Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00217253 Unannounced Monitoring 01/09/2023 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Individual #1's bedroom closet door was off the track at the time of the inspection.Floors, walls, ceilings and other surfaces shall be in good repair. This noncompliance was rectified immediately upon communication of its identification. 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 because it minimizes the risk of an individual suffering an injury while ambulating, and also to provide dignified living conditions. During the ODP monitoring in January 2023, as the inspector pulled to open the closet door in Individual #1's bedroom, the closet door came off the track that enable to doors to slide back and forth - the wheels run along a track that sits in place. The Residential Property Manager was contacted immediately, and he put the door back on the track. There were no broken pieces, and no repairs were needed. To prevent this from happening again, the staff that work in this home were trained to open the closet door in a slower fashion, and all staff in the Residential Department have been retrained in regulation #67a. Additionally, per the settlement agreement signed 5/15/23, a house visit checklist has been developed for use by Lead Management Staff or Program Specialists on a biweekly basis. This tool includes assessing compliance with the content of this regulation and documentation of its completion will be kept in an accessible digital format. All staff using this tool will be trained on its implementation by 6/1/23. 06/05/2023 Accepted
SIN-00195596 Unannounced Monitoring 11/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)During this inspection, the bathmat located in the upstairs bathtub was not clean and sanitary.Clean and sanitary conditions shall be maintained in the home. At the date of the inspection, the bathmat was cleaned to correct the cleanliness of the upstairs 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
6400.141(c)(6)Individual #1 had a TB test completed on 4/10/19 and not again until 5/21/21, which is outside the required timeframe.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. At the date of the inspection the TB test for Individual #1 had been completed. All individual files will be evaluated for compliance with the 2-year timeframe for TB testing by 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
6400.34(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 this 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
6400.163(h)Individual #1's prescription for Ibuprofen 200mg (3 tablets) was discontinued on 10/8/21. During this inspection, this medication was available at the home and not been disposed of when discontinued.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.As of 11/18/21, all programs have been evaluated for the presence of discontinued or expired medications. Any medications identified have been disposed of. All staff working at this home will be re-trained in the process of handling discontinued medications by 12/31/21. Documentation of this training will be kept. 02/01/2022 Implemented
SIN-00145393 Unannounced Monitoring 11/07/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16January 24, 2018- Individual # 1 had medical appointment with Dr. Boyle who ordered a stool sample to be completed and sent. Additionally Blood work was ordered every 4 months and 8 months due to low platelette count. Upon site inspection on 11/07/18, an unopened stool sample envelope was found at the residence with an exp date of July 2018. Staff person # 1, Associate Director (Home manager) informed Licensing staff (CL,GS) that a stool sample was never completed or sent and he reported that there is no documentation that the Physician cancelled the order for the stool sample until 11/07/18 when staff called Physician to inquire about if the stool sample was still needed. Staff did state to CL and GS 11/8/2018 that he does recall contacting the doctor at some point and asking if this stool sample was still needed because the indiv was doing well. He stated the doc office said it was not required. That is why it was not done. There is no documentation to back this up. Blood work was completed February 13, 2018 and April 10, 2018 but not in September 2018 as ordered. Additionally, during the 1/24/2018 appt Dr. Boyle requested documentation from staff of when Individual # 1's last colonoscopy was completed. No documentation that staff sent physician requested documentation of date of last colonoscopy. His last colonoscopy w completed 5/6/2014.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.All medical appointments and medical testing will be completed by assigned days. The individual #1 will have all medical records reviewed to make sure they are getting proper care. Then all individuals in the agency will have the medical records reviewed by nursing staff to make sure they are in compliance. All staff in agency will be retrained on this regulation to meet compliance in the future. Program specialist will review records on a monthly basis and then their supervisor will review on a quarterly basis and complete tracking form. 12/31/2018 Implemented
6400.74No non-skid on the interior staircase.Interior stairs and outside steps shall have a nonskid surface. 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-00105242 Unannounced Monitoring 12/14/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16individual # 1 was interviewed on 12/14/16. He/she reported that they had had visits with program #62 and they have had visitors come to their home. He/She reported that he/she does not like going to other homes and he told staff that he did not want to go. 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.When individual #1 complained to upper management, the visits for this home stopped immediately. 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 increased 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. 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..(The residential Associate Director On Call Supervisor will review this policy monthly and sign off on the monthly ratio checklist form. All management and staff schedulers will be retrained in the policy to not combine homes due to staffing issues. A rights training will be provided to all staff in the agency by 3/1/17)JR 1/31/17 11/16/2016 Implemented
SIN-00082836 Renewal 07/07/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The carpet on the steps leading in the basement is extremely dirty and stained. The carpet it supposed to be tan and it was mostly black. Floors, walls, ceilings and other surfaces shall be in good repair. The carpet was in good repair. Due to the individuals working in the workshop, the oil from machinery is often on their shoes. The carpet was replaced on the stairway and individuals were encouraged to remove their shoes or wipe their feet better before proceeding upstairs. The Associate Director will monitor the carpet on future house visits and ensure that it is appropriately cleaned should it become dirty and soiled. 09/10/2015 Implemented
6400.67(b)The drawer to the left of the sink in the kitchen was broken and had nails sticking out of the wood. The corner of the wall by the closet in the living room had a large piece of the corner frame exposed. Floors, walls, ceilings and other surfaces shall be free of hazards.The Shadowfax maintenance man fixed the broken cabinet door and ensured there was no nails sticking out of the wood. This kitchen is on the list of repairs and the entire kitchen is being remodeled in the fall/winter 2015. The Associate Director is responsible to monitor all cabinets and drawers are in good repair and follow through with maintenance orders as necessary. See picture attachment 13023023r098. The maintenance man also fixed the wall by the closet in the living room that had a piece of the corner frame exposed. 07/15/2015 Implemented
6400.68(b)The water temperature at the home was 123.8 degrees fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. The water temperature was immediately turned down (the day of inspection). Staff did not chart water temperature until August 6, 2015-8/19/2015. See attachment #oueruqer for water testing dates, places, and temperature. The Associate Diector is responsible for the ongoing monitoring of the water temperature laadbaljflkfds 08/06/2015 Implemented
6400.104The letter sent to the local fire department on 12/21/12 stated that all four individuals in the home are independent with evacuation. Another letter has not been sent ot the fire department since then and licensing was conducted on 7/7/15. Individuals #1 and #2 required assistance to evacuation the home on two separate occasions in the past year. The home did not notify the fire department of the updated needs of assistance for Individuals #1 and #2. The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. An updated fire letter was sent to the local fire department. See attachment 203r03rut. The fire log will be checked on a quarterly basis and all fire drills will be compared to the fire letter by the Associate Director to ensure the local fire company has the most current information at all times. 07/15/2015 Implemented
SIN-00236061 Renewal 12/12/2023 Compliant - Finalized
SIN-00207639 Unannounced Monitoring 07/05/2022 Compliant - Finalized
SIN-00202701 Unannounced Monitoring 03/31/2022 Compliant - Finalized
SIN-00194450 Unannounced Monitoring 10/15/2021 Compliant - Finalized
SIN-00190744 Unannounced Monitoring 07/29/2021 Compliant - Finalized
SIN-00182616 Unannounced Monitoring 01/25/2021 Compliant - Finalized
SIN-00158725 Unannounced Monitoring 07/03/2019 Compliant - Finalized
SIN-00106599 Renewal 11/30/2016 Compliant - Finalized