Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00227393 Renewal 07/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill completed on 10/17/23 did not include the date of the fire drill.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. SOP is being developed for Team Leads & Program managers regarding Fire drill forms and administrative review requirements (Completed 7/31/23) Training on the Fire Drill form itself, SOP, and the administrative review process will be completed by 8/15/23. 08/15/2023 Implemented
SIN-00180184 Renewal 12/01/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.34(a)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 there after. The individual rights need to be updated to reflect the current regulations.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.Client service team did not match the new regulations to the current documentation being given to individuals. Client Rights policy was revised and is being reviewed with all staff and individuals during January 2021.Client Rights policy will be reviewed with all clients upon admission and annually there after. Quality Management will review updates from ODP regularly to ensure policy is updated to comply with current regulations. 01/07/2021 Implemented
6400.163(h)The prescription was dispensed on 10/29/19. This PRN is out of date. Also Ocean Nasal Spray 0.65% nose spray directed to give 2 sprays in each nostril as needed every 2 hours was dispensed on 10/29/19. This PRN is also out of date.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Pharmacy had not removed the medication from the MAR after it was discontinued and staff failed to remove the medication from the home & MAR. Medication was removed on 12/02/2020 and discontinue order was confirmed . LVAS is in process to switch pharmacies to Hartzell's Pharmacy. This decision was made due to ongoing issues with the current pharmacy. Switch should be full by 3/15/2021 03/15/2021 Implemented
6400.166(a)(6)The medication record shall be kept including the diagnosis or purpose for the medication. Medication Clozapine 50mg listed on the MARS sheet does not have diagnosis or purpose for the medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form.The pharmacy refuses to add this information and no-one has been handwriting it onto the MAR . Diagnosis and reason for medication added to January MARs by 1/14/2021. LVAS is in process to switch pharmacies to Hartzell's Pharmacy. This decision was made due to ongoing issues with the current pharmacy. Hartzell's will print this information on the forms Switch should be full by 3/15/2021 . 03/15/2021 Implemented
6400.166(a)(7)The medication record shall be kept including the dose of medication. Individual #1 medication for Clozapine 50mg is listed on the MARS to take one tablet twice a day daily. The blister pack directions states that 1.5 tablets is to be taken twice a day. The blister pack also reflected 1.5 tablets in the blister.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.Administrtive and direct care staff failed to conduct the proper checks. The MAR was corrected on 12/2/2020. Team leads will be given refresher training on how to check MARs during leadership week starting 1/18/2021. 01/22/2021 Implemented
SIN-00137947 Initial review 07/12/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)The handrail on the stairs leading from the elevated back deck to ground level was loose and needed to be secured.. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The recently installed hand rail was secure by facilities maintenance with two screws. Handrails have been added to the quarterly fire safety review. On a Quarterly basis the Director of Residential services will ensure all railings inside and outside of homes are secured. 07/13/2018 Implemented
6400.110(e)The home had three levels, including the basement and attic, and the smoke detectors were not interconnected.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. Interconnected smoke detectors/ carbon monoxide detectors have be install on all three floors on the home. The Executive Director will inspect future homes for interconnected smoke detectors prior to procurement for licensure. The new smoke detectors will be added to the monthly residential fire safety checklist as well as the quarterly review process. 07/12/2018 Implemented
SIN-00159814 Renewal 07/10/2019 Compliant - Finalized