Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00236971 Renewal 01/08/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(11)On 1/04/2024 Individual #1's January 2024 medication administration record did not include the diagnosis or purpose for any of the prescribed medications. Individual #2's January 2024 medication administration record did not include the diagnosis or purpose for any of the prescribed medications.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The MAR has been updated to include the purpose for each medication. Please see supporting documents. 01/18/2024 Implemented
6400.169(a)Direct Service Worker #1 completed a Department-approved medications administration course 5/13/2021 and not again since. On 1/04/2024, Individual #1's January 2024 medication administration record documented Direct Service Worker #1 administered the following 8:00AM medications to Individual #1 on 1/01/2024, 1/02/2024, 1/03/2024 and 1/04/2024: Carvedilol 12.5mg Tablet, Losartan Potassium 50mg, Prednisone 5mg Tablet, and Mycophenolate 500mg Tablet. Direct Service Worker #1 administered Furosemide 20mg Tablet 1/02/2024 and 1/04/2024 at 8:00AM to Individual #1.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).On-call personnel is currently in the process of completing department-approved medication administration training and will become trainers. They will maintain files with oversight from Human Resources to ensure compliance. Please see supporting documents. 01/18/2024 Implemented
SIN-00104346 Renewal 12/01/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)The physical examination for Individual #1, completed on 10/13/16, did not include medical information pertinent to diagnosis and treatment in case of an emergency. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. On 1/20/17 the Medical Coordinator called and faxed a request for an addendum from the doctor to state whether or not each individual cited requires medical information pertinent to diagnosis and treatment in case of emergency. This will occur for all other individuals as well. The Medical Coordinator and Compliance Director were trained on 12/5/16 on the regulation and process moving forward to ensure compliance. The Medical Coordinator will review the Annual Physical upon completion and turn it in to the Program Director for further review prior to being filed in the ABDD Medical Charts to assure that the Annual Physical includes and the section is completed to meet the regulation. The Medical Coordinator will ensure the current and valid Annual Physical form is available prior to each appointment. If the Annual Physical form returns and it not the current form or the section has not been completed, the staff member who accompanied and turned in the Annual Physical form will be retrained and/or reprimanded. The Annual Physical form will immediately be returned to the physician for proper completion by the Medical Coordinator, then the process will begin again. The Compliance Director will review a sample (15) of Annual Physicals every three months again to assure that the regulation is in compliance. The Medical Coordinator changed the Annual Physical to include the regulation to meet compliance on 12/2/16. 01/28/2017 Implemented
SIN-00073103 Renewal 12/10/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)The handrail going from the main floor to the basement was not secure and was pulling away from the wall. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Maintenance fixed this immediately. Program Specialist and House managers will continue to monitor and forward any repairs to the maintenance department to be fixed. 12/10/2014 Implemented
SIN-00215912 Renewal 12/06/2022 Compliant - Finalized
SIN-00164450 Renewal 10/16/2019 Compliant - Finalized
SIN-00067431 Initial review 08/21/2014 Compliant - Finalized