Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00218729 Renewal 01/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There was no lock on the bathroom closet in Hallway B, which had poisons stored inside of it. There was a prescription lotion stored in the unlocked closet in Hallway BPoisonous materials shall be kept locked or made inaccessible to individuals. Supervisors will complete daily rounds in respective homes to ensure chemicals are properly secured. 03/16/2023 Implemented
6400.65The fan in the bathroom was inoperable and there was no window.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. Last year we implemented a plan to address the environmental citations. As a result of this plan, we had about a 35% decrease in physical plant citations. We will continue with the same plan as indicated below. Three times per year an unannounced walk through/inspection will be conducted in all licensed homes by a Residential Director and/or Assistant Vice President of Residential Program. A plan of correction along with a compliance score sheet will be issued to the building manager who will have 30 days to respond and correct all areas that are not in compliance with regulatory standards. The scores will be used to develop a performance improvement plan for the assigned Residential Manager. Residential Directors will not complete unannounced inspection in their assigned programs. 03/16/2023 Implemented
6400.142(a)Individual 1 was last seen by the dentist on 4/14/22 which requested a six month follow up. There was no other dental in the record.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. Starting on 2/17/23, Penn Dental agreed to upload dental examinations daily into the individual¿s electronic health record. A member of the individual¿s treatment team will track the individual¿s appointments to coordinate dental care. 05/01/2023 Implemented
6400.216(a)The record room was unlocked and the cabinet that the records were stored in could not be locked. An individual's records shall be kept locked when unattended. Supervisors will complete daily rounds in respective homes to ensure records are properly secured. 03/16/2023 Implemented
6400.165(g)Individual 1 was seen by psychiatry on the following dates for medication reviews: 1/27/22, 4/25/22, 5/17/22, 8/16/22 and 11/18/22. On 11/18/22 the form was unsigned due to errors on the electronic exam form. It has been over two months and the error has gone unseen/unfixed.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.Schedule a monthly provider meeting with all the psychiatry providers to discuss related issues to address the barriers and improve documentation. 04/01/2023 Implemented
SIN-00199968 Renewal 01/31/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(e)There were no non-slip surface or mats in the individual's showers located throughout the facility. Bathtubs and showers shall have a nonslip surface or mat. The bathmat was replaced. Compliance and Licensing Department reviewed all drills for the past year and confirmed all had been completed as required. 03/01/2022 Implemented
6400.34(b)Individual 1 has been appointed a Legal Guardian by the Court. The statement acknowledging the receipt of information on Individual Rights present in Individual 1's Individual Record, dated 08/20/2021, was signed by Individual 1, not Individual 1's Court-Appointed Legal Guardian. Individual 2 has been appointed a Legal Guardian by the Court. The statement acknowledging the receipt of information on Individual Rights present in Individual 2's Individual Record, dated 08/17/2021, was signed by Individual 2, not Individual 2's Court-Appointed Legal Guardian.The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights.The Individual Rights and Grievance Procedures along with the Parent Guardian signature form were emailed to Individual's parents on 2/18/2022 and hard copies were mailed on 2/23/2022 with a stamped return envelope addressed to the Director, Record Services. There was no need to check any other records because these documents have not been mailed out to any parents or guardians. If this system is approved, the process will begin on Monday, March 7, 2022. 02/23/2022 Implemented
6400.165(b)Medication (CELECOXIB CAB 100mg) for Individual #2 could not be located at time of inspection. Woods stated after the inspection that the medication was located in another medication Cart.A prescription order shall be kept current.There are two medication carts located in the Wildwood residence due to the number of individuals living in that home. Celebrex 100mg was located in the 2nd cart. 03/04/2022 Implemented
SIN-00190085 Unannounced Monitoring 07/06/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(b)(1)In April 2020, The Office of Developmental Programs published guidance to providers related to masking, screening and infection control procedures in congregate care settings established by the Department of Health. ODP has updated this guidance many times, In April 2021, the guidance was updated as follows: According to a study from Jefferson Health, individuals with an intellectual disability who are not fully vaccinated are at a substantially increased risk of dying from COVID-19. As a result, ODP continues to recommend that providers, individuals, and families adhere to measures that have shown to prevent the spread of COVID-19 infection, including physical distancing (maintaining at least 6 feet between people), mask wearing, and frequent hand washing. Licensing staff observed staff not wearing masks and no screening was conducted byWildwoodstaff upon ODPs arrival at the home.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. Retrain all managers and supervisors that all visitors must have their temperature taken and complete the COVID screening tool. Mask wearing will continue to be monitored daily. Managers and supervisors will address issues as needed. 07/29/2021 Implemented
SIN-00183411 Renewal 02/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The Toilet tank lid in the bathroom attached to Individual#2's bathroom was missing. The right handle on the second dresser drawer in individual#3's bedroom was missingFloors, walls, ceilings and other surfaces shall be in good repair. A work order was submitted on 2/3/2021, another work order submitted on 3/23/2021. Attachment #2 05/31/2021 Implemented
6400.81(k)(6)There were no personal mirrors located in the bedrooms of individuals# 2,4,5,6, and 7. Doors that were replaced in the bedroom where the mirrors were located and not replacedIn bedrooms, each individual shall have the following: A mirror. Mirrors were purchased and will be hung around 3/25/2021. 05/31/2021 Implemented
6400.82(e)There was no non slip surface or mat in the shower area in the bathroom attached to individual#1's bedroom. Bathtubs and showers shall have a nonslip surface or mat. All bathrooms will be provided with nonslip surface at all times. 05/31/2021 Implemented
6400.141(c)(6)The TB test completed for Individual#4 has insufficient documentation. The documentation was in the form of a word document with no doctor's name or signature on the documentation. Additionally, on the 5/7/20 documentation it was stated the individual received a T-spot test, however on the Physical dated 6/15/20 states the individual received a Montoux test on that date.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. Mantoux will be planted at the Annual Physical for all Woods' residents beginning in April 2021. Attachment #7 04/30/2021 Implemented
6400.241(b)The Kitchen Freezer was measured at approximately 16 degrees Fahrenheit at the time of inspection on 2/8/21 and 12 degrees (-8 celcius) again the subsequent day on 2/9/21 at 2pm.Food shall be kept at the proper temperature. Cold food shall be kept at OR below 45°F. Hot food shall be kept at OR above 140°F. Frozen food shall be kept at OR below 0°F.Temperature on 3/23/21 is 0 degrees. 05/31/2021 Implemented
6400.166(b)The 8am dose of Vitamin D3 for individual#4 was not signed out immediately after administration on the medication administration record dated 2/4/21. The medication was logged and corrected on 2/8/2021 during physical site inspection.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Disciplinary action given to responsible employee 05/31/2021 Implemented
6400.181(f)The assessment for Individual#8 was sent to the team on 10/23/2020 and the meeting was held on 11/19/2020. This is 27 days prior to the meeting and the assessment should be sent at least 30 days prior to the meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.A detailed email was sent to the Care Coordinators on 3/22/2021 stating the enforcement of Resident Assessment completion expectations moving forward. Attachment #4 03/22/2021 Implemented
SIN-00113056 Technical Assistance 02/06/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)In the closet located in bathroom #15 Degree deodorant, No rinse Body wash shampoo, and incontinent cleanser were found unlocked. Poisonous materials shall be kept locked or made inaccessible to individuals.The closet was locked immediately. All poisonous materials will be locked at all times. If observed at any time, staff, including housekeepers and counselors are to remove and lock up any chemicals immediately upon discovery. 02/10/2017 Implemented
6400.141(c)(13)Individual #1's physical examination dated 10/24/16 did not contain any allergies. The physical examination shall include: Allergies or contraindicated medications.The Nursing department updated the physical form to include information pertinent to allergies/drug sensitivities. (see attachment) 03/27/2017 Implemented
6400.141(c)(14)Individual #1's annual physical examination dated 10/124/16 did not contain information pertinent to diagnosis in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The Nursing department revised the physical form to include information pertinent to diagnosis or treatment in case of an emergency. As new physicals are completed, the new form will be utilized. (See attachment) 02/13/2017 Implemented
SIN-00087826 Renewal 10/26/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The bathroom between rooms 4 & 6 had a circle of a rust colored stain on the floor underneath the sink.Clean and sanitary conditions shall be maintained in the home. Rust stain was removed from the bathroom floor. Please see attached work order. (See attachment B) Monthly area inspections will be completed by the Residential Manager. Issues will be documented and forwarded to maintenance. 10/30/2015 Implemented
6400.67(a)The soap dispenser in the bathroom between bedrooms 30 & 32 was broken.Floors, walls, ceilings and other surfaces shall be in good repair. New soup dispenser was ordered and put in bathroom 32 by maintenance. Please see attached work order. (See attachment B) Monthly area inspections will be completed by the Residential Manager. Issues will be documented and forwarded to maintenance. 10/30/2015 Implemented
6400.76(a)The door handle in bedroom four was loose. The door handle leading to the bathroom between rooms 33 & 35 was loose. Furniture and equipment shall be nonhazardous, clean and sturdy. Bathroom door lock covers were adjusted and tightened. Please see attached work order. (See attachment B) Monthly area inspections will be completed by the Residential Manager. Issues will be documented and forwarded to maintenance. 10/30/2015 Implemented
6400.213(9)Individual # 1 who was admitted 6/23/15 and did not have a current ISP in his file. Each individual's record must include the following information: A copy of the current ISP. The ISP for Individual #1. was obtained and placed in the data book and Records Services on 11/19/15 by the Director of Program Coordination. (Sent via fax to BHSL) In the future, the receiving program specialist is expected to contact the Supports Coordinator during the individual's first week after admission, and request a copy of the existing ISP. This request is to be documented on a Contact form for Records. Continued requests need to occur until the ISP is received. This was discussed during the Program Specialist meeting, held by the Director of Program Coordination, that occurred on 11/17/15. (See attachment A) 11/19/2015 Implemented
SIN-00078312 Unannounced Monitoring 04/22/2015 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(a)On 4/4/15, sometime between 8:45pm and 8:55pm, Individual #1 who is a 17 year old non-verbal minor male was sexual assaulted by Individual #2, who is a 22 year old adult male. According to Individual #2's assessment dated 7/25/14, this Individual has a history of inappropriate sexual behaviors, has a habit of infringing on others personal space and requires line of sight supervison until 9pm or asleep. On 4/4/15, Individual #2 was not supervised and was not asleep at the time of the sexual assult. An individual may not be neglected, abused, mistreated or subjected to corporal punishment. In order to maintain safety of Individual #1, the Residential Director moved Individual #1 into a bedroom with another roommate who is under the age of 18. Individual #2 remained in the same bedroom of the home since there were no other rooms available. Individuals #2's supervision was increased to 1:2 visual range during all waking hours, 10 minute checks during sleeping hours and the private bedroom has been equiped with an indicator on the door to notify staff when the Individual exits the room. Individual #1 received counseling on 4/4/15 from the Woods Psychologist and will continue to provide services on a monthly basis to ensure Individual #1's safety. Individual #2 receives weekly counseling on healthy relationships and safe interactions with others. Individual #2's behavior plan will be modified on 7/10/15 and a risk assessment will be completed by a Woods psychologist before 7/31/15. Woods has an Admissions Committee in place to review all individuals who seek placement. The Admission Committee will review placement of adults with children to ensure the safety of the children at all times. Adults with a history of inappropriate sexual behaviors will have increased staff supervision and a behavior plan, with training to all staff on the behavior plan, starting within 30 days of receipt of this plan of correction [SW 7.14.15}. All staff of the provider agency will receive training from an outside organization on neglect, abuse and sexual abuse within 30 days of receipt of this plan of correction. At quarterly staff meetings, over the next 12 months, management staff will discuss with direct care staff issues related to abuse, specificall sexual abuse and its prevention, where children and adults live together in community homes, starting within 30 days of receipt of this plan of correction. [SW 7.14.15] 07/14/2015 Not Implemented
6400.185(b)Individual #1's ISP dated 7/15/14, indicates that close reach supervision is required until 9pm at which time intermittent visual check every 30 minutes is required. Individual #2's ISP dated 11/26/14, indicates that level 2 (line of sight) supervision is required unless this individual is in the bathroom or asleep. On 4/4/15, sometime between 8:45pm and 8:55pm, Individual #1 and #2 were in the bedroom unsupervised when Individual #2 sexually assulted Individual #1.The ISP shall be implemented as written.The current staffing levels for Individual #2 is a 1:2, with a visual range during ALL waking hours (7:01 am to 8:59 pm) and 10 minute checks during all sleeping hours. (Sleeping hours is defined as 9:00 pm to 7:00 am) No additional staff was needed to satisfy this level of supervision. The team is confident that visual range during all waking hours will keep all the individuals in Wildwood safe and free from abuse. Individual #2 has a private bedroom and does not have any roommates. All staff working in Wildwood has been retrained on the Levels of Supervision by Wildwood Management Staff on May 23, 2015. The plan of supervision audits are completed monthly by the Residential Managers and supervisors. These audit checks are then reviewed by the Residential Director. Audits are always completely unannounced. If staff are not following the level of supervision, and or not aware of the needs of the individual the staff will receive appropriate discipline up to an including termination. The decision will be based on many different factors, such as type of supervision the individual requires, past performance issues with the staff and supervision level, ect. Management will conduct unannounced visits to the home during all three shifts to observe the required staffing levels, starting within 30 days of receipt of this plan of correction. [SW 7.14.15] 05/23/2015 Submitted
SIN-00063875 Renewal 07/28/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Metal lids were found rusty around handles for trash cans located in bathrooms #18 and #23.Clean and sanitary conditions shall be maintained in the home. Kathy Hunt, Residential Director, discarded the rusty lids along with the trashcans and replaced them with new ones. The housekeeper will continue to clean and monitor the unit on a daily basis and report any needed repairs not in their ability to clean/fix to their immediate supervisor who will contact the needed person for any repairs/replacement items needed. In addition, the unit Supervisor or Manager completes a monthly environmental checklist of the unit and reports any needed duties, repairs, and/or replacement items to the necessary person. i.e. housekeeper, maintenance, housekeeping, Residential Director. Daily, it is the expectation of staff, to report any maintenance issues they may see to their immediate supervisor. 08/04/2014 Implemented
6400.67(a)Bedroom doors were found damaged and chipped for rooms #21, #26, #28 and #30. The door into the activity room was found damaged and scrapped.Floors, walls, ceilings and other surfaces shall be in good repair. Kathy Hunt, Residential Director, submitted a work order to the Woods' maintenance department to evaluate the doors on the noted four rooms which they did. Protective coverings will be ordered by Kathy Hunt and will be placed on the doors to prevent further damage that may be caused by the client wheelchairs. The unit Supervisor or Manager completes a monthly environmental checklist of the unit and reports any needed duties and/or repairs to the necessary person. i.e. housekeeper, maintenance, housekeeping, Residential Director. Daily, it is the expectation of staff to report any maintenance issues they may see to their immediate supervisor. 11/30/2014 Implemented
6400.76(a)Bedroom #22 has a music console with damaged edges and wood scrapped, and the console seat has a detached back with a stained seat. Hall B bench cushion was found stained. The lobby has a sofa with a tear in the cushion top. The striped sofa in the lobby had stains on all three cushions. Furniture and equipment shall be nonhazardous, clean and sturdy. Kathy Hunt, Residential Director, completed the following: The music console and console seat have been thrown away and the ripped cushion has been replaced. The stained bench cushion in Hall B and the cushions on the striped sofa in the lobby were all cleaned by the housekeeper. The housekeeper will continue to clean and monitor the unit on a daily basis and report any needed repairs not in their ability to clean/fix to their immediate supervisor who will contact the needed person for any repairs needed. In addition, the unit Supervisor or Manager completes a monthly environmental checklist of the unit and reports any needed duties and/or repairs to the necessary person. i.e. housekeeper, maintenance, housekeeping, Residential Director. Daily, it is the expectation of staff, to report any maintenance issues they may see to their immediate supervisor. 08/04/2014 Implemented
SIN-00091284 Renewal 10/26/2015 Compliant - Finalized