Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00292871 Renewal 07/28/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.142(d)Individual #1's dental examinations, occurring 4/01/2025 and 5/04/2026, did not include teeth cleaning.The dental examination shall include teeth cleaning or checking gums and dentures. Provider CEO updated dental appointment forms to ensure these specific areas are included and documented at time of appointment. CEO and PS will conduct monthly audit of appointment documentation/forms for completeness sand regulatory compliance. 08/13/2026 Implemented
6400.181(e)(4)Individual #1's current assessment, completed on 7/1/2026, did not address their supervision needs specific to the length(s), type(s), settings or environments within both the home and community. The assessment must include the following information: The individual's need for supervision. Program specialist will update accordingly and email SC for ISP revision. 08/28/2026 Implemented
6400.181(e)(8)Individual #1's individual support plan, last updated 6/24/2026, documents "Staff report that she does need some support to get out, mostly because of the stairs going out of her home and the need to be emergent as [Individual #1] does move slowly." A notification letter was sent to the local fire department 6/14/2026, documenting Individual #1 requires verbal and physical prompts to evacuate in her home, in the event of a fire. Individual #1's assessment, completed 1/04/2026, documents the individual requires no support in evacuating during a fire.The assessment must include the following information: The individual's ability to evacuate in the event of a fire. Program specialist will update accordingly and email SC for ISP revision. 08/28/2026 Implemented
6400.165(g)Individual #1's psychiatric medication reviews completed 11/04/2025, 12/03/2025, and 3/18/2026 did not include the medications reason for prescribing nor necessary dosage. Individual #1's psychiatric medication reviews completed 1/21/2026 did not include the reason for prescribing. [Repeated Violation-10/21/2026, et al]If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Provider obtained visit summaries for these specific dates. Three-month psychiatric medication review form was updated by provider to ensure documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage. 08/13/2026 Implemented
SIN-00287830 Unannounced Monitoring 04/30/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101On 4/30/2026 at 1:28 PM the exterior swing door of the detached garage was equipped with a metal latch bar secured by a keyed pad lock. There was no other exit from the garage, creating an entrapment risk.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Lock has been removed from the garage door. 05/11/2026 Implemented
6400.142(a)Individual #1 had no record of having had a current dental examination, including teeth cleaning or checking gums. There was a 4/01/2025 dental appointment, where an abscessed tooth was extracted, and nothing since.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Provider has obtained a letter from dental provider stating that 5/4/2026 was the earliest appointment available. Individual #1 completed the required annual examination on 5/4/2026. 05/04/2026 Implemented
6400.216(a)On 4/30/2026 at 1:15 PM there were (2) copies of Individual #1's individual support plan, last updated 8/22/2024 and 1/21/2026, unlocked and accessible in the bottom drawer of a dresser located in the home's entryway. Individual #1's service note, completed 3/22/2026, was also present in the bottom drawer. There was a pile of Individual #1's blank service note forms, including the individuals full name and master client index number, unlocked and accessible in the top drawer of another dresser located in the home's front entryway. An individual's records shall be kept locked when unattended. Paperwork was securely locked at time of inspection. 04/30/2026 Implemented
6400.166(a)(5)Individual #1 is prescribed Clotrimazole and Betamethasone Dipropionate Cream USP 1%/0.5%, with instructions to "Apply topically to affected areas on foot twice a day for fungal irritation." On 4/30/2026 Individual #1's April 2026 medication administration record did not include strength of the medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.Pharmacy was contacted and strength of medication was added to MAR for both medications. 05/04/2026 Implemented
6400.195(a)Individual #1's restrictive procedure plan, last updated 11/07/2025, the individual cannot access knives, sharp items, metal utensils, or chemicals. On 4/30/2026 at 1:00 PM plastic grocery bags, garbage bags, and hangers were locked in the closet between the kitchen and the living room. At 1:02 PM agency interviews revealed Individual #1 is unable to have shoelaces and belts due to a history of suicidal ideations and self-injurious behaviors.For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures.Behavioral Specialist will update restrictive procedures plan to include grocery bags, garbage bags, hangers, shoelaces, and belts. 05/12/2026 Implemented
SIN-00254652 Renewal 10/29/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(11)Individual #1's physical examination, completed on 04/24/24, did not include an assessment of the individual's health maintenance needs or medication regimen.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. CEO and PS will review with all house managers immediately and ensure awareness of the need to complete all medical documentation in its entirety. It is the responsibility of the house manager to ensure that all areas of the physical examination documentation are filled out completely. CEO and PS will consult with HMs prior to appointment date and time to remind HM and staff accompanying individual to medical appointment that all areas of the documentation are completed. 11/11/2024 Implemented
6400.141(c)(14)Individual #1's physical examination, completed on 04/24/24, did not include medical information pertinent to diagnosis and treatment in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. CEO and PS will immediately review with house managers the importance of completing all areas of medical forms/documentation. CEO and PS will maintain list of all medical appointment dates and will consult with house managers and staff accompanying individuals to medical appointments that all areas of medical documents are to be completed. 11/15/2024 Implemented
6400.151(a)Program Specialist #1 last had a physical examination completed on 06/03/22. Direct Service Worker #2 had a physical examination completed on 05/25/21, and then again on 10/03/23. 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. CEO will develop tracking documentation for all employees to ensure regulatory compliance. Tracking document will include physical dates to be reviewed monthly for each employee to maintain compliance. Administration will complete a tracking checklist on each employee at least monthly to ensure compliance is met. 11/15/2024 Implemented
6400.46(b)Program Specialist #1 and Direct Service Worker #2 most recently completed annual fire safety training by a fire safety expert on 06/28/23. This exceeds the annual requirement.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).CEO will ensure all staff attend the annual fire safety training by a fire safety expert and that documentation of such training shall be kept at each location as well as a copy of the training placed in the Policy and Procedure Manual as soon as possible so that documentation is maintained and available at any time for review. 11/11/2024 Implemented
SIN-00234169 Renewal 11/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.18(a)(3)EIM Incident #: 9261236 for a behavioral health crisis involving psychiatric hospitalization was discovered on 8/7/23 and reported on 8/9/23. EIM Incident #: 9272545 for a serious illness requiring hospitalization was discovered on 8/25/23 and reported on 8/30/23.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Inpatient admission to a hospital. CEO to monitor EIM and ensure compliance with current reporting. 01/31/2024 Implemented
6400.18(i)EIM Incident #: 9261236 for a behavioral health crisis involving psychiatric hospitalization was discovered on 8/7/23 and finalized on 9/27/23. The due date for finalization was 9/6/23, and no extensions were filed. EIM Incident #: 9272545 for a serious illness requiring hospitalization was discovered on 8/25/23 and finalized on 10/9/23. The due date for finalization was 9/24/23, and no extensions were filed.The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension.CEO will conduct an initial audit of EIM reporting timelines to ensure regulatory compliance. 01/31/2024 Implemented
SIN-00215604 Renewal 11/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency's Certificate of Compliance expiration date was 8/19/2022. The agency completed the self-assessment of the home on 11/28/2022.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Self-assessments were completed, however not within a timely manner. CEO and Program Specialist will complete future self-assessments within the required timeframe of 3 to 6 months prior to expiration date of the certificate of compliance. CEO and Program Specialist will complete all self-assessments by 5/19/23 and will begin self-assessments no later than 3/1/23 to measure compliance with applicable regulations and correct any identified deficiencies. Violations will be identified, and written summaries of corrective actions taken will be documented. 03/01/2023 Implemented
6400.15(c)Violations were identified by marking the "V" on the self-assessment; however, the agency did not identify the violations and complete a written summary of corrections made.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. Self-assessments were completed, however not within a timely manner. CEO and Program Specialist will complete future self-assessments within the required timeframe of 3 to 6 months prior to expiration date of the certificate of compliance. CEO and Program Specialist will complete all self-assessments by 5/19/23 and will begin self-assessments no later than 3/1/23 to measure compliance with applicable regulations and correct any identified deficiencies. Violations will be identified, and written summaries of corrective actions taken will be documented. 03/01/2023 Implemented
6400.141(c)(4)Individual #1's vision screening was completed on 7/1/21, and then again on 8/3/22. Individual #1's hearing screening was completed on 1/26/21, and then again on 2/15/22.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Vision screening to be scheduled immediately along with physical examination due by 2//16/23 and TB screening. CEO and program specialist will conduct audit of all individuals' files for compliance purposes. Any issues/noncompliance identified during the audit will be immediately corrected. CEO will develop a checklist for continued monthly monitoring by CEO and program specialist of all individual files in order to maintain compliance in the future. All staff, especially house managers, will be trained on the importance of completing all areas of medical records/documentation at the time of examination. 03/01/2023 Implemented
6400.141(c)(7)Individual #1 had a gynecological exam on 6/28/21, and then again on 8/1/22.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. CEO will develop checklist for monthly audit by Program Specialist of all individuals' files. CEO will then monitor for compliance and that checklists are completed monthly to ensure regulatory compliance with all annual requirements. House managers will be provided with list of annul date requirements for compliance purposes. HMs will be responsible for scheduling all appointments and will be verified/confirmed by Program specialist during monthly audit. Any concerns will be addressed immediately by PS and HM. 03/01/2023 Implemented
6400.142(a)Individual #1 had a dental examination on 6/8/21, and then again on 8/17/22.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. CEO will develop checklist for monthly audit by Program Specialist of all individuals' files. CEO will then monitor for compliance and that checklists are completed monthly to ensure regulatory compliance with all annual requirements. House managers will be provided with list of annul date requirements for compliance purposes. HMs will be responsible for scheduling all appointments and will be verified/confirmed by Program specialist during monthly audit. Any concerns will be addressed immediately by PS and HM. 03/01/2023 Implemented
6400.181(f)The program specialist provided Individual #1's annual assessment, completed 2/2/22 to the invidual plan team members on 2/2/22 for an individual plan meeting on 2/14/22.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.CEO will develop and implement a checklist for Program Specialist to conduct monthly audit of all individuals' assessments to ensure they are completed and submitted to team members in a timely manner and within regulatory timeframes. Program Specialist to review applicable regulations for future compliance. 03/01/2023 Implemented
SIN-00182300 Renewal 01/26/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(a)Individual #1 most recently had an annual assessment completed on 01/09/20. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Effective immediately, Program Specialist will begin monitoring/tracking assessments for all individuals on a monthly basis in order to ensure and maintain compliance with 6400.181(a). Documentation of PS monitoring will be kept and CEO will review monthly tracking by PS to ensure compliance. In addition, Program Specialist will review 6400.181(a)-(f) on the regulatory requirements for assessments. [Individual #1's assessment was completed on 1/27/21 and provided to the SC. Immediately, the CEO or designee shall develop and implement a tracking system to ensure accurate, up-to-date and timely completion of individual's assessments. (DPOC by AES,HSLS on 2/16/21)] 02/10/2021 Implemented
SIN-00163237 Renewal 09/25/2019 Compliant - Finalized