Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00251032 Renewal 09/04/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(b)For individual #1 Docusate 100 mg PRN and Triamcinolone Cre 0.1% are on the MAR but not with medications. Docusate100 mg PRN, Benzonatate 100 mg PRN, Cepacol PRN, Mucus relief PRN and Hydroxyz PRN were with the medications but not on the MAR.A prescription order shall be kept current.A review of participant #1¿s medications and MAR was conducted by the nurse. All medications currently prescribed to Participant #1 were cross-checked with the MAR to ensure accuracy and all medication refills were completed. ¿ Docusate 100 mg PRN and Triamcinolone Cre 0.1% have been refilled and added to the medications and the MAR was reviewed for accuracy and compliance ¿ Docusate 100 mg PRN, Benzonatate 100 mg PRN, Cepacol PRN, Mucus Relief PRN, and Hydroxyz PRN have been added to the MAR, ensuring that all current medications are accurately reflected on the record. All PRN medications for participant #1 were reviewed with the nurse to ensure that the correct, current prescriptions are in place and followed up with the prescribing physician for any changes. ¿ Any discrepancies between the medications present and the MAR were clarified and documented. ¿ All discrepancies were resolved, and prescription orders were updated. The MAR now reflects the correct medication list for Participant #1. All discontinued medications for participant #1 have been removed from the participants home and discarded of in accordance with local laws. ¿ The MAR now reflects the correct medication list for Participant #1. 09/30/2024 Implemented
6400.185(5)The 03/08/24 assessment for individual #1 states that staff assistance is needed with avoiding poisons and the ISP states that the individual is safe around poisons.The individual plan, including revisions, must include the following: Risks to the individual's health, safety or well-being, behaviors likely to result in immediate physical harm to the individual or others and risk mitigation strategies, if applicable.It has been determined that the ISP correctly reflects the participant's ability to be safe around poisons. The assessment contains an error indicating a higher level of staff assistance than is necessary. The assessment for participant #1 will be updated to reflect the accurate level of risk related to poisons, as documented in the ISP. The correction will state that the participant does not require staff assistance in avoiding poisons, aligning with the ISP. All staff who work with participant #1 will be retrained on the specific needs identified in the revised assessment, particularly the participant's safety risks regarding poisons. The training will emphasize: ¿ The importance of following the ISP as the primary guide for support. ¿ The importance of reporting any changes in the participant¿s ability to function at the level documented in their ISP, assessments, behavior plans etc. 09/30/2024 Implemented
SIN-00219317 Unannounced Monitoring 02/13/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(e)The outside trash receptacles did not have lids.Trash receptacles over 18 inches high shall have lids. Trash receptacles have been replaced and receptacles with lids have been purchased. 02/17/2023 Implemented
6400.165(b)Regarding the medication review for Individual #1: The Medication Administration Record shows Acetaminophen 500 MG PRN (1 tablet by mouth every 4 hours as needed), however the medication that was present in the home was Acetaminophen 325 MG PRN (2 tablets by mouth every 6 hours as needed).A prescription order shall be kept current.New medication has been ordered. Nighttime staff will complete an audit of all medications to ensure that all rules of medication administration have been followed every day. This audit will address and ensure that all medications are onsite and medications match prescriptions and labels. Incident reports have been completed and errors have been entered into EIM. 02/20/2023 Implemented
SIN-00212206 Renewal 09/01/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill dated 12/3/2021 did not indicate whether the fire system and fire extinguishers were checked.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. Lilly of the Valley will ensure that all fire drills will be completed and accurate. 10/17/2022 Implemented
6400.112(d)The fire drills from March 2022-August 2022 indicated that evacuation time for each drill was exactly 2 minutes. 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. Lilly of the Valley will ensure that all fire drills will be completed and accurate. 10/17/2022 Implemented
6400.141(a)Individual #1's annual physical exam exceeded one year. The last exam was completed 6/2021.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Annual physical has been completed on 9-15-22. Participant was admitted to Lilly of the Valley¿s program from rehab on June 30, 2022, was re-admitted to the hospital on July 11, 2022 and discharged on August 31, 2022. Once released from the hospital all of the participants current insurances were no longer accepted by his doctors. Lilly of the Valley assisted the participant in finding new doctors that would accept the current insurance and all medical appointments were then completed. *see attached physical for I.J. 10/17/2022 Implemented
6400.142(a)Individual #1's last annual dental exam was dated 5/20/2021.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. Annual dental has been completed on 9-8-22. Participant was admitted to Lilly of the Valley¿s program from rehab on June 30, 2022, was re-admitted to the hospital on July 11, 2022 and discharged on August 31, 2022. Once released from the hospital all of the participants current insurances were no longer accepted by his dentist. Lilly of the Valley assisted the participant in finding a new dentist that would accept the current insurance and the dental appointment was then completed. *See attached dental form for I.J. 10/17/2022 Implemented
SIN-00192330 Renewal 09/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66Individual #1's bedroom does not have an operative light. The remote controlled ceiling fan/light combo is the only light source. At time of inspection, the remote was missing, causing the light fixture to be inoperable.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The ceiling fan has been replaced by the landlord with a ceiling fan that does not require a remote control. The light source is the ceiling fan, which is controlled by the light switch on the wall. 09/03/2021 Implemented
6400.67(b)An amount of lint approximately the size of a golf ball was found in the dryer's lint trap. It was cleaned out at point of inspection. Floors, walls, ceilings and other surfaces shall be free of hazards.Lent filters will be checked after each use of the dryer to maintain safety. The DSP Daily Staff list of duties will include checking the lent filter. 09/01/2021 Implemented
6400.77(b)The house's first aid kid did not have a thermometer or scissors. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. First aid kits will be inspected after medication administration is complete during the evening disbursement. Any missing items will be reported immediately to the house manager. 09/03/2021 Implemented
6400.151(a)Staff #1 did not have a physical completed 12 months prior to employment. They were hired on 7/1/21 and the physical was completed on 7/23/21 and also does not indicate if the staff is free of communicable diseases. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Staff will return to their physician's office to be assessed for communicable diseases; and have the physical updated. 09/23/2021 Implemented
6400.151(c)(3)Staff #2's 8/13/21 physical examination does not address if they are free of communicable diseases. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Staff will return to their physician's office to be assessed for communicable diseases; and have the physical updated. 09/23/2021 Implemented
SIN-00175598 Renewal 08/27/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The kitchen had a layer of grease on top of the microwave.Clean and sanitary conditions shall be maintained in the home. Clean and sanitary conditions will be maintained in the home via the Daily Shift Cleaning Log. The Log will be completed and initialed by each direct support professional during their shift. At the end of each work week, the Daily Shift Cleaning Log will be picked up for review and stored at the office with our files by the House Manager. The House Manager will review the Daily Shift Log weekly, in addition to conducting regular home inspection checks for cleanliness throughout the week. Each house has cleaning supplies in addition to 409 spray and brillo pads for de-greasing the stoves and overhead fixtures. On Wednesday, September 23rd the Daily Shift Cleaning Log was reviewed with the staff by the House Manager during our virtual meeting. The Daily Shift Log is currently in use at each house. On Friday, September 18th M&M's Cleaning Solutions was contracted by the Administrator to degrease each home along with the overhead fixtures and cabinets. M&M's Cleaning Solutions has been contracted out to provide a deep cleaning on a monthly basis by the Administrator. Their next scheduled deep cleaning is on Friday, October 30th. See Attachment: #1, #2, #3 10/07/2020 Implemented
6400.67(a)The front door cement landing and steps have broken cement and therefore it is a hazard to walk on its surfaces.Floors, walls, ceilings and other surfaces shall be in good repair. R&S Home Improvements was contracted out on September 20, 2020. The estimate for repair includes: Tear landing at the entrance to house; remove top step creating trip hazard; tear out and remove next two steps because of crumbling; remove debris; form and pour new concrete.All dirt, concrete, stone, brick, etc. will be cleaned up at the completion of the job. Staff and the current resident have been informed that the steps will be torn down on Friday, October 9th. The concrete will be poured and the work will be completed by Monday, October 12th. The front stairs will not be used during the time that the stairs are being repaired. The back staircase will be used while the construction work is under way. The Landlord, Andrew Trotter, has provided the receipt for payment. On October 1, 2020 during a Senior Staff Meeting The Administrator contacted the Landlord regarding the completion of repairs in a timely manner. If repairs are not completed within 30 days of notifying the Landlord, The Administrator will contract out the repairs to a third party and provide the receipt for payment to the Landlord. Any out of pocket repair expenses will be deducted from the monthly rental amount until the out of pocket repair expenses are paid in full. All home repairs are reported to the House Manager, who then informs The Administrator, who is the liaison between the residents and the Landlord. See Attachment: #4, #5 10/07/2020 Implemented
6400.181(e)(12)The assessment for individual # 1 dated 12/7/19 did not include any recommendations.The assessment must include the following information: Recommendations for specific areas of training, programming and services. The Program Specialist has updated the assessment for Zamiere Jackson to include current Goals/ Outcomes that meet the Individual's Needs. The Goals include: Behavior Supports focusing on anger management, financial management, personal trainer for exercise, sex therapy as relates to trauma, daily chores, de-escalation techniques and employment. The Program Specialist revised the Assessment and reviewed the goals/ outcomes with Mr. Jackson on September 29, 2020. Mr. Jackson signed the updated assessment, and a copy was emailed to Mr. Jackson's Support's Coordinator, DaBriana Johnson on September 30, 2020 in a request to update Mr. Jackson's Individual Support Plan. The Program Specialist was trained on September 16, 2020 by Tauris Colbert, Training Consultant, regarding the inclusion of Goals/ Outcomes in the Assessment. The Program Specialist has a clear understanding of the Assessment requirements and will email the Assessment to the Support's Coordinator to update the ISP moving forward. Attachments: #6, #7 09/30/2020 Implemented