Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00102276 Renewal 10/13/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(1)The program specialist did not complete Individual #1's assessment dated 4/3/16.The program specialist shall be responsible for the following: Coordinating and completing assessments. The Program Specialist will complete all individuals' annual assessments, sign and date. Annual calendars will be developed by Program Specialist and approved by CEO by 11/1/16. A quality assessment tool will be completed by Program Specialist and reviewed by CEO beginning on 11/1/16 and each month thereafter. An in-service occurred on 10/31/16, attended by all Program Specialists. In-service done on 10/31/16 included all of the above requirements. Documentation of in-service done. In-service signed and dated by all Program Specialists. 11/03/2016 Implemented
6400.141(c)(6)Individual #1 had a Tuberculin skin test read on 1/7/13 and then again on 2/2/15.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. On 10/31/16 CEO met with Program Specialist to discuss 6400.141(c )(6). The Program Specialist will develop new calendars to track every 2 year physical requirements, including Tuberculin skin testing by Mantoux method with negative results. If Tuberculin skin test is positive, an initial chest x-ray with results noted. An in-service occurred on 10/31/16 with all Program Specialists on the above requirement. Documentation of in-service done and signed and dated by all Program Specialists. A quality assessment tool will be completed by Program Specialist and forwarded to CEO for review beginning on 11/1/16 and each month thereafter. 11/03/2016 Implemented
6400.181(d)The program specialist did not sign and date Individual #1's assessment dated 4/3/16.The program specialist shall sign and date the assessment. The Program Specialist will complete all individuals' annual assessments, sign and date. Annual calendars will be developed by Program Specialist and approved by CEO by 11/1/16. A quality assessment tool will be completed by Program Specialist and reviewed by CEO beginning on 11/1/16 and each month thereafter. An in-service occurred on 10/31/16, attended by all Program Specialists. In-service done on 10/31/16 included all of the above requirements. Documentation of in-service done. In-service signed and dated by all Program Specialists. 11/03/2016 Implemented
SIN-00083938 Renewal 09/15/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone number of the nearest ambulance was not on or by the telephones in the living room and the kitchen.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. All telephones located in the residential homes will have new phone numbers applied with telephone numbers of the nearest hospital, police department, ambulance service and fire department. Poison control center phone number will also be listed on the phones. Residential Supervisors will replace old stickers with new numbers by October 12, 2015. Residential Directors will validate that each home has been completed and report back to the CEO. Residential Directors will notify all staff of the above change by an education event. 10/10/2015 Implemented
6400.81(k)(6)The bedroom for Individual #1 did not have a mirror. In bedrooms, each individual shall have the following: A mirror. A mirror was placed in individual #1 bedroom on September 15, 2015 by Residential Supervisor. At staff meetings all staff will be reminded that mirrors are to remain in rooms. If a resident refuses a mirror it must then go to an ISP meeting and be placed in the resident's ISP. On rounds, staff and supervisor will verify that all mirrors are present. 10/10/2015 Implemented
SIN-00215085 Renewal 11/08/2022 Compliant - Finalized
SIN-00197631 Renewal 12/14/2021 Compliant - Finalized
SIN-00142441 Renewal 09/18/2018 Compliant - Finalized
SIN-00141894 Renewal 09/18/2018 Compliant - Finalized
SIN-00048354 Renewal 04/18/2013 Compliant - Finalized