Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00224546 Unannounced Monitoring 05/11/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill record for 2/17/23 did not include the amount of time it took for evacuation.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. The Program Supervisor of the home fixed the written fire drill record to include the amount of time it took for evacuation. 05/30/2023 Implemented
SIN-00222346 Unannounced Monitoring 04/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The garage was accessible through a basement door. The garage had a lot of garbage just scattered around the garage floor. Clean and Sanitary conditions shall be maintained in the home.Clean and sanitary conditions shall be maintained in the home. The garage was thoroughly cleaned to ensure sanitary conditions by DSPs and the Program Supervisor of the home. 04/17/2023 Implemented
6400.67(a)The basement had a bathroom. In this bathroom the toilet seat was broken. The seat was off of the toilet and laying against the side of the bathroom wall. The toilet was not in good repair.Floors, walls, ceilings and other surfaces shall be in good repair. The toilet seat was fixed by the Property Manager. 04/17/2023 Implemented
6400.76(a)At the time of inspection there was a picture which was in the garage area. This picture frame was glass, and it was broken with several pieces laying on the frame. This is hazardous and should be disposed of to avoid any injury. Furniture and equipment shall be nonhazardous, clean and sturdy. The broken picture frame was removed from the garage area and disposed of. 04/17/2023 Implemented
6400.80(b)There is what appears to be a gazebo area behind the home. This is a wooden structure. This area was not in good repair. There was several wooden slates in the deck that were lose and popped up while walking on the deck surface. There was also old pieces of scrap wood laying on this deck and along the side of the yard. The scrap wood all had rusty nails sticking out of the wood, which is very unsafe. In addition, there was a small red gasoline container on the wooden deck which was placed directly next to a gas tank which is used for a gas grill. All of which is unsafe and can present 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 wooden structure/gazebo in the yard behind the house was repaired by the Property Manager. The scrap wood and small gas container was removed and disposed of as well. 04/17/2023 Implemented
6400.171At the time of the inspection, there was a container of moldy strawberries in the home.Food shall be protected from contamination while being stored, prepared, transported and served. The Program Supervisor disposed of the moldy strawberries and checked all of the food items in the home to ensure that they are not expired and/or moldy after discovery of the strawberries. 04/17/2023 Implemented
6400.166(a)(4)At the time of the inspection individual is prescribed benzonate 100mg capsule to be taken as needed for a cough. This medication was not on the medication administration record. Medications, including those which are administered as needed, must be entered into the medication record. The medication record should always reflect all prescribed medications.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.After checking with the pharmacy, the Benzonatate 100 mg capsules were discontinued in February 2023 by the doctor that prescribed the medication. The Program Supervisor sent the discontinued medication back to the pharmacy for proper disposal. 04/17/2023 Implemented
6400.166(b)The individual is prescribed Quetiapine furate 100mg tab to be given daily at 3pm. The staff did not initial for the date of 4/4/23. The medication was removed from the blister pack however the staff did not initial the medication administration record (MAR). The individual is also prescribed Prazosin 2mg, 1 tablet to be given at bedtime. The medication appeared to be removed from the blister pack however it was not signed for on the date of 4/3/2023.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The staff that did not initial the Medication Administration Record was retrained on properly documenting the administration of medications. Also, the Medication Administration Record was corrected by the DSP that did not initial originally after ensuring that the medications were properly administered. 04/17/2023 Implemented
SIN-00217609 Unannounced Monitoring 01/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)The mirror on the medicine cabinet in the bathroom was too small for the track and fell out when touched. This presented a hazard as it could have fallen out and shattered, injuring anyone who may have been in the bathroom at the time. Floors, walls, ceilings and other surfaces shall be free of hazards.The Property Manager removed the broken medicine cabinet fixture. The Program Supervisor replaced it with a stand-alone mirror. 01/24/2023 Implemented
SIN-00214666 Unannounced Monitoring 10/28/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The kitchen cabinet next to the oven was not in good repair. The handle was missing off of the cabinet. (Repeat Violation 6/7/22 and 9/16/22)Floors, walls, ceilings and other surfaces shall be in good repair. A new kitchen cabinet handle was affixed onto the cabinet that had a missing handle by the Program Supervisor on 11/16/22. 10/31/2022 Implemented
6400.144Health services including pharmaceutical services are not being planned for Individual #9. Individual #9 is prescribed Natural Balance Tears Eye drops. Instill into eye 2 drops 3 times a day as needed for itchy dry eyes. This medication was not available in the home. (Repeat Violation 9/16/22)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 Natural Balance Tear Eye drops were ordered and picked up from the pharmacy by the Quality Manager on 10/28/22. 10/28/2022 Implemented
6400.165(c)Individual #9's medications were not administered as prescribed. Individual #9 self-administered medications until 10/20/22 when it was discovered that the individual was not taking the medications as prescribed. Individual #9 had the individuals' medications in a medication planner. Individual #9 threw the planner scattering the medications. Staff attempted to go through the medications to try to determine which medications were which and placed them back into the blister packs and taped the back of the blister pack. It is unknown if the individual was administered the correct medications at the correct times.A prescription medication shall be administered as prescribed.The Quality Manager contacted the pharmacy, ordered, and picked up new blister packs of the remaining doses of medication for individual #9 for the rest of the month to ensure that Individual #9 gets administered the right medications. 11/17/2022 Implemented
SIN-00211527 Unannounced Monitoring 09/16/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(1)At time of inspection there was no up to date financial record in the home for Individual #2. Last documented amount that could be found was an ending balance for June 2022 in the amount of $235.88. A Wendy's receipt dated 7/3/22 in the amount of $6.56 was located with the individuals debit card. Staff#1 indicated that no money was kept in the home, that all purchases were made with a debit card belonging to Individual #2. The individual does not manage their own finances. A separate record of financial resources, including the dates and amounts of deposits and withdrawals must be maintained. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. The financial statements which included the dates and amounts of deposits and withdrawals were missing for months July 2022 and August 2022 at the time of the licensing inspection. These statements were printed off from Individual # 2¿s bank account, organized, and filed along with their respective monthly financial envelopes for Individual # 2 on 9/19/22 by the new Program Supervisor of the home. A current financial ledger/audit sheet was also added so that all staff that assist Individual # 2 with financial expenditures know how much money he has in his account so that they can assist Individual # 2 with budgeting as well. 09/19/2022 Implemented
6400.64(a)At time of inspection the bathroom of the home was unsanitary with a soiled washcloth laying on the shower floor, a small puddle of what appeared to be dried urine and a black hair on the base of the toilet, several black hairs were on the tiled floor, three tubes of open and oozing toothpaste were located in the medication cabinet, a used bar of soap was laying on the windowsill with a soapy residue underneath, the grout between the floor tiles and the tub in the bathroom was discolored and appeared to be soiled. The rug in the bedroom of Individual #2 was littered with small debris such as lint and small pieces of paper. The twin bed and sheet of Located in Individual # 2's room had a large round wet area in the middle of the bed that extended to both sides, the area had an unsoiled disposable incontinence bed pad placed on top of it. The carpeted stairs leading to the basement office area were unvacuumed with dust and debris in the corners, the end table in the office area had a thick layer of dust covering the glass top. Kitchen surfaces were sticky to the touch with what appeared to be a layer of grease. An open bag of flour was found in the kitchen cabinet with a best by date of 8/10/22.Clean and sanitary conditions shall be maintained in the home. The new Supervisor along with Direct Support Professionals cleaned and organized the entire home including the basement, hallways, living room, bathrooms, bedrooms, kitchen, and outside premises of the home after licensing inspection on 9/16/22. The rug of Individual # 2¿s bedroom was replaced with a new rug. The Program Supervisor also went through all the kitchen cabinets and refrigerator to check for expired food items and dispose of any expired food. 09/16/2022 Implemented
6400.67(b)At the time of inspection, a large, sharp splinter of wood approximately 6 inches long was found on the carpet in the bedroom of Individual #2. Floors shall be free of hazards. Floors, walls, ceilings and other surfaces shall be free of hazards.The piece of wood was removed and disposed on 9/16/22 after discovery. 09/19/2022 Implemented
6400.77(b)At time of inspection the First Aid kit did not contain tape, scissors or a thermometer. 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 Program Supervisor purchased new tape, scissors, and thermometer on 9/19/22 and replaced the items that were missing. 09/19/2022 Implemented
6400.80(b)The area between the deck and the heating unit of the home was littered with debris that included but was not limited to a chair pad, various containers and a pair of shoes. The area was not well maintained as required. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The new Program Supervisor along with DSPs cleaned and organized the outside premises of the house after the licensing visit. The new Program Supervisor has monitored and maintained this since the inspection date on 9/16/22. 09/16/2022 Implemented
6400.166(a)(11)The September 2022 Medication Administration Record for Individual #2 did not contain the diagnosis or purpose for the medications listed. Diagnosis or purpose for the medication, including pro re nata is required.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.After discovery of the diagnosis of each medication was not listed on the Medication Administration Records for Individual # 2 on 9/16/22, the Program Supervisor fixed the Medication Administration Records to include the diagnosis of all medications after licensing inspection. 09/16/2022 Implemented
SIN-00189359 Renewal 06/29/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The toilet in the hallway bathroom had several hairs under the seat, at the base of the tank. Additionally, there were hairs and a small puddle of urine on the base of the toilet near the floor. The front vent area of the window air conditioner in the bedroom of Individual #2 was caked with a black substance. The edge of ceiling fan blades in this same bedroom had a thick layer of dust on each. A pile of garbage was noted on the floor in the garage of the home.Clean and sanitary conditions shall be maintained in the home. The toilet and the floor were cleaned around the toilet in the main bathroom. The front vent area of the window air conditioner in the bedroom of Individual # 2 was cleaned and the ceiling fan in the same bedroom was cleaned as well. The pile of garbage was removed from the garage of the home as well. This was all done by the Program Supervisor after discovery on 06/29/21. 06/29/2021 Implemented
6400.76(a)A dresser drawer in the bedroom of Individual #1 was sticking out from the dresser, broken and missing a handle. Furniture and equipment shall be nonhazardous, clean and sturdy. A new dresser for Individual # 1 was ordered on 7/15/21 by the Program Supervisor. 07/15/2021 Implemented
6400.80(b)A hole, approximately 12 inches long, 8 inches wide and several inches deep, was noted at the edge of the parking area of the home, near the sidewalk to the front door of the home. The yard was not properly maintained and overgrown with weeds and grass. An unattached patio/deck area was located along the back fence of the yard. There is one step running along the length of the deck. Supports for the step area were broken allowing two boards(1x4) of this step to sink, creating a hole on one end and raised surface area of the wood on the other. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The hole at the edge of the parking area of the home, near the sidewalk, was filled with cement on 7/13/21. The yard was maintained and the overgrown weeds and grass was cut on 7/1/21. The Program Supervisor followed up on yard maintenance again on 7/14/21. The step that was broken that is attached to the unattached patio/deck was repaired on 7/13/21. 07/14/2021 Implemented
6400.112(d)The fire drill conducted on 5/12/21 listed an evacuation time of 2:45. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. On 5/26/21, there was a fire drill conducted in which the evacuation time is 1 minute and 20 seconds. On 6/20/21, there was a fire drill conducted in which the evacuation time is 1 minute and 35 seconds. On 7/10/21, there was a fire drill conducted in which the evacuation time is 1 minute and 17 seconds. Administrative staff followed up with the Program Supervisor on 7/13/21 to ensure that fire drills were being completed monthly and that everyone in the home was evacuating in a timely manner within the 2 minute and 30 second time frame. 07/10/2021 Implemented
6400.165(g)Medication reviews conducted for Individual #1 on 3/31/21, 9/4/20 and 11/6/20 did not contain the reason for prescribing the medications, the medications and dosages or the need to continue the medications. Medication reviews conducted on 1/4/21 and 6/9/20 did not contain the need to continue the medications as required.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.These appointments were conducted over the phone due to the pandemic and communication with physician forms were completed in lieu of the Quarterly Medication Review forms. The Program Supervisor dropped off our Quarterly Medication Review forms at Individual #1's psychiatrist office on 7/15/21 to have them complete the form so that they can add the reason for prescribing the medications, the medications and dosages, or the need to continue the medications. The psychiatrist will also complete the need to continnue the medications as required as well. 07/15/2021 Implemented
6400.213(1)(i)A photo of Individual #1 dated 3/17/20 was in the individuals record at time of inspection on 6/29/21. Individual #1's weight and hairstyle changed significantly since the 3/17/20 photo. Weights documented between 6/20 and 2/26/21 show a 42lb difference. Hair photographed on 3/17/20 was partially blue and neck length. Hair at time of inspection was dark and a buzz cut. Current photos, updated annually and when significant changes to their appearance occur, are required.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.A new photo was taken of Individual # 1 on 7/15/21 and was updated in his individual records. 07/15/2021 Implemented
SIN-00177106 Renewal 09/29/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)There was a pink spray bottle located on the windowsill in the kitchen containing an unidentified cleaning product. There was a spray bottle with bleach and water located under the kitchen cabinet in an unmarked bottle.Poisonous materials shall be stored in their original, labeled containers. The poisonous material without an original, labeled container was removed on 10/01/20 from the home and Direct Support Staff were informed to not use containers for poisonous materials that are not original and labeled. Direct Support Staff will be trained that poisonous material must be stored in original, labeled containers on 10/27/20 at the monthly staff meeting. The Program Supervisor will continuously monitor that staff are using poisonous materials in original, labeled containers. 10/27/2020 Implemented
6400.67(a)There was heating vent located on the floor near the sliding glass door that did not have a cover on it.Floors, walls, ceilings and other surfaces shall be in good repair. A heating vent cover was purchased and placed on the floor where the heating vent is located on 10/07/20. 10/07/2020 Implemented
6400.77(c)The first aid kit in the home did not contain a first aid manual. A first aid manual shall be kept with the first aid kit.A first aid manual was placed in the first aid kit on 10/12/2020. The Program Supervisor will monitor monthly that all contents of the first aid kit are available. 10/12/2020 Implemented
6400.101The sliding glass door exiting the home was locked using a baseball bat which was jammed in the bottom frame.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. A lock was installed on the sliding door so that it can be locked without anything obstructing the passageway on 10/7/20. 10/07/2020 Implemented
6400.46(c)Staff #3 was hired on 12/13/19 and did not receive training in first aid techniques until 8/14/2020.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.The Vice President will monitor monthly which staff are due for their initial and bi-annual CPR/First Aid training and notify the agency CPR/First Aid Instructor for a training session to be arranged. 10/12/2020 Implemented
6400.51(b)(1)Staff #3 did not receive training on the application of person-centered practices, community integration, individual choice or supporting individuals to develop and maintain relationships during his orientation prior to working with individuals.The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Staff # 3 will be trained on the applications of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships by 10/13/2020. The Vice President will ensure that all newly hired staff are trained on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships during orientation. After an orientation class is completed, the Vice President will verify that all training records are filed accordingly to reflect that the training was completed. 10/13/2020 Implemented
6400.51(b)(3)Staff #3 did not receive training on individual rights during his orientation prior to working with individuals.The orientation must encompass the following areas: Individual rights.Staff # 3 will be trained on individual rights by 10/13/2020. The Vice President will ensure that all newly hired staff are trained on individual rights during orientation. After an orientation class is completed, the Vice President will verify that all training records are filed accordingly to reflect that the training was completed. 10/13/2020 Implemented
6400.51(b)(5)Staff #3 did not receive training on the individuals' Individual Plan during his orientation period, prior to working with individuals.The orientation must encompass the following areas: Job-related knowledge and skills.Staff # 3 will be trained on the each Individual's Plans for each individual that he works with on 10/13/2020 before his next shift. The Vice President will ensure that all newly hired staff are trained on each Individual's Plans for each individual that they work with during orientation. After an orientation class is completed, the Vice President will verify that all training records are filed accordingly to reflect that the training was completed. 10/13/2020 Implemented
SIN-00206348 Renewal 06/07/2022 Compliant - Finalized