Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00258787 Renewal 01/14/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency completed the self-assessment of this home from 1/5/2025 through 1/10/2025 which was not completed during the 3 to 6 months prior to the expiration of the Certificate of Compliance or 6 to 9 months after the previous year's inspection. Additionally, the following sections of this self-assessment were left blank and not assessed for compliance: Staffing, Staff Health, Home Services, Day Services, Restrictive Procedures, Individual Records, Emergency Placement, Respite Care, and Semi-Independent Living.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The agency is creating a schedule for each house to have a complete self-assessment within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance to measure and record compliance. 01/17/2025 Implemented
6400.73(a)On 1/15/2025 at 11:29am, the exterior stairs near the rear basement exit of the home were observed without a secure handrail. The staircase included four steps leading from the egress up to a small landing. From the landing, three additional steps that lead to a sidewalk were observed. On 1/15/2025 at 11:35am, the 3 steps at the bottom of the basement stairwell were observed without a secure handrail. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The exterior stairs near the rear basement exit and staircase leading from the egress up to a small landing have been scheduled to install a handrail once the ground thaws and can be secured into the ground. The 3 steps at the bottom of the basement stairwell now have a secure handrail leading the entire way down the stairs. The staff will continue to observe the handrails and report to supervisors if they become loose due to wear and tear of the house. 01/17/2025 Implemented
6400.34(a)Individual #1 was last informed of their individual rights and the process to report a rights violation on 1/5/2024.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Individual rights and the process will be added to an annual checklist and set up in the electronic health record with reminders 60 days before they are due to be signed again. 01/17/2025 Implemented
SIN-00130808 Renewal 03/08/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment for the home did not include a date of completion, therefore, compliance could not be measured.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The 6400.15 regulations have been reviewed by the Program Director and the Clinical Director. Once the self-assessments have been completed the Program Director and the Clinical Director will review to insure accuracy and completeness. Effective Date: June 1, 2018 Responsible Party: Program Director and Clinical Director [Within 30 days of receipt of the plan of correction, the CEO or designee shall training all staff person responsible for completing and reviewing the self-assessments of their responsibilities to ensure accurate and timely completion of the self-assessment. Documentation of the trainings shall be kept. Documentation of the aforementioned reviews by the Directors of the self-assessments shall be kept. (AS 6/21/18)] 06/01/2018 Implemented
SIN-00237945 Renewal 01/23/2024 Compliant - Finalized
SIN-00185633 Renewal 03/30/2021 Compliant - Finalized