Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00233306 Renewal 10/17/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(a)Individual #1, admitted on 07/01/05, had an assessment completed on 08/11/22 and then again on 10/13/23.This exceeds the annual requirement. 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. Annual assessment for Individual #1 was updated on 10/13/2023 and shared with the ISP team and direct support staff. 10/31/2023 Implemented
SIN-00214476 Renewal 11/08/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101During the physical-site inspection on 11/9/22, the following was observed: the basement's only exit door to the outside opens into a passageway measuring 3.5 feet by 7 feet with eight steps leading to two Bilco basement doors that require precision movement of latches and tension rods to unlock in order to exit outside. The basement's exit door contains a key lock facing the passageway that is enclosed by the two Bilco basement doors making this passageway both a blocked egress and a potential entrapment area.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Maintenance Supervisor removed latches and tension rods from basement Bilco doors on 11/22/2022 (photo to be submitted). 11/22/2022 Implemented
6400.32(r)Individual #1's bedroom door was observed without a lock during the physical-site inspection on 11/9/22. Individual #1's record does not include documentation of their declination of a bedroom door lock or their incapacity to decide regarding this matter. Individual #2's bedroom door was observed without a lock during the physical-site inspection on 11/9/22. Individual #2's record does not include documentation of their declination of a bedroom door lock or their incapacity to decide regarding this matter. Individual #3's bedroom door was observed without a lock during the physical-site inspection on 11/9/22. Individual #3's record does not include documentation of their declination of a bedroom door lock or their incapacity to decide regarding this matter. Individual #4's bedroom door was observed without a lock during the physical-site inspection on 11/9/22. Individual #4's record does not include documentation of their declination of a bedroom door lock or their incapacity to decide regarding this matter.An individual has the right to lock the individual's bedroom door.Individual Rights, Responsibilities, & Review Attestation document (ID-225A - to be submitted) has been updated to reflect the individual's declination of a bedroom door lock or their incapacity to decide regarding this matter. 12/31/2022 Implemented
SIN-00197249 Renewal 12/07/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)Individuals were not able to evacuate the entire building within 2 1/2 minutes during the following fire drills: 11/10/2021 - 4 minute and 9 second evacuation time. 10/25/2021 - 3 minute and 20 second evacuation time. 9/21/2021 - 2 minute and 45 second evacuation time. 8/22/2021 - 3 minute and 42 second evacuation time. 4/20/2021 - 3 minute and 12 second evacuation time. 3/31/2021 - 5 minute evacuation time. 2/19/2021 - 2 minute and 47 second evacuation time. 1/22/2021 - 2 minute and 52 second evacuation time. 12/21/2020 - 4 minute and 47 second evacuation time. 11/17/2020 - 4 minutes and 14 seconds. The home does not have an extended evacuation time, designated in writing by a fire safety expert, within the past 12 months. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. 1. Fire Chief sent letter on 12/10/2021 clarifying evacuation time, but additional required regulatory content was missing. 2. Program Director sent new request on 12/28/2021 with sample template and copy of required regulatory content clearly identified. Support document #1. 3. Proof of the Fire Chief's certification was obtained on 12/29/2021. Support document #2. 4. Program Director will contact Fire Chief on a daily basis and ensure new letter with all regulatory content is obtained by 1/10/2022. 01/10/2022 Implemented
6400.51(b)(1)Direct Service Worker #2, hire date of 11/01/2021, did not complete the following training during orientation or within 30-days from date of hire: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.DSW #2 completed trainings on person-centered practices, community integration, consumer choice, and developing/maintaining relationships by 11/2/2021 as evidenced by Person Centered Planning for Individuals with Developmental Disabilities, People with Disabilities: Building Relationships and Community Membership, and Everyday Lives trainings in Relias. Support document #3. 11/02/2021 Implemented
6400.52(c)(1)Executive Director #1, hire date of 7/09/2020, did not complete the following annual training for the training year dated 7/1/2020 through 6/30/2021: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Executive Director completed training on person-centered practices, community integration, consumer choice, and developing/maintaining relationships on 12/22/2021 as evidenced by Everyday Lives training in Relias. Support document #5. 12/22/2021 Implemented
6400.52(c)(3)Executive Director #1, hire date of 7/09/2020, did not complete the following annual training for the training year dated 7/1/2020 through 6/30/2021: Individual rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Executive Director completed training on consumer rights on 12/22/2021 as evidenced by Rights of Individuals with IDD training in Relias. Support document #5. 12/22/2021 Implemented
6400.52(c)(4)Executive Director #1, hire date of 7/09/2020, did not complete the following annual training for the training year dated 7/1/2020 through 6/30/2021: Recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Executive Director completed training on incident management on 12/22/2021 as evidenced by DCI I.M. Policy training in Relias. Support document #5. 12/22/2021 Implemented
SIN-00141054 Renewal 09/05/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill records dated 12/31/17, 1/3/18 and 5/25/18 did not include problems encountered. The section on the form was left blank.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. Staff will be retrained on proper completion of fire drill forms. (submitted as D)They will be instructed in their duty to ensure full completion of the fire drill forms as completed monthly. In addition, all completed fire drill forms are submitted to the supervisor who then has the final responsibility in ensuring the forms are fully completed.112c [Prior to conducting future fire drills, all staff person with the responsibility of conducting fire drills shall be educated by the program specialist of the requirements of fire drill records as per 6400.112c and the process to complete the aforementioned audits by the supervisor. Documentation of training shall be kept. Documentation of audits shall be kept to ensure all required information is in the written fire drill record and addressed as needed. (DPOC by AES, HSLS on 9/27/18)] 09/24/2018 Implemented
SIN-00121655 Renewal 09/21/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(9)Individual #1's most recent prostate examination was 1/8/16.The physical examination shall include: A prostate examination for men 40 years of age or older. The consumer in question is scheduled for a physical/prostate exam on November 28, 2017. This consumer was retrained by LPN on the importance of the prostate exam on 9/25/2017. LPN and Program Supervisor will meet on a monthly basis over the next 12 months to ensure that all physical exams are completed in their entirety. If there are any discrepancies in physical completion, it will be addressed immediately by LPN and Program Supervisor.[Documentation of audits shall be kept. (AS 10/3/17)] 11/28/2017 Implemented
6400.143(a)Individual #1 refused a prostate examination on 11/21/16; there is no documentation in Individual #1's record of continued attempts to educate Individual #1 about the need for a prostate examination.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. LPN retrained consumer regarding the need for the prostate exam on 9/25/2017. Program Supervisor and LPN will review physical exams on a monthly basis to ensure that all are complete in their entirety and retrain consumers if necessary regarding the importance of routine medical treatment. [Documentation of aforementioned trainings shall be kept in the individual's records as required. (AS 10/3/17)] 10/31/2017 Implemented
SIN-00101134 Renewal 09/20/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)The physical examination completed 5/24/16 for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of an emergency; this section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. They physical exam completed on 5/24/16 for Individual #1 (to be submitted as C) has been updated by the doctor to include medical information pertinent to diagnosis and treatment in case of an emergency. Wording on the Physical Examination Form (to be submitted as D) has been updated to clarify information needed from the doctor for this section. Staff have been retrained (9/29/16 meeting agenda to be submitted as E) and instructed in their duty to ensure full completion of the physical exam form before leaving any appointment. In addition, all completed physical exam forms are submitted to the Residential LPN upon completion of appointments. The LPN has final responsibility in ensuring the forms are fully completed. 10/13/2016 Implemented
6400.151(a)Direct Service Worker #1's most recent physical examination was completed on 8/21/14. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Direct service worker #1's physical was completed on 9/23/16 (to be submitted as A). Going forward, the program supervisor has created a new system to ensure timely completion of staff physicals. There is a new tracking form (to be submitted as B). The supervisor checks this form bi-weekly and notifies all staff who have physicals due within the next month. The staff person is expected to make their appointment, and the supervisor sets a reminder on her Outlook calendar to ensure the physical date is set within the appropriate time frame. The supervisor then notes the appointment date on her Outlook calendar and reminds the staff member one day prior to the appointment. An internal electronic training system is also used as a backup to send email alerts to staff and the supervisor of upcoming physical dates.[At least quarterly for 1 year, the Compliance and Risk Manager shall review tracking form and completed physical examinations to ensure timely completion of staff person's physical examinations. Documentation of all reviews shall be kept. (AS 10/20/16)] 10/13/2016 Implemented
6400.151(c)(2)The two most recent Tuberculin skin testing with negative results for Direct Service Worker #1 were completed on 8/21/14 and 9/19/16. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Direct service worker #1's TB test was completed on 9/19/16 as previously confirmed. Going forward, the program supervisor has created a new system to ensure timely completion of staff TB tests. There is a new tracking form (to be submitted as B). The supervisor checks this form bi-weekly and notifies all staff who have physicals/TB tests due within the next month. The staff person is expected to make their appointment, and the supervisor sets a reminder on her Outlook calendar to ensure the physical/TB test date is set within the appropriate time frame. The supervisor then notes the appointment date on her Outlook calendar and reminds the staff member one day prior to the appointment. An internal electronic training system is also used as a backup to send email alerts to staff and the supervisor of upcoming physical/TB test dates..[At least quarterly for 1 year, the Compliance and Risk Manager shall review tracking form and completed physical examinations including Tuberculin skin testing to ensure timely completion of staff person's physical examinations including Tuberculin skin testing. Documentation of all reviews shall be kept. (AS 10/20/16)] 10/13/2016 Implemented
SIN-00180762 Renewal 12/21/2020 Compliant - Finalized
SIN-00161324 Renewal 08/20/2019 Compliant - Finalized
SIN-00085063 Renewal 10/06/2015 Compliant - Finalized
SIN-00064615 Renewal 09/24/2014 Compliant - Finalized
SIN-00052530 Renewal 08/01/2013 Compliant - Finalized