Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00241283 Renewal 03/18/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(a)At time of inspection the smoke detector located in the basement of the home did not alarm when tested. Alarm was reset and shown to be functioning after inspection was completed. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. The agency representatives inspected the detector and chose to replace the unit on 3/20/2024 for greater assurance of a reliable unit. 04/19/2024 Implemented
6400.112(c)Documentation of the fire drill conducted on 7/6/23 did not list the exit route used or the time that the drill was conducted as required. (Repeat Violation 3/1/23)A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The agency has created a tracking sheet for the Residential Directors use throughout the calendar year to address and meet each required portion of information (in particular the exit route used and the time the was conducted) is documented on the Fire Drill form. This will ensure the information is completed in it's entirety moving forward in this home and all others operated by the agency. 04/19/2024 Implemented
6400.112(e)Documentation of fire drills conducted during the 3/23 to 3/24 review period noted that only one sleep fire drill had been completed on 11/14/23. A fire drill shall be held during sleeping hours at least every six months.A fire drill shall be held during sleeping hours at least every 6 months. The agency has created a tracking sheet for the Residential Directors use throughout the calendar year to address and meet the Asleep designated Fire Drills to fall within the 6 months requirement for frequency. This will ensure the frequency is maintained moving forward in this home and all others operated by the agency. Asleep Drill for this home was conducted on March 21, 2024. 04/19/2024 Implemented
6400.141(c)(3)The physical for Individual #5 dated 8/17/23 did not include documentation that the Tdap had been completed as required.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. The agency pulled the information from his portal that logs the information on each Patient's My Chart and after visit summary. This summary will be used in conjunction with the ECR agency Individual Form for each year. The Tdap was administered 3/9/2022 for this specific individual. The agency has instituted a Medical Tracker Sheet for assurance of medical information documents retained in Home and Office Records. 04/19/2024 Implemented
6400.141(c)(11)The physical for Individual #5 dated 8/17/23 did not include documentation that an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals had been completed. The designated section was blank.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. The agency representative circled back with the physician who conducted the 8/17/23 Annual Physical to fill out the section aforementioned addressing health maintenance. The physician opted to use the My Chart Visit Summary for the requested documentation. The agency will fill out the sections of the physical with a notation to "see attached" in order to maintain compliance with the regulation specifics. 04/19/2024 Implemented
6400.141(c)(14)The physical for Individual #5 dated 8/17/23 did not include documentation medical information pertinent to diagnosis and treatment in case of an emergency. The designated section was blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The agency representative circled back with the physician who conducted the 8/17/23 Annual Physical to fill out the section aforementioned addressing medical information pertinent to diagnosis and treatment in case of emergency. The physician opted to use the My Chart Visit Summary for the requested documentation. The agency will fill out the sections of the physical with a notation to "see attached" if the physician is documenting the required information in their electronic notes which we print and place in the individuals house and office record in order to maintain compliance with the regulation specifics. 04/19/2024 Implemented
6400.163(a)Individual #5 is prescribed Minerin cream and Balsam Peru ointment. The labels and wording on both medications were worn away so that the pharmacy labels were not legible.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.Each agency Residential Director as well as the agency RN will assess the packaging labels for creams, ointments and alike to ensure the label is legible and not marred due to the product use and wear and tear for the duration. In this particular incident the agency representative contacted the pharmacy for new labels. The pharmacy referred the representative to the prescriber who then discontinued the use of the 2 items in question. The visit notes show the 3/25/2024 communication with the prescriber. 04/19/2024 Implemented
6400.165(c)Individual #5 is prescribed Lactulose Solution "Take 1 teaspoonful(15ML) by mouth three times a day." The bottle in use at time of inspection was filled on 1/10/24. The 473 ml bottle contains 31 doses of the medication. At time of inspection approximately ¼ of the solution remained in the bottle with the fluid level line visible approximately one-half inch below the pharmacy label. Administered as prescribed the bottle in use labeled 1/10/24 would have been empty by 2/15/24. A proper measuring device was not in the home for the Lactulose at time of inspection. It was noted that the medication was administered using a utensil tablespoon. Using a utensil does not ensure that the correct amount of the medication is administered as prescribed each time. Individual #5 is prescribed Bisacodyl 10mg Supp to be given "Insert 1 suppository rectally (10mg) daily. Each box contains 12 suppositories. The box in use at time of inspection had a pharmacy fill date of 2/21/24 and 9 suppositories remaining in the box. Only three suppositories had been used from the box since the refill date of 2/21/24. Administered as prescribed a new box would have been stated by 3/9/24. (Repeat Violation 2/5/24)A prescription medication shall be administered as prescribed.The agency representative acquired a proper device in the plastic cup for use of measuring for the Lactulose moving forward. Cup was in place on 3/22/2024. With regard to the suppositories an additional count sheet with the Residential Directors and the Agency RN monitoring throughout the week as well as notation of new container start to ensure administration as directed. 04/19/2024 Implemented
SIN-00239277 Unannounced Monitoring 02/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)Individual's funds shall be used for the Individual's benefit. The provider purchased a shower chair for Individual #1 on 12/04/2023 for the amount of $578.33. The Individual's representative payee, Advocacy Alliance, purchased the chair based on the request from the provider for a specific shower chair. The purchase agreement clearly stated that the chair was not returnable. At the time I visited the home on 2/05/24, the shower chair was in the box in the living room and was not usable as it was too big for the tub/shower in the individual's home, and the individual did not have a safe, usable shower chair, two months after his funds were used to make the purchase.Individual funds and property shall be used for the individual's benefit. The agency has reimbursed the individual for the Shower Chair and purchased a new Sliding Shower Chair. Photos sent for verification. 02/27/2024 Implemented
6400.61(a)A home serving individuals with a physical disability shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within, and exit from the home based upon the individual's needs. There was not a ramp at the rear door of the home located off the kitchen, the only other entrance to or exit from the home on the main living level.A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. The agency has installed ramping at the door indicated by the inspector at the time of inspection. The agency has provided an image for verification as well. 02/24/2024 Implemented
6400.61(b)A home serving an individual with a physical disability shall have adaptive equipment necessary for the individual to move about and function in the home. At the time of the inspection, there was not a shower chair or other adaptive equipment to allow Individual #1 to bathe or utilize the only bathtub/shower in the home in a safe manner.A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have adaptive equipment necessary for the individuals to move about and function at the home.The agency has reimbursed the individual for the Shower Chair and purchased a new Sliding Shower Chair. Photos sent for verification. 02/27/2024 Implemented
6400.67(b)Surfaces shall be free of hazards. At the time of the inspection, the lower spigot in the bathtub was missing, exposing several inches of bare pipe which creates a potential hazard for an individual utilizing the bathtub. Floors, walls, ceilings and other surfaces shall be free of hazards.The agency reinstalled the spigot the same day. Please see photo for verification. 02/05/2024 Implemented
6400.165(c)Medications shall be administered as prescribed. The medication Onelax (Bisacodyl) rectal suppositories is prescribed for Individual E.V. to be administered on a pro re nata (PRN) basis, one suppository daily as needed for constipation. According to the medication administration records for the months of December 2023 through February 8, 2024, the medication was administered every day except for two days (12/31/2023 and 1/06/2024. By administering the medication 68 of 70 days, the provider is administering the medication as a daily medication and not pro re nata, or on an as needed basis, as it was ordered by the prescriber. The medication lacosamide (Vimpat) was discontinued by the individual's neurologist on 12/28/2023 but was still listed on the January 2024 medication administration record (MAR), and staff had initialed the January MAR to indicate that the medication was administered from 1/01/2024 to 1/18/2024. **The medication blister packs for January are no longer available so it is impossible to determine if the medication was actually available and administered, or if staff just initialed the MAR without administering the medication.A prescription medication shall be administered as prescribed.The agency contacted the prescribing physician to rewrite the order as previously verbally directed to staff for use daily, please see documentation submitted for verification as well. 02/12/2024 Implemented
6400.165(e)The medication administration record (MAR) shall be updated as soon as written notice of a medication change is received. The medication lacosamide (Vimpat) was discontinued on 12/28/2023 by the Individual's neurologist but the January 2024 MAR shows that the medication was still listed on the MAR and staff had initialed the MAR as having administered the medication twice per day from 8:00 AM on 1/01/2024 through 8:00 AM on 1/18/2024. From 1/18/2024 at 8:00 PM through to the end of January 2024, the MAR is not initialed as though the medication has been administered, nor has the medication been discontinued on the MAR. The December 2023 MAR indicates that the medication was discontinued for the entire month of December and was not administered on any day during the month, even though documentation from the provider shows that the medication was not discontinued until 12/28/2023.Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received.The agency staff have been retrained to properly and promptly make the necessary changes to the MAR's and discuss the changes with every staff person in the home. 02/12/2024 Implemented
6400.166(a)(11)A medication administration record (MAR) shall be kept, including the following for each individual for whom a medication is administered: a diagnosis or purpose for the medication, including pro re nata medications. On the February 2024 MAR, the following medications do not have a diagnosis or purpose recorded: Bacitracin Ointment, Fluvoxamine tablets, Gabapentin capsules, Lorazepam tablets, Minerin Cream, Thera M tabs, Quetiapine Fumarate tablets, Guanfacine Hydrochloride tablets and Guanfacine Hydrochloride ER (extended release) tablets.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 Residential Director corrected the omission of information on the MAR, please see the images for further verification. 02/05/2024 Implemented
SIN-00219633 Renewal 03/01/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(6)In bedrooms, each individual shall have a mirror. At the time of inspection. Individual #7 did not have a mirror in their bedroom.In bedrooms, each individual shall have the following: A mirror. The mirror has been installed in the bedroom. (Please see image sent via email) 03/20/2023 Implemented
6400.112(c)A written fire drill record shall be kept of the time of day, including designation of AM / PM. The fire frill conducted on 3/24/22 did include the designation of AM/PM.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The drill was corrected by the staff person and signed. The form will now include a Large Circle AM or PM. 03/20/2023 Implemented
SIN-00201436 Renewal 04/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill conducted on 11/15/21 did not include the time of day the fire drill was conducted.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The Residential Director has notes from his time at this home as being very involved with a high profile Individual. The time of the day has been inserted. Moving forward a review of the Fire Drill Form by another party will take place before being considered completed. 04/15/2022 Implemented
6400.141(c)(4)Individual #2 did not have an annual hearing exam completed.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The same facility has documented the Hearing for this Individual and recently decided they aren't certain of his hearing ability. We have requested clarification and a referral to an audiologist. I doubt the individual will cooperate but we can then record a refusal for compliance with the service being provided. We are awaiting directive from the practitioner after requesting on 4-18-22. 05/27/2022 Implemented
6400.144Individual #2 is prescribed Melatonin Cap 10mg. Sub for sundown Melatonin 10mg cap. Take 1 cap by mouth at bedtime. Individual #2 did not receive this medication on April 9 and April 10 as it was not available in the home.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. To receive the medication from the Mother/Legal Guardian as she has requested, we have made this clear to the pharmacy as to what items they are to send versus the mother. In the past the mother called the pharmacy and cancelled medication and supplement medications, those pharmacy workers were working off past notations on the files. 04/15/2022 Implemented
6400.151(a)Staff #1's date of hire is 12/20/19. Staff #1 did not have an initial physical or a biannual physical completed. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Staff had physical please see attachment in email. 05/05/2022 Implemented
6400.211(b)(2)Individual #2's emergency information sheet did not list the name, address and telephone number of the individual's physician or source of health care. Emergency information for each individual shall include the following: The name, address and telephone number of the individual's physician or source of health care.The name, address, telephone number for provider has now been added. 04/13/2022 Implemented
6400.165(f)Individual #2 is prescribed Olanzapine tablet Disint. 10mg, dissolve 1 tablet in mouth and allow to dissolve daily as needed for anxiety. The pharmaceutical label does not include specific symptoms displayed by the individual in order for the medication to be administered. A written protocol to address the individual's social, emotional and environmental needs related to the symptoms of the psychiatric illness and the administration procedure for the Olanzapine is required.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.The SEEN Plan has been updated to include the use of the PRN instructions for the individual. 04/20/2022 Implemented
6400.165(g)Individual #2 had medication reviews completed on 9/29/21 and 10/12/21. There was no documentation signed by a physician of these appointments. There were billing encounter forms indicating the date of the appointments. Individual #2 had a medication review completed on 3/8/22, this medication review did not include the reason for prescribing the medication.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.These were not actual reviews for 3 month medications reviews per the Provider but consult forms sent to this agency to sign off on the services for Merakey billing moving forward. The 3/8/2022 had an attachment with a front back due to space use. The attachment had the reason for each medication. Please see attached. 04/20/2022 Implemented
6400.213(1)(i)Individual #2's emergency information sheet did not list the individuals religion.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.The individual's Mother/ Legal Guardian stated he has no religion. None has now been listed on the form. 04/20/2022 Implemented
SIN-00198181 Unannounced Monitoring 12/14/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The entire kitchen floor was very sticky.Clean and sanitary conditions shall be maintained in the home. Agency Staff used proper cleaning agent to remove the substance from the kitchen floor creating a clean surface. 12/14/2021 Implemented
6400.214(a)Individual #1 did not have a record with all information required in 6400.213(1) located in the home.Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home.The individual's record in the home now contains all required documentation per the regulations follows; 213 (1). 01/01/2022 Implemented
6400.165(c)Individual #1 is prescribed Fluticasone Prop 50mcg Spray, two sprays by alternating nostrils daily. The medication is documented on the MAR as administered, however the bottle was last filled in April 2021 with a 30 day supply and the bottle was approximately 1/2 full. The medication would have required at least 7 refills since April 2021 if being administered as prescribed.A prescription medication shall be administered as prescribed.A medication audit revealed other open bottles in the homes medication closet, that is locked, that were in use at some point. Staff were retrained as to proper efficient storage with back up bottles/containers stored separately from active use medications. 12/14/2021 Implemented