Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00235686 Renewal 12/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(6)The individual physical shall include TB testing every two years. Individual #1 was admitted to Eihab on 8/29/22. Individual had no documentation that reflects a TB test was completed upon admission. Individual did have a TB test completed on 10/17/23, however nothing was provided for the 2022 year.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Individual #1¿s tuberculin skin test was completed on 10/17/23. 10/17/2023 Implemented
6400.216(a)At the time of inspection in the basement area of the home there was old records of an individual who resides in this residence. The basement door is not locked, and these files were just on the floor in the basement and accessible to anyone. An individual's records shall be kept locked when unattended. Individual¿s records were moved to the local office to be stored in a locked closet on 12/9/23. 12/09/2023 Implemented
6400.34(a)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. Individual #1 was admitted to Eihab on 8/29/22 and there was no documentation to reflect that she was informed of her individual rights at time of her admission. The individual did sign a copy of her individuals rights on 10/17/23, however there was nothing before that date.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.Individual #1 signed a new form regarding individual rights on 1/11/24. 01/11/2024 Implemented
6400.165(g)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 documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Individual #1 had psychiatric medication reviews 3/7/23; 5/17/23, 8/9/23 and 11/27/23. These medication reviews did not list the reason for prescribing the medication and or the medication name and the dosage.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¿s completed psychiatric medication review on 11/27/23 indicated in attached MAR which was not attached in the documentation binder. The MAR was added to the medical binder. Individual #1 was scheduled for a psychiatric medication review on 2/19/2024. 01/10/2024 Implemented
SIN-00204262 Unannounced Monitoring 04/20/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66There was no light outside the basement door exit. This did not allow for adequate lighting to assure safety.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Maintenance installed a new light on 4.21.22 04/21/2022 Implemented
6400.163(h)Individual #1 has a physician's order for sunscreen. The sunscreen available in the home expired on 1/2022.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The individual in the home does not have a standing order for sunscreen. The agency keeps sunscreen as a part of the first aid kit for the individuals to use as needed. The expired sunscreen was discarded at the time of inspection and will be replaced as needed. 04/20/2022 Implemented
SIN-00199086 Renewal 12/27/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The door in the basement leading to the furnace room and the exit to the home from the basement level was stuck and difficult to open.Floors, walls, ceilings and other surfaces shall be in good repair. Maintenance repaired the door to the furnace room on 12/29/21 Maintenance will complete monthly checks of all fire exits in all homes and will make repairs as needed. Monthly checks to be recorded on monthly maintenance check list. 12/29/2021 Implemented
6400.101The fire escape door at the bottom of the steps from the second floor opened after multiple attempts by the inspector and later the staff. Upon being opened, the door did not function appropriately. The push bar on the door was stuck and did not function.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Maintenance repaired the door to the furnace room on 12/29/21 12/29/2021 Implemented
6400.106The furnace has not been inspected annually. There is no documentation of any inspections on the furnace.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. Furnaces inspections throughout Eihab homes have begun and will be completed by 2/28/22 02/28/2022 Implemented
6400.112(b)Fire drills conducted on 12/22/21, 11/18/21, 11/17/21, 10/28/21, 6/21/21 and 4/28/21 were not conducted under normal staffing conditions. The normal staffing ratio of the home is between 1:2 and 1:3 with occasional additional staff dependent upon activities. During the fire drill on 6/21/21, there were two staff in the home and during the fire drills 12/22/21, 11/18/21, 11/17/21, 10/28/21, and 4/28/21 there were three staff in the home. Fire drills shall be held during normal staffing conditions and not when additional staff persons are present. All staff will be retrained on conducting and documenting fire drills, to include conducting drills under normal staffing conditions by 2.28.22 02/28/2022 Implemented
6400.113(a)Individual #1's admission date is 11/18/21. Individual #1 did not receive fire safety training until 12/1/21. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. Agency VP of Operations will create an admissions packet for all new individuals to include fire safety training upon admission. All agency administration will be trained on admissions requirements and packet by 2.28.22 02/28/2022 Implemented
6400.51(b)(5)Staff #2 did not receive orientation training in Job-related knowledge and skills. Staff #2 was hired on 9/20/21 and was not trained in Behavior Support Plans or Individual Service Plans.The orientation must encompass the following areas: Job-related knowledge and skills.Staff trained on the ISP and BSP on 9/29/21 02/28/2022 Implemented
6400.163(a)Individual #1 has a bottle of Azelastine HCL Nasal spray with medications. There is no label issued by the pharmacy on the medication.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.Medication has been labeled by pharmacy 1/30/21 01/30/2022 Implemented
6400.207(4)(II)Individual #2 is prescribed Hydroxyzine HCL 50mg tab, take one tablet twice daily as needed for anxiety. The prescription label does not include specific symptoms of anxiety for which the medication should be administered. Individual #1 does not have a Restrictive Procedure Plan that addresses the need for the use of medication for controlling acute or episodic aggressive behavior. The Medication Administration Record indicates that the medication is administered almost every day. Staff indicated that Individual #1 needs this medication regularly to control behavior.A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Pretreatment prior to a medical or dental examination or treatment.Individual #2 was seen by the physician and medication was ordered routinely twice daily 01/15/2022 Implemented
SIN-00193648 Unannounced Monitoring 09/24/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(c)The first aid kit did not have a first aid manual. A first aid manual shall be kept with the first aid kit.During this monitoring there were three first aid kits on site, one of which contained two manuals. The kit which was missing a manual has had it replaced. 09/24/2021 Implemented
6400.82(e)The bathrooms on first and second floor did not have non slip mats in the showers. Bathtubs and showers shall have a nonslip surface or mat. Immediately following this monitoring non-slip bathmats were purchased and put in place. 09/24/2021 Implemented
SIN-00190467 Unannounced Monitoring 07/16/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)A spray bottle with an original label of LA's Totally awesome spray was bearing a masking tape label that said "Dawn/vinegar" was found in a cabinet under the kitchen sink which was not the original labeled container.Poisonous materials shall be stored in their original, labeled containers. These substances have been removed as of 7/16/21. 07/21/2021 Implemented
6400.67(a)The upstairs bathroom ceiling had what resembled water or mildew stains approximately the size of a softball, and in the middle of the stain in the ceiling was a hole approximately the size of a quarter. Paint was peeling off from the lower right corner of the interior side of the kitchen door. An area of concrete approximately the size of a softball is missing and crumbling from the left side of the second step from the back steps of the home.Floors, walls, ceilings and other surfaces shall be in good repair. This damage has been repaired as of 8/19/21. 08/19/2021 Implemented
6400.214(b)During the inspection on 7/16/21, there was no copy or documentation of an annual assessment in the records at the home for Individual #2. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. This assessment was completed as of 7/25/21. 09/01/2021 Implemented
6400.163(h)Individual #2's pro re nata (PRN) Acetaminophen expired on 3/1/21 and has not been disposed of in a safe manner.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.This medication has been returned to the pharmacy for disposal, as of 7/19/21. 09/15/2021 Implemented
SIN-00183784 Unannounced Monitoring 01/25/2021 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.45(e)Individual #3 and Individual #4's alone time was being used at the convenience of the home due to staff shortages. Several staff reported coming onto different shifts and there being no staff on duty due to staff call offs or not having enough staff to cover shifts. Exact dates are unknown, but it was reported this has occurred several times in recent months.An individual may not be left unsupervised solely for the convenience of the home or the direct service worker.Program administration meets on a weekly basis to review the staffing schedule and that individuals are not left unsupervised solely for the convenience of the staff or the agency. On a weekly basis, the facility is scheduled with 24-hour coverage. Staff will be retrained by March 15, 2021 to notify management in the event (and follow the chain of command) in the event they arrived for their shift and there is no staff on duty due to call off or an emergency. In the event of an emergency and/or the scheduled staff cannot or fail to arrive on shift, management staff will expedite to arrange coverage for the shift. Staff will be mandated to ensure individual #3 and individual #4's needs are met and that individuals are not left unsupervised solely for the convenience of the staff shortage or program needs. Administrative staff are currently working on a designated per diem list and a staffing agency to assist with on-call emergency staffing needs in the facilities. 03/15/2021 Not Implemented
SIN-00181623 Renewal 01/19/2021 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104Notification to the local fire department letter submitted for review was dated 9/21/2016. Fire drill submitted for 12/15/2020 indicated that Individual #8 was at the home. Further documentation shows that Individual #8 resided at the home at times during 11/2020, all of 12/20 and up to 1/3/21. An updated fire letter was not completed and sent.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Since the time of the survey, the letter was located which was sent to the local fire department to indicate that Individual #8 was in the residence, however it was on file at the time of review. Program Specialist will be trained that whenever there has been change in location, bedrooms, evacuation assistance a certified letter will be sent to the local fire department. The QA Department will conduct quarterly reviews to ensure that all letters are on file and letter is current. 02/10/2021 Implemented
6400.112(f)Exits recorded as used during fire drills were Front, Back and Kitchen. Upon inspection of the home a clearly marked exit from the second floor near the bedrooms was found. This exit was not used during fire drills.Alternate exit routes shall be used during fire drills. The Vice President has developed a Fire Drill Report Review Procedure which includes a Shared Fire Drill Annual Calendar amongst management and administration. On the shared calendar, drills will be scheduled to ensure various conditions with indicate alternate exits to be used. This shared calendar will be reviewed on a daily basis by the Program Specialist to ensure and verify that all scheduled drills have been completed. Training will be done with all Management and Administrative Staff on this procedure and implementation will be in effect by March 15, 2021. This procedure will be monitored on a daily basis by the Program Specialist for oversight and ensure that all drill reports completed as indicated. The Quality Assurance Department will be conducting quarterly reviews of all fire drills to ensure this procedure is followed and fire drills procedures are in compliance. 03/15/2021 Implemented
6400.141(c)(3)The immunization section of Individual#6's physical dated 8/13/20 was blank. No date for the last Diphtheria/Tetanus was listed. The physical dated 6/13/19 did not contain a date for the last Diphtheria/Tetanus. The immunization section was marked "See list." There was no list.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. Since the time of survey, individual #6's immunization will be retrieved from the primary care physician. The Vice President has developed an agency Medical Appointment Review Procedure which includes a shared Medical Appointment Monthly Calendar amongst management and administration. On the shared calendar, medical appointments will be entered upon scheduling. This shared calendar will be reviewed on a daily basis by the Management and the Program Specialist to ensure and verify that all scheduled appointments have occurred, and any recommended follow up appointments are entered. In addition, the Medical Visit Report will be uploaded for the Management and Program Specialist to review within 24-72 hours to ensure all recommendations are followed. The Quality Assurance Director has developed an internal self-assessment tool to assist management and administration to conduct routine medical record reviews. The medical record reviews will consist of all medical and health requirements, including the physical examination including immunization records. Program Management will review this on a monthly basis and the QA Department on a quarterly basis. The training and implementation for this procedure will be conducted by March 15,2021. 03/15/2021 Implemented
6400.142(e)Individual #6's dental exam and cleaning on 8/4/20 indicated that cavities were noted on two teeth with restorative work required. As of 1/25/21 documentation was not provided to illustrate that the restorative work was completed.Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed.Since the time of survey, individual #6 dental exam has been scheduled which was dated on 2/9/21 and a follow up dental appointment is scheduled on 8/10/21. The Vice President has developed an agency Medical Appointment Review Procedure which includes a shared Medical Appointment Monthly Calendar amongst management and administration. On the shared calendar, medical appointments will be entered upon scheduling. This shared calendar will be reviewed on a daily basis by the Management and the Program Specialist to ensure and verify that all scheduled appointments have occurred and any recommended follow up appointments are entered. In addition, the Medical Visit Report will be uploaded for the Management and Program Specialist to review within 24-72 hours to ensure all recommendations are followed. The Quality Assurance Director has developed an internal self-assessment tool to assist management and administration to conduct routine medical record reviews. The medical record reviews will consist of all medical and health requirements, including adequate dental work follow up indicted in dental examinations. Program Management will review this on a monthly basis and the QA Department on a quarterly basis. The training and implementation for this procedure will be conducted by March 15,2021. 03/15/2021 Implemented
6400.181(e)(9)Assessment for Individual #6 was completed on 1/12/21. The sections for current disabilities and medical limitations were blank.The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. Individual #6 assessment has been updated to include current disabilities and medical limitations. The Vice President has developed a procedure to monitor the timeliness of the required skills assessment. Assessments will be completed within 30 days of admissions and quarterly reviews thereafter. Program Specialist will be trained to review skills assessment on a quarterly basis and to complete the assessment during the quarter prior the annual review date. The Program Specialist will review that the assessments on file are completed to included but no limited to the Current Disabilities and Medical Limitations. There will be shared calendar to provide oversight to indicate when each individual¿s skills quarterly review and annual assessment will be completed. Training will be done with all Management and Administrative Staff on this procedure and implementation will be in effect by March 15, 2021. 03/15/2021 Implemented
6400.181(e)(10)Assessment for Individual #6 dated 1/12/21 did not include a lifetime medical history.The assessment must include the following information: A lifetime medical history. Individual #6 assessment has been updated to include Lifetime Medical History. The Vice President has developed a procedure to monitor the timeliness of the required skills assessment. Assessments will be completed within 30 days of admissions and quarterly reviews thereafter. Program Specialist will be trained to review skills assessment on a quarterly basis and to complete the assessment during the quarter prior the annual review date. The Program Specialist will review that the assessments on file are completed to included but no limited to the Lifetime Medical History. There will be shared calendar to provide oversight to indicate when each individual¿s skills quarterly review and annual assessment will be completed. Training will be done with all Management and Administrative Staff on this procedure and implementation will be in effect by March 15, 2021. 03/15/2021 Implemented
6400.32(r)(1)Locking (key only) doorknobs were in place on bedroom doors of Individual #6 & Individual #7. When asked Individual #7 stated that he did not have a key to his door. Individuals that desire shall have a key to their bedroom door.Locking 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.Since the time of the survey, Individual #7 has been given a key to lock her bedroom door. Individual #7 key to obtain a key will be reviewed to monitor if she still wants a key, needs supports and that she is aware of her rights to lock her bedroom door. A Key Assessment will be completed by the Behavior Specialist. The completed the assessment will be shared with the team and forwarded to Service Coordinator. Moving forward, all individuals, including Individual #6 will be assessed including new admissions. Staff, Behavior Specialist, Management and Administration will be trained on this procedure by March 15, 2021. 03/15/2021 Implemented
6400.165(g)Individual #6's medication review conducted on 5/5/20 was completed via telephone. The documentation of this review did not include the name of the medication prescribed, the reason, the need to continue or the dosage as required. The medication review conducted on 7/30/20 did not include the need to continue the prescribed medication.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.Since the time of survey, individual #6 medical record has been reviewed and required 3-month psychiatric medication review was scheduled on 2/12/21 and the follow up appointment is scheduled on 5/14/21. The Vice President has developed an agency Medical Appointment Review Procedure which includes a shared Medical Appointment Monthly Calendar amongst management and administration. On the shared calendar, medical appointments will be entered upon scheduling. This shared calendar will be reviewed on a daily basis by the Management and the Program Specialist to ensure and verify that all scheduled appointments have occurred, and any recommended follow up appointments are entered. In addition, the Medical Visit Report will be uploaded for the Management and Program Specialist to review within 24-72 hours to ensure all recommendations are followed. The Quality Assurance Director has developed an internal self-assessment tool to assist management and administration to conduct routine medical record reviews. The medical record reviews will consist of all medical and health requirements and ensuring a licensed physician review occurs at least every 3 months and the reason for prescribing the medication is documented with the need to continue the medication and the necessary dosage. A Psychiatric Medical Visit Report will be revised by February 28, 2021 to ensure all required indications by the license physician. Program Management will review this on a monthly basis and the QA Department on a quarterly basis. The training and implementation for this procedure will be conducted by March 15,2021. 03/15/2021 Implemented
6400.166(a)(8)Individual #6's January 2021 Medication Administration Record(MAR) has an entry for "Vagisil Intimate Wash- Administer into vagina(for patient private use) as needed." The pharmacy label on the bottle matched the MAR. Directions on the bottle further stated, "For external use only." The route of the wash is incorrect on the MAR and pharmacy label.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.Since the time of the survey, Individual #6's Medication Administration Record has been reviewed and updated to indicate the correct route of Vagisil Intimate Wash for external use only. As a result of pharmacy not meeting the agencies needs and causing potential medication errors, in January 2021, administration has changed pharmacies. Prior to licensing, the new pharmacy has been notified of MAR requirements to meet the agency¿s medication administration practices and ODP regulations. Staff will be retrained on the Accountability Log Procedure to include each shift reviewing the MAR in preparation to administer medication. Residence management will be conducting weekly reviews to ensure that all medications are transcribed correctly to include the diagnosis or purpose of the medication and pro re nata. The Medication Trainer will conduct monthly reviews in addition to the Quality Assurance Department conducting quarterly reviews. Staff will be retrained to review the five rights when administering medication. Staff, Management and Administration will be trained on the oversight and monitoring procedure by March 15, 2021 03/15/2021 Not Implemented
6400.166(b)Individual #6's December 2020 Medication Administration Record (MAR) had an entry for "Hydrocortisone 2.5% Cream. Administrations on 12/22, 12/24, 12/26, 12/28 and 12/31 were not initialed as being given or otherwise marked. Entries for SF 5000 Plus, Citalopram, Nutrogena T-Sal, Mediketoconazole 2%, Ketaconazole 2% were not initialed as being given or otherwise marked for 12/31/20. Ketaconazole 2% was also not marked on 12/26/20.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Since the time of the survey, a Medication Error Report has been completed and will be reviewed by the Incident Review Committee. All Medication Trained staff will be trained by February 22, 2021 on accurate Medication Administration Record documentation. Staff will be retrained on the Accountability Log Procedure to include each shift reviewing the MAR in preparation to administer medication and reporting documentation concerns. Residence management will be conducting weekly reviews to ensure that all medications documentation are complete; the Medication Trainer will conduct monthly reviews in addition to the Quality Assurance Department conducting quarterly reviews. Staff, Management and Administration will be trained on the oversight and monitoring procedure by March 15, 2021 03/19/2021 Not Implemented
6400.169(a)Staff #3 medication administration training records indicated that only one medication administration observation was completed for 2019. This occurred on 6/5/19. There was no documentation that a second required observation was completed in 2019. Documentation provided for 2020 noted observations on 5/6/20 and 9/30/20. Documentation for review of Medication Administration Records (MAR) was not provided. Two observations and two MAR reviews must be completed to meet annual certification requirements.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).Since the time of survey, Staff #3 has received and pass two additional medication observations. The new hire orientation training process has been revised to include new staff designated to administer medication will not administer medication without the required two medication observations. There will be a review whereby the Medication Trainer will schedule the required medication observations and were completed prior to being approved to administer medication. The Training Director will provide an approval to the Program Specialist and the HR Department to indicate employees has passed all required training and medication observations. The Quality Assurance Director has developed an internal self-assessment tool to assist management and administration to conduct routine training record reviews. The training record reviews will consist of ensuring required medication observations The Training Coordinator will review this on a monthly basis and the QA Department on a quarterly basis. The training and implementation for this procedure will be conducted by March 15,2021. 03/15/2021 Implemented
SIN-00139345 Renewal 08/14/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)Self-assessments are not being done for each home. 1 self-assessment is being used for all 7 homes on this license.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, 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. To prevent this from happening in the future, a single self-assessment will be used for each home 3 to 6 months prior to the expiration date of the COC, 9/2/2019. ((Staff responsible for completing self-assessments will be trained in the regulation and EIhab's procedures -CH 9/20/18)) 09/10/2018 Implemented
6400.22(e)(3)According to Individual #2's financial records, he spent $52.87 at Walmart on 4/12/2018. A receipt for this purchase couldn't be found at the time of this inspection. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. ISP was incorrect and the individual manages his own funds. The individual has confirmed making the purchase. SC has been notified of the error in the ISP and the ISP will be updated to reflect this. 09/10/2018 Implemented
6400.181(a)Individual #2's assessment dated 8/24/2017 was not updated from the previous year. All of the information was the same and it contained the same typos and misspellings as the assessment dated 10/9/2016. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Assessment was obviously cut and pasted by program specialist. Skill assessment redone and sent. To prevent this from happening in the future, this program specialist has been terminated from the agency. 08/01/2018 Implemented
6400.186(a)Individual #2 had ISP Reviews on 9/5/17, 1/7/18, 4/4/18, and 7/9/18. The timeframe between 9/5-1/7/18 exceeds the 3 month requirement.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. To prevent this from happening in the future, the quarterly due dates will be added to the appointment tracking spreadsheet to more closely track dates that quarterlies are due. ((Program Specialist will be retrained in the regulatory requirements -CH 9/20/18)) 09/10/2018 Implemented
SIN-00124566 Renewal 11/14/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(b)Individual #1's rights statements are supposed to be signed annually and were signed late. They were signed 07-20-16, then not again until 10-24-17.Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. Staff to be retrained on individual rights requirements, documentation submitted. To prevent this from happening in the future, a spreadsheet was created with due dates of all licensing requirements that will be updated monthly by program specialists. 01/09/2018 Implemented
6400.141(a)Individual #1's annual physical exam was late. She had one on 04-07-16, then not again until 05-26-17.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Staff retrained on medical appointment requirements on 1/10/2018; training documentation submitted. To prevent this from happening in the future, a spreadsheet was created with due dates of all assessments, physicals, dental appointments, and other requirements that will be updated monthly by program specialists and submitted. 01/10/2018 Implemented
6400.141(c)(10)The section on Individual #1's physical form pertaining to communicable diseases was left blank.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. The individual's physical form was returned to physician to complete areas left blank and provided to licensing.To prevent this from happening in the future, a cover sheet was developed for the physical exam form explaining to healthcare providers of the necessity to complete all areas of the physical exam form. Cover sheet provided to licensing. 01/09/2018 Implemented
6400.141(c)(11)The section on Individual #1's physical form pertaining to assessment of health maintenance needs was left blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The individual's physical form was returned to physician to complete areas left blank and provided to licensing. To prevent this from happening in the future, a cover sheet was developed for the physical exam form explaining to healthcare providers of the necessity to complete all areas of the physical exam form. Cover sheet provided to licensing. 01/09/2018 Implemented
6400.141(c)(14)The section on Individual #1's physical form pertaining to info pertinent to diagnosis in case of emergency was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The individual's physical form was returned to physician to complete areas left blank and provided to licensing. To prevent this from happening in the future, a cover sheet was developed for the physical exam form explaining to healthcare providers of the necessity to complete all areas of the physical exam form. Cover sheet provided to licensing. 01/09/2018 Implemented
6400.141(c)(15)The section on Individual #1's physical form pertaining to diet was left blank.The physical examination shall include: special instructions for the individual's diet.The individual's physical form was returned to physician to complete areas left blank and provided to licensing. To prevent this from happening in the future, a cover sheet was developed for the physical exam form explaining to healthcare providers of the necessity to complete all areas of the physical exam form. Cover sheet provided to licensing. 01/09/2018 Implemented
6400.142(a)Individual #1 had a dental exam on 06-16-16 and there is no documentation in her file that she has had one since.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Individual attended a dental appointment in January 2017; however, there was no documentation of the appointment in the record. Provider unable to get a copy of the record due to the dental office closing down. To prevent this from happening in the future, a spreadsheet was created with due dates of all assessments, physicals, dental appointments, and other requirements that will be updated monthly by program specialists. Dental appointment scheduled for 1/10/18 was cancelled due to hospitalization; dental appointment rescheduled for 1/25/2018 at 9AM. 01/25/2018 Implemented
6400.167(b)Individual #1's MAR had a script on it that has not been administered at all in November 2017. It stated Betameth 0.1% lot - apply topically to affected area 2x daily on scalp and face. Staff stated it was DC'd, but there was no documentation confirming that and the med was not on site. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.Discontinuation script submitted to licensing. To prevent this from happening in the future, staff will be retrained on obtaining discontinue scripts from the individual's physician. Training documentation submitted. 01/10/2018 Implemented
6400.181(e)(10)There was no lifetime medical history included in Individual #1's assessment.The assessment must include the following information: A lifetime medical history. The individual's lifetime medical was inadvertently removed from the record and located in storage. The lifetime medical was submitted to licensing. To prevent this from happening in the future, staff will be re-trained to understand that records may not be removed from the record. Completed training document submitted. 01/09/2018 Implemented
6400.181(f)There was no documentation in Individual #1's file that showed the assessment was sent to team members at least 30 days prior to the ISP meeting.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). Individual's current skills assessment sent to SC at least 30 days prior on 1/12/2018. Confirmation e-mail submitted to licensing. To prevent this from happening in the future, a spreadsheet was created with due dates of all assessments, physicals, and other requirements that will be updated monthly by program specialists. Spreadsheet provided to licensing. 01/09/2018 Implemented
SIN-00082695 Renewal 10/22/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There was garbage including ripped plastic bags left behind after opening purchased items and crushed Q-tips, some appearing to have been used, on the floor of Individual #3's bedroom.Clean and sanitary conditions shall be maintained in the home. Corrected at time of licensing. To prevent this from happening in the future, all residential staff will be retrained on the Cleaning & Disinfection Policy and Procedure #602 (See attachment #7) on 11/10/2015 (see attachment #8) The house manager will provide oversight to all 6400 homes to monitor for compliance at least weekly. 11/10/2015 Implemented
6400.82(f) The downstairs bathroom did not have a towel to dry hands. 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. Corrected at time of licensing. To prevent this from happening in the future, all residential staff were retrained on the Cleaning & Disinfection Policy and Procedure #602 (See attachment #7) on 11/10/2015. The house manager will provide oversight to all 6400 homes to monitor for compliance at least weekly. Training documents (attachment #8) will be forwarded by 11/11/2015. 11/10/2015 Implemented
6400.161(e) Ketoconazole Shampoo 2% was prescribed by Dr. Harasym for individual #2 and filled on 7/24/2015. Staff #2 stated that the doctor had discontinued this prescription; which was not listed on the individual's medication log. Also not on individual #2's medication log but in the house was Flovent Disk 100 mcg AER prescribed by Dr. Lynn Heard (1 puff inhaled orally twice per day) was filled on 8/19/2015. This Flovent Disk was still in a sealed bag from the manufacture.Discontinued prescription medications shall be disposed of in a safe manner.Meds were destroyed or returned to pharmacy at the time of licensing. To prevent this from happening in the future, all residential staff were retrained on the Medication Policy and Procedure #500 (attachment #6) on 11/10/2015. Training documents #8 will be forwarded. In addition, there will be an additional level of oversight added by a recently hired RN who will provide medication room inspections at least monthly. 11/10/2015 Implemented
SIN-00100812 Renewal 11/21/2016 Compliant - Finalized