Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00265357 Renewal 04/30/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.169(a)Direct Service Worker #1's Department-approved medication administration course was not signed as completed by the Certified Medication Trainer. Direct Service Worker #1 administered the following medications to Individual #1: Allopurinol 300 MG TABS at 8:00AM on April 4, 5, 6, 12, 13, 19, 20, 26, 27. Clonidine HCL 0.1 MG TABS at 8:00AM on April 4, 5, 6, 12, 13, 19, 20, 26, 27. Clonidine HCL 0.1 MG TABS at 3:00PM on April 4, 5, 6, 8, 10, 12, 13, 19, 20, 25, 26, 27. Clonidine HCL 0.1 MG TABS at 8:00PM on April 1, 3, 4, 5, 6, 8, 10, 11, 12, 13, 15, 17, 18, 19, 20, 22, 24, 26, 27, 29. Escitalopram 20 MG Tablet at 8:00AM on April 4, 5, 6, 12, 13, 18, 19, 20, 26, 27. Fexofenadine HCL 180 MG TAB at 8:00AM on April 4, 5, 6, 12, 13, 18, 19, 20, 26, 27. Levothyroxine 137MCG TAB at 7:00AM on April 4, 5, 6, 12, 13, 19, 20, 26, 27. Lithium Carb ER 300 MG TAB at 8:00AM on April 4, 5, 6, 12, 13, 19, 20, 26, 27. Lithium Carb ER 300 MG TAB at 8:00PM on April 1, 3, 4, 5, 6, 8, 10, 11, 12, 13, 15, 17, 18, 19, 20, 22, 24, 25, 26, 27, 29. Quetiapine 100 MG TAB at 8:00PM on April 1, 3, 4, 5, 6, 8, 10, 11, 12, 13, 17, 18, 19, 20, 22, 24, 25, 26, 27, 29. Quetiapine 300 MG TAB at 8:00AM on April 4, 5, 6, 12, 13, 18, 19, 20, 26, 27. Quetiapine 400 MG TAB at 8:00PM on April 1, 3, 4, 5, 6, 8, 10, 11, 12, 13, 17, 18, 19, 20, 22, 24, 25, 26, 27, 29. Trazodone HCL 150 MG TABS at 10:00PM on April 1, 3, 4, 5, 6, 8, 10, 11, 12, 13, 15, 17, 18, 19, 20, 22, 24, 25, 26, 27, 29. Vitamin D3 1,000 Unit Soft G at 8:00AM on April 4, 5, 6, 12, 13, 19, 20, 26, 27.A 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).Certified Medication Trainer #2 reviewed the MAR Reviews and Medication Observations completed by Practicum Observer #3 for staff DSP #1. All were found to be compliant and Certified Medication Trainer #2 recertified staff DSP #1 on 5/1/25. Practicum Observer #3 was inserviced on proper procedures for Student - Annual Practicum and PIT Care Services medication administration policy. 05/01/2025 Implemented
SIN-00244863 New Provider Agency 05/22/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)On 5/22/2024 at 10:31am, the water temperature at the kitchen sink measured 124.1 degrees Fahrenheit.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. Hot water tank was adjusted and periodically checked until water temperature was 122F or below for the remainder of the day. 05/22/2024 Implemented
6400.68(b)On 5/22/2024 at 10:23am, the water temperature in the main floor bathroom measured 123.2 degrees Fahrenheit at the bathtub. Hot water temperatures in bathtubs and showers may not exceed 120°F. Hot water tank was adjusted and periodically checked until water temperature was 122F or below for the remainder of the day. 05/22/2024 Implemented
6400.72(a)On 5/22/2024 at 10:24am, the operable window located above the toilet in the main floor bathroom was observed without a securely fitting screen. On 5/22/2024 at 10:35am, the operable window located above the kitchen sink was observed without a securely fitting screen.Windows, including windows in doors, shall be securely screened when windows or doors are open. The maintenance department was contacted and screens were installed same day. 05/22/2024 Implemented
SIN-00254026 Unannounced Monitoring 10/23/2024 Compliant - Finalized