Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00228031 Renewal 07/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(1)Individual #1's financial record did not include the deposits and withdrawals for VISA gift cards ending in #4429, #5631 and #5039. 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. On 8/2/23 - staff were retrained on the importance of assuming 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. Effective 7/23/23 - A new process was created in order to track the client fund of the assigned individual - which includes capturing each gift card to have its own account tracking and it resets once the gift card ends. 08/02/2023 Implemented
6400.106A furnace inspection was completed 1/06/2022 and then again 6/16/2023.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 (lead staff) were trained on 8/2/23 regarding the importance of ensuring that the 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. 08/08/2023 Implemented
6400.113(a)Individual #1, date of admission 11/19/2020, had no record of having been instructed in fire safety. 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. On 8/2/23 , staff were retrained on the importance of 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. The individual was trained on refresher fire safety on 8/3/23 and reviewed fire safety within the home. 08/03/2023 Implemented
6400.165(g)Individual #1 had psychiatric medication reviews completed 1/25/2023 and then again 6/07/2023. Individual #1's psychiatric medication review conducted 1/25/2023 did not include a physician's signature and date ("Repeated Violation- 3/17/2022, 12/15/2022 et al").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.on 8/2/23 - Staff were retrained on the importance ensuring that 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. Also reviewed with staff was the process of making appointments and also paperwork to be sent prior if appointment is telehealth related as paperwork to go with the appointment. 08/02/2023 Implemented
6400.166(a)(13)Individual #1's July 2023 medication administration record did not include name and initials of the person who administered Oxybutynin 5mg at 8:00am on 7/13/2023 (Repeat violation from 8/15/22, et al).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.Staff on 8/2/23 were retrained on the importance of ensuring that 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. A training of the home checklist was also completed on 8/2/23 and the components were reviewed with the staff. 08/14/2023 Implemented
6400.181(f)Individual #1's assessment, completed 1/19/2023, was sent to the plan team 7/05/2023, for the individual support plan meeting on 7/05/2023.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.on 8/3/23 - The program specialist was retrained on importance of providing the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. He was also trained on who needs to be included on the email and the assessment due dates were also reviewed and calendar appointments made as reminders to send. 08/03/2023 Implemented
SIN-00216579 Renewal 12/15/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)Individual #1 had a physical examination completed 7/01/2021 and then again 7/22/2022.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. On 12/19/22 all staff (director of residential, direct care, program specialist) have all been retrained on the requirements of the annual physical for individuals which should be completed on an annual basis. 12/19/2022 Implemented
6400.141(c)(1)Individual #1's physical examination completed 7/22/2022 did not include a review of previous medical history. It was left blank "Repeated Violation- 3/17/2022, et al".The physical examination shall include: A review of previous medical history. On 12/19/22 all staff (director of residential, direct care, program specialist) have all been retrained on the requirements of the annual physical for individuals which should be completed on an annual basis- the components and importance of the annual physical were reviewed during the training, which includes previous medical history. 12/19/2022 Implemented
6400.141(c)(5)Individual #1's physical examination completed 7/22/2022 did not include immunizations "Repeated Violation- 3/17/2022, et al".The physical examination shall include: Immunizations and screening tests for individuals 17 years of age or younger, as recommended by the Standards of Child Health Care of the American Academy of Pediatrics, Post Office Box 1034, Evanston, Illinois 60204. On 12/19/22 all staff (director of residential, direct care, program specialist) have all been retrained on the requirements of the annual physical for individuals which should be completed on an annual basis- the components and importance of the annual physical were reviewed during the training, which includes immunizations. 12/19/2022 Implemented
6400.141(c)(11)Individual #1's physical examination completed 7/22/2022 did not include medication regimen [Repeated Violation- 3/17/2022, et al].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. On 12/19/22 all staff (director of residential, direct care, program specialist) have all been retrained on the requirements of the annual physical for individuals which should be completed on an annual basis- the components and importance of the annual physical were reviewed during the training, which should include medication regimen. 12/19/2022 Implemented
6400.141(c)(13)Individual #1's physical examination completed 7/22/2022 did not include allergies. It was left blank.The physical examination shall include: Allergies or contraindicated medications.On 12/19/22 all staff (director of residential, direct care, program specialist) have all been retrained on the requirements of the annual physical for individuals which should be completed on an annual basis- the components and importance of the annual physical were reviewed during the training, which should include allergies. 12/19/2022 Implemented
6400.141(c)(14)Individual #1's physical examination completed 7/22/2022 did not include medical information pertinent to diagnosis and treatment in case of an emergency. It was left blank "Repeated Violation- 3/17/2022, et al".The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. On 12/19/22 all staff (director of residential, direct care, program specialist) have all been retrained on the requirements of the annual physical for individuals which should be completed on an annual basis- the components and importance of the annual physical were reviewed during the training, which should include medical information pertinent to diagnosis and treatment in case of an emergency. 12/19/2022 Implemented
6400.181(d)Individual #1's assessment completed 1/19/2022 was electronically signed by Program Specialist #1 1/19/2021.The program specialist shall sign and date the assessment. on 12/19/22-Staff (program specialist and director) were retrained on the due dates and importance of assessments and having the correct sign off on assessments. manual sign off was printed and created for individual and program specialist updated it to reflect the correct information. 12/19/2022 Implemented
6400.181(e)(1)Individual #1's assessment completed 1/19/2022 did not include functional strengths. The assessment must include the following information: Functional strengths, needs and preferences of the individual. on 12/19/22- Staff (program specialist and director of residential) were retrained on the due dates, importance of assessments, sign off on assessments and components including functional strengths. the 1/19/2022 assessment was updated to include functional strengths of the individual and reviewed for compliance by the director of residential and director of operations 12/19/2022 Implemented
6400.165(g)Individual #1 had a psychiatric medication review by a licensed physician 4/27/2022 and then again 8/02/2022 "Repeated Violation- 3/17/2022, et al".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.On 12/19/22 all staff (director of residential, direct care, program specialist) have all been retrained on the requirements of completing a psyche medication review, documentation involved, frequency and the importance of a licensed physical completing the psyche review and components to be filled out. 12/19/2022 Not Implemented
6400.213(1)(i)Individual #1's record did not include identifying marks. "Repeated Violation- 3/17/2022, et al".Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.on 12/19/22- Staff (program specialist and director of residential) were retrained on the due dates, importance of assessments, sign off on assessments and what should due be included on a demographic sheet for the individual records such as identifying marks. the demographic sheet was updated to include identifying marks of the individual and reviewed for compliance by the director of residential and director of operations1/9/2023 01/09/2023 Implemented
SIN-00214182 Unannounced Monitoring 11/01/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(1)During the inspection conducted 11/01/2022, Individual #1 did not have a separate record of financial resources including dates and amounts of deposits and withdrawal. 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. Client funds reconciliation sheet was reimplemented and items added to the sheet and expenditures. lead staff (11/10/22) and residential director (11/9/2022) was retrained regarding client funds procedures. 12/01/2022 Implemented
6400.216(a)During the inspection conducted 11/01/2022 Individual #1's records were kept unlocked in the staff office. An individual's records shall be kept locked when unattended. A cabinet was purchased and assembled in the common area on the main level with a lock. all client books were locked and accounted for. lead staff (11/10/22) and residential director (11/9/22) were trained on the importance of keep client files locked and secure. 11/11/22. 11/21/2022 Implemented
SIN-00210428 Unannounced Monitoring 08/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)In Individual #1's bedroom, a triangular-shaped area of missing plaster, measuring approximately 1.5' x 1.5' x 1.5,' was observed at 10:27 AM on 8/15/22. This area is located to the right of the bedroom's only window upon entrance. [Repeat violation from 3/17/22.]Floors, walls, ceilings and other surfaces shall be in good repair. During inspection it was discovered that floors, walls, ceilings and other surfaces were not in good repair. There was a triangular-shaped area of missing plaster on individual #1's bedroom wall. The wall was repaired on 10-2-22 with spackling and paint. The Residential Director was trained on 9-21-22 of the importance of keeping all surfaces in good repair. The staff at the home received training on 9-26-22 about floors, walls, ceilings and other surfaces being in good repair. 10/17/2022 Implemented
6400.72(b)The storage room located in front of the stairwell in the basement was observed at 10:44 AM on 8/15/22, having a door with a broken doorknob. The doorknob facing the basement was functional. However, the door side facing the interior of the storage room was missing a doorknob to exit this room. Screens, windows and doors shall be in good repair. Upon Inspection it was discovered that screens, windows and doors were not in good repair. In the storage room located in the front of the stairwell in the basement had a door with a broken doorknob. On 9-30-22 the doorknob was removed from the door because this storage room is not utilized for anything. The Residential Director was trained on 9-21-22 of the importance of keeping all surfaces in good repair. The staff at the home received training on 9-26-22 about floors, walls, ceilings and other surfaces being in good repair. 10/17/2022 Implemented
6400.80(b)Sections of the retaining wall were observed collapsed in the driveway at 10:04 AM on 8/15/22. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.Upon Inspection, the outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions, and it was discovered that there were sections of the retaining wall that were observed to have collapsed. The sections of the retaining wall that collapsed were cleared away on 9-30-22. The Residential Director was trained on 9-21-22 of the importance of keeping the outside of the building and the yard or grounds being well maintained, in good repair and free from unsafe conditions. The staff at the home received training on 9-26-22 about importance of keeping the outside of the building and the yard or grounds being well maintained, in good repair and free from unsafe conditions 10/17/2022 Implemented
SIN-00202069 Renewal 03/17/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency certificate of compliance expired 1/12/2022 and the self-assessment of the home was completed 2/09/2022. The self-assessment form used was last updated in 2018.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. The agency (CSL) conducted a retraining with the Director of residential 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. 05/27/2022 Not Implemented
6400.110(e)During the onsite inspection on 3/18/2022 the home which has three stories did not have interconnected smoke detectors.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. The laketon home at the time of inspection had functioning smoke detectors but they were not interconnected. Interconnected smoke detectors were ordered and were delivered, a fire drill was completed in order to ensure that the new smoke detectors were functioning properly. staff were retrained on the 6400.110 ( e) regulation which indicates if a home is 3 or more stories it should have interconnected smoke detectors installed 04/28/2022 Implemented
6400.111(f)During the onsite inspection on 3/18/2022, the fire extinguisher located in the basement was last serviced in February 2021. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. Although the fire extinguishers were updated earlier that month, unfortunately the basement fire extinguisher was overlooked. ABC fire is scheduled to come out to check the fire extinguisher in the basement on 5/3/2022. Staff (direct care/ director of residential )were retrained on what is due annually as it pertains to the fire extinguisher being inspected by a fire safety expert annually 04/28/2022 Implemented
6400.141(c)(4)Individual #1 had a hearing screening completed 11/17/2020 and then again 1/05/2022. Individual #1's most recent vision screening was completed 1/06/2021.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. on individuals #1 physical did not include vison/hearing on physical and the doctor's office will complete the missing info on the physical by 5/9/22. Staff (lead staff - and director were retrained on the importance of managing medical appointments and follow ups and following doctors recommendations. 05/30/2022 Not Implemented
6400.141(c)(14)Individual #1's physical examination completed 7/20/2021 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. on individuals #1 physical did not include medical information on physical and the doctor's office will complete the missing info on the physical by 5/9/22. Staff (lead staff - and director were retrained on the importance of managing medical appointments and follow ups and following doctors recommendations. 05/30/2022 Not Implemented
6400.142(a)Individual #1, date of admission 11/19/2020, had an initial dental examination completed 12/28/21.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. lead staff -and director of residential were retrained on the importance of managing medical appointments and follow ups and following doctors recommendations including dental appointment. A dental appointment for individual was made for June 5, 2022 @ 2pm 06/05/2022 Not Implemented
6400.142(f)Individual #1, date of admission 11/19/2020, does not have a written plan for dental hygiene nor has documentation in writing from the interdisciplinary team stating the individual has achieved dental hygiene independence.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. individual dental hygiene plan was updated on 3/23/2022 to reflect current status . Staff ( lead staff and director and program specilaist) were retrained on the need for a dental hygiene plan for each client and how to document progress and or completion via an interdisciplinary team meeting 06/01/2022 Not Implemented
6400.143(a)Individual #1, date of admission 11/19/2020, had scheduled an initial gynecological examination and pap smear for 2/25/2022. Individual #1 refused the appointment, but there was no documentation of any counseling provided to the individual.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. individual #1 attended her Gyn appointment but still did not feel comfortable completing the entire exam. Staff, lead staff and direct care, were retrained on the importance of appointments and documenting refusals 06/01/2022 Not Implemented
6400.18(a)(4)Abuse incident #8935219 involving Individual #1 was discovered by the agency on 11/11/2021 and reported throught the Department's information management system on 11/16/2021.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Abuse, including abuse to a individual by another client. Staff (lead staff and director ) were retrained on the reporting process of incidents and the timelines for closing an incident 3/23/22. 04/28/2022 Implemented
6400.18(b)(2)On 3/6/2022, the agency discovered that Individual #1 did not have the prescribed Docusate Sodium 100mg administer on 3/6/2022 at 8:00am. This was not reported through the Department's information management system.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person: A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner.Staff (lead staff and director) were retrained on the reporting process of incidents and the timelines for closing an incident 3/23/22. Error was reported via EIM 04/28/2022 Not Implemented
6400.163(h)Individual #1 is prescribed Famotidine 20mg tablet, with instructions to take one tablet by mouth daily as needed for heartburn or reflux, with a use by date of 12/21/2021. The medication was administered to Individual #1 3/12/2022 and was present in the home during the inspection on 3/18/2022.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The medication Famotidine was replaced due to it being expired. Staff (lead and director) were retrained on checking that medication is not expired within the home 04/28/2022 Implemented
6400.165(c)Individual #1 is prescribed Melatonin 3mg capsule, with instructions to take 3mg by mouth nightly as needed for sleep. The March 2022 medication administration record for Individual #1 documents individual refused the medication 3/02/2022, 3/04/2022,, 3/05/2022, 3/11/2022, 3/12/2022, and 3/16/2022, but this is to be administered only as needed.A prescription medication shall be administered as prescribed.The melatonin being listed was a documentation error and prior the staff used a electronic MAR which didn't always work accurately so caresense transitioned to a paper mar format. Staff ( lead and director ) were retrained on the step's for giving meds . 04/28/2022 Implemented
6400.166(a)(11)Individual #1's March 2022 medication record did not include diagnosis or purpose for the following medications: Haloperidol 5mg, Olanzapine 20mg, Clozapine 100mg, Benztropine Mesylate 1mg, Docusate Sodium 100mg, Hydroxyzine 50mg, Lithium Carbonate 150mg, Lithium Carbonate 300mg, Melatonin 3mg, Metformin Hydrochloride 500mg, and Famotidine 20mg.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Due to the documentation errors due to the electronic mar not always being functional, the Direct care staff and lead and lead staff and director of residential were retrained on the process of documentation and medication errors, giving medication and reporting medication issues as well as what needs to be included on a MAR. 04/28/2022 Implemented
6400.166(a)(13)Individual #1 is prescribed Hydroxyzine 50mg capsule, take 1 capsule by mouth 4 times a day. There is no record of administration on 3/1/2022, 3/8/2022, 3/13/2022 for the 3/16/2022 for the 12pm dose. On 3/10/22 the 12pm does was administered at 2:14pm. On 3/13/2022 the 4pm dose was administered at 5:34pm. On 3/16/2022 the 4pm dose was administered at 8:55pm. Individual #1 is prescribed Lithium Carbonate 150mg capsule, take 1 capsule by mouth daily, in the evening along with 300mg for a total of 450mg. There is no record of administration on 3/14/2022 for the 5pm administration. Individual #1 is prescribed Haloperidol 5mg, take 1 tablet by mouth 3 times a day. There is no record of administration on 3/01/2022 and 3/16/2022 for the 12pm dose. There is no record of administration on 3/01/2022, 3/06/2022, 3/08/2022, and 3/14/2022 for the 9pm dose. On 3/10/2022 the 12pm dose was administered at 2:04pm.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.Due to the documentation errors due to the electronic mar not always being functional, the Direct care staff and lead and lead staff and director of residential were retrained on the process of documentation and medication errors, giving medication and reporting medication issues. 04/28/2022 Not Implemented
6400.167(a)(1)Individual #1 is prescribed Docusate Sodium 100mg capsule, with instructions to take one capsule by mouth two times a day. The agency failed to administered the medication to the individual on 3/06/2022 at 8:00am. The note on the 2022 medication administration record stated awaiting pharmacy refill.Medication errors include the following: Failure to administer a medication.Direct care staff and lead and lead staff and director of residential were retrained on the process of medication errors, giving medication and reporting medication issues as well as how to obtain approval form the doctor's office if a medication needs to be on hold. medication error was submitted in EIM. 04/28/2022 Not Implemented
SIN-00183648 Renewal 02/23/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace of the home was inspected and cleaned 11/27/19 and then again 2/17/21. [Repeat Violation-11/13/19; et al]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. The furnace of the home was delayed in inspection, due to COVID-19 exposure/quarantine within the home during the time of the regular inspection in December 2020. To avoid the error in the future, the furnace inspection will be scheduled more than a month in advance. The furnace inspection company, Restano was already contacted by the program director (MS) and the next available time to schedule inspection for yearly inspection/cleaning is September 2021 for February 2022. The furnace inspection reminder has been created in outlook as an appointment reminder to scheduled annual furnace inspection for all homes. 03/11/2021 Implemented
6400.112(e)The most recent fire drill held during sleeping hours was on 5/8/20.A fire drill shall be held during sleeping hours at least every 6 months. Program director and assistant director were retrained on the regulations as it pertains to a fire drill being completed during sleep hours every 6 months. The may 2020 drill was completed but the individual, although late, was not asleep at the time of the drill ¿ staff were also trained on proactive strategies to trouble shoot if the person is awake at the time the drill, which included reporting the issue and completing another drill during the same month while the person is asleep , in order to remain in compliance. 03/10/2021 Implemented
6400.141(c)(6)Individual #1's Tuberculin skin test, administered on 11/17/20 did not include the results of the testing or the person who read the test.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 Tb was completed but did not reflect the results of the TB test, staff were retrained on what to look for on a medical consult and the importance of getting all required information for a physical completed in full. The PC checklist will be completed monthly which will track due dates for appointment, which includes TB results. 03/10/2021 Implemented
6400.181(e)(14)Individual #1's assessment completed 1/19/21 does not include the individual's knowledge of water safety and ability to swim.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. Since the Individual #1 assessment did not reflect her knowledge of water safety and ability to swim, her assessment has been updated to reflect her knowledge of tempering water / water safety and or ability to swim. The Program specialist has been retrained on the regulation requirement. 02/26/2021 Implemented
6400.166(a)(11)Individual #1's February 2021 medication administration record did not include a diagnosis or purpose for the following medications: Benztropine, 1mg; Betamethasone DP; Clozapine, 100 mg; Docusate Sodium, 100mg.; Guanfacine ER, 2 mg; Haloperidol, 5 mg; Haloperidol, 10 mg, Hydroxyzine HCL, 50 mg; Lithium Carbonate, 300 mg; Metformin, 500 mg; Olanzapine, 10 mg and Oxybutynin, 5 mg.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Individual #1 medication administration record was updated, per the doctor¿s feedback, to reflect the diagnosis or purpose for all medications. The Program Director and Assistant operations director were retrained on the regulations pertaining to diagnosis on medication administration record. 02/26/2021 Implemented
SIN-00166901 Renewal 11/13/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)On 11/14/19, at 10:20AM, the hot water temperature at the bathtub in the bathroom on second floor of the home measured 128.6 degrees Fahrenheit . [Repeat violation 11/30/18]. Hot water temperatures in bathtubs and showers may not exceed 120°F. Regional manager and program supervisor will be retrained on Hot water temperature compliance. Direct care staff will be trained on the hot water check compliance as well as the daily monitoring. The Hot water temperature will be taken/recorded daily and submitted for review monthly. [The hot water temperature was manually turned down by the regional Manger on 11/14/19. The hot water temperature was remeasured on 11/14/19 and measured 115°F. Daily since 11/14/19, the direct service workers working in the home have measured the hot water and documented the temperatures. The documentation is monitored by the program supervisor, weekly. The program supervisor and regional manager complete random hot water tests at the homes. Documentation of aforementioned trainings shall be kept. (DPOC by AES, HSLS on 1/2/20)] 11/15/2019 Implemented