Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00258783 Renewal 01/14/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency completed the self-assessment of this home on 1/8/2025 which was not completed during the 3 to 6 months prior to the expiration of the Certificate of Compliance or 6 to 9 months after the previous year's inspection. Additionally, the following sections of this self-assessment were left blank and not assessed for compliance: staffing, staff health, home services, day services/recreational and social activities, restrictive procedures, individual records, nine or more individuals, emergency placement, respite care, and semi-independent living sections.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The agency is creating a schedule for each house to have a complete self-assessment within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance to measure and record compliance. 01/17/2025 Implemented
6400.112(a)For the calendar year 2024, there was no documentation provided for fire drills conducted in the months of June or October. An unannounced fire drill shall be held at least once a month. The fire drills will be checked by each house supervisor/specialist every week, ensuring that one fire drill has been ran according to the fire drill schedules. 01/17/2025 Implemented
6400.112(e)For the calendar year 2024, the only fire drill record provided that occurred during sleeping hours was conducted in April.A fire drill shall be held during sleeping hours at least every 6 months. Each house will run a sleep fire drill every 6 months and be tracked with the fire drill schedules created for each house. 01/17/2025 Implemented
6400.141(c)(4)For individual #1, annual physical examinations conducted on 06/07/23 and 06/11/24 indicate that the physician recommends screenings by a specialist for both vision and hearing. Individual #1 had hearing screenings on 03/01/2022 and again on 04/11/2024; and vision screenings on 09/05/2023.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. For individual #1, the recommendations by the physician will be followed for both vision and hearing specialists within the appropriate timeframes set forth by ODP requirements. 01/17/2025 Implemented
6400.34(a)Individual #1 was informed of and explained their individual rights and the process to report a rights violation on 01/05/2024 and again on 01/13/2025.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.The PC supervisor will add a checklist with annual due dates for individual rights signatures on the electronic health record of the individual. 01/17/2025 Implemented
6400.44(c)(2)Program Specialist #1, date of hire 06/03/24, possesses a bachelor's degree but does not have the pre-requisite 2 years of experience working directly with individuals with intellectual disabilities or autism.A program specialist shall have one of the following groups of qualifications: A bachelor's degree from an accredited college or university and 2 years of work experience working directly with individuals with an intellectual disability or autism.Program Specialist #1 is now a house supervisor, and the residential director will take on the caseload until pre-requisites for experience are met. 01/17/2025 Implemented
6400.165(g)Individual #1 is prescribed medication to treat symptoms of a psychiatric illness and had a medication review by a licensed physician on 05/21/2024, and then not again until 10/22/2024. The review on 10/22/2024 did not include the medication name, dosage, or the reason for prescribing the medication.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.The individual¿s psychiatric medication review dates will be added to the electronic health record with alerts to the program coordinators and PC supervisor to ensure each review is done at least every 3 months, including documenting the reasons for prescribing the medication, the need to continue and the necessary dosage. 01/17/2025 Implemented
SIN-00090657 Renewal 02/29/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(1)Individual #1's assessment, dated 11/4/15, was completed by a program coordinator and reviewed by a program specialist.The program specialist shall be responsible for the following: Coordinating and completing assessments. Effective March 1, 2016, Program Specialists are required to complete the assessment in whole. They will meet with the individual's staff plus the individual to complete each section of the assessment. After completing the assessment, the Clinical Director will review it to make sure that the assessment is completed correctly and that it was done by the Program Specialist [A meeting was conducted with all program specialist on March 2, Residential Director and Clinical Director reviewed the assessments with program specialist and reviewed that program specialist must complete the assessments and the procedures to do so. Documentation of aforementioned reviews by the clinical director shall be kept. (AS 4/1/16)] 03/12/2016 Implemented
6400.181(f)Individual #1 had an annual ISP meeting on 11/20/15. The assessment was sent to the SC and plan team members on 11/4/15.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). The Program Specialist will assure that assessments are sent out to all team members at least 30 days prior to an ISP meeting, revision or update. The Clinical Director will meet weekly with the Program Specialists to review upcoming ISP meetings scheduled 45 to 60 days away. The Clinical Director will review and sign the assessment to make sure it is getting sent out according to our regs [The Clinical Director will develop and implement a tracking system to ensure all individual assessments are provided to all plan team members within required time frames. The Clinical Director shall keep documentation of aforementioned weekly reviews with the Program Specialist to ensure the program specialists provided assessments to all individual's plan team members within required time frames. (AS 4/1/16)] 03/12/2016 Implemented
SIN-00077202 Renewal 03/10/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The home's self inspection was completed on 12-29-14. The agency's license expires on 3-19-15.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The self assessment will be started in October 2015 and will be compelted, with all areas brought into compliance, by 12/1/15. Staff performing the assessment will be notified by email and memo on or about October 1, 2015. [CEO or Designee will notify staff as stated above. (AS 6/10/15)] 05/15/2015 Implemented
6400.101The door from the house to the garage can be locked from inside the house. There is no man door in the garage.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The lock has been replaced so that it cannot be locked from either way.[CEO or Designee will completed a walk-through of each home to ensure stairways, halls, doorways, passageways and exits from rooms and from the building are unobstructed and implement a procedure for on going monitoring. (AS 6/10/15)] 04/27/2015 Implemented
SIN-00201575 Renewal 03/08/2022 Compliant - Finalized
SIN-00149892 Renewal 02/13/2019 Compliant - Finalized
SIN-00043244 Renewal 09/26/2012 Compliant - Finalized