Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00231205 Unannounced Monitoring 09/15/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)The closet door in individual number one's bedroom is off the door jam and needs to be repaired. Also, the closet door in the office is jammed, unable to open and close, and needs to be repaired.Windows, including windows in doors, shall be securely screened when windows or doors are open. Closet door will be fixed. Optimal Lifestyle has a maintenance person that will be assigned to fix the issue with the door. 10/28/2023 Implemented
6400.181(d)The current assessment for individual number one was not signed or dated.The program specialist shall sign and date the assessment. Individual assessment was signed. 09/28/2023 Implemented
6400.166(a)(9)The medication administration record for individual number one incorrectly states that the prescribed Vitamin D-3 2000 dietary supplement should be taken 2 times per day. The prescription for Vitamin D-3 2000 units tablet states "take 1 tablet by mouth every day".A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.MAR was updated to reflect the change in frequency of administration for the Vitamin D3 supplement. 09/28/2023 Implemented
6400.181(f)The provider did not have records showing that the current assessment was sent to the Plan team. What was communicated was that the assessment was given to the team at the ISP meeting on 8/1/2023, therefore the assessment was not provided to the team 30 calendar days prior to the ISP meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Everyone on the individuals team has a copy of the most current assessment. A new SC was just assigned to the case and she was emailed a copy of it as well. 09/28/2023 Implemented
6400.195(b)The provider has a practice in place where the staff are required to lock the refrigerator and freezer in order to prevent individual number 1 from overeating. The provider's record shows that this individual has a history of excessive overeating and is taking medication (Tamomax) that is intended to decrease this overeating behavior, however this restriction is not covered in the behavior support plan. The behavior plan needs to be updated to reflect this practice and how to educate the individual on their condition.The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews.The behavior support plan was updated to reflect the restriction. A meeting will be scheduled with the members of the team including the legal guardian of the individual. 10/28/2023 Implemented
6400.195(b)Individual number one has a current behavior support plan that is being implemented by staff, however the plan has not been reviewed by the provider's human rights team within the past 6 months.The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews.The human rights team will schedule a meeting which will include the legal guardian of the individual. In this meeting we will discuss the behavioral support component and will do this quarterly. 10/28/2023 Implemented
SIN-00222604 Renewal 04/03/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)There is no physical for Individual #1.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Our Program specialist is the person responsible for monitoring and ensuring compliance with this issue. The individual has an upcoming doctors appointment with his PCP. We have requested the completion of a physical examination. Once completed we will receive a copy of it. Program Specialist will also make sure that the individuals we support complete their physical exams prior to onboarding and maintain compliance annually. In each individuals folder we will include a log of physical exams to track and make sure thy are done in time. We will also add the Physical Exam as an item in our Participant Checklist which is used to gather all necessary documentation required prior to accepting a new client. This way we can make sure physical exams are done in a timely manner. 06/20/2023 Implemented
6400.181(a)There is no assessment for Individual #1. 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 individual reviewed did not have an assessment done by our agency. Our program specialist will be responsible for completing the initial assessment and continue doing them yearly. In addition we will create an assessment log that will track the dates each assessment was completed and attach the written assessments to it. We will also add the initial assessment to our Participant Checklist which is used to gather all necessary documentation required prior to accepting a new client. This way we can make sure our initial assessments are done in a timely manner. 06/20/2023 Implemented
6400.34(b)There is no individual rights form for Individual #1.The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights.The individual reviewed or their legal guardian did not sign an Individual Rights form. Optimal Lifestyle will create a document that informs all participants and their legal guardians of their rights while attending our program. This task is to be fulfilled by our program specialist. The form will then be signed by the individual and / or their legal guardian. The item Participant Individual Rights will be then added to our Participant Checklist which is used to gather all necessary documentation required prior to accepting a new client. This way we can make sure the Individual Rights form is signed before someone enters our program and maintain compliance thereafter. 06/20/2023 Implemented
6400.165(g)There are no psychotropic medication reviews for Individual #1.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 individual reviewed did complete a recent appointment with a psychiatrist and all psych meds have been reviewed. We will contact the providers office and gather all documentation required in this regulation. Our program specialist will be the person designated to ensure compliance with this item. We will also require a psych med review every 3 months and document all needed information about psychotropic medications. In order to track compliance we will develop a tracker / checklist that will ensure medication reviews are done. 06/20/2023 Implemented