Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00236057 Renewal 12/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual # 1 is recommended to have 64 oz of fluid each day. Individual # 1 only had 60 oz fluid on 09/01/23, 36oz fluid on 09/04/23 and 60 oz fluid on 09/05/23Health 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. This regulation is important because it protects the individual¿s health and safety by following the orders/recommendations of all medical and psychological physicians. This violatiopn occurred due to three days where appropriate documentation was not present to reflect the intake of 64 oz of fluids, as recommended by a physician. The monitoring process in place did not notice this shortage of documentation. To rectify this, the fluid chart has been moved, as of 12/18/23, to Carasolva, the EMAR in use. This will allow for easier monitoring and will streamline the process for staff by limiting the locations needed to go to for documentation. All staff assigned to the program were trained on the new documentation and the importance of the regulation, by 12/20/23. Record of this documentation will be kept by the Director of Residential. 01/01/2024 Implemented
6400.181(e)(4)Individual # 1's Assessment dated 02/28/23 does not include the amount of time which he can be left unsupervised in the home. The assessment instead reads that he can be left unsupervised in the home "for periods of time". The assessment must include the following information: The individual's need for supervision. This regulation is important so that all parties have a comprehensive knowledge of each person's services and supports to ensure their health and safety in the most appropriate manner. This violation occured due to an attempt to better clarify the expectations of a general supervision need in the program. During this process the semantics opened the assessment to interpretation that Individual #1 has the ability to be home alone under certain circumstances. On 12/18/23, Individual #1s assessment was updated to clarify the language used to illustrate that staff had to be present on the premises at all times when Individual #1 is in the home. All assessments will be evaluated for proper semantics by 12/22/23 and will be updated, if necessary. This process will be monitored by the program specialist coordinator. 01/01/2024 Implemented
6400.211(b)(3)Individual #1's Emergency Information sheet does not identify who can provide Emergency Medical Consent.Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. This regulation is important because it ensures that all parties have access to critical information in the case of an emergency. This violation occurred due to a misperception that "Next of Kin" was synonymous with emergency conesent. The Face sheet for Individual #1 was updated on 12/18/23 to reflect the proper terminology. All facesheets will be evaluated for proper semantics by 12/22/23 and will be updated, if necessary. This process will be monitored by the program specialist coordinator. 12/22/2023 Implemented
SIN-00194448 Unannounced Monitoring 10/15/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)The bathroom on the main level of the home that the individuals use did not have individual hand towels nor paper towels available at the time of the inspection on 10/15/21.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Missing items were replaced by the end of the inspection. All staff working in this home will be re-trained in this regulation by the Director of Residential before 10/30/21. Documentation of this training will be kept. All homes will be checked to ensure compliance with this regulation. 11/01/2021 Implemented
6400.110(e)The home has three or more stories and the smoke detectors in the home are not interconnected.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. The smoke detectors in this home were interconnected by the end of the inspection. All homes that fall within the requirements of this regulation will be checked by 10/30/21 and if not, in-compliance, fixed immediately. The Director of Residential will ensure this review is completed by due date. 11/01/2021 Implemented
SIN-00190736 Unannounced Monitoring 07/29/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)The twelve, accessible steps leading into the attic were not equipped with a handrail. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Well-secured handrail was placed near attic steps on 7/29/21. Continual monitoring by all staff working in the home, will visually occur daily to ensure all steps inside and out of the home are equipped with a well-secured handrail. Any step, exceeding two steps, found without a well-secured handrail will be immediately fixed the same day. 08/13/2021 Implemented
6400.74Twelve wooden steps leading into the attic, accessible from the first floor, were not equipped with non-skid surfaces.Interior stairs and outside steps shall have a nonskid surface. Non-skid surfaces were placed on steps on 7/29/21. Continual monitoring by all staff working in the home, will visually occur daily to ensure all steps inside and out of the home are equipped with non-skid surfaces. Any step found without nonskid surfaces will be immediately fixed the same day. 08/13/2021 Implemented
SIN-00187224 Unannounced Monitoring 04/21/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #1 was ordered to begin a pureed diet on 11/24/20. The new choking protocol for Individual #1 was not developed until 12/1/20.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. Current menus implemented in this home do not meet specific dietary needs of individuals served. Agency Nurse will review and update each current menu in ALL homes by 5/11/21, to ensure menus meet dietary needs of all individuals in each home. Specific individual dietary needs will be printed on each menu to assist staff with ensuring dietary needs are being met by 5/11/21. Beginning immediately, all menus for the next month will be completed by the house supervisor/program specialist by the 15th of the current month and reviewed by the Agency nurse (prior to implementation) to ensure that all dietary requirements are satisfied. If new dietary restrictions or choking protocols are recommended by a medical professional, the agency nurse will review orders and the program specialist will update all required documents within 24 hours of receipt. 05/11/2021 Implemented
6400.52(c)(6)On 12/1/20, a new choking protocol was developed for Individual #1. The following staff worked with Individual #1 prior to receiving the training on the new choking protocol: Staff person #1, #2, #3, #4, #5, and #6.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.All staff must be trained in an individual's specific dietary needs before working in a home to ensure the health and safety of all individuals. All staff who are currently not trained will be trained by 5/11/21 or will not work with that individual until training is complete. Beginning immediately, ALL staff will be trained in individual dietary needs prior to their first shift in a new home or where a new protocol is implemented. If new dietary restrictions or choking protocols are recommended by a medical professional, the agency nurse will review orders and the program specialist will update all required documents within 24 hours of receipt. Staff will be trained on updates/changes prior to working their first shift with individual. 05/11/2021 Implemented
SIN-00149734 Unannounced Monitoring 02/05/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)The patio screen door does not function properly, it does not slide in its track. Screens, windows and doors shall be in good repair. Agency will correct the immediate issue. Agency will review the issue for violation and correct. Then agency will train all staff on the violation. Program specialist will review monthly and supervisor will review quarterly and complete tracking form. 02/28/2019 Implemented
SIN-00145382 Unannounced Monitoring 11/07/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Poisons unlocked under the kitchen sink included Liquid Alive, Clorox Wipes, Lysol Cleaner. Poison unlocked in basement bathroom, Clorox wipes.Poisonous materials shall be kept locked or made inaccessible to individuals. Agency will correct the immediate issue. Agency will review the issue for violation and correct. Then agency will develop procedure to ensure poisons locked and train all staff on the violation. Program specialist will review monthly and supervisor will review quarterly and complete tracking form. 12/31/2018 Implemented
6400.64(a)Strong odor in rear bedroom. Feces on toilet seat, Brown smear stain on wall by bathroom.Clean and sanitary conditions shall be maintained in the home. Agency will correct the immediate issue. Agency will review the issue for violation and correct. Then agency will train all staff on the violation. Program specialist will review monthly and supervisor will review quarterly and complete tracking form. 12/31/2018 Implemented
6400.67(a)Closet doors in side bedroom have bottom bracket brokenFloors, walls, ceilings and other surfaces shall be in good repair. Agency will correct the immediate issue. Agency will review the issue for violation and correct. Then agency will train all staff on the violation. Program specialist will review monthly and supervisor will review quarterly and complete tracking form. 12/31/2018 Implemented
6400.182(a)No current ISP in record for Individual # 2. ISP in record last updated 08/31/17(a) An individual shall have one ISP. Agency will correct the immediate issue. Agency will review the issue for violation and correct. Then agency will develop procedure to ensure ISP's are up to date and within record, then train all staff on the violation. Program specialist will review monthly and supervisor will review quarterly and complete tracking form. 12/31/2018 Implemented
SIN-00128592 Renewal 02/20/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Repeat 5/9/17: A 128 ounce container of smart living windshield washer fluid was left unlocked and accessible to individuals in a cabinet in the garage. All individuals in the home are not assessed to be safe around poisonous materials.Poisonous materials shall be kept locked or made inaccessible to individuals. All Associate Directors were re-trained on the regulation regarding poisons needing to be locked or being made inaccessible to individuals - see attachment # ____ from training on 3-26-18. The only full time staff (she was the staff that left the washer fluid unlocked) that works in this home was also re-trained on this regulation and the need to ensure the safety of the individuals at all times by ensuring items are appropriately locked. Implemented
SIN-00215256 Unannounced Monitoring 11/21/2022 Compliant - Finalized
SIN-00207640 Unannounced Monitoring 07/05/2022 Compliant - Finalized
SIN-00200289 Unannounced Monitoring 02/15/2022 Compliant - Finalized
SIN-00195604 Unannounced Monitoring 11/01/2021 Compliant - Finalized
SIN-00170340 Unannounced Monitoring 01/15/2020 Compliant - Finalized
SIN-00165808 Unannounced Monitoring 11/01/2019 Compliant - Finalized
SIN-00164215 Unannounced Monitoring 10/10/2019 Compliant - Finalized
SIN-00106582 Renewal 11/30/2016 Compliant - Finalized
SIN-00070187 Renewal 06/30/2014 Compliant - Finalized