Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00208699 Unannounced Monitoring 07/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(13)Amoxicillin 875mg Tab, take one tablet by mouth twice a day for ten days for ear infection, prescribed to Individual #1 was not initialed as administered at 10:00PM on 7/4/22 and 7/11/22 and 9:00AM on 7/8/22. Latuda 60mg Tab, take one tablet in the evening with a meal, prescribed to Individual #1 was not initialed as administered at 6:00PM on 7/21/22. Famotidine 70mg Tab, take one tablet at bedtime, prescribed to Individual #1 was not initialed as administered on 7/21/22 at 9:00PM. Nitrofurantoin, take one capsule twice daily for seven days, prescribed to Individual #1 was not initialed as administered at 9:00PM on 7/21/22 and 9:00AM on 7/23/22. Guanfacine HCL 2mg Tab, take one tablet by mouth once daily at 9am, prescribed to Individual #1 was not initialed as administered at 9:00AM on 7/23/22 and 7/25/22. Sertraline HCL 25mg Tab, take one tablet every morning, prescribed to Individual #1 was not initialed as administered at 9:00AM on 7/23/22 and 7/25/22. Vitamin D3 2,000IU Cap, take one capsule daily at 9am, prescribed to Individual #1 was not initialed as administered at 9:00AM on 7/23/22 and 7/25/22. Tri-Lo -Spinetectab, take one tablet daily, prescribed to Individual #1 was not initialed as administered at 9:00AM on 7/23/22.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.Provider confirmed through medication count that all medications were administered. Provider reached out to staff whose signatures were missing and the corrections were made to the medication administration record. An in-service was sent to all staff on August 3, 2022 and will be completed by August 17, 2022. 08/04/2022 Implemented
SIN-00205504 Unannounced Monitoring 05/16/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)On 5/18/2022, at 12:38PM, the interior bottom and interior door glass of the oven in the kitchen was coated with splattered, baked-on grease and charred remains of burnt food particles.Clean and sanitary conditions shall be maintained in the home. The oven was cleaned as of 5/19/22 by NHCS direct support professional. The oven was checked for cleanliness on 5/19/22 by CEO. 06/21/2022 Not Implemented
6400.64(d)On 5/18/2022, at 1:03PM, the bathroom in the game room did not have a trash receptacle.Trash in the bathroom, dining and kitchen areas shall be kept in cleanable receptacles that prevent the penetration of insects and rodents. A new trash can was purchased and placed in the bathroom in the game room on 5/18/22 by NHCS administration. NHCS ensured that all areas of the home had a trash can as required by the regulatory compliance guide. 06/21/2022 Not Implemented
6400.64(f)On 5/16/2022, the trash in the driveway of the home was not in a closed receptacle. The one trash receptacle was overflowing with various plastic bottles. In addition, there was a large piece of folded discarded carpeting on the driveway next to the trash receptacles.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.An additional trash receptacle was placed at the site on 5/16/22 by NHCS administration. NHCS administration ensured that the trash that was overflowing was removed from the site 5/16/22. 06/21/2022 Not Implemented
6400.65On 5/18/2022, at 1:03PM, the bathroom in the game room was without an exhaust fan or HVAC system to provide mechanical ventilation. The air duct vent above the shower was covered with tape. The bathroom's window does not open to the outside for air flow.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. There is not a window in the bathroom in the game room. An exhaust fan was added to the bathroom in the game room on 5/20/22 by a contractor. NHCS verified that the exhaust fan was operable in the game room bathroom and the window opens in the bathroom upstairs on 5/20/22 06/21/2022 Not Implemented
6400.66On 5/18/2022, at 1:10PM, the back section of the game room's main living space adjacent to the bathroom was noted without lighting. The ceiling lighting fixture in the back section of the game room near the bathroom did not have a light bulb or a covering. There is not another source of lighting in this area.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The light bulb and covering were placed into the fixture on 5/18/22 by NHCS administration. NHCS reviewed the physical site to ensure that all areas of the home have adequate lighting on 5/20/22. 06/28/2022 Not Implemented
6400.72(a)On 5/16/2022, the sliding glass door from the dining room to the back of the home does not have a screen. The screen was leaning up against the house.Windows, including windows in doors, shall be securely screened when windows or doors are open. The screen was removed from the home on 5/18/22 by NHCS administration. NHCS reviewed the physical site to ensure that all other screens were present on 5/20/22. 06/21/2022 Not Implemented
6400.72(b)On 5/16/2022, the screen to the sliding door from the dining room to the back of the home has a four by five-inch hole. Screens, windows and doors shall be in good repair. The screen was removed on 5/18/22 by NHCS administration. NHCS reviewed the physical site to ensure that all other screens were in good repair on 5/20/22. 06/21/2022 Not Implemented
6400.76(a)On 5/18/2022, at 1:03PM, the toilet roll paper holder in the bathroom in the game room was missing the roll bar. The toilet paper roll was atop the tank of the toilet. Furniture and equipment shall be nonhazardous, clean and sturdy. A toilet paper holder was placed in the bathroom in the game room on 5/18/22 by NHCS administration. NHCS administration verified that \there was a toilet paper in the other bathroom in the home on 5/18/22. 06/21/2022 Not Implemented
6400.101On 5/16/2022, there was a metal bar between the door and the wall across the middle of the sliding glass door obstructing egress from this exit from the home.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The metal bar was removed from the sliding glass door on 5/16/22 by NHCS administration. NHCS reviewed the home to make sure that there all stairways, halls, doorways, passageways, and exits are unobstructed on 5/20/22. 06/21/2022 Not Implemented
6400.110(a)On 5/16/2022, at 4:30PM when tested, the smoke detector system was inoperable and continuously repeated "two devices connected, attempting to pair." A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. The smoke detectors were paired and corrected on site 5/16/22 by CEO. CEO checked the smoke detector on the three following shifts and the smoke detector was operable. An ODP licensing representative was at the site on 5/18/22 and verified the smoke detector was operable. 06/21/2022 Not Implemented
6400.171On 5/16/2022, the freezer section of the kitchen refrigerator contained a crumbled, torn piece of aluminum foil loosely laying over top of what appeared to be a raw pork chop on a foam tray.Food shall be protected from contamination while being stored, prepared, transported and served. The food identified in the freezer was removed and thrown away on site 5/16/22 by CEO. An ODP licensing representative was on site 5/18/22. The CEO ensured there was no other food improperly stored on 5/16/22. 06/21/2022 Not Implemented
SIN-00201827 Renewal 03/15/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)A fire drill during sleeping hours was not held from October 2020 to September 2021, when a fire drill during sleep hours was held on 9/14/2021.A fire drill shall be held during sleeping hours at least every 6 months. Error on violation description it states September 2022. Drills in question were completed October 2020 to September 2021. Program Specialist has been retrained on 6400.112(e) CEO will monitor monthly drills for compliance ensuring sleep drills are implemented as required, staff have been instructed to follow sleep drills schedule. 03/17/2022 Implemented
6400.141(a)Individual #1's most recent annual physical examination was completed on 11/30/2020.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. During inspection, provider informed of the issues surrounding medical records and individuals responsible person not wanting provider to have access to any records and would not allow staff to take to any appointments, responsible person for individual instructed PCP not to release any records. Several attempts were made and provided documentation to show efforts. On 3/17/22 Program specialist contacted PCP again to request records and informed PCP once again that individuals responsible person signed a consent for release of records. 3/17/22 PCP faxed 2021 physical . 03/17/2022 Not Implemented
6400.165(g)Individual #1, date of admission 4/27/2021, did not have a review of medications prescribed to treat symptoms of a diagnosed a psychiatric illness until 3/4/2022.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.During inspection, provider informed of the issues surrounding medical records and individuals responsible person not wanting provider to have access to any records, responsible person for individual dictates all appointments and does not want individual to attend any psychiatric appointments. Several attempts were made and provided documentation to show efforts. 3/1/22 requested a a most recent review of medications from (PCP) prescribing doctor that was received 3/7/22 medication review was provided during inspection.. Will continue efforts to inform individual and responsible person the importance of routine med reviews. Program Specialist made attempt on 3/18/22 03/18/2022 Not Implemented
6400.166(a)(13)Individual #2's March 2022 Medication Administration Record did not include a master key of names and initials of staff administering medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.CEO went to the home and replaced master key signature page with MAR. Staff have been instructed to notify CEO immediately if master key signature page is discovered not to be present and that this page should always remain with MAR. 03/16/2022 Implemented
SIN-00186008 Renewal 04/09/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)Individual #1 had a physical examination completed on 01/15/2020 and again on 03/29/2021An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Immediately the Program Specialist will create a tracking sheet for each individual that indicates the annual due date of the physical. The Program Specialist will receive an alert within 3 months of the due date to ensure the appointment has been scheduled. CEO will follow up on the date scheduled to ensure that the appointment was completed. 04/14/2021 Implemented
6400.141(c)(3)The most recent Tetanus immunization for Individual #1 was 1/19/09.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. Owner reviewed regulations with Program Specialist and program CEO concerning Immunizations. 4/12/21 program specialist contacted individual #1 doctor to discuss tetanus immunization. Doctor agreed to review records and provide a schedule of when immunizations should take place. PS will develop a system to track Immunizations and follow up with doctors yearly to ensure immunizations are up to date. 04/12/2021 Implemented
6400.141(c)(4)Individual #1 had a vision screening and hearing screening completed on 01/15/2020, and then again on 03/29/2021.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Immediately the Program Specialist will create a tracking sheet for each individual that indicates the annual due date of hearing and screening. The Program Specialist will receive an alert within 3 months of the due date to ensure the appointment has been scheduled. CEO will follow up on the date scheduled to ensure that the appointment was completed. 04/15/2021 Implemented
6400.143(a)Individual #1 refused a gynecological examination on 06/28/2020 and there was no documentation of continued attempts to train the individual about the need for health care.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. Documentation was provided to the individual at the time of refusal. Immediately and ongoing program specialist or CEO will provide continued education at each refusal of health care appointments. 04/12/2021 Implemented
6400.166(a)(7)Individual #1 is prescribed Melatonin 3 mg tablet, take 2 tablets a day at bedtime. The Medication Administration Record for April 2021 states that Individual #1 should be administered Melatonin 3 mg tablet, take a tablet a day at bedtime.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.Owner had a meeting with program CEO to address failure to ensure MAR accurately reflects medications and the responsibilities of the program and home as well as a review of regulations. CEO has been directed to always use monitoring tools put into place to monitor compliance and to review regulations monthly. Immediate action, Program specialist obtained medication list on 4/12/21 from doctor and pharmacy documentation was provided during inspection process. Program specialist will review CEO's entries of medications against MAR to ensure accuracy and owner will monitor for six months. Owner had a meeting with staff regarding the importance of paying attention to meds and MAR staff has been directed to inform CEO or program specialist if necessary if an error is noticed. 04/26/2021 Implemented
6400.181(f)The assessment for individual #1 that was completed and signed by program specialist on 10/14/2020 was sent to the individual plan team on 10/28/20, for an individual plan meeting that occurred on 11/16/2020.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Provider will ensure that assessments are submitted within the specified timeframe per regulations to team. Program Specialist will be responsible for submitting the assessment to the team at least 30 days prior to an individual plan meeting. The assessment 30-day window will be placed on Program Specialist calendar as reminder. [Immediately, CEO or designee shall monitor at least quarterly] 04/13/2021 Implemented
SIN-00172037 Renewal 02/27/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(r)Individual #1's bedroom door did not have a lock.An individual has the right to lock the individual's bedroom door.Owner purchased locks and placed them on all bedroom doors 3/25/20. Program Specialist talked to individuals 3/23/20 regarding the new regulations and the right to lock bedroom door. Staff were made aware of this change and where the key is kept and when they should use it [At least monthly for at least 1 year, the CEO or program specialist shall interview the individuals and staff persons to ensure individual are exercising their right to lock their bedroom doors and any changes in the process need to be made. (DPOC by AES,HSLS on 5/6/20)] 03/25/2020 Implemented
SIN-00232602 Renewal 10/11/2023 Compliant - Finalized
SIN-00214223 Renewal 11/01/2022 Compliant - Finalized
SIN-00211796 Unannounced Monitoring 09/23/2022 Compliant - Finalized
SIN-00157353 Initial review 06/18/2019 Compliant - Finalized