Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00257418 Renewal 01/13/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The agency completed their self-assessment on 12/20/24. The violations documented by the agency did not contain the summery of corrections. The agency just noted what the violation was that they found.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. The plan to fix the immediate problem was to complete the summary of corrections and add it to the self-assessment completed on 12/20/24. 01/31/2025 Implemented
6400.104The home now has 2 Individuals residing in the home. An updated fire letter, letting the fire department be aware of the needs of both Individuals was not completed.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. The plan to fix the immediate problem was completed on 1/14/2025. An updated letter was sent to the fire department with the correct information. See attachment # 3. 01/14/2025 Implemented
6400.141(b)The most recent physical exam for Individual #1 did not contain the date of the exam by the licensed physician. There was no line on the physical for the physician to put the date.The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. The plan to fix the immediate problem was the physical was returned to the PCP's office requesting the physician date the physical. 01/31/2025 Implemented
6400.211(b)(1)Individual #2's Emergency contact information was left blank on the personal data summary.Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. The plan to fix the immediate problem was completed on 1/15/25 by the CEO and Administrator. The name, address, telephone number, and relationship were added to the record. See attachment # 4. 01/15/2025 Implemented
6400.46(b)Staff person #2's annual fire safety training was completed late-5/16/23- 5/22/24. Staff person #3's fire safety training was completed late-5/20/23- 5/25/24.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).The plan to fix the immediate problem is the understanding that annual staff fire training is provided to staff with no more than 12 months lapse from the last training. Staff #2s fire safety training will be completed BEFORE 5/22/25. Staff #3s fire safety training will be completed BEFORE 5/25/25. 01/24/2025 Implemented
6400.213(1)(i)Individual #2 's religion affiliation was left blank on the personal data summary.6400.213(1)i-vi - Each individual's record must include the following personal information, including: The religious affiliation.The plan to fix the immediate problem was completed on 1/15/25 by the CEO and Administrator. The religious affiliation was added after speaking to individual #2. See attachment #4. 01/24/2025 Implemented
SIN-00237446 Renewal 01/23/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.167(a)(1)The September 2023 Mar indicates that the following medications were not given to individual #1 on 9/22/23 at 8pm as prescribed: Donepezil 5mg tablet, Sertraline 100mg, and Trazodone 100mg.Medication errors include the following: Failure to administer a medication.The medication adminstrator has sole responsibility to ensure that all steps of the med admin cycle is completed in it's entirety. The staff responsible reviewed the med admin cycle procedures and completed HCQU Medication Error training. The September 2023 Mar indicates that the following medications were not given to individual #1 on 9/22/2023 at 8pm as prescribed: Donepezil 5mg, Sertraline 100mg, and Trazodone 100mg. The Program Director reviewed all other MAR records and found no other non compliance items related to medication omissions. As of 1/30/2024 all correction tasks were completed for this non-compliance. See attachment #1 (HCQU Medication Error Certificate) A plan to prevent future occurrences is reinforcing the use of a checklist for medication administrators to verify the MAR is accurate and complete. See attachment #2 (Checklist). All staff responsible in implementing the plan of correction have been trained. 01/30/2024 Implemented