Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00261615 Renewal 03/04/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Easy off Heavy Duty Cleaner, Lysol Shower Foam and Fabuloso cleaner were under the kitchen sink unlocked during the physical site walk through.Poisonous materials shall be kept locked or made inaccessible to individuals. The unlocked Easy off Heavy Duty cleaner, Lysol shower foam, and Fabuloso were immediately secured during licensing on 3/5/25. All other poisonous materials were checked for proper storage throughout all residential sites. A mandatory training will be conducted for all staff to review the regulation, violation, and safety risk this presents to individuals with proper storage identified for each site. 05/01/2025 Implemented
6400.101The egress from the staff office was blocked from opening fully by lamp posts and a laundry basket.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Lamp and laundry basket removed (see document #1) following licensing. All pathways leading to exits have been cleared to ensure that there is no obstruction that could prevent safe evacuation. Mandatory staff training to review violations from licensing will be conducted by the Program Director during staff monthly training including the safety risk blocked exits presents to individuals. 05/01/2025 Implemented
6400.214(b)- Individuals # 1 and # 2 did not have current physicals at the home during the physical site walk through The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The individual site books have been updated to include only the essential site information for each individual. All site books also have an electronic version stored in a shared Teams folder, allowing documents to be quickly printed and added to physical books when needed. ( See document #3 for resident life plan book list) Individual books contain: 1. Resident information a. Personal information sheet b. Insurance cards c. Identification cards d. Current physical/annual exams e. Medication list f. Care protocols 2. Consents and Intake a. Money management b. Room and board c. Consents d. HIPPA 3. Medical consults/annual exam forms 4. ISP a. Current ISP b. ISP training sheets 5. Current Assessment 6. Current BSP/SEEN plans 05/01/2025 Implemented
SIN-00241526 Renewal 03/26/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(2)Individual #1's MARS from the last 3 months (January through March) did not indicate the name of the prescriber for PRN "Dentip Swab untreated".A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.MAR audits will be completed quarterly at each site. With the MAR audit, the Healthcare Manager or Healthcare Assistant will review all medications for diagnosis, prescriber, and directions for each specific medication. If issues are noted in the MAR audit, Healthcare Manager will contact the pharmacy to rectify and document the communication. New medications will be reviewed prior to approval in the electronic system to ensure all diagnoses, prescriber and directions are listed. If information is not in the electronic system from the pharmacy, the Healthcare Manager or Healthcare Assistant will contact the pharmacy and document the communication. 05/31/2024 Implemented
6400.166(a)(11)Individual #1's MARS from the last 3 months (January through March) did not indicate the diagnosis or purpose for the following medications: GS Clear lax powder, Potassium CL 10%, QC Clear Fiber Powder, Desitin, and Dentips Swab Untreated.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.MAR audits will be completed quarterly at each site. With the MAR audit, the Healthcare Manager or Healthcare Assistant will review all medications for diagnosis, prescriber, and directions for each specific medication. If issues are noted in the MAR audit, Healthcare Manager will contact the pharmacy to rectify and document the communication. New medications will be reviewed prior to approval in the electronic system to ensure all diagnoses, prescriber and directions are listed. If information is not in the electronic system from the pharmacy, the Healthcare Manager or Healthcare Assistant will contact the pharmacy and document the communication. 05/31/2024 Implemented
6400.166(d)Individual #1's MARS from the last 3 months (January through March) indicate that PRN "Dentip Swab untreated" is to be used "as directed". However, staff will not be able to follow the directions for appropriate use and administration if non are given/written on the MARS.The directions of the prescriber shall be followed.MAR audits will be completed quarterly at each site. With the MAR audit, the Healthcare Manager or Healthcare Assistant will review all medications for diagnosis, prescriber, and directions for each specific medication. If issues are noted in the MAR audit, Healthcare Manager will contact the pharmacy to rectify and document the communication. New medications will be reviewed prior to approval in the electronic system to ensure all diagnoses, prescriber and directions are listed. If information is not in the electronic system from the pharmacy, the Healthcare Manager or Healthcare Assistant will contact the pharmacy and document the communication. 05/31/2024 Implemented
6400.181(f)Individual #1's annual assessment was completed and sent to the team on 3/6/2024. The ISP meeting is scheduled for 3/26/2024, which is not a full 30 calendar days prior to the scheduled ISP meeting. Last year, the ISP meeting was held on 3/21/2023 and the annual assessment wasn't completed and sent to the team until 3/23/23, which was 2 days after the ISP meeting occurred. The annual assessment for individual #1 needs to be adjusted so that it is completed and sent in February.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Provider will offer retraining to all Program Specialists on regulation 6400.181 (a-f) to include dates of each individual's assessment and planning meeting. Program Specialist are responsible to track the assessment dates and ensure assessment is sent 30 days prior to individual planning meeting. 05/31/2024 Implemented
SIN-00201251 Renewal 03/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)At the time of the inspection individual #1's bathroom had a water temperature of 123 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. Maintenance personnel adjusted the water temperature while Licenser was still on site, from 120 degrees to 116 degrees. All ID Management were trained on the licensing plans of correction on 3/30/2022 (attachment #1) and all DSP will be trained by 4/08/2022. 04/30/2022 Implemented
6400.142(a)Individual #1 had a dental appointment on 7/21/21 and not another one in 6 months as directed by the dental recommendationsAn individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. This individual had a Dental appointment scheduled for 3/24/2022, prior to this licensing. The appointment was completed as scheduled (attachment #5) and a 6 month follow-up appointment has been scheduled for 10/03/2022, the first available appointment. All ID Management were trained on the licensing plans of correction on 3/30/2022 (attachment #1) and all DSP will be trained by 4/08/2022. 04/08/2022 Implemented
6400.52(c)(4)Staff # 4 received annual training in recognizing and reporting incidents on 04/01/20 and not again until 06/04/21. This annual training requirement is not to be more than 12 months between trainings.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Previous Training Facilitator resigned in February 2022. The new Training Facilitator started on 3/14/2022. Her training included reviewing the annual and new hire orientation training requirements for staff per the 6100 and 6400 regulations. She has revamped the training format to ensure we are meeting all regulations. All training modules have been labeled to match the language used in the corresponding regulations. All ID Management were trained on the licensing plans of correction on 3/30/2022 (attachment #1) and all DSP will be trained by 4/08/2022. 04/30/2022 Implemented
6400.52(c)(5)Staff # 4 received annual training in behavioral supports for individuals on 02/08/21 and not again until 02/24/22 exceeding the annual training requirement.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.Previous Training Facilitator resigned in February 2022. The new Training Facilitator started on 3/14/2022. Her training included reviewing the annual and new hire orientation training requirements for staff per the 6100 and 6400 regulations. She has revamped the training format to ensure we are meeting all regulations. All training modules have been labeled to match the language used in the corresponding regulations. All ID Management were trained on the licensing plans of correction on 3/30/2022 (attachment #1) and all DSP will be trained by 4/08/2022. 04/30/2022 Implemented
SIN-00167854 Renewal 02/25/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)No record of written summary of corrections in self-assessment complete 02/17/20.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. 1. Between January 14- February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 3-10, 2020, 3 new Program Specialists have joined the ID managment team. 2. A Self-Assessment binder was assembled and each site has it's own section. 3. All Program specialists were trained/retrained on the purpose of the self-assessment, how to complete and where they will be kept on 3/12/2020. 4. Self-assessments will be completed in January and July of every year. This will be scheduled by the Compliance Officer (hired 7/28/19) and completed as a group with assistance. 03/12/2020 Implemented
6400.68(b)Water temperature measured at 128.1 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. 1. A new thermometer was purchased on 3/1/2020 for taking water temperatures. 2. Daily water temperatures are being taken beginning 3/1/2020. 3. If temperature above 120, a maintenance request is submitted. This occurred once on 3/19/2020. Looking into a water heat extender that can be set to govern the temp at 120. 03/01/2020 Implemented
6400.104The most recent notification to the fire department dated 12/04/18 indicates that three individuals reside in the home. There are currently two individuals in the home.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. 1. Between January 14- February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 3-10, 2020, 3 new Program Specialists have joined the ID managment team. 2. February 27, 2020, the Fire department was notified. 3. A move guide was developed in 2015 and available for all Program Specialists to follow when a new resident moves in. 4. All Program specialists were trained/retrained on on notification of fire department on 3/12/2020. 03/12/2020 Implemented
6400.112(a)No successful fire drill completed in the months of May, June, and November 2019. An unannounced fire drill shall be held at least once a month. 1. Between January 14- February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 3-10, 2020, 3 new Program Specialists have joined the ID managment team. 2. All Direct Support Professionals were trained/retrained on Fire Safety and the requirements of fire drills on 3/11/2020. 3. All Program specialists were trained/retrained on on 3/12/2020 and Site Coordinators on 3/13/2020 on the requirements of fire safety. 4. All program specialists will review and initial the fire drill. If follow up action is required, copies of communication will be included with the unsuccessful fire drill. 03/13/2020 Implemented
6400.112(e)No successful asleep fire drill completed in the year 2019.A fire drill shall be held during sleeping hours at least every 6 months. 1. Between January 14- February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 3-10, 2020, 3 new Program Specialists have joined the ID managment team. 2. All Direct Support Professionals were trained/retrained on Fire Safety and the requirements of fire drills on 3/11/2020. 3. All Program specialists were trained/retrained on on 3/12/2020 and Site Coordinators on 3/13/2020 on the requirements of fire safety. 4. All program specialists will review and initial the fire drill. If follow up action is required, copies of communication will be included with the unsuccessful fire drill. 5. After there were only 2 residents in the home beginning in December 2019, 2 overnight staff were still maintained. 6. Maintenance team had previously contacted 3 separate agencies for quotes on a sprinkler system for this site. One on site walk through was completed and a quote for installation is still pending. 03/13/2020 Implemented
6400.32(r)No locks on any individual bedroom doors.An individual has the right to lock the individual's bedroom door.1. Developed bedroom door lock education/determination/condition form to be completed for each individual. This is to be completed by 4/17/20. 2. Door locks will be installed on individuals' bedroom doors as soon as COVID-19 protections are lowered and visitation to homes is safer. Anticipated installation date by 6/30/2020. 06/30/2020 Implemented
SIN-00149781 Renewal 02/07/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)Hot water temperature was measured at 138.7 F at the kitchen sink, 137.1 F at the bathroom sink, and 131.0 F at the bathtub. Hot water temperatures in bathtubs and showers may not exceed 120°F. 1. The maintenance team leader was contacted immediately and was on site at the time of licensing on 2/8/19. The temperature gauge on the hot water tank was adjusted manually and water temperatures were measured at 104 and 121 that day. 2. All Program Specialists were retrained on water temperature regulation requirements on 3/7/19. 3. A daily water temperature log was implemented at the 201 W. Whittier location on 3/4/19. Staff will all be trained on this and implemented at the 4/3/19 monthly training that will also present fire safety. 4. If at any time the temperature exceeds 120, staff are instructed to call a program specialist or maintenance to have the temperature gauge adjusted. 5. At this time, 3 other Family Services residential locations have a hot water extender placed on the hot water tank to keep the temperature from rising above 120. The maintenance team would like to install these at all locations but there is currently no time frame for completion. 6. A new Training and Compliance Officer has been hired with a start date of 3/25/19. 7. Once initial training is completed, the Training and Compliance Officer will work in conjunction with the ID Program Team to develop a Site Coordinator training to include all aspects of the job. Site Coordinator training development completion date is projected for 4/26/19. 8. Site Coordinator training will be presented once weekly to all 10 Site Coordinators to cover a variety of topics which will include their responsibility in monitoring the water temperature as per regulations. Site Coordinator training completion date is projected for 5/31/19. 02/08/2019 Implemented
SIN-00104669 Renewal 12/19/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(f)Individuals #2-#10's personal funds and the agency's funds are commingled into one Family Services agency account. Individuals #2-#10 had non-Family Services Inc. representative payees handling their finances. At the begining of each month, the Individuals' rep-payee would send a large sum of money into the Family Services account. According to the Personal Funds spreadsheet provided by Family Services at the time of licensing, Individual #2's rep-payee sent money to the Family Services account around 10/1/16 to cover the cost of room and board and any other personal spending money he/she needed. At the point when the room and board and other Individuals' personal spending money was in the account, the room and board monies belonged to Family Services and not the Individual. The Personal Funds spreadsheet indicated that by 11/30/16 two room and board payments were taken out of the comingled account for Individual #2 and there was still personal spending money available. Personal spending checks for Individuals are be written to direct support staff, who cash the check themselves. There may be no commingling of the individual's personal funds with the home or staff person's funds. Family Services Process for individuals who FSI is not representative payee is as follows: 1. The Room and Board contracts used are template from DPW and are written as agreement between person served and agency, not payee. (Attachment ) 2. Check made payable to Family Services is needed because of checking account being a business account, as per financial institution. (Attachment) 3. One check is received from payee for room and board and personal spending of person served and is deposited into the Client Personal Accounts checking account. 4. On or around the 10th of each month, room and board payments are transferred electronically to the Agency account for all residents. Monthly personal spending stays in Client Personal Account which is accounted for per individual by FSI. (Attachment ) 5. The room and board payments are paid by the residents through the ID Client checking account. (Attachment) 6. Once payments are made to the agency, the funds then become ¿agency funds¿. Up to the transfer they are resident¿s funds. After review of the non-complaint area explained above it is believed that there was a misunderstanding during the review of these records and that FSI¿s process for this does meet the requirements of this chapter, and that funds are not co-mingled, but are actually individuals funds (in the shared individual account) until the time in which they pay their Room and Board for the month. Attachment #22 outlines process and supporting documentation examples of implementation of that process. 01/24/2017 Implemented
6400.31(b)Individual #1 signed and dated acknowledgment of receipt of his/her rights on 12/12/2014 and not again until 2/10/2016.Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. Person Responsible: Elizabeth Hogue (Training and Compliance Officer), Terry Campbell (Program Director), Angela Long (Program Specialist). Consents will be updated annually moving forward, attached are due dates for Program Specialist to show when consents will be completed in the next year. Each year after that, the due date will move back one month to ensure compliance with the annual requirement. Attached are Individual #1¿s current and previous year¿s consents to show compliance with this chapter (Attachment #21 ). Review of All house records will take place no later than February 10, 2017 to ensure compliance in this chapter for all people served. Plan to Prevent Future Occurrence: All Program Specialists were retrained on this requirement on January 25, 2017 and instructed to add annual consent due dates to tickler/due date tracking system to prevent reoccurrence (Attachment #2). 01/31/2017 Implemented
6400.68(b)Water temperature of the home was 124 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. The water temperature was adjusted at the time of discovery by FSI maintenance crew. The water temperature was then checked periodically for the next several days to ensure that it remained under 120 degrees. (Attachment #20-emails from the house indicating the water temperature on several different days and times, all which show the temperature as being under 120 degrees.) Review of All house records will take place no later than February 10, 2017 to ensure compliance in this chapter for all people served. Water temperatures are checked at houses on a monthly basis. Plan to Prevent Future Occurrence: Program Specialists were retrained on the requirements of this chapter on January 25, 2017 (Attachment #2). This includes the need to address any water temperature reading that is above 120 degrees immediately. 01/25/2017 Implemented
6400.112(a)An unannounced fire drill was not conducted in the month of May 2016 An unannounced fire drill shall be held at least once a month. Person Responsible: Elizabeth Hogue (Training and Compliance Officer), Program Specialists Training with staff was held on January 11, 2017 which covered Fire Drill logs and the requirements surrounding a Fire Drill. The makeup training for staff who did not attend occurred on January 19, 2017 and January 25, 2017. (Attachment #16)This training included the need to evacuate in less than 2.5 minutes during a fire drill, with the exception of 2 sites, which have 10 minutes to evacuate during a fire drill per the extended evacuation time in writing by the local fire chief. This training also included the requirements around overnight/asleep drills being completed every 6 months and the months in which FSI conducts those drills, as well as review of new fire drill logs which will implement February 1, 2017. Review of All house records will take place no later than February 10, 2017 to ensure compliance in this chapter for all people served. A plan to prevent future occurrences: All Program Specialists were retrained on January 25, 2017 around the requirement to ensure that Fire Drills are completed on a monthly basis and evacuation times are less than 2.5 minutes. (Attachment #2) Fire Drill logs were updated on January 19, 2017 to include in the evacuation time section the statement which reads, ¿*If exit time greater than 2.5 minutes for all sites (Upper Beech and Respite 10 Minutes) drill must be re-done & supervisor notified.* A ¿review¿ line was also added so that all drills will be reviewed one turned in by responsible Program Specialist to ensure ongoing compliance with this chapter (Attachment #18). All staff were trained on new Fire Drill Log at the dates above and it will be implemented effective 2/1/2017. 01/31/2017 Implemented
6400.112(e)A fire drill was held during sleeping hours on 11/30/2015 and not again until 6/11/2016. A fire drill shall be held during sleeping hours at least every 6 months. Person Responsible: Elizabeth Hogue (Training and Compliance Officer), Program Specialists Training with staff was held on January 11, 2017 which covered Fire Drill logs and the requirements surrounding a Fire Drill. The makeup training for staff who did not attend occurred on January 19, 2017 and January 25, 2017. (Attachment #16)This training included the need to evacuate in less than 2.5 minutes during a fire drill, with the exception of 2 sites, which have 10 minutes to evacuate during a fire drill per the extended evacuation time in writing by the local fire chief. This training also included the requirements around overnight/asleep drills being completed every 6 months and the months in which FSI conducts those drills, as well as review of new fire drill logs which will implement February 1, 2017. Review of All house records will take place no later than February 10, 2017 to ensure compliance in this chapter for all people served. A plan to prevent future occurrences: All Program Specialists were retrained on January 25, 2017 around the requirement to ensure that Fire Drills are completed on a monthly basis and evacuation times are less than 2.5 minutes. (Attachment #2) Fire Drill logs were updated on January 19, 2017 to include in the evacuation time section the statement which reads, ¿*If exit time greater than 2.5 minutes for all sites (Upper Beech and Respite 10 Minutes) drill must be re-done & supervisor notified.* A ¿review¿ line was also added so that all drills will be reviewed one turned in by responsible Program Specialist to ensure ongoing compliance with this chapter (Attachment #18). All staff were trained on new Fire Drill Log at the dates above and it will be implemented effective 2/1/2017. 02/01/2017 Implemented
6400.213(11)Individual #1¿s physical dated 9/6/16 indicated dietary restrictions as ¿pureed diet, thick it added liquids, diabetic.¿ The "medical limitations" section of Individual #1¿s 9/9/16 assessment indicated "liquids should be thickened and food mechanically chopped into small pieces¿. Individual #1's Individual Support Plan (ISP) indicated that he/she should follow ¿a mechanical soft diet with liquids using thick added to them to get a nectar consistency¿. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. Person(s) Responsible: Angela Long (Program Specialist for home), Elizabeth Hogue (Training and Compliance Officer) All documents were reviewed and updated on 1/26/2017 to ensure that they all reflect the correct dietary restrictions for individual #1. Updates were sent in the form of track changes to Individuals SC and team (Attachment #19) includes updates to all documents and proof of send to SC). Review of All individual records will take place no later than February 10, 2017 to ensure compliance in this chapter for all people served. Plan to Prevent Future Occurrence: Program Specialists were retrained on January 25, 2017 and reminded on the importance of consistent documentation in these documents (Attachment #2). 01/26/2017 Implemented
SIN-00064677 Renewal 06/09/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)No fire drill completed in July of 2013. An unannounced fire drill shall be held at least once a month.   Implemented
SIN-00128614 Renewal 02/13/2018 Compliant - Finalized
SIN-00076847 Renewal 05/06/2015 Compliant - Finalized
SIN-00048637 Renewal 05/21/2013 Compliant - Finalized