Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00278866 Renewal 12/08/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #1 has a bowel protocol that their bowel movements are to be tracked daily. From April 2025 to the present, Individual #1's bowel movements were not tracked a total of 9 times (04/12, 04/20, 05/21, 06/01, 070/5, 07/18, 10/30, 11/27, and 11/28). If Individual #1 goes three days with no bowel movement, they were to receive a dose of Milk of Magnesium on Day 3 and again on Day 4 if they still had no bowel movement. In August, the Milk of Mag was discontinued, and Lactulose was to be administered if Individual #1 went three days with no bowel movement and again on Day 4 with no bowel movement. The Milk of Mag was administered on 06/18/25 and 06/19/25 despite the Individual having had bowel movements in the previous days Individual #1 has a prescription in the record dated 11/03/25 that Individual #1 should not consume any caffeine. Per Individual #1 financial record, Individual #1 purchased both a "Pepsi" and a "Mt Dew", two beverages that contain caffeine, on 11/13/25.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The provider acknowledges the citation. Immediate corrective action was taken to ensure all prescribed health services are followed as ordered., Individual #1's bowel protocol, medication orders, and dietary restrictions were reviewed with all staff. Staff will be re-trained on daily bowel movement documentation, proper PRN medication administration per physician orders, and the discontinuation of Milk of Magnesia with appropriate use of Lactulose. The MAR and bowel tracking logs were reviewed for accuracy. Staff will be also re-educated on Individual #1's no-caffeine medical restriction. Supervisory oversight by wellness coordinator will be increased to ensure compliance with health service plans and prescriptions 01/28/2026 Implemented
6400.181(f)Individual #1 ISP meeting was held on 10/23/25; the most recent Annual Assessment, completed 08/16/25 was sent to all members of Individual #1's Individual Support Plan (ISP) team, excluding Individual #1's mother.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.The provider acknowledges the citation. the Program Specialist reviewed Individual #1's ISP records and confirmed that the Annual Assessment dated 08/16/25 was not provided to Individual #1's mother prior to the ISP meeting. The assessment was immediately provided to Individual #1's mother. The Program Specialist was re-trained on ISP requirements, including ensuring that all ISP team members receive required assessments at least 30 calendar days prior to ISP meetings. 01/28/2026 Implemented
6400.213(1)(i)Individual #1's Guardian is listed as the next-of-kin; however, the Guardian is not a relative.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.The provider acknowledges the citation. On 12/15/25 Individual #1's record was reviewed and corrected to accurately reflect the Guardian's role. The Guardian was removed from the "next-of-kin" section and properly identified as the legal Guardian. The individual's personal information record was updated to ensure accuracy and compliance with regulatory requirements. Wellness coordinator and program specialist reviewed the corrected record to confirm accuracy 01/28/2026 Implemented
SIN-00221338 Renewal 03/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.70The telephone for the home was locked in the staff office and not accessible to Individual #1 in their apartment. There was a telephone accessible to staff outside the apartment, located in the agency's main office building space. If the individual wanted to use this telephone, they have to leave their apartment to locate the phone.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. o When this was discovered, 3.29.2023, the team placed the phone back inside the apartment on a small table. 04/06/2023 Implemented
SIN-00146194 Renewal 01/29/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(7)Most recent physical dated 11/14/18 and most recent ISP dated 1/14/19 indicate that the last gynecological exam Individual #1 had was on 12/19/2017. This is a yearly requirement and the individual should have had another exam on or before 12/19/2018.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. Individual #1 received her gynecological exam on 1/24/19. Future plan to prevent this from occurring again is to schedule once the appointment summary is returned to the Wellness Coordinator by staff. This will ensure that the appointment is scheduled within the 1 year time frame. Individual #1 has next appointment scheduled for 1/28/20. Wellness Coordinator is responsible for scheduling the appointment. Executive Program Director will ensure that all yearly appointments are scheduled and utilize the Gynecological tracker to check for accuracy. 02/11/2019 Implemented
SIN-00237664 Renewal 03/19/2024 Compliant - Finalized
SIN-00123120 Renewal 01/03/2018 Compliant - Finalized
SIN-00076367 Renewal 04/13/2015 Compliant - Finalized