Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00246512 Renewal 06/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.207(5)(III)On 6/06/2024, Individual #1 and Individual #2 had dual side bed rails that restrict the movement or function of the individual's body.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.* Provider confirmed that Individual #1 and Individual #2 are able to move freely and get in and out of bed independently with the bedrail. * Separate IDT meetings were held and it was determined that both Individual #1 and Individual #2 are incapable of removing the rails independently, however, they are able and will continue to ask staff when they want the rails to be removed at any time for any reason. Both prefer the bedrails to be up often as they use them for support and balance when getting in and out of bed. *Provider obtained scripts for Individual #1 and Individual #2 from the PCP. * Provider updated the assessment for Individual #1 and Individual # 2. * Provider requested that the Supports coordinator for Individual #1 and Individual #2 update the ISP. 07/10/2024 Implemented
SIN-00115943 Renewal 06/13/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(10)Individual #1's physical examination, dated 8-2-2016, did not address communicable disease. This section was left blank.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. We are unable to correct this deficiency. We did contact individual #1's PCP. They gave us written verification that Individual #1 was free from communicable disease, as of 5/11/17. This was the last time he physically examined her with lab-work. She will have her annual exam on 9/3/17. In an effort to prevent this from happening in the future, all supervisors and program specialist will be trained on 141(c)(10) and the importance of making sure all sections of the physical exam are completed.[On 7/10/17, six staff were trained by the program director on 6400.141c10 and "stressed the importance of making sure all sections of the physical examination are completed prior to leaving the appointment." Within 30 days of receipt of the plan of correction, all staff person responsible for ensuring Individuals' physical examinations are completed with all required information and that there are not any areas of required information left blank shall be trained by the program director. Documentation of trainings shall be kept. Immediately and upon completion, the program specialist shall review all individuals' physical examinations to ensure all required information is included and there are not any areas of required information left blank and missing information shall be immediately obtained from the completing medical professional. Documentation of reviews shall be kept. (AS 7/21/17)] 07/02/2017 Implemented
SIN-00095538 Renewal 05/18/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(1)The annual assessment for Individual #1, completed 10/6/15 was not completed by the Program Specialist. The program specialist shall be responsible for the following: Coordinating and completing assessments. We are unable to correct the assessment(s) completed by the Program Supervisor, then reviewed and finalized by the Program Specialist. As of 5/25/16, the procedure for completing the assessment was changed to, include the Supervisor in the assessment process, but have the Program Specialist actually complete and sign the assessment. The cover sheet to the assessment was changed to indicate that the Program Specialist did complete the assessment. All supervisory and administrative staff were trained on 6400.44(b)(1) and 6400 regulatory Q&A from October of 2015. Training verification and a copy of the assessment cover sheet will be forwarded.[At least quarterly for the next year, a supervisory and/administrative staff will review a 25% sample of individual assessments to ensure the program specialist is coordinating and completing assessments as required. (AS 6/24/16)] 06/09/2016 Implemented
6400.112(c)The written fire drill records for the fire drills held on 5/28/15 and 3/14/16 did not include the exit route used.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. We are unable to go back and correct the previous fire drills. In an effort to prevent this error from occurring again, we trained all direct-care and supervisory staff on regulation 6400.112(C). Special emphasis was made on not leaving any section of the drill blank. A copy of the training verification is being forwarded.[At least monthly for the next 6 months all fire drill from all community homes shall be reviewed by supervisory or administrative staff upon completion to ensure all required information is documented. Documentation of supervisory and/or administrative staff review of fire drills shall be kept. (AS 6/24/15)] 06/10/2016 Implemented
SIN-00077763 Renewal 05/07/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(g)The home conducted three fire drills during sleeping hours between 5/15/14 and 4/22/15. The times of the drills were 5:10 AM, 5:20 AM and 5:30 AM. Fire drills shall be held on different days of the week and at different times of the day and night. Supervisory and administrative staff reviewed the requirements of 6400.112 on 5/29/15. We will continue to make every fourth drill a "sleep-time" drill, however, supervisors will be responsible for initiating the drills at varying times during the nite. In addition, during our current monthly review of the Fire Log, we will monitor for compliance with this regulation. A reminder was added to the "Monthly House Monitoring" checklist to ensure these variations in time are occurring.[Supervisors of each home will ensure that all fire drills remain unannounced to staff and individuals who are participating in the fire drills. (AS 6/17/15)] 05/29/2015 Implemented
6400.171On 5/7/15, there were open bags of sweet potato fries, breaded chicken fingers and mini corn dogs in the freezer in the kitchen.Food shall be protected from contamination while being stored, prepared, transported and served. The discovered bags of food were disposed of upon discovery (5/7/15). Staff are aware of this regulation/requirement, however, supervisor reviewed procedures with responsible staff. The inspection of the refrigerator/freezer was also added to the "Monthly House Monitoring" checklist. A different supervisor inspects each home and turns this form in monthly. The adjusted form was reviewed with supervisors on 5/29/15. Administration will continue to monitor. 05/29/2015 Implemented
SIN-00228368 Renewal 07/10/2023 Compliant - Finalized
SIN-00208766 Renewal 07/26/2022 Compliant - Finalized
SIN-00191846 Renewal 08/24/2021 Compliant - Finalized
SIN-00175990 Renewal 09/09/2020 Compliant - Finalized
SIN-00155269 Renewal 05/09/2019 Compliant - Finalized
SIN-00046428 Renewal 01/15/2013 Compliant - Finalized