Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00238724 Renewal 02/06/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)Individual #1 had a physical examination completed on 2/28/2022 and then again on 3/27/2023.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Effective 2/12/2024 The medical records coordinator will work with the administrative coordinator to ensure that individual #1's future physical examination appointments are within the regulated time frame. 02/12/2024 Implemented
SIN-00219193 Renewal 02/13/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65The bathroom in the hallway outside the bedrooms did not have an operable window and the mechanical ventilation system was inoperable.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. The agency has an appointment scheduled with BC Electric for March 10, 2023, to install a new vent fan in the bathroom. 03/10/2023 Implemented
6400.142(a)Individual #1 had a dental examination on 08/02/21, and then again on 11/14/22.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. The individual refused several appointments, all of which were documented. The agency will continue to document refusals of the agency refusal of service form, which includes the date of the refusal, services refused, and the out come, including the date of the rescheduled appointment. In addition, to ensure follow up appointments are scheduled within the regulatory compliance guidelines, The agency has re- implemented the individual data tracking schedule, in which the agency will collect all individual records and dates and place them into Google Calendar. The renewal completion due date will be set for 30 days prior to the expiration date of the current documents. For example, if an individual's dental exam expires on 04/30/23, the renewal completion due date will be 03/30/23. The schedule will be placed into google calendar, which all admin staff are connected via email. The administrative coordinator and staff supervisors will be responsible for the review of all staff documents. 03/13/2023 Implemented
6400.165(g)The psychiatric medication reviews completed 8/29/22, 10/19/22, and 12/14/22 for Individual #1 did not include the name and necessary dosage of the medication(s), and the reason for prescribing the medication(s). [Repeat Violation, 3/2/2022]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.The provider has changed the individual's psychiatric medication provider, as the previous medical provider continuously refused to complete the requested form, despite written instructions on the forms sent with the individual to the appointment. Documentation of the mentioned issue is in the individual's file. 03/02/2023 Implemented
SIN-00202480 Renewal 03/02/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(g)Individual #1 is prescribed medication to treat the symptoms of a diagnosed psychiatric illness; however, individual #1 did not have a record of psychiatric medication review being completed prior to 9/7/2021.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.The agency CEO has sent several request (verbal phone conversation) to the psychiatric doctor to receive proof of med reviews for 2021 - in which the response was "they will eventually send them when they find them". On another occasion, the medical office stated the records were at another office and they would get back to us. As of April 20, 2022, the psychiatric office has not located or answered ALC's request. The agency has developed an "information request form". The form includes the following: 1. Date of request 2. Staff making request 3. information requested 4. reason for request 5. who staff made contact with 6. Results of the request Going forward, all information request will be documented on this form and placed in the individual's file. ["Information Request Form" received on 5/19/22 and reviewed on 5/20/22. "Individual Data Tracking" system received 5/19/22 and reviewed 5/20/22. Weekly reviews by Administrative Liaison received 5/19/22 and reviewed 5/20/22. DPOC by HDKP, HSLS, on 5/20/22]. 03/29/2021 Implemented
SIN-00185650 Renewal 03/31/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106A furnace inspection was completed on 1/03/2020 and then again on 2/12/2021.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. It is now ALC policy that all furnace inspections be scheduled 30 days prior to the expiration of the current furnace inspection date. An ¿ALC Agency Schedule Calendar¿ has been created and is connected to the emails of the CEO and administrative assistant. The administrative assistant will be responsible for scheduling the furnace inspections with ARS. ¿ALC Agency Schedule Calendar¿ includes a December 5th 2021 schedule reminder (including two days & one day before) for the administrative assistant to contact ARS to schedule the next inspection for January 5, 2022. The confirmed scheduled appointment will be placed into the ¿ALC Agency Schedule Calendar¿. 04/12/2021 Implemented
6400.141(c)(4)Individual #1, date of admission 3/27/17, had a vision screening 12/29/2020 and not one prior. Individual #1 has no record of having a hearing screening completed.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The individual attended a hearing and vision appointment today, April 13, 2021. The documentation of the hearing and vision exam will be obtained from the primary care physician and placed into the individual¿s file. 04/13/2021 Implemented
6400.151(c)(3)Direct Service Worker #1 had a physical examination completed on 3/18/2021 which did not include a signed statement that the staff person is free from communicable diseases. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. The staff¿s physical has been updated to reflect the ¿free from a communicable disease¿ statement. The physical was updated by the MedExpress medical personnel, where the staff completed his exam and TB. 04/01/2021 Implemented
SIN-00169859 Renewal 02/06/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(5)Individual #1, date of admission 10/4/19, had an immunization Tetanus Diphtheria booster on 9/1/09 then again 10/23/19.The physical examination shall include: Immunizations and screening tests for individuals 17 years of age or younger, as recommended by the Standards of Child Health Care of the American Academy of Pediatrics, Post Office Box 1034, Evanston, Illinois 60204. The appointment was scheduled for 10/23/19 for the individual to receive TD. This appointment was scheduled prior to her admission to ALC on 10.4.19. Agency took individual to appointment on 10/23/19, where she received her TD. Going forward, the TD has been added to our admission list, to ensure new admissions have required vaccinations. Agency will ensure individuals receive vaccinations according to doctor recommendations and timelines. [Immediately, the CEO shall educate all staff persons on their responsibilities to ensure all individuals are supported as needed to ensure timely completion physical examination to include all required information including immunizations. Immediately, upon completion and at least quarterly for 1 year, the CEO or Designee shall audit all individuals current physical examinations to ensure timely completion with all required information and individuals health needs are arranged and provided for. Documentation of audits shall be kept. (DPOC by AES, HSLS on 3/3/20)] 10/23/2019 Implemented
6400.143(a)Individual #1 refused the gynecological examination during a physical examination, completed 2/27/19. Individual #1's record did not included continued attempts to train the individual about the need for health care.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record.We have a letter from the individual's doctor deferring the gynecological exam, due to anxiety and lack of sexual activity. Please see attached. Going forward, agency has added gynecological exam to the admissions list, to ensure exams are current and/or scheduled during admission. Agency will continue exams annually, or as recommended my physician. [Immediately, the CEO shall develop and implement policies and procedures to address if an individual refuses a medical or dental examination and treatment. Documentation of the policies and procedures shall be kept. Within 30 days of receipt of the plan of correction, the CEO shall educate all staff persons on their responsibilities to ensure all individuals are educated about the need for health care if an individual refuses a medical or dental examination or treatment. Documentation of the training shall be kept. are supported as needed to ensure timely completion physical examination to include all required information including immunizations. Immediately, upon completion and at least quarterly for 1 year, the CEO or Designee shall audit all individuals' records to ensure documentation of the refusal and continued attempts to train the individual about the need for health care is in the individuals' records. (DPOC by AES,HSLS on 3/3/20)] 02/18/2020 Implemented