Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00192253 Renewal 08/31/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)A fire drill was held during sleeping hours on 9/25/2020 and again on 4/21/2021.A fire drill shall be held during sleeping hours at least every 6 months. QCL will hold an overnight fire drill on Tuesday, September 14, 2021 and hold another overnight drill the first week in March of 2022 to remain complaint. Keeping the 6 month drill after the last one on 6/20/21 would have us doing another drill in December of this year. I would like to avoid having all residents complete a fire drill by 12/20/21 to avoid cold weather or snow. 09/14/2021 Implemented
6400.141(c)(6)The Tuberculin skin test completed 4/23/2021 for Individual #1 did not include the signature and credentials of who read the test so compliance was unable to be measured.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. 141d Immunization, vision and hearing screening and tuberculin skin testing may be completed, signed and dated by a registered nurse or licensed practical nurse instead of a licensed physician, certified nurse practitioner or licensed physician's assistant.Program specialist was retrained on the protocol for the credentials of the person signing off on a TB test result and a signature is required to show validation that is was read for the results by a doctor. 09/07/2021 Implemented
SIN-00137127 Renewal 06/18/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)The "Fire Book" kept at the residence contained a schedule of fire drills for the 2018 calendar year, including the dates and times of fire drills. All staff had access to this schedule. An unannounced fire drill shall be held at least once a month. Upon inspection all fire drill schedules were removed from the homes. The program specialist or manger will contact the staff the day of the drill to notify them of the time frame the drill needs to be held. The day after the completed drill is held management will check all documentation for compliance.[Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff persons working in community homes of the requirements of fire drills and documentation of fire drills including that fire drill shall be unannounced to all staff and individuals unless the staff person is conducting the fire drill. Documentation of the trainings shall be kept. Documentation of the aforementioned audits of the fire drills by the program specialist shall be kept. (AS 7/19/18)] 07/09/2018 Implemented
6400.186(a)The ISP review from 1/1/18 to 3/31/18 for Individual #1 was signed by the individual and program specialist on 4/18/18.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. The Program Specialist was retained by the CEO on the 3 month ISP review with each individual or as needed upon any change in services or outcomes. A sign off sheet was created for the individual and the program specialist to sign off on upon the completion of the review. The CEO will monitor the reviews to ensure they are compliant.[Documentation of the quarterly reviews by the CEO shall be kept. (AS 7/19/18)] 07/09/2018 Implemented
SIN-00229374 Renewal 08/15/2023 Compliant - Finalized
SIN-00210588 Renewal 08/30/2022 Compliant - Finalized
SIN-00177153 Renewal 09/29/2020 Compliant - Finalized
SIN-00157276 Renewal 06/18/2019 Compliant - Finalized
SIN-00117015 Renewal 07/06/2017 Compliant - Finalized