Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00240485 Renewal 03/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(f)The home's outdoor trash receptacle was found next to the curb in front of the home at the time of inspection. This trash receptacle was over-filled with bags of trash that propped its lid open approximately 6 to 8 inches, exposing the contents of the receptacle to penetration by insects and rodents.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.On 3/14/24 - Staff were trained on the importance of making sure that trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. Due to the trash not being picked up CareSense Living contacted the trash company to report the late pick up and confirm pick up date of the following Friday. Trash was picked up on the following Fridays after that with the last pick up being 4/5/24, Regular scheduled weekly pick up is on Friday(s). 04/05/2024 Implemented
6400.68(b)At the time of inspection, the water temperature taken at the bathtub faucet in the home's only bathroom was 145° Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. on 3/14/24 staff were trained on the importance of ensuring that the Hot water temperatures in bathtubs and showers may not exceed 120°F. Water temperature was turned down and tested on 3/5/24 and again on 4/5/24 during the home check. 04/05/2024 Implemented
6400.72(a)At the time of inspection, one of the activity room's windows was fully open without the use of a window screen. In addition, five windows on the second story of the home lacked window screens. As there were no screens within the home that could be fit into these five windows' window frames should the windows be opened, they were incapable of being securely screened when opened.Windows, including windows in doors, shall be securely screened when windows or doors are open. On 3/14/24 all staff were trained on the importance of ensuring that windows, including windows in doors, shall be securely screened when windows or doors are open. All window screen assessed and repaired by 4/5/24. 04/05/2024 Implemented
6400.72(b)There was a hairline crack in one of the activity room's windows. In addition, the window screen in another of the activity room's windows was severely torn; approximately half of the window screen was missing. Screens, windows and doors shall be in good repair. On 3/14/24 all staff were retrained on the importance of ensuring that all screens, windows and doors shall be in good repair. The window for Fairmount was assessed and fixed on 4/5/24. 04/05/2024 Implemented
6400.171A plastic storage container of an unidentifiable, orange-red, pureed food item was found in the home's refrigerator with its lid visibly loosened from the container, exposing the food inside to the outside environment. This food item was not stored in a manner that would protect it from contamination.Food shall be protected from contamination while being stored, prepared, transported and served. On 3/14/24 all staff were retrained on the importance of ensuring that food shall be protected from contamination while being stored, prepared, transported and served. On 4/5/24 a home check weas completed and all containers in the home were matched up with correct lids and any containers that did not have lids were removed. 04/05/2024 Implemented
6400.32(r)The doorknob on Individual #1's bedroom door was not equipped with a locking mechanism.An individual has the right to lock the individual's bedroom door.On 3/14/24 all staff were retrained on the importance of ensuring that an individual has the right to lock the individual's bedroom door. As of 4/5/24 the Indvidual bedroom door lock form was updated to reflect that he would not like to have a bedroom lock on his door and due to his seizures, it would be a health and safety risk since he has had prior, and the team is in agreement. 04/05/2024 Implemented
SIN-00217271 Renewal 02/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Rotting, lose and raised boards were found on the back deck of the home. One area covering approximately eight inches by twenty inches was found to be weatherworn and rotting that created a depressed area and hole. There were no obvious repairs or new boards on the deck. Several new deck boards were laying in the yard to the left of the deck with grass growing around them. (Repeat Violation)Floors, walls, ceilings and other surfaces shall be in good repair. On 2/17/2023 all staff were retrained on the importance of Floors, walls, ceilings and other surfaces shall be in good repair. The contractor replaced the floorboards on the deck and resurfaced and painted the deck on 2/25/2023 the deck boards were removed that were not in use on 2/28/2023. 02/25/2023 Implemented
6400.80(b)At time of inspection there were approximately eight pavers located in front of the steps of the deck leading into the backyard. The pavers were uneven and sunken in spots creating a tripping hazard. Exterior conditions shall be free from unsafe conditions. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.On 2/17/2023 staff were retrained on the importance of having the outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. On 2/25/2023 the contractor ensured that all pavers were rooted properly and provided and were all even and in good repair. 02/25/2023 Implemented
6400.32(r)(4)The bedroom door lock for Individual #5 had a coin key lock on the bedroom door. Coin key locks do not allow for easy and immediate access. (Repeat Violation)The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency.on 2/17/2023 all staff were retrained on the importance of ensuring that the locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. Locks were updated for the individual #1 on 2/25/2023 and the coin key lock was replaced. 02/25/2023 Implemented
SIN-00200556 Renewal 03/31/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Poisons were found unlocked and accessible in the home. Individual #3 has been assessed as not safe with poisons and there was a gallon-size jug of Olympic brand Multi-surface waterproofer on the floor of the living room closet, and a large jug of powdered laundry detergent on the floor of the unlocked laundry room area located off the kitchen. Both products were labelled with the warning to contact poison control if ingested.Poisonous materials shall be kept locked or made inaccessible to individuals. direct care staff were retrained on the safety hazards as related to poisons being kept in the home as well as the individuals required level of safety as it relates to poisons. staff were trained on the importance of keeping poisonous items locked when not in use. all poisons were identified and locked up. 05/27/2022 Implemented
6400.67(a)Surfaces shall be free of hazards. There was a board with a large hole in one of the boards on the deck at the rear exit of the home. The molding around the bathroom door entrance to the hall bathroom, and transition piece on the floor of the doorway were missing. The molding under the kitchen sink and cabinet were missing There were two large areas on the kitchen ceiling where the paint was peeling.Floors, walls, ceilings and other surfaces shall be in good repair. Handy man was contacted, and he had limited availability and will be able to complete the renovations on 6/13/22.Direct care staff were retrained on recognizing and reporting any floors, walls and ceiling that are not in good repair and next steps in the follow up including reporting to the leads staff and or program coordinator . 06/13/2022 Implemented
6400.68(b)The hot water temperature was measured at 124.3 in the hall bathroom. The water temperature was lowered at the time of the inspection and staff was advised to wash a load of laundry to get the hot water out of the tank. Hot water temperatures in bathtubs and showers may not exceed 120°F. staff was retrained on doing temperature checks during firedrills and how to lower the temperature to an appropriate temperature if needed. 05/30/2022 Implemented
6400.70The telephone line in the home was not operable. The staff that was on shift at the time of the inspection stated that the telephone had not worked since he began working in the home about two months before.A home shall have an operable, non coin-operated telephone with an outside line that is easily accessible to individuals and staff persons.the telephone was checked to see current working order, updated and service was started with another telephone provider since the current service was inconsistent. Staff were retrained on the importance of having an operable phone within the home. 05/30/2022 Implemented
6400.71There were no emergency telephone numbers posted on or near the telephone.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. staff were retrained on the importance of ensuring that the emergency telephone list is updated and always posted in the home near the telephone. the emergency telephone number was updated and posted 05/30/2022 Implemented
6400.77(b)There was no thermometer in the 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. Staff were retrained on all components that need to be in a first aid kit and the importance of the first aid kit. thermometer was placed in the first aid kit. 05/30/2022 Implemented
6400.82(f)There was no hand soap available in the hall bathroom. There was an empty bottle of hand soap in the cabinet under the sink.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. Hand soap was replaced in the hall bathroom. direct care staff were trained on all what is required and should be accessible in the bathroom at all times which includes hand soap. 05/30/2022 Implemented
6400.106The annual furnace inspection was late. The most current furnace inspection occurred on 3/18/2021.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. Staff (program coordinator) were retrained on the importance of completing annual furnace inspection. furnace inspections were scheduled for 2023. 05/30/2022 Implemented
6400.15(b)The self-assessment completed for Levering Place was not completed on the correct Department form. The form that the provider used was an outdated form and did not contain the current, updated 6400 regulations.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.The agency (CSL) conducted a retraining with the Program coordinator and program specialist regarding the due dates of the self-assessment as well as the importance of completing Lii, which are due 3 to 6 months prior to the certificate of compliance expiration. During the training a new self-assessment was completed for each home to utilize as a sample moving forward. 05/30/2022 Implemented
6400.18(f)The home shall take immediate action to protect the health, safety and well-being of individuals following the initial knowledge or notice of an incident, alleged incident or suspected incident. At the time of the inspection, Individual #3 was sitting in a wheelchair in the living room. The individual's nose appeared swollen and bruised, with dried blood on the tip of the nose. Staff stated that the individual had injured his nose a couple of days before by banging his knee to his nose, and the blood was because the individual was rubbing his nose. The individual's Individual Support Plan (ISP) does document that the individual has a significant history of self-injurious behavior. Staff had not reported the injury and no medical attention had been provided to the individual. Whether an injury occurs from self-injurious behavior or another way, an injury that may require more than first aid needs to be assessed and treated by a medical professional.The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident.staff and program coordinator were retrained on the importance of taking immediate action if any health and safety concerns arise for individuals under our care. individual who exhibits constant self-injurious behavior, was taken to his scheduled urgent care appointment and cleared for return home. 05/30/2022 Implemented
SIN-00183559 Renewal 03/30/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Documentation of funds received by the home for Individual #1 were requested and not received. It could not be determined that up to date financial records of deposits made to the home for Individual #1 were kept. Per CareSense assessment for Individual #1 dated 4/03/21 "Joan is unable to maintain her funds safely. She would need total staff assistance. There have been no changes in this area."The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. Both the lead staff and program coordinator were retrained on the client fund process . Individual #1 funds wee reconciled and inputted into an online system that automatically calculates funds , the goal would de to better track the receipts and balances. Although CareSense is not the current rep payee , any funds at the home for individual #1 will be tracked accordingly and reconciled. All client funds for ind. #1 is reconciled. 04/02/2021 Implemented
6400.22(d)(2)Documentation of disbursements made to or for Individual #1 were requested and not received. It could not be determined that up to date financial records of disbursements made to or for the individual were kept. Per CareSense assessment for Individual #1 dated 4/03/21 "Joan is unable to maintain her funds safely. She would need total staff assistance. There have been no changes in this area."(2) Disbursements made to or for the individual. Both the lead staff and program coordinator were retrained on the client fund process . Individual #1 funds were reconciled ( deposits and wihdrawals and inputted into an online system that automatically calculates funds , the goal would de to better track the receipts and balances. Although CareSense is not the current rep payee , any funds at the home for individual #1 will be tracked accordingly and reconciled. All client funds for ind. #1 is reconciled. 04/02/2021 Implemented
6400.22(e)(1)Documentation of dates and amounts of deposits and withdraws for Individual #1 were requested and not received. It could not be determined that a record of financial resources, including the dates and amounts of deposits and withdrawals were kept. Per CareSense assessment for Individual #1 dated 4/03/21 "Joan is unable to maintain her funds safely. She would need total staff assistance. There have been no changes in this area." If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. Although CareSense is not the current rep payee , any funds at the home for individual #1 will be tracked accordingly and reconciled. All client funds for ind. #1 is reconciled. Both the lead staff and program coordinator were retrained on the client fund process . Individual #1 funds were reconciled ( deposits and withdrawals and inputted into an online system that automatically calculates funds , the goal is to track better the receipts and balances. 04/02/2021 Implemented
6400.22(e)(2)Documentation of financial transactions for Individual #1 were requested and not received. It could not be determined that withdrawals were properly logged as required. Per CareSense assessment for Individual #1 dated 4/03/21 "Joan is unable to maintain her funds safely. She would need total staff assistance. There have been no changes in this area." If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: For a withdrawal when the individual is given the money directly, the record shall indicate that funds were given directly to the individual. Both the lead staff and program coordinator were retrained on the client fund process . Individual #1 funds were reconciled ( deposits and wihdrawals and inputted into an online system that automatically calculates funds , the goal is to track better the receipts and balances. Although CareSense is not the current rep payee , any funds at the home for individual #1 will be tracked accordingly and reconciled. All client funds for ind. #1 is reconciled. 04/02/2021 Implemented
6400.22(e)(3)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 was requested and not received for Individual #1. It could not be determined that receipts and/or expense records were kept satisfying regulation. Per CareSense assessment for Individual #1 dated 4/03/21 "Joan is unable to maintain her funds safely. She would need total staff assistance. There have been no changes in this area." 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. Both the lead staff and program coordinator were retrained on the client fund process . Individual #1 funds were reconciled ( deposits and wihdrawals and inputted into an online system that automatically calculates funds , the goal is to track better the receipts and balances. Although CareSense is not the current rep payee , any funds at the home for individual #1 will be tracked accordingly and reconciled. All client funds for ind. #1 is reconciled. 04/02/2021 Implemented
6400.112(g)The asleep drill conducted on 5/6/20 was held at 4:45am. The asleep drill conducted on 11/2/20 was held at 4:45am. All drills must be held at different times of the day and night to satisfy regulation. Fire drills shall be held on different days of the week and at different times of the day and night. Retraining of the fire drill process occurred with the Program coordinator and assistant director - where the importance of varying the drills and having unplanned drills on different days of the week and different is important to the overall safety of all the individuals. 04/02/2021 Implemented
6400.141(c)(3)Physical was completed for Individual #1 on 3/3/21. The physical did not include documentation of the required immunizations. Tetanus (Td) is required every 10 years.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. Per the ISP individual # 1 was given a tetanus booster on 2/17/2015 and would not be due for another shot until 2025. Her pcp is updating her physical to reflect this . 04/28/2021 Implemented
6400.141(c)(10)Physical was completed for Individual #1 on 3/3/21. The "Individual free from contagious disease" section was blank. Neither "Yes" or "No" boxes were checked, and no additional recommendation or specific instructions were made is the designated section.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 physical was resubmitted to the PCP for individual #1 and the section was updated to reflect her current status of free from communicable disease. Lead staff retrained on medical appointments and what should be completed on a physical . 04/23/2021 Implemented
6400.141(c)(11)Physical was completed for Individual #1 on 3/3/21. The physical did not include documentation of the need for blood work at recommended intervals.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 physical was resubmitted to the PCP for individual #1 and the section was updated to reflect her bloodwork needs. Lead staff retrained on medical appointments and what should be completed on a physical . 04/23/2021 Implemented
6400.142(a)A dental visit occurred on 11/19/19, cleaning was not completed due to lack of cooperation. Return was to be in one year. A dental visit did not occur in 2020 through 3/31/2021. Annual dental exam and cleaning is required.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. An updated special smiles dental consent form was completed and a new dental date has been requested from special smiles . staff retrained on the importance of medical appointments and due dates . 04/30/2021 Implemented
6400.143(a)Individual #1 refuses dental exams. No documentation of refusals or continued attempts to train Individual #1 about the need for health care was provided.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. Staff was retrained on the process , if the situation arises that individual #1 refuses dental exams or any other appointments.. 04/02/2021 Implemented
6400.34(a)Individual #1 rights were reviewed on 1/1/21. The review did not include all rights as outlined in § 6400.32. Rights of the individual. (b) An individual has the right to civil and legal rights afforded by law, including the right to vote, speak freely, practice the religion of the individual's choice and practice no religion. (c) An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. (d) An individual shall be treated with dignity and respect. (e) An individual has the right to make choices and accept risks. (f) An individual has the right to refuse to participate in activities and services. (g) An individual has the right to control the individual's own schedule and activities. (i) An individual has the right of access to and security of the individual's possessions. (j) An individual has the right to voice concerns about the services the individual receives. (n) An individual has the right to unrestricted and private access to telecommunications. (p) An individual has the right to choose persons with whom to share a bedroom. (q) An individual has the right to furnish and decorate the individual's bedroom and the common areas of the home in accordance with § 6400.33 (relating to negotiation of choices). (r) An individual has the right to lock the individual's bedroom door. (1) 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. (2) Access to an individual's bedroom shall be provided only in a life-safety emergency or with the express permission of the individual for each incidence of access. (3) Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance. (4) The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. (5) Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. (s) An individual has the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home. (1) Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance. (2) The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. (3) Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. (t) An individual has the right to access food at any time. (u) An individual has the right to make health care decisions.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 retrained on her rights to include all rights base on the regulation . The updated rights were reviewed with staff as well . 04/23/2021 Implemented
6400.165(c)Medications Administration Record (MAR) for Individual #1 recorded an entry for "Ergocalciferol 8,000 unit/ML Give 1 milliliter VIA J-TUBE once daily." The label on the Ergocalciferol was written as "Ergocalciferol 8.00 unit/ML Give 0.3 milliliters (2,400 units total) via tube once daily." MAR for Individual #1 recorded an entry for "Clozapine 100mg tablet (generic for Clozaril)/EA take 1 tablet by mouth every morning and 4 tablets at bedtime." Staff #1 reported that they do not give the medication by mouth but rather crush all and give via J-Tube.A prescription medication shall be administered as prescribed.There was a med change and the new April MAR reflected the correct dose , which was .3 milliliters for Ergocalciferol . Staff was retrained on ensuring that the medication should be administered as prescribed 04/02/2021 Implemented
6400.166(a)(2)The March 2021 medication administration record for Individual #1 did not contain the name of the prescriber.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.The name of the prescriber has been updated for April 2021. Staff was retrained on what to look for on a MAR , while doing checks , which includes the prescriber. 04/23/2021 Implemented
SIN-00167272 Renewal 12/17/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Up and Up brand anticavity fluoride rinse, which is labeled "contact poison control if ingested," was found unlocked in the medicine chest in the hall bathroom. The individuals who live in the home have been assessed as not being safe with poisons.Poisonous materials shall be kept locked or made inaccessible to individuals. Staff were retrained on poisons and the importance of keeping all poisons locked , per isp of Individual #1, since she is not safe around poisons.( 12/24/2019) The biweekly home checklist will be conducted at least twice a month and during that time , staff will check the house and ensure that all poisons are locked and ensure to document results and if any out compliance items arise, fix immediately and notify the next level supervisor. 12/24/2019 Implemented
6400.110(f)Individual #1 is hearing-impaired and not able to hear the smoke detector. At the time of the inspection, the bed shaker was not charged or plugged into a power source, and was not operational.If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire.Individual #1's Bed shaker was repositioned so that it is plugged in ongoing while on the bed. Originally the bed shaker was being charged in a different area of the home and now it is being charged on the bed only. Staff were retrained on the location of the bed vibrator and the importance of keeping it charged. Ongoing during monthly fire drills staff will check that the bed vibrator is working appropriately and document on the fire drill. 12/18/2019 Implemented
6400.141(c)(6)The initial physical examination completed on 6/12/19 for Individual #1 did not include Tuberculin skin testing by Mantoux method. Individual #1 was admitted on 6/29/19 and did not have a Tuberculin test administered until 7/01/19 and read on 7/03/19.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 tuberculin skin test will be updated by 2/14/2020. Staff was retrained on what to do during appointments and also what a tuberculin test should include (12/24/2019). Client Physicals will be reviewed quarterly by assistant director to ensure that TB and physical is completed in full, per cluster to prevent occurrence of missing items and corrected if deemed necessary. 02/14/2020 Implemented
6400.141(c)(14)The physical examination completed on 6/12/19 for Individual #1 did not include information pertinent to diagnosis in case of emergency (the area was left blank).The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Individual #1 physical will be updated by 2/14/2020. Staff was retrained on what to do during appointments and also what a physical should include (12/24/2019). Client Physicals will be reviewed quarterly by assistant director per cluster to prevent occurrence of missing items and corrected if deemed necessary. 02/14/2020 Implemented
6400.181(a)Individual #1's date of admission was 6/29/19 and the initial assessment was not completed until 9/29/19.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.The program specialist was retrained on appropriate time frames for completing initial assessments and assessments overall 12/24/2019. Ongoing the PS will submit monthly checklist which will track all assessments completed as well as due dates . 12/24/2019 Implemented
6400.183(5)Individual #1 is prescribed medication to treat the symptoms of a diagnosed psychiatric illness and there was not a protocol to address the social, emotional and environmental needs of the individual in the record.The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. A behavior plan was recently created by her behavior specialist that addresses proactive and reactive strategies to aid in helping her with her social emotional and environmental needs ( 12/24/2019) . Training was done with the program specialist to address items that should be reflected in her plan.12/24/2019 which will be reviewed monthly during team meetings. 12/24/2019 Implemented
6400.165(g)Individual #1 was admitted on 6/29/19 and did not have a 3 month review of psychiatric medication until 10/29/19.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.Staff ( SM) was retrained on the compliance timeframe for psychiatric med reviews ( retrained occurred on 12/24/2019) . Individual #1 went to psych appointment 1/15/2020 for a med review. In order to ensure that this occurrence does not happen again , all med appts including psych appts will be reviewed monthly during team meeting . Also a med calendar was created for the home. Next psych appt is March20,2020 01/15/2020 Implemented
6400.166(b)The staff persons administering medication to Individual #1 failed to initial the medication record at the time the medication was administered on the following dates: the 8am dose of Gabapentin on 12/06/19; the 8am dose of Muro eye drops on 12/03/19; the 8am application of Ammonium Lactate cream on 12/01/19 and 12/02/19; and the 4pm dose of Omeprazole on 12/10/19.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Staff that failed to initial based on the dates listed were retrained on key rules to medication documentation/administration. Staff (SS) will send monthly program coordinator checklist that will document Monthly mar reviews and also check weekly mars for accuracy . The monthly Mar checks will be subsequently checked by assistance director and director for any issues ongoing. 12/24/2019 Implemented