Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00236967 Renewal 01/03/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(11)On 1/04/2024 Individual #1's January 2024 medication administration record did not include the diagnosis or purpose for any of the prescribed medications.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The MAR has been updated to include the purpose for each medication. Please see supporting documents. 01/18/2024 Implemented
6400.195(b)Individual #2's behavior support component of the individual plan was reviewed by the human rights team 2/21/2023 and then again 8/29/2023.The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews.The Director of Behavioral Services has been retrained to meet the 6-month review period when updating plans. Please see supporting documents. 01/18/2024 Implemented
SIN-00104344 Renewal 12/01/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(11)The physical examination completed on 7/18/16, for Individual #1, did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Annual Physicals for all individuals have been reviewed by the Medical Coordinator, Program Director, and Compliance Director to ensure that all sections have been completed. This was completed on 12/5/16. The Medical Coordinator and Compliance Director were trained on 12/5/16 on the regulation and process moving forward to ensure compliance. The Medical Coordinator will review the Annual Physical upon completion and turn it in to the Program Director for further review prior to being filed in the ABDD Medical Charts to assure all sections have been completed by the physician. If the sections have not been completed, the staff member who accompanied and turned in the Annual Physical form will be retrained and/or reprimanded. The Annual Physical form will immediately be returned to the physician for proper completion by the Medical Coordinator, then the process will begin again. The Compliance Director will review a sample (15) of Annual Physicals every three months again to assure that the regulation is in compliance. 01/28/2017 Implemented
6400.141(c)(14)The physical examination completed on 7/18/16, for Individual #1, did not include medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. On 1/20/17 the Medical Coordinator called and faxed a request for an addendum from the doctor to state whether or not each individual cited requires medical information pertinent to diagnosis and treatment in case of emergency. This will occur for all other individuals as well. The Medical Coordinator and Compliance Director were trained on 12/5/16 on the regulation and process moving forward to ensure compliance. The Medical Coordinator will review the Annual Physical upon completion and turn it in to the Program Director for further review prior to being filed in the ABDD Medical Charts to assure that the Annual Physical includes and the section is completed to meet the regulation. The Medical Coordinator will ensure the current and valid Annual Physical form is available prior to each appointment. If the Annual Physical form returns and it not the current form or the section has not been completed, the staff member who accompanied and turned in the Annual Physical form will be retrained and/or reprimanded. The Annual Physical form will immediately be returned to the physician for proper completion by the Medical Coordinator, then the process will begin again. The Compliance Director will review a sample (15) of Annual Physicals every three months again to assure that the regulation is in compliance. The Medical Coordinator changed the Annual Physical to include the regulation to meet compliance on 12/2/16. 01/28/2017 Implemented
SIN-00086299 Renewal 11/03/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(b)The "Rights" form, signed by Individual #1 on 9/25/15, did not state the full rights per the following regulations: 33(d) regarding program planning; 33(e) regarding privacy; 33(f) regarding personal property; 33(g) regarding visitors; 33(h) regarding telephone access; 33(i) regarding mail; 33(j) regarding voting; 33(k) regarding religion; 33(l) regarding no excess medication; and 33(m) regarding required to work. Per 6400.33(d) An individual has the right to participate in program planning that affects the individual. Per 6400.33 (e) An individual has the right to privacy in bedrooms, bathrooms and during personal care. Per 6400.33 (f) An individual has the right to receive, purchase, have and use personal property. Per 6400.33 (g) An individual has the right to receive scheduled and unscheduled visitors, communicate, associate and meet privately with family and persons of the individual¿s own choice. Per 6400.33 (h) An individual has the right to reasonable access to a telephone and the opportunity to receive and make private calls, with assistance when necessary. Per 6400.33 (i) An individual has the right to unrestricted mailing privileges. Per 6400.33 (j) An individual who is of voting age shall be informed of the right to vote and shall be assisted to register and vote in elections. Per 6400.33 (k) An individual has the right to practice the religion or faith of the individual's choice. Per 6400.33 (l) An individual has the right to be free from excessive medication. Per 6400.33 (m) An individual may not be required to work at the home, except for the upkeep of the individual's personal living areas and the upkeep of common living areas and grounds. Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. The compliance director Will assure that all rights are sent out in a timely manner and assure that all of the rights are visible on the copy presented to the individual one time a quarter. The Program Director Will assure that the compliance director has sent out all of the correct individuals rights by checking the compliance directors work one time quarter. [The compliance director or designee will immediately review the most current rights statement for all individuals in the community homes and ensure all individuals have been informed of all the rights and have a corresponding signed statement, and address immediately if needed. Documentation of reviews will be kept, as well as, quarterly checks by the program director. (AS 12/8/15)] 11/22/2015 Implemented
6400.71The telephone number for the nearest ambulance was not on or by the telephones in the kitchen and in the basement.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The Program Manager will check monthly to assure that the appropriate emergency numbers are placed on the phone one time a month. The program Specialist will also check to assure that the Program Manager is checking the phone labels by doing inspections of the homes one time a moth as well to again assure the phone labels are placed on all phones in the homes. 11/22/2015 Implemented
SIN-00257948 Renewal 12/17/2024 Compliant - Finalized
SIN-00182130 Renewal 01/26/2021 Compliant - Finalized
SIN-00124757 Renewal 11/16/2017 Compliant - Finalized
SIN-00094635 Unannounced Monitoring 02/01/2016 Compliant - Finalized
SIN-00087136 Unannounced Monitoring 11/03/2015 Compliant - Finalized
SIN-00055140 Renewal 10/10/2013 Compliant - Finalized