Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00156724 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 6/28/18, 7/26/18, 9/28/18, 10/27/18, 12/16/18, 3/20/19, 5/15/19 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-00105260 Renewal 12/13/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(4)The most recent hearing screening for Individual #1 was completed on 9/29/15.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The Individual had an Audiology appointment scheduled for 10/3/16. He had been hospitalized due to gall bladder surgery and was being discharged on this date. The Audiologist was contacted and instructed him not to attend the appointment, as he had abdominal staples and was recovering from surgery. A case note was written by the Supervisor and was placed in the Individual's record. The appointment was rescheduled for 1/13/17. On 1/9/17, all Supervisors were reminded to obtain a written letter or script from the physician regarding their recommendation for appointments, treatment, or testing that they feel is not required or that occurs outside of the regulation timeframes. [Immediately and after completion, the Supervisors shall review all individuals' current physical examinations to ensure all required information is included and will immediately obtain missing information from the physician. (AS 1/12/17)] 01/10/2017 Implemented
SIN-00233649 Renewal 10/31/2023 Compliant - Finalized
SIN-00215201 Renewal 11/01/2022 Compliant - Finalized
SIN-00051291 Renewal 09/05/2013 Compliant - Finalized