Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00093361 Renewal 04/20/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.213(1)(i)The record for Individual #1 does not include the religious affiliation.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.All Program Specialists have until May 16th 2016 to verify that all of their admission sheets are completely filled out and have no blanks. All Program Specialists will be retrained on all parts of regulation 213 (1) at the May 9th 2016 staff meeting. The Program Directors will spot check 3 records each month to assure that this standard is maintained. Admission records for individuals newly admitted to the program or transferring to new locations will be submitted to the Program Director for review. Training records and records for spot checks will be kept on file. [Individual #1's record was updated to include religious "belief" on 4/20/16 by the program specialist. (AS 5/10/16)] 05/06/2016 Implemented
SIN-00077217 Renewal 04/09/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(e)On 4-10-15, at approximately 11:45 AM an audio monitor was present and in use in the shared bedroom belonging to Individual #1 and Individual #2. 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 chicken 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-00205021 Renewal 05/11/2022 Compliant - Finalized
SIN-00172310 Renewal 03/10/2020 Compliant - Finalized
SIN-00113766 Renewal 05/09/2017 Compliant - Finalized
SIN-00085810 Unannounced Monitoring 10/05/2015 Compliant - Finalized
SIN-00086089 Unannounced Monitoring 10/05/2015 Compliant - Finalized
SIN-00058506 Renewal 04/22/2014 Compliant - Finalized