Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00253712 Renewal 10/16/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(1)Individual #1's physical examination, completed 6/17/2024 did not include a review of past medical history.The physical examination shall include: A review of previous medical history. Residential supervisors addressed the missing documentation in the physical examination by coordinating with healthcare providers to gather the necessary information. Once retrieved, they attached the missing documentation to the physical examination form. 10/25/2024 Implemented
6400.141(c)(11)Individual #1's physical examination, completed 6/17/2024 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Residential supervisors addressed the missing documentation in the physical examination by taking action to retrieve the necessary information. They worked with healthcare providers involved in the patient's care to gather the undocumented details. Once the missing documentation was obtained, supervisors attached it to the physical examination form. 10/25/2024 Implemented
6400.181(e)(1)Individual #1's assessment, completed 5/9/2024 did not include functional strengths, needs, preferences of the individual. This section was left blank. The assessment must include the following information: Functional strengths, needs and preferences of the individual. The program specialist took the initiative to review all skills assessments for any incomplete sections. After identifying the missing information in Individuals assessment, she quickly filled in the blank with detailed insights about the individual's strengths, needs, and preferences. Once this important information was updated, the program specialist informed the treatment team of the changes. 10/25/2024 Implemented
6400.181(e)(10)Individual #1's assessment, completed 5/9/2024 did not include a lifetime medical history.The assessment must include the following information: A lifetime medical history. The program specialist reviewed all skills assessments for any incomplete sections. Upon discovering the missing lifetime medical history, she used the new form to document this essential information within the assessment. After updating the details, the program specialist quickly informed the treatment team of the changes. 10/25/2024 Implemented
6400.181(e)(12)Individual #1's assessment, completed 5/9/2024 did not include recommendations for specific areas of training, programming, and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. The program specialist proactively reviewed all skills assessments for any incomplete areas. Upon discovering that recommendations for specific training, programming, and services were missing, she completed all relevant sections of the assessment. After updating the necessary details, the program specialist promptly informed the treatment team of the changes. 10/25/2024 Implemented
6400.182(c)Individual #1's assessment, completed 5/9/2024 indicates Individual #1 independently tempers water. Individual #1's Individual Plan, last updated 9/20/2024 reads that Individual #1 may require assistance to properly temper water. [Repeated Violation, 10/31/23-11/1/23 et al.]The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The program specialist updated the Individual Plan to accurately reflect the current assessment findings. This involved modifying the language to align with the assessment results, ensuring clear communication regarding the support required by Individual #1. After making the necessary changes, the program specialist promptly informed the treatment team about the updates, ensuring that all team members were aware of the revised information and could adjust their strategies accordingly. 10/25/2024 Implemented
SIN-00229398 Unannounced Monitoring 07/27/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(b)At 10:31AM, mouse droppings were on a shelf in a closet in the basement of the home. [Repeat Violation, 3/29/2023]There may not be evidence of infestation of insects or rodents in the home. Orkin Pest Control came out to the residence to provide treatment to observe and exterminate mice. Mouse traps were put in place where the mouse drop was found on 7/27/23. A mandatory meeting was held on August 2, 2023, discussing how DSP staff will be observing for mice, keeping areas clean, and garbage removal. 08/28/2023 Implemented
6400.77(c)There is not a first aid manual in the home's first aid kit. A first aid manual shall be kept with the first aid kit.A printed first aid manual was put in the first aid kit immediately after findings. 08/28/2023 Implemented
6400.81(k)(6)There is not a mirror in Individual #1's bedroom.In bedrooms, each individual shall have the following: A mirror. A stick-on mirror was put in place so that the Individual #1 is unable to remove it. The self-adhesive mirror is safe and will not break; it is glued to smooth part of the consumer's wall. 08/28/2023 Implemented
6400.105At 10:33AM, there was an 3/4 inch thick of accumulation of lint in the dryer lint trap.Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. A mandatory meeting was held on August 2, 2023 concerning the removal and disposal of lint form the lint trap. A laminated sign was put on all dryers reminding to remove lint after every use. DSP staff were trained by the Residential Supervisor on the new visible lint removal sign located within the laundry room. DSP staff were trained on the safety precautions of the lint being removed from the dryer after each use. 08/28/2023 Implemented
6400.166(a)(7)Individual #1 is prescribed Clobazam 10MG tablets with instructions to increase the dosage with the following pattern, "take 1/2 tablet by mouth twice daily for 1 week for seizures," then "take 1/2 tablet by mouth in the morning and 1 tablet at bedtime for 7 days for seizures." The increased medication dosage was scheduled to start on 7/27/2023 and end on 8/2/2023 per physician's orders. It is initialed as administered at 8:00and 8:00PM daily from 8/22/2023 through 8/26/2023. [Repeat Violation, 3/29/2023]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.On 07/28/2023 The physician's office was contacted for clarification on the titration instructions the pharmacy was contacted, and a new MAR was received with corrected instructions. At a mandatory meeting on August 2, 2023, the staff was trained by the Residential Supervisor to review the medication administration documentation with the staff. 08/28/2023 Implemented
6400.166(a)(15)Individual #1 is prescribed Polyethylene Glycol with instructions to, "Mix 1/2 capful (titrated down to 1/8 capful if loose stools) in flavored water and drink by mouth once daily for constipation." Individual #1's July 2023 Medication Administration Record reads, "Scoop powder mix and dissolve 1/2 cap in 6 ounces of flavored water for constipation." The Medication Administration Record does not include the special precaution to titrate down if loose stools.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable.A mandatory meeting was held on August 2, 2023. DSP staff were trained by the Residential Supervisor to properly complete and utilize the Bristol Stool Chart to record drug effectiveness and how to monitor dosage administered. Staff are trained on tracking Individual #1's bowel movements and what to do if there are causes for concern. 08/28/2023 Implemented
SIN-00221741 Renewal 03/28/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At 10:22AM on 3/29/2023, the plate and interior walls of the microwave had food splatter and food crumbs. The dish drying rack, on the counter in the kitchen, had yellow and white residue and food crumbs. The shelves in the refrigerator have sticky brown substances. At 10:27AM on 3/29/2023, two large bags of garbage were on the floor of the garage.Clean and sanitary conditions shall be maintained in the home. Residential supervisors will review agency policy, guidelines and practices through document reviews and interviews with staff. This is to ensure that staff know and understand that at all times and all areas of the home must be clean and sanitary. 04/17/2023 Not Implemented
6400.64(f)At 10:30AM on 3/29/2023, there were two larger cardboard boxes, overflowing with smaller cardboard pieces and discarded items including a beverage can, a plastic bag and a plastic bottle, on the patio outside the door at the rear of the home. In addition, there was other discarded items including a tied shopping bag containing discarded items, several blue plastic bags and a water bottle, throughout the yard in the rear of home.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.All trash noted in description was removed by TFS maintenance on 4/5/23. Pictures will be sent to licensing for review. 04/05/2023 Not Implemented
6400.68(b)At 10:42AM on 3/29/2023, the hot water temperature measured 139.8F at the bathtub in the batroom on the second floor of the home. [Repeat Violation, 10/18/2022] Hot water temperatures in bathtubs and showers may not exceed 120°F. The water heater dial has been adjusted so that the water temperature will fall within (110° -119° ) 6400 regulation guidelines. Anti-scald devices are being installed on each faucet to prevent temperatures of 120° and above. 04/17/2023 Not Implemented
6400.72(a)There is not a screen in the window on the right side of Individual #1's bedroom.Windows, including windows in doors, shall be securely screened when windows or doors are open. TFS maintenance installed and replaced all missing screens to ensure the safety of the residence and to lower the risk of insect or rodent infestation. TFS maintenance has already replaced any/all missing screens on 4/5/2023. 04/17/2023 Not Implemented
6400.101There is a turn lock, on the basement side of the door between the basement and the garage posing an obstructed egress from the garage when engaged. There is not swing door in the garage.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. TFS Maintenance is installed a doorknob without a locking key mechanism. The door can only be locked from the inside of the home and not from the garage entry. This was completed on 4/5/23. 04/17/2023 Implemented
SIN-00233743 Renewal 10/31/2023 Compliant - Finalized