Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00237600 Renewal 12/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.107On 12/20/23, a portable space heater was discovered in the staff office of the home at 11:44 AM.Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms. The portable space heater at the 1033 North Main Street location was disposed of on 12/20/2023. 02/29/2024 Implemented
6400.144Individual #1 had a physical examination completed on 6/26/23 where the physician recommended further vison and hearing examinations. The home had no record of these examinations having ever been completed.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The follow up appointments for vision and hearing recommended during Individual #1¿s annual physical were mistakenly overlooked and not completed. Individual #1 saw her PCP again on 12/28/23 and discussed the recommendations for vision and hearing. Staff explained that the team was having difficulty finding a provider that accepted Individual #1¿s insurance and Individual #1 experienced anxiety during appointments when personal exams were often performed. During this appointment on 12/28/23, the PCP attempted to assess Individual #1¿s vision and hearing by examining her eyes and ears and Individual #1 was non-compliant. The PCP prescribed a medication to help with her anxiety and staff will work on making her more comfortable during doctor¿s appointments and physical exams. 02/29/2024 Implemented
6400.181(e)(12)Individual #1's most recent assessment completed on 3/1/23, did not address or provide recommendations for specific areas of training, programming, and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. For this individual, the assessment has been reviewed again and recommendations included for areas of training, programming, and/or services for the upcoming year. 02/16/2024 Implemented
SIN-00185564 Renewal 03/11/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(e)The home serves four individuals. The home does not have at least one smoke detector on each floor interconnected and audible throughout the home. This was confirmed when tested on 03/11/2021 at 1:19 PM.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. The fire alarm system for 1033 North Main Street has been evaluated and was updated on 3/31/21 to include interconnected alarms. All other sites were assessed during the inspection and were within compliance. The system at 609 North Main Street, which was not in violation due to the number of individuals in the home, has been updated as well to include the interconnected alarms. In the future, any new residence will be assessed and an interconnected system installed if one is not already. All staff will be trained on the interconnected alarm system. [Documentation of audit of homes for interconnected fire alarms shall be kept. Documentation of staff training shall be kept. DPOC by HDKP, HSLS, on 5/4/2021]. 04/16/2021 Implemented
6400.34(a)Individual #1 was informed and explained individual rights on 07/03/20. The rights document did not include the following rights: 6400.32e through 6400.32i, to choose, accept risks, refusal and control the individual's schedule, activities and services, privacy and access to person and possessions; 6400.32n, unrestricted and private access to telecommunications; 6400.32p through 6400.32u, choosing with whom they share a bedroom, decorating and furnishing bedroom and common areas, locking doors in bedrooms and in the home, access to food at any time, and making healthcare decisions.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.The individual rights form used by the agency has been updated to include all of the rights listed in the regulations. The updated individual rights have been reviewed with this individual and the individual has signed the form in acknowledgement of these rights. [Updated Individual Rights forms verified 5/4/2021. A signed copy of the updated Individual Rights form for Individual #1 was not provided by the agency for verification. DPOC by HDKP, HSLS, on 5/4/2021]. 04/30/2021 Implemented
SIN-00148617 Renewal 01/07/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The first aid kit did not contain tweezers. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. For the 1033 North Main Street residence a pair of tweezers has been purchased and added to the first aid kit. The residential managers for all other sites will inspect the first aid kits for all required items monthly. A monitoring log will be kept in the first aid kit to document this inspection. If any items are missing they will be purchased and replaced immediately. The waiver supervisor will review the monitoring logs at all sites each month to ensure completion and will be responsible for this plan of correction. 02/22/2019 Implemented
SIN-00131457 Unannounced Monitoring 02/16/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)Between November 2017 and December 2017, House Manager #1 was responsible for management of Individual #1, Individual #2, Individual #3, Individual #4, funds and purchasing Christmas gifts for each of the Individuals. On December 25, 2017, it was reported to President #2, by several direct service workers in the home that the individuals did not receive the Christmas gifts believed to have been purchased. Per agency policy revised December 1, 2016, The Manager is responsible for that money and will have two (2) days from the issue date of the check to return the receipt(s) and/or change. If the receipt(s) and/or change is not returned within two (2) days, the entire amount will be deducted from the Manager's next paycheck.' On December 28, 2017, President #2 requested via text message that House Manager #1 submit receipts to Fiscal Employee #3 to verify expenses. House Manager #1 provided incomplete receipts that were missing dates and details of the purchased items. On January 5, 2017, House Manager #1 reported to the agency office to discuss the incident and a request to the return of the missing items was made. House Manager #1 left the meeting and ceased communication with the agency. City of Washington Police report, #18000170, filed January 9, 2018 that charges to be filed' against House Manager #1. The following total amount of funds for the specified individuals were not accounted for and/or not used for the individuals: Individual #1, $1,198.66; Individual #2, $497.21; Individual #3, $211.95 and Individual #4, $688.37.Individual funds and property shall be used for the individual's benefit.On 1/31/18, the missing funds were returned to each of the four individuals: #1 $1,198.66; Individual #2 $497.21; Individual #3 $211.95 and Individual #4 $688.37. The Residential Cash Procedure has been revised by WGARS, Inc. President - Staff #2, to include the following: If there is a need for an individual greater than $100.00, the Manager will submit a purchase request to Administration Fiscal Employee for review and/or approval. Depending on the circumstances, the Administration Fiscal Employee may help with the purchase (i.e. on-line order) or a separate check may be issued. If a separate check is issued: the Manager will sign an individual Funds Sign-out Sheet in order to receive the check. The Manager is responsible for that money and will have two (2) days from the issue date of the check to return the receipts (s) and/or remaining money. If the receipts(s) and change are not returned within two (2) days, the entire amount of the check will be deducted from the Manager's next paycheck. All funds have been reviewed during the month of February, 2018, by the Fiscal Employee #3 and currently the records balance. The review is documented. All fiscal employees were trained on the policy on 2/26/18. All managers will be trained by April 15, 2018. The Manager will train each employee on the Resident Cash Procedure and the reporting process for any violations of that policy during individual residential staff meetings during April, 2018. The Fiscal Employee will review all funds for each individual once per month to verify that funds, receipts, and money left over are accounted for and that the records balance. The review will be documented including issues that may arise on the Resident Personal Account Audit Detail. The Director will review 25% of the individuals' funds each quarter for one year to verify that policies have been followed and records balance. The Director will document the review. The police case continues. WGARS, Inc. has not been advised of any formal proceedings as of this time. [House Manager #1 as terminated effective 1/5/18. (AS 4/4/18)] 04/30/2018 Implemented
SIN-00128214 Renewal 01/23/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(6)Individual #1 had a Tuberculin skin testing completed 5/19/14 then again on 6/13/17.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. All physical examinations will include the Tuberculin skin testing by Mantoux method every two years. The physical will be scheduled by the manager in enough time for the test not to exceed the two year deadline. The managers will be trained on this and the Director will review 25% of the physicals for each quarter and maintain documentation of the review. [Immediately, the Director shall develop and implement a tracking and notification system to ensure timely completion of physical examinations including Tuberculin skin testing. Within 30 days of receipt of the plan of correction, the Director shall educate staff responsible for ensuring timely completion of individuals' physical examinations of the tracking and notification system and their responsibilities to ensure all individuals' physical examinations including Tuberculin skin testing is completed timely. (AS 2/12/18)] 02/28/2018 Implemented
6400.142(f)Individual #1 did not have a written plan for dental hygiene plan. There is not documentation that Individual #1 is independent with dental hygiene.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. Individual #1 has a written dental hygiene plan now. All records will be reviewed and if any are found to be without dental hygiene plans, one will be developed in the event the individual is not independent in that area. Both program specialists will be trained by the Director and that training documentation will be kept. The Director will review 25% of the plans each quarter and maintain documentation of that review. [Aforementioned reviews and trainings shall be completed within 30 days of receipt of the plan of correction. (AS 2/12/18)] 02/28/2018 Implemented
6400.186(b)Individual #1's ISP review for review period 8/15/17 through 11/15/17 was not signed by the individual.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. The Program Specialist will ensure that the ISP review is signed by the individual at each review period. The Program Specialists will be trained and the documentation of the training will be maintained. The Director will review 25% of the ISP reviews for signatures each quarter and documents the review. [Immediately, the Director shall train the program specialist(s) of the responsibilities of the position as per 6400.44(b)(1)-(19). Aforementioned reviews shall begin within 30 days of receipt of the plan of correction. (AS 2/12/18)] 02/28/2018 Implemented
6400.213(1)(i)Individual #1's record did not include 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. Individual #1's religious affiliation has been added to the face sheet. All Face sheets will be reviewed by the Program Specialists immediately and any needed additions made if religious affiliation is not identified. The face sheets will be reviewed quarterly by the Program Specialists to ensure they are complete. The Director will review 25 % of the Face Sheets quarterly. Training will occur by the director regarding this issues. [Aforementioned training shall be completed and the quarterly reviews shall begin within 30 days of receipt of the plan of correction. (AS 2/12/18)] 02/28/2018 Implemented
6400.251(b)Individual #1 began an emergency placement in the home on 3/24/17. Individual #1 had a physical examination completed 6/13/17. If an emergency placement occurs, § 6400.141 (relating to individual physical examination) shall be met within 31 calendar days after placement. When an emergency placement occurs, the physical examination will be scheduled within 7 days so that it can be completed by the 31st calendar day. The Residential Manager will contact the Director immediately upon scheduling the exam. Upon completion, the RN will review the physical exam document and approved that it meets regulations. The RN will document the review and maintain a record of it. [Immediately, the Director shall train all staff person responsible for the timely completion of individuals' physical examination of the aforementioned procedures and requirements to ensure if an emergency placement occurs individual physical examination shall be completed within 31 calendar days after placement. Documentation of the trainings shall be kept. (AS 2/12/18)] 02/28/2018 Implemented
SIN-00217758 Renewal 01/18/2023 Compliant - Finalized
SIN-00199897 Renewal 02/10/2022 Compliant - Finalized
SIN-00168313 Renewal 12/18/2019 Compliant - Finalized
SIN-00057498 Renewal 03/03/2014 Compliant - Finalized