Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00248322 Renewal 07/23/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66There was no light outside of the backdoor.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Program Coordinator A maintenance request was submitted 8/21/2024 to the Landlord to install light outside the backdoor. See attached. 08/29/2024 Implemented
6400.68(a)The water pressure of the individuals' bathroom was very poor.A home shall have hot and cold running water under pressure. Program Coordinator A maintenance request was submitted to the landlord on 8/21/24 to fix water pressure issues. 08/29/2024 Implemented
6400.113(a)Individual Fire Safety Training conducted on 2/16/2024. Individual #1 moved into the home on 1/16/2024. Instruction did not occur upon initial admission. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. Program Coordinator will ensure that all newly admitted individuals will be trained on fire safety within 24 hours of admission. 08/29/2024 Implemented
6400.142(f)No written plan for dental hygiene on file. The two most recent ISP suggest that individual #1 needs support in locating a dentist for an exam, and it is not certain if they have seen a dentist since they were under 17.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. Nurse Manager Special Smiles. Online application was rejected. Will begin the process again on 8/23/2024 Family was contacted and they did not have any dental information for the individual. Typically, Dental Hygiene plans are done by dentist. OFP created a Dental hygiene plan until he sees the dentist. 08/29/2024 Implemented
6400.166(a)(2)None of the doctors that prescribed medications for individual #1 were on the MAR.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.Nurse Manager/Medical Coordinator Nurse Manager and Medical Coordinator will add the prescribing physician¿s names to the individual¿s MAR starting on 9/1/2024. 09/01/2024 Implemented
6400.166(a)(4)The name of the medication for individual #1, Nayzilam spray 5 MG was not on the MAR, just the dosage and route of the medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.Program Coordinator/Nurse Manager This was corrected during the inspection: the medication name was written on the MAR in front of the inspector. 09/01/2024 Implemented
SIN-00190759 Renewal 07/27/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71There were no emergency phone numbers by the living room telephone.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 Emergency Contact Telephone List was posted by each phone on 7/27/2021. 07/27/2021 Implemented
6400.112(a)The Fire Drill log was reviewed the home for the past 6months. There was no documentation that a sleep drill was held. An unannounced fire drill shall be held at least once a month. An overnight fire drill be conducted by 8/31/2021. 09/30/2021 Implemented
6400.144Individual 1 did not have as needed (PRN) medications lorazepam, promethazine, Mucinex, and triple antibiotic ointment present in medication box on site during the medication review.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 Nurse called the PCP, and a script was sent to the pharmacy on 7/28/2021. All the PRN medications are currently in the home and the MAR was updated accordingly. 09/30/2021 Implemented
6400.181(d)The assessment for individual 1 on February 15, 2021, was not signed or dated by Program Specialist. The Program Specialist signed the Assessment at the time of licensing inspection.The program specialist shall sign and date the assessment. The Program Specialist signed and dated the Assessment during on 7/27/2021. 09/30/2021 Implemented
SIN-00145569 Renewal 11/06/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The outside light was inoperable.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Program Coordinator replaced the light bulb in the outside light on 11/8/2018. Program Administrator completed training with Program Director and Program Coordinator on 12/12/2018. Program Director/Program Coordinator will complete a training with the Site Supervisors/Program Managers and Direct Care Staff by 1/15/2019on the Daily Safety Checklist which includes ensuring all lights are operable. The Daily Safety Checklist will be completed during the overnight shift for all homes. Direct Care Staff will report all areas of noncompliance to the On-Call Supervisor. Upon correction the On-Call Supervisor will indicate corrective action on the Daily Safety Checklist. 01/15/2019 Implemented
SIN-00172048 Renewal 02/05/2020 Compliant - Finalized