Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00251202 Renewal 10/07/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(h)Individual #1 did not evacuate to a designated meeting spot during the fire drills held on 7/21/2024, 8/05/2024 and 9/15/2024. During each of those fire drills the individual evacuated to the porch of the home but would not proceed to the designated meeting place. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Meeting held with Behavioral Specialist (BS) on 10/11/2024 to address concerns of Individual #1 not willing to walk to designated meeting spot. BS met with Individual #1 on 10/11/2024 in afternoon and again on 10/17/2024 where during a practice session with a fire drill Individual was willing to walk to the designated meeting place. BS will be reaching out to ODP Regional Clinical Director to discuss plans to implement that are not restrictive. In the interim while a plan is being developed, staff will offer to walk hand in hand or push Individual via wheelchair if walking is refused. 10/17/2024 Implemented
6400.165(g)The documentation signed by the prescriber for the psychiatric medication review that occurred on 8/12/2024 for Individual #1 did not include the need to continue the medication alprazolam 2 mg. tablets to be administered on a pro re nata (PRN) basis. The area on the medical visit form to document the need to continue the medication was not completed.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.Form was reviewed with Dr. on 10/17/2024 and corrected. 10/17/2024 Implemented
SIN-00210856 Renewal 09/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill conducted on 3/8/22 at 4:10 did not documentation the designation of AM / PM for the time that the fire drill was completed.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. Fire drill forms were updated to include circling designation of AM or PM. Staff responsible for conducting fire drills were trained on the new form on 9/20/2022. Program Specialist verified with staff conducting the fire drill that this was completed on 3/8/22, that 4:10 should have been designated as PM. Form was corrected to include the PM designation correction on 9/22/22. 09/22/2022 Implemented
SIN-00178786 Renewal 11/02/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.182(c)Individual #1's assessment states that he reports he does not know how to swim, but Individual #1's Individual Plan states he enjoys swimming, and he is able to swim independently. The individual plan is not updated to reflect a needs change based on the current assessment.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.Corrective action plan for citation issued as follows: 6400.182(c) ¿ The individual plan shall be initially developed, revised annually and revised when an individual¿s needs change based upon a current assessment. What happened: Individual #1's assessment states that he reports he does not know how to swim, but Individual #1's Individual Plan states he enjoys swimming, and he is able to swim independently. The individual plan is not updated to reflect a needs change based on the current assessment. Why did it happen: After review of this assessment and plan it has been determined the ISP is inaccurate and it was not identified upon review of the ISP. Supports Coordinator received copy of annual assessment on 4/30/2020 but ISP did not reflect the same information. Immediate Action taken to resolve the cited issue: Supports Coordinator was notified on 11/7 by email and requested to make necessary correction in ISP. AE was notified on 11/10/20 that changes were required in plan due to SC responding they currently were not able to update the plan. Plan to prevent reoccurrence of same or similar violations: Each ISP will be reviewed for content accuracy at plan renewal date as well as fiscal plan renewals. Program Specialist will be responsible for ensuring accuracy, notifying SC of needed updates, revising assessments as needed, and keeping documentation of requested changes made to SC. Program Specialist will notify Program Director if repeated request to update a plan does not result in changes being reflected in ISP. Program Director will notify SC supervisor and AE of concerns of plans not being updated. Training Provided: On 11/10/20 Regulation 182c was reviewed with Program Specialist. After verifying the SC did receive the Annual Assessment, Program Specialist and Program Director discussed creating a schedule to verify information in each Individual¿s ISP is consistent with assessment and that the information is correct. Program Specialist will follow plan to prevent reoccurrence of same or similar violations. 11/10/2020 Implemented
SIN-00231183 Renewal 09/05/2023 Compliant - Finalized
SIN-00192175 Renewal 10/19/2021 Compliant - Finalized
SIN-00157797 Initial review 06/19/2019 Compliant - Finalized