Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00262214 Renewal 03/11/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.216(a)Individual records were found in an unlocked filing cabinet in the home's front entryway during the physical site inspection. An individual's records shall be kept locked when unattended. These records were moved into the locking file cabinets in the staff office on 3.13.25 by the Program Specialist. (see attachment A). All other Program Specialists checked homes for similar issues by 3.17.25, no other issues found but one home needed additional locked storage to more adequately house books. This was done on 3.18.25 03/17/2025 Implemented
6400.186Individual #1's assessment dated 2/6/2025 and Restrictive Procedure Plan with an update date of 1/28/2025 state that they receive 1 hour total per day of phone usage. Of that 1 hour, 30 minutes are to be supervised by staff and the other 30 minutes are unsupervised. On the following dates it is documented that Individual #1 received only 15 minutes of unsupervised time on their phone instead of the allotted 30 minutes; 3/1/2025, 3/2/2025, 3/4/2025, 3/7/2025, 3/8/2025, 3/9/2025, and 3/11/2025.The home shall implement the individual plan, including revisions.The program specialist updated all logs and put them in the home on 3.14.25 (attachment C). No other restrictive plans are in place with this provider at this time. 03/14/2025 Implemented
SIN-00220361 Renewal 03/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)The screen in the upstairs window had a hole about the size of a quarter that had not been repaired. Screens, windows and doors shall be in good repair. Manager, contacted Landlord to remind of issue (had been previously submitted), he replaced the screen on 3.13.23. Other properties were checked by Site Supervisors, no outstanding issues for screens exist. Please see attachment A. 03/13/2023 Implemented
SIN-00085134 Renewal 10/07/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(a)Staff #1 only completed 3 medication administration reviews for her 2014 annual medication training. Staff #1 did not retake the medication administration course but continued to complete annual medication practicums even though she did not complete the 2014 training in it's entirety. 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. A Med Admin Trainer completed training with Staff #1 on 10.27.15 as seen in attachment B1. Other staff were also found to have this issue and completed training as of 11.3.15 as seen in training records which are attachment B2. Med Trainers reviewed all MARS on a daily basis for all untrained staff until training completion as seen in attachment B3. To correct this issue in the future, the medical team will reveiw 25% of each trainer's staff each quarter to ensure MARS are being done correctly and documentation is in place. Also the Med Trainers have established a relationship with the ODP Med Training consultant so they can ask questions or get feedback on processes at any time. 11/03/2015 Implemented
6400.168(d)Staff #1 continued to administer medications throughout the year even though she did not complete her 2014 medication administration training in it's entirety. A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. A Med Admin Trainer completed training with Staff #1 on 10.27.15 as seen in attachment B1. Other staff were also found to have this issue and completed training as of 11.3.15 as seen in training records which are attachment B2. Med Trainers reviewed all MARS on a daily basis for all untrained staff until training completion as seen in attachment B3. To correct this issue in the future, the medical team will reveiw 25% of each trainer's staff each quarter to ensure MARS are being done correctly and documentation is in place. Also the Med Trainers have established a relationship with the ODP Med Training consultant so they can ask questions or get feedback on processes at any time. 11/03/2015 Implemented
SIN-00185977 Renewal 03/16/2021 Compliant - Finalized
SIN-00146137 Renewal 01/29/2019 Compliant - Finalized
SIN-00125166 Renewal 01/17/2018 Compliant - Finalized