Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00241248 Renewal 03/19/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)Individual #1, date of admission 12/18/23 was initially instructed in fire safety training on 12/28/23. 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. All individuals will be trained on fire safety the day that they are admitted. Training Manager will provide the appropriate training materials and Program Supervisor will ensure that this is completed. This will occur prior to the move-in day fire drill so that the individual is aware of the evacuation process and meeting place. After the initial training all individuals will be trained annually during fire safety month. 03/22/2024 Implemented
6400.181(d)Individual #1's assessment, completed on 2/1/24, was not signed or dated by the program specialist.The program specialist shall sign and date the assessment. Program Specialist had typed and dated the assessment. Program Specialist provided a wet signature and dated the assessment. All current assessments were reviewed to ensure they were signed and dated. 03/25/2024 Implemented
SIN-00241643 Unannounced Monitoring 03/04/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Individual #1's individual support plan, last updated 11/09/2023, states "the individual needs assistance and direction to prevent her form ingesting non-food items that could potential affect her health. All cleaning products are locked or out of reach in the individual's home". Individual #2's individual support plan, last updated 5/22/2023, states "the individual does not have access to cleaning products, hygiene products, or poisonous chemicals. She is not able to use these products safely. In the past the individual has attempted to drink nail polish remover and she has tried to clean her bed with Bleach and then laid on it". On 3/04/2024 the following poisonous materials, with instructions to contact poisons control for treatment advice, were located unlocked and accessible in a closet at the bottom of the second-floor staircase: 946ml bottle of Lysol Advanced Power toilet cleaner, (3) 19oz cans Lysol Disinfectant Spray, and (3) 35 count containers of Clorox Disinfectant Wipes. The closet in the second-floor hallway had a 19oz can of Lysol Disinfectant Spray unlocked and accessible. The garage contained a 18.3L can of ProMar 400 Paint and (3) 50lb containers of Snow & Ice Melt, with instructions to seek medical attention immediately if swallowed.Poisonous materials shall be kept locked or made inaccessible to individuals. All poisons were locked immediately after discovery on 3-5-24. Staff were retrained on the ISP including locking poisonous substances on 4-1-2024. 04/01/2024 Implemented
6400.71On 3/04/2024 the telephone located in the living room, under the television, did not include numbers of the nearest hospital, police department, fire department, ambulance and poison control center.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. Emergency numbers were added to the phone on 3-5-2024. 03/05/2024 Implemented
6400.81(i)On 3/04/2024 Individual #1's bedroom windows did not have drapes, curtains, shades, blinds or shutters.Bedroom windows shall have drapes, curtains, shades, blinds or shutters. Curtains were replaced on 3/5/2024. They were replaced with curtains that secure with Velcro so they would be easy to put back up in the event that the individual supported pulls them down. 03/18/2024 Implemented
6400.81(k)(6)On 3/04/2024 Individual #1 and Individual #2 did not have a mirror in their bedrooms.In bedrooms, each individual shall have the following: A mirror. A mirror was placed in both of the individuals' bedrooms on 3-5-2024. 03/05/2024 Implemented
6400.82(f)On 3/04/2024 the second-floor bathroom did not have a trash receptacle.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. Trash can was purchased and placed in the second-floor bathroom on 3-5-2024 03/18/2024 Implemented
6400.32(e)Individual #1 individual support plan, last updated 11/09/2023, states "Knives are locked in the home". Individual #1's assessment, completed 8/16/2023, states knives and sharps are locked as the individual is not safe with them unless under direct supervision. The individual can use knives under direct supervision but should be locked otherwise. Individual #1 does not have a restrictive procedure plan knives and sharps to be locked.An individual has the right to make choices and accept risks.Provider collaborated with BSC, Individual supported and Team and adding sharps was proposed to the HRT and subsequently added to the current restrictive procedure plan on 4/12/2024. 04/12/2024 Implemented
6400.166(a)(11)Individual #1's March 2024 medication administration record did not include a diagnosis or purpose for the following medications: Aripiprazole 15mg, Carbamazepine 200mg, Clonidine .2mg, Fluoxetine 40mg, Melatonin 3mg, and Trazadone 100mg. Individual #2's March 2024 medication administration record did not include a diagnosis or purpose for the following medications: Clonazepam .5mg, Divalproex 500mg, Escitalopram 10mg, Escitalopram 20mg, Risperidone 2mg, and Risperidone 4mg.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Program Supervisors audited the medication administration record at all homes on 3-20-2024 to ensure that all required components were present. Diagnosis was added to any medications in which it was missing. 04/01/2024 Implemented
SIN-00224939 Renewal 04/11/2023 Compliant - Finalized