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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(e) | A fire drill shall be held during sleeping hours at least every 6 months. The Edison Street home only held 1 asleep fire drill during 2022 which was done in May 2022. | 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. Due to this program currently being vacant, no immediate rectification of this regulation was possible specific to this location. Issue Identified -- A fire drill shall be held during sleeping hours at least every 6 months. The Edison Street home only held 1 asleep fire drill during 2022 which was done in May 2022.
Correction Required -- A fire drill shall be held during sleeping hours at least every 6 months.
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, neither the March 2022 nor the September 2022 drill during sleep hours were conducted and, although there was an awake drill conducted, there was not effective oversight to identify the absence, and timeliness of this type of fire drill. This would normally have occurred during a regular visit by the Associate Director and/or assigned Residential Supervisor.
Due to this program currently being vacant, no immediate rectification of this regulation was possible specific to this location.
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. |
06/01/2023
| Implemented |
| 6400.144 | REPEAT VIOLATION from 4/11/22 and 8/15/22 - 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 choking prevention plan for individual #1 dated 12/13/22 states food is to be pureed. However, ISP last updated 10/4/22 states food is to be cut nickel sized in the meals/eating section. | 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.
| Due to the death of Individual #1, prior to this monitoring, no changes to the ISP were possible. All programs were assesses for consistent content, in relation to the ISP, by 6/1/23. If any information was deemed to be inconsistent, confirmation of communication with the Supports Coordinator was assessed. Issue identified - REPEAT VIOLATION from 4/11/22 and 8/15/22 - 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 choking prevention plan for individual #1 dated 12/13/22 states food is to be pureed. However, ISP last updated 10/4/22 states food is to be cut nickel sized in the meals/eating section.
Correction required - 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.
This regulation is important because it protects the individual's health and safety by following the orders/recommendations of all medical and psychological physicians.
On 12/13/23, Individual #1's PCP changed their diet texture to a pureed diet. After this appointment the Program Specialist created a choking prevention care plan document to be kept in their home (and in the electronic health record) and trained the staff that work with this individual. However, the Program Specialist was then terminated that afternoon, and did not send an addendum to the Supports Coordinator. After their termination the Residential Program Specialist Coordinator completed training of all staff and ensured that all documentation was correct but did not check to see if an addendum to the ISP was created. She incorrectly assumed that the Program Specialist already took care of this as it is typically the first step taken after a plan change of this type.
This error was not identified until the January 2023 monitoring. By then, individual #1 had already passed away (12/21/23) so sending an addendum to update the ISP at this point was not needed.
To prevent this from happening again, all staff will be retrained on this regulation by 6/5/23. Documentation of this training will be kept. Program Specialists currently send an addendum for the ISP to the supports coordinators when there is a change in any plan that is referenced in the ISP. Program Specialists do monthly content reviews to assess whether identified changes have been included in the ISP. Repeat communication occurs with the SC if this has not taken place. Documentation of these requests are kept in the individual's files. |
06/05/2023
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | There was a small amount of lint in the dryer vent during the 11/01/21 inspection. The appliance was not in use at the time. | Floors, walls, ceilings and other surfaces shall be free of hazards. | At the date of the inspection, the lint was removed from the dryer vent. All homes will be assessed for current compliance with this regulation by 12/15/21. 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 |
| 6400.82(f) | There was no soap in the bathroom during the 11/01/21 inspection. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | At the date of the inspection, the soap was placed in the bathroom. All homes will be assessed for current compliance with this regulation by 12/15/21. 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 |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The side of the bathroom vanity was pealing due to water from the shower penetrating the medium-density fibreboard (MDF). The small wooden steps leading from the side deck to the front fence egress, were not attached to the deck on the right side of the steps. They were falling down and slanted slightly. | Floors, walls, ceilings and other surfaces shall be in good repair. | Shadowfax will conduct home inspection of each home to assure compliance. Then monthly senior management will conduct a home inspection and sign off that this step has been completed. |
11/30/2019
| Implemented |
| 6400.74 | REAPEAT from 2/20/18 annual inspection and 11/7/18 and 3/6/19 unannounced inspection: The strip of non-skid material was almost completely pealed off of the top step on the side deck. | Interior stairs and outside steps shall have a nonskid surface.
| Shadowfax will conduct home inspection of each home to assure compliance. Then monthly senior management will conduct a home inspection and sign off that this step has been completed. |
11/30/2019
| Implemented |
| 6400.80(a) | REPEAT from 3/6/19 unannounced monitoring: The walkway leading from the side porch to the backyard, contained a long, coiled up garden hose covering half of the walkway. A large, outdoor trashcan was completely covering the walkway leading from the side porch to the front fence egress. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Shadowfax will conduct home inspection of each home to assure compliance. Then monthly senior management will conduct a home inspection and sign off that this step has been completed. |
11/30/2019
| Implemented |
| 6400.101 | REPEAT from 11/7/18 and 5/15/19 unannounced monitorings: The front fence egress from the side yard, was hard to open. The sliding lock at the top of the door was sticking and hard to operate in order to open the door. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Shadowfax will conduct home inspection of each home to assure compliance. Then monthly senior management will conduct a home inspection and sign off that this step has been completed. |
11/30/2019
| Implemented |
| 6400.214(b) | Individual #1's current copy of his physical examination and Individual Support Plan (ISP) were not located at his residence during the 9/27/19 onsite visit. The ISP onsite indicated it was last updated on 11/9/18. According to the electronic system where the ISP is generated, there have been 3 new updates to the individual's ISP since 11/9/18. The staff working in the home do not have access to the electronic system to pull the current ISP up, online. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Shadowfax will assure that every physical is located in the residence. They will conduct monitoring and sign off on a document that states they have completed this step monthly. |
11/30/2019
| Implemented |
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