Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00216715 Renewal 12/20/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(f)Individual #1 is diagnosed with hearing loss in both ears and is prescribed hearing aids. Individual #1's bed does not contain a bed shaker. If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. Individual #1 has agreed to have a bed shaker placed in her bed. We are currently working with our contracted security company to have this placed in the home professionally to ensure that the bed shaker is linked in with the current fire system. 01/30/2023 Implemented
SIN-00168220 Renewal 12/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.169(d)Direct Services Worker #1, date of hire 10/27/15, who administers medications, does not have documentation of qualifications to administer medications.A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.Documentation of the original date of certification of 11/11/2015 for DSP Jesse James were recovered from Training Manager Jim Robertson. [Immediately and at least quarterly for 1 year, the CEO or designee shall audit all staff persons records to ensure all staff persons who administer medications have a record of their qualifications to administer medications. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 1/23/20)] 01/22/2020 Implemented
SIN-00148623 Renewal 01/16/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill record for the fire drills held from 12-19-17 to 12-16-18 documented the front door as the exit route used. The home as two doors in the front of the home.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. Manager has done an monthly chart alternating the dates, times, days and routes of fire drills. Also an January 2019 drill was done using an different door. [At least quarterly for 1 year, the CEO or designee shall audit at least a 10% sample of fire drill records to ensure fire drills are held and documented as required. Documentation of audits shall be kept. Within 60 days of receipt of the plan of correction, the CEO or designee shall train all staff persons who are responsible for conducting and reviewing fire drill records of the requirements of fire drills as per 6400.112(a)-(I). In addition, all fire drills shall be unannounced and those aware of the aforementioned chart shall not participate in fire drills. (DPOC by AES,HSLS on 3/5/19)] 01/28/2019 Implemented
6400.141(c)(7)Individual #1, date of birth 6-12-1960, date of admission 2-20-18 had an initial gynecological examination completed on 1-14-19.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. Manager will review all paperwork prior to admission in our agency to ensure completeness. UCIP will not admit anyone without all regulatory paperwork being done prior to admission. [Within 30 days of receipt of the plan of correction, the CEO or designee shall train all staff persons responsible for auditing physical examinations of the requirements of individual physical examinations as per 6400.141(a)-(c)(1)-(15) to ensure all individuals' physical examinations are completed, timely, with all required information, there are not any areas of required information left blank and individual health care is provided and arranged for. Documentation of trainings and aforementioned audits shall be kept. (DPOC by AES,HSLS on 3/5/19)] 01/28/2019 Implemented
6400.141(c)(8)Individual #1, date of birth 6-12-1960, date of admission 2-20-18 had an initial mammogram on 4-3-18.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. Manager will review all paperwork prior to admission in our agency to ensure completeness. UCIP will not admit anyone without all regulatory paperwork being done prior to admission.[Within 30 days of receipt of the plan of correction, the CEO or designee shall train all staff persons responsible for auditing physical examinations of the requirements of individual physical examinations as per 6400.141(a)-(c)(1)-(15) to ensure all individuals' physical examinations are completed, timely, with all required information, there are not any areas of required information left blank and individual health care is provided and arranged for. Documentation of trainings and aforementioned audits shall be kept. (DPOC by AES,HSLS on 3/5/19)] 01/28/2019 Implemented
SIN-00088523 Renewal 01/12/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill record dated 5/14/15 did not indicate whether the drill occured in the AM or PM.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. Program Specialist will check fire drills to make sure all information is complete. They will sign off on them, then send to their Manger for his review. This will be done on an monthly basis. [At least quarterly, the CEO or Director of Residential will review at least 25% sample of community home monthly fire drill records to ensure review of all fire drills records is being completed by the program specialist to ensure fire drill records include all required information. Documentation of all fire drill record reviews shall be kept. (AS 5/4/16)] 04/21/2016 Implemented
SIN-00096979 Renewal 01/12/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(g)The fire drill record dated 5/14/15 did not indicate whether the drill occured in the AM or PM. Fire drills shall be held on different days of the week and at different times of the day and night. 4.21.16 Program Specialist will check fire drills to make sure all information is complete. They will sign off on them, then send to their Manger for his review. This will be done on an monthly basis. [At least quarterly, the CEO or Director of Residential will review at least 25% sample of community home monthly fire drill records to ensure review of all fire drills records is being completed by the program specialist to ensure fire drill records include all required information. Documentation of all fire drill record reviews shall be kept. (AS 5/4/16)] 04/21/2016 Implemented
SIN-00113073 Unannounced Monitoring 03/20/2017 Compliant - Finalized
SIN-00041217 Renewal 08/22/2012 Compliant - Finalized