Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00217255 Unannounced Monitoring 01/09/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)The home conducted a sleep drill on 9/17/21 and not again until 9/13/22. This was not within the 6-month criteria.A fire drill shall be held during sleeping hours at least every 6 months. All homes will be assessed for current compliance with this regulation by 6/1/23. All staff working in this home will be retrained in this regulation by 6/5/23. Documentation of this training will be kept. This regulation is important to be able to assess the competencies of the people living in a group home to be able to evacuate effectively during sleep hours. This assists in ensuring that safety is maintained in the event that a fire might occur during any hour of the day and that staff understand their roles and expectations in this situation. Shadowfax has an expectation that fire drills during sleep hours occur during the months of March and September. At this site, the March 2022 drill during sleep hours was not conducted and, although there was an awake drill conducted, there was not effective oversight to identify the absence of this type of fire drill. This would normally have occurred during a regular visit by the Associate Director and/or assigned Residential Supervisor. All staff working in this home will have been retrained in this regulation and the associated expectations by 6/5/23, reinforcing the need to have biannual fire drills during asleep hours. Documentation of this training will be kept by the Director of Residential. All residential programs conducted a fire drill in March of 2023 and this was confirmed by the Director of Residential. In February of 2023, a process was implemented that includes an expectation that all fire drill forms are to be scanned to the residential administrative office, for review, by the 15th of the month. These scans are then housed in a centrally accessible digital format. Included in this review is documentation, and confirmation, of drills occurring during sleep hours. The practice has been reiterated that drills during sleep hours are occurring during March and September months of the year, at a minimum. 06/05/2023 Implemented
SIN-00207637 Unannounced Monitoring 07/05/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(f)REPEAT from 1/11/22, 11/1/21, and 3/29/21 unannounced monitorings: Individual #1 requires the smoke alarms in the home to be equipped with strobe lights to alert them in the event of an emergency. The upstairs hallway strobe light and the strobe light in Individual #1's hallway bathroom did not activate when certain smoke detectors were activated throughout the home. If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. On 7/5/22, a loose wire was identified and repaired, making the system fully compliant. All homes will be assessed for current compliance with this regulation by 8/15/22. All staff working in this home will be re-trained on this regulation by 8/15/22. Documentation of this training will be kept 08/15/2022 Implemented
SIN-00195602 Unannounced Monitoring 11/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(a)The basement smoke detector was not operable at the time of the inspection. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. On the date of the inspection, the smoke detector was identified to be inoperable due to the forceful manual depression of the test function of the smoke detector. This was repaired and confirmed to be operating normally. All homes will be assessed for current compliance with this regulation by 12/15/21. 01/01/2022 Implemented
SIN-00194455 Unannounced Monitoring 10/15/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The phone in the kitchen was not equipped with emergency numbers at the time of the inspection on 10/15/21.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The emergency numbers were posted by the end of the inspection. All staff working in this home will be re-trained in this regulation by the Director of Residential before 10/30/21. 11/01/2021 Implemented
SIN-00149739 Unannounced Monitoring 02/05/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Cleaning supplies that require poison control labeling unlocked in upstairs bathroom.Poisonous materials shall be kept locked or made inaccessible to individuals. 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. 02/28/2019 Implemented
SIN-00145388 Unannounced Monitoring 11/07/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Nail polish remover was found in bedroom unlockedPoisonous materials shall be kept locked or made inaccessible to individuals. Agency will correct the immediate issue. Agency will review the issue for violation and correct. Then agency will develop procedure to ensure poisons are locked and train all staff on the violation. Program specialist will review monthly and supervisor will review quarterly and complete tracking form. 12/31/2018 Implemented
6400.67(a)Basement door knob is broken. It would not unlock initially. Needs replacedFloors, 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-00105234 Unannounced Monitoring 12/14/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16Individual #1 reported that she was prescribed Anxiety medications because she has anxiety about being in other people¿s homes. They reported that she did not have a choice to decline visits. He/she was prescribed Buspirone 7.5 mg BID for Anxiety by her Primary Care Physician on 10/14/16. He/she was also prescribed Trazedone 50 MG QD for Insomnia on 10/14/16. Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.Individual # 1 was prescribed anxiety and insomnia medications. The reasons according to individual # 1 was about visiting other peoples homes. While this may be true, individual # 1 was sexually abused by a family member and placed in a Shadowfax home. During the time the medication was prescribed (and currently continuing), individual # 1 has been having a great deal of anxiousness because meetings with the DA and lawyers have been happening more frequently in preparation for the upcoming trial (she has also been having night terrors and not being able to sleep as she recalls the abuse). Despite this, individual 1 stated the reason was due to going to other homes and not declining visits. The individual was informed of her right to be vocal and deny things she does not want to do. The Shadowfax residential department has stopped having individuals visit other homes as of the date of 11-16-16 when MH-IDD informed us this could not be done. All Management & schedulers were notified on 11/16/2016 that they will not combine any programs for the convenience of staffing and there will be no exception. All targets of the investigation that are still employed were given performance feedback and it was discussed that this is not an option in the future. Residential has instituted sign on bonuses to hire more staff, have offered bonus/incentive pay to fill shifts, have worked with temp agencies to get additional staff, have downsized by 2 homes, and have worked with other departments to have additional staff available to work in residential. Recruiting efforts were also stepped up to hire additional staff. A new position of ¿On-Call Associate Director¿ was established, effective 11/22/2016. This Ad will be responsible for all scheduling and to supervise the scheduling department to ensure that individuals are not visiting other homes and to ensure adequate staffing per home. The Quality Assurance coordinator had a discussion with MH/IDD supervisor and asked that at any time the SC¿s are aware of something that is happening in our programs, we would like to be notified. Finally, as this individual has not visited other homes in 2 months, staff will discuss with the doctor the need for medication and will continue to monitor the use of the medications and have them reduced if/when her anxiety and insomnia levels lessen. 11/16/2016 Implemented
6400.31(c)Individual #1 was interviewed on 11/29/16 and described the following circumstances surrounding her 19 visits with individuals from other TSC residences. When asked if any staff informed he/she that she had a choice not to visit other homes, They reported that ¿I said that I didn¿t want to go, they said that I had to¿I had to go to other homes. 800 and 850 all the time¿. .¿ Interviews with staff #1, (part time direct care), staff #2 (Assistant Program Manager), staff #3 (Assistant Program Manger) and staff #4 confirm that individuals were not given the opportunity to participate in program planning or the scheduling of visitations.Each individual shall be encouraged to exercise his rights.The Shadowfax residential department has stopped having individuals visit other homes as of the date of 11-16-16 when MH-IDD informed us this could not be done. Residential has instituted sign on bonuses to hire more staff, have offered bonus/incentive pay to fill shifts, have worked with temp agencies to get additional staff, have downsized by 2 homes, and have worked with other departments to have additional staff available to work in residential. Recruiting efforts were also stepped up to hire additional staff. Moving forward, Individual #2 will be encouraged to exercise her rights in being vocal about who can and cannot visit her home. Shadowfax will not have homes visit other homes. If individuals wish to visit friends in another home, a written consent will be obtained and kept on file to show their desire to do so. 11/16/2016 Implemented
6400.33(d)Individual #! was interviewed on 11/29/16 and described the following events. When asked about if she was given the opportunity to participate in program planning or the scheduling of visitations either from other programs or to go to other programs, They reported that she ¿had to go to other homes and she is ¿.not comfortable at other homes.¿ Interviews with Staff #1, (part time direct care), Staff #2(Assistant Program Manager, staff #3 (Assistant Program Manger) and staff #4 (Associate Director) confirm that individuals who were involved in visits were not given the opportunity to participate in program planning or the scheduling of visitations. An interview conducted with staff #5, Residential Director/CEO indicated that 80 out of 95 individuals who are part of Shadowfax were impacted by the visits. Individual #2 was interviewed on 12/15/16. They reported that she has had visitors to her home. He/she does not remember who visited although "Wendy" has a dog. They reported that she has visited other people¿s homes but does not recall where. They stated that there have been times that she has not wanted to go on visits but does not recall dates. An individual has the right to participate in program planning that affects the individual.Shadowfax does not have an individual named Wendy, nor do any of the current group homes at Shadowfax have a dog. The Shadowfax residential department has stopped having individuals visit other homes as of the date of 11-16-16 when MH-IDD informed us this could not be done. Residential has instituted sign on bonuses to hire more staff, have offered bonus pay to fill shifts, have worked with a temp agency to get additional staff, have downsized by 2 homes, and have worked with other departments to have additional staff available to work in residential. Recruiting efforts were also stepped up to hire additional staff. Moving forward Shadowfax will not have homes visit other homes. If individuals wish to visit friends in another home, a written consent will be obtained and kept on file to show their desire to do so. Individuals will be given the right to participate in the program planning that affects them. If individual # 2 does not want to participate in an outing or other activity then she will not partake in it and staffing needs will be adjusted so that she does not need to attend. 11/16/2016 Implemented
6400.113(a)Individual #1's ISP dated 11/09/16 indicates that she would require assistance in all aspects of Fire Safety. She does know to leave the home in case of a Fire. She is unable to call 911 in the event of an emergency due to her inability to use the phone however this can be a foreseeable goal as she is able to recognize numbers. Individual #1 was interviewed on 11/29/16 and described that when she was made to visit other homes, she did not know where to go in case of a fire. They stated that the staff never explained to her where the fire exits are. Interviews with, staff #3(Assistant Program Manager) and staff #1 confirmed that individuals did not receive fire safety training upon visits to other homes. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. The Shadowfax residential department has stopped having individuals visit other homes. Residential has instituted sign on bonuses to hire more staff, have offered bonus pay to fill shifts, have worked with a temp agency to get additional staff, have downsized by 2 homes, and have worked with other departments to have additional staff available to work in residential. Recruiting efforts were also stepped up to hire additional staff. Moving forward Shadowfax will not have homes visit other homes. If individuals wish to visit friends in another home, a written consent will be obtained and kept on file to show their desire to do so. At that time, the individual will be instructed in fire safety when first entering the home to ensure they are aware of general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire 11/16/2016 Implemented
6400.213(11)Individual #1's Individual Support Plan (ISP) dated 11/09/16 indicates that he/she is not diagnosed with any mental health disorders or illness, does not take any psychotropic medications and has no behavior support plan. H/she was prescribed Buspirone 7.5 mg BID for Anxiety by her Primary Physician on 10/14/16. She was also prescribed Trazedone 50 MG QD for Insomnia on 10/14/16 Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. Individual¿s quarterly review (the ISP update) had the correct information in it and was mailed on 11-1-16 to all team members. See attached quarterly review. The ISP reviewed at the on site visit by ODP did not have the correct information because the meeting was held on 11-9-16 and the SC was updating the ISP with the information from that meeting. The ISP was updated 12-6-16 and mailed to all team members. 12/06/2016 Implemented
SIN-00106581 Renewal 11/30/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The lightbulb was non operable in the light fixture at the top of the interior stairway on the second floor. Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The light bulb was replaced by maintenance. See attached picture. Going forward, the maintenance man for the Shadowfax residential homes will check for any light fixtures that are hard to reach and change them. The staff were also reminded to fill out a maintenance request so that he is alerted to come and change the light bulb since it is too high and on the staircase for staff or individuals to do. Moving forward, the home supervisor will check all bulbs are working properly on their weekly home visits and document on the attached form. 12/22/2016 Implemented
6400.80(b)There was missing fascia board along top right of the roof. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The fascia was replaced. See attached picture. Maintenance replaced fascia as it came off due to high winds. Staff were reminded to use maintenance request orders to inform maintenance of needed repairs. Moving forward, the house supervisor will ensure all items are in good repair on weekly house visits. See attached house visit report form modified in 1.2017 12/22/2016 Implemented
6400.101The kitchen exit was blocked with individuals personal belongings which included large plastic tote, lamp, keybaord, and clothing hamper. Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. All items were moved immediately. The home supervisor reminded the individuals that live in this home and the staff that they cannot place things in front of the doors as they need to have a clear way to get out in the event of a fire or emergency. Moving forward, the home supervisor will check on their weekly home visits and document on the attached home visit report (line added to the report for this issue). 12/05/2016 Implemented
SIN-00236056 Renewal 12/12/2023 Compliant - Finalized
SIN-00210419 Unannounced Monitoring 08/15/2022 Compliant - Finalized
SIN-00200288 Unannounced Monitoring 02/15/2022 Compliant - Finalized
SIN-00182623 Unannounced Monitoring 01/25/2021 Compliant - Finalized
SIN-00170342 Unannounced Monitoring 01/15/2020 Compliant - Finalized
SIN-00165799 Unannounced Monitoring 11/01/2019 Compliant - Finalized