Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00218932 Renewal 02/13/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(a)Individual #1's initial assessment was completed 10/8/2021 and not again until 10/24/2022 which is beyond the regulatory timeframe. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Sunset¿s CEO of Community Homes has reviewed the new Regulatory Compliance Guide (February 14, 2023 edition) which further explained the grace periods for annual assessments. A training was completed on 2/21/2023 with Sunset¿s Program Specialists concerning the further explanation in the new RCG to ensure that all annual assessments are completed within 380 days. 02/22/2023 Implemented
6400.186Individual #1 was seen by her dental provider DMD on 1/18/2023. The provider documented a dental plan for individual #1 to brush teeth 2x day and floss 1x day. This is not documented in individual #1's current individual plan 2/2/2032.The home shall implement the individual plan, including revisions.Sunsets CEO of Community Homes completed a training on 2/21/2023 with Sunset¿s Program Specialists and Sunsets Medical Compliance Specialist which reviewed the Regulatory Compliance Guide (RCG) which further explained person-centered Individual Plans. The RCG stated, ¿The Individual Plan and the assessment required at 6400.181 are inseparably linked; information in the assessment must match the Individual Plan exactly. Additionally, any documentation of Individual Health requirements identified at 6400.141-145 must match both the assessment and the Individual Plan. Sunset¿s Director of Programming will create an email template that all Program Specialist will use to update SCs to ensure that all individual health requirements are identified in all individuals ISPs. Sunsets Program Specialists will email all SCs this template before April 1, 2023 to ensure compliance. 02/22/2023 Implemented
SIN-00199204 Renewal 02/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.145(3)All of the homes had an emergency medical plan that did not specify what the staffing plan was in the event of an emergency.The home shall have a written emergency medical plan listing the following: An emergency staffing plan.All individuals Emergency Medical plans were updated with person-specific information that includes the preferences of the individual (guardian) and what the staffing ratios will be, additional staffing if needed, in the case of an emergency. 03/08/2022 Implemented