Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00231455 Renewal 09/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)On 9/20/2023, at 10:20 AM, the bathroom on the second floor had a water temperature of 133.3 degrees Fahrenheit.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. On 9.20.23, the maintenance director turned the water temperature down at the hot water tank. 09/20/2023 Implemented
6400.67(a)On 9/20/2023, multiple ceiling tiles were missing in the basement drop ceiling.Floors, walls, ceilings and other surfaces shall be in good repair. Ceiling tiles were replaced on 10.15.23. 10/15/2023 Implemented
6400.67(b)On 9/20/2023, the basement ceiling had multiple tiles missing, exposing the electrical wires and insulation. Floors, walls, ceilings and other surfaces shall be free of hazards.Ceiling tiles were replaced on 10.15.23. 10/15/2023 Implemented
6400.68(b)On 9/20/2023, at 10:07 AM, the bathtub in the bathroom on the first floor had a water temperature that measured 136.4 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. On 9.20.23, the maintenance director turned the water temperature down at the hot water tank. 09/20/2023 Implemented
6400.72(a)On 9/20/2023, bedroom #2, the staff office space, had no screens in the two windows. Bedroom #3 on the second floor, belonging to individual #1, had no screen in the window next to the bed.Windows, including windows in doors, shall be securely screened when windows or doors are open. Screens were put in the windows. 10/13/2023 Implemented
SIN-00212718 Renewal 10/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(10)Individual #1's October 2022 medication record did not include the administration time for Trulicity INJ 1.5/0.5 administered on 10/5/22.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.On 10.14.22, the Director of Operations contacted the prescribing doctor and requested the documentation for administration time for this medication. As soon as the information is received, the Director of Operations will document the administration time in the individual¿s MAR. Additionally, the Director of Operations will contact the pharmacy to add the administration time in his MAR. This is expected to be complete 11.18.22 11/18/2022 Implemented
6400.166(a)(11)Individual #1's October 2022 medication record did not include the diagnosis and purpose for Latuda Tab 20mg and Divalproex 250mg.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The Director of Operations reached out to the doctor for written documentation on the diagnosis/purpose for Latuda and Divalproex. The Director of Operations requested this be completed before 11.18.22. 11/18/2022 Implemented
6400.167(a)(1)Latuda 20mg., take one tablet by mouth daily prescribed to Individual #1 was not administered from 9/29/22 to 10/3/22 at 8:00AM.Medication errors include the following: Failure to administer a medication.The Director of Operations reported the med error on 10.14.22. The Health Director called the pharmacy on 9.29.22 to request a refill of the medication. A new medication tracking protocol has been established. The Health Director will be trained on this new protocol by 10.31.22. 10/31/2022 Implemented
6400.182(c)Individual #1's assessment, completed 4/21/22, indicates Individual #1 is able to safely use poisonous materials. Individual #1's ISP, updated 9/16/22, indicates all toxic substances are locked at the home.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The Director of Operations notified the SC on 10.14.22 to request an update to the ISP in order to reflect the current assessment. The Director of Operations will check in with the SC on weekly basis until the update is made. This documentation will be kept. The update is expected to be completed by 11.18.22 11/18/2022 Implemented
6400.207(4)(I)Hydroxyz Pam Cap 50mg., take one capsule by mouth twice a day as needed for agitation or sleep, prescribed to Individual #1 was administered at 5:30PM on 10/1/22. The physician has not documented the well-defined descriptions of the explicit psychiatric symptoms of when to administer this medication. Reportedly, Individual #1 does not request the medication or express the need for the medication.A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior.The Director of Operations contacted the doctor on 10.13.22 to define psychiatric symptoms. Once that information is received, staff will be trained on what a psychiatric symptom that requires this medication looks like. A PRN approval process will also be a part of this training, which is expected to occur by 11.18.22. 11/18/2022 Implemented
SIN-00180275 Renewal 12/08/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)The hot water temperature in the sink in the bathroom off the hallway on the second floor of the home measured at 122.5°F at 11:30am on 12/9/2020.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. The immediate correction was to have a maintenance person check to see why the water temperature varied within the home. It was identified that the hot water tank needed to be adjusted. This was completed and the current temperature at the tubs is 112.5 degrees F. To prevent future reoccurrences of this violation, the Program Manager and maintenance will monitor and document the water temperatures in vacant homes monthly. Once a site has ben occupied, water temperatures will be monitored monthly when the fire drill is being completed. The water temperature will be documented on the fire drill form monthly. Quarterly audits will be completed on the fire drill forms to monitor progress on the plan of correction. All staff will be retrained on the regulation that resulted in this violation. [Documentation of all aforementioned audits and trainings shall be kept. (DPOC by AES,HSLS on 1/6/20)] 01/11/2021 Implemented
6400.74The outside steps attached to the porch in the back of the home do not have a nonskid surface.Interior stairs and outside steps shall have a nonskid surface. The immediate correction for this violation was to place a non-skid surface on the steps attached to the porch. This was completed on 12/9/20. To prevent a reoccurrence of this violation all staff involved with opening new homes will be retrained on the self-assessment tool. The self-assessment tool will be completed by the Program Manager and Maintenance prior to the submission for the license. They will be retrained on the self inspection declaration tool. Additionally, the Program Director will walk through new homes with the Program Manager to ensure all areas of the self inspection tool have been properly addressed. The Program Director will continue to do monthly walk throughs of all vacant sites to ensure they are within compliance. [Documentation of all aforementioned audits and trainings shall be kept. (DPOC by AES,HSLS on 1/6/20)] 01/11/2021 Implemented
6400.111(f)The date of the inspection was not on the fire extinguishers in the kitchen and the basement of the home. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The immediate correction was to take the fire extinguisher to ABCO to be retagged. This was competed on 12/9/20. To prevent a reoccurrence of this violation, all staff will be retrained on the regulation that resulted in this violation. The Leads will complete a weekly checklist containing a question specifically asking if the tags are present on the fire extinguishers. The Program Manager will do unannounced site reviews with the Leads to ensure this process is occurring and to monitor effectiveness of the plan of correction. The Program Director will complete monthly site walk throughs with the Program Manager to monitor progress on the plan of correction. When the site is vacant, the Program Manager will complete the weekly check on the fire extinguishers. 01/11/2021 Implemented