Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00100981 Renewal 09/01/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.186(b)The ISP reviews for the following time periods: 8/17/15-11/7/15, 11/7/15-2/4/16, 2/5/16-5/4/16 and 5/5/16-8/4/16 were not signed and dated by Individual #1. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. A procedure for change was written to ensure that the 3 month ISP is signed by the Program Specialist and individual. The procedure also contains a letter when the individual is unable to sign that states: As per ODP 6400 Regulations 186(b), the ISP 3 month review is to be signed by the Program Specialist and the individual. (Name) is unable to sign, therefore, as his/her (blank to list Legal Guardian, etc), we need your signature. Please complete the bottom section and sign. I have included a self-addressed stamped envelope for you to return this sheet to our office by (date) Note: The bottom section of the form is a check off if they agree with review or disagree with comments and place for signature and date. This procedure went into effect today, 9/28/16 and will remain in effect on-going over a substantial period of time per regulation. This change was made by the Program Specialist and approved by the Executive Director. This procedure will be added to the Policy and Procedure Manual to be followed by staff for all 3 month ISP reviews so the violation will not occur again. The Program Specialist received training for this procedure on 09/28/16. A copy of the Procedure, Letter and Training Documentation will be sent via e-mail to BHSL. [Within 30 days of receipt of the plan of correction, the program specialist shall review the last four quarterly reviews for all individuals to ensure the program specialist and the individuals reviewed the ISP review and signed and dated upon review. At least bi-annually the Executive Director shall review a 25% sample of ISP reviews to ensure the program specialist and the individual have signed and dated the ISP review upon review of the ISP. Documentation of all reviews shall be kept.(AS 10/4/16)] 09/28/2016 Implemented
SIN-00077930 Renewal 09/09/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment did not include a completion date; therefore, compliance was unable to be measured.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. A procedure will be written and staff trained that the Executive Director will disburse the current Licensing Inspection Instrument Scoresheet Facility Chapter 6400 Community Homes annually on or before January 19th which is 6 months prior to the expiration date of the Certificate of Compliance. The inspection instruments will be due from the following positions on or before March 31st: Residential Program Supervisor and Program Specialist. The inspection instrument will be due from the Administrative Officer who completes the Staffing section including the training requirements in Regulation 46 and Staff Health including physicals on or before April 15th which is approximately 3 months prior to the expiration of the Certificate of Compliance. The Executive Director will ensure the deadlines are met and then compile the data into one scoresheet for each residential home on or before April 18th which is 3 months prior to the expiration date. 10/04/2015 Implemented
SIN-00232244 Renewal 10/03/2023 Compliant - Finalized
SIN-00213319 Renewal 10/19/2022 Compliant - Finalized
SIN-00196572 Renewal 11/22/2021 Compliant - Finalized
SIN-00180244 Renewal 12/17/2020 Compliant - Finalized
SIN-00161210 Renewal 08/20/2019 Compliant - Finalized
SIN-00140659 Renewal 08/28/2018 Compliant - Finalized
SIN-00120687 Renewal 08/30/2017 Compliant - Finalized
SIN-00062978 Renewal 09/04/2014 Compliant - Finalized
SIN-00052535 Initial review 09/04/2013 Compliant - Finalized