Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00280055 Renewal 12/18/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(7)A gynecological exam including a breast exam and pap is required annually for women 18 years of age and older. There was no documentation that Individual #5 had an exam completed. This individual date of birth is 7/3/2005 which makes her 20 years old and of age to be recommended for this exam.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. According to 6400.141 (c)(7) 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. During the ODP site inspection on December 18, 2025, a violation was issues because no documentation was available to show that Individual #5 had an exam completed. This individual date of birth is 7/3/2005, which makes her 20 years old and of age to be recommended for this exam. On 1/8/2026, the supervisor spoke with Individual #5 again to encourage her to participate in this required test and to share with her the importance of these tests for women but the individual once again refused it. 01/08/2026 Implemented
6400.181(f)The program specialist shall provide the assessment to the individual team members at least 30 calendar days prior to the individual plan mtg. There was no documentation to reflect that the assessment was sent prior to Individual #5's Individual Support Plan Meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.26. The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting (6400.181 (f). On the date of the ODP site visit on December 18, 2025, there was no documentation to reflect that the assessment was sent prior to Individual #5's Individual Support Plan Meeting. The PS immediately sent a copy of the assessment to the team on December 23, 2025. 12/23/2025 Implemented
SIN-00261242 Renewal 03/19/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(11)The March 2025 medication administration record (MAR) for Individual #1 did not contain a diagnosis or purpose for prescribing the medication Sucralfate, 1 gm. tablet.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.The MAR for this individual has ben updated to include the purpose for the Sucralfate 1gm tablet. 04/30/2025 Implemented