Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00258366 Renewal 01/07/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)On 1/8/2025 at approximately 11:30am, the window overlooking the street in individual #1's bedroom was observed with three small holes in the screen measuring approximately 1 inch by 0.75 inches, 1 inch by 0.25 inches, and 0.5 inches by 0.5 inches. [Repeated violation: 4/30/2024 et al and 9/27/2024 et al]Windows, including windows in doors, shall be securely screened when windows or doors are open. on 1/8/2025, maintenance immediately repaired the holes in the screen on site to ensure it was securely intact and in compliance. The window screen was inspected by the inspector to confirm no further issues remained. 01/08/2025 Implemented
6400.141(a)Individual #1's annual physical examinations were completed on 7/20/2023 and again on 8/6/2024. [Repeated violation: 8/6/2024 et al]An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The nurses will input all physical examination dates into a shared calendar system and set reminders to ensure each individual receives their annual physical examination on time. Nurses will also confirm appointments are scheduled well in advance of due dates and document completed examinations promptly to ensure compliance. 01/17/2025 Implemented
6400.141(c)(13)Individual #1's annual physical examination, completed on 8/6/2024, indicates they are allergic to Influenza virus. Individual #1'a Support Plan, last updated 2/7/2024, indicates that they are allergic to peanuts, peas, and pollen. A medical consultation form, dated 12/10/2024, indicates that the individual is allergic to lactose, peanuts, peas, and pollen. [Repeated violation: 8/6/2024 et al]The physical examination shall include: Allergies or contraindicated medications.Individual #1 is scheduled to undergo an allergy test on 2/17/25 to confirm the accuracy of their reported allergies. Following the test, the nurse will ensure that all confirmed allergies or contraindicated medications are updated in the individual's medical records. The program specialist and nurse will collaborate with the individual's doctor and ISP team to verify that the information is accurate and aligns with ISP. 02/17/2025 Implemented
6400.151(a)Direct Service Worker #1's most recent physical examination was completed on 9/19/2022. [Repeated violation: 8/6/2024 et al] A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. The dsp #1 was scheduled and completed a tb and physical on 1/11/2025 this information has been documented in their personnel file. 01/11/2025 Implemented
6400.181(a)Individual #1's assessment, completed on 8/10/2024, indicates that the individual requires assistance with managing their finances. The assessment indicates that the individual does not take complete care of the spending money and that the individual cannot independently pick out and purchase all needed items at a store. Interviews with agency staff revealed that Individual #1 has the ability to independently manage their cash-on-hand, select items to purchase, and completed transactions; however the individual's assessment has not been updated to accurately reflect their current abilities. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The program specialist has updated the assessment on 1/8/2025 and attached the updates into the assessment dated 8/10/2024. 01/08/2025 Implemented
6400.181(e)(11)Individual #1's assessment, completed 8/10/2024, did not include their psychological evaluation.The assessment must include the following information: Psychological evaluations, if applicable. The program specialist has contacted the individual supports coordinator and successfully obtained a psychological evaluation from when the individual was a child. The program specialist is continuing efforts to gather any additional information, including collaborating with the SC to reach out to the individual's previous SC for further records. Once all relevant documentation is obtained, the individual's assessment will be updated to include the required psychological evaluation. 01/28/2025 Implemented
6400.15(b)The self-assessments completed on 5/23/2024, 11/23/2024, and 12/28/2024 were completed on the 6400 Scoresheet that was last updated in June 2018. This scoresheet does not measure compliance with all the current 6400 regulations.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.The agency will immediately (1/8/2025) transition to using the Department's licensing inspection instrument for community homes to measure and record compliance, The outdated scoresheet used on 5/23/2024, 11/23/2024, and 12/28/2024 will no longer be utilized. 01/08/2025 Implemented
6400.52(c)(1)Direct Service Worker #1 did not have documented training to encompass the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships during the 7/1/2023 through 6/30/2024 training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The DSP #1 has completed the necessary training on person centered, community integration, individual choice and supporting individuals in developing and maintaining relationships. 01/15/2025 Implemented
6400.182(c)Individual #1's Support Plan, last updated 2/7/2024, indicates that the individual can swim. Individual #1's assessment for, completed on 8/10/2024, also indicates that the individual has the ability to swim. Individual #1's functional assessment, completed 8/10/2024, indicates that the individual cannot swim, hold onto the side of a pool and kick, float on their stomach, float on their back, swim using doggie paddle, swim using a crawl stroke, or tread water. [Repeated violation: 8/6/2024 et al]The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The program specialist has updated the assessment on 1/8/2025 and attached the updates into the assessment dated 8/10/2024. 01/08/2025 Implemented
SIN-00229750 Renewal 08/22/2023 Compliant - Finalized