Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00227308 Renewal 07/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(d)Direct Service Worker #1, date of hire 4/02/2015, had training in First aid Heimlich techniques and cardio-pulmonary resuscitation on 8/24/2022. There is no record of any other trainings in first aid, Heimlich techniques and cardio-pulmonary resuscitation for Direct Services Worker #1.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.Direct care service worker is currently certified is currently certified in CPR, heimlich techniques, and first aid. He is not due for recertification until 2024. 07/13/2023 Implemented
SIN-00209144 Renewal 08/02/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(g)Individual #1 had a review of psychiatric medications on 2/22/22, and then again on 6/27/22.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.Residential Nurse will create a spreadsheet of all annual and necessary appointments and share the spreadsheet with Residential Program Manager and Director. 09/10/2010 Implemented
SIN-00192046 Renewal 08/31/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)The home conducted monthly fire drills from 11/27/20 through 8/1/21. The only drill held during sleeping hours was 6/18/21.A fire drill shall be held during sleeping hours at least every 6 months. Residential Program Manager will update the fire drill forms, retrain staff on the regulations on fire drills, and schedule at least two overnight fire drills a year between the hours of 2am and 4am. 10/01/2021 Implemented
6400.141(c)(9)Individual #1, date of birth 7/31/74, had a prostate examination 12/18/19 and then again 1/7/21.The physical examination shall include: A prostate examination for men 40 years of age or older. Clinical Coordinator will be the designated staff to accompany all individuals on their annual exams. This will include but not limited to annual physicals, prostate exams, dental exams, mammograms', etc. to ensure compliance. 10/01/2021 Implemented
6400.165(g)Individual #1's is prescribed Depakote, 250 mg every morning and 500 mg every evening to treat mood disorder. The psychiatric medication reviews completed on 1/7/21, 4/8/21 and 8/23/21 did not include a diagnosis. Individual #1 had a psychiatric medication review 4/8/21 and then again 8/23/21.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.Clinical Coordinator will update the medical forms including those for psychiatric medication reviews and the 90-day psychiatric reviews to include all pertinent information and an accurate diagnosis. 10/01/2021 Implemented
SIN-00177363 Renewal 10/06/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(c)There was not written record of fire safety training for Individual #1. A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept.This documentation was unable to be located. 2020 Individual Fire Safety Training will be scheduled as soon as possible due to limited availability of the Fire Dept due to COVID-19. This item will be added to the Residential Program (shared) calendar to ensure that the Director and Program Specialist are aware of approaching the due date. [Individual #1 was trained in fire safety on 11/10/20, documentation provided to the department on 12/8/20. Immediately and at least quarterly for 1 year, the CEO or designee shall audit all individuals' records to ensure fire safety training has been completed, timely, and retraining shall occur as needed. Immediately, the CEO or designee shall develop and implement a tracking system to ensure all individuals are educated in fire safety, timely, and documentation is kept as required. (DPOC by AES,HSLS on 12/8/20)] 10/30/2020 Implemented
6400.181(a)Individual #1 had an assessment completed on 3-6-19 and then again on 5-18-20. 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. The Director will retrain the Residential Program Manager on regulations pertaining to Individual Assessments. The Director will conduct an inspection prior to the Individual Assessments being sent out to the ISP team to ensure compliance. Immediately, the CEO or designee shall develop and implement a tracking system to ensure timely completion of all individuals' assessments and educate the program specialist on the system. Documentation of trainings shall be kept. 10/30/2020 Implemented
6400.34(a)Individual #1 was informed and explained individual rights on 12-1-18 and then again on 2-14-20.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.All annual paperwork, including Individual Rights, will be sent out no later than December 31 annually. This paperwork will be due to be returned to the agency no later than January 15 annually. This item will be added to the Residential Program (shared) calendar to ensure that the Director and Program Specialist are reminded of approaching the due date. 12/31/2020 Implemented