Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00227945 Renewal 07/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103The evacuation plan does not indicate what the individual's responsibilities are during an evacuation.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. The evacuation plan was revised and updated on 7.21.2023 to include the individuals responsibilities during an emergency evacuation. All staff will be retrained on the plan by 08/31/2023. (Attachment # 1) 08/31/2023 Implemented
6400.141(c)(11)Individual #1's most recent physical dated 7/3/23 did not indicate recommendations for health maintenance needs. It was left blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The Supervisor contacted the PCP on 7.19.2023 to update information on the physical form on the section for individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. (Attachment #8) 08/01/2023 Implemented
SIN-00175243 Unannounced Monitoring 08/18/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103The written emergency evacuation procedures did not include an emergency shelter location at the time of inspection.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. This was corrected during the inspection on 8/19/2020. The Residential Director retrained the managers and supervisors on this regulation to ensure the emergency evacuation procedures include the list of the emergency shelter location on 8/31/2020. The Supervisors will check and ensure that the emergency shelter location list is attached to the evacuation procedures as they review the monthly fire drill and documented on the monthly monitoring form, the Supervisor will complete the initial review for each home by 9/30/2020 to ensure the emergency shelter location list is attached. Managers will randomly review the emergency evacuation procedures every quarter to ensure compliance. The quarterly internal audit teams will review the emergency evacuation procedures to ensure the list of emergency shelter is attached during the audits. 09/30/2020 Implemented
SIN-00190386 Renewal 08/03/2021 Compliant - Finalized