Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00232795 Renewal 09/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The fire drill conducted on 7.28.23 had an individual who refused to evacuate. All individuals did not evacuate the home during the fire drill. 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. Program Manager of the home will review fire safety concerns with all individuals and provide schedule a time for the fire chief to give additional training to consumers. All team members will be made aware of concerns regarding previously failed fire drills will be discussed so that actionable plans can be implemented to prevent reoccurrence. Fire Chief will be scheduled to assess whether or not the home requires an extended evacuation time. 12/31/2023 Implemented
SIN-00210810 Renewal 09/20/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66At the time of inspection, the outside back door which led to the garage lightbulb was burned out. This was the only light source in that area.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Lightbulb was replaced at time of inspection. 10/31/2022 Implemented
6400.112(a)During the time of inspection, there were no fire drills provided for the months of August 2022, or November 2021. An unannounced fire drill shall be held monthly. An unannounced fire drill shall be held at least once a month. Program Manager received individual feedback and training from CEO. Program Manager is required to submit all fire drills to Compliance Department at the end of every month. Training on importance of fire safety provided to Program Manager. Program Manager to provide training to DSP's on the importance of fire drills and fire safety. 10/31/2022 Implemented
6400.112(e)There was only one fire drill completed during sleeping hours which was conducted on 5/15/2022 at 6am. There should be asleep drills completed every 6 months.A fire drill shall be held during sleeping hours at least every 6 months. Program Manager received individual feedback and training from CEO. Program Manager is required to submit all fire drills to Compliance Department at the end of every month. Requirements of asleep overnight drills reviewed with Program Manager. Training on importance of fire safety provided to Program Manager. Program Manager to provide training to DSP's on the importance of fire drills and fire safety. 10/31/2022 Implemented
6400.32(r)(1)At the time of inspection, the bedroom doors had locks on the doors, however no individuals had a key to open their door if they chose to lock it.Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.Individual was asked if they wished to have lock. Individual declined and lock was immediately removed. 10/31/2022 Implemented
6400.32(r)(5)At the time of the physical site inspection. The bedroom doors had locks; however individuals nor staff had a key to open the doors.Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.Individual was asked if they wished to have lock. Individual declined and lock was immediately removed. DSP's were educated on the importance o having a key to enter locked bedrooms in case of emergency. 10/31/2022 Implemented
SIN-00183905 Unannounced Monitoring 02/02/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(c)Throughout an investigation that included an allegation of staff sleeping while on shift, Staff 1 indicated that they have been given "sleep shifts" where they sleep during the 11-7 overnight shift if they are working more than 16 hours. There were no specific dates provided for these "sleep shifts". Institute for Human Resources and Services' CEO confirms that "sleep shifts" occur. This has left the home without proper supervision as the Individual #1,#2, #3 and# 4's Individual Support Plans (ISP) indicate that the home has awake overnight staffing. This is neglect as the residents were not properly supervised per their ISP.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.Provider has immediately reviewed all supervision needs for all individuals in the home with the Program Specialist. Due to indicators in the Individual Support Plan, all shifts staffed at this location will be awake shifts. Provider will conduct routine monitoring (announced and unannounced visits) to determine compliance. 03/16/2021 Implemented
6400.186Residents #1 and #2's Individual Support Plans were not implemented appropriately as their plans state that there is awake overnight staff available in the home. Staff #1 has been given "sleep shifts" when working in excess of 16 hours leaving Individual #1 and #2 without proper supervision as required in their individual plans.The home shall implement the individual plan, including revisions.Provider has immediately reviewed all supervision needs for all individuals in the home with the Program Specialist. Due to indicators in the Individual Support Plan, all shifts staffed at this location will be awake shifts. Provider will conduct routine monitoring (announced and unannounced visits) to determine compliance. 03/16/2021 Implemented
SIN-00178640 Unannounced Monitoring 10/29/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.52(c)(5)Staff are not being trained in the safe and appropriate use of updated Behavior Support Plans (BSP) at this residence. BSP's were updated on 9/15/2020 for Individual #1, Individual #2 and Individual #3. The current BSP training dates for staff at this residence are as follows: Staff #1: 6/17/2020; Staff #2: 12/13/2019; Staff #3: 8/24/2020; and Staff #4: 3/19/2020.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.Program Specialist in conjunction with the Behavior Specialist will make sure all staff working in the home are trained properly on the implementation of the Behavior Plan. Staff are being trained by the Program Specialist and/or the Behavior Specialist but proper documentation is not being kept to indicate this is being done. Compliance department and training department will assist in the tracking of employee training. 11/30/2020 Implemented
6400.196(a)Staff are not being trained on updated Restrictive Procedure Plans (RPP). Individual #1's BSP is restrictive and was updated on 9/15/2020. The current RPP training dates for staff at this residence are as follows: Staff #1: 6/17/2020; Staff #2: 12/13/2019; Staff #3: 8/24/2020; and Staff #4: 3/19/2020.A staff person who implements or manages a behavior support component of an individual plan shall be trained in the use of the specific techniques or procedures that are used.Program Specialist in conjunction with the Behavior Specialist will make sure all staff working in the home are trained properly on the implementation of the Behavior Plan. Staff are being trained by the Program Specialist and/or the Behavior Specialist but proper documentation is not being kept to indicate this is being done. Compliance department and training department will assist in the tracking of employee training. 11/30/2020 Implemented
SIN-00174631 Unannounced Monitoring 07/28/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(i)The window in Individual #9's bedroom did not have curtains, drapes, blinds, or shutters.Bedroom windows shall have drapes, curtains, shades, blinds or shutters. IHRS will ensure that all individuals have blinds, curtains, drapes or shutters on their bedroom windows. Program Specialist will ensure that individual #9 has this requirement met. 09/15/2020 Implemented
6400.101The door leading into the garage was had a double-key lock.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The double key lock is being removed to ensure that all passageways are unobstructed. IHRS is completing an audit of all homes to ensure there are no other issues of this nature. 09/15/2020 Implemented
6400.141(c)(9)Individual #5 had a prostate exam on 11/7/2018. He didn't have another prostate exam until 7/2/2020, which exceeds the annual requirement.The physical examination shall include: A prostate examination for men 40 years of age or older. Program Specialist will be re-trained on annual appointment requirements for clients. IHRS will conduct routine audits to ensure compliance. 09/15/2020 Implemented
6400.141(c)(11)Bloodwork for Individual #5 was to be completed before 4/2/2020 and was ordered again on 7/2/2020. There is no documentation of any bloodwork being completed. Staff confirmed this was not completed and reported it was being completed the next day.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Bloodwork was completed. Program Specialist and staff will be retrained on health matienence needs and ensuring that all appropriate follow-up is completed. 09/15/2020 Implemented
6400.141(c)(14)This section was blank on Individual #5's physical exam dated 7/2/2020.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. IHRS will send physical back to PCP for proper completion. IHRS will audit all physicals to ensure that all proper and necessary information is listed. 09/15/2020 Implemented
6400.34(a)Individual #5 was informed of his rights on 12/26/2018. He wasn't informed of his rights again until 3/20/2020, which exceeds the annual requirement.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.IHRS will retrain Program Specialists on protocols regarding explaining client rights. All individuals entering a residential program will have client rights reviewed the day of admission and annually thereafter. 09/15/2020 Implemented
6400.213(1)(i)The photo in Individual #5's record was not dated.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. 213 (1)vi: A current, dated photograph.IHRS compliance department in conjunction with the Program Specialist will ensure that all photos are dated and current. IHRS will conduct a file audit to ensure that this is completed. 09/15/2020 Implemented
SIN-00082850 Renewal 08/25/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.201(b)Individual #1 and #2's Restrictive Procedure Plans state that they will be charged for property damages caused by their behaviors. No verification was provided that either individual or their representative payees agreed to pay for such damages. An individual's personal funds or property may not be used as payment for damages unless the individual consents to make restitution for the damages. Both individuals have signed letters to indicate that during a team meeting it was discussed and agreed upon that both individuals would be responsible to pay for property that they broke during a physical altercation. The representative payee has both letters on file. If the individual(s) destroys property, a letter specific to what was destroyed and how much money the individual(s) is responsible to pay for will be reviewed with the individual(s) and signed before payment can be made. If the individual refuses to pay at any time, payments will not commence. Kimberly LaLuna will continue to monitor this process, as necessary. 09/17/2015 Implemented
SIN-00124091 Renewal 10/17/2017 Compliant - Finalized