Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00283926 Renewal 03/02/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66There is no light outside of the laundry room egress.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. On 3/13/2026, the Maintenance Manager, , installed an exterior light at the laundry room exit. (Attachment 11). 03/16/2026 Implemented
6400.71Emergency telephone numbers were not on or by the office telephone.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 Residential Supervisor,, placed an Emergency Contact sheet by the office phone on 3/5/2026 to ensure that emergency numbers are easily accessible to both staff and individuals. (Attachment 9). 04/30/2026 Implemented
6400.144Repeat 05/23/25- Individual # 1 is prescribed Lurasidone HCL 40 mg tablet. The prescription reads, One tablet by mouth every day with 350 calories. There is no documentation that the 350 calories is being provided with this medication administration.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. On 3/4/2026, the Director of Training, , added a 350-calorie tracker to the individual's eMAR in accordance with their recommended 2,000-calorie daily diet. Staff are required to sign off in the eMAR and document the exact calories consumed in the comment section to ensure accurate tracking of daily intake. (Attachment 12). 03/16/2026 Implemented
6400.181(e)(7)Individual # 1' assessment dated 10/10/25 does not assess his ability to sense heat sources.The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. On 3/13/2026, the Director of Operations, , updated the individual's Assessment to include their ability to sense heat sources. (Attachment 8). 03/13/2026 Implemented
6400.162(a)Staff # 4 completed a Medication Annual Practicum on 10/01/24 and not again until 10/17/25.A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication.On 3/12/2026 the location's Practicum Observer and Compliance Coordinator, completed training on the Medication Administration/Medication Administration Training regulations to ensure understanding of the annual requirements. (Attachment 16). 04/30/2026 Implemented
6400.165(c)The PRN medication Ibuprofen 600 mg tablet has directions on the MAR which reads "2 tablets orally every 6 hours as needed". The label on the medication does not include the directions which are found on the MAR.A prescription medication shall be administered as prescribed.On 3/10/2026, the location's Residential Supervisor, , contacted the pharmacy that dispensed the individual's PRN Ibuprofen to request a new label with detailed medication instructions for placement on the bottle. The Residential Supervisor picked up the new label on 3/10/2026; however, the instructions were printed separately due to the pharmacy's labeling system. In the interim, the Residential Supervisor secured the instructions to the bottle to ensure they were readily available. (Attachment 14). Additionally, on 3/13/2026, the Medical Case Manager, , contacted the individual's Primary Care Physician to request a new prescription for the same medication to be sent to the individual's primary pharmacy so that the medication can be dispensed in a blister pack with the instructions clearly labeled. The medication labeling is expected to be fully corrected by 3/20/2026. (Attachment 15). 03/20/2026 Implemented
6400.169(a)Staff # 4 administered medications on 10/03,06, 07, 08, 16 & 17/25 although she had not completed her annual Medication Administration practicum which was due on 10/01/25.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).On 3/12/2026 the location's Practicum Observer and Compliance Coordinator, completed training on the Medication Administration/Medication Administration Training regulations to ensure understanding of the annual requirements. (Attachment 16). 04/30/2026 Implemented
SIN-00266344 Renewal 05/23/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104Individual #1 moved into the home on 7/3/2024. An updated fire department notification letter was not sent until 4/25/2025.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. , Compliance Manager, received training (Attachment 1) on the applicable 6400.104 regulation on 6/5/2025. 06/05/2025 Implemented
6400.113(a)Individual #1 received fire safety training on 4/9/2024, then not again until 4/29/2025. Additionally, Individual #1 moved into their current home on 7/3/2024 and they were not retained on fire safety upon admission into their new home. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. Individual #1 successfully completed Fire Safety Training (Attachment 2) on 6/4/2025. 06/04/2025 Implemented
6400.144Individual #1's most recent physical dated 1/31/2025 states that they are diagnosed with a seizure disorder. Individual #1 regularly sees the neurologists to address seizure disorder, and on 11/8/2024, Individual #1 reported to their neurologists that they "think (they) had a seizure". Individual #1 also takes daily medication for a seizure disorder. There is no seizure plan or protocol for Individual #1 to address what their seizures look like, how they may be managed, or what to do if a seizure occurs. · Individual #1 is prescribed the following medications as PRN that were not available in the home at the time of the physical site walkthrough: Pink Bismuth liquid 360ml, Saline Mist 0.65%, and Hyoscamine 0.125mg.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. On 6/2/2025, Director of Operations, requested that , the Neurodiverse Specialist assigned to the location, obtain documentation from Individual #1's neurologist outlining the recommended seizure protocol. On 6/6/2025, developed a draft seizure protocol (Attachment 10), which will be revised and finalized once the neurologist's recommendations have been obtained to ensure accuracy and alignment with medical guidance. Additionally, , Chief Financial and Operating Officer (CFOO), developed an agency wide Fatal Five Policy (Attachment 11) on 6/6/2025. 06/06/2025 Implemented
6400.32(f)Individual Rights signed by Individual #1 on 7/24/2023 and 5/23/2025 did not include the right for the Individual to be involved in decision making.An individual has the right to refuse to participate in activities and services.Individual #1 reviewed and signed the updated Individual Rights, Choices, and Services Policy (Attachment 3 & Attachment 4) on 6/4/2025. 06/04/2025 Implemented
6400.32(r)(5)Individual Rights signed by Individual #1 on 7/24/2023 and 5/23/2025 did not include the acknowledgement that direct service worker shall have a key to lock and unlock the Individual's bedroom door.Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.Individual #1 reviewed and signed the updated Individual Rights, Choices, and Services Policy (Attachment 3 & Attachment 4) on 6/4/2025. 06/04/2025 Implemented
6400.32(s)(3)Individual Rights signed by Individual #1 on 7/24/2023 and 5/23/2025 did not include the acknowledgement that direct service worker shall have a key to lock and unlock the entrance door of the home.Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.Individual #1 reviewed and signed the updated Individual Rights, Choices, and Services Policy (Attachment 3 & Attachment 4) on 6/4/2025. 06/04/2025 Implemented
6400.32(t)Individual Rights signed by Individual #1 on 7/24/2023 and 5/23/2025 did not include the right for the Individual to have access to food.An individual has the right to access food at any time.Individual #1 reviewed and signed the updated Individual Rights, Choices, and Services Policy (Attachment 3 & Attachment 4) on 6/4/2025. 06/04/2025 Implemented
6400.32(v)Individual Rights signed by Individual #1 on 7/24/2023 and 5/23/2025 did not include Individual's rights may only be modified to mitigate health and safety risk to Individual and others.An individual's rights may only be modified in accordance with § 6400.185 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others.Individual #1 reviewed and signed the updated Individual Rights, Choices, and Services Policy (Attachment 3 & Attachment 4) on 6/4/2025. 06/04/2025 Implemented
6400.33(a)Individual Rights signed by Individual #1 on 7/24/2023 and 5/23/2025 did not include Individual's rights to be exercised to that another individual's rights are not violated.An individual's rights shall be exercised so that another individual's rights are not violated.Individual #1 reviewed and signed the updated Individual Rights, Choices, and Services Policy (Attachment 3 & Attachment 4) on 6/4/2025. 06/04/2025 Implemented
6400.33(b)Individual Rights signed by Individual #1 on 7/24/2023 and 5/23/2025 did not include that the provider shall assist the individual to negotiate choices.The Provider shall assist the affected individuals to negotiate choices in accordance with the Provider's procedures for the individuals to resolve differences and make choices.Individual #1 reviewed and signed the updated Individual Rights, Choices, and Services Policy (Attachment 3 & Attachment 4) on 6/4/2025. 06/04/2025 Implemented
6400.34(a)Individual #1 was informed of their individual rights on 7/24/2023, then not again until 5/26/2025. Provider identified the missing 2024 individuals' rights statement on their 30-day self-assessment document, prior to licensing. However, the self-citation was not fully corrected until 5/26/2025, which is after the provider's annual inspection began and following when the inspection sample was already provided to the provider (5/23/2025).The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter., Program Specialist, completed training (Attachment 5) on the applicable 6400.34(a) regulation on 6/5/2025. 06/05/2025 Implemented
6400.165(b)Individual #1's May 2025 Medication Administration Record (MAR) states that they are prescribed medication, Gavilax Powder as PRN. This medication is not available in the home, and the prescriber discontinued this medication in August 2024, however the MAR has not been updated accordingly.A prescription order shall be kept current.On 6/5/2025, , Director of Training, updated Individual #1's Medication Administration Record (Attachment 14) to reflect the discontinuation of the Gavilax Powder and it has been removed accordingly. 06/05/2025 Implemented
6400.166(a)(2)Individual #1's March and April 2025 Medication Administration Record does not include the prescriber for Citalopram 20 mg tablet, Lamotrigine 200 mg tablet, Risperidone 0.25 mg tablet, and Rosuvastatin 5mg tablet.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.On 6/5/2025, , Director of Training, updated Individual #1's Medication Administration Record (Attachment 6) to include all previously missing prescriber information. 06/05/2025 Implemented
6400.166(a)(11)· Individual #1 was prescribed Amox-Clav 875-125mg tablets to be taken 1 tablet by mouth 2 times daily for 7 days beginning 5/10/25. There is no diagnosis or purpose for this medication recorded on the May 2025 Medication Administration Record. · Individual #1 is prescribed Clearlax Powder 17 gram/dose, Resperidone 0.25mg tablet, Rosuvastin 5mg tablet. March, April, and May 2025 Medication Administration record does not include the diagnosis or purpose of the medication. · Individual #1 was prescribed Doxycycline Hyclate 100 mg cap to be taken 1 capsule by mouth 2 times daily (with meals) for 7 days beginning on 5/10/2025. There is no diagnosis or purpose for this medication recorded on the May 2025 Medication Administration Record.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., Director of Training, received training (Attachment 7 & Attachment 9) on the applicable 6400.166(a)(11) regulation on 6/5/2025. On 6/5/2025, , Director of Training, updated Individual #1's Medication Administration Record (Attachment 8) to include all previously omitted medication diagnoses. 06/05/2025 Implemented
SIN-00245026 Renewal 06/03/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)During the walk-through of the on home on 6/4/24 the first-floor bathroom 1 sink was documented as 129.3F and the kitchen sink water temperature was 128F. This exceeds the 120F. The agencies self-assessment started on 5/27/24- completed 5/31/24 indicated that water temperature exceeded 120F. The boiler was turned down by maintenance & temperature would be checked again in 48hrs to ensure correction. A plumber would be called if issue continues. The agency was aware when the walk-through was completed by Licensing on 6/4/24 that the water temperature was still over the 120F. The agency contacted a plumber while the walk-through of the home was being completed. The agency did not follow their plan of correction for this issue. Hot water temperatures in bathtubs and showers may not exceed 120°F. On 6/4/2024 a plumber was called to repair the boiler. The boiler was repaired on 6/13/2024 and the water temperature has been lowered to 118.5 degrees. Attachment #11. Attachment #12. 06/13/2024 Implemented