Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00287311 Renewal 04/21/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104The provider agency sent a notification letter to the local fire department on 5/4/2023. This notification did not include the exact location of the individuals' bedrooms.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. An updated notification letter was sent to the local fire department on 4/28/2026, including the exact location of the individual's bedroom. Future letters to local fire departments will be updated if the individuals change in the home, or if the individual's bedroom changes location in the home. All letters will notify with specific infomation as to bedroom locations and assistance needed for evacuation. 04/28/2026 Implemented
6400.32(r)Individual #1 has opted to have a lock on the door in the hallway leading to their bedroom. On 4/22/2026 at 1:07PM, the lock was inoperable on the pocket door inside Individual #1's bedroom leading to the only bathroom of the home causing Individual #1's bedroom to be unlocked and accessible. Individual #2 has opted to have a lock on the door in the hallway leading to their bedroom. On 4/22/2026 at 1:08PM, the lock was inoperable on the pocket door inside Individual #2's bedroom leading to the only bathroom of the home causing Individual #2s bedroom to be unlocked and accessible.An individual has the right to lock the individual's bedroom door.The locks were fixed on 4/28/2026. The lock for the pocket door for individual # 1 is now operable, and the lock for the pocket door for individual #2 is now operable. 04/28/2026 Implemented
6400.165(b)Individual #1 is prescribed Polyethylene Glycol Powder with instructions to, "Dissolve 1 capful (17GM) in 8OZ of water and take by mouth daily DX: Constipation." Individual #1 is also prescribed Polyethylene Glycol Powder with instructions to, "Dissolve 1 capful (17GM) in 8OZ of water and take by mouth daily as needed DX: Constipation (if no bowel movement for 2 days or having blood in stool due to constipation then take an extra dose to equal twice daily for 4 days then resume back to once daily). The only container of Polyethylene Glycol Powder present had a label taped it stating, "Dissolve 1 capful (17GM) in 8oz of water and take by mouth daily as needed DX: Constipation (if no bowel movement for 2 days or having blood in stool due to." The instructions are cut off and in a different area of the label state, "daily for 4 days then resume back to once daily."A prescription order shall be kept current.The pharmacy issued labels that correctly reflect the doctor's current orders. Program Specialist and Program Coordinators received re-training on the items required in the medication administration record, including the need for a current prescription order. 05/04/2026 Implemented
6400.166(a)(7)Individual #1 is prescribed Fluticasone Spray with instructions to, "Use 2 sprays in each nostril every day as needed DX: Allergies." Individual #1's April 2026 Medication Administration Record states, "Use 1 spray in each nostril twice a day as needed DX: ETD"A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.The pharmacy was contacted to clarify the disparity between the Medication Administration Record and the label. After review of their records a corrected label was issued. 05/05/2026 Implemented
6400.166(a)(9)Individual #1 is prescribed Fluticasone Spray with instructions to, "Use 2 sprays in each nostril every day as needed DX: Allergies." Individual #1's April 2026 Medication Administration Record states, "Use 1 spray in each nostril twice a day as needed DX: ETD"A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.The pharmacy was contacted to clarify the disparity between the Medication Administration Record and the label. After review of their records a corrected label was issued. 05/04/2026 Implemented
6400.166(a)(15)Individual #2 is prescribed Ibuprofen 600MG with instructions to, "Take 1 tablet by mouth 3 times a day as needed DX: Pain." Individual #2's April 2026 Medication Administration Record states, "Take 1 tablet by mouth 3 times a day as needed DX: Pain "Crushable Med, may be mixed in applesauce." The medication label does not state that the medication can be crushed. There were no physicians' orders to crush this medication and the Food and Drug Administration guidance, "strongly advises against crushing Ibuprofen tablets, as they should be swallowed whole to avoid throat irritation and to maintain proper release mechanisms."A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable.The pharmacy was contacted to clarify the disparity between the Medication Administration Record and the label. After review of their records a corrected label was issued. The pharmacy also advised that the Ibuprofen is safe to crush, as this is an uncoated ibuprofen for the purpose of crushing and that it is the coating that most ofen causes issues when crushed. 05/04/2026 Implemented
SIN-00269132 Renewal 07/01/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(r)(1)On 7/2/25 at 10:47AM, Individual #1 and Individual #2 have not been provided a specific locking mechanism to lock and unlock their bedroom doors. Their bedroom doors are equipped with "thumbnail" locking mechanisms.Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.Program specialist and program coordinators have been re-trained on the regulation. Agency policy indicates that individuals may exercise their right to lock their bedroom and access their bedroom with a key, a keypad code, an access card or other entry mechanism as they choose. Individuals had previously been provided with a key to their bedroom to exercise their right to lock their room as they chose to do so. Bedroom locks have been changed to digital keypads, and the individuals may use a key, or a keypad code of their choosing to access their bedroom as they choose. Staff are being trained on the rights of the individuals to lock their bedroom doors, the new locking mechanisms and how to access in an emergency. Staff will have keys to access as well as access codes, and will access only in emergency situations or with permission from the individual in non-emergency situations. 07/25/2025 Implemented
SIN-00249616 Renewal 07/24/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)The most recent fire drill during sleeping hours was conducted on 10/27/2023. This exceeds the every 6-month requirement.A fire drill shall be held during sleeping hours at least every 6 months. A fire drill during sleeping hours was held on 7/25/24. 07/25/2024 Implemented
6400.165(g)Individual #1 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness. Individual #1 had a psychiatric medication review conducted on 8/25/2023 and then again on 1/9/2024. This exceeds the at least every 3-month requirement. Individual #2 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness. Individual #2 had a psychiatric medication review on 3/27/2024 and then again on 7/3/2024. This exceeds the at least every 3-month requirement.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.Individual # 1 had a change in medication management providers, and was unable to access the previous provider for review while waiting for their first appointment. In the future documentation from providers will be kept of such changes. Individual #2 had a change in insurance and their long term provider was no longer covered. A scheduled appointment on 5/22/24 was cancelled due to this. The individual did not wish to change providers if at all possible, and the provider sought an exception to be able to continue to provide services. 08/26/2024 Implemented
SIN-00229308 Renewal 08/15/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)A single use packet of a 500mg Tylenol was unlocked and accessible in the first aid kit in a drawer in the living room on the first floor of the home. Individual #2 is not assessed safe around poisons.Poisonous materials shall be kept locked or made inaccessible to individuals. The single use packet of 500 mg Tylenol was immediately removed from the first aid kit and and secured in a locked area. 09/01/2023 Implemented
6400.141(c)(4)Individual #1's physical examination, completed 2/28/23 did not include a vision and hearing screening. These sections were left blank.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The program specialist has been trained on the regulation and the need to ensure that all required information is completed in full by the individual's physician. 09/01/2023 Implemented
6400.141(c)(14)Individual #1's physical examination, completed 2/28/23 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. The individual's physician has been contacted to complete the medical information pertinent to diagnosis and treament in case of emergency. The program specialist has been trained on the regulation and need to ensure that all required information is completed in full by the individual's physician. 09/01/2023 Implemented
6400.181(a)Individual #2, date of admission 2/1/23, had an initial assessment completed 4/16/23. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The program specialist has been trained on the regulation and timely completion of the initial and annual updated assessment. 09/01/2023 Implemented
6400.181(d)Individual #1's initial assessment was dated as completed on 7/1/23; however, the program specialist signed the assessment on 7/31/23. Individual #2's initial assessment was dated as completed on 4/16/23; however, the program specialist signed the assessment on 5/2/23.The program specialist shall sign and date the assessment. The program specialist has been trained on the regulation and the need to sign the assessment on the date the assessment is completed. 09/01/2023 Implemented