Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00292283 Renewal 06/24/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(8)Individual 1 did not have a mammogram documented for 2025.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. - Upon discovery of the missed preventative health screening, Individual #1's mammogram appointment was scheduled. Documentation of the scheduled appointment is attached as Attachment H1. 08/31/2026 Implemented
6400.144Individual 1's gynocologist suggested a Cologuard screening on 11/4/2024 and PCP recommended it on 7/28/2025 but a follow-up screening was not scheduled.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 individual was scheduled to see the gynecologist on August 20, 2026. 08/31/2026 Implemented
SIN-00228624 Renewal 08/02/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.142(e)Individual #7 was seen on 10/18/21 by the dentist. A recommendation and referral was made for the individual to have all remaining teeth removed. Since that time the recommendation has not been fulfilled.Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed.The Healthcare Practitioner's office was contacted on 8/14/23 to make the appointment, the consent was completed and returned via fax on 08/29/23. We received a call back indicating there were not any appointments available until after 10/31/2023. (correspondence attached) 10/31/2023 Implemented
6400.181(d)Individual #7's annual assessment dated 8/10/22 was not dated and signed by the program specialist.The program specialist shall sign and date the assessment. The assessment for individual #7 was documented and revised on 08/04/2023 (J.T assessment document) to reflect the Program Specialist signature. 10/31/2023 Implemented
SIN-00126864 Renewal 12/12/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)THE FIRE DRILL RECORD FOR THE DRILL CONDUCTED ON 07/30/2017 DID NOT INCLUDE THE TIME IT TOOK FOR EVACTUATION.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. A new user friendly fire drill report form as well as a new fire drill review form will be developed in order to ensure all fire drill related regulations are met. Staff and Program Specialists will be trained when the forms have been approved. 03/31/2018 Implemented
SIN-00172444 Renewal 03/10/2020 Compliant - Finalized
SIN-00082916 Renewal 03/03/2015 Compliant - Finalized