Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00231350 Renewal 09/15/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(b)Staff member#2 was not trained annually by a fire safety expert in 2022.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).The trainer credentials were shared and the train the trainner training was shared as well via email. 11/10/2023 Implemented
6400.46(b)Staff member#2 cannot conduct fire safety training until train the trainer training is provided by a fire safety expert.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).The trainer credentials were shared and the train the trainner training was shared as well via email. 11/10/2023 Implemented
6400.46(d)Staff member #3's CPR/first aid training was not trained by an individual certified as a training by a hospital or other recognized health care organization.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.The staff member #3 has not been here for 6 months, she stated in August 2023. 10/10/2023 Implemented
6400.50(a)There were no records of training or copies of certificates received for staff member #1. The length of the orientation training could not be determined for staff member#3 as only the ending date of the training was provided.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.Form was updated to ensure dates are included for each training topic by Executive Director. Training staff were retrained on how to complete the form properly. 10/10/2023 Implemented
SIN-00212235 Renewal 09/19/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(6)There was no mirror in individual 1 and individual 2's bedroom.In bedrooms, each individual shall have the following: A mirror. The bedroom mirrors were missed during house setup. 10/01/2022 Implemented
6400.141(a)There is no current up-to-date physical for individual 1.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. We sent individual 1 for a physical. 10/01/2022 Implemented
6400.217There is no release of information form signed by individual 1.Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. This was missed during intake. 10/01/2022 Implemented
6400.217There is no release of information form signed by individual 2.Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. This was missed during intake. 10/01/2022 Implemented
6400.165(g)Individual 2 had a gap in his psychiatric medication reviews greater than three months. He had appointments on 2/10/22 and 8/17/22If 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.We plan to track doctors appointments and visits for each individual. 10/01/2022 Implemented
6400.166(b)Synthroid 15 mg was not initialed on September 14, 2022. Vitamin b-12 500 mg was not signed September 14, 2022The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.We have retrained staff on documenting correctly. 12/01/2022 Implemented