Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00183598 Renewal 02/23/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The shower in the downstairs bathroom had a black substance resembling mold/mildew along the bottom of the shower caulking.Clean and sanitary conditions shall be maintained in the home. Maintenance responded at the time of inspection and re-caulked the shower. Staff will be retrained on the home chore checklist on March 22, 2021 by the Coordinator. 03/30/2021 Implemented
6400.112(f)For fire drills reviewed from January of 2020 through January 2021, the front door was used as the primary exit for every drill. Alternate exits are to be used for fire drills.Alternate exit routes shall be used during fire drills. A violation occurred due to staff failing to ensure the use of all routes were being utilized throughout the year. All staff will be retrained on fire drill procedures on March 22, 2021. Coordinator will monitor fire drill reports and provide feedback to staff to ensure compliance. Director of the program will review monitoring protocol with the Coordinator on March 19, 2021. 03/30/2021 Implemented
SIN-00126068 Renewal 12/19/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(7)Individual #3 had a Gynecological exam on 1/15/2016. She didn't have another gynecological exam until 2/10/2017 which exceeds the annual requirement.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. The agency has created and begun to implement a system that will track all required medical appointments. This system will be utilized by both the residential team and nursing department to ensure completion of a yearly Gynecological examination. The Residential Program Manager that oversees the medical needs of this individual will be trained on the regulation and updated tracking system by 2/1/2018. The managers within each identified KIL location will be responsible for ensuring completion of an annual Gynecological exam moving forward. 02/01/2018 Implemented
6400.186(a)Individual #3 had ISP Reviews completed on 2/24/17, 5/22/17, 8/1/17, and 12/1/17. The timeframe between 8/1-12/1/17 exceeds the 3 month requirement.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. The agency has created a system that will track all required ISP reviews. This system will be utilized by the case management (program specialist) department to track, review and ensure timely completion of all ISP reviews. This system tracks compliance dates compared to completions dates for this regulation and will be used by department directors to ensure program compliance. All program specialists will be trained and the system will be fully implemented by 2/1/2018. The program specialist assigned to each identified KIL location will be responsible for ensuring timely completion of all ISP reviews. 02/01/2018 Implemented
SIN-00107462 Renewal 01/25/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)Individual #1 had a physical examination on 02/26/15 and then not again until 05/13/16.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Physical examinations will be reviewed monthly during each program¿s Clinical/Health Team Meeting. The current physical examination date along with the physical exam due date will be identified with in the clinical / health team meeting minutes. During the meeting the team will review the physical examination due date to ensure the appointment has been scheduled in advance and will occur according to regulation. The program manager and or designee will be responsible for ensuring the appointment is scheduled and completed on time annually. All program managers, program coordinators, case managers, and area nurses have been made aware of the above process. The clinical / health team meeting note has been amended to reflect both the current date and due date for each consumers physical examination. 03/17/2017 Implemented
SIN-00087817 Renewal 01/13/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)The Dryer Vent on the outside of the home has encrusted lint hanging out of it. There was also a layer of lint on the ground in an approximate 6 inch circle and lint on the exterior siding of the home below and to the left of the dryer vent. This is a fire hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.Facilities Work Order #7659 to clean/ensure that all lint be removed from the dryer vent was completed on 1/14/16. At the staff meeting on 1/25/2016 at the Carol Street Residence to all staff were trained on removing excess lint from the dryer vent and lint trap to ensure that the dryer vent is free from hazards. 01/14/2016 Implemented
6400.112(d)During the fire drill conducted on 9/29/2015 at 4:05pm, Individual 1 did not evacuate the home. The agency staff documented on the fire drill record that Individual 1 "was in her bedroom because she wasn't feeling well, and staff MK stayed with her in the home." 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. All staff at the Carol Street Resident attended a staffing meeting on 1/25/2016 where they were retrained on agency standard that all individuals must evacuate the entire building during a fire drill. Additionally, staff who were present for the Fire Drill on 9/29/15 received, reviewed and signed a Meeting Summary Note from their supervisor summarizing the violation and the expectation that all individuals present must evacuate the entire building during a fire drill and that staff must assist individuals if necessary to ensure they successfully evacuate. The Residential Coordinator will review fire drill documentation to confirm compliance for future fire drills. 01/25/2016 Implemented
SIN-00068488 Renewal 10/22/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(a)The area in front of the house where Individuals usually walk to access the van or evacuate during a fire drill is full of exposed tree roots which are hazardous . Outside walkways shall be free from ice, snow, obstructions and other hazards. The tree roots will be removed and the walkway will be widened to allow for easier access to the van and for evacuation purposes. Program Manager will continue to monitor to ensure future compliance. 11/15/2014 Implemented
SIN-00218948 Renewal 02/07/2023 Compliant - Finalized
SIN-00199733 Renewal 01/31/2022 Compliant - Finalized
SIN-00144667 Renewal 12/13/2018 Compliant - Finalized
SIN-00085901 Renewal 12/23/2015 Compliant - Finalized
SIN-00052840 Renewal 09/04/2013 Compliant - Finalized