Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00177884 Renewal 10/20/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)This home has an approved extended evacuation time of 3 minutes however, the fire drill record dated 9/18/2020 records the evacuation time of 4.32 min. This exceeds the allotted time allowed per regulation. The fire drill was not repeated for this specific month to achieve compliance. The fire drill record dated 8/24/2020 records the evacuation time of 3.27 min. This also exceeds the allotted time allowed per regulation. The fire drill was not repeated for this specific month to achieve compliance. 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. 11/2/20 Director of Residential Services reviewed and modified the fire safety policy to reflect that If the evacuation time exceeds the specified time during any fire drill, another drill will be held within 24 hours. See Exhibit# 122 11/2/20 Director of Residential Services provided training to Residential Home Leads who conduct the monthly fire drills on modified Fire Safety Policy. It was also recommended to hold fire drills earlier in the month and not wait until the last week in case the drill has to be redone.. See Exhibits #123 Moving forward, all staff who conduct fire drills will conduct the drills earlier in the month. Residential Home Leads who conduct fire drills are responsible for conducting the 2nd fire drill. Any issues or difficulties which may cause the evacuation time to exceed the specified time is noted on the fire drill record and if it cannot be corrected, the local fire department will be contacted by the Director of Residential Services Director or Program Manger for guidance. 11/17/20 A fire drill was conducted at this home and the evacuation time exceed the allotted time frame. 11/18/20 After reviewing the Fire Drill Record from 11/17/20, Director of Residential Services modified the Fire Drill Record to reflect the requirement for another fire drill to be conducted within 24 hours if evacuation time exceeds designated time from local fire department. See Exhibit #124 11/18/20 Residential Home Lead from another home facilitated another fire drill at this home and provided education on proper evacuation procedures to ensure timely evacuation of all individuals. This fire drill was completed within the allotted evacuation timeframe. See Exhibits #124- #125 11/18/2020 Implemented
SIN-00117489 Renewal 07/27/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The first aid kit did not contain antiseptic. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. A First Aid Kit Check List has been implemented. An inventory of all items in first aid kit will be taken at the end of every month. The 2nd shift RPW Lead will be responsible for the completion of the First Aid Kit Check List. Any items missing will be replaced. All staff have been informed of this new procedure. This regulation has been reviewed and signed off by all staff. Documentation will be forwarded 07/31/2017 Implemented
6400.112(d)The 07/18/17 and 06/22/17 fire drills did not indicate evacuation times. Spaces left blank on fire drill logs. 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. Evacuation times were listed on computer copy, however times were not transcribed on to fire drill log hard copy. Individuals were able evacuate building to a safe area within designated time. Going forward, when information is transcribed from computer to hard copy, Program Manager will have another staff exam the fire drill logs to ensure all necessary information has been transcribed. Fire drill logs have also been revised with a highlight space where "Evacuation Time" has to be noted. Documentation will be forwarded 08/03/2017 Implemented
SIN-00080396 Renewal 12/16/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(6)Individual #1's TB test was late. Not completed until 8/27/2014. Should have been comleted prior to date of admission. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Paper LIS completed. POC received via email. Implemented
6400.183(5)Individual #1 does not have a SEEN plan in place. Individual #1 should have a SEEN plan if Psychiatric medications are prescribed. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. Paper LIS completed. POC received via email. Implemented
6400.183(7)(iii)Individual #1's ISP did not include potential to advance in vocational programming. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. Paper LIS completed. POC received via email. Implemented
6400.183(7)(iv)Individual #1's ISP did not include potential to advance in community-integrated employment. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Competitive community-integrated employment. Paper LIS completed. POC received via email. Implemented
SIN-00044576 Renewal 12/04/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(b)None of the staff physical exam forms reviewed were dated by the physician. All were dated by the agency. (b) The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. PARTIALLY IMPLEMENTED, INADEQUATE PROGRESS. JW The Staff Health Appraisal forms have been modified, physician has been added to the date line and the date moved to correspond directly with the signature line (attachment 5). All staff have been trained on the protocol for staff physicals and the need to review physical forms prior to leaving the physician¿s office (attachment 6). In the event a health appraisal form is returned without the required information a new fax memo cover sheet has been developed by ALUCP which specifically states information to be completed by the attending physician (attachment 7). While the agency cannot validate a specific form is dated by a physician, certified nurse practitioner, or licensed physician¿s assistant this protocol will help ensure increased accuracy in overall staff health records. 01/29/2013 Implemented
6400.181(b)The assessment for Individual #1 was not updated when a behavioral support plan was added to her ISP. (b) If the program specialist is making a recommendation to revise a service or outcome in the ISP as provided under § 6400.186(c)(4) (relating to ISP review and revision), the individual shall have an assessment completed as required under this section. PARTIALLY IMPLEMENTED, INADEQUATE PROGRESS. JW The assessment for Individual #1 (attachment 1) has been updated to include the behavioral support plan. To work toward overall compliance to this regulation the ALUCP Program Specialist and Program Manager have been trained in their responsibility to respond to every section of the assessment and the requirements related to assessment revisions as mandated in chapter 6400 186(c)(4)(i) through 186(c)(4)(iii) and 186(c )(5) relating to documentation supporting Program Specialist recommendations to revise the ISP (attachment 4). 01/09/2013 Implemented
SIN-00225221 Renewal 06/06/2023 Compliant - Finalized
SIN-00193507 Renewal 09/21/2021 Compliant - Finalized
SIN-00157389 Renewal 08/20/2019 Compliant - Finalized
SIN-00097230 Renewal 07/06/2016 Compliant - Finalized
SIN-00057788 Renewal 12/02/2013 Compliant - Finalized
SIN-00057874 Renewal 12/02/2013 Compliant - Finalized