Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00234777 Renewal 11/14/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(g)Individual #1's review by a licensed physician for medication prescribed to treat symptoms of a psychiatric illness conducted on 11/08/2023 did not include the correct necessary dosage of the medication Guanfacine, the dosage listed was 1 mg, but the dosage was changed to 2 mg on 09/13/2023.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.TRIAD BEHAVIOR SUPPORT SERVICES POC RE: Plan of Correction for Medication Summary Form and Documentation of Training Email notification sent to staff on 11/20/2023 for immediate correction and then a detailed training on 11/20/2023 was also conducted. 348 E PIKE Individual #1's review by a licensed physician for medication prescribed to treat symptoms of a psychiatric illness conducted on 11/08/2023 did not include the correct necessary dosage of the medication Guanfacine, the dosage listed was 1 mg, but the dosage was changed to 2 mg on 09/13/2023. Please read and sign by your name on the attached training form. All staff have been immediately retrained on ¿How to complete the medical summary form and medication documentation procedures¿. It is important that all medications (regardless of who is administering the medication) be appropriately and accurately recorded and documented on all paperwork that outlines medications for each individual. To prevent this from reoccurring Triad CEO has immediately retrained the Program Director and Program Specialist and the Program Specialist has retrained all direct care residential staff at all residential homes specifically on current and accurate medication documentation. Additionally, the program specialist and medication administrator is tasked with a plan to check and sign off on the Medication Administration Records monthly and then once again during the quarterly progress report time. Every month all required forms will be reviewed again for accuracy by management personnel. Both the staff and the program specialist have roles and responsibilities to ensure accurate form completion. During a medical appointment the DSP is responsible for ensuring that the medical forms have accurate and current information prior to the appointment. This is extremely important so that all medical personnel are aware of any and all medications that are currently being prescribed. All medications will be listed on all paperwork regardless of who administers the medication. Staff are tasked with ensuring the name of the medication, the reason for prescribing the medication, and the dosage of the medication is accurate. The DSP will immediately notify the Program Specialist if any concerns arise as it relates to medication documentation. If any changes are made regarding any and all medication, then this information is immediately updated on all paperwork. The Program Specialist will review the medical summary forms monthly and then again during the quarterly review. The Program Specialist will cross-reference all medical appointment summary forms to ensure that all prescribed medications are current and accurate. Triad Behavior Support Services Training Form Plan Of Correction 11/20/2023 Heather Betts / CEO / Trainer ______________________________ Gary Betts / Program Director / Trainer ________________________ Jacob Hanning Program Specialist ____________________________ STAFF PRINT NAME STAFF SIGNATURE 11/20/2023 Implemented
SIN-00197213 Renewal 12/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)During the 12/01/2021 inspection, the water temperature taken at the tub, in the only bathroom, measured 124.8°F at 1:08pm. The water temperature taken at the kitchen sink measured 124.5°F at 1:01pm. Hot water temperatures in bathtubs and showers may not exceed 120°F. 12/1/2021 (date of inspection) the water temperature in shower was 124.8 at 1:08PM. The water temperature taken at the kitchen sink measured 124.5 at 1:01PM. Program Specialist immediately and manually turned the water heater down during inspection at 1:00PM. At 4:00PM on 12/1/2021 the water was shut off to the house. Per technical assistance, Program Specialist ordered 2 new temperature measuring devices on 12/2/2021. The current home temperature gauge was not high enough quality and measured 5 degrees colder and needed to be replaced. 12/2/2021 Water was restored in the home by manually turning on the water heater tank by the program specialist. To allow water temperature to rise the water temp was gauged 48 hours later on 12/4/2021. The water temperature in both shower and kitchen sink measured at 110 degrees on 12/4/2021. A picture was taken as proof of water temperature. Water temperature is important because individuals may need assistance in tempering water to avoid scalding. Regardless of individual assessment, the hot water cannot exceed 120 degrees. The steps Program Specialist took was: manually shut off water tank on 12/1/2021, ordered 2 new temperature gauges on 12/2/2021, hot water tank was manually turned back on 12/2/2021, water temperature was measured on 12/4/2021, water temperature was 110 degrees on 12/4/2021, form was created and signed that indicated water temperature on 12/4/2021. Program Specialist will check water temperature using 2 new gauges monthly starting on 1/4/2022. 12/04/2021 Implemented
6400.110(e)During the 12/01/2021 inspection, the smoke detectors tested at 1:04pm were not interconnected, and the home has three stories.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. 6400.110(e) - If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. 12/1/2021 (date of inspection) the three story home does not have interconnected fire alarms. Each floor has an independent smoke detector but the detectors are not interconnected. This violation was due to an oversight of interpretation. The alarms can be heard (audible) from all floors of the home but are not connected. Program Specialist immediately on 12/1/2021 notified CEO of the smoke detectors not being interconnected. Program Specialist immediately informed CEO that a purchase of interconnected smoke detectors were needed. 12/1/2021 compliance with 6400.110e began with scheduling a meeting with our First Safety Training Expert to discuss options for interconnected smoke detectors. Program Specialist is responsible for reviewing physical site for smoke detector safety for accuracy. Program Specialist will verify that smoke detectors are interconnected if the home has three floors. The steps Program Specialist took was on 12/1/2021 notify the CEO that this home did not have interconnected smoke detectors. Program Specialist on 12/2/2021 called our fire safety training expert to discuss how to safely install and which product the expert recommended for this purpose. 12/20/2021 Implemented
SIN-00215323 Renewal 11/23/2022 Compliant - Finalized