Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00281208 Renewal 01/20/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71At the time of the inspection, none of the phones in the home had emergency numbers on the phones.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The numbers have been added to the phone. 01/30/2026 Implemented
6400.103Individual #1's emergency evacuation procedure does not document the mode of transportation.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. Mode of transportation during an emergency evacuation was added to the Emergency Evacuation Plan. 01/30/2026 Implemented
6400.106(Repeat from 4/14/25 Inspection) On 6/3/25, the HVAC technician went to the home to check on the 11-year-old heat pump system. Per the service invoice, no one was home, but the technician was able to determine the system was not running correctly. No work or additional inspections have been completed.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. This maintenance was scheduled. 01/30/2026 Implemented
6400.113(a)Individual #1's date of admission was 10/4/25. They did not receive fire safety training until 10/11/25. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. This form was completed out of compliance and there is no correction that can be made. 01/22/2026 Implemented
6400.151(a)Staff #3's date of hire was 11/21/25. They did not have their staff physical completed until 11/25/25. 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 person's date of hire was entered erroneously on the 6400 Prep List provided ahead of the inspection. There is no means to correct this. 01/30/2026 Implemented
6400.181(e)(4)Individual # 1's assessment dated 12/02/25 does not assess the ability to self-medicate as identified in regulation 161e. The assessment must include the following information: The individual's need for supervision. An addendum to the assessment was made and a request to align the information in the ISP was sent to the SC. 01/22/2026 Implemented
6400.181(e)(5)Individual # 1's assessment dated 12/03/25 identifies unsupervised time in the home for two hours, however, the ISP dated 01/12/26 reads "can be left home alone during the day for a few hours.The assessment must include the following information:  The individual's ability to self-administer medications.The Lead Program Specialist will make a request to the SC to update the ISP with the appropriate verbiage. 01/22/2026 Implemented
6400.50(b)Staff # 4 was trained in an individual's ISP on 12/05/25, but the length of training is not documented.The home shall keep a training record for each person trained.The training completed for ISP was added as training hours to the Relias transcript. 01/30/2026 Implemented
6400.51(b)(1)Staff #3 did not have the following orientation training: Community integration or Supporting individuals to develop and maintain relationships.The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.All current employees were assigned the following Relias trainings: Supporting People with IDD in Building Healthy Personal Relationships, Person-Centered Thinking and Supporting Quality of Life for Individuals with IDD. 02/11/2026 Implemented
6400.169(a)(Repeat from 10/14/25) Staff #4 does not have documentation (scoresheet) of training required for Medication Administration Qualification. There is an original qualification date of 12/23/25, however, all required training documentation is unavailable (i.e. written examination results) to verify that staff # 4 completed all required trainings and examinations to pass medications.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).The Training and Development Coordinator and Medication Administration Trainer will review all current employee Medication Administration Training packets. Any packet found to have a deficiency will be enrolled in a Medication Administration Training Course on either 2/5/2026, 2/12/2026 or 2/19/2026.Any staff persons with a packet that is found to be deficient will not be allowed to pass medications without completing the full Medication Administration Course. 02/27/2026 Implemented
Article X.1007Staff # 4 was initially hired on 11/26/24 and had a criminal check on 11/28/24. Staff # 4 discontinued work on 07/16/25 and was subsequently rehired on 12/02/25, however, a criminal background check was not completed upon rehire.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.The staff's EPATCH was re-run. 01/20/2026 Implemented