Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00242475 Renewal 04/02/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(b)On 4/3/24 at 11:52AM, the closest smoke detector that was located outside of Individual #1's bedroom was approximately 29 feet 4 inches away.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. The LCARC maintenance repairman contacted Aven Fire Systems on 4/04/24 when the agency was made aware of the missing detector at the service location. On 4/9/24 an X-Sense battery operated Smoke alarm approved by Underwriters Laboratory was ordered from Amazon by Residential Program Director. The smoke detector arrived on 4/10/24 and was installed by maintenance repairman on 4/11/24, invoice and photo sent via email. On 4/15/24 Aven Fire Systems installed an interconnected smoke detector within 15 feet of #1's bedroom door, replacing the battery-operated X-Sense Smoke Alarm. Photo and invoice sent via email. Residential Direct Support Staff will complete form 235 Fire System Check monthly to ensure smoke detectors are present and in working condition, form sent via email. Residential location staff were trained by Residential Program Specialist on regulation 6400.110(b) between 4/10 and 4/15/2024, the training content and names of staff trained are documented on the Staff Training Verification form #930, sent via email. 04/16/2024 Implemented
SIN-00133035 Renewal 04/11/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(c)The psychiatric medication reviews completed 12-28-17, 10-18-17, 8-9-17, 5-31-17 and 3-22-17 for Individual #1 did not include the need to continue the medications. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Residential staff were instructed to inspect all records for individuals who have medication reviews completed. The records for individual #1 were corrected by the provider on April 18th. (copies sent via email) The agency wide inspection did reveal that there was a systemic issue with one particular MH provider not consistently answering all questions. All records were submitted for correction to the particular provider of MH service for completion. At a staff meeting/training on Monday April 23rd (training record emailed) it was decided that residential program directors will review 100% of med check questionnaires after they are scanned in. A list of individuals who have such questionnaires was developed for this purpose. Program Specialists will train all staff who complete medical appointments to make sure that documentation is filled out in its entirety before leaving the appointment. RPD will review all forms for a period of one year to assure compliance. [Aforementioned training for staff supporting individuals with psychiatric medication review appointments shall be completed prior to attending the next appointment. A designated staff person certified to administer medications and trained in the requirements of psychiatric medication reviews shall audit all psychiatric medication review documentation within 5 days of the medication review appointment to ensure all required information is included and Individuals are administered medications as prescribed. Documentation of all audits shall be kept. (AS 4/24/18)] 04/23/2018 Implemented
SIN-00077216 Renewal 04/09/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(e)On 4-10-15, at approximately 10:00 AM an audio monitor was present and in use in the bedroom belonging to Individual #1. Individual #1 is not able to operate the audio monitor.An individual has the right to privacy in bedrooms, bathrooms and during personal care. The audio monitor was disabled as part of an interim plan of correction. Staff will conduct bed checks every 30 minutes to prevent individual #1 from being injured by attempting to get out of bed without assistance. PS's made staff aware of this new procedure and will monitor to assure that it continues. The agency intends to apply for a regulatory waiver in the near future. 04/25/2015 Implemented
6400.71The emergency telephone numbers by each of the telephones in the home do not include the fire department, police department and ambulance.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The Emergency phone list was revised for all residential sites to include the proper language. New labels were also created for portable phones. Program specialists had the new lists and labels in place at all sites by 4-18-15. They will monitor to assure they remain current. A copy of the phone list was emailed to Andrea Kurtz. 04/27/2015 Implemented
6400.171An open bag of frozen chicken patties was in the freezer.Food shall be protected from contamination while being stored, prepared, transported and served. LCARC Program Specialists will be retraining all direct care staff on proper food storage during the month of May 2015. Staff will be trained during monthly house meetings and also during the May in service. We have made storage part of our pre service training curriculum and annual training. It will be part of the special diets, nutrition and risk management. Posters were also developed to hang in kitchens to remind staff of this important responsibility. A copy of the training material and poster will be emailed to Andrea Kurtz as part of the POC. PS's will spot check houses during weekly house visits to assure the proper storage standards are maintained. All trainings will be complete by May 31 2015 04/27/2015 Implemented
SIN-00188071 Renewal 05/25/2021 Compliant - Finalized
SIN-00093360 Renewal 04/20/2016 Compliant - Finalized