Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00231500 Renewal 09/26/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.171At the time of the inspection, there was a bowl of pretzels in the lower cabinet. Left over snacks mut be stored in a closed container or zip lock bag to prevent contamination.Food shall be protected from contamination while being stored, prepared, transported and served. 1. A clip was placed on all open bags or food was placed in sealed container. 2. Staff will be trained on regulation 6400.62c and sign off by 12-31-2023. 12/31/2023 Implemented
SIN-00137778 Renewal 08/29/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)There was no indication that a self-assessment was completed for 241 2nd Street, Elmora. The self-assessment form did not include an address for the home that it was completed for. The legal entity address was recorded on all self-assessment forms.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. 1. The CEO trained Vice President on regulation 6400.15A on 09/04/2018 to have addresses properly identified on the self-assessment. 2. All other locations were not in compliance with this regulation. This violation was addressed by the licensor on 08/29/2018 during on-site inspection. 3. The President and Vice President and house team leads were trained on regulation 6400.15A by the CEO to ensure that all self-assessments will have the proper addresses listed with reference to Regulation 6400.15A. The President, Vice-President and House Team Leads will sign off on signature paper by 12/31/2018. 4. The CEO will review with the Vice President the self- assessments on a yearly basis to ensure compliance. 10/12/2018 Implemented
6400.67(a)The paint is peeling and splintering on the handrails outside the backdoor entrance of the home.Floors, walls, ceilings and other surfaces shall be in good repair. 1. A maintenance request form was submitted to the maintenance manager to have the handrails painted on 08/30/2018. 2. All other homes were checked for this violation. All other homes were in compliance. This was completed on 09/04/2018. This was completed by the quality compliance manager. 3. All staff will be trained on regulation 6400.67A by the quality compliance manager to ensure that all individuals are trained on this regulation with reference to having hand rails painted. Staff will sign off on signature paper by 12/31/2018. 4. This violation will be added to the group home checklist and the quality compliance manager will be responsible to check to make sure that handrails are painted at all houses. This will occur on a weekly basis 10/12/2018 Implemented
6400.73(a)REPEAT from 7/12/17 renewal inspection: The bottom three steps of the basement steps were not equipped with a handrail. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. 1. A maintenance request form was submitted to the maintenance department for a hand rail to be installed at this location on 8/30/2018. 2. All other houses were checked for this violation. All other locations were in compliance. This was completed on 09/04/2018. This was completed by the quality compliance manager. 3. All staff will be trained on regulation 6400.73A by the quality compliance manager to ensure that all individuals are properly trained on this regulation with reference to hand rails. Staff will sign off on signature paper by 12/31/2018. 4. This violation will be added to the group home checklist and the quality compliance manager will be responsible to check to make sure that any step over 18 inches or any steps more than three will have a hand rail on a weekly basis. 10/12/2018 Implemented
6400.112(a)A fire drill was not held in October 2017. An unannounced fire drill shall be held at least once a month. 1. The Fire Safety Expert trained all team leads at all houses on regulation 6400.112A on 09/04/2018. 2. All houses were checked to make sure that all fire drills were checked and completed throughout the agency by the fire safety expert on 09/04/2018. 3. All staff will be trained on regulation 6400.112A by the Fire Safety Expert to make sure that all individuals are properly trained on when to conduct fire drills with reference to Fire Safety Training -Training Outline. Staff will sign off on signature paper by 12/31/2018. 4. The Fire Safety Expert will review all fire drills on a monthly basis and will sign off on all fire drills in compliance with regulation 6400.112A starting 11/01/2018. 10/12/2018 Implemented
6400.113(a)There was no indication to identify who received fire safety training within the home. The individual's signature was illegible, and the agency did not document who received fire safety training. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. 1. The Program Specialist went back and printed the individuals name on 09/04/2018 to go along with the individual¿s initials and or signature that was illegible . The Fire Safety Expert will sign off on all of the individual¿s fire safety training to make sure that the individuals are getting trained correctly. 2. The Program Specialist reviewed all other fire safety trainings and made corrections and clearly identified the individuals were trained in fire safety on 9/4/2018 to 9/06/2018. 3. All staff will be trained on regulation 6400.113A by the Fire Safety Expert to make sure that all individual are properly trained in fire safety with reference to Fire Safety Training-Training outline, staff will sign off on training signature paper by 12/31/2018. 4. The CEO will review all individual¿s fire safety on a quarterly basis to ensure compliance with the CEO review signature sheet starting on 01/2019. 10/12/2018 Implemented
SIN-00077255 Renewal 04/16/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(c)The medication reviews for Individual #1 completed on 3/16/15 and 4/10/15 did not review the medications and dosages. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.added policy for medical review psychiatric. which states that a copy of all physicians orders will be attached to the psychiatric appointment sheet for medical personal review. 05/01/2015 Implemented
6400.181(e)(1)The assessment for Individual #1 did not include functional strengths, needs, and preferences. The assessment must include the following information: Functional strengths, needs and preferences of the individual. added the functional strengths, needs, and preferences to the assessment. 04/28/2015 Implemented
6400.181(e)(2)The assessment for Individual #1 did not include likes, dislikes, and interests.The assessment must include the following information: The likes, dislikes and interest of the individual. added likes, dislikes and interests to the assessment.Program specialist will review all records and will review records in the future to assure compliance. 04/28/2015 Implemented
6400.181(e)(10)The assessment for Individual #1 did not include a lifetime medical history.The assessment must include the following information: A lifetime medical history. added lifetime medical history to assessment.Program specialist will review all records and will review records in the future to assure compliance. 04/28/2015 Implemented
6400.181(e)(12)The assessment for Individual #1 did not include recommendations for specific areas of training, programming and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. added recommendations to the assessment.Program specialist will review all records and will review records in the future to assure compliance. 04/28/2015 Implemented
6400.181(e)(13)(viii)The assessment for Individual #1 did not include progress 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. added managing personal property to the assessment. Program specialist will review all records and will review records in the future to assure compliance. 04/28/2015 Implemented
6400.183(5)The Individual Support Plan (ISP) for Individual #1 did not include a protocol to address the social, emotional, and enviornmental needs of the individual. Individual #1 was prescribed Risperdal, Seroquel, and Neuontin for Mood Disorder and Fluoxetine for Depression. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. emailed support coordinator on 5/11/15 to have social, emotional, and environmental needs added to ISP. Have documentation that the email was sent. Program specialist will review all records and will review records in the future to assure compliance. 05/11/2015 Implemented
6400.183(7)(iii)The Individual Support Plan (ISP) for Individual #1 did not include an assessment of their potential to advance in vocational programming. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. emailed support coordinator on 5/11/15 to have vocational added to ISP. Have documentation that the email was sent.Program specialist will review all records and will review records in the future to assure compliance. 05/11/2015 Implemented
6400.186(b)Individual #1 did not sign and date their quarterly. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. Had individual sign and date quarterly review on 5/1/15 and had a received and sent signature page added to the quarterly review.Program specialist will review all records and will review records in the future to assure compliance. 05/01/2015 Implemented
6400.213(11)The 3/1715 physical for Individual #1 had that they were allergic to mushrooms. The Individual Support Plan (ISP) and identification sheet for Individual #1 had that they were only allergic to Penecillin, ivory soap, wool, and bee stings. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. went to pcp and had documentation stating that individual was not allergic to mushrooms.Program specialist will review all records and will review records in the future to assure compliance. 04/30/2015 Implemented
SIN-00195548 Renewal 11/16/2021 Compliant - Finalized
SIN-00178850 Renewal 11/04/2020 Compliant - Finalized
SIN-00163252 Unannounced Monitoring 09/24/2019 Compliant - Finalized
SIN-00118018 Unannounced Monitoring 07/12/2017 Compliant - Finalized