Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00219631 Renewal 03/01/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)The individual's bathroom did not have hand soap at the sink at the time of inspection.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Hand soap was installed and will be monitored for correction moving forward. 03/20/2023 Implemented
6400.32(r)(5)At the time of inspection, the individual had locks on their doors, however the staff did not have the key or device which would unlock the door.Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.The keys have been located and are properly stored for staff to have on person and the back up set. 03/20/2023 Implemented
SIN-00201434 Renewal 04/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The fire drill completed on 10/3/21 had an evacuation time of 2:49. The fire drill completed on 9/15/21 had an evacuation time of 3:10. The fire drill completed on 8/10/21 had an evacuation time of 4:25. The fire drill completed on 7/13/21 had an evacuation time of 4:32. Evacuation times exceed the allowed 2:30 without waiver and extended time specified in writing within the past year by a fire safety expert. 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. Residential Director staff reeducated the Staff and Individual's in the home as to how to perform a fire drill by guidance and prompting given to the individuals, the staff need to time the drill evacuation only not to include other activities before recording the actual evacuation time. The Agency conducted awake and asleep drills which showed that the individuals can and did evacuate in a timely fashion. 04/16/2022 Implemented