Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00278701 Renewal 11/24/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill conducted at this residence on 1/5/2025 did not indicate if it was conducted at 9:00 AM or 9:00 PM. The agency's fire drill form has a section for staff to indicate if the drill was conducted ante meridiem or post meridiem; however, this section was left blank.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The Program Director, Program Specialist, Quality Assurance Associate, and Program Managers were retrained on the regulation. 12/12/2025 Implemented
6400.207(5)(III)On 11/25/2025 at 10:26 AM, Individual #1's bed contained bilateral upper half bedrails that restricted the movement or function of the individual's body. The agency did not have a prescription order for the bedrails. Individual #1's individual plan last updated 8/14/2025, does not indicate the need for the bedrails, nor does it include periodic relief of the device to allow freedom of movement.A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Protection from injury during a seizure or other medical condition, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement.The Program Director, Quality Assurance Associate, Program Specialists, Program Managers, and the Facilities Director have been retrained on the regulation. The bedrails were removed on 11/26/25. 11/26/2025 Implemented
SIN-00257949 Renewal 12/17/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)On 12/18/2024 at 11:08 am, the hot water temperature in Individual #1's ensuite bathroom sink measured 132.2°F.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. Maintenance adjusted the hot water tank on 12/18/24 and was below 120F. The Operations Manager and Program Managers were retrained on 1/7/25 on 6400.63(a). 01/10/2025 Implemented
6400.68(b)On 12/18/2024, at 11:09 am, the hot water temperature in Individual #1's ensuite bathroom shower measured 127.4°F. Hot water temperatures in bathtubs and showers may not exceed 120°F. Maintenance adjusted the hot water tank on 12/18/24 and was below 120F. The Operations Manager and Program Managers were retrained on 1/7/25 on 6400.68(b). 01/10/2025 Implemented
SIN-00197703 Renewal 12/14/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.143(a)Individual #1 refuses routine medical and dental examinations, and no documentation was provided of the continued attempts to train the individual about the need for health care.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. ITA requested by Program Specialist from Supports Coordinator on 12/23/21. HCQU referral to train and educate individual scheduled for 1/12/22. Educational materials requested. Supplemental procedure for refusal of medications and medical appointments has been updated to be reviewed monthly. The Program Specialist will document on Monthly Progress Notes and Quarterly Reviews. Behavior Specialist will track refusals and address through behavior supports. 12/30/2021 Implemented
6400.165(g)Individual #1 has been prescribed medication to treat symptoms of a psychiatric illness. The agency did not complete a review by a licensed physician at least every 3 months.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.New PCP intake scheduled for 1/5/22 in-person with Dr. Angela Hogue (Greenville Community Health Center). Routine telehealth appointments to follow to assist in attendance. New Psychiatrist intake scheduled for 2/24/22 in-person with Dr. Tracey Rusnak (Greenville Community Health Center). Routine telehealth appointments to follow to assist in attendance and ensure 3-month reviews are completed. All appointments will be documented on Monthly Progress notes and Quarterly Reviews. 12/30/2021 Implemented
6400.185(5)Individual #1 routinely refuses all medical appointments. Individual #1's plan, last updated 04/26/21, does not include adequate information to address the risk to the individual's health, safety, or well-being and risk mitigation strategies.The individual plan, including revisions, must include the following: Risks to the individual's health, safety or well-being, behaviors likely to result in immediate physical harm to the individual or others and risk mitigation strategies, if applicable.Operations Manager and Program Specialist requested the Supports Coordinator to update the ISP with information to address the risk of individuals health, safety, and well-being and risk mitigation strategies to include history of appointment and medication refusals, information on recent hospitalizations, supplemental procedures to guide staff, behavioral data, behavior support plan, HCQU and ITA information, etc.. DSP's will continue to follow the behavior support plan which includes supplemental procedures for medication and appointment refusals and document any such occurrences. Incidents will be sent to the Supports Coordinator upon completion and a quarterly summary will be sent. 12/30/2021 Implemented
SIN-00086302 Renewal 11/03/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(c)The fire extinguisher located in the kitchen was not fully charged. A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). The maintenance department will check each homes fire extinguisher bimonthly to assure that all agencies fire extinguisher are fully charged in each residential home. The maintenance department will turn in a checklist to the Program Director to review bi-monthly. 11/22/2015 Implemented
SIN-00182133 Renewal 01/26/2021 Compliant - Finalized
SIN-00144002 Renewal 10/23/2018 Compliant - Finalized
SIN-00124760 Renewal 11/16/2017 Compliant - Finalized