Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00188141 Renewal 06/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.214(b)The ISP in the program book for individual #1 was not the most recent ISP. Most recent ISP updated 1/22/21. The ISP in the program book was 8/7/20. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The plan in the home has been updated in the consumer record to the most current revision. 07/01/2021 Implemented
SIN-00151036 Renewal 04/03/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The handrails that are on the ramp leading up to the home have chipped paint and is rusting. The downstairs, locked bathroom, had 4 spots of cracked dry wall above and around the shower/tub stall that needs replaced.Floors, walls, ceilings and other surfaces shall be in good repair. 1:1 feedback was provided to Program Manager and Site Supervisor regarding each area of the citation as it relates to our current self-inspection process. This was also part of post-licensing review with all site supervisors on 4/10 and 4/11. Attachment 1 is attendance log of meeting. These areas were less frequented and/or less used by support staff and residents and did not receive as significant scrutiny. These areas will be reviewed more thoroughly as part of IFC¿s quarterly site inspection process. An example of home inspection tool done since licensing is attached as number 4. Pictures of corrected railing and shower surround are attachment 5. The railing was sanded and re-painted. The top of the surround has surface prepped and a border was painted. 04/30/2019 Implemented
6400.112(f)This home only evacuated using the kitchen door for the last 14 fire drills.Alternate exit routes shall be used during fire drills. Site Supervisor received 1:1 feedback regarding citations within the home. An administrative meeting with all 6400 supervisors and programmatic staff occurred on 4/10 and 4/11. Regulations specific to fire drills and expectations were reviewed. Attachment 1 is attendance log of meeting. Additionally, we have provided each site with a tracking tool similar to the department¿s licensing tool for fire safety. This is identified as attachment 2. This will allow supervisors to track their monthly trainings over the year to insure variation and completeness. Attachment 3 is a fire drill from this site done since licensing that includes use of two different exits, front door and side door, with a fire source located in basement of home. 04/28/2019 Implemented
6400.216(a)There were records specific to each individual's diagnosis in a binder laying on the counter in the dining room, not in use and not locked. An individual's records shall be kept locked when unattended. Staff training materials specific to diagnosis have been relocated to the secure office. Additionally, a number of administrative items such as a filing cabinet and medication cabinet have been relocated to the second floor office as to discourage those functions in common areas of the home. Site Supervisor received 1:1 feedback regarding citations within the home. An administrative meeting with all 6400 supervisors and programmatic staff occurred on 4/10 and 4/11. Standards for record security and related citations were reviewed. Attachment 1 is attendance log of meeting. 04/11/2019 Implemented
SIN-00083819 Renewal 07/13/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Staff #1 physical was late. Completed 10/4/2011 and not again until 6/4/2014. 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. The staff responsible for employee compliance left her job without notice on 5/1/14. At that time, duties were reassigned to another staff who began to review records in order to maintain compliance. This staff also completed an electronic database for ongoing record keeping, compliance, and transition should the staff holding the position change without notice. The corrective action for this non-compliance was implemented over a year ago and has been successful. Attachment 2a is a listing of all staff with current and previous physical dates. Since transition in 2014, all physicals have been renewed in compliance. This data was extracted from the electronic database. Attachment 2b represents a current physical renewed since licensing and attachment 2c is the staff¿s previous physical showing compliance. 08/01/2015 Implemented
6400.151(c)(2)Staff #1 TB test was late. Completed 10/7/2011 and not again until 6/7/2014. 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. The staff responsible for employee compliance left her job without notice on 5/1/14. At that time, duties were reassigned to another staff who began to review records in order to maintain compliance. This staff also completed an electronic database for ongoing record keeping, compliance, and transition should the staff holding the position change without notice. The corrective action for this non-compliance was implemented over a year ago and has been successful. Attachment 2a is a listing of all staff with current and previous physical dates. Since transition in 2014, all physicals have been renewed in compliance. This data was extracted from the electronic database. Attachment 2a represents a current physical renewed since licensing and attachment 2b is the staff¿s previous physical showing compliance. 08/01/2015 Implemented
6400.216(a)Files containing individual information was left unlocked on the kitchen counter. Individual files kept in the closet at the top of the stairs were not locked. An individual's records shall be kept locked when unattended. Consumer files that were left out have been relocated back to the locked staff office. Records that had been stored in a closet outside of staff office have been transferred to our main office for scanning and/or destruction. Staff for the home have been retrained on this regulation through routine staff meetings in order to maintain future compliance. Attachment 1 is a copy of meeting minutes for this home. 08/26/2015 Implemented
SIN-00062668 Renewal 06/09/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(4)Individual #1's current physical did not include a hearing exam. No hearing examination was done seperate from the physical either.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Individual #1¿s PCP noted `N/A¿ on the hearing section of her physical. At this time, we are working with her PCP¿s office to complete a screening or receive referral to an audiologist. Due to an extended absence by the PCP, we have been unable to confirm a date for this consult. A completed med consult will be sent as an addendum upon completion. To maintain future compliance, our consumer physical has been modified to separate and clarify those screenings that are mandatory by regulation. This new form will be reviewed with all site supervisors via their scheduled staff meeting on 7/15/14. A copy of the meeting agenda, attendance sheet, and updated physical will be sent as addendum. 07/15/2014 Implemented
6400.144Individual #1's dental examinations were not completed every six months as recommended by her dentist. Her most recent examination was completed on 5-27-14. Her prior examination was completed on 10-23 13. Also, Individual #1's gynocologist recommended during a 10-23-13 appointment that she return in 6 months. She had not returned to her gynocologist as of the licensing visit.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The designated health support person has been trained on the requirements of their role. Disciplinary action has been taken with respect to non-compliance. A new PS has been assigned to assist in the coordination of care and monitoring of compliance. Attached is a copy of dental consults completed in compliant timeframe that includes a post-licensing visit. 07/10/2014 Implemented
6400.181(d)Individual #1's assessment was not signed or dated by the Program Specialist.The program specialist shall sign and date the assessment. A new Program Specialist has been assigned to this home. This regulation was included in a post-licensing training for Residential Specialists. A copy of the training records will be sent as addendum. Continued compliance will be monitored through periodic record audits completed by assigned Program Managers. They will utilize the LII self-assessment tool as a checklist. A completed, compliant assessment since the licensing inspection will be sent as an addendum. 07/10/2014 Implemented
6400.181(f)There was no indication that Individual #1's current assessment was sent to all Plan Team members.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). A new Program Specialist has been assigned to this home. This regulation was included in a post-licensing training for Residential Specialists. A copy of the training records will be sent as an addendum. Continued compliance will be monitored through periodic record audits completed by assigned Program Managers. They will utilize the LII self-assessment tool as a checklist. 07/10/2014 Implemented
6400.186(a)Individual #1 did not have an ISP review completed for the fourth quarter.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. A new Program Specialist has been assigned to this home. This regulation was included in a post-licensing training for Residential Specialists. A copy of the training records will be sent as an addendum. Continued compliance will be monitored through periodic record audits completed by assigned Program Managers. They will utilize the LII self-assessment tool as a checklist. 07/10/2014 Implemented
SIN-00262748 Renewal 03/18/2025 Compliant - Finalized
SIN-00223653 Renewal 04/25/2023 Compliant - Finalized
SIN-00102678 Renewal 12/05/2016 Compliant - Finalized