Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00251159 Renewal 10/09/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Clean and sanitary conditions are not maintained in the home. Ceiling vents in all bedrooms of the home contained significant amounts of dust.Clean and sanitary conditions shall be maintained in the home. Vents were referred to maintenance to address immediately. Items will be cleaned and replaced as necessary. 11/30/2024 Implemented
6400.112(a)There was not an unannounced fire drill conducted in April 2024. (Repeat Violation 9/13/23) An unannounced fire drill shall be held at least once a month. Program Manager and CEO met to discuss concerns of repeat violation. Program Manager is new to the home and understands that issues like this moving forward will be subject to disciplinary action. Program Manager presented CEO with checklist to ensure fire drills are not missed moving forward. All staff in the home will be retrained on the regulation. 11/30/2024 Implemented
6400.112(d)All individuals did not evacuate the home within 2 ½ minutes on August 20, 2024. Documentation from the fire drill stated that "Individual #2 refused to get out of bed. Tried Multiple times." (Repeat Violation 9/13/23) 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. Program Manager and team will meet with client to discuss concerns regarding the refusal to evacuate for fire drills.. Education will be provided. 11/30/2024 Implemented
6400.142(a)Individual #1 had a dental exam completed on 10/12/23 and was to return in April 2024. There was no documentation that Individual #1 attended an appointment in April. Individual #1's record indicated that an appointment was refused on 7/1/24 and rescheduled to 8/1/24. There was no documentation that the appointment on 8/1/24 occurred.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Program Manager met with client to discuss importance of dental hygiene and review desensitization plan. 11/30/2024 Implemented
6400.46(d)Staff #1, works in the role of Program Specialist in addition to being the CEO. Staff #1 is not trained annually in first aid, Heimlich techniques, and cardio-pulmonary resuscitation.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.CEO will be trained in CPR/First Aid as soon as possible. 11/30/2024 Implemented
6400.52(c)(5)Staff #1 did not receive annual training in the safe and appropriate use of behavior supports if the person works directly with an individual.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.Staff #1 has reviewed and signed off on client's BSP. 11/30/2024 Implemented
SIN-00232800 Renewal 09/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Surfaces shall be in good repair. At the time of inspection, the individual #1 bedroom dresser had broken handles and was missing a drawer.Floors, walls, ceilings and other surfaces shall be in good repair. Dresser was replaced. IHRS will conduct audit of all locations bedroom furniture to ensure no other items need to be replaced. 12/31/2023 Implemented
6400.67(b)Surfaces shall be free from hazards. At the time of the inspection the dryer had a golf ball size amount of lint in the lint trap. This creates a fire hazard when not cleaned out regularly. Floors, walls, ceilings and other surfaces shall be free of hazards.Dryer was cleaned immediately. IHRS often issues memos and correspondence regarding cleaning lint from the dryer. This is also covered in fire safety training. Individual follow-up will occur with house staff. 12/31/2023 Implemented
6400.81(k)(6)The individual bedrooms shall have a mirror. Both individual #2 and #3 did not have mirrors in their room at the time of inspection.In bedrooms, each individual shall have the following: A mirror. Program Manager and DSP's working at location will be re-trained in the above mentioned regulation. Mirror was purchased and placed in individual #2 and #3¿s bedroom. 12/31/2023 Implemented
6400.82(e)The first bathroom containing the stand up shower did not have a non slip mat. Bathtubs and showers shall have a nonslip surface or mat. Program Manager and DSP's working at location will be re-trained in the above mentioned regulation. Bathtub/shower mat was purchased and placed in the home. 12/31/2023 Implemented
6400.112(a)There was no documentation to reflect that a fire drill occurred during the months of February, March, July, August or September of 2023. A fire drill shall be conducted every month. An unannounced fire drill shall be held at least once a month. Program Manager and DSP's working at all locations will be re-trained in the above mentioned regulation. Fire drill was completed. Fire drills will be conducted on a monthly basis. 12/31/2023 Implemented
6400.112(e)A sleep drill must be held every 6 months. The agency conducted a fire drill on 5.23.23 at 9:46pm which they documented was a sleep drill. However, the comment section of this drill reflects that not all individuals were sleeping.A fire drill shall be held during sleeping hours at least every 6 months. Program Manager's will be retrained on fire safety and fire drill requirements under Chapter 6400.112 (c). Program Managers will review all fire drill records and provide individual feedback to employees of missing or incorrect data. IHRS's Quality Assurance and Regulatory Compliance Manager will be responsible to collect and review all sites fire drill records on a monthly basis. 12/31/2023 Implemented
SIN-00210815 Renewal 09/20/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66At the time of inspection there was no light bulb in the outdoor light which led to the kitchen door entrance. (this was corrected at the time of inspection)Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Lightbulb was replaced at time of inspection. 10/31/2022 Implemented
6400.112(c)The fire drill held on 3/28/2022 reports the time of the fire drill was "around 3:40pm". The fire drill held on 01/12/2021 reports the time of the fire drill was "around 3:49pm". The time of the fire drill was not entered accurately on the report.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. Individual training was provided to the staff that completed fire drills. Training covered that an exact time is needed to appropriately assess evacuation times. Staff stated that they understood requirements and will time fire drills by exact time moving forward. 10/31/2022 Implemented
6400.112(d)The fire drill held on 4/30/22 at 3:19pm reports it took 2 minutes and 38 seconds to evacuate. This exceeds the time period under the regulation. The fire drill held on 3/28/2022 at the time around 3:40pm reports that it took 3minutes and 23 seconds to evacuate which also exceeds the time frame recommended under this regulation. 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. Program Manager will contact fire safety expert to clarify if an extended evacuation time is necessary and meets safety needs. Program Manager will provide additional fire safety training to all individuals that live in the home and monitor compliance. 10/31/2022 Implemented
SIN-00173792 Unannounced Monitoring 06/25/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Individual #1's bedroom was severely unkempt. There was a large open bag of garbage on the floor at the foot of his bed and clothing and items strewn everywhere.Clean and sanitary conditions shall be maintained in the home. The treatment team will address concerns surrounding the cleanliness of client's bedroom. Client is hesitant to allow staff to assist but the team will try to build this in to his behavior plan. The bag of papers has been removed. 07/31/2020 Implemented
6400.67(a)The baseboard in the bathroom was rusty. It has been painted over once, but the rust is coming back through the paint.Floors, walls, ceilings and other surfaces shall be in good repair. Electrician was contacted and baseboard is being replaced. Baseboards are a regular part of monthly compliance checks and monthly Program Specialist checklists. 07/31/2020 Implemented
6400.81(k)(6)Individual #1 has no mirror in his bedroom. Staff asked him where his mirror was and he replied, "I don't know. I never had one."In bedrooms, each individual shall have the following: A mirror. A mirror was purchased and placed in client's bedroom. Checking for mirrors in client bedrooms has been added to the monthly IHRS compliance check. 07/31/2020 Implemented