Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00220399 Renewal 02/08/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(a)The exterior stairs leading outside from the basement are covered in a thick layer of moss. This exit is used as an evacuation route and was utilized as the evacuation route for the fire drill conducted on 7/25/2022. Outside walkways shall be free from ice, snow, obstructions and other hazards. Maintenance personnel arrived at the site on 2/9/2023 and removed the thick layer of moss from the stairway. A photograph of the moss-free stairway was taken on 4/4/2023 and will be emailed to the licensing supervisor for proof of maintenance. 02/09/2023 Implemented
SIN-00090656 Renewal 03/01/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(1)Individual #1's assessment, dated 1/2/16, was completed by a program coordinator and reviewed by a program specialist.The program specialist shall be responsible for the following: Coordinating and completing assessments. The Program Specialist will assure that assessments are sent out to all team members at least 30 days prior to an ISP meeting, revision or update. The Clinical Director will meet weekly with the Program Specialists to review upcoming ISP meetings scheduled 45 to 60 days away. The Clinical Director will review and sign the assessment to make sure it is getting sent out according to our regs [A meeting was conducted with all program specialist on March 2, Residential Director and Clinical Director reviewed the assessments with program specialist and reviewed that program specialist must complete the assessments and the procedures to do so. Documentation of aforementioned reviews by the clinical director shall be kept. (AS 4/1/16)] 03/12/2016 Implemented
6400.113(a)Individual #1's most recent date of being instructed 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 was 8/14/14. 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. Fire safety training is provided annually for both staff and clients by a local fire chief. Upon completion of the training, a Program Specialist will be designated to check the house rosters to make sure that every individual has received fire safety training. Any individual who did not receive fire safety training will be re-scheduled to receive the training by the due date.[Immediately, Individual #1 shall be instructed in fire safety. Program Specialist will review all individuals required fire safety instruction documentation to ensure timeliness and will ensure instruction as required. Residential Director will develop, implement and train Program Specialist on a tracking system to ensure all Individuals are instructed in required fire safety within required time frames. At least quarterly, the Residential Director or designated management staff will review aforementioned tracking system to ensure timely instruction of required fire safety for all individuals. (AS 4/1/16)] 03/12/2016 Implemented
SIN-00043243 Renewal 09/26/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.45(d)The staff ratio as specified in Individual #1's ISP was not implemented. One-on-one staffing is required during waking hours. According to HCSIS incident #4489888, on 12-25-11, Individual #1 did not have one-on-one staffing for approximately eight waking hours. Partially implemented - adequate progress - cs - 3/6/13. (d) The staff qualifications and staff ratio as specified in the ISP shall be implemented as written, including when the staff ratio is greater than required under subsections (a), (b) and (c). A back-up plan has been developed and implemented to assure that the services provided to an individual are provided at the frequency and duration established in the ISP. A copy of the back-up plan protocol was submitted. Program managers and coordinators will be trained 3/6/13 and/or 3/8/13 on back-up plan, and training documentation will be submitted. Staff time records for Individual #1's home for months of January and February, 2013 were submitted and indicate staffing ratio was met. Program managers are responsible to insure that staff ratios are met. Residential Services Director is responsible to review with the program managers on a monthly basis the staff ratios in homes. 01/01/2013 Implemented
SIN-00170820 Renewal 02/12/2020 Compliant - Finalized
SIN-00110352 Renewal 03/09/2017 Compliant - Finalized
SIN-00061483 Renewal 03/13/2014 Compliant - Finalized