Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00219207 Renewal 02/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The September 2022 Fire Drill Log for this location does not specify the date on which the fire drill occurred. Although all other documentation requirements are met with respect to this Fire Drill, the calendar date of occurrence is missing---with respect to the Fire Drill's time of occurrence, only the month ("September"), calendar year ("2022"), and clock time ("5:00pm") are listed on the Fire Drill Log. A written fire drill record shall be kept of the date of occurrence of each fire drill.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. Fire drill documentation redone to state "Month", "Date", and "Year" instead of "Day", "Month", and "Year" on the top portion of the Fire Drill. Updated fire drill attached. 02/27/2023 Implemented
SIN-00184405 Renewal 03/16/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.211(b)(3)Individual # 1 does not have the name, address and phone number of the person able to give consent for medical treatment if the individual is unable to do so.Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. Individual #1 intake form has been updated to include who is responsible to give medical consent for emergency treatment. In the event individual #1 is unable to provide his own sent, the Executive Director would provide such approval according to the decision making bulletin. See attached 03/18/2021 Implemented
6400.34(a)Individual #1 moved into the home on 7/1/2020. Individual was not informed of his rights upon admission. Individual was informed of his rights on 1/25/21.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Upon admission, individuals will be informed of his/her rights by the Program Specialist. Written documentation of the notification shall be kept on file. 03/30/2021 Implemented
6400.165(g)Individual #1 had a psychiatric medication review completed on 7/28/2020. No other psychiatric medication review was documented in the individual's file. Appointments visit forms from 10/8/2020, 11/17/2020, and 2/23/2021 indicate the appointment was for follow up and medication check, however, the forms did not include the reason for prescribing the medication, the need to continue the medication, and the necessary dosage.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Implementation of a new medication form to accompany individual #1 as well as others to primary care physician who reviews psychotropic medications prescribed. See attached. 03/25/2021 Implemented
6400.213(1)(i)Individual #1 does not have next of kin documented in his record.Each individual's record must include the following information: Personal information, including: (v) Next of Kin.Individual #1 record updated and they do not have a next of kin. 03/30/2021 Implemented
SIN-00147559 Renewal 01/23/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(6)There was no mirror in Individual #2 bedroom.In bedrooms, each individual shall have the following: A mirror. Individual #2 did not have a mirror in his bedroom. Staff did realize the importance of the individual having a mirror in his bedroom. House supervisor has been made aware that the individual needs a mirror and will complete weekly checks to ensure the individual has a mirror in his room. The individual has a history of breaking mirrors when upset so a non-breakable mirror will be purchasedf no later than 2/22/19. 02/21/2019 Implemented
6400.141(c)(6)Individual #1 has not had a TB test since 2015.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Individual #1 refused her TB testing which was marked on the previous year's physical but was omitted from 2018's physical. Program Specialist has contacted the individual's Behavior Specialist to have a desensitization plan for the refusal of TB. Program Specialist will also contact the primary care physical to discuss options for receiving the TB test, possibly a referral for sedation as the individual does not do well with medical appointments (noted in her behavior support plan and desensitization plan). Program Specialist to contact primary care physician no later than 2/22/19 in order to arrange for TB testing. 02/21/2019 Implemented
6400.141(c)(8)Individual #1 has not had a mammogram since 2012.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. Individual #1 refused her mammogram testing and the testing was rescheduled to be competed in August 2018 when she was sedated for dental work. The mammogram was not completed due to the hospital not receiving the mammogram orders. Program Specialist has contacted the individual's Behavior Specialist to have a desensitization plan for the refusal of the mammogram. Program Specialist will also contact the primary care physician to discuss options for receiving the mammogram, possibly a referral for another sedation as the individual does not do well with medical appointments. Program Specialist to contact the primary care physician no later than 2/22/19 to make arrangements for mammogram. 02/21/2019 Implemented
6400.164(b)On the day of inspection, 01/24/19, Chlorhexidine Gluconate .12% rinse was reportedly used for/administered to individual #1 at 8AM and the MAR was not signed. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. Individual #1 was given her medication on 1/24/19, however the medication was not logged it was given. The importance of logging medications which were administered was reviewed with the staff on duty. The staff was retrained and medication administration on 1/26/19 by an Arc medication trainer. Additionally, incoming staff will review previous shifts med logs, CLA Supervisor will review med logs daily, and Programs Specialists will review med logs at every visit. 01/26/2019 Implemented
SIN-00089412 Renewal 02/02/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The 2014 furnace inspection was done 10/13/2014; the furnace wasn't inspected again unitl 2/1/2016.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. Furnace was inspected on 2/1/16. All furnace inspections will be completed annually and due dates marked on calendars of program specialists, program supervisors and maintenance department. Completion Date: 12/31/2016 02/01/2016 Implemented
6400.141(a)Individual #1's 2014 physical exam was done on 3/14/2014; he didn't have his 2015 physical exam until 4/8/2015.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual Appointment form is in place. All necessary medical appointments/procedures/vaccinations will be tracked on the form and monitored by supervisory staff and program specialists. Forms will be reviewed and implemented at supervisory meeting on 3/25/2016. Target Date: 4/1/2016 Responsible Person: Sheila Nealon 04/01/2016 Implemented
6400.141(c)(6)Indivual #1 had a late TB test this year. His TB tests were done on 6/4/2013 and then on 9/28/2015.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Individual Appointment form is in place. All necessary medical appointments/procedures/vaccinations will be tracked on the form and monitored by supervisory staff and program specialists. Forms will be reviewed and implemented at supervisory meeting on 3/25/2016. Target Date: 4/1/2016 Person Responsible: Sheila Nealon 04/01/2016 Implemented
SIN-00055914 Renewal 11/20/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(f)The inspection on all of the fire extinguishers in the house expired in October of 2013.(f) A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. Fire extinguishers were inspected and approved by a fire safety expert on 11/19/13. Written confirmation of inspected fire extinguishers will be submitted by safety expert and reviewed by program specialists and program director. Monthly fire system checks will continue to be completed by program specialist. 11/19/2013 Implemented
6400.112(a)There was not record of a fire drill being held in March of 2013.(a) An unannounced fire drill shall be held at least once a month. All home fire drills will continue to be reviewed at the home by the PS and a copy will be submitted monthly for review by PS. 11/19/2013 Implemented
6400.141(c)(6)Individual #1 did not have a tuberculin skin test within the two year time frame.(6) Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. TB test for individual #1 was completed on June 15, 2013. TB test will be pursued on or before March 2015, the time of the annual physical. 11/19/2013 Implemented
6400.144Lorazepam 1 mg was prescribed for Individual #2 to be given prior to a medical appointment. Individual #2 had a Urologist appointment on November 6, 2013 and did not receive the Lorazepam.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. Prescribing physician contacted for clarification of administration. Lorazepam 1mg one hour prior to medical appts as needed for anxiety. Medication will be administered as prescribed. 11/20/2013 Implemented