Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00206915 Renewal 09/09/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(a)On 7/2/21 the fire system was listed as inoperable. No further explanation was provided. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. This was a typing error for the document in question as the fire system was operable and is currently operable. However, our 6400.110(a) protocol has been updated and the following procedures have been instituted; ¿ A fire safety monitoring tool to be used in the event of the fire system being inoperable has been updated. See Attachment #1. ¿ The fire safety monitoring tool will be in effect immediately a fire system is discovered to be inoperable. ¿ Notification for repair shall be made within 24 hours and the repairs completed within 48 hours of the system being found to be inoperative. ¿ Program specialist will be trained on the use of the fire safety monitoring tool and the expectation to ensure notification for repair for any inoperable fire system is made within 24 hours of being discovered and repairs are completed within 48 hours of the system being found to be inoperative. The fire safety monitoring tool will be completed at least hourly by the Program Specialist or staff while the system is inoperative and reviewed by Assistant Directors/Directors. ¿ Person Responsible; Program Specialist, Assist. Director and Director of Programs 07/13/2022 Implemented
6400.112(d)On 12/8/2020 the drill took 6 minutes due to unresponsive staff. No reason was given at time of inspection. 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. Our 6400.112 (d) protocol has been updated and the following procedures have been instituted; ¿ Onsite Fire Safety training has been updated to include staff expectations during a fire drill. See attachment # 2. ¿ All staff will be trained to prioritize on assisting individuals out of the building in allotted 2 minutes and 30 seconds, report to the emergency relocation area and complete head count to verify that all individuals have been evacuated. ¿ Program Specialist will be trained to ensure that all drills are completed by the 15th of every month to allow for any repeat drill that exceeds 2 minutes and 30 seconds. ¿ Person Responsible: Program Specialist, Assist. Director and Director of Programs. 07/13/2022 Implemented
6400.112(h)No designated meeting places were listed on the fire drill records for all homes. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Our 6400.112(h) protocol has been updated and the following procedures have been instituted; ¿ All Fire Drills forms for all homes have been updated to include respective designated meeting places. See Attachment # 3. ¿ All Program specialist will be trained on how to complete the updated Fire Drill Form when conducting a fire drill and indicate the designated meeting place used during a fire drill. ¿ Person Responsible; Program Specialist, Assist. Director and Director of Programs 07/13/2022 Implemented
SIN-00175948 Renewal 09/08/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(6)There was no mirror located in Individual #2 bedroom.In bedrooms, each individual shall have the following: A mirror. For immediate correction, mirror was installed in individual #1's bedroom. See appendix I. To prevent future occurrence, all program managers will be trained on regulation 6400.81(k)(6) . Person Responsible for carrying out and oversight: Program manager, Assist. Director and Director of Programs. 11/11/2020 Implemented
6400.144Medication Polyethylene Glycol 3350 17mg. for individual #1 was listed on the MAR (Medication Record) but the medication was not in the individual's medication container.Health 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. The medication Polyethylene Glycol 3350 17mg was obtained on the date of inspection for individual #1. To prevent future recurrence, all program managers and other personnel who are responsible for the oversight of medications will be on regulation 6400.144, as well as the expectation to ensure new medication is ordered at least 5 days prior to any medication running out. this training will be documented in the team meeting minutes. medication checks will be completed weekly by the program manager to ensure all medication is present (see appendix K). Person responsible: program manager, director or programs, primary care nurse, healthcare coordinator, nurse manager 11/11/2020 Implemented
SIN-00148679 Renewal 01/15/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(d)There was no curtain covering the window in the upstairs bathroom.Privacy shall be provided for toilets, showers and bathtubs by partitions or doors. Curtains are acceptable dividers if the bathroom is used only by one sex or only by individuals 9 years of age or younger. Our 6400.82 (d) protocol has been updated and the following procedures have been instituted; Work order was completed and curtains have been installed in the bathroom. See attachment P. A check for all windows and doors for privacy will be added to our monthly environmental checklist completed by managers/program specialists by 3/31/19. All Program Specialists/Managers will be trained on how to utilize the environmental check list by 4/30/19. The environmental check list will be completed monthly and any concerns noted will be reported to facilities within 24 hours. Target Date 4/30/2019. Person Responsible: Program Specialist. 04/30/2019 Implemented
SIN-00126641 Renewal 10/30/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There was a bottle of Opti-free Disinfecting solution in an unlocked cabinet under the bathroom sink.Poisonous materials shall be kept locked or made inaccessible to individuals. The chemical has been removed from the area and the managers have been retrained on this requirement. See Appendix A. 03/16/2018 Implemented
6400.110(a)There was no smoke detector in the basement. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. This has been corrected. A smoke detector has been installed in the basement. See Appendix B_W. 03/16/2018 Implemented
6400.110(e)The smoke detectors in the home were not interconnected.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. The home will have smoke detectors interconnected not mater than May 17th, 2018. Detectors have been installed on all floors. See appendix B_W 05/17/2018 Implemented