Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00220400 Renewal 02/08/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Direct Services Worker #1, date of hire 09/19/21, had an initial physical completed on 09/21/22. 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. The Direct Service Worker was hired on 9/19/2022 and had his initial physical completed on 9/21/2022. This staff member did not work directly with any individual in services until 9/23/2022 as they were completing their initial orientation in the office setting. HR Personnel were retrained on regulation 6400.151(a) and proof of that training will be emailed to the licensing supervisor. 02/09/2023 Implemented
SIN-00130804 Renewal 03/08/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)A fire drill was not held in February 2018. An unannounced fire drill shall be held at least once a month. On May 22, 2018 all House Managers, Clinical Director, Clinical Supervisor and the Program Director reviewed the 6400.112 requirements. Fire drills were conducted the week of May 28, 2018 through June 1, 2018. In services for all staff were held May 23, 29,30, June 1,4,6,8 to review the record of fire drill and fire equipment checks. An example was used for staff to complete the form in its entirety. When the fire drill and Fire equipment check is completed after each fire drill, it is to be submitted to their supervisor by the next business day. The House manager will review the form to assure compliance to the regulation. The house manager will verify that the form is complete and accurate by signing and dating the form. It is then given to the Clinical Director who reviews and approves it by signing and dating the form. Additionally, the agency compliance officer will check houses randomly, on a monthly basis. The Compliance Officer will select one house from each House manager monthly. Any deficiencies noted by the Compliance Officer will be identified and a retraining of the House Managers will occur. Effective Date: June 1, 2018 Responsible Party: Program Director, House Manager, Compliance Officer [Within 30 days of the receipt of the plan of correction, the CEO shall train the aforementioned staff persons in the aforementioned procedures and their responsibilities to ensure an unannounced fire drill is held at least once a month. Documentation of trainings shall be kept. (AS 6/21/18)] 06/01/2018 Implemented
6400.112(c)The written fire drill record for the fire drill held on 12/28/17 did not include the time or the amount of time it took for evacuation.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. On May 22, 2018 all House Managers, Clinical Director, Clinical Supervisor and the Program Director reviewed the 6400.112 requirements. Fire drills were conducted the week of May 28, 2018 through June 1, 2018. In services for all staff were held May 23, 29,30, June 1,4,6,8 to review the record of fire drill and fire equipment checks. An example was used for staff to complete the form in its entirety. When the fire drill and Fire equipment check is completed after each fire drill, it is to be submitted to their supervisor by the next business day. The House manager will review the form to assure compliance to the regulation. The house manager will verify that the form is complete and accurate by signing and dating the form. It is then given to the Clinical Director who reviews and approves it by signing and dating the form. Additionally, the agency compliance officer will check houses randomly, on a monthly basis. The Compliance Officer will select one house from each House manager monthly. Any deficiencies noted by the Compliance Officer will be identified and a retraining of the House Managers will occur. Effective Date: June 1, 2018 Responsible Party: Program Director, House Manager, Compliance Officer [Within 30 days of the receipt of the plan of correction, the CEO shall train the aforementioned staff persons in the aforementioned procedures and their responsibilities to ensure fire drills are conducted and documented as required. Documentation of trainings shall be kept. (AS 6/21/18)] 06/01/2018 Implemented
6400.112(e)A fire drill during sleeping hours was held on 3/21/17 and then again on 1/21/18.A fire drill shall be held during sleeping hours at least every 6 months. On May 22, 2018 all House Managers, Clinical Director, Clinical Supervisor and the Program Director reviewed the 6400.112 requirements. Fire drills were conducted the week of May 28, 2018 through June 1, 2018. In services for all staff were held May 23, 29,30, June 1,4,6,8 to review the record of fire drill and fire equipment checks. An example was used for staff to complete the form in its entirety. When the fire drill and Fire equipment check is completed after each fire drill, it is to be submitted to their supervisor by the next business day. The House manager will review the form to assure compliance to the regulation. The house manager will verify that the form is complete and accurate by signing and dating the form. It is then given to the Clinical Director who reviews and approves it by signing and dating the form. Additionally, the agency compliance officer will check houses randomly, on a monthly basis. The Compliance Officer will select one house from each House manager monthly. Any deficiencies noted by the Compliance Officer will be identified and a retraining of the House Managers will occur. Effective Date: June 1, 2018 Responsible Party: Program Director, House Manager, Compliance Officer [Within 30 days of the receipt of the plan of correction, the CEO shall train the aforementioned staff persons in the aforementioned procedures and their responsibilities to ensure fire drills are conducted and documented as required. Documentation of trainings shall be kept. (AS 6/21/18)] 06/01/2018 Implemented
SIN-00077204 Renewal 03/10/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The home completed a self-inspection on 12-30-14. The agency's license expires on 3-19-15.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The self assessment will be started in October 2015 and will be compelted, with all areas brought into compliance, by 12/1/15. Staff performing the assessment will be notified by email and memo on or about October 1, 2015. [CEO or designee will be responsible for notifying staff as stated. (AS 6/10/15)] 04/27/2015 Implemented
6400.141(a)The most recent physical examination for Individual #1 was completed on 4-15-14. The previous examination was completed on 3-18-13.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Coordinators will perform monthly auditing of all client files. This will identify upcoming required annual exams. The Coordinator Supervisor will inform the coordinators by memo of all upcoming required annual exams. 04/10/2015 Implemented
6400.213(1)(i)The photo in Individual #1's record was not dated.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.The photo is dated. during monthly audits, Coordinators will review individual pictures to assure they are current and are dated. 04/01/2015 Implemented
SIN-00061480 Renewal 03/14/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(c)For Individual #1's psychiatric consult on 2-19-2014, the "Reason for Prescribing the medications" was not on the agency consult form. (c) 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. program coordinators will assure that all required documntation is completed by the attending physician. Coordinators will review the review the completed form to make sure the physician has provided the required information 04/01/2014 Implemented
SIN-00043246 Renewal 09/26/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(a) Individual #1 was not informed of individual's rights on an annual basis. Individual #1 was last informed of rights on 1-7-11. Partially implemented - adequate progress - cs - 3/5/13.(a) Each individual, or the individual's parent, guardian or advocate, if appropriate, shall be informed of the individual's rights upon admission and annually thereafter. Program Coordinators will inform their clients of their rights annually in January. Director of Residential Services will send a reminder to Coordinators and Managers in December so that individual rights are reviewed and signed off on by the required due date. Program managers will be responsible for insuring that individuals' rights are reviewed on an annual basis. Documentation of annual review of rights on 1-7-12 and 1-4-13 for Individual #1 submitted. Annual review of rights completed 1-5-12 and 1-5-13 submitted for two other individuals. On 3-6-13 and 3-8-13 program managers and program coordinators will be retrained on requirement for annual review of individuals' rights. Training documentation will be submitted. 01/01/2013 Implemented
6400.74RNC. On 9-27-12, the steps that exit the living area of Individual #1 onto the porch did not have a non-skid surface. Partially implemented - adequate progress - cs - 3/7/13.Interior stairs and outside steps shall have a nonskid surface. Non-skid paint was applied to steps by a contractor 10/26/12. Provider submitted copy of invoice from "Handyman Klaus" for completed work. Established schedule for annual maintenance/reapplication of non-skid paint every August. Program Managers are responsible to monitor steps and stairs and other physical aspects of home on a monthly basis. Program Managers will use a Physical Site checklist (submitted) to ensure that physical site is maintained to regulatory standards. 01/01/2013 Implemented
6400.181(e)(1)Individual #1's assessment dated 9-21-12 did not include functional strengths, needs, and preferences of the individual. Partially implemented - adequate progress - cs - 3/5/13(e) The assessment must include the following information: (1) Functional strengths, needs and preferences of the individual. The DAT (Development Assessment Tool) has been revised to include the regulations outlined in 6400.181 (e)(1), (e)(2), (11) and (14). Copies of the revised sections were submitted. Assessments, using the revised assessment tool, were completed for two individuals on 11-12-12 and 1-5-13 respectively and were submitted. Program Managers are responsible to review and ensure that revised assessment tools are completed in their entirety. Program managers and coordinators will be trained on 3-6-13 and 3-8-13 regarding assessment requirements and utilization of revised assessment. Training documentation will be submitted. 10/01/2012 Implemented
6400.181(e)(2)Individual #1's assessment dated 9-21-12 did not include the likes, dislikes, and interests of the individual. Partially implemented - adequate progress - cs - 3/5/13.(2) The likes, dislikes and interest of the individual. The DAT (Development Assessment Tool) has been revised to include the regulations outlined in 6400.181 (e)(1), (e)(2), (11) and (14). Copies of the revised sections were submitted. Assessments, using the revised assessment tool, were completed for two individuals on 11-12-12 and 1-5-13 respectively and were submitted. Program Managers are responsible to review and ensure that revised assessment tools are completed in their entirety. Program managers and coordinators will be trained on 3-6-13 and 3-8-13 regarding assessment requirements and utilization of revised assessment. Training documentation will be submitted. 10/01/2012 Implemented
6400.181(e)(11)Individual #1's assessment dated 9-21-12 did not include a psychological evaluation. Partially implemented - adequate progress - cs - 3/5/13(11) Psychological evaluations, if applicable. The DAT (Development Assessment Tool) has been revised to include the regulations outlined in 6400.181 (e)(1), (e)(2), (11) and (14). Copies of the revised sections were submitted. Copies of the revised sections were submitted. Assessments, using the revised assessment tool and including psychological evaluations were completed for two individuals on 11-12-12 and 1-5-13 respectively and were submitted. Program Managers are responsible to review and ensure that revised assessment tools are completed in their entirety. Program managers and coordinators will be trained on 3-6-13 and 3-8-13 regarding assessment requirements and utilization of revised assessment. Training documentation will be submitted. 10/01/2012 Implemented
6400.181(e)(14)RNC. Individual #1's assessment dated 9-21-12 did not include individual's knowledge of water safety and ability to swim. Partially implemented - adequate progress - cs - 3/5/13.(13) The individual's progress over the last 365 calendar days and current level in the following areas: (14) The individual's knowledge of water safety and ability to swim. The DAT (Development Assessment Tool) has been revised to include the regulations outlined in 6400.181 (e)(1), (e)(2), (11) and (14). Copies of the revised sections were submitted. Assessments, using the revised assessment tool which includes water safety knowledge and ability to swim, were completed for two individuals on 11-12-12 and 1-5-13 respectively and were submitted. Program Managers are responsible to review and ensure that revised assessment tools are completed in their entirety. Program managers and coordinators will be trained on 3-6-13 and 3-8-13 regarding assessment requirements and utilization of revised assessment. Training documentation will be submitted. 10/01/2012 Implemented
6400.186(b)The program specialist (Staff #1) and Individual #1 did not sign and and date the signature sheets for reviews of Individual #1's ISP completed on 1-5-12, 4-5-12, and 7-5-12. Partially implemented - adequate progress - cs - 3/5/13(b) The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. Quarterly Report Protocol dated October 1, 2012 was developed to clarify requirements of 3-month ISP reviews including signing and dating by program specialist and individual. Signed and dated ISP reviews for Individual #1 for periods 7/5/12 to 10/4/12 and 10/5/12 to 1/4/13 were submitted. Program managers and coordinators will be trained on new protocol on 3-6 and 3-8-13 and training documentation will be submitted. Per the new protocol, the Clinical Director is responsible to review and approve the completed ISP-reviews, and program managers are responsible to ensure that 3-month ISP reviews signed and dated by the individual. 10/01/2012 Implemented
6400.186(e)The program specialist (Staff #1) did not notify Individual #1's plan team members of the option to decline the documentation of ISP reviews. Partially implemented - adequate progress - cs - 3/5/13.(e) The program specialist shall notify the plan team members of the option to decline the ISP review documentation. Team members have been notified and declination letters are in the casefile. Copies of declination letters sent to Individual #1's plan team members were submitted. Program managers (i.e. program specialists) will be trained on 3-6-13 and/or 3-8-13 regarding requirement to notify plan team members of option to decline ISP review documentation. Training documentation will be submitted. Residential Services Director is responsible to insure implementation of declination notices. 12/01/2012 Implemented
6400.195(c)On 9-26-12, the restrictive procedure review committee did not review Individual #1's restrictive procedure plan at least every 6 months. The last review was dated 11-8-11. Partially implemented - adequate progress - 3/6/13.(c) The restrictive procedure plan shall be reviewed, and revised, if necessary, according to the time frame established by the restrictive procedure review committee, not to exceed 6 months. The restrictive procedure plan was reviewed by the Human Rights Committee on 10/9/2012. The next review will be 4/9/2013. Copy of review of restrictive procedure plan on 10/9/12 submitted. Clinical Director is responsible to schedule and insure that reviews occur at least every 6 months. Residential Services Director will re-train Clinical Director on requirement during 3/13 and submit documentation of training. 10/31/2012 Implemented
SIN-00237944 Renewal 01/23/2024 Compliant - Finalized
SIN-00170822 Renewal 02/12/2020 Compliant - Finalized