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-00278316 Renewal 12/01/2025 Compliant - Finalized
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