Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00285085 Renewal 02/10/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(g)Individual #1 is prescribed medication to treat the symptoms of a diagnosed psychiatric illness. Individual #1 had a psychotropic medication review completed on 4/7/2025, and then again 7/15/2025. This exceeds the every 3-month requirement. Individual #1 had a psychotropic medication review completed on 10/15/2025, and then again on 1/21/2026. This exceeds the every 3-months 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.On 3/25/26 the Med-Check Questionnaire Form was updated by Administrative Support Supervisor, to include the date in which the next review of the psychiatric medication must occur by related to 6400.165g. The Agency procedure was updated to reflect the changes. (Attachment 5 sent via email) 03/31/2026 Implemented
SIN-00088543 Unannounced Monitoring 12/15/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(e)An audio "baby" monitor is being used to monitor Individual #1 while in his/her bedroom.An individual has the right to privacy in bedrooms, bathrooms and during personal care. The "baby" monitor was removed from Individual #1's home during the inspection. All employees are signing a statement that they are aware that auditory devices are a violation of individual rights. This statement is also now part of the Agency's positive approaches training packet. This will assure that all new hires will be aware as well. There were no other auditory devices found at program sites. Program Specialists will monitor during their home visits to assure that none are in use unless there is a regulatory waiver. All staff will have signed off on this clarification of "privacy during personal care" by February 29, 2016. It is being reviewed at their monthly in service training. [Individual #1 moved to another community home on 2/29/16. (AS 3/9/16)] 01/30/2016 Implemented
6400.33(f)A chain and pad lock is being used to lock the refrigerator in the kitchen of the home. An individual has the right to receive, purchase, have and use personal property. Three Individuals reside at the Randolph Home. Individuals #2 and #3 have a diagnosis of Prader Willi. Individual #1 does not. We have contacted individual #1's family and supports coordinator. Individual #1 will be moving to another home. There is a team meeting scheduled for February 4th 2016 to develop Individual #1's transition plan to her new home. She is expected to move on or before February 29, 2016. Food is not locked at any other site operated by the Agency. Individuals #2 and #3 will remain at the Randolph home. The Agency is pursuing a regulatory waiver for those two individuals given that locking the food is an integral part of the treatment plans developed for them by the Prader Willi Institute. [Individual #1 moved to another community home on 2/29/16. Waiver was granted by the Department on 3/3/16 for 2 individuals currently living in the home. All conditions of the waiver will be followed. Immediately, staff persons working in the home will be trained on the conditions of the waiver. (AS 3/9/16)] 01/30/2016 Implemented
SIN-00077219 Renewal 04/09/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The emergency telephone numbers by each of the telephones in the home do not include the fire department, police department and ambulance.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The Emergency phone list was revised for all residential sites to include the proper language. New labels were also created for portable phones. Program specialists had the new lists and labels in place at all sites by 4-18-15. They will monitor to assure they remain current. A copy of the phone list was emailed to Andrea Kurtz. 04/27/2015 Implemented
SIN-00223388 Renewal 04/26/2023 Compliant - Finalized
SIN-00172315 Renewal 03/10/2020 Compliant - Finalized
SIN-00113772 Renewal 05/09/2017 Compliant - Finalized
SIN-00094418 Unannounced Monitoring 05/04/2016 Compliant - Finalized