Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00218725 Renewal 01/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There were unlocked chemicals in room #18 including Lysol.Poisonous 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
6400.62(c)The office area contained two bottles which contained unmarked cleaning chemicals.Poisonous materials shall be stored in their original, labeled containers. Supervisors will complete daily rounds in respective homes to ensure chemicals are properly secured. 03/16/2023 Implemented
6400.72(b)There was a screen ripped out of window frame in room #18. Screens, windows and doors shall be in good repair. 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(e)Individual 1's dental exam on 4/28/22 notated a 6 month follow-up is needed. The follow up appointment has not been completed.Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed.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
SIN-00199973 Renewal 01/31/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65The ventilation system in 2 bathrooms is inoperable. These bathrooms are attached to bedrooms belonging to Individual #2 and Individual #3.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. Maintenance requested sent for repair and completed. All Residential Directors and Residential Managers will be trained in the new procedure in March 2022 and implementation will begin in April of 2022. 04/30/2022 Implemented
6400.67(a)The roller shades in Individual #4 room are ripped and fell down when staff attempted to pull up the shades. There is spackling on the wall outside room 2 that has not been sanded or painted. Staff states the spackling was put up a week ago.Floors, walls, ceilings and other surfaces shall be in good repair. Email sent to maintenance and completed. All Residential Directors and Residential Managers will be trained in the new procedure in March 2022 and implementation will begin in April of 2022. 02/28/2022 Implemented
6400.76(a)The nightstand in Individual #2's bedroom is broken; the top slides off. The top dresser drawer in Individual #4's bedroom is broken and will not open. Furniture and equipment shall be nonhazardous, clean and sturdy. Email sent to maintenance-per maintenance observation this is NOT broken. This is a swivel table located next to resident's bed and can be adjusted if needed. Dresser replaced and old one discarded. All Residential Directors and Residential Managers will be trained in the new procedure in March 2022 and implementation will begin in April of 2022. 02/28/2022 Implemented
6400.81(k)(4)There is no dresser in Individual #5's bedroom. He has a plastic bin and a crate for some of his clothing. The rest of his clothing is piled on top. There is not enough storage for his belongings. Some items could be hung in the closet but were not.In bedrooms, each individual shall have the following: A chest of drawers. Dresser placed in room and straightened. All Residential Directors and Residential Managers will be trained in the new procedure in March 2022 and implementation will begin in April of 2022. 02/20/2022 Implemented
6400.216(a)The individual files were located in an unlocked cabinet in the sitting room area of the home. An individual's records shall be kept locked when unattended. Files removed and placed in locked drawer. All Residential Directors and Residential Managers will be trained in the new procedure in March 2022 and implementation will begin in April of 2022. 02/24/2022 Implemented
6400.163(h)Individual #1 Johnson's Baby Powder prescription label expired in 11/21.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.An assigned MTS will perform medication cart checks on a monthly basis to ensure any expired or discontinued meds are appropriately removed from the cart. The certified Med Trainer will educate the MCS/MTS during ODP Med Admin training classes. 03/01/2022 Implemented
SIN-00183416 Renewal 02/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(b)(1)The Woods services policy/procedure is not being implemented as it relates to the individual#3's comfort, dignity, privacy and safety.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. Individual respect and privacy (specifically knocking on bedroom doors and promoting privacy during personal care) will be discussed at the monthly Managers meeting in March, 2021 and in all staff meetings in April, 2021. 02/12/2021 Implemented
6400.72(b)Individual#2's bedroom window opened, but unable to close. Screens, windows and doors shall be in good repair. Fixed on 2/8/21. Attachment # 2 05/31/2021 Implemented
6400.142(a)Individual#1was seen for Annual Dental Exams on 11/06/2019 and 02/03/2021. The period between these two exams exceeds 1 year and is therefore outside of regulatory compliance.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. The Dental clinic was closed for the Months of April, May and June of 2020 due to restrictions set by the Centers for Disease Control and the Pennsylvania Dental Association to postpone annual checkups, elective procedures and non-urgent dental visits during the height of the COVID-19 pandemic. 02/09/2021 Implemented
6400.144Individual#1's-anbesol gel 10% not in med box at inspection-prnHealth 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. Anbesol is currently in med box. All nurses and medication trained/certified staff will document that they have read and understand the Woods' Medication Administration Manual. 05/31/2021 Implemented
6400.32(d)Individual#3 at inspection-violation of rights and privacy individual was not fully clothed at inspection-staff was dressing him when Woods staff walked in the room.An individual shall be treated with dignity and respect.Individual respect and privacy (specifically knocking on bedroom doors and promoting privacy during personal care) will be discussed at the monthly Managers meeting in March, 2021 and in all staff meetings in April, 2021. 02/12/2021 Implemented
6400.181(f)There is no evidence within Individual#1's Individual Record to indicate that the Annual Assessment (dated 12/01/2020) was sent to the members of the Individual Support Plan (ISP) Team at least 30 days prior to the individual's ISP Annual Review. There is evidence in the Individual Record that the Annual Assessment was sent to ISP Team Members on 02/10/2021, which falls outside of the required time frame.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 re-emphasizing the enforcement of Resident Assessment completion expectations moving forward. Attachment #1. 03/22/2021 Implemented
SIN-00156311 Renewal 04/29/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(i)Staff #1 CPR and first aid was not completed annually, last completed on 1/8/18.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 trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. Staff completed CPR and First Aid training on 05/09/2019. Going forward, an audit will be completed monthly by the Residential Mangaer and Residential Director to ensure staff are in compliance for required trianing and have a least 6 hours of training every quarter to make the 24 hour training requirement. (attachment #2) 05/09/2019 Implemented
6400.164(b)Individual #20's Medical Administration Record (MAR) for Glucometer readings were missing on 4/12/18, 4/15/18, 4/29/18, not logged immediately after use and readings dated on 4/19/19 were inaccurate. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. All missing glucometer readings were at 8 am. Addressed with the day nurse to log each accucheck result onto MAR immediately after obtaining. Medication administration as outlined in the Department of Public Welfare Administering Medications the Right Way reviewed and documented on Employee Training Documentation Form (attachment 1). 06/30/2019 Implemented
SIN-00133737 Renewal 02/12/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(e)There was a video monitoring device in Individual #2's bedroom which violates the Individual's right to privacy.An individual has the right to privacy in bedrooms, bathrooms and during personal care. A team meeting was held for Individual #2 on 2/21/18 (attachment #3). The monitor was discontinued and the team agreed to try Individual #2 with a floor alarm mat and a call bell. The team discussed with Individual #2 when he wants assistance from staff when he is in his bedroom to ring his bell and staff will come and assist. The floor mat was ordered on 3/11/18 by the Residential Director. Individual #2 has been discharged from Woods Services. In addition, the Residential Manager will complete monthly environmental inspections of the residence to ensure no areas of noncompliance. 03/19/2018 Implemented
6400.141(c)(9)Individual #1's physical exam dated 6/7/17 did not include a prostate exam.The physical examination shall include: A prostate examination for men 40 years of age or older. Individual #1 is scheduled for routine urology appoiontment on 10/5/18 during this appointment a digital exam will be completed. Prostate exams due date will be placed on an excel spreadsheet by the Nursing Manager (attachment #2). This information will be posted in each nursing station. Once EMR is operational, each due date will be flagged and timely alerts will be generated for nursing to implement and/or follow-up. Each nurse covering each residence will be responsible to assess the spreadsheet monthly and follow-up appropriately. Nursing Manager will have oversite to ensure timely completion. 10/05/2018 Implemented
6400.186(b)Individual #1's Individual Support Plan reviews were no sign by the Individual.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. Individual's ISP 3 Month Reviews will be reviewed, signed and dated by the individual and Program Specialist. Attachment #1 shows this process is in place. 04/12/2018 Implemented
SIN-00108180 Renewal 02/06/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65The ventilation in the bathrooms between bedrooms was inoperableLiving areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. Ventilation was repaired by Woods maintenance department on 2/14/17. (see attachment) The Residential Manager will complete monthly environmental inspections to ensure no areas of noncompliance. Any noted repairs will be submitted to the appropriate department. If repairs cannot be completed, appropriate action will be taken to replace the item. Any area of non compliance will be forwarded to Residential Director. If observed at any time, Program Supervisors are to report any issues to the Residential Manager so that immediate action can be taken. 02/15/2017 Implemented
6400.141(c)(14)Individual #1's annual physical examination, dated 8/11/16, did not document information pertinent to diagnoses and treatment 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
6400.164(b)Individual #1'sMAR was not initialed on 2/5/17 for administration of the 8am dose of Levothyroxine 112mcg, Fluoxetine 40mg, and Fluoxetine 20mg. Individual #1'sMAR was not initialed on 2/5/17 for administration of the 8pm dose of Mucinex 600mg. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. Individual #1's MAR was corrected to initials and the #5 for missing initials. In addition, Medication Incident Reports were completed on 2/9/17 at 7:30pm for each of the missing initials. Going forward, the nurse or medication trained staff will complete daily checks of the MAR to ensure all medications are initialed for accordingly. If any are missing, the nurse or medication trained staff will complete an incident report with the missing information and forward it to nursing management. Nursing management will then follow up to ensure completion. (see attachments) 02/09/2017 Implemented
6400.165Individual #1's medication errors that occurred on 2/5/17 at 8am and 8pm were not documented.Documentation of medication errors and follow-up action taken shall be kept. Nursing completed a Medication Incident Report on 2/9/17 at 7:30pm. Going forward, the nurse or medication trained staff will complete daily checks of the MAR to ensure all medications are intialied for accordingly. If any are missing the nurse or medication trained staff will complete an incident report with the missing information and forward it to nursing management. Nursing management will then follow up to ensure completion. (see attachments) 02/09/2017 Implemented
SIN-00063871 Renewal 07/28/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65The ventilation in bathrooms #15 and #18 were not operable. Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. Woods Services' maintenance department inspected the ventilation in Harewood on 10/29/14. While there, the maintenance staff replaced the fan motors in both bathroom #15 and #18. (See attachment A) Woods Services' maintenance department will do a regular inspection of the heating and ventilation system. 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, etc. Daily, it is the expectation of staff to report any maintenance issues they may see to their immediate supervisor. 10/29/2014 Implemented
SIN-00091120 Renewal 10/26/2015 Compliant - Finalized