Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00281447 Renewal 12/16/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At the time of inspection, at the time of inspection the upstairs bathroom ceiling vent had a significant layer of dust on it.Clean and sanitary conditions shall be maintained in the home. The ceiling vent was immediately cleaned. 12/17/2025 Implemented
6400.141(c)(4)Individual #1's 8/21/25 and 8/19/24 physical examinations both noted NA for hearing. Individual #1 had an Audiology appointment on 6/8/24 that noted that Individual #1 refused earphones his head, test could not be done. Individual #1 had an audiology appointment on 9/12/24 and it noted Individual #1 refused headphones on his head, and test could not be completed. Individual #1 had an audiologist appointment on 6/12/25, and the form did not indicate if a hearing test was complete. The form only states that Individual #1 's left ear is clean and right ear is blocked." It cannot be determined if Individual #1 had a hearing examination completed on 6/12/25.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. -Medical appointment summary form has been developed specifically for hearing exams. This indicate the specific outcome of the examination including whether it was successful or unsuccessful. -The individual's desensitization plan was amended to include dates and description of education given to the individual for each unsuccessful examination. 12/19/2025 Implemented
6400.181(e)(13)(vii)Individual #1's Individual Support Plan (ISP) under the Know and Do section states that Individual #1 needs full support for managing money. However, the agencies' consumer financial record for Individual #1 notes on 8/18/25 Personal spending for $20.00, 7/22/25 personal spending for $5.00, 6/18/25 Personal spending for $10.00, 4/22/25 Personal spending for $5.00 3/17/25 Personal spending for $20.00, 2/27/25 Personal spending for $20.00, and 12/13/24 Personal spending for $15.00. Individual #1's assessment dated 4/23/25, under the financial Independence section indicates that Individual #1 is a "1", which is unable to complete, for all areas assessed in the category of financial independence such as: recognizes money as a medium of exchange, has cash in possession without losing, can make small purchases, handles personal cash for a week, discriminates amount of currency, and produces exact change amounts. The agency did not assess Individual #1 appropriately in their financial management/independence.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. The individual no longer signs for cash as personal spending, Receipts are utilized to account for individual's spending. 12/18/2025 Implemented
6400.193(a)At the time of inspection, all sharps were locked in the home and neither of the two individuals in the home had a restrictive procedure plan in place with regards to sharp safety.A restrictive procedure may not be used as retribution, for the convenience of staff persons, as a substitute for the program or in a way that interferes with the individual's developmental program.Sharps were immediately placed in an unlocked cupboard. 12/17/2025 Implemented
SIN-00241457 Renewal 04/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66Outside steps, doorways and porches are not lighted to ensure safety and avoid accidents. The light outside of the kitchen door on the second floor of the home did not work.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The maintenance staff was called to the site and instructed to remove (blown bulb) and replace it with a new one. 04/05/2024 Implemented
6400.141(c)(4)Individual #1's annual hearing exam was completed late. Individual #1 had a hearing exam completed on 6/1/22 and did not have another completed until 6/29/23.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. An appointment has been for scheduled for this years annual hearing exam on 6/07/24. 04/08/2024 Implemented
6400.166(b)Individual #1 is prescribed over the counter, pro nata medications including Tylenol, Robitussin, Alegra, Tums, Colace, Imodium, Preparation H, Hydrocortisone cream, and Neosporin. These medications and dosing instructions are not recorded on the medication administration record.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Updated OTC, pro nata list is with the PCP for reviewing and approval. This will be forwarded to the pharmacy by 4/22/24. The Pharmacy will provide the medications and create a medication record. Medication record will be utilized to record administrations.. 04/18/2024 Implemented
6400.185(1)Individual #1's Individual Service Plan (ISP) does not contain revisions including the Individuals ability to manage money. Individual #1's annual assessment dated 2/8/24 states "Individual #1 recognizes money as a medium exchange and has cash in the individual's possession without losing it. The assessment does not indicate how much money Individual #1 is able to manage or carry. " Individual #1's ISP's does not address Individual #1's ability to manage any amount of money. Individual #1 is provided between $10-20 in spending money that the individual maintains on their person.The individual plan, including revisions, must include the following: The individual's strengths, functional abilities and service needs.The ISP was revised to include the individuals' strengths functional ability and service needs as illustrated below. The Individual understands money as a medium of exchange. He recognizes one dollar. five dollar and ten-dollar bills but prefers to use one-dollar bills for shopping. Individual is able to make purchases up to $20 with staff assistance and will stand in line to wait for his receipt. Individual is able to have up to $20 in his possession without losing it. 04/22/2024 Implemented
SIN-00218654 Renewal 03/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)The bathroom did not have a mirror.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. A new medicine cabinet with a mirror was installed in the bathroom on 3/30/23 03/30/2023 Implemented
6400.111(a)The kitchen must have an operable fire extinguisher. The fire extinguisher in the kitchen was serviced in July 2022 however the gage was in the "needs recharging" area.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. The extinguisher was immediately replaced at the time of inspection with a serviced and charged extinguisher. 03/28/2023 Implemented
SIN-00170285 Renewal 02/27/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(h)The medication diphenhydramine, which was prescribed for Individual #1 to be administered on a pro re nata (PRN) basis, was labeled "discard after 12/26/19" and found stored with the individual's current medications.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The medication was removed and destroyed in a safe manner according to Federal and State regulations, specifically by the use of PDC Pharmacy's, RX Destroyer. Kereen Palmer, Medication Administration Trainer took the action on 2/27/20. The same staff contacted the pharmacy ordering a current medication, that was placed in the home on 3/3/20. Our Pharmacy vendor does not track and autofill PRN medications. We have now instituted the practice of reviewing the list of all PRN's agency wide at our weekly Administrative Review meetings to prevent a reoccurrence of this incident. 03/03/2020 Implemented
SIN-00186093 Renewal 04/20/2021 Compliant - Finalized
SIN-00150495 Renewal 02/21/2019 Compliant - Finalized
SIN-00111055 Renewal 04/25/2017 Compliant - Finalized