Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00258716 Renewal 01/14/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.151(e)(13)(ii)The annual assessment must include the individual's progress and growth over the last 365 days in motor and communication skills. Individual #1 annual assessment dated 8.15.24 was missing this section.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills.The program specialist will update the current assessment to include the progress and growth over the last 365 days in motor and communication 01/30/2025 Implemented
6500.151(e)(13)(iii)The annual assessment must include the individual's progress and growth over the last 365 days in activities of residential living. Individual #1 annual assessment dated 8.15.24 was missing this section. 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 program specialist will update the current assessment to reflect the progress and growth in the area of residential Living over the last 365 days. 01/30/2025 Implemented
6500.151(e)(13)(iv)The annual assessment must include the individual's progress and growth over the last 365 days in personal adjustment. Individual #2 annual assessment dated 12.02.24 was missing this section. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment.The program specialist will update the current assessment to reflect the progress and growth in the area of Personal Adjustment over the last 365 days. 01/30/2025 Implemented
6500.151(e)(13)(viii)The annual assessment must include the individual's progress and growth over the last 365 days in managing personal property. Individual #1 annual assessment dated 8.15.24 was missing this section. 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 program specialist will update the current assessment to reflect the progress and growth in the area of managing personal property over the last 365 days. 01/30/2025 Implemented
6500.151(e)(13)(viii)The annual assessment must include the individual's progress and growth over the last 365 days in managing personal property. Individual #2 annual assessment dated 12.02.24 was missing this section. 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 program specialist will update the current assessment to reflect the progress and growth in the area of managing personal property over the last 365 days. 01/30/2025 Implemented
6500.151(e)(13)(ix)The annual assessment must include the individual's progress and growth over the last 365 days in community integration. Individual #1 annual assessment dated 8.15.24 was missing this section. 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 program specialist will update the current assessment to reflect the progress and growth in the area of Community integration over the last 365 days. 01/30/2025 Implemented
6500.151(e)(13)(ix)The annual assessment must include the individual's progress and growth over the last 365 days in community integration. Individual #2 annual assessment dated 12.02.24 was missing this section. 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 program Specialist will update the current assessment to include the progress and growth over the last 365 days in community integration. 01/30/2025 Implemented
6500.182(c)(1)(iv)Individual #1 record did not list religion, that area was left blank.Each individual's record must include the following information: Personal information, including: The religious affiliation.The program specialist will ensure that no areas of the fact sheet are left blank, if information is not available or unknown then indicate that on the document. 01/30/2025 Implemented
SIN-00216734 Renewal 01/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.32(r)(4)The locking mechanism shall allow easy and immediate access by the individual or staff in the event of an emergency. The door locking mechanism on the two individuals' bedroom doors was a "coin-lock" style locking mechanism which requires a special tool to open and is not an acceptable locking mechanism, per the Office of Developmental Programs (ODP).An individual has the right to lock the individual's bedroom door. The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency.Will install locks with conventional key access on both individuals bedroom doors. Each individual and staff will continue to have access using a key rather than the coin lock mechanism used before. 02/06/2023 Implemented
SIN-00197751 Renewal 02/08/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.110(c)There was no documentation of annual fire safety training for Staff #2.Family members and individuals, including children, shall be trained within 31 calendar days of an individual living in the home and retrained annually, in accordance with the training plan specified in subsection (a).Fire Safety Officer training will only be scheduled on days that the entire family and the individuals will be able to attend. 02/28/2022 Implemented
6500.121(c)(3)Current physical for Individual #1 is documented as being completed on 1/31/22. Diphtheria and Tetanus immunization is documented on this form as being completed on 1/4/22. Previous physical for Individual #1 completed on 1/26/21 indicates that the prior Diphtheria and Tetanus immunization was completed on 12/5/11. Diphtheria and Tetanus immunization is required every ten years. This exceeds the required time frame and 15-day grace period.Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Staff will schedule the immunizations with the individual¿s physician at least every 10 y years. Staff will be retrained on the regulation¿s requirements regarding individuals¿ annual physicals. Ensuring that all individuals have up to date Immunizations 02/28/2022 Implemented
6500.121(c)(6)Current physical for Individual #1 is documented as being completed on 1/31/22. Corresponding Mantoux Screening form documents the Mantoux as given on 1/31/22. Previous Mantoux for Individual #1 is documented on the prior Mantoux Screening form as being given on 1/13/20. Mantoux is required every two years. This exceeds the required time frame and 15-day grace period.Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if a tuberculin skin test is positive, an initial chest x-ray with results noted.Staff will schedule the TB/Mantoux screening with the individual¿s physician at least every 2 years. Staff will be retrained on the regulation¿s requirements regarding individuals¿ annual physicals. Ensuring that all individuals have up to date TB screening. 02/28/2022 Implemented
6500.121(c)(7)Individual #1 had an annual GYN exam completed on 2/4/21. No PAP was completed. Physician noted "not performed, next pap Jan 2025." No additional documentation was present to indicate the reason why the annual requirement should be waived. Annual pap screenings are required unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. The physical examination shall include: A gynecological examination, including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations.Staff will be retrained on proper documentation for medical appointments. Training will include emphasis on areas that require explanation from the physician regarding their recommended screening intervals. The agency did seek further explanation from the physician but have not received a return on our requests. 02/28/2022 Implemented
SIN-00147180 Renewal 12/07/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.17(a)The self-assessment was completed 10/28/18, which was not within 3 to 6 months prior to the expiration date of the agency's certificate of compliance which is 11/04/18.If an agency is the legal entity for the family living home, the agency shall complete a self-assessment of each home the agency is licensed to operate 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.On 12/7/2018 the Residential Manager reviewed all the self-assessments for each of the residential sites to ensure they were completed within 3-6 months prior to the expiration of the certificate of compliance which is 11/4/2018. All sites were in compliance except for site 0030 Stephanie Way which is also on the violations list and will have a separate Corrective Action Plan. The Agency had not understood the regulation 17(a) correctly. After discussion between the licensing inspector and HHOS agency officials we now understand it correctly. The licensing protocols and plans developed by the agency will be adjusted to include the correct timing of self-assessments that will be with 3-6 months of the certificate of compliance. 12/07/2018 Implemented
6500.151(e)(12)The annual assessment dated 9/02/18 for Individual #1 did not document 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.On 12/10/2018 the Program Specialist reviewed the assessment and other documentation regarding the individual and added some recommendations to the assessment dated 9/02/2018. The recommendations included monthly reviews from the provider on the individual¿s specific nutritional progress and council from the Lifesharing provider with the individual on healthy snack choices and portion control. The Program Specialist also reviewed the other individual¿s assessments to record recommendations on specific areas of training, programming and services are documented. In the future the Program specialist will include the recommendations in a separate section of the assessment titled Recommendations for specific areas or training, programming and services. Previously, we had the recommendations being made throughout the body of the assessment. 12/10/2018 Implemented
SIN-00124157 Renewal 01/03/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.121(c)(6)Individual #1's TB test was late. She had one 04-29-14, then not again until 05-17-16.Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if a tuberculin skin test is positive, an initial chest x-ray with results noted.Staff will schedule the TB/Mantoux screening with the individuals physician at least every 2 years. Staff will be retrained on the regulations on 1/31/2018. Ensuring that all individuals have up to date TB screening. 01/22/2018 Implemented
6500.121(c)(11)The section on Individual #1's physical form pertaining to the assessment of health maintenance needs was left blank. 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.Staff will be retrained on proper documentation for medical appointments. Training will include emphasis that all areas of the medical forms and documentation are completed. Staff will complete the sections of the medical forms that are necessary for the doctor to review prior to the appointments and make sure that the doctors have completed the sections they are responsible for. ((The physical forms have been faxed to the physician with a request to complete the missing information on 2/1/2018 - CH 2/6/2018)) 01/25/2018 Implemented
6500.121(c)(14)The section regarding medical information pertinent to diagnosis and treatment in case of an emergency was left blank on Individual #1's physical form. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Staff will be retrained on proper documentation for medical appointments. Training will include emphasis that all areas of the medical forms and documentation are completed. Staff will complete the sections of the medical forms that are necessary for the doctor to review prior to the appointments and make sure that the doctors have completed the sections they are responsible for. ((The physical forms have been faxed to the physician with a request to complete the missing information on 2/1/2018 - CH 2/6/2018)) 01/25/2018 Implemented
SIN-00085895 Renewal 01/08/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.125(c)(1)The Provider's son (staff 1) has a DOB of 6/10/2007. The Provider began to provide services in their home in Dec. 2007. During the physical for the Provider's son on 12/11/2007, the PCP stated that the child was too young to complete the Tuberculin skin test for him. The child has not received the test since this date. The physical examination shall include: (1) A general physical examination.(2.) Tuberculin skin testing by Mantoux method with negative results every 2 years for family members 1 year of age or older; or, if a tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or licensed practical nurse instead of a licensed physician. (3.)A signed statement that the person is free of communicable diseases or specific precautions to be taken if the person has a communicable disease. (4.)Information of medical problems which might interfere with the health of the individuals.On 1/11/2016 The Program Director will discuss with the minor¿s (staff 1) mother the violation and ask that she re-evaluate the physician decision regarding the TB screening. After agreement with the physician the TB and Physical completed for staff 1 on 1/22/2016. New Agency Policy Effective 2/1/2016: When a physician recommends forgoing a TB screening the staff or family member will have to re-evaluate the recommendations every Two years with their physician, physician assistant or nurse practitioner. Documentation regarding the re-evaluation with the medical personnel will need to be signed, dated and filed along with the other staff/family records. 01/22/2016 Implemented
SIN-00235591 Renewal 01/17/2024 Compliant - Finalized
SIN-00182428 Renewal 02/23/2021 Compliant - Finalized
SIN-00165212 Renewal 10/30/2019 Compliant - Finalized
SIN-00104405 Renewal 01/17/2017 Compliant - Finalized
SIN-00066577 Renewal 10/29/2014 Compliant - Finalized