Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00199879 Renewal 02/08/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.52(c)(3)The annual training for training year, April 1, 2020 to March 31, 2021, for Chief Executive Officer #1 did not encompass individual rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.1. What we did to correct? o CEO completed the required training focusing on individual rights on 2/9/22. 02/14/2022 Implemented
6400.165(b)Individual #1's February 2022 Medication Administration Record includes, "Tussin DM SYP 100-10/5, take 1 TSP (5ML) orally every 4 hours as needed for cough." This medication was not present in the home on 2/9/2022. There was another medication labeled, "Mucus Relief DM Tablets," in Individual #1's medication box.A prescription order shall be kept current.1. What we did to correct? o Tussin was re-ordered from Mainline Pharmacy and delivered on 2/9/22 to individual¿s #1 home. 02/14/2022 Implemented
SIN-00167312 Renewal 12/03/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(3)Individual #1 had a Tetanus and Diphtheria vaccination completed 7/30/09 and then again 9/16/19.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. LSS Consumer medical tracker currently utilized. Additional column added to list out not only the date of the last Tetanus and Diphtheria, but the date of the future due date of Tetanus and Diphtheria. Wellness Coordinators will manage, Compliance Coordinator will review, Program Director and Executive Program Director will also review to ensure compliance. An email will be sent at the beginning of each month by Compliance Coordinator to Wellness and Directors listing anyone due for the next month. [Wellness Coordinator was educated on the aforementioned process and tracking system on 12/11/19. At least quarterly for 1 year, a designated management staff person shall audit the aforementioned tracking system and a 25% sample of individuals' documentation of completed immunizations to ensure completion, timely. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 12/26/19)] 12/16/2019 Implemented
6400.195(b)The behavior support component of the restrictive procedure plan for Individual #1 was reviewed by the human rights team on 4/24/19 and then again 10/30/19.The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews.Human Rights Restrictive Committee 2020 meetings will be revised. All Human Rights Committee meetings will be held on the third Wednesday of the month to ensure compliance with 6 months. If a meeting is changed for any reason, the next 6 month meeting will be moved up as well to be in compliance. The first meeting was held on 12/18/19. [At least quarterly for 1 year, a designated management staff person shall audit the "Human rights restrictive committee 2020 meeting dates" document (provided to Department) and a 25% sample of reviews and revisions of behavior supports to ensure completion, timely. Documentation of audits shall be kept. (DPOC by AES,HSLS on 12/26/19)] 12/18/2019 Implemented
SIN-00052184 Renewal 10/21/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(b)There is a ditch on the left side of the driveway that is approximately 6 feet 6 inches long by 3 feet wide and 2 feet deep that presents an unsafe condition.(b) The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. A water leak was suspected on neighboring property. Alverda Community Water Association authorized the digging adjacent to the 25 Maple Avenue property in order to assess the leak. This ditch/hole has since been filled by the municipality on 10/30/2013. See attached letter from the Water Authority and photo of the site of the hole which is now filled. 11/01/2013 Implemented
6400.101The hallway door that opens into the garage is equipped with a locking mechanism that presents an entrapment hazard.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Locking mechanism on this door was changed so there is no longer an entrapment hazard for this exit. See attached photos. 11/01/2013 Implemented
SIN-00235826 Renewal 12/07/2023 Compliant - Finalized
SIN-00107518 Renewal 01/24/2017 Compliant - Finalized