Inspection ID

Reason for Inspection

Inspection Date

Inspection Status

SIN-00214478

Renewal

11/08/2022

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.181(e)(4)	Individual #1's assessment, completed on 4/5/22, does not address their need for supervision.	The assessment must include the following information: The individual's need for supervision.	The Program Specialist created an addendum to Individual #1's assessment on 11/22/2022. The addendum (to be submitted) addressed the individual's need for supervision, and will be shared with all ISP team members and direct support staff.	11/22/2022	Implemented
6400.181(e)(5)	Individual #1's assessment, completed on 4/5/22, does not address their ability to self-administer medications.	The assessment must include the following information: The individual's ability to self-administer medications.	The Program Specialist created an addendum to Individual #1's assessment on 11/22/2022. The addendum (to be submitted) addressed the individual's ability to self-administer medications, and will be shared with all ISP team members and direct support staff.	11/22/2022	Implemented
6400.181(e)(8)	Individual #1's assessment, completed on 4/5/22, does not address their ability to evacuate in the event of a fire.	The assessment must include the following information: The individual's ability to evacuate in the event of a fire.	The Program Specialist created an addendum to Individual #1's assessment on 11/22/2022. The addendum (to be submitted) addressed the individual's ability to evacuate in the event of a fire, and will be shared with all ISP team members and direct support staff.	11/22/2022	Implemented
6400.181(e)(13)(viii)	Individual #1's assessment, completed on 4/5/22, does not address their ability to manage personal property.	The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property.	The Program Specialist created an addendum to Individual #1's assessment on 11/22/2022. The addendum (to be submitted) addressed the individual's ability to manage personal property, and will be shared with all ISP team members and direct support staff.	11/22/2022	Implemented
6400.32(r)	Individual #1's bedroom door was observed without a lock during the physical-site inspection on 11/9/22. Individual #1's record does not include documentation of their declination of a bedroom door lock or their incapacity to decide regarding this matter. Individual #2's bedroom door was observed without a lock during the physical-site inspection on 11/9/22. Individual #2's record does not include documentation of their declination of a bedroom door lock or their incapacity to decide regarding this matter. Individual #3's bedroom door was observed without a lock during the physical-site inspection on 11/9/22. Individual #3's record does not include documentation of their declination of a bedroom door lock or their incapacity to decide regarding this matter. Individual #4's bedroom door was observed without a lock during the physical-site inspection on 11/9/22. Individual #4's record does not include documentation of their declination of a bedroom door lock or their incapacity to decide regarding this matter.	An individual has the right to lock the individual's bedroom door.	Individual Rights, Responsibilities, & Review Attestation document (ID-225A - to be submitted) has been updated to reflect the individual's declination of a bedroom door lock or their incapacity to decide regarding this matter.	12/31/2022	Implemented
6400.34(a)	Individual #1's date-of-admission is 2/9/22. They were informed and explained individual rights on 2/10/22. Individual #1 was informed and explained individual rights on 2/10/22. Individual #2 was informed and explained individual rights on 12/22/21. The rights document did not include the following rights: 6400.32r1···the right to have access to the bedroom locking mechanism (i.e.: key, keypad code, etc.); 6400.32r2···the right of limiting access to their bedroom to only life-safety emergencies or with the individual's permission; 6400.32r5···the protection of providing direct service workers with a key or other entry device to lock and unlock the individual's bedroom door.	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.	Individual Rights, Responsibilities, & Review Attestation document (ID-225A - to be submitted) has been updated to reflect the individual's additional rights (6400.32r1, 32r2, and 32r5).	12/15/2022	Implemented
6400.165(g)	Individual #2 receives psychotropic medication. Their record does not include any 3-month reviews of this medication by a licensed physician.	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.	Psychotropic medication review (to be submitted) was completed on 11/18/2022.	11/18/2022	Implemented
6400.181(f)	Individual #1's initial assessment was completed and sent to their individual plan team members on 4/5/22. Individual #1's individual plan annual review meeting was held on 5/4/22.	The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.	Program Director will document any future changes in ISP meeting dates on the ISP meeting invitation form. Residential staff have been instructed to do the same.	11/23/2022	Implemented
6400.182(a)	Regarding the ability to identify and quickly move away from dangerous heat sources, Individual #1's 10/26/22 individual plan states they "[do]es not possess the skills to understand the danger of heat sources or sense to move away from heat sources." Individual #1's 4/5/22 assessment states they are "aware of things that could potentially be hot and will not go near them."	The program specialist shall coordinate the development of the individual plan, including revisions with the individual and the individual plan team.	The Program Specialist created an addendum to Individual #1's assessment on 11/22/2022. The addendum (to be submitted) addressed the individual's ability to identify and quickly move away from dangerous heat sources.	11/22/2022	Implemented

SIN-00197251

Renewal

12/07/2021

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.52(c)(3)	Program Specialist #1, hire date of 11/28/2017, did not complete the following annual training for the training year dated 7/1/2020 through 6/30/2021: Individual rights.	The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.	Evidence was found that Program Specialist had completed a review of consumer rights on 12/22/2020. Support documents #6.	12/21/2021	Implemented
6400.52(c)(5)	Program Specialist #1, hire date of 11/28/2017, did not complete the following annual training for the training year dated 7/1/2020 through 6/30/2021: The safe and appropriate use of behavior supports.	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.	Program Specialist had completed behavior supports training on 2/1/2021 as evidenced by Relias transcript - Restrictive Procedures and Physical Intervention Policy training. Support documents #8.	12/21/2021	Implemented

SIN-00141056

Renewal

09/05/2018

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.141(c)(6)	Individual #1, date of admission 6/1/18, had a Tuberculin skin testing by Mantoux method with negative results completed on 6/8/18.	The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted.	Individual #1's TB test was completed on 6/8/18 as previously confirmed. Going forward, the program supervisor has created a new admission packet to ensure all requirements are completed before admission. (submitted as C). Supervisor will review the packet before a new consumer is admitted into the program. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure all individuals have physical examination including Tuberculin skin testing completed, timely. Immediately and upon completion, the CEO or designee shall audit all individuals' physical examinations including Tuberculin testing to ensure all individuals have Tuberculin skin testing completed, as required. Documentation of audits shall be kept. (DPOC by AES on 9/24/18)]	09/12/2018	Implemented
6400.213(1)(i)	Individual #1's record did not include religious affiliation.	Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.	Individual #1's face sheet as been corrected (submitted as B). The program supervisor has created a new admission packet to track required documents for new consumers. (submitted as C). She has also reviewed the regulations to ensure her understanding of the required individual records. [Immediately, the CEO or designee shall educate the program specialist and any other staff persons responsible for ensuring all required personal information is included in the individuals' records of the required personal information as per 6400.213(1)(I)-(vi). Documentation of the training shall be kept. Immediately and continuing at least quarterly, the program specialist or designee shall audit all individuals' records to ensure all required information is included in all individuals records. Documentation of audits shall be kept. (DPOC by AES on 9/24/18)]	09/12/2018	Implemented

SIN-00121658

Renewal

09/20/2017

Compliant - Finalized

SIN-00107115

Unannounced Monitoring

12/22/2016

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.45(e)	Individual #1, Individual #2 and Individual #3 accompanied by Direct Service Worker #1, date of hire 6/22/15 went to Direct Service Worker #1's family member's home approximately 2 blocks. The individuals were left in the supervision of the family member who is not a trained staff person of the agency so reportedly Direct Service Worker #1 "could run errands" and "take breaks."	An individual may not be left unsupervised solely for the convenience of the residential home or the direct service worker.	Direct Service Workers were immediately retrained on ISP information, including supervision needs, for all individuals. (Supporting documentation of this training will be submitted via email.) During the week of 10/24/16, Supervisor met independently with each Direct Service Worker and reviewed agency protocols relating to ensuring individual supervision needs while in the the home and in the community. The Supervisor continues with her regular presence at the group home, and has increased her unplanned visits at the home to at least one unplanned visit/shift/DSW. In addition, the Potter County Operations Supervisor has increased her unplanned visits at the home to at least one unplanned visit every three months. [Direct Service Worker #1 was dismissed from employment at the home. Prior to working with individuals and continuing with changes in assessments and/or ISPs and at least annually, direct service workers shall be trained by the program specialist in the health and safety needs relevant to each individual. (AS 2/23/17)]	02/21/2017	Implemented

SIN-00101137

Renewal

09/20/2016

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.181(f)	The program specialist provided the assessment, dated 11/16/15 for Individual #1 to the plan team members on 11/16/15 for the ISP meeting held on 12/10/15.	(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).	The assessment for Individual #1 has been completed for this year, as previously confirmed. The Program Specialist has established a new system for meeting assessment time frames. Going forward, the Supports Coordinator (SC) will provide the Program Specialist with the name of any individual who is coming due for an ISP meeting. The Program Specialist will then set an ISP meeting date in cooperation with the Supports Coordinator based on when the Program Specialist can complete the individual's assessment. She then records the ISP date on a tracking sheet (to be submitted as H) to ensure the assessment is mailed to the team 30 days in advance of the ISP meeting. [At least quarterly for 1 year the compliance and risk manager will review tracking sheet and correspondence documentation to ensure the program specialist has provided all individuals' assessments to plan team members, timely. Documentation of reviews shall be kept. (AS 10/20/16)]	10/07/2016	Implemented

SIN-00085066

Renewal

10/08/2015

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
Article X.1007	Dickinson is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 ¿ 10225.5102) and its regulations (6 Pa. Code Ch. 15). Direct Service Worker #1, date of hire 6/22/15, currently lives in New York and has not had the FBI clearance completed through Agency Area on Aging.	When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.	The staff member's FBI clearance has been submitted through the FBI/Department of Aging. The staff member has registered online and a copy of that registration will be submitted via email. She has also submitted her fingerprints to the FBI and we are waiting for her completed clearance to arrive in the mail. Going forward, all prospective staff will be given printed instructions (copy to be submitted via email) for requesting the FBI clearance through the Department of Aging. Dickinson Center's program supervisor and HR department will ensure the applicant follows these instructions and applies through the correct FBI department before a start date for employment is confirmed.	11/07/2015	Implemented

SIN-00064618

Renewal

09/25/2014

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.33(b)	The "Rights" form signed by Individual #1 on 3/21/14 did not indicate that an individual may not be required to participate in research projects.	An individual may not be required to participate in research projects.	The rights form has been revised to indicate that an individual may not be required to participate in research projects. The new form is being reviewed with each consumer for their signature.[The program specialist will review and obtain a signed version of the updated rights form for every individual in the 6400 program within 30 days upon receipt of the plan of correction. (CHG 11/21/14)]	10/01/2014	Implemented

SIN-00052533

Renewal

08/01/2013

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.64(b)	There was evidence of a bat infestation in the attic of the home. Approximately 8 square feet of floor was covered in guano. Staff person 1 reported that the bat infestation has not been able to be exterminated.	(b) There may not be evidence of infestation of insects or rodents in the home.	The entire attic has been vacuumed and all guano is removed. A hole in the framework of the attic has been filled with caulking. Group home staff will inspect the attic on a weekly basis to ensure there is no evidence of bats or guano. The group home Supervisor will complete a monthly inspection to ensure the home is free from any evidence of insect and rodent infestation and free from evidence of bats or guano in the attic. The Program Director will monitor this process.	08/16/2013	Implemented
6400.67(b)	There was an empty light socket above the sink in the basement.	(b) Floors, walls, ceilings and other surfaces shall be free of hazards.	A light bulb has been installed in the empty light socket in the basement. The group home Supervisor will complete a monthly inspection to ensure that all areas of the home are free of hazards and there are no empty light sockets in the home. The Program Director will monitor this process.	08/01/2013	Implemented
6400.71	The telephone in the living room did not have emergency numbers on or near the phone.	Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.	Emergency phone numbers have been posted by the phone in the living room. The group home Supervisor will complete a monthly inspection to ensure that emergency phone numbers are posted by every phone with an outisde line. The Program Director will monitor this process.	08/01/2013	Implemented
6400.101	The staff¿s office/file room had a locking mechanism on the outside of the door that required a key for egress.	Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.	The lock has been removed from the office door. The group home Supervisor will complete a monthly inspection to ensure that stairways, halls, doorways, passageways and exits from rooms and the building are unobstructed and no new locks have been installed on doors without fully ensuring unobstructed egress.	08/01/2013	Implemented

SIN-00233308

Renewal

10/17/2023

Compliant - Finalized

SIN-00180764

Renewal

12/21/2020

Compliant - Finalized

SIN-00161326

Renewal

08/20/2019

Compliant - Finalized