Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00231086 Renewal 09/14/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.34(a)Individual Rights were reviewed with and signed by Individual #1 but the Rights statement that was reviewed was not complete and did not reflect all the current rights afforded to individuals as documented in the current Chapter 6400 regulations. The individual rights that are missing include: 32c, 32e ,32f, 32g, 32i, 32p, 32q, 32r1-5 32s, 32s1-3 and 32t.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.On 9/19/23, The individual rights statement was updated to include 32c, 32e ,32f, 32g, 32i, 32p, 32q, 32r1-5 32s, 32s1-3 and 32t. Updated Individual Rights were reviewed with and signed by the individuals between 9/19/23 to 9/29/23. 09/19/2023 Implemented
6400.165(c)At time of inspection on 9/15/23 medications for Individual #1 included: Best Fiber sugar free powder- "Give 1 scoop by mouth every morning before breakfast for constipation." At time of inspection on 9/15/23 there was no "scoop" available in the home. Staff #2 stated that a one teaspoon measuring spoon was used to measure and administer the medication. The manufacturer recommended dose on the manufacturer label was 2 teaspoons. Pharmacy label notes that it was filled on 6/27/23 and that there were three bottles provided. Staff #1 noted that bottles one and two had already been used and discarded with the in-use bottle #3 being half full. Manufacturer label notes that each bottle contains 62 doses; the two bottles reported to have been used would have contained 124 doses. At time of inspection the calendar allows for only 80 doses to have been administered between 6/27/23 and 9/15/23. Haloperidol Oral Solution USP (Concentrate)- "Take 2.5ml(S) by mouth daily (5mg) for mood/psychosis." The Haloperidol bottle contained a clearly marked measuring dropper. When asked how the medication was administered Staff #3 indicated that staff would draw medication into the dropper than squirt it into a medication cup. The medication cup used did not have a 2.5ml line. The medication cup in use had a 5 ml line. Staff #3 explained that they would squirt medication into the cup halfway between the bottom of the medication cup and the 5ml line. Staff estimating the position of the 2.5ml line for each administration would not produce consistent and prescribed doses of the medication. Medications shall be administered as prescribed.A prescription medication shall be administered as prescribed.On 9/15/23, Program Specialist replaced the scoop and the dropper. 09/15/2023 Implemented
SIN-00210659 Unannounced Monitoring 08/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)Individual#4's funds are not being used for the individual's benefit. On 8/3/22, Individual purchased 3 packages of Hug Ref 3x (wipes refills) at $5.82 each and HG Ref 10x (wipes refill) at $15.27. Individual #4 is prescribed Ensure and on 8/4/22, they purchased Ensure at Giant for $19.98. These items should not be purchased using individual's funds as they would be included in Room and Board.Individual funds and property shall be used for the individual's benefit. On 8/29/22, SCS conducted an internal audit of individual petty cash logs to ensure that funds are used for the benefit of the individuals. On 9/8/22, a check was issued to the individual in the amount of $68.70. On 9/8/22, all staff working, at this location, were retrained by Program Services Lead on utilizing individual funds and property for the benefit of the individual. 09/08/2022 Implemented
6400.67(a)The top front piece of kitchen drawer located to the left of the dishwasher was loose, and not attached to the right side of the drawer. Surfaces shall be in good repair.Floors, walls, ceilings and other surfaces shall be in good repair. On 8/26/22, the top front piece of kitchen drawer located to the left of the dishwasher was repaired. 08/26/2022 Implemented
6400.111(f)A fire extinguisher shall be inspected and approved annually by a fire safety expert. The fire extinguisher located in the kitchen and the fire extinguisher located in the attic inspection tags were dates 7/21, and the fire extinguisher located in the basement tag was dated 6/21.This exceeds the requirement. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. On 8/30/22, a local Fire Protection company inspected and approved all fire extinguishers at this location. The date of service is on the fire extinguishers. In addition, every fire extinguisher in SCS programs was checked and is up-to-date. On 9/8/22, staff were retrained on the importance of meeting requirement for all fire extinguishers. 08/30/2022 Implemented
SIN-00193974 Unannounced Monitoring 10/05/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)The individuals at this residence aren't safe with poisons. In the bathroom on the main level was a bottle of hand sanitizer. The label stated, "if swallowed, seek medical help or contact poison control." This must be kept locked.Poisonous materials shall be kept locked or made inaccessible to individuals. House Managers and DSPs are responsible for assuring that all poisonous materials are kept safely away from individuals as required by their ISPs. Both of the individuals in this home are considered poison safe, however, the ISP states that we do lock the poisons in the home. Residential Supervisors are responsible for checking on this during their weekly visits to assure any poisonous materials are locked no matter where they are in the home. This container of hand sanitizer was immediately removed during inspection. The existence of unlocked chemicals was checked in remaining homes across the region on 10/8/21 and none were present, but staff were trained across the region. 12/01/2021 Implemented
6400.165(c)Individual #5's Melatonin is not being administered as prescribed. Her October Medication Administration Record (MAR) states: Melatonin (5mg) take 1 tablet QD at 8pm. The package for Melatonin states "Melatonin (5mg) take 2 tablets (10mg) at 8pm.A prescription medication shall be administered as prescribed.Updated MAR information was sent to the corporate office and added to the MAR 10/6/21 to correct the instructions on the MAR. All EOPS and House Managers are trained and responsible for checking for matching labels and MAR, and for sending and changes to label information to our corporate contact to be added to the MAR permanently until discontinued so the MAR will show correct and current medication information. The Residential Supervisor has final sign off on shadowing and preparedness of staff to work in the home. All staff, regardless of position, are required to be undergo Medication Administration Training before working in the home alone during a medication administration time. All staff are trained by a licensed Medication Administration Trainer within the company, including two onsite observations, before administering any medication to individuals. 10/05/2021 Implemented
6400.166(a)(11)Individual #5 is prescribed the following medications: Acetaminophen (650mg) PRN, Calcium/D (600-400mg) BID, Carbamazepine (200mg) BID, Cerovite (1 tablet) QD, Citalopram 20mg) QD, Colace Clear (50mg) PRN, Gabapentin (300mg) BID, Lansoprazole 30mg) QD, Melatonin (5mg) QD, Metoprolol (50mg) BID, Oxybutynin Syrup (5mg/5ml) BID, PEG 3350 Powder (17gm) PRN, Risperidone (0.5mg) QD, Tussin DM (5ml) PRN, and Zolpidem (5mg) PRN. There is no diagnosis or purpose for these medications listed on her Medication Administration Record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Residential Supervisor contacted pharmacy to have new labels made including the reason for the medication on 10/11/21.This is being done in conjunction with the prescribing physicians. All EOPS and House Managers are trained and responsible for adding new medications prescribed to the MAR and sending the label information to our corporate contact to be added to the MAR permanently until discontinued so the MAR will show correct and current medication information. The Residential Supervisor has final sign off on shadowing and preparedness of staff to work in the home. All staff, regardless of position, are required to be undergo Medication Administration Training before working in the home alone during a medication administration time. All staff are trained by a licensed Medication Administration Trainer within the company, including two onsite observations, before administering any medication to individuals. 11/05/2021 Implemented
SIN-00083670 Renewal 09/01/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(c)Individual #1 is prescribed medications to treat her psychiatric illness. Individual #1 received a med check on 6/4/2014 and again on 4/7/2015. On two different occasions, the residential staff noted that they were unable to take individual #1 to her schedule psych appointments due to them not knowing she had an appointment scheduled. The medication continued to be refilled by the doctor without documentation of the reason for the prescribed medication, the need to continue the medication and the necessary dosage being documented between the 10 month period. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Individual #1 had her med check/psych appointment rescheduled for September 16, 2015 and it occurred on that date. All consumer records were audited for the past fiscal year to ensure that no other appointments were missed, and if so to have those appointments completed. It was found as noted in #2 above that one additional appointment was missed by another individual, that appointment was rescheduled and occurred on September 16, 2015. In order to ensure greater compliance with appointments, the following process has been set up and is now in place: All consumer appointments are logged on master list by Program Specialist or designee. The system used for the master appointment list (current system is Outlook) sends reminder email and notices to SDSP, Program Specialist, and Residential Supervisor with date, time, and location of consumer appointment. SDSP updates on daily report/log that appointment occurred and if not provide a reason and a date for rescheduling. The SDSP or designee provides the MVR (Medical Visit Report) to the Program Specialist or designee to be entered on the master list to log next visit. All consumer appointments are reviewed in bi-weekly SDSP meetings attended by the Program Specialist, Residential Supervisor, and Regional Director. By January 1, 2016 a form will be built for use in CREDIBLE that functions in a similar manner to OUTLOOK. This form will also have consumer demographic information that can be printed and taken to the appointment. 09/16/2015 Implemented
SIN-00076149 Unannounced Monitoring 03/10/2015 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(a)On 2/27/2015, Individual #1 was in the living room pacing. Staff #1 was in the kitchen preparing cubed steak in a crock pot for dinner. Staff #2 was in a bedroom of the home folding clothes. Staff #1 left the filled crock pot on the kitchen counter and went into the bedroom to get assistance from Staff #2 with opening a jar. Individual #1 remained pacing in the living room and could not be seen from the bedroom by Staff #1 or Staff #2. When Staff #1 returned to the kitchen, Individual #1 was not in the living room. It was reported that Individual #1 was lying on the couch in the dining room and appeared to be turning blue. Staff #1 yelled to Staff #2 for assistance. Staff #2 began CPR and Staff #1 called 911. Individual #1 passed away due to choking on a piece of steak. Individual #1 was a known choking risk. Individual #1 was hospitalized on 1/12/15 for aspiration pneumonia and respiratory failure due to a choking incident. On 2/3/15, Individual #1 was seen by her Primary Care Physician and was diagnosed with dysphagia/swallowing trouble. Individual #1 has a diet protocol that states she cannot be alone when eating and that she does not chew properly. The Individual Support Plan states that Individual #1 is a safety risk as she is ¿food driven¿ and will grab food from the stove top and oven. The Restrictive Procedure Plan states that Individual #1 should be closely monitored while staff is cooking, especially when she is in the living room. If Individual #1 begins pacing or peeking into the kitchen excessively, she should be redirected immediately. Staff#1 and Staff #2 did not provide adequate supervision as defined by the needs of Individual #1 and specified in her program plans. An individual may not be neglected, abused, mistreated or subjected to corporal punishment. Plan of Correction exceeded character limit. Licensing Inspection Summary is on file. Not Implemented
6400.167(b)Individual #1 receives Ativan 1.5mg three times daily for anxiety. Individual #1 did not receive this medication on 2/25/15, 2/26/15, and 2/27/15 because the medication was not available in the home. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.There was a HCSIS report # 7184773 entered for 2/25 and 2/26. Our Pharmacy attempted to contact the prescribing doctor that they needed a new prescription. When the doctor did not respond with a new script, the pharmacy contacted the house manager (SDSP). The SDSP then contacted that prescribing doctor on 2/22/2015. The doctor was on vacation. The pharmacy was notified that the SDSP spoke to the doctor¿s office. The Pharmacy did not receive and deliver the script until 4pm on 2/27/2015. Documentation of the pharmacy delivery will be sent via email to licensing. All medication errors will be documented as soon as we discover the error. We will be proactive in assuring a that all refill prescriptions are obtained prior to any individual going with out a medication. If we are unable to receive a prescription from the prescribing physician as needed we will take the individual to urgent care or the ER to assure continual suppy while we continue to work with the doctors office to receive the necessary prescription. In addtion we have signed a contract with a new pharmacy on 3/13/15. We have been assigned a liason who is personally going out to meet all of our prescriving doctors to establish a relationship. She will also be another avenue to help us to work with doctors office should anything like this occur in the future. 02/27/2015 Implemented
SIN-00079145 Unannounced Monitoring 03/10/2015 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(a)On 2/27/2015, Individual #1 was in the living room pacing. Staff #1 was in the kitchen preparing cubed steak in a crock pot for dinner. Staff #2 was in a bedroom of the home folding clothes. Staff #1 left the filled crock pot on the kitchen counter and went into the bedroom to get assistance from Staff #2 with opening a jar. Individual #1 remained pacing in the living room and could not be seen from the bedroom by Staff #1 or Staff #2. When Staff #1 returned to the kitchen, Individual #1 was not in the living room. It was reported that Individual #1 was lying on the couch in the dining room and appeared to be turning blue. Staff #1 yelled to Staff #2 for assistance. Staff #2 began CPR and Staff #1 called 911. Individual #1 passed away due to choking on a piece of steak. Individual #1 was a known choking risk. Individual #1 was hospitalized on 1/12/15 for aspiration pneumonia and respiratory failure due to a choking incident. On 2/3/15, Individual #1 was seen by her Primary Care Physician and was diagnosed with dysphagia/swallowing trouble. Individual #1 has a diet protocol that states she cannot be alone when eating and that she does not chew properly. The Individual Support Plan states that Individual #1 is a safety risk as she is ¿food driven¿ and will grab food from the stove top and oven. The Restrictive Procedure Plan states that Individual #1 should be closely monitored while staff is cooking, especially when she is in the living room. If Individual #1 begins pacing or peeking into the kitchen excessively, she should be redirected immediately. Staff#1 and Staff #2 did not provide adequate supervision as defined by the needs of Individual #1 and specified in her program plans. An individual may not be neglected, abused, mistreated or subjected to corporal punishment. Plan of Correction on File. Exceeded 4000 character limit. 01/01/1900 Not Implemented
6400.167(b)Individual #1 receives Ativan 1.5mg three times daily for anxiety. Individual #1 did not receive this medication on 2/25/15, 2/26/15, and 2/27/15 because the medication was not available in the home. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.Plan of Correction on File. Exceeded 4000 character limit. 04/03/2015 Implemented
SIN-00138199 Renewal 07/24/2018 Compliant - Finalized