Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00280109 Renewal 12/09/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)The fire drill records reflect that all fire drills utilized the front door as their exit. The regulation states that alternate exits should be utilized.Alternate exit routes shall be used during fire drills. Effective immediately, all scheduled fire drills will incorporate the use of alternate exit routes in accordance with regulatory requirements. The next scheduled fire drill will utilize a different designated exit- side exit to ensure staff and individuals are familiar with all available egress options. 01/14/2026 Implemented
SIN-00257195 Renewal 12/16/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.185(1)Individual #1's Individual Support Plan (ISP) is not updated to address the individual's current level of assessed supervision. Individual #1's annual assessment dated 6/13/24 stated that Individual #1 had 16 hours of unsupervised time in the home. Individual #1's ISP dated 12/3/24 contained conflicting information. Individual #1's ISP dated 12/3/24 contains conflicting information. The supervision section on the ISP states "Individual #1 has the skills necessary to remain safe in the individual's home and community. Individual #1 currently has a fade plan developed to help promote independence. At this time, Individual #1's schedule 7 days per week includes up to 6-8 hours of alone time per day. Typically, Individual #1 will have staff available from 7:00AM to 3:00PM and alone time from 3:00PM-11:00PM with staff returning at 11:00PM to be with individual #1 overnight. Time frames of alone time may be adjusted per Individual #1's choice and discussion with staff if individual #1 has a medical appointment or other community activity and needs support later in the afternoon. Individual #1 will check in with staff every two hours via text or phone call.The individual plan, including revisions, must include the following: The individual's strengths, functional abilities and service needs.Individual Assessment and Individual support plan (ISP) have been updated to reflect the current level of supervision. Individual #1 has up to 16 hours of alone time per day under the staffing ratio in the ISP. 12/24/2024 Implemented