Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00198572 Unannounced Monitoring 12/14/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(7)Individual #1's current physical dated 7/12/21 states that they are unable to tolerate pelvic exams due to the exam being stressful. There were no attempts made to discuss alternative procedures or educate Individual #1 of the importance of completing this screening.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. On 1/11/22, the PCP was contacted to request alternatives for mammograms and PAP smears, as Individual #1 does not tolerate them. All individual files will be evaluated to determine if there are other individuals in need of alternative methods to access the preventative care associated with mammograms and PAP smears. This will be completed by 2/15/22. All staff working in this home will be re-trained in this regulation by the Associate Director before 2/15/22. Documentation of this training will be kept. The wellspan attachment shows the physicians response to our clarification regarding the exams and the exercise. However, Individual #1, on 2/3/22, completed a transabdominal pelvic ultrasound. Due to the results being limited because of "patient cooperation," we will continue to follow up with the PCP at Individual #1, next appointment. (see Wellspan test details attachment) 03/01/2022 Implemented
6400.141(c)(8)Individual #1's current physical dated 7/12/21 states that they are unable to tolerate mammograms due to the exam being stressful. There were no attempts made to discuss alternative procedures or to educate Individual #1 in the importance of completing this screening.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. On 1/11/22, the PCP was contacted to request alternatives for mammograms and PAP smears, as Individual #1 does not tolerate them. All individual files will be evaluated to determine if there are other individuals in need of alternative methods to access the preventative care associated with mammograms and PAP smears. This will be completed by 2/15/22. All staff working in this home will be re-trained in this regulation by the Associate Director before 2/15/22. Documentation of this training will be kept. 03/01/2022 Implemented
6400.144Individual #1's current physical dated 7/12/21 states to continue daily exercise. The Shadowfax Corporation was not able to provide verification of this recommendation being followed.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. On 1/11/22, the PCP was contacted to receive clarification for quantified expectations of exercise for Individual #1. All individual physicals will be evaluated for nonspecific exercise recommendations. This will be completed by 2/15/22. All staff working in this home will be re-trained in this regulation by the Associate Director before 2/15/22. Documentation of this training will be kept. As per the Wellspan attachment, we have not been able to acquire any quantifiable expectations regarding the exercise recommendation. We are continuing our discussion with the PCP at the next appointment. Due to Individual #1 having Covid on 1/19/22, there has been limited ability to attend appointments until recently. 03/01/2022 Implemented
6400.32(c)Individual #1 resides in a community home and attends a day program operated by The Shadowfax Corporation. Individual #1 has an unsteady gait and utilizes a gait belt (device used for lifting, transferring, and walking patients who have limited mobility issues) at the day program and while in the community. Individual #1 does not communicate with words, but uses gestures, facial expressions, and vocalizations. On 12/2/21, Staff #1 picked up Individual #1 from the day program and was told by Staff #4 (day program staff) that Individual #1 was walking weird. On 12/3/2021, Staff #5 told Staff #1 that day program staff said Individual #1 was having trouble walking. Staff #1 relayed the day program staff members' concerns to Staff #2 and was instructed to watch Individual #1 over the weekend. Staff #1 documented the concerns of the day program staff and Staff #2's instructions on Individual #1's 12/3/2021 transfer of care document. On Monday, 12/6/2021, Individual #1 required a wheelchair to get to the restroom at the day program. Using a wheelchair to navigate to the restroom is atypical for Individual #1. Staff #3 sent an email to Staff #1 with concerns of Individual #1's ambulation struggles and discomfort while enroute to the restroom. Individual #1's scream chart, used to document Individual #1's screaming episodes, showed Individual #1 screamed for 45 minutes while sitting and walking around the home on 12/6/2021. On 12/7/2021, Staff #1 took Individual #1 to an urgent care center to have Individual #1 assessed before returning to the day program. The urgent care center referred individual #1 to Orthopedics. X-rays from the Orthopedics showed a left fibular fracture. The Shadowfax Corporation was informed on three occasions that Individual #1 was having trouble walking at the day program and at times, appeared to be in discomfort. Failure to timely seek medical care such that an individual is ambulating with discomfort on a fractured bone for 5 days constitutes mistreatment.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.On 12/7/21 an incident was reported (EIM8945186) for a serious injury/injury unexplained. On 12/9/21, an additional incident was filed (EIM8946040) to reflect alleged neglect, abuse, or mistreatment. An internal investigation took place regarding this event. Individual #1 had a follow up appointment/x-ray on 12/21/21 that showed healing of the fracture. Individual #1 is scheduled for a further follow-up on 1/18/22. Due to a previous plan of correction, all staff, working directly with individuals, were retrained on the Health Alert issued by Dr. Cherpes on 1/4/2015, regarding calling 911 in a medical emergency. By 3/15/22, all individuals will be assessed as to their ability to competently communicate physical discomfort. If the individual is deemed unable to competently communicate this information, it will be reflected in their assessment and alternative means of relaying this information will be explored. The excel spreadsheet shows all the staff and their completion dates for the Health Alert. I apologize for the quantity because we required this training across all staff that work with individuals. The few that have not completed it were assigned the training incorrectly or are on leave. The Health Alert is related to this incident because it was ascertained that, regardless of other times that intervention should have occurred, when Individual #1 stopped walking, this was a significant enough difference in her presentation that it should have triggered an emergency phone call. There were no corrective actions for the nurse. The nurse had been notified by the home staff on 12/3/21 of the day programs concerns and instructed the staff to continue observing for deviation in Individuals #1's behavior. Due to the home staff relaying that, at that time, there were no noted changes, the nurse was deemed to be correct in stating the need for continued observation. The nurse followed up the next day and received the same feedback. Given the information provided to the nurse, it is appropriate that they did not assess the individual directly. Their primary function is to provide consultation, education, and communication with medical professionals. We did speak with the psychiatrist and he declined to remove the scream chart without further data. We therefore implemented an ABC chart to collect data regarding the function of that specific behavior. We have reached out, at your recommendation, to orchestrate a training for staff to be able to better communicate with individuals that are unable to do so verbally. We are in the process of scheduling this training. 03/01/2022 Implemented
6400.165(g)Individual #1 had a medication review completed by their psychiatrist on 4/16/21 and not again until 10/13/21, which is outside of the required time frame.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Individual #1 has a medication review scheduled for 1/13/22, which was the first available appointment, set by the psychiatrist, from the 10/13/21 appointment. All individual files will be evaluated, by 2/15/22, to identify any other person that might be out of compliance. All staff working in this home will be re-trained in this regulation by the Associate Director before 2/15/22. Documentation of this training will be kept. 03/01/2022 Implemented
SIN-00187230 Unannounced Monitoring 04/21/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #1's Nutritionist order from 10/19/20 indicates that individual is to have no citrus, tomato products, iced tea, spicy food, or gravies. At least 15 meals with these items were given to individual between 3/1/21 and 4/20/21.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. Current menus implemented in this home do not meet specific dietary needs of individuals served. Agency Nurse will review and update each current menu in ALL homes by 5/11/21, to ensure menus meet dietary needs of all individuals in each home. Specific individual dietary needs will be printed on each menu to assist staff with ensuring dietary needs are being met by 5/11/21. Beginning immediately, all menus for the next month will be completed by the house supervisor/program specialist by the 15th of the current month and reviewed by the Agency nurse (prior to implementation) to ensure that all dietary requirements are satisfied. If new dietary restrictions or choking protocols are recommended by a medical professional, the agency nurse will review orders and the program specialist will update all required documents within 24 hours of receipt. 05/11/2021 Implemented
SIN-00151262 Unannounced Monitoring 03/06/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)In the bathroom that contained the washer and dryer, on the ceiling, the trim to the crawl space was broken and needed repaired. also, the slab of wood that was covering the crawl space was not completely covering the hole therefore leaving the length of the opening open. A bigger board will need to be placed over the opening to sufficiently cover it or the current board must be bolted down so it does not open.Floors, walls, ceilings and other surfaces shall be in good repair. Reference previous POC issued by the department. 04/05/2019 Implemented
SIN-00128588 Renewal 02/20/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(i)Staff #1 was trained in cardio-pulmonary resuscitation (CPR) on 11/11/15 and not again. Staff #2 was hired on 3/22/17 and did not receive CPR training within six months of initial employment.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. Both staff received CPR training (staff # 1 received it on time and staff # 2 had it during her orientation. The regulation explanation states that staff do not require formal certification; it only requires training. As our training department was short staffed, the trainer trained people in CPR prior to working in the homes and annually as specified. However, formal training was not completed. This licensing administration's interpretation of this regulation is that the compressions must be demonstrated even though formal certification is not required. Therefore, our training department has been training all staff that have completed CPR during the past year to get them officially formally trained. Staff # 2 is scheduled to complete her CPR formal training on April 20, 2018 and Staff # 1 is scheduled 5-18-18. Moving forward, all staff will have the formal CPR training and be certified by the Red Cross by the company trainer on or before their due dates. 05/18/2018 Implemented
6400.106The furnace was inspected and cleaned on 9/27/16 and not again. There is no documentation of another furnace inspection occurring. The furnace was replaced on 11/30/17.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. Furnaces will now be cleaned every 9 months - see attached email (attachment # 15) sent 2-28-18 to the owner of the plumbing business that Shadowfax utilizes. The owner conversed with the Shadowfax maintenance man that this will occur as per our request. Moving forward, the Shadowfax maintenance man will keep track of the 9 month mark to ensure it is completed for every home, instead of assuming the plumbing contractor is doing them as specified. There will also be spot checks from the Director at the 9 month mark to ensure all furnace inspections are done and if not done, that it is arranged to occur before the 12 month mark. Our first inspection will be due by 5-28-18 so the documentation of the inspection will be forwarded upon receipt. 02/28/2018 Implemented
SIN-00119297 Unannounced Monitoring 08/10/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(18)Repeat Violation- 05/09/17 -Individual # 1's Individual Support Plan was not reviewed by Staff # 3 and 4. ISP review signature page was not signed by staff working with individuals. The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. The Program Specialist that is responsible to coordinate the training of direct service workers in the content of health and safety needs relevant to each member has re-trained the 2 staff that had not signed off on the ISP review signature sheet by 8-18-17.. The Program Specialist also re-trained all staff by 8-17-17 that are familiar with this home and may get scheduled in this home as relief staff for vacations, etc. See attachment # 1 of all training signature sheets as well as attachment # 2 of the ISP review sheet showing the 2 staff have been trained on the ISP. All staff were also re-trained on the Corporation policy (attachment # 3) for ISP's and the regulations pertaining to the ISP. In the future, the Program Specilaist will be responsible to train all staff, as well as confirm with staff members that the correct ISP is in the home file. The Associate Director will check the house books on site to ensure that all staff members working in the home have been trained and signed off on the signature sheet.. DSP staff will be held accountable for promptly filing all new ISP's in each person's book and the corrective action policy will be applied for those staff who do not file the documents promptly. New hires will meet with their Program Specialist to be trained on the ISP's prior to shadowing. They will then re-read the ISP's during shadowing and ensure they have signed off on the ISP signature sheet. All residential management will be meeting on August 31, 2017 to discuss methods to ensure all staff are trained and don't "fall through the cracks." 08/18/2017 Implemented
6400.213(9)Repeat Violation - 05/09/17- Individual # 2 did not have a copy of the current Individual Support Plan in the site records. No ISP contained within the record. Each individual's record must include the following information: A copy of the current ISP. The Program Specialist filed the correct ISP in the home book on 8-18-17. All staff were re-trained on the Corporation policy (attachment # 3) for ISP's and the regulations pertaining to the ISP. In the future, the Associate Director will check the house books on site on weekly visits to ensure that all correct, current ISP's are filed in the record. The corrective action policy will be applied for those staff who do not file the documents promptly. 08/18/2017 Implemented
SIN-00068629 Renewal 06/30/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.142(e)Indivdual #1 went to the dentist on 8/28/13 for routine cleaning. The dentist recommended a 3 month follow-up. Individual #1 did not return for the follow up until 3/31/14. Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed.The staff scheduled to run the appt. was terminated. To prevent this in the future, a plan has been implemented that after each appointment, staff call the office and tell them the next scheduled appointment date or when the next appointment is due. The information is transferred to a central base calendar that is given to the scheduling department so that they can ensure all appt.'s are listed on all scheduling cards so that in the event of a sick call, or someone is terminated, the appt. is not missed. 07/30/2014 Implemented
SIN-00070186 Renewal 06/30/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.142(e)Individual #1 went to the dentist on 8/28/13 for routine cleaning. The dentist recommended a 3 month follow-up. Individual #1 did not return for the follow up until 3/31/14.Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed.The staff scheduled to run the appointment was terminated. A new procedure has been implemented as of the beginning of August 2014. After running an appt., staff will call in to the residential office and report the next scheduled appointment date and time. This information will be relayed to the home supervisor and put on the scheduler's calendar so that if a staff calls in sick or is terminated, the schedulers can find another staff to run the appt. so it is not missed. See attached dental examinations of individuals that have had dental examinations (since our inspection) that have been completed on time. 08/01/2014 Implemented
SIN-00236054 Renewal 12/12/2023 Compliant - Finalized
SIN-00220641 Unannounced Monitoring 01/20/2023 Compliant - Finalized
SIN-00217252 Unannounced Monitoring 01/09/2023 Compliant - Finalized
SIN-00207642 Unannounced Monitoring 07/05/2022 Compliant - Finalized
SIN-00202700 Unannounced Monitoring 03/31/2022 Compliant - Finalized
SIN-00195617 Unannounced Monitoring 11/01/2021 Compliant - Finalized
SIN-00192070 Unannounced Monitoring 08/30/2021 Compliant - Finalized
SIN-00189496 Unannounced Monitoring 06/29/2021 Compliant - Finalized
SIN-00183890 Unannounced Monitoring 02/25/2021 Compliant - Finalized
SIN-00167180 Unannounced Monitoring 12/03/2019 Compliant - Finalized
SIN-00164211 Unannounced Monitoring 10/10/2019 Compliant - Finalized
SIN-00106578 Renewal 11/30/2016 Compliant - Finalized