Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00278655 Renewal 11/13/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Individual #1's Service Plan, last updated 11/3/25, stated that "[Individual #1] requires total assistance with managing [their] money." Therefore, Individual #1 is unable to manage their own finances. However, on 11/14/25, the home did not keep an up-to-date financial and property record for Individual #1 that includes the following: personal possessions and funds received by or deposited with the family or home, as there was a receipt presented documenting an initial deposit of $140.00 on 11/2/25.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. Site Coordinator updated the financial ledger on 11/14/2025 to show all funds received by the family for the individual. On 11/20/2025, Site Coordinator was retrained on Administration and Management of Individual Funds Policy and Procedure by Program Specialist. 11/14/2025 Implemented
6400.22(d)(2)Individual #1's Service Plan, last updated 11/3/25, stated that "[Individual #1] requires total assistance with managing [their] money." Therefore, Individual #1 is unable to manage their own finances. However, on 11/14/25, the home did not keep an up-to-date financial and property record that includes the following: disbursements made to or for Individual #1, as there were two receipts presented documenting purchases made at Dollar General for $6.36 on 11/2/25, and at Eat'n Park for $14.48 on 11/11/25.(2) Disbursements made to or for the individual. Site Coordinator updated the financial ledger on 11/14/2025 to show all funds spent by the individual on community outings. On 11/20/2025, Site Coordinator was retrained on Administration and Management of Individual Funds Policy and Procedure by Program Specialist. 11/14/2025 Implemented
6400.64(a)At 11:36 AM on 11/14/25, the ceiling exhaust fan vents in the full bathroom connected to Individual #2's bedroom on the home's first floor were covered in layers of dust. In addition, the interior light combination cover of this fixture contained dark-colored debris and what appeared to be dead insects.Clean and sanitary conditions shall be maintained in the home. On 11/14/2025, the ceiling exhaust fan was cleaned immediately after the finding of dust and debris by the site coordinator and DSP on shift. On 11/20/2025, Program Director completed training with Site Coordinator on the Implementation of a new Sanitation Checklist. Site Coordinator was instructed to show DSP's how to complete sanitation checklist and will submit the form monthly to Program Specialists for review. 11/14/2025 Implemented
6400.67(b)At 11:13 AM on 11/14/25, In the office room located in the home's basement, there were two exposed electrical wires with metal conductors on their ends and extending approximately six inches from inside the wall located nearest to the entry way. In addition, below these two wires on the same wall was exposed wiring of a phone jack, extending one and one-half feet from inside the wall. Floors, walls, ceilings and other surfaces shall be free of hazards.Immediately following violation, on 11/14/2025, O'Neal Electrical Services was contacted. Electrician advised he would be out the next day to check the wires. On 11/15/2025, O'Neal Electrical Services technician removed all exposed wires. 11/15/2025 Implemented
6400.110(a)At 11:43 AM on 11/14/25, the home's accessible attic, constructed with five and one-half feet of standing room and used for storage only, contained an inoperable automatic smoke detector. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. On 11/14/2025, immediately upon finding that the smoke detector in the attic was inoperable, batteries were replaced and the detector was in working condition. 11/14/2025 Implemented
6400.141(c)(11)Individual #1's date-of-admission is 11/1/25. Individual #1's current physical examination, completed on 1/14/25, did not include an assessment of their health maintenance needs, medication regimen, and the need for bloodwork at recommended intervals, as the corresponding field was left blank.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. On 11/18/2025, Program Director and CEO developed a new internal protocol on reviewing all individual's physical examinations. On 11/19/2025, Program Director trained Program Specialists and Agency Nurse on the change in internal protocol for review of all individual's physical examination forms to make sure they are completed in entirety. 11/19/2025 Implemented
6400.50(a)Direct Service Worker #1's annual training for the 2024 calendar year did not document a trainer or source that conducted the sessions for the following required topics: person-centered practices and individual choice, completed on 12/4/24; community integration and supporting individuals to develop and maintain relationships, completed on 11/20/24; the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse, completed on 6/25/24; individual rights, completed on 3/20/24; individual-specific reviews on the safe and appropriate use of behavior support plans, completed on 2/27/24, 3/20/24, and 6/25/24; and individual-specific reviews on the implementation of individual support plans, completed on 2/27/24.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.On 11/20/2025, Program Director updated training template to include the topic of training, trainer's name, location of training, date and time. 11/20/2025 Implemented
SIN-00260225 Renewal 02/05/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.186On 2/6/2025 on 11:52AM, a spray bottle of All Purpose Cleaner with Bleach, a container of Triple Action Dishwasher Detergent Pods and a container of Glisten Dishwasher Cleaner were unlocked and accessible in the cabinet under the sink. Individual #1's Service Plan, last updated 2/5/2025 reads, "All poisonous materials, cleaning products, etc., in [Individual #1's] house are secured and not readily available. [Individual #1] requires verbal assistance when in the vicinity of poisons."The home shall implement the individual plan, including revisions.On 2/6/2025, an ISP meeting was held with Individual #1's team. A revision was requested in regards to Individual #1's awareness of poisonous materials. On 2/11/2025, Supports Coordinator verified revision was made and emailed Program Specialist. On 2/12/2025, Program Director completed licensing overview including all non-compliances for all sites with Site Supervisors. Program Director relayed to Site Supervisors the importance of following the individual plan including revisions. 02/11/2025 Implemented
SIN-00239417 Renewal 02/14/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.207(5)(III)On 2/15/2024 at 12:10 PM, Individual #1's bed is equipped with dual bed rails. The Individual's current assessment and the Individual Service Plan, updated, 5/26/2023, do not include if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement.A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Protection from injury during a seizure or other medical condition, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement.On 2/21/2024, Program Director completed licensing overview with Site Supervisors including all non-compliances for all sites. On 2/19/2024, Program Director completed an addendum and added it to Individual #1's assessment to include a medical summary of seizure conditions, when bedrails are in use, and that Individual is able to verbalize to staff when he wants the bed rails down. Individual #1's Supports Coordinator was notified of the addendum and a copy was sent to be added to the ISP by the Program Specialist on 3/5/2024. 02/19/2024 Implemented
SIN-00077940 Renewal 12/09/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(a)There was not an operable smoke detector located in the attic. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. A new operable smoke detector was placed in the attic crawl space on 12-9-15..[CEO or designee will immediately go to all homes to ensure all required smoke detectors are present. CEO or designee will check smoke detectors and fire extinguishers at least monthly. Documentation of checks will be maintained and reviewed by the CEO quarterly if CEO has designated another to complete monthly checks. (AS 1/13/16)] 12/09/2015 Implemented
6400.111(a)There was not an operable fire extinguisher located in the attic.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. A new fire extinguisher was purchased on 12-14-15 and placed in the attic crawl space.[CEO or designee will immediately go to all homes to ensure all required smoke detectors are present. CEO or designee will check smoke detectors and fire extinguishers at least monthly. Documentation of checks will be maintained and reviewed by the CEO quarterly if CEO has designated another to complete monthly checks. (AS 1/13/16)] 12/14/2015 Implemented
SIN-00071294 Renewal 10/02/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The hot water temperature at the bathroom tub measured at 134 degrees Fahrenheit at 12:15 PM. Hot water temperatures in bathtubs and showers may not exceed 120°F. Extech 39240 Digital Waterproof pocket thermometers were purchased for all houses on 10-6-14. Pittsburgh Street staff were trained on checking hot water temperature with the new thermometer on 10-29-14 by Ashley McLaughlin and the house staff are monitoring the hot water temperature once a week for three months to ensure correct temperature of under 120F. [The program specialist or designee will check the hot water temperature in each home at least monthly to ensure the temperature stays below 120 degrees Fahrenheit. (CHG 12/8/14)] 12/01/2014 Implemented
SIN-00049603 Renewal 08/23/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(9)The prostate examination for Individual #1 was not completed annually. The current prostate examination was completed on 2/7/13. The previous prostate examination was completed on 9/1/11.(9) A prostate examination for men 40 years of age or older. A training was conducted on 09-03-13 with all house supervisors and the program specialist to review 6400.141(c)(9) and the agency physical form. A checklist has been developed to assist staff in making sure that the required information is on the physical form. No annual physical form will be accepted unless the necessary documentation is on the form. The supervisor of the house is the first check to ensure the physical is completed correctly. The Program Specialist is the second check. All physical's that do not have the required information will be returned to the Dr.'s office for completion. Follow-up paperwork will be sent. [The program specialist will perform an audit of all current individual physical examinations to ensure that they contain all of the required information by 11/1/13. (CHG 9/16/13)] 09/05/2013 Implemented
6400.151(c)(3)The physical examination for Staff person #1 dated 9/28/12 did not include a statement affirming that staff is free of communicable disease. (3) 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. A training was conducted on 08-28-13 to review 6400 regulations under staff health; 151(a) through 151(c). The office receptionist is the person staff turn in physical forms to. She was instructed on what to look for on the physical to ensure it is complete. The Human Resource Specialist is responsible to do a double check of the physical form prior to entering the date in the data base and filing the form. A checklist has been developed to assist in this process. Any physical truned in incomplete will be rejected and staff will be required to return to their physician for completion. Follow-up paperwork will be sent. [A physical will be obtained for staff #1 within 30 days that includes documentation that the staff person is free from communicable disease or 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. The Human Resource Specialist will audit all current staff records to ensure that they contain all of the required information by 11/1/13. (CHG 9/16/13)] 09/05/2013 Implemented
6400.163(c)The psychotropic medication reviews dated 4/8/13, 5/6/13, 6/5/13 and 7/3/13 for Individual #1 did not include the reason for prescribing the medications. (c) If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Repeat violation - 5/16/12A training was conducted on 09-03-13 with all house supervisors and the program specialist to review 6400 regulation 163(c) and the agency psychotropic review form. A checklist has been developed to assist staff in making sure that all required information is on the appointment form. No review form will be accepted unless completed correctly. The supervisor of the house (site coordinator) is the first check to ensure the form is completed correctly. The Program Specialist will be the second check. All forms that do not have the required information will be returned to the Dr.'s office for completion. Follow-up paperwork will be sent. 09/05/2013 Implemented
SIN-00202229 Renewal 03/22/2022 Compliant - Finalized
SIN-00166683 Renewal 11/25/2019 Compliant - Finalized
SIN-00126300 Renewal 12/18/2017 Compliant - Finalized
SIN-00106198 Renewal 12/20/2016 Compliant - Finalized