Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00218945 Unannounced Monitoring 02/01/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Paint cans, which were observed during the inspection on 12/15/22, were still in the laundry room floor, unlocked. The hallway closet, which contains many cleaning agents, was unlocked.Poisonous materials shall be kept locked or made inaccessible to individuals. Program manager reviewed locking poisons with team on 1/30/23. Implemented
6400.64(a)A gallon of whole milk with an expiration date of 1/11/23, was still in the refrigerator.Clean and sanitary conditions shall be maintained in the home. Expired milk was discarded. 02/01/2023 Implemented
6400.67(a)The window blinds covering the backdoor were broken and should be replaced.Floors, walls, ceilings and other surfaces shall be in good repair. Blinds were damaged and a maintenance request was submitted on 1/30/23. 02/20/2023 Implemented
6400.171A bag of frozen sausages was open in the deep freezer, which will cause freezer burn.Food shall be protected from contamination while being stored, prepared, transported and served. Food is stored in freezer bags. 02/01/2023 Implemented
6400.45(d)Timecards provided does not meet staffing ratio for coverage regarding allotted individual time. Timecards provided only show coverage for 8am-4pm shift. All time periods were requested and not received.The staff qualifications and staff ratio as specified in the individual plan shall be implemented as written, including when the staff ratio is greater than required under subsections (a), (b) and (c ).Agency will have staff schedules available for review. 05/11/2023 Implemented
6400.163(h)Acetaminophen 500 was present in current medication bin of individual number 1 medication label indicated medication was to be used by December. 8, 2022Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Expired medication was discarded. 02/01/2023 Implemented
6400.163(h)Medication Fluicaisone 50 mg expired December 8, 2022 and was still present in current medications for individual. 1Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Expired medication was discarded. 02/20/2023 Implemented
6400.165(b)Acetaminophen 500 was present in current medication bin. medication label indicated medication was to be used by December. 8, 2022A prescription order shall be kept current.Expired medication was discarded. Current medication is on site. 02/20/2023 Implemented
6400.165(c)Expired Acetaminophen was administered to individual number 1. This was reflected on the MAR as being administered in the month of January 2023. The medication was administered on January 5, January 7, January 9, January 12, January 16, January 25, January 27.A prescription medication shall be administered as prescribed.Expired medication was discarded. 02/20/2023 Implemented
6400.185(5)Individual number 2 ISP indicated that he has stranger awareness and will not open the door for strangers, however, Individual number 2 opened the door for us to enter the home to conduct the home inspection although we were strangers.The individual plan, including revisions, must include the following: Risks to the individual's health, safety or well-being, behaviors likely to result in immediate physical harm to the individual or others and risk mitigation strategies, if applicable.Program manager and staff team continue to review stranger awareness and not opening the door to strangers with Individual #2. 03/07/2023 Implemented
SIN-00216825 Renewal 12/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Cascade Dishwasher detergent, as well as paint cans were left unlocked in the home.Poisonous materials shall be kept locked or made inaccessible to individuals. Dishwasher detergent/packs and paint cans were moved to locked cabinet. 12/19/2022 Implemented
6400.64(a)Bathroom attached to the master bedroom space needs a thorough cleaning.Clean and sanitary conditions shall be maintained in the home. All team members are being held accountable on the cleanliness of the home on a daily basis. The individual's bathroom was cleaned while he was on an activity. 12/19/2022 Implemented
6400.67(a)The window blinds in Individual #2's bedroom are torn and should be replaced.Floors, walls, ceilings and other surfaces shall be in good repair. A maintenance request was submitted on 12/19/22 to replace the blinds. 01/31/2023 Implemented
6400.112(e)Greater than 6 months between sleep drills: The most recent documented overnight sleep drill occurred on February 24,2022A fire drill shall be held during sleeping hours at least every 6 months. Last overnight drill held September 2022. Next overnight drill to be held by March 2023. Overnight drills will be conducted at least every six months. 01/31/2023 Implemented
6400.144The following daily medications for individual #2 were not present at the time of inspection: Amphetamine 10 MG Cap Fexofenadine 180 MG tab The following PRNs medications for individual #2 were not present at the time of inspection: Hydrocortisone 1% cream Naproxen 500 MG TabHealth services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Pharmacy was called to ensure scripts were present for current meds and medications were re-ordered. 12/31/2022 Implemented
6400.181(a)Annual assessments for indivisual #2 were dated 4/12/21 and 5/13/22 which is greater than 1 year apart 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. ISPs are scheduled by supports coordinators. While ISPs should be scheduled 60 days in advance, SCs have more recently been scheduling ISPs 30 days in advance. 01/13/2023 Implemented
6400.163(h)In the medication box of individual #2 the following mediations were found: Triple Antibiotic ointment PRN had an expiration date of 11/19/22. Acetaminophen 325 MG Tab PRN (not on MAR, but present with medications) is expired as of 12/8/22.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Expired PRNs were removed and were replaced with new PRNs. 12/31/2022 Implemented
6400.165(b)There is contradicting information regarding individual #2's Divalproex 500 MG tab 8 PM medication. The MAR states "take one tablet by mouth at bedtime", while a blister pack states "take three tablets by mouth at bedtime". The MAR needs to be reflect the current prescription order.A prescription order shall be kept current.MAR corrected to reflect current order. 01/13/2023 Implemented
6400.166(b)Several medications were not signed as administered on several dates for Individual #2 Fluticasone Nasal Spray: 12/4 & 12/15 at 8 AM Clonidine .1 MG Tab: 12/1 & 12/4 & 12/14 at 8 AM and 12/2, 12/13, & 12/14 at 4 PM and 12/13 at 8 PM. Divalproex 500 MG tab: 12/3 at 8 PM Chlorpromazine 50 MG tab: 12/11 at 8 PM Mirtazapine 30 MG tab was signed as administered at 8 PM on 12/15 (day of inspection) although med review was done around 11 AM that same day. According to the MAR of Individual #2, Chlorpromazine 50 MG tab was started on 12/6/22, however meds are missing from the blister pack for dates 12/4 and 12/5.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The staff have been retrained in MAR documentation. The staff have a checklist that they must sign off on indicating that they have checked the MAR and compared the medication to ensure the medications were given and signed for. 12/31/2022 Implemented
SIN-00180934 Renewal 12/21/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The window blinds in the bedroom of individual #1 were broken.Floors, walls, ceilings and other surfaces shall be in good repair. Staff inspected the blinds. Upon review it was discovered that the blind was tangled, but not broken. Staff untangled the string. It is in good working order. Blinds did not need to be replaced as they were still in working order. Should and item in the home be found to be not in good repair, staff complete a facilities request to have the item repaired or replaced. The facilities department then goes to the home to repair or replace the item. In addition, staff will complete a monthly health and safety checklist which includes ensuring that floors, walls, ceilings and other surfaces are in good repair. A facilities request can be submitted with the form should staff find an item that is not in good repair. See attachment # 1 12/22/2020 Implemented