Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00240084 Renewal 03/19/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(2)The financial ledger for individual #1 for December 2023 indicates there was a purchase made at Rite Aid in the amount of $51.21 on 12/18/23 however the purchase was actually for $50.21. This discrepancy caused the ending balance for December to be incorrect by $1.00 and thus threw off the balance for all subsequent months.(2) Disbursements made to or for the individual. Ending balance was updated to accurate total and $1 was put into the lockbox. Payee was advised of the error and correction. 04/30/2024 Implemented
6400.141(c)(4)Individual #1's annual physical, dated 5/23/23, does not include a vision and hearing screening.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The doctor was contacted through the portal and we are awaiting recommendations for vision and hearing screening. 04/30/2024 Implemented
6400.141(c)(7)Individual #1 had a gynecological visit on 4/26/23 however it did not include a pap smear and/or manual breast exam. A PAP and manual breast exam also were not completed at the individual's annual physical on 5/23/23. There is no documentation that a licensed physician recommended no or less frequent gynecological examinations.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. The team has reached out to the physician to get a better definition of why pap test and breast exams are not being completed annually. 04/30/2024 Implemented
6400.181(e)(11)Individual #1's assessment, dated 11/28/23, does not address whether or not the individual has had a psychological exam so it is unclear if it is or is not applicable.The assessment must include the following information: Psychological evaluations, if applicable. This error has been corrected with an addendum to the assessment. All assessment templates include psychological section and now contains a note that this section must be completed. 04/05/2024 Implemented
6400.46(b)Staff #3 had fire safety training on 2/23/22 and not again until 6/18/23.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).This error cannot be corrected. It was a simple oversight. 04/03/2024 Implemented
SIN-00223995 Renewal 05/09/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)At the time of the inspection, there was an approximately 4-inch circular patch of paint missing above the towel rack in the bathroom closet, closest to the front door. The metal edging on the corners of the walls inside the front door were exposed where the paint was missing. On the inside of the kitchen island, there was approximately a 6-inch-long strip of missing paint.Floors, walls, ceilings and other surfaces shall be in good repair. All areas of concern were touched up prior to exit. A respite coordinator has been hired for this location so monthly checks will be reimplemented. After speaking with the landlord, it was decided that the entire house will be repainted (painter is booked until 8/2/23). 06/02/2023 Implemented
6400.111(f)The date of the fire extinguisher inspections was not provided for 2022, only an invoice for the inspection that was crated on 4/5/22. The fire extinguishers were not inspected again until 4/24/23. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. Unable to correct this violation. Will implement strategy listed below to prevent recurrence. 06/02/2023 Implemented
SIN-00205325 Renewal 05/17/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)On March 14, 2022, Individual #1's personal funds were used to purchase body wash totaling $7.42.Individual funds and property shall be used for the individual's benefit. On 5/23/2021 a check for $7.42 was mailed to the rep payee for Individual #1. All support staff were retrained on what supplies are to be purchased by BOLD 05/23/2022 Implemented
6400.143(a)(REPEAT VIOLATION FROM 7/13/21) Individual #1's dental hygiene plan says that Individual #1 is to brush their teeth after every meal and snack. In February 2022, Individual #1 refused to have their teeth brushed after a meal and/or snack 25 times. In March 2022, the Individual refused to have their teeth brushed after a meal and/or snack 16 times. In April 2022, Individual #1 refused to have their teeth brushed after a meal and/or snack 40 times. Through May 18, 2022, Individual #1 refused to have their teeth brushed after a meal and/or snack 11 times. There is no documentation that Individual #1 was educated on the importance of following the dental hygiene plan.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. House coordinator will meet with Individual #1 monthly to educate him on the importance of good dental hygiene. This will be documented in his service notes. 05/31/2022 Implemented
SIN-00260144 Renewal 02/24/2025 Compliant - Finalized
SIN-00248918 Unannounced Monitoring 07/10/2024 Compliant - Finalized
SIN-00194204 Initial review 10/12/2021 Compliant - Finalized