Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00236701 Unannounced Monitoring 12/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(b)The fence on the side of the home is in need of repair or replacement, there is missing wood pillars and a tree laying over the fence which could pose a hazard. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The L.I.F.E. Group will ensure the outside of the building and the yard or grounds will be maintained, in good repair and free from unsafe conditions. A contractor has been identified to complete repair the fence on the property. 01/31/2024 Implemented
6400.144Medication ACETAMINOPHEN COD#3 TAB is not being documented as administered for Individual #1, the control log count shows there is 17 pills remaining however, there is only 16 pills in the blister pack the one pill is not accounted for.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The L.I.F.E Group will ensure that all services planned or prescribed will be provided. The violation was corrected on site with Mr. Brown during the inspection. 01/17/2024 Implemented
6400.165(c)Medication LEVOTHROXINE 112mcg Tab was to be administered to individual #1 for 30 days, 1 pill per day at 8am beginning on 11/25/2023 and ending on 12/24/2023. While reviewing individual's medication review it was discovered that a pill was still in the bottle rendering that the individual was not given the medication as prescribed.A prescription medication shall be administered as prescribed.The L.I.F.E. Group will ensure that all prescription medication will be administered as prescribed. The prescribing doctor was informed about the missed dose. An incident was submitted to EIM 12/28/2023 Implemented
6400.188(a)Individual #1 has not received adequate staffing or behavioral support services. The individual does not have staffing overnight (the agency staffing hours are from 7AM to 7PM), and the does not have documentation showing necessary progress on the development and implementation of behavioral supports, interventions, and staffing adjustments. This resulted in an incident late in the evening on 12/25/23, after staff had left: after an emotionally exhausting Christmas holiday, the individual #1 contacted the police, and later reported to the agency they had been attacked by a home invader wielding a bat and wearing clown make-up or a mask. The individual's plan indicates they have a history of creating stories in response to the feeling their needs have not been met, as happened here. The agency must ensure that staff is available to provide the supports listed in the individual's behavioral support plan, and they must document their progress in bolstering the individual's supports and staffing, or else more incidents like this are likely to occur.The home shall provide services, including assistance, training and support for the acquisition, maintenance or improvement of functional skills, personal needs, communication and personal adjustment.The L.I.F.E. Group will ensure services are provided, including assistance, training and support for acquisition, maintenance or improvement of functional skills, personal needs, communication and personal adjustment. A team meeting on 1/8/24 (virtually) was held to discuss the difficulties the individual has been having over the holiday season. An FBA will be completed by the BS within 2 weeks to determine if additional behavior supports, and staffing is needed to support the individual. The Program Specialist will continue to provide support to the individual and communicate to the team as needed. 01/26/2024 Implemented
SIN-00235209 Unannounced Monitoring 11/16/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The light bulbs inside of the refrigerator are missing.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The L.I.F.E. Group will ensure that all areas of concern will be lighted to assure safety. A new refrigerator will be purchased to replace the current one at the site. 12/20/2023 Implemented
6400.73(a)The back steps leading down to the yard from the patio is a total of three steps and there is no railing on either side of the steps. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The L.I.F.E Group will ensure each ramp and interior stairway and outside steps exceeding 2 steps will have a well secured handrail. A contractor has been secured to install a handrail for the back steps 12/27/2023 Implemented
6400.76(a)The shelves on the inside of the refrigerator door are missing. Furniture and equipment shall be nonhazardous, clean and sturdy. The L.I.F.E Group will ensure furniture and equipment will be nonhazardous, clean and sturdy. A new refrigerator will be purchased to replace the current one at the site. 12/20/2023 Implemented
6400.77(b)The first aid kit did not contain tweezers. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. The LIFE Group will ensure all required items are in the first aid kit at all times. Tweezers were put in the first aid kits. 11/16/2023 Implemented
6400.77(c)The first aid kit did not contain a first aid manual. A first aid manual shall be kept with the first aid kit.The LIFE Group will ensure all sites keep a complete first aid kit in the home. A first aide manual was obtained and placed in the kit. 11/16/2023 Implemented
6400.110(e)The smoke detectors when sounded did not work in conjunction with each other. Also, the smoke detector should be placed closer to the individual's bedroom. A video of the smoke detectors working was received within 24 hours of the violation..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. The L.I.F.E Group will ensure smoke detectors are interconnected and audible throughout the home. A contractor was secured, and the issue was fixed within the requested time frame. 11/18/2023 Implemented
6400.144Individual #1's medication BENZONATATE 200mg Caps is being administered every day at 8am, 5pm and 8pm. This medication is listed as a PRN and given as a daily medication. It is to be given as needed. No script was in individuals MAR.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The L.I.F.E Group will ensure that all services planned or prescribed for the individual will be provided. The prescribing Doctor was contacted to give direction because the consumer wanted to take the medication daily. The doctor sent documentation after speaking with the individual about resuming the mediation on a PRN basis. the MAR was updated to reflect this clarification. 11/17/2023 Implemented
SIN-00232832 Unannounced Monitoring 10/11/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(b)There is evidence of infestation of rodents in the home, it was observed at the time of inspection a mice run across the stove, and droppings were noticed in the basement.There may not be evidence of infestation of insects or rodents in the home. The LIFE Group will ensure the home is free of infestation of rodents or insects. Terminix was called to complete a treatment in the home. 10/16/2023 Implemented
6400.67(b)There was lint in the dryer filter (the size of a golf ball) which is a serious hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.The LIFE Group will ensure that floors, walls, ceilings and other surfaces will be free of hazard. The lint trap was clean out while the inspector was on site. 10/11/2023 Implemented
6400.68(b)The hot water in the bathtub and shower was measured at 148.6*F. (This must be corrected by 10/12/2023) Hot water temperatures in bathtubs and showers may not exceed 120°F. The LIFE Group will ensure hot water temperatures will not exceed 120F. The water heater was adjusted to ensure the water temp registers at 120F 10/12/2023 Implemented
6400.80(b)The outside of the home is in need of yard maintenance, the grass needs cut, and bushes trimmed. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The LIFE Group Will maintain the yards and grounds to ensure repairs are made as needed and the area is free from unsafe condition. The grass was cut, and the area was landscaped. 10/13/2023 Implemented
6400.144Staff recorded in the medication record (MAR) that the medication was administered at the prescribed time, this is incorrect as the staff did not administer the medication to the individual. The medication was left out for the individual, (individual is not self-medicating) it could not be determined if the individual took the prescribed medication as no staff was present.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The LIFE Group will ensure that all health services that are planned and prescribed for the individual will be provided. The staff was identified and retrained on the 5 Rights of Medication Administration and the Medication administration Cycle. 10/17/2023 Implemented
6400.213(3)There was no current physical examination record for the individual on site at the time of the review.Each individual's record must include the following information: Physical examinations. The LIFE Group will ensure that up to date physicals are located in the Medical Book on site. 10/16/2023 Implemented
6400.213(6)The individual's current assessment was not on file. It was requested and was never received.Each individual's record must include the following information: Assessments as required under § 6400.181 (relating to assessment). The LIFE GROUP will ensure that assessment for each individual will be updated annually and stored in their Program book. 10/16/2023 Implemented
6400.163(b)The prescription medication was removed from its original labeled container before the individuals scheduled administration time,A prescription medication may not be removed from its original labeled container in advance of the scheduled administration, except for the purpose of packaging the medication for the individual to take with the individual to a community activity for administration the same day the medication is removed from its original container.The LIFE Group will ensure the proper MEDICATION ADMINISTRATION processes will be followed. The staff was identified and retrained on the 5 Rights when administering meds and the Medication Administration Protocol 10/16/2023 Implemented
6400.165(b)There was a PRN medication in the medication box that was not written on the current MARS.A prescription order shall be kept current.The LIFE Group will ensure that all prescription orders are kept current. The PM checked to ensure all PRN medications were listed on the current MAR. Any medications found were discarded. 10/16/2023 Implemented
6400.165(g)The individual is prescribed a number of psychotropic medications, however there was not a documented record on file showing that the medications were being reviewed by the prescribing physician.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 Life Group Will ensure the individual is assessed by a licensed physician every 90 days while on psychotropic medications. Individual had their 90-day appointment on 10/18/23.. 10/16/2023 Implemented
6400.186The records only include daily documentation of the individual's preferences related to relationship, communication, community participation, employment, income, and saving, healthcare care, wellness and education for the months of September and October. The last dated daily documentation was completed on 8/23/2023.The home shall implement the individual plan, including revisions.The LIFE Group will ensure the home implements the ISP and completes daily documentation on the progress of the ISP Goals. In late August the organization began to document daily notes in a computerized system (Therap). The notes from 8/23 to 10/11 are included in the supporting documents. 10/16/2023 Implemented
SIN-00227819 Unannounced Monitoring 07/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The first-floor bathroom tub has some brown residue around the fixtures and the drain hole.Clean and sanitary conditions shall be maintained in the home. The LIFEGROUP will ensure that clean and sanitary conditions will be maintained in the home. The brown residue was identified as rust spots. Rust remover was used to remove the brown stains. 08/11/2023 Implemented
6400.64(b)There were numerous flying insects observed in the basement where individual 1 washes clothes.There may not be evidence of infestation of insects or rodents in the home. The LIFEGROUP will ensure there will not be evidence of infestation of insects or rodents in the home. The LIFEGROUP has contracted with an extermination service to visit the homes quarterly and exterminate as needed. 08/11/2023 Implemented
6400.66There is no lighting source in the first-floor bathroom. This room is lighted by ceiling florescent light bulbs however all of the bulbs are non-operational.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The LIFEGROUP will ensure all areas of the home to be lighted to assure safety and to avoid accidents. The florescent light bulbs were ordered, and the old ones were replaced with new ones. 08/04/2023 Implemented
6400.67(b)The basement stairs are shaky and move when walking on them. Floors, walls, ceilings and other surfaces shall be free of hazards.The LIFEGROUP will ensure all surfaces are free of hazard. The organization has contacted a contractor to assess and repair the shaky basement stairs. 08/16/2023 Implemented
6400.67(b)The first-floor bathroom medicine cabinet is rusted out on the bottom shelf. Floors, walls, ceilings and other surfaces shall be free of hazards.The LIFEGROUP will ensure all surfaces are free of hazards. A contractor was contacted to repair/replace the medicine cabinet. 08/11/2023 Implemented
6400.67(b)The first floor utility closet has a partially exposed pipe access panel, as the panel is not securely affixed to the wall. Floors, walls, ceilings and other surfaces shall be free of hazards.The LIFEGROUP will ensure that all surfaces in the home will be free of hazards. A contractor has been contacted to assess and repair the exposed pipes. 08/11/2023 Implemented
6400.76(a)The kitchen cabinet nearest the microwave bottom hinge is loose and not operating properly. Furniture and equipment shall be nonhazardous, clean and sturdy. The LIFEGROUP will ensure all furniture and equipment will be nonhazardous, clean and sturdy. The bottom hinge was repaired. 08/04/2023 Implemented
6400.77(b)The first aid kit was missing adhesive bandages and tape. [REPEATED VIOLATION 4/5/22] A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. The LIFEGROUP will ensure all first aid kits will have all required contents at all times. 08/04/2023 Implemented
6400.77(c)The first aid kit did not contain a first aid manual. A first aid manual shall be kept with the first aid kit.A first aid manual was put in the first aid kit. 08/04/2023 Implemented
6400.80(b)There is a large amount of trash and debris including food trash all over the backyard grounds. [REPEATED VIOLATION 10/12/22] The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The LIFEGROUP will ensure the outside of the building and the yard will be well maintained, in good repair and free from unsafe conditions. The trash was removed from the yard and the grass was cut. 07/21/2023 Implemented
6400.214(b)Individual #1's behavior support plan was not present in the home. [REPEATED VIOLATION 10/12/22] The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The LIFEGROUP will ensure the most recent behavior support plan is present in the home. The most recent support plan has been placed in the home. 08/11/2023 Implemented
6400.186The daily progress notes/outcome/goals log for individual #1 does not specific list which outings are done on a daily basis to integrate into the community, nor does it demonstrate how opportunities are afforded for this individual to exercise per the individual. [REPEATED VIOLATION 10/12/22]The home shall implement the individual plan, including revisions.The LIFEGROUP will ensure implementation of the ISP including revision. The Program Specialist will update the progress note/outcome/goals log for individual #1 to indicate what outings are done daily for community integration. 08/11/2023 Implemented
SIN-00213204 Unannounced Monitoring 10/12/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The kitchen oven and toaster oven tray had grease buildup. The second floor bathtub needs to be cleaned, as there is a brown substance around the perimeter of the drain.Clean and sanitary conditions shall be maintained in the home. The kitchen oven was cleaned to remove the grease buildup. After further assessment the toaster oven was discarded and replaced with an air fryer. The second-floor bathtub was scrubbed to remove the brown stains. 10/14/2022 Implemented
6400.70The only accessible phone in the home was located in the living room and could only receive incoming calls, as the number plate which contains the numbers to dial was not on the phone. These numbers were removed due to the restrictive plan of individual #1, however there should be another phone in the home that is made inaccessible to individual #1, but accessible to staff. There was another phone that was unplugged and locked in the staff office in a cabinet, however the staff person on shift at that time was not aware that this phone was in the home.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. An operable phone has been placed in the home. Per the restrictive plan for the consumer, the phone is kept locked in the office and is only accessible to the individual at designated times. 10/13/2022 Implemented
6400.72(b)The screen on the sliding glass door in the kitchen that leads to the backyard, was torn in multiple places at the bottom. Screens, windows and doors shall be in good repair. The screen panel has been removed and will be replaced when the screen has been repaired. 11/01/2022 Implemented
6400.80(b)The backyard had exit landing had two table tops laying on the ground, creating a potential tripping hazard. There was lots of trash and debris strewn around the backyard, including ripped opened trash bags full of trash and florescent light bulbs. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The tabletops were removed in the presence of the ODP Inspectors. The florescent bulbs were placed in the trash receptacle in the presence of the ODP Inspectors. The CEO began the process of cleaning up the debris in the presence of the ODP Inspectors. 10/12/2022 Implemented
6400.144Individual #1 has a prescription medication acetaminophen 325 mg with instructions to take 2 tablets by mouth every 4 hours as needed for pain. This medication was listed on the medication administration record was not present in the home.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. After review of the MAR, it was concluded that the acetaminophen 325mg was discontinued because the individual was not able to tolerate it; the MAR was not adjusted to reflect the discontinuation of the medication. Ibuprofen was prescribed because the individual was not tolerating the acetaminophen 325mg. When the medication was discontinued, it was discarded. 10/14/2022 Implemented
6400.214(b)Individual #1's most recent behavior support plan was not present in the home. The behavior support plan from 2020 was in the home only. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The current behavior support plan was obtained while the ODP Inspectors were still at the home. The current plan is kept in a binder in the office. 10/12/2022 Implemented
6400.163(h)Individual #1 had prescription medication that was discontinued still present in their medication box. This medication was ondansetron (substitute for zofran) 4 mg with instructions to take 1 tablet my mouth every 8 hours as needed and ibuprofen 400 mg with instructions to take 1 tablet by mouth as needed three times daily with food as needed.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Ondansetron 4mg was removed from the medication box in the presence of the ODP Inspectors. The dosage on the Ibuprofen 400 mg was corrected 10/24/2022 Implemented
6400.186Individual #1 behavior support plan is not being followed. This individual is to be able to make up to 4 phone calls per day to persons on the approved phone list, per their 5-18-22 behavior support plan. However staff present stated that if the individual wants to call someone, the staff texts that person and asks for them to call the individual and the individual then waits to receive an incoming phone call. The individual states that they are not being allowed to make calls or request calls at all and only speaks on the phone when someone calls them.The home shall implement the individual plan, including revisions.The current behavior support plan is now being followed. Staff is aware that the individual can make 4 phone calls on Friday form the approved list provided to them. 10/14/2022 Accepted
6400.186Individual #1's behavior plan states that the home will keep a daily log to document their behaviors and precursors to behaviors. A daily log is not consistently being maintained and for the period of October 1 through October 11, no behaviors or what happened with the individual is being documented. The only documentation for this time period is if an outing occurred or not. Documentation of any type was not done on 10/1/22 3 pm-11pm, 10/2/22 entire day, 10/4/22 3 pm-11pm, 10/5/22 3pm-11pm, 10/6/22 3pm-11pm, 10/8/22 7am-3pm, 10/9/22 entire dayThe home shall implement the individual plan, including revisions.DIRECTED PLAN OF CORRECTION: The Life Group will retrain all staff on individual #1's support plan. Ensuring that the individual #1 is allowed to make phone calls of their choosing, and that staff are documenting on daily logs of their behaviors and precursors to behaviors. 11/08/2022 Accepted
6400.196(a)No documentation could be shown to verify that all staff whom have worked with individual #1 in October 2022 have been trained in their behavior support plan. Training documentation for staff #1, 2 and 3 could not be provided.A staff person who implements or manages a behavior support component of an individual plan shall be trained in the use of the specific techniques or procedures that are used.DIRECTED PLAN OF CORRECTION: The Life Group will have Staff 1,2, and 3 trained on individual #1's support plan and will submit those trainings to ODP licensing. 11/08/2022 Accepted
SIN-00205654 Renewal 05/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The utility sink in the basement is filled with a substance consistent with dirt and should be cleaned.Clean and sanitary conditions shall be maintained in the home. Staff cleaned the utility sink in the basement. 05/24/2022 Implemented
6400.110(a)The smoke detector on the second floor of the home is inoperable. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. New hired wired automatic smoke detector was installed in its place. 05/24/2022 Implemented
6400.144Individual 1PRN Sumatriptan 50 MG was listed on the MAR but the blister pack was empty during the time of inspection. Individual 1PRN Acetaminophen 325 MG is listed on the MAR but was not present at the time of inspection. Ibuprofen 400 MG tablets PRN (blister pack) were in the medication box for Individual 1, but this medication was not listed on the MAR.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Program Specialist called pharmacy to fill prescriptions needed and update MAR. 05/24/2022 Implemented