Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00295322 Renewal 09/08/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There was a black substance consistent with mold, in the caulk surrounding the tub. The oven had a buildup of grease inside.Clean and sanitary conditions shall be maintained in the home. The Community Support Facilitator removed the black substance, replaced the damaged tub caulk, and cleaned the oven. 09/17/2026 Implemented
6400.141(c)(10)The presence of a serious communicable disease and the specific precautions that shall be taken was not completed on the physical dated May 4, 2026 for the Individual #1.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. The Health and Wellness Mentor obtained a corrected physical examination documenting the required communicable disease responses. 09/21/2026 Implemented
6400.144The agency used an electronic medication administration record to record medication administration but did not keep a backup hard copy of the MAR for times when the internet might be unavailable.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. On 9/16/26, the Community Support Facilitator informed staff of the new backup Medication Administration Record (MAR) process. On 9/17/26, the Health & Wellness Mentor placed a current paper backup of the MAR in the home. 09/17/2026 Implemented
6400.165(b)Individual 1's medication Diphenhydramine 25 mgs capsule was on the MAR, but not available. There were 3 medications in Individual 1's medication box that were not currently listed on the MAR.A prescription order shall be kept current.On 9/17, the Health & Wellness Mentor (LPN) reconciled prescription orders, medications, and the Medication Administration Record and corrected all discrepancies. On 9/18/26, the Health and Wellness Mentor sent a reminder to staff of medication storage requirements. 09/18/2026 Implemented
SIN-00256111 Renewal 11/22/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.24For individual 1 there was no count of the controlled substance Lorazepam 1 mg between 11/01/24 -- 11/03/24 and 11/05/24 -- 11/21/24. The count of the medication on 11/22/24 was 9 when there were 18 tablets available. The 1970 Controlled Substances Act requires accurate counts to be kept for controlled medications.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.In Values Into Actions¿ effort to move to an electronic health record and electronic MAR, the current EHR program that is used (Therap) did not provide for a way to count Controlled Substances. As identified during our licensing visit, the system we created using a customized program in Therap did not meet regulatory requirements. As a result, on 11/23/2024, the Associate Director (agency Medication Administration trainer) implemented a separate Medication Count Sheet to be used for this individual that is and will be documented by staff at the time of administration (Attachment #1-Blank Medication Count Sheet). All staff working with Individual 1 were trained on how to complete the Medication Count Sheet (Attachment #2-Staffing training form) and began using this form effective 11/23/24 (Attachment #3-completed Medication Count Sheet effective 11/23/24-11/30/2024). The Medication Count Sheet will be used for any individual within Residential Services receiving medication administration support from staff moving forward, effective 11/23/24. 11/23/2024 Implemented
SIN-00215076 Renewal 11/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The window blinds in Individual #3's bedroom are torn and should be replaced.Floors, walls, ceilings and other surfaces shall be in good repair. The damaged miniblind was replaced by the Service Director on 11/21/22. Please see attached receipt for replacement miniblind on 11/21/22 (ATTACHMENT #18) 11/21/2022 Implemented
6400.82(f)There is no trash can in the bathroom.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. The new trashcan was purchased and placed in the bathroom by the Service Director on 11/21/22. Please see Attachment #18 that shows the purchase and ATTACHMENT # 21 shows the trashcan in bathroom 11/21/2022 Implemented
SIN-00181018 Renewal 11/18/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(b)Training non-compliant-initial fire safety training was not provided at inspection, current 10/24/20.If an individual is medically or functionally unable to participate in the fire safety training, documentation shall be kept specifying why the individual could not participate. Annual fire safety training for this individual was not completed on time due to COVID-19 risk mitigation protocols in place at the time it was due. Individual Fire Safety Training was completed in October 2020 for all persons accepting support and October chosen as Values Into Action¿s Fire Safety Month; moving forward all individuals will receive annual fire safety training during this month to ensure ongoing compliance with receiving annual fire safety training. Service Director also located this individual¿s initial fire safety training documentation and has ensured it is stored in the individual¿s file. Ongoing compliance will be monitored by Service Director. 12/22/2020 Implemented
6400.181(a)Assessment non-compliant-initial assessment was completed on 5/12/19, annual assessment was completed 12/7/19. Only 7 months passed between initial and current assessment. It could not be determined the progress for the last year. 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. Values Into Action¿s Service Director, Clinical Support Director, and Program Specialist have created a new tracking system to ensure that each individual supported has a timely annual assessment, based on his/her initial assessment date. Timeframes were corrected and Program Specialist will continue to use the corrected tracking system to ensure ongoing compliance with annual assessments moving forward for all individuals supported. Service Director will complete periodic reviews of assessments to ensure ongoing compliance. Attachment 8: Copy of Tracking System for Service Documentation Timelines 12/22/2020 Implemented
6400.166(b)Individual #1's medications for 7 AM on 11/18/2020 were not logged at the time of inspection. These medications are: Keppra 1000 mg KCL ER 10 meq Polyethylene Glycol 3350 Enulose 10 gm/15 ml Fluticasone Nasal Spray Combigan Artificial TearsThe information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Medication Administration Record (MAR) documentation error was corrected and verified by Values Into Action Service Coordinator. Staff received retraining on proper MAR documentation on 11/18/2020. Values Into Action Service Coordinator and Clinical Support Director have created MAR documentation system via Therap (online medical record/documentation system) and will ensure all staff are trained on the new system for implementation as of 2/1/2021. New e-MAR system will allow Service Coordinator to complete remote oversight of MAR documentation moving forward to immediately identify and address any MAR documentation issues/concerns for all individuals supported with medication administration. Attachment 9: Memo regarding staff re-training Attachment 10: Copy of e-MAR 11/18/2020 Implemented
SIN-00153173 Renewal 02/27/2019 Compliant - Finalized