Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00279758 Renewal 12/09/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(c)Outside doors shall have operable locks. The door coming into the home through the garage off of the back deck of the home did not have a lock and allowed easy access to the home. Outside doors shall have operable locks.A lock was installed on the garage door. Photo Attached. Complete 12/16/25. 12/16/2025 Implemented
6400.112(g)Fire drills are not held at different times of the day/night. Sleep fire drills were held on 3/25/25 at 5:30am, 9/12/25 at 5:18am and 12/7/24 at 4:15am. These fire drills were all within 15 minutes of each other. Fire drills shall be held on different days of the week and at different times of the day and night. The Residential Director retrained all Managers on fire drill procedures including requirements to be held on different days of the week, different times of the day, using different exits, and the requirement that fire drills are unannounced. Copy attached. Completed 12/19/25 12/19/2025 Implemented
6400.193(a)At the time of inspection all sharps were locked in the home despite there being no restrictive procedure plans in place for any of the individuals residing in the home identified as unsafe with sharps.A restrictive procedure may not be used as retribution, for the convenience of staff persons, as a substitute for the program or in a way that interferes with the individual's developmental program.The Program Specialist will complete a review of the annual assessment and ISP for each individual receiving residential services to ensure that the ISP contains information on poisons, sharps, and safety needs which accurately reflect the unique needs of each individual. Changes, if needed, will be communicated to the Supports Coordinator. The Clinical Director and Clinical Program Administrator will support the Program Specialist in completing these reviews/revisions by target date. Staff will be trained on updated ISPs. Due 3/11/26 03/11/2026 Implemented
SIN-00263139 Renewal 03/11/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.51(b)(5)Staff #1 has a hire date documented as 12/2/24. Documentation indicates that training on job related skills and knowledge in the form of the Individual Support Plan (ISP) and Behavioral Support Plan (BSP) for Individual #1 did not occur until 3/10/25. Training on job related skills and knowledge must include all knowledge and skills necessary for the health, safety, and welfare of the specific individuals served. Training is required within 30 days after hire. The training was completed outside of the regulatory time frame.The orientation must encompass the following areas: Job-related knowledge and skills.The staff was hired on 12/2/24 and was trained on the ISPs of the residents on 1/10/25. The staff did not begin working with residents at that home until 2/1/25. Documentation of the training on 1/10/25 is attached. 03/27/2025 Implemented
6400.166(a)(10)At time of inspection on 3/11/25 the March 2025 Medication Administration Record (MAR) for Individual #1 included an entry for Triple Antibiotic Ointment to be given as "Apply topically 2 times a day as needed. There were no times assigned for administration due to being given as needed. The front page of the MAR documented administrations on 3/1/25, 3/2/25, 3/3/25 and 3/5/25. The back of the MAR included times of administration for 3/1/25 and 3/2/25. Times of administration were missing for administrations on 3/3/25 and 3/5/25. The time of administration must be recorded.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.The Manager has retrained staff on recording times of PRN medication administration. 04/21/2025 Implemented
SIN-00189708 Renewal 04/20/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)A fire drill was conducted during the month of September 2020. An unannounced fire drill shall be held at least once a month. Fire drill record was located after inspection had concluded. 05/31/2021 Implemented
6400.112(e)Fire drill review for the dates of January 2020 through March 2021 indicate unannounced sleep drills were held on 2/27/20 and 8/9/20. No sleep drills have been conducted since 8/9/2020, exceeding the 6 month requirement. Unannounced sleep drill shall be held at least every 6 months.A fire drill shall be held during sleeping hours at least every 6 months. A review of center practices occurred to ensure current practices were able to meet DHS regualtions. 05/31/2021 Implemented
SIN-00172826 Renewal 03/02/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)The sliding screen door to the deck from the living room was warped and would not securely shut. Screens, windows and doors shall be in good repair. The facilities maintenance team repaired the screen door at Hemlock Cottage on 3/4/2020 and ensured the sliding door securely closed and was able to lock in the closed position (Attachment #5). On-going the facility will conduct monthly quality audits (Attachment #1) on the home to assist in identifying the needs of the homes. The audit tool will consist of not only physical site needs, but also ensuring all homes are in compliance with ODP regulations. All audits will be completed by individuals well versed in ODP regulations, Devereux policies & procedures, and local township requirements. All audits will be collected by the facilities Quality Improvement Manager for review and secure document storage. All needs identified during the audits will immediately be disseminated to the proper department by the individual completing the audit in accordance with Devereux policy. 03/03/2020 Implemented
SIN-00136798 Renewal 03/20/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(d)Staff #2 had 22.0 hours of annual training, which is 2 hours short of the 24 regulated hours of training.Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. Training hours will be reviewed quarterly by Learning Manager to ensure compliance. First review was done on training hours through April 30, 2018 and Managers were notified of any staff who were behind on hours. 04/30/2018 Implemented
SIN-00070729 Renewal 03/24/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(i)The 2 windows in the bedroom of Individual #1 did not have curtains. blinds, drapes, shades, or shutters.Bedroom windows shall have drapes, curtains, shades, blinds or shutters. Due to the challenging behaviors of the individual that resides in the room without curtains, adhesive privacy coating was used on the window instead of curtains. This coating will be removed and curtains attached with velcro will be utilized on both windows instead in order to allow for privacy. The manager of the residence will purchase and hang the curtains. The Director of Operations will ensure that all residential managers are notified ongoing that privacy coating is not to be used. Effective date: 4/9/15 A picture of the hung curtains will be forwarded to BHSL 04/09/2015 Implemented
SIN-00242461 Renewal 04/02/2024 Compliant - Finalized
SIN-00222533 Renewal 03/28/2023 Compliant - Finalized
SIN-00152341 Renewal 03/18/2019 Compliant - Finalized
SIN-00130508 Renewal 03/20/2018 Compliant - Finalized
SIN-00130487 Renewal 03/20/2018 Compliant - Finalized
SIN-00111939 Renewal 05/03/2017 Compliant - Finalized
SIN-00091010 Renewal 04/04/2016 Compliant - Finalized
SIN-00057377 Renewal 01/23/2014 Compliant - Finalized
SIN-00051612 Initial review 07/23/2013 Compliant - Finalized