Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00278424 Renewal 11/12/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(11)For Individual 1, the diagnosis or purpose for the medication was not listed on the MAR or pharmacy label(s).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.Language about the corresponding diagnosis was added to individual entries for each medication on the daily Medication Record. 11/18/2025 Implemented
6400.166(a)(13)For Individual 1, Medication Busprone HCL 10 mg tablet was given on 11/2, 11/6, and 11/7 per blister pack for the PM dose however it was not initialed on the MAR.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.Staff should always follow policy and procedure for accurate documentation on medication records. Staff responsible received written feedback and retraining. 11/14/2025 Implemented
SIN-00237142 Renewal 11/08/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)67b Inside railing leading to upper level in apartment is loose. This poses a hazard as the railing may not be able to support weight. Floors, walls, ceilings and other surfaces shall be free of hazards.The inside railing was repaired by tightening the bolts and securing the railing to the wall. 11/09/2023 Implemented
6400.112(c)112c Fire drill records for this location does not address if there were problems encountered during the drill.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. Based on the licensing review of November 8-9, 2023, the BHID Director verified the correct form to use, removed incorrect forms from the site and implemented the correct form on 11/10/23. The BHID Director retrained the program supervisor on fire drill completion protocol. 11/10/2023 Implemented
SIN-00087258 Renewal 09/09/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.216(a)Individual #1's medication record was found unlocked in the home. An individual's records shall be kept locked when unattended. This citation was resolved immediately on 9/11/15 and the medication record which was in an entertainment center and behind an unlocked glass door was placed in a locked closet. During the weekly site visits the Program Supervisor/Specialist will utilize the newly revised CLA Site Checklist to assure compliance with this regulation. On 9/17/15 all of the PATH Program Supervisors/Specialists responsible for the site as well as the Assistant CLA Director were retrained on the importance of keeping the Medication Administration Record (MAR) locked. 09/11/2015 Implemented
SIN-00180960 Renewal 11/09/2020 Compliant - Finalized
SIN-00067775 Renewal 06/26/2014 Compliant - Finalized