Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00247898 Renewal 08/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The home shall complete self-assessments of the home 3-6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. The agency completed the self assessments on 4.23.24 through 4.26.24. The license is good from 5.1.24 through 5.1.25.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. Program Specialist will complete a self assessment 3-6 months prior to the expiration of the COC. 08/27/2024 Implemented
SIN-00227060 Renewal 08/15/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(c)Prescription medications shall be administered as prescribed. Individua #1l is prescribed Amiloride 5mg tablets. One tablet to be taken at 8am and 2 tablets to be taken at 4pm. During the time of the inspection on 8/16/23 the 8am was administered and signed and dated on both the blister pack and the MAR. However, the 4pm medication for the date of 8/16/23 was not in the blister pack and it is unknown where the 2 pills were.A prescription medication shall be administered as prescribed.Provider immediately contacted program staff who had administered medication the day of and day prior to investigate a possible medication error. Although it is uncertain, the team believes that the medication was popped by mistake by a family member while Individual #1 was on a home visit on 8/15/23. 08/18/2023 Implemented
SIN-00116076 Renewal 06/28/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(f)Individual #1 had an ISP meeting on 10/20/16. The assessment was sent to the team on 10/16/16 which is out of the regulated time frame.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). The ID Department Administrative Assistant has scheduled next year's Annual Assessment. Please see the attached Outlook Calendar with the Assessment scheduled for 9/8/17 07/27/2017 Implemented
6400.199(k)Individual #1 has an order for Lorazepam 1mg to be administered every 8 hours as needed for anxiety/agitation. This medication was administered on 6/4/17, 6/6/17, 6/9/17, and 6/23/17. The medication order does not include written instructions by a physician or medical practitioner listing the specific mental illness symptoms that would warrant the use of an "as needed" psychotropic medication. Documentation of compliance with subsections (b)¿(i) shall be kept. The physician has written a PRM Psychiatric Medication Protocol for the PRN Medications specifying which behaviors/thoughts necessitate when the PRN medication can be given. Please see attached PRN Psychiatric Medication Protocol 07/07/2017 Implemented
SIN-00078763 Unannounced Monitoring 04/08/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)Individual #2's date of admission to the residential program was 6/19/2014. Individual #2 received her fire safety training on 6/20/2014. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. The AVP of the department will ensure that upon entrance into a program, the individual is instructed on fire procedures and will complete a fire drill along with the documentation. 04/30/2015 Implemented
SIN-00178333 Renewal 10/20/2020 Compliant - Finalized
SIN-00071399 Initial review 11/19/2014 Compliant - Finalized