Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00243776 Renewal 04/23/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)An unknown liquid was stored in an unlabeled plastic bottle on the kitchen sink, which should be locked or made inaccessible to individuals.Poisonous materials shall be kept locked or made inaccessible to individuals. The unlabeled plastic bottle was removed from the site on 4/24/2024. 07/01/2024 Implemented
6400.66There was no outside light for exit outside of individual #1's bedroomRooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. A work order was submitted on 4/24/2024 to have an exterior light installed. The work was completed on 5/2/2024 (Attachments #15 and #16). 06/30/2024 Implemented
6400.70The house phone not easily accessible to individuals and was kept locked in the staff office.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. The house phone was moved outside the office area into the common area accessible to all individuals and staff on 4/25/2024 (Attachment #17). 07/01/2024 Implemented
6400.113(a)The most recent fire safety training for individual #1 was late. The two most recent trainings occurred on 9/16/22 and 10/5/23 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. The Program Specialist will ensure Individual #1 has their next fire safety training on or before 10/5/2024. 07/31/2024 Implemented
6400.34(a)Individual Rights for individual #1 did not have a date so it cannot be determined if he received the training within the last year. The most recently dated one occurred on 4/15/22The 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.We are unable to resolve this citation at this time as Individual #1 was hospitalized on 5/8/2024 and has been diagnosed with an end-stage diagnosis. If Individual #1 is discharged and experiences a substantial improvement in their condition, the Program Specialist will review their individual rights with them. 07/31/2024 Implemented
SIN-00159125 Renewal 07/16/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The kitchen cabinets located over the stove were found greasy to the touch.Clean and sanitary conditions shall be maintained in the home. The kitchen cabinets cleaned of grease. See attachments # 47. The House Supervisor is responsible to conduct monthly Physical Plant Walk-Through of home. The form includes ¿kitchen counter and cabinets are free of grease.¿ Form is to be given to Program Manager by 10th of each month. See attached procedure for physical Plant Walk-Through # 04 and completed form attachment # 44. 07/23/2019 Implemented
6400.67(a)The kitchen countertop was found damagedFloors, walls, ceilings and other surfaces shall be in good repair. Program Director has requested quote for counter top replacement. See attachments # 46. The Program Manager has placed cutting boards in the home. The House Supervisor is responsible to conduct monthly Physical Plant Walk-Through of home. The form includes ¿Kitchen counters are free of damage.¿ Form is to be given to Program Manager by 10th of each month. See attached procedure for physical Plant Walk-Through # 04 and completed form attachment # 44. 09/09/2019 Implemented
6400.67(b)The living room sofa had torn covers. Floors, walls, ceilings and other surfaces shall be free of hazards.Program Director has ordered new furniture. To be delivered by 9-19-19. See attachments #45. The House Supervisor is responsible to conduct monthly Physical Plant Walk-Through of home. The form includes ¿all furniture is clean & in good repair.¿ Form to be given to Program Manager by 10th of each month. See attached procedure for physical Plant Walk-Through # 04 and completed form attachment # 44. 09/19/2019 Implemented
6400.67(b)The bathroom shower rod had endcaps that were rusted. Floors, walls, ceilings and other surfaces shall be free of hazards.: Shower rod and end caps were replaced. See attachments # 43. The House Supervisor is responsible to conduct monthly Physical Plant Walk-Through of home. The form includes ¿Shower area is clean.¿ Form is to be given to Program Manager by 10th of each month. See attached procedure for physical Plant Walk-Through # 04 and completed form attachment # 44. 07/23/2019 Implemented
6400.181(a)Individual #1's record did not contain an assessment. 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. All Program Specialist are re-trained regarding 6400.181 (a),(f) It is the responsibility of the Residential Program Specialist to confirm the completion of the initial and annual assessment for individuals. This includes individuals who are new admissions to the residential program. The Residential Program will continue monthly Case Record Review process in order to maintain compliance with regulations. See Attachment #41. The Residential Assistant Director is responsible to collect the monthly sample of case record reviews and report to the Director the percentage of compliance. All Program Specialist will be responsible to make all corrections and report to Residential Assistant Director a monthly update on progress towards compliance. See 2019 Assessment, Attachment # 42. 09/09/2019 Implemented
6400.213(1)(i)Individual #1's record was missing Religious affiliation. Individual #1's record was missing identifying marks.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.All Program Specialist were re-trained regarding 6400.213(1) (I) and (I) (iv) on 7-31-19. CS, Quality Assurance Director, provided instruction. It is the responsibility of Residential Program Specialist to confirm the completion of Personal Information form for individuals. This form is printed from CADES EPESI electronic data system. The Residential Program will continue monthly CASE Record Review process in order to maintain compliance. Thirty records will be reviewed monthly. Every chart is to be reviewed quarterly. 94 records reviewed: 89% compliance (Identifying Marks), 64% compliance (religion) as of 8-30-19. The Residential Assistant Director is responsible to collect the monthly sample of case record reviews and report to the Director the percentage of compliance. All Program Specialist are responsible to make all corrections and report to Residential Assistant Director monthly on progress towards compliance. Individual #1 Personal Information was updated and includes Religion and Identifying marks. See attachment Broadleaf # 40 and Procedure #41. 08/22/2019 Implemented
SIN-00130233 Renewal 02/20/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The concrete floor on the back porch was cracked and needed to be repaired.Floors, walls, ceilings and other surfaces shall be in good repair. The cracks on the back porch were repaired by contractor on 3-15-18. It is the responsibility of the Direct Support Professionals, Team Manager and Program Manager to report repairs in electronic work order system. Repair request are completed by sub-contractor and monitored by Residential Assistant Director. 03/15/2018 Implemented
6400.110(a)The smoke detector in the attic was inoperable due to dead battery. The battery was replaced during inspection and the smoke detector became operable. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. It is the responsibility of the Team Manager and Program Manager to check all smoke detectors monthly. Inspections are documented and monitored by Assistant Director. 02/28/2018 Implemented
6400.151(c)(2)Staff #1 was hired on 6/19/17 before completing a TB screening. The TB Screening was completed on 7/10/17. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. It is the responsibility of the Human Resources Director to monitor all new employee documents including a completed physical with results of TB test and/or initial chest x-ray results noted. Staff #1 had his initial physical and TB test. He did not return for reading of TB test for results. Staff #1 had another TB test conducted which was read negative on 7-7-17. HR Department will review all compliance documents on-going. 02/23/2018 Implemented
SIN-00108163 Renewal 02/01/2017 Compliant - Finalized