Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00222857 Renewal 04/11/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(e)There were no nonslip shower mats or surfaces in the showers on the basement and first levels. Bathtubs and showers shall have a nonslip surface or mat. On 4/12/23 a non-skid mat was added to the shower. The Program Specialist will complete retraining with house staff related to reporting when non-slip surfaces or mats are in need of repair or replace. The training will include the process of submission of a maintenance request email or the application of non-skid products based on the homes specific need. This training will be completed by 5/8/23. Documentation will be maintained in staff files. 05/08/2023 Implemented
6400.162(a)Staff members 5,6,7,8, and 9 do not have current and complete medication administration training annual practicums on file. They cannot pass medications until their training is remediated or recertified.A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication.Staff identified during licensing as having issues had medication pass privileges suspended 4/12/23. Medication practicum files were reviewed for staff members 5,6,7,8 and 9. Individual plans were developed based on the staff member either needing remediation or full certification. An additional review of all other med passers was completed by training and administrative staff. This review was completed prior to end of business on 4/14/23. Any staff requiring remediation or full certification had passing privileges suspended until required certifications or remediations have been completed. Additional training will be completed with supervisors and trainers related to the initial and annual requirements of the medication certification process. These trainings will be completed by 5/5/23. 05/08/2023 Implemented
SIN-00112390 Technical Assistance 04/18/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)THERE WAS A BOTTLE OF HAND SANITIZER UNLOCKED ON A DESK IN THE LIVING ROOM WHICH HAD A LABEL THAT STATED A PERSON SHOULD CALL POISON CONTROL IF INGESTED.Poisonous materials shall be kept locked or made inaccessible to individuals.On 4/19/17 the hand sanitizer was moved and locked in a cabinet. The Manager of Residential Services will conduct a retraining with the Program Specialists to ensure that all areas of the annual assessment are completed. The Manager of Residential Services will review all annual assessments upon completion. The residential staff will conduct daily site checks to ensure poisonous substance are locked and will document on daily log. The Residential Managers will also complete weekly checks to ensure poisonous substance are locked and will document on weekly checklists. The weekly checklist will be submitted to the Program Specialists for review on a weekly basis. If poisonous materials are found during the daily check, staff will return them to the locked cabinet immediately. 06/02/2017 Implemented
6400.64(e)THE TRASH CAN THAT MEASURED 30 INCHES HIGH IN THE BATHROOM DID NOT HAVE A LID.Trash receptacles over 18 inches high shall have lids. A new trash can was purchased on 4/20/17. The Manager of Residential Services will conduct training with the Program Specialists and Residential Managers. The training will focus on ensuring that all trash receptacles in the facilities that are over 18 inches high have lids. The Residential Managers during their weekly checks will ensure that all trash receptacles over 18 inches high have lids and will document on the weekly checklist and submit to the Program Specialists for review. 06/02/2017 Implemented
6400.81(k)(2)THE BED IN INDIVIDUAL #1'S ROOM WAS NOT ON A SOLID FOUNDATION AND WAS ON THE FLOOR. In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. The Manager of Residential Services will conduct training with the Program Specialists and Residential Managers with the focus on ensuring that all individuals on their caseloads have mattresses on solid foundation. In the event modification is required in consideration for the health and safety of any of the individuals, there has to be supporting documentation that the individual¿s team reviewed and agreed on such modification. *Individual # 1 had fallen from her bed a few times and sustained a fracture. The team agreed that for the safety of client #1 the mattress and frame be placed on the floor. The team will reconvene and review the situation by 6/15/17. 06/15/2017 Implemented
6400.112(c)THE FIRE DRILL RECORD DATED 01/08/2017 AND 11/05/2016 DID NOT DOCUMENT WHETHER OR NOT THE FIRE ALARM SYSTEM WAS OPERATIVE. ALSO THE FIRE DRILL RECORD DATED 03/05/2017 DID NOT DOCUMENT ANY PROBLEMS ENCOUNTERED. A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The agency has implemented the use of an electronic fire drill form in which all regulatory requirements are mandatory fields. Utilization of the electronic form began in May 2017 and all staff have been trained on how to complete the form using our electronic records system. 06/02/2017 Implemented
SIN-00067513 Renewal 09/22/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The basement walls and the first floor bathroom's shower head was covered with a substance consistent with mold. Clean and sanitary conditions shall be maintained in the home. All staff, supervisors, maintenance personnel and management personnel have been retrained on ensuring that all areas of the home are in good repair and on timely reporting of any issues to the appropriate staff. See attached training sheets. Residential Managers will complete an outlined inspection of their sites on a monthly basis and submit checklist to their supervisor. Maintenance personnel will also complete an outlined inspection of their assigned sites monthly and submit the checklist to their supervisor. Please see attached checklists. Third Shift Supervisor has a revised nightly checklist to ensure all areas are checked thoroughly. Administrative staff conduct site inspections twice per month. See attached reports. An outside contractor was brought in and completed an inspection of the basement walls. All mold was resolved 9/23/14 and shower head was cleaned on 9/23/14. See attached work order. 09/23/2014 Implemented
6400.67(a)The ramp outside in front of the home had a large hole, creating a hazard for Individuals of the home. Floors, walls, ceilings and other surfaces shall be in good repair. All staff, supervisors, maintenance personnel and management personnel have been retrained on ensuring that all areas of the home are in good repair and on timely reporting of any issues to the appropriate staff. See attached training sheets. Residential Managers will complete an outlined inspection of their sites on a monthly basis and submit checklist to their supervisor. Maintenance personnel will also complete an outlined inspection of their assigned sites monthly and submit the checklist to their supervisor. Please see attached checklists. Third Shift Supervisor has a revised nightly checklist to ensure all areas are checked thoroughly. Administrative staff conduct site inspections twice per month. See attached reports. The effected board was replaced on 9/23/14. See attached work order. 09/23/2014 Implemented
SIN-00158967 Renewal 07/18/2019 Compliant - Finalized