Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00227384 Renewal 07/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The exit door leading to the home's sunroom did not have an exterior light. All outside doorways should be well lighted to assure safety to avoid accidents.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. A light was added to the outside of the steps with an interior switch that staff or individuals can turn on prior to exiting. 07/07/2023 Implemented
6400.112(c)Fire drills during the months of January 2023, and June 2023 did not specify which date the fire drill was conducted on. The fire drill record should reflect the date.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. Staff were retrained on writing the date on both the fire extinguishers AND the log. 07/07/2023 Implemented
6400.181(e)(13)(i)Individual #1 annual assessment dated 2/20/23 did not reflect the individuals progress over the last year in the area of Health.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. This information was in the new assessment template however the staff completing the form used the old version. This staff no longer works here and the old version was removed from the system. 07/14/2023 Implemented
6400.181(e)(13)(ii)Individual #1 annual assessment dated 2/20/23 did not reflect the individuals progress over the last year in the area of motor and communication skills.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. This information was in the new assessment template however the staff completing the form used the old version. This staff no longer works here and the old version was removed from the system. 07/14/2023 Implemented
6400.181(e)(13)(iii)Individual #1 annual assessment dated 2/20/23 did not reflect the individuals progress over the last year in the area of residential living.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. This information was in the new assessment template however the staff completing the form used the old version. This staff no longer works here and the old version was removed from the system. 07/14/2023 Implemented
6400.181(e)(13)(iv)Individual #1 annual assessment dated 2/20/23 did not reflect the individuals progress over the last year in the area of personal adjustment.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. This information was in the new assessment template however the staff completing the form used the old version. This staff no longer works here and the old version was removed from the system. 07/14/2023 Implemented
6400.181(e)(13)(v)Individual #1 annual assessment dated 2/20/23 did not reflect the individuals progress over the last year in the area of socialization.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. This information was in the new assessment template however the staff completing the form used the old version. This staff no longer works here and the old version was removed from the system. 07/14/2023 Implemented
6400.181(e)(13)(vii)Individual #1 annual assessment dated 2/20/23 did not reflect the individuals progress over the last year in the area of financial independence.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. This information was in the new assessment template however the staff completing the form used the old version. This staff no longer works here and the old version was removed from the system. 07/14/2023 Implemented
6400.181(e)(13)(viii)Individual #1 annual assessment dated 2/20/23 did not reflect the individuals progress over the last year in the area of managing personal property.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. This information was in the new assessment template however the staff completing the form used the old version. This staff no longer works here and the old version was removed from the system. 07/14/2023 Implemented
6400.169(d)Staff #1 had the cover sheet of the initial medication training however the date was missing to reflect when she passed the course. In addition, the cover sheet reflects that there were 4 observations conducted on 5/8/23; 5/8/23; 5/13/23; 5/14/23, however the observation sheets only reflect one entry of observation on 5/8/23; 5/13/23; and 5/14/23. There are no entries to reflect a second observation was conducted on 5/8/23. Staff #2 initial medication training cover sheet reflects that 4 observations were completed, with 2 observations on 6/11/22 and 2 observations on 6/12/22. However, there was only one entry for observation on 6/11/23 and one entry of observation on 6/12/22. This some not provider sufficient evidence that 4 observations were completed in accordance with the regulation.A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.Medication administration trainer was shown the issue and corrected it for future trainings. 07/07/2023 Implemented
SIN-00208386 Renewal 07/11/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(13)(ii)Individual #2's annual assessment dated 3/1/22 did not include progress and growth over the past 365 days in motor and communication skills.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. Staff changed the assessment to include a progress section for all areas where progress needs to be documented. Staff compared the new assessment to state regulations to assure each piece was satisfied. Staff provided assessment to inspector for review to assure it was meeting state regulations. 07/20/2022 Implemented
6400.181(e)(13)(iii)Individual #2's annual assessment dated 3/1/22 did not include progress and growth over the past 365 days in activities of residential living.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. Staff changed the assessment to include a progress section for all areas where progress needs to be documented. Staff compared the new assessment to state regulations to assure each piece was satisfied. Staff provided assessment to inspector for review to assure it was meeting state regulations. 07/20/2022 Implemented
6400.181(e)(13)(iv)Individual #2's annual assessment dated 3/1/22 did not include progress and growth over the past 365 days in personal adjustment.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. Staff changed the assessment to include a progress section for all areas where progress needs to be documented. Staff compared the new assessment to state regulations to assure each piece was satisfied. Staff provided assessment to inspector for review to assure it was meeting state regulations. 07/20/2022 Implemented
6400.181(e)(13)(vii)Individual #2's annual assessment dated 3/1/22 did not include progress and growth over the past 365 days in financial independence.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. Staff changed the assessment to include a progress section for all areas where progress needs to be documented. Staff compared the new assessment to state regulations to assure each piece was satisfied. Staff provided assessment to inspector for review to assure it was meeting state regulations. 07/20/2022 Implemented
6400.181(e)(13)(viii)Individual #2's annual assessment dated 3/1/22 did not include progress and growth over the past 365 days in managing personal property.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. Staff changed the assessment to include a progress section for all areas where progress needs to be documented. Staff compared the new assessment to state regulations to assure each piece was satisfied. Staff provided assessment to inspector for review to assure it was meeting state regulations. 07/20/2022 Implemented
SIN-00189876 Renewal 07/12/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The railing on the front porch is rusted and chipping paint. The front door has peeling paint.Floors, walls, ceilings and other surfaces shall be in good repair. Maintenance sanded, repaired, and painted both the railing and the door. The railing was painted using anti-rust paint to reduce rusting in the future. 07/21/2021 Implemented
6400.144Individual #1 is prescribed Clonazepam 0.5 mg once a day for anxiety, and then as needed. There are no instructions detailing what symptoms of anxiety would require the medication to be administered on an as needed basis. Individual #2 is prescribed Xanax .25mg, take 1 tablet by mouth 3 times a day as needed for anxiety. Individual #1 is unable to identify when he needs this medication and staff administer it for baby talk, increased stimming, cursing and prior to medical appointments. There is no written plan or documentation on the prescription that indicates when or what anxiety issues the medication should be administered for.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. A written plan for each individual of when to administer PRN for anxiety was created and approved by doctor. A copy is kept in the MAR and will be reviewed at psychiatry appointments and med reviews. The plan will be reviewed and updated at least yearly. 07/30/2021 Implemented
6400.32(r)(1)Individual's #1 and #2 have locks on their bedroom doors. The locks on the bedroom doors are pin hole locks. Individual's #1 and #2 do not have their own keys to these locks. Individual #2 is blind and does not have the ability to utilize the key for a pin hole lock appropriately.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 door knobs were replaced to allow each individual to have a different key to their room. Each individual was given a key and shown how to use it. A spare key is kept in the desk at the house in case of emergencies. 07/21/2021 Implemented
6400.34(a)Individual #1 and Individual #2 was informed of their rights however the Individual Rights have not been updated to reflect the new Chapter 6400 regulations. The missing rights include: control schedule, receive scheduled and unscheduled visitors, and to communicate and meet privately with whom the individual chooses, An individual has the right to unrestricted access to send and receive mail and other forms of communications, unopened and unread by others, including the right to share contact information with whom the individual chooses, telecommunications, manage and access the individual's finances ,choice of roommate, furnish/decorate bedroom and common areas, lock bedroom door, entry mechanism to lock/unlock the front door, access to food, make health care decisions, and rights may only be modified in accordance with § 6400.185 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Individuals reviewed their rights according to Chapter 6400 regulations with their program specialist and DSPs. They had the opportunity to ask questions and were provided with explanations. A copy of their rights with a signature acknowledging they were reviewed and understood is kept in each individual's personal file. 07/13/2021 Implemented
6400.51(b)(1)Staff #1's Date of Hire was 7/22/19 and their orientation did not include the application of Person Center Practices, Community integration, Individual choice, and Supporting individuals to develop and maintain relationships.The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Staff 1 was trained at day program and did the CPS training to encompass the topics discussed. Day program day program and residential orientation and yearly training were updated to include these topics specified individually. Relias learning (online), my odp.org, and in person trainings are used to frequently review these topics. Staff 1 was trained later in 2019. She was trained again in 2020 and will be trained again in the 21-22 training year. 07/13/2021 Implemented
6400.165(g)Individual #1 is prescribed Xanax .25mg, take 1 tablet by mouth 3 times a day as needed for anxiety. Individual #1 did not have 3-month medication reviews with the prescribing physician.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Doctors appointments were and will be made to meet the 3 month requirement. A specific document was created to document the medication, the dosage, the reason for the medication, and whether to continue/change/discontinue medication. This document will be taken to psychiatric appointments and medication reviews. 07/20/2021 Implemented
6400.166(a)(11)Individual #2's July Medication Administration Record (MAR) did not have the diagnosis or purpose for the following medications: Omeprazole, Mag64, Benztropine, Latuda, Trazodone, Women's Multivitamins, and Junel Fe.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.Diagnosis for each medication was added to the MAR for each correlating medication. 07/21/2021 Implemented
6400.213(1)(i)Individual #1 and Individual #2 had a photos in their files, however the photos were not dated.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.Each individual has the name, sex, admission, date, birthday, and social security number on their emergency forms. However they had undated pictures. New pictures were taken and dated on 7/14/21. 07/14/2021 Implemented
SIN-00175685 Initial review 08/31/2020 Compliant - Finalized