Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00205347 Renewal 05/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)The stairs leading up the walk-up attic do not have a handrail even though they are in excess of 3 stairs. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Holcomb maintenance installed a handrail on 05/09/2022. 05/09/2022 Implemented
6400.111(f)All fire extinguishers in the home, with the exception of the one located in the attic area, were last inspected in April 2021. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. All fire extinguishers were inspected by the fire company on 05/09/2022. 05/09/2022 Implemented
6400.112(c)There was no evacuation time listed for fire drills held in May 2021, Nov 2021, and December 2021. There is also no indication of exact time the drill took place during fire drills held in Nov 21 and Dec 21. There is no AM or PM listed on the form. The drills held between June and Sept 2021 all state "1 min or 2 min" for evacuation time.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 form is being updated to capture the missing information and will begin to be used on 07/01/2022. 07/01/2022 Implemented
SIN-00161681 Renewal 08/27/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The license date for the agency is 12/29/18 through 12/29/19 and the self assessment was completed on 3/22/19 which is not within the regulatory timeframe.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. Self- Assessment was done by a new IDD coordinator who did not understand the full process of the assessment including the timeframes in which it should be completed. All IDD Coordinators were trained and shown an example of what a proper self-assessment should contain and within what time frame it is to be completed within. A new Self-Assessment for this upcoming inspection year was completed correctly on 6/29/19. This assessment was done within the time frame for the agency license of 12/29/19 through 12/29/20. For ongoing compliance, IDD Manager receives the completed assessment, they will thoroughly be reviewed by the Manager and Director. Any areas that are not completed properly will be corrected on the self-assessment 09/02/2019 Implemented
6400.15(c)On the 3/22/19 self-assessment noted that several items were out of compliance. There was no indication that the items were corrected.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. Self- Assessment was done by a new IDD coordinator who did not understand the full process of the assessment. The areas on non-compliance were corrected prior to inspection, but they were not noted on the self- inspection tool as required. All IDD Coordinators were trained and shown an example of what a proper self-assessment should contain and within what time frame it is to be completed within. A new Self-Assessment for this upcoming inspection year was completed correctly and all areas of non-compliance are documented on the actual assessment. For ongoing compliance, IDD Manager receives the completed assessment, they will thoroughly be reviewed by the Manager and Director. Any areas that are not completed properly will be corrected on the self-assessment 09/02/2019 Implemented
SIN-00115555 Renewal 06/01/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(f)STAFF #1 INDICATED A CURRENT FIRE SAFETY TRAINING THAT OCCURRED ON 02/22/2017 AND THE PREVIOUS FIRE SAFETY TRAINING OCCURRED ON 02/18/2016 WHICH IS LONGER THAN 1 YEAR. Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. Staff #1's Fire Safety Training was over a year old--initially 2/18/16 and not done again until 2/22/17. Spread sheets have been developed to assure that time limits are not exceeded in the future. The Coordinator will be responsible to assure that timely trainings are in compliance. see attached 06/16/2017 Implemented
6400.62(a)POISONOUS MATERIALS WERE FOUND IN THE FOLLOWING AREAS OF THE HOME: 1 TUBE OF AIM AND 1 TUBE OF COLGATE FLOURIDE TOOTHPASTE WERE IN THE MEDICINE CHEST ABOVE THE SINK AND 1 CONTAINER OF DIAL ANTIBACTERIAL HAND SOAP WAS ON THE SINK VANITY IN THE SECOND FLOOR BATHROOM. THERE WAS 1 BOTTLE OF CARE ONE BRAND HAND SANITIZER UNLOCKED ON THE HALLWAY TABLE AND 1 BOTTLE OF PURELL HAND SANITIZER NEAR THE FRONT DOOR. 1 STICK OF SAUVE BRAND ANTIPERSPERANT SOLID AND 2 TUBES OF CREST AND COLGATE BRAND FLOURIDE TOOTHPASTE WERE FOUND IN INDIVIDUAL #2'S ROOM UNLOCKED. 1 TUBE OF SUAVE BRAND ANTIPERSPERANT SOLID IN INDIVIDUAL #1'S BEDROOM. 1 BOTTLE OF LUCKY SUPER SOFT BRAND HAND SANITIZER WAS FOUND UNLOCKED IN A KITCHEN CABINET THAT HAS A LABEL THAT READS "CONTACT POISON CONTROL IF SWALLOWED".Poisonous materials shall be kept locked or made inaccessible to individuals. Aim and Colgate Fluoride tubes have been removed from the medicine cabinets. Assuring that poisonous materials are kept in a locked area has been added to Sup/Coord Schedule and will be assured on the daily house inspection every AM. See attached 06/05/2017 Implemented
6400.62(d)1 BOTTLE OF LUCKY SUPER SOFT BRAND HAND SANITIZER WAS STORED IN A KITCHEN CABINET WITH 1 CAN OF FOLGER'S BRAND COFFEE, RED ROSE BRAND TEA BAGS, AND HERBAL TEA.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.Lucky Super Soft hand Sanitizer stored in the kitchen cabinet with coffee & tea has been removed. The supervisor will assure that all poisonous materials are kept locked when the AM house inspection is completed. This has been added to the Sup./Coord. Schedule see attached 06/05/2017 Implemented
6400.71EMERGENCY TELEPHONE NUMBERS FOR LOCAL FIRE, POLICE, AMBULANCE AND POISON CONTROL WERE NOT POSTED NEAR THE TELEPHONE IN THE LOWER LEVEL OF THE HOME. Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. All required phone numbers have been posted at all phones. Supervisor will assure this during every AM house inspection--added to Sup./Coord. Schedule See attached 06/05/2017 Implemented
6400.141(c)(4)THE PHYSICAL EXAM DATED 04/03/2017 DID NOT INCLUDE A HEARING SCREENING. The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Individual #1 saw n ENT physician on 6/22/17 for a hearing screening--see attached The Coordinator will assure that whenever a physical is done that all sections are completed prior to leaving the physician's office. This information was reinforced to all staff via the attached memo. 06/22/2017 Implemented
6400.183(1)THERE WAS NO DOCUMENTATION IN INDIVIDUAL #1'S RECORD THAT INDICATED SERVICES RELATED TO VERBAL REDIRECTION AS SPECIFIED IN THE SAFE AND HEALTHY ACTION PLAN WERE PROVIDED. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Services provided to the individual and expected outcomes chosen by the individual and individual's plan team. The services and outcomes provided to individual #1 are noted in her current ISP , however, there is no clear statement re Verbal re-direction. The SC was sent an e mail on 8/11/17 requesting a revision to her ISP stating this. see attached 08/31/2017 Implemented
6400.184(b)THERE WAS NO DOCUMENTATION IN INDIVIDUAL #1'S RECORD TO INDICATED THAT INDIVIDUAL #1 ATTENDED OR DECLINED TO ATTEND ISP MEETING ON 02/02/2017. At least three plan team members, in addition to the individual, if the individual chooses to attend, shall be present for an ISP, annual update and ISP revision meeting. Individual #1 did attend the ISP Meeting on 2/7/17 as noted by her X on the attached Signature Form. She was not able to stay for the duration of the meeting, however. see attached 02/07/2017 Implemented
6400.186(a)AS SPECIFIED INDIVIDUAL #1'S ISP DATED 05/11/2016 HOLCOMB STAFF IS REQUIRED TO PROVIDE VERBAL REDIRECTION WHEN THE INDIVIDUAL ENGAGES IN SELF INJURIOUS BEHAVIOR. THERE WAS NO DOCUMENTATION IN THE RECORD INDICATING THAT THIS HAS OCCURRED WHEN NEEDED. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. The attached ISP Monthly Review indicates that verbal redirection occurs when needed for Individual #1. Quarterly Reviews will indicate the occurrence of verbal redirection as well as will Daily Progress Notes. The Coordinator will assure that all staff are aware that this documentation is required whenever verbal redirection occurs. see attached 06/16/2017 Implemented
6400.186(d)THERE WAS NO DOCUMENTATION TO SHOW THAT AN INVITATION WAS SENT TO THE PLAN LEAD OR THE INDIVIDUAL TO ATTEND THE ISP MEETING HELD ON 02/17/2017.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. The Coordinator requested & received a copy of the ISP Invitation dated 1/24/17 to attend the ISP meeting on 2/7/17 from the Supports Coordinator on 6/5/17. The Coordinator will assure that the Invitation letter is always obtained and in the individual's file on a timely basis and provides ISP review documentation & applicable recommendations to the SC/team members within 30 calendar days after the mtg. see attached 06/05/2017 Implemented
SIN-00090728 Renewal 01/26/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(d)Staff 1's previous medication training was completed on 11/20/14 and the most recent training was not completed. Staff 2's previous medication training was completed on 12/29/14 and the most recent was completed on 1/21/16. Staff 3's previous medication training was completed on 12/30/14 and the most recent was completed on 1/20/16. Staff 4's previous medication training was completed on 11/25/14 and the most recent was completed on 1/20/16. Staff 5's previous medication training was completed on 11/20/14 and the most recent was completed on 12/23/15. "repeated violation-10/30/14, et al"A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. Per instructions from state inspectors, remediation would need to occur for this staff to give meds. On 1/28/16 --4 MARs were completed with passing results. On 1/28/16 --2 practicum observations were completed for this individual # 1 with passing results. See supporting documents .[The Program Director will develop an auditing document to include the dates of each staffs annual practicum to ensure that the practicums are conducted timely. In addition, The Program Director will review the document to ensure only trained staff are administering medications, starting immediately. SW 3.8.17] 01/28/2016 Implemented
6400.181(a)Individual #3's annual assessment dated 8/7/15 was completed late as the previous annual assessment was completed on 6/15/14. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. All supervisors have been informed to complete annual assessments in a timely manner. see supporting documents for memo distributed and another assessment that was done on time,[The Program Director will develop an auditing document to note the date of each individuals assessment to ensure the annual assessments are completed timely. The Program Director will review the auditing document at least bi-annually, starting once the auditing document is developed within the next 30 days. SW 3.8.17] 03/24/2016 Implemented
6400.185(a)Individual #3' ISP quarterly review dated 11/29/15 covering the period of September, October and November overlapped the ISP dated 10/1/15, which means that the review covered two separate ISP's. The ISP shall be implemented by the ISP's start date. All Program Specialists will use the quarterly chart to ensure they are in compliance with ISP start date for a residential clients. The supervisor and the site coordinator will be responsible for ensuring compliance. A copy of the Quarterly chart will be submitted with supporting documents.[The Program Director will review the quarterly chart at least quarterly to ensure the ISP reviews are conducted timely, starting immediately. SW 3.8.17] 02/16/2016 Implemented
SIN-00077836 Renewal 10/29/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(a)Individual #4 was informed of residential rights on 3/5/13, and on 9/13/14. Each individual, or the individual's parent, guardian or advocate, if appropriate, shall be informed of the individual's rights upon admission and annually thereafter. It is the provider's responsibility to inform all individuals of their rights on admission & annually. The supervisor/coordinator will ensure that this is completed annually without a lapse of time. Program records will be reviewed quarterly by the program director. 12/28/2014 Implemented
6400.46(i)Staff A's most recent first aid training expired on 3/10/14. Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. Staff A attended and passsed First Aid/CPR training on 11/7/14. It is the responsibility of the supervisor and coordinator to ensure staff have current First Aid/CPR training. The Training Coordinator will review of all staff training records quarterly to ensure that trainings are up-to-date. 11/07/2014 Implemented
6400.168(a)Staff A administers medication, but has not completed medication administration training. Staff F administers medication, but has not completed medication administration training. Staff K administers medication, but has not completed medication administration training. Staff L administers medication but has not completed medication administration training. In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. Staff F & L attended & passed the Medication Course on 11/24-25/2014. Staff A attended and passed the medication course on 12/29-30/2014. Staff K attended and passed medication training on 11/19-20/2014. A Policy has been developed and put in effect that requires require Medication Administration Trainers to train all staff prior to that staff administering medications. The Medication Administration Policy also outlines that all medication administrators are to ensure that each staff who administers medication will be monitored as outline in the Medication Administration Course. All Practicums will be completed in the required time frame. Documentation to support this ongoing training is to be submitted quarterly. Staff not in compliance will not be permitted to administer medications. The Training Coordinator will review of all staff training records quarterly to ensure that trainings are up-to-date. 12/30/2014 Implemented
SIN-00140984 Renewal 06/21/2018 Compliant - Finalized
SIN-00065358 Technical Assistance 07/07/2014 Compliant - Finalized