Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00215913 Renewal 12/06/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)At 10:30AM, the floor in the basement of the home had puddles of water posing a slipping hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.The hazard was immediately reported to the maintenance department upon discovery. They cleaned the puddling immediately with no further concern reported. 12/14/2022 Implemented
6400.165(g)Individual #1 is prescribed medications to treat symptoms of a psychiatric illness. Since Individual #1's admission on 6/29/2022, Individual #1 has not had a review by a licensed physician of the medications prescribed to treat the symptoms of the psychiatrist illness. [Repeat Violation, 12/15/2021]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.The Program Manager and Program Specialist are continuing to make referrals with providers for psychiatric services. They will also follow up with the PCP in an attempt to review medications prescribed to treat the symptoms of the psychiatric illness. [As per Operations Manager on 12/21/22, Individual #1 has a medication review with the PCP scheduled for 12/29/22, and a psych consult referral for 1/5/23. Upon completion of the aforementioned reviews for Individual #1, the Program specialist and Operations Coordinator shall audit the documentation and information to ensure Individual #1 is administered medication as prescribed and all required information is included. (AES,HSLS on 12/22/22)] 12/14/2022 Implemented
6400.166(b)Divalproex Sodium DR 250mg prescribed to Individual #1 was not initialed as administered on 12/1/2022 at 8:00PM. Eliquis 5mg prescribed to Individual #1 was not initialed as administered on 12/6/2022 at 8:00PM.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.All medication errors are to be reported to the Incident Manager and placed on EIM when applicable, upon discovery. 12/14/2022 Implemented
6400.167(a)(1)Divalproex Sodium DR 250mg prescribed to Individual #1 was not administered on 12/4/2022, 12/5/2022 and 12/6/2022 at 12:00PM. Divalproex Sodium DR 250mg prescribed to Individual #1 was not administered on 12/5/2022 and 12/6/2022 at 8:00PM. Tamsulosin HCL 0.5mg cap prescribed to Individual #1 was not administered on 12/6/2022 at 8:00PM.Medication errors include the following: Failure to administer a medication.All medication errors are to be reported to the Incident Manager upon discovery and placed on EIM accordingly. The Program Manager is to ensure that medications are available. On-call personnel, the Program Manager, and Program Specialist are responsible for ensuring that a certified med passer is available to administer medications. 12/14/2022 Implemented
SIN-00086301 Renewal 11/03/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(b)The "Rights" form, signed by Individual #1 on 9/25/15, did not state the full rights per the following regulations: 33(d) regarding program planning; 33(e) regarding privacy; 33(f) regarding personal property; 33(g) regarding visitors; 33(h) regarding telephone access; 33(i) regarding mail; 33(j) regarding voting; 33(k) regarding religion; 33(l) regarding no excess medication; and 33(m) regarding required to work. Per 6400.33(d) An individual has the right to participate in program planning that affects the individual. Per 6400.33 (e) An individual has the right to privacy in bedrooms, bathrooms and during personal care. Per 6400.33 (f) An individual has the right to receive, purchase, have and use personal property. Per 6400.33 (g) An individual has the right to receive scheduled and unscheduled visitors, communicate, associate and meet privately with family and persons of the individual's own choice. Per 6400.33 (h) An individual has the right to reasonable access to a telephone and the opportunity to receive and make private calls, with assistance when necessary. Per 6400.33 (i) An individual has the right to unrestricted mailing privileges. Per 6400.33 (j) An individual who is of voting age shall be informed of the right to vote and shall be assisted to register and vote in elections. Per 6400.33 (k) An individual has the right to practice the religion or faith of the individual's choice. Per 6400.33 (l) An individual has the right to be free from excessive medication. Per 6400.33 (m) An individual may not be required to work at the home, except for the upkeep of the individual's personal living areas and the upkeep of common living areas and grounds. Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. The compliance director Will assure that all rights are sent out in a timely manner and assure that all of the rights are visible on the copy presented to the individual one time a quarter. The Program Director Will assure that the compliance director has sent out all of the correct individuals rights by checking the compliance directors work one time quarter. [The compliance director or designee will immediately review the most current rights statement for all individuals in the community homes and ensure all individuals have been informed of all the rights and have a corresponding signed statement, and address immediately if needed. Documentation of reviews will be kept, as well as, quarterly checks by the program director. (AS 12/8/15)] 11/22/2015 Implemented
SIN-00217839 Unannounced Monitoring 01/20/2023 Compliant - Finalized
SIN-00164451 Renewal 10/16/2019 Compliant - Finalized
SIN-00144001 Renewal 10/23/2018 Compliant - Finalized