Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00247712 Renewal 07/09/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There was a bottle of Lysol cleaner located in a cabinet under the kitchen sink of the home. This cabinet had a child safety lock, which could be opened by pinching the sides of the lock and pulling that device off to open the cabinet. This type of lock does not make the poisons inaccessible to the individual.Poisonous materials shall be kept locked or made inaccessible to individuals. Lysol was immediately moved to the locked black cabinet with the rest of the poisons. 08/01/2023 Implemented
6400.106The latest furnace inspection on record for this location was conducted on 10/25/2022. There was no evidence of a more recent furnace inspection occurring. The furnace at this location was not inspected annually as required.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. Furnace was inspected on 7/17/24. 07/17/2024 Implemented
6400.15(b)The self-assessment of this location, conducted 06/01/2024, was completed on the Department's "Self-Inspection and Declaration Tool," which is intended to be used for opening a new location, rather than the Department's "Self-Assessment Licensing Inspection Instrument," which is intended to be used for the annual self-assessment of a location. In addition, the self-assessment was not completed at least 3-6 months prior to the provider's 07/12/2024 license expiration date. As such, there was no valid self-assessment conducted for this location as is required within the specified time frame(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.Standard Operating Procedure was created for the Residential Licensing process. 08/31/2024 Implemented
6400.46(d)Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. Staff #2 had CPR certification on 8.24.20 which was valid through 8.2022. Staff #2 did not have her current CPR training completed until 6.18.23. This exceeded the time frame.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.We have hired an additional Human Resources Professional to ensure on going compliance and accurate recording keeping, especially when an employee is out on leave as was the case with Staff #2. 08/12/2024 Implemented
SIN-00208294 Renewal 07/19/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(b)Prescription orders shall be kept current. Individual #1 had two topical medications ordered to be administered on a pro re nata (PRN) basis had expired prescriptions. The medication Secura Protective 10% cream was last filled on 7/02/2021 and the order stated that the medication could be refilled 2 times until 7/02/2022; and Triamcinolone cream which was last filled on 6/04/2021 and the order stated that the medication could be refilled 2 times until 6/01/2022.A prescription order shall be kept current.The doctor's office was contacted to determine if the medications should have the script renewed or if it would be more appropriate to discontinue the medications. The doctor determined that the medications were still necessary and resent the script to the pharmacy. These medications were left in the home until the new medications were present as it was the script from the doctor that had expired, not the medication itself. In addition, all other individual's medications were audited to ensure that the scripts were still valid. Any medications that were found to not have valid scripts were referred back to the doctor to be renewed or discontinued. 08/05/2022 Implemented
SIN-00180183 Renewal 12/01/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(6)The bedroom of Individual #1 did not contain a mirrorIn bedrooms, each individual shall have the following: A mirror. At some point her former mirror was broken and staff did not inform anyone , Mirror installed on12/04/2020, Facilities and Leadership will check during house check at least quarterly 12/04/2020 Implemented
6400.112(a)Record of a fire drill being conducted in 12/2019 was requested and not produced. There is no evidence that a fire drill was conducted in 12/2019. An unannounced fire drill shall be held at least once a month. Staff conducted another review of documents and still could not find 12/2019. There were not systems in place to ensure all fire drills are completed. A schedule for residential fire drills was produced upon completion staff are to bring the drill to the office for admin review and scanning. 12/30/2020 Implemented
SIN-00159813 Renewal 07/10/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(2)Staff #4 had a TB test on 2/6/2019. The results of her TB test are not documented on her physical exam. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Staff #4 did have a TB test. The results were not indicated on the physical, they were indicated a separate document. The staff completed their TB test prior to the initial offer of employment. The proof/ reading of the TB was not attached the physical. Prior to the start date of employment all employees will have their TB test completed, this includes the final reading. The reading will be documented on the appropriate physical form, unless the licensed medical professional choses to use an alternative method or the candidate has TB test with results within a year of their start date. In this case the alternative method of documentation will be attached to the physical. It is the responsibility of the Human Resources Recruiter to ensure initial compliance and the Human Resources Generalist thereafter. 08/14/2019 Implemented
6400.151(c)(3)This section was blank on Staff #4's physical exam dated 2/6/2019. 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 #4 did have a completed physical. However, the signed statement indicating the staff person is free of communicable diseases was not completed and signed. This was not signed because the staff member had their TB test completed prior to the initial offer for employment. The TB results were provided the licensed medical professional, who then was able to verify that staff #4 was free of communicable diseases. An updated physical was entered into staff #4's employee record. It is the responsibility of the Human Resources Recruiter to ensure initial compliance and the Human Resources Generalist thereafter. 08/16/2019 Implemented
SIN-00137946 Initial review 07/12/2018 Compliant - Finalized