Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00232783 Renewal 09/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104The notification letter to the fire department was not current. The current documented letter states that there are three individuals residing in the home. The current census of the home is 2.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Program Managers will be retrained on the above regulation. All fire department letters will be reviewed and updated by the Program Manager for all locations. Letters will be submitted to Quality Assurance and Regulatory Compliance Manager for review. 12/31/2023 Implemented
6400.181(a)Individual #1's annual assessment dated 3/12/23 did not include all sections. Missing sections of the assessment included 181e1, 181e2, 181e3(I-IV), 181e4, 181e5, 181e6, 181e7, 181e8, 181e11, 181e12, 181e(13)(II-VI), 181e14. 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. Program Manager will be provided training on all regulations as they relate to Program Assessments. Individual feedback from CEO will be provided to this Program Manager to ensure Program Manager understands the concerns with the previously presented Program Assessment. Assessment will be updated and revised to meet regulatory compliance. 12/31/2023 Implemented
6400.34(a)Individual #1 was not informed of the individuals' rights. Several rights, including 32r1-5, 32s1-3 and 32v are missing from the document reviewed.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.Program Manager will be retrained on the above cited regulation. Quality Assurance and Regulatory Compliance Manager will review current Individual Rights to ensure that all required information is present. All old forms will be removed from offices and electronic storage to ensure they are no longer used. Program Manager will meet with Individual #1 to review updated forms. 12/31/2023 Implemented
6400.52(c)(6)Staff #1 did not complete annual training in the implementation of the individual service plan.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Program Manager and DSP's will be retrained on the cited regulation. Program Manager will ensure that all staff providing services to individuals are trained in the ISP. ISP training books were created and sent to all 24 sites. 12/31/2023 Implemented
6400.165(g)Individual #1 takes medications to treat symptoms of psychiatric illness. Indiviudal #1 had a review of these medications completed on 8/15/23. This review did not include the reason for prescribing the medications.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Program Managers will be retrained on the above regulation. All files will be reviewed by Quality Assurance and Regulatory Compliance Manager for compliance in aforementioned areas. Individual follow-up and feedback will take place with DSP's and Program Managers. 12/31/2023 Implemented
SIN-00173830 Unannounced Monitoring 06/25/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(13)(i)Progress and growth was not assessed in this area on Individual #2's assessment dated 3/5/2020.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. IHRS compliance department in conjunction with the Program Specialist are updating the Program Assessment to include progress over the last year in regards to health. IHRS will check all other Program Assessments to ensure that they indicate progress as well. Compliance will review all Program Assessments before they are sent as a completed document. 08/31/2020 Implemented
6400.181(e)(13)(ii)Progress and growth was not assessed in this area on Individual #2's assessment dated 3/5/2020.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. IHRS compliance department in conjunction with the Program Specialist are updating the Program Assessment to include progress over the last year in regards to motor and communication skills. IHRS will check all other Program Assessments to ensure that they indicate progress as well. Compliance will review all Program Assessments before they are sent as a completed document. 08/31/2020 Implemented
6400.181(e)(13)(iii)Progress and growth was not assessed in this area on Individual #2's assessment dated 3/5/2020.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. IHRS compliance department in conjunction with the Program Specialist are updating the Program Assessment to include progress over the last year in regards to activities of residential living. IHRS will check all other Program Assessments to ensure that they indicate progress as well. Compliance will review all Program Assessments before they are sent as a completed document. 08/31/2020 Implemented
6400.181(e)(13)(iv)Progress and growth was not assessed in this area on Individual #2's assessment dated 3/5/2020.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. IHRS compliance department in conjunction with the Program Specialist are updating the Program Assessment to include progress over the last year in regards to personal adjustment. IHRS will check all other Program Assessments to ensure that they indicate progress as well. Compliance will review all Program Assessments before they are sent as a completed document. 08/31/2020 Implemented
6400.181(e)(13)(v)Progress and growth was not assessed in this area on Individual #2's assessment dated 3/5/2020.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. IHRS compliance department in conjunction with the Program Specialist are updating the Program Assessment to include progress over the last year in regards to socialization. IHRS will check all other Program Assessments to ensure that they indicate progress as well. Compliance will review all Program Assessments before they are sent as a completed document. 08/31/2020 Implemented
6400.181(e)(13)(vi)Progress and growth was not assessed in this area on Individual #2's assessment dated 3/5/2020.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. IHRS compliance department in conjunction with the Program Specialist are updating the Program Assessment to include progress over the last year in regards to recreation. IHRS will check all other Program Assessments to ensure that they indicate progress as well. Compliance will review all Program Assessments before they are sent as a completed document. 08/31/2020 Implemented
6400.181(e)(13)(vii)Progress and growth was not assessed in this area on Individual #2's assessment dated 3/5/2020.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. IHRS compliance department in conjunction with the Program Specialist are updating the Program Assessment to include progress over the last year in regards to financial independence. IHRS will check all other Program Assessments to ensure that they indicate progress as well. Compliance will review all Program Assessments before they are sent as a completed document. 08/31/2020 Implemented
6400.181(e)(13)(viii)Progress and growth was not assessed in this area on Individual #2's assessment dated 3/5/2020.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. IHRS compliance department in conjunction with the Program Specialist are updating the Program Assessment to include progress over the last year in regards to managing personal property. IHRS will check all other Program Assessments to ensure that they indicate progress as well. Compliance will review all Program Assessments before they are sent as a completed document. 08/31/2020 Implemented
6400.181(e)(13)(ix)Progress and growth was not assessed in this area on Individual #2's assessment dated 3/5/2020.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.IHRS compliance department in conjunction with the Program Specialist are updating the Program Assessment to include progress over the last year. IHRS will check all other Program Assessments to ensure that they indicate progress as well. Compliance will review all Program Assessments before they are sent as a completed document. 08/31/2020 Implemented
SIN-00173256 Unannounced Monitoring 05/27/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(4)Individual #1's assessment dated 3/5/2020 states she "does not require 'line of sight' supervision in the home. She is able to be in other rooms of the home without a staff member present. Staff needs to repeatedly monitor for health and safety due to her seizure disorder." Her 2019-2020 Individual Support Plan states "She requires Line of Sight when using the bathroom & bathing. Individual #1 requires physical assistance using the toilet and bathing. Thus, staff are to be physically present in the bathroom with Individual #1 as she's performing these tasks in order to assist and supervise." The supervision needs in the assessment are not accurate according to the Individual Support Plan. The assessment must include the following information: The individual's need for supervision. Program Specialist will update the assessment to reflect supervision needs identified in the ISP. All staff will be trained on updated assessment. 06/30/2020 Implemented
6400.32(d)Individual #1 was not treated with dignity and respect on 5/23/2020. In the attempt to ensure a proper fit, Staff #1 adjusted Individual #1's Depends after toileting. This made Individual feel uncomfortable. Staff #1 did not explain to Individual #1 the purpose of the physical contact to nor did he ask permission to assist Individual #1.An individual shall be treated with dignity and respect.The target of the aforementioned citation will no longer work with client (PM). IHRS will issue training to all employees regarding dignity and respect in general, with a focus on hygiene and toileting. Victim's Resource Center has provided counseling to client (PM) to discuss her discomfort. All employees working with PM will be trained on ways to properly assist client (PM) during hygiene. 07/10/2020 Implemented
6400.165(f)Individual #1 is prescribed Clonazepam for Anxiety. Presently, there is no written protocol addressing her social, emotional and environmental needs related to her symptoms of Anxiety.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.Upon review of the violation, Program Specialist reached out to client (PM's) PCP. It was determined that client (PM) is prescribed Clonazepam for a seizure disorder and not anxiety. PCP faxed documentation to IHRS that verifies what the medication is prescribed for. This documentation was forwarded to ODP licensing. Upon review of the ISP, it was determined that the SC changed diagnosis at some point to state anxiety. Clonazepam is commonly prescribed to treat anxiety. IHRS recognizes the error lies in the fact that the ISP did not represent accurate information. Program Specialist sent email to SC to ask for change to the diagnosis. IHRS will review all client ISP's to ensure that the correct information is present. Compliance department will also review ISP's on a rotating schedule to ensure that ISP's reflect the correct information. 06/30/2020 Implemented
6400.165(g)Individual #1 is prescribed Clonazepam for Anxiety. She does not have her medications reviewed every 3 months by a licensed physician.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Upon review of the violation, Program Specialist reached out to client (PM's) PCP. It was determined that client (PM) is prescribed Clonazepam for a seizure disorder and not anxiety. PCP faxed documentation to IHRS that verifies what the medication is prescribed for. This documentation was forwarded to ODP licensing. Upon review of the ISP, it was determined that the SC changed diagnosis at some point to state anxiety. Clonazepam is commonly prescribed to treat anxiety. IHRS recognizes the error lies in the fact that the ISP did not represent accurate information. Program Specialist sent email to SC to ask for change to the diagnosis. IHRS will review all client ISP's to ensure that the correct information is present. Compliance department will also review ISP's on a rotating schedule to ensure that ISP's reflect the correct information. 06/30/2020 Implemented
SIN-00138082 Renewal 08/16/2018 Compliant - Finalized
SIN-00082847 Renewal 08/26/2015 Compliant - Finalized