Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00214477 Renewal 11/08/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(6)Individual #1's assessment, completed on 1/15/22, does not address their ability to safely use or avoid poisonous materials in general.The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. The Program Specialist created an addendum to Individual #1's assessment on 11/22/2022. The addendum (to be submitted) addressed the individual's ability to safely use or avoid poisonous materials when in the presence of poisonous materials, and will be shared with all ISP team members and direct support staff. 11/22/2022 Implemented
6400.181(e)(14)Individual #1's assessment, completed on 1/15/22, does not address their knowledge of water safety and ability to swim.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. The Program Specialist created an addendum to Individual #1's assessment on 11/22/2022. The addendum (to be submitted) addressed the individual's knowledge of water safety and ability to swim, and will be shared with all ISP team members and direct support staff. 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.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
6400.34(a)Individual #1 was informed and explained individual rights on 8/8/22. The rights document does not include the following rights: 6400.32r1···the right to have access to the bedroom locking mechanism (i.e.: key, keypad code, etc.); 6400.32r2···the right of limiting access to their bedroom to only life-safety emergencies or with the individual's permission; 6400.32r5···the protection of providing direct service workers with a key or other entry device to lock and unlock the individual's bedroom door.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.Individual Rights, Responsibilities, & Review Attestation document (ID-225A - to be submitted) has been updated to reflect the individual's additional rights (6400.32r1, 32r2, and 32r5). 12/15/2022 Implemented
SIN-00161325 Renewal 08/20/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The evacuation time for the fire drill held on 4/16/19 was 2 minutes and 42 seconds. The home does not have an extended evacuation time specified in writing by a fire safety expert. 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. Fire drill form has been revised to remind staff of required evacuation time and notification processes (supporting document A). Staff will be retrained by Supervisor during next scheduled staff meetings on proper completion of fire drills and accurate completion of fire drill forms as per 6400.112(c). A fire drill monitoring spreadsheet (supporting document B) has also been created and placed on the Supervisor shared drive. Operations Director will review the spreadsheet with Supervisors at least quarterly during regular supervision to help ensure regulatory compliance. Documentation of trainings and reviews shall be kept. 09/13/2019 Implemented
SIN-00141055 Renewal 09/05/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill records dated 9/30/17, 12/5/17, 4/25/18 and 7/11/18 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. [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
6400.151(a)Direct Service Worker #1 had a physical examination completed on 5/10/16 and then again on 8/1/18. 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. The program supervisor will monitor staff physical due dates in the new HR online system once monthly. She will set a reminder on her Outlook calendar to complete these checks. When a staff has an upcoming physical due, supervisor notifies staff via email. Staff are 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. An internal electronic training system is also used as a backup to send email alerts to staff and the supervisor of upcoming physical dates. [Documentation of monthly audits of the tracking system of staff person physical examination shall be kept. Upon completion of all staff persons physical examination and at least monthly, the CEO or designee shall audit all individuals' current and past physical examination and update the aforementioned tracking system to ensure all staff person have physical examinations completed, timely. Documentation of all audits shall be kept. The 2 most recent physical examinations for all staff persons shall be kept and available upon request by the Department. (DPOC by AES, HSLS on 9/27/18)] 09/17/2018 Implemented
SIN-00101136 Renewal 09/20/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(a)Individual #1, date of admission 5/29/16 did not have an initial assessment. 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. Assessment for Individual #1 was completed on 9/28/16 (to be submitted as G). The program supervisor will use her existing tracking form (to be submitted as H) to track annual assessments. She has also reviewed the regulations to ensure her understanding of the time frames attached to initial assessments for new individuals.[At least quarterly for 1 year the compliance and risk manager will review tracking sheet and completed assessments to ensure the program specialist has completed all individuals' assessments, timely. Documentation of reviews shall be kept. (AS 10/20/16)] 10/13/2016 Implemented
SIN-00064617 Renewal 09/24/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(b)The "Rights" form signed by Individual # 1 on 1/9/14 did not indicate that an individual may not be required to participate in research projects. An individual may not be required to participate in research projects. the rights form has been revised to indicate that an individual may not be required to participate in research projects. The new form is being reviewed with each consumer for their signature.[The program specialist will review and obtain a signed version of the updated rights form for every individual in the 6400 program within 30 days upon receipt of the plan of correction. (CHG 11/21/14)] 10/01/2014 Implemented
6400.68(b)The hot water temperature at the bathtub in the upstairs bathroom was 133 degrees Fahrenheit at 4:50 P M. Hot water temperatures in bathtubs and showers may not exceed 120°F. The termperature for the hot water tank had been set too high by a building contractor who had recently been working in the home. The provider's maintenance staff are now completing regular water temperature checks when they complete their regular furnace checks. [The hot water temperature was turned down on the day of the inspection. Auditing of the hot water temperature will be completed on the quarterly inspection checklist. (CHG 11/21/14) 10/01/2014 Implemented
6400.77(c)There was no first aid manual with the first aid kit. A first aid manual shall be kept with the first aid kit.The first aid manual has been returned to the first aid kit. [Monitoring of the first aid kit in every community home has been added to the quarterly inspection checklist. (CHG 11/21/14).] 10/01/2014 Implemented
SIN-00233307 Renewal 10/17/2023 Compliant - Finalized
SIN-00197250 Renewal 12/07/2021 Compliant - Finalized
SIN-00180763 Renewal 12/21/2020 Compliant - Finalized
SIN-00121657 Renewal 09/21/2017 Compliant - Finalized
SIN-00085065 Renewal 10/06/2015 Compliant - Finalized
SIN-00052532 Renewal 08/01/2013 Compliant - Finalized