Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00243502 Unannounced Monitoring 04/16/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(15)Individual #1 has a prescription for Citalopram 20 MG, and the medication label from the pharmacy has the instructions to "Take one tablet by mouth once day with half of 10 mg to total 25 mg," while the April 2024 Medication Administration Record (MAR) states Take one 20 MG tablet by mouth in the morning.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable.The individual's MAR was updated to include the special precautions applicable to the medication, Citalopram 20 MG. 05/01/2024 Implemented
SIN-00235841 Renewal 12/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(11)The December 2023 medication administration record (MAR) does not include a diagnosis or purpose for the following prescribed medications for Individual #1: Benzoyl Per Gel 2.5%- Apply to affected area once daily, Best Fiber FF SF- Mix 1 tablespoon in 8 oz. water or sprinkle on food and take 2 times daily, Citracal D3 ER- Take 1 tablet by mouth once daily. Hydrochlorothiazide 25 mg- Take 1 tablet by mouth once daily Linzess 290 mcg- Take 1 capsule by mouth once daily Magnesium Oxide 400 mg- Take 1 tablet by mouth once daily Omega 3 Acid Ethyl Ester 1 gram capsule- Take capsules by mouth twice daily Propranolol ER 60 mg- Take 1 capsule by mouth once a day Vitamin C 500 mg- Take 1 tablet by mouth once daily Vitamin D 400 IU - Take 1 tablet by mouth once a dayA 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.On the December 2023 MAR, for individual number one, diagnosises and purpose for the prescribed medications have been added. 12/14/2023 Implemented
SIN-00216363 Renewal 12/16/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)Individual #1's physical examination, completed 9/8/22 did 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. The physical examination that was missing the medical information pertinent to diagnosis and treatment in case of an emergency was completed at the individual's previous residence. Our agency's physical examination paperwork includes an area for this information and will be used for all individuals in our care's physicals. 12/28/2022 Implemented
6400.151(c)(2)Direct Service Worker #1, date of hire 9/1/22, had an initial Tuberculin skin testing by Mantoux method with negative results, completed 9/8/22. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Direct Service Worker #1 completed their physical on 9/2/22 and had their first shift on 9/3/22. We did not know that their TB test was scheduled for a few days later. Our Human Resource Officer will begin a checklist which includes verifying that the TB has been completed upon our next hire. 12/28/2022 Implemented
SIN-00233300 Unannounced Monitoring 10/20/2023 Compliant - Finalized
SIN-00209620 Add an Addendum 08/01/2022 Compliant - Finalized