Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00232792 Renewal 09/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Clean and sanitary conditions shall be maintained in the home. There was a substantial amount of a black substance consistent with mold or mildew around the grout line in the tub/shower enclosure located in the hall bathroom.Clean and sanitary conditions shall be maintained in the home. Issue has been forwarded to maintenance for follow-up. IHRS will conduct evaluation of issue in all 24 homes to ensure that this is addressed across the board. 12/31/2023 Implemented
6400.104The most recent notification letter to the fire department is dated January 2022 and does not contain current information; the letter states that there are three individuals residing in the home but the current census is two.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
6400.112(a)An unannounced fire drill shall be held at least once per month. There is no documentation that a fire drill was held during the months of August 2023, June 2023 or April 2023. An unannounced fire drill shall be held at least once a month. Program Manager and DSP's working at all locations will be re-trained in the above mentioned regulation. Fire drill was completed. Fire drills will be conducted on a monthly basis. 12/31/2023 Implemented
SIN-00177220 Unannounced Monitoring 09/09/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The cabinet under the sink in Individual #2's bathroom had doors that were warped and in disrepair.Floors, walls, ceilings and other surfaces shall be in good repair. The bathroom has been estimated and approved for repair. Maintenance department will begin work shortly. The bathroom was already on the list for repair at time of inspection. IHRS assess items that may possibly need repair on a monthly basis. 10/31/2020 Implemented
6400.70The home did not have an operable landline telephone.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. Phone company was contacted and line was examined. Phone is currently in good working order and no problems have been identified. Site has a back up phone in the emergency kit should issue with equipment arise. Program Specialist and on-call worker have access to phone company information and account numbers should a problem arise with the line. 10/31/2020 Implemented
6400.81(k)(6)Individual #1 did not have a mirror in the bedroom.In bedrooms, each individual shall have the following: A mirror. A mirror was purchased and placed in client's bedroom. Checking for mirrors in client bedrooms has been added to the monthly IHRS compliance check. 10/31/2020 Implemented
6400.82(f)There was no hand soap in the bathroom located in Individual #2's bedroom.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. IHRS has issued a memo to all sites regarding appropriate hand soaps. All soaps have been assessed to ensure they are safe to be unlocked. IHRS compliance department assisted Program Specialists in calling the CLA's to ensure proper soap was accessible to the clients. 10/31/2020 Implemented
6400.163(a)Individual #2 had Vic's Vapo Rub and there was no pharmacy label on the container.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.Upon review of citation, staff reported the box became crushed and was thrown away. Program Specialist reviewed regulation with staff that all medications require a pharmacy label. New label was ordered from pharmacy and placed on the container. 10/31/2020 Implemented
SIN-00062527 Unannounced Monitoring 04/07/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16Verbal and Physical Abuse occurred on 3-Verbal Abuse by Staff #1 on 2-19,20,21,25-14, to individual #1 and Individual #2. Withholding of juice drink, requested repeatedly on 3-18-14, by individual #2, drink then withheld by Staff #2.. Verbal and Physical Abuse occurred on 3-18-14 to Individual #2 by Staff #3. Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.Verbal abuse by Staff #1 to individual #1 & #2: IHRS investigator found this incident to be inconclusive for verbal abuse. Individual #1 & #2 did not confirm that the target had made the alleged statements. Although two witnesses confirmed that they heard the target make the alleged statements, it is believed that due to personal agendas, false accusations were made. It seemed that one witness had shared information in regards to the target with other employees in the home. This information was eventually adopted by other witnesses as their own statements. Even though the two individuals wanted the target to return to the site (and continue to ask for her), IHRS relocated the target due to the personnel issue. Withholding of juice by staff #2 to individual #2: Staff #2 was terminated as a result of this incident, the other incident mentioned in 6400.18(b), and personnel issues. She was terminated on 4/14/14. Verbal & physical abuse to individual #2 by Staff #3: It was not reported to IHRS that verbal & physical abuse occurred. It was reported that Staff #3 yelled at another staff during incidents that occurred on 3/18/14, when staff #3 discovered that the other staff was recording her instead of helping her while individual #2 was attacking Staff #3. The only physical contact that Staff #3 had with individual #2 was when the individual physically attacked her & when she held up her arm to try to block the attacks. Staff #3 received additional training, non-harassment training & a review of how to handle situations in a professional matter, on 5/1/14. All IHRS employees receive trainings on individual rights & abuse upon hire & annually. 05/01/2014 Implemented
6400.18(b)Failure to follow policy by Staff #2 as she contacted a co-worker at another group home rather than contacting on-call.(b) Written policies and procedures on the prevention, reporting, investigation and management of unusual incidents shall be developed and kept at the home. Staff #2 was terminated on 4/14/14 due to this incident, the incident mentioned above, & personnel issues. All IHRS employees receive training on how & when to notify IHRS about incidents upon hire & monthly 04/14/2014 Implemented
SIN-00160714 Renewal 08/27/2019 Compliant - Finalized