Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00257468 Renewal 12/17/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34There were cabinets in the kitchen that were locked. Staff Member 1 stated that the individuals use those cabinets and are the only ones who have keys.The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients.The locks were changed by maintenance to be code locks rather than key locks. Codes were given to the individuals and the program specialist only. On 12/19/2024 conference were held with supervisors to advise that authorization is needed to Department agents for audit purposes during inspections. On 12/20/2024 conferences were held with staff to advise that authorized individuals should have access to areas for inspection purposes. 12/23/2024 Implemented
6400.68(b)The water temperature in the home was tested and found to be 154.2 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. Maintenance was sent to the home on 12/17/2024 to turn down the temperature on the boiler. Scheduled conferences were had with DSP Supervisors on 12/19/2024 and a monthly water temperature log was implemented for monthly reviews of water temperatures. 12/24/2024 Implemented
6400.216(a)There were individual records unlocked in the dining room of the home. An individual's records shall be kept locked when unattended. Locks were purchased by the supervisor for cabinets to lock up individual records and maintenance installed the locks. Conferences were held with all program specialists and supervisors on 12/19/2024 to review the required regulations. In-service for all DSPs were held on 12/20/2024 to review the policy of locking up individual records when not in use and/or when away from the home. 12/24/2024 Implemented
6400.32(d)The agency has completed an excessive amount of overnight fire drills causing frequent interruptions to the Individual's sleep. The dates of the overnight fire drills are 11/21/24; 8/26/24; 5/2/24; 3/7/24.An individual shall be treated with dignity and respect.Conferences were held on 12/19/2024 with supervisors to review the amount of overnight drills held during the year. Policy was reviewed for only 2 overnight drills throughout the year being held every six months. Quarterly home assessment was updated to review the overnight drills (exhibit 4). 12/23/2024 Implemented
SIN-00236384 Renewal 12/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)Individual 1 physical on 10/12/23 did capture all the necessary information that included pertinent information as it relates to case of emergency, record of immunizations, and/or communicable disease.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The CEO updated the agency¿s policies and procedures to include the updated annual physical form, which captures all of the pertinent information, including information as it related to case of emergency, record of immunizations, and/or communicable disease (See attachment #1). On 1/5/2024 all staff were retrained by the CEO on implementation of the mandatory physician form (see attachment 2). The quarterly review document was updated to include monitoring of ongoing compliance (See attachment 3). 01/05/2024 Implemented
6400.142(c)Individual 1 dental examination on 1-18-23, did not capture the dentist's name or what procedure was completed..A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. The CEO updated the dental form to include pertinent information, such as the date of examination, dentist¿s name, procedures completed and any recommended follow-up treatments (See attachment 6). On 1/5/2024 the CEO retrained all staff on utilizing the updated for, regulatory and agency requirements to ensure compliance, and the required information to make the document complete (see attachment 2). The CEO also updated the quarterly review to ensure ongoing compliance with the requirement (see attachment 3). 01/05/2024 Implemented
6400.181(c)The assessment for individual 1 that was completed on 7/14/23, did not list the source of the information..The assessment shall be based on assessment instruments, interviews, progress notes and observations. The CEO updated the annual assessment to include a specific section on where information was obtained from and the program specialist will indicate assessment instruments, interviews, progress notes or observations when completing the annual assessment (see attachment 4). On 1/4/2024, the CEO retrained the Program Specialist and director on the updated assessment (see attachment 5). To maintain ongoing compliance, the CEO updated the quarterly review assessment to include ongoing compliance review of active charts (see attachment 3). 01/04/2024 Implemented