Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00270411 Renewal 07/22/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(c)Individual #1's annual assessment, which was completed on 5/13/2025 by Program Specialist #1, indicated that it was based on the Individual Support Plan.The assessment shall be based on assessment instruments, interviews, progress notes and observations. Individual #1's assessment will be updated by Residential Program Specialist to reflect that it is based on assessment instruments, interviews, progress notes and observations 08/25/2025 Implemented
6400.214(b)On 7/23/2025 at approximately 10:20am, the following documents from Individual #1's record were not accessible at the residential home: current assessment and psychological evaluation. The agency utilizes Therap to digitally store individual record information; however, these documents had not been uploaded to Individual #1's electronic record. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The most current copies of record information required in § 6400.213(2)(14) will be uploaded to an electronic file accessible to staff in all ResHab locations. 09/15/2025 Implemented
6400.207(5)(II)On 7/23/2025 at 10:24am, Individual #2's bed contained bilateral upper-half bedrails that restricted the movement or function of the individual's body. The agency obtained a prescription for a hospital bed with half rails on 5/9/2025. Although the bed rails are prescribed by the medical practitioner, Individual #2's most current assessment, completed 5/8/2025, does not address if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual. Individual #2's support plan last updated 7/23/2025 does not indicate the need for the bedrails nor does it include periodic relief of the device to allow freedom of movement.A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Balance or support to achieve functional body position, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement.Bedrails will be removed from individual #2's bed. Wedges will be used to ensure individual safety. Staff will continue to reposition every 2 hours and document overnight. 08/15/2025 Implemented
SIN-00229721 Renewal 08/21/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(11)Individual #1's prescribed pro re nata, Deep Sea Spray 0.65% Nasal Solution, was missing a diagnosis or purpose on their August 2023 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.The Individual's Medication Administration Record and Medication Label was corrected to include the diagnosis and purpose for the prescribed Deep Sea Spray 0.65% which is utilized as a pro re nata medication. All other medications and Medication Administration Records were checked for accurate information and were accurate. 09/01/2023 Implemented
6400.182(c)In the domain of supervision on Individual #1's assessment completed on 4/3/23, it indicates they require 24/7 direct supervision at home and in the community without any unsupervised time for periods of less than 4 hours. Individual #1's most recent individual plan updated on 6/28/23, explains their level of care is 24/7 direct supervision at home with up to 30 minutes of alone time per day in their bedroom and up to one hour of unsupervised time daily in the community to walk.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The Individual assessment was revised to reflect proper supervision guidelines. All other individual assessments were checked for accurate information in comparison to the Individual Support Plan. 09/01/2023 Implemented
SIN-00211200 Renewal 09/07/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The home conducted a fire drill on 05/26/22. The fire drill record did not indicate the exit route used to evacuate the home.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. Fire Drill check was completed on 9/12/22 for all Fire Drills conducted in 2022 to ensure all lines were completed. If information was missing on Fire Drill staff were notified that it needs to be completed. If missing information is unclear, Program Specialist will watch video to determine exit that was used so that it can be included on the fire drill form. 09/13/2022 Implemented
6400.181(e)(14)Individual #1's Assessment, dated 5/9/22, did not include a complete assessment of the individual's ability to swim and knowledge of water safety. In the assessment the following sections were left blank: For pools: kicks holding onto wall, floats on stomach, floats on back, swims using doggie paddle, swims using crawl stroke, treads water; For body of water other than pool: wades in water waist deep, wades in water chest deep, holds breath under water for 10, 20, 30 seconds or more.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. All individual assessments will be checked by 12/19/22 to make sure there are no unanswered areas of the assessment¿. Special attention will be paid to Assessment results, Progress over the last year, strengths and needs. These sections will be compared to MCAR individual demographics and details pages as well as the ISP to ensure that all information is synonymous. Also all lines of functional assessment will be double checked to ensure they were completed and that the information is correct. 12/12/2022 Implemented
SIN-00178159 Renewal 10/20/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(6)Individual #1 had a Tuberculin skin test by Mantoux method completed on 02/16/16 and then again on 02/27/20.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Individual 1 did have a tb test administered in 2020 and will be scheduled to receive another tb shot in 2022 with his annual physical. A check will be completed of all individual records to ensure all are on track to receive TB shots within the appropriate time frame. Case Managers will look at TB shot date when scheduling annual physicals for each of their individuals and ensure that they schedule TB shots as needed with future physicals 11/19/2020 Implemented
6400.34(a)Individual #1 was informed and explained individual rights and the process to report a rights violation on 12/19/19 and then again on 01/07/20.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.Administrator of Residential Services will ensure that Individual Rights for all individuals will be signed between 1.2. and 1.15 of each year this will ensure that Individual Rights for all Individuals are explained and signed off on in a timely manner each year. This will be done universally for all individuals in Community Homes. Operations Manager will send a reminder to Administrator no later than 12/27 reminding them of the upcoming documentation of individual rights for Community Homes. 01/15/2021 Implemented
SIN-00046683 Renewal 02/07/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(6)Individual # 2 does not have a mirror in his bedroom. (Partially implemented. Adequate Progress. CHG 5/9/13)(6) A mirror. Individiual does not want to have a mirror and he breaks them when he is having behaviors. The ISP team meet on 3/19/13 and added that he doesn't need a mirror in his bedroom. [The program specialist will perform a monthly audit of all bedrooms to ensure each room contains the requirements set forth per 6400.81(k). Documentation shall be kept. (CHG 5/9/13)] 03/19/2013 Implemented
6400.112(a)There's no record of a fire drill being held in September 2012. (Partially Implemented. Adequate Progress. PE 5-15-13) (a) An unannounced fire drill shall be held at least once a month. The Residential Director informs the Program Specialists on the 20th of each month which group homes still need their fire drills completed. The Program Specialist have the group home complete them by the 25th of each month. The Program Specialist does an inservice on fire drills with the staff. We will fax three completed fire drills from this home. 02/17/2013 Implemented
6400.163(c)On the medication psychiatric illness review for Individual # 1 dated 1-7-13 did not include the reason for prescribing and the need to continue medications. (Partially Implemented. Adequate Progress. CHG 5/9/13)(c) If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. The individual was having a behavior and was able to attend his appointment. THe physican will not see the staff person unless the individual is present. The appointment was rescheduled and the medication was refilled. [The program specialist will monitor all individuals psychiatric appointments and medication reviews to ensure that they are scheduled far enough in advance of regulatory timeframes to allow for unforeseen circumstances. (CHG 5/9/13)] 03/08/2013 Implemented
SIN-00117451 Renewal 07/13/2017 Compliant - Finalized
SIN-00096253 Renewal 06/09/2016 Compliant - Finalized