Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00238430 Unannounced Monitoring 01/18/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.162(c)(4)Staff # 1 reported in an investigation interview that on January 13, 2024 at approximately 6:45 am, Staff # 2 was observed to have "···came out with a handful of meds and put in Individual # 1's breakfast." Additionally, on January 15, 2024, Staff # 1 observed Staff # 2 administer medications in the following way. Staff # 2, "dumped a handful of pills into breakfast from her hand". Proper administration of medication activities/process is to place medications into a cup or the individual's hand and not to be held or physically handled by the medication administrator. Furthermore, the witness statements indicate that Staff # 2 placed the medications into the bowl and instead of completing the administration process in it's entirety, Staff # 1 took over and physically fed the medications to Individual # 1.Medication administration includes the following activities, based on the needs of the individual: Place the medication in a medication cup or other appropriate container, or in the individual's hand, mouth or other route as ordered by the prescriber.This regulation is important because proper medication administration limits the possibility of an error that may impact the health and welfare of a person supported. This violation occurred due to staff misunderstanding and not prioritizing certain elements of the administration process. Both of the staff referred to in the violation have received corrective actions, including targeted retrainings, identified in the internal investigation associated with these interviews. Currently there are the required medication administration observations conducted biannually as required by the medication administration training. There are also monthly administration observations of staff for respective programs, conducted by the nurses, as outlined in Shadowfax's settlement agreement with ODP. 02/29/2024 Implemented
SIN-00226893 Unannounced Monitoring 06/08/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Individual # 1's desk has masking tape on the desk corner where the veneer is pulling off.Floors, walls, ceilings and other surfaces shall be in good repair. This regulation is important because it minimizes the risk of an individual suffering an injury while ambulating, and also to provide dignified living conditions. The desk not being repaired was due to staff's confusion as they attempted to balance family wishes. The family of Individual #1 had purchased the desk and openly stated they would not replace it. The repair floundered as staff attempted to identify if the family wanted to replace it or have it repaired. The desk was repaired with a new veneer on 6/9/23. All staff working in this home will have been retrained in this regulation and the associated expectations by 7/31/23. Documentation of this training will be kept by the Director of Residential. 07/31/2023 Implemented
SIN-00195591 Unannounced Monitoring 11/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)In August 2020, Individual #1 spent $134.93 on products for incontinence. On 10/2/20, Individual #1 spent $18.94 on incontinence products and on 4/13/21, $15.74 was spent on incontinence products. These items are to be purchased by the provider.Individual funds and property shall be used for the individual's benefit. On 10/20/20 individual #1 was reimbursed $18.94, on 4/15/21 individual #1 was reimbursed $15.74, on 11/9/21 individual #1 was reimbursed $134.93 for incontinence products that are included as part of the room and board cost, as per 6100.684(x). All staff working in this home will be re-trained on both the 6400 and 6100 applicable regulations by 12/31/21. By 2/1/22, all individuals, who have Shadowfax as their representative payee, will be reviewed to identify any other instances where monies were used for incontinence products. 02/01/2022 Implemented
6400.141(c)(7)Individual #1 had a gynecological exam on 5/1/19 and not again until 12/15/20; when the Individual was seen for a visible cyst on the vulva. The Individual had the cyst for months prior to having a gynecological exam.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. At the date of the inspection the gynecological exam for Individual #1 had been completed. All individual files will be evaluated for compliance with the guidelines for gynecological exams 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 and 8/4/20) Individual #1 had a gynecological exam on 5/1/19 and not again until 12/15/20; when the Individual was seen for a visible cyst on the vulva. The Individual had the cyst for months prior to having a gynecological exam.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. All staff working in this home will be re-trained in this regulation 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
6400.151(a)Staff person #1 had a physical completed on 8/3/18 and not again until 8/19/20; outside of the biannual time frame. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. At the date of the inspection, staff person #1 had completed their biannual physical. By 12/1/21, all staff records will be reviewed to insure that all applicable staff are within compliance of this regulation. 12/01/2021 Implemented
6400.32(c)(Repeat from Inspection dated 7/27/20) On 5/24/21, a miscellaneous debit for $500 was removed from Individual #1's checking account for a credit card. Shadowfax applied for a secure credit card for Individual #1 on 5/24/21, without consent from the Individual. This does negatively impact the Individual's credit. In addition, as of 11/3/21, the Individual has yet to receive the secure credit card.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment."An EIM(8929299) was initiated, and an investigation is in process to evaluate where the root cause of the misuse of individual funds that resulted in a negative impact on their credit. On 11/9/21 individual #1 was reimbursed $500 for the secure credit card debit which was made on 5/24/21. By 2/1/22, all individuals, who have Shadowfax as their representative payee, will be reviewed to identify any other instances where monies were used in ways that could reasonably be assumed to have damaged their credit." 02/01/2022 Implemented
6400.34(a)The Department issued updated regulatory rights, effective 2/3/2020, stating that individuals have additional rights they need to be informed of. At the time of the 11/1/2021 annual 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
SIN-00167178 Unannounced Monitoring 12/03/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)An assortment of adhesive bandages were not in the first aid kit during the inspection. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. The assorted Band-Aids were placed in the first aid kit on 12/3/2019. On 12/11/19, the team members were trained on this regulation. Once per month the Associate Director will review the contents of the first aid kit to assure compliance with this regulation. 12/11/2019 Implemented
SIN-00149290 Unannounced Monitoring 01/14/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The pathway that leads from the front of the house to the rear deck was not equipped with a light to ensure safe travel around the side/back of the home.Rooms, 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. 02/28/2019 Implemented
6400.185(b)Individual #1's ISP indicated that she has grand mal, petit mal and drop seizures that are tracked at home. The home did not have any seizure tracking logs from the end of June 2018 until the beginning of January 2019. There was a note in her record from 10/9/18 that indicated she was taken to the emergency room on 10/9/18 for a "10+ min seizure" but no other record/documentation about the seizure. She does not have a seizure protocol in her record to address all of her seizures.The ISP shall be implemented as written.Shadowfax will correct the immediate issue. They will verify that the ISP 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 ISP 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 #1's 5/18/18 physical indicated for her diet "all food pureed no exceptions, thick it to all liquids to nectar thick and refer to choking plan." The choking plan attached to the physical indicated that her diet was "ground, mashed, or mechanical soft diet." The ISP indicated that all food is pureed and al liquids are nectar thick. --Individual #1's record also include another 5/18/18 physical examination form that had allergies to Penicillin and Cefepime while the other 5/18/18 physical form included allergies to Penicillin. Her ISP include allergies to both Penicillin and Cefepime. 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
6400.216(a)Individual #2's 2017 food choking protocol was found unlocked and accessible in the staff filing cabinet off of the dining room. An individual's records shall be kept locked when unattended. Shadowfax will correct the immediate issue. They will verify that the protocol 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 protocol 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-00128603 Renewal 02/20/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.74Repeat 11/30/16: The steps leading to the basement did not all have a nonskid surface. There were only nonskid strips on the top three steps.Interior stairs and outside steps shall have a nonskid surface. The Associate Director of the home was re-trained on this regulation on 3/26/18 as well as the other Associate Directors. The maintenance man applied non skids to all stairs on 2-22-18. See attached pictures. Moving Forward, the Associate Director will be responsible to check all stairs for non skids during house visits. Furthermore, the maintenance man, Director, or Senior Associate Director will provide ongoing monitoring of all stairs, inside and out, by visiting all homes frequently in the next year to ensure all stairs have appropriate non-skid material. 03/26/2018 Implemented
SIN-00082833 Renewal 07/07/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103The written emergency evacuation procedures for all the individuals living in the home did not contain the individual's 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 22 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
SIN-00219402 Unannounced Monitoring 02/08/2023 Compliant - Finalized
SIN-00215260 Unannounced Monitoring 11/21/2022 Compliant - Finalized
SIN-00205804 Unannounced Monitoring 05/31/2022 Compliant - Finalized
SIN-00200300 Unannounced Monitoring 02/15/2022 Compliant - Finalized
SIN-00192064 Unannounced Monitoring 08/30/2021 Compliant - Finalized
SIN-00183888 Unannounced Monitoring 02/25/2021 Compliant - Finalized
SIN-00151263 Unannounced Monitoring 03/06/2019 Compliant - Finalized
SIN-00106593 Renewal 11/30/2016 Compliant - Finalized