Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00232784 Renewal 09/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)Fire drills shall be completed in under 2 minutes, 30 seconds. The following fire drills were not completed within 2 minutes and 30 seconds: 4/30/2023 -- 4 minutes, 25 seconds 3/23/2023 -- 2 minutes, 57 seconds 1/27/2023 -- 3 minutes, 20 seconds 10/21/2022 -- 3 minutes, 3 seconds. The home does not have an extended evacuation time. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Program Manager of the home will review fire safety concerns with all individuals and provide schedule a time for the fire chief to give additional training to consumers. All team members will be made aware of concerns regarding previously failed fire drills will be discussed so that actionable plans can be implemented to prevent reoccurrence. Fire Chief will be scheduled to assess whether or not the home requires an extended evacuation time. 12/31/2023 Implemented
6400.112(h)Individuals shall evacuate to a designated meeting place. The fire drill records for the drills held on 12/19/2022 and 9/15/2022 did not document if the individuals evacuated to a designated meeting place. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Program Manager of the home will review fire safety concerns with all individuals and provider will schedule a time for the fire chief to give additional training to consumers. All employees and consumers will be trained on meeting places for their respective sites. 12/31/2023 Implemented
SIN-00178646 Unannounced Monitoring 10/29/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.52(c)(5)Staff #2 Staff#3, Staff#4, and Staff #5 were not trained on the Behavior Support Plans of Individual #1, or Individual #2.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.Program Specialist in conjunction with the Behavior Specialist will make sure all staff working in the home are trained properly on the implementation of the Behavior Plan. Staff are being trained by the Program Specialist and/or the Behavior Specialist but proper documentation is not being kept to indicate this is being done. Compliance department and training department will assist in the tracking of employee training. 11/30/2020 Implemented
6400.196(c)Staff #1, Staff #2, Staff #3, Staff #4, and Staff #5 were not trained on Individual #3 Restrictive Procedure Plan that was implemented on 10/21/2020. The individual's plan was reviewed and approved by the Restrictive Procedure Review Committee on 10/21/2020.Documentation of the training provided, including the staff persons trained, dates of training, description of training and training source, shall be kept.Program Specialist in conjunction with the Behavior Specialist will make sure all staff working in the home are trained properly on the implementation of the Behavior Plan. Staff are being trained by the Program Specialist and/or the Behavior Specialist but proper documentation is not being kept to indicate this is being done. Compliance department and training department will assist in the tracking of employee training. 11/30/2020 Implemented
SIN-00174628 Unannounced Monitoring 07/28/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(1)There is no Medical History listed on Individual #4's current physical exam dated 10/7/2019.The physical examination shall include: A review of previous medical history. IHRS will send physical back to PCP for proper completion. IHRS will audit all physicals to ensure that all proper and necessary information is listed. 09/15/2020 Implemented
6400.141(c)(13)On Individual #4's physical exam dated 10/7/2019, Amoxicillin was not listed as an allergy, but it is listed on previous physical forms as well as listed as an allergy in his ISP. The only allergy listed on the physical exam form was Penicillin.The physical examination shall include: Allergies or contraindicated medications.IHRS will send physical back to PCP for proper completion. IHRS will audit all physicals to ensure that all proper and necessary information is listed. 09/15/2020 Implemented
6400.141(c)(14)This section was blank on Individual #4's physical exam dated 10/7/2019.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. IHRS will send physical back to PCP for proper completion. IHRS will audit all physicals to ensure that all proper and necessary information is listed. 09/15/2020 Implemented
SIN-00160706 Renewal 08/27/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment was completed late. The expiration date of the Agency's certificate of compliance is 8/01/2019 and the self-assessment was completed on 8/14/2019.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.IHRS will develop a protocol that requires all self assessments to be completed by May 1st of the current calendar year. This will ensure that all homes are assessed prior to the expiration date of our certificate of compliance. Our compliance manager, will ensure that these assessments are completed. 10/31/2019 Implemented
6400.67(a)There were several areas in the bedroom hallway between the bathroom and two individual bedrooms where plaster from the walls is chipping in large chunks.Floors, walls, ceilings and other surfaces shall be in good repair. Administrative staff has sat with our maintenance contractor to discuss a better way to fix this particular area of the home. Wall has been submitted for repair and different materials have been used to secure the wall. This area is in bad repair because one of the residents hits this part of the hallway. The residents treatment team is working on a plan to decrease this behavior. 10/31/2019 Implemented