Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00236053 Renewal 12/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.211(b)(3)Individual #1's Emergency Information sheet does not identify who can provide Emergency Medical Consent.Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. This regulation is important because it ensures that all parties have access to critical information in the case of an emergency. This violation occurred due to a misperception that "Next of Kin" was synonymous with emergency conesent. The Face sheet for Individual #1 was updated on 12/18/23 to reflect the proper terminology. All facesheets will be evaluated for proper semantics by 12/22/23 and will be updated, if necessary. This process will be monitored by the program specialist coordinator. 12/22/2023 Implemented
SIN-00195595 Unannounced Monitoring 11/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(f)In order to obtain petty cash for individual #1's home account, Staff person #1 reported that staff is writing checks from Individual #1's bank account directly to staff who work in the home to cash and deposit into Petty Cash.There may be no commingling of the individual's personal funds with the home or staff person's funds. Starting immediately, all checks that are issued using individual's funds, will be made out to the individual. The Director of Administration will confirm that no checks are continuing to be made out to staff using individual funds, by 12/2/21. All staff that issue funds from individual's accounts will be retrained on this regulation by 12/15/21 and record pf this training will be kept by the Director of Administration. 12/15/2021 Implemented
6400.141(c)(8)Individual #1 receives breast ultrasounds in lieu of mammograms. Individual #1 had an ultrasound completed on 7/31/20 and not again until 8/25/21; outside of the annual timeframe.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. At the date of the inspection the breast ultrasound for Individual #1 had been completed. All individual files will be evaluated for compliance with the guidelines for breast ultrasounds/mammograms for all applicable individuals 12/31/21. All staff working in this home will be re-trained in this regulation by the Associate Director before 12/31/21. Documentation of this training will be kept. 01/01/2022 Implemented
6400.144(Repeat from Inspections dated 7/27/20 & 8/4/20) On Individual #1's appointment summary forms from the physician, it is indicated that Individual #1 was due for a colonscopy on 8/15/21. As of the 11/3/21 inspection, this procedure has not been completed or scheduled.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 colonoscopy for Individual #1 is scheduled for 12/29/21. All staff working in this home will be re-trained in this regulation, the importance of following doctor recommendations, and resources that can be accessed when a change in physical presentation is identified, by the Associate Director before 12/31/21. Documentation of this training will be kept. 02/01/2022 Implemented
6400.212(a)At the time of the 11/1/21 inspection, there was a medication review form for Individual #2 in Individual #1's record. A separate record shall be kept for each individual. At the date of the inspection, the document that contained another persons information was removed. All program specialists will be retrained on this regulation by the program specialist coordinator by 12/31/21. Documentation of this training will be kept. 01/01/2022 Implemented
6400.34(a)The Department issued updated rights, effective 2/3/2020, stating that individuals have additional rights they need to be informed of. At the time of the 11/1/21 inspection, individual #1 was never informed of the individual rights as described in 6400.32.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.The current Individual Rights have been acquired and every individual receiving residential services from Shadowfax are being informed of the individual rights as described in 6400.32. The Program Specialists will confirm that these have been reviewed and signed by the individuals by 12/31/21. 01/01/2022 Implemented
6400.163(h)At the time of the 11/3/21 inspection, Individual #1's prescription medication, albuterol sulfate, was in the home. This prescription was discontinued by Individual #1's physician on 7/14/21.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.As of 11/18/21, all programs have been evaluated for the presence of discontinued or expired medications. Any medications identified have been disposed of. All staff working at this home will be re-trained in the process of handling discontinued medications by 12/31/21. Documentation of this training will be kept. 02/01/2022 Implemented
6400.166(a)(11)There is no diagnosis or purpose listed on Individual #1's Medication Administration Records for Gabapentin and Poly Glycol.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.Clarification on the diagnosis is being sought from the prescribing physician. All MARs will be assessed for the presence of correlating diagnosis by 12/31/21 for existing medications. 01/01/2022 Implemented
6400.166(b)The following doses of Individual #1's medications were administered as prescribed but were not initialed at the time of administration: 6/22/21 8pm dose of Levothyroxin, 5/25/21 8pm dose of Montelukast, 1/28/21 8pm dose of Ziprasidone, 11/8/20 8pm dose of Ziprasidone, 11/11/20 8pm dose of Divalproex, 10/11/20 9pm dose of Ziprasidone, 10/17/21 8pm dose of Levothyroxin, 8/8/20 8am dose of Miralax, 10/17/21 8am dose of Fluticasone, 10/17/21 8am dose of Gabapentin, 10/1/21 8pm dose of Oxcarbazepin, 10/2/21 8pm dose of Oxcarbazepin, and 10/3/21 8pm dose of Ziprasidone.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.All staff working in this home will be re-trained on the 15 steps of medication administration, by the Associate Director before 12/31/21. Documentation of this training will be kept. 01/01/2022 Implemented
SIN-00179682 Unannounced Monitoring 11/09/2020 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.162(b)(1)Staff person #1's Medication Administration Training expired on 1/18/20, and she administered medications 63 times after this date. Staff person #2's Medication Administration Training expired on 6/25/20, and she has administered medications 401 times after this date. Staff person #3's Medication Administration Training expired on 9/14/20, and they have administered medication 68 times after this date. Staff person #4's Medication Administration Training expired on 10/11/20, and she has administered medication 16 times after this date. Staff person #5's Medication Administration Training expired on 7/24/20, and they have administered medication 184 times after this date. Staff person #6's Medication Administration Training expired on 7/3/20, and she has administered medication 32 times after that date. Staff person #7's Medication Administration Training expired on 7/28/20, and she has administered medication 172 times after that date. Staff person #8's Medication Administration Training expired on 4/4/20, and she has administered medications 169 times after that date. Staff person #9's Medication Administration Training expired on 2/8/20, and they have administered medications 917 times after that date. Staff person #10's Medication Administration Training expired on 10/22/20, and she administered medication 10 times after this date. Staff person #11's Medication Administration Training expired on 4/4/20, and she administered medication 16 times after this date. Staff person #12's Medication Administration Training expired on 8/11/20, and he administered medication 97 times after this date. Staff person #13's Medication Administration Training expired on 7/14/20, and he administered medication 75 times after this date. Staff person #14's Medication Administration Training expired on 3/28/20, and he administered medication 131 times after this date. Staff person #15's Medication Administration Training expired on 12/1/19, and she administered medication 15 times after this date. Staff person #16's Medication Administration Training expired on 7/11/20, and she administered medication 74 times after this date. Staff person #17's Medication Administration Training expired on 7/22/20, and she administered medication 210 times after this date. Staff person #18's Medication Administration Training expired on 4/17/20, and she administered medication 125 times after this date. Staff person #19's Medication Administration Training expired on 5/2/20, and she administered medication 774 times after this date.A prescription medication that is not self-administered shall be administered by one of the following: A licensed physician, licensed dentist, licensed physician's assistant, registered nurse, certified registered nurse practitioner, licensed practical nurse, licensed paramedic or other health care professional who is licensed, certified or registered by the Department of State to administer medications.1. The 2 nurses that were not completing the observations accurately, will repeat the Medication Administration Trainers training. 2. The Medication Training process was updated by nurses and the process will be reviewed with the HR department, Nurses and Residential Management. 3. There will be an audit of all medication administration training records for all staff, to ensure that everyone is in current. At any time if a staff is not current, they will not be able to administer medications until training is current. 4. The nurses will be instructors for medication training and hand over all documentation to the HR Department. The HR Department will be responsible for tracking all medication training & observation dates. These dates will be put into the staff training portal, that all staff has access to and can monitor when they are due. 5. All staff that are not current have either completed the training and are current or they are not able to administer medication until the training is current. 12/11/2020 Not Accepted
6400.169(a)Staff person #1's Medication Administration Training expired on 1/18/20, and she administered medications 63 times after this date. Staff person #2's Medication Administration Training expired on 6/25/20, and she has administered medications 401 times after this date. Staff person #3's Medication Administration Training expired on 9/14/20, and they have administered medication 68 times after this date. Staff person #4's Medication Administration Training expired on 10/11/20, and she has administered medication 16 times after this date. Staff person #5's Medication Administration Training expired on 7/24/20, and they have administered medication 184 times after this date. Staff person #6's Medication Administration Training expired on 7/3/20, and she has administered medication 32 times after that date. Staff person #7's Medication Administration Training expired on 7/28/20, and she has administered medication 172 times after that date. Staff person #8's Medication Administration Training expired on 4/4/20, and she has administered medications 169 times after that date. Staff person #9's Medication Administration Training expired on 2/8/20, and they have administered medications 917 times after that date. Staff person #10's Medication Administration Training expired on 10/22/20, and she administered medication 10 times after this date. Staff person #11's Medication Administration Training expired on 4/4/20, and she administered medication 16 times after this date. Staff person #12's Medication Administration Training expired on 8/11/20, and he administered medication 97 times after this date. Staff person #13's Medication Administration Training expired on 7/14/20, and he administered medication 75 times after this date. Staff person #14's Medication Administration Training expired on 3/28/20, and he administered medication 131 times after this date. Staff person #15's Medication Administration Training expired on 12/1/19, and she administered medication 15 times after this date. Staff person #16's Medication Administration Training expired on 7/11/20, and she administered medication 74 times after this date. Staff person #17's Medication Administration Training expired on 7/22/20, and she administered medication 210 times after this date. Staff person #18's Medication Administration Training expired on 4/17/20, and she administered medication 125 times after this date. Staff person #19's Medication Administration Training expired on 5/2/20, and she administered medication 774 times after this date.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).1. The 2 nurses that were not completing the observations accurately, will repeat the Medication Administration Trainers training. 2. The Medication Training process was updated by nurses and the process will be reviewed with the HR department, Nurses and Residential Management. 3. There will be an audit of all medication administration training records for all staff, to ensure that everyone is in current. At any time if a staff is not current, they will not be able to administer medications until training is current. 4. The nurses will be instructors for medication training and hand over all documentation to the HR Department. The HR Department will be responsible for tracking all medication training & observation dates. These dates will be put into the staff training portal, that all staff has access to and can monitor when they are due. 5. All staff that are not current have either completed the training and are current or they are not able to administer medication until the training is current. 12/11/2020 Not Accepted
SIN-00149286 Unannounced Monitoring 01/14/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(15)Individual #1's physical examination form indicated a "regular diet" and refer to choking prevention plan. According to the choking prevention plan, he required specific food to be cut up or removed from his diet when he was "cycling" with behaviors. The plan did not include a definition for cycling to determine when the dietary information needed to change.The physical examination shall include:Special instructions for the individual's diet. Shadowfax will correct the immediate issue. They will verify that the physical is completed and at the home in the record. They will complete a survey of each home to make sure they are in compliance with this regulation. They will provide training to all staff on the importance of the physical in providing care to the individuals. Shadowfax will out in place a management oversight to make sure this is checked on at least a quarterly basis. 02/28/2019 Implemented
6400.213(11)Individual #2's 5/3/18 physical examination indicated regular diet and refer to choking plan. Choking plan indicated to cut food into nickle-sized pieces. The ISP indicated to cut food into nickle-sized pieces. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. Shadowfax will correct the immediate issue. They will verify that the physical is completed and at the home in the record. They will complete a survey of each home to make sure they are in compliance with this regulation. They will provide training to all staff on the importance of the physical in providing care to the individuals. Shadowfax will out in place a management oversight to make sure this is checked on at least a quarterly basis. 02/28/2019 Implemented
SIN-00146273 Unannounced Monitoring 12/04/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The ceiling tile with the smoke detector attached, in basement hallway leading to bedroom, was loose and beginning to fall.Floors, walls, ceilings and other surfaces shall be in good repair. Agency will correct the immediate issue. Agency will review the issue for violation and correct. Then agency will train all staff on the violation. Program specialist will review monthly and supervisor will review quarterly and complete tracking form. 12/31/2018 Implemented
SIN-00082828 Renewal 07/07/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The sliding door downstairs would not open unless pulled with both hands and by using all your body weight to assist with opening. Floors, walls, ceilings and other surfaces shall be in good repair. The sliding glass door was replaced with a new door on 7-21-15 (see attached invoice - attachment # 11). To prevent future occurrences, Shadowfax's maintenance man will inspect all doors on at least a quarterly basis on his home visits. Furthermore, Associate Directors will check on regular house visits and report any issues to the maintenance man for prompt attention.. 07/21/2015 Implemented
6400.103The written emergency evacuation procedure for all the individuals that live at the home did not contain their individual responsibilities. There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. There are written emergency evacuation procedures that include staff responsibilities, means of transportation and an emergency shelter location. Our procedures did not include specific emergency procedures for each person. An emergency plan was developed for each home listing the individual responsibilities during an emergency. See attachment 10. This plan of individual responsibilities is now filed in the fire log and the Associate Director is responsible for ongoing monitoring of the responsibilities to ensure they are current and updated. 07/21/2015 Implemented
6400.216(a)A kitchen cabinet that was unlocked contained the names of all the individual's that lived in the home and a list of all the medications they were on. There was also a staff cabinet in the living room that wasn't locked and contained individual's Individual Support Plan (ISP) reviews, medical appointment papers with medical information on, etc. An individual's records shall be kept locked when unattended. All of the papers were removed on the day of licensing and put in the locked hallway closet. As this home is limited on space, a new cabinet was purchased on 9-4-15 (Attachment 9) to file all the miscellaneous papers and other pertinent information to ensure the information is appropriately locked at all times. The Associate Director of the home is responsible for the ongoing monitoring of this to ensure all information is appropriately locked. 07/10/2015 Implemented
SIN-00224669 Unannounced Monitoring 04/25/2023 Compliant - Finalized
SIN-00219404 Unannounced Monitoring 02/08/2023 Compliant - Finalized
SIN-00211284 Unannounced Monitoring 09/12/2022 Compliant - Finalized
SIN-00190740 Unannounced Monitoring 07/29/2021 Compliant - Finalized
SIN-00185542 Unannounced Monitoring 03/29/2021 Compliant - Finalized
SIN-00173219 Unannounced Monitoring 05/26/2020 Compliant - Finalized
SIN-00167174 Unannounced Monitoring 12/03/2019 Compliant - Finalized
SIN-00151256 Unannounced Monitoring 03/06/2019 Compliant - Finalized
SIN-00106575 Renewal 11/30/2016 Compliant - Finalized
SIN-00070184 Renewal 06/30/2014 Compliant - Finalized