Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00230689 Unannounced Monitoring 09/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The two cordless phones in the home, one in the office area and the other in the kitchen, did not have emergency numbers on or near them.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. This regulation is important because it minimizes the risk to people supported by facilitating quicker emergency responses. A new phone had been purchased a day and a half prior to monitoring and the emergency numbers had not been moved to the new device. Existing measures to catch this oversight were not followed appropriately. The emergency numbers were added on the day of the moniroting, 9/13/23. All staff working in this home will have the importance of this regulation reiterated by 10/15/23. Documentation of this will be kept by the Director of Residential. 10/15/2023 Implemented
SIN-00217251 Unannounced Monitoring 01/09/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66REPEAT VIOLATION from 1/11/22 - Egress between the two backdoors did not have a working light at the time on the inspection.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. 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. Correction Required - Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. This regulation is important because it helps the individuals and staff evacuate in the event of an emergency and decreases the risk of falls or other injuries due to poor lighting. At the time of ODP's monitoring in January 2023, the inspector identified that one of the light bulbs was not operational. This light was located between two doors that led outside. The bulb burned out and, that morning, the staff identified the issue during their daily check. However, they were unable access the bulb and maintenance were unable to remedy the issue prior to monitoring. The Residential Property Manager was contacted, and he immediately replaced the outside lightbulb with one that was in working order. No further repairs were needed. To prevent this from happening again, the staff that work in this home were trained on the importance of this regulation and completing the daily Regulation Shift checklist correctly. All staff in the Residential Department have been retrained in regulation #66. 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 Implemented
6400.67(b)REPEAT VIOLATION from 11/1/2021 - At the time of the inspection, the cover to the sump pump located in the basement was off, leaving a hole exposed in the basement floor. Floors, walls, ceilings and other surfaces shall be free of hazards.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. At the time of ODP's monitoring in January 2023, the inspector identified that the cover of the sump pump located in the basement was off. This resulted in a hole being exposed in the basement floor. This happened because whoever took the cover off prior to this failed to return the cover to the sump pump. There is a dehumidifier in the basement and the staff were emptying its contents into the sump pump. The Residential Property Manager was contacted, and he immediately replaced the cover. No further repairs were needed. To prevent this from happening again, staff were instructed to stop pouring the water from the dehumidifier into the sump pump hole, and instead carry the water upstairs to pour out. All staff in the Residential Department have been retrained in regulation #67b. 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 Implemented
6400.46(d)Staff # 1 received First Aid and CPR training on 06/18/19 and not again until 07/23/21.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.This was unable to be remedied for Staff #1 due to not needing another CPR/FA training until 7/2023. All staff were reviewed for compliance with this regulation and all staff will be retrained on this regulation by 6/5/23. Correction Required - Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. This regulation is important to ensure staff are able to respond immediately to medical emergencies in order to protect the health and safety of the individuals supported. Staff #1 completed Part 1 of the blended learning portion of American Red Cross First Aid/CPR/AED Course on 5/31/2021, within the required 2 years. However, staff #2 failed to complete the Part 2 skills test out portion of American Red Cross First Aid/CPR/AED course until 7/23/2021. This resulted in the certification lapsing. This was not noticed by the training manager at the time. This was unable to be remedied for Staff #1 due to not needing another certification until 7/23/23, and they were terminated 1/3/2023. All staff were reviewed for compliance with this regulation and will be retrained on this regulation by 6/5/2023. Beginning in 11/2021, Shadowfax implemented a new training accountability procedure. This procedure states that a weekly report will be run by the electronic learning management system and disseminated to all supervisors that includes a list of trainings, including CPR/FA, that are coming due within the next 28 days. This report will be used for management to track compliance. The electronic learning management system will automatically send weekly reminders of upcoming due dates directly to staff members. 06/05/2023 Implemented
6400.52(c)(5)Staff # 3 did not receive training in Positive Behavior Supports in 2022.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.Staff #3, and all of that same position, will have received this training, appropriate to their assignments, by 6/1/23. Correction Required - The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. This regulation is important to ensure staff working directly with an individual are properly trained to safely support the health, safety, and welfare needs of the individual. It also ensures that staff are knowledgeable of the needs of individuals they work with directly and best practices when directly caring for individuals with intellectual disabilities. Staff member #3 was not trained in the implementation of positive behavior supports in 2022. The job description for staff member #3 does not include direct care, nor do they provide direct support to any individual, which resulted in a misinterpretation of the training requirements for positive behavior supports for that position. Upon clarification of the training requirements, staff #3 and all other staff members of this position were trained in positive behavior supports for all individuals in the residential programs that they oversee. This training was completed and records are kept by the Executive Director of Residential. A new process has been developed and implemented as of 5/25/23, to ensure that all LPNs are receiving training in positive behavior supports for the individuals in the programs that they oversee. This process was confirmed by the Director of Residential. Documentation of this training is kept by the Director of Residential. With the clarification that we have regarding training requirements on positive behavior supports, the training expectations for LPNs have been updated to include that all LPNs will receive training in positive behavior supports for all individuals in the programs they oversee in order to maintain compliance with this regulation moving forward. 06/01/2023 Implemented
6400.52(c)(6)Staff # 3 did not receive training in the implementation of Individual Plans in 2021 or 2022.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Staff #3, and all of that same position, will have received this training, appropriate to their assignments, by 6/1/23. Correction Required - The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. This regulation is important to ensure staff working directly with an individual are properly trained to safely support the health, safety, and welfare needs of the individual. It also ensures that staff are knowledgeable of the needs of individuals they work with directly and best practices when directly caring for individuals with intellectual disabilities. Staff member #3 was not trained in the implementation of the individual plan in 2021 and 2022. The job description for staff member #3 does not include direct care, nor do they provide direct support to any individual, which resulted in a misinterpretation of the training requirements for individual plans for that position. Upon clarification of the training requirements, staff #3 and all other staff members of this position were trained in the individual plans for all individuals in the residential programs that they oversee. This training was confirmed 5/25/23 and records are kept by the Executive Director of Residential. A new process has been developed and implemented as of 5/25/23, to ensure that all LPNs are receiving ISP training for the individuals in the programs that they oversee. This process was confirmed by the Director of Residential. Documentation of this training is kept by the Director of Residential. With the clarification that we have regarding training requirements on individual plans, the training expectations for LPNs have been updated to include that all LPNs will receive ISP training for all individuals in the programs they oversee in order to maintain compliance with this regulation moving forward. 06/01/2023 Implemented
SIN-00210423 Unannounced Monitoring 08/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(b)Individual #1's physician ordered the discontinuance of Ferrous Sulfate on 6/16/22. This medication was not discontinued in the home until 6/21/22.A prescription order shall be kept current.On 6/21/2022, EIM #9043643 was submitted after the identification of this error. The corrective actions identified in the EIM were that the Target staff received remediation with agency LPN and education on following the policies and procedures of discontinuing medications. Target staff also received progressive disciplinary action per Shadowfax Policy. All programs are being evaluated for medication accuracy against third party patient portals. This is being completed by the nursing department. This will be completed by 10/1/22 and documentation of this process will be kept by the Director of Nursing. 11/01/2022 Implemented
SIN-00195613 Unannounced Monitoring 11/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101The living room storm door was not operable at the time of the inspection.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. At the date of the inspection, the living room storm door was repaired to allow appropriate functionality of the door. All other programs will be assessed, by the Associate Director for operable and unobstructed doorways by 12/15/21. 01/01/2022 Implemented
SIN-00185552 Unannounced Monitoring 03/29/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(s)Individuals #1-#3 were not offered their right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of their home. At the time of the 3/29/2021 inspection, none of the individuals were offered this nor did any of their plans indicate that they were offered such locking/unlocking mechanisms or what their wishes were.An individual has the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home.Individuals will have their right to have a locking mechanism to an entry door of their home will be completed by 4/16/2021. The individuals' decisions on their right to have to ability to lock and unlock an entrance door of their home will be documented in their plans. The program specialist will update each individual's assessments by 4/16/2021 to include their decisions. The program specialist will ensure the supports coordinator has the individuals' individual plans updated within 30 days to include the individuals decisions. If at any point the individuals' decisions change, their new decision shall be documented in all plans and granted as such. If the individual chooses to, or their abilities have changed, have access via another locking mechanism other than a key, the home must ensure the individual has an mechanism that suits their needs/wants installed on an entry door of the home immediately. The individuals will be given access to an entry door immediately if that is their decision. This individual right will be reviewed with individuals on an annual basis. 04/16/2021 Implemented
SIN-00155510 Unannounced Monitoring 05/15/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)Four screens were missing from the family room windows. Screens were located on site in the basement.Windows, including windows in doors, shall be securely screened when windows or doors are open. The Shadowfax been direct to follow plan of correction from the previous month and send documentation that this issues has been fixed. 05/17/2019 Implemented
SIN-00105236 Unannounced Monitoring 12/14/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16Interview with staff #1 (Assistant Program Manager) indicates that she ¿thought that they (indivual #1 and other residents) did not like being there really long when they came to visit.. Individual #1 thought that staff forgot her one time.¿ 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.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. 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. If individual # 1 wants to visit another home, it will be shorter in duration and she will be accompanied by a staff from her home to assure her she has not been forgotten. 11/16/2016 Implemented
6400.18(d)On 07/02/16 individual #1 did not receive her 8 am dosage of Calcium 600 vit D400. No incident report was submitted for the medication error. On 07/03/16 individual #1 received her 5 pm dosage of Calcium 600 Vit D400 at 6:30 pm. No incident report was submitted for the medication error. The home shall initiate an investigation of the unusual incident and complete and send copies of an unusual incident report on a form specified by the Department to the county mental retardation program of the county in which the home is located, the funding agency and the appropriate regional office of mental retardation, within 72 hours after an unusual incident occurs. "On 07/03/16 individual #1 received her 5 pm dosage of Calcium 600 Vit D400 at 6:30 pm. No incident report was submitted for the medication error" - This medication has been authorized to be given 2 hours past the prescribed time per the prescribing physician orders. The medication was given in the appropriate time frame and does not require an incident report. See attached Medication Questionnaire Form which states these instructions. The documentation was detailed on the medication record of OOP and medication and charting error form. 7/2/16 - Staff member who did not administer the medication no longer works for the Shadowfax Corporation. An incident report has been written and submitted on 1/13/17. See attached form. The medication trainers will reiterate in all future medication training classes that if a MAR is left blank, that the proper procedure must be followed and a report completed within 72 hours of the incident. All Program specialists are aware if paperwork comes in at the end of the month with an omission to double check HCSIS to ensure a report has been filed. If not, they are responsible to complete the required documentation and subsequent follow up. 01/13/2017 Implemented
6400.33(d)Interviews with staff #1 (part time direct care), saff #3(Assistant Program Manager), staff #1 (Assistant Program Manger) confirm that Individual #1 was not given the choice to participate in program planning or the scheduling of visitations. He/she visited other homes approximately 65 times from August 2016 ¿ November 2016.An individual has the right to participate in program planning that affects the individual.The Shadowfax residential department stopped having individuals visit other homes on11-16-16 when MH-IDD notified us that we could not do this. 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. 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 # 1 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
6400.81(k)(1)An interview with staff #4 on 12/15/16 it was disclosed that Individal #1 was sleeping on weekends in an empty room in the house when sleeping over on weekends. Staff would bring up a cot for he/she to sleep on as there was no bed in the spare bedroom. In bedrooms, each individual shall have the following: A bed of size appropriate to the needs of the individual. Cots and portable beds are not permitted. Bunkbeds are not permitted for individuals 18 years of age or older. Shadowfax no longer has individual # 1 visiting other homes (will not be sleeping at the other home). Individual #1 has her own bedroom and bed that is appropriate per the 6400 regulations. The Shadowfax residential department has stopped having individuals visit other homes. 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 staffing, 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. Moving forward Shadowfax will not have individuals 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. All management staff and staff that work in the homes are aware that homes cannot be combined. Individiuals will never sleep in another home unless they are planning to move to that home and are trying an overnight visit and the visit is documented and approved by all team members. In this case, the bedroom will have a bed that is appropriate to the person's needs. 11/16/2016 Implemented
6400.164(b)Individal #1's 5 pm 07/09/16 dosage of Calcium 600 & Vit D 450 was not signed by staff who administered the medication on the July medication log. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. The staff member that did not sign the Medication Administration Record (MAR) after the administration of the medication has received discipline on 1-18-17. The medication trainers will continue to stress the importance of correct administration of medication procedures and the importance of signing upon administering doses of medications. Moving forward, staff not documenting correctly will be dealt with via progressive disciplinary action. 01/18/2017 Implemented
SIN-00082834 Renewal 07/07/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103The written emergency evacuation procedure for all the individuals that live in the home did not include their 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 23. 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
6400.110(f)Individual #1 was hearing impared and required a bed shaker to alert her in the event of a fire when she was sleeping. The only smoke detector that set off the bed shaker, was located right outside her room. The bed shaker did not activate when any other smoke detector throughout the home was 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. A Safe Awake bed shaker have been purchased to ensure the bed shaker goes off when any smoke detector is set off (currently the bed shaker in use goes off based on one detector and when that alarm is sounded the bed shaker will go off). In the future, the Associate Director will monitor on house visits by testing the alarm system as part of their home visits. See attached for receipts for the bed shakers (Attachment # 20) 09/28/2015 Implemented
SIN-00219403 Unannounced Monitoring 02/08/2023 Compliant - Finalized
SIN-00215259 Unannounced Monitoring 11/21/2022 Compliant - Finalized
SIN-00206450 Unannounced Monitoring 06/09/2022 Compliant - Finalized
SIN-00205805 Unannounced Monitoring 05/31/2022 Compliant - Finalized
SIN-00198628 Unannounced Monitoring 01/11/2022 Compliant - Finalized
SIN-00190739 Unannounced Monitoring 07/29/2021 Compliant - Finalized
SIN-00174685 Unannounced Monitoring 08/04/2020 Compliant - Finalized
SIN-00170344 Unannounced Monitoring 01/15/2020 Compliant - Finalized
SIN-00164217 Unannounced Monitoring 10/10/2019 Compliant - Finalized
SIN-00106594 Renewal 11/30/2016 Compliant - Finalized