Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00240346 Renewal 03/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(7)Individual #1 had a gynecological examination completed on 08/19/21, and then again on 06/20/23, with no documentation from a licensed physician recommending no or less frequent gynecological examinations. This exceeds the annual requirement.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. 1. Annual GYN appointments will be tracked in the Electronic Health Record Appointment Tracking System. A calendar within this system documents appointments coming due. 2. The IDD Group Home Manager will meet with Program Specialists (PS) once a month to review appointments that are due over the next 3 months to ensure they are scheduled in a timely manner. 3. When possible, during the appointment the next appointment will be scheduled at the doctor¿s office prior to leaving the office. The new appointment will be added in the EHR system. 4. The IDD Group Home Program Manager will review the medication consultation form to ensure that the PS added the next appointment in the EHR system and if no appointments were made then this will be added to the monthly meeting to review the appointments that are due in 3 months. 5. Any appointment that is missed, cancelled, rescheduled or refused will be tracked in the EHR and appointment refusal forms will be completed by the Program Specialist and reviewed and signed by the individual to be uploaded and attached to the appointment in the EHR system. 03/15/2024 Implemented
SIN-00222368 Renewal 03/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65On 4/7/23, the air duct vent above the shower in the bedroom hallway bathroom was discovered clogged with dust and debris, obstructing proper ventilation.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. The air duct was cleaned on the day of inspection by staff working at the home and is no longer obstructing proper ventilation. 04/07/2023 Implemented
6400.151(a)The most recent physical examination for Direct Support Professional #1, date-of-hire 2/3/14, was completed 1/15/2020. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Human Resources notified the staff person that they must complete or submit a valid bi-annual physical exam in order to continue working their regularly scheduled shifts. 05/05/2023 Implemented
6400.151(c)(2)The most recent tuberculin skin test for Direct Support Professional #1, date-of-hire 2/3/14, was read 1/17/2020. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Human Resources notified the staff person that they must complete or submit a valid bi-annual TB test in order to continue working their regularly scheduled shifts. 05/05/2023 Implemented
SIN-00187287 Renewal 05/04/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment of the home.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. A self-assessment will be completed for each home Between April 1st and July 30th, annually. Prior to the self-assessment being printed for use, the IDD Administrator will check the ODP website for the most current version and supply it to his House Coordinators and Program Specialist to complete the site parts of the assessment. The Program Specialist, Program Director and Program Manager will receive training on how to complete a self-assessment on 6/24/21 from 10am-3pm from the Regional Director. The Program Manager will review and advise House Coordinator and Assistant Program Directors on how to properly fill out the form on 06/29/21 during the weekly managers meeting. The Self Assessments will be completed on 6/30/21. 06/30/2021 Implemented
6400.65The bathroom in the master bedroom does not have a screen in the window which is able to be opened and does not have mechanical ventilation.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. The window screen was found in the garage of the site and placed in the window on 5/11/21 06/23/2021 Implemented
6400.112(c)The written fire drill records for the monthly fire drill held from 12/2020 through 3/2021 did not include the exit routes used.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The provider has included in manager training that two categories are to be included in fire drills moving forward. 1. The route of escape. 2. The meeting location area. on 5/25/21. The Fire Drills from May and June had the exit route and meeting area, but was not specifically defined. The provider add " exit route used" to the form. On 6/17/21 a fire drill was conducted on this site, on 6/21/21 the site administrator filled out the correct form using the data from the 6/17/21 fire drill and signed off on it. 06/21/2021 Implemented
SIN-00167571 Renewal 12/11/2019 Compliant - Finalized