| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
|
SIN-00240462
|
Renewal
|
02/21/2024
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The bathroom off of the kitchen had a stand-up shower. This was reported to not be in use. There was no shower head attached. However, the shower floor was visibly dirty and filled with dust and grime. | Clean and sanitary conditions shall be maintained in the home. | The management team (AVP, Program Director, Site Supervisor, and Program Specialist) will meet at the Bichler Lane home to review all aspects of 6400.64 as related to Sanitation. The Site Supervisor/Program Specialist will conduct monthly site walk-throughs of kitchen, bathrooms, living areas, bedrooms, and storage areas to ensure clean/sanitary conditions exist throughout the home. A Monthly Site Walk-Through and Record Checklist will be completed based on Site Supervisor/Program Specialist¿s review ¿ follow-up will be completed and documented based on findings. |
05/01/2024
| Implemented |
| 6400.67(a) | At the time of inspection, the refrigerator door handle was missing. | Floors, walls, ceilings and other surfaces shall be in good repair. | The management team (AVP, Program Director, Site Supervisor, and Program Specialist) will meet at the Bichler Lane home to review all aspects of 6400-67 as related to Surfaces. A work order request has been submitted to Facilities for repair of refrigerator door handle. The Site Supervisor/Program Specialist will conduct monthly site walk-throughs of kitchen, bathrooms, living areas, bedrooms, and storage areas to ensure surfaces are in good repair and free of hazards. A Monthly Site Walk-Through and Record Checklist will be completed based on Site Supervisor/Program Specialist¿s review ¿ follow-up will be completed and documented based on findings. |
05/01/2024
| Implemented |
| 6400.80(a) | The door which exits the home from individual bedroom was not clear from snow. This is used as a fire escape and all individual use wheelchairs upon exit. This could pose a hazard. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | The management team (AVP, Program Director, Site Supervisor, and Program Specialist) will meet at the Bichler Lane home to review all aspects of 6400-80 as related to Exterior Conditions. The Site Supervisor/Program Specialist will conduct monthly site walk-throughs of the home to include exterior conditions and to ensure outdoor walkways are free from ice, snow, obstructions, and other hazards. A Monthly Site Walk-Through and Record Checklist will be completed based on Site Supervisor/Program Specialist¿s review ¿ follow-up will be completed and documented based on findings. |
05/01/2024
| Implemented |
| 6400.80(a) | The door which exits the home from individual bedroom was not clear from snow. This is used as a fire escape and all individual use wheelchairs upon exit. This could pose a hazard. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | DUPLICATE VIOLATION --The management team (AVP, Program Director, Site Supervisor, and Program Specialist) will meet at the Bichler Lane home to review all aspects of 6400-80 as related to Exterior Conditions. The Site Supervisor/Program Specialist will conduct monthly site walk-throughs of the home to include exterior conditions and to ensure outdoor walkways are free from ice, snow, obstructions, and other hazards. A Monthly Site Walk-Through and Record Checklist will be completed based on Site Supervisor/Program Specialist¿s review ¿ follow-up will be completed and documented based on findings. |
05/01/2024
| Implemented |
| 6400.81(f) | The 2 bathrooms did not have hand soap at the sink. | Each bedroom shall have direct access to a corridor, living area, dining area or outdoors. | The management team (AVP, Program Director, Site Supervisor, and Program Specialist) will meet at the Bichler Lane home to review all aspects of 6400-82 as related to Bathrooms. Hand soap has been placed in both bathrooms. The Site Supervisor/Program Specialist will conduct monthly site walk-throughs of the home to include bathrooms and the availability of hand soap at bathroom sinks. A Monthly Site Walk-Through and Record Checklist will be completed based on Site Supervisor/Program Specialist¿s review ¿ follow-up will be completed and documented based on findings. |
05/01/2024
| Implemented |
|
|
|
SIN-00217265
|
Renewal
|
02/13/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Poisonous materials are not kept locked or made inaccessible to individuals. All of the home individuals in the home are not safe with poisonous substances and require poisons to be locked. There was a container of Tide Pods located under the sink in the bathroom of the laundry room area. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Provider Correction Date: Completed 2/13/23
Provider Plan of Correction:
The Home Supervisor locked the Tide Pods in a secure cabinet on 2/23/23, and only the staff has access to the key. Staff are all aware this material will no longer be unlocked. |
02/23/2023
| Implemented |
| 6400.110(f) | Individual #2 is legally blind and 70% deaf. All smoke detectors are not equipped to alert the individual in the event of a fire. The smoke detector in Individual #2's bedroom has a light that turns on when the alarm sounds. The light does not strobe or provide any additional indication that the alarm is sounding. Individual #2 does not have a bed shaker or device that would alert the Individual in the event of a fire. Smoke detectors in the common areas of the home are not equipped to alert the Individual that the alarm is sounding. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | A hard wired, interconnected smoke detectors with strobes system will be installed in the home. The system will also include a bed-shaker connected to the system for individual # 2¿s bed. The home has overnight awake staff that conducts routine bed checks, but until such a time that the interconnected alarm, strobe, and bed shaker are installed, bed checks will occur every 30 minutes. |
05/01/2023
| Implemented |
| 6400.112(e) | Fire drills are not being held during sleeping hours at least every 6 months. Fire drills documented as asleep drills were conducted on June 9, 2022, at 9:45pm and December 18, 2022, at 9:15PM. These fire drills were conducted outside of sleeping hours. | A fire drill shall be held during sleeping hours at least every 6 months. | The Provider will run semi-annual overnight asleep fire drills in accordance with chapter regulations and the Regulatory Compliance Guide (RCG). It should be noted that the 9:15 and 9:45 pm ¿asleep¿ fire drills, according to the RCG, were technically 30 minutes after the Residents had gone to sleep; however, the provider is deficient in that the home was past the 6-month window. The Provider will conduct the semi-annual sleep drills as recommended by O.D.P. |
06/01/2023
| Implemented |
| 6400.141(c)(4) | Individual #2 does not have documentation of completed annual hearing examinations. Individual #2's annual physical indicates that Individual #2 has abnormal hearing and Individual #2's Individual Service Plan states that Individual has 70% hearing loss. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual # 2¿s sister coordinates these appointments. The Provider will ensure that Individual # 2¿s sister receives adequate notice regarding due dates for scheduled annual hearing examinations should she wish to remain involved in these scheduled exams, otherwise, the Provider will schedule the annual hearing examination in a timely fashion and communicate the scheduled date to the Individual¿s sister. |
05/01/2023
| Implemented |
| 6400.141(c)(8) | Individual #2 has not had an annual mammogram completed every year. Individual #2 last had a mammogram completed on 12/28/21. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | Individual #2 was scheduled in a timely basis for the mammogram; however, due to her receiving a COVID vaccination, her regular Imaging Center pushed the examination back six weeks per their policy. The Imaging Center recommendation was that due to the COVID vaccine a ¿false read¿ could occur with the mammogram image. Individual #2 is very comfortable with this particular Imaging provider. Still, the Service Provider recognizes the non-compliance with 6400.141(c) (8). The mammogram is now scheduled for March 15, 2023. A correction plan will be to contact the Imaging Center for direction in the event of any further vaccinations well in advance of prescribed due dates. If necessary, another Imaging Center will be contacted for a timely appointment.
This practice will hold for all three individuals in the home to remain in compliance with this regulation |
03/15/2023
| Implemented |
| 6400.144 | Health Services including pharmaceutical are not being planned for and arranged. Individual #2 is prescribed Mucinex- 600mg tab, take 1 or 2 tablets orally every 12 hours as needed for congestion, do not exceed 4tabs/24hrs. Individual #2 is prescribed Guaifensin DM syrup, take 1 teaspoonful (5ml) orally every 4 hours as needed for cough. Individual #2 is prescribed Flonase 0.05% nasal spray, instill 2 sprays in each nostril twice daily as needed for allergies. These medications were not available in the home. Individual #3 is prescribed Acetaminophen 325mg tablet, take two tablets every 6 hours as needed for temp greater than 101, do not exceed 4gms/24hs, this medication expired on 10/6/21 and current unexpired medication was not available in the home and Individual #2 is prescribed Imodium AD 2mg caplet/antidiarrheal 2mg. Take 2 tablets by mouth after first loose stool and 1 tablet after each subsequent loose stool not to exceed 4 tablets/day, this medication expired on 2/7/20 and current unexpired medication was not available 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.
| All of the aforementioned medications were replaced on 2/13/23. All medications including aforementioned OTC/PRN medications will be reviewed by Home Supervisor (an LPN) during monthly M.A. R. checks. Any and all medications with expired or nearly expired dates will be replaced immediately and be available for resident use. |
02/13/2023
| Implemented |
| 6400.181(e)(13)(i) | Individual #2's annual assessment dated 9/26/22 does not address progress and growth over the past 365 days in
the following areas: Health | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| In accordance with language taken from the Regulatory Compliance Guide (RCG): ¿Assessments are essential to maximizing personal growth and development, the person¿s ability to self-direct through choice and control over decisions affecting them directly while protecting the health and safety of the individual¿. VIOLATIONS #10 THROUGH # 18 SHALL REFLECT THIS LANGUAGE IN THE REMAINING PLANS OF CORRECTION.
The existing assessment form at the time of the on-site review did not reflect a dedicated section to Health; rather, it fell into a scoresheet.
The Program Specialist shall revise the assessment form to reflect a dedicated section to ¿Health¿ with commentary within each 365 day period to record progress related to every individual¿s health. |
05/01/2023
| Implemented |
| 6400.181(e)(13)(ii) | Individual #2's annual assessment dated 9/26/22 does not address progress and growth over the past 365 days in
the following areas: Motor and Communication skills | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | The existing assessment form at the time of the on-site review did not reflect a dedicated section to Motor and Communication Skills.
The Program Specialist shall revise the assessment form to dedicate a section to ¿Motor/Communication Skills¿ with commentary within each 365 day period on progress related to each individual¿s motor/communication skills |
05/01/2023
| Implemented |
| 6400.181(e)(13)(iii) | Individual #2's annual assessment dated 9/26/22 does not address progress and growth over the past 365 days in
the following areas: Activities of residential living. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | The Program Specialist shall revise the assessment form to dedicate a section to¿ Activities of Residential Living¿ with commentary within each 365 day period on progress related to each individual¿s Activities of Residential Living. |
05/01/2023
| Implemented |
| 6400.181(e)(13)(iv) | Individual #2's annual assessment dated 9/26/22 does not address progress and growth over the past 365 days in
the following areas: Personal adjustment | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | The Program Specialist shall revise the assessment form to dedicate a section to ¿Personal Adjustment¿ with commentary on within each 365 day period on progress related to each individuals¿ Personal Adjustment |
05/01/2023
| Implemented |
| 6400.181(e)(13)(v) | Individual #2's annual assessment dated 9/26/22 does not address progress and growth over the past 365 days in
the following areas: Socialization | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | The Program Specialist shall revise the assessment form to dedicate a section to ¿Socialization¿ with commentary within each 365 day period on progress related to each individual¿s Socialization. |
05/01/2023
| Implemented |
| 6400.181(e)(13)(vi) | Individual #2's annual assessment dated 9/26/22 does not address progress and growth over the past 365 days in
the following areas: Recreation | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | The Program Specialist shall revise the assessment form to dedicate a section to ¿Recreation¿ with commentary within each 365 day period on progress related to each individual¿s Recreation. |
05/01/2023
| Implemented |
| 6400.181(e)(13)(vii) | Individual #2's annual assessment dated 9/26/22 does not address progress and growth over the past 365 days in
the following areas: Financial Independence | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| The Program Specialist shall revise the assessment form to dedicate a section to ¿Financial Independence¿ with commentary within each 365 day period on progress related to each individual¿s Financial Independence |
05/01/2023
| Implemented |
| 6400.181(e)(13)(viii) | Individual #2's annual assessment dated 9/26/22 does not address progress and growth over the past 365 days in
the following areas: Managing Personal Property | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | The Program Specialist shall revise the assessment form to dedicate a section to ¿Managing Personal Property¿ with commentary with each 365 day period on progress related to each individual¿s Management of Personal Property. |
05/01/2023
| Implemented |
| 6400.181(e)(13)(ix) | Individual #2's annual assessment dated 9/26/22 does not address progress and growth over the past 365 days in
the following areas: Community-integration | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | The Program Specialist shall revise the assessment form to dedicate a section to ¿Community Integration¿ with commentary within each 365 day period on progress related to each individual¿s Community Integration |
05/01/2023
| Implemented |
| 6400.32(r) | Individual #3 does not have a lock on the Individual's bedroom door allowing the Individual to lock the Individual's door. There is no documentation in the Individual Service Plan that the individual or the individual's team do not want a lock on the bedroom door. | An individual has the right to lock the individual's bedroom door. | The Provider recognizes that individual #3 has the right to lock her bedroom door if so desired. The Provider will review the right to have a locked door with Individual #3, family or guardian, and the interdisciplinary team to ascertain whether or not individual desires a lock. Although right to a lock was present in Individual #¿s annual ¿Rights¿ packet, it was absent in the ISP. Individual # 3¿s sister acts as Power of Attorney and does not wish the door to be locked. On 2/22/23, the Home Supervisor and the Director of Developmental Services interviewed Individual #3 at the home, who stated she ¿does not want her door locked¿. The Supports Coordinator was contacted and a critical revision to the ISP will be made to include this information.
The facility team has reviewed the wishes of decision makers for the other two individuals in the home, who also state that locks should not be in place, with no objection from those residents. The team will ensure that critical revisions to those ISP¿s also include this information. |
05/01/2023
| Implemented |
| 6400.163(h) | Expired medications are not destroyed in a safe manner according to applicable Federal and State statutes and regulations. Individual #3 is prescribed Acetaminophen 325mg tablet, take two tablets every 6 hours as needed for temp greater than 101, do not exceed 4gms/24hs, this medication expired on 10/6/21 and Individual #2 is prescribed Imodium AD 2mg caplet/antidiarrheal 2mg. Take 2 tablets by mouth after first loose stool and 1 tablet after each subsequent loose stool not to exceed 4 tablets/day, this medication expired on 2/7/20. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The Provider plan of correction is to return expired medications immediately upon discovery to the pharmacy of origin. Since the origin of COVID 19, some pharmacies may not accept returned medications. Should this occur, the Home Supervisor will deliver expired medications to the Borough Police Station medication drop box. |
04/01/2023
| Implemented |
| 6400.165(g) | Individual #2 is prescribed medication to treat symptoms of a psychiatric illness. A review by a licensed physician at least every 3 months is completed, however, documentation from the reviews does not include the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | 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. | Individual # 2¿s sister had been making the arrangements for the medication review visits and the documentation was insufficient to satisfy 6400.165(g). The Home Supervisor /LPN will work with the sister in scheduling these visits. Additionally, the Home Supervisor/LPN has developed a new form, approved by the Program Director, with the heading Psychiatric Medication Physician Review Form. The form includes the following fields: Must be completed every three Months; Name of Client, Name of Dr; Type of Dr.; Other Physicians, Medication and Dosage, Diagnosis and Symptoms, To be Completed by Physician Quarterly: ¿If a medication is prescribed to treat symptoms of psychiatric illness, please include documentation on symptoms, need for continuation, increase or decrease in prescribed dosage; Physician Signature, Date, Date of next three month appointment¿. |
05/01/2023
| Implemented |
|
|
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SIN-00200552
|
Renewal
|
03/29/2022
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | Individual #2's most recent physical exam is dated 7/14/20. This exceeds the annual requirement. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The Provider will ensure that Individual #2¿s next annual physical exam date falls within the required 365 day +15 day grace period.
To ensure that the deficient practice does not reoccur, the management team, site supervisor, and Program Specialist will identify the most recent Annual Physical date for Individual #2 and the (2) remaining residents, and schedule the follow-up Annual Physical (60) days in advance to ensure there is ample opportunity to have the appointment date within the 365 day + 15 day grace period time frame.
The Site Supervisor will be responsible for making Annual Physical date, and as a quality assurance measure the Program Specialist will not only document medical appointments within their Monthly Progress Note, but include ¿Due Dates¿ for the Annual Physical and any other medical discipline. |
05/02/2022
| Implemented |
| 6400.141(c)(7) | Individual #2 had a gynecological exam completed on 8/16/19 with the notation to return every 2 years and her next gynecological examination was completed on 1/18/22. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | The physical examination shall include: A gynecological evaluation including breast exam and Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations.
To ensure that the deficient practice does not reoccur, the management team, Site Supervisor, and Program Specialist will convene and develop a ¿Gynecological Evaluation Form¿ that specifies mammogram, ultrasound, Pap Test, and any other related to test women/reproductive health. In addition, documentation on the form will include the follow-up appointment either within the two year period as per regulation or documentation from the physician for no or less frequent gynecological examinations.
The ¿Gynecological Form¿ will document whether the resident complied with the examination or refused treatment.
To ensure that Individual #2, and (2) other residents meet the (2) gynecological requirement, the management team, Site Supervisor, and Program Specialist will identify the most recent gynecological evaluations for residents, and identify the ¿Due Date¿ for each resident. As a quality assurance measure, the Program Specialist will document ¿any¿ medical intervention, within the body of the Monthly Progress Note, and also include ¿Due Dates¿ for all required medical interventions pertinent to regulation and to the individual.
For the Annual Physical Form, the Site Supervisor will provide relevant details, date and exam specifics, on to the form for review by the Primary Physician for the Annual Physical Examination. |
07/29/2022
| Implemented |
| 6400.141(c)(8) | Individual #2 had a mammogram completed on 9/16/20 and her next one was completed on 12/28/21. This exceeds the requirement. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | The physical examination shall include: A mammogram for women at least every two years for women over 40 through 49 years of age, and at least every year for women 50 years of age or older.
To ensure that Individual #2, and (2) other residents meet the (2) mammogram requirement, the management team, Site Supervisor, and Program Specialist will identify the most recent gynecological evaluations for residents, and identify the ¿Due Date¿ for each resident. As a quality assurance measure, the Program Specialist will document ¿any¿ medical intervention, within the body of the Monthly Progress Note, and also include ¿Due Dates¿ for all required medical interventions pertinent to regulation and to the individual.
For the Annual Physical Form, the Site Supervisor will provide relevant details, date and exam specifics, on to the form for review by the Primary Physician for the Annual Physical Examination. |
07/29/2022
| Implemented |
| 6400.142(g) | Individual #2's record had a dental hygiene plan dated 2/1/19. A dental hygiene plan shall be rewritten at least annually. | A dental hygiene plan shall be rewritten at least annually. | 6400.142 (g): Individual #2¿s record had a dental hygiene plan dated 2/1/19. A dental hygiene plan shall be written at least annually.
To address the deficient practice identified in 6400.142 (g), the facility will implement the following corrective action:
The Site Supervisor, in conjunction with the Program Specialist, review Individual #2 and (2) other resident charts for the most recent dental evaluation and history of dental evaluations. From these documents/dental evaluations, a current Dental Hygiene Plan, will be developed for Individual #2, and (2) other residents. At the next future dental appointment, the Dental Hygiene Plan will be updated as needed. |
07/29/2022
| Implemented |
| 6400.144 | Individual #2 is hearing impaired and there were no records of audiology appointments in her record. The agency states that the family takes her to this appointment. Individual #2 had a gynecological exam on 8/16/19 with the notation to return every 2 years and her next gynecological examination was completed on 1/18/22. Individual #2 had a mammogram completed on 9/16/20 and her next one was completed on 12/28/21. This exceeds the requirement. Health services are not being provided by the agency. | 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.
| Health Services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for and provided.
To address the deficient area identified in 6400.144, the facility will implement the following corrective action:
The Site Supervisor and Program Specialist will convene to review all ¿Health Services¿ related appointments for Individual #2, and the (2) other residents of the Bichler home. Based on the most recent ¿Health Service¿-medical appointment new ¿Health Service Due Dates¿ will be established and adhered to for compliance in the Health Service Requirement, including audiological, gynecological, and mamograms that were cited.
The Program Specialist will document medical appointments within Monthly Progress Notes as a quality assurance measure to monitor adherence to the Health Services requirement. |
07/29/2022
| Implemented |
| 6400.151(c)(3) | Staff #3 had a physical exam dated 6/3/21 and Staff #4 had physical exam dated 10/1/21 that did not include documentation on if they were free communicable diseases/precautions. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | The physical examination shall include: A signed statement that the staff person is free from communicable diseases or that the staff person has a communicable disease but is able to work in home if specific precautions are taken that will prevent the spread of disease to individuals.
To address the deficiencies identified in 6400.151 (c)(3), the facility will implement the following corrective action:
The management team, in conjunction with the Site Supervisor, will review all staff due dates for their physical exams related to the Bichler Street Program who come into direct contact with the individuals to address their status as it relates to compliance with the DHS/ODP Regulatory Compliance Guide. The management team will ensure that all new employees have a physical examination within 12 months prior to employment and every two years thereafter, including a statement that addresses free from communicable diseases. |
07/29/2022
| Implemented |
| 6400.151(c)(4) | Staff #3's physical exam dated 6/3/21 did not include documentation information of medical problems which might interfere with the health of the individuals. | The physical examination shall include: Information of medical problems which might interfere with the health of the individuals. | The physical examination shall include: information on medical problems which might interfere with the health of the individuals.
To address the deficiencies identified in 6400.151 (c)(4), the facility will implement the following corrective actions:
The management team, in conjunction with the Site Supervisor, will review all staff related to the Bichler Street Program who come into direct contact with the individuals to address their status as it relates to compliance with the DHS/ODP Regulatory Compliance Guide. The management team will ensure that all new employees have a physical examination within 12 months prior to employment and every two years thereafter, including a statement that addresses information of medical problems which might interfere with the health of the individuals.. |
07/29/2022
| Implemented |
| 6400.181(e)(13)(vii) | Individual #2's assessment dated 9/27/21 did not address her growth over the past 365 days in Financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| The assessment must include the following information: The individual¿s progress over the last 365 days and current level in the following areas: Financial Independence.
To address the deficient area noted in 6400.181, the facility will implement the following corrective action:
The management team, Site Supervisor, and Program Specialist will review the current DHS/ODP Regulatory Compliance Guide as it relates to the Individual Annual Assessments to ensure all aspects of the February 2020 RCG assessment criteria are addressed. Through the survey process, the facility team acknowledged the annual assessment form needs to adapt to be more in compliance with the new Regulatory Compliance Guide, namely Financial Independence and growth over the past 365 days. The team will have to be cognizant of Individual #2¿s Annual ISP date and (2) other Individuals in the Bichler Lane Home. |
07/29/2022
| Implemented |
| 6400.32(r) | Individuals have the right to lock their bedroom doors. None of the bedroom doors had locks on them. | An individual has the right to lock the individual's bedroom door. | Provider Plan of Correction:
The Provider will review all three bedroom doors to ensure they are equipped with locks even if the individual does not lock his or her door unless the individual clearly expresses that he or she does not want the door to be equipped with a lock.
In order to ensure individuals have had the opportunity to express their desire for a lock, the Supervisor/Program Specialist will provide the resident and/or substitute decision maker with a document that specifies their desire for a lock and key for their respective bedroom.
Duplicate keys for each respective bedroom will be made available for staff in the event of any ¿Life-Safety Emergencies¿ such as events that require evacuation from home, and for acute/chronic medical or behavioral emergencies. |
07/29/2022
| Implemented |
| 6400.165(g) | Individual #2 is prescribed psychotropic medications and she had a 3-month med review on 4/5/21 and then not again until 8/2/21. This exceeds the requirement. | 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. | To address the deficient area noted in 6400.165 (g), the facility will implement the following corrective actions:
The Site Supervisor and Program Specialist will convene to review all ¿Prescription Medications¿, namely ¿medications prescribed to treat symptoms of a diagnosed psychiatric illness¿ for Individual #2, and the (2) other residents of the Bichler home. Based on the most recent ¿medication review¿, a new 3-month ¿ Due Date¿ will be established and adhered to for compliance in the Prescription Medications Requirement.
The Program Specialist will document medication reviews within Monthly Progress Notes as a quality assurance measure to monitor adherence to the Prescription Medication requirement. |
07/29/2022
| Implemented |
| 6400.166(a)(11) | Individual #2's Medication Administration Record (MAR) did not include the diagnosis or purpose for their medications: Rosuvasatin, Levothyroxine, Furosemide, Telmisartan, Olanzapine, Citalopram, Amlodipine, Vitamin D3, Certa-Vitra, Brimonidine, Dorzolamide, Lumigan. | 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. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for medication, including PRN.
To address the deficient area noted in 6400.166 (a) (11), the facility will implement the following corrective actions:
The Site Supervisor, in conjunction with the Program Specialist, will review the Physicians Orders and Medication Administration Record (MAR) to cross reference all medications prescribed for Individual #2, and the (2) other Individuals who reside at the Bichler Lane home. All medications should have ¿diagnosis or purpose¿ of prescribed medication entered in the Physician Order and MAR. The Site Supervisor, in conjunction with the management team should follow with the vender pharmacy to have each ¿next month¿s Physicians Orders and MARs have the necessary diagnosis entered in with the prescribed medication. |
07/29/2022
| Implemented |
| 6400.213(1)(i) | 213(1)(vi): Individual #2 did not have a current dated photo in her record. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Each individual¿s record must include the following information: Personal information, including name, sex, admission date, birthdate and social security number.
To address the deficient areas identified in 6400.213 (1) (i), the following corrective action will be implanted:
The Site Supervisor, in conjunction with the Program Specialist, will review the ¿Content of Records¿ section of the Regulatory Compliance Guide for Individual #2, and the (2) other Individuals who reside at the Bichler Lane home. Records for photo, name, sex, admission date, birthdate and social security number will be updated and current. The Program Specialist will provide quality assurance checks during monthly Progress Notes to ensure compliance. |
07/29/2022
| Implemented |
|
|
|
SIN-00183504
|
Renewal
|
03/16/2021
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | Self-assessment of the home were completed, however it was not completed within 3-6 months prior to the expiration of the agency's certificate of compliance. The agency's certificate of compliance expired on 12/31/2020, the self assessment was completed on 12/1/2020. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| 6400.15(a): Self Assessment of the home was completed, however it was not completed within the 3-6 months prior to the expiration of the agency¿s certificate of compliance. The agency¿s Certificate of Compliance expired on 12/31/20. The Self-Assessment was completed on 12/1/20.
Plan of Correction:
In order to address the deficient area identified in 6400.15, the agency will implement the following corrective action:
Under the direction of the Program Director and in conjunction with the Bichler Lane Supervisor and Program Specialist, the Self Assessment will be completed on (2) occasions before the current expiration date of the Certificate of Compliance (Current Date: 12/25/21).
The initial Self Assessment will be completed by June 16, 2021, (3) months following the Renewal Inspection to review progress on the Plan of Correction, and then again by September 25, 2021, (3) months prior to the expiration date of the Certificate of compliance.
This will provide the agency with the ability to monitor the progress of Plan of Correction from the 3/16/21 Renewal Inspection, and then to further monitor the compliance to the 6400 Regulations leading up to the next Renewal Inspection. |
06/16/2021
| Implemented |
| 6400.62(a) | Individual 1's ISP indicates that poisons need to be locked. During the inspection, dishwashing liquid was unlocked under the kitchen sink. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The Site Supervisor locked up the dishwashing fluid at the time of the Inspection Renewal tour once it was identified. The Program Director, in conjunction with the Site Supervisor & Program Specialist, will conduct an in-service for all residential staff as it relates to the "poisonous materials" deficiency, any item that includes "seek medical attention if swallowed" or "Contact Poison Control if swallowed". Storage will be locked or stored in inaccessible as per the Individual's ISP. The Site Supervisor will identify a location for storage that is inaccessible/locked from individuals but accessible for staff needs for sanitation. Use of "soft soaps" and "non-toxic" cleaners will be addressed. |
04/09/2021
| Implemented |
| 6400.67(a) | The top of the washing machine had a significant amount of rust at the time of the inspection. | Floors, walls, ceilings and other surfaces shall be in good repair. | The Site Supervisor notified Allied Services Facilities Services Department on the date of the Inspection Renewal, 3/16/21. A new replacement washer was installed by 3/26/21. |
04/09/2021
| Implemented |
| 6400.67(b) | The concrete on the ramp outside the front of the house is broken and cracked. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The Program Director communicated the violation to the Vice President and the Allied Services Facility Services Department. "Patching" compromised areas of the sidewalk will be performed by Allied Services personnel, as a short term solution, until a full assessment can be made to determine whether or not there is a need for sidewalk replacement. "Patching" will be completed by 6/1/21. |
06/01/2021
| Implemented |
| 6400.110(b) | At the time of the inspection there was no smoke detector located within 15 feet of the individual's bedrooms. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | The Site Supervisor removed a smoke detector from a bedroom at the time of the survey tour to correct this deficient area on March 16, 2021. A replacement smoke detector was installed for the bedroom which is not a requirement in the 6400 Regulations. |
03/16/2021
| Implemented |
| 6400.34(a) | Individual 1's father/guardian signed her individual rights on May 1, 2020; Individual Rights have not been updated to reflect the current Chapter 6400 regulations. The missing rights include: 6400.32a An individual may not be discriminated against because of race, color, creed, disability, religious affiliation, ancestry, gender, gender identity, sexual orientation, national origin or age. 6400.32(d) - An individual shall be treated with dignity and respect. 6400.32(e) -An individual has the right to make choices and accept risks. 6400.32(f) - An individual has the right to refuse to participate in activities and services. 6400.32(g) - An individual has the right to control his own schedule and activities. 6400.32(i) - An individual has the right of access to and security of the individual's possessions. 6400.32(j) - An individual has the right to voice concerns about the services the individual receives. 6400.32(k) - An individual has the right to participate in the development and implementation of the individual plan. 6400.32(m) - An individual has the right to unrestricted access to send and receive mail and other forms of communications, unopened and unread by others, including the right to share contact information with whom the individual chooses. 6400.32(n) - An individual has the right to unrestricted and private access to telecommunications. 6400.32(p) - An individual has the right to choose persons with whom to share a bedroom. 6400.32(q) - An individual has the right to furnish and decorate the individual's bedroom and the common areas of the home in accordance with § 6400.33 (relating to negotiation of choices). 6400.32(r) - An individual has the right to lock the individual's bedroom door. 6400.32(r)(1) -- Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to unlock and lock the door. 6400.32(r)(2) -- Access to an individual's bedroom shall be provided only in a life-safety emergency or with the express permission of the individual for each incidence of access. 6400.32(r)(3) --Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance. 6400.32(r)(4) -- The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. 6400.32(r)(5) -- Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. 6400.32(s) -- An individual has the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home. 6400.32(s)(1) -- Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance. 6400.32(s)(2) -- The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. 6400.32(s)(3) -- Direct service workers who provide service to the individual shall have the key or entry device to lock and unlock the door. 6400.32(t) -- An individual has the right to access food at any time. 6400.32(u) -- An individual has the right to make health care decisions. 6400.32(v) -- An individual's right may only be modified in accordance with § 6400.185 (relating to content of individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | 6400.34 (a) INDIVIDUAL RIGHTS: The Individual Rights were signed by the resident¿s father/guardian, but the Individual Rights that were signed did not have ¿updated¿ rights that are identified in the following regulations:
6400.32(a): ¿discrimination¿
6400.32(d): ¿dignity and respect¿
6400.32(e): ¿choices and risks¿
6400.32(f): ¿right to refuse activities¿
6400.32(g): ¿right to control activities¿
6400.32(i): ¿access to and security of possessions¿
6400.32(j): ¿express concerns over services¿
6400.32(k): ¿participation in development and implementation of ISP¿
6400.32(m): ¿unrestricted access to send and receive mail¿
6400.32(n): ¿unrestricted access to technology¿
6400.32(p): ¿share a bedroom¿
6400.32(q): ¿furnish and decorate bedroom and common areas¿
6400.32(r): ¿lock bedroom door¿
6400.32(r1): ¿locking mechanism that can be locked and unlocked by individual¿
6400.32(r2): ¿staff access to bedroom with permission-life safety emergency¿
6400.32(r3): ¿available technology to lock and unlock bedroom door¿
Page 2
6400.32(r4): ¿locking mechanism that allows easy and immediate access in emergency¿
6400.32(r5): ¿workers having access to key, access card¿
6400.32(r6): ¿individual has access to key, access card¿
6400.32(s): ¿individual has access to key, access card, key pad to home door¿
6400.329s1): ¿Assistive Technology to lock/unlock home door¿
6400.32(s2): ¿individual-home door locking mechanism- easy and immediate access in emergency¿
6400.32(s3): ¿staff-home door locking mechanism-easy and immediate access in emergency¿
6400.32(t): ¿access to food at anytime¿
6400.32(u): ¿health care decisions¿
6400.32(v): ¿right modification-ISP-significant health and safety risk to self or others¿
Plan of Correction:
In order to address the deficiency identified in 6400.34 related to review of ¿current¿ Individual Rights with individual and persons designated by the individual, the agency will implement the following corrective action:
Through the direction of the Program Director and in conjunction with the Bichler Lane Supervisor and Program Specialist, the content of the new Individual Rights compatible with the Regulatory Compliance Guide, 55 Pa.Code Chapter 6400, February 3, 2020 Edition will be developed and reviewed with individual and individuals designated person for the individual identified during the Renewal Survey, and (2) other residents residing in the Bichler Lane Program.
The review of the Individual Rights will be completed upon admission for any new residents and annually thereafter. |
06/16/2021
| Implemented |
| 6400.52(c)(3) | Staff #1 did not receive annual training on Individual Rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | This deficient area is related to the lack of a review of Individual Rights to the individual and the individual¿s designated person, excepting in this case residential staff were not in-serviced on the February 2020 edition of the Regulatory Compliance Guide/55 Pa.Code Chapter 6400 Regulations. Training had occurred on the Individual Rights on the ¿Old Regs.¿ omitting the enhancement of current Individual Rights that broadened the scope of an individual¿s rights.
Under the direction of the Program Director, and in conjunction with the Bichler Lane Supervisor and Program Specialist, all staff will be in-serviced on the February 2020 Edition of 6400 Individual Rights. The training will occur on (2) occasions, within 30 days of the 4/14/2021 due date for the Plan of Correction, then again ¿cycled¿ in with the programs annual training dates for individual staff. |
05/14/2021
| Implemented |
|
|
|
SIN-00167266
|
Renewal
|
12/19/2019
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | Individual #1's annual rights were signed late. They were signed on 02-28-18, then not again until 05-05-19. | The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights. | Regulation Number (31b)
The facility failed to have Individual #1¿s Individual Rights signed by the individual, parent, guardian, or advocate in a timely manner. Records showed that Individual #1 Individual Rights were signed in February 2018, then in the following year, May of 2019.
The regulation states ¿receipt of information¿¿..¿upon admission, and annually thereafter¿.
To address the deficient practice the facility will implement the following systematic changes and corrective action to address Individual #1, and the (2) other individuals who could be affected by the current deficient practice:
1. Individual #1 and (2) other individuals at the Bichler Lane residence will have their Individual Rights reviewed with them, their parent/family and/or legal guardian by 2/14/20. This will establish the same time of the calendar year that all (3) residents had documentation of timely Individual rights review and ¿acknowledgment of receipt¿. This will address the immediate problem for Individual #1, and the other (2) residents at the Bichler residence, by making them current and timely.
2. A second Individual Rights review and receipt process will occur in 2020. Individual #1 and (2) other individuals at the Bichler Lane residence will have their Individual Rights reviewed with them and ¿acknowledgment of receipt¿, at least (30) days prior to their Annual ISP in 2020, then replicate this practice in following years. The purpose of establishing this practice is to include the Individual Rights document with the Annual Lifetime Medical History and Annual Assessment in the (30) day window with the Individual Support Plan process. By including the Individual Rights process into the Annual ISP, it should eliminate the deficient practice from reoccurring as it will be tied into the ISP process.
The Program Director, in conjunction with the Program Specialist and Site Supervisor, will be responsible for ensuring both Step #1 and Step #2 are completed within a timely manner to adequately address the deficient area identified in Regulation Number 31b. |
02/14/2020
| Implemented |
| 6400.181(f) | There is no documentation in Individual #1's file proving the assessment was sent to the SC or team members at least 30 days prior to the ISP meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Regulation Number 181(f)
The facility failed to provide written documentation to prove that Individual #1¿s Annual Assessment was sent to the Individual Supports Coordinator and team members at least 30 days prior to the Annual ISP Meeting.
To address the deficient practice, the Program Director will implement the following systematic change and corrective action:
Individual #1¿s most recent Annual ISP was conducted in November of 2019, and approved by the ISP Coordinator. To address the deficient practice, the Program Director, in conjunction with the Program Specialist and Site Supervisor will ensure that documentation of the Annual Assessment, at least 30 days prior to the Annual ISP, is kept on file. Individual #1¿s next scheduled Annual ISP will be scheduled for October/November 2020 provided there are no critical changes.
Two (2) other individuals reside in the Bichler Lane Program, with their respective 2020 Annual ISPs being conducted in September and October 2020 provided there are no critical changes in the most recent approved 2019 ISPs.
To maintain consistency in the Annual ISP process, the Program Director, in conjunction with the Program Specialist and Site Supervisor, will ensure that the following documentation for Individual #1 and (2) other residents is on file in a timely manner:
Facility Letter with acknowledgement Annual ISP Date to the ISP Supports Coordinator at least 30 days prior to meeting.
¿ Facility Letter will contain attachments:
o Annual Lifetime Medical History
o Annual Assessment of Current Developmental Skills
The 2019 Annual ISPs for the three women that reside at Bichler Lane followed a September/October/November schedule. To meet the criteria for the deficient practice, the correction date will be 7/31/20 to maintain ¿at least 30 days before¿ the first ISP meeting that will prevent reoccurrence of the deficient practice for Individual #1 and others in the Bichler Lane Program. |
07/31/2020
| Implemented |
|
|
|
SIN-00147531
|
Renewal
|
12/11/2018
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.151(a) | Staff #1 had a physical exam on 4/11/216. She didn't have another physical exam until 5/3/2018, which exceeds the bi-annual requirement. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | 55 PA Code Chapter 6400.151 (a)
The facility failed to ensure that all staff persons who come into direct contact with individuals have their physical examinations within a (2) year period from their previous physical. To ensure that the deficient practice does not reoccur, the facility will implement the following corrective action:
The Program Director will meet with the Site Supervisor & Program Specialist for a review of all current staff most recent physical examinations. All residential staff, with the exception of one, are not due for their next physical until the calendar year 2020. One staff person is due in July 2019. There are no new staff who must be reviewed for a physical examination for the regulation that specifies the physical within 12 months prior to employment.
The Site Supervisor will schedule all residential staff for their physical examinations with the Allied Services Health Service Provider (Contracted Service) in sufficient time frames to ensure the exams occur in compliance with the regulation. At this time, there is only one employee due in 2019.
As a quality assurance measure, the Site Supervisor will forward monthly documentation to the Program Director as to any staff due dates for the up-coming month. (If there are no due dates, documentation will indicate as such.) Due to the small number of employees and the duration of time before the next follow-up physical exams, this quality assurance measure will supervisor and director aware of the specifications of the regulation. |
02/01/2019
| Implemented |
| 6400.186(b) | Neither Individual #1 nor Individual #2 sign their 3 month ISP Reviews. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | 55 PA Code Chapter 6400.186 (b):
This deficiency was issued due to failure of the facility not having Individual #1 and #2¿s Quarterly ISP¿s signed by the ¿Individual¿ receiving the residential service. In order to ensure that the deficient practice does not reoccur, the following corrective actions will be implemented:
The Program Director will review the 2019 schedule for (3) month reviews with the Program Specialist/Site Supervor for Individual #1 & #2, and for the third individual residing within the Bichler Lane home.
The Program Specialist will ensure that all (3) month reviews have the ¿Individual¿s¿ signatures/marks for each (3) month or Quarterly Review since the most recent Annual ISP. All (3) individuals had their 2018 Annual ISP between September-November 2018, so there may be (1) 3 month review for 2018 in the current charts. 2019 3 month or Quarterly Reviews will have both the Program Specialist and Individual signature or mark.
The Program Director will review all three resident respective charts as a quality assurance measure to ensure the corrective action has been adequately established. The Program Director will document this quality assurance measure with an administrative review of the (3) month ISP. |
03/01/2019
| Implemented |
|
|
|
SIN-00127895
|
Renewal
|
02/20/2018
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | Individual #1's rights were signed late. They were signed on 01-05-16, then not again until 03-01-17. | Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | 6400.31 (b) The regulation pertains to statements signed and dated by the individual, individual¿s parent, guardian or advocate acknowledging receipt of information on rights upon admission and annually thereafter.
Individual #1¿s Individual rights document was signed several months past the due date. In order to address the deficient area the Program Director, in conjunction with the Site Supervisor, will review the individual record for with compliance for 2018, and for subsequent years thereafter, to ensure that signed acknowledgement by the appropriate party is timely.
For all others who could be adversely affected by the deficient practice, the Program Director and Site supervisor will review the (2) remaining residents Individual Rights for compliance in 2018, and for subsequent years. The Program Director and site supervisor can determine whether to secure the signed acknowledgements based on admission date, calendar year, or in conjunction with the Annual ISP date providing there is adherence to the 365 days. |
06/30/2018
| Implemented |
| 6400.46(g) | There is no current fire safety training for Staff #1. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). | 6400.46 (g) Program Specialist and direct service workers receive training by fire safety expert in the training areas specified in 46 (f) within the previous training year.
Staff #1, the Program Specialist, was not in compliance with the regulation requirement. The Program Director/Program Specialist fulfill both roles for the Bichler Lane Program at this time. The established training period is 7/1 to 6/30 for each year.
The Program Director and Site Supervisor will review the facility¿s established annual training year which corresponds to the fiscal year (July 1 for previous year to June 30 of following year), and ensure that the Program Specialist, Site Supervisor, and Direct Support Professionals all adhere to the Regulation 6400.46 (g).
((Staff #1 received fire safety training on 5/4/2018 - CH 5/7/2018)) |
06/30/2018
| Implemented |
| 6400.141(c)(3) | There is no record of immunizations in Individual #1's file. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Individual Health 141 © (3).
The facility failed to provide an immunization history on the annual physical examination form for Individual #1. In order to address the deficient area, the following corrective actions will be implemented:
The Program Manager, in conjunction with the Site Supervisor, will review immunizations consistent with the Center of Disease Control for individuals over the age of 18, compare to current immunizations received by Individual #1, and determine which immunizations are required to be in compliance with the regulations.
The Program Specialist, in conjunction with the Site Supervisor, will review the Individual #1¿s Annual Physical form for Immunization Record information, and amend the form or add an addendum to the physical to provide relevant immunizations compatible with the CDC and the ODP 6400 Regulations.
For all other residents who could be adversely affected by the deficient practice, the Program Specialist and Site Supervisor will review the immunization record and current annual physicals to ascertain whether the two remaining residents are current and compatible with the CDC and ODP 6400 regulations. In addition, the annual physical forms will be reviewed and modified, as needed, in order to present each individual¿s immunization record. At this time, the remaining (2) residents are in compliance with immunizations, more specifically the DPT that was not evident in Individual #1 Completion: 08/01/2018 |
08/01/2018
| Implemented |
| 6400.141(c)(4) | There is no indication on the physical form or anywhere else in the file that Individual #1's hearing has been evaluated. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual Health 141 © (4)
The facility failed to document the extent of vision and hearing screening on the annual physical form for Individual #1. In order to address the deficient area, the following corrective actions will be implemented:
The Program Specialist, in conjunction with the Site Supervisor, will review the Individual #1¿s Annual Physical form for a documentation space for the evaluation of vision and hearing screening, and amend the form or add an addendum to the annual physical form to document the status of both vision and screening. This individual actually has both vision and hearing deficits, and is followed by an ophthalmologist for glaucoma and hearing specialists due to hearing loss and use of hearing aids. Information can be reviewed by the primary physician and documented onto the annual physical form or attachment.
For all others who could be adversely affected by the deficient practice, the Program Specialist and Site Supervisor will review the current annual physical forms to ascertain whether the two remaining residents are current with specifies vision and hearing screening. In addition, the annual physical forms will be reviewed and modified, as needed, in order to present each individual¿s vision and screening evaluation.
For the remaining (2) individuals, the site supervisor will schedule vision and hearing appointments for a thorough evaluation by 9/1/18. Information from the specialist reviews can be transferred to the annual physical form or attachment for the annual physical, one due in 8/18 and one due in 12/18. |
09/01/2018
| Implemented |
| 6400.141(c)(8) | Individual #1 is required to have a yearly mammogram. She had one 02-11-16, then not again until 05-03-17. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | Individual Health 141 (C.) (8)
The facility failed to document a timely mammogram on the annual physical form for Individual #1. In order to address the deficient area, the following corrective actions will be implemented:
For Individual #1, her most recent mammogram was 5/3/17, approximately (3) months past the due date. The Site Supervisor will schedule the 2018 annual mammogram well before the may 2018 due date to avoid interruptions in compliance such as weather, and or cancellations. The mammogram is scheduled 5/10/18, within an acceptable grace period specified by ODP.
The Program Specialist, in conjunction with the Site supervisor will review the annual physical form, amend or provide an attachment to the annual physical to document status of mammogram for Individual #1, and all other individuals who could be adversely affected by the deficient practice.
One individual is between the age of 40 and 49, due every two years and currently scheduled for April 2018, and the remaining individual is only 34 years of age and not required to have a mammogram at this time. The 34 year old individual does have regular gynecological evaluations and will follow recommendations from the gynecologist.
Completion: 07/01/2018 |
07/01/2018
| Implemented |
| 6400.141(c)(14) | Nowhere on Individual #1's physical form does it address medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual Health 141 (C.) (14) Medical information pertinent to diagnosis and treatment in emergency
The facility failed to provide pertinent information to diagnosis and treatment on the annual physical form Individual #1. In order to address the deficient area, the following corrections will be implemented:
For Individual #1, and all others who could be adversely affected by the deficient practice, the Program Director, in conjunction with the Site Supervisor, will amend the annual physical form, or an attached document will be provided that documents pertinent information related to her diagnosis, developmental and cognitive abilities, and communication abilities that would be beneficial for a physician or healthcare specialist to successfully treat our individuals in an emergency situation. For example, Individual #1 has vision (glaucoma) and hearing deficits (utilizes hearing aids), can be very anxious in social situations, and has unsteady gait.
For the other individuals who may be adversely affected by the deficient practice, the Program director, in conjunction with the Site Supervisor amended annual physical form or attachment will provide pertinent medical information for diagnosis and treatment in an emergency situation. At Bichler Lane, specific individuals have medical issues such as ¿clotting issues¿, orthopedic issues such as Harrington Rods, nonverbal communication, peg tube nutrition and medication administration. Each individual¿s annual physical form will provide essential information for the healthcare provider to provide adequate care in an emergency. |
08/01/2018
| Implemented |
|
|
|
SIN-00106799
|
Renewal
|
02/06/2017
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | Individual #1's rights were signed on 01/05/16. Individual rights were not signed as of this inspection date, 2/6/2017. Individual Rights were not signed annually. | Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | 55A Code Chapter 6400.31 (b.)
The deficiency was related to the facility failing to have an annual verification of signed ¿receipt of information on rights¿ on the chart. The facility will implement the following corrective action to prevent reoccurrence of the deficient practice by implementing the following:
For the immediate problem, the Program Specialist, in conjunction with the Health Services Supervisor, will be responsible for ensuring that Individual #1 will have timely review and signature of their individual rights by the individual, individual¿s parent, guardian or advocate as acknowledgment of receipt of their rights information. Immediate correction will be completed by April 15, 2017, and the subsequent Annual ISP Meeting This will occur at the time between the Annual Assessment completion and the Annual ISP Meeting, October 2017 and November 2017.
To ensure that the deficient practice does not reoccur with the two other individuals at the Bichler Lane Program, the Program Specialist, in conjunction with the Health Services Supervisor/Site Supervisor will review the ¿ISP Timeline Process¿ from Annual Review Update Date, back to the ISP Meeting and Annual Assessment due dates to ensure that appropriate review and signatures in place with the individual, family member guardian or advocate. The first individual in the Bichler Lane Annual ISP process will occur in September 2017, therefore, appropriate review and signatures of the ¿individual rights¿ will occur between August 2017-September 2017.
The Program Director will be ultimately responsible to ensure that the corrective action is implemented for 6400.31 (b), and eliminate reoccurrence of the deficient practice. |
03/30/2017
| Implemented |
| 6400.62(a) | The individuals are not poison safe. There was soap and hand sanitizer in the bathroom that the individuals use (in the kitchen) that stated poison control and/or a doctor should be called if it's ingested. | Poisonous materials shall be kept locked or made inaccessible to individuals. | 55A Code Chapter 6400.62 (a)
The deficiency related to ¿poisons not be locked or made inaccessible¿, and more specifically was related to hand soap that specified the need to ¿seek medical attention, if ingested¿. The facility will implement the following corrective action to prevent reoccurrence of the deficient practice:
The facility will establish policy that all hand soaps that could be poisonous are locked and inaccessible to residents of the Bichler Lane home.
As an alternative, non-toxic hand soaps will be purchased that can be accessible for hand washing without posing an individual health care risk.
The Program Director and Health Services Supervisor will be responsible for ensuring that the corrective action to address 6400.62 is addressed and prevented from reoccurrence. |
04/01/2017
| Implemented |
| 6400.141(c)(14) | Individual #1's physical form did not include a section or information regarding medical information pertinent to diagnosis and treatment in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | 55A Code Chapter 6400.141 (c) (14)
The deficient area addresses the lack of information on Individual #1¿s Annual Physical related medical information pertinent to diagnosis and treatment in case of emergency. To address the deficient practice, the facility will implement the following corrective action to prevent reoccurrence of the deficient practice:
For the immediate problem, to address the Program Director and Health Services Supervisor will review the all current Annual Physical form(s) that are utilized for Bichler Lane residents, and develop an Annual Physical form that includes ¿medical information pertinent to diagnosis and treatment in case of emergency¿. Communication with other 6400 Regulation providers be sought to see how their forms address this information. The new Annual Physical form will be developed by May 2017, in time for Individual #1¿s, Annual Physical of the 2017, slated for no later than June 2017.
The two remaining residents are due for their Annual Physicals in September 2017 and December 2017, respectively. The new Annual Physical Form will be utilized that will provide ¿medical information pertinent to diagnosis and treatment in case of emergency.¿
The Program Director, in conjunction with the Health Services Supervisor, will be ultimately responsible for ensuring all aspects of 6400.141 (Individual Health) documentation are in compliance with regulations. |
05/01/2017
| Implemented |
| 6400.151(a) | Staff #1's physical was late. She had one 08/24/14, the not again until 10/14/16. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | 55A Code Chapter 6400.151 (a)
The deficiency relates to ¿Staff Health¿, and the site supervisor not having a physical examination within the (2) years of the previous staff physical. The facility will address the immediate issue by implementing the following corrective measures:
For the immediate citation issue, the site supervisor was out of compliance with the ¿two year window¿, but completed her physical on 10/4/16. Her new ¿due date will be September/October 2018.
To address all staff within the Bichler Lane Program, the Health Services Supervisor/Site Supervisor and Program Director reviewed all existing staff physical dates. All staff had their annual physical within 2016. The follow-up Annual Physicals will fall in a time span of December 2017 ¿ December 2018.
The Program Director, in conjunction with the Health Services Supervisor/Site Supervisor will review the current staff physical examination due dates in order to ensure compliance with the regulation, and prevent reoccurrence of the deficient practice. |
03/17/2017
| Implemented |
| 6400.181(e)(10) | Individual #2's assessment said "see attached" for the lifetime medical history, but there was no attachment. | The assessment must include the following information: A lifetime medical history. | 55PA Code Chapter 6400.181 (10)
The deficiency related to this tag number is failure for the facility to have a lifetime medical history attached to the resident¿s Annual Assessment. To address this deficient area the facility will implement the following corrective action to address the immediate problem and future occurrences:
For the immediate issue and citation, the Program Specialist will meet with the ISP Supports Coordinator and Health Services Supervisor of the Bichler Lane site related to Individual #2¿s Annual Assessment and Lifetime Medical History. Individual #2¿s Annual Review Update Date is 12/16/16 (most recent year). The last date of compliance for the ISP Meeting for 2017 is 10/17/17 (60 days), and the Annual Assessment and Lifetime Medical History will be attached no later than (30) days prior to the ISP Meeting date. The Health Services Supervisor will update the Lifetime Medical History, and the Program Specialist will update the Annual Assessment
For the two remaining individuals who reside at the Bichler Lane site, the Program Specialist will meet with the ISP Coordinator and Health Services Supervisor of Bichler Lane, acknowledge the Annual Review Update Date, and ensure that the ISP Meeting is timely (no later than 60 days prior to Annual Review Update Date), and the Annual Assessments are also timely (30 days prior to ISP Meeting). The Program Specialist will update the Annual Assessment, and the Bichler Lane Health Services Supervisor will update the Lifetime Medical History, and both will be submitted to the ISP coordinator in preparation for the Annual ISP Meeting.
The Program Specialist/Program Director will be ultimately responsible for ensuring the corrective action is completed for the deficient area noted in 6400.181 (10), and to ensure there is no reoccurrence of the deficient practice. Completion date: 9/1/2017 |
09/01/2017
| Implemented |
| 6400.181(f) | Neither Individual 1's nor 2's assessment were provided to the supports coordinator and/or team members at least 30 calendar days prior to an annual ISP meeting. Staff indicated that the assessment is given to the supports coordinator and team members on the date of the ISP meeting. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| 55PA Code Chapter 6400.181 (f)
The deficiency related to this tag number specifies that the Program Specialist failed to provide the Annual Assessment to the ISP Coordinator at least 30 days prior to the ISP Meeting for the development, annual update and revision. The Program Specialist¿s past practice was to submit the Annual Assessment for all Bichler Lane residents at the time of the Annual ISP (includes Individual #1 & #2). To address this deficient area the facility will implement the following corrective action to address the immediate problems and future reoccurrences:
For the immediate problem, the Program Specialist will meet with the ISP Supports Coordinator and Health Services Supervisor of Bichler Lane to review and acknowledge the ¿Annual Review Update Date¿ for Individual #1 and Individual #2, and plan for timely Annual ISP Meeting Dates, and Annual Assessments.
Individual #1¿s Annual Review Update Date is 1/23/17 (most recent ISP). The last date the ISP Meeting Date could have occurred was 11/24/16. The subsequent Annual ISP Meeting will be conducted no later than 11/24/17 to maintain compliance with the Annual ISP requirements, and to maintain compliance with 6400.181 (f), the Annual Assessment will be completed and submitted to the ISP Coordinator no later than 10/25/17, or no later than 30 days prior to the Annual ISP Meeting
Individual #2¿s Annual Review Update Date is 12/16/16 (most recent ISP). The last date the ISP Meeting Date could have occurred was 10/17/16. The subsequent Annual ISP Meeting will be conducted no later than 10/17/17 to maintain compliance with the Annual ISP Meeting Date requirements, and to maintain compliance with 6400.181 (f), the Annual Assessment will be completed and submitted to the ISP Coordinator no later than 9/17/17, or no later than 30 days prior to the Annual ISP Meeting.
The same planning exercise will occur for the remaining resident of the Bichler Lane Program to ensure timely development and submittal to the ISP coordinator for development, update and revision of the ISP.
The Program Director/Program Specialist (same employee) will be ultimately be responsible for ensuring the timely compliance with Annual Assessments for each of the three individuals residing at the Bichler Lane program. |
08/01/2017
| Implemented |
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SIN-00070070
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Renewal
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11/19/2014
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.151(a) | Staff #1 had a physical on 12/09/2010 and another on 02/18/2013. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Bichler Lane
55 PA Code Chapter
November 2014
6400.151 a:Allied Services Bichler Lane Program received a deficiency related to 6400.151 which relates to physical examinations, (12) months prior to employment and within (2) years following employment thereafter. In response to the citation, Allied Services will implement the following corrective actions to remedy the exact violation that was cited and implement systemic changes to prevent the deficient practice from occurring with other residential staff. The following corrective actions will be implemented by the appropriate responsible parties:
(1.) Staff #1 received a physical examination on 12/9/10, and again on 2/18/13, which was beyond the specified target date of (2) years following start of employment. The Program Supervisor, in conjunction with the Program Director, will be responsible for ensuring that Staff #1 has their physical examination by 2/18/15.
(2.) The Program Supervisor, in conjunction with the Program Director, will review all other staff who could be affected by the deficient practice, and devise a ¿Staff Physical Exam Schedule¿. There are only (8) residential staff (7) CNA or Resident Assistant, LPN Supervisor, and Program Specialist) who work within the 6400 regulated Bichler Lane home, with 7/8 currently in compliance.
The Program Supervisor will develop a ¿Physical Exam Schedule Form¿ that will identify the ¿most recent¿ Physical Exam Date, Due Date, and Actual Date of follow-up.
(3.) The Program Supervisor will submit a memo request to a staff for the need to complete the bi-annual physical exam one month prior to the due date.
(4.) The Program Director of Allied Services Developmental Services Division will be ultimately responsible for the corrective action related to the deficient practice identified in 6400.151 (a) and monitor progress in the plan of correction.
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01/10/2015
| Implemented |
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SIN-00088200
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Renewal
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02/10/2016
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Compliant - Finalized
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SIN-00053442
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Renewal
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11/06/2013
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Compliant - Finalized
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SIN-00042600
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Initial review
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09/28/2012
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Compliant - Finalized
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