Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00232944 Renewal 09/26/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill record for the fire drill conducted on 02/12/23 did not include the time it took for evacuation from the site.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. Residential homes managers will be responsible for conducting and documenting all fire drills to ensure accuracy of forms and compliance. 10/27/2023 Implemented
SIN-00196557 Renewal 11/18/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self assessment of the home.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. The Senior Residential Homes Managers will complete the self-assessment of their assigned homes by December 20, 2021. The Residential Director will review each plan prior to submission. 12/20/2021 Implemented
6400.112(c)The written fire drill record for the fire drill conducted on 01/19/21 did not include the time of day that the drill was conducted.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. The Compliance Coordinator will do a review of all fire drill reports received from the Residential Homes Coordinators and with the assistance of the Program Specialists will ensure all information is completed and correct, including day and time that the drill was conducted. 12/06/2021 Implemented
6400.52(c)(5)Direct Service Worker #1's annual training hours for July 1, 2020 through June 30, 2021 did not encompass: the safe and appropriate use of behavior supports.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.Direct Service Worker #1 will complete this training by 12/17/21. 12/17/2021 Implemented
6400.52(c)(6)Direct Service Worker #1's annual training hours for July 1, 2020 through June 30, 2021 did not encompass: implementation of the individual plan.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Direct Service Worker #1 will complete this training by 12/17/21. 12/17/2021 Implemented
6400.165(g)Individual #1 is prescribed medication to treat symptoms of a psychiatric illness. There was a medication review by a licensed physician on 05/07/21, and then again on 10/18/21, exceeding the 90-day requirement.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.Individual #1's next scheduled appointment is 1/14/2022, which is within 90 days from his last appointment on 10/18/21. 12/08/2021 Implemented
SIN-00160394 Renewal 08/08/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The fire drill held on 1/12/19 at 8:19 AM had an evacuation time of 3 minutes 10 seconds. The fire drill held on 5/6/19 at 2:00 AM had an evacuation time of 3 minutes. The home does not have an extended evacuation time in writing by a fire safety expert. [Repeat Violation 8/21/18, et. al.]Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home.Program specialists will work with quality compliance coordinator to ensure houses with evacuation times over 2 ½ minutes obtain yearly letters from the fire department allotting extra time for evacuation. Staff will be retrained to clearly understand that the drill time ends as soon as the last resident exits the home and not when they reach the designated meeting place. [Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff person responsible for conducting fire drills of the requirements of fire drill and the agency's policies and procedures if problems are encountered and fire drills are not conducted as required. Documentation of trainings shall be kept. At least quarterly for 1 year, the CEO or designee shall audit a 25% sample of fire drill records to ensure fire drill are held and documented as required. Documentation of audits shall be kept. (DPOC by AES,HSLS on 9/17/19)] 09/13/2019 Implemented
6400.166(a)(13)Individual #1's August 2019 medication administration record did not include the name for Direct Service Worker #1 that corresponded with the initials for medication administration.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.Staff will be retrained on how to complete MARS by the medication trainer. Staff will also implement a master list of signatures and initials at the front of the binder as an extra precaution to ensure the information is included. [On 9/13/19, the names and corresponding initials were observed on Individual #1's current medication administration record. All staff persons were reeducated on administering medications on 8/16/19. At least weekly for 3 months and then continuing at least monthly, a staff person certified to administer medication shall audit all individuals' current medication administration records, current medications and physicians' orders to ensure all individuals are administered medications as prescribed and documented as required. Documentation of all medications audits shall be kept. (DPOC by AES,HSLS on 9/17/19)] 09/01/2019 Implemented
6400.166(b)Individual #1's prescription medications Flexeril 10 mg, take 1 tablet by mouth 2 times a day as needed for muscle spasm, Calcium-Vitamin D3 500-400, take 1 tablet by mouth 2 times a day, Baclofen 10 mg, take 1 tab by mouth 2 times a day, Colace 100 mg capsule, take 1 capsule by mouth at bedtime, Senna Lax 8.6 mg, take 2 tabs by mouth at bedtime, and Nortriptyline HCL 10 mg cap, take 1 capsule by mouth at bedtime were initialed for the 8:00PM medication administration at 2:45PM on 8/8/19 by Direct Service Worker #1. Individual #1's prescription medication Topririmate administered from 8/1/19 to 8/7/19 at bedtime at 8:00PM was not initialed as administered.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Staff will be retrained on signing MARS by the medication trainer. [All staff persons were reeducated on administering medications on 8/16/19. At least weekly for 3 months and then continuing at least monthly, a staff person certified to administer medication shall audit all individuals' current medication administration records, current medications and physicians' orders to ensure all individuals are administered medications as prescribed and documented as required. Documentation of all medications audits shall be kept. (DPOC by AES,HSLS on 9/17/19)] 09/01/2019 Implemented
SIN-00140421 Renewal 08/21/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill record for the fire drill held on 10/16/17 does not include the exit used for evacuation. The written fire drill record for the fire drill held on 6/12/18 does not include the time it took for evacuation. The written fire drill record for the fire drill held on 9/17/17 does not include whether the fire alarm or smoke detector was operable. The written fire drill record for the fire drill held on 10/16/17 does not include whether the fire alarm or smoke detector was operable.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. Residential staff will be reinstructed on the proper completion of fire drills with a focus on completion of the drill form in it's entirety. In addition, completed fire drills will be reviewed and signed by the assigned Residential Homes Manager as well as the Coordinator of Residential Homes on a monthly basis. If errors are found, they will be addressed with the staff completing the drill and corrected before being placed in the fire drill log book[Documentation of the trainings and audits shall be kept. (DPOC by AES, HSLS on 10/9/18)] 10/12/2018 Implemented
SIN-00121259 Renewal 09/12/2017 Compliant - Finalized