Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00145354 Renewal 11/14/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The home has an extended evacuation time of 13 minutes. The fire drill held on 5/21/18 at 4:05AM had an evacuation time of 13 minutes and 14 seconds. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Program Directors will review with all Program Specialists, Community Home Coordinators, and Third Shift Team Leader the appropriate evacuation time for their assigned location(s). The Program Specialist for each location will review the fire drill form once completed by the Community Home Coordinator or Third Shift Team Leader to ensure the drill meets the appropriate evacuation time. If the drill does not meet the appropriate evacuation time a re-drill will be completed within 24 hours of the initial drill. The Quality Compliance and Safety Specialist will review all drills monthly. [As per Quality compliance and Safety Specialist, the fire drill form is a workflow paperless document and the Program specialist receives notification that the fire drill is complete and can completed aforementioned review and procedures. The third shift lead who conducted the fire drill on 5/21/18 was retrained on the day of inspection of the evacuation time for the home as specified by the fire safety expert. In addition the Program specialist were retrained in the evacuation times and aforementioned procedures and additional staff persons shall be trained in evacuation times and aforementioned procedures to ensure individuals are able to evacuate the home within the period of time specified in writing with in the past year by a fire safety expert for the health and safety of the individuals. Documentation of trainings shall be kept. (DPOC by AES,HSLS on 11/29/18)] 12/31/2018 Implemented
SIN-00085562 Renewal 10/21/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(b)The "Rights" form, signed by Individual #1 on 2/20/15, did not state the full rights per regulation 33(h) regarding telephone access. Per 6400.33(h) "An individual has the right to reasonable access to a telephone and the opportunity to receive and make private calls, with assistance when necessary."Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. The Quality Compliance Specialist revised the ¿Rights¿ form to include telephone access (attached). The Program Specialist reviewed the revised ¿Rights¿ with Individual #1 and obtained a signed copy on 11/2/15. The Records Technician sent the revised rights form to their family/guardian (attached). The Records Technician will send all individuals and their guardians a copy of the revised rights form at the annual update cycle date in January 2016. 11/02/2015 Implemented
SIN-00240796 Renewal 03/12/2024 Compliant - Finalized
SIN-00203102 Renewal 04/05/2022 Compliant - Finalized