Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00121704 Renewal 09/19/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(11)The physical examination, for Individual #1, completed on 10/17/16 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section on the physical examination form was left blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The Health Services Coordinator will take the original physical to the Dr's office for Dr to complete the missing information for Health Maintenance and pick up from from Dr on 10/18/17. The Health Services Coordinator When the Health Service Department receives the completed physical form, the LPN will review the form for accurate and complete information, initial the form and forward it to the Health Services Coordinator who will also review the form for accurate and complete information and initial the form. If any information is missing, the Health Services Coordinator will return the form to the Dr to obtain the missing information. [Documentation of reviews shall be kept. (AS 10/20/17)] 10/18/2017 Implemented
6400.141(c)(12)The physical examination, for Individual #1, completed on 10/17/16 did not include the physical limitations of the individual. This section on the physical examination form was left blank.The physical examination shall include: Physical limitations of the individual. The Health Services Coordinator will take the original physical to the Dr's office for Dr to complete the missing information for physical limitations. The Health Services Coordinator will pick up the physical form from the Dr on 10/18/17. The Health Services Coordinator When the Health Service Department receives the completed physical form, the LPN will review the form for accurate and complete information, initial the form and forward it to the Health Services Coordinator who will also review the form for accurate and complete information and initial the form. If any information is missing, the Health Services Coordinator will return the form to the Dr to obtain the missing information. [Documentation of reviews shall be kept. (AS 10/20/17)] 10/18/2017 Implemented
SIN-00085205 Unannounced Monitoring 07/17/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.45(d)Per Individual #1's ISP, updated 2/26/15, Individual #1 is to receive "24 hour general supervision." Individual #1 does not receive "Additional Individual Staffing" services or "Supplemental Habilitation" staffing services. Per Individual #2's ISP, updated 3/26/15, Individual #2 is to receive "Additional Individual Staffing" service "Sunday-Saturday 8A-8PM (12 hrs per day) including holidays." Per the ISP for Individual #3, updated 5/7/15, Individual #3 is to receive "Supplemental Habilitation" staffing services, "Mon-Sun 9AM-9PM." All individuals are to have awake overnight staff. On 5/16/15, while there was "Additional Individual Staffing/Supplemental Habilitation" staff providing services to Individual #2 and Individual #3, there was no Agency Direct Service Worker present from 2:00 PM to 2:52 PM, leaving Individual #1 unsupervised. Per Individual #3's ISP, updated 6/25/15 and effective 7/10/15, the "Supplemental Habilitation" services were reduced to 5:00 PM-9:00 PM, Monday through Friday plus 16 hours Saturday/Sunday. On the weekend of 7/11/15 to 7/12/15, Individual #3 received "Supplemental Habilitation" staffing services from 6:47 AM to 4:00 PM and then from 5:00 PM to 10:00 PM, which totals 14.25 hours. Individual #4 moved into the home on 5/29/15 and began receiving "Supplemental Habilitation" staffing services on 7/9/15. Per the ISP, updated 7/10/15, Individual #4 is to receive this service "Sun-Sat 7AM-3PM and 3PM-12AM (12 hrs/day)." On Saturday, 7/11/15, Individual #4 did not have any "Supplemental Habilitation" staffing services from 7:00 AM to 7:30 AM. On Sunday, 7/12/15, Individual #4 did not receive "Supplemental Habilitation" staffing services from 3:00 PM to 3:30 PM. On 7/13/15, Individual #4 did not receive "Supplemental Habilitation" staffing services from 7:00 AM to 7:38 AM and from 3:18 PM to 5:00 PM. There was no Agency Direct Service Workers working at the home on 7/9/15 from 11:00 PM to Midnight.The staff qualifications and staff ratio as specified in the ISP shall be implemented as written, including when the staff ratio is greater than required under subsections (a), (b) and (c). The Residential Program Supervisor will continue to provide training to staff on the importance of clocking in/out correctly and accordingly to reduce occurrences of neglect and being out of ratio. The Assistant Program Directors and Program Specialists will continue to train staff and supervisors on complying with ratios and assuring ISP¿s are correct, accurate, and clear in regards to times of services and ratio¿s. The above mentioned trainings will be documented by having the staff sign and date all training materials and sign in sheets.For the following statements supporting documentation will be emailed: In Individuals #3¿s ISP it states in the Staffing Ratio-Home section ¿7/10/15 S.H. REQUEST FOR 4HRS/DAY MON-FRI. EFF 7/10/2015 JASON¿S STAFF RATIO AT HIS HOUSE DAY SHIFT (7AM-5PM) 1:4 AND SH, 2:4 (5PM-10PM PLUS 16 HRS SAT/SUN¿. The 16 hours Saturday and Sunday is not referring to his Supplemental Habilitation but the CLA staff. Effective 7/10/15 this individual receives Supplemental Habilitation Mon-Fri 5pm-9pm no Supplemental Habilitation on Saturday or Sunday (Attachment #1) On 7/11/15 Supplemental Habilitation was provide to this individual 5:10pm-10:01pm. On 7/12/15 Supplemental Habilitation was provide to this individual 5:04pm-9:01pm. (Attachment #2) . MITC Clock In /Out report shows staff clocked out at 00:06:26. That is not 6:26am, it 12:06am. (Attachment #3)The staff member that was scheduled to provide Supplemental Habilitation to Individual #4 3pm-12am on 7/12/15 was working a double. She was working 8am-3pm as CLA staff and 3pm-12am as Supplemental Hab staff. At 3pm she failed to clock out of CLA and into Supplemental Hab, she did it at 3:24 pm when she realized she forgot at 3pm. (attachment # 4 and attachment #5)Mamawa Kpakra was clocked in to the CLA 2:02pm-11:01pm on 7/10/15 (Attachment # 6) on 7/11/15 form 3:00PM to 9:55PM; on 7/12/15, from 3:24 PM to 4:50PM Danyaro Boatwright was clocked in to the CLA 9:02am-5:02pm on 7/12/15 (Attachment #7) and on 7/13/15 form 11:00PM to Midnight. [CEO or designee will immediately request clarification from SC on Individual #3's ISP regarding weekend Supplemental Habilitation hours and will follow according to clarification. Documentation of clarification will be submitted to the Department via email to narmstrong@pa.gov. PS will review staff clocking in and out records at least monthly for the next 3 months to ensure accuracy. All staff at all homes will receive the above mentioned trainings by 2/2/16 and time record reviews at least quarterly for 6 months. (AS 12/2/15)] 11/09/2015 Implemented
SIN-00081299 Unannounced Monitoring 04/30/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16On 3/9/15, Individual #1 woke up at 5:00 AM and requested breakfast. Direct Service Worker #3 began preparing breakfast for Individual #1. Direct Service Worker #1 told Individual #1 that it was not time for breakfast and s/he would have to wait for the other individuals living in the home to eat breakfast. Individual #1 left the kitchen and went upstairs. Individual #1 reports, Direct Service Worker #1 "yells" at her/him every time s/he gets up early in the morning and "(S/he) don't talk very nice. (S/he) yells at me." Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.dFs will continue to provide training during orientation to all new staff on the Policy and Procedure ¿Abuse and the Management of Abuse¿. dFs will also continue to train all staff annually on this same policy and procedure. The policy and procedure includes the definition of abuse as well as the categories of abuse and the definition of each category and neglect and the definition of neglect. The Policy and procedure includes the reporting of abuse and neglect. Specific corrective actions for this incident: 3/11/15 and on-going The staff member was suspended for the duration of the investigation and reassigned after it was determined that a rights violation and verbal abuse had occurred. 03/11/2015 Prior to returning to work the target staff member completed the following trainings and reviewed the following policies: ¿Skills of Courtesy-Quality of Interaction¿, ¿Universal language-It¿s All in How You Say It¿, ¿Is This Abuse?¿ , ¿ Fundamentals of Effective Communication¿, and Personnel Policy 701 (behavior of employees) as well and the Policy and Procedure on Abuse and the Management of Abuse. She also reviewed ¿Client Rights¿ 3/25/15 Upon her return to work the target staff member was reassigned and has been banned from working with the victim in the future. 3/25/15 [As per conversation with Assistant Program Director on 8/10/15, the executive team will meet monthly and review the incident management policy and review the orientation and annual trainings to update and change as needed to prevent future occurrences of abuse and untimely reporting. (AS 8/10/15)] 07/20/2015 Implemented
6400.18(c)On the morning of 3/9/14, Direct Service Worker #2 witnessed Direct Service Worker #1 allegedly verbally abuse Individual #1. The incident of suspected verbal abuse, Incident ID # 7223142 was not reported in HCSIS until 3/11/15 at 11:30 AM.The home shall orally notify the county mental retardation program of the county in which the home is located, the funding agency and the appropriate regional office of mental retardation, within 24 hours after abuse or suspected abuse of an individual or an incident requiring the services of a fire department or law enforcement agency occurs. dFs will continue to provide training during orientation to all new staff on the Policy and Procedure, "Management of Unusual Incidents" and the Policy and Procedure, "Abuse and Management of Abuse" dFs will also continue to train all staff annually on these same policies and procedures. Included in these policies and procedures are unusual incident categories as well as timelines for reporting and to whom to report. dFs will complete staff supervision with staff that do not report incidents within time line and will complete progressive disciplinary action for further infractions. [As per conversation with Assistant Program Director on 8/10/15, the executive team will meet monthly and review the incident management policy and review the orientation and annual trainings to update and change as needed to prevent future occurrences of abuse and untimely reporting. (AS 8/10/15)] 07/20/2015 Implemented
SIN-00065035 Renewal 09/23/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The bathroom on the second floor has a strong urine smell. The rug in Individual #1's bedroom contained numerous soiled areas.Clean and sanitary conditions shall be maintained in the home. A maintenance request has been submitted on 10-9-14 to replace the flooring in the Bathroom on the second floor and the rug in individual#1 bedroom. The bathroom floor will be replaced with ceramic tile, and the rug in the bedroom will be replaced with non-porous flooring. This will be completed by 12-1-14. The Program Director, Lorraine Livosky, will oversee the progress. 10/17/2014 Implemented
6400.112(a)Based on interviews, staff are discussing with each other when a fire drill is going to be held. An unannounced fire drill shall be held at least once a month. The Residential Program Supervisors have been notified on 10-10-14 to conduct a staff meeting for all CLA's and will reiterate to all staff that Fire Drills must be unannounced and held at least once a month. It must be held without prior notice to staff persons and individuals, except for the staff person responsible for setting off the alarm and record the results on the drill. The CLA staff meeting will be conducted by 12-1-14.The Assistant Program Directors, Cathy Proctor and Angel Karenbauer, will be responsible for overseeing the meeting minutes to assure that Fire Drill Procedures are covered. 10/17/2014 Implemented
SIN-00233504 Renewal 10/03/2023 Compliant - Finalized
SIN-00181163 Renewal 01/06/2021 Compliant - Finalized