Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00193988 Unannounced Monitoring 10/05/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.62(a)The current Individual Support Plan (ISP) dated 9/08/2021 for Individual #2 states that the individual is "not able to handle or avoid all poisonous substances such as detergents, cleaners, medications and automotive products." Several cleaning and automotive products including "Goo Gone" (label states to contact poison control if ingested) and "Armor All" were found in an unlocked and accessible cabinet in the kitchen.Poisonous materials shall be kept locked or made inaccessible to individuals.Poisonous substances including all cleaners and automotive products including "Goo Gone" and :"Armor All" were removed from unlocked areas and placed in locked areas. All members of the lifesharing family including the LSP's children will be retrained/trained in the handling and storage of poisonous materials 11/10/2021 Implemented
6500.32(i)At the time of the inspection, Individual #2 had no clothes in the individual's bedroom closet or dresser. Staff #1 (the Family Living Provider) opened a locked closet in the hallway where all of the Individual's clothing was kept. Staff #1 stated that if the clothes were not locked up, the individual would put clothes on and take them off at all hours of the day and night. The individual's current Individual Support Plan does not document this behavior or the need to keep the individual's clothing locked and inaccessible. There is no restrictive procedure plan in place. This violates the Individual's right to access to their possessions.An individual has the right of access to and security of the individual's possessions.Individual #2 has had her seasonally appropriate clothing returned to her bedroom. The life sharing providers have been retrained on individual rights including the right of the individual to have access to her possessions. The team will meet to discuss whether or not is is necessary to implement a restrictive procedure or whether or not a non-restrictive behavioral plan can be developed and implemented to discourage Individual #2 from constantly changing her clothes. 11/10/2021 Implemented
6500.32(r)(1)There was no locking mechanism on Individual #1's bedroom door. Staff #2 (the Family Living Specialist) stated that the individual did not want a door lock and had stated so when asked at the time that the annual rights and releases packet was reviewed and signed. Staff #1 (the Family Living Provider) stated that the individual had told the provider that the individual does want a lock on the bedroom door. This information is not documented in the Individual Support Plan.An individual has the right to lock the individual's bedroom door. Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.The team will meet with Individual #1 to review with and educate her the right to have a lock on her bedroom door and her right to change her mind about having or not having a lock. at any time. This meeting and outcome of the meeting will be added into her ISP. 11/10/2021 Implemented
6500.136(a)(11)The October 2021 medication administration record (MAR) for Individual #2 did not include a diagnosis or purpose for the medications Loratadine and Vitamin D.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 diagnosis or purpose for the medications Loratadine and Vitamin D has been added to the October 2021 medication log for Individual #2. 11/20/2021 Implemented
SIN-00161232 Renewal 08/15/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.73The handrail on the staircase leading from the first to the second floors was loose and not well-secured.An interior stairway exceeding two steps that is accessible to individuals, ramp and outside steps exceeding two steps, shall have a well-secured handrail.The handrail on the staircase between the first and second floors is no longer loose and detaching from the wall at the top near the second floor. The handrail has been repaired and is now secure. The lifesharing specialists shall check all handrails during their visits to ensure that they are all secure. Any handrails that are determined not to be secure will be repaired as soon as possible 10/04/2019 Implemented
SIN-00084034 Renewal 09/10/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.24(e)(3)On 06/10/2015 the Family Living Provider #1 made a purchase for Individual #1 in the amount of $90. at Ross's store for which there is no receipt.If the agency or family assumes the responsibility for an individual's financial resources, the following shall be maintained: documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by family members or agency staff.The receipt was lost. An attempt to get a duplicate receipt from the Ross store was unsuccessful. Photographs will be sent to Advocacy Alliance as proof of purchase. Individual will be reimbursed if Advocacy Alliance will not accept this as proof of purchase. The lifesharing specialist will be responsible to review all receipts and address any missing receipts at that time. Lifesharing specialist will responsible to copy and scan receipts for the individuals records. 10/02/2015 Implemented
6500.109(e)As of 09/10/2015 there was only one sleep drill held during the past twelve months on 08/31/2014.A fire drill shall be held during sleeping hours at least every 12 months.A sleep drill was conducted at this site on 9/9/15. In the future sleep drills will be held at all lifesharing homes in the months of October and April. A tracking form has been developed and will be utilized by the residential director to ensure compliance 10/02/2015 Implemented
6500.121(c)(7)Individual #1 did not have an annual gynecological examination. There were no physician orders changing the frequency of these examinations. The physical examination shall include: A gynecological examination, including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations.An annual gyn exam for individual #1 was not completed because her physician had left a voicemail stating that it was not needed. This provider understands that this is not adequate documentation. Individual # will be counseled as the importance of the exam and her physician will be consulted as to the need for an annual gyn exam. The physician's recommendations in writing by the physician will be kept as part of her record. An appointment will be scheduled no later than October 6, 2015. Should the physician recommend an annual exam for individual #1, then an exam will be conducted or scheduled at that time. If the physician recommends no exam is needed that will be documented in writing. 10/06/2015 Implemented
SIN-00234938 Renewal 11/08/2023 Compliant - Finalized
SIN-00122745 Renewal 10/10/2017 Compliant - Finalized