Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00191767 Renewal 08/11/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(g)Individual #1's psychiatric medication review completed 4/27/21 did not include medications, dosages and the reasons for prescribing the medications. The documentation read "No changes". Individual #1's psychiatric medication reviews completed 3/2/21 and 1/5/21 did not include medications, dosages, or reasons for prescribing the medications the documentation read "No Changes" and "Completed virtually due to Covid-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.The Executive Director provided prefilled Psychiatric Medication Review appointment forms to the House Manager, with the purpose of each medication listed as well as the other required information, and will continue to provide them as needed. 08/13/2021 Implemented
6400.166(a)(11)Individual #1's August 2021 medication administration record did not include the purpose or diagnosis for the following medications: Bupropion HCL Sr, Clonazepam, Divalproex, Lantus Solostar, Novolog Flexpen Syringe, Omeprazole Dr, Prazosin, Quetiapine Fumarate, Sertraline HCL, Vitamin C, and Vitamin D3.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.The Executive Director wrote the diagnosis for each medication onto the MAR in the box with the name of the medication, rather than just being at the bottom of the MAR. 08/12/2021 Implemented
SIN-00227479 Renewal 06/21/2023 Compliant - Finalized
SIN-00209153 Renewal 07/19/2022 Compliant - Finalized
SIN-00182480 Add an Addendum 12/17/2020 Compliant - Finalized