Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00217657 Renewal 01/17/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)Individuals #1-#3 received fire safety training on 9/22/2021 and not again until 1/6/2023, outside the annual time frame requirement. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. Individuals #1, #2, and #3 were trained on their fire safety on 01/06/2023, once it was discovered that they had not received the training in the allotted time, per regulation 6400.113(a). Program Managers and Program Specialists were trained on this regulation by the Central Region Operations Director on February 23, 2023. Outline and attendance record has been submitted for review. To ensure no further infractions occur, all individuals current Fire Safety Training will be placed on SharePoint. The Quality Assurance Department will review at the end of the month and email Program Managers, cc: Program Specialists with the name and due date for each person served within their assigned homes. Once completed the Program Manager will be responsible for scanning and the submission of the new fire safety training form. 02/23/2023 Implemented
SIN-00182100 Renewal 01/25/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.145(3)The emergency medical plan for Individual #1 does not include a complete emergency staffing plan. It indicates that staff is to call "724/XXX-XXXX", however, this is not a working number.The home shall have a written emergency medical plan listing the following: An emergency staffing plan.Program Managers were trained on regulation 6400.145(3) by the Director of Quality Assurance and Training on March 9, 2012. The outline and attendance record are submitted for review (#3). The emergency medical plan was placed in pdf format to ensure no information is inadvertently omitted. The form and Individual #1 form have been submitted for review. Program Managers were instructed to review each person we serves emergency medical plan to ensure accuracy. All updated forms are to be sent to the Quality Assurance department by 03/11/21. To ensure no further infractions occur, the Program Specialist will review each plan for assigned persons. An email will be sent to the Operations Director by 03/12/21 with completion of the task. Monitoring of the document will be completed by the Quality Assurance & Training Associate during biannual inspections. 03/09/2021 Implemented
SIN-00097493 Renewal 07/19/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The carpet in the kitchen has approximately 10 or more large stains and appears to be dirty; even when it was attempted to be cleaned. Floors, walls, ceilings and other surfaces shall be in good repair. VCS will ensure floors, walls, ceilings and other surfaces shall be in good repair. The carpet in the kitchen area replacement will be ordered by the facilities director prior to September 15, 2016 for immediate installment. The operations director will retrain program managers on 6400.67(a) prior to September 30, 2016. Major maintenance requests submitted by program managers will be reviewed by the operations director and then by the facilities director. To ensure no further infractions occur, program managers will complete monthly checklist of the physical sites, and the operations director will complete monthly random checks of the home physical sites. The facilities director will do a walk-through of each home on a semi-annual basis. Additionally, the quality assurance department will complete random monthly walk-throughs of homes to ensure compliance. 09/30/2016 Implemented
6400.104The notification letter must be updated to include that individual #1 and individual #2 require many verbal prompts to evacuate. The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Valley Community Services (VCS) will ensure homes notify the local fire department in writing the locations of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. Although both Individual #1 and Individual #2 bedrooms were listed on the current notification and both are ambulatory, the letter to the local fire department did not include that each required many verbal prompts to evacuate during fire drills. The operations director will retrain program managers on regulation 6400.104 prior to September 30, 2016. The program managers will submit an amended fire department letter to the operations director for approval and then submitted to the local fire department. The amended, approved letter will be placed in the house maintenance book. This will be completed prior to October 14, 2016. To ensure no further infractions occur, the operations director will inspect the notification letter every six months to assure compliance. 10/14/2016 Implemented
SIN-00146159 Renewal 12/06/2018 Compliant - Finalized
SIN-00061009 Renewal 02/06/2014 Compliant - Finalized
SIN-00043676 Renewal 02/11/2013 Compliant - Finalized
SIN-00043227 Initial review 10/16/2012 Compliant - Finalized