Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00243146 Renewal 04/18/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.113(a)Direct Service Worker #1 had a physical examination completed on 11/5/21 and then again 1/19/24.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 persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.Direct Service Worker #1 obtained a physical examination on 1/19/24 and will complete the next physical examination prior to 1/18/26. 04/23/2024 Implemented
2380.21(u)Individual #1 was informed of the individual rights on 6/21/22 and then again 8/3/23. Individual #2 was informed of the individual rights on 4/6/22 and then again 5/2/23.The facility 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 facility and annually thereafter.The remaining individuals that were not part of the sample were reviewed 4/19 - 4/22 to document their annual review dates. All individuals in the program will have their rights reviewed no later than 4/26/24. 04/26/2024 Implemented
SIN-00224924 Renewal 05/16/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #1 had a physical examination on 11/26/2021 and then again on 12/19/2022.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.A new Physical Exam Checklist will be developed by 6/15/23. The Program Specialist(s) will complete the checklist after receiving a completed physical from any individual, as needed. 06/15/2023 Implemented
2380.111(c)(1)Individual #1's physical examination, completed 12/19/2022, does not include a review of previous medical history.The physical examination shall include: A review of previous medical history.A new Physical Exam Checklist will be developed by 6/15/23. The Program Specialist(s) will complete the checklist after receiving a completed physical from any individual, as needed. 06/15/2023 Implemented
2380.111(c)(5)Individual #1 had a Tuberculin Skin Testing by Mantoux Method completed on 1/29/2021 and then again on 3/1/2023.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.A new Physical Exam Checklist will be developed by 6/15/23. The Program Specialist(s) will complete the checklist after receiving a completed physical from any individual, as needed. 06/15/2023 Implemented
2380.111(c)(10)Individual #2's physical examination, completed 4/22/2023, does not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.A new Physical Exam Checklist will be developed by 6/15/23. The Program Specialist(s) will complete the checklist after receiving a completed physical from any individual, as needed. 06/15/2023 Implemented
2380.36(b)Program Specialist #1 was trained in fire safety on 2/10/2022 and then again on 3/8/2023. Direct Service Worker #2 was trained in fire safety on 2/10/2022 and then again on 3/8/2023.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).The Program Supervisor will ensure all current staff fire safety training is updated by 6/15/23. 06/15/2023 Implemented
SIN-00122166 Renewal 10/11/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(10)Individual #1's physical examination, completed on 4/13/17, did not include medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Effective immediately, the SC waiver physical will not be accepted as it is not compliant with 2380 regulations. A memo was added to the notice that is mailed to all individuals 2 months prior to the expiration of the physical stating that the SC physical will no longer be accepted, in addition to the physical form that is used by the agency that meets all licensing requirements. [Upon completion, the CEO or designated staff person (who is educated in the requirements of physical examinations as per 2380.111(c)(1)-(11)) shall review all individuals' physical examination documentation to ensure all required information is included as per 2380.111(c)(1)-(11). Documentation of the audits shall be kept. (AS 11/7/17)] 10/26/2017 Implemented
2380.181(f)The program specialist did not provide Individual #2's assessment, completed 12/29/16, to all plan team members, specifically the In-Home/Community Support provider.The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).The functional assessment was sent to the In Home/Community Supports provider on 10/27/17. All records were audited by the Program Director on 10/26/17 to ensure that the entire team is receiving reviews and functional assessments, based on the ISP Sign in sheet for the current plan year. 10% of records will be audited by the Program Director monthly to ensure that all team members who attended the individual¿s ISP meeting will receive reviews and functional assessments. Documentation of the audits will be maintained at the site.[Not Acceptable. (AS 11/7/17)] [Immediately, the CEO or designated management staff person shall train the program specialist in the responsibilities of the program specialist position as per 2380.33(b)(1)-(19). Documentation of the training shall be kept. Prior to providing individuals' assessments to individuals' plan team members the program specialist shall the review the individuals' records to include ISPs, invitation letters and other documentation to ensure the program specialist provides individuals' assessments to all plan team members. The program Director shall audit 10% of the correspondence documentation to ensure the program specialist has provided individuals' assessments to all plan team members as required. (AS 11/7/2017)] 10/26/2017 Implemented
2380.186(b)Individual #3 did not sign and date the ISP review end dated 4/4/17.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.The review was reviewed with the individual on 10/12/17 and was signed. All records were audited Program Director on 10/26/17 to ensure that they were all completed. The program staff were retrained on the requirements for ISP review signatures. 10% of records will be audited by the Program Director monthly to ensure that all reviews are signed within proper time frames. Documentation of the audits will be maintained at the site. [Immediately, the CEO or designated management staff person shall train the program specialist in the responsibilities of the program specialist position as per 2380.33(b)(1)-(19). Documentation of the training shall be kept. (AS 11/7/17)] 10/26/2017 Implemented
2380.186(d)The program specialist did not provide Individual #2's ISP reviews end dated 11/30/16, 3/1/17, 6/1/17, and 8/30/17 to all plan team members, specifically the In-Home/Community Support provider.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.All reviews were sent to the In Home/Community Supports provider on 10/27/17. All records were audited by the Program Director on 10/26/17 to ensure that the entire team is receiving reviews and functional assessments, based on the ISP Sign in sheet for the current plan year. 10% of records will be audited by the Program Director monthly to ensure that all team members who attended the individuals ISP meeting will receive reviews and functional assessments. Documentation of the audits will be maintained at the site. [Not Acceptable. (AS 11/7/17)] [Immediately, the CEO or designated management staff person shall train the program specialist in the responsibilities of the program specialist position as per 2380.33(b)(1)-(19). Documentation of the training shall be kept. Prior to providing individuals' ISP review documentation to individuals' plan team members the program specialist shall the review the individuals' records to include ISPs, invitation letters, option to decline documentation and other documentation to ensure the program specialist provides individuals' ISP review documentation to all plan team members. The program Director shall audit 10% of the correspondence documentation to ensure the program specialist has provided individual's IPS review documentation to all plan team members as required. (AS 11/7/2017)] 10/26/2017 Implemented
2380.186(e)The program specialist did not notify all of Individual #2's plan team members of the option to decline the ISP review documentation, specifically the In-Home/Community Support provider.The program specialist shall notify the plan team members of the option to decline the ISP review documentation.All reviews were sent to the In Home/Community Supports provider on 10/27/17. All records were audited by the Program Director on 10/26/17 to ensure that the entire team is receiving reviews and functional assessments, based on the ISP Sign in sheet for the current plan year. 10% of records will be audited by the Program Director monthly to ensure that all team members who attended the individuals ISP meeting will receive reviews and functional assessments. Documentation of the audits will be maintained at the site.[POC does not address the violation and not acceptable. Immediately, the Program specialist shall notify Individual #1's In-home/community support provider of the option to decline the IPS review. Immediately, the program director shall audit all individuals' records including ISPs, invitation letter and other information to ensure the program specialist has notified all plan team members of the option to decline ISP review documentation and correspondence documentation is kept. (AS 11/7/17)] 10/26/2017 Implemented
SIN-00205882 Renewal 06/02/2022 Compliant - Finalized
SIN-00188395 Renewal 06/09/2021 Compliant - Finalized
SIN-00162867 Renewal 09/19/2019 Compliant - Finalized
SIN-00142233 Renewal 09/27/2018 Compliant - Finalized
SIN-00101829 Renewal 10/06/2016 Compliant - Finalized
SIN-00083207 Initial review 09/24/2015 Compliant - Finalized