Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00261620 Renewal 03/04/2025 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The self-assessment completed on 2/27/25 did not include a written summary of corrections for citations that were identified at the home locations discussed at the exit.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. All provider Program Specialists will receive training to review the violation and the need for written summary for each self-assessment completed. 05/01/2025 Accepted
6400.22(d)(1)Individual #1 was admitted on 12/3/2024. As of this annual licensing date of review, 3/4/2025, a personal possessions list has not been completed and put in the individual's record.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. The personal inventory sheet was added to the providers moving procedure guide (see document #9). All Program Specialists will receive training on the regulation, violation, and addition of the inventory sheet to be moving procedure. 05/01/2025 Accepted
6400.22(f)Individual #1's monies left over from biweekly spending is being transferred into an account with other individual's monies. This is a comingling of funds which is not permitted per this regulation.There may be no commingling of the individual's personal funds with the home or staff person's funds. The provider will revise the "Management of Personal Assets" policy for client funds to include the creation of an individual checking account for each resident for whom the provider serves as representative payee. Each resident will have a separate account, with all deposits and withdrawals made directly from their individual account. All monthly checks to individuals for whom the agency is representative payee are either sent directly to the agency for deposit or automatically deposited in the Individual checking account. Funds will not be transferred to a joint account and back to a resident account 05/01/2025 Accepted
6400.64(a)At the time of the inspection, there was a golf ball size of lint in the dryer. There were no clothes in the dryer at the time of the inspection. Also, at the time of the inspection, there were soiled clothing in a plastic grocery bag sitting in the wash sink beside the washing machine. The staff stated that the individual had an accident this morning. So, it was placed in a plastic grocery bag and put in the wash sink. The inspection took place at 12:10pm in the afternoon and the soiled clothing was found still in the wash sink at that time. The washing machine was empty.Clean and sanitary conditions shall be maintained in the home. Notice signs will be posted near the laundry areas at all residential sites. (See document #4) A mandatory training will be conducted for staff to review the regulation, discuss violations from licensing, and explain the fire risk associated with leaving lint in the dryer. 05/01/2025 Accepted
6400.113(a)Individual #2 moved into the home on 11/25/2024; a fire drill was completed, however their fire safety training for the new location was not completed. 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. Resident received fire safety training for the new site. Program Specialist will receive training on this regulation and violation conducted by the Program Director. 05/01/2025 Accepted
6400.141(c)(11)Individual #1's most recent physical dated 11/25/2024 did not contain instructions for health maintenance needs. It was left blank.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. The provider will audit all individuals¿ physicals to ensure all sections are the physicals are completed in entirety. A training will be conducted by the Program Director for all Program Specialists on this violation and importance of completing all sections of the physicals. 05/01/2025 Accepted
6400.141(c)(14)Individual #1's most recent physical dated 11/25/2024 did not contain information pertinent to diagnosis/treatment in case of an emergency. It was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The provider will audit all individuals¿¿ physicals to ensure all sections are the physicals are completed in entirety. A training will be conducted by the Program Director for all Program Specialists on this violation and importance of completing all sections of the physicals. 05/01/2025 Accepted
6400.167(a)(1)On 12/5/2024 staff failed to administer two prescribed medications to individual #1 and the staff indicated on the MAR the reason was for the following: "Meds were not at the home to pass that morning". It is the agency's responsibility to make sure that all medications are in the home, including refills, on a timely manner to ensure medications are not missed.Medication errors include the following: Failure to administer a medication.The provider will hold admission meetings prior to any individual transferring from one residential site to another or transitioning into residential care. These meetings will include the provider's registered nurse/Healthcare Manager and will cover a review of medications, the development of the MAR, review of additional relevant records, and evaluation of the provider¿s moving procedure (document #9) 05/30/2025 Submitted
6400.181(f)REPEAT- 03/26/24- Individual #1's annual assessment was written on 1/16/2025, however it was not reviewed with the individual and signed off on by both the individual and the program specialist until 1/21/2025. The assessment was then sent to the team on 1/21/2025, however the ISP team meeting was held on 2/20/2025. Thus, the assessment was not sent a full 30 calendar days prior to the ISP meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Program specialist will receive retraining on the regulation to ensure understanding that assessments must be sent 30 days prior to ISP meeting date. 05/30/2025 Submitted
6400.213(1)(i)REGULATION 213 1 ii- Individual #1's demographic sheet did not include the following required information: Hair color, eye color, race, and identifying marks.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.The demographic sheet for the individual has been revised and added to the record. An audit of all demographic sheets will be completed to ensure all necessary information is included. Program Specialist will receive retraining on the regulation conducted by the Program Director. 05/01/2025 Accepted
6400.213(1)(i)REGULATION 213 1. iv- Individual #1's demographic sheet did not include information regarding religious affiliation.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.The demographic sheet for the individual has been revised and added to the record. An audit of all demographic sheets will be completed to ensure all necessary information is included. Program Specialist will receive retraining on the regulation conducted by the Program Director. 05/01/2025 Accepted
6400.213(1)(i)Individual #1's demographic sheet did not include his social security number.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.The demographic sheet for the individual has been revised and added to the record. An audit of all demographic sheets will be completed to ensure all necessary information is included. Program Specialist will receive retraining on the regulation conducted by the Program Director 05/01/2025 Accepted