Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00270021 Unannounced Monitoring 07/14/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(7)Individual #1 is to have a gynecological exam every five years. The exam was due on 5/13/24. There is no documentation for the exam taking place.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. Individual #1 had a pap/gyn exam with their physical on 6/18/24 (This was late). Pap exemption note signed by the PCP was provided for current medical guidelines stating because she had a normal HPV test result on 6/18/24. The provider received a note from the PCP to state the GYN exam was also given a five-year exemption due to the gold standard being every 5 years with a negative HPV screening per the doctor on 7/29/25. Breast exam exemption note signed 6/18/24 has also been included that states the individual does not need a breast exam for 5 years because they had a normal mammogram and no other risk factors. In order to ensure appointments are completed as required, the last two pap-gyn exams were added to external services in Welligent (EHR), an appointment tracking system on 8/14/24. A due date of every 5 years was added for this service so it can be scheduled on or before, 6/18/29 when it is due again. If there was a need to change this exemption due to a medical need for the individual due to signs/symptoms of illness, the PCP will be notified so that the testing will be performed before the exemption period. Staff for individual #1's home will be trained by 8/1/25 on regulation 6400.141(c)(7) and provider's procedure to obtain a medical/dental exemption. See supporting documentation 08/15/2025 Implemented
SIN-00217368 Renewal 01/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.195(a)During the physical inspection, there were two refrigerators in the lower level of the home that had locking mechanisms on them. CSG stated that individual #1 had issues with sneaking and eating food that didn't correspond with their previous prescribed diet. Individual #1 does not have a restrictive procedure plan related to this practice nor is this information noted in their ISP.For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures.Locks on the freezer and fridge downstairs were unlocked on 1/12/23, the date of discovery and the locks were permanently removed by maintenance on 1/13/23. On 1/17/23, all staff at Walker Drive were trained in 195(a) by the Program Director, training sign in sheet attached. 02/07/2023 Implemented
SIN-00164796 Renewal 01/27/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The smoke detectors were not checked during the fire drills completed on 12/20/19.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. The smoke detectors were checked on the day of inspection, 1/30/20. Smoke detectors were checked during each subsequent fire drill in July, August and September; see the attachments. The Safety and Fire Drill tool will be reviewed and revised as necessary by 6/15/2020 and will include the requirements of this regulation. The Safety and Fire Drill tool will be completed by the Supervisor at the time of Monthly Safety Check and Fire Drill. The Manager will review the completed form with the Supervisor during supervision meetings to ensure thorough and accurate completion of the form verifying the requirements of this regulation. DSPs, Supervisors and Managers will be retrained in the Policy and Procedures for Completion of Fire Drills and Monthly Safety System Checks, as well as the procedures for completion of the revised Safety and FIre Drill tool by 6/30/2020. On a quarterly basis the Manager is responsible to complete the quarterly tool for all physical site and safety requirements, including this regulation. The tool for all physical site and safety requirements will be reviewed and revised by 6/15/2020 and all Managers will be trained on the use of the tool and the quarterly inspection requirements by 6/30/2020. The Manager¿s quarterly inspections will be completed in July, October, January and April. PDs will review the outcomes of the quarterly tools by the last day of each month, July, October, January and April. Program Directors will complete a walk through of each home in CSG to insure agency wide compliance with all physical site and safety requirements utilizing CSG¿s Risk Management tool. The Risk Management tool will be reviewed and revised to include a check of operable alarm systems and smoke detectors and fire extinguisher locations by 7/31/2020 and PDs will be trained in the tool by 8/15/2020. All walkthroughs will be completed by October 31, 2020. 10/31/2020 Implemented
SIN-00099191 Renewal 08/01/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)Individual #6 physical was late. It was completed 9/23/14 and not again until 10/20/15. An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Each individual will have a physical examination within 12 months prior to admission and annually thereafter. The physical for Individual #6 was completed on 9/19/16, which was within the required 12 months of the last physical on 10/20/15. (Attachment #2) All Program Specialists and house supervisors will be retrained in Regulation 141(a) and the CSG Policy D.3.c.1 IDD Individual Physical Exam Record. All house supervisors will utilize Microsoft Outlook to track appointments. All Program Specialists will utilize Microsoft Outlook to monitor and ensure completion of appointments. 11/30/2016 Implemented
6400.141(c)(9)Individual #6 prostate exam was late. It was completed 9/23/2014 and not again until 10/21/2015.The physical examination shall include: A prostate examination for men 40 years of age or older. Each physical examination will include a prostate examination for men 40 years of age or older. Individual #6 had a physical examination on 9/19/16, which included a prostate examination. (Attachment #2) All Program Specialists and house supervisors will be retrained in Regulation 141(c)(9) and the CSG Policy C.7.3 Health Services for Individuals in IDD Services. All house supervisors will utilize Microsoft Outlook to track appointments. All Program Specialists will utilize Microsoft Outlook to monitor and ensure completion of appointments. 11/30/2016 Implemented
6400.181(e)(13)(vii)Individual #6 his assessment dated 2/1/16 did not show progress and growth for financial independence.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. The assessment will include progress and growth over the last 365 days and the current level in the area of financial independence. The Program Specialist has revised the assessment for Individual #6 on 10/13/16 to include her progress and growth over the last 365 days in the area of financial independence. (Attachment #1) All Program Specialists will be retrained in Regulation 181(e)(13)(vii) to ensure that the assessments include the individual¿s progress and growth over the last 365 days in the area of financial independence. Each individual record will be reviewed by the Program Specialist to ensure that the assessment includes the information by 11/30/16. 11/30/2016 Implemented
6400.181(e)(13)(ix)Individual #6 his assessment dated 2/1/16 did not show progress and growth for community integration. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.The assessment will include progress and growth over the last 365 days and the current level in the area of community integration. The Program Specialist has revised the assessment for Individual #6 on 10/13/16 to include his progress and growth over the last 365 days in the area of community integration. (Attachment #1) All Program Specialists will be retrained in Regulation 181(e)(13)(ix) to ensure that the assessments include the individual¿s progress and growth over the last 365 days in the area of community integration. Each individual record will be reviewed by the Program Specialist to ensure that the assessment includes the information by 11/30/16. 11/30/2016 Implemented
SIN-00047084 Renewal 04/22/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Individual #1's bedroom had cat litter covering the carpet, in the corners of the room and behind her furniture.(a) Clean and sanitary conditions shall be maintained in the home. Partially Implemented - Adequate Progress Cleaning Individual #1's room has been added to the home's daily chore list. The carpet is being replaced with new flooring that will be easier to keep clean. 06/15/2013 Implemented
6400.67(a)Individual #1's closet door is in disrepair. (a) Floors, walls, ceilings and other surfaces shall be in good repair. Fully Implemented Individual #1 has requested that we install a curtain instead of a door on her closet. 05/31/2013 Implemented
SIN-00252515 Renewal 09/30/2024 Compliant - Finalized
SIN-00252607 Renewal 09/30/2024 Compliant - Finalized
SIN-00199492 Renewal 02/07/2022 Compliant - Finalized
SIN-00200087 Renewal 02/07/2022 Compliant - Finalized
SIN-00182673 Renewal 02/01/2021 Compliant - Finalized
SIN-00118895 Renewal 09/18/2017 Compliant - Finalized