Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00235335 Renewal 11/08/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)At 3:23PM on 11/8/2023, a tube with a manufactured label reading "poison" was in an unlocked cabinet in the basement of the home. [Repeat Violation, 4/27/2023]Poisonous materials shall be kept locked or made inaccessible to individuals. The tube labeled poison was removed from the home. 11/08/2023 Implemented
6400.66The outside light at the back door of the home did not turn on when switched to the on position. [Repeat Violation, 7/25/2023]Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. This should not have been a violation. The light outside is a solar light and the light only comes on at night. I sent pictures of the light being on at night for the 7/25/23 violation. 11/08/2023 Implemented
6400.67(b)At 2:50PM on 11/8/2023, the wooden railing attached to the second set of stairs leading to the attic of the home is jagged with splintering pieces of wood. Floors, walls, ceilings and other surfaces shall be free of hazards.The wooden railing attached to the second set of stairs leading to the attic was jagged with splintering pieces of wood was repaired. 11/09/2023 Implemented
6400.86At 3:23PM on 11/8/2023, loose bullets and boxes of ammunition including plastic shotgun shells, 25/16 gauge bullets, 25/12 guage bullets, copperhead pellets, .22 gauge bullets, long range Remington bullets and 38 Special Centerfire Cartridges were in an unlocked cabinet in the basement of the home.Firearms and ammunition are not permitted in the home or on the property of the home. All of the bullets, pellets, and Centerfire Cartridges were removed from the home. 11/08/2023 Implemented
6400.113(a)Individual #1, date of admission 2/5/2021, 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 1 was instructed in Fire Safety upon admission. The Fire Safety Training was documented. 11/08/2023 Implemented
6400.141(a)Individual #1, date of admission 2/5/2021, has not had a physical examination.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. 11/08/2023 Implemented
6400.141(c)(6)Individual #1, date of admission 2/5/2021, has not completed an initial Tuberculin skin testing.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 test was completed. He had it completed last year. 11/09/2023 Implemented
6400.142(a)Individual #1, date of admission, 2/5/2021, has not had an initial 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. 11/08/2023 Implemented
6400.142(f)Individual #1, date of admission 2/5/2021, does not have a dental hygiene plan. [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. This should not have been a violation. Individual 1 does not have a dental hygiene plan. Individual 1 has achieved dental hygiene independence. 11/08/2023 Implemented
6400.171At 2:20PM on 11/8/2023 an uncovered plastic cup with milk and dried milk around the top of the inside was on the shelf inside the refrigerator in the kitchen of the home. [Repeat Violation, 7/25/2023, 8/8/2023]Food shall be protected from contamination while being stored, prepared, transported and served. The uncovered plastic cup with milk was disposed in the sink. 11/08/2023 Implemented
6400.181(a)Individual #1, date of admission 2/5/2021, has not had an individual assessment completed. 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. Individual #1's assessment was completed and in individual's #1's binder. 11/08/2023 Implemented
6400.34(a)Individual #1, date of admission 2/5/2021, has not been 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 was 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. 11/08/2023 Implemented
6400.163(d)At 3:23PM on 11/8/2023, a bottle of prescription medication belonging to an individual that does not reside in the home was in an unlocked cabinet in the basement of the home. At 2:38PM on 11/8/2023, Individual #1's prescribed medication, Vyvanse, a controlled substance, was stored in a plastic container inside a locked closet in the kitchen of the home. The controlled substance was not double locked. [Repeat Violation, 7/25/2023]Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.The bottle of prescription medication belonging to an individual that does not reside in the home was removed from the home. The Vyvanse medication was stored in a locked box and placed in the locked medication closet. 11/08/2023 Implemented
6400.163(g)At 2:30PM on 11/8/2023, a loose pill belonging to Individual #1 was at the bottom of Individual #1's medication storage container. [Repeat Violation, 4/27/2023]Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions.The loose pill that was found in individual's #1 medication storage container was removed from the home and disposed in the garbage. The loose pill was not a pill that Individual # 1 takes. 11/08/2023 Implemented
6400.165(g)Individual #1 is prescribed medication to treat symptoms of a psychiatric illness. Individual #1 has not had a review of prescribed psychiatric medications by a licensed physician. [Repeat Violation, 8/4/2022]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.Individual 1 had a med review completed. 11/10/2023 Implemented
6400.166(b)On 2:36PM on 11/8/2023, Individual #1's Prazosin HCL 4mg capsule with instructions to, "Take one capsule by mouth 3 times daily," was initialed as administered for 11/08/23 4:00PM administration. [Repeat Violation, 4/27/2023]The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.CEO reminded staff to record the medication record at the time the medication was administered, which should have been at 3:00pm. 11/08/2023 Implemented
SIN-00232480 Unannounced Monitoring 09/21/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Individual #1's family member reportedly gave the provider a check for the individual in the amount of $400.00 on an unspecified date in August 2023. As of 9/21/2023, this deposit has not been documented on the individual's financial ledger.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. Individual 1¿s August 2023 financial ledger reflects that he was given $400.00 from his cousin. 09/25/2023 Not Implemented
6400.22(d)(2)Interviews reveal, that the provider is disbursing $100.00 weekly directly to Individual #1. These disbursements have not been documented on Individual #1's financial ledger.(2) Disbursements made to or for the individual. Individual 1¿s August 2023 financial ledger reflects that he was given $100.00 weekly from CEO. 09/25/2023 Not Implemented
6400.171At 11:50AM, a carton of eggs with a use by date of 7/31/2023 was in the refrigerator in the kitchen of the home. [Repeat Violation, 7/25/2023, 8/8/2023]Food shall be protected from contamination while being stored, prepared, transported and served. The carton of eggs with a use by date of 7/31/23 was removed from the refrigerator and disposed in the garbage. 09/21/2023 Not Implemented
6400.214(b)Individual #1's most recent assessment was not in the home. Individual #2's assessment was not in the home. [Repeat Violation, 7/25/2023, 8/8/2023] The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. Individual 1¿s and Individual¿s 2 most recent assessment was placed in their binder. 09/21/2023 Not Implemented
SIN-00229392 Unannounced Monitoring 07/25/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)At 1:56PM, a one-gallon container of "Mold Armor" and an aerosol can of Disinfectant Spray were in the unlocked and accessible in a cabinet under the sink in the first-floor bathroom. At 1:57PM, a bottle of Clorox Bleach, a bottle of Cloralen, two aerosol cans of Disinfectant Spray and a spray bottle of Window Clean were in an unlocked and accessible in a cabinet in the staff office. At 2:05PM, an open container of Multi-Purpose Cleaner was in Individual #2's bedroom closet. There was a box of partially eaten food with a container of Murphy's Oil Cleaner inside the box with the food in Individual #1's bedroom. Individual #1 is not assessed safe with poisons. [Repeat Violation, 4/27/2023]Poisonous materials shall be kept locked or made inaccessible to individuals. The one-gallon container of "Mold Armor" and the aerosol can of Disinfectant Spray were locked in the Chemical closet. 07/25/2023 Implemented
6400.64(a)At 2:05PM, there was a box of partially eaten food in Individual #2's closet. A bag containing discarded items was on Individual #2's bedroom floor. Dried, cooked noodles were on the top of Individual #2's dresser. [Repeat Violation, 4/27/2023]Clean and sanitary conditions shall be maintained in the home. The box of partially eaten food and the items that were on the bedroom floor were discarded in the garbage. As well as the dried cooked noodles were discarded in the garbage. 07/25/2023 Not Implemented
6400.72(a)There is a temporary screen in Individual #1's bedroom window that is not secure. There is an air conditioner in Individual #2's bedroom window with a gap on each side allowing room for insects to enter the home. There is an air conditioner in the window in bedroom #3 with a gap on each side allowing room for insects to enter the home. [Repeat Violation, 4/27/2023]Windows, including windows in doors, shall be securely screened when windows or doors are open. Individual 1's bedroom has a full screen that is secure. Individual's 1 and Individual 2 air conditioners are secured to prevent the insects from entering the bedroom. 07/29/2023 Implemented
6400.73(a)There is not a handrail on the interior stairway leading to the attic of the home. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The handrail was installed on the interior stairway leading to the attic of the home. 07/27/2023 Implemented
6400.74The bottom, wooden step on the second set of stairs leading to the attic does not have a nonskid surface.Interior stairs and outside steps shall have a nonskid surface. A non-skid surface was installed on the bottom, wooden step on the second set of stairs leading to the attic. 07/26/2023 Implemented
6400.83(c)At 2:08PM, there was a plastic cup with dried milk on the dresser in Individual #2's bedroom. [Repeat Violation, 4/27/2023]Utensils used for eating, drinking and preparation of food or drink shall be washed and rinsed after each use.The dried milk that was located on Individual's 2 dresser in the bedroom was disposed in the garbage. 07/25/2023 Implemented
6400.101There was a padlock on the door leading to the attic of the home posing an obstructed egress from the attic when engaged.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The padlock was removed and a dead bolt was installed so the attic would not be obstructed. 07/29/2023 Implemented
6400.110(e)At 2:22PM, the smoke detector on the fourth floor was not interconnected with the smoke detectors on the other three floors of the home.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. A new smoke detector was installed in the attic, so all the smoke detectors are interconnected. 07/25/2023 Not Implemented
6400.144Individual #1 is prescribed Guanfacine Tab 2MG with instructions to, "Take 1 tablet by mouth twice a day. Please monitor blood pressure." The provider has not been monitoring Individual #1's blood pressure.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. CEO contacted Dr. Gauthier and asked how often individual 1's blood pressure is to be checked? Dr. Gauthier stated: "Every 7 days." individual 1's blood pressure was checked that day. Individual 1 will have his blood pressure checked every 7 days. 07/25/0223 Not Implemented
6400.171At 12:27PM, there was an uncovered plate on the second shelf of the refrigerator in the kitchen of the home with a hamburger, French fries and a fork. There was another uncovered plate with a cheeseburger and an uncovered bowl with an unidentified green food. There was an uncovered bowl of ice cream in the freezer in the kitchen of the home. [Repeat Violation, 4/27/2023]Food shall be protected from contamination while being stored, prepared, transported and served. The uncovered plate on the second shelf of the refrigerator that contained a hamburger, and french fries was covered with aluminum foil. The fork was washed and dried and stored with the other utensils. 07/25/2023 Not Implemented
6400.214(b)The most recent copy of Individual #1's assessment was not present in the residential home. The most recent copy of Individual #2's assessment was not present in the residential 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 assessment was placed in a binder. An Individual 2 assessment was placed in a binder. 08/14/2023 Not Implemented
6400.163(d)The individuals' medications were stored in an unlocked closet in the kitchen of the home.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.The medications were locked in the medication closet. 07/25/2023 Implemented
6400.166(a)(4)Individual #2's July 2023 Medication Administration Record does not include the name of Tums Antacid Chewable Tablets. [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 of medication.The name of the Medications that are prescribed will be entered on the MAR. 07/25/2023 Implemented
6400.166(a)(5)Individual #2's July 2023 Medication Administration Record does not include the strength of Tums Antacid Chewable Tablets. [Repeat Violation, 4/27/2023]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.The strength of the Medications that are prescribed will be entered on the MAR. 07/25/2023 Implemented
6400.166(a)(6)Individual #2's July 2023 Medication Administration Record does not include the dosage of Tums Antacid Chewable Tablets. [Repeat Violation, 4/27/2023]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form.The dosage of the Medications that are prescribed will be entered on the MAR. 07/25/2023 Implemented
6400.166(a)(7)Individual #2's July 2023 Medication Administration Record does not include the dose of Tums Antacid Chewable Tablets. [Repeat Violation, 4/27/2023]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.The dose of the Medications that are prescribed will be entered on the MAR. 07/25/2023 Implemented
6400.166(a)(8)Individual #2's July 2023 Medication Administration Record does not include the route of administration for Tums Antacid Chewable Tablets. [Repeat Violation, 4/27/2023]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.The route of the Medications that are prescribed will be entered on the MAR. 07/25/2023 Implemented
6400.166(a)(9)Individual #2's July 2023 Medication Administration Record does not include the frequency of administration for Tums Antacid Chewable Tablets. [Repeat Violation, 4/27/2023]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.The frequency of the Medications that are prescribed will be entered on the MAR. 07/25/2023 Implemented
6400.166(a)(10)Individual #2's July 2023 Medication Administration Record does not include the administration times for Tums Antacid Chewable Tablets. [Repeat Violation, 4/27/2023]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.The administration times of the Medications that are prescribed will be entered on the MAR. 07/25/2023 Implemented
6400.166(a)(11)Individual #2's July 2023 Medication Administration Record does not include the diagnosis or purpose for Tums Antacid Chewable Tablets. [Repeat Violation, 4/27/2023]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 diagnosis or purpose of the Medications that are prescribed will be entered on the MAR. 07/25/2023 Implemented
SIN-00224162 Unannounced Monitoring 04/27/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)At 1:36PM on 4/27/2023, the hot water temperature measured 125.6°F at the sink in the bathroom on the first floor of the home.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. Hot water was turned down, and the water temperature read 119°F degrees. 04/28/2023 Implemented
6400.64(a)At 1:50PM on 4/27/2023, Individual #3's bedroom had an inordinate amount of food items, empty food wrappers, fast food cups, vaping devices, chargers and trash on the mattress, floor, dresser and other surfaces. At 1:41PM on 4/27/2023, the toilet in the second floor bathroom had several streaks of fecal matter along the outside and inside the bowl.Clean and sanitary conditions shall be maintained in the home. Individual¿s 3 bedroom was cleaned and the second floor bathroom was cleaned. 04/27/2023 Implemented
6400.64(e)At 1:57PM on 4/27/2023, two trash receptacles in the back yard of the home were overflowing with various discarded items. In addition, there were discarded gutter pipes and a bag containing trash next to one of the trash receptacles.Trash receptacles over 18 inches high shall have lids. The Tri-Counties Sanitation Department did not pick up the trash until 4/28/23. 04/29/2023 Implemented
6400.67(a)There is a six-inch by four-inch hole at the bottom of the wall near the door in Individual #1's bedroom. There is a leak in the roof causing dark spots on the ceiling, water leaking and plaster falling onto the floor in Individual #2's bedroom. The water from the roof has also leaked through Individual #2's floor causing dark spots on the ceiling next to the front door of the home.Floors, walls, ceilings and other surfaces shall be in good repair. The walls in individual¿s 1¿s bedroom was repaired. The ceiling in Individual¿s 2 bedroom was repaired. The roof was repaired, so individual¿s 2¿s ceiling no longer leaked. 04/29/2023 Not Implemented
6400.67(b)The metal plate, in the front of the baseboard heating register in the dining room, is detached from the register and on the floor posing a tripping hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.The repairs for the heating register have been communicated to our Maintenance employee and scheduled to be repaired. 06/16/2023 Not Implemented
6400.72(a)There is not a screen in Individual #1's bedroom window. There is not a screen in Individual #2's bedroom window. There is not a screen in Individual #3's bedroom window.Windows, including windows in doors, shall be securely screened when windows or doors are open. The screens were installed back in the windows. 04/29/2023 Not Implemented
6400.77(b)The first aid kit did not contain a tweezers. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Tweezers were placed in the First Aid Kit. 04/28/2023 Implemented
6400.81(k)(3)Individual #3 does not have linens on his bed.In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season.Linens were in the washer. CEO purchased extra linens for the individuals to have placed on their bed. 04/28/2023 Implemented
6400.81(k)(6)There is not a mirror in Individual #2's bedroom.In bedrooms, each individual shall have the following: A mirror. Staff put mirror in Individual¿s 2 room. 04/28/2023 Implemented
6400.82(f)There are not individual clean paper or cloth towels in the bathroom on the second floor of the home.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 and cloth towels were placed in the bathroom on the second floor of the home. 04/27/2023 Implemented
6400.163(h)Individual #1's prescribed medication, Fluticasone Propionate Nasal Spray USP, has a discard by date of 1/31/2023.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Individual¿s 1 medication Fluticasone Propionate Nasal Spray was destroyed in a safe manner in accordance with Federal and State statutes and regulations. 04/27/2023 Implemented
6400.166(a)(4)Individual #1's April 2023 Medication Administration Record does not include the name of Fluticasone Propionate Nasal Spray USP and Vitamin D3.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.Individual¿s 1 medication Fluticasone Propionate Nasal Spray and Vitamin D3 was listed on the MAR. 04/27/2023 Not Implemented
6400.166(a)(5)Individual #1's April 2023 Medication Administration Record does not include the strength of Fluticasone Propionate Nasal Spray USP and Vitamin D3.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.Individual¿s 1 strength of medication Fluticasone Propionate Nasal Spray and Vitamin D3 was listed on the MAR. 04/27/2023 Implemented
6400.166(a)(6)Individual #1's April 2023 Medication Administration Record does not include the dosage form of Fluticasone Propionate Nasal Spray USP and Vitamin D3.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form.Individual¿s 1 dosage of medication Fluticasone Propionate Nasal Spray and Vitamin D3 was listed on the MAR. 04/27/2023 Implemented
6400.166(a)(7)Individual #1's April 2023 Medication Administration Record does not include the dose of Fluticasone Propionate Nasal Spray USP and Vitamin D3. Individual #1's April 2023 Medication Administration Record states, "Prazosin HCL 1mg, take 2 tablets by mouth in the evening." The plastic medication single dose package states, "Prazosin HCL 1mg QTY: 3."A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.Individual¿s 1 dose of medication Fluticasone Propionate Nasal Spray and Vitamin D3 was listed on the MAR. Individual¿s 1 Prazosin HCL 1Mg now states: ¿Take 3 tablets by mouth in the evening¿ on the MAR. 04/27/2023 Implemented
6400.166(a)(8)Individual #1's April 2023 Medication Administration Record does not include the route of administration for Fluticasone Propionate Nasal Spray USP and Vitamin D3.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.Individual¿s 1 route of medication Fluticasone Propionate Nasal Spray and Vitamin D3 was listed on the MAR. 04/28/2023 Not Implemented
6400.166(a)(9)Individual #1's April 2023 Medication Administration Record does not include the frequency of administration of Fluticasone Propionate Nasal Spray USP and Vitamin D3.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.Individual¿s 1 frequency of medication Fluticasone Propionate Nasal Spray and Vitamin D3 was listed on the MAR. 04/28/2023 Not Implemented
6400.166(a)(10)Individual #1's April 2023 Medication Administration Record does not include the administration times for Fluticasone Propionate Nasal Spray USP and Vitamin D3.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.Individual¿s 1 time to administer the medication Fluticasone Propionate Nasal Spray and Vitamin D3 was listed on the MAR. 04/28/2023 Implemented
6400.166(a)(11)Individual #1's April 2023 Medication Administration Record does not include diagnosis or purpose for Fluticasone Propionate Nasal Spray USP 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.Individual¿s 1 diagnosis or purpose of the medication Fluticasone Propionate Nasal Spray and Vitamin D3 was listed on the MAR. 04/28/2023 Not Implemented
SIN-00209754 Renewal 08/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)On 8/5/22, at 1:04 PM the water temperature measured 148.6 degrees Fahrenheit at main floor bath at sink adjacent to the staff office. On 8/5/22, at 1:12 PM the water temperature measure 148.8 degrees Fahrenheit at the kitchen sink. On 8/5/22, at 1:31 PM the water temperature measured degrees 141.6 Fahrenheit at the 2nd floor bathroom sink.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. Program Specialist will conduct water checks on the fifth of every month so the water temperature does not exceed 120°F. If the water exceeds 120°F, Program Specialist will document how the problem was corrected. The Program Specialist will turn the hot water thermostat down, and will check the water to make sure the water does not exceed 120°F. The CEO will review the water temperature documentation every six months. 08/06/2022 Implemented
6400.68(b)On 8/5/22, at 1:31 PM the water temperature measured degrees 141.6 Fahrenheit at the 2nd floor bathtub. Hot water temperatures in bathtubs and showers may not exceed 120°F. Program Specialist will conduct water checks on the fifth of every month so the water temperature does not exceed 120°F. If the water exceeds 120°F, Program Specialist will document how the problem was corrected. The Program Specialist will turn the hot water thermostat down, and will check the water to make sure the water does not exceed 120°F. The CEO will review the water temperature documentation every six months. 08/06/2022 Implemented
6400.72(a)On 8/5/22, the window in the staff office across from the restroom on the main floor did not have a screen. The second window in the staff office adjacent to the restroom on the main floor did not have a screen. The two windows in the dining room did not have a screen. Bedroom #1 (vacant) did not have a screen in the window. Individual #2's bedroom window did not have screens in the two-bedroom windows. Bedroom #3 did not have a screen in the window. The second-floor restroom did not have a screen in the window.Windows, including windows in doors, shall be securely screened when windows or doors are open. Within 30 days, the CEO or Program Specialist shall train all staff working in homes on reported needed repairs. Documentation of training shall be maintained. At least monthly, for a period of at least one year, the CEO or Program Specialist shall conduct a review of each licensed residence to identify needed repairs. Documentation of the monthly repair checks shall be maintained. [Training form, dated 8/11/22, related to identifying and reporting repairs at residential locations was received on 10/5/22 and reviewed 10/18/22. A completed Maintenance and Repairs Tool for each residential location, dated 8/11/22, was received on 10/5/22 and reviewed 10/18/22. DPOC by HDKP, HSLS, on 10/18/22]. 08/06/2022 Implemented
6400.72(b)There was an approximate 3 inch long by 1-inch-wide section of missing glass with an approximate 12-inch crack leading from the left side of the section of missing glass on the window across from the restroom on the main floor. The bottom panel of glass on the window adjacent to the staircase leading to the second floor was missing. The lower quarter portion of the top panel of glass on the window adjacent to the staircase leading to the second floor was missing. Screens, windows and doors shall be in good repair. Within 30 days, the CEO or Program Specialist shall train all staff working in homes on reported needed repairs. Documentation of training shall be maintained. At least monthly, for a period of at least one year, the CEO or Program Specialist shall conduct a review of each licensed residence to identify needed repairs. Documentation of the monthly repair checks shall be maintained. [Training form, dated 8/11/22, related to identifying and reporting repairs at residential locations was received on 10/5/22 and reviewed 10/18/22. A completed Maintenance and Repairs Tool for each residential location, dated 8/11/22, was received on 10/5/22 and reviewed 10/18/22. DPOC by HDKP, HSLS, on 10/18/22]. 08/06/2022 Implemented
6400.73(a)The first series of 9 steps leading to the attic did not have a handrail. The second series of 5 steps leading to the attic did not have a handrail. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Within 30 days, the CEO or Program Specialist shall train all staff working in homes on reported needed repairs. Documentation of training shall be maintained. At least monthly, for a period of at least one year, the CEO or Program Specialist shall conduct a review of each licensed residence to identify needed repairs. Documentation of the monthly repair checks shall be maintained. [Training form, dated 8/11/22, related to identifying and reporting repairs at residential locations was received on 10/5/22 and reviewed 10/18/22. A completed Maintenance and Repairs Tool for each residential location, dated 8/11/22, was received on 10/5/22 and reviewed 10/18/22. DPOC by HDKP, HSLS, on 10/18/22]. 08/06/2022 Implemented
6400.74The first series of 9 steps leading to the attic did not have a nonskid surface.  The second series of 5 steps leading to the attic did not have a nonskid surface.Interior stairs and outside steps shall have a nonskid surface. Within 30 days, the CEO or Program Specialist shall train all staff working in homes on reported needed repairs. Documentation of training shall be maintained. At least monthly, for a period of at least one year, the CEO or Program Specialist shall conduct a review of each licensed residence to identify needed repairs. Documentation of the monthly repair checks shall be maintained. [Training form, dated 8/11/22, related to identifying and reporting repairs at residential locations was received on 10/5/22 and reviewed 10/18/22. A completed Maintenance and Repairs Tool for each residential location, dated 8/11/22, was received on 10/5/22 and reviewed 10/18/22. DPOC by HDKP, HSLS, on 10/18/22]. 08/06/2022 Implemented
6400.110(e)The smoke detector in the attic was not interconnected with the smoke detectors in the basement, main level, and 2nd floor of the home.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 agency installed the interconnect fire alarm on 8/10/22. It was installed, tested and functioned as designed. [Receipt for purchase of 3 wireless, battery operated fire alarms, dated 10/9/21, received on 10/5/22 and reviewed on 10/18/22. DPOC by HDKP, HSLS, on 10/18/22]. 08/11/2022 Implemented
6400.113(a)Individual #1 signed a copy of the 6400.113(a) on 1/31/22. No actual fire safety training occurred. Individual #2 signed a copy of the 6400.113(a) regulation on 2/5/21, and then again on 6/21/22, exceeding the annual requirement. No actual fire safety training occurred. 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)(11)Individual #2 had a physical examination on 2/28/2022; however the physical examination did not include an assessment of medications.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 RO's physical examination included an assessment of medications. [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
6400.142(a)Individual #1, date of admission 1/31/2022, has not had a dental examination completed.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. Waiting to obtained documentation from the Dentist that states they were unable to see MM until 1/9/23 due to COVID related issues; their schedule is backed up. 08/06/2022 Implemented
6400.142(f)Individual #1 does not have a written plan for dental hygiene. Individual #1 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. Staff will observe MM 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 MM has achieved dental hygiene independence. This information will be reflected in MM¿s assessment and his ISP. [Dental Hygiene Plans for Individual #1, dated 9/30/22, were received on 10/5/22 and reviewed 10/18/22. DPOC by HDKP, HSLS, on 10/18/22]. 08/06/2022 Implemented
6400.144Individual #2 had a psychiatric medication review on 5/16/2022. The psychiatric medication review form states in the section labeled "Labs, tests, and referrals ordered" that bloodwork "was ordered in March 2022, I gave another requisition on 5/16/22." The agency could not provide documentation that the bloodwork was completed.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 1/31/2022, had an initial assessment completed on 4/5/2022, exceeding the 60 calendar day requirement. The assessment was not completed within 60 calendar days. Individual #2 had an assessment completed 2/5/2021 and again on 3/30/2022, exceeding the annual 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
6400.181(e)(4)Individual #2's assessment, dated 3/30/22, does not describe the individual's need for supervision. The assessment states "needs supervision due to him engaging in mischievous behaviors," but does not address the type of supervision, how many hours per day the supervision is required, nor include a description of the behaviors that warrant supervision. The assessment must include the following information: The individual's need for supervision. Five hours a day RO needs supervision to complete chores, daily tasks and to maintain proper behavior when in public. When RO is around minors in public or in private; he needs be supervised so he can maintain proper distance and behavior. [Updated supervision information in the individual assessment, not dated, was received on 10/5/22 and reviewed on 10/18/22. DPOC by HDKP, HSLS, on 10/18/22]. 08/06/2022 Implemented
6400.34(a)Individual #2 was informed and explained individual rights on 2/5/21, and then again on 6/21/22, exceeding the annual requirement.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.Obtained documentation of RO's individual's rights being explained. CEO will follow up and make sure documents are retrieved and received when scanned. 08/06/2022 Implemented
6400.34(b)Individual #1's record did not contain a signed statement signed by the individual acknowledging the receipt of information on individual rights.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.Obtained documentation of MM's individual's rights being explained. CEO will follow up and make sure documents are retrieved and received when scanned. [Signed copy of individual rights for Individual #1, dated 1/31/22, received on 10/5/22 and reviewed on 10/18/22. DPOC by HDKP, HSLS, on 10/18/22]. 08/06/2022 Implemented
6400.165(g)Individual #1 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness. Individual #1 did not have any psychiatric medication reviews since admission 1/31/2022. [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