Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00146205 Renewal 01/29/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104Fire notification letter was not sent until 01/16/19, Individual #1 moved into the home 11/08/18.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. To prevent this from happening again, all fire letters will be sent to the local fire department within 5 days of a move or change. The fire letter shall include the address of the home and exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. Compliance Coordinator will be responsible to send the fire letter. Program Director will review to ensure letter has been sent within 5 days. Tracking will be completed through the fire letter tracker. 02/08/2019 Implemented
6400.213(11)Safety Plan reviewed 09/26/18 states that Individual #1 can be alone in the house for thirty minutes while staff "must shovel or take care of lawn care outside of home". ISP updated 11/06/18 states that Individual #1 can be alone for 1 hour with 15 minute checks while staff is clearing snow or performing yard maintenance. And the ISP also states that Individual #1 can be left inside for 30 minutes. 09/26/18 Human Rights Committee meeting notes do not indicate any alone time. 08/15/18 Behavior Support Training Minutes and Signature Page notes state "alone time in the house- not at this time". Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. SC notified to make changes to ISP to match Behavioral Support plan for current discrepancies. The plan for the future is to have bi-weekly book reviews to include Program Specialist, Compliance Coordinator, Assistant Program Director. During these bi-weekly book reviews, all paperwork to include ISP, BSP, Safety Plan, yearly assessments and quarterly reviews will be checked for accuracy that all documentation matches. Program Specialist will be responsible to notify Supports Coordinator through an email to ask for any changes needed to ISP. Assistant Program Director is responsible to ensure bi-weekly book reviews occur. 02/22/2019 Implemented
SIN-00103587 Renewal 10/26/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(8)Individual #2 had a mammogram on 5/27/15 and then again on 6/17/16.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. All consumers annual mammograms will be tracked through a medical tracker that entails entering the date of the mammogram and will be reviewed weekly through nursing and the compliance department to ensure licensing requirements are met. 10/31/2016 Implemented
SIN-00237674 Renewal 03/19/2024 Compliant - Finalized
SIN-00221348 Renewal 03/28/2023 Compliant - Finalized