Partially Implemented-Adequate Progress; 5/21/13; CEM)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 smoke detector was operative.Fire drills will be filled out in their entirety, including time. FLS reviewed fire drill logs documentation and regulation 6500.109(d)(doc sent) with family living provider. FLS will review fire drills as they are submitted by family living providers and ensure that they are filled out. 04/15/2013 Implemented
6500.133(c)1. Psychiatric medication reviews for Individual #1 were not completed every 3 months. A review occurred on 5/10/12 and not again until 9/24/12. 2. The psychiatric medication reviews for Individual #1, dated 5/10/12, 9/24/12, and 12/14/12, did not address the need to continue medications. (Partially Implemented-Adequate Progress; 5/21/13; CEM)If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Psychiatric medication reviews will occur every three months and address that there is a need to continue with medication. FLS has been trained on regulation 6500.133(c)(send doc)FLS is also tracking these appointments on a designated calendar to remind him when medication reviews are scheduled with attending physician. FLS will be responsible to ensure that this occurs. 04/15/2013 Implemented
6500.151(f)The annual assessment for Individual #1, dated 10/1/12, was not sent to the supports coordiantor and plan team members. The meeting was held on 11/16/12. There is no documentation to indicate when the assessment was sent. (Partially Implemented-Adequate Progress; 5/21/13; CEM)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 of the ISP, the 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).A line has been added to the bottom of the assessment that will be signed off by the FLS to show that the assessment was sent and dated when it was sent. FLS was trained on regulation 6500.151(f(send doc) FLs will ensure that the assessment is sent and that documentation of it is in the individual file. Clinical coordinator has this added to her monthly supervision note with FLS to review that he has completed this. 04/15/2013 Implemented
6500.156(c)(2)Individual Support Plan reviews for Individual #1, dated 3/2/12, 6/2/12, 9/2/12, 11/16/12, and 1/16/13, do not include a review of each section of the Individual Support Plan specific to the family living home. Only the signature pages were in the record. The content of the review was not available. (Partially Implemented-Adequate Progress; 5/21/13; CEM)(c) The ISP review must include the following: (2) A review of each section of the ISP specific to the family living home licensed under this chapter.All sections within the ISP will be added to quarterly progress reviews. FLS was trained on regulation 6500.156 (c)(2)(sent doc)FLS is responsible for ensuring this is completed quarterly. 04/15/2013 Implemented
6500.156(d)Individual Support Plan documentation for Individual #1 was not sent to the supports coordinator and plan team members. Meetings were conducted on 3/2/12, 6/2/12, 9/2/12, 11/16/12, and 1/16/13. (Partially Implemented-Adequate Progress; 5/21/13; CEM)The family living specialist shall provide the ISP review documentation, including recommendations if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting.A line was added to ISP to indicate that the ISP was sent to supports coordinator and all team members and when it was sent. FLS was trained on 6500.156(d)(send doc) FLS is responsible to ensure all team members and SC receive ISP plans for all meetings. 04/15/2013 Implemented
6500.156(e)The family living specialist did not notify the plan team members of the option to decline the Individual Support Plan review documentation for Individual #1. (Partially Implemented-Adequate Progress; 5/21/13; CEM)The family living specialist shall notify the plan team members of the option to decline the ISP review documentation.Declination form was created. (send doc) FLS was trained on regulation 6500.156(e)FLS has sent Declination option to all team members. FLS will be responsible for sending out option for team members to decline receiving ISP review documentation. 04/15/2013 Implemented
6500.182(c)(8)The most recent Individual Support Plan was not in Individual #1's record. (Partially Implemented-Adequate Progress; 5/21/13; CEM)( c) Each individual's record must include the following information: A copy of the current ISP.ISP was printed and put in book during license review. ISP will be put in book as it is approved in HCSIS. It had not been available to print prior audit therefore it was not placed in file. If unavailable to print in the future FLS will print a screen shot of HCSIS showing that is awaiting approval and place in file. FLS will check weekly to see when it is approved and then file in individuals record. FLS was trained on regulation 6500.182(c) (8) and will be responsible that all current ISPs are in file. 04/15/2013 Implemented
SIN-00178422 Renewal 10/27/2020 Compliant - Finalized
SIN-00157706 Renewal 06/20/2019 Compliant - Finalized
SIN-00117829 Renewal 07/05/2017 Compliant - Finalized
SIN-00077790 Renewal 06/11/2015 Compliant - Finalized