Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00228617 Renewal 07/31/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)individual 4 started program 2/20/23. most recent exam completed was 3/9/23. Last physical received prior to beginning the program 12/9/2021An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Going forward all physical examinations will be completed not greater than 1 year apart to include all information. Royal Home Care will also request for a complete physical examination using ODP standard form before admitting any individual for placement. Physical examination will be completed, signed, and dated by a licensed physician, certified nurse practitioner or licensed physician assistant. 08/02/2023 Implemented
6400.144Individual 4 prescribed medication omeprazole 40 mg capsule, with directions to take 1 capsule by mouth daily was not present in the home.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. Individual went on a family visit and took her medication with her. She was due back the following morning. Per individual ISP, ¿Residential staff organize her medications so she can take them independently. The staff were retrained on 8/2/23 on medication administration foundation, procedure, and documentation by the agency¿s med trainer. 08/02/2023 Implemented
6400.32(r)(1)Individual rights do not reflect the individual's right to lock their doorLocking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.Royal Home Care administrator immediately updated policy containing the rights of the individual to include individuals¿ right to lock their bedrooms (see attached). Individuals¿ files have been updated 8/01/23 to ensure compliance. 08/01/2023 Implemented
SIN-00208325 Renewal 07/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(f)A trash can with trash in it was found behind the property without a lid.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.Royal Home Care administrator immediately bought a new trashcan with a lid to replace the old one. (See the attached). 07/22/2022 Implemented
6400.77(b)The first aid kit did not have tweezers. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Royal Home Care administrator immediately bought a tweezer and placed it in the first aid kit. (See the attached). 07/22/2022 Implemented
6400.111(a)The property had no fire extinguishers on any floor. The agency later provided photos showing extinguishers had been placed on each floor.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. Fire extinguishers were immediately placed at designated places (see the attached). 07/21/2022 Implemented
SIN-00190682 Renewal 07/26/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The first aid kit was missing scissors, thermometer and antiseptic at time of inspection. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Royal Home Care administrator immediately bought a scissors, thermometer, and antiseptic and placed them in the first aid kit. (See attached). 08/02/2021 Implemented
6400.144Medications for Individual #1 were not available at time of inspection. Included were two prescription meds: Mupirocin 2% ointment and Deep Sea Spray and two PRN meds Quetiapine 25 mg and Clonazepam 1 mg.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. Individual #1 likes to keep the two medications (Mupirocin 2% ointment and Deep-Sea Spray) in her room so she can use it. The nurse and the residential director talked to individual to have the medications in the med box along her other medications. Individual was hesitant at first but later cooperated. The two PRN medication were in another med box (reserve medication) at the time of inspection 08/02/2021 Implemented
6400.46(a)Staff #1 did not receive annual fire safety trainingProgram specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.Royal Home Care contracted the service of a new fire safety trainer. All the staff members were trained on fire safety, evacuation procures and use of fire extinguisher on 8/12/2021 (see attached). 08/12/2021 Implemented
6400.46(b)No verification of a current fire safety expert completing the annual trainingsProgram specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).The agency fire safety trainer could not bring his training up to date due to covid-19 lockdown. However, the agency has contracted with another fire safety expert on 8/02/21 who will be responsible for training the staff on fire safety and evacuation procedures. 08/02/2021 Implemented
6400.165(g)Psychological medical reviews were not completed every 3 months as required for Individual #1.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Individual #1 completed all her psychotropic med reviews via telehealth. Individual could not attend the sections in-person because of covid-19 concerns. Royal Home did not have all the supporting documents available at the time of inspection because the forms were awaiting signature from the psych doctor. The forms were subsequently completed, signed, and sent to Royal Home Care on 8/10/21 08/10/2021 Implemented
SIN-00170100 Renewal 01/31/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The second floor of the home did not have emergency telephone numbers located near each of the three telephones.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. A list of emergency telephone number was posted in the second floor by the telephone on 01/31/2020. The residential director will periodically monitor that it is present by the telephone. Training regarding 6400 compliance was completed with residential director on 02/11/2020. 01/31/2020 Implemented
6400.76(a)The dining room table was not sturdy. One table leg nearest the radiator was loose. Furniture and equipment shall be nonhazardous, clean and sturdy. The maintenance contractor repaired the dining table on 01/31/2020. See attached. Going forward, the residential director will carry out a monthly physical inspection of the homes and ensure that needed repairs are done in timely fashion. Training regarding 6400 compliance was completed with residential director on 02/11/2020. 01/31/2020 Implemented
6400.77(b)During inspection there was no thermometer in the home's first aid kit. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Royal Home Care bought a thermometer and placed it in the first aid kit. See attached. Going forward, the residential director will carry out a monthly physical check to ensure that missing items are in place. Training regarding 6400 compliance was completed with residential director on 02/11/2020. 02/11/2020 Implemented
6400.82(f)The lower level bathroom had no hand or paper towels.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. Royal Home stock paper cloth in the bathroom on 01/31/2020. The residential director will ensure all paper products are purchased and replenished every two weeks during house shopping. Training regarding 6400 compliance was completed with residential director on 02/11/2020. 01/31/2020 Implemented
6400.141(a)The current physical was completed 1/21/20 for individual no. 1 and the previous physical was documented as being done on 12/10/18..An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual no. 1 physical was completed 1/21/20 due to insurance and intake delay. Going forward the residential director will ensure that individuals¿ physicals are completed, signed and dated prior to expiration of the current one. The residential director has developed a chart to track the due dates for physical, assessments, monthly, quarterly etc. see attached. 02/11/2020 Implemented