Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00221333 Renewal 03/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(11)Individual #1's March 2023 Medication Administration Record (MAR) does not include the diagnosis or reason for dispensing "Chlorhex Glu Sol 0.12%".A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The team immediately (3.29.2023) spoke with the pharmacy to get a diagnosis placed on the Chlorhex Glu Sol as oral hygiene. This was then printed with a new label and delivered to the house. Quik mar and the paper mars were also updated to add this diagnosis. 04/06/2023 Implemented
6400.181(f)The Annual Assessment for Individual #1, completed 01/02/23 was sent to Individual #1's Individual Support Plan (ISP) team on 01/06/23 (The form contained a typo that it was sent on 01/06/22, prior to the form being completed), which is outside of the 30-day time frame required for it to be sent prior to the 02/02/23 ISP meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.o Lead Program Specialist will hold a training with other Program Specialists to review the regulation of sending the assessment 30 days prior to the ISP meeting. 04/17/2023 Implemented
SIN-00123114 Renewal 01/03/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Door Jamb for Individual # 1's room is missing 4 inches at bottom of jamb. Carpet hole approximately 3 inches and carpet pulling up by individual # 1's closet door.Floors, walls, ceilings and other surfaces shall be in good repair. LSS maintenance department will ensure that the door jamb is replaced and the hole in the carpet is repaired by 2/26/18. 02/26/2018 Implemented
6400.67(b)Curtain rod above dining room egress not secured. (Rod fell upon opening door during site inspection) Floors, walls, ceilings and other surfaces shall be free of hazards.LSS maintenance department will ensure that the curtain rod is replaced. 02/26/2018 Implemented
6400.151(c)(4)Staff # 1's 11/25/17 physical does not identify medical problems which would impact health and safety of individuals. Space left blank.The physical examination shall include: Information of medical problems which might interfere with the health of the individuals.Staff # 1's physical was faxed to the DR and the DR completed the section that was blank and faxed it back to LSS on 1-4-18. Recruitment /Training Coordinator will ensure all staff physical blank spaces are fill out. 01/04/2018 Implemented
SIN-00116864 Unannounced Monitoring 03/08/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)A container of Dollar General Triple Antibiotic Ointment 1 ounce was left unlocked and accessible to individuals on the end table in the living room located closest to the main entryway.Poisonous materials shall be kept locked or made inaccessible to individuals.By 8/1/17 the house staff will be educated by Program Specialist and Wellness Coordinator on poison awareness and the individual¿s ISP as it pertains to individuals being poison aware or not. 08/01/2017 Implemented
6400.67(a)The basebord moldings in the bathroom of the home were ripped off the wall surrounding the toilet and a piece of the molding was coming off of the wall between the toilet and the tub. Floors, walls, ceilings and other surfaces shall be in good repair. LSS received an estimate for remodeling the bathroom on 2/15/17. Remodeling began 5/30/17 and was completed 6/16/17. 06/16/2017 Implemented
6400.76(a)The dresser in Individual #1's bedroom was missing the top and bottom dresser drawers. Furniture and equipment shall be nonhazardous, clean and sturdy. LSS would like to appeal this citation due to individual #1 making his own choice to use the dresser as a CD case. Management did encourage the purchase of a new dresser however individual #1 did not want to purchase a new dresser. Individual #1 signed a statement about his desire not to purchase a new dresser. Individual #1, as his own guardian, has the right to make that decision. 07/14/2017 Implemented
6400.77(b)The first aid kit did not contain scissors. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. On 7/7/17 Wellness Coordinator replaced the Frist Aid Kit at the house to ensure all items are present A First Aid Kit checklist was developed by the Wellness Coordinators to ensure that the house First Aid Kits contain the following: antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Beginning 8/1/17 the Wellness Coordinators will conduct monthly inspections of the house First Aid Kits to ensure compliance with the regulations. 08/01/2017 Implemented
6400.141(c)(3)According to Individual #2's physical dated 1/5/17 he/she has not had received any immunizations. 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. Sent the information to Jim concerning this citation. 07/14/2017 Implemented
6400.141(c)(6)According to Individual #2's physical dated 1/5/17 he/she has not been tested for tuberculosis.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Sent the information to Jim concerning this citation. 07/14/2017 Implemented
6400.183(5)The Individual Support Plan for Individual #2 updated 3/17/17 does not include his/her social, emotional and environmental support plan. Individual #2 is prescribed psychotropic medications. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. By 8/1/17 Program Specialist will personally ensure that a copy of the most recent SEE Plan for each individual is placed in their respective homes. The Residential Support Team will conduct ongoing audits of the house records to ensure compliance with the regulations. 08/01/2017 Implemented
6400.214(a)Individual #2's most recent physical which was dated 1/5/17 was not present and available at his/her home.Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home.By 8/1/17 Program Specialist will personally ensure that a copy of the most recent physical for each individual is placed in their respective home. The Residential Support Team will conduct ongoing audits of the house records to ensure compliance with the regulations. 08/01/2017 Implemented
SIN-00076361 Renewal 04/13/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(13)(ii)Individual #1's assessment did not show progress and growth over the last 365 calendar days and current level in motor and communication skills. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. 1. LSS Case Coordinators is responsible to ensure the assessments include the individual¿s progress over 365 days and current level in motor and communication skills. 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 motor and communication skills (see attached assessment). 05/07/2015 Implemented
6400.181(e)(13)(v)Individual #1's assessment did not show progress and growth over the last 365 calendar days and current level in socialization. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. 1. LSS Case Coordinators is responsible to ensure the assessments include the individual¿s progress over 365 days and current level in socialization skills. 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 socialization skills (see attached assessment). 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). 05/07/2015 Implemented
6400.187Individual #1's ISP approval letter and signature sheet was not provided to plan team members within 30 calendar days after the ISP. The ISP meeting was on 12/16/2014 and the approval letter and signature sheet was received on 1/20/2015.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
SIN-00237659 Renewal 03/19/2024 Compliant - Finalized
SIN-00167933 Renewal 02/19/2020 Compliant - Finalized
SIN-00047778 Renewal 03/18/2013 Compliant - Finalized