Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00220298 Unannounced Monitoring 03/03/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.61(a)Individual #1's bed shaker was not operable at the time of the inspection.A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. On 3/3/23, the inoperable bed shaker was rectified. All homes will be assessed, where applicable, for current compliance with this regulation by 3/31/23. All staff working in this home will be retrained in this regulation by 3/31/23. Documentation of this training will be kept. 04/01/2023 Implemented
SIN-00215798 Unannounced Monitoring 11/22/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.61(b)While there is a video relay services phone provided in the home, most of the staff are not trained in how to utilize the phone. (Staff #4 knew how to use the system due to personal familiarity with the system, Staff #2 and Staff #5 indicated that they did not know how to use the system.A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have adaptive equipment necessary for the individuals to move about and function at the home.On 12/13/22, all staff were retrained on the use of the vide phone relay system that is located in the home. Additionally, written instructions are now posted with the video relay system for the staff and individuals to use as a reference guide. Records of this training will be kept by the Director of Residential. 01/31/2023 Implemented
6400.32(n)Only 1 staff (staff #4) that works in the home that agreed to an interview knew how to use the video relay services phone that is installed in the home. Staff #2 and staff #5 indicated that they did not know how to use the system. Individuals do not have access to telecommunications if staff are unable to use the equipment necessary for them to make phone calls.An individual has the right to unrestricted and private access to telecommunications.On 12/13/22, all staff were retrained on the use of the vide phone relay system that is located in the home. Additionally, written instructions are now posted with the video relay system for the staff and individuals to use as a reference guide. Records of this training will be kept by the Director of Residential. 01/31/2023 Implemented
SIN-00207633 Unannounced Monitoring 07/05/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.61(b)Individual #1 requires the home to be equipped with strobe lights to notify them in the event of an emergency. Individual #1's half bathroom on the lower-level floor was not equipped with a strobe light or any device that activated when the smoke alarms in the home were activated.A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have adaptive equipment necessary for the individuals to move about and function at the home.On 7/5/22, a strobe light was ordered for installation in the half bath. This was installed on 7/13/22. All homes will be assessed for current compliance with this regulation by 8/1/22. 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-00187225 Unannounced Monitoring 04/21/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #1 is to have an increased intake of carrots, leafy lettuce, red lettuce, spinach, sweet potatoes, and yams because of low beta-carotene. Only 25 of 150 total meals from 3/1/21 -- 4/19/21 contained these items.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-00185532 Unannounced Monitoring 03/29/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(f)Individual #1 is unable to hear the smoke detectors/fire alarm system in the home and requires a bed-shaker devise to be placed under the individual's mattress and strobe lights in the rooms throughout the home to alert the individual in the event of a fire or emergency that requires evacuation of the home. During the 3/30/2021 onsite inspection of the home, Individual #1's bed-shaker did not activate with the smoke detectors/fire alarm system when they were triggered. Staff working in the home reported to the Department representative that the individual had deactivated the bed-shaker device, so it did not turn on when the smoke detectors were set off. 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. The agency will provide training to all staff working in the home, as part of their orientation prior to working with individuals and semi-annual training, of the requirement to ensure all smoke detectors and fire alarms are to be equipped so that each person with a hearing impairment will be alerted in the event of a fire. Training on this requirement will be completed with all current staff (full-time, part-time, volunteer, etc.) working in the home by 4/16/2021. Each staffing shift change will check the individual's bed-shaker device to ensure it is plugged in and turned on, and document this check on a bed-shaker monitoring form. This will be implemented immediately. If at any point the individual's bed-shaker device is found to be unplugged or inoperable, staff will immediately rectify the situation by a solution that will activate the bed-shaker device again. If at any point the bed-shaker device is deemed inoperable, immediate repairs will be made. If the device is found unplugged or inoperable, staff must notify the home supervisor and program specialist within 24 hours. The program specialist will record how often the individual's bed-shaker is found unplugged or inoperable. The program specialist will conduct a team meeting with the individual's plan team members to discuss any issues regarding the individual's bed-shaker and complete a plan to address said issues. These meeting will be held after every 3rd time an issue has been identified with the individuals bed-shaker. The individual will be informed, in their mode of communication, of the importance of keeping the bed-shaker operable and activated at all times. 04/16/2021 Implemented
SIN-00170977 Unannounced Monitoring 02/06/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(f)Individual #1 is assessed by the agency to be unable to hear the smoke detectors/fire alarms in the home if they are activated. He requires a bed shaker in his bedroom to alert him during sleeping hours if there is a fire and the smoke detectors are activated. During the 2/6/2020 inspection of the home, Individual #1's bed shaker did not activate when the smoke detectors were activated. 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. The ShadowFax will comply with settlement agreement for compliance with this POC. 02/06/2020 Implemented
SIN-00165809 Unannounced Monitoring 11/01/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.214(b)Individual # 1's Individual Support Plan (ISP) located at the home in the programming book is not the most current. The date of the ISP contained in the programming book is 08/08/18. Individual # 1's ISP was last updated 07/15/19. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The most recent isp was in the home at the time of the inspection, but was filed incorrectly. Due to this the isp was not found by management when ask that it be shown to the licensing representative. On the day of the inspection, the house supervisor was educated on the correct place to file the current isp's and KB's most recent isp was filed correctly so all staff had access to the current isp. To prevent further incidents, all management and house supervisors will be trained on proper filing of the most recent isp and the importance of filing it correctly so all staff have access. During home inspections the associate director and program specialist will check to ensure that he most recent isp is filed correctly and this will be completed 2x's monthly. 12/13/2019 Implemented
SIN-00145386 Unannounced Monitoring 11/07/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The non-skid mat in the shower has mold growing on itClean and sanitary conditions shall be maintained in the home. 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
6400.66Basement bathroom light not functionalRooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. 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
6400.101Second living room egress did not open fully. Doll set on floor. Individual uses Wheelchair within the home.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. 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-00128600 Renewal 02/20/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(c)The coliform water test was completed on 11/18/16 and not again until 2/20/17 and on 5/15/17 and not again until 8/21/17.A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept.Prior licensing personnel had stated that this regulation is every 3 months. They informed us that the 3 month mark meant if it was due in February, so long as it was done in February, it was compliant. This licensing administration is stating that the 3 month mark means every 90 days and there is no leeway. Therefore, according to this licensing representative, we were 2 days late with one water test and 6 days late during the next 3 month testing. The Director contacted the company that does our water testing on 2-27-18 and changed the water testing to every 2 months instead of 3 months (see attached email - attachment ________). The Director will continue to monitor that the water is being tested every 2 months. As the first water testing that is coming due will be in April 2018, a copy will be forwarded to ODP licensing personnel as soon as the results are obtained. Implemented
6400.113(a)Repeat 12/14/16: Individual #1 moved into this home on 2/19/17 and did not receive fire safety training regarding the designated meeting place and evacuation procedures of his/her home until 2/22/17. 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. A fire drill was held 2/19/17, the day the individual moved in. As part of the fire drill for all Shadowfax homes, the evacuation procedures, individual responsibilities during a drill, the designated meeting place, and smoke safety procedures were reviewed - see attached fire drill log - attachment # ______ . What did not occur was the actual fire safety training pertaining to different types of fires and how to use a fire extinguisher. This was to occur on the day the individual moved in as well and did not. Staff were re-trained on this regulation on 4/2/18 by the Associate Director - see attachment # ______. Moving forward, when a new individual moves in, the Associate Director(s) will use attachment # ____ as the guideline to follow the day an individual moves into Shadowfax to ensure all fire safety training needs are met. Implemented
SIN-00226866 Unannounced Monitoring 06/08/2023 Compliant - Finalized
SIN-00215254 Unannounced Monitoring 11/21/2022 Compliant - Finalized
SIN-00200301 Unannounced Monitoring 02/15/2022 Compliant - Finalized
SIN-00195605 Unannounced Monitoring 11/01/2021 Compliant - Finalized
SIN-00194445 Unannounced Monitoring 10/15/2021 Compliant - Finalized
SIN-00189500 Unannounced Monitoring 06/29/2021 Compliant - Finalized
SIN-00164213 Unannounced Monitoring 10/10/2019 Compliant - Finalized
SIN-00155511 Unannounced Monitoring 05/14/2019 Compliant - Finalized
SIN-00106590 Renewal 11/30/2016 Compliant - Finalized
SIN-00070191 Renewal 06/30/2014 Compliant - Finalized