Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00225869 Renewal 06/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)There is no handrail on the thirteen interior steps leading to the attic of the home. The handrail on the four exterior steps leading to the front porch of the home is not well-secured and moves when in use. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. A handrail to the attic will be installed. The program director will arrange for a contractor to install the handrail by 7/7/2023. The handrail on the four exterior steps leading to the front porch of the home will be secured by a contractor. The program director will arrange for a contractor to repair the handrail by 7/7/2023. 07/10/2023 Implemented
6400.112(d)The fire drill conducted on 2/10/2023 had an evacuation time of 2 minutes and 48 seconds. The home does not have an extended evacuation time designed 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. A fire safety expert will be contacted to assess the home for an extended evacuation time. If the time is extended for the home then the evacuation procedure for the home will be updated and the staff will be trained on the evacuation time change. Contact with a fire safety expert will occur by 6/30/2023 by the program director and staff training on any changes will be completed within two weeks of the date that any changes are made to the evacuation time. By 6/30/3023 the facility supervisor will review with the facility staff the regulation 6400.112 for evacuation time and tips to be able to achieve that evacuation time with those individuals. Currently one of the individuals requires that a hoyer lift be used for transfer to and from his bed. A piece of equipment is being purchased for the facility to enable a quicker transfer of this individual from his bed to a transport stretcher for a quicker evacuation time. The equipment folds and will be able to be kept in the individual's room, near his bed. The facility director will complete this purchase by 6/30/2023. Training for all the staff will take place by the program supervisor within two weeks upon the arrival of the equipment at the facility. 07/10/2023 Implemented
SIN-00043381 Renewal 11/26/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)On 11-27-12, the top part of the wooden door frame above the inside front door was missing. Fully implemented - cs - 3/5/13(a) Floors, walls, ceilings and other surfaces shall be in good repair. The landlord had made repairs to the wall and did not replace all of the trim around the door. He returned to the home and put a new piece of trim across the top of the door. Heather Ruth, Program Supervisor, will inspect the home for all maintenance repairs as they are completed to insure all components have been corrected as required by regulation and will use a Property Damage Report to notify the administrative office that the landlord or repairman needs to correct the deficiency. Documentation (photo) of repair and property damage report submitted. 01/18/2013 Implemented
6400.162(a)The pharamaceutical labels on two different prescribed medications for Individual #1 were unreadable. The pharmaceutical labels on Nystatin 1000,000 u/gm cream and on Mupirocin 2% ointment were not able to be read. Fully implemented - cs - 3/5/13(a) The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. The Mupirocin 2% ointment had been replaced on 11/27/12 in the presence of Christine Smith as our inspection was being completed. The old tube was removed that same day for proper disposal. Arrangements were made with Mission Pharmacy to provide a new tube of Nystatin cream which was delivered to the agency administrative office on 11/27/12 and the home staff picked it up that same day. The unreadable tub was returned to the office for proper disposal. Program Director Daren Rumbaugh completed training On 12/04/12 and 12/07/12 with the home staff on Medication Administration Modules 1 and 5 with a review of agency policy regarding how to maintain proper medication labels and what to do if the label cannot be read. Program Supervisor Heather Ruth will check all medications weekly to make sure staff are following proper procedure and all labels are readable. Staff are to use clear tape over the label of the cream to prevent smearing of the print type but once any part of the label becomes unreadable they are not to administer the cream. If it is found that staff are not following this procedure, disciplinary action will occur. Documentation (photo) of Nystatin cream label and staff re-training submitted. 12/07/2012 Implemented
SIN-00244056 Renewal 05/07/2024 Compliant - Finalized
SIN-00175657 Renewal 09/01/2020 Compliant - Finalized
SIN-00133818 Renewal 04/25/2018 Compliant - Finalized
SIN-00077778 Renewal 07/02/2015 Compliant - Finalized