Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00235334 Renewal 11/08/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)Th bathroom in the laundry room of the home did not have individual clean paper or cloth towels. [Repeat Violation, 8/8/2023]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. The bathroom in the laundry room has paper towels. 12/17/2023 Implemented
6400.113(a)Individual #2, date of admission 7/23/2023, has not been instructed in general fire safety. [Repeat Violation, 8/4/2022] 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. Individual # 2 was instructed in Fire Safety upon admission. The Fire Safety Training was documented. 11/15/2023 Implemented
6400.141(a)Individual #1's most recent physical examination was completed on 12/7/2021.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual #1's current Physical examination was placed in his binder. 11/15/2023 Implemented
6400.141(c)(3)Individual #2's physical examination, completed 1/25/2023, does not include immunizations. The physical examination states, "no immunizations recorded for this patient."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. Individual's 2 Physical examination includes an immunization record. 12/15/2023 Implemented
6400.141(c)(4)Individual #1's most recent vision and hearing screenings were completed on 12/7/2021. [Repeat Violation, 8/4/2022]The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Individual's #1 most recent vision and hearing screenings are completed and stored in the individual's binder and their file. 11/15/2023 Implemented
6400.141(c)(6)Individual #1, date of admission 11/29/2022, has not completed Tuberculin skin testing. Individual #2 , date of admission 7/24/2023 had an initial Tuberculin skin testing completed on 7/28/2023.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 completed a TB test prior to being admitted on 11/29/22. Individual #2 was placed in our agency for an emergency placement from Adult Protective Services therefore he was unable to get a TB test prior to being admitted. Individual #2 received a TB test when an appointment became available. 11/09/2023 Implemented
6400.141(c)(12)Individual #2's physical examination, completed 1/25/2023, does not include physical limitations of the individual.The physical examination shall include: Physical limitations of the individual. CEO contacted the physician to confirm if individual #2 has any physical limitations. 12/07/2023 Implemented
6400.141(c)(14)Individual #2's physical examination, completed 1/25/2023, does not include medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. CEO contacted the physician to confirm if individual #2 has any medical information pertinent to diagnosis and treatment. CEO asked Individual #2 who did he want contacted if their was an emergency. 12/07/2023 Implemented
6400.142(a)Individual #1, date of admission 11/29/2022, has not had a dental examination. [Repeat Violation, 8/4/2022]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. Individual's # 1 dental examination was located in the binder and file. 11/14/2023 Implemented
6400.142(f)Individual #2, date of admission, 7/28/2023, does not have a dental hygiene plan. The individual's Individual Service Plan, last updated 11/08/2023, reads, "[Individual #2] requires minimal assistance to ensure he brushes his teeth daily." [Repeat Violation, 8/4/2022]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 #2 has a dental hygiene plan. 12/07/2023 Implemented
6400.181(d)Program Specialist #1 did not sign and date Individual #2's assessment, completed 9/11/2023.The program specialist shall sign and date the assessment. The Program Specialist signed and dated the assessment and placed the copied document in the individual's binder. 11/14/2023 Implemented
6400.181(e)(1)Individual #2's assessment, completed 9/11/2023, did not include the individual's functional strengths, needs and preferences. The assessment must include the following information: Functional strengths, needs and preferences of the individual. Individual #2's assessment included the individual's functional strengths, needs and preferences. The document was located in the individual's #2 binder. 11/09/2023 Implemented
6400.181(e)(2)Individual #2's assessment, completed 9/11/2023, did not include the individual's likes, dislikes and interests.The assessment must include the following information: The likes, dislikes and interest of the individual. Individual #2's assessment included the individual's likes and dislikes. The document was located in the individual's #2 binder. 11/09/2023 Implemented
6400.181(e)(3)(i)Individual #2's assessment, completed 9/11/2023, did not include the individual's current level of performance and progress in the acquisition of functional skills.The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. Individual #2's assessment included the individual's current level of performance and progress in the acquisition and functional skills. The document was located in the individual's #2 binder. 11/09/2023 Implemented
6400.181(e)(3)(ii)Individual #2's assessment, completed 9/11/2023, did not include the individual's current level of performance and progress in communication. The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. Individual #2's assessment included the individual's current level of performance and progress in the following areas: Communication. The document was located in the individual's #2 binder. 11/09/2023 Implemented
6400.181(e)(3)(iv)Individual #2's assessment, completed 9/11/2023, did not include the individual's current level of performance and progress in personal needs with or without assistance from others.The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others. Individual #2's assessment included the individual's current level of performance and progress in the following areas: Personal needs with or without assistance from others. The document was located in the individual's #2 binder. 11/09/2023 Implemented
6400.181(e)(9)Individual #2's assessment, completed 9/11/2023, did not include documentation of the individual's disability, including functional and medical limitations.The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. Individual #2's assessment included the individual's disability, including functional and medical limitations. The document was located in the individual's #2 binder. 11/09/2023 Implemented
6400.181(e)(11)Individual #2's assessment, completed 9/11/2023, did not include the individual's psychological evaluation.The assessment must include the following information: Psychological evaluations, if applicable. Individual #2 does not have an Psychological evaluation. He does not take any medication. 11/09/2023 Implemented
6400.181(e)(13)(i)Individual #2's assessment, completed 9/11/2023, did not include the individual's progress and current level in health.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. Individual #2's assessment included the individual's progress over the last 365 calendar days and current level in the following areas: Health. The document was located in the individual's #2 binder. 11/09/2023 Implemented
6400.181(e)(13)(ii)Individual #2's assessment, completed 9/11/2023, did not include the individual's progress and current level in motor and communication skills.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. Individual #2's assessment included the individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. The document was located in the individual's #2 binder. 11/09/2023 Implemented
6400.181(e)(13)(iii)Individual #2's assessment, completed 9/11/2023, did not include the individual's progress and current level in activities of residential living.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. Individual #2's assessment included the individual's progress over the last 365 calendar days and current level in the following areas: activities of residential living. The document was located in the individual's #2 binder. 11/09/2023 Implemented
6400.181(e)(13)(iv)Individual #2's assessment, completed 9/11/2023, did not include the individual's progress and current level in personal adjustment.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. Individual #2's assessment included the individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. The document was located in the individual's #2 binder. 11/09/2023 Implemented
6400.181(e)(13)(v)Individual #2's assessment, completed 9/11/2023, did not include the individual's progress and current level in socialization.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. Individual #2's assessment included the individual's progress over the last 365 calendar days and current level in the following areas: Socialization. The document was located in the individual's #2 binder. 11/09/2023 Implemented
6400.181(e)(13)(vi)Individual #2's assessment, completed 9/11/2023, did not include the individual's progress and current level in recreation.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. Individual #2's assessment included the individual's progress over the last 365 calendar days and current level in the following areas: Recreation. The document was located in the individual's #2 binder. 11/09/2023 Implemented
6400.181(e)(13)(vii)Individual #2's assessment, completed 9/11/2023, did not include the individual's progress and current level in financial independence.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. Individual #2's assessment included the individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. The document was located in the individual's #2 binder. 11/09/2023 Implemented
6400.181(e)(13)(viii)Individual #2's assessment, completed 9/11/2023, did not include the individual's progress and current level in managing personal property.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. Individual #2's assessment included the individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. The document was located in the individual's #2 binder. 11/09/2023 Implemented
6400.181(e)(13)(ix)Individual #2's assessment, completed 9/11/2023, did not include the individual's progress and current level in community-integration.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.Individual #2's assessment included the individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. The document was located in the individual's #2 binder. 11/09/2023 Implemented
6400.181(e)(14)Individual #2's assessment, completed 9/11/2023, did not include the individual's progress and current level in 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. Individual #2's assessment included 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. The document was located in the individual's #2 binder. 11/09/2023 Implemented
6400.34(a)Individual #1, date of admission 11/29/2022, was not informed and explained individual rights. Individual #2, date of admission 7/24/2023, was not informed and explained individual rights. [Repeat Violation, 8/4/2022]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's #1 and Individual#2 were informed and explained of their individual rights upon admission. A copy of their Individual Rights and signature are in their binder. The original is located in their file. 11/09/2023 Implemented
6400.46(a)Program Specialist #1, date of hire 8/14/2023 does not have initial fire safety training.Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.Program Specialist completed initial fire safety. 11/12/2023 Implemented
6400.46(c)Program Specialist #1, date of hire 8/14/2023 does not have training in first aid techniques.Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques.Program Specialist, CPR training is recorded, available and current. 11/09/2023 Implemented
6400.51(b)(1)The orientation for Program Specialist #1, date of hire 8/14/2023 did not include the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Program Specialist completed Person Centered Practices. 11/09/2023 Implemented
6400.51(b)(5)The orientation for Program Specialist #1, date of hire 8/14/2023 did not include job related knowledge and skills.The orientation must encompass the following areas: Job-related knowledge and skills.Program Specialist completed job related knowledge and skills. 11/09/2023 Implemented
SIN-00233352 Unannounced Monitoring 10/19/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)The bathroom near the front entrance of the home did not have hand soap. [Repeat Violation, 4/27/2023]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. The hand soap was placed in the bathroom near the front entrance. 10/19/2023 Implemented
6400.214(b)Individual #1's most recent incident reports were not present at the home. Individual #2's most recent dental examination was not present in the home. [Repeat Violation, 4/27/2023, 7/25/2023] The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The most recent incidents were placed in Individual's 1 binder. Individual's 2 most recent dental exam was placed in individual's 2 binder. 10/19/2023 Not Implemented
6400.32(c)Individual #1 was recently diagnosed with Bell's Palsy and is prescribed Refresh Relieva with instructions to, "administer 1 drop into the affected eye every 2 hours while awake until his condition resolves." Individual #1's October 2023 Medication Administration Record reads, "Carboxymethylcellulose Sodium, instill 1 or 2 drops in eyes affected as needed for infection every two hours." Individual #1 missed the 10:00AM administration from 10/3/2023 through 10/19/2023, the 12:00PM, 2:00PM and 8:00PM administrations from 10/1/2023 through 10/19/2023, the 4:00PM and 6:00PM administrations from 10/13/2023 through 10/15/2023.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.The medication and directions for the Refresh Relieva were rewritten with the correct information and directions on the MAR. Individual #1 missed the 10:00AM administration from 10/3/2023 through 10/19/2023, the 12:00PM, 2:00PM because he was in school. The New MAR also states the 8pm dose as well. 10/19/2023 Implemented
6400.165(c)Individual #1 is prescribed Refresh Relieva with instructions to, "administer 1 drop into the affected eye every 2 hours while awake until his condition resolves." Individual #1's October 2023 Medication Administration Record reads, "Carboxymethylcellulose Sodium, instill 1 or 2 drops in eyes affected as needed for infection every two hours." [Repeat Violation, 4/27/2023, 7/25/2023]A prescription medication shall be administered as prescribed.The medication and directions for the Refresh Relieva were rewritten with the correct information and directions on the MAR. Individual #1 missed the 10:00AM administration from 10/3/2023 through 10/19/2023, the 12:00PM, 2:00PM because he was in school. The New MAR also states the 8pm dose as well. 10/19/2023 Implemented
6400.166(a)(4)Individual #1 is prescribed Refresh Relieva with instructions to, "administer 1 drop into the affected eye every 2 hours while awake until his condition resolves." Individual #1's October 2023 Medication Administration Record reads, "Carboxymethylcellulose Sodium." [Repeat Violation, 4/27/2023, 7/25/2023]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.CEO will make sure the MAR reads the same exact information that is from the Doctor's order, "Name of the Medication." 10/19/2023 Implemented
6400.167(a)(4)Individual #1 is prescribed Refresh Relieva with instructions to, "administer 1 drop into the affected eye every 2 hours while awake until his condition resolves." Individual #1's October 2023 Medication Administration Record reads, "Carboxymethylcellulose Sodium, instill 1 or 2 drops in eyes affected as needed for infection every two hours." Individual #1 missed the 10AM administration from 10/3/2023 through 10/19/2023, the 12:00PM, 2:00PM and 8:00PM administrations from 10/1/2023 through 10/19/2023, the 4:00PM and 6:00PM administrations from 10/13/2023 through 10/15/2023.Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time.The medication and directions for the Refresh Relieva were rewritten with the correct information and directions on the MAR. Individual #1 missed the 10:00AM administration from 10/3/2023 through 10/19/2023, the 12:00PM, 2:00PM because he was in school. The New MAR also states the 8pm dose as well. 10/19/2023 Implemented
6400.167(a)(7)Individual #1 is prescribed Refresh Relieva with instructions to, "administer 1 drop into the affected eye every 2 hours while awake until his condition resolves." Individual #1's October 2023 Medication Administration Record reads, "Carboxymethylcellulose Sodium, instill 1 or 2 drops in eyes affected as needed for infection every two hours." [Repeat Violation, 4/27/2023, 7/25/2023]Medication errors include the following: Administration while the individual is in the wrong position.The medication and directions for the Refresh Relieva were rewritten with the correct information and directions on the MAR. Individual #1 missed the 10:00AM administration from 10/3/2023 through 10/19/2023, the 12:00PM, 2:00PM because he was in school. The New MAR also states the 8pm dose as well. 10/19/2023 Implemented
SIN-00229395 Unannounced Monitoring 08/08/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)At 12:17PM, two open 32oz bottles of charcoal lighter fluid, with instructions to contact poison control if ingested, were near the sliding glass door of the side patio of the home. The individuals residing in the home are not assessed safe with poisons. [Repeat Violation, 4/27/2023]Poisonous materials shall be kept locked or made inaccessible to individuals. The two open bottles of charcoal lighter fluid were removed from the home. 08/08/2023 Implemented
6400.64(a)At 12:05PM, the top of the inside of the microwave had a multitude of splattered, dried food particles. There were multiple food wrappers on top of the dresser in Individual #1's bedroom.Clean and sanitary conditions shall be maintained in the home. The microwave was cleaned. The food wrappers that were on top of the dresser in individual's 1 bedroom was disposed in the garbage. 08/08/2023 Not Implemented
6400.72(a)There was an adjustable screen in Individual #2's bedroom window that does not securely fit the window. [Repeat Violation, 4/27/2023]Windows, including windows in doors, shall be securely screened when windows or doors are open. A new screen was installed in individual's 2 bedroom. 08/11/2023 Implemented
6400.76(a)The heating vent in the living room of the home is not secured to the floor posing a tripping hazard. Furniture and equipment shall be nonhazardous, clean and sturdy. The heating vent in the living room was repaired to prevent a tripping hazard. 08/10/2023 Implemented
6400.82(f)There are not individual clean paper or cloth towels in the bathroom of the home. [Repeat Violation, 4/27/2023]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. Paper towels were distributed in all the homes. 08/08/2023 Implemented
6400.107At 12:23PM, a portable space heater was in Individual #1's bedroom closet. [Repeat Violation, 4/27/2023]Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms. The portable space heater was removed from the home. 08/08/2023 Implemented
6400.214(b)The most current copy of Individual #1's assessment was not at the home. The most current copy of Individual #2's assessment was not at the home. The most current copy of Individual #3's assessment was not at the home. [Repeat Violation, 4/27/2023] The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. Individual 1's assessment was placed in the binder. Individual 2's assessment was placed in the binder. Individual 3 has not been in the home long enough for an assessment to be completed. 08/14/2023 Not Implemented
6400.166(a)(13)Direct Service Worker #1 administered medications to Individual #1 on 8/3/2023 and 8/7/2023. Individual #1's August 2023 Medication Administration Record did not include Direct Service Worker #1's name. [Repeat Violation, 4/27/2023]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.Direct Service Worker 1's name was written in the Medication Administration Record. 08/08/2023 Implemented
6400.193(b)(2)The home is locking sharp items to include knives in the "medication cabinet" in the kitchen of the home. The individuals residing in the home do not have restrictive procedures requiring the locking of sharp items.For each incident requiring restrictive procedures: A restrictive procedure may not be used unless less restrictive techniques and resources appropriate to the behavior have been tried but have failed.Program Specialist is in the process of having it placed in individual's 1 ISP that any sharp objects such as knives are to be secured and locked in closet, due to his current and past history with violence and suicidal attempts, and suicidal ideations. 08/08/2028 Not Implemented
SIN-00224160 Unannounced Monitoring 04/27/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)There is not a screen in the window in bedroom #3.Windows, including windows in doors, shall be securely screened when windows or doors are open. Bedroom 3 screen was out for repair. 05/02/2023 Not Implemented
6400.81(i)There are not drapes, curtains, shades, blinds or shutters in the window in Individual #2's bedroom. There are not curtains or blinds in the window in bedroom #3.Bedroom windows shall have drapes, curtains, shades, blinds or shutters. The curtain was installed on the window. 05/01/2023 Implemented
6400.81(k)(6)There is not mirror in Individual #2's bedroom.In bedrooms, each individual shall have the following: A mirror. A mirror was purchased and placed in the room. 04/29/2023 Implemented
6400.110(a)At 12:53PM on 4/27/2023, the smoke detector in the home was inoperable. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Smoke detector was installed and operable. 04/29/2023 Not Implemented
6400.214(b)Individual #1's most recent assessment and dental examination were not present at the home. Individual #2's most recent assessment and dental examination were not present at the home. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. Individual¿s 1 most recent assessment and dental assessment is in his binder. Individual¿s 2 most recent assessment and dental assessment is in his binder. 04/27/2023 Implemented
6400.163(a)At 11:57AM on 4/27/2023, Individual #1's medications were stored in a weekly medication organizer. The original labeled containers were not present at the home.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.Individual¿s 1 medication was returned to their original labeled containers. 04/29/2023 Implemented
6400.163(b)At 11:57AM on 4/27/2023, Individual #1's medications were removed from the original containers and stored in a weekly medication organizer with the administrations dispensed in advance for the next three days of administrations.A prescription medication may not be removed from its original labeled container in advance of the scheduled administration, except for the purpose of packaging the medication for the individual to take with the individual to a community activity for administration the same day the medication is removed from its original container.Individual¿s 1 medication was returned to their original labeled containers. 04/28/2023 Implemented
6400.163(h)Individual #2's Epinephrine Injection USP expired in 2/2022.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Individual¿s 2 expired medication Epinephrine Injection USP was discarded. 04/28/2023 Implemented
6400.166(a)(4)Individual #2's April 2023 Medication Administration Record does not include the name of Epinephrine injection USP, and Cyanocobalamin (Vitamin B-12).A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.Individual¿s 2 medication Epinephrine Injection USP and Cynanocobalamin (Vitamin B-12) was listed on the MAR. 04/28/2023 Not Implemented
6400.166(a)(5)Individual #2's April 2023 Medication Administration Record does not include the strength of Epinephrine injection USP, and Cyanocobalamin (Vitamin B-12).A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.Individual¿s 2 strength of medication Epinephrine Injection USP and Cynanocobalamin (Vitamin B-12) was listed on the MAR. 04/27/2023 Implemented
6400.166(a)(6)Individual #2's April 2023 Medication Administration Record does not include the dosage form of Epinephrine injection USP, and Cyanocobalamin (Vitamin B-12).A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form.Individual¿s 2 dosage of medication Epinephrine Injection USP and Cynanocobalamin (Vitamin B-12) was listed on the MAR. 04/27/2023 Implemented
6400.166(a)(7)Individual #2's April 2023 Medication Administration Record does not include the dose of Epinephrine injection USP, and Cyanocobalamin (Vitamin B-12).A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.Individual¿s 2 dose of medication Epinephrine Injection USP and Cynanocobalamin (Vitamin B-12) was listed on the MAR. 04/27/2023 Implemented
6400.166(a)(8)Individual #2's April 2023 Medication Administration Record does not include the route of administration for Epinephrine injection USP, and Cyanocobalamin (Vitamin B-12).A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.Individual¿s 2 route of medication Epinephrine Injection USP and Cynanocobalamin (Vitamin B-12) was listed on the MAR. 04/27/2023 Not Implemented
6400.166(a)(9)Individual #2's April 2023 Medication Administration Record does not include the frequency of administration for Epinephrine injection USP, and Cyanocobalamin (Vitamin B-12).A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.Individual¿s 2 frequency of medication Epinephrine Injection USP and Cynanocobalamin (Vitamin B-12) was listed on the MAR. 04/27/2023 Not Implemented
6400.166(a)(10)Individual #1's April 2023 Medication Administration Record Extra Strength Melatonin 10mg with instructions to, "take 1 tablet by mouth everyday at bedtime" and Aripiprazole 10mg with instructions to, "take 1 tablet by mouth everyday at bedtime." Both medications are listed on the Medication Administration Record at 8:00PM and 9:00PM. Individual #2's April 2023 Medication Administration Record does not include the administration times for Epinephrine injection, USP and Cyanocobalamin (Vitamin B-12).A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.Individual¿s 2 administration time of Epinephrine Injection USP and Cynanocobalamin (Vitamin B-12) was listed on the MAR. Individual¿s 1 administration time for Aripiprazole 10mg and Extra Strength Melatonin was corrected on the MAR. 04/27/2023 Implemented
6400.166(a)(11)Individual #2's April 2023 Medication Administration Record does not include the diagnosis or purpose of Epinephrine injection, USP and Cyanocobalamin (Vitamin B-12).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¿s 2 diagnosis or purpose of Epinephrine Injection USP and Cynanocobalamin (Vitamin B-12) was listed on the MAR. 04/28/2023 Not Implemented
6400.166(a)(13)Individual #1's April 2023 Medication Administration Record does not include the full name of the persons administering the medications.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.Individual¿s 1 has staff¿s full name listed on the MAR. 04/28/2023 Implemented
6400.166(b)Individual #1's April 2023 Medication Administration Record Extra Strength Melatonin 10mg with instructions to, "take 1 tablet by mouth everyday at bedtime" and Aripiprazole 10mg with instructions to, "take 1 tablet by mouth everyday at bedtime." Both medications are listed on the Medication Administration Record at 8:00PM and 9:00PM and both times are initialed as administered from 4/1/2023 through 4/26/2023.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Individual¿s 1 administration time for Aripiprazole 10mg and Extra Strength Melatonin was corrected on the MAR. 04/28/2023 Implemented
SIN-00209753 Renewal 08/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)Individual #2, date of admission 12/20/21, was most recently trained in fire safety on 8/6/22. No other documentation of fire safety training was provided, therefore compliance could not be measured. 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. Upon admission and reinstructed annually, individuals will watch ¿Get Out¿ video, review exits, and house specifics information, review meeting areas, and make sure the individuals understand their responsibility to get out in a timely fashion. 08/06/2022 Implemented
6400.141(c)(4)Individual #1 had a physical examination completed on 4/6/22; however, the physical examination did not include a hearing screening. Individual #2 had a physical examination on 12/16/20; however, the physical examination did not include a hearing screening.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Obtained documentation that HB had a hearing and vision screening completed on 8/15/22. Individual #1 is scheduled to have an Hearing Screening on 11/15/22 at 3:45pm at the R.W. Petruso Hearing & Audiology. [Updated physical examination form for Individual #2 that includes a hearing and vision screening indicating within normal limits received on 10/5/22 and reviewed 10/18/225. DPOC by HDKP, HSLS, on 10/18/22]. 08/06/2022 Implemented
6400.141(c)(11)Individual #2 had physical examination on 12/16/2020; however, the physical exmaination did not include a review of medication.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. Obtained documentation that HB had an assessment of his health maintenance needs, medication regimen and the need for blood work at recommended intervals. [Updated physical examination form for Individual #2 that includes a review of the Individual #2's medication regime was received on 10/5/22 and reviewed 10/18/225. DPOC by HDKP, HSLS, on 10/18/22]. 08/06/2022 Implemented
6400.141(c)(13)Individual #2 had physical examination on 12/16/2020; however, the physical examination does not address allergies or contraindicated medications.The physical examination shall include: Allergies or contraindicated medications.Obtained documentation that the Physical examination addressed allergies or contraindicated medications. [Updated physical examination form for Individual #2 that includes allergies and contraindicated medications was received on 10/5/22 and reviewed 10/18/225. DPOC by HDKP, HSLS, on 10/18/22]. 10/03/2022 Implemented
6400.141(c)(14)Individual #2 had a physical examination on 12/16/2020; however, the physical examination did not address medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Obtained documentation that physical examination included: Medical information pertinent to diagnosis and treatment in case of emergency. [Updated physical examination form for Individual #2 that includes medical information pertinent to diagnosis and treatment in the event of an emergency received on 10/5/22 and reviewed 10/18/225. DPOC by HDKP, HSLS, on 10/18/22]. 10/03/2022 Implemented
6400.141(c)(15)Individual #2 had a physical examination on 12/16/2020; however, the physical examination did not address the individual's diet.The physical examination shall include:Special instructions for the individual's diet. Obtained documentation that HB's physical examination addressed his diet. [Updated physical examination form for Individual #2 that includes special instructions for the individual's diet was received on 10/5/22 and reviewed 10/18/225. DPOC by HDKP, HSLS, on 10/18/22]. 10/03/2022 Implemented
6400.142(f)Individual #1 does not have a written plan for dental hygiene. individual #1 has not achieved dental hygiene independence. Individual #2 does not have a written plan for dental hygiene. individual #2 has not 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. NS has a Dental Hygiene Plan that is in his file. Staff will observe NS brush his teeth and instruct him to brush his teeth thoroughly. This observation will be documented on a daily basis and reviewed quarterly to the interdisciplinary team until NS has achieved dental hygiene independence. This information will be reflected in NS¿s assessment and his ISP. HB has a Dental Hygiene Plan that is in his file. Staff will observe HB brush his teeth and instruct him to brush his teeth thoroughly. This observation will be documented on a daily basis and reviewed quarterly to the interdisciplinary team until HB has achieved dental hygiene independence. This information will be reflected in HB¿s assessment and his ISP. [Dental Hygiene Plans for Individual #1 and Individual #2, dated 9/30/22, were received on 10/5/22 and reviewed 10/18/22. DPOC by HDKP, HSLS, on 10/18/22]. 09/29/2022 Implemented
6400.144Individual #2 had a psychiatric medication review on 5/26/2022. In the section of the medication review form labeled "Labs, tests, and referrals ordered" the form states: " ordered in March 2022 still not done." The agency was not able to provide documentation that the ordered bloodwork was completed, as ordered by the healthcare provider.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Bloodwork will be completed within 5 days. [Individual #2's completed bloodwork results, dated 6/14/22, received on 10/5/22 and reviewed 10/18/22. DPOC by HDKP, HSLS, on 10/18/22]. 08/06/2022 Implemented
6400.181(a)Individual #1, date of admission 4/26/22, had an initial assessment completed on 6/30/22, exceeding the 60 calendar day requirement. Individual #2, date of admission was 12/20/21, had an initial assessment completed on 2/25/22, exceeding the 60 calendar day requirement. 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. Upon an individual's admission, CEO or Program Specialist will complete the initial assessment on day 50. CEO or Program Specialist will document day 50 on calendar as a reminder of when the initial assessment is due. An the assessment will be updated annually 50 days and placed on a calendar before the ISP is due. 08/06/2022 Implemented
6400.44(b)(2)Individual #1's Individual Support Plan (ISP), last updated 7/25/22, contains the following information that is contradicted in the assessment, dated 6/30/22: Meals/Eating, Poison safety, heat source safety, fire safety. For Meals/Eating, the ISP states that individual does not have the skills to use any appliances in the kitchen for cooking; however, the assessment states [Individual #1] is able to cook meals. For Poison safety, the ISP states all poisonous substances should be kept out of [their] reach and/or locked away from [them]; however, the assessment states able to identify poisonous materials and use them in a safe manner. For heat source safety, the ISP states needs protection from heat sources; however the assessment states does have the ability to understand and avoid the danger of heat source which exceeds 120 degrees. For fire safety, the ISP states [they] would need assistance to evacuate, especially in an unfamiliar environment; however, the assessment states has the ability to evacuate the building by himself without assistance from staff.The program specialist shall be responsible for the following: Participating in the individual plan process, development, team reviews and implementation in accordance with this chapter.The Program Specialist will inform the Supports Coordinator in writing of the discrepancies identified in NS¿s assessment. 10/03/2022 Implemented
6400.165(g)Individual #2 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness. Individual #2 had a psychiatric medication review completed on 7/7/2022; however, it did not include Lexapro 10mg ordered at the 6/24/2022 review. Individual #1 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness. Individual #1 has not completed a psychiatric medication review since admission on 4/26/22. [Repeat violation 8/18/21, 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.If individual is unable to been seen by a Psychiatrist or a Licensed Physician within 3 months, Program Specialist will retrieve documentation that states this was the first available appointment for the individual. This documentation will be maintained in the individual's file. 08/06/2022 Implemented
6400.213(7)Individual #2's record did not include the Individual Plan meeting invitation or annual ISP meeting signature sheet. Individual #2's annual ISP meeting occurred on 12/29/21.Each individual's record must include the following information: Individual plan documents as required by this chapter.Obtained documentation of HB's ISP meeting invitation and retrieved the ISP signature sheet. [The invitation and ISP Meeting Attendance sheet for Individual #2, dated 12/29/21, received on 10/5/22 and reviewed 10/18/22. DPOC by HDKP, HSLS, on 10/18/22]. 08/06/2022 Implemented
SIN-00192280 Renewal 08/18/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(1)The separate record of financial resources for Individual #1, admission date 4/01/2021, did not include the dates and amounts of deposits and withdrawals after 7/06/2021. The agency maintained receipts for purchases after 7/6/2021; however, these expenditures were not documented. 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. Each individual will have a record of their financial resources. The CEO and Program Specialist will create a record of the individual¿s financial resources. The record will consist of the dates and amounts of deposits and withdrawals. [Within 30 days, the CEO, or designee, shall review all individual financial records to ensure that all expenditures are documented. Documentation of the financial record review shall be maintained. Documentation of the aforementioned quarterly audit of individual financial records shall be maintained. DPOC by HDKP, HSLS, on 10/22/2021]. 09/06/2021 Implemented
6400.67(a)On 8/19/2021 at 10:27 AM, the bathroom door latch in the main hallway of the home was not in good repair, preventing the door from being able to be locked. The door could be easily pushed open when locked and closed.Floors, walls, ceilings and other surfaces shall be in good repair. On 8/24/21, Program Specialist had the bathroom door latch repaired. [Within 30 days, the CEO, or designee, shall train all staff working in homes on reporting needed repairs. Documentation of training shall be maintained. At least monthly, for a period of at least one year, the CEO, or designee, shall conduct a review of each licensed residence to identify needed repairs. Documentation of the monthly repair checks shall be maintained. DPOC by HDKP, HSLS, on 10/22/2021]. 08/24/2021 Implemented
6400.141(a)Individual #2, admission date 2/05/2021, did not have a physical examination within 12 months prior to admission.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. CEO and Program Specialist will make sure every individual will have a physical examination prior to them being admitted to our agency and annually thereafter. 09/06/2021 Implemented
6400.181(d)The initial assessment completed for Individual #1, admission date 4/01/2021, was not dated by the Program Specialist. The initial assessment completed for Individual #2, admission date 2/05/2021, was not dated by the Program Specialist.The program specialist shall sign and date the assessment. Program Specialist will sign and date the assessment. [Immediately, the CEO, or designee, shall ensure that the CEO and Program Specialist are trained on regulation 6400.181(d). Documentation of the training shall be maintained. Documentation of aforementioned quarterly review of individual assessments shall be maintained. DPOC by HDKP, HSLS, on 10/22/2021]. 09/06/2021 Implemented
6400.51(b)(3)The orientation for Direct Services Worker #1, date of hire 7/24/2021, did not encompass Individual rights. The orientation for Direct Services Worker #2, date of hire 7/24/2021, did not encompass Individual rights.The orientation must encompass the following areas: Individual rights.CEO will review all staff files to ensure that orientation topics as required by 6400.51 (b) (1) ¿(5) have been provided. [Immediately, the CEO, or designee, shall train Direct Services Worker #1 and Direct Services Worker #2 on the topic of Individual Rights. Within 30 days, the CEO, or designee, shall review all staff records to ensure that orientation documents include training on the topic of Individual Rights. DPOC by HDKP, HSLS, on 10/22/2021]. 09/06/2021 Implemented
6400.51(b)(4)The orientation for Direct Services Worker #1, date of hire 7/24/2021, did not encompass recognizing and reporting incidents. The orientation for Direct Services Worker #2, date of hire 7/24/2021, did not encompass recognizing and reporting incidents.The orientation must encompass the following areas: recognizing and reporting incidents.CEO will review all staff files to ensure that orientation topics as required by 6400.51 (b) (1) ¿(5) have been provided. [Immediately, the CEO, or designee, shall train Direct Services Worker #1 and Direct Services Worker #2 on the topic of Recognizing and Reporting Incidents. Within 30 days, the CEO, or designee, shall review all staff records to ensure that orientation documents include training on the topic of Recognizing and Reporting Incidents. DPOC by HDKP, HSLS, on 10/22/2021]. 09/06/2021 Implemented
6400.165(g)Individual #1, admission date 4/01/2021, had a psychiatric medication review completed on 3/18/2021 and has not had another psychiatric medication review completed since. Individual #2, admission date 2/05/2021, had a psychiatric review completed 8/04/2021 but did not have one completed prior to that.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.Program Specialist will ensure that each individual be seen by a licensed physician at least every 3 months. The Program Specialist will create a Medication Review form that the licensed physician will complete. The licensed physician will document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. The Program Specialist will ensure that the Medication Review is completed thoroughly. [Documentation of the aforementioned reviews of Psychiatric medication reviews by Program Specialist shall be maintained. DPOC by HDKP, HSLS, on 10/22/2021]. 09/01/2021 Implemented
6400.166(b)Individual #1, admission date 4/01/2021, is prescribed Perphenazine 4 MG Tablet -- Take 1 tablet by mouth at bedtime. This medication was not listed on the Medication Administration Record from 8/01/2021 forward.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The Chief Executive Officer will make sure that each medication is listed on the Medication Administration Record. An the Medication Administration Record will have the date and time of the medication administered. An their will be a record of the name and initials of the person administering the medication. [Within 30 days, the CEO, or designee, shall train all staff responsible for administering medications on the requirement to immediately document administration of any medication to any individual on the Medication Administration Record (MAR). Documentation of the training shall be kept. Documentation of the aforementioned daily and quarterly audits of all individual Medication Administration Records (MARs) shall be maintained. DPOC by HDKP, HSLS, on 10/22/2021]. 09/06/2021 Implemented
6400.195(b)The behavior support component of the Restrictive Procedure Plan and Individual Support Plan for Individual #1, admission date 4/01/2021, was reviewed on 1/28/2021. There has not been another review completed since. Reviews by the Human Right Team shall not exceed 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.Moving forward Program Specialist will sign and date the assessment. [Human Rights Team meetings have been added to the agency's calendar to ensure that meetings occur within the 6 month requirement. Documentation of the training for CEO and Program Specialist on the requirements of 6400.195(b) shall be maintained. DPOC by HDKP, HSLS, on 10/22/2021]. 08/24/2021 Implemented
SIN-00189852 Add an Addendum 06/25/2021 Compliant - Finalized