Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00219024 Renewal 09/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)A sleep drill has not been held since December 2021A fire drill shall be held during sleeping hours at least every 6 months. A sleep drill was completed on 10/13/2022 at asleep hours to correct the citation. Additionally, a recurring reminder has been set up in the company calendar for all House supervisors and Program Manager to be alerted to perform a fire drill once every six months for each home in the program during asleep hours. 10/13/2022 Implemented
6400.217For individual 3, there was no signed release of information provided.Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. A sIgned release of information form was provided for the individual to sign right after the inspection was completed. 09/28/2022 Implemented
6400.34(a)For individual 3, the provided consent forms are past due, with those dated 1/4/21The 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.New consent forms were provided for the individual to sign right after the inspection was completed. 09/28/2022 Implemented
6400.34(b)For individual 3, the provided bill of rights is not dated on the signature line, making it impossible to determine if this was provided and reviewed with the individual within the compliant annual time frame.The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights.New bill of rights form was provided for the individual to sign and also explained to the individual right after the inspection was completed. 09/28/2022 Implemented
6400.165(b)PRN medication (ACETAMINOPHEN 325mg and BENZONATATE 100mg) was in individual 3's medication box and not listed on the MAR. PRN medication (ROBAFEN DM) is listed on individual 3's MAR and not in the medication box at time of inspection.A prescription order shall be kept current.The acetaminophen and Benzonatate were discarded from the box immediately after the inspection. 09/28/2022 Implemented
6400.166(b)For individual 3, the 8pm dosage medication (SENNA 8.6mg and TRAZODONE 50mg) was not logged as administered.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The staff responsible for administering the medication was retrained on med administration documentation 09/28/2022 Implemented
SIN-00149159 Renewal 01/24/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71Emergency telephone numbers were not on or close to the telephone in the living room.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. Emergency numbers were located in the home on the staff bulletin Board, but were not posted by the fixed telephone in the living room. The posting was placed by house phone located in the living room by the Program Specialist on 01/25/2019. A new posting was created with more visual effect on 03/11/2019 and replaced the original posting in all locations. See Exhibit 14 The CLA Site Supervisor will monitor to ensure that postings are at each fixed telephone and document on the weekly CLA House Inspection checklist, which will be submitted to the Program Specialist. If the emergency number posting is missing it will be replaced immediately. The Program Specialist is responsible to oversee the work of the CLA Site Supervisor. The documentation is preserved in the Program Specialist office in the Residential Site Weekly Checklist Binder. All current staff have been retrained on ( 6400.71) the regulation that emergency numbers must be in place by the fixed house telephone. If the number list is missing it must reported to their supervisor immediately up discovery so it can be replaced. All incoming staff will be trained on the location of the emergency numbers as part of their initial CLA orientation. All current staff have been retrained on the location of the telephone numbers. 01/25/2019 Implemented
6400.77(c)The first aid manual was not in the first at kit. A first aid manual shall be kept with the first aid kit.The Program Specialist placed a first aid manual for the first aid kit in the kit on 01/30/2019. See Exhibit 13 The CLA Site Supervisor will monitor to ensure that the first aid kit has a first aid manual as required by 6400.77(c) and will document the presence of the first aid manual in the kit on the weekly CLA House Inspection Checklist which will be submitted to the Program Specialist. If a first aid manual is missing during the inspection it will be documented and replaced within 24 hours. The Program Specialist is responsible to oversee the work of the CLA Site Supervisor. The documentation is preserved in the Program Specialist office in the Residential Site Weekly Checklist Binder. All current staff have been retrained on the regulation that the first aid kit must contain a first aide manual. If a first aid manual is missing, damaged or destroyed the staff must inform their supervisor and the manual will be replaced within 24 hours. All incoming staff, as part of their initial CLA orientation, will be trained that a manual must be present as required content of the first aid kit and their obligation to report any missing, damaged or destroyed first aid manual to their supervisor so the materials will be replaced within 24 hours. Documentation of the training is to be kept as part of the initial staff training record in the employees training file. 01/30/2019 Implemented