Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00108978 Renewal 02/23/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)A self-assessment was completed on 7-1-2016, and the certificate of compliance expired on 2-5-2017.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The Residential Program Coordinators were all re-trained on the Plan of Correction for the 6400 audit. The Program Director will generate a reminder for all Self-Assessments to be completed when we are six months from the expiration of our current license, which is due to expire on 02/05/2018. The reminder will be sent by email.[Prior to 3 months of the expiration date of the agency's certificate of compliance, the Program Director shall review all self-assessments to ensure timely completion. Documentation of the review shall be kept.(AS 3/10/17)] 03/06/2017 Implemented
6400.141(c)(9)The physical examination completed 4-18-2016 for Individual #1, date of birth 11-2-1960 does not include a prostate examination.The physical examination shall include: A prostate examination for men 40 years of age or older. The Residential Program Coordinators were all re-trained on the Plan of Correction for the 6400 audit. The Program Director has sent a memo to all male Residential homes informing them that the PSA blood work is acceptable if the individuals¿ physician puts that in writing and it is filed in the individuals¿ records. If an individual refuses a Prostate exam and the subsequent blood work they are to desensitizate the individual each month. This training/desensitization can be talking with the individual, taking them to the physicians¿ office to become comfortable, having the individual watch an informational video about the prostate exam, etc.[Individual #1 has a physical examination to include a prostate examination scheduled on 4/21/17. Within 30 days of receipt of the plan of correction the Program Director shall train all residential program coordinators as to the required information for individual physical examinations as per 6400.141(c)(1)-(15). Documentation of the training shall be kept. Immediately and upon completion, the residential program coordinators shall review all individuals' physical examination to ensure all required information is included and there are not any areas of required information left blank. Designated staff persons shall obtain missing information or follow aforementioned refusal plan as needed. (AS 3/10/17)] 03/06/2017 Implemented
SIN-00059987 Renewal 02/05/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(b)The "Rights" form, signed by Individual #1, did not include the right ot privacy per 6400.33(e) -- that "an individual has the right ot privacy in bedrooms, bathrooms and during personal care. (b) Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. The Director of the Residential Services, updated the Individual Rights Acknowledgement form. Once the form was updated to inclue the 31(b), all Program Coordinators were trained on the change and new forms were reviewed and signed by ALL individuals. In additon to the Program Coordiators being trainined all Residential staff were also trainined on the basics of the 6400 regulations and the most recent updates for this audit. 02/25/2014 Implemented
SIN-00200730 Renewal 02/23/2022 Compliant - Finalized
SIN-00169627 Renewal 01/22/2020 Compliant - Finalized