Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00217249 Unannounced Monitoring 01/09/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)REPEAT VIOLATION from 11/1/2021 - Floor rug located in Individual #2's bedroom was covered in debris and in need of cleaning.Clean and sanitary conditions shall be maintained in the home. 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 - Clean and sanitary conditions shall be maintained in the home. This regulation is important because it protects both individuals and staff from illness, infection, injury, and also provides the individuals with a dignified living environment. In January 2023 when ODP monitored the home, there seemed to be debris of an unknown origin on Individual #2's sensory rug on the floor of his bedroom. The inspector felt that it was in need of cleaning. Since the debris was unknown, it is not possible to say how it happened, or when it occurred. There is a daily shift checklist that is done once a day and this debris was not noted on this checklist. Once it was discovered however, and that it was not able to be cleaned, the sensory carpet was dispositioned and thrown out. To prevent this occurrence from happening again, all staff in the Residential Department have been retrained in regulation #64a. 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
6400.112(d)On 3/24/22 the fire drill conducted was not completed within 2.5 minutes. The fire drill record shows that it took 2 minutes and 57 seconds. The drill was not repeated that month to be in compliance with this regulation. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. 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. Issue Identified -- On 3/24/22 the fire drill conducted was not completed within 2.5 minutes. The fire drill record shows that it took 2 minutes and 57 seconds. The drill was not repeated that month to be in compliance with this regulation. Correction Required - Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. This regulation is important because the ability to evacuate a home in an appropriate time helps prevent serious injury or death, in the event of a fire. In March of 2022, there was a fire drill conducted in which the individuals living in the home did not evacuate in the two and a half minutes, as defined in this regulation. This should have resulted in a repeated fire drill during that month to ensure that the inability to evacuate in an appropriate time was not an anomaly. This repeated fire drill did not occur; however, the subsequent monthly drills were successfully completed in the appropriate time. This should have been identified by regular checks of the fire drills by the Associate Director and the staff conducting the drill appeared to be unaware of the timeframe necessitated for a successful evacuation. All staff working in this home will have been retrained in this regulation and the associated expectations by 6/5/23, reinforcing the need to evacuate within 2.5 minutes. Documentation of this training will be kept 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 in under 2.5 minutes. 06/05/2023 Implemented
SIN-00211279 Unannounced Monitoring 09/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)During this inspection, there were multiple brown substance stains on the bathroom floor near the shower chair. The bathroom floor also had dust and particles in the corners of the floor.Clean and sanitary conditions shall be maintained in the home. On 9/12/22, this issue was rectified at this location. By 10/31/22, all staff will be retrained on this regulation and records of this training will be kept by the Director of Residential. 10/31/2022 Implemented
6400.82(f)During the inspection, there were no paper towels or individual hand towels available in the full bathroom on the left side of the home. There was also no toilet paper available in the full bathroom on the left side of the home.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. On 9/12/22, this issue was rectified at this location. By 10/31/22, all staff will be retrained on this regulation and records of this training will be kept by the Director of Residential. 10/31/2022 Implemented
SIN-00210421 Unannounced Monitoring 08/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.143(a)Individual #2 has prescribed home physical therapy to complete. Individual #2 routinely refuses to complete these exercises. There is no documentation of the continued attempts to train Individual #2 in the importance of this medical order.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. On 8/22/22, the daily documentation for Individual #2 included a question, that was added, requiring staff to document that a discussion with Individual #2 took place, if the physical therapy had been refused. 11/01/2022 Implemented
6400.144Individual #1 had a follow-up appointment with their physician on 7/22/22 regarding repeated constipation issues. At this time, the physician recommended that Individual #1 receive a colonoscopy to determine the source of Individual #1's repeated bowel issues. As of the 8/24/22 inspection, this procedure has not been scheduled or repeated.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. LPN is in ongoing communication with the physician, ordering a colonoscopy, to attempt to identify an alternative that is amenable to the intent of the order and Individual #1. 11/01/2022 Implemented
6400.18(a)(5)Individual #1's morning Depakote dosage was reduced from 750mg to 500mg on 6/7/22 by Individual #1's physician. This reduction in dosage was not implemented for Individual #1 at their home. This was discovered by staff person #1 on 7/7/22. This neglect incident was not reported in EIM until 7/21/22 at 10:31am.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Neglect. On 7/21/2022, EIM #9059052 was submitted after the identification of this error. The corrective actions identified in the EIM were that the appropriate staff would be retrained on the existing policy and/or procedure with an evaluation of its effectivenes. The Target resigned prior to the completion of the investigation. Had the target not resigned, they would have received progressive discipline and the aforementioned reeducation. On 7/21/22, Individual #1 had their Valproic Acid levels checked, per doctors order, to evaluate if further actions were needed. 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
6400.18(f)Staff person #1 discovered that Individual #1 had been receiving the wrong dose of medication on 7/7/22, however, Individual #1's doctor was not contacted until 7/20/22 and the medication was not discontinued until 7/20/22. Individual #1 was not taken for follow-up required blood work ordered by the physician until 7/21/22. The Shadowfax Corporation delayed seeking medical attention for Individual #1 after discovering the wrong dose of medication was being given for 13 days after the incident was discovered, which did not protect the heath, safety, and well-being of the individual.The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident.On 7/21/2022, EIM #9059052 was submitted after the identification of this error. The corrective actions identified in the EIM were that the appropriate staff would be retrained on the existing policy and/or procedure with an evaluation of its effectivenes. The Target resigned prior to the completion of the investigation. Had the target not resigned, they would have received progressive discipline and the aforementioned reeducation. On 7/21/22, Individual #1 had their Valproic Acid levels checked, per doctors order, to evaluate if further actions were needed. 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
6400.18(g)An investigation for the neglect incident that was discovered for Individual #1 on 7/7/22 did not begin until 7/21/22.The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person.On 7/21/2022, EIM #9059052 was submitted after the identification of this error. The corrective actions identified in the EIM were that the appropriate staff would be retrained on the existing policy and/or procedure with an evaluation of its effectivenes. The Target resigned prior to the completion of the investigation. Had the target not resigned, they would have received progressive discipline and the aforementioned reeducation. On 7/21/22, Individual #1 had their Valproic Acid levels checked, per doctors order, to evaluate if further actions were needed. 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
6400.32(c)On 6/6/22 at 3:08pm, a medication renewal request was sent to Individual #1's prescriber for a refill of Depakote 250mg from Shadowfax One. At 3:11pm on the same date, a message was sent from Shadowfax One to the prescriber to confirm the medication prescription for the pharmacy. On 6/7/22 at 754am, a confirmation was received from Individual #1's physician indicating that Depakote 250mg once daily in the morning was to be discontinued and that the Individual should only be receiving 500mg in the morning and 1000mg in the evening. Individual #1's 250mg dose of Depakote was not discontinued in the home until 7/20/22. Additionally, Staff person #1 discovered that Individual #1 had been receiving the wrong dose of medication on 7/7/22, however, Individual #1's doctor was not contacted until 7/20/22 and the medication was not discontinued until 7/20/22. Individual #1 was not taken for follow-up required blood work ordered by the physician until 7/21/22. The Shadowfax Corporation delayed seeking medical attention for Individual #1 after discovering the wrong dose of medication was being given for 13 days after the incident was discovered. The initial failure to update Individual #1's medications and Medication Administration Records in the home, as well as the delay in seeking care for the individual when an error was recognized is neglectful and created conditions that could have led to a serious health risk for Individual #1.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.On 7/21/2022, EIM #9059052 was submitted after the identification of this error. The corrective actions identified in the EIM were that the appropriate staff would be retrained on the existing policy and/or procedure with an evaluation of its effectivenes. The Target resigned prior to the completion of the investigation. Had the target not resigned, they would have received progressive discipline and the aforementioned reeducation. On 7/21/22, Individual #1 had their Valproic Acid levels checked, per doctors order, to evaluate if further actions were needed. 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
6400.167(a)(3)On 6/6/22 at 3:08pm, a medication renewal request was sent to Individual #1's prescriber for a refill of Depakote 250mg from Shadowfax One. At 3:11pm on the same date, a message was sent from Shadowfax One to the prescriber to confirm the medication prescription for the pharmacy. On 6/7/22 at 754am, a confirmation was received from Individual #1's physician indicating that Depakote 250mg once daily in the morning was to be discontinued and that the Individual should only be receiving 500mg in the morning and 1000mg in the evening. Individual #1's 250mg dose of Depakote was not discontinued in the home until 7/20/22.Medication errors include the following: Administration of the wrong dose of medication.On 7/21/2022, EIM #9059052 was submitted after the identification of this error. The corrective actions identified in the EIM were that the appropriate staff would be retrained on the existing policy and/or procedure with an evaluation of its effectivenes. The Target resigned prior to the completion of the investigation. Had the target not resigned, they would have received progressive discipline and the aforementioned reeducation. On 7/21/22, Individual #1 had their Valproic Acid levels checked, per doctors order, to evaluate if further actions were needed. 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
6400.167(d)(1)The medication error described in 6400.167a3 was discovered by staff person #1 on 7/7/22. Individual #1's physician was not contacted until 7/20/22.A medication error shall be reported to the prescriber under any of the following conditions: As directed by the prescriber.On 7/21/2022, EIM #9059052 was submitted after the identification of this error. The corrective actions identified in the EIM were that the appropriate staff would be retrained on the existing policy and/or procedure with an evaluation of its effectivenes. The Target resigned prior to the completion of the investigation. Had the target not resigned, they would have received progressive discipline and the aforementioned reeducation. On 7/21/22, Individual #1 had their Valproic Acid levels checked, per doctors order, to evaluate if further actions were needed. 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-00198633 Unannounced Monitoring 01/11/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The grout between tiles of the Individuals #1's and #2's bathroom shower floor, located on the floor by the entrance to shower, has cracked.Floors, walls, ceilings and other surfaces shall be in good repair. On 1/19/22, the floor seam was re-caulked to ameliorate the crack in the grout outside of Individuals #1's and #2's bathroom shower. All homes will be assessed for current compliance with this regulation by 2/15/22. All staff working in this home will be re-trained on this regulation by 3/1/22. Documentation of this training will be kept 03/01/2022 Implemented
SIN-00195593 Unannounced Monitoring 11/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(9)Individual #1 has not had a prostate exam nor a PSA test since turning age 40 on 9/5/21. A prostate exam nor a PSA test has been scheduled as of the date of the inspection on 11/2/21.The physical examination shall include: A prostate examination for men 40 years of age or older. On 11/8/21, a letter was acquired from the PCP, specific to Individual #1, that states that he does not need a prostate exam or PSA until the age of 50 All individual files will be evaluated for compliance with the PSA or prostate exam guidelines for 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
6400.144(Repeat from Inspections dated 7/27/20 and 8/4/20) Individual #1 has a bowel movement protocol in which the Individual is to take medication on the morning of day 5 with no bowel movement for four days. 12/22/20, Individual #1 went 4 days with no bowel movement. Individual #1 did not receive a dose of Senexon-S on the morning of 12/23/20. Individual #1 was administered Senna Plus on 8/30/21. However, that was only Day 4 with no BM. The first dose of Senna Plus was to be administered on 8/31/21. Individual #1 went three more days with no bowel movement. There is no documentation the PCP was contacted as per the BM protocol.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 with Individual #1 will be retrained, by the program specialist, on the Bowel Movement (BM) protocol by 12/31/21. 01/01/2022 Implemented
6400.34(a)Individual #1 had their rights reviewed on 1/25/19 and not again until 1/25/21. 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
6400.163(h)On, 1/18/21, Individual #1's doctor prescribed the individual to take a quarter of a bottle of Magnesium Citrate beginning that day every two hours until the individual has a bowel movement. The individual was administered four doses of medication: 3 on 1/18/21 and 1 on 1/19/21. The medication was still in the home at the time of the inspection on 11/3/21. The medication is not on the Individual's approved list of OTC medications.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-00189495 Unannounced Monitoring 06/29/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Individuals residing in the home are assessed to be unsafe around poisonous materials. During the 6/29/2021 inspection of the home, Microban 24 hour antibacterial spray that contained a label stating to contact poison control center if ingested, was unlocked and accessible sitting on the toilet in the foyer hallway.Poisonous materials shall be kept locked or made inaccessible to individuals. Individuals will be assessed of their ability to avoid poisonous substances at least annually, and again throughout the year if any concerns arise. Poisonous materials will be locked immediately. Every staff shift change will ensure poisonous materials are locked or made inaccessible to individuals, and document their checks immediately. Continual monitoring by staff will occur throughout the day to ensure poisonous materials are inaccessible. 06/30/2021 Implemented
SIN-00187233 Unannounced Monitoring 04/21/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #2 is to have a mechanical soft diet and avoid tough meats, nuts, seeds, raw fruits and vegetables, and dried fruit. Individual is also to get 3 servings of vegetables and 2 servings of fruits daily, only eat brown rice and wheat bread, and limit 3 servings per day of potato, pasta, bread and rice. Individual is to limit beef or pork to one time per week, cheese to one time per day, chocolate to one time per week, and fried foods to one time per month. Individual is to eat chicken, fish, lentils and beans for protein and to not have grapefruit or fruit juices. There were numerous occasions in March and April 2021 where individual #2 had raw fruits as well as eating beef and pork multiple times per week in the form of sausage, bacon, hamburgers, and pork chops.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
6400.52(c)(6)Staff person #1 works in this home and has not been trained in Individual #1's specific dietary needs.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.All staff must be trained in an individual's specific dietary needs before working in a home to ensure the health and safety of all individuals. All staff who are currently not trained will be trained by 5/11/21 or will not work with that individual until training is complete. Beginning immediately, ALL staff will be trained in individual dietary needs prior to their first shift in a new home or where a new protocol is implemented. 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. Staff will be trained on updates/changes prior to working their first shift with individual. 05/11/2021 Implemented
SIN-00183887 Unannounced Monitoring 02/25/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)The shared bathroom in the home did not have hand soap available as required by regulation.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. The DSP will check all of the bathrooms in the home at the start of their shifts to assure the bathrooms have all needed items. If there are items missing from the bathrooms, the DSP will immediately replace the items or notify the supervisor that the items need purchased as soon as possible. 03/08/2021 Implemented
SIN-00167175 Unannounced Monitoring 12/03/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Individual #1's dresser is broken and missing the second drawer on the right side.Floors, walls, ceilings and other surfaces shall be in good repair. The dresser was temporarily repaired and a new dresser was ordered and awaiting delivery. Staff were educated on the regulation and will complete a physical site regulations checklist 1x a week to ensure compliance. The Associate Director will ensure compliance with the checklists being completed. 12/04/2019 Implemented
6400.182(c)Individual #2's Individual Support Plan (ISP) is outdated (8/15/18) and his current ISP was not available at his home during the inspection.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The current isp was printed and placed in the home on 12/3/2019. The Program Specialists will complete a home visit once a month to all homes to ensure compliance with this regulation. The Director will enusre these visits are are completed 12/11/2019 Implemented
SIN-00163843 Unannounced Monitoring 09/27/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.214(b)Individual #1's current copy of his Individual Support Plan (ISP) and annual ISP signature sheet was not located in his record at his home during the 9/27/19 onsite inspection. The ISP located in his home was last updated on 9/17/18. According to the electronic system where the ISP's are generated, there has been 9 updates made to his plan, including the annual update. The copy of the annual ISP meeting signature page for those in attendance of his 2019 ISP meeting was not at the home. 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 ISP is located in the residence. They will conduct monitoring and sign off on a document that states they have completed this step monthly. 10/31/2019 Implemented
SIN-00164529 Unannounced Monitoring 08/15/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144The medication Divalproex 125mg was not administer to individual #1on 8/11/19 at 9pm and 8/15/19 at 9pm. EIM report #8586839 was filed. The medication Simvastatin 20mg was not administered to individual #1at 8pm on 8/13/19. EIM report #8586307 was filed. The medication Qvetiapine 300mg was not administered to individual #1 at 9pm on 8/15/19. EIM report #8623064 was filed. The medication Carafate was not given as ordered beginning 7/23/19 due to insurance not covering medication and able to get from pharmacy. EIM report #8586746 was filed.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. Staff responsible for the medication errors received education and/or discipline as this is the procedure for all staff responsible for any error. Medication checks were increased for all homes with a high amount of medication errors. Daily medication checks will be completed in all homes. 12/23/2019 Implemented
6400.151(c)(2)Staff #1 DOH is 4/8/19. Her TB test was read as negative on 3/22/19; however, it is documented as being read by a Registered Medical Assistant. This staff person was relieved of her duties until she had her TB test retaken and met regulatory guidelines. Additional staff that had their TB results read by a registered medical assistant and also relieved of their duties that same day until redone included staff #2, staff #3, and staff #4. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Staff that were relieved of duties did not return until they had a new TB test that was read by the appropriate medical professional. The Agency staff physical form was updated to include what medical professional is approved to read the TB. The HR staff was educated on the regulations related to the staff TB test. 08/30/2019 Implemented
6400.165(c)The medication Divalproex 125mg was not administer to individual #1on 8/11/19 at 9pm and 8/15/19 at 9pm. EIM report #8586839 was filed. The medication Simvastatin 20mg was not administered to individual #1at 8pm on 8/13/19. EIM report #8586307 was filed. The medication Qvetiapine 300mg was not administered to individual #1 at 9pm on 8/15/19. EIM report #8623064 was filed. The medication Carafate was not given as ordered beginning 7/23/19 due to insurance not covering medication and able to get from pharmacy. EIM report #8586746 was filed.A prescription medication shall be administered as prescribed.Staff responsible for the medication errors received education and/or discipline as this is the procedure for all staff responsible for any error. Medication checks were increased for all homes with a high amount of medication errors. Daily medication checks will be completed in all homes. 12/23/2019 Implemented
6400.186Individual #1 has a diagnosis of PICA. There is no documentation of the PICA charts in his record for the months May 2019, June 2019, and July 2019.The home shall implement the individual plan, including revisions.The staff were educated on the PICA chart and the importance of documentation. Upon implementation of any new chart, the staff will be educated on how to complete the chart. The Program Specialists do monthly visits to monitor the charts and will review all completed charts within 30 days of the end of the month. 12/17/2019 Implemented
SIN-00151259 Unannounced Monitoring 03/06/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The dishwasher in the kitchen was difficult to open, broken, and had foul smelling stagnate water accumulated inside that had not been previously drained once staff discovered it was inoperable.Floors, walls, ceilings and other surfaces shall be in good repair. Reference previous POC issued by the department. 04/05/2019 Implemented
6400.67(b)The Mirrors in both bathrooms had metal brackets on either side of the mirror sticking straight out and presents a potential hazard should an individual stumble and fall against the mirror. Floors, walls, ceilings and other surfaces shall be free of hazards.Reference previous POC issued by the department. 04/05/2019 Implemented
6400.80(a)There was an accumulation of ice along the length of the inside railing of the front porch. Outside walkways shall be free from ice, snow, obstructions and other hazards. Reference previous POC issued by the department. 04/05/2019 Implemented
SIN-00105238 Unannounced Monitoring 12/14/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.45(e)Individual # 1 was interviewed on 12/14/16. Individual # 1 reported that there are supposed to be 2 staff in the home and it is pretty frequently that there is not enough staff. Individual # 1 reports that there is only one staff at a time in the home. Individual # 1 reported that he told staff # 1 that there is not enough staff since Individuals 2, 3, and 4 need help getting dressed. An individual may not be left unsupervised solely for the convenience of the residential home or the direct service worker.This home is double staffed on a regular basis. Individual # 1 reports that "there is only one staff at a time in the home." As evidenced by the randomly chosen attached schedule cards (for the month of Sept into October), individual # 1 provided inaccurate information during his interview. Individual # 1 has a history in which he will misconstrue the actual facts. This home has had 2 staff on the majority of the time in the morning and in the evenings (see attached documentation). The Shadowfax residential department has trained all managers and schedulers that this home is to be double staffed the majority of the time. . Residential has instituted sign on bonuses to hire more staff, have offered bonus pay to fill shifts, have worked with a temp agency 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. Moving forward Shadowfax will continue to ensure this home is double staffed the majority of the days to help care for the individuals needs. 11/16/2016 Implemented
SIN-00236060 Renewal 12/12/2023 Compliant - Finalized
SIN-00202699 Unannounced Monitoring 03/31/2022 Compliant - Finalized
SIN-00106596 Renewal 11/30/2016 Compliant - Finalized