Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00209862 Renewal 08/03/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65The basement bathroom does not have an operable window or ventilation system in place.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. 1. A vent/fan was installed in the basement bathroom on 9/21/22. (Attachments 25-26) Implemented
6400.141(c)(7)The most recent GYN exam for individual #1 took place on 10/23/19.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. 1. GYN exam was completed for Individual #1 on 8/10/22. 10/31/2022 Implemented
6400.141(c)(8)The most recent Mammogram for #1 took place on 10/23/19.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. 1. GYN exam was completed for Individual #1 on 8/10/22. (Attachments #33-45) 10/31/2022 Implemented
SIN-00153684 Renewal 03/06/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The ceiling in individual #1's bedroom was peeling paint.Floors, walls, ceilings and other surfaces shall be in good repair. 1. Maintenance request was submitted on 3/12/19 to paint the ceiling and walls, hallway, spare room and dining room ( Attachment #4 ) The painting of the ceiling was completed on 3/18/19 (Attachment # 5). 2. A new weekly Admin) checklist (Attached Form #1.section2) has been developed to supplement the daily checklist that is completed by DSPs. The Admin weekly checklist will be completed by (Team Facilitator, Program Specialist, Lead Staff or designated person) Staff will be trained and form implemented by June 30, 2019 03/18/2019 Implemented
6400.161(b)There was a packet of Tylenol found in the first aid kit.Prescription and potentially toxic nonprescription medications shall be kept in an area or container that is locked, unless it is documented in each individual's assessment that each individual in the home can safely use or avoid toxic materials. 1. The packet of Tylenol was removed from the First Aid kit while inspector was at site (Attachment #3) 2. A new weekly Admin) checklist (Attached Form #1.section5) has been developed to supplement the daily checklist that is completed by DSPs. The Admin weekly checklist will be completed by (Team Facilitator, Program Specialist, Lead Staff or designated person) Staff will be trained and form implemented by June 30, 2019 3. Admins will be re-trained to ensure all new First Aid kits do not have medications 03/09/2019 Implemented
SIN-00057821 Renewal 02/24/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.164(b) Individual #1 is prescribed Betaseron injection 0.3 mg. subcutaneously every other day. The medication was not signed as administrated on 2/15/14 and 2/17/14. (b) The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. The Agency protocol has been updated to have all medications administered by a party outside of the agency to be added to the MAR. The outside party will then on the new be required to document the administration on the MAR. All Agency staff will be retrained procedure and to prompt and instruct the outside parties where to document the administration. Compliancy for this new procedure will be monitored by the assigned Cluster Administrator and documented on the Weekly Medication Inspection forms. 06/30/2014 Implemented
SIN-00152589 Renewal 03/06/2019 Compliant - Finalized