Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00170291 Renewal 02/27/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(f)The fire extinguisher located on the second floor of the home was most recently inspected by a fire safety expert in July 2018. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. On 2/27/20, at the time of inspection, Quality Assurance Manager, Beth Ann Puchalsky removed an extra 2A 10BC extinguisher from the first floor and placed it on the second floor for use. Moving forward we have initiated a practice of employing a House Visit Check List form that will be utilized on two levels of staff structure in the agency. House Supervisors and Administrative Staff will perform Physical Site checks weekly with documentation of that activity to prevent recurrence of the incident. 02/27/2020 Implemented
SIN-00150501 Renewal 02/21/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(a)The two walkways from the rear exits on Navajo were completely snow and ice covered. A maintenance crew was called and the problem was corrected at the time of inspection. . Outside walkways shall be free from ice, snow, obstructions and other hazards. The walkways were cleared of snow and ice at the Navajo location while the Inspector was on site. The COO went to each house in operation at the agency immediately, (2-21-19) and inspected each egress pathway from the homes. On 2-21-19, the COO, Mr. Colville Brown trained the maintenance team to clear all means of egress walkways, from every home, on an on going basis, as snow and ice present themselves. On 2-25-19, The agency Supervisors and the Administrative Team were educated in the practice of visually checking each means of egress, from each home in operation, when snow and ice present themselves. If clearance is needed the staff in the homes; or the maintenance team will clear the walkways immediately. This training and observation practice will continue for the upcoming year and be incorporated into daily operations permanently. 02/25/2019 Implemented
6400.163(c)Individual #1's initial med review was on 07-02-18, then not again until 12-20-18. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Individual #1's medication was discontinued by the Psychiatrist on 12-20-18. The agency has implemented an Administrative Review Team process starting on 2-26-19. The AR Team will meet bi-weekly, for a time frame of no less than one year, to review the medication categories, reasons for prescribing, ISP documentation content, and daily progress notes for each individual. The Admin Review Team will measure the presenting documentation for compliance with regulation 6400.163(c). On 2-26-19, the Administrative Staff were trained to review the adherence to Psychotropic Medication reviews for each applicable individual. 02/26/2019 Implemented
SIN-00218660 Renewal 03/28/2023 Compliant - Finalized
SIN-00201455 Renewal 04/14/2022 Compliant - Finalized
SIN-00150687 Change in Location Capacity 02/21/2019 Compliant - Finalized
SIN-00089394 Renewal 03/02/2016 Compliant - Finalized
SIN-00071141 Renewal 02/19/2015 Compliant - Finalized
SIN-00057436 Renewal 12/04/2013 Compliant - Finalized