Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00260079 Renewal 02/04/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)At 1:16PM on 2/5/25, the house petty cash log documented a cash balance of $203.77. This matched the cash on hand in the home. There was no individual up-to-date record for Individual #1. Agency staff stated that the individual is invoiced for his personal expenses and required to replenish the house petty cash money.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. Petty cash will be reviewed at all sites by 2/28. Supervisors will be trained on how to better document personal expedenitures and receipts on 2/20/25. Documentation of the agenda will be maintained by the Res Director and the training record will be sent to HR for review and maintenance. 02/20/2025 Implemented
SIN-00239101 Renewal 02/13/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The fire drill held on 3/27/23 had an evacuation time of 2 minutes 48 seconds. The home does not have an extended evacuation time. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. The Site Supervisors were retrained on 2/29/24 and given a training infographic to provide to each site for DSPs. DSPs will all be trained on running a correct fire drill, proper documentation, and what to do if there are issues with a drill on 2/29/24 02/29/2024 Implemented
6400.18(a)(5)On 1/12/24, the home became aware of a suspected incident of neglect. The agency did not report the incident in Enterprise Incident Management system, the Department's information management system until 1/16/24. This incident number is 9346502.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Neglect. The Site Supervisors were retrained on recognizing and reportable incidents that are classified as neglect due to medication errors on 2/29/24 . The DSPs will be trained on medication errors and recognizing neglect incidents no later than 3/30/24. 02/29/2024 Implemented
6400.18(b)(2)On 1/12/24, the home became aware of a medication error. The agency did not report the incident in Enterprise Incident Management system, the Department's information management system, until 1/16/24. This incident number is 934674.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person: A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner.The Site Supervisors were retrained on recognizing and reportable incidents that are classified as neglect due to medication errors on 2/29/24 . The DSPs will be trained on medication errors and recognizing neglect incidents no later than 3/30/24. 02/29/2024 Implemented
6400.182(c)Individual #1's assessment, completed 4/28/23, assessed Individual #1 with the ability to safely use and avoid poisonous materials with hand over hand physical assistance. Individual #1's individual plan, last updated on 8/22/23, in the safety precaution section reads "[Individual #1] is aware of the hazards of poisons. He needs verbal prompts for recognizing and appropriately using poisonous materials."The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The Program Specialist requested revisions to the ISP on 2/21/24 via email. All Program Specialists were instructed to review and compare all Functional Assessments and ISPs no later than 3/31/24 and report requested changes to the Dir of IDD Systems. 02/21/2024 Implemented
SIN-00203053 Renewal 03/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(11)Individual #1's March 2022 Medication Administration Record does not include the diagnosis or purpose for the following medications: Certavite, Florastor Cap, Gavilax Pow, Lansoprazole Cap, Levothyroxin Tab, and Xifaxan Tab.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 Site Supervisors were informed of the need to include purpose of medications and diagnosis on 3/31/22. The ADs will review all MARs by 7/31/22. [Immediately, Individual #1's current MAR shall be updated to include the diagnosis or purpose for each medication. At least monthly, a staff person qualified to administer medication shall audit all individual current medication record to ensure all required information is included. (AES,HSLS on 4/27/22) Copy of Individual #1's April 2022 MAR to included diagnosis or purpose for each medication was provided to the Department on 4/27/2022 (AES,HSLS on 5/5/22)] 03/31/2022 Implemented
SIN-00164651 Renewal 10/22/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)Individual #1 was instructed in fire safety on 6/4/18 and then again on 7/14/19. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. Assistant Directors will complete a full audit of the most recent quarters fire drills to ensure that exits that are being used for evacuation are ¿man doors¿. They will also review that all individuals are evacuating the site within 2 mins 30 secs. The Site Supervisors will be trained in the following areas of fire safety by 11/13/19: 1) Types of exits to use as an alternate exit 2) How to properly time an evacuation 3) Reporting an evacuation that exceeds 2:30 to management 4) When/how to alert the Fire Chief of individuals that require assistance living at a site and requesting a waiver for evacuation times 5) Requirements for times frames to complete annual fire safety training with DSPs and individuals. Documentation of the training provided by the Directors will be kept. Site Supervisors will train the DSPs at each site on the above information by 12/18/19 and submit all records to the Office Manager.[Immediately, the CEO or designee shall develop and implement a tracking system to ensure timely completion of staff fire safety training to include all required information. At least quarterly for 1 year, the CEO or designee shall audit the tracking documentation and a 10% sample of staff fire safety training to ensure timely completion. (DPOC by AES,HSLS on 11/5/19)] 11/13/2019 Implemented
6400.165(g)Individual #1, date of admission 8/28/08, had a review of medications prescribed to treat symptoms of a diagnosed psychiatric illness on 9/25/18 and then again on 3/12/19. The review of medications completed on 3/12/19 did not include the need to continue the medications. (Repeated Violation-11/19/19, et al)If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The IDD Nurse will create a universal spreadsheet for all scheduled appointments and due dates for evaluations by 11/15/19. The IDD Nurse will review all appointments with the IDD Res. Director, who will communicate any appointments that need scheduled to the Site Supervisors and Assistant Directors. The Site Supervisors will be trained on the protocol for reporting upcoming appointments as well as reporting to the IDD Nurse with all pertinent medical information provided at attended appointments at their next department meeting in December. The IDD Nurse will review the appointment tracker monthly and the Assistant Directors will complete monthly reviews of on site medical documentation. Documentation of spreadsheet reviews and audits will be maintained by the responsible party and shared with the IDD Res. Director on at least a quarterly basis. 11/15/2019 Implemented
SIN-00125478 Renewal 12/04/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The time for the individuals to evacuate the home for the fire drills held on 8/3/17 and 10/5/17 was 2 minutes and 45 seconds. The time for the individuals to evacuate the home for the fire drill held on 8/12/17 was 2 minutes and 50 seconds. The home does not have an extended evacuation time specified in writing by a fire safety expert. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Site Supervisors will be retrained on fire drill requirements no later than 12/22/17. All staff will be retrained on evacuation procedures at the monthly staff meeting in January. All staff will also be retrained on reporting guidelines for any fire drill that takes longer than 2.5 minutes. Site Supervisors will audit Fire Drill documentation monthly and audited quarterly by the Program Specialist and/or Asst. Director. Documentation of completed audits will be maintained in the Residential office. [Within 60 days of receipt of the plan of correction and within 30 days of notification of any fire drill exceeding the allotted evacuation time, a designated management staff person shall observe a fire drill to evaluate and implement procedures, trainings etc to ensure all individuals are able to evacuate in the allotted time. Documentation of the observation and subsequent activities shall be kept. (AS 12/21/17)] 12/22/2017 Implemented
6400.163(c)Venlafaxine ER 37.5 mg, take one capsule by mouth every day for depression prescribed on 6/22/17 for Individual #1 was not included in the psychiatric medication review completed 9/13/17. 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.Health Care Contacts will be reviewed for accuracy by 12/22/17 to ensure that the list matches the individual¿s MAR. The Site Supervisors will be retrained on the regulation by 12/31/17. The Program Specialists and/or Asst. Director will review Health Care Contacts at least quarterly to ensure that all medications are listed as prescribed. Documentation of audits will be maintained in the Residential office. [Immediately, after completion at staff person trained on the requirements of psychiatric medication review shall review the documentation to ensure all required information is included and the individual are administered medications as prescribed. (AS 12/21/17)] 12/22/2017 Implemented
SIN-00104494 Renewal 12/05/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(g)The agency is utilizing video cameras to monitor and record in the hallways, living room, dining room and other common areas of the home. An individual has the right to receive scheduled and unscheduled visitors, communicate, associate and meet privately with family and persons of the individual's own choice. The use of the cameras was discontinued and will not be utilized in the future. Residential staff are trained on Client Rights including the right to privacy at orientation and annually thereafter. 01/30/2017 Implemented
SIN-00072065 Renewal 11/13/2014 Compliant - Finalized