Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00263141 Renewal 03/11/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(e)The home has two floors and a basement. Four individuals reside in the home. The smoke detectors in the home are interconnected. When tested at time of inspection the basement detector did not signal when the other detectors in the home were activated. The detector in the basement was tested and signaled independently from the others in the home. On the day of inspection, the Provider contacted those responsible for the system who noted that the detectors are paired and likely out of synchronization. The detectors did not appear to be working properly at the time of inspection.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. The Maintenance department completed a synchronization of the smoke detectors on 3/31/25. Video attached. 03/31/2025 Implemented
6400.141(c)(4)Individual #1 receives services from an Optometrist as recommended. Documentation indicates that Individual #1 was evaluated on 8/24/23. with a recommendation to "return in 6 months." The next documented examination was completed on 11/26/24. This extended beyond the recommendation of the physician and beyond the regulated one year timeframe.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Individual #1 has a vision appointment scheduled for 7/22/25. This was the first available appointment offered by the physician at the prior appointment. A copy of the appointment is attached. 04/15/2025 Implemented
SIN-00222518 Renewal 03/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The back of the toilet bowl rim of the toilet in the bathroom located on the second floor of the home was soiled with a large, reddish-brown stain.Clean and sanitary conditions shall be maintained in the home. Toilet was confirmed to be cleaned through visual review conducted by the center¿s QI Director (Attachment: Confirmation of cleaning) 04/28/2023 Implemented
6400.66The outside light at the front entrance of the home was not working at the time of the inspection.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The center¿s Facilities Maintenance team replaced the outside light at the front entrance of the home. (Attachment: Confirmation of replacement) 04/28/2023 Implemented
6400.112(h)The fire drills that were held from March 2022 through February 2023 recorded five different meeting places including the backyard drive, the backyard, the stump in the yard, the basketball hoop, and the pole in the yard. The home shall have one consistent designated meeting place where all staff and individuals know to meet after evacuating in the event of a fire. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.The center¿s QI, Operations, and Facilities Maintenance team has developed a training document to be trained to all employees, by the residential home¿s manager or designee during May¿s monthly IDT meeting. Training document includes, but is not limited to, the requirement that the evacuation location exactly match the annual fire safety report without other identifiers such as basketball hoop, stump or pole in yard being noted. (Attachment: Training summary) 05/01/2023 Implemented
6400.207(4)(I)Individual #1 is prescribed the medication Ativan 1mg. tablets, to be administered 1 tablet by mouth every 6 hours as needed for acute anxiety. The Social, Emotional, Environmental Needs (SEEN) plan dated 1/18/2023 describes the behaviors that the individual would display in order for the medication to be administered: rapid mood changes, cursing at others that is not easily redirected, shaking fist, threatening others and repetitive actions. On March 6, 2023, the medication was administered by staff to Individual #1 and there is no documentation in the medication administration record (MAR) that staff obtained authorization from the CEO or CEO designee prior to administering the medication. The current Chapter 6400 regulations require that authorization from the CEO or CEO designee must be obtained prior to each instance that a pro re nata (PRN) psychotropic medication is administered and the authorization must be documented in the applicable medication administration record (MAR).A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition.The home received training on documentation of PRN, and psychotropic PRN approval. The center's clinical team provided clinical approval documentation of PRN for the identified PRN administration Attachment: PRN administration clinical approval 05/01/2023 Implemented
SIN-00203483 Renewal 04/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The 3 to 6 months completion window for the agencies self-assessments prior to the expiration date of the agency's certificate of compliance was 9/30/21 to 12/31/21, and the self- assessment was dated 2/1/22. This exceeds the requirement.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. 2022-2023 self-assessment was completed on 02/01/2022. 01/01/2023 Implemented
SIN-00172832 Renewal 03/02/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.143(a)Individual #2 refused his TB test and there is no documentation in his file that any training was completed with him regarding the importance of following medical directives and cooperating at appointments.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. Phone call was held with guardians on 3/3/2020 at 2:15pm to discuss the need to attain the TB test, along with the options available to attain the test. In attendance were: MS, AM, CP, and the individuals two guardians by phone. Initially, the guardians declined the TB test being planted, stating they did not want the individual to go through it. Discussed were the options, such as taking him to his physician, or having a Devereux nurse plant the test in his group home. It was explained to the guardians that the individual would also need the TB test to access his summer services, such a prevocational programming. The guardians agreed review the situation, contact the family physician to ask questions, and would call back once they are able to have those questions answered. At this time the individual is residing at family¿s home due to families COVID-19 concerns. Individual left facility on 3/14/20 and has not returned to our care as of this time. Continued contact will occur with family once the family contacts the facility to plan the individuals return to rectify the need for the TB test upon. If family prefers to have the individual¿s PCP complete testing, the facility will work in coordination with the PCP. Ongoing, all current residents testing needs will be tracked by the facilities nursing department to ensure all current individuals remain in compliance with all medical testing needs. The facilities Quality Improvement Manager will conduct monthly audits (Attachment 13) on a percentage of individuals that reside within the facility to ensure on-going compliance. All new admits medical documentation will be reviewed by the facilities Admissions and Nursing Department to ensure proper testing has been completed. All noted concerns will be immediately disseminated to the proper departments to ensure immediate rectification of noted concern. The facility implemented a desensitization plan (Attachment 11) for the individual on 3/9/2020 in preparation for family consent to administer TB test. Due to pandemic and individuals temporarily residing at home with family since 3/14/2020, attempts to complete TB testing have not occurred. The facility will resume the desensitization plan and attempts to complete TB testing once the individual returns to the facility, and family provides consent for testing. On-going, the facilities Nursing Department will document all refusals of testing by individuals and inform the clinical department of stated refusal in order to implement a desensitization plan immediately. The facilities Quality Improvement Manager will oversee monthly audits (Attachment 13) on a percentage of individuals that reside within the facility to ensure on-going compliance. All noted concerns will be immediately disseminated to the proper departments to ensure immediate rectification of noted concern. 04/30/2020 Implemented
SIN-00279748 Renewal 12/09/2025 Compliant - Finalized
SIN-00242463 Renewal 04/02/2024 Compliant - Finalized
SIN-00190154 Renewal 04/20/2021 Compliant - Finalized
SIN-00152352 Renewal 03/18/2019 Compliant - Finalized
SIN-00130492 Renewal 03/20/2018 Compliant - Finalized
SIN-00136804 Renewal 03/20/2018 Compliant - Finalized