Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00256100 Renewal 11/19/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(13)(viii)The annual assessment dated for Individual #1 10/23/24 did not contain the individuals progress over the last 365 days in the area of managing personal property.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. The information regarding the managing personal property was added to the current assessment. 11/22/2024 Implemented
6400.166(a)(4)The medication administration record (MAR) shall be kept for each individual for whom a prescription medication is administered; the name of the medication shall be on each individual MAR. At the time of the inspection, induvial #1 had a standing order from a doctor which included Tylenol, Aloe Gel, Hydrocortisone cream, Benadryl, aspirin, pepto bismuth, cough drops, ear wax removal, desitin, motrin, milk of magnesia, tussin, bacitracin ointment. None of these medications were listed on the MAR for Individual #1 for the month of November 2024.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.All OTC's were added to the medication logs. 11/25/2024 Implemented
SIN-00236847 Unannounced Monitoring 12/01/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(c)According to Individual #1's Individual Support Plan (ISP) the community home is normally staffed with 2 staff:4 residents during awake/evening hours, 2 awake overnight staff, and 2 staff for the weekends. On 11/28/23, on the overnight shift there was 2 staff scheduled however only 1 staff, Staff #1, was on shift that night as the other staff called off. When conducting interviews with staff that work in the home all staff communicated that the home is staffed with 2 staff on the overnight shift. On 11/28/23, the agency neglected and failed to provide the needed supervision on the overnight shift in the home.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.Individual #1¿s Individual Support Plan (ISP) has been revised by the Supports Coordinator and is awaiting approval from the AE. The ISP reflects their accurate supervision care needs which does not require 2 staff overnight. All other ISPs were reviewed to be certain the supervision needs are accurate. 01/08/2024 Implemented
SIN-00214388 Renewal 12/06/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment of the home within 3 to 6 months prior to the expiration of the agency's certificate of compliance. The certificate of compliance expired on 8/15/2022 and the self-assessment was completed on September 7, 2022.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter.The Residential Supervisor will complete each homes self-assessment within 3 to 6 months prior to the expiration date of the agency's certificate of compliance. The Residential Supervisor will submit the correct self-assessment to licensing upon request. 04/30/2023 Implemented
6400.112(b)The fire drill completed on 10/14/2022 was not held during normal staffing conditions. Normal staffing conditions include 3 staff during waking hours and 2 staff during overnight hours. The fire drill completed on 10/14/2022 included 4 staff. Fire drills shall be held during normal staffing conditions and not when additional staff persons are present. Program Specialist Supervisors will continue to train individuals and staff on fire drill regulations, including normal staffing conditions during fire drills. 12/21/2022 Implemented
6400.46(b)Staff #1 was not trained annually by a fire safety expert. Staff #1 received fire safety training on 12/14/2020, then not again until 1/02/2022.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Training records for all staff will be reviewed by supervisors to ensure all training requirements are met. Supervisors train staff on tracking their trainings to ensure they are meeting deadlines. 12/14/2022 Implemented
SIN-00181942 Renewal 12/21/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(g)Individual #1 is prescribed medication to treat symptoms of a psychiatric illness and the 3 month medication review by a licensed physician did not include documentation to verify the reason for prescribing the medication, the need to continue the medication and the necessary dosage.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The Dr. was notified to make the corrections immediately. All other three month medication review forms were reviewed by the physician and filled out completely. House managers will review the 3 month medication review documentation to be sure it includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage (no blanks left on the form). Program Specialist Supervisor will review the documentation quarterly. 12/30/2020 Implemented
SIN-00137296 Renewal 07/10/2018 Compliant - Finalized
SIN-00083926 Renewal 09/16/2015 Compliant - Finalized
SIN-00051423 Renewal 05/23/2013 Compliant - Finalized