Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00275944 Renewal 09/19/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)The only physical exam on file for Individual Barry Whitest is dated 09/16/2025, which is after their admission date.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual had the physical examination completed but Program Specialist did not provide it to licensing officer during the audit. The proof has been attached as part of supporting documents for the plan of correction. Additionally, Program Specialist has been coached to ensure all prior documentation of individuals that were provided prior to onboarding are properly filed with the individual's program book 10/13/2025 Implemented
6400.141(c)(14)Physical exam for Individual 2 does not list information pertinent to diagnosis and treatment in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The violation noted during the exit interview was that the tuberculosis test portion of the annual physical was not completed by the physician. The annual physical form has been updated and the proof of the completed TB test has been included in the supporting documents 09/26/2025 Implemented
6400.181(a)Initial assessment for Individual 2 was completed 09/11/2025, which is 92 days after their admission date of 06/11/2025. 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. Program Specialist has updated the Agency's onboarding policy to reflect a review to be completed before the 60 day anniversary from the admission date into the program 09/26/2025 Implemented
SIN-00252986 Renewal 09/19/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66There was not lighting outside of the individual's bedroom sliding door area, which is used as an exitRooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. A new outdoor light was installed on the back porch of the home 10/24/2024 Implemented
6400.67(a)The closet door in individual #3 bedroom requires reattachment.Floors, walls, ceilings and other surfaces shall be in good repair. A new curtain rod and curtain was installed. This was per the feedback of the consumers who felt it was easier for them to navigate into the closet on their wheel chairs as opposed to the closet door which sometimes required the assistance of their staff to open it for them. 09/19/2024 Implemented
6400.77(b)The first aid kit is missing antiseptic. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. New packs of antiseptic wipes were purchased and added to the first aid kit. 10/28/2024 Implemented
6400.151(c)(3)The physical dated 8/25/2023 for Staff Person #1 did not indicate whether or not they were free of communicable diseases statement. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. The caregiver returned to their physician to update her annual physical records to indicate that she is free of communicable diseases. A copy of the updated record is included in the POC emailed to the county. 10/30/2024 Implemented
6400.24The individual's Room and Board Residency Agreement dated 1/10/2024 charges individual $701.06 which exceeds 72% of the maximum SSI and SSP amounts for the year 2024. The maximum charge the individual should be incurring is $694.87 as the SSI maximum is $943 and SSP rate is f $22.10 currently per Chapter 6100.686 a-1 for individual #3.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.A revised calculation was done from start of the year to August of 2024 which is the last reconciled room and board transaction. The difference of $6.188 was paid for all 8 months to the individual's account for a total of $49.50. 10/28/2024 Implemented
6400.165(b)Individual #1's Dicyclomine is written on the blister as 10mg as an AM dose and then as a PRN. Both are on the MAR.A prescription order shall be kept current.As per the Pharmacy, Nyame which was on our mar in Therap is a brand name that is no longer carried by the pharmacy a different brand name is in use now called NYSTOP. They stated this is the same medication as the Nyame just a different name. The mar was clarified and updated. 09/19/2024 Implemented