Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00219639 Renewal 03/01/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)At the time of the inspection there was no gauze tape in the first aid kit. 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. Gauze tape has been added to the kit by agency staff. 03/20/2023 Implemented
6400.81(k)(6)Individual #2 did not have a mirror in his bedroom.In bedrooms, each individual shall have the following: A mirror. The mirror has been added to his bedroom for compliance with the regulations. 03/20/2023 Implemented
6400.141(a)At the time of inspection, the only physical provided for this individual was dated 1/12/2023. The date of admission was 9/17/22. There shall be a physical within 12 months prior to admission. A copy of the previous physical and TB were requested, with no follow documentation.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The agency staff did not follow the regulatory requirements despite the emergency admission. There were no previous medical records for the individual he lived at home with his mother. 03/20/2023 Implemented
6400.141(c)(3)The individual had a physical dated 1/12/2023 and this did not list the immunizations.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 medical provider has been contacted and has no record of previous immunizations. We are working with him and his mother to agree to the immunizations to come into compliance with the regulations. 04/30/2023 Implemented
6400.141(c)(12)The individual had a physical dated 1/12/2023 which did not list any physical limitations of the individual. This section was left blank.The physical examination shall include: Physical limitations of the individual. The staff are working with the individual and his mother to schedule another appointment, the agency will pay for, to have the areas addressed according to the regulations. 04/30/2023 Implemented
6400.141(c)(13)The individual had a physical dated 1/12/2023 did not list any allergies or contraindicated medications. This area was left blank.The physical examination shall include: Allergies or contraindicated medications.The staff are working with the individual and his mother to schedule another appointment, the agency will pay for, to have the areas addressed according to the regulations. 04/30/2023 Implemented
6400.141(c)(15)The individual had a physical dated 1/12/2023 did not list any special instructions for diet. This area was left blank.The physical examination shall include:Special instructions for the individual's diet. The staff are working with the individual and his mother to schedule another appointment, the agency will pay for, to have the areas addressed according to the regulations. 04/30/2023 Implemented
6400.32(r)(1)At the time of inspection individual #2 did not have a key to lock and unlock his door. When asked about his key, the individual said " I was not given a key so I guess I'm not supposed to have one".Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.A key has been provided to the individual to come into compliance with the regulations. 03/20/2023 Implemented
6400.32(r)(5)At the time of inspection, the individual had locks on their doors, however the staff did not have the key or device which would unlock the door.Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.The kays have been placed in the home to provide access to staff for carrying on their person and a back up set. 03/20/2023 Implemented
6400.163(h)At the time of the inspection the staff brought out 2 medication boxes with the MAR. The one box contained several bottles of prescription medications for the individual that was said to have been brought upon his admission. The second box of medication contained blister packs of medications which matched the medication administration records. Upon review of the mediations from container one it appears that several of the medications either changed the frequency of administration and or was discontinued. The medications from box one included Lamotrigine 100mg, the bottle directions stated to take twice a day, and the new pharmacy directions are to only take during the morning. The medication Ziprasidone HCL 60 mg tab was to be taken 2 a day, but is not on current MAR. The medication Fexfofenadine 180 mg tablet to be taken a needed was also not on the current MAR. Any prescription that are discontinued shall be destroyed in a safe manor.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Agency staff has destroyed the medications according to the regulatory standards. 03/20/2023 Implemented
6400.182(c)The current ISP states that this individual struggles with budgeting money and making purchases that may not be necessary. ISP also reflects that he has stolen family members credit cards and money and struggles with electronic safety. The ISP states that the individual is monitored on phone and with internet to ensure he is not making inappropriate purchases. The annual assessment created on 11.12.22 reflects that this individual is independent with financial independence. Due to the conflict of these documents, it is unclear if the ISP is reflective of the most up to date assessment of the individual needs.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The staff have reached out to the Supports Coordinators requesting a meeting to correctly document the needs of the individual in the ISP. 04/30/2023 Implemented