Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00209152 Renewal 07/19/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)Fire drills were conducted during sleeping hours on 09/23/21 and then again on 05/16/22, exceeding the 6 month requirement.A fire drill shall be held during sleeping hours at least every 6 months. The Residential Program Director implemented a new fire drill procedure. A yearly fire drill schedule was implemented which states that every April, August, and September sleep drills are completed. The Director sent out the yearly schedule to only the managers to ensure they remain unannounced. 07/20/2022 Implemented
SIN-00191765 Renewal 08/11/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(b)Individual #1's August 2021 medication administration record included Kids first D3 1000 unit, take one tablet daily. This medication was not available in the home and was reportedly discontinued.A prescription order shall be kept current.The Executive Director crossed this item off the MARs and wrote discontinued. 08/13/2021 Implemented
6400.166(a)(11)Individual #1's August 2021 medication administration record did not include the purpose or diagnosis for the following medications: Novolog, Divalproex, Haloperidol, Levemir Flextouch, Lorazepam, Naltrexone, Prazosin, Vit D2, and Melatonin.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 Executive Director wrote the diagnosis for each medication onto the MAR in the box with the name of the medication, rather than just being at the bottom of the MAR. 08/13/2021 Implemented
SIN-00227477 Renewal 06/21/2023 Compliant - Finalized
SIN-00176155 Initial review 09/09/2020 Compliant - Finalized