Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00243080 Renewal 04/18/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104Notifications to the fire department did not include exact locations of the bedrooms of individuals who need assistance in the event of an actual fire.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Immediately after the licensing, the letter to the fire department was revised and mailed out with the exact locations of the individual's bedroom and the assistance needed to evacuate. 04/19/2024 Implemented
6400.141(a)The physical exam for individual#1 was last completed 5/10/22, and then 6/7/23 which was not within the annual timeframe to maintain compliance.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. House Managers will schedule appointments three months in advance of due date or as far in advance as possible to meet the licensing requirements. 06/03/2024 Implemented
6400.141(c)(4)The last vision screening was completed on 3/17/23.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. House Managers will schedule appointments three months in advance of due date or as far in advance as possible to meet the licensing requirements. 06/03/2024 Implemented
6400.141(c)(7)The last gynecological exam for individual#1 was conducted on 3/12/19.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. House Managers will schedule appointments three months in advance of due date or as far in advance as possible to meet the licensing requirements. 06/18/2024 Implemented
SIN-00224040 Renewal 04/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There were chemicals including "Clorox" and "EZ off" oven spray unlocked in the home.Poisonous materials shall be kept locked or made inaccessible to individuals. This home does not require poisonous materials/chemical to be locked away. Both gentlemen are able to understand the use of the cleaning products and can handle them safely. 05/01/2023 Implemented
SIN-00203991 Renewal 04/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)Dryer Lint was located in the dryer during inspection, the size when cleaned and rolled was larger than a golf ball. Floors, walls, ceilings and other surfaces shall be free of hazards.lint was immediately removed and discarded. 05/04/2022 Implemented
6400.141(a)The two latest physical examinations present in Individual #1's Record were dated 03/25/2019 and 05/05/2021. As the elapsed time between these two dates exceeds one year, a physical examination was not conducted for this individual annually as required.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. While the recent appointments are in compliance it is accurate that an appointment was missed during the height of Covid and we failed to properly document our efforts to make up this appointment or to receive virtual care. 05/13/2022 Implemented
6400.141(c)(6)The latest Mantoux test present in Individual #1's Record was dated 08/14/2019. There was no documentation of a more recent test found within the individual record. Evidence does not support that a Mantoux test was conducted once every 2 years as required.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. this has been scheduled and we will carefully document any refusals by the individual. We also have written a medical support plan to ensure best success at appointments. 05/13/2022 Implemented
6400.141(c)(7)According to the documentation present in Individual #1's Record, the latest gynecological examination conducted for the individual occurred on 03/19/2019. Although an individual physical examination was conducted on 05/05/2021, no gynecological examination took place during the visit. No documentation was available stating that a licensed physician recommended none or less frequency for gynecological examinations for this individual. As there was no documentation of a more recent gynecological examination found within the individual record.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. this has been scheduled and we will carefully document any refusals by the individual. We also have written a medical support plan to ensure best success at appointments. 05/13/2022 Implemented
6400.143(a)During the review of the documentation within Individual #1's Record, it was found that the following required medical appointments were out of compliance: Individual Physical Examination, Mantoux Testing, Gynecological Examination, and Dental Examination. Provider staff on site during Individual Record review stated that Individual #1 has a history of appointment refusals. The provider staff also stated that it was their belief that Individual #1 had attended more recent appointments; however, provider staff were unable to locate documentary evidence that more recent appointments had taken place. It was noted in Individual #1's most recent Individual Support Plan (ISP), dated 06/21/2021 in the Home and Community Based Services Information System (HCSIS), that the individual "···HAS A HISTORY OF REFUSING TO PARTICIPATE IN MEDICAL APPOINTMENTS." This ISP also notes that the individual "···CONTINUES TO REFUSE MEDICAL APPOINTMENTS. [The individual] SHOULD BE ENCOURAGED TO ATTEND AND PARTICIPATE IN HER MEDICAL APPOINTMENTS." Upon review of the individual record, neither documentation of Individual #1's appointment refusals nor documentation of continued attempts to train the individual about the need for health care were found.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. all appointments have been scheduled and we will carefully document any refusals by the individual. We also have written a medical support plan to ensure best success at appointments that discusses refusals specifically, how to prep the individual for an appointment and how to document what occurs. Our nurse also has accompanied the individual to her appointments this week to try to ensure the best success. 05/13/2022 Implemented
6400.144The following as needed medications prescribed to individual #1 and listed in the medication record were not located in the medication box or at location during review: Benedryl, Trazadone, Sarna, Refresh eye drops. In addition, Robotussin prescribed to be taken as needed was in the medication box but expired as of 10/21/2021. A Medication called Mupirocin prescribed to individual #1 was located in the medication box but not listed on the record. There was a tube of mupirocin open and used. According to the documentation available within Individual #1's Record, the individual was last seen for a dental examination on 07/22/2021. On the dental exam form, the dentist indicated that follow-up should occur in 6 months, i.e., in January 2022. There was no evidence of a more recent appointment found within the individual record. It could not be established that Individual #1 received a dental examination at the frequency recommended by the dentist.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. Multiple medications have been ordered by the resident and by the residents mother which has contributed to some confusion and redundancy in medications being prescribed. As a follow up to this citation, our nurse called each prescriber to discontinue or change all medications to PRN and also order any continued medications to be on site. 05/04/2022 Implemented
6400.165(c)Nystatin Triamcinolone cream and mycolog ointment to applied twice a day to individual #1 were not located on site during inspection but listed on the medication record as a daily medication. Santyl Ointment to be applied to the chin every day with dressing changes was not located onsite but was listed in the record. Fish Oil, Systane and Travatan was not located in the medication box but was listed as refused daily. These medications were not being administered as prescribed and were not available for the individual to actively accept or refuse administration.A prescription medication shall be administered as prescribed.Multiple medications have been ordered by the resident and by the residents mother which has contributed to some confusion and redundancy in medications being prescribed. Medication that is prescribed must be available for the individual. As a follow up to this citation, our nurse called each prescriber to discontinue or change all medications to PRN and also order any continued medications to be on site. 05/04/2022 Implemented
6400.166(b)There were the following documentation issues on the April MAR for individual #1 Eurcerin cream to be applied topically daily was left blank and not logged for the month of April, April 1-21st Hydrocortisone 1% cream apply to area of rash two times a day for itches was left blank april1 -12 am and 1-16 pm applications. Both medications were not being logged immediately after administration or refusal.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.A med audit was completed for oral medications and the pharmacy and doctor was called to address the topical medication errors. A medical support plan has been written to address refusals and staff have been retrained in the importance of documenting medication refusals on the MAR. 05/04/2022 Implemented
6400.166(c)Refusals for medication did not indicate the prescriber was notified or if guidelines from the prescriber was followed. A Letter was provided in January 31, 2022 discussing recent refusals from individual #1 but no subsequent follow ups were had regarding February through current day refusals (4/21/22)If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual.A med audit was completed for oral medications and the pharmacy and doctor was called to address the topical medication errors. A medical support plan has been written to address refusals and staff have been retrained in the importance of documenting medication refusals on the MAR. In addition, our nurse contacted each physician who prescribed a mediation the individual was refusing to have it discontinued or changed to PRN. 05/04/2022 Implemented
6400.181(f)Individual #1's Assessment was not sent to the to the individual's Individual Plan Team members by the program specialist at least 30 calendar days prior to an individual plan meeting, which took place on 02/01/2022. Documentation within the Individual Record indicates that the Individual Assessment was not sent to Individual Plan Team members until 02/09/2022.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Program Specialist will send Assessment 30 days prior to the Annual Review meeting. Unfortunately, and in this case, supports coordinators give us so little time to prep for the ISP that we do not have the option to send 30 days in advance. 05/04/2022 Implemented
SIN-00187195 Renewal 04/22/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Clean and sanitary conditions were not maintained throughout the home. A large red-brown spot consistent with dirt, grease, or grime was observed in an empty compartment of the silverware tray in a kitchen drawer.Clean and sanitary conditions shall be maintained in the home. We are aware of the importance of keeping the home free and clear of dirt, grease or grime. The silverware tray was cleaned to rectify this issue. 04/23/2021 Implemented
6400.32(d)Staff 3 was observed to not have a mask on when she was sitting in the living room while other staff and individual were present at the start of the inspection on 4/22/21.An individual shall be treated with dignity and respect.Staff 3 was observed to not have a mask on when she was sitting in the living room while other staff and individual were present at the start of the inspection on 4/22/21. Due to the current pandemic we are aware of the importance of following CDC guidelines in regards to PPE. In order to protect the safety of our individuals, all staff are required to wear double masks inside the home as well as wearing face shields when doing direct close ADL¿ s, meals, or medication administration. The staff who made this error was new. Staff received a supervision for failing to follow PPE policies and protocols set forth by Merakey, and all co-workers in the home received a supervision as well. Corrective discipline action will occur if an event is noted again. 04/23/2021 Implemented
6400.46(b)Staff 2 did not have a current and up to date annual fire safety training completed. Previously documented fire safety training was unknown.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).We understand the importance of staff being trained on the annual fire safety plan. In the event of an emergency, it is imperative that staff know what to do to ensure the safety of everyone in the home. Staff 2 actually did complete fire safety during the 2020 calendar year, however she will still past her due date, and fire safety should always be a priority in ensuring its completion (2020 certificate copied below). 08/01/2021 Implemented
6400.50(a)Records were not kept for staff 2's trainings completed for the 2020 calendar year. Documentation did not include training source, content, length of training, staff in attendanceRecords of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.We understand the importance of staff being trained. In the event of an emergency, it is imperative that staff know what to do and that all training is in accordance with our compliance and regulation requirements. We are aware that of the potential issues that could arise based on the staff being untrained. We also understand the importance of documenting and keeping an organized record of all trainings. Training documents will clearly highlight, training source, content, length of training and all attendees for group trainings will be noted. 04/30/2021 Implemented
6400.52(c)(1)The 11 training hours staff 1 completed in the 2020 training year did not include the mandatory core trainings required by ODP such as community integration, person-centered practices, individual rights and reporting incidentsThe annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.We understand the importance of staff being trained. In the event of an emergency, it is imperative that staff know what to do. We are aware that of the potential issues that could arise based on the staff being untrained. This staff has been assigned these trainings in our electronic training system with an expectation that they be completed by 6/30/2021. The provider would like to note that this lapse in trainings is not consistent with prior years citations, and that the Covid crisis did contribute to us failing to prioritize these important required trainings. 06/30/2021 Implemented
6400.169(a)Staff 1 did not have a completed annual medication practicum and was still administering medication during the current medication administration record. Last medication training was the initial training which was completed on 5/9/19A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).To prevent the occurrence of medication errors it is important that staff are properly trained. As a provider we understand the importance of annual medication practicums. We will ensure practicums are completed annually to protect the health and safety of our individuals and meet compliance standards. This staff did have completed MAR¿s for the 2020 training calendar year, but no observations were completed. She has been removed from being allowed to administer medication and is doing remediation with an expectation of completed by 6/30/21. 06/30/2021 Implemented
SIN-00161364 Renewal 08/13/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.143(a)Individual #1's mammogram was scheduled for May 2019 but staff indicated that she refused the appointment. There was insufficient follow up documenting the refusal and continued attempts to train the individual about the need for health care services and appointments.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. Individual #1 refused to attend her mammogram appointment. The provider did not sufficiently document the attempts to train the individual about the need for health care services. When the individual refused to attend the follow up appointment, there should have been documentation about the appointment refusal/cancellation. A medical appointment cancellation consult sheet will be used if an individual refuses health care services and appointments. The provider will document how the individual was educated and trained, and continued attempts will be documented in the individual¿s record on a cancelled medical appointment form. If he or she refuses in the future, he will be trained by a different team member (staff, house manager, nurse, program specialist, etc) to see if there is a different outcome. A training will be completed with staff on how to facilitate the conversation after an appointment has been cancelled/refused, and how to complete the document or form. The program specialist will complete the training for the staff and will do on going training as necessary. 08/15/2019 Implemented
6400.144Individual #1's annual gynecological exam held on 1/3/18 recommended a return visit in January of 2019 and this appointment was not 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. Health services that are planned or prescribed will be arranged and provided for the individual. Health services appointments will be made in advance and suggested behavior strategies that are recommended by the psychologist will be followed. In the individual refuses to attend an appointment, the provider will document the attempts to train the individual about the need for health care services. A medical appointment cancellation consult sheet will be used if Michelle refuses health care services and appointments. The provider will document how the individual was educated and trained, and continued attempts will be documented in the individual¿s record on a cancelled medical appointment. If the individual refuses a health service a second time, she will be trained by a different team member (staff, house manager, nurse, program specialist, etc) to see if there is a different outcome. 08/15/2019 Implemented
6400.181(d)Individual #1s annual assessment dated 1/2/19 was not signed and dated by the program specialist.The program specialist shall sign and date the assessment. In order to address the non-compliance, the program specialist made an addendum to the assessment. The assessment addendum was dated for 8/15/19 after the non-compliance was cited and attached to the end of the 1/2/19 assessment. In the future, the program specialist will sign and date the assessment upon it being completed and printed. The assessment be review for the program specialist's signature and date during quarterly audits. A copy of the assessment addendum is included for review (attachment #8). 08/15/2019 Implemented
SIN-00114618 Renewal 05/23/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104There was no documentation notifying the local fire department of indivduals who need assistance to evacuate.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. There was a notification to the fire department, however the notification did not include the exact location of the bedrooms in the event of an actual fire. Both individuals in this home are fully ambulatory and are able to evacuate independently, however the notification has been updated to include more information about the residents in the home and the location of their respective bedrooms. Please see attachment for updated notification. 08/17/2017 Implemented
6400.112(e)The sleep drills were held on 01/16/2016 and 08/22/2016.A fire drill shall be held during sleeping hours at least every 6 months. A fire drill shall be held during sleeping hours at least every 6 months. The provider failed to do this and had a lapse in sleep drills. It is essential that the provider practice drills during multiple hours to ensure that the individuals¿ know how to react in the event of fire were to occur in the overnight hours. Please see attached sleep frills addressing this issue. 08/17/2017 Implemented
6400.141(a)Individual # 1's previous physical examination was dated 03/02/2016 and the most current physical examination was dated 03/21/2017.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The medical book review showed a lapse in physical of just over the 2 week grace period. The provider made every attempt to have the annual physical completed within the required period however the doctor¿s office could not accommodate this need. The provider will continue to strive to meet this necessary requirement to ensure the optimum healthcare for the individual¿s served. 08/17/2017 Implemented
6400.141(c)(6)Individual # 1's previous TB test was dated 03/03/2015 and the most recent TB test was dated 05/08/2017.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. The medical book reviewed showed a lapse in TB testing over 2 months. The provider will continue to strive to meet this necessary requirement to ensure the optimum healthcare for the individuals served. Quarterly audits are completed of our medical books to ensure compliance in this area. 08/17/2017 Implemented
6400.141(c)(7)Individual # 1's most recent gynecological examination was dated 11/12/2015.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. The medical book reviewed showed that Individual #1 had not had an annual gynecological and breast examination. The doctor indicated that Individual #1 should have this every 2 years which would make her due in 11/2017. The provider is seeking documentation from the doctor to further clearly indicate this. The provider will continue to strive to meet this necessary requirement to ensure the optimum healthcare for the individuals served. Quarterly audits are completed of our medical books to ensure compliance in this area. 08/17/2017 Implemented
6400.142(a)Individual # 1's most recent dental examination was dated 03/01/2016.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. The medical book reviewed showed a lapse in dental care for Individual #1. It is required that an individual have an examination at least annually. The provider is fully aware of this requirement and had several appointments cancelled by the office that was being used for dentistry. As a result of these frequent cancellations, a new dental provider was located and will be utilized moving forward. Please see attached dental visit form to show her most recent appointment. 08/17/2017 Implemented
6400.163(c)Individual # 1's psychiatric reviews were completed on 07/11/2016, 11/18/2016 and 03/30/2017. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.It is essential that individuals¿ who receive psychiatric care receive a medication review every 90 days or more frequently if needed. As a result of cancellation with the doctor¿s office there was a lapse in psychiatric care. Please see attachment to note that this is currently being followed up on and addressed to ensure compliance. 08/17/2017 Implemented
6400.181(e)(13)(i)Individual # 1's annual assessment dated 01/02/2017 did not document progress and growth in the area of 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. The assessment failed to address progress, growth, and change in the area of health in M. Schechtman¿s assessment. It is essential this be included so that change can be noted year to year and so current need level is accurately reflected in documentation. This has been addressed and included in the assessment and is attached. 08/17/2017 Implemented
6400.181(e)(13)(ii)Individual # 1's annual assessment dated 01/02/2017 did not document progress and growth in the area of motor and communication.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. The assessment failed to address progress, growth, and change in the area of motor communication skills in M. Schechtman¿s assessment. It is essential that this be included so that change can be noted year to year, and so current need level is accurately reflected in documentation. This has been addressed and included in the assessment and is attached. 08/17/2017 Implemented
6400.181(e)(13)(viii)Individual # 1's annual assessment dated 01/02/2017 did not document progress and growth in the area of 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. Progress needs to be noted in the assessment of the individual¿s skills around maintaining personal property. This was included in the assessment but not in the required detailed to give a clear picture of progress and growth in the individual¿s ability to maintain his personal property. Additional information has been added to the assessment to ensure that an accurate picture of progress and growth in the area of maintaining one¿s personal property is clearly demonstrated. 08/17/2017 Implemented
6400.181(e)(13)(ix)Individual # 1's annual assessment dated 01/02/2017 did not document progress and growth in the area of 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.Progress needs to be noted in the assessment of the individual¿s skills around community integration. This was included in the assessment but not in the required detailed to give a clear picture of progress and growth in the individual¿s access and ability to integrate into the community. Additional information has been added to the assessment to ensure that a clear picture of progress and growth in the area of community integration is accurately represented. 08/17/2017 Implemented
6400.181(e)(14)Individual # 1's annual assessment dated 01/02/2017 did not document the individual's 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. The assessment failed to address the individual¿s ability to swim. Te assessment did document details around water safety; this point was not noted and should be included in all assessments to give a clear picture of the individual¿s abilities. In addition to noting, a baseline of this skill, progress and growth in this area shall be documented. 08/17/2017 Implemented
6400.186(c)(2)Individual # 1's three month ISP review documentation dated 05/11/2016, 08/11/2016, 11/11/2016 and 02/11/2017 reviewed the outcomes and did not review medical information, therapies, etc. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. It is essential that the ISP quarterly review communicates information regarding and medical appointments or therapies that occurred during the time period reviewed. Any medical information related to health promotions or therapies described and documented in the ISP, should be reviewed and reflected in the quarterly ISP. Please see attached ISP review which demonstrates this occurring. 08/17/2017 Implemented
6400.186(c)(4)(iii)The methodology used to track progress towards Individual # 1's outcome of community involvement remained the same over two plan years and was not modified. The program specialist shall make a recommendation regarding the following, if applicable: The modification of an outcome or service to support the achievement of an outcome in which no progress has been made. It is essential that outcomes and progress related to outcomes be reviewed quarterly or more frequently if needed. Should it be noted that achievement hasn¿t been reached in an outcome; tweaks should be made to the methodology to ensure that the individual is moving forward and getting closer to achieving the outcome. The individual reviewed had an outcome for community involvement over 2 ISP plans, with no change in methodology for achieving success in that outcome. As a result of this review, the methodology was tweaked to ensure that this is being properly worked on and monitored. 08/17/2017 Implemented
6400.186(d)There is no documentation Individual # 1's three month ISP review documentation dated 05/11/2016, 08/11/2016 and 11/11/2016 were sent to team members.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. ISP reviews should be sent to team members to include the Supports coordinator within 30 calendar days of the ISP review. Email correspondence of the distribution of ISP reviews will be filled into program books to shoe the accurate distribution of documentation. 08/17/2017 Implemented
SIN-00043225 Initial review 09/27/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(7)INDIVIDUAL # 1 DID NOT HAVE A CURRENT GYN. HER LAST WAS 6/20/11.(7) A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. Indvidual #1 had her Gynecological appointment on 5/7/2012; Pap smear completed on 10/8/2012. 10/08/2012 Implemented
6400.144TWO MEDICATIONS FOR INDIVIDUAL # 1 WERE NOT AVAILABLE FOR ADMINISTRATION AS LISTED IN THE MED. LOG. SANTOL OINTMENT AND A PRN MED. DESMIDE.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. Both medications were discontinued, medication logs were not updated to reflect this, this has been corrected on the medication logs moving forward 10/01/2012 Implemented
SIN-00138786 Renewal 06/18/2018 Compliant - Finalized
SIN-00089224 Renewal 01/14/2016 Compliant - Finalized