Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00230419 Renewal 10/20/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(a)There was no documentation on the "Day Program Fire Drill Log" that a fire drill had been conducted in May 2023. Staff #4 noted that a drill was held as indicated on her desk calendar, but details were not noted on the fire drill log.An unannounced fire drill shall be held at least once a month.The Program Director reviewed the regulation in regards to monthly fire drill documentation on October 20, 2023. 10/20/2023 Implemented
2380.89(d)Documentation of fire drills conducted noted the following to be over the allowed evacuation time of 2 minutes and 30 seconds: 1/22/23- 2:40, 2/14/23- 2:59, 3/29/23- 2:38, 4/17/23- 2:42, 7/3/23- 2:35 and 9/12/23- 2:40. No concerns were noted on the "Day Program Fire Drill Log" for any of the fire drills listed. There was no documentation from a fire safety expert that extended the 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 firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.Program Director has the center run a fire drill on 10/23/2023 and all Vip's and staff exited well within the limits. (2 mins. 4 Seconds) If in the future, we would run into instances of fire drills exceeding the allotted time we would request an extended fire evacuation time. 10/23/2023 Implemented
SIN-00158472 Renewal 07/26/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(g)Staff #1 has not been trained in first aid and Heimlich techniques (staff is trained only in CPR and AED, per documentation in the employee's file), and regularly works alone in the community with 1 to 3 individuals.There shall be at least one staff person for every 18 individuals, with a minimum of two staff persons present at the facility at all times who have been trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation within the past year. If a staff person has formal certification from a hospital or other recognized health care organization that is valid for more than 1 year, the training is acceptable for the length of time on the certification.The individual was trained in First Aid on 7/29/2019. The HR department and hiring PS will review the CPR/First aid cards to endure that they have both certifications of new hires upon hire and being assigned to Vip's in the community 07/29/2019 Implemented
SIN-00138693 Initial review 07/24/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.61There is no phone available for use yet at the facility.The facility shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.A working phone has been installed at the facility. Implemented
2380.62The emergency numbers are not yet posted in the facility.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line.Telephone numbers of the nearest hospital, police department, fire department, ambulance, and poison control center is posted on the telephone at the facility. Implemented
2380.70(b)The program's first aid area does not yet have a bed/cot, blanket, pillow, or first aid kit.The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit.The first aid area now has a cot, a blanket, a pillow, and a first aid kit. Implemented
2380.70(c)There is not yet a first aid kit at the program site.Each floor of the facility shall have a first aid kit accessible to staff persons.There is now a first aid kit at the program site. Implemented
2380.72(b)The rear exit from the building is a step off a porch onto a grassy slope that leads down to a paved area. The slope will be difficult to maintain as a safe passageway in the winter should there be inclement weather.The outside of the building and the facility grounds shall be well maintained, in good repair and free from unsafe conditions.There is now a walkway leading from the back porch down to the paved area. There are rocks all along the walkway for traction and there are railings on both sides of the walkway for stability when walking down it. Implemented
SIN-00213338 Renewal 10/18/2022 Compliant - Finalized
SIN-00192055 Renewal 11/30/2021 Compliant - Finalized