Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00192607 Renewal 11/15/2021 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.142(a)Individual #4 had a dental exam on 9/9/2020. He didn't have another dental exam until 11/10/2021, which exceeds the annual requirement.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 Specialist will perform monthly monitoring to ensure that all medical appointments are up to date. Program specialist will complete a CLA visit form which will be turned in to the appropriate Regional Director. 02/17/2022 Implemented
6400.143(a)Individual #4 refused a prostate exam on 10/7/2021. There is no documentation that the agency has trained individual #4 on the importance of these medical exams.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. Refusal forms will be utilized for any refused appointments in the future and education will be provided to the individuals regarding the importance of maintaining medical appointments. Documentation will be kept going forward, 02/17/2022 Implemented
6400.51(b)(1)Staff #3 did not receive orientation training on application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationshipsThe orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Staff was trained on the Everyday Lives policy on 2/18/22 as a part of his annual training hours. These documents have been uploaded into his employee profile at this time. All employee files have been reviewed to ensure compliance with orientation and annual training guidelines on the following topics: Application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships, Individual Rights, recognizing and reporting abuse, incident reporting, implementation of the individual plan, understanding and implementing behavioral support plan, and refusal of treatment. 03/16/2022 Implemented
6400.165(g)Individual #4's 3-month psychiatric appointments on 10/1/21, 8/13/21, 6/14/21, and 4/13/21 did not include documentation on the reason for prescribing the medications.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.House manager and Program Specialist will be responsible for reviewing all MVRs following the psych appointments to ensure that they are completed fully and accurately and include documentation on the reason for prescribing the medications. In the event that information is missing, the form will be resent to the provider for completion. 01/31/2022 Not Implemented
SIN-00193977 Unannounced Monitoring 10/05/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)The sink counter in the bathroom on the main level had a large section broken off, leaving behind jagged edges. This is a safety hazard as it cause injury to individuals and staff. Floors, walls, ceilings and other surfaces shall be free of hazards.The broken sink was replaced by SCS Maintenance on 10/14/21. House Managers are responsible for informing the Residential Supervisor of any maintenance items as they occur. Updated maintenance concerns are to be reported daily by EOPs on the proper maintenance form located on Extended Reach, our current Electronic Management System. Residential Supervisors are to verify that items are entered in our electronic maintenance request system and inform Regional Director within 24 hours. The Regional Director keeps a running list of all outstanding maintenance items to discuss with maintenance and have resolved if they linger for more than a week. Maintenance issue are to be addressed in a timely manner. 10/14/2021 Implemented
6400.67(b)There was a hole approximately 2 inches in diameter in the door to the bathroom. Floors, walls, ceilings and other surfaces shall be free of hazards.The hole in the bathroom closet door was patched by SCS Maintenance on 10/14/21. House Managers are responsible for informing the Residential Supervisor of any maintenance items as they occur. Updated maintenance concerns are to be reported daily by EOPs on the proper maintenance form located on Extended Reach, our current Electronic Management System. Residential Supervisors are to verify that items are entered in our electronic maintenance request system and inform Regional Director within 24 hours. The Regional Director keeps a running list of all outstanding maintenance items to discuss with maintenance and have resolved if they linger for more than a week. Maintenance issue are to be addressed in a timely manner. 10/14/2021 Implemented
6400.72(b)The sliding screen exit door from the basement is off track and not securely in place Screens, windows and doors shall be in good repair. The screen was fixed by SCS Maintenance on 10/14/21. House Managers are responsible for informing the Residential Supervisor of any maintenance items as they occur. Updated maintenance concerns are to be reported daily by EOPs on the proper maintenance form located on Extended Reach, our current Electronic Management System. Residential Supervisors are to verify that items are entered in our electronic maintenance request system and inform Regional Director within 24 hours. The Regional Director keeps a running list of all outstanding maintenance items to discuss with maintenance and have resolved if they linger for more than a week. Maintenance issue are to be addressed in a timely manner. 10/14/2021 Implemented
6400.111(a): The fire extinguisher in the basement did not meet the requirement of a 2-A rating. The fire extinguisher had a 1-A rating.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. The House Manager is responsible for checking all fire extinguishers in the home to ensure they are in good working condition and meet regulation requirements. The Fire Extinguisher in question was replaced with an appropriate size extinguisher on 10/6/21 The House Manager will notify the Residential Supervisor if they are in need of a new fire extinguisher or service to the extinguishers to ensure compliance. Fire Extinguishers in all home across the region were checked on 10/21/21. No further issues or concerns found. 10/06/2021 Implemented
6400.166(a)(5)October Medication Administration Record (MAR) for Individual #4 states: Levothyroxine (175mcg) QD at 8am. The package for Levothyroxine states: Levothyroxine (200mcg) QD 8am. The proper strength of the medication is not listed on the MAR.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.Updated MAR information was sent to the corporate office and added to the MAR 10/5/21 to correct dosage information. All EOPS and House Managers are trained and responsible for adding new medications prescribed to the MAR and sending the label information to our corporate contact to be added to the MAR permanently until discontinued so the MAR will show correct and current medication information. The Residential Supervisor has final sign off on shadowing and preparedness of staff to work in the home. All staff, regardless of position, are required to be undergo Medication Administration Training before working in the home alone during a medication administration time. All staff are trained by a licensed Medication Administration Trainer within the company, including two onsite observations, before administering any medication to individuals. 10/05/2021 Implemented
6400.166(a)(11)Individual #4 is prescribed the following medications: Acne Medication Gel QD, Clonazepam (1mg) TID, Folic Acid (1000mcg) QD, Ibuprofen (600mg) PRN, Levothyroxine (200mcg) QD, Melatonin (3mg) QD, Minocycline (100mg) QD, Olanzapine (20mg) QD, Oxcarbazepin (150mg) BID, Oxcarbazepin (150mg) BID, Risperidone (1mg) QD, Risperidone (2mg) QD, and Trazadone (2mg) QD. There is no diagnosis or purpose for these medications listed on his Medication Administration Record for these 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.Residential Supervisor contacted pharmacy to have new labels made including the reason for the medication on 10/11/21.This is being done in conjunction with the prescribing physicians. All EOPS and House Managers are trained and responsible for adding new medications prescribed to the MAR and sending the label information to our corporate contact to be added to the MAR permanently until discontinued so the MAR will show correct and current medication information. The Residential Supervisor has final sign off on shadowing and preparedness of staff to work in the home. All staff, regardless of position, are required to be undergo Medication Administration Training before working in the home alone during a medication administration time. All staff are trained by a licensed Medication Administration Trainer within the company, including two onsite observations, before administering any medication to individuals. 11/05/2021 Implemented
SIN-00122685 Renewal 09/19/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(d)Staff #1's had 14 hours of training for the 2016/2017 training year.Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. This staff person is no longer with the agency. The HR Director will ensure that all employee training requirements occur in a timely manner according to regulations. The HR Director is having all HR and training activities electronicized by 12/31/2017 in a new software system what will notify HR and Directors of all HR related requirements that are due from staff prior to the due date. Additionally, the immediate supervisors will receive monthly updates on training hour once their employees. 12/01/2017 Implemented
6400.46(f)Staff #1 did not have fire safety training.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. The HR Director and the Residential Supervisor will ensure that all staff are trained on Fire Safety Training during new hire orientation and on an annual basis per regulations. Training will also include a review of fire training records for each employee and tracking process. Fire Safety and all other training requirements will be tracked in the new software package Spectrum is using as of 12/31/2017. The Residential Supervisor will review and monitor all trainings on a monthly basis ((staff #1 is no longer with the agency - CH 10/31/17)) 12/31/2017 Implemented
6400.151(a)Staff #1 had a physical exam on 7/8/2014. She did not have another physical exam until 6/2/2017, which exceeds the annual requirement. 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. This staff person is no longer with the agency. The HR Director will ensure that all employee physicals occur in a timely manner according to regulations. The HR Director is having all HR activities electronicized by 12/31/2017 in a new software system what will notify HR and Directors of all HR related requirements that are due from staff prior to the due date. Additionally, the immediate supervisors will receive monthly updates on training hour once their employees. 12/01/2017 Implemented
SIN-00204247 Unannounced Monitoring 04/15/2022 Compliant - Finalized
SIN-00179911 Renewal 11/30/2020 Compliant - Finalized
SIN-00066913 Renewal 07/10/2014 Compliant - Finalized