Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00275470 Renewal 10/02/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65At 1:02 PM on 10/3/25, the mechanical exhaust fan located in the full bathroom on the home's main floor was inoperable. Furthermore, this bathroom did not have any windows that open.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. On 10/8/25, Laurel House Maintenance Team replaced the bathroom exhaust fan at the residential site. A picture has been provided for review. 10/08/2025 Implemented
6400.104Individual #1's Service Plan, last updated 6/30/25, states that "[Individual #1] will evacuate within 2.5 minutes with verbal prompts during a fire drill [and] [that] [they] may also need some physical assistance while evacuating, as [they] may become anxious or scared." Individual #2's Service Plan, last updated 9/10/25, indicates that "[Individual #2] requires verbal and some physical assistance from staff···to evacuate [their] residence." Individual #3's Service Plan, last updated 7/1/25, explains that "[Individual #3] requires physical assistance to evacuate the building within 2.5 minutes." However, the home's Fire Department Notification Letter, dated 1/4/25, stated that the four residing individuals "can evacuate with verbal assistance." Therefore, the home's Fire Department Notification Letter, dated 1/4/25, was not kept current, as it did not include the following: indication that any of the four individuals residing at the home require physical assistance to evacuate in the event of an actual fire; and the exact locations of Individual #1's, Individual #2's, Individual #3's, and Individual #4's 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. Laurel House, Inc is currently getting layout designs of all residential sites that will show where bedrooms are located within the homes. Once all updated information is obtained, New Fire Department letters will be mailed out that contain maps of the residential sites with bedroom locations and exits clearly marked. The letter will also state if the individuals require physical assistance when evacuating the residential home. 11/26/2025 Implemented
6400.111(c)At 12:52 PM on 10/3/25, the closest extinguisher to the kitchen was located on the other side of a dividing wall in the staff office area near the entrance to the bedroom hallway. A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). Laurel House, Inc Maintenance Team relocated the fire extinguisher to the kitchen area of the home. Documentation/picture submitted for review 10/08/2025 Implemented
6400.214(b)At 1:11 PM on 10/3/25, neither hard nor electronic copies of the following regarding Individual #2's most current records were kept at the home: a current, dated photograph; the most current Service Plan, and an applicable psychological evaluation. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. Laurel House Inc Program Supervisor/Specialist will update client's chart at the residential site with a current photo, current/available HCSIS Individual Support Plan, and psychological evaluation. 11/26/2025 Implemented
6400.18(a)(9)Enterprise Incident Management #9610811 for an unexplained serious injury requiring treatment beyond first aid was discovered on 4/14/25 at 12:00 AM and reported on 4/27/25 at 11:52 AM.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Injury requiring treatment beyond first aid. Laurel House Inc continues to schedule Incident Management Training with all Laurel House Inc employees (DSP's, Nursing, and Program Staff) so that everyone can better understand the Incident Management Process and when to appropriately report and file incidents. 11/06/2025 Implemented
SIN-00198371 Renewal 01/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)Individual #1 had fire safety training on 5-6-20, and then again on 5-25-21. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. A checklist was created to track all Individuals' Fire Safety training dates, listing the previous training date to provide organization for Individuals' fire safety training. Program Specialists/Supervisors have been instructed to fill in the checklist and provide the date needed for the next fire safety training. The Program Director will review the checklist on a monthly basis to ensure the fire safety training is set up within the required time frame. The Program Specialist/Supervisor has been made aware of the training date needed for the Individual #1 at 177 Bailey Avenue. 01/24/2022 Implemented
6400.151(a)Direct Service Worker #1 had a physical examination completed on 3-13-19, and then again on 4-14-21. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Laurel House, Inc. has Implemented a new procedure to obtain staff physicals and TB Mantoux tests within the regulatory timeframes. Procedure for regulatory requirement for all staff physicals 1. Staff will be notified by memo minimum of 3 months in advance of when employment physical/TB Mantoux test is due. 2. A copy of the physical will be attached to the memo. 3. The employee¿s supervisor will be advised by email of the upcoming due date of staff `s physical. 4. Supervisor will remind the staff one month week, then one week prior to due date of the physical/TB Mantoux (not including grace period). 5. Supervisor will encourage employee to go to Cherry Tree Urgent Medical Care for employment physical as walk-ins are permitted and Laurel House, Inc. has a contract with the Doctor¿s Office to bill the agency, not the employee. The employee may elect to go to their own doctor. 6. After the completion of the grace period and the employee did not complete and turn in a valid physical, the employee will not be able to work. The employee will be suspended from work at that time. 7. When out on suspension, the employee can use vacation time first and then be off without pay until the employment physical is turned into the office. 8. Once the employment physical is turned into the office, the employee can resume working scheduled shifts. 08/23/2021 Implemented
6400.151(c)(2)Direct Service Worker #1 had a Tuberculin skin test completed on 3-15-19, and then again on 4-16-21. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Laurel House, Inc. has Implemented a new procedure to obtain staff physicals and TB Mantoux tests within the regulatory timeframes. Procedure for regulatory requirement for all staff physicals 1. Staff will be notified by memo minimum of 3 months in advance of when employment physical/TB Mantoux test is due. 2. A copy of the physical will be attached to the memo. 3. The employee¿s supervisor will be advised by email of the upcoming due date of staff `s physical. 4. Supervisor will remind the staff one month week, then one week prior to due date of the physical/TB Mantoux (not including grace period). 5. Supervisor will encourage employee to go to Cherry Tree Urgent Medical Care for employment physical as walk-ins are permitted and Laurel House, Inc. has a contract with the Doctor¿s Office to bill the agency, not the employee. The employee may elect to go to their own doctor. 6. After the completion of the grace period and the employee did not complete and turn in a valid physical, the employee will not be able to work. The employee will be suspended from work at that time. 7. When out on suspension, the employee can use vacation time first and then be off without pay until the employment physical is turned into the office. 8. Once the employment physical is turned into the office, the employee can resume working scheduled shifts. 08/23/2021 Implemented
SIN-00124739 Renewal 11/14/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(10)The program specialist did not date the April 2017 and March 2017 monthly documentation for Individual #1.The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of an individual's participation and progress toward outcomes.Monthly progress notes for March and April 2017 were si9gned by the program specialist and training was given on regulation 6400.44(b)(10). Program director to review progress notes monthly to ensure that the program specialist signed each month. Supporting documentation attached.[Within 30 days of receipt of the plan of correction, the program director shall educate the program specialist on the responsibilities of the positions as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. Documentation of aforementioned audits by the Program Director shall be kept. (AS 12/12/17)] 11/16/2017 Implemented
6400.112(f)The door in the back of the home was used as the exit route for the monthly fire drills held from November 2016 to October 2017. The home has three exit routes.Alternate exit routes shall be used during fire drills. Fire drill completed on 12/4/2017 using the front door as the exit route. Training given to the program specialist and direct care staff on regulation 6400.112(f). Fire safety section on the LII to be completed by the program specialist monthly to verify that alternate exit routes have been used on the monthly fire drills. Supporting documentation attached. [At least quarterly for 1 year, the program director shall audit a 10% sample of fire drill records to ensure fire drills are being held as required as per 6400.112(a)-(I). Documentation of audits shall be kept. (AS 12/12/17)] 12/04/2017 Implemented
SIN-00104319 Renewal 11/22/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(1)The assessment dated 10/4/16 for Individual #1 was completed by a direct service worker.The program specialist shall be responsible for the following: Coordinating and completing assessments. Signature page of assessment corrected. Assessment to be done by the program specialist and reviewed by the program director. Program specialist was trained on this regulation as well as Ch. 6400 regulations and Laurel House policies. Review of the LII to be done quarterly. Any issues of concern will be brought to the program director for immediate attention and to be corrected. Annual training to be given to the program specialist. Supporting documentation attached. [On 1/12/17, the Program Director trained the program specialist and 5 staff, "assessments shall be completed by the program specialist." At least quarterly, the program specialist shall review the Q & As available on the Department web site and apply. (AS 1/25/17)] 01/28/2017 Implemented
6400.81(k)(6)Individual #1, Individual #2, Individual #3 and Individual #4 did not have mirrors in their bedrooms.In bedrooms, each individual shall have the following: A mirror. Mirrors were added to the bedrooms of individuals #1, #2, #3, and #4. Program specialist will complete the LII on a quarterly basis to review any issues with the physical site of the home. They will then report this information to the program director and corrections will be made immediately. Program specialist and staff trained on this regulation as well as Laurel House policies. Ongoing and annual training to be given. Supporting documentation attached. [Immediately and at least quarterly thereafter the program specialist shall complete an onsite check of all individual bedrooms to ensure all required items are present including mirrors. (AS 1/25/17)] 01/28/2017 Implemented
6400.141(c)(9)The two most recent prostate examinations for Individual #1 were completed on 7/27/15 and 11/18/16.The physical examination shall include: A prostate examination for men 40 years of age or older. Prostate exam for individual #1 was completed on 11/18/16. The next scheduled appointment for a prostate exam for Individual #1 is 5/17/17. The staff will be responsible for accompanying the individual to the appointment. The program specialist will follow up with a review of the physical to ensure that all timeframes are within regulation and that all sections of the physical have been completed by the physician. The program director will review the physical as well. Staff and program specialists trained on this regulation. Annual and ongoing training to be given. Supporting documentation attached.Correction Date: 1/15/17[Immediately, the program director shall develop and implement a tracking system to ensure all individuals have physical examination including prostate examinations completed, timely. Documentation of reviews of physical examinations shall be kept. (AS 1/25/17] 01/28/2017 Implemented
6400.141(c)(12)The physical examination completed 6/8/16 for Individual #1 did not include the physical limitations of the the Individual. This section was left blank.The physical examination shall include: Physical limitations of the individual. A new physical exam was completed on 11/18/16 with this section being completed by the physician. The staff will be responsible for accompanying the individual to the appointment. The program specialist will follow up with a review of the physical to ensure that all timeframes are within regulation and that all sections of the physical have been completed by the physician. The program director will review the physical as well. Staff and program specialists trained on this regulation. Annual and ongoing training to be given. Supporting documentation attached.[On 1/12/17, Program Director trained 3 staff and the program specialist, "a physical exam shall include physical limitations. Documentation of reviews of physical examinations shall be kept. (AS 1/25/17] 01/28/2017 Implemented
6400.141(c)(15)The physical examination completed 6/8/16 for Individual #1 did not include special instructions for the individual's diet. This section was left blank.The physical examination shall include:Special instructions for the individual's diet. A new physical exam was completed on 11/18/16 with this section being completed by the physician. The staff will be responsible for accompanying the individual to the appointment. The program specialist will follow up with a review of the physical to ensure that all timeframes are within regulation and that all sections of the physical have been completed by the physician. The program director will review the physical as well. Staff and program specialists trained on this regulation. Annual and ongoing training to be given. Supporting documentation attached.[On 1/12/17, Program Director trained 3 staff and the program specialist, "a physical exam shall include special instructions for the individual's diet." Documentation of reviews of physical examinations shall be kept. (AS 1/25/17)] 01/28/2017 Implemented
6400.143(a)Individual #1 refused a dental examination on 3/2/16. Individual #1 was not trained about the need for health care.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. Individual and staff trained on importance of dental care. Individual was seen by a dentist on 4/1/16 with no issues. Form developed for training and will be completed by the staff. Staff and program specialist will be responsible for counseling and completion of form. Program director will review the form. Ongoing and annual training on this regulation as well as Laurel House policies will be conducted. Supporting documentation attached. 01/28/2017 Implemented
SIN-00256057 Renewal 11/13/2024 Compliant - Finalized
SIN-00234792 Renewal 11/15/2023 Compliant - Finalized
SIN-00182845 Renewal 02/08/2021 Compliant - Finalized
SIN-00164025 Renewal 10/08/2019 Compliant - Finalized
SIN-00144562 Renewal 10/31/2018 Compliant - Finalized