Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00270070 Renewal 08/11/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(1)Per Individual #2's financial record, the individual used gift cards to make purchases on 05/22/2025. A Weis Gift card was used to make a purchase at Weis grocery store and a Giant gift card was used to make a purchase at a Giant grocery store on this date. There was no record related to the origin of these gift cards, such as the individual choosing to purchase them for themselves. Further, the gifting of these gift cards to the individual would have constituted a deposit for the individual at the time of occurrence. In either case, the provider failed to keep a complete financial record of the purchase or deposit, whichever it might have been. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. Staff will receive retraining on maintianing the financial logs. 10/31/2025 Implemented
6400.22(e)(3)Individual #2's financial record contained a receipt for an ATM withdrawal that occurred on 06/04/2025 in the amount of $60.00. Staff noted on accompanying documentation that these funds were utilized to pay for a haircut; however, the financial record did not contain documentation of the haircut occurring, an expense that reportedly exceeded $15.00 per the documentation accompanying the ATM withdrawal. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. Staff will receive retraining on maintianing the financial logs. 10/31/2025 Implemented
6400.82(f)At the time of inspection, the home's bathroom was lacking soap and a trashcan. Both were located within the home and placed in the bathroom by the provider prior to the conclusion of the on-site inspection.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Expectations for supply needs will be reviewed with staff. 09/30/2025 Implemented
6400.141(c)(4)Per the Individual Record, Individual #2's two most recent vision examinations occurred on 04/16/2024 and 05/31/2025---more than 365 calendar days apart. This individual did not receive vision examinations annually as required.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. A case manager was hired on 3/3/25 to replace the previous client services director who left in July of 2024. 10/31/2025 Implemented
6400.142(a)Per Individual #2's Individual Record, Individual #2's most recent dental examination took place on 10/31/2023. Records indicated that the individual refused to attend dental examinations on 05/05/2025, 06/26/2025, and 06/27/2025. There was no record that the provider attempted to secure dental care for this individual between 10/31/2023 and 05/05/2025. This individual did not receive a dental examination annually as required.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. Another dental appointment was scheduled for Individual #2. 10/31/2025 Implemented
6400.143(a)Per Individual #2's Individual Record, Individual #2's most recent dental examination took place on 10/31/2023. Records indicated that the individual refused to attend dental examinations on 05/05/2025, 06/26/2025, and 06/27/2025. There was documentation of the refusal of treatment on 05/05/2025. While documentation of refusal of treatment was present for the 06/26/2025 and 06/27/2025 appointment attempts, neither form noted that training on the importance of healthcare was completed with the individual. The section of the 06/26/2025 form designed for this information was left blank. The 06/27/2025 form noted "Staff would need to work with [Individual #2]···" in order to educate the individual; however, the specific phrasing of this documentation suggested that the training did not actually occur.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. New case manager was given education on how to complete the forms for missed appointments. 09/30/2025 Implemented
6400.165(g)Individual #2 is prescribed psychotropic medication to treat the symptoms of a psychiatric illness. Per the Individual Record, this individual saw a psychiatrist for management of these medications on 08/13/2024, 10/11/2024, 12/13/2024, 02/11/2025, and 04/09/2025. Per documentation, the individual's 06/10/2025 psychotropic medication review was canceled due to "unsafe behaviors," and there is no other record of a visit more recent than 04/09/2025. The documentation did not classify this as a refusal of treatment. This individual did not have a psychotropic medication review conducted at least once every 3 months as required.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.Another psychiatric appointment was already completed in August for this individual. 09/30/2025 Implemented
6400.181(f)Per Individual #2's most recent Individual Support Plan (ISP), dated 07/30/2025 in the Home and Community Based Information System (HCSIS), this individual's most recent Individual Plan meeting took place on 04/24/2025. The most recent Annual Assessment for this individual was dated 04/09/2025, less than 30 calendar days prior to the Individual Plan meeting. An email provided as record of the transmission of the ISP to the Individual Plan team was dated 07/15/2025. The documentation showed that the ISP was not provided to Individual Plan team members at least 30 calendar days prior to the Individual Plan meeting as required.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Newly hired Case Manager was given education in completion and time frames for Annual assessments 10/31/2025 Implemented
SIN-00249129 Unannounced Monitoring 06/07/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #1 spent six days on their bedroom floor during an extended behavioral episode, during which medical complications were developing due to skin breakdown, contamination of the wounds from contact with feces and urine, as well as dehydration from reduced fluid intake. The individual was subsequently found to be hypothermic, with cellulitis and sepsis, and required an extended stay in the hospital for treatment. The medical conditions experienced by the individual were potentially life-threatening in severity, and may have been prevented or reduced if emergency medical care had been provided to the individual sooner.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. During this behavioral episode the individual was physically seen by a program nurse on two separate days. The individual also had a telemed visit with her Primary Care Physician the day before she was hospitalized. the individual also had a telepsych appointment. In the future during prolonged behavioral episode (more than 1 day) the Crisis Manager will call emergency medical services. 08/28/2024 Implemented
6400.32(c)Individual #1 was subjected to neglect when the provider agency allowed the individual to remain on their bedroom floor for six days in urine and feces during an extended behavioral episode, during which medical complications were developing due to skin breakdown, contamination of the wounds from contact with feces and urine, as well as dehydration from reduced fluid intake. The individual was subsequently found to be hypothermic, with cellulitis and sepsis, and required an extended stay in the hospital for treatment.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.A review of individual rights was completed with our Residential leadership team. A training on the new protocol is scheduled for 8/28/2024. 08/28/2024 Implemented
6400.185(5)Individual #1 has a documented history of laying on the ground or floor and refusing to get up, or refusing to get out of bed for extended periods of time, often resulting in skin breakdown. During these episodes, the individual will refuse to use the bathroom or allow staff to clean them after soiling themself. On some occasions, the individual will refuse to eat or drink. The Individual Support Plan (ISP) in effect during the current episode that resulted in hospitalization on 5/29/2024 documents generally the individual's behavior of refusals, but does not address specifically the behavior of refusing to get up from the floor or bed for extended periods of time, and the medical implications of that behavior. The current behavior support plan (BSP) revised 3/28/2024 mentions the behavior in the "relevant history section" but offers no strategies to address the behavior. The current individual assessment completed on 9/19/2023 does not mention the behavior at all, but does state that the individual has a history of pressure ulcers and is at risk for skin breakdown. Additionally, the home does not have a written protocol or procedures for staff to assess for the development of medical complications during an episode of refusing to get up, and when to seek medical help.The individual plan, including revisions, must include the following: Risks to the individual's health, safety or well-being, behaviors likely to result in immediate physical harm to the individual or others and risk mitigation strategies, if applicable.The Consumer is currently admitted In-Patient Psychiatrically. Prior to her return to program we will have a well documented meeting with her entire team and ensure that her Individual Support Plan is updated and reflect her current status and needs. 09/04/2024 Implemented
SIN-00227395 Renewal 07/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill conducted on 2/2/23 did not include the time of day that the fire drill was completed as this section of the form was left blank.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. SOP is being developed for Team Leads & Program managers regarding Fire drill forms and administrative review requirements (Completed 7/31/23) Training on the Fire Drill form itself, SOP, and the administrative review process will be completed by 8/15/23. 08/15/2023 Implemented
6400.112(h)The fire drill conducted on 8/13/22 did not indicate if all of the Individuals evacuate to a designated meeting place outside the home during each fire drill as this section of the form was left blank. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.SOP is being developed for Team Leads & Program managers regarding Fire drill forms and administrative review requirements (Completed 7/31/23) Training on the Fire Drill form itself, SOP, and the administrative review process will be completed by 8/15/23. 08/15/2023 Implemented
6400.142(f)There was no record or documentation of a dental hygiene plan for Individual #1An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. Client services called all dentists on record and received recommendations (8/1/23) 08/15/2023 Implemented
6400.151(c)(2)Tuberculin skin testing by Mantoux method with negative results every 2 years. Staff #1's date of hire is 2/6/23 and their Tuberculin skin testing by Mantoux method with negative results occurred on 4/7/23. 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. New ADP workforce NOW contract will keep track of all HR requirements (Criminal Histories, Physicals, TB Tests) 01/01/2023 Implemented
6400.181(e)(6)Individual #1's assessment dated 1/27/2023 did not assess or address the individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. Poison Safety question was added retroactively to all 2022/2023 Annual Assessments. 07/24/2023 Implemented
6400.32(r)Individual #1's bedroom door lock was "coin key" lock, this type of lock does not provide the level of privacy and security of person and possessions as expected by the regulation.An individual has the right to lock the individual's bedroom door.Operations will make lock changes to all possible doors 08/31/2023 Implemented
6400.165(g)Individual #1 prescribed medication to treat symptoms of a psychiatric illness. Individual #1 had a 3-month psychiatric medication review on 3/28/23 and 6/27/23, and the form used for the visit did not include the necessary dosage of medication.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.Medication lists will be attached to all psych notes for physician review and available when viewed in the scanned BOX paperwork (7/19/23 and ongoing) Medical note updated to reflect Psychiatric med review of medications and the symptoms requiring ongoing treatment. 07/21/2023 Implemented
SIN-00159816 Renewal 07/10/2019 Compliant - Finalized