Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00290926 Renewal 06/23/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.207(5)(III)On 6/24/2026 at 10:05 AM, Individual #1's bed contained partial bilateral bedrails that restricted the movement or function of the individual's body. The agency obtained a prescription for the bed rails on 8/22/2024. Although the bed rails are prescribed by the medical practitioner, Individual #1's most current assessment completed 3/27/2026 does not indicate the need for the device, 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. Individual #1's individual support plan last updated 4/25/2026 does not include periodic relief of the device to allow freedom of movement. On 6/24/2026 at 10:05 AM, Individual #2's bed contained partial bilateral bedrails that restricted the movement or function of the individual's body. The agency obtained a prescription for the bed rails on 8/22/2024. Although the bed rails are prescribed by the medical practitioner, Individual #1's most current assessment completed 4/20/2026 does not indicate the need for the device, 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. Individual #1's individual support plan last updated 4/25/2026 does not include periodic relief of the device to allow freedom of movement. On 6/24/2026 at 10:10 AM, Individual #3's bed contained partial bilateral bedrails that restricted the movement or function of the individual's body. The agency obtained a prescription for the bed rails on 8/22/2024. Although the bed rails are prescribed by the medical practitioner, Individual #1's most current assessment completed 7/25/2025 does not indicate the need for the device, 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. Individual #1's individual support plan last updated 4/23/2026 does not include 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 06-30-26 the Program Specialist for Individual #1, #2 and #3 completed an addendum to each Individuals current assessment to include each Individuals need for the device, if the individual can easily remove the device, or if the device is removed by a staff person immediately upon the request or indication of the Individual. The Program Specialist sent to each Individuals team members the addendum, signed and dated by the Individual and Program Specialist. 07/08/2026 Implemented
SIN-00251416 Renewal 08/20/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #1 is provided a hospital bed, with attached bedrails, as a bed. This equipment was not prescribed by an authorized prescriber nor was it indicated in the Individual Support Plan, (ISP). Individual #2 is provided a hospital bed, with attached bedrails, as a bed. This equipment was not prescribed by an authorized prescriber nor was indicated in the Individual Support Plan, (ISP). Individual #3 is provided a hospital bed, with attached bedrails, as a bed. This equipment was not prescribed by an authorized prescriber nor was it indicated in the Individual Support Plan, (ISP).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. On August 22, 2024, 6400 Program Supervisor contacted Individual #1 PCP who prescribed and faxed a copy of the prescription for bedrails with the written diagnosis of 80.9. A copy of the script was sent to Individual #1 Support Coordinator to update in the Individual Support Plan usage of bedrails. On August 22, 2024, 6400 Program Supervisor contacted Individual #2 PCP who prescribed and faxed a copy of the prescription for bedrails with the written diagnosis of G80.9. A copy of the script was sent to Individual #2 Support Coordinator to update in the Individual Support Plan usage of bedrails. On August 22, 2024, 6400 Program Supervisor contacted Individual #3 PCP who prescribed and faxed a copy of the prescription for bedrails with the written diagnosis of G71.0. A copy of the script was sent to Individual #3 Support Coordinator to update in the Individual Support Plan usage of bedrails. 09/20/2024 Implemented
SIN-00212272 Renewal 09/28/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.34(a)Individual #1 was informed and explained individual rights on 1/21/22. The rights document did not include the following: 6400.32v··· their rights may only be modified to the extent necessary to mitigate a significant health and safety risk to the individual or others.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.The Individual Rights Form has been redone to include language compliant with regulation 6400.32v. The new individual rights form will be reviewed with Individual # 1 by 10/17/22 and annually thereafter. The new individual rights form will be used for all individuals in the 6400 programs operated by Community Living & Learning effective 10/17/22. 10/17/2022 Implemented