Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00226514 Renewal 07/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment for the home completed on 11/17/22 did not assess compliance with 6400.51a1.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Associate Directors of Operations and the Director of Operations shall standardize the annual self-assessment process, including assigning point people to ensure that all self-assessment items are marked appropriately. 10/01/2023 Implemented
6400.15(c)(Repeated Violation - 7/11/22) The self-assessment for the home completed on 11/17/22 did not include a written summary of corrections for 6400.151c2.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. Director of Operations and Associate Directors of Operations will model after RCG guide to follow the five steps and instruct point people to write an effective Plan of Correction and focus on prevention of citations by 9/1/23. 10/01/2023 Implemented
SIN-00191547 Renewal 08/10/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The specific information required in 6400.112c to document for fire drills was not recorded and completed at the time of the drill. It is unknown if the information recorded for fire drills on 10/17/20, 11/21/20, 1/5/21, 2/17/21, 4/17/21, 5/11/21, and 7/1/21 was accurate information as the information was not recorded until a few days after each fire drill was held.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. The Program Manager received immediate retraining on the need to complete successful unannounced fire drills once monthly on 8/13/21. Successful monthly drills have been documented since the violation occurred in October 2020, demonstrating a pattern of compliance. All Program Managers and Program Coordinators received retraining on 8/13/21 regarding the requirement to complete successful unannounced fire drills once monthly. 09/23/2021 Implemented
SIN-00076717 Renewal 02/18/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)The dishwasher soap was not kept in it¿s original container. It was in a plastic jug.Poisonous materials shall be stored in their original, labeled containers. On 2/20/2015, unmarked dishwasher container was replaced with an orginail labeled container. each home will be inspected by the supervisor of that home to assure that all poisonous materials shall be stored in their orginal labeled containers. Utilizing care tracker, all team members will be trained on the necessity to assure that all poisonous materials are stored in their original labeled containers. Implemented
6400.103The written evacuation procedure does not contain the means of transportation.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. Means of transportation was corrected on 5/11/2015 for the 348 westview drive home evacuation procedures. All homes will be verified by that supervisors to assure that means of transportation is noted on evacuation procedures. Copy of updated evacuation procedures for 348 westview drive home will be provided. Using care tracker each supervisor will verify that each home has evacuation procedures that includes means of transportation. Implemented
6400.141(c)(6)Individual #1 had a TB test done on 8/3/12 and not again until 8/20/14.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. All supervisors will be trained on the necessity of TB testing every 2 years. Record review of all individuals will be completed by the supervisors of each home to verify compliance with TB testing every two years and at least within the 15 day grace period and document that information. Utilizing care tracker, all supervisors will be trained on the necessity to complete TB testing every two years for each individual. Implemented
6400.187The Individual Support Plan (ISP) meeting for Individual #1 was on 9/11/14 and a copy of the ISP was not sent to team members until 11/6/14.A copy of the ISP, including the signature sheet, shall be provided to plan team members within 30 calendar days after the ISP, annual update and ISP revision meetings. Record review of all individuals will be completed by the supervisors of each home to verify complaince of receipt of ISP within 30 days of ISP meeting, or documentation of request for such. Using care tracker, supervisors will be trained to request ISP within 30 days of ISP meeting and maintain documentation. Implemented
SIN-00137761 Renewal 08/21/2018 Compliant - Finalized