Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00281437 Renewal 01/13/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(1)Individual #3, date of admission 6/27/2019, had a physical examination completed 1/04/2025 that did not include a review of previous medical history.The physical examination shall include: A review of previous medical history.On 1/12/26, the Program Specialist reached out to individual #3's team and requested proof that medical history was reviewed at the time of the physical. 01/23/2026 Implemented
2380.111(c)(4)Individual #2 had a vision and hearing screening completed 12/11/2024, and not again since.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Program Specialist received documentation from the individual's physician 1/15/26 confirming that his vision and hearing was assessed in 2025, within one year from the last assessment. 01/14/2026 Implemented
2380.181(e)(5)Individual #1's assessment completed 4/17/2025, did not include the individual's ability to self-administer medications. It was documented can't assess, not applicable.The assessment must include the following information: The individual's ability to self-administer medications.Agency developed a new assessment that requires open-ended questions eliminating can't assess, not applicable responses. 01/23/2026 Implemented
2380.181(e)(6)Individual #1's assessment completed 4/17/2025, did not include the individual's ability to safely use or avoid poisonous materials. It was documented can't assess, not applicable.The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.Agency developed a new assessment that requires open-ended questions eliminating can't assess, not applicable responses. 01/23/2026 Implemented
2380.181(e)(7)Individual #1's assessment completed 4/17/2025, did not include the individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. It was documented can't assess, not applicable.The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.Agency developed a new assessment that requires open-ended questions eliminating can't assess, not applicable responses. 01/23/2026 Implemented
2380.36(b)Program Specialist #1 was trained in fire safety 6/05/2024 then again 6/25/2025. Direct Service Worker #2 was trained in fire safety 6/05/2024 then again 7/14/2025.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).On 1/14/2026 PS #1 was retrained using the cyclical date tracker which lists annual dates for a variety of areas, including fire safety annual date. 01/16/2026 Implemented
2380.125(f)Individual #2 is prescribed Abilify for anxiety and impulse control. On 1/13/2026 there was no record of Individual #2 having a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.On 1/19/2026, the agency developed a new Social, Emotional Needs document that addresses how staff support individuals taking psychotropic medications. 01/23/2026 Implemented
2380.173(5)On 1/13/2026 Individual #1's record included the individual's individual support plan, last updated 6/27/2025. Individual #1 had an updated individual support plan, dated 9/26/2025 that was not present in the record.Individual plan documents as required by this chapter.On 1/14/2026 Program Specialist #1 was trained to go onto HCSIS at least bimonthly to check for any updated ISPs that the PS may not have been made aware of. If changes are made aware to the PS, the new ISP must be put in the individual's record and staff must be trained on the change and sign the Individual's ISP training record. 01/23/2026 Implemented
2380.182(c)Individual #2's individual support plan, last updated 11/13/2025, documents the individual would be unable to move in the event of a fire and would need full assistance. Individual #2's assessment completed 12/15/2025 documents the individual can evacuate with verbal prompting. Individual #2's individual support plan, last updated 11/13/2025 does not include his ability using and avoiding poisonous materials. Individual #2's assessment completed 12/15/2025 documents he is independent with avoiding poisonous materials and needs verbal prompting while using poisonous materials. Individual #2's individual support plan, last updated 11/13/2025 does not include his ability to recognize and move away from heat sources. Individual #3's assessment, completed 12/29/2025, documents verbal prompts are needed for water safety. Individual #3's individual support plan, last updated 12/16/2025, documents individual #3 is able to independently regulate water temperature.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.On 1/14/2026, Program Specialist #1 was trained on notifying the supports coordinator and the rest of the individual's team of any changes to their assistance level by updating the annual assessment and providing that assessment to the team so the individual's support plan can be updated to match the new assessment. 01/23/2026 Implemented
SIN-00259681 Renewal 01/16/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.21(u)Individual #1 was informed of their individual rights and the process to report a rights violation on 6/21/2022 and then again on 1/13/2024. This exceeds the annual requirement. Individual #2 was informed of their individual rights and the process to report a rights violation on 8/14/2023 then again 8/20/2024. This exceeds the annual requirement.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.The Program Specialist was retrained on this regulation on 1/21/25. Additionally, the agency reached out to individual #1¿s home and the individual rights signed form was turned in on 1/20/25 and dated 1/13/25. For individual #2, their annual date has been updated to 8/20/25. [Training documentation for Program Specialists, which was not dated and did not indicate training content, was provided to the Department on 5/19/25 and review 5/29/25. A Post-It Note states that the training was completed 1/21/25. Individual Rights document for Individual #1, dated 1/7/25, was received on 5/19/25 and reviewed 5/29/25. Tracking document for Individual #2 related to individual rights was received on 5/19/25 and reviewed 5/29/25. A blank letter template for notification of individual rights coming due was received on 5/19/25 and reviewed 5/29/25. DPOC by HDKP, HSLS, on 5/29/25.] 01/21/2025 Implemented
2380.182(c)Individual #2's individual support plan, last updated 12/03/2024, does not address the individual's knowledge of the danger of heat sources and ability to sense and move away quickly. Individual #2's assessment completed 3/19/2024, states Individual #2 needs verbal prompts regarding knowledge of the danger of heat sources and ability to sense and move away quickly.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The individual¿s assessment has been updated to reflect the correct response per the ISP. Additionally, the Program Specialist was trained on 1/21/25 that moving forward, if the ISP does not provide an appropriate response, we will request the SC to update the plan. They were also retrained on the regulation. [An updated page of the assessment for Individual #2, with undated changes made to the assessment, was received on 5/19/25 and reviewed 5/29/25. Training documentation for Program Specialists, which was not dated and did not indicate training content, was provided to the Department on 5/19/25 and review 5/29/25. A Post-It Note states that the training was completed 1/21/25. DPOC by HSKP, HSLS, on 5/29/25.] 01/21/2025 Implemented
SIN-00237449 Renewal 01/17/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(4)Individual #1's annual physical examination, completed on 12/6/2023, did not include a hearing screening. This section was left blank. Individual #2's annual physical examination, completed on 9/1/2023, did not include vision and hearing screenings. The Primary Care Physician noted that individual #2 should follow-up with specialists; however, no documentation of these examinations could be provided by the agency. Individual #3's annual physical examination, completed on 7/27/2023, did not include a vision screening. The Primary Care Physician noted that individual #3 is followed by an optometrist; however, documentation of this examination could not be provided by the agency.The physical examination shall include: Vision and hearing screening, as recommended by the physician.On 1/26/24, the Program Specialist contacted the caregiver for individual #1 to request that the physical exam be completed in its entirety, or to provide missing information in the form of documentation. For individual #2 ¿ on 1/26/24 documentation from follow up specialist has been requested by the Program Specialist to caregiver. For individual #3 ¿ on 1/26/24 documentation from the optometrist has been requested by the Assistant Director. Assistant director contacted individual #3s residential provider. 01/26/2024 Implemented
2380.111(c)(10)Individual #3's annual physical examination, completed on 7/27/2023, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Following inspection, on 1/26/24, the Program Specialist requested residential provider that a physical form be completed in its entirety, which includes the section about medical information being pertinent to diagnosis and treatment in case of emergency. 01/26/2024 Implemented
SIN-00219879 Renewal 02/01/2023 Compliant - Finalized
SIN-00200048 New Provider Agency 02/22/2022 Compliant - Finalized