Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00261619 Renewal 03/04/2025 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The bathroom in the basement was visibly dirty with urine stains on the outsides of the toilet and the bathroom smelled strongly of urine. The toilet in the bathroom on the main floor was visibly dirty, inside, outside and the toilet seat at the time of the inspection.Clean and sanitary conditions shall be maintained in the home. The affected bathroom was thoroughly cleaned and sanitized on 3/7/2025 All urine stains and other visible dirt were removed, and the area was disinfected to ensure it meets cleanliness standards. All residential bathrooms were inspected to ensure there are no other areas of concerns with cleanliness standards. 05/01/2025 Accepted
6400.67(a)a. In the bathroom on the main floor, the cabinet door is loose and falling down causing it to not shut properly. It appears that the hinge needs to be tightened. b. In individual #1's bedroom, there is a golf ball sized hole in the ceiling above the TV. There are 6 large screw sized holes in the wall, near the ceiling, to the left of the individual's bedroom lounge chair and there are two holes of similar size on the ceiling above those 6 holes. There are also two small patches of exposed drywall on the wall behind the individual's dresser. These all need to be repaired. c. In individual #2's bathroom, the curtain rod and shower curtain were found lying diagonally in the bathtub; stretching from the shower wall to the tub floor and overlaying the shower lift/chair at the time of the inspection. If they are not in use or need to be removed, they should be stored elsewhere in the home and not in the bathtub that is being actively used by the individual.Floors, walls, ceilings and other surfaces shall be in good repair. 6400.64(a)¿Hinge was tightened 3/14/25 (see document #8) 6400.64(b)¿all repairs were completed to holes in the wall. Exposed dryer wall repaired. 6400.64(c)¿curtain rod was removed from the bathtub area as this is a private restroom for the individual. 04/30/2025 Accepted
6400.81(k)(3)Individual #1's did not have a comforter for her bed. There were items all over her bed and it appeared to not be in use. Staff stated that individual #1 prefers to sleep in the lounge chair in her room and without a blanket, however, this information was not found in the most recent ISP dated 2/24/2025.In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season.A comforter and sheet set have been purchased for the individual. ISP track changes were sent to the Supports Coordinator on 3/12/24 to outline the individual¿s desire to sleep in her recliner. Provider Program Director will conduct a training for staff and Program Specialists to review the violation and expectations. 05/01/2025 Accepted
6400.82(f)The bathroom located in the basement did not have a towel to dry hands and there was no toilet paper at the time of the inspection. The bathroom on the main floor did not have hand soap at the time of the inspection.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. All residential sites were evaluated for appropriate supplies. All staff will receive a training conducted by the Program Director to review the violation and regulation to ensure understanding of supplies required in each restroom. 05/01/2025 Accepted
SIN-00241528 Renewal 03/26/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71There were no emergency numbers on the phone in the kitchen at the time of the inspection.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Emergency number audits will be complete with each fire drill monthly. Fire drill logs have been updated to include the review of emergency numbers at each site and location of the numbers. All sites will have new laminated emergency numbers posted at each site by the Program Specialist. 05/31/2024 Implemented
SIN-00184941 Renewal 03/15/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(a)The nonslip mats on the exterior ramps in the front and back of the home have tears in the material. Outside walkways shall be free from ice, snow, obstructions and other hazards. Previously on 3/9/21, a maintenance request was submitted to the maintenance supervisor and missed. The nonskid ramp mat was replaced on 3/17/21. On 3/18/2021, an email from the Director of Operations was sent to the entire agency reminding of the process for Maintenance Requests. On 3/18/21 and 3/22/21, all ID Management was retrained on the Maintenance Request Procedure. Retraining of the Maintenance Request Procedure will be reviewed by staff at all sites by 4/16/2021. 04/12/2021 Implemented
6400.81(k)(6)Individual #1 does not have a bedroom mirror.In bedrooms, each individual shall have the following: A mirror. A full length mirror was placed on the back of the bedroom door on 3/17/21. The FSI ID Moving Procedure was updated on 3/18/21 to include the required bedroom furniture, including mirror. On 3/18/21 and 3/22/21, all ID Management was trained on the updates to the Moving Procedure. Training of the Moving Procedure will be completed by staff at all sites by 4/16/2021. 04/16/2021 Implemented
6400.82(f)There were no towels or paper towels in the main bathroom at the time of 03/16/21 inspection.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. ISP Track changes were sent on 3/19/21 regarding the main bathroom and why cloth or paper towels are not present due to a history of flushing inappropriate items down the toilet. For this reason, hand towels, wash cloths and rolls of paper towels are not kept in the bathroom. On 3/18/2021 and 3/22/2021, all ID Management was trained on the regulation and if not all items are present, then it must be reflected in the ISP with a reason. Training of the regulation and necessary updates to ISPs will be completed by staff at all sites by 4/16/2021. 04/16/2021 Implemented
6400.34(a)The Department issued updated regulatory rights, effective 2/3/2020, stating that individuals have additional rights they need to be informed of. At the time of the 03/15/2021 annual inspection, Individual #1 was never informed of the individuals rights as described in 6400.32.The home 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 home and annually thereafter.FSI Individual Consents/Rights were updated on 3/18/2021. On 3/18/21 and 3/22/2021, all ID Management was trained on the updates to the form. Training of the updates will be completed by staff at all sites by 4/16/2021. The updated Individual Consent/Rights will be reviewed with and signed by individuals and mailed out for guardians review and signatures by 4/16/2021. 04/16/2021 Implemented
SIN-00171673 Unannounced Monitoring 02/25/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)Results- Self Assessment- The self-inspection was completed on 2/20/20, but does not contain a written summary of corrections made. The violations are written out, but there is no POC indicated.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. 1. Between January 14- February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 3-10, 2020, 3 new Program Specialists have joined the ID management team. 2. A Licensing Self-Assessment binder was assembled and each site has it's own section. 3. All Program specialists were trained/retrained on the purpose of the self-assessment, how to complete and where they will be kept on 3/12/2020. 4. Self-assessments will be completed in January and July of every year. This will be scheduled by the Compliance Officer (hired 7/28/19) and completed as a group with assistance. 03/12/2020 Implemented
6400.76(a)Furniture safe, clean and sturdy-- There is a red recliner in the living room of the home that is so badly torn on the front and side that the stuffing material is hanging out. The patio chair cushions were also torn, shredded, and the stuffing material was all exposed. Furniture and equipment shall be nonhazardous, clean and sturdy. 1. The recliner in the living room and patio cushions were removed from the site on 3/4/2020. 2. Purchase of a new recliner and patio set is pending until COVID-19 parameters are lifted so individuals may choose their replacements. Anticipated to be replaced by 6/30/2020 06/30/2020 Implemented
6400.141(c)(9)Prostrate exam- The 10/15/19 annual physical exam indicated for the prostrate exam for Individual #1 "not indicated." The exam in 2018 also has "not indicated."The physical examination shall include: A prostate examination for men 40 years of age or older. 1. Between January 14- February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 3-10, 2020, 3 new Program Specialists have joined the ID management team. 2. All Program specialists were trained/retrained on the requirements for the prostate exam on 3/12/2020. 3. The individual had a PSA completed on 4/2/2020. 04/02/2020 Implemented
6400.141(c)(11)Health Maintenance- The 10/15/19 annual physical exam for Individual #1 does not assess the health maintenance needs. This section is blank on the physical form.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. 1. Between January 14- February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 3-10, 2020, 3 new Program Specialists have joined the ID management team. 2. All Program specialists were trained/retrained on the requirements of the physical on 3/12/2020 3. The Health Care Coordinator updated all individual physicals to electronic form, ensuring all sections were completed according to the ISP diagnosis and parameters by 4/6/2020. These forms are available to Site Coordinators to update at the individuals' next physical. 04/06/2020 Implemented
6400.181(e)(7)Heat sources- Individual #1's 8/12/19 annual assessment does not assess the ability to move away from heat sources. It acknowledges Individual #1's ability to recognize the heat source, not if he/she has the ability to move away from it.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. 1. Between January 14- February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 3-10, 2020, 3 new Program Specialists have joined the ID management team. 2. All Program specialists were trained/retrained on the timeline of assessments, the information that must be updated within the report and the importance of track changes being sent to the Supports coordinator on 3/12/2020. 3. As of 12/2019, Compliance officer sends out a monthly reminder email reviewing all upcoming due reports and meetings. 4. The individual's assessment was amended 3/20/2020 to update heat source and ability to move away. 03/20/2020 Implemented
6400.181(e)(10)Lifetime medical history- Individual #1's Lifetime medical history on the 8/12/19 has not been updated with current information since 2013.The assessment must include the following information: A lifetime medical history. 1. Between January 14- February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 3-10, 2020, 3 new Program Specialists have joined the ID management team. 2. All Program specialists were trained/retrained on the timeline of assessments, the information that must be updated within the report and the importance of track changes being sent to the Supports coordinator on 3/12/2020 3. As of 12/2019, Compliance officer sends out a monthly reminder email reviewing all upcoming due reports and meetings. 4. The individual's assessment was amended 3/20/2020 to update the lifetime medical history. 03/20/2020 Implemented
6400.32(r)Rights- Locks on doors- Individual #1's bedroom door did not contain a locking mechanism for privacy.An individual has the right to lock the individual's bedroom door.1. Developed bedroom door lock education/determination/condition form to be completed for each individual. This is to be completed by 4/17/20. 2. Door locks will be installed on individuals' bedroom doors as soon as COVID-19 protections are lowered and visitation to homes is safer. Anticipated installation date by 6/30/2020. 06/30/2020 Implemented
6400.44(b)(2)The program specialist shall be responsible for the following: Participating in the individual plan process, development, team reviews, and implementation in accordance with this chapter. The program specialist has not updated the lifetime medical history in Individual #1's annual assessment since 2012. There is no documentation that the Supports coordinator was given the documents such as ISP reviews (none in the record since 6/20/18) so Individual #1's ISP could be updated in a timely manner.The program specialist shall be responsible for the following: Participating in the individual plan process, development, team reviews and implementation in accordance with this chapter.1. Between January 14- February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 3-10, 2020, 3 new Program Specialists have joined the ID management team. 2. All Program specialists were trained/retrained on the timeline of assessments, the information that must be updated within the report and the importance of track changes being sent to the Supports coordinator as well as completion of ISP reviews on 3/12/2020. 3. As of 12/2019, Compliance officer sends out a monthly reminder email reviewing all upcoming due reports and meetings. 4. The individual's assessment was amended 3/20/2020 to update the lifetime medical history. The individual's ISP reviews are current through March 2020. 04/16/2020 Implemented
6400.183(c)There was no ISP signature sheet of who attended the ISP in 2019. There was no invite letter to the ISP meeting to verify the date of the ISP for Individual #1.The list of persons who participated in the individual plan meeting shall be kept.1. Between January 14- February 21, 2020, 4 Program Specialists left the employ of Family Services. Between February 3-10, 2020, 3 new Program Specialists have joined the ID management team. 2. All Program specialists were trained/retrained on the requirements of the invite and signature page in relation to the ISP meeting on 3/12/2020. When the invite letter is received, it is to be filed in the ISP section of the individual's book. And prior to leaving the ISP meeting, the PS shall request a copy of the signature page and this will be filed in the ISP section of the individual's book. 3. The Program Specialist requested a copy of the invite letter and signature sheet for the individuals last ISP meeting. 03/27/2020 Implemented
SIN-00128620 Renewal 02/13/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(c)There was no first aid manual kept with the first aid kit. A first aid manual shall be kept with the first aid kit.First-Aid manual will be placed with the first aid kit. 02/16/2018 Implemented
6400.112(a)There was no fire drill was held during the month of January 2019. An unannounced fire drill shall be held at least once a month. Site coordinators will be tasked with this oversight. Site Coordinator training will be completed by 4/30/2018. 04/30/2018 Implemented
6400.142(f)Individual #1 had no dental hygiene plan in the record. She requires assistance for her oral care.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. The ISP will be updated to include the dental plan. 02/28/2018 Implemented
6400.181(a)Individual #1's current assessment was completed on 1/22/16 and then again on 1/19/17 and not again. 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. Review of the updated deadlines will be sent to the Program Director. Program Director will be CC'd on all encrypted quarterlies, track changes, and assessments to monitor timeliness of reports. 04/06/2018 Implemented
6400.183(5)Individual #1's ISP review completed on 1/3/18 indicates they were discharged from behavior supports on 11/5/17. However there is no SEEN plan present in record or ISP to address social emotional needs which takes psychiatropic medications of abilify and clonazepam.The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. Guide of Support was written and implemented on November 6, 2017. It was placed into her individual file. 02/16/2018 Implemented
6400.186(a)Individual #1's ISP reviews covering 1/4 from 8/27-11/26 was not completed until 1/3/18.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. Updated deadline will be forwarded to Program Director. Program Director will be CC'd on all encrypted quarterlies, track changes, and assessments to monitor timeliness of reports. 04/06/2018 Implemented
6400.186(c)(2)In September individual #1 had 5 seizures. Only documented on 1/3/18 that she a 4 minute 55 second seizure and went to the ER. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. Quarterlies will include charting tracking information. 04/06/2018 Implemented
6400.186(d)Individual #1's ISP reviews have no documentation that the reviews sent on 6/6/17 and 9/2/17 were sent to ISP team members.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. Program Specialist training, review of the back page, and signature page of the quarterly to ensure all Program Specialists are completing the same. 04/04/2018 Implemented
6400.186(e)Individual #1's record did not have the option to decline provided to all team members until the ISP review was completed on 9/2/17. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. Signature page of the quarterlies will include the option to decline. 02/23/2018 Implemented
SIN-00048643 Renewal 05/21/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)There was no night time fire drill held from May 2012 until November 2012.(e) A fire drill shall be held during sleeping hours at least every 6 months. A review of the records shows that FSI¿s 6400 licensing occurred on May 30 & 31, 2012 and a nighttime drill was reviewed then dated 5-28-12. Following that drill a second one was done on 11-22-12 and has since been done on 5-7-13. FSI has maintained compliance with this regulation. Attachment #5a, b & c. Fully implemented. 06/05/2013 Implemented
6400.164(a)The medication log for Individual #2 did not list the time a PRN medication (Ambien) was given during May 2013(a) A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. To prevent this from happening in the future, an email was sent out to the ID Program staff on June 18, 2013 to inform staff of their responsibility to list the time given for each administration of a PRN medication. Program Specialists will monitor the MARS to ensure compliance. See attachment #1 MAR and attachment #2 email to program staff signed by Program Specialists. Partially implemented - adequate progress. 06/18/2013 Implemented
6400.213(11)The ISP and current assessment for Individual #2 indicates allergies and special diet cosiderations. This information is not contained on the physical.(11) Content discrepancy in the ISP, The annual update or revision under § 6400.186. A review of the individual's record reveals that the physical needed to have the allergies and special diet added and this was done on 6-18-2013 by the Program Specialist. To prevent this from happening in the future, Program Specialists will coordinate the pre-population of physicals prior to being seen by doctors so that all information is consistent. See attachment #3 for the updated physcial and #4 for the training record. Partially implemented - adequate progress. 06/18/2013 Implemented
SIN-00220661 Renewal 03/13/2023 Compliant - Finalized
SIN-00104675 Renewal 12/19/2016 Compliant - Finalized