Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00123113 Renewal 01/03/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Door to bathroom 1 had drywall patch approximately 3 inches in diameter. Flooring in hallway has crack in seam approximately 2 feet across which is pulling up. (Individual in home uses walker for mobility).Floors, walls, ceilings and other surfaces shall be in good repair. LSS Maintenance department will ensure the door is painted and the floor is repaired by 2/26/18. 02/26/2018 Implemented
6400.243(a)A menu was not prepared and accessible to individuals. Staff unable to locate menu during site inspection.A written daily menu shall be prepared and accessible to an individual.Compliance Coordinator spoke to Jim Richards concerning this citation as it does not apply to our agency. 01/29/2018 Implemented
SIN-00076360 Renewal 04/13/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(13)(iii)Individual #1's assessment did not show progress and growth over the last 365 calendar days and current level in activities of residential living.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. 1. LSS Case Coordinators is responsible to ensure the assessments include the individual¿s progress over 365 days and current level in activities of residential living. LSS Case Coordinators will indicate and/or be more specific when reporting progress and/or non-progress from year to year. LSS Case Coordinators will also specify reasons for progress and/or non-progress areas as well as what we will be done differently regarding interventions to help promote progress. 2. LSS Case Coordinators corrected Individula¿s#1 assessment summary which included more detailed progress and growth over the 365 days in regards to activities of residential living (see attached assessment). 3. LSS¿s Compliance Coordinator is responsible review individual¿s assessments ensuring regulatory requirements are met by communicating with LSS Case Coordinators on information needed to ensure compliance with the regulation. 05/07/2015 Implemented
6400.181(e)(13)(vii)Individual #1's assessment did not show progress and growth over the last 365 calendar days and current level in financial independence. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. 1. LSS Case Coordinators is responsible to ensure the assessments include the individual¿s progress over 365 days and current level in financial independence. LSS Case Coordinators will indicate and/or be more specific when reporting progress and/or non-progress from year to year. LSS Case Coordinators will also specify reasons for progress and/or non-progress areas as well as what we will be done differently regarding interventions to help promote progress. 2. LSS Case Coordinators corrected Individula¿s#1 assessment summary which included more detailed progress and growth over the 365 days in regards to financial independence (see attached assessment). 3. LSS¿s Compliance Coordinator is responsible review individual¿s assessments ensuring regulatory requirements are met by communicating with LSS Case Coordinators on information needed to ensure compliance with the regulation. 05/07/2015 Implemented
6400.181(e)(13)(viii)Individual #1's assessment did not show progress and growth over the last 365 calendar days and current level in managing personal property. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. 1. LSS Case Coordinators is responsible to ensure the assessments include the individual¿s progress over 365 days and current level in managing personal property. LSS Case Coordinators will indicate and/or be more specific when reporting progress and/or non-progress from year to year. LSS Case Coordinators will also specify reasons for progress and/or non-progress areas as well as what we will be done differently regarding interventions to help promote progress. 2. LSS Case Coordinators corrected Individula¿s#1 assessment summary which included more detailed progress and growth over the 365 days in regards to managing personal property (see attached assessment). 3. LSS¿s Compliance Coordinator is responsible review individual¿s assessments ensuring regulatory requirements are met by communicating with LSS Case Coordinators on information needed to ensure compliance with the regulation. 05/07/2015 Implemented
6400.181(e)(13)(ix)Individual #1's assessment did not show progress and growth over the last 365 calendar days and current level in community-integration. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.1. LSS Case Coordinators is responsible to ensure the assessments include the individual¿s progress over 365 days and current level in community integration. LSS Case Coordinators will indicate and/or be more specific when reporting progress and/or non-progress from year to year. LSS Case Coordinators will also specify reasons for progress and/or non-progress areas as well as what we will be done differently regarding interventions to help promote progress. 2. LSS Case Coordinators corrected Individula¿s#1 assessment summary which included more detailed progress and growth over the 365 days in regards to community integration (see attached assessment). 3. LSS¿s Compliance Coordinator is responsible review individual¿s assessments ensuring regulatory requirements are met by communicating with LSS Case Coordinators on information needed to ensure compliance with the regulation. 05/07/2015 Implemented
6400.187Individual #1's ISP approval letter and signature sheet was not provided to the plan team members within 30 calendar days after the ISP. The plan meeting was held on 8/7/2014 and the approval letter and signature sheet was received 9/9/2014. A copy of the ISP, including the signature sheet, shall be provided to plan team members within 30 calendar days after the ISP, annual update and ISP revision meetings. 1. LSS Case Coordinators is responsible to provide email reminders to the individuals SC¿s requesting a copy of the ISP, including the signature page sheet to be provided to all plan team members within 30 calendar days after the ISP, annual update and ISP revision meetings. 2. LSS Case Coordinator is responsible to send out an enclosure letter to all team members with a copy of the outcome goals attached within 30 days after ISP planning meeting (see attached letter). 05/07/2015 Implemented
6400.213(1)(i)Individual #1's record did not list next of kin. Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.1. LSS Case Coordinators is responsible to ensure to complete and/or update the consumers face sheet which identifies next of kin on a ¼ basis. 2. LSS Case Coordinators corrected Individual¿s #1 face sheet to include next of kin (see attached face sheet). 3. LSS face sheet was revised to include a picture of the consumer as well as a section at the bottom for dates when reviewed every 2 months (see attached face sheet). 4. LSS Medical Coordinator & LSS Case Coordinators are responsible to review the consumers face sheets every 2 months to ensure all information is updated and/or accurate. The face sheet will be re-dated on the bottom of the face sheet every 2 months. 05/07/2015 Implemented
SIN-00047777 Renewal 03/18/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #3 was scheduled for an appointment with the psychiatrist on 12/17/12 but was not seen until 2/4/13.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. 1. All scheduled psychiatric appointments will be identified on the individual's psychiatric appointment summary at the conclusion of each session. 2. LSS Medical Coordinator, Assistant Medical Coordinator, Behavioral Specialist and/or Executive Program Director will communicate with outpatient psychiatrist when an appointment occurs eithger at the physician office and/or via teleconference to ensure follow-up dates are confirmed. When an appointment needs to be re-scheduled for a particular reason, the medical department, Behavioral Specialist and/or Executive Program Director will ensure an appointment summary is completed indicating with the appointment was re-scheduled. [Partially Implemented] 04/02/2013 Implemented
6400.163(b)Individual #3 is prescribed medication to treat symptoms of a diagnosed psychiatric illness but there is no SEEN plan written to address the individual's needs.(b) If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the ISP to address the social, emotional and environmental needs of the individual related to the symptoms of the diagnosed psychiatric illness. LSS Program Case Coordinators are responsible in ensuring a SEEN plan is completed for all individuals being served in order to assure no individuals are missed when a Behavior Support Plan is discontinued. (Attachement 11). [Fully Implemented] 04/02/2013 Implemented
6400.167(b)The prescription from the psychiatrist on 2/14/13 prescribes the medication Effexor XR, 225 milligrams, two times a day. The medication log indicates that Individual #3 is receiving Effexor 225 milligrams, only once a day.(b) Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. To ensure medications administered are matching directions specified by the physician, certified nurse and or LPN, the Residential Service Workers and/or House Supervisors will attach a current copy of the individual's physician's order sheet or medication administration record to the appointment summary so that an accurate and current up to date list of medications are available for the physician to review. LSS's medical department (Medical Coordinator & Assistant Medical Coordinator) will be responsible for ensuring medications administered are matching the individual's MAR. (Attachment 12). [Partially Implemented] 04/02/2013 Implemented
6400.181(e)(13)(vii)The assessment for Individual #3 does not include progress and growth in the area of financial independence.(13) The individual's progress over the last 365 calendar days and current level in the following areas: (vii) Financial independence. LSS revised the Assessment Summary to include check boxes identifying either progress or no progress for each specific domain (see attachment 9). LSS Program Case Coordinators are responsible to identify whether the individual has either progressed or not progressed in the area of financial independence (see attachment 9). [Partially Implemented] 04/02/2013 Implemented
6400.181(e)(14)The assessment for Individual #3 does not include information regarding his ability to temper water.(13) The individual's progress over the last 365 calendar days and current level in the following areas: (14) The individual's knowledge of water safety and ability to swim. LSS Program Case Coordinator revised Individual #3's Assessment Summary to specify his ability to temper water (see attachment 9). [Partially Implemented] 04/02/2013 Implemented
6400.183(7)(iii)The ISP for Individual #3 does not include the potential to advance in vocational programming.(7) Assessment of the individual's potential to advance in the following: (iii) Vocational programming. LSS program Case Coordinator revised Individual #3's ISP to specify his potential to advance in vocational programming (see attachment 10). [Partially Implemented] 04/02/2013 Implemented
6400.183(7)(iv)The ISP for Individual #3 does not include the potential to advance in competitive community-integrated employment.(7) Assessment of the individual's potential to advance in the following: (iv) Competitive community-integrated employment. LSS Program Case Coordinator revised Individual #3's ISP to specify his potential to advance in competitive employment (see attachment 10). [Partially Implemented] 04/02/2013 Implemented
6400.187Copies of the ISP were not sent to all plan team members within 30 calendar days after the ISP meeting. The meeting was held on 8/10/12 and the ISP was sent out on 10/14/12.A copy of the ISP, including the signature sheet, shall be provided to plan team members within 30 calendar days after the ISP, annual update and ISP revision meetings. LSS Program Case Coordinators are responsible to ensure all plan team members receive copies of the individual's ISP within 30 days after the ISP meeting. LSS Program Case Coordinators will create a 30 day calendar alert as to when the new ISP should be available from the Support Coordinator. If the ISP is not available, email reminders will be sent to the Support Coordinator and copies of the emails will be filed in the individuals' Program Books as proof that the ISP have not been made available. [Partially implemented] 04/02/2013 Implemented
SIN-00237658 Renewal 03/19/2024 Compliant - Finalized
SIN-00224041 Unannounced Monitoring 02/23/2023 Compliant - Finalized
SIN-00167932 Renewal 02/19/2020 Compliant - Finalized