Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00278077 Renewal 11/18/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.24(f)On 11/18/2025 at 2:17pm, it was discovered that Individual #1's funds were comingling with Family Living Provider #1's as the individual and provider were sharing a cell phone plan and Individual #1 was paying money directly to Family Living Provider #1 to cover the costs of minute overages. It was observed that Family Living Provider #1 loaned Individual #1 funds on three separate occasions to cover the costs of minute overages on their cell phone plan. As Individual #1's representative payee, the agency then issued reimbursements from Individual #1's bank account to Family Living Provider #1. On 7/28/2025 an amount of $38.27 was refunded to Family Living Provider #1 via check #108, on 9/18/2025 an amount of $38.27 was refunded to Family Living Provider #1 via check #118, and on 10/17/2025 and amount of $38.41 was refunded to Family Living Provider #1 via check #122. Additionally, the agency did not provide sufficient documentation to demonstrate that the minute overages were directly tied to Individual #1's phone usage.There may not be commingling of the individual's personal funds with agency or household funds.Any funds that the individual needs to cover expenses will be issued to the individual himself or directly to the individuals cell phone provider network. Investigation being conducted. 12/11/2025 Implemented
6500.136(a)(4)Individual #1 is prescribed Fluticasone Spr 50mcg with instructions to administer 2 sprays in each nostril once daily as needed for allergy symptoms and Albuterol SER HFA 90mcg with instructions to inhale 2 puffs by mouth four times a day as needed for dyspnea/wheezing/shortness of breath. On 11/19/2025 at 10:50am, Individual #1's November 2025 medication administration record did not include the names of these medications. These medications were omitted entirely from Individual #1's November 2025 medication administration record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.Provider will utilize an electronic MAR configured on Therap by nursing with all appropriate medications, and PRNs listed with correct names of medications provided to them. 12/01/2025 Implemented
6500.136(a)(5)Individual #1 is prescribed Fluticasone Spr 50mcg with instructions to administer 2 sprays in each nostril once daily as needed for allergy symptoms and Albuterol SER HFA 90mcg with instructions to inhale 2 puffs by mouth four times a day as needed for dyspnea/wheezing/shortness of breath. On 11/19/2025 at 10:50am, Individual #1's November 2025 medication administration record did not include the strengths of these medications. These medications were omitted entirely from Individual #1's November 2025 medication administration record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.Provider will utilize an electronic MAR configured on Therap by nursing with all appropriate medications, and PRNs listed with correct strength of medications provided to them. 12/01/2025 Implemented
6500.136(a)(6)Individual #1 is prescribed Fluticasone Spr 50mcg with instructions to administer 2 sprays in each nostril once daily as needed for allergy symptoms and Albuterol SER HFA 90mcg with instructions to inhale 2 puffs by mouth four times a day as needed for dyspnea/wheezing/shortness of breath. On 11/19/2025 at 10:50am, Individual #1's November 2025 medication administration record did not include the dosage forms of these medications. These medications were omitted entirely from Individual #1's November 2025 medication administration record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form.Provider will utilize an electronic MAR configured on Therap by nursing with all appropriate medications, and PRNs listed with correct dosage form of the medications provided to them 12/01/2025 Implemented
6500.136(a)(7)Individual #1 is prescribed Fluticasone Spr 50mcg with instructions to administer 2 sprays in each nostril once daily as needed for allergy symptoms and Albuterol SER HFA 90mcg with instructions to inhale 2 puffs by mouth four times a day as needed for dyspnea/wheezing/shortness of breath. On 11/19/2025 at 10:50am, Individual #1's November 2025 medication administration record did not include the prescribed doses of these medications. These medications were omitted entirely from Individual #1's November 2025 medication administration record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.Provider will utilize an electronic MAR configured on Therap by nursing with all appropriate medications, and PRNs listed with correct Dose of medications provided to them 12/01/2025 Implemented
6500.136(a)(8)Individual #1 is prescribed Fluticasone Spr 50mcg with instructions to administer 2 sprays in each nostril once daily as needed for allergy symptoms and Albuterol SER HFA 90mcg with instructions to inhale 2 puffs by mouth four times a day as needed for dyspnea/wheezing/shortness of breath. On 11/19/2025 at 10:50am, Individual #1's November 2025 medication administration record did not include the route of administration for these medications. These medications were omitted entirely from Individual #1's November 2025 medication administration record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.Provider will utilize an electronic MAR configured on Therap by nursing with all appropriate medications, and PRNs listed with correct Route of administration of medications provided to them. 12/01/2025 Implemented
6500.136(a)(9)Individual #1 is prescribed Fluticasone Spr 50mcg with instructions to administer 2 sprays in each nostril once daily as needed for allergy symptoms and Albuterol SER HFA 90mcg with instructions to inhale 2 puffs by mouth four times a day as needed for dyspnea/wheezing/shortness of breath. On 11/19/2025 at 10:50am, Individual #1's November 2025 medication administration record did not include the frequency of administration for these medications. These medications were omitted entirely from Individual #1's November 2025 medication administration record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.Provider will utilize an electronic MAR configured on Therap by nursing with all appropriate medications, and PRNs listed with correct Frequency of administration of medications provided to them. 12/01/2025 Implemented
6500.136(a)(10)Individual #1 is prescribed Fluticasone Spr 50mcg with instructions to administer 2 sprays in each nostril once daily as needed for allergy symptoms and Albuterol SER HFA 90mcg with instructions to inhale 2 puffs by mouth four times a day as needed for dyspnea/wheezing/shortness of breath. On 11/19/2025 at 10:50am, Individual #1's November 2025 medication administration record did not include the administration times for these medications. These medications were omitted entirely from Individual #1's November 2025 medication administration record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.Provider will utilize an electronic MAR configured on Therap by nursing with all appropriate medications, and PRNs listed with correct Time of administration of medications provided to them. 12/01/2025 Implemented
6500.136(a)(11)Individual #1 is prescribed Fluticasone Spr 50mcg with instructions to administer 2 sprays in each nostril once daily as needed for allergy symptoms and Albuterol SER HFA 90mcg with instructions to inhale 2 puffs by mouth four times a day as needed for dyspnea/wheezing/shortness of breath. On 11/19/2025 at 10:50am, Individual #1's November 2025 medication administration record did not include the diagnosis or purpose for prescribing these medications. These medications were omitted entirely from Individual #1's November 2025 medication administration record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Provider will utilize an electronic MAR configured on Therap by nursing with all appropriate medications, and PRNs listed with correct diagnosis or purpose for medications provided to them including pro re nata 12/01/2025 Implemented
SIN-00258027 Renewal 12/11/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.45(a)Family Living Provider #1 was certified to perform first aid, Heimlich, and cardiopulmonary resuscitation techniques from 07/08/2022 through 07/31/2024. Family Living Provider #1 was subsequently trained on First Aid and Heimlich techniques by the agency's Registered Nurse #2 on 12/12/2024.The primary caregiver shall be trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid and Heimlich techniques prior to an individual living in the home and annually thereafter.FLP was trained in First Aid and the Heimlich techniques by RN immediately on 12/11/2024. 12/11/2024 Implemented
SIN-00236549 Renewal 12/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.122(a)Individual #1 had a dental examination completed 4/05/2022 and then again 9/05/2023.An individual 17 years of age or younger, shall have a dental examination performed by a licensed dentist semiannually. Each individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually.Dental examination was completed on 9/05/2023. 03/29/2024 Implemented
6500.48(b)(4)Program Specialist #1 and Life Sharing Provider #2s' annual training hours from 1/01/2022 through 12/31/2022 did not encompass recognizing and reporting incidents.The annual training hours specified in subsection (a) must encompass the following areas: Recognizing and reporting incidents.Program Specialist and Provider did complete 6500.48(b)(4) annual training which includes recognizing and reporting incidents for the 2023 calendar year. 01/03/2024 Implemented
6500.133(d)On 12/19/2023 there were two packets of Extra Strength Non-Aspirin Acetaminophen two tablets 500mg, two packets of Ibuprofen two tablets 200mg, and a packet of Aspirin 2 tablets 225mg unlocked and accessible in the first aid kit, in the bathroom. Individual #1 is assessed to be unable to self-administer medication.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.The two packets of Extra Strength Non-Aspirin Acetaminophen two tablets 500mg, two packets of Ibuprofen two tablets 200mg, and packet of Aspirin 2 tablets 225mg were immediately removed from the first aid kit. All prescribed and PRN medications are kept stored in locked container. 01/05/2024 Implemented
6500.133(h)On 12/19/2023, the following medication was identified in the first aid kit: two packets of Extra Strength Non-Aspirin Acetaminophen two tablets 500mg which expired October 2015, two packets of Ibuprofen two tablets 200mg which expired September 2014, and a packet of Aspirin 2 tablets 225mg which expired January 2016.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Expired medications including two packets of Extra Strength Non-Aspirin Acetaminophen two tablets 500mg, two packets of Ibuprofen two tablets 200mg, and a packet of Aspirin 2 tablets 225mg were removed from the home immediately and discarded appropriately. 01/05/2024 Implemented
6500.135(b)Individual #1 is prescribed Vitamin D3 1000IU, with instructions to take two soft gels in the morning for supplement." On 12/19/2023, the prescription order was not kept current and the Vitamin D3 over the counter bottle directions stated to take one soft gel one to two times daily, preferably with a meal.A prescription order shall be kept current.Individual's Vitamin D3 1000IU with instructions to take two soft gels in the morning for supplement was corrected to reflect proper labelling from the Pharmacy. Information on Pharmacy label matches Medication Administration Record. 01/05/2024 Implemented
6500.136(a)(6)Individual #1 is prescribed Vitamin D3 1000IU, with instructions to take two soft gels in the morning for supplement." On 12/19/2023, Individual #1's December 2023 medication administration record did not include dosage form.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form.The Vitamin D3 1000IU supplement will be received through the Pharmacy for proper labelling, which includes medication instructions, including dosage form. Any changes to this medication will go through Pharmacy for changes if needed. Program Specialist will monitor Medication Administration Record in Therap system. 01/05/2024 Implemented
6500.136(a)(8)Individual #1 is prescribed Vitamin D3 1000IU, with instructions to take two soft gels in the morning for supplement." On 12/19/2023, Individual #1's December 2023 medication administration record did not include route of administration.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.Individual's Vitamin D3 1000IU with instructions to take two soft gels in the morning for supplement was corrected to reflect proper labelling from the Pharmacy, including route of administration. Medication Administration Record was also updated to reflect instructions of medications and the route medication is to be taken. 01/05/2024 Implemented
6500.136(a)(11)Individual #1 is prescribed Vitamin D3 1000IU, with instructions to take two soft gels in the morning for supplement." On 12/19/2023, Individual #1's December 2023 medication administration record did not include diagnosis or purpose for the medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The Vitamin D3 1000IU supplement will be received through the Pharmacy for proper labelling, which includes medication instructions, including the diagnosis and/or purpose for the medication. Any changes to this medication will go through Pharmacy for changes if needed. Medication Administration Record was also updated to reflect instructions of medications and purpose of the medication. 01/05/2024 Implemented
SIN-00166650 Renewal 11/20/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.121(c)(6)Individual #1 had a Tuberculin skin test completed on 7/28/17, and then again on 9/11/19.Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if a tuberculin skin test is positive, an initial chest x-ray with results noted.MCAR POC is as follows: Residential director has reviewed all individuals in the Family living program physicals to ensure all are in compliance. Residential director has retrained Case Managers on the regulations and procedures for individuals Mantoux and physicals. All Case Managers have scheduled in there outlook calendars with reoccurring reminders of when physicals and Mantoux are due for all individuals in the program. Compliance Officer will be conducting quarterly documentation audits for the Family living program. During these audits the CCO will be reviewing physicals and Mantoux for a 25% of the individuals in the program. 12/02/2019 Implemented
6500.136(b)Latanoprost 0.005% solution, instill one drop into each eye every evening for glaucoma prescribed to Individual #1 was not documented as administered from 11/1/19 to 11/20/19.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Family Living Provider is scheduled to attend Med Admin Training on 12/8/19. During that training the provider will be shown how to document all medications properly. Case Manager will be making weekly checks for 8 weeks on the medication documentation. If no errors during those 8 weeks medication documentation checks will be made monthly for 3 months. If no errors are seen during those 3 months then the provider will go back on the quarterly documentation checks made by the CCO. The first Med Documentation check being made is on 12/6/19 12/06/2019 Implemented
SIN-00147643 Renewal 12/10/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.110(c)Family Living Provider #1 received annual fire safety training on 08/05/17 and was re-trained in fire safety on 09/04/18.Family members and individuals, including children, shall be trained within 31 calendar days of an individual living in the home and retrained annually, in accordance with the training plan specified in subsection (a).MCAR has retrained the management staff responsible for this program on all regulations that are associated with the program. The department head will make monthly compliance checks to ensure that the managers supervising the program have a clear understanding of their job and are meeting the deadlines assigned to them. During the time of these citations MCAR was going through a large turnover in our residential management employees. We are confident that with this retraining our new managers have a clear understanding of their responsibilities. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure family members and individuals are trained on fire safety, timely. At least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking system to ensure timely completion of fire safety trainings. (DPOC by AES,HSLS on 1/11/19)] 01/03/2019 Implemented
SIN-00088506 Renewal 01/12/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.17(a)The agency's certificate of compliance had an expiration date of 12/30/15; the self-assessment was completed on 10/21/15.If an agency is the legal entity for the family living home, the agency shall complete a self-assessment of each home the agency is licensed to operate 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.Self Inspections have been added on re-occurrence to Administrator of Residential Services and Family Living Specialists Outlook Calendar for 8/29/2016 to begin Self Inspections and Annually thereafter.[Annually: The CEO will review the self-assessments within 5 days of completion for each home to ensure timeliness and accuracy. (AS 2/9/16)] 01/30/2016 Implemented
6500.101The door leading into the basement from the kitchen has an eye/hook lock on the kitchen side of the door obstructing egress from the basement when engaged. There are no other exits from the basement.Stairways, halls, doorways and exits from rooms and from the home shall be unobstructed.This has been removed from the basement door. documentation will be sent. Family Living Specialist will review physical site inspection quarterly documentation will be kept on Family Living Specialist weekly checklist. This will be reported to Administrator of residential Services every week at Residential/Family Living Meeting. [Immediately: CEO or designee will do on-site physical site checks to ensure all egresses are unobstructed. Documentation of all on-site checks shall be kept. (AS 2/9/16)] 01/30/2016 Implemented
6500.151(d)Individual #1's assessment, dated 4/8/15, was not signed and dated by the family living specialist.The family living specialist shall sign and date the assessment.Once the Family Living Specialists completes an Individual assessment the Administrator of Residential Services will review the complete Assessment Packet to ensure all information is filled out and accurate. The Administrator of Residential Services will initial the packet once reviewed. [Immediately: CEO or designee will review all current assessments for individuals to ensure the family living specialist signed and dated all assessments. Documentation of reviews shall be kept. (AS 2/9/16)] 01/30/2016 Implemented
SIN-00218901 Renewal 01/31/2023 Compliant - Finalized
SIN-00200495 Renewal 02/08/2022 Compliant - Finalized
SIN-00184323 Renewal 03/05/2021 Compliant - Finalized