Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00294211 Renewal 08/13/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.124(4)Records for Individual #3 did not include written consent from client, parent, or guardian for emergency medical treatment.Each client's record must include the following information: Written consent from the client, parent or guardian for emergency medical treatment.Individual #3 has signed the emergency medical consent form, as he is able to without a legal guardian. The document has been placed in his file on 8/28/26. Emergency Medical consent in their file for an emergency. See attachment #1 09/17/2026 Implemented
2390.21(l)Records for Individuals #1 and #3 did not include quarterly conversations with the individual relating to their preferred community participation and activities (as outlined in ODP Announcement 24-061: Individuals' Participation in Decisions about Community Participation: Requirements for Regulatory Compliance.A client has the right to make choices and accept risks.Individual #1 completed client conversation on 8/31/26 and #3 completed client conversation on 9/2/26 and has been placed in file on respective dates. See attachment # 3, 3a, 4, 4a. 09/17/2026 Implemented
2390.124(8)Records for Individual #3 did not include a copy of the individual's current Individual Support PlanIndividual plan documents as required by this chapter.A copy of Individual #3's current ISP has been printed and placed in the file on 8/28/26. This will be updated as new versions of the plan are created. See attachment 5 pages 1-24. 09/17/2026 Implemented
2390.151(f)Records for Individual #2 did not include documentation that the annual Assessment was sent to plan team members at least 30 days prior to the 12/14/25 ISP Meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting.Individual #2's 9/26/25 assessment was sent to the individual's plan team members on 9/1/26 and a message to expect the new assessment will be sent prior to his scheduled meeting on 11/12/26. See attachment #6, 7 pages 1-16, showing the assessment and lifetime medical history was sent. 09/17/2026 Implemented
2390.152(c)Records for Individual #1 did not include a copy of the individual's 2025 Individual Support Plan or meeting sign-in sheet, and therefore, it could not be determined that a 2025 ISP was completed.The Individual plan shall be initially developed, revised annually and revised when a client's needs change based upon a current assessment.The 2025 ISP had been pulled from the file and archived when the current 2026 was reviewed and available. The 2025 has been pulled from archives and placed in the current individual file. PTC attachment #8 pages 1-25 09/17/2026 Implemented
2390.153(c)Records for Individual #2 did not include a list of individuals that participated in the 12/14/25 ISP Meeting. Records for Individual #3 did not include a list of persons who participated in the 09/17/2025 individual plan meeting. The 09/17/2025 meeting was the last meeting held during the review period.The list of persons who participated in the individual plan meeting shall be kept.Individual #2 sign off sheet received from SC, corrected and placed in file. Shows meeting occurred on 11/14/2025. Attachment #9, 9a, 9b Individual #3 sign off sheet received from SC, corrected and placed in file. Shows meeting occurred on 9/17/25. and sign off sheet for 8/19/26. Attachment #10, 10a, 10b, 10c. 09/17/2026 Implemented
SIN-00233582 Renewal 10/10/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(e)(10)The annual assessment for individual #1dated 9/28/23 did not include lifetime medical review.The assessment must include the following information: A lifetime medical history.The annual assessment for individual #1 dated 9/28/23 did not include lifetime medical review and was acquired shortly after licensing had occurred. 02/09/2024 Implemented
SIN-00213060 Renewal 10/11/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(e)(8)On two separate documents/assessments dated 5/20/22 and 3/25/22 the fire safety portion of the assessment listed another individual in place of Ind. #4. The assessment must include the following information: The client's ability to evacuate in the event of a fire.The assessment must include the following: the client's fire safety portion of the assessment with the correct Ind. #4. The program specialist for individual #4 updated (on 12/21/2022) her assessment (dated 5/20/22 and 3/25/2022) to include the correct name in the fire safety portion of the assessment. 12/21/2022 Implemented
SIN-00195267 Renewal 10/19/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.71(a)There was no ventilation in the ladies restroom either by operable window or mechanical ventilation.Work areas, dining areas, kitchens and bathrooms shall be ventilated by operable windows or mechanical ventilation.Work areas, dining areas, kitchens and bathrooms shall be ventilated by operable windows or mechanical ventilation. The maintenance team inspected the fan in the women¿s bathroom; the fan was running but the hose had a blockage, so the vent was not working. They unclogged the hose and adjusted the placement of the fan in the ceiling on 10/19/21. The fan and ventilation are now operable (attachment 8). The fan in the men¿s bathroom was frozen; a new fan was purchased and installed on 10/20/21 (attachment 9). 10/20/2021 Implemented
2390.195(b)It cannot be determined if the medication (DICYCLOMINE 10mg) that is administered at 11:30am for individual #1 is being administered as prescribed. The blister pack that houses the medication varies from the log kept by the program. Example: The log states on 10/07/21 the medication was administered however; the medication was still present in the blister pack. Also, the log states that 9 tabs were administered however, the blister pack does not match.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. The Facility Director and Program Specialist reviewed the blister pack and MAR for individual #1. It cannot be determined how the error occurred, however, it was confirmed that individual #1 received her medication on 10/7/21. 10/20/2021 Implemented
SIN-00107119 Renewal 01/18/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.156(a)Individual #1's 90 day ISP reviews have not been completed since 10/26/15. Individual #2's 90 day ISP reviews have not been completed since 10/20/15. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP.The program specialist will complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP. Program Specialists received verbal reprimand for not completing quarterly file reviews thoroughly. The 3 month reviews were completed; quarterly files reviews will continue. Addendum #1. 03/31/2017 Implemented
SIN-00086175 Renewal 10/13/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.62The first stall in the men's bathroom, adjacent to the cafeteria, had a brown stain on the toilet seat and stains in the toilet bowl. Sanitary conditions shall be maintained in bathrooms, kitchens, dining areas and first aid areas.Sanitary conditions shall be maintained in bathrooms, kitchens, dining areas and first aid areas. Bathrooms are cleaned on a daily basis after lunch. A more concontrated cleaning solution will be used to address the stains in the toilet bowl. Individuals were reminded to inform staff of any issues in the bathrooms after their use. Staff will continue to do random checks throughout the day. 11/16/2015 Implemented
2390.111(a)Individual #1 was admitted to the program on 8/12/2015 and Individual #2 was admitted to the program on 1/12/15. There were no preadmission interviews for either individual.A client shall have a preadmission interview.An individual shall have documentation of the preadmission interview. Intake form will be used for preadmission interviews. All staff completed training on form. The form is included in the Intake Packet and will be filled out by the Program Specialist completing the preamission interview. Form will be filed in the individual central file. Documentation will be forwarded. The program specialist will review all new admissin packets within 5 days of admission, starting within 30 days of receipt of this plan of correction. In addition, all of the participants records will be reviewed to determine if any other Individuals did not have a pre-admission interview to ensure that the program is familiar with the Individuals ISP. [SW 11.18.15] 10/16/2015 Implemented
2390.155(a)Individual #2's Individual Support Plan (ISP) review covering the period of 3/12/15 through 6/12/15 was not implemented by the ISP start date of 3/26/15.The ISP shall be implemented by the ISP's start date.The ISP shall be implemented by the ISP's start date. Facility will conduct training on Admission Key Dates form and become part of referral packet. Form will be filled out by responsibile staff (Program Specialist and/or Facility Director). Tracking form of review dates will be completed on all new admissions and approved by Facilty Director within first week of admission. Documentation will be submitted for review. The program specialist reviewed the ISP for Individual #2 and will ensure that it is implemented within 30 days of receipt of this plan of correction. In addition, the program specialist will audit all of the participants ISP's to ensure that they have been implemented timely, within 30 days of receipt of this plan of corrections. [SW 11.18.15] 11/16/2015 Implemented
SIN-00063492 Renewal 07/07/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)Individual #1 was admitted 9/3/13, and did not have their initial assessment until 11/5/13. Individual #2's assessment dated 3/3/14 was not done annually. The previous assessment was done 12/18/12. Each client shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.Initial assessment for each client will be completed within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. Retraining in admission procedures and required documentation is scheduled with Program Specialists. All requirements of the assessments will be reviewed. Checklist is being developed to track dates of needed information and all reports which is required of all Program Specialists to complete. Monthly review of tracking system to be completed and initialed by Director as well as quarterly file reviews by management team. Training on the POC is scheduled. 08/29/2014 Implemented
2390.151(f)Individual #2's assessment dated 3/3/14 was not sent to the supports coordinator and the plan team 30 days prior to the ISP meeting dated 1/27/14.The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).The program specialist shall provide the assessment to the SC and plan team members at least 30 calendar days prior to an ISP meeting for the development of an annual update and revision of the ISP. All requirements of the assessments will be reviewed. A checklist is being developed to track dates of needed information and all reports which is required of all Program Specialists to complete. Monthly reviews of the tracking system will be completed and initialed by the Program Director as well as quarterly file reviews by the management team. Training on the POC is scheduled. 08/29/2014 Implemented
SIN-00276422 Renewal 10/22/2025 Compliant - Finalized
SIN-00253853 Renewal 10/16/2024 Compliant - Finalized
SIN-00152431 Renewal 02/26/2019 Compliant - Finalized
SIN-00049763 Renewal 07/08/2013 Compliant - Finalized