Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00227047 Renewal 08/30/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.52(a)(1)Staff #1 completed more than 24 hours of training during the agency's training year 10/01/2021 to 9/30/2022, but that training did not include the following required trainings: Person centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships (52c1); the prevention, detection and reporting of abuse, alleged abuse and suspected abuse (52c2); individual rights (52c3); recognizing and reporting incidents (52c4); the safe and appropriate use of behavior supports (52c5) and implementation of the individual plan (52c6). NOTE; The agency has taken steps to include the required trainings in their training curriculum and Staff #1 has completed most of the missing trainings since the end of the training year that was reviewed for this inspection.The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.The CEO will ensure that all required yearly training is listed on the annual training curriculum and all staff will complete all the mandatory training within the training year. 09/05/2023 Implemented
SIN-00207750 Renewal 08/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Poisonous materials are not locked or made inaccessible to individuals. There were four packets of aspirin, 4 packets of acetaminophen and 4 packets of ant-acid located in the first aid kit in the home.Poisonous materials shall be kept locked or made inaccessible to individuals. All new first aid kits will be checked by the Nurse before being placed in any of the homes. 09/01/2022 Implemented
SIN-00191835 Renewal 08/25/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(4)The current physical examination dated 10/16/2020 for Individual #1 did not include an assessment of hearing.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The Program Specialist will check the physical form to ensure that all required fields are completed and if there are any incomplete field, the Program Specialist will arrange to have the Doctor¿s Office complete same. 08/24/2021 Implemented
6400.141(c)(6)Individual #1 is overdue for a TB test; the most recent TB test for the individual occurred on 4/09/2019.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. The Program Specialist and or the Administrative Assistant will start documenting the dates of all Tuberculin Skin Testing and when the next test is due to ensure that consumer is up to date on TB tests. 08/31/2021 Implemented
6400.34(a)The Individual Rights that were reviewed with Individual #1 on 12/27/2020 had not been updated to reflect the current rights as outlined in 6400.32a-v. Therefore, the Individual was not informed of all the rights afforded to him/her.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.The Individual Rights Statement was revised to include the 6400.32 a-v regulations. 08/31/2021 Implemented
6400.46(c)Staff #2 did not have training in basic first aid as part of Orientation training and prior to working with individuals.Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques.Staff #2 completed the first aid training on 8/19/2021, and the Administrative Assistant will ensure that basic first aid is part of the orientation training prior to working with the individuals. 08/19/2021 Implemented
6400.207(4)(I)A chemical restraint, defined as the use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior, is a prohibited restrictive procedure. Individual#1 is prescribed Lorazepam, 2mg. tablet, "take 1 tab by mouth once per day as needed for anxiety," but there is no description of the symptoms that need to be exhibited or observed in order to administer the medication for the specific mental condition of anxiety [207(4)(i)PART 2].A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition.Program Specialist reached out to the individual¿s psychiatrist and requested a written protocol for the medication in question. 08/20/2021 Implemented
SIN-00178518 Renewal 10/20/2020 Compliant - Finalized