Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00220680 Renewal 02/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The home's self-assessment, completed on 2/1/23, the agency certificate of compliance expires 8/27/2023.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. LIIs are scheduled to be completed beginning on the week of 3/20/23. Once completed, the LIIs will be turned into the Director of Compliance for review and to maintain. 05/27/2023 Implemented
6400.104The home's Local Fire Department Notification Letter did not include the exact location of the individuals' bedrooms.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Letters to the local Fire Department were updated to include bedroom locations and mailed on 3/20/23. All supervisors were instructed to review their letters and confirm that they include the location of bedrooms and are accurate with the needs of the individuals no later than 3/17/23. 03/20/2023 Implemented
6400.141(c)(9)Individual #1 had prostate examinations completed 1/5/22 and then 1/25/23.The physical examination shall include: A prostate examination for men 40 years of age or older. All Site Supervisors were instructed to report the last PSA date to Res Management no later than 3/24/23. 03/24/2023 Implemented
6400.165(g)Individual #1 is prescribed psychotropic medication. Individual #1 had a three-month medication review by a licensed physician on the following dates: 2/9/22, 2/10/22, 7/29/22, and 2/9/23.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.All Site Supervisors were instructed to report the last psychiatric completion date to Res Management no later than 3/31/23. Res Management will maintain physical dates and confirm that psychiatric appointments for 2023 are scheduled within annual time frames and monitor due dates. 03/31/2023 Implemented
SIN-00184015 Renewal 02/23/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace was inspected on 9/27/19 and then again 12/01/20.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The Director of Res spoke to the Maintenance Director regarding time frames for annual furnance inspections. A tentative date was scheduled for furnace inspections for 2021 in September. Furnance inspections will be added for discussion to the Health and Safety agenda for the September and October meetings as a reminder for upcoming inspections and subsequent review of completed inspections by the Health and Safety Committee.[Documentation of all audits and trainings shall be kept (DPOC by RM, HSLS on 3/25/2021)] 03/10/2021 Implemented
6400.151(c)(1)Direct Service Worker #1's physical examination completed, 3/12/20 did not include the results of the general physical examination. This section was left blank. The physical examination shall include: A general physical examination. The annual physical for DSP #1 has been scheduled. Upon completion of the DSPs physical, the documentation will be reviewed by the Director of Residential for completion. Every quarter for the next year, 10% of completed staff physicals will be reviewed for completion by the Director of Residential. Documentation of the reviews will be kept.[Documentation of all audits and trainings shall be kept (DPOC by RM, HSLS on 3/25/2021)] 03/15/2021 Implemented
6400.46(b)Direct Service Worker #1 had fire safety training on 3/15/19 and then again on 8/10/20. [repeat violation 10/22/19]Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).All DSP fire safety trainings were reviewed. Site Supervisors were trained on the expectations for training timelines on 3/1/21. Quarterly, for the next year, 10% of staff records will be reviewed by the Assistant Director of Residential to confirm their fire safety training due date and, if due, the training was completed. Documentation of every review will be kept.[Documentation of all audits and trainings shall be kept (DPOC by RM, HSLS on 3/25/2021)] 03/01/2021 Implemented
6400.46(d)Direct Service Worker #1 most recently had training in first aid, Heimlich techniques and cardio-pulmonary resuscitation by a certified trainer on 7/10/18.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.CPR/First Aid in person trainings are resuming in April 2021. All employees whose certification has expired during the pandemic have been identified and will be trained in one of the multiple offerings in April. The Res Director will review all of the class sign in sheets to ensure all DSPs attend and complete training who require the training. Regular in-person CPR/First Aid classes resume in May 2021. Every quarter for the next year, the Res Director will review training records to ensure all DSPs are maintaining CPR/First Aid training.[Documentation of all audits and trainings shall be kept (DPOC by RM, HSLS on 3/25/2021)] 04/01/2021 Implemented
SIN-00086539 Renewal 11/09/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water temperature at the bathtub in the bathroom near Individual #1's bedroom was 134.7 degrees Fahrenheit at 10:28 AM. Hot water temperatures in bathtubs and showers may not exceed 120°F. Water temperatures will be checked weekly in all sites..[The CEO or designee will immediately check all the water temperatures in all the homes, if any of the temperature are above 120 degrees Fahrenheit then water temperature will be taken at least daily until 120 degrees Fahrenheit or below for 7 days and then taken weekly as specified in aforementioned POC. All water temperatures will be recorded and maintained and reviewed by the CEO or designee at least quarterly. Within 30 days of receiving the Inspection Summary, the CEO or designee will develop procedures for staff who are taking water temperatures to follow for taking temperature and to follow if water temperatures exceed 120 degrees Fahrenheit. Staff will be educated on the procedures, documentation of education will be maintained. (AS 11/24/15)] 11/28/2015 Implemented
SIN-00089174 Unannounced Monitoring 11/09/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.45(e)On 8/8/2015, at 3:32 AM, Direct Service Worker #1 left Individual #1 home without supervision to complete ATM transaction.An individual may not be left unsupervised solely for the convenience of the residential home or the direct service worker.As a result of the allegation that DSW #1 left individual #1 without supervision to use the ATM, the target was immediately suspended, pending the results of an investigation. DSW #1 resigned during the course of the interview with the Certified Investigator, therefore, the allegation was never confirmed that the target had left the site. Had the allegation been founded and the DSW #1 had not resigned, appropriate disciplinary action would have been implemented. All DSWs receive staff effectiveness/positive approaches training upon hire and annually thereafter. This training details appropriate techniques to use with the individuals, as well as job performance expectations. All staff at the site will be retrained on the individual¿s ISPs by 2/29/16, focusing on the need for 24 hour supervision.[Within 60 days of receipt of the plan of correction, the program specialists will train all direct services workers at all community homes on each of the individuals' supervision needs with whom the direct services workers are providing care. Documentation of training shall be kept and reviewed by the CEO for completion and to ensure all staff are providing the required supervision for all individuals in the community homes. (AS 3/30/16)] 02/14/2016 Implemented
6400.46(d)Direct Service Worker #1 had 17.5 hours of training in training year, 1/1/2014 to 12/31/2014.Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. A new tracking spreadsheet was developed by the Residential Program Specialist, with a focus on total training hours and due dates for trainings on a quarterly basis. The 2016 training curriculum for new and current staff was updated and distributed to Site Supervisors, with a corresponding training binder with documents and resources for trainings. Site Supervisors were given a checklist to complete quarterly to ensure that trainings are completed by DSWs throughout the 2016 training year at their monthly Site Supervisor¿s meeting on 2/10/16.[At least quarterly, the Residential Program Specialist or designated management staff person will review the new tracking spreadsheet and training binders to ensure completion and program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually.(AS 3/30/16)] 02/14/2016 Implemented
6400.185(b)Direct Service Worker #1 was sleeping while on shift at from approximately 8:30 AM until 9:10 AM on 8/8/2015. Individual #1's Bi-annual review ISP approved 6/3/2015 reads "[Individual #1] needs 24 hour (awake overnight) supervision in the home to ensure his safety. [Individual #1] has a ratio of 1:3 overnight."The ISP shall be implemented as written.Upon the report that DSW #1 was sleeping, an investigation was conducted for neglect ¿failure to provide needed supervision and the target was immediately suspended. The target, DSW #1 resigned during his investigative interview. Had the target not resigned, the target would have been terminated for a confirmed allegation of sleeping while on duty. Due to the needs of the individuals at the site, all DSWs at the site will be retrained in all of the ISPs by 2/29/16, with particular attention to the need for 24 hour awake supervision. [Within 60 days of receipt of the plan of correction, the program specialists will train all direct services workers at all community homes on each of the individuals' ISP with whom the direct services workers are providing care. Documentation of training shall be kept and reviewed by the CEO for completion and to ensure all staff implements ISPs as written. (AS 3/30/16)] 02/14/2016 Implemented
SIN-00125480 Renewal 12/04/2017 Compliant - Finalized
SIN-00054192 Renewal 09/24/2013 Compliant - Finalized