Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00210856 Renewal 09/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill conducted on 3/8/22 at 4:10 did not documentation the designation of AM / PM for the time that the fire drill was completed.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. Fire drill forms were updated to include circling designation of AM or PM. Staff responsible for conducting fire drills were trained on the new form on 9/20/2022. Program Specialist verified with staff conducting the fire drill that this was completed on 3/8/22, that 4:10 should have been designated as PM. Form was corrected to include the PM designation correction on 9/22/22. 09/22/2022 Implemented
SIN-00178786 Renewal 11/02/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.182(c)Individual #1's assessment states that he reports he does not know how to swim, but Individual #1's Individual Plan states he enjoys swimming, and he is able to swim independently. The individual plan is not updated to reflect a needs change based on the current assessment.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.Corrective action plan for citation issued as follows: 6400.182(c) ¿ The individual plan shall be initially developed, revised annually and revised when an individual¿s needs change based upon a current assessment. What happened: Individual #1's assessment states that he reports he does not know how to swim, but Individual #1's Individual Plan states he enjoys swimming, and he is able to swim independently. The individual plan is not updated to reflect a needs change based on the current assessment. Why did it happen: After review of this assessment and plan it has been determined the ISP is inaccurate and it was not identified upon review of the ISP. Supports Coordinator received copy of annual assessment on 4/30/2020 but ISP did not reflect the same information. Immediate Action taken to resolve the cited issue: Supports Coordinator was notified on 11/7 by email and requested to make necessary correction in ISP. AE was notified on 11/10/20 that changes were required in plan due to SC responding they currently were not able to update the plan. Plan to prevent reoccurrence of same or similar violations: Each ISP will be reviewed for content accuracy at plan renewal date as well as fiscal plan renewals. Program Specialist will be responsible for ensuring accuracy, notifying SC of needed updates, revising assessments as needed, and keeping documentation of requested changes made to SC. Program Specialist will notify Program Director if repeated request to update a plan does not result in changes being reflected in ISP. Program Director will notify SC supervisor and AE of concerns of plans not being updated. Training Provided: On 11/10/20 Regulation 182c was reviewed with Program Specialist. After verifying the SC did receive the Annual Assessment, Program Specialist and Program Director discussed creating a schedule to verify information in each Individual¿s ISP is consistent with assessment and that the information is correct. Program Specialist will follow plan to prevent reoccurrence of same or similar violations. 11/10/2020 Implemented
SIN-00231183 Renewal 09/05/2023 Compliant - Finalized
SIN-00192175 Renewal 10/19/2021 Compliant - Finalized
SIN-00157797 Initial review 06/19/2019 Compliant - Finalized