Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00221007 Renewal 03/14/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.66The exterior light at the outside doorway at the side of the home is inoperable.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes, that are used by individuals shall be lighted to assure safety and to avoid accidents.LSP had exterior light installed outside of the doorway at the side of the home on 3/29/23. (Photo sent) 03/29/2023 Implemented
6500.74The exterior stairs leading to the front porch of the home did not have a nonskid surface. The interior basement stairs of the home did not have a nonskid surface.Interior stairs and outside steps that are accessible to individuals shall have a nonskid surface.LSP installed non-skid strips to the basement stairs on 3/29/23 and on the porch stairs on 3/30/23.(Photos sent). 03/29/2023 Implemented
6500.183Individual #1's most current record information was not kept at the family living home.Copies of the most current record information required in §6500.182(c)(1)¿(14) (relating to individual records) shall be kept in the family living home.The Specialist compiled a binder for each person receiving Life Sharing Supports that contains current copies of their information as required by the regulations. This will be presented to the LSP and will be reviewed that it is current and being kept in the home on each monthly home visit. This has occurred for this home on 3/30/23. 03/30/2023 Implemented
6500.136(a)(7)The medication label for Risperidone 1MG/ML solution prescribed to Individual #1 reads, "take 0.5ML (0.5mg) in the morning and 1ML (1mg) in the evening daily via feeding tube. Individual #1's March 2023 Medication Administration Record reads, "take 0.5ML (0.5mg) in the morning and 1.5ML (1.5mg) in the evening a day via feeding tube."A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.Achieva¿s Clinical Team Nurse corresponded with Dr. Taylor, Dr. Uribe (PCP) and CVS Pharmacist beginning on 3/17/23 to ascertain how the discrepancy between the Risperdone label and the MAR occurred. Dr. Taylor is the prescribing physician and did not change the order. It was discovered that the PCP sent orders to CVS for the Rispersdone unbeknownst to Achieva or Dr. Taylor. It was confirmed with the PCP that [Individual #1] is taking the correct dosage of Risperdone as stated on the MAR, which is the dosage prescribed by Dr. Taylor since 9/16/21. The PCP agreed to discontinue their oder. This is what was required by CVS to make the label change to correctly reflect the prescribed dosage of 1.5mg of Risperdone. The MAR and label are both correct as of 4/3/23. (Photos of Label, MAR, and Clinical team documentation have been sent.) 04/03/2023 Implemented
SIN-00166718 Renewal 11/25/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.109(f)The quarterly fire drills completed 1/26/19, 4/02/19, 7/15/19 and 10/06/19 used the front door as the exit route. There are alternate exit routes on the side and back of the home.Alternate exit routes shall be used during fire drills.The Life Sharing Specialist will review with each Life Sharing Provider that alternate exits must be used during fire drills. The Life Sharing Specialist will discuss quarterly fire drills with each Life Sharing Provider, so that they may plan drills to ensure alternate exits are used. The Life Sharing Specialist will keep a chart of exits used for each Life Sharing Provider¿s home to ensure that this occurs. The Associate Director will then review this documentation on a quarterly basis.The above has already occurred with the Life Sharing Provider for Individual #1 at the home visit at Division St. on 12/4/19. 12/04/2019 Implemented
6500.136(b)Latanoprost 0.005% solution, instill one drop into left eye at bedtime prescribed to Individual #1 was not documented as administered from 11/1/19 to 11/25/19.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The Life Sharing Provider told the Inspector that she had mistakenly thrown away the November 2019 MAR for the pm administration of Latanoprost 0.005% Solution . The Associate Director and Life Sharing Specialist observed that this MAR was present during a home visit on 11/6/19 and verify that it was correctly documented for the pm administrations from 11/1/19 -11/5/19. As stated at the exit interview, we feel secure that even though the MAR was not present, that Individual #1 did receive the appropriate administration of the medication. During each monthly home visit, the Life Sharing Specialist will continue to physically check each MAR and ensure that one is present and appropriately documented for each medication being taken. The Life Sharing Specialist will keep monthly documentation that this has occurred. The Associate Director will then review this documentation on a monthly basis.The Life Sharing Specialist has completed the above with the Life Sharing Provider for Individual #1 during a home visit on 12/4/19. She will continue to complete this on a monthly basis during each home visit with each of the Life Sharing Providers. In addition, each Life Sharing Provider will be reminded that they are responsible for the safe keeping and retention of records for each person. 12/04/2019 Implemented
SIN-00072780 Renewal 12/08/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.17(a)The most recent self-assessment for the home was completed on 3/7/13. If an agency is the legal entity for the family living home, the agency shall complete a self-assessment of each home the agency is licensed to operate within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter.The Family Living Specialist states that she did complete the self-assessment in March 2014. It is unknown if the most recent self-assessment was misdated or misplaced. The self-assessments for the other six people in Family Living Supports are present and appropriately dated for 2014. The Family Living Specialist has been counseled regarding this regulation and will be required to submit completed self-assessments for review upon completion. 01/10/2015 Implemented
SIN-00239567 Renewal 02/21/2024 Compliant - Finalized
SIN-00186467 Renewal 04/21/2021 Compliant - Finalized
SIN-00146634 Renewal 12/06/2018 Compliant - Finalized
SIN-00125763 Renewal 12/07/2017 Compliant - Finalized
SIN-00087567 Renewal 12/15/2015 Compliant - Finalized