Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00237599 Renewal 12/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(b)On 12/20/23, there was no smoke detector observed within fifteen feet of Individual #1's bedroom, which is located off the home's living room and kitchen.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. A smoke detector, inter-connected with the other smoke detectors, was installed in the residence outside of the bedroom door on 1/23/24. 02/29/2024 Implemented
6400.141(c)(9)Individual #2's date-of-birth is 8/2/61. Their most recent prostate examination was completed on 3/3/22, and the physician did not provide any recommendations to have their next examination conducted beyond the annual requirements. [Repeated Violation- 1/18/23, et al.]The physical examination shall include: A prostate examination for men 40 years of age or older. For Individual #2, his prostate exam was mistakenly overlooked when his physical was completed and not done within the year. It has since been completed on 1/3/24. 02/29/2024 Implemented
6400.151(a)Direct Support Worker #1 had a physical examination completed on 12/2/20, and then again on 12/27/22. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. For this particular staff person, the situation cannot be corrected as the physical has already been completed past the grace period. All other staff records have been reviewed to ensure that physicals have been completed on time and any upcoming physicals are scheduled within the allowed timeframe. 02/16/2024 Implemented
6400.181(e)(12)Individual #2's most recent assessment completed on 6/1/23, did not address or provide any 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-00217757 Renewal 01/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(7)Individual #1, date of admission 2/17/21, had a gynecological examination completed on 3/4/22 but nothing prior.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. Individual #1 did not have a gynecological exam in 2021 but was seen in 2022. This cannot be corrected because it has already occurred. However, moving forward, an appointment is scheduled for 3/10/23 at 9AM which will be in compliance with her last appointment in 2022. 03/10/2023 Implemented
6400.141(c)(8)Individual #1 date-of-birth is 5/23/55 and date of admission 2/17/21, had a mammogram completed on 4/14/22 but nothing prior.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. Individual #1 did not have a mammogram in 2021 but was seen in 2022. This cannot be corrected because it has already occurred. However, in order to remain in compliance with last year¿s date an appointment was attempted to be made but the doctor¿s office does not schedule the particular type of exam she requires past a month in advance. Therefore, we must wait until approximately 3/14/23 before calling to schedule the exam. 03/14/2023 Implemented
6400.141(c)(9)Individual #2, date-of-birth is 4/5/50, had a prostate examination completed on 11/19/21 and then again on 1/12/23.The physical examination shall include: A prostate examination for men 40 years of age or older. For Individual #2, his prostate exam did not coincide with his physical date which caused the exam to be overlooked and not done within the year. In order to get on track, the exam will be repeated on 3/2/23 when he is scheduled for his annual physical and will continue to be performed during his annual physical in the future. 03/02/2023 Implemented
6400.165(g)Individual #2 is prescribed psychotropic medication. Individual #2's record contained only one psychiatric medication review that was conducted on 2/2/22.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.For Individual #2 there was no record of a psychiatric medication review since 2/2/22 but he did continue to receive the refills each month; therefore, the doctor would had to have at least approved the medications for refills. The Program Director had contacted the doctor¿s office several times over January 18-19, 2023 concerning records of previous appointments and was told that he had been seen on 10/13/22 but the office did not provide a record of that appointment. However, moving forward, Individual #2 will be scheduled for the earliest available appointment and a medication review form will be completed. 02/28/2023 Implemented
6400.181(f)Individual #1's functional assessment was completed 3/19/22 and sent to individual plan team members on 3/21/22 for the Individual Plan Annual Review held on 4/13/22.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Individual #1¿s assessment results have already been sent to the team for the 2022 annual plan review. This cannot be corrected. However, the assessment has been prepared and will be sent out immediately in order to be completed and reviewed to ensure that the results are sent to the team at least 30 days prior to this year¿s annual plan review. 02/28/2023 Implemented
SIN-00199896 Renewal 02/10/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(9)Individual #1 has not had a prostate examination completed.The physical examination shall include: A prostate examination for men 40 years of age or older. For this individual, the earliest available appointment will be made with the PCP to have the prostate exam completed. [As per agency director, Individual #1 had prostate examination completed on 3/4/2022.(ASE,HSLS on 3/4/22)] 03/04/2022 Implemented
6400.181(e)(5)Individual #1 assessment completed 6/15/2021 did not included Individual #1's ability to self administer medications. The assessment questions were marked as "N/A".The assessment must include the following information:  The individual's ability to self-administer medications.For this individual, the self-administration portion of the annual assessment has been corrected to accurately reflect the individual skill level and supports needed. The corrected assessment has been included in the record. 03/04/2022 Implemented
6400.165(g)Individual #1 had a review of medication prescribed to treat symptoms of a psychiatric illness completed on 9/20/2021 and then again on 1/24/2022.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The appointment for this individual was scheduled within the 3 months but missed due to scheduling problems. When it was rescheduled, the earliest available appointment was scheduled and was past the 3 months. This particular situation cannot be corrected since it has already occurred, but in the future appointment dates will be monitored to ensure compliance. 03/04/2022 Implemented
SIN-00185563 Renewal 03/11/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(5)Individual #2 does not have a closet or wardrobe space with clothing racks and shelves in his bedroomIn bedrooms, each individual shall have the following: Closet or wardrobe space with clothing racks and shelves accessible to the individual. This individual now has a wardrobe in his room and all other individuals¿ bedrooms have been checked to ensure that a functioning closet or wardrobe is available. [Documentation of audit of all individual bedrooms to ensure a closet or wardrobe space accessible to the individual 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 2/17/21. 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
6400.165(g)Individual #1 has been prescribed medication to treat symptoms of a psychiatric illness, and the review by a licensed physician on 03/05/21 did not include the need to continue the medication.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The psychiatric medication review form for this individual has been completed and has been forwarded to the doctor¿s office for his review and signature. The psychiatric medication review forms for all other individuals will be reviewed to ensure that they have been completed properly. [Individual #1's psychiatric medication review, dated 3/5/2021, has been verified. Documentation of psychiatric medication reviews shall be kept. DPOC by HDKP, HSLS, on 5/4/2021]. 04/16/2021 Implemented
SIN-00168312 Renewal 12/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(3)Direct services worker #1, date of hire 7/11/19 had a physical examination, dated 7/8/19; however, the physical examination does not address communicable diseases. This form states that the employee is free from communicable TB. Direct services worker #2, date of hire 11/2/18 had a physical examination, dated 10/29/18; however, the physical examination does not address communicable diseases. This form states that the employee is free from communicable TB. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. The physicals for these staff will be reviewed by the administrative assistant and any staff that do not currently have a physical form which states they are free from communicable disease will have that part of the physical completed and placed in their file. The Occupational Medicine office which completes our staff physicals has been consulted and has agreed to revise their physical form to include ¿free from communicable disease¿ on the physical form. The administrative assistant will monitor the staff physicals once they are sent to the main office to determine that all areas are complete, including the ¿free from communicable disease¿. The administrative assistant will monitor at least 25% of the staff physicals each month to ensure that they are complete and have the ¿free from communicable disease¿ section on the form and completed. The administrative assistant will be responsible for this plan of correction. 02/29/2020 Implemented
SIN-00148616 Renewal 01/07/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The fire drill conducted on 9/19/18 had evacuation time of 2 minutes and 50 seconds. The fire drill conducted on 8/28/18 had evacuation time of 2 minutes and 45 seconds. The home does not have an extended evacuation time as documented by a fire safety expert. 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. For the Sumner Avenue residence a fire safety professional will be consulted to visit the residence during a fire drill in order to evaluate the drill evacuation time and determine if more time is needed for a safe evacuation. All sites are to conduct their fire drills by the 15th of the month in order to have adequate time should the drill need to be repeated. For all other sites, the residential manager will review the drill evacuation times after conducting the drill. If the time exceeds the 2 1/2 minutes the drill will be repeated. If the evacuation time continues to be an issue, the program director will be notified and the fire safety professional consulted for an evaluation of that site's fire drills and to make recommendations. If an extended time is needed the fire safety professional will submit a written letter including the reasons for the extended evacuation time and the length of time the fire safety professional is recommending. This letter will be reviewed and resubmitted annually if necessary. The administrative assistant will receive a copy of each site's fire drill and notify the program director of any drills that exceed the 2 1/2 minute evacuation time. The program director will be responsible for this plan of correction and will monitor at least 25% of the fire drills each month.[NOT ACCEPTABLE, unannounced fire drills must be completed throughout the each month, and not by the 15th of each month. Immediately, the CEO or designee shall develop and implement policies and procedures to ensure unannounced fire drills are conducted monthly as required including 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. Prior to conducting fire drills, the CEO or designee shall train all staff persons responsible for conducting fire drills of the requirements as per 6400.112(a)-(I) and the aforementioned policies and procedures to ensure fire drills are conducted and documented as required. Upon completion of all fire drills for at least one year, the CEO or designee shall audit all fire drill records to ensure fire drills are conducted and documented as required. Documentation of audits shall be kept. (DPOC by AES,HSLS on 2/4/19)] 02/22/2019 Implemented
6400.163(c)Individual #1's psychiatric medication review completed 12/5/18, 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.For this individual the psychiatrist will be contacted for a review of prescribed psychiatric medications and then complete in its entirety the psychiatric medication review form. For this and all individuals, the psychiatric medication review form has been revised to include the required components (medication, dose, reason for the medication, and the need to continue). The residential managers were trained on 1/9/19 on how to assist the medical professional in completing this form. The residential managers will review the form prior to leaving the appointment to ensure that all necessary information has been included on the psychiatric medication review form. The Waiver Supervisor will be responsible for overseeing this plan of correction and will keep copies of all psychiatric medication review forms in a binder and sign each form once she has reviewed it. 02/22/2019 Implemented
6400.164(b)Individual #1's prescription medication, Atovastatin 50mg tablet, take 1 tablet by mouth at bedtime was not initialed as administered on 1/1/19 at 8:00PM. Individual #1's prescription medication Potassium Cl ER 10 Meq Ta, take 1 tablet by mouth twice daily was not initialed as administered on 1/1/19 at 9:00PM. Individual #1's prescription medication, Quetiapine Fumarate 200mg, take 1 tablet by mouth every morning and 2 tablets at bedtime was not initialed as administered on 1/19/19 at 8:00PM. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. The staff member responsible for administering medications to this individual on 1/1/19 will be retrained on the proper medication administration procedure, including signing and initialing the medication administration record. This staff will then be monitored one time per month over the next three months to ensure that they are continuing to follow the correct medication administration procedure. In the future, any staff member who commits a medication error will be retrained and then monitored at least one time per month over the next three months. The medication coordinator, nursing staff, program specialists, and residential managers will complete the retraining and monitoring. The medication coordinator will be responsible for this corrective action and will review 25% of the medication administration records each month to ensure that the medication administration records are being documented correctly. 02/22/2019 Implemented
SIN-00128213 Renewal 01/23/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)The monthly fire drills held between 12/8/16 and 1/1/18 used the back door as an exit route.Alternate exit routes shall be used during fire drills. The alternate route that is not the back door will be used during fire drills at least quarterly. The exit route used will be indicated on the Fire Drill Record. All staff will be trained regarding use of alternate exit routes and the training record will be kept. The Director will review the Training records each month and sign off on them to indicate the completion of the review. [Within 30 days of receipt of the plan of correction, the Director or designee shall train all staff person responsible for completing fire drills in the requirements of fire drills and documenting fire drills as per 6400.112(a)-(I). At least quarterly for 1 year, the Director shall review the fire drill records to ensure fire drills are conducted and documented as required. Documentation of reviews shall be kept. (AS 2/12/18)] 02/28/2018 Implemented
6400.181(a)The assessments for Individual #1 were completed on 5/15/16 and then again on 6/17/17. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Each individual will receive the initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The Program Specialist or designee will begin the assessment within one week of admission and at least two months prior to the annual updated assessment time. The Program Specialist will sign and date the assessment upon its completion. The Director will monitor all new admission assessments and 25% of the annual assessments each quarter and maintain documentation of the monitoring and its results. [Immediately, the Director shall train the program specialist(s) of the responsibilities of the position as per 6400.44(b)(1)-(19) and the aforementioned procedures to ensure timely completion of individuals' assessments. Documentation of the training shall be kept. (AS 2/12/18)] 02/28/2018 Implemented
SIN-00107483 Renewal 01/26/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(c)There was not a fire extinguisher in kitchen. A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). The fire extinguisher was placed in the kitchen during the inspection. A photo was presented to the Licensing Inspector. All homes have been checked to ensure that there is a fire extinguisher in the kitchen. No changes need to be made at this time. In the event a new home opens, the Residential Supervisor will ensue one is in the kitchen of the home. All managers will be trained on this regulation by 2/28/2017. 02/16/2017 Implemented
6400.141(a)Individual #1 had physical examinations completed on 9/4/15 and then again on 9/26/16.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual #1 will be scheduled an annual physical for 2017 within the regulatory window of times. All physicals have been checked by the Residential Supervisor and have been completed within the regulatory window. The date of each person's current physical will be forwarded to the Assigned staff at the main office. Approximately 4 weeks before the due date for a physical, a memo will be sent to each manager. The Manager will report to the Assigned Staff the scheduled date for the physical to be completed and that staff will check that the physical is completed by the date required. Managers and the Assigned office staff will be trained by 2/28/17. 02/16/2017 Implemented
6400.163(c)The psychiatric medication review completed on 6/1/16 for Individual #1 did not include the necessary dosage for Depakote, Paxil and Risperdal. 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.The Psychiatric Re-evaluation form for Individual #1 will be corrected to add the dosages for Depakote, Paxil and Risperdal. The form "Report of Psychiatric Re-Evaluation is being revised to add "dosages" after the name of the current medication. ARS staff completing the form will ensure current doses of the medications are listed. The Assigned office staff will revise the form by 2/17/17. The new form will be distributed to all sites and old forms destroyed. All managers will begin to utilize the new form immediately. Each form will be reviewed at Team meetings for completeness including dosages. All Managers and Program Specialists will be trained by 2/28/17. 02/16/2017 Implemented
6400.186(d)The program specialist did not provide the ISP review documentation completed 11/3/16, 8/4/16, 2/4/16 for Individual #1 to all plan team member including the behavioral supports. The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. The documentation completed on 11/3/16, 8/4/16 and 2/4/16 will be provided to the behavioral supports personnel by 2/17/17. All individuals' records will be reviewed to ensure that all individuals who need to receive the ISP Review documentation are currently listed on the transmittal letter. Any individual who is not listed on the transmittal letter will be added to ensure they receive the ISP review documentation. The Program Specialists will do the review and present needed changes to the main office so any letters can be revised to add necessary Team member. This change will be made by 2/17/17. The Office staff person assigned will revise any transmittal letters to include necessary Team members. The Program Specialists and assigned office staff will be trained on the procedure by the Acting Director by 2/28/2017. [At least quarterly for 1 year the Director shall review a 25% sample of correspondence documentation showing that all team members have been provided the Individuals' ISP reviews as required. (AS 2/23/17)] 02/16/2017 Implemented
SIN-00073438 Renewal 01/13/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(c)Individual #1 is prescribed psychiatric medications including but not limited to: Celexa, Seroquel, Buspar and Depakote. Individual #1 had psychiatric medication reviews completed on 5/1/14 and 8/7/14. 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.House manager was retrained on setting up appointments. Attached is training. The psych appointment was changed by the psychiatrist (see attached). [The CEO or designee will monitor documentation of psychiatric medication review appointments monthly to ensure they were completed timely and contain all required components. (CHG 1/30/15)] 01/25/2015 Implemented
6400.186(b)Individual #2 did not sign the ISP review signature sheet indicating that the ISP had been reviewed for the review dated February 6, 2014 through May 6, 2014.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. The Program Specialist reviewed the ISP and the individual signed it (see attached). [The CEO or designee will audit individual records monthly to ensure all documentation is completed and in the record and that all required signatures have been obtained. (CHG 1/30/15)] 01/25/2015 Implemented
6400.213(8)(ii)Individual #1's record did not include a copy of the signature sheet for the annual update meeting held 2/19/14. Each individual's record must include the following information: A copy of the signature sheets for the annual update meeting. After every annual meeting, if the supports coordinator does not give our agency a copy of the sign-in sheet, the program specialist will call said support coordinator and request it. They will also document the date and time of the call. They will then send an email requesting the signed documents and print the email.This will be done within one week of the meeting and each week after until said document is received. [The CEO or designee will audit individual records monthly to ensure that all required documentation is present in the record including a copy of the signature sheet for the annual update meetings. (CHG 1/30/15)] 01/25/2015 Implemented
SIN-00088998 Renewal 01/07/2016 Compliant - Finalized
SIN-00057496 Renewal 03/04/2014 Compliant - Finalized