Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00290262 Renewal 06/16/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101At 12:07 PM on 6/17/2026, the interior basement door leading to the home's attached garage was equipped with a standard door lock assembly, requiring a key to disengage it from the garage side. Since the attached garage did not have an exterior swing door, an entrapment area existed within this area. [Repeated Violation---6/17/25, et al.]Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. 6400.101- Stairways, halls, doorways, and exits from rooms and from the building shall be unobstructed. The doorknobs were inadvertently installed with the key side being in the garage. All doorknobs will be re-installed to have the key side in the basement. 06/25/2026 Implemented
6400.151(a)Direct Service Worker #1 had biennial physical examinations completed on 11/29/2023, and then again on 12/4/2025. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. 6400.151(a)- A staff person who comes into direct contact with the individuals or who prepares or serves food for more than 5 days in a 6-month period, including temporary, substitute, and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. The agency has implemented a centralized Staff Tracking System to monitor and maintain all required staff qualifications, including: · Mandatory trainings and annual training requirements · Criminal background clearances · Child abuse clearances (if applicable) · FBI clearances (if applicable) · Pre-employment and annual physical examinations · TB testing requirements and renewal dates 06/23/2026 Implemented
6400.181(e)(1)Individual #1's current assessment, completed on 12/31/2025, did not address their functional strengths, needs, and preferences, as the document neither included corresponding fields, nor contained such information throughout its entirety. [Repeated Violation---6/17/25, et al.] The assessment must include the following information: Functional strengths, needs and preferences of the individual. 6400.181(e)(1)_-- The assessment must include functional strengths, needs and preferences of the individual. A section was added to the annual assessment to document each individual's functional strengths, needs, and preferences. Individual #1's assessment dated 12/31/2025 was revised to reflect the functional strengths, needs and preferences and sent to the Supports coordinator on 6/25/2026. 06/25/2026 Implemented
6400.181(e)(12)Individual #1's current assessment, completed on 12/31/2025, did not include recommendations for skill growth with specific areas of training, programming, and services for implementation, as the corresponding field was marked, "N/A," and such information was not addressed elsewhere in the document.The assessment must include the following information: Recommendations for specific areas of training, programming and services. 6400.181(e)(12)- - The assessment must include the following information: Recommendations for specific areas of training, programming, and services. The agency has reinforced procedures requiring that all individual assessments include documented recommendations, and that follow-up actions are clearly recorded in the individual's record. The Operations Manager will provide targeted training to the Program Specialist(s) on: · Completing and reviewing individual assessments · Identifying and documenting recommendations · Ensuring recommendations are translated into actionable supports and services · Tracking completion and outcomes of recommendations within required timeframes Individual #1's assessment dated 12/31/2025 was revised to reflect recommendations for training, programming and services and sent to the supports coordinator. 06/25/2026 Implemented
6400.181(e)(14)Individual #1's current assessment, completed on 12/31/2025, did not address their ability to swim, as the corresponding skill criterion read: "Ability to swim: Yes or No," without a response indicated, and such information was not contained elsewhere in the document.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. 6400.181(e)(14)- - The assessment must include the following information: . The individual's knowledge of water safety and ability to swim. The agency reinforced procedures for completing and implementing all ISP/assessment requirements. The Operations Manager will provide targeted training to the Program Specialist on: - - Understand requirements of ISP and assessment implementation - Ensure recommendations are documented and followed through - Accurately update individual records - Track outcomes and progress of assigned supports - Maintain compliance with regulatory documentation requirements Individual #1's assessment dated 12/31/2025 was revised to reflect the knowledge of water safety and ability to swim and was sent to the supports coordinator. 06/25/2026 Implemented
6400.46(b)Direct Service Worker #1's fire safety trainings completed on 3/25/2025, and then again on 3/24/2026, did not include home or site-specific content in relation to evacuation routes, fire extinguisher locations, and designated meeting places.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).6400.46(b)- Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). The agency has developed a standardized annual fire safety training program specific to the In-Home and Community Support component. This training encompasses both computerized training and in home residential fire safety training. Direct Service Worker #1 was retrained on 6/25/2026 and will be trained annually on the in home component of the fire safety and emergency training by the Training Specialist A training tracking system will be utilized to monitor annual training due dates and provide advance notifications prior to expiration. 06/25/2026 Implemented
6400.50(a)On 3/23/2025, Direct Service Worker #1 completed annual training for the 2025 calendar year regarding the safe and appropriate use of behavior support plans as well as the implementation of the Individual Support Plan by reviewing Individual #1's Positive Behavior Support Plan and Service Plan. However, the trainer(s) who had conducted these sessions were not documented.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.6400.50(a)- Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received, and staff persons attending, shall be kept. The agency has already implemented standardized training documentation forms in 2026 to ensure all required elements of training records are consistently documented and maintained. These forms include fields for the training title, training source, content summary, date completed, trainer signature, and employee signature. 06/30/2026 Implemented
6400.182(c)Individual #1's Service Plan, last updated 6/5/2026, and their current assessment, completed on 12/31/2025, contained discrepancies in the following health and safety skills domains: regarding non-insulated heat sources exceeding 120 degrees Fahrenheit, Individual #1's Service Plan, last updated 6/5/2026, contained no information or directives indicating Individual #1's knowledge of the danger of such heat sources as well as their ability to sense and quickly move away from them. However, Individual #1's assessment, completed on 12/31/2025, indicates that Individual #1 is knowledgeable of the danger of such heat sources and can independently sense as well as quickly move away from them; and regarding home supervision, Individual #1's Service Plan, last updated 6/5/2026, explained that Individual #1 requires 24-hour daily supervision with an awake overnight staff and that Individual #1 can be alone in their bedroom with periodic checks. In contrast, Individual #1's assessment, completed on 12/31/2025, informed that Individual #1 cannot be left alone when at home. [Repeated Violation---6/17/25, et al.]The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.6400.182(c) -- 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 will be retrained on the procedures for notifying the Supports Coordinator of any necessary changes to an individual's service needs that may require revisions to the Individual Support Plan (ISP). The Program Specialist will be retrained on documenting all notifications, communications, and corresponding actions taken in accordance with agency policy. Individual #1's Assessment dated 12/31/2025 was revised on 6/25/2026 to reflect the individual's ability to have alone time in her room with periodic checks and sent to the supports coordinator. 06/25/2026 Implemented
SIN-00268410 Renewal 06/17/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(1)Individual #1 was assessed on 1/6/25 to not be able to manage their own funds. The individual does receive $50.00 on a regular basis from the rep-pay. The individual is given complete control of the monies with no agency interventions/monitoring, despite the assessment indicating the individual can manage $0.00 money. On 6/18/25, there was no financial ledger kept at the home for Individual #1's financial resources, including the dates and amounts of deposits and withdrawals as well as any corresponding receipts. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. On June 18, 2025, it was identified that Individual #1, who was assessed on January 6, 2025, as unable to manage their own funds, receives $50.00 monthly. However, financial transaction records were not being kept in accordance with the regulation. Upon review, it was determined that the individual is, in fact, capable of managing their own funds, and the current assessment does not accurately reflect this. On July 2 , 2025, a review meeting was held with Individual #1 and the support team to reassess financial capability. The team determined that Individual #1 is able to manage their own funds independently. The individual's Assessment and Individual Support Plan (ISP) are being reviewed to accurately reflect their ability to independently manage their monthly funds. The updated assessment will be completed The Supports Coordinator will be contacted to revise the ISP to reflect Individual #1 is capable of managing her own funds. The Program Specialist will be retrained on : The importance of accurately documenting individuals¿ capabilities. Ensuring that assessments and ISPs are person-centered and reflect current functioning 07/31/2025 Implemented
6400.65On 6/18/25 at 12:02 pm the only bathroom in the basement was without a window or proper ventilation. [Repeat Violation-7/1/24 et al.]Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. On June 18, 2025, during a licensing audit, it was observed that the only bathroom located in the basement did not have a window or an operable mechanical ventilation system. Immediate Corrective Action Taken: A licensed contractor was hired, and installation of a code-compliant mechanical ventilation system (bathroom exhaust fan vented to the outside) was completed on June 25, 2025. The exhaust fan is hardwired with the light switch to ensure it operates during bathroom use. Retraining of all House Supervisors and Program Specialist will be conducted to review 6400.65 requirements and the importance of environmental safety standards. 07/31/2025 Implemented
6400.141(b)Individual #1's annual physical examination, dated 10/1/24, was not dated by the physician.The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. During a licensing audit, it was found that Individual #1's annual physical exam, dated October 1, 2024, was not dated by the physician, resulting in noncompliance with the regulation. Correction Plan 1. Immediate Corrective Action Taken: On June 18 ,2025, the original physical exam form was returned (faxed) to the physician's office for completion. The physician dated the form on July 18, 2025 and faxed back to the provider's office. The dated copy was placed in Individual #1's medical file. House Managers and Program Specialist will be trained on the importance of regulatory compliance of 6400.141(b) and documentation standards as well as the Physical exam checklist. 07/31/2025 Implemented
6400.181(d)Individual #1 assessment dated 1/6/24 was not signed by a program specialist.The program specialist shall sign and date the assessment. During a licensing review, it was found that Individual #1's assessment dated January 6, 2024, was not signed by the program specialist, resulting in noncompliance of regulation 6400.181(d). Immediate Corrective Action: The program specialist originally conducting the assessment from 1/6/25 is no longer employed by the provider agency. The current Program Specialist will review the assessment completed on January 6, 2024 for accuracy and completion and signed and dates the document. The signed assessment was refiled in the individual's record and sent via email to the team. A Individual Assessment Checklist will be used to ensure all required components including the program specialist's signature and date are completed before filing. 07/31/2025 Implemented
6400.181(e)(1)Individual #1's assessment dated 1/6/25 did not identify strengths, needs and preferences. The assessment must include the following information: Functional strengths, needs and preferences of the individual. During a licensing inspection, it was identified that Individual #1¿s assessment dated January 6, 2025, did not include documentation of the individual's strengths, needs, and preferences, in violation of the regulatory requirement. The program specialist will meet with Individual #1, to gather accurate and current information regarding the individual's strengths, functional needs, and personal preferences. A revised assessment will be completed and signed, and now includes a clearly defined section outlining strengths, needs, and preferences as required. Long-Term Corrective Action: A review of all current assessments will be conducted, to ensure that the required elements under 6400.181(e)(1) were properly documented for all individuals. Any assessments found to be lacking will be corrected immediately with updated input from the individual and their support team. Program specialists will be retrained regarding assessment content requirements under 6400.181(e) and person-centered planning practices 07/31/2025 Implemented
6400.32(n)On 6/18/25 at 11:50 am the only house telephone was located in the staff office, which is locked, at times. the individual residing at the home does not have a restrictive procedure plan approved by a human rights team, limiting the right to unrestricted and private access to telecommunications.An individual has the right to unrestricted and private access to telecommunications.On June 18, 2025, during a licensing inspection, it was noted that the only house phone was located in the staff office, which is locked at times, thereby restricting individuals¿ access to a telephone. Immediate Corrective Action Taken: On June 20, 2025, a second phone was placed in the common area in the home ( Livingroom) where it is readily accessible to individual at all times and allows for private use. Individual was informed new location of the phone and encouraged to use it freely. The House Supervisor and all House staff will be retrained , on individual rights under 6400.32(n), with emphasis on privacy, dignity, and accessibility. 07/31/2025 Implemented
6400.165(b)The individual is prescribed Aripiprazole 30 Mg Tablets to be taken at 8PM for mental health. This medication was not in the home, as it was placed "on hold" and was not administered from 6/14/25 to 6/17/25, due to an expired script. The agency did not provide the current physician's orders, and the prescribed medication, itself, was not at the home due to the physician's orders not being kept current.A prescription order shall be kept current.During a licensing inspection, it was identified that Individual #1, who is prescribed Aripiprazole 30 mg daily at 8:00 PM for mental health treatment, did not receive the medication from June 14, 2025, through June 17, 2025. The lapse in administration occurred because the prescription expired and the doctor's office did not respond to refill requests, despite multiple follow-up attempts made by both the pharmacy and provider staff beginning 7 days prior to the expiration date. On June 19, 2025, after continued attempts, the provider and pharmacy escalated the issue by contacting the medical office's on-call physician . A new prescription was received and filled on June 26, 2025, and medication administration resumed immediately. A Medication Escalation Protocol was implemented on June 30, 2025, outlining the following steps:: Escalation Procedure 1. Initiate prescription renewal request 10 days prior to expiration. 2. Contact the prescriber¿s office via phone or fax. Document the request in the Medication Communication Log. 3. If no response within 48 hours, initiate the first follow-up: o Call the prescriber¿s office again. o Send a second written fax request, marked URGENT. 4. If still no response after another 48 hours (96 hours total): o Contact the office manager or practice administrator. o Leave a message or request a callback from the on-call or backup physician. 5. Notify the Program Specialist and Program Director immediately after 4 days of no response. 6. If unresolved within 5 days of the initial request: o Call the individual¿s Primary Care Provider or psychiatrist (if different). o Contact the pharmacy to explore emergency refill options or alternate plans. 7. Document every communication attempt in the Medication Communication Log including: o Date, time, who was contacted, summary, and staff initials. 8. Once the prescription is received and filled: o Resume administration. o Complete a Medication Error Report if any dose was missed. o Finalize the log with the prescriber¿s instructions and resolution date. House Supervisors were trained on the escalation process, documentation standards, and their responsibilities to act proactively when responses are delayed. 07/18/2025 Implemented
6400.165(g)Individual #1 had a psychotropic medication review on 8/28/24 and not again until 1/21/25 exceeding the three-month requirement.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.During a licensing inspection, it was determined that Individual #1, who is prescribed a psychotropic medication, had a medication review on August 28, 2024, and not again until January 21, 2025, exceeding the required three-month interval. The delay occurred because the individual refused video appointments and requested in-person visits, but the previous provider was unable to accommodate this. The first available appointment with a new provider was January 21, 2025. The individual was scheduled with a new provider who offers in-person appointments, and a psychotropic medication review was successfully completed on January 21, 2025. The individua's support plan and assessment will be updated , to reflect their preference for in-person psychiatric appointments only. House Supervisor and Program Specialist will be retrained on 6400.165(g) ,The importance of timely psychotropic reviews, respecting individual choice while maintaining regulatory compliance, escalating concerns when provider delays impact compliance. 07/31/2025 Implemented
SIN-00247226 Renewal 07/01/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill record for the fire drill held on 11/17/2023 did not include the amount of time it took for evacuation. The written fire drill record for the fire drill held on 1/25/24 did not include the exit route used, problems encountered, or if the smoke detectors were operable.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The Program Specialist and House Manager will be retrained on regulation 6400.112(c), a written fire drill record shall be kept of the date ,time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The House Manager will also be retrained on the importance of accurately completing the fire drill and evacuation record, and well as reviewing the record for completeness and accuracy. The Program Specialist will review the fire drill and evacuation record monthly to ensure compliance, completeness and accuracy. 07/12/2024 Implemented
6400.112(e)The most recent fire drill held during sleeping hours was 8/7/2023.A fire drill shall be held during sleeping hours at least every 6 months. The house manager and Program Specialist will be retrained on regulation 6400.112(e) , A fire drill shall be conducted during asleep hours every six months. The asleep fire drill will be conducted by the House Manager between the hours of 11:00pm and 7:00 am every six months. The Program Specialist will ensure the compliance of this asleep fire drill by scheduling the asleep fire drill for the House Manger to implement. The Program Specialist will review the fire drill and evacuation record for accuracy and compliance. 07/12/2024 Implemented
6400.112(f)The front door was used as the exit route for the monthly fire drills held from 7/5/2023 through 6/12/2024.Alternate exit routes shall be used during fire drills. The House Manager and Program Specialist will be retrained on regulation 6400.112(f), alternate exit route shall be used during fire drills. The House Manager will ensure compliance by rotating all exit routes in the residence , using a different evacuation route each month. The Program Specialist will ensure the compliance of the House Manager by reviewing monthly the fire drill and evacuation record. 07/12/2024 Implemented
SIN-00225103 Unannounced Monitoring 05/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16On 5/14/23, at 8:13PM Individual #1 was near the refrigerator in the kitchen in the home. Direct Service Worker #1 was engaged in her cell phone while sitting on the couch in the living room of the home. Individual #1 and Direct Service Worker #1 began a verbal exchange and then Individual #1 approached Direct Service Worker #1. Individual #1 made two attempts to take Direct Service Worker #1's cell phone. Direct Service Worker #1 stood up and a physical altercation between Individual #1 and Direct Service Worker #1 ensued, lasting approximately 3 minutes. The physical altercation involved Direct Service Worker #1 pushing Individual #1 to the floor, grabbing Individual #1 by the shirt and hair and throwing an object at Individual #1. At approximately, 8:16PM, Direct Service Worker #1 departed the living room to the porch in the front of the home and interacted with a neighbor. Emergency Services were contacted, and the Police and an ambulance arrived at the home. Medical care was not provided to Individual #1.Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.5/14/2023 , a physical altercation between Individual #1 and Direct Support Worker #1 ensued lasting approximately 3 minutes. The Direct Support worker #1 engaged with Individual #1 instead of separating from the situation. HNA recognizes the need for more extensive training for the staff On 6/20/2023, all Direct Support Workers, supporting individual#1 will receive, Safe Crisis Management training. This training will be instructed by the Program Specialist. This training will be tailored to Individual #1 Prevention: Utilizing the proactive strategies, recognizing triggers and conditions as presented in Individual #1' s behavior support plan. De-escalation: How to properly respond to an individual in crisis by utilizing active listening skills, voice tone , body language and non-verbal cues. Management of the Crisis: strategies on dealing with the crisis ( changing task, possible removing the trigger, bargaining/negotiation) utilizing coping skills. Recognizing the Cycle of Escalation: Knowing the individuals baseline behaviors, what are the stress responses that trigger behavior, bring the individual back to baseline after behavior. after successfully completing the 6 hour course, students will receive a certificate of completion for their training files. 10/31/2023 Implemented
6400.80(b)A six feet long by six-inch wide section of outdoor siding, on the driveway side of the home, was loose and protruding from outside wall of the home posing a free falling hazard. The retaining wall on the driveway side of the home was haphazardly stacked with varying size, rough edged, bricks and rocks, had vegetation growing through and leaning presenting a free falling and laceration hazards. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The outside of the building and the yard shall be well maintained, in good repair and free from unsafe conditions. A 6 foot by 6 inch piece of outdoor siding, on the driveway side of the home was loose and could pose a free-falling risk due to a recent inclement weather. HNA's contractor was immediately contacted, and the outside 6 foot 6 inch piece of siding was repaired on 5/22/2023 and no longer a free-falling hazard. The retaining wall on the driveway side of the home was haphazardly stacked with varying size, rough edged rocks and bricks, had vegetation growing through areas and leaning presenting a free falling and laceration hazard. HNA's landscaping contractor was contacted immediately and construction on a new Versa Lok wall was scheduled to be installed on 7/12/2023. The monthly site audit form was amended on page 7, Section 9 Outside, to reflect the inspection of all retaining walls to assure the wall / s are in good condition, as well as siding, gutters, rainspouts, sofit and facia are in good condition and not a free-falling hazard. 06/30/2023 Implemented
6400.51(b)(5)Direct Service Worker #1, date of hire 10/25/22 was not trained on Individual #1's Behavior Support Plan prior to working with Individual #1.The orientation must encompass the following areas: Job-related knowledge and skills.HNA recognizes, Direct Service Worker #1 was not trained on Individual #1's Behavior Support Plan prior to working with Individual #1. On 5/19/2023 ,the House Manager immediately began to re-train the Direct Support Workers , working with Individual #1 on Individual #1's Behavior Support Plan . All DSWs working with Individual #1 were re-trained and completed a sign off sheet by 5/31/2023.The House Manager will onboard All Direct Service Workers prior to working with Individual #1 on Individual #1's " Getting to Know Me " book which encompasses Individual #1's ISP, Behavior Support Plan and synopsis of individual #1's like, dislikes, and needs. On going Training of individual #1's staff will consist of :The Behavior Specialist attending one house meeting every quarter. to review the Behavior Supports Plan and any changes made to the plan. As well as discuss any concerns from staff . 07/01/2023 Implemented
SIN-00228002 Renewal 07/20/2023 Compliant - Finalized