| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
|
SIN-00240463
|
Renewal
|
02/21/2024
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | At the time of the inspection there was a powder blue spray bottle under the bathroom sink on the second floor. This bottle had no label on it and in a black marker it read "bath tub only please". It is unknown what chemical was in this bottle as there was no label to identify the product. Poisons shall be stored in their original labeled containers. | Poisonous materials shall be stored in their original, labeled containers. | 6400-62 (c) ¿ VIOLATION #9
Poisonous materials must be kept in their original, labeled containers. During the survey, an unlabeled spray bottle was located under the second floor bathroom sink. Poisonous materials must be kept in original, labeled containers.
The management team (AVP, Program Director, Site Supervisor, and Program Specialist) will meet at the Richmont St. home to review all aspects of 6400.62 as related to Poisons. The Site Supervisor/Program Specialist will conduct monthly site walk-throughs of kitchen, bathrooms, and storage areas to ensure that poisonous materials are maintained in their original, labeled containers.
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.
The Site Supervisor/Program Specialist will be responsible for ensuring compliance with the regulation related to Poisons on an ongoing basis.
To ensure the deficient practice does not reoccur, the AVP and/or the Program Director will review Monthly Site Walk-Through/Record Checklists during Monthly Incident Management Meetings. |
05/01/2024
| Implemented |
| 6400.66 | The light over the kitchen door side exit was burned out. All outside doorways and porches shall be lighted to assure safety and avoid accidents. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| 6400.66 ¿ VIOLATION #10
Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps, and fire escapes shall be lighted to assure safety and to avoid accidents. During the survey, the outdoor light by the kitchen door side exit was burned out.
The management team (AVP, Program Director, Site Supervisor, and Program Specialist) will meet at the Richmont St. home to review 6400.66 as related to Lighting. The Site Supervisor/Program Specialist will conduct monthly site walk-throughs of rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps, and fire escapes to ensure those areas are properly lighted.
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.
The Site Supervisor/Program Specialist will be responsible for ensuring compliance with the regulation related to Lighting on an ongoing basis.
To ensure the deficient practice does not reoccur, the AVP and/or the Program Director will review Monthly Site Walk-Through/Record Checklists during Monthly Incident Management Meetings. |
05/01/2024
| Implemented |
| 6400.141(c)(4) | Individual #1 had a physical dated 4/12/23. There was no vision screening documented on the Allied physical. This individual also had a Goodwill annual physical form completed on the same day which also did not have a vision screening.
Repeat violation from 2023 | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | 6400.141 (c)(4) ¿ VIOLATION #11
Annual physical examinations should include vision and hearing screenings. During the survey, it was noted that Individual #1 had an annual physical examination on 4/12/23, however, there was no information re: a vision screening being completed.
The management team (AVP, Program Director, Site Supervisor, and Program Specialist) will meet to review all aspects of regulation 6400.141 as related to annual Individual Physical Examination and all components that need to be addressed in same. A revised Annual Physical Examination Form has been developed that includes all components in 6400.141 (including vision and hearing screenings) will be implemented with all physical examinations.
The Annual Physical (and Form), and any specialist related to Hearing Evaluations or Vision Evaluations should and will be recognized for regualtory compliance.
In addition, Program Specialists perform Monthly Progress Notes which include any medical appointments that occur between reviews. The Progress Notes should also include each individuals' respective "due dates" as cues to time frames to maintain regulatory compliance.
In order to ensure the deficient practice does not reoccur, the AVP and/or Program Director will review the Medical Appointment/Vaccine form/grid during Monthly Incident Management Meetings and identify any opportunities for improvement. |
05/01/2024
| Implemented |
| 6400.142(a) | Individual #1 had a dental exam on 5/23/22 and then not again until 2/12/24. This exceeds the annual time frame. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | 6400.142 (a) ¿ VIOLATION #12
An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. During the survey, individual #1 had a dental exam on 5/23/22 and then not again until 2/12/24, thus exceeding the annual time frame.
The Richmont Team needs to be cognizant of the 2/12/24 date and to not exceed 365 days for an annual review or earlier for more urgent dental issues as identified by the dentist.
The management team (AVP, Program Director, Site Supervisor, and Program Specialist) will meet to review all aspects of regulation 6400.142 as related to Dental Care. A new Medical Appointment/Vaccine Form/Grid was developed for use by Site Supervisor/Program Specialist to more effectively track appointments (including dental) to ensure compliance with due dates and time frames for completion of same.
In addition, Program Specialist Monthly Progress Notes should reflect medical appointments (including dental) that occur between monthly reviews. "Due Dates" should also be noted in each residents notes as additional cues for all medical compliance and follow-up.
In order to ensure the deficient practice does not reoccur, the AVP and/or Program Director will review the Medical Appointment/Vaccine Form during Monthly Incident Management Meetings and identify any opportunities for improvement. |
05/01/2024
| Implemented |
| 6400.142(c) | Individual #1 had a dental appointment on 5/25/23. There was no information to reflect if a cleaning or exam was completed and or any other procedures.
Repeat violation from 2022 | A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. | 6400.142 (c) ¿ VIOLATION #13
A written record of the dental examination, including the date of the examination, the dentist¿s name, procedures completed, and follow-up treatment recommended shall be kept. During the survey, it was noted that during a dental appointment for individual #1 on 5/25/23, there was no information to reflect what procedures were performed and no information related to follow-up treatment recommended.
The management team (AVP, Program Director, Site Supervisor, and Program Specialist) will meet to review all aspects of regulation 6400.142 as related to Dental Care. A new Physician Visit Form has been revised to include all components contained in 6400.142 (c). The Site Supervisor/Program Specialist will monitor the completeness of Physician Visit Forms to ensure compliance and identify opportunities for improvement.
In addition, Program Specialists, during Monthly progress Notes, should review medical visit forms to ensure that the physician's name, date of examination, procedures completed and follow-up are clearly identified on the form.
In order to maintain compliance, AVP and/or Program Director will review a sample of Physician Visit Forms during monthly site visits. |
05/01/2024
| Implemented |
| 6400.143(a) | Individual #1 December 2023 Medication administration record reflects that he refused his Deep Sea nasal spray, vitamin D, Lamictal tablet, lithium carb tablet, and Colace tablets on the dates of December 1 through December 7, 2023. The continued attempts to train the individual about the need for his health care were not documented. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | 6400.143 (a) ¿ VIOLATION #14
If an individual refuses routine medical/dental examinations or treatment (including medications), the refusal and continued attempts to train the individual about the need for healthcare shall be documented in the individual¿s record. During the survey, it was noted that individual #1 refused medications several times from December 1 through December 7, 2023. The continued attempts to train individual #1 were not documented.
The management team (AVP, Program Director, Site Supervisor, and Program Specialist) will meet to review all aspects of regulation 6400.143 as related to Refusal of Treatment. An Education/Reinforcement for Medication Refusal Form (to be attached to M.A.R.) was developed to be utilized by Site Supervisor/Program Specialist/Direct Service Workers (any staff person that administers medication); this form will document date of refusal, reinforcement/education provided, and, if appropriate, physician notification/response.
In addition, Program Specialist Monthly Notes should reflect "medication refusals" and any education offered to the individual about the benefit/risks related to refusals.
Site Supervisor and/or Program Specialist will review refusal of medications in M.A.R. to ensure it corresponds with entries on Education/Reinforcement for Medication Refusal Form.
In order to maintain compliance, AVP and/or Program Director will review a sample of Physician Visit Forms during monthly site visits. |
05/01/2024
| Implemented |
| 6400.144 | Individual #1 had a podiatrist appointment on 10/17/23 with a follow up to occur on 12/19/23. There was no follow up documentation to reflect that appointment was kept.
Repeat violation from 2023 | 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.
| 6400.144 ¿ VIOLATION #15
Health Services, such as medical, nursing, pharmaceutical, dental, dietary, and psychological services that are planned or prescribed for the individual shall be arranged for/provided. During the survey, it was noted that individual #1 had a podiatry appointment on 10/17/23 with follow up scheduled for 12/19/23 ¿ no follow-up information was documented to reflect that 12/19/23 appointment was kept.
The management team (AVP, Program Director, Site Supervisor, and Program Specialist) will meet to review all aspects of regulation 6400.144 as related to Health Services. A Medical Appointment/Vaccine Form/Grid was developed for use by Site Supervisor/Program Specialist to more effectively track appointments (including podiatry) to ensure compliance with due dates and time frames for completion and follow-up of same.
In addition, Program Specialist Monthly Progress Notes identify any medical appointments that occur form month to month. All medical appointments, including podiatry, should include the name of the phsyician, the date of appointment, the procedure performed, and the next follow-up date.
In order to ensure the deficient practice does not reoccur, the AVP and/or Program Director will review the Medical Appointment/Vaccine Form during Monthly Incident Management Meetings and identify any opportunities for improvement. |
05/01/2024
| Implemented |
| 6400.46(a) | The current full training year ran from July 1, 2022, through June 30, 2023. Staff #1 did not have documentation that reflects training in general fire safety, evacuation procedures, responsibilities during a fire drill, the designated meeting place outside the building, smoking safety procedures, use of fire extinguishers, smoke detectors, fire alarms and notification of the fire department. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | 6400.64(a): Program Specialists and direct service staff must be trained in all aspects of fire safety prior to working with individuals, and then annually thereafter.
Staff #1 (Acting Program Specialist) did not receive training in fire safety prior to working with residents. The Assistant Vice President assumed the Acting Program Specialist position due to a resignation in order to maintain Progress Notes, Quarterly and Annual ISP compliance but failed in-servicing in some of the Program Specialist ODP requirements (Including Fire Safety).
To address the immediate issue, the following corrective actions will be implemented:
1. The Assistant Vice President/Acting Program Specialist will be in-serviced on fire safety. To remain in compliance with the current training year (7/1/23-6/30/24), the Acting Program Specialist will be trained in fire safety prior to the 6/30/24 expiration date.
2. The Assistant Vice President will assign/hire a Program Specialist for the Bichler/Richmont Street Programs. Before the assigned/hired Program Specialist works with any individual, the all aspects of Staff Training 46(a): General Fire Safety, Evacuation Procedures, Fire Drill responsibilities, Designated meeting Places, ¿Smoking Safety¿, Use of Fire Extinguishers, and Notification of local fire department.
Thereafter, Program Specialists, will be re-in-serviced annually in accordance with the facility¿s ¿training year. (46 b)
3. The management team will develop a Staff Training form that encompasses training before working with individuals, training within the first 30 days, 6 months of hire (CPR/First Aid), then Annual Training for Program Specialists, Direct Service Workers, Management & Ancillary personnel.
To prevent recurrence of the deficient practice, the facility will utilize their monthly Incident Management/Program Audit meetings to assess ¿Staff Training¿ compliance for orientation of new staff:
¿ Before Working With Individuals:
o Fire Safety Procedures as noted above in #2
¿ Orientation (Within 30 Days)
o Person-Centered Practices
o Community Integration
o Individual Choice
o Supporting Individuals/Establishing Relationships
o Prevention of Detection & Reporting of Abuse
o Individual Rights
o Recognizing & Reporting Incidents
o Job-Related Knowledge and Skills
Page 2
Richmont Street:
6400.64(a): Program Specialists and direct service staff must be trained in all aspects of fire safety prior to working with individuals, and then annually thereafter.
¿ Annual Training: (Within Agency Specified Training period)
o Person-Centered Practices
o Community Integration
o Individual Choice
o Supporting Individuals/Establishing Relationships
o Prevention of Detection & Reporting of Abuse
o Individual Rights
o Recognizing & Reporting Incidents
o Safe Use of Behavioral Supports if directly working with individual
o Implementation of Individual Supports Plan, if directly working with individual
The Assistant Vice President, in conjunction with the Program Manager, in conjunction with site Supervisors, will be responsible for maintaining the documentation related to all staff orientation and training. |
06/28/2024
| Implemented |
| 6400.46(b) | The current full training year ran from July 1, 2022, through June 30, 2023. Staff #1 did not have documentation that reflects he completed the annual fire safety training 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). | 6400.64(a): Program Specialists and direct service staff must be trained in all aspects of fire safety prior to working with individuals, and then annually thereafter.
Staff #1 (Acting Program Specialist) did not receive training in fire safety prior to working with residents. The Assistant Vice President assumed the Acting Program Specialist position due to a resignation in order to maintain Progress Notes, Quarterly and Annual ISP compliance but failed in-servicing in some of the Program Specialist ODP requirements (Including Fire Safety).
To address the immediate issue, the following corrective actions will be implemented:
1. The Assistant Vice President/Acting Program Specialist will be in-serviced on fire safety. To remain in compliance with the current training year (7/1/23-6/30/24), the Acting Program Specialist will be trained in fire safety prior to the 6/30/24 expiration date.
2. The Assistant Vice President will assign/hire a Program Specialist for the Bichler/Richmont Street Programs. Before the assigned/hired Program Specialist works with any individual, the all aspects of Staff Training 46(a): General Fire Safety, Evacuation Procedures, Fire Drill responsibilities, Designated meeting Places, ¿Smoking Safety¿, Use of Fire Extinguishers, and Notification of local fire department.
Thereafter, Program Specialists, will be re-in-serviced annually in accordance with the facility¿s ¿training year. (46 b)
3. The management team will develop a Staff Training form that encompasses training before working with individuals, training within the first 30 days, 6 months of hire (CPR/First Aid), then Annual Training for Program Specialists, Direct Service Workers, Management & Ancillary personnel.
To prevent recurrence of the deficient practice, the facility will utilize their monthly Incident Management/Program Audit meetings to assess ¿Staff Training¿ compliance for orientation of new staff:
¿ Before Working With Individuals:
Fire Safety Procedures as noted above in #2
¿ Orientation (Within 30 Days)
Person-Centered Practices
Community Integration
Individual Choice
Supporting Individuals/Establishing Relationships
Prevention of Detection & Reporting of Abuse
Individual Rights
Recognizing & Reporting Incidents
Job-Related Knowledge and Skills
6400.64(a): Program Specialists and direct service staff must be trained in all aspects of fire safety prior to working with individuals, and then annually thereafter.
¿ Annual Training: (Within Agency Specified Training period)
Person-Centered Practices
Community Integration
Individual Choice
Supporting Individuals/Establishing Relationships
Prevention of Detection & Reporting of Abuse
Individual Rights
Recognizing & Reporting Incidents
Safe Use of Behavioral Supports if directly working with individual
Implementation of Individual Supports Plan, if directly working with individual
The Assistant Vice President, in conjunction with the Program Manager, in conjunction with site Supervisors, will be responsible for maintaining the documentation related to all staff orientation and training. |
06/28/2024
| Implemented |
| 6400.46(d) | Staff #3 date of hire was 6/20/23. Staff should be trained within 6 months of their initial employment and annually there after in CPR. This staff did not have her CPR training until 2/21/24. | 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. | 6400.46(d): Staff #3 was hired on 6/20/23, and as per regulation should have received CPR and First Aid Training within (6) months of hire, by December of 2023, but did not receive training until 2/21/24.
As per regulation all Program specialists, direct care staff, drivers and aides in vehicles need to be trained in 6 months of hire and annually thereafter.
Under the direction of the Assistant Vice President, in conjunction with the Program Director, all staff certification for CPR & First Aid, and annual training dates will be assessed to determine time lines, to be in compliance with certifications and trainings related to CPR and First Aid related to 6400.46d.
To prevent recurrence of the deficient practice, the facility will utilize their monthly Incident Management/Program Audit meetings to assess all ¿Staff Training¿ in order to achieve compliance in all aspects of training which includes orientation of new staff & existing staff:
¿ Before Working With Individuals:
o Fire Safety Procedures
¿ Orientation (Within 30 Days)
o Person-Centered Practices
o Community Integration
o Individual Choice
o Supporting Individuals/Establishing Relationships
o Prevention of Detection & Reporting of Abuse
o Individual Right
¿ Orientation (Within 30 Days)
o Recognizing & Reporting Incidents
o Job-Related Knowledge and Skills
¿ Within 6 months of hire
o CPR Training/Certification
o First Aid Training/Certification/Heimlich
¿ Annual Training: (Within Agency Specified Training period)
o Person-Centered Practices
o Community Integration
o Individual Choice
o Supporting Individuals/Establishing Relationships
o Prevention of Detection & Reporting of Abuse
o Individual Rights
o Recognizing & Reporting Incidents
o Safe Use of Behavioral Supports if directly working with individual
o Implementation of Individual Supports Plan, if directly working with individual
The Assistant Vice President, in conjunction with the Program Manager, in conjunction with site Supervisors, will be responsible for maintaining the documentation related to all staff orientation and training. |
06/28/2024
| Implemented |
| 6400.52(c)(1) | The most recent full training year ran from July 1, 2022 through June 30, 2023. Staff #1 did not have annual training in the application of person-centered practices, community integration, individual choice, and supporting induvial develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | 6400.52 (c) (1): Program Specialists and direct service staff must be trained in all aspects of person centered practices, community integration, individual choice, and supporting individuals in the development and maintaining of relationships. Staff #1, Program Specialist, did not have training during the 7/1/22-6/30/22 training period.
To address the immediate issue, the following corrective actions will be implemented:
1. The Assistant Vice President/Acting Program Specialist will be in-serviced on person centered training, community integration, individual choice, and in supporting individuals in development and maintaining relationships.. To remain in compliance with the current training year (7/1/23-6/30/24), the Acting Program Specialist will be trained in all of these areas prior to the 6/30/24 expiration date to maintain compliance for this program year.. |
06/30/2024
| Implemented |
| 6400.52(c)(2) | The current full training year ran from July 1, 2022, through June 30, 2023. Staff #1 and Staff #2 did not have annual training in the prevention, detection, and reporting of abuse, suspected abuse and alleged abuse. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | This deficiency involves Staff #1 and #2 who did not receive annual training in prevention, detection, and reporting abuse, suspected abuse and alleged abuse in accordance with the Older Adult Protected Services Act, Adult Protected Services, Child Protected Services, and applicable (ODP) agencies.
This absence of training was evident for the 7/1/22-6/30/23 agency training review period.
To address the immediate issue, the following corrective actions will be implemented:
Staff #1 and #2 are the Assistant Vice President/Acting Program Specialist & Vice President of Operations. The training review period expired on 6/30/23. To remain in compliance with the current training year (7/1/23-6/30/24), the Acting AVP/Program Specialist & VP of Operations will be trained in in all aspects of prevention, detection, and reporting abuse, alleged abuse and suspected abuse by the 6/30/24 expiration date of the current training year. This will address the current deficiency, and training records will be on file and reproducible. |
06/28/2024
| Implemented |
| 6400.52(c)(3) | The current full training year ran from July 1, 2022, through June 30, 2023. Staff #1 did not have annual training in individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | VIOLATION 6: Individual Rights
6400.52 (c)(3)
This deficiency involves Staff #1 (Assistant Vice President/Acting Program Specialist), and the lack of annual training in the implementation Individual Rights for staff who work directly with the individuals. The last full training review period was 7/1/22-6/30/23.
To accommodate compliance for Staff #1, the Site Supervisor and/or Program Specialist will train Staff #1, and all staff, by 6/30/24, or utilize training through MyODP related to Individual Rights. This will result in an immediate correction to the deficient practice for the current training year. |
06/28/2024
| Implemented |
| 6400.52(c)(5) | Staff #3 did not have training in the appropriate use of behavior supports for the 2023 calendar year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | 6400.52 (c)(5): Training Behavior Supports (Staff #3)
This deficiency involves Staff #3, and the lack of annual training for safe and appropriate use of behavior supports who works directly with the individuals. The last full training review period was 7/1/22-6/30/23.
To accommodate compliance for Staff #3, and all staff working with individuals with behavioral supports, the Site Supervisor and/or Program Specialist will train Staff #3, and all staff, by 6/30/24, which is the end of the current training review period. The in-service will include all individuals who are administered psychotropics, and who either have a Social Emotional Environmental Plan (SEEP) and/or formalized Behavior Support Plan (with/without Restrictive procedures). This will result in an immediate correction to the deficient practice. |
06/28/2024
| Implemented |
| 6400.52(c)(6) | Staff #3 did not have annual training in the implementation of the individual plan. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | 6400.52 (c)(6)
This deficiency involves Staff #3, and the lack of annual training in the implementation of the individual plan for staff who work directly with the individuals. The last full training review period was 7/1/22-6/30/23.
To accommodate compliance for Staff #3, and all staff working with individuals, the Site Supervisor and/or Program Specialist will train Staff #3, and all staff, by 6/30/24, in the implementation of the (3) individual plans. This will result in an immediate correction to the deficient practice.
6400.52 (c)(6)
This deficiency involves Staff #3, and the lack of annual training in the implementation of the individual plan for staff who work directly with the individuals. The last full training review period was 7/1/22-6/30/23.
To accommodate compliance for Staff #3, and all staff working with individuals, the Site Supervisor and/or Program Specialist will train Staff #3, and all staff, by 6/30/24, in the implementation of the (3) individual plans. This will result in an immediate correction to the deficient practice. |
06/28/2024
| Implemented |
| 6400.165(g) | Individual #1 did not have completed medication reviews every 3 months. The documentation provided reflects that the individual went to the friendship house on the dates of 3/7/23, 6/15/23. 12/27/23, 1/2/24 and 2/14/24. However, the forms did not reflect the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Also, the forms were not all signed by the physician.
Repeat violation from 2022 annual inspection. | 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. | 6400.165 (g) ¿ VIOLOATION #16
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 documentation of the reason for prescribing the medication, the need to continue the medication, and the necessary dosage. During the survey, it was noted that individual #1 had scheduled psychiatric consults within appropriate time frames, however, the documentation from the consults did not contain the elements listed in 6400.165 (g).
The management team (AVP, Program Director, Site Supervisor, and Program Specialist) will meet to review all aspects of regulation 6400.165 as related to Prescription Medications specifically the components of 165 (g) that address: reason for prescribing medication, the need to continue the medication, and the necessary dosage. A Psychiatric Medication ¿ Physician Review Form was revised to capture all elements of this regulation.
The Site Supervisor/Program Specialist will monitor the completeness of Psychiatric Medication ¿ Physician Review Forms to ensure compliance and completeness.
In order to maintain compliance, AVP and/or Program Director will review a sample of Psychiatric Medication -- Physician Review Forms during monthly site visits. |
05/01/2024
| Implemented |
| 6400.166(a)(11) | Individual #1 is prescribed Loratadine 10mg tab. The diagnosis for the medication was not on the medication administration record.
Repeat violation from 2023 | 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 diagnosis or purpose for the medication for each individual for whom a prescription medication is prescribed. During a review of Medication Administration Record, individual #1¿s prescription for Loratadine 10 mg tab did not have diagnosis/purpose for this medication documented in record.
The management team (AVP, Program Director, Site Supervisor, and Program Specialist) will meet to review all aspects of regulation 6400.166 as related to Medication Record and specifically the importance of documenting diagnosis for each medication prescribed. The Site Supervisor/Program Specialist will conduct monthly M.A.R. reviews to monitor compliance with this regulation. 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. The Site Supervisor works with Allied Services Pharmacy for accurate representation of the Physician Orders/MARs. At the end of each month, new medications, modifications, and in this case ¿diagnosis for a medication¿ can be entered for the new month, then will automatically be forwarded to facility each month unless there are changes (additions of new medications, dosages, discontinuations, new diagnosis)
The Site Supervisor/Program Specialist will be responsible for ensuring compliance with the regulation related to Physician Orders/Medication Administration Record on an ongoing basis.
To ensure the deficient practice does not reoccur, the AVP and/or the Program Director will review Monthly Site Walk-Through/Record Checklists during Monthly Incident Management Meetings. |
05/01/2024
| Implemented |
|
|
|
SIN-00217266
|
Renewal
|
02/13/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | The home does not maintain a financial record for Individual #1 that includes documentation of funds received by or deposited with the family or home. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | The facility failed to provide documentation on the financial records for Individual #1. Individual #1¿s family provides spending money to the facility for Individual #1¿s personal expenses such as recreation and shopping that is kept locked up until a need occurs.
Under the direction of the Assistant Vice President and Program Director, the Site Supervisor and/or Program Specialist will develop a financial ledger that tracks incoming monies, and identifies expenditures that Individual #1 makes throughout his day, week, and month.
The team will review Individual #1¿s Individual Support Plan to identify Individual #1¿s capabilities to handle his own monies, and provide him with monies he is capable of handling in accordance with the ISP in order to promote self-direction, choice and control in financial management.
The facility team will review the financial record documentation for all other residents and review the Individual Support Plans to identify their respective capabilities in handling their own monies. Documentation of financial records for the other individuals residing at the Richmont home will be in accordance with their respective ISPs promoting self-direction, choice and control of financial management.
In order to maintain compliance, the Site Supervisor, in conjunction with the Program Specialist, will conduct weekly reviews of the financial records for Individual #1 and other individuals in the Richmont home. The Assistant Vice President and/or the Program Director will conduct quality assurance reviews every two months reviews on the documentation of the financial records. |
05/01/2023
| Implemented |
| 6400.62(c) | Poisonous materials are not stored in their original, labeled containers. A Dawn dishwashing liquid bottle located at the kitchen sink contained a pink substance that was identified as from a gallon located under the kitchen sink labeled Reliable Pink dish soap. | Poisonous materials shall be stored in their original, labeled containers. | Poisonous materials must be kept in their original, labeled containers. During the survey, it was identified that a larger container of ¿Reliable Pink Dish soap¿ was used to replenish a smaller bottle of Dawn Dishwashing Soap.
The management team (Assistant Vice President, Program Director, Site Supervisor, Program Specialist) will meet at the Richmont Home and review all aspects of 6400.62, ¿Poisons¿, including dish soap contained in their original labeled container. The team will conduct a walk through kitchen, bathrooms, and storage areas to ensure that ¿poisons¿ are maintained in their original labeled containers.
The Site Supervisor/Program Specialist will be responsible for ensuring compliance with the regulation on storage of ¿Poisons¿ on an ongoing basis.
To ensure that the deficient practice does not reoccur, the Assistant Vice President and/or the Program Director will conduct quality assurance checks every two months in review of all aspects of 6400.62, ¿Poisons¿. |
05/01/2023
| Implemented |
| 6400.64(a) | The bathmat located in tub in the bathroom of the second floor of the home had several spots of mold/mildew on the bottom of the mat. | Clean and sanitary conditions shall be maintained in the home. | The facility must ensure that the condition of the home is clean and sanitary. During the survey process, it was discovered that the 2nd floor bath mat had mold/mildew on the bottom of the mat.
To address the immediate issue, a new bathtub mat was purchased for the 2nd floor bathroom tub. The management team (Assistant Vice President, Program Director, Site Supervisor, Program Specialist will meet and perform a walk through physical site inspection within one month of the accepted plan of correction to review routine housekeeping and maintenance, proper food storage and disposal to establish a common agree baseline on cleanliness.
The Site Supervisor/Program Specialist will be responsible for a clean and sanitary home on an ongoing basis, on an ongoing basis, and document their findings in the next timely Annual Self-Assessment.
To ensure that the deficient practice does not reoccur, the Assistant Vice President and/or the Program Director will conduct quality assurance checks every two months to perform a walk through inspection to maintain compliance on home cleanliness in accordance with 6400.64(a). |
05/01/2023
| Implemented |
| 6400.113(a) | Individual #1 moved into the home on 8/1/22. Individual #1 was not instructed in the individual's primary language or mode of communication, upon initial admission in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home until 8/8/22. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | The facility must ensure that all residents receive general fire safety, evacuation procedures, responsibilities during drills, designated meeting places outside and fire safe spaces inside upon admission, then annually thereafter. Individual #1 was admitted on 8/1/22, but did not receive fire safety training until 8/8/22.
At this time, the Richmont Street home has a full census of (3) individuals with no anticipation of discharge or new admissions. Therefore, at this time, there is no opportunity to provide a new admission with fire safety upon admission.
The management team (Assistant Vice President, Program Director, Site Supervisor, Program Specialist) will review the Fire Safety Training for Individuals (6400.113 a-b-c). and complete a timely Annual Self-Inspection as per regulation.
To reinforce the importance of fire safety for Individual #1, and all other individuals who reside in the home, all residents will receive re-in-servicing on the fire safety, evacuation procedures, responsibilities during drills, and to identify meeting places inside and outside the home in the event of a real fire. This fire safety in-service reinforces the importance of fire safety protocols, and establishes all (3) residents on the same calendar for annual training.
In order to prevent reoccurrence of the deficient practice, the Assistant Vice President and/or Program Director will conduct quality assurance visits within two months of the accepted plan of correction to ensure all residents have received the fire safety in-service, and engage Individual #1 and all others in communicating fire safety procedures. |
05/01/2023
| Implemented |
| 6400.151(a) | Staff #3 did not complete a physical examination every two years following the annual physical examination. Staff #3 completed a physical examination on 10/25/19 and no further documentation of a biannual physical examination with all required components was completed. | 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. | Staff #3 did not complete a physical examination every two years following the initial annual physical exam. Staff #3 had an annual physical on 10/25/19, but had no follow-up thereafter.
To address the immediate issue, Staff #3 will be scheduled for an annual physical. Allied Services contracts out to an outside medical vender for new hire, annual physicals for current staff, and employee injury.
The management team (Assistant Vice President, Program Director, Site Supervisor and Program Specialist) will review the status of all current employees, namely last physical date and due dates, schedule annual physicals for staff not in compliance, and/or establish due dates.
The Site Supervisor, in conjunction with the employee, will be responsible for scheduling staff
to maintain compliance with staff physical exams.
In order to prevent reoccurrence of the deficient practice, the Assistant Vice President and/or Program Director will conduct quality assurance visits within two months to review the status of all employees in terms of annual physical follow-up exams to stay in compliance with 6400.151(a) |
06/01/2023
| Implemented |
| 6400.181(a) | Individual #1 did not have an assessment completed by the current provider within 60 days after moving into the home. Individual #1 had an assessment completed by the Individual's previous provider specific to the living environment the Individual was residing in during the assessment. Individual #1 moved to the current provider on 8/1/22 and an assessment was not completed. Individual #1's assessment is not current to the Individual's current living situation and needs. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Individual #1 moved into the home on 8/1/22 from another local agency. There was no completed assessment on file.
To address the immediate issue, the Program Specialist will complete an initial assessment for Individual #1 within 30 days of the approved Plan of Correction that includes an assessment of adaptive behavior and skills level performance in the agency assessment form. In addition, the Program Specialist will complete a follow-up annual assessment within 30 days prior to the next annual Individual Support Plan. The Site supervisor/Program Specialist will conduct timely Annual Self-Assessment to review compliance to 6400.181 (a).
To ensure the deficient practice does not reoccur, the Assistant Vice President and/or Program Director will conduct quality assurance visits every two months to monitor and/or provide guidance to appropriately address the timeliness of the annual assessment process in accordance with the annual Individual Support Plan process.
Page 11 |
06/01/2023
| Implemented |
| 6400.32(r) | Individual #1 has a lock on the individual's bedroom door, but the Individual does not have a key to the lock. The Individual's guardian reportedly does not want a lock on the door. The Individual Service Plan does not contain documentation that the Individual's guardian does not want the Individuals' bedroom door to have a lock. | An individual has the right to lock the individual's bedroom door. | Individual #1 has a lock on his bedroom door, but does not have a key. It is documented on the Individual Rights that Individual #1¿s guardian does not want a lock on the door. However the ISP does not contain documentation regarding the guardian¿s decision on the bedroom door.
In order to correct the immediate deficient area, the Site Supervisor/Program Specialist will contact Individual #1¿s guardian to revisit the Individual Right related to the ¿locked bedroom door and key¿ and notify the Individual #1¿s Individual Support Coordinator to amend the Annual ISP to document his choice/right on the bedroom door/lock/key.
The facility team will review the status of the other individuals who reside in the home to identify whether the Individual Rights and the ISP are compatible related the deficient area identified in 6400.32.
In order to maintain compliance, the facility team will utilize the next timely Annual Self-Inspection Tool that to assess compliance, and/or to correct this area if out of compliance.
To prevent reoccurence of the deficient practice, the Assistant Vice President/Program Director will conduct quality assurance checks every two months to ensure compliance with 6400.32 (r) |
05/01/2023
| Implemented |
| 6400.32(r)(1) | Individual #1 has a lock on the individual's bedroom door. Individual #1 does not have access to a key to the lock. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | Individual #1 has a lock on his bedroom door but does not possess a key. In order to address the immediate deficient area, the Site Supervisor/Program Specialist meet with Individual #1 and the family/guardian regarding the lock on his bedroom door with key to lock/unlock. Based on this meeting, Individual #1 will either have a key in his possession to lock/unlock his door, or the bedroom door lock will be removed.
The facility team will review the status of the other residents residing within the home to ensure they have access to a key for their locked bedroom doors. In addition, the facility team will assess where spare keys will be stored for staff access, if consent is provided by the individual(s) and/or there is life-safety emergency.
The Site Supervisor/Program Specialist will monitor the status of ¿keys¿ on an ongoing basis, conduct timely Annual Self-Inspection in order to maintain compliance and prevent reoccurrence of the deficient practice.
To prevent reoccurrence of the deficient practice, the Assistant Vice President and/or the Program Director will conduct quality assurance checks every two months review on the status of the Regulatory Compliance Guide 6400 (r) (1-5). |
05/01/2023
| Implemented |
| 6400.46(a) | Staff #1 did not receive fire safety training prior to working in the home. Staff #1 was hired on 7/17/22 and did not receive fire safety training until 8/18/22. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Staff #1 was hired on 7/17/22 and did not receive safety training until 8/18/22, though the regulation documents staff to be safety trained prior to working with individuals.
At present, there are no pending new hires to satisfy safety training requirements prior to working with individuals. To address the immediate issue, the management team (Assistant Vice President, Program Director, Site Supervisor, and Program Specialist will meet to discuss all aspects of 6400.46 Staff Training, and for this specific deficiency, 6400.46 (a). All aspects of 6400.46(a) will be reviewed: general fire safety, evacuation procedures, responsibilities during drills, designated meeting place (outside or safe space), smoking safety, use of fire extinguishers, and notification of fire department after fire is discovered.
Though this deficient area does not include ¿annual fire safety training¿, all current staff will be in-serviced by April 2023 to establish a common month for the fire safety training for all current staff.
To ensure that the deficient practice does not reoccur, the Assistant Vice President and/or the Program Director will conduct quality assurance checks every two months fire safety training records. |
06/01/2023
| Implemented |
| 6400.165(g) | Individual #1 has resided in the home since 8/1/22. Individual #1 has not had a review of medications prescribed to treat symptoms of psychiatric illness since moving into the home. | 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 #1 was admitted to the home on 8/1/22 and has not had a licensed physician or psychiatrist conduct a follow-up since moving into the home.
Individual #1¿s mother has utilized a psychiatrist in New Jersey, and had not been partial to ¿local¿ psychiatrists. The Site Supervisor/Program Specialist will meet with the family on the regulation 6400.165 (g) and the need to establish a licensed physician to review psychotropic
Page 6
6400.165 (g): Treatment of psychiatric illness¿¿licensed physician every 3 months
Medication prescribed to treat symptoms of psychiatric illness shall be reviewed by a licensed physician at least every three months that includes documentation for the reason the medication is prescribed.
medications at least every three months, the need to continue the medication(s), and the necessary dose.
The Site Supervisor/Program Specialist will review the remaining two residents¿ compliance with the 6400.165 (g). The other (2) residents take medications for psychiatric illness and have established licensed psychiatrists/primary physicians. A review of the last psychiatric appointment will be identified and the target date for the next follow-up will identified to determine if the follow-up/medication review is within the (3) month requirement for 6400.165 (g).
To ensure that the deficient practice does not reoccur, the Assistant Vice President and/or the Program Director will conduct quality assurance checks every two months to review compliance on regulation 6400.165 (g) for Individual #1 and the other two residents residing within the home. |
06/01/2023
| Implemented |
| 6400.166(a)(2) | Individual #1's Medication Administration Record did not include the name of the prescribing physician. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | The facility utilizes Allied Services Pharmacy that generates a monthly computerized Physician Orders and Medication Administration Record (MAR). The Medication Administration Record was incomplete, and for this deficient area, void of the prescribing physician.
To address the immediate issue, the Assistant Vice President/Program Director and Site Supervisor will meet with the pharmacy and will review Individual #1¿s ISP and medications prescribed by the physician(s) to update the Physician Orders and the Medication Administration Record (MAR) to ensure the prescribing physician is documented in the Physician orders and the Medication Administration Record (MAR).
The Site Supervisor and the Program Specialist will be responsible for maintaining updated and current Physician Orders and Medication Administration Records which includes ensuring ¿new¿ medications have corresponding diagnoses.
To ensure that the deficient practice does not reoccur, the Assistant Vice President and/or the Program Director will conduct quality assurance checks every two months to review compliance on the Physician Orders and the Medication Administration Record (MAR) for Individual #1 and the two other residents who reside in the home. |
04/03/2023
| Implemented |
| 6400.166(a)(11) | Individual #1's Medication Administration Record does not include the 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 the medication, including pro re nata. | The facility utilizes Allied Services Pharmacy that generates a monthly computerized Physician Orders and Medication Administration Record (MAR). The current (MAR) was void of diagnoses associated with the prescribed medication for Individual #1.
To address the immediate issue, the Assistant Vice President/Program Director and Site Supervisor will meet with the pharmacy and will review Individual #1¿s ISP and medications prescribed by the physician(s) to update the Physician Orders and the Medication Administration Record (MAR) to the diagnosis for each medication.
The facility team will review the Physician Orders and Medication Administration Record (MAR) for the other individuals who reside in the home to ensure that prescribed medications have an associated diagnosis identified by the treating physician. The management team will communicate with Allied Services Pharmacy to ensure that Physician Orders and Medication Administration Records (MAR) for each individual is current and accurate with the appropriate diagnosis for each medication.
The Site Supervisor and the Program Specialist will be responsible for maintaining updated and current Physician Orders and Medication Administration Records which includes ensuring ¿new¿ medications have corresponding diagnoses, including over-the ¿counter and pro re nata medications.
To ensure that the deficient practice does not reoccur, the Assistant Vice President and/or the Program Director will conduct quality assurance checks every two months to review the Physician Orders and the Medication Administration Record (MAR) for Individual #1, and the two other residents residing in the home. |
04/03/2023
| Implemented |
| 6400.166(a)(13) | Individual #1's medication administration record did not include the name or initials of the person administering the medications on 2/3, 2/4, 2/5, 2/6, 2/10, 2/11 and 2/12 at 8AM and 2/1 through 2/12 at 8PM. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | The facility utilizes Allied Services Pharmacy that generates a monthly computerized Physician Orders and Medication Administration Record (MAR). The current (MAR) was void of name and/or initials for medications dispensed to Individual #1 on a number occasions in February 2023.
To address the immediate issue, the facility will identify those staff who are Medication Administration Certified, and their names and initials will be entered onto the back of the Medication Administration Record (MAR) for Individual #1 and the other residents within the home.
As additional staff become Medication Administration Certified, the Site Supervisor/Program Specialist will be responsible for adding their names and initials to the (MAR).
To ensure that the deficient practice does not reoccur, the Assistant Vice President and/or the Program Director will conduct quality assurance checks every two months in review of Physician Orders and the Medication Administration Record (MAR) to review all aspects of the 6400.166 (a) regulation related to Medication Record. |
02/24/2023
| Implemented |
| 6400.166(b) | Individual #1 is prescribed Azelastine HCL 137mcg spray, administer 1 spray into each nostril int the morning and 1 spray before bedtime. This medication and the required information is not documented on the Medication Administration Record. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The facility utilizes Allied Services Pharmacy that generates a monthly computerized Physician Orders and Medication Administration Record (MAR). The current (MAR) was void of the specific time the medication was administered on numerous occasions in February 2023.
The Assistant Vice President/Program Director will meet with the Site Supervisor/Program Specialist to review Individual #1¿s medications, those identified on the Physician¿s Orders/Medication Administration Record (MAR), and any other medications that may be at the home, including over-the-counter and PRNs. The Site Supervisor/Program Specialist will be responsible for contacting Allied Services Pharmacy to ensure there is an updated, accurate and current Physician Orders/(MAR).
The Site Supervisor/Program Specialist will be responsible for updating the Physician Order/MAR for Individual #1 and other residents of the home, as new medications are introduced and/or deleted, and communicating changes to the pharmacy.
To ensure that the deficient practice does not reoccur, the Assistant Vice President and/or the Program Director will conduct quality assurance checks the Medication Administration Record (MAR) to review name/initials of persons who administered medications and at the specific
time the medications were dispensed. The quality assurance checks will initially be weekly for two months, then every two months thereafter. |
04/03/2023
| Implemented |
| 6400.169(a) | Staff #1, Staff #2, and Staff #4 have been administering medications without successfully completing a department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Staff #1, Staff #2 and Staff #4 were administering medications without successfully completing the Department-approved medication administration course.
To address the immediate issue, the management team (Assistant Vice President-Program Director-Site Supervisor-Program Specialist) will contact Allied Services residential programs that have Department-approved medication trained staff to develop a schedule of ¿trained¿
staff who can dispense medications at the home until there is a sufficient number of to cover a daily, weekly, monthly, etc. schedule of medication administration over a 24 hour period.
At present, there are sufficient staff who are Medication Administration Certified within the Allied Services Developmental Services Division to provide 24 hour coverage for medication administration.
To prevent reoccurrence of the deficient practice, the Assistant Vice president and/or Program Director will coordinate Department-approved Medication Administration Courses in order to augment the number certified medication administrators/staff. Several facility Medication Trainers are due to start the renewal course.
In order to ensure the deficient practice does not reoccur, the Assistant Vice President and/or Program Director will secure the present number of staff who are medication certified , and conduct quality assurance visits every two months to review the ¿staff medication administrators¿ and the Medication Administration Record (MAR) to ensure timely medications are dispensed by ¿medication certified staff¿ only. |
02/24/2023
| Implemented |
| 6400.186 | Individual #1's Individual Service Plan does not include revisions to address the Individual's current living situation. Individual #1 moved into the home on 8/1/22. Individual #1's Individual Service Plan indicates that the Individual is safe with poisons, however poisons are locked in the home as a precaution. The poisons in Individual #1's current home are not locked. Information throughout the ISP is not reflecting of Individual #1's current living situation. | The home shall implement the individual plan, including revisions. | Individual #1 moved into the home on 8/1/22, and the ISP indicates that the he is ¿safe with poisons¿, as are the other residents of the home, though during the survey the ¿poisons are locked¿ as a precaution.
To address the immediate issue, the Program Specialist will complete an initial assessment on Individual #1 for adaptive behavior and skill development on the agency assessment document, , then the team (Site Supervisor/Program Specialist/Staff) will review and compare the current ISP to see if revisions are necessary. If revisions are necessary, the Program Specialist/Site Supervisor will notify Individual #1¿s Individual Support Coordinator to discuss any required changes. The issue of ¿locked poisons¿ will be determined following this process.
The Program Specialist/Site Supervisor will review the current ISPs for the two other residents, and compare it to the agency¿s current annual assessment on adaptive behavior/skill development to ensure there is continuity between both documents, or if revisions are required. The issue of ¿locked/unlocked poisons¿ will be addressed when all three individuals¿ abilities are ascertained.
As a quality assurance measure, every two months, the Assistant Vice President/Program Director will review the agency annual assessment and ISP of Individual #1 and the other two residents, to ensure these documents compatible and an accurate representation of adaptive behavior and skill development. |
06/01/2023
| Implemented |
| 6400.195(b) | Individual #1's Individual Service Plan indicates that the Individual has a Behavior Support Plan (BSP), the BSP was requested but not provided. Individual #2's Behavior Support Plan was not reviewed and revised at least every 6 months. The date of the most recent review of the BSP that was documented in the Individual Service Plan was 2/21/22. | The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews. | Individual #1 does not have a Behavior Support Plan, and Individual #2 was not reviewed and revised within a 6 month period.
The management team met with the Individual Support Coordinator on 2/24/23 to review the Annual Review Meeting Date (5/6/22) and then the Plan Last Updated Date (10/25/22) for Individual #1. The ISP does indicate, ¿Is there a Behavior Support Plan in place?¿ Answer: ¿Yes¿. However the ISP indicates a ¿SEESP¿¿¿ a Social Emotional Environmental Plan. The facility will work to correct the ISP to ensure accuracy. The Supports Coordinator and the facility team will review Individual #2¿s plan for review/revision. There are no restrictive procedures.
Individual #1 and #2, and the 3rd individual who resides in the home all have tentative dates for their next Annual ISP in April 2023. The team will use this opportunity to be clear as to the behavior support components used to address any behaviors.
The facility does need to secure a Program Specialist.
To ensure the deficient practice does not reoccur, the Assistant Vice President/Program Director will be available for the Annual ISP for Individual #1 and #2, and the remaining third individual in April 2023.
To ensure that the deficient practice does not reoccur, the Assistant Vice President/Program Director will conduct quality assurance checks every two months to ensure compliance on 6400.195, ¿Behavior Support Component of the Individual Plan¿ |
06/01/2023
| Implemented |
|
|
|
SIN-00200553
|
Renewal
|
03/29/2022
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | Located at both the kitchen sink and upstairs bathroom sink were clear decorative soap dispensers both filled with an orange liquid. Located at the basement bathroom sink was a soft-soap soothing aloe vera filled with an orange liquid. Under the basement bathroom sink cabinet was a 32fl oz container of spa soap antibacterial liquid soap. Staff stated that they refill the soap dispensers with the larger container. Poisonous materials shall be stored in their original, labeled containers. | Poisonous materials shall be stored in their original, labeled containers. | Poisonous materials shall be stored in their original, labeled containers.
To address this deficient area noted in 6400.62(c), the facility will implement the following corrective action:
The management team, Site Supervisor, and Program Specialist will meet to review all ¿poisonous materials¿, namely those items that indicate ¿seek medical attention if swallowed¿, in addition to their
respective storage areas. This deficient area specifically identified ¿soap¿ and ¿being stored in their original labeled container¿. The team will identify ¿soaps¿ that do not indicate ¿seek medical attention if swallowed¿ and ensure all staff are in-serviced on the deficient area related to 6400.62 (c) |
04/01/2022
| Implemented |
| 6400.68(b) | The upstairs bathroom water temperature measured 124 degrees F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Hot water temperatures in bathtubs and showers may not exceed 120F.
To address the deficient area, the facility will implement the following corrective action: The Site Supervisor contacted Allied Services Facility Services Department, and the water heater temperature
was reduced to be no greater than 120 F. |
04/01/2022
| Implemented |
| 6400.142(d) | Individual #1 had dental examinations on 2/1/22, 4/27/21, and 3/9/21 but none of the examinations included documentation on if the individual received a teeth cleaning. | The dental examination shall include teeth cleaning or checking gums and dentures. | The dental examination shall include teeth cleaning or checking gums and dentures.
To address the deficient area identified in 6400.142 (d) related to dental service documentation, the facility will implement the following corrective action:
The Site Supervisor updated the dental form to include all procedures completed at the dental exam including treatment for cavities, restoration, cleaning, checking of gums and dentures. |
05/04/2022
| Implemented |
| 6400.151(a) | Staff #1 had a physical exam completed on 10/23/19 and Staff #2 had a physical exam completed on 12/16/19 and neither staff has not had another physical exam completed since. | 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. | A staff person who comes into direct contact with the individuals or 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.
To address the deficient area identified in 6400.151 related to staff physicals, the facility will implement the following corrective action:
The management team and Site Supervisor will meet to review all staff who have direct contact with the individuals, identify when their last physical exam occurred, and identify ¿due dates¿ for all employees. The management team and Site Supervisor will review monthly to ensure adherence to regulations related to the staff physical due dates. |
05/31/2022
| Implemented |
| 6400.151(c)(2) | Staff #2 had a Tuberculin skin testing by Mantoux method with negative results on 6/23/18 and has not had one completed since. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The physical examination shall include: Tuberculin testing by Mantoux method with negative results every two years; or, if tuberculin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a physician, licensed physician¿s assistant or certified nurse practitioner.
To address the deficient area identified in 6400.151 (c)(2), related to tuberculin skin testing, the facility will implement the following corrective action:
The management team and Site Supervisor will meet to review all staff who have direct contact with the individuals, identify when their last physical exam occurred, and identify ¿due dates¿, and when their last Mantoux Skin test occurred for all employees. The management team and Site Supervisor will review monthly to ensure adherence to regulations related to the staff physical due dates and Mantoux skin testing every 2 years or chest x-ray (positive result). |
06/30/2022
| Implemented |
| 6400.181(d) | Individual #1's assessment dated 11/11/21 was not signed by the Program Specialist. | The program specialist shall sign and date the assessment. | To address the deficient area identified in 6400.181 (d) related to Program Specialist signature on the Annual Assessment:
The Program Specialist was informed of the signature omission, and signed the Annual Assessment on the shortly after the 3/30/22 survey date. |
04/01/2022
| Implemented |
| 6400.181(e)(13)(ix) | Individual #1's assessment dated 11/11/21 did not address his progress over the last 365 calendar days in 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 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 that the current agency annual assessment form needs to be updated to be more in compliance with the new Regulatory Compliance Guide, namely Community Integration and growth over the past 365 days. The team will have to be cognizant of Individual #1¿s Annual ISP date and (1) other Individuals in the Richmont Street Home. |
07/29/2022
| Implemented |
| 6400.34(a) | Individual #1 was informed of his individual rights on 1/6/21 and then not again until 2/17/22.This exceeds the annual requirement. | 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. | The home shall inform and explain individual rights and process to report rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.
To address the deficient areas identified in 6400.34 (a.), the facility will implement the following corrective action:
The management team, Site Supervisor and Program Specialist will meet to review the DHS/ODP Regulatory Compliance Guide related to ¿Individual Rights¿, and namely ¿Informing of Rights¿. Individual #1 has a 2/17/22 ¿informed date¿ for individual rights. The Site Supervisor and Program Specialist will ensure that the next annual review is completed before 2/17/23. Attention will be made to whether communication is made with the individual and/or individual/designated person.
To address all other residents who may be affected by the deficient practice, the management team, Site Supervisor, and Program Specialist will review when the Individual Rights were reviewed with the other individuals and ensure that the subsequent Individual Rights review are completed within 365 days. |
05/31/2022
| Implemented |
| 6400.165(g) | Individual #1's 3-month medication review dated 6/14/21 did not include documentation on medications and the necessary dosages. | 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. | If a medication is prescribed to treat symptoms of psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes documentation on the reason for prescribing the medication, the need to continue the medication and the necessary dosage.
To address the deficient area identified in 6400.165 (g) related to psychiatric medication documentation, the facility will implement the following corrective action:
The management team, Site Supervisor, and Program Manager will review the current psychiatric/psychotropic medication review form and ensure that documentation is available to note reason to for prescribing medication, the need to continue the medication, and necessary dosage. In addition, the facility will work with the agency pharmacy vender to have Physician Orders and Medication Administration Records note the diagnosis/reason for medication/psychotropic medication. |
05/27/2022
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include identifying marks. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | To address the deficient area identified in 6400.213 (1)(i) related to ¿identifying marks¿, the facility will implement the following corrective action:
The Site Supervisor, in conjunction with the Program Specialist, will review the ¿Content of Records¿ section of the Regulatory Compliance Guide for Individual #1, and the other Individual who resides at the Richmont Street home. Records for photo, name, sex, admission date, birthdate, social security number, ¿identifying marks¿ and all demographics will be updated and current. The Program Specialist will provide quality assurance checks during monthly Progress Notes to ensure compliance. |
06/30/2022
| Implemented |
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SIN-00183505
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Renewal
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03/16/2021
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(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 1/18/2021. | 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. | 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 Certificate of Compliance date 12/31/20. |
06/16/2021
| Implemented |
| 6400.67(b) | The pavers/patio outside area of the home coming out of the basement door is uneven with multiple pavers sticking up out of the ground presenting a trip/fall hazard. There is a hole in the attic floor that presents a hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The Program Director met with Allied Services Vice President and Facility Services Department for an assessment of the rear patio of the Richmont Street Home. As of 4/9/21, discussion has ensued to either concrete or black top the patio deck. This process may take some time to complete due to scheduling with concrete/blacktop contractors. In the meantime, as a short term solution, uneven pavers will be lifted and leveled from the rear door entrance to the (4) step stone stairway to the lower backyard. |
06/01/2021
| Implemented |
| 6400.73(a) | The steps leading to the front porch of the home do not have a handrail. There are 4 steps located at the entrance to the home. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | The Program Director communicated with Allied Services Facility Services Department at the conclusion of the Renewal Inspection on 3/16/21 regarding the need for handrails on stairways. Allied Services Facility Services staff installed handrails on the front porch area and in the backyard area where there were (4) steps. |
04/09/2021
| Implemented |
| 6400.77(b) | At the time of the inspection, there were not scissors in the first aid kit. | 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 site supervisor obtained scissors for the First Aid Kit following the Inspection Renewal survey on 3/16/21. |
03/16/2021
| Implemented |
| 6400.106 | At the time of the inspection, the furnace was not inspected by a professional cleaning company. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The Program Director communicated with Allied Services Facility Services Department following the 3/16/21 Inspection Renewal survey regarding the missing furnace inspection. Allied Services Facility Services Department contracted with Scranton Electric Heating and Cooling services, Inc. and the Richmont furnance was inspected on 4/7/21. Furnace cleaned and checked and is in good working order. |
04/07/2021
| Implemented |
| 6400.32(r)(4) | Individual 1 has a lock on his bedroom door, however there is no key or means to unlock the door allowing easy and immediate access to the individual or staff in the event of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | In order to address the citation related to individual Rights that promotes self-direction, choice and control, the right to lock/unlock bedroom door with key, access card, or keypad, the agency will implement the following plan of correction:
Under the direction of the Program Director and in conjunction with the Richmont Street Supervisor/Program Specialist, new locks with keys were be installed onto Individual #1 and all resident bedroom doors that allow residents to lock/unlock their bedroom door. An additional key will be available for staff, for ¿life-safety emergencies¿, and the locking systems will allow easy and immediate access in the event of an emergency. |
04/09/2021
| Implemented |
| 6400.52(c)(3) | Staff #1, #2 and #3 were not trained annually on Individual Rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | In order to address the citation for (3) staff not receiving training on Individual Rights, the agency will implement the following corrective action:
Under the direction of the Program Director, and in conjunction with the Richmont Street Supervisor, Staff #1, #2 and #3 will receive in-service training on Individual Rights compatible with the February 2020 Edition of the 6400 Regulations within (30) days of the due date of the Plan of Correction for the Renewal Survey (4/14/21).
The Program Director and Supervisor/Program Specialist will review all staff required trainings to establish ¿our training year¿ to ensure that there is training for all staff within the 12-month requirement. |
05/14/2021
| Implemented |
| 6400.165(g) | Individual #1's medications were reviewed on August 22, 2020 by his treating psychiatrist. They were not reviewed again until December 30, 2020 which is more than 90 days between reviews. | 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. | 6400.165(g) Individual #1¿s prescribed medications for psychiatric illness were reviewed on 8/22/20 and 12/30/20, (130 days) between reviews, violating the (90 day) regulation requirement. In order to address the deficient area, the agency will implement the following corrective action for Individual #1 and all residents of the home:
Under the direction of the Program Director and in conjunction with the Richmont Street Supervisor, a review of Individual #1, and other residents of the home will be conducted to review the prescribed medications, and to identify the last physician review, and bookmark the latest due date, within the (90 days). The site Supervisor/Program Specialist will be responsible for timely scheduling through relationship with Individual #1 and other residents of the Richmont home. |
06/01/2021
| Implemented |
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