Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00263130 Renewal 03/11/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(4)Individual #1 had a vision examination under sedation completed 4/25/22 and the form noted a follow up appointment in one year, and Individual #1's next vision examination was completed on 7/15/24. The agency is responsible to ensure vision examinations are scheduled within regulatory timeframes.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The guardian has requested that they schedule all apointments. The guardian was informed of regulatory requirements. The guardian has scheduled a follow-up vision exam for 6/16/25. 04/11/2025 Implemented
6400.142(a)Individual #1 had a dental examination on 5/11/23 and their next one occurred on 9/20/24. The agency is responsible to ensure dental examinations are scheduled within regulatory timeframes.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. The guardian has requested to schedule all medical appointments. The guardian was informed of regulatory requirements. The guardian has scheduled a follow-up dental exam for 9/19/25. 04/11/2025 Implemented
6400.144Individual #1 had a neurology appointment on 2/14/24 and the form noted to follow up in 1 year. There was no record or document that this appointment occurred.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. The guardian has requested to schedule all medical appointments. The guardian was informed of regulatory requirements. The guardian has scheduled a follow-up neurology appointment for 7/22/25. This was the first available appointment. 04/18/2025 Implemented
6400.195(a)Individual #2's Individual Support Plan (ISP) dated 3/30/24, states under the general health and safety risk section that Individual #2 is not provided with knives due to a history of using sharps to threaten/aggress towards self and/or others. At the time of the inspection, the knives and sharps were locked in a cabinet in the home. The provider is implementing a restrictive procedure without a behavior support plan reviewed by a human rights team that addresses the need for the restrictive procedure.For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures.The Behavior Specialist will complete a restrictive procedure plan for Individual #2 which will be reviewed at the next Human Rights Team meeting scheduled for May 12, 2025. Documentation attached. 05/12/2025 Implemented
SIN-00222524 Renewal 03/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)At the time of inspection there were two money pouches in the home identified as belonging to Individual #8. One money pouch contained $5 and two receipts totaling $10.25. The other money pouch contained $34.58. There was no documentation to illustrate when the money was deposited at the home or a record of the money being in the home. An up-to-date financial record that includes funds received by or deposited with the home shall be kept.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. The center¿s finance director updated individual funds protocol to always include the availability of $25.00 in a single locked location, accessible to all staff members for use. (Attachment: Updated Individual Funds Protocol) 05/30/2023 Implemented
6400.181(a)The annual assessment was not completed by the annual date of 1/22/23. The "Integrated Assessment" for Individual #3 submitted for review is dated as being completed on 1/22/23. Electronic signature of Staff #9 indicates that the document was completed on 3/20/23. Additional electronic signatures on the "Integrated Assessment" indicate that the portions of the document were signed on 3/20/23, 3/21/23 and 3/23/23 by Staff #9. The "Biosocial" section was electronically signed as completed by Staff #10 on 3/21/23. The "Adult Training Facility Annual Assessment" included as part of the residential assessment was electronically signed on 3/20/23. The "Assessment Review" signature page indicates that the results of the assessment were reviewed with Individual #3 on 2/17/23. The "Progress and Growth Domains Assessment" was electronically signed on 3/22/23. A cover letter submitted to indicate the document was sent to team members was dated as being completed on 2/17/23. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Assistant Clinical conducted training with the clinical department on 04/26/2023 to review Devereux and regulatory requirements regarding assessments, due dates, and the contents of assessments. (Attachment: Clinical Meeting 04/26/2023) 04/26/2023 Implemented
6400.51(b)(5)Staff #3 has a documented hire date of 5/16/22. There was no documentation to support that training on the Individual Support Plan (ISP) was completed.The orientation must encompass the following areas: Job-related knowledge and skills.The home¿s assigned program specialist has completed ISP training with Staff #3. Attachment (Staff ISP training) 05/01/2023 Implemented
SIN-00203493 Renewal 04/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment is to completed within 3 to 6 months prior to the expiration of the expiration of the certificate of compliance. The expiration date for the certificate of compliance was 3/31/2022 and the Self-Assessment was completed on 2/01/2022.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
6400.66The exterior light outside the utility room exit door was not functioning 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 exterior light bulb was replaced prior to the end of the inspection date on 4/13/2022. 04/13/2022 Implemented
SIN-00279746 Renewal 12/09/2025 Compliant - Finalized
SIN-00242458 Renewal 04/02/2024 Compliant - Finalized
SIN-00190153 Renewal 04/20/2021 Compliant - Finalized