Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00156717 Renewal 06/04/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill records for the fire drills held on 6/25/18, 7/8/18, 8/30/18, 9/21/18, 10/4/18, 11/16/18, 12/19/18, 1/6/19, 2/28/19, 3/29/19, 4/28/19, 5/10/19 do not address problems encountered; this section was left blank.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. Historically, we have instructed staff to document on the fire drill only if there was a problem encountered. If nothing occurred, there would be no documentation in this section. This has been our process for many years. It has not been discussed with us during any previous licensing inspection that we were not meeting the regulation or that we needed to consider making any changes. This would have been greatly appreciated, as we always value the guidance received during inspections and have made adjustments as needed. Going forward, all staff at all homes will be instructed to document ¿none¿ under ¿Problems Encountered¿ if there is no occurrence to be documented. Specialists will be trained by the Associate Director on 7/1/19. In turn, Specialists will train the Supervisors and they will train the DSPs. This training will be completed by 7/31/19. We will continue our current fire drill review process with an emphasis on no part of the documentation being left blank. The Supervisor of each home will review the Fire Drill to ensure that staff running the drill has completed the documentation in its entirety. The Supervisor will present the drill to the Specialist, who will also review the drill for accuracy and completion. The drill will then be submitted to the next reviewer, who will do the same. The Associate Director, Community Living will then complete a final review of the drill before filing. 07/31/2019 Implemented
SIN-00105251 Renewal 12/13/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)The physical examination completed on 8/23/16 for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The Physical Examination form has been re-formatted, so that it is more user friendly for the physician to complete. It is now more clearly defined that "medical information pertinent to diagnosis and treatment in case of an emergency" is a separate question. On 1/9/17, an email was sent to all Supervisors reminding them to ensure that nothing is left unanswered on the physical examination form prior to leaving the appointment.[Individual #1's physical examination was updated to include medical information pertinent to diagnosis and treatment in case of an emergency. Immediately, the vice president residential supports shall train all supervisors of the required information to be included in individuals' physical examination as per 6400.141(c)(1)-(15). Documentation of training shall be kept. Within 30 days of receipt of the plan of correction, and upon completion, the supervisors shall review all individuals' current physical examinations to ensure all required information is present and there are not any areas of required information left blank and will immediately obtain missing information from the complete physician. Documentation of all reviews shall be kept. At least quarterly for 1 year, the program specialist shall review a 25% sample of physical examinations completed that quarter to ensure all required information is present and there are not any areas of required information left blank. (AS 1/24/17)] 01/10/2017 Implemented
SIN-00051284 Renewal 09/05/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(h)Individual #1 did not to evacuate to the designated meeting place during fire drills held on 6/21/12, 9/26//12, 11/17/12, 12/5/12, 3/18/13, 4/7/13 and 6/14/13.(h) Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.The Individual has a diagnosis of Obsessive Compulsive Disorder and Anxiety Disorder NOS, along with Down Syndrome. OCD symptoms include strict rituals and routine; over-hygiene with lengthy showers and toileting; the need for an orderly room; and the strict need for privacy in the bathroom and her bedroom. As a result of her nighttime anxiety, her bedtime ritual is such that she completes certain tasks in her room prior to going to bed. Once in bed, she will not get up until the morning. In Dec. 2005, there was a home invasion and she was sexually assaulted. As a result of this trauma, she has been inconsistent with her evacuation for overnight fire drills. She has increased her need for bedroom ritual and routine. After her mother¿s death, she became more oppositional regarding fire evacuation. Attempts to engage professional supports for her were refused, even when encouraged by her family. We have seen an increase in her nighttime anxiety and the ritualistic behaviors have intensified. Attempts continued to be made to engage professional support. She is in a ranch- style home. Her bedroom is in the front of the house, with a large window facing the street. The fire department is aware of her assault and is annually reminded in writing that she will need assistance in evacuating should a fire occur. Staff will protect her in place by opening her window /closing her door & direct the first responder to her rescue. In April 2013, she agreed to psychiatric care and behavioral supports. A letter from the psychiatrist will be submitted. In May 2013, she evacuated. June 2013 was a sleeping drill, which she refused. The drill was re-run on 6/22/13 and she evacuated. In July and Aug. 2013, she evacuated. She is cooperating with both the psychiatric and behavioral supports. She is more receptive and making progress. We will continue to monitor her progress with fire evacuation. Should she not continue to progress, we will request a waiver of Chapter 6400. 112 (h). 09/22/2013 Implemented
SIN-00215192 Renewal 11/01/2022 Compliant - Finalized