Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00190311 Renewal 07/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)A Fire Drill was not held monthly, the agency did not conduct a drill for the month of December 2020. An unannounced fire drill shall be held at least once a month. The QM Director will confirm with the Residential Lead Staff, monthly, that a drill was completed successfully with an evacuation time of 2.30 minuets or less, and conduct an additional drill in the event of an unsuccessful drill. The QM Director will track this information monthly and report out to the QM Team quarterly. 07/19/2021 Implemented
6400.112(d)The individual did not evacuate the home within the 2 ½ minutes period On June 21, 2021, the evacuation time was logged at 3 minutes and 24 seconds. No follow-up drill was completed and there was no extended time authorized by a fire safety expert. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. The QM Director will confirm with the Residential Lead Staff, monthly, that a drill was completed successfully with an evacuation time of 2.30 minuets or less, and conduct an additional drill in the event of an unsuccessful drill. The QM Director will track this information monthly and report out to the QM Team quarterly. 07/19/2021 Implemented
6400.141(c)(6)Physical from 7/10/20 reports that a Quantiferon test (for TB) was ordered for Individual #1; no report citing the results of that test could be found in the file at the time of inspectionThe 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. A TB shot was administered July 26, 2021 and read July, 28, 2021. 07/26/2021 Implemented
6400.32(r)(4)The locking mechanism (Heating and cooling) thermostat was locked and neither staff nor the individuals have immediate access in the event of an emergency. Staff must notify a supervisor in order to utilize the air/heat.The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency.The covering was removed from the temperature system. 07/09/2021 Implemented
SIN-00168481 Renewal 12/17/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The dining room chair had a loose seat and legs and screws were exposed, not in good repair.Floors, walls, ceilings and other surfaces shall be in good repair. We purchased the protection plan with this table and chair set which is good for 5 years. The repair person recommended an Allen wrench to tighten it regularly. 01/06/2020 Implemented
6400.104A current and up to date letter to the local fire department notifying them the individuals who need assistance evacuating in the event of a fire was not provided during inspection.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. This letter was emailed to you (Brain) as requested. We were in compliance with this section and you asked that we email it to you by the following day. 12/18/2019 Implemented
6400.113(a)Fire safety training was not completed annually for individual 1. The last dated training was 4/3/18 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 fire safety training will be conducted annually and immediately filed in the corresponding individuals annual binder and checklist. 12/20/2019 Implemented
6400.141(c)(10)Physical exam dated 4/15/19 for individual 1 did not contain whether individual was free from communicable diseases in order to determine if any precautions need to be taken.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 Agency Physical exam form has been updated to ask the question of whether the individual was free from communicable diseases. 12/31/2019 Implemented
6400.141(c)(14)Information pertinent to diagnosis in case of an emergency was not notated on the current physical examination form dated 4/15/19 for individual #1.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Our physical form was updated to reflect the pertinent diagnosis and emergency treatment. 12/31/2019 Implemented
6400.181(d)Program specialist did not sign and date the assessment dated 5/3/19 for individual 1.The program specialist shall sign and date the assessment upon completion. The requirement to sign has been added to the binder checklist.The Program Specialist will sign the completed assessment and file in the corresponding person's binder immediately. 12/20/2019 Implemented
6400.34(a)The Copy of Rights were not signed annually for individual 1, the last dated rights were signed 4/3/18The 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.The Program Specialist will file the Client Rights (Individual Rights) form immediately upon completion in the corresponding person's binder. 01/01/2020 Implemented
6400.165(g)Documentation of the 3 month psychotropic medication reviews were not in record for individual 1. Medications Divalproex and lorazepam .5mg were not reviewed by a licensed physician.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.All psychiatrist appointments will have a blank medical form as well as a blank 3 month medication review from (3 Month Psychotropic Review) for the doctor to complete for each appointment. Also, the policy 122 (medical appointments) was updated to include this information. 01/22/2020 Implemented
SIN-00144128 Renewal 10/25/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(3)Individual #1's physical dated 6/15/18 did not document if a diphtheria and tetanus shot had been administered.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. This issue was corrected by scheduling and attending an appointment (10/30/18) with the individual's PCP and having the shot administered. Going forward we have developed a policy and procedure that requires the physical form to be completed with known information BEFORE the appointment. 10/30/2018 Implemented
6400.141(c)(9)Individual #1's last documented prostate exam was completed on 6/6/17.The physical examination shall include: A prostate examination for men 40 years of age or older. A medical appointment was scheduled and attended to have the prostate exam completed. Going forward a policy and procedure was developed requiring the staff attending the appointment to know what the nature of the appointment is, as well as to have the doctor complete the necessary paperwork to show record of what happened during the appointment. 10/30/2018 Implemented
6400.141(c)(13)Individual #1's ISP states that they are allergic to penicillin, but the physical dated 6/15/18 did not document any allergies.The physical examination shall include: Allergies or contraindicated medications.A policy and procedure was developed requiring the physical and all medical forms to be completed with information that is known BEFORE the medical appointment. Known information includes, name, DOB, current medications & immunization history. 10/30/2018 Implemented
SIN-00123177 Initial review 10/06/2017 Compliant - Finalized
SIN-00124521 Renewal 10/06/2017 Compliant - Finalized