Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00131763 Renewal 12/06/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(3)Individual #1's financial record shows that fifty dollars was expended on 11/7/16, however, there was no receipt for the expense. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. As the missing receipts for the $50 withdrawal from individual #1¿s fiscal account could not be found, the money withdrawn was replaced back into his account by COMHAR fiscal department from COMHAR funds. Staff were retrained on procedures for accounting for consumer funds and the necessity for proper receipts returned to COMHAR¿s fiscal office. 12/14/2017 Implemented
6400.77(b)There was no thermometer 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 thermometer that was missing from the first aid kit was placed into the kit from where it had been taken. Staff at all sites were retrained to always replace the thermometer back into the first aid kit after each use. The Assistant Site Manager will verify its placement in the first aid kit monthly using the Quality Assurance review checklist. In addition, during site visits nursing will spot check all COMHAR sites to assure proper location of the thermometer within the first aid kits. 12/08/2017 Implemented
6400.151(b)Staff #1's physical exam was not signed and dated by the physician. This was corrected during the inspection. The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. Staff #1¿s missing signature and date of the physician on her physical examination form was completed during the inspection. To assure HIPAA compliance protected health information the process for monitoring staff physical examinations is being moved from the CLA program to COMHAR¿s Human Resources Department. For new staff, the process will start with submitting completed physical to the Recruitment Coordinator. The Senior Generalist and /or Recruitment Coordinator receiving the completed staff physical will do document check for appropriate completion of all licensing required items. The HR Credentialing Coordinator will serve as back up to this process when volume exceeds the capacity of the Generalist and Recruitment Coordinator. Ongoing annual staff physicals will be checked for completeness by the Senior Generalist, HR Coordinator and filed by the Credentialing Coordinator. 04/23/2018 Implemented
SIN-00057043 Renewal 12/09/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(e)(13)(ii)There was no progress and growth listed on Individual #3¿s assessment dated 7/16/13 in the areas of motor and communication. (13) The individual's progress over the last 365 calendar days and current level in the following areas: (ii) Motor and communication skills. Individual#3¿s assessment was amended to include progress and growth specific to motor and communication skills. A revised, standardized Annual Assessment form was developed and includes the missing skill areas that will need to be responded to by the Program Specialist. Training for all Program Specialists on the proper items to be included in the Annual Assessment and on the new form occurred on 1/23 and 1/24/2014. The Assistant Residential Directors will monitor compliance with this regulation 01/31/2014 Implemented
6400.181(f)Individual #3's ISP meeting was held on 7/15/13; the assessment was dated 7/16/13. (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). Going forward all Program Specialists will ensure that annual assessments are distributed to the SC and plan team members 30 days prior to an ISP meeting for the development, annual update and revision of ISP¿s. If the Program Specialist is unable to comply with this due to inadequate time notification of the plan meeting by the SC, the Program Specialist will document the discrepancy in the individual¿s chart. Oversight of this requirement will be addressed by the Assistant Residential Directors for consistency purposes. Training for Program Specialists occurred on 1/23 and 1/24/2014 and included proper protocols for timely dissemination of the annual assessment. 01/31/2014 Implemented
6400.185(b)Individual #3's ISP dated 10/20/12, list community life , social recreation, mental health support, and having a birthday party as needs; these outcomes were not implmented as written. (b) The ISP shall be implemented as written. All current services and supports as identified in the ISP for individual #3 are being implemented as written. Specifically, the ISP goal areas identifying: community life, social recreation, mental health support, and having a birthday party are being implemented as written in the ISP. Training occurred on 1/23 and 1/24/2014 with the site manager/program specialist responsible for individual #3 as well as with all current site managers and program specialists. Assistant Residential Directors will monitor for compliance with this regulation. 01/31/2013 Implemented
6400.186(d)Individual #3's ISP reviews dated 1/20/13, 4/20/13, 7/20/13 and 10/20/13 were not fowared to the Supports Coordinator. (d) The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. ISP Reviews for individual #3 that were not sent to the SC and plan team members ((1/20/13, 4/20/13, 7/20/13, 10/20/13) were forwarded and documentation of transmittal was kept. Training occurred on 1/23 and 1/24 with the site manager/program specialist responsible for individual #3 as well as with all current site managers/ program specialists to maintain documentation that SC and Plan Team members were sent ISP review documentation. Compliance with this regulation will be monitored by Assistant Residential Managers. 01/31/2014 Implemented
SIN-00044556 Renewal 01/22/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(b)Agency did not have verfication that staff person #1 lived in the state of Pennsylvania for two years prior to hire date 7/23/12 and a FBI clearance was not completed.(b) If a prospective employee who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire. Human Resources Department will determine whether applicants for employment in COMHAR¿s ID programs are Pennsylvania residents and if so, that the applicant has been residing in Pennsylvania, without interruption, for at least 2 years. If they are not Pennsylvania residents or have not resided in Pennsylvania without interruption for a minimum of two years, an FBI background check will be requested for the applicant in addition to the Pennsylvania criminal record check. The applicant will not commence duties that would involve direct contact with any consumers until FBI background check and Pennsylvania criminal records check affirm that the applicant has no record of conviction of any offense as stipulated within the Older Adult Protective Services Act, Act 169 of 1969 as amended by Act 13 of 1997. The HR Department has revised their disclosure statements to determine residency in Pennsylvania for the last 2 years without interruption. 02/21/2013 Implemented
6400.151(c)(2)Staff person #1 did not have results for tuberculin skin testing completed on 6/25/12.(2) 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 results of the tuberculin skin test for employee #1 was obtained and affirmed as negative. Going forward the nursing department will ascertain the results of any staff tuberculin skin test before signing off on the staff physical examination. Random checks will be conducted by the residential training coordinator to assure compliance. 01/22/2012 Implemented
SIN-00214763 Renewal 11/14/2022 Compliant - Finalized