Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00210887 Renewal 09/06/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.52(c)(6)Staff person #1 has not been trained in the individual plans and protocols for Individual #1 in training year July 1, 2021 through June 30, 2022. Staff person #1 was last trained on Individual #1's plan on 1/1/20. Individual #2 moved into the home on 4/4/22, and there is no documentation provided verifying that staff person #1 has been trained on this individual's plans and protocols.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Staff person #1 reviewed all plans and protocols for the individuals at the home and signed off the acknowledgement forms on 9-11-22. 10/03/2022 Implemented
SIN-00154515 Renewal 06/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.213(11)Individual #1's current physical states Individual must drink 4 liters of liquid a day. In the Know and Do section of the Individual's current ISP it states Individual is to drink says 5 liters a day at minimum. In the same ISP under the Meals/Eating section it says the Individual should drink at least 3 liters of fluid a day. Per discussion with staff #1 , it was determined that Individual #1 no longer needs to monitor liquid intake. No evidence in the record stating this. In the Meals/Eating section of Individual #1's current ISP states individual is without direct supervision at mealtime. According Individual #1's current eating/food preparation protocol the individual is supervised during mealtime. In the current ISP under the Know and Do section it says Individual #1 can be out of staff eyesight for 10 minutes at a time if comfortable in the situation and there is immediate access to staff should they be needed. The current Assessment Dated says Individual #1 can remain in the car if needed if staff go into a store. Otherwise, Individual #1 should be within eye sight of staff, in regards to Community Supervision. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. An e-mail was sent on 6/20/19 by Rebecca Lueders, Program Specialist, to Lindsay Hoover, Supports Coordinator, requesting that the amount of water Individual #1 drinks to be removed from the Know and Do section of the ISP. This e-mail also included a request changing information under the Meals/Eating section to ¿she will drink water throughout the day¿. I, Sara Quay, updated the current physical to reflect that Individual #1 should drink water throughout the day on 7/9/19. An e-mail including changes to the current ISP was sent to Lindsay Hoover from Rebecca Lueders on 7/9/19. This included requests to have the statement ¿Individual #1 needs to be within eye sight when eating¿ added to the Meals/Eating section. Following this e-mail, I responded on 7/9/19 requesting that the supervision mentioned under the Know and Do section be updated to match what is currently in the assessment "Individual #1 can remain in the car if needed when staff go into a store as long as it is appropriate regarding the temperature, location, and if the keys are removed from the car"). I, Sara Quay, retrained Rebecca Lueders on the importance of all information in all documents, including the ISP, Assessment, etc., be accurate and consistent throughout on 7/10/19. Copies of documents are attached. 07/10/2019 Implemented
SIN-00079666 Renewal 03/31/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(13)(iii)Indvidual #1's assessment did not include progress over the last 365 calendar days and current level in activities of residential living.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. The assessment for Individual #1, who resides at Brian Drive-not Swarthmore, was reviewed by the Program Specialist. The PS compared the current assessment to the previous assessment noting progress in this section over the last 365 calendar days. This information is included in individual #1's current assessment. This review occurred on 4/27/15. To prevent future occurrences, regulation 181(e)(13)(I-IX) regarding Progress and Growth was reviewed with all Program Specialists. They have been trained in their responsibilities of including progress over the last 365 calendar days and current level of skill in this area. This training occurred on 4/28/15. 04/28/2015 Implemented
6400.181(e)(13)(vii)Indvidual #1's assessment did not include progress over the last 365 calendar days and current level in financail independence. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. The assessment for Individual #1, who resides at Brian Drive-not Swarthmore, was reviewed by the Program Specialist. The PS compared the current assessment to the previous assessment noting progress in this section over the last 365 calendar days. This information is included in individual #1's current assessment. This review occurred on 4/27/15. To prevent future occurrences, regulation 181(e)(13)(I-IX) regarding Progress and Growth was reviewed with all Program Specialists. They have been trained in their responsibilities of including progress over the last 365 calendar days and current level of skill in this area. This training occurred on 4/28/15. 04/28/2015 Implemented
6400.181(e)(13)(viii)Indvidual #1's assessment did not include progress over the last 365 calendar days and current level in managing personal property.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. The assessment for Individual #1, who resides at Brian Drive-not Swarthmore, was reviewed by the Program Specialist. The PS compared the current assessment to the previous assessment noting progress in this section over the last 365 calendar days. This information is included in individual #1's current assessment. This review occurred on 4/27/15. To prevent future occurrences, regulation 181(e)(13)(I-IX) regarding Progress and Growth was reviewed with all Program Specialists. They have been trained in their responsibilities of including progress over the last 365 calendar days and current level of skill in this area. This training occurred on 4/28/15. 04/28/2015 Implemented
6400.181(e)(13)(ix)Indvidual #1's assessment did not include progress over the last 365 calendar days and current level in community-integration. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.The assessment for Individual #1, who resides at Brian Drive-not Swarthmore, was reviewed by the Program Specialist. The PS compared the current assessment to the previous assessment noting progress in this section over the last 365 calendar days. This information is included in individual #1's current assessment. This review occurred on 4/27/15. To prevent future occurrences, regulation 181(e)(13)(I-IX) regarding Progress and Growth was reviewed with all Program Specialists. They have been trained in their responsibilities of including progress over the last 365 calendar days and current level of skill in this area. This training occurred on 4/28/15. 04/28/2015 Implemented
SIN-00105085 Renewal 02/07/2017 Compliant - Finalized