Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00285232 Renewal 03/16/2026 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(2)Individual #1 had a cash ledger in May 2025, but there is no other cash ledger present in the home ongoing. In June 2025, November 2025, and December 2025, there were ATM withdrawals from Individual #1's True Link account, but there is no documentation of where that money went or how it was spent.(2) Disbursements made to or for the individual. 1. To address the area of non-compliance, the Team Facilitator will review all the financial transactions from May 2025 to March 2026 to ensure all the monthly financial reports have been completed. The audit will ensure all transactions have been accounted for, and where funds are unaccounted for or documentation is found, the Team Facilitator will request the funds be reimbursed to the individual. 04/27/2026 Accepted
6400.22(e)(3)Individual #1's True Link card was used to make the following purchases, but no receipt is available in documentation: 5/13/25 Walmart $20.17; 9/19/25 Hobby Lobby $15.88; 10/11/25 Michael's $15.89 If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. 1. A reimbursement request was submitted on 03/27/26 for the agency to reimburse Individual #1 in the amount of $51.94 (attachments #12B and #12C) 04/27/2026 Accepted
6400.73(a)At the time of the 03/17/26 inspection, there was no handrail for the stairs leading out of the basement to ground level. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. 1.) Upon notification of the issue, a maintenance request was submitted for the installation of a handrail on the basement stairs leading to ground level. This was completed on 3.26.26. (attachments 14A-14C) 04/27/2026 Accepted
6400.144(Repeated Violation -- 4/14/25) On 2/16/26, Individual #1 went to the doctor for a potential UTI. It was recommended that Individual take multiple warm sitz baths and drink cranberry juice. There is no documentation that these recommendations were followed.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. 1.) The Director of Quality and Incident management will Re-Train all nurses on importance of following Doctor's recommendations. 04/27/2026 Accepted
6400.181(e)(4)Individual #1's 2/25/26 Individual Support Plan indicates that they have 4 hours of community alone time. The individual's 1/30/26 annual assessment has not been updated with this change in supervision. This assessment indicates that Individual #1 has no community alone time. The assessment must include the following information: The individual's need for supervision. 1. Upon notification of citation, the assessment was reviewed and updated to reflect information on reg 181(e) (4) (attachments #15A &15B) 04/27/2026 Accepted
6400.18(b)(2)The medication errors described in 6400.167a1 and 6400.167a4 were not reported in the department's incident management system.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person: A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner.1.) All Program Specialists, Team Facilitators, and Direct Support Professionals will be retrained by the IM Representative with an emphasis on incident reporting requirements, including what constitutes a reportable medication error. 04/27/2026 Accepted
6400.32(c)(Repeated Violation -- 4/14/25) Individual #1's Tower Behavioral discharge paperwork from 1/6/26 indicates that Lorazepam is to be held if Individual #1's Systolic Blood Pressure is under 100 or Diastolic blood pressure is under 60. These changes were not made in the home, and Individual #1's blood pressure is not being tracked per this medical order.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.1.) Upon discovery, the medical order from the 1/6/26 discharge was immediately reviewed. Clarification was obtained from the prescribing physician, confirming that Lorazepam is to remain a standing order and that blood pressure monitoring parameters are not required at this time (attachments 13A1 -- 13A5) 04/27/2026 Accepted
6400.165(c)Individual #1 was prescribed a decrease in Divalproex from 750mg daily to 500mg daily on 10/15/25. This decreased dosage was not administered to Individual #1 until 10/24/25.A prescription medication shall be administered as prescribed.1.) The Agency Nurse will document in Therap any discrepancies related to the pharmacy that may result in an individual not receiving a prescribed medication as ordered. All discrepancies will be reported promptly, communicated to the appropriate team members, and followed up to ensure timely resolution and continuity of care. 04/27/2026 Accepted
6400.167(a)(1)Individual #1's Feirza was held on 8/8/25. There was no prescribers' order for this hold.Medication errors include the following: Failure to administer a medication.1.) All Direct Support Professionals (DSPs), Team Facilitators, and Program Specialists will be retrained on proper medication administration practices, including verifying the right date, time, and dose prior to administration by the agency nurse. 04/27/2026 Accepted
6400.167(a)(4)Individual #1's 8am medications were administered at 9:01am on 9/28/25.Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time.1.) All Direct Support Professional will be retrained by a Medication Administration Trainer on the adherence of administering medication within the 1 hour before or after the prescribed timeframe. 04/27/2026 Accepted
6400.213(1)(i)Individual #1's demographic information does not include their height and weight.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number, height and weight.1. Upon notification of citation, individual #1 demographics form was updated to reflect height and weight (Attachments #16A -- 16B) 04/27/2026 Accepted
6400.213(1)(i)(Repeated Violation -- 4/14/25) Individual #1's demographic information does not include their next of kin.Each individual's record must include the following information: Personal information, including: ((v) Next of KinUpon notification of citation, individual #1 demographics form was updated to reflect the individual's next of kin (attachments #16A -16D) 04/27/2026 Accepted