Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00266480 Unannounced Monitoring 03/01/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144During the PCP appointment on 2/13/2025 for individual #1 an x-ray was ordered. According to staff #5 and confirmed during the investigation the x-ray was never completed as ordered.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. Individual #1 has been discharged from services on 3/3/2025. Program Case Administrators will conduct a review of all individuals medical appointments and prescribed follow-up services for the past 90 days to ensure that all recommended health services are completed and properly documented. This review will specifically identify any incomplete follow-up orders. If any missed or incomplete services are identified, immediate steps will be taken to schedule and complete the required care. Quality Management Department will retrain Program Case Administrators on Regulation 6400.144 to ensure health services that are planned or prescribed for the individual will be arranged for or provided. Program Case Administrators will conduct weekly reviews of all individuals on their caseloads to verify that all medical appointments and prescribed health services have been documented, arranged, and completed as recommended. Documentation will be maintained in the Individual Record. 06/30/2025 Implemented
SIN-00251584 Unannounced Monitoring 08/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)Sleep drill was conducted on 5/7/2024 at 10:00pm. However, in the note section of the drill it states that Individual #2 & Individual #3 were asleep, but that Individual #1 was awake on the couch at the time of the drill. This cannot be considered a sleep drill if all participants are not asleep. Previous sleep drill was conducted on 11/30/2023.A fire drill shall be held during sleeping hours at least every 6 months. Program Specialist will ensure the next sleep drill will be conducted when all individuals in the home are sleeping. The sleep drill will be conducted in October 2024. Program Specialist will ensure the subsequent fire drill during sleeping hours will occur every 6 months. Residential Program Specialists will inspect every licensed 6400 facility home¿s fire drills to ensure all individuals in the home were sleeping for a conducted sleep drill. Program Specialist will ensure fire drills held during sleeping hours are conducted every 6 months. Any non-compliances identified will result in a sleep drill being conducted in October 2024. Documentation will be maintained and available for on-site review. Manager of Compliance and Training will retrain Residential Program Specialists and Residential Supervisors on Regulation 6400.112(e) regarding the discussion points noted in the Regulatory Compliance Guide for ¿Sleeping Hours¿ to ensure sleep drills conducted indicates all individuals in the home are sleeping and sleep drills are completed every 6 months. Documentation will be maintained and available for on-site review. 10/31/2024 Implemented
6400.182(c)Individual #3's current ISP dated 7/9/2024 states that they have no concept of safety precautions and poisonous materials, and hygiene supplies are locked in their home. At the time of the physical site inspection (8/16/2024) it was discovered that poisonous materials were not locked in Individual #3's home. Current assessment dated 3/18/2024 states that poisonous materials and hygiene supplies are not locked in the home. There was no request to update the ISP sent until 8/19/2024.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.On 9/19/2024, Program Specialist sent an email to Individual #3s Supports Coordinator to update her ISP indicating that poisons are not locked within the home as she would not ingest them. Documentation will be maintained and available for on-site review. Program Specialists will review each individual¿s ISP to ensure their safety precautions regarding poisons are consistent on how they are stored within the home. The Supports Coordinator will be notified for any discrepancies found during the review to update the ISP. Documentation will be maintained and available for on-site review. Manager of Compliance and Training will retrain Residential Program Specialists on Regulation 6400.182(c) regarding the discussion points noted in the Regulatory Compliance Guide ensuring any change identified by an assessment requires the ISP to be updated. Documentation will be maintained and available for on-site review. 10/31/2024 Implemented
SIN-00248106 Renewal 07/22/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)The bathroom in individual #1's bedroom did not have soap in it at the time of the inspection.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. During Licensing inspection on 7/24/2024, Residential Program Specialist placed soap in the bathroom off of Individual #1s bedroom. Documentation will be maintained and available for on-site review. Residential Program Specialist and/or Residential Supervisor will inspect every licensed 6400 facility home to ensure each bathroom has soap. Hope Enterprises will immediately replace any missing soap identified during inspection. Documentation will be maintained and available for on-site review. Individual #1 removed the soap from the bathroom prior to licensing inspecting the home. Facilities Department will install a wall mounted hand soap dispenser in the bathrooms where individuals tend to remove the portable hand soaps. Documentation will be maintained and available for on-site review. 08/31/2024 Implemented
SIN-00186250 Unannounced Monitoring 04/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(2)Staff #1 received a TB test on 08/06/18 and not again until 09/02/20. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. PROVIDER PLAN OF CORRECTION DISCLAIMER: THE DEPARTMENT DOES NOT PERMIT APPEAL/RESOLUTION OF DISPUTED DEFICIENCIES UNTIL AND UNLESS A PROVIDER SUBMITS A PLAN TO CORRECT DEFICIENCIES THAT THE DEPARTMENT HAS ALLEGED. ACCORDINGLY, THIS PLAN OF CORRECTION IS SUBMITTED TO MEET REGULATORY REQUIREMENTS. IT IS NOT AN ADMISSION OF ANY ALLEGED DEFICIENCY OR ALLEGED VIOLATION AND SHOULD NOT BE UTILIZED AS AN ADMISSION BY ANY COURT OR TRIBUNAL IN ANY LEGAL PROCEEDING. 1. STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED WITH RESPECT TO THE INDIVIDUAL/INDIVIDUALS IDENTIFIED WITHIN THIS DEFICIENCY: Hope Enterprises will ensure Staff #1 has a current tuberculin skin test completed on or before 09/02/2022 and every 2 years thereafter. Hope Enterprises will provide a written reminder to Staff #1 of the need for tuberculin skin testing 1 month prior to due date. Documentation will be maintained and available for on-site review. 2 STEPS HOPE WILL TAKE TO IDENTIFY ANY OTHER INDIVIDUALS THAT MAY BE AT RISK ON ACCOUNT OF THE DEFICIENCY AND STEPS HOPE WILL TAKE TO ENSURE THAT THE DEFICIENCY IS CORRECTED FOR ANY OTHER AT RISK INDIVIDUALS: Hope Enterprises will review 100% of staff records to ensure tuberculin skin testing is completed every 2 years. Hope Enterprises will provide a written reminder of the need for tuberculin skin testing to each staff member found to be within 1 month of his or her Tuberculin skin testing due date. If any staff member is found to be past the 2 year due date for tuberculin skin testing, Hope will require proof of tuberculin skin testing with negative test results or, if positive, initial chest x-ray with results noted prior to returning to work. Documentation will be maintained and available for on-site review. 3. STEPS HOPE WILL TAKE TO ENSURE THAT THE CORRECTION OF THIS DEFICIENCY IS PERMANENT AND THAT THE DEFICIENCY DOES NOT REOCCUR: Hope Enterprises will retrain all staff on the requirement to have a Tuberculin skin testing completed every 2 years. Hope Enterprises will update its policies to provide that a complete physical examination, including Tuberculin skin testing, is required to work in a licensed residential facility. Hope will update its policies to include a written reminder of the need for tuberculin skin testing to each staff member 1 month prior to due date. Documentation will be maintained and available for on-site review. 05/31/2021 Implemented
SIN-00189052 Unannounced Monitoring 06/16/2021 Compliant - Finalized
SIN-00168060 Unannounced Monitoring 12/06/2019 Compliant - Finalized
SIN-00161772 Unannounced Monitoring 08/27/2019 Compliant - Finalized
SIN-00155946 Unannounced Monitoring 05/17/2019 Compliant - Finalized