Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00222793 Renewal 04/11/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency completed a self-assessment on 3/20/23; however, the following 6400 regulations were left blank: 19a3, 25c, 141c10, 141c11, 141c12, 141c15, 141d, 142b, 142c, 142d, 142e, 142g, 145(2), 145(3), 165f, 165g, 166a11, 181e9, and 212.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. By May 26, 2023, CEO, Program Specialist and ID Director will obtain the necessary education/training on utilization and guidelines on the Self-assessment licensing inspection instrument that is featured in the ODP 6400 Regulatory Compliance Guide as appendix A. II. The Program Specialists and Program Director will be responsible for completing these self-assessments, including marking "NA" for any areas that do not apply to the house that they are assessing. III. Self-assessment forms will be submitted to the Director and/or CEO for their review. 05/04/2023 Not Implemented
6400.15(c)The agency completed a self-assessment on 3/20/2023 and identified a violation of regulation 6400.217(4); however, a written summary of corrections was not kept by the agency.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. By 4.10.23, all individuals had updated Lifetime Medical History records. II. By 4.10.23, all individuals had current release of information in their chart. 05/04/2023 Not Implemented
6400.141(a)Individual #1 had a physical examination on 6/10/2021 and then again on 7/6/2022. [Repeat Violation, 10/5/2022]An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual #1 was seen for his annual physical on 6/9/2022; The original form is signed by the MD and dated 6/9/2022. The correct document was not used and the MD redid the exam document after the appointment on the correct form. The MD completed a new exam form with the date of the revisions of 7/6/23 not the exam date of 6.9.22. The individual #1 was not seen in Dr. Rebecca Behr¿s office for an exam on 7/6/2022; The physician¿s office confirmed the exam appointment was on 6/9/2022. 05/04/2023 Not Implemented
6400.141(c)(9)Individual #1, date of birth 3/12/1974, has not had a prostate examination. [Repeat Violation, 10/5/2022]The physical examination shall include: A prostate examination for men 40 years of age or older. Individual has appointment with PCP scheduled for May 18, 2023, specifically for prostate screening evaluation, preventive education of prostate cancer and recommendations regarding follow-up to include time frame for prostate exam or PSA blood test in lieu of exam. 05/04/2023 Not Implemented
6400.151(a)Direct Service Worker #1, began working with individuals on 1/6/2023 and completed an initial physical examination on 3/3/2023. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Temporary Staff who work at both our psychiatric and intellectual disabilities sites follow an agency calendar for required physical and TB tests as per regulations. DS #1 worker was compliant according to Transitional Services-wide calendar. DS #1 began work with Transitional Services on 11.2020 and has completed recurrent physicals according to guidelines. 05/04/2023 Implemented
6400.151(c)(2)Direct Service Worker #1, began working with individuals on 1/6/2023 and completed an initial Tuberculin testing on 3/6/2023. The physical examination shall include: 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. Temporary Staff who work at both our psychiatric and intellectual disabilities sites follow an agency calendar for required physical and TB tests as per regulations. DS #1 worker was compliant according to Transitional Services-wide calendar. DS #1 began work with Transitional Services on 11.2020 and has completed recurrent physicals according to guidelines. 05/04/2023 Implemented
6400.46(a)Direct Service Worker #1, began working with individuals on 1/6/2023 and was initially trained in fire safety on 1/25/2023.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.. Day -1 Site-Specific Temporary Staff orientation will be implemented with Direct Service Workers/Temporary staff to include: o Transitional Services Policies and Procedure on Individual Rights; and Incident Management o Emergency Red Book (Emergency telephone numbers; Evacuation/Floor Plans; Utility Directions; Fire Preparedness inclusive of Fire Drill Procedures; Emergency/Disaster Plan; Individualized Disaster Guides; and TSI¿s Safety Policies and Procedures) o Shift Activities/Responsibilities (Job Related Knowledge/Skills) o On-call Procedures o Keys, Phones, 05/04/2023 Implemented
6400.46(b)Direct Service Worker #2 was trained in fire safety on 9/2/2021 and then again on 10/26/2022.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Casual Pool/Part Time employees are required to follow the ID training protocols for all Transitional Services staff. 05/04/2023 Implemented
6400.51(b)(1)Direct Service Worker #1's orientation, completed from 12/15/2022 to 12/22/2022, did not include person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.I. By June 5, 2023, Direct Service #1/temporary staff will complete required MYODP trainings. II. By Friday May 5, 2023, Transitional Services will communicate with Delta T, temporary staffing agency, to inform them that Direct Service #1 will be required to complete the MYODP series of trainings to include: (Person Centered: Community Integration; Individual Choice; Supporting Individuals to Develop/Maintain Relationships; Individual Rights; and Recognizing and Reporting Incidents) before they will be permitted to an assignment at any site that serves the ID population. III. By Friday May 5, 2023, Transitional Services will communicate with Delta T, temporary staffing agency, to inform that that all current temporary staff will have 30 days to complete the MYODP series of trainings to include: (Person Centered: Community Integration; Individual Choice; Supporting Individuals to Develop/Maintain Relationships; Individual Rights; and Recognizing and Reporting Incidents). If not completed in the 30-day time frame, they will not be permitted to continue an assignment at any site that serves the ID population until completion can be verified. 05/04/2023 Not Implemented
6400.51(b)(3)Direct Service Worker #1's orientation, completed from 12/15/2022 to 12/22/2022, did not include individual rights.The orientation must encompass the following areas: Individual rights.I. By June 5, 2023, Direct Service #1/temporary staff will complete required MYODP trainings. II. By Friday May 5, 2023, Transitional Services will communicate with Delta T, temporary staffing agency, to inform them that Direct Service #1 will be required to complete the MYODP series of trainings to include: (Person Centered: Community Integration; Individual Choice; Supporting Individuals to Develop/Maintain Relationships; Individual Rights; and Recognizing and Reporting Incidents) before they will be permitted to an assignment at any site that serves the ID population. III. By Friday May 5, 2023, Transitional Services will communicate with Delta T, temporary staffing agency, to inform that that all current temporary staff will have 30 days to complete the MYODP series of trainings to include: (Person Centered: Community Integration; Individual Choice; Supporting Individuals to Develop/Maintain Relationships; Individual Rights; and Recognizing and Reporting Incidents). If not completed in the 30-day time frame, they will not be permitted to continue an assignment at any site that serves the ID population until completion can be verified. IV. By May 8, 2023 a Site-Specific Temporary Staff orientation will be implemented to include: ¿ Transitional Services Policies and Procedure on Individual Rights; and Incident Management ¿ Emergency Red Book (Emergency telephone numbers; Evacuation/Floor Plans; Utility Directions; Fire Preparedness inclusive of Fire Drill Procedures; Emergency/Disaster Plan; Individualized Disaster Guides; and TSI¿s Safety Policies and Procedures) ¿ Shift Activities/Responsibilities (Job Related Knowledge/Skills) ¿ On-call Procedures ¿ Keys, Phones, 05/04/2023 Not Implemented
6400.51(b)(4)Direct Service Worker #1's orientation, completed from 12/15/2022 to 12/22/2022, did not include recognizing and reporting incidents. [Repeat Violation, 10/5/2022]The orientation must encompass the following areas: recognizing and reporting incidents.I. By June 5, 2023, Direct Service #1/temporary staff will complete required MYODP trainings. II. By Friday May 5, 2023, Transitional Services will communicate with Delta T, temporary staffing agency, to inform them that Direct Service #1 will be required to complete the MYODP series of trainings to include: (Person Centered: Community Integration; Individual Choice; Supporting Individuals to Develop/Maintain Relationships; Individual Rights; and Recognizing and Reporting Incidents) before they will be permitted to an assignment at any site that serves the ID population. III. By Friday May 5, 2023, Transitional Services will communicate with Delta T, temporary staffing agency, to inform that that all current temporary staff will have 30 days to complete the MYODP series of trainings to include: (Person Centered: Community Integration; Individual Choice; Supporting Individuals to Develop/Maintain Relationships; Individual Rights; and Recognizing and Reporting Incidents). If not completed in the 30-day time frame, they will not be permitted to continue an assignment at any site that serves the ID population until completion can be verified. IV. By May 8, 2023 a Site-Specific Temporary Staff orientation will be implemented to include: ¿ Transitional Services Policies and Procedure on Individual Rights; and Incident Management ¿ Emergency Red Book (Emergency telephone numbers; Evacuation/Floor Plans; Utility Directions; Fire Preparedness inclusive of Fire Drill Procedures; Emergency/Disaster Plan; Individualized Disaster Guides; and TSI¿s Safety Policies and Procedures) ¿ Shift Activities/Responsibilities (Job Related Knowledge/Skills) ¿ On-call Procedures ¿ Keys, Phones, 05/04/2023 Not Implemented
6400.51(b)(5)Direct Service Worker #1's orientation, completed from 12/15/2022 to 12/22/2022, did not include job-related knowledge and skills.The orientation must encompass the following areas: Job-related knowledge and skills.By June 5, 2023, Direct Service #1/temporary staff will complete required MYODP trainings. II. By Friday May 5, 2023, Transitional Services will communicate with Delta T, temporary staffing agency, to inform them that Direct Service #1 will be required to complete the MYODP series of trainings to include: (Person Centered: Community Integration; Individual Choice; Supporting Individuals to Develop/Maintain Relationships; Individual Rights; and Recognizing and Reporting Incidents) before they will be permitted to an assignment at any site that serves the ID population. III. By Friday May 5, 2023, Transitional Services will communicate with Delta T, temporary staffing agency, to inform that that all current temporary staff will have 30 days to complete the MYODP series of trainings to include: (Person Centered: Community Integration; Individual Choice; Supporting Individuals to Develop/Maintain Relationships; Individual Rights; and Recognizing and Reporting Incidents). If not completed in the 30-day time frame, they will not be permitted to continue an assignment at any site that serves the ID population until completion can be verified. IV. By May 8, 2023 a Site-Specific Temporary Staff orientation will be implemented to include: ¿ Transitional Services Policies and Procedure on Individual Rights; and Incident Management ¿ Emergency Red Book (Emergency telephone numbers; Evacuation/Floor Plans; Utility Directions; Fire Preparedness inclusive of Fire Drill Procedures; Emergency/Disaster Plan; Individualized Disaster Guides; and TSI¿s Safety Policies and Procedures) ¿ Shift Activities/Responsibilities (Job Related Knowledge/Skills) ¿ On-call Procedures ¿ Keys, Phones, 05/04/2023 Not Implemented
6400.181(f)The program specialist provided Individual #1's assessment, completed 2/15/2023, to the plan team members on 3/30/2023 for Individual Plan meeting on 3/30/2023. [Repeat Violation, 10/5/2022]The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.. By May 26, 2023, ID team (Program Specialist/ID Director) will develop and implement an ISP/Assessment tracking system that will collect the following data by person served: ¿ ISP annual date ¿ 120 days prior to ISP date for completion of assessment ¿ Verification of submission of assessment and accompanying email to Supports Coordinator immediately upon completion. ¿ 60 days prior reminder email to Supports Coordinator for ISP meeting date. ¿ 30 days post verification of ISP attendance 05/04/2023 Not Implemented
SIN-00221582 Unannounced Monitoring 03/21/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At 11:13AM on 3/21/2023, the floors throughout the apartment had dirt and debris. There were food crumbs inside the sink. There was food splatter on the walls and ceiling of the microwave. There was brown splatter on the wall inside the kitchen. There was a white substance on the floor of Individual #1's bedroom. There were food crumbs and sticky residue on the dresser inside Individual #1's bedroom. [Repeat Violation, 10/5/2022, 1/19/2023]Clean and sanitary conditions shall be maintained in the home. The Callowhill staff immediately on 3/21/23 corrected the violation by providing a thorough cleaning to address all the items listed in this violation by the end of business day. 04/13/2023 Implemented
6400.70At 11:15AM on 3/21/2023, the telephone was inoperable.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. The Callowhill staff immediately on 3/21/23 corrected the violation by providing a thorough cleaning and verification of a working phone as listed in this violation by the end of business day. 04/13/2023 Implemented
6400.171At 11:10AM on 3/21/2023, an uncovered package of frozen French Toast inside Individual #1's freezer. [Repeat Violation, 1/19/2023]Food shall be protected from contamination while being stored, prepared, transported and served. The Callowhill staff immediately on 3/21/23 corrected the violation by providing a thorough cleaning to address all the items listed in this violation by the end of business day. 04/13/2023 Implemented
SIN-00217892 Unannounced Monitoring 01/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At 10:57AM, the refrigerator used Individual #1 had sticky substances, food crumbs and debris inside. There was food splatter throughout the microwave. At 11:04AM, the bathtub and the nonslip mat inside the bathtub had a thick layer of what appeared to be soap scum and residue. In addition, there was what appeared to be mildew or mold on the ceramic tile around the bathtub.Clean and sanitary conditions shall be maintained in the home. Staff cleaned refrigerator and tub used by individual 1 with in 8 hours of inspection. Staff meeting held on 2/3 /23 Daylight and afternoon shift cleaning duties have been assigned. 02/15/2023 Implemented
6400.83(c)At 10:59AM, a soiled bowl containing food residue was in the dish drying rack next to the sink in the kitchen of the home.Utensils used for eating, drinking and preparation of food or drink shall be washed and rinsed after each use.Bowl was cleaned with the day of inspection. 02/15/2023 Implemented
SIN-00212599 Renewal 10/04/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At 10:48AM, there was food splatter and crumbs on the plate and ceiling of the microwave in the kitchen of the home. [Repeat Violation, 2/28/2022, 5/3/2022]Clean and sanitary conditions shall be maintained in the home. [Immediately, the CEO or designee shall instruct all direct care staff persons/supervisors to complete a walkthrough of each home at least 2 times daily (one being at the end of their shift) to ensure each home is in compliance with regulatory standards to include but not limited to; operable telephones, clean and sanitary conditions, furniture and equipment are in good repair, food is properly stored and protected, garbage is covered and in receptables or removed from the home, cooking and serving utensils are clean and put away, medication is locked, required Individuals' documentation is present, egresses are unobstructed and evidence of infestation of insects or rodents. Training of staff shall include the agency's policies and procedures to ensure the staff person immediately rectifies any issues or the process to report and ensure findings are addressed, timely. Documentation of the home walk through audits shall be kept and reviewed by a management staff person at least weekly. (DPOC by AES,HSLS on 10/18/2022)] 11/01/2022 Not Implemented
6400.112(c)The written fire drill records for the fire drills completed from February 2022 through September 2022 do not address problems encountered.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. [Immediately, the CEO or designee shall audit the written fire drill documentation to ensure all required information including problems encountered is included on the documentation and revised as needed. Within 2 weeks of receipt of the plan of correction, the CEO or designee shall educate all staff person on conducting fire drills and documenting as required to ensure all required information is included including if problems are encountered and their responsibility if problems are encountered. Documentation of the trainings shall be kept. Upon completion of fire drills, a designated management staff person shall audit all fire drills to ensure fire drills are conducted as required and documented as required to ensure the safety of the individuals and if problems are encountered, they are addressed, timely. Documentation of audits shall be kept. (DPOC by AES,HSLS on 10/18/2022)] 11/01/2022 Implemented
SIN-00208228 Unannounced Monitoring 07/06/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The vinyl baseboard trim along the wall near the closet in the bathroom is delaminating causing a one inch gap. In addition, there is a section of tile that is separating from the wall near the base of the bathtub.Floors, walls, ceilings and other surfaces shall be in good repair. Baseboard trim and tile will be replaced by TSI maintenance staff by 8/8/22. Staff are currently working to repair the bathroom trim and tile. 08/08/2022 Implemented
6400.107On 7/6/2022 at 11:47AM, a portable space heater was underneath the table in the staff office.Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms. On 7/6/22 space heater was removed from the office. 07/21/2022 Not Implemented
SIN-00204510 Unannounced Monitoring 05/03/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At 10:39AM, the glass shelves in the refrigerator in the kitchen of the home had numerous spots of unknown sticky substances and spoiling food including grapes, tomatoes and a jar of pickles that was adhered to the top shelf. The inside of the microwave in the kitchen of the home contained numerous stains, burn marks, food splatter and food crumbs. There is a drinking glass size ring-shaped sticky residue and a few dead flies on the windowsill in the kitchen of the home.Clean and sanitary conditions shall be maintained in the home. Staff cleaned the refrigerator immediately and all expired food was removed from the refrigerator and new, fresh food replaced. The microwave in the kitchen was removed and is the process of being replaced. The window sill in the home was cleaned along with mopping and sweeping of the entire kitchen. Staff training with the topic of maintaining a healthy, safe living environment was completed on 5/27/22. 06/01/2022 Not Implemented
6400.64(b)There were a multitude of dead insects collected on several sticky insect traps on the floors in the bedrooms and kitchen of the home.There may not be evidence of infestation of insects or rodents in the home. Staff removed insect sticky traps from the floors in the bedrooms and kitchen. Staff cleaned the floors with a vacuum cleaner. Staff were retrained on their responsibilities to ensure a clean, safe, healthy living environment. 06/01/2022 Not Implemented
6400.67(b)There were seven screws laying on the door frame sill of the door at the rear exit of the home posing slipping and laceration hazards. Floors, walls, ceilings and other surfaces shall be free of hazards.Staff removed hazards immediately. Staff were retrained on the protocol to report hazards to the maintenance department of 5/27/22. 06/01/2022 Not Implemented
6400.83(c)There were two mugs each containing a used tea bag and spoon on the nightstand in Individual #1's bedroom.Utensils used for eating, drinking and preparation of food or drink shall be washed and rinsed after each use.Staff removed mugs and disposed of used tea bags and cleaned spoons from individual #1's room. Staff were trained on the use of the newly formed cleanliness checklist on 5/27/22. 06/01/2022 Not Implemented
6400.171At 10:39AM, the refrigerator in the kitchen of the home contained two carton of eggs with expiration dates of 4/4/2022 and 3/13/2022, prepared fried chicken with a sell by date of 3/25/2022, an eight ounces carton of skim milk with an expiration date of 4/28/2022, a 12 container of cream cheese with expiration date of 10/23/2021, a quart plastic bottle of skim milk, with an expiration date of 4/8/2022, a package of ham lunchmeat with a sell by date of 3/25/2022, and a bottle of Red Hot sauce with an expiration date of 5/6/2021. In addition, the following food items were not sealed or stored to protect from contamination or spoiling: a bowl of lettuce containing a plastic fork, a partial stick of butter, a partially eaten sandwich, a gallon size bag of thawed frozen French-fried potatoes, and bag of grapes.Food shall be protected from contamination while being stored, prepared, transported and served. all expired food was removed from the refrigerator and new, fresh food replaced by staff with the assistance of the individual. On May 5th and 6th Staff met with individual to review the importance of properly storing food and discarding expired food. The individual agreed to a schedule in which staff and individual will plan meals and review expiration dates on food packages. 06/01/2022 Not Implemented
SIN-00200933 Renewal 02/28/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.70The telephone with the cords wrapped around located on the coffee table was unplugged from the wall and had a dead battery.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. The telephone was moved to another location in the apartment by the direct support staff. Direct support workers were provided with education and a review of policy on the procedure and process to report maintenance issues to ensure compliance with regulations by the ID Department Director. 03/31/2022 Not Implemented
6400.72(a)The window on the right in Individual #2's bedroom did not have screen.Windows, including windows in doors, shall be securely screened when windows or doors are open. The window screen was replaced in Individual #3¿s apartment. Direct support workers were provided with training on the procedure and process to report maintenance issues to ensure compliance with regulations. 03/03/2022 Not Implemented
6400.110(b)The smoke detector in the hallway of the home was 18 feet and 4 inches from Individual #1's bedroom door.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. A smoke detector was installed in Apartment 4 within 15 feet of each individual's bedroom door on 3/1/2022. Staff were trained on this regulation on 3/3/2022. 03/03/2022 Not Implemented
6400.15(b)The agency did not use the current Department's licensing inspection instrument when completing a self-assessment of the home on 11/18/21. The self-assessment used was modified 6/2018 and did not included the current community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.The agency did not use the Regulatory Compliance Guide Appendix A 55Pa.Code Chapter 6400 Community Homes for Individuals with an Intellectual Disability or Autism Self Assessment Licensing Inspection Instrument to complete the annual pre licensing inspection paperwork. The Department director discarded the outdated pre licensing inspection checklist immediately. The department director immediately created a pre licensing inspection folder which now included the Regulatory Compliance Guide Appendix A 55Pa.Code Chapter 6400 Community Homes for Individuals with an Intellectual disability or Autism. The file is in hard copy form in the director's office. An electronic version is found on the agency's U drive. The ID Director will complete the tool in the month of April. 03/31/2022 Not Implemented
SIN-00183178 Renewal 02/09/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)Individual #1's physical examination completed on 9/14/20 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The medical provider was contacted and requested to complete the missing information on the physical examination form. Auditing of each individual's physical exam will occur upon receipt of physical exam paperwork. Staff will contact the medical provider to request any blank spaces be completed by medical provider prior to filing exam in individual's chart. [Immediately, the CEO or designee shall audit all individuals'' records to ensure physical examinations are complete. Immediately, the CEO or designee shall train all staff on the regulatory requirements of the chapter for physical examinations. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 03/16/2021 Implemented
6400.181(e)(14)Individual #1's assessment completed on 12/13/20 did not include the Individual's ability to swim. This section was left blank.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim.The individuals assessment was updated completing the individual's ability to swim. Review of all individual's assessment will occur to ensure all sections of the assessment is complete. The review by a staff person other than the staff completing the assessment will be conducted . Any missing information will be added to the assessment prior to filing in the individual's chart. [Immediately, the CEO or designee shall train all staff responsible for completing the individual assessments on the requirement of the assessment per the regulation in the chapter. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 03/16/2021 Implemented
6400.34(a)Individual #1 was informed and explained individual rights on 1/01/21. The rights document did not include the following rights: 6400.32e through 6400.32g, to choose, accept risks, refusal and control the individual's schedule, activities and services; 6400.32j to voice concerns and 6400.32k to participation in the development and implementation of the individual plan; 6400.32r and 6400.32s relating to locking doors in bedrooms and in the home.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.A revised Individual rights sign off form was created to included 6400.32 e-6400.32 g, 6400.32j, and 6400.32 s. The individual signed an updated form. The form has been included in the individual's chart. Each individual living at the site will be provided a copy of the updated form which will be reviewed with them and a signature will be obtained. A review of all forms will be conducted annually and new signatures obtained if required. [Updated individual rights form was signed by individual on 2/18/21. Immediately, the CEO or designee shall develop policies and procedures for reviewing agency documents to ensure they meet the requirements of the regulations. (DPOC by RM, HSLS on 3/18/2021)] 03/16/2021 Implemented
6400.166(a)(11)Individual #1's February 2021 medication administration record did not include the diagnosis or purpose for the medication for the following medications: Amlodipine, 10 mg, take one tablet by mouth once a day; Buspirone, 15 mg, take one tablet by mouth twice a day; Certa-Vit, take one tablet by mouth every morning; Chlorthalidone, 25 mg, take one tablet by mouth every morning with food; Citalopram, take one tablet by mouth in the morning; Docusate Sodium, 100mg, one capsule by mouth once daily; Fluticasone, 50 mcg/inh, spray one spray into each nostril twice weekly for one week then daily; Loratadine, 10 mg, take one tablet once daily; Metformin, 500 mg, take one table once daily with a meal; Metoprolol Tartrate, 100mg, take one tablet by mouth twice a day; Topiramate, 50 mg, take one tablet by mouth once a day; Lisinopril, 40 mg, take one tablet by mouth once daily; Trazadone, 50 mg, take one tablet by mouth at bedtime.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The current medication administration record was updated with the purpose for each medication. Monthly, upon updating the medication administration record, staff will review each record to ensure each medication purpose is listed. If the medication purpose is found to me missing, staff are to enter the information into the record. A monthly audit of medication administration records will occur by a program supervisor or administrator. [Immediately, the CEO or designee shall train all staff on the requirements of the medication record per the regulations of the chapter. Documentation of all trainings and audits shall be kept. DPOC by RM, HSLS on 3/18/2021)] 03/16/2021 Implemented
SIN-00164033 Renewal 10/09/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.142(a)Individual #1 had a dental examination on 9/6/18 then again 10/3/19.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. Program Specialist will implement medical tracking form to document all medical appointments. Medical tracking form will be updated as appointments are completed and scheduled as well as a calendar for the direct care staff and person served. Program Specialist will review medical tracking form monthly for reminders to ensure appointments are scheduled and attended timely. Utilization of Medical Tracking Form and adherence to compliance with all medical appointment schedules will be reviewed during staff supervision. Attachment: Medical Tracking Form 10/18/2019 Implemented
6400.142(f)Individual #1's most recent dental hygiene plan was completed 9/6/18.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. Program Specialist will implement a Dental Hygiene Plan in which person served will be prompted and assisted with dental care by direct care staff twice per day(AM and PM). Program Specialist will utilize a new developed tracking sheet to be initialed by direct care staff and person served at the time of assistance is provided. Program Specialist will ensure all necessary documentation is completed until next assessment is conducted to assess independence. Attachment: Dental Tracking Sheet 10/18/2019 Implemented
SIN-00143625 Renewal 10/18/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone number of the nearest hospital was not on or by the telephone in the living room of the home.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. Stickers on all of the phones at the site were immediately updated to include all previous information PLUS the number of the nearest hospital - UPMC Shadyside (completed 10.19.18). Program Specialist sent an email to all program staff informing them that the hospital number had been added to the phone stickers. This was also addressed at the staff meeting on 10.24.18 as well as at the house meeting with all persons served on 10.25.18. To ensure that this violation does not occur again in the future, the program specialist will scan/email the phone/emergency number audit to the ID Director monthly. The document will be kept and filed in the on site safety binder at Callowhill. Furthermore, regulation 6400.71 will be reviewed and signed off on at the all staff ID training on 11.5.18. The training slips will be kept on file in human resources. 11/05/2018 Implemented
SIN-00123550 Renewal 10/26/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the telephone in the living room of the home. (Repeated Violation-11/9/16, et al)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. What specific change will be made-Immediately, site staff placed all required per regulation 6400.71 emergency numbers on all Individual's phones. Who will make the change-Site Staff When will the change be made-10/27/2017 How will the change be made-Immediately and during November's house meeting for the Individuals, staff will review the importance of having emergency numbers stickers on their phone. Immediately and then monthly, site staff will complete an audit to make sure all Individual's phones have emergency stickers on all individual's phones. If during the audit a sticker needs replaced, one will be immediately be replaced. What system have you implemented to make sure that the same violation will not occur again- Program specialist will scan and email the Phone/Emergency Numbers Audits to the ID Director monthly. These audits will be filed in the onsite Safety binder. What training will be provided to your staff- Staff will be re-trained on regulation 6400.71 and on the Phone/Emergency Numbers Audit within 30 days of receipt of the plan of correction. Documentation of the training shall be kept. 10/27/2017 Implemented
SIN-00103401 Renewal 11/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the telephone in the living room of the home. 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. What specific change will be made. An emergency numbers sticker was placed on this cordless phone handset. Who will make the change. Site staff. When will the change be made. 11-10-16. How will the change be made. During the December house meeting for residents, staff will review the importance of having emergency numbers on each phone. What system have you implemented to make sure that the same violation will not occur again. Staff will check this individual¿s phone during the next two months to ensure that the emergency numbers sticker has remained on the phone. What training will be provided to your staff. Staff will be re-trained on the need for emergency numbers to be on each phone and the requirements contained in 6400.71.[Immediately and at least quarterly thereafter, the site supervisor shall check all phones in all community homes to ensure all required telephone numbers are on or by each telephone in the home with an outside line. Documentation of trainings and site audits shall be kept. (AS 11/29/16)] 12/01/2016 Implemented
SIN-00230022 Renewal 07/06/2023 Compliant - Finalized
SIN-00215100 Unannounced Monitoring 11/08/2022 Compliant - Finalized
SIN-00211956 Unannounced Monitoring 09/22/2022 Compliant - Finalized
SIN-00210603 Unannounced Monitoring 08/22/2022 Compliant - Finalized
SIN-00085621 Renewal 10/15/2015 Compliant - Finalized
SIN-00055048 Renewal 09/16/2013 Compliant - Finalized