Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00280125 Renewal 12/16/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104The fire drills conducted 3/4/2025, 4/19/2025, 5/23/2025, and 8/9/2025 documented that Individual #1 required physical and verbal prompts in order to evacuate. The agency notified the local fire department on 2/13/2025 that one person with intellectual disabilities resides in the home; however, the notification indicated that Individual #1 is able to evacuate with verbal prompting.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. The fire department will be notified in writing of the following: The address of the home, the exact location of the bedroom of Individual #1, and the accurate level of evacuation assistance required, including physical and verbal prompting. A copy of the written notification will be placed in the home's fire safety file. 01/01/2026 Implemented
6400.141(c)(14)Individual #1's physical examination completed 6/12/2025 did not include medical information pertinent to diagnosis and treatment in case of an emergency. The physical examination form stated "see attached", but nothing was attached to the physical examination document.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The missing medical information pertinent to diagnosis and treatment in case of an emergency for Individual #1 was obtained on 12/17/25. The information was secured from the medical provider and placed with the completed physical examination documentation. 12/17/2025 Implemented
6400.181(e)(8)Individual #1's assessment, completed 7/21/2025, documented that the individual needs verbal prompting for evacuating quickly. The fire drills conducted on 3/4/2025, 4/19/2025, 5/23/2025, and 8/9/2025 documented that Individual #1 needed physical and verbal prompts in order to evacuate. The assessment does not accurately reflect the individual's ability to evacuate in the event of a fire.The assessment must include the following information: The individual's ability to evacuate in the event of a fire. The Program Specialist reviewed fire drill documentation and reassessed Individual #1's evacuation ability. The assessment will be updated to accurately reflect that Individual #1 requires physical and verbal assistance to evacuate safely in the event of a fire. All necessary parties will be notified of the change including the Fire Department and the SC to ensure accurate reflection in the ISP. 01/02/2026 Implemented
6400.163(h)Individual #1 is prescribed Minerin Crème with instructions to "apply topically to feet once daily at 1:00 AM for dry skin." On 12/17/2025 at 11:18 AM, Individual #1's Minerin Crème was observed with an expiration date of 11/25/2025. Individual #1 is prescribed Olopatadine Hydrochloride Ophthalmic Solution 0.1% with instructions to "instill 1 drop into affected eye twice daily as needed for dry eyes for seasonal allergies". On 12/17/2025 at 11:18 AM, Individual #1's Olopatadine Hydrochloride Ophthalmic Solution 0.1% was observed with an expiration of August 2025.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Expired Minerin Crème and Olopatadine Hydrochloride were removed from the home immediately. Replacement medications were obtained on 12/17/2025. 12/17/2025 Implemented
SIN-00102827 Renewal 10/25/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(e)The home has three stories including a basement and attic. The smoke detectors on each floor of the home are not interconnected.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. On October 26, 2016, interconnected smoke detectors were installed. Maintenance personnel installed the smoke detectors.[Immediately and at least semi annually, the maintenance personnel shall check all homes to ensure homes with three or more stories and homes serving four or more individuals have interconnected fire alarm systems. (AS 11/30/16)] 11/12/2016 Implemented
6400.181(f)Program Specialist #1 provided Individual #1's assessment, completed 8/15/16 to the plan team members on 8/15/16 for the annual update ISP meeting on 8/23/16.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). Agency protocol is to complete the assessment 3 months prior to the Annual Review Update Date and to mail the results of the assessment upon completion. Individual #1¿s Individual Review Update Date was 11/15/2016. The assessment results were mailed on 8/15/2016. The invitation to the meeting was mailed on 07/29/2016. In the future, the protocol will be revised to update the assessment 4 months prior to the Annual Review Update Date or sooner when the Plan Lead¿s invitation letter provides a meeting date that would cause non-compliance. Should a situation arise when mailing the assessment would cause non-compliance because the meeting was scheduled more than 90 days prior to the Annual Review Update Date, the Program Specialist will send notification requesting a later meeting date to remain in compliance. All Program Specialists will be trained on this regulation and the revised protocol on 11/18/2016. [Documentation of training shall be kept. At least quarterly for 1 year, a designated management staff person shall review a 25% sample of assessment correspondence to ensure revised protocol is working and the program specialist(s) are providing assessments to plan team members, timely. (AS 11/30/16)] 11/12/2016 Implemented
SIN-00085765 Renewal 10/26/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The fire drill completed on 9/20/15 had an evacuation time of 2 minutes 32 seconds. There is not an extended time period for evacuation specified in writing by a fire safety expert. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. The individuals in the home typically evacuate under 2 ½ minutes. Since the 9/20/15 drill, the individuals have safely evacuated under 2 ½ minutes for the October and November drills. Prior to the 9/20/15 drill, the individuals safely evacuated under 2 ½ minutes. A new Program Specialist was hired in October 2015. This Program Specialist and all other Program Specialists will be trained regarding this regulation. To ensure future compliance, part of this training will include notification of administration for any drill exceeding 2 ½ minutes. In the future, any drill exceeding the allowed time will be reviewed and decisions will be made to conduct another drill, offer training to the individuals of the home, or some other acceptable correction. 11/20/2015 Implemented
6400.213(1)(i)The record for Individual #1, admission date 2/17/15, did not include identifying marks.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.Records for other individuals have been checked and are in compliance. To ensure future compliance: All Program Specialists will be trained in the regulation. The Pertinent Information Form is used to document ¿identifying marks¿. The Program Specialist erroneously left the area blank. The Program Specialist has updated the form.[CEO or designee will review a sample of Individual records at least quarterly for the next 6 months to ensure all required personal information including identify marks is accurate and present. (AS 12/8/15)] 11/16/2015 Implemented
SIN-00067092 Renewal 10/17/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The hot water temperature in the bathtub of bathroom #1 measured 126.6 degrees Fahrenheit at 11:00 AM. Hot water temperatures in bathtubs and showers may not exceed 120°F. The home is awaiting PROMISe enrollment and sets vacant at this time. The hot water tank was adjusted and the temperature is now in compliance. Once the home is occupied, the water will be checked routinely by the Program Specialist of the home to ensure compliance. [The program specialist or designee will check the hot water temperature at all community homes monthly to ensure the temperature stays at or below 120 degrees Fahrenheit. (CHG 11/25/14)] 10/31/2014 Implemented
SIN-00216122 Renewal 12/08/2022 Compliant - Finalized
SIN-00183391 Renewal 02/17/2021 Compliant - Finalized
SIN-00144050 Renewal 10/16/2018 Compliant - Finalized
SIN-00073195 Initial review 01/08/2015 Compliant - Finalized
SIN-00067681 Initial review 08/26/2014 Compliant - Finalized