Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00232798 Renewal 09/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)A written fire drill shall be kept of the date, time, amount of time of evacuation, the exit route, and any problems encounter. The fire drill conducted on 7.4.23 did not list the time that the drill was held. The fire drill conducted on 3.17.23 did not list the meeting place.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. Program Manager's will be retrained on fire safety and fire drill requirements under Chapter 6400.112 (c). Program Managers will review all fire drill records and provide individual feedback to employees of missing or incorrect data. IHRS's Quality Assurance and Regulatory Compliance Manager will be responsible to collect and review all sites fire drill records on a monthly basis. 12/31/2023 Implemented
6400.112(d)The fire drills conducted on 8.19.23; 6.22.23; 3.17.23; 10.24.22; and 9.22.22 reflect that there was an individual refusal to evacuate the home. Individuals did not all evacuate the home during fire drills. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Program Manager of the home will review fire safety concerns with all individuals and provide schedule a time for the fire chief to give additional training to consumers. All team members will be made aware of concerns regarding previously failed fire drills will be discussed so that actionable plans can be implemented to prevent reoccurrence. Fire Chief will be scheduled to assess whether or not the home requires an extended evacuation time. 12/31/2023 Implemented
SIN-00210813 Renewal 09/20/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104The notification letter to the local fire department for this home dated October 5, 2016 did not contain current information detailing the ability to evacuate of Individual #6. The letter stated that "all three individuals are ambulatory, but one individual may require verbal prompting to exit the home in the event of a fire or an emergency." Fire drill documentation reviewed for this inspection, however, states that Individual #6 has failed to respond to verbal prompting during fire drills and has failed to evacuate the building during every fire drill conducted from September 2021 through August 2022.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. Program Manager has sent an updated letter to the fire chief to outline all needs and locations of individuals. Program Specialist will also contact a fire safety expert to provide training to all individuals in the home regarding fire safety. 10/31/2022 Implemented
6400.112(d)Individual #6 has failed to evacuate the building during every fire drill conducted from September 2021 through August 2022. The individual evacuates as far as the kitchen or other interior room of the home, then drops to the floor and refuses to leave the building. Attempts have been made to evacuate the individual with a wheelchair, but the individual still refuses to exit the building. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Program Manager has contacted the fire chief to provide aforementioned individual with fire safety training. Team has met to discuss ways to improve participation in fire drills and maintain health and safety of individual. Individual's participation in fire drills will be closely monitored by Program Manager in the event that more aggressive measures need to be taken. 10/31/2022 Implemented
6400.34(a)The Individual Rights that were reviewed with and signed by Individual #3 on 12/10/2021 were not the current, updated rights contained in the revised Chapter 6400 regulations.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.IHRS had revamped all their individual rights forms. However, it is believed that an old form was used to complete the individual rights when client had yearly review. IHRS will review updated form with client that covers all rights as listed in 6400.32. IHRS Program Specialists will be retrained in Individual Rights so that they may identify any discrepancies moving forward. 10/31/2022 Implemented
SIN-00177223 Unannounced Monitoring 09/09/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There was a significant amount of dust and dirt on the windowsills in Individual #1's bedroom.Clean and sanitary conditions shall be maintained in the home. All windowsills in the home have been cleaned. The site has been issued a chore list to ensure that the site maintains cleanliness. Program Specialist will monitor on a weekly basis. 10/31/2020 Implemented
6400.68(b)The hot water temperature was measured at 129 degrees Fahrenheit in the hall bathroom. Hot water temperatures in bathtubs and showers may not exceed 120°F. The plumber was called to the site the same day. Hot water was adjusted and work order was sent to ODP licensing for verification. Program Specialist, lead worker and compliance department have hot water checks on their monthly checklist to ensure compliance. 10/31/2020 Implemented
6400.112(d)Fire drill documentation shows that the fire drill conducted on 1/14/20 had a recorded evacuation time of 3 minutes, and 5 seconds which exceeds the maximum evacuation time of 2 minutes and 30 seconds.Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home.Client will be trained on fire safety. Treatment team will meet to discuss ways to improve fire safety for individual who is not evacuating. 10/31/2020 Implemented
6400.112(h)Fire drill documentation shows that Individual #1 failed to evacuate to the designated meeting place during fire drills held on 9/26/19, 4/23/20 and 6/21/20. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Client will be trained on fire safety. Treatment team will meet to discuss ways to improve fire safety for individual who is not evacuating. 10/31/2020 Implemented
6400.186The supervision levels stated in the Individual Support Plans (ISP) for Individuals #1 and #2 is 2:3. The provider has been staffing the 3 person home at 1:3 which is not in agreement with the individuals" ISP's. By not following the staffing levels documented in the individuals' ISP's, the home has failed to implement the individual plans.The home shall implement the individual plan, including revisions.SC has been emailed regarding staffing ratio. The staffing ratio in the plan is incorrect. Program Specialist has asked for a revision. Program Specialists will review plans for accuracy on a monthly basis. 10/31/2020 Implemented
SIN-00067244 Unannounced Monitoring 08/14/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(a)On July 29th and 30th of 2014 Individuals 1,2 and 3 were mistreated by staff #1 in the following ways: 1) they were not allowed to finish their meal if they did not comply with staff #1 repeated command to put their forks on the table 2) Individuals #1, 2 and 3 were instructed to stay in their rooms to watch television and wait for medication time.An individual may not be neglected, abused, mistreated or subjected to corporal punishment. The target was transferred to another IHRS location. Additional training was provided to the target including "Everyday Lives," "Individual Rights," "Abuse/Neglect/Exploitation of Residents, & "Proactively Supporting behavior." The target also received a written reprimand. 09/04/2014 Implemented
6400.33(k)On July 29th and 30th of 2014 staff #1 would not allow Individuals 1, 2 and 3 to eat their meals until they said "Grace" and "Amen".An individual has the right to practice the religion or faith of the individual's choice. The target was transferred to another IHRS location. Additional training was provided to the target including "Everyday Lives," "Individual Rights," "Abuse/Neglect/Exploitation of Residents, & "Proactively Supporting behavior." The target also received a written reprimand. 09/04/2014 Implemented
SIN-00065166 Renewal 06/04/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)Individual #1 evacuated the building in 4 minutes and 10 seconds on 03/31/2014 during a sleep drill. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. IHRS will continue to run monthly fire drills at the home. Staff will continue to remind the individuals about the importance of evacuating the site during a drill. Individuals will continue to receive annual fire safety training. Staff will continue to verbally prompt the individuals during a fire drill. 06/04/2014 Implemented
SIN-00124093 Renewal 10/17/2017 Compliant - Finalized