Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00280767 Renewal 01/05/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water temperature registered at 124.7 degrees Fahrenheit at the kitchen sink. Hot water temperatures in bathtubs and showers may not exceed 120°F. Beyond Care Services acknowledges that the water temperature at the kitchen sink was measured at 124.7°F at the time of the inspection. Although the regulation applies to bathtubs and showers, Beyond Care Services recognizes the importance of maintaining safe water temperatures throughout the home. To correct this issue, Beyond Care Services immediately adjusted the hot water temperature to ensure that water temperatures in all bathtubs and showers do not exceed 120°F. The water temperature was rechecked following the adjustment to confirm compliance. Documentation of the corrective action has been completed. 01/05/2026 Implemented
6400.72(b)The door to the basement is off track and requires mending. Screens, windows and doors shall be in good repair. Beyond Care Services acknowledges that the basement door was found to be off track and in need of repair at the time of inspection. To correct this issue, Beyond Care Services arranged for the door to be repaired and properly placed back on track to ensure it functions safely and correctly. Once repairs were completed, the door was inspected to confirm it is secure and in good working order. Documentation of the repair has been completed. 01/09/2026 Implemented
6400.110(e)The home has three levels, and the smoke detectors did not sound in an interconnected fashion when tested.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. Beyond Care Services acknowledges that the home consists of three levels and that the smoke detectors did not sound in an interconnected manner when tested. To correct this issue, Beyond Care Services arranged for the evaluation of the smoke detection system to ensure compliance with regulatory requirements. Interconnected smoke detectors were installed and/or existing detectors were repaired or replaced to ensure that at least one smoke detector on each floor is interconnected and audible throughout the home. The system was tested after installation to confirm proper interconnected functionality. Documentation of the corrective action and system testing has been completed. 01/05/2026 Implemented
6400.141(c)(6)Evidence of TB was not present in Individual One's documentation.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Beyond Care Services acknowledges that documentation verifying Tuberculin (TB) testing was not present in Individual One's record at the time of review. To correct this issue, Beyond Care Services has obtained documentation confirming that Individual One has received a Tuberculin skin test using the Mantoux method with negative results. In the event of a positive test, documentation of an initial chest X-ray with results noted would be obtained. The appropriate documentation has been placed in Individual One's file to ensure compliance with physical examination requirements. 02/02/2026 Implemented
6400.141(c)(14)Info pertinent to diagnosis is blank on Individual One's physical.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Beyond Care Services acknowledges that the section for medical information pertinent to diagnosis was left blank on Individual One's physical examination at the time of review. To correct this issue, Beyond Care Services has obtained updated medical documentation from the appropriate healthcare provider to ensure that all medical information pertinent to diagnosis and treatment in the event of an emergency is accurately documented. The completed information has been placed in Individual One's medical record. 01/06/2026 Implemented
6400.52(c)(1)Staff One met the annual 24 credits in trainings, but none of them were the ODP required trainings.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Beyond Care Services acknowledges that although Staff One met the required annual 24 training credits, documentation reflecting completion of ODP-required training content areas was not presented at the time of inspection. The ODP-required trainings had been completed; however, the documentation was not requested during the inspection and therefore was not provided at that time. To correct this issue, Beyond Care Services has ensured that documentation verifying completion of ODP-required trainings---including application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships---has been placed in Staff One's personnel file and is readily accessible. 01/05/2026 Implemented
6400.52(c)(1)Recognizing and reporting incidents and detection and reporting of an abuse is in trainings were present, but the rest of the required ODP trainings are not in Staff Two's file.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Beyond Care Services acknowledges that during the inspection, documentation for certain ODP-required training content areas was noted as missing from Staff Two's personnel file. Training documentation for recognizing and reporting incidents and detection and reporting of abuse was present. Documentation for the remaining required ODP training areas---including application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships---was available at the time of inspection but was not reviewed, resulting in an oversight during the inspection process. To correct this issue, Beyond Care Services has ensured that all documentation verifying completion of the required ODP training content areas for Staff Two is centrally maintained within the personnel file and readily accessible. 01/05/2026 Implemented