Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00203232 Renewal 04/05/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The bathroom light in Individual 5's master bathroom was not functioning.Floors, walls, ceilings and other surfaces shall be in good repair. The bathroom light in Individual 5's master bathroom was not functioning. A work order was put in with facilties to fix the light and circuit breaker. Facilities fixed the light in the bathroom.House manager will check condition of site furniture during site checks while completing environmental checks weekly for the site. Staff received additional on-site orientation training on regulation requirements in regard to site furniture conditions. Site checks will be completed twice weekly and results will be turned into the Program Director for review and follow up on items that need to be addressed and corrected. 05/31/2022 Implemented
6400.71The nearest fire department, Police station or ambulance phone number was not located on the phone list near the first floor telephone. 911 was also not listed on the emergency phone list.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. The nearest fire department, Police station or ambulance phone number was not located on the phone list near the first floor telephone. 911 was also not listed on the emergency phone list. A new emergency contact list was created to include the fire department, police station, and 911. Updated emergency list will be completed annually specific to each sites area by the office manager and will be handed out to the specific House Managers for each site. 04/08/2022 Implemented
6400.81(k)(6)There was no mirror located in Individual 5's bedroom.In bedrooms, each individual shall have the following: A mirror. There was no mirror located in Individual 5's bedroom. Another mirror was purchased for Individual #5's bedroom and placed in the room. Individual #5 discarded the first mirror in the trash after breaking it, documentation of the incident was not completed in the daily progress note or quarterly report by the Program Specialist. A review on proper reporting of daily events in the home and individually specific for each individual was completed. The review was for site staff and Program Specialist. Emphasis on reporting individuals behavior on progress notes as well as their behavior charts is imperative to the further support from the Behavior Specialist and Program Specialist to adjust support needs. Progress notes will be added to the quarterly audit of charts completed by the Program Director to ensure proper documentation is occurring. 04/15/2022 Implemented
6400.112(c)The 11/5/21 fire drill document does not list the evacuation time.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. The 11/5/21 fire drill document does not list the evacuation time. A review of properly documenting fire drills was completed with site lead staff who conducts the fire drills monthly for the site. The sites lead direct support professional will complete the monthly fire drill by the 15th of each month according to the yearly department rotation schedule, then will submit the drill to the House Manager for an accuracy review per the calendar directions prior to being logged in the department spreadsheet by the departments Administrative Assistant as completed and uploaded to the agency's Sharepoint system. Once the fire drill has been logged and upload a copy with a confirmation time stamp will be given to the House Manager to file in the sites fire drill logbook held on site. If the drill has been found to be completed in correctly it will be returned the following day to be redone prior to the end of the month correctly. The Department Director will audit the fire drills quarterly to ensure they are completed accurately per the department¿s yearly rotation calendar. 05/19/2022 Implemented
6400.141(c)(13)The Physical Examination Form dated 03/09/2022 for Individual 4 did not indicate if the individual had allergies/sensitivities to medication, this portion was omitted.The physical examination shall include: Allergies or contraindicated medications.The Physical Examination Form dated 03/09/2022 for Individual 4 did not indicate if the individual had allergies/sensitivities to medication, this portion was omitted.Shawn Johnson's annual physical examination form was completed to reflect if he has any allergies/sensitivity to medications. It was noted that S. Johnson has no known allergies/sensitivity to medications on 4/7/22. Program specialist will track annual appointments in a spreadsheet updated quarterly when completing quarterly reports. The Nurse will review all medical appointment documentation to ensure the forms are properly filled out prior to filing in individuals¿ medical charts. 04/08/2022 Implemented
6400.141(c)(14)Medical information pertinent to diagnosis and treatment in case of an emergency was left blank on the physical examination form dated 03/09/2022 for Individual 4.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Medical information pertinent to diagnosis and treatment in case of an emergency was left blank on the physical examination form dated 03/09/2022 for Individual 4. Individual #4's annual physical form has been corrected to reflect medical information pertinent to diagnosis and treatment in case of an emergency on 4/7/22. Program specialist will track annual appointments in a spreadsheet updated quarterly when completing quarterly reports. The Nurse will review all medical appointment documentation to ensure the forms are properly filled out prior to filing in individuals¿ medical charts. 04/08/2022 Implemented
6400.142(a)Individual 4 did not have a dental examination performed by a licensed dentist annually. Previous exam was conducted on 11/08/2018 and most current examination was completed 02/25/2022.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. Individual 4 did not have a dental examination performed by a licensed dentist annually. Previous exam was conducted on 11/08/2018 and most current examination was completed 02/25/2022. Refusal appointment forms were completed for the 2019 and 2021 year. Program Specialists will track annual required medical appointments within an agency database to ensure proper tracking of appointments within the regulated timeframe. Program Specialist will send out alerts a month prior to expirations to the house managers and Nurse to confirm appointments. The Nurse will make schedule all medical appointments and send out updates of upcoming appointments on the shared calendar. Once the appointment is completed all paperwork including refusal forms if the appointment was refused will be submitted to the Nurse for review prior to being filed in the medical chart. The Nurse will complete any follow up instructions left by the doctor on the medical appointment forms. 04/08/2022 Implemented
6400.144The Glucose Sugar Readings on the one touch device did not match the glucose log for Individual 4. There were missing dates not recorded or stored on the device but notated on the logbook. The device was missing recorded levels for 4/4/2022 PM, 3/18- 3/20 AM and PM, 3/27-3/29 AM and PM no dates were recorded. The sugar level on 4/3 read 85 on the device but 185 on the log book.Health 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. The Glucose Sugar Readings on the one touch device did not match the glucose log for Individual 4. There were missing dates not recorded or stored on the device but notated on the logbook. The device was missing recorded levels for 4/4/2022 PM, 3/18- 3/20 AM and PM, 3/27-3/29 AM and PM no dates were recorded. The sugar level on 4/3 read 85 on the device but 185 on the log book.Training was completed with Shawn Johnson and Lead DSP on 4/7/22 on how to properly use his blood sugar monitor and communicate the correct reading to staff to document as well as implement a two-step check process by staff to ensure the sugar was taken correctly and then document the correct numbers. 04/08/2022 Implemented
6400.18(i)The agency failed to finalize the incident reports through the Department's information management system within 30 days of discovery of an incident, nor did the agency request in writing that an extension is necessary and the reason for the extension. Incidents: 8989134 - Discovery date: 03/02/22- Neglect- Individual 5; 8987868 - Discovery date: 03/01/22 Behavi - Individual 4; 8986006 - Discovery date: 02/26/22- Neglect - Individual 4.The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension.The agency failed to finalize the incident reports through the Department's information management system within 30 days of discovery of an incident, nor did the agency request in writing that an extension is necessary and the reason for the extension. Incidents: 8989134 - Discovery date: 03/02/22- Neglect- Individual 5; 8987868 - Discovery date: 03/01/22 Behavi - Individual 4; 8986006 - Discovery date: 02/26/22- Neglect - Individual 4. The agency has been actively recruiting to hire a new quality assurance assistant to complete incident management oversight for the program. Until the vacant is filled the Program Director and VP will complete the incident management oversight for the Program. Incident management review will meet every Thursday to work on incident closures and follow ups. 05/27/2022 Implemented
6400.52(c)(1)It cannot be determined that the CEO's 2020/2021 annual training covered the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships, as documentation was not provided.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.It cannot be determined that the CEO's 2020/2021 annual training covered the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships, as documentation was not provided. The CEO's annual training tracking was updated with Human Resources to included the trainings for person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. A training session with the CEO to complete required trainings was scheduled to ensure his training compliance. 05/31/2022 Implemented
6400.52(c)(2)It cannot be determined that the CEO's 2020/2021 annual training covered the prevention, detection and reporting of abuse, suspected abuse and alleged abuse, as documentation was not provided.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.It cannot be determined that the CEO's 2020/2021 annual training covered the prevention, detection and reporting of abuse, suspected abuse and alleged abuse, as documentation was not provided. The CEO's annual training tracking was updated with Human Resources to included the trainings for the prevention, detection and reporting of abuse, suspected abuse and alleged abuse. A training session with the CEO to complete required trainings was scheduled to ensure his training compliance. 05/31/2022 Implemented
6400.52(c)(3)It cannot be determined that the CEO's 2020/2021 annual training covered individual rights, as documentation was not provided.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.It cannot be determined that the CEO's 2020/2021 annual training covered individual rights, as documentation was not provided. The CEO's annual training tracking was updated with Human Resources to included the trainings for individual rights A training session with the CEO to complete required trainings was scheduled to ensure his training compliance. 05/31/2022 Implemented
6400.52(c)(4)It cannot be determined that the CEO's 2020/2021 annual training covered recognizing and reporting incidents, as documentation was not provided.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.It cannot be determined that the CEO's 2020/2021 annual training covered recognizing and reporting incidents, as documentation was not provided.The CEO's annual training tracking was updated with Human Resources to included the trainings for recognizing and reporting incidents. A training session with the CEO to complete required trainings was scheduled to ensure his training compliance. 05/31/2022 Implemented
SIN-00200512 Unannounced Monitoring 02/18/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)The chair located in the dining room was damaged and not safe to sit in. Floors, walls, ceilings and other surfaces shall be free of hazards.The chair located in the dining room was damaged and not safe to sit in. Staff removed the damaged chair from the dinning room again and put it back in the trash. Individuals removed the chair from trash prior and continue to do so, Program Director spoke with them again about not picking through the house trash once outside and bringing it back inside. 02/18/2022 Implemented
6400.77(b)The first aid kit did not contain antiseptic. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. The first aid kit did not contain antiseptic. A new first aid kit was placed on site containing antiseptic, bandages, gauze, thermometer, tweezers, tape. The previous kit was placed in the staff office storage to use to refill the corrected kit as items are used. 02/18/2022 Implemented
6400.144Medication(s) TYENOL 500mg, MOTRIN 600mg, COLACE 100MG AND VENTOLIN prescribed to be taken as needed for individual 1 was not in the medication box at time of inspection. Management stated that the medication was just removed from the individual's med box this morning as it was expired. The current prescribed aforementioned medications were discovered at another location stored unsecurely prior to review.Health 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. Medication(s) TYENOL 500mg, MOTRIN 600mg, COLACE 100MG AND VENTOLIN prescribed to be taken as needed for individual 1 was not in the medication box at time of inspection. Management stated that the medication was just removed from the individual's med box this morning as it was expired. The current prescribed aforementioned medications were discovered at another location stored unsecurely prior to review. A medication check was completed the morning of 2/17/22 by the agency nurse, program director, and vp. New prn medication was ordered for individual 1 and was to be delivered that evening to the site. The previous medication was left in the box until the new medication arrived. The next morning the staff bought the old medication to the office thinking the new medication had been delivered there instead of the site. Once discovered the medication was not delivered to either the Program director contacted Robin at Willits to see if the medication had been sent out. Robin confirmed it was sent out but was sending out a new set since was an issue with the delivery. Later that morning the office received a call from the odp inspector that he was at one of our closed sites to do an unannounced visit and to inform us there was medication for individual 1 on the step. The director informed that was the medication we ordered the day before and had been looking for all morning and that we had just spoke with the pharmacy. The inspector said they would bring it over to the roosevelt site for us. The program Director contacted the pharmacy back to let them knwo the medication had been found at the old address due to the driver delivering it to the wrong address and not to send out anymore since we found the previous ones. When the odp inspector reached roosevelt the new medication was placed in the medication box. The vp went to retrieve the medication at the office the staff dropped off int he morning to switch out with the new medication due to the inspector wanting to see the old medication. When old medication reached roosevelt the inspector had left before it arrived and with out reviewing it. 02/17/2022 Implemented
6400.166(a)(13)The Medication CLARITIN 10mg was administered to individual 1 on 2/18/22, the staff that administered the medication did not initial the medication was given on the medication record for the 8am scheduled dose.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.The Medication CLARITIN 10mg was administered to individual 1 on 2/18/22, the staff that administered the medication did not initial the medication was given on the medication record for the 8am scheduled dose. The 8 am does was administered but the staff did not document his initials in the box as given. Staff was held accountable for not properly documenting the medication administration process. Staff will receive remediation training on 3/28/2022 with the agency medication trainer to review the documentation process. 02/21/2022 Implemented
6400.166(c)Medication CAPLYTA 42mg. was not administered as prescribed to individual 1 at the 8pm dosage time on 2/14/22, 2/15/22, 2/26/22 and 2/17/22. Management stated individual refused that medication. The Medication record was not documented that individual 1 refused the medication. The agency did not provide a report that the refusal was reported to the prescriber.If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual.Medication CAPLYTA 42mg. was not administered as prescribed to individual 1 at the 8pm dosage time on 2/14/22, 2/15/22, 2/16/22 and 2/17/22. Management stated individual refused that medication. The Medication record was not documented that individual 1 refused the medication. The agency did not provide a report that the refusal was reported to the prescriber. Individual started refusing the newly prescribed medication on 2/14 due to how it made him feel. On the third refusual the agency nurse at spoke with him about it and he said he didn't like the way it made him feel and after explaining that these were usual side effects individual 1 still refused the medication. The agency nurse contacted the psych doctor inregard to the refusals and the doctor want individual 1 to continue to take the medication until his next appointment on 3/24/22. The nurse informed individual 1 what the doctor said and he said he would try and take it until then. The staff were held accountable for not documenting the refusals as trained as well as like directed by the agency nurse to do for the days that individual refused the medication. Staff will receive remediation training the agency medication trainer on 3/28/22 to review the documenting process of medication administration. 02/21/2022 Implemented
SIN-00192835 Renewal 09/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)Sleep drills were not performed every six months.A fire drill shall be held during sleeping hours at least every 6 months. Sleep drills were not performed every six months, and a fire drill shall be held during sleeping hours at least every 6 months. Each home received a yearly rotation department fire drill calendar. The calendar was posted in each sites office and in the front of each sites fire drill log book as an attention bulletin on what type of drill and what time of day the drill is required for the drill of the month. The sites lead direct support professional will complete the monthly fire drill by the 15th of each month, then will submit the drill for an accuracy review prior to being logged in the department spreadsheet as completed and uploaded to the agency's Sharepoint system. 09/14/2021 Implemented
6400.112(f)At time of inspection the front door was used 11 out of 12 times for purposes of exit during fire drills. The only alternate exit was 12.20.2021 in the kitchen.Alternate exit routes shall be used during fire drills. At time of inspection the front door was used 11 out of 12 times for purposes of exit during fire drills. The only alternate exit was 12.20.2021 in the kitchen, sites with alternative exits will ensure use of the Alternate exit routes monthly during fire drills. Each home received a yearly rotation department fire drill calendar. The calendar was posted in each sites office and in the front of each sites fire drill log book as an attention bulletin on what type of drill, what exits to use if site has multiple exits, and what time of day the drill is required for the drill of the month. The sites lead direct support professional will complete the monthly fire drill by the 15th of each month, then will submit the drill for an accuracy review prior to being logged in the department spreadsheet as completed and uploaded to the agency's Sharepoint system. 09/14/2021 Implemented
SIN-00191706 Unannounced Monitoring 07/28/2021 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(4)The physical examination dated 6/28/21 omitted the individuals Vision and Hearing screenings for Individual #2.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. DIRECTED PLAN: The nurse will contact this individual's physician to inquire whether a vision/hearing screening is required and if so, the nurse will schedule the appointment. Documentation of this inquiry should be kept in the individual's record. The nurse will assess the medical needs of each individual served , prior to the admission of individuals, and on a quarterly basis to: · Ensure health care appointments are completed timely, recommendations are completed, and follow up care is received. · Make recommendations for additional supports to meet individual's needs. · Ensure individuals needs are accurately documented on all individual care plans including assessment 6400.181 and ISP 6400.183. VOA will ensure there is a current quarterly review for each individual served by January 3, 2022. Quarterly reviews for all individuals will be sent to ODP by January 3, 2022 01/03/2022 Accepted
6400.144The medication Nitrate 2% Cream for Individual #2 is not being administered as prescribed. The medication is to be administered twice daily. The medication was located in the individual's medication box not opened, the medication is listed on the MAR, staff is signing as though it was given, when it has not been administered.Health 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. DIRECTED PLAN The Agency Nurse will do a weekly audit of medications to ensure medications are given properly, that medications are available, and to dispose of expired or discontinued medications as specified in the November 24, 2020 Settlement Agreement, paragraph 14: Review of individual medication administration records to ensure that: · Individuals are receiving correct medications and dosages as listed on the pharmaceutical label · Medication errors are identified, reported, and the individual's physician was contacted and recommended next steps are documented. The initial weekly review will be sent to licensing by Thursday, December 23, 2021. VOA will update the IDS Site Med Checks form to be completed weekly by the agency nurse and submitted to the agency director. The form shall be modified to include a description of any issues noted and documentation of their resolution. The updated checklist will be sent to ODP by Thursday, December 23, 2021. VOA will develop a written procedure for reporting, categorizing and analyzing medication issues discovered by the nurse (beyond entering reportable incidents into EIM) which will include: · When staff will be retrained · Who will retrain staff Documentation of the information noted above will be maintained by VOA and will include how and when issues have been corrected/resolved. This procedure will be submitted to ODP by January 3, 2022 The agency director will review the weekly med check forms on a monthly basis and create a plan for managing any home or agency deficiencies and remediation actions if there are staff with multiple medication errors. This shall occur within 10 days, after the end of the month. This will be sent to ODP no later than the 10th day of the following month. 12/23/2021 Accepted
6400.212(a)Individual #2's record was not updated with general information also did not include Individual #2's face sheet and when moving to new location. A separate record shall be kept for each individual. Individual #2's record was not updated with general information also did not include Individual #2's face sheet and when moving to new location. The Program Specialist completed an update on Individual #2's face sheet as requested and filed it in the program file. 07/29/2021 Implemented
6400.163(h)The medication Triamcinolone Cream for Individual #2 was found in the medication box at time of inspection, the medication had expired on 04/29/21.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.DIRECTED PLAN The Agency Nurse will do a weekly audit of medications to ensure medications are given properly, that medications are available, and to dispose of expired or discontinued medications as specified in the November 24, 2020 Settlement Agreement, paragraph 14: Review of individual medication administration records to ensure that: · Individuals are receiving correct medications and dosages as listed on the pharmaceutical label · Medication errors are identified, reported, and the individual's physician was contacted and recommended next steps are documented. The initial weekly review will be sent to licensing by Thursday, December 23, 2021. VOA will update the IDS Site Med Checks form to be completed weekly by the agency nurse and submitted to the agency director. The form shall be modified to include a description of any issues noted and documentation of their resolution. The updated checklist will be sent to ODP by Thursday, December 23, 2021. VOA will develop a written procedure for reporting, categorizing and analyzing medication issues discovered by the nurse (beyond entering reportable incidents into EIM) which will include: · When staff will be retrained · Who will retrain staff Documentation of the information noted above will be maintained by VOA and will include how and when issues have been corrected/resolved. This procedure will be submitted to ODP by January 3, 2022 The agency director will review the weekly med check forms on a monthly basis and create a plan for managing any home or agency deficiencies and remediation actions if there are staff with multiple medication errors. This shall occur within 10 days, after the end of the month. This will be sent to ODP no later than the 10th day of the following month. 12/23/2021 Accepted
6400.165(c)The medication Nitrate 2% Cream for Individual #2 is not being administered as prescribed. The medication is to be administered twice daily. The medication was located in the individual's medication box not opened, the medication is listed on the MAR, staff is signing as though it was given, when it has not been administered.A prescription medication shall be administered as prescribed.DIRECTED PLAN The Agency Nurse will do a weekly audit of medications to ensure medications are given properly, that medications are available, and to dispose of expired or discontinued medications as specified in the November 24, 2020 Settlement Agreement, paragraph 14: Review of individual medication administration records to ensure that: · Individuals are receiving correct medications and dosages as listed on the pharmaceutical label · Medication errors are identified, reported, and the individual's physician was contacted and recommended next steps are documented. The initial weekly review will be sent to licensing by Thursday, December 23, 2021. VOA will update the IDS Site Med Checks form to be completed weekly by the agency nurse and submitted to the agency director. The form shall be modified to include a description of any issues noted and documentation of their resolution. The updated checklist will be sent to ODP by Thursday, December 23, 2021. VOA will develop a written procedure for reporting, categorizing and analyzing medication issues discovered by the nurse (beyond entering reportable incidents into EIM) which will include: · When staff will be retrained · Who will retrain staff Documentation of the information noted above will be maintained by VOA and will include how and when issues have been corrected/resolved. This procedure will be submitted to ODP by January 3, 2022 The agency director will review the weekly med check forms on a monthly basis and create a plan for managing any home or agency deficiencies and remediation actions if there are staff with multiple medication errors. This shall occur within 10 days, after the end of the month. This will be sent to ODP no later than the 10th day of the following month. 12/23/2021 Accepted
6400.181(f)The ISP meeting was held 3/20/20 for individual #2 and the assessment was not sent 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.The ISP meeting was held 3/20/20 for individual #2 and the assessment was not sent 30 days prior to the meetingDates will be tracked so that assessments go out to SC providers a month prior to the annual review date. Program specialist received training on 12/10 and 12/18 on regulations for timeframes that assessments and quartiles must go out to SC providers with a printout of the email to confirm documentation was sent. Program specialist were also trained that are to send out assessment based off of annual review date and not to wait until they hear from an SC who schedule ISPs late to ensure the agency remains within compliance. Program Specialist will receive monthly trainings and audits of charts to ensure understanding of required position functions and 6400 regulations. Program specialist will track annual required reports for individuals to ensure that assessments are being completed annually and dates remain in compliance. 08/10/2021 Implemented
SIN-00174174 Unannounced Monitoring 07/20/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144The medication for individual#1-Zestil 5mg tablet, which is given at 8am indicates that it should be held if the SBP is<90. A record of SBP being taken prior to administering medication was not available during inspection.Health 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. The medication for individual#1-Zestil 5mg tablet, which is given at 8am indicates that it should be held if the SBP is<90. A record of SBP being taken prior to administering medication was not available during inspection. The house manager misplaced the treatment form for the blood pressure tracking. The house manager was held responsible for the misplacement of the form. As of 7/20 the site will now document the blood pressure readings on the MAR every morning prior to the administration of the Zestril 5mg 8am dose. If the reading is greater then 90 the MAR will be documented to show the holding of the medication. House manager will check the MARS daily during site checks to ensure proper documentation and administration of medication 07/21/2020 Implemented
SIN-00165361 Renewal 10/30/2019 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The top of the refrigerator was covered in a black substance consistent with grease and dust. There was a plate of food in the microwave oven with French fries and part of a sandwich. Individual 1 stated at the time of inspection, that the food was there since the previous day.Clean and sanitary conditions shall be maintained in the home. The top of the refrigerator was covered in a black substance consistent with grease and dust. There was a plate of food in the microwave oven with French fries and part of a sandwich. Individual 1 stated at the time of inspection, that the food was there since the previous day. The top of the refrigerator was cleaned.Staff received additional on site orientation training reviewing regulation requirements on site cleanliness. House manager will check site cleanliness during site checks while completing environmental checks of the site weekly. 12/06/2019 Not Implemented
6400.66There was no light in the bathroom located in the basement.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. There was no light in the bathroom located in the basement. Individuals will be emergency moved while the process of having the site repaired to be within guidelines is occurring. Due to safety reasons individual 1 will be moved to another a site temporarily while repairs are being completed since the repairs will require the individuals evacuation. 12/11/2019 Not Accepted
6400.67(a)During physical site inspection the following was not in good repair: One of the lower cabinets in the kitchen was detached from the bottom hinge causing it to be unstable and unable to be closed. There was paint chipping on the living room wall by the window. There was paint chipping and peeling from the wall going up the stairway to the second floor. The bathroom located in the foyer of the home had a sink that was disconnected from the wall. There was a hole in the wall of a bedroom.Floors, walls, ceilings and other surfaces shall be in good repair. During physical site inspection the following was not in good repair: One of the lower cabinets in the kitchen was detached from the bottom hinge causing it to be unstable and unable to be closed. There was paint chipping on the living room wall by the window. There was paint chipping and peeling from the wall going up the stairway to the second floor. The bathroom located in the foyer of the home had a sink that was disconnected from the wall. There was a hole in the wall of a bedroom. Individuals will be emergency moved while the process of having the site repaired to be within guidelines is occurring. Due to safety reasons individual 1 will be moved to another a site temporarily while repairs are being completed since the repairs will require the individuals evacuation. 12/11/2019 Not Accepted
6400.68(b)The water in the bathroom tub of the main bathroom of the home was tested and found to be 127 degrees Fahrenheit.[Repeated Non-Compliance 2/4/19] Hot water temperatures in bathtubs and showers may not exceed 120°F. The water in the bathroom tub of the main bathroom of the home was tested and found to be 127 degrees Fahrenheit. Individuals will be emergency moved while the process of having the site repaired to be within guidelines is occurring. Due to safety reasons individual 1 will be moved to another a site temporarily while repairs are being completed since the repairs will require the individuals evacuation. 12/11/2019 Not Accepted
6400.72(b)The front door to the home had a torn screen window. and The screen door to the home had one Jalousie window missing. Screens, windows and doors shall be in good repair. The front door to the home had a torn screen window. and The screen door to the home had one Jalousie window missing. Individuals will be emergency moved while the process of having the site repaired to be within guidelines is occurring. Due to safety reasons individual 1 will be moved to another a site temporarily while repairs are being completed since the repairs will require the individuals evacuation. 12/11/2019 Not Accepted
6400.77(b)There was no thermometer in the found in the first aid kit. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. There was no thermometer in the found in the first aid kit. Thermometer was placed in the site first aid kit. House manager will check first aid kit during site checks while completing environmental checks weekly at the site to ensure all required items are present in the kit . 12/06/2019 Not Implemented
6400.113(a)General Fire safety training was not completed annually for the year 2018 , documentation of training on 1/29/19 was the most recent training but no prior record existed for individual 1. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. General Fire safety training was not completed annually for the year 2018 , documentation of training on 1/29/19 was the most recent training but no prior record existed for individual 1. Fire safety training will be completed with individual 1 to ensure compliance with annual regulation requirements. Target month for each following year will be in December to ensure every individual is up to date on training. 12/11/2019 Not Accepted
6400.114(a)Physical exam for individual 1 was not completed annually. 3/19/18 was the previous completed annual physical exam and the current physical was completed late on 4/23/19.If an individual or staff person smokes at the home, there shall be written smoking safety procedures. Physical exam for individual 1 was not completed annually. 3/19/18 was the previous completed annual physical exam and the current physical was completed late on 4/23/19. Program specialist will track annual physical dates in agency database to ensure continued compliance. 12/09/2019 Not Accepted
6400.141(c)(3)Immunizations for Hepatitis for individual 1 were not listed on most recent physical dated 4/23/19. Also, the dates for immunization were not found in the record.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. Immunizations for Hepatitis for individual 1 were not listed on most recent physical dated 4/23/19. Also, the dates for immunization were not found in the record. Individual 1 completed tb appointment on 12/9/2019 . Program specialist will track annual physical dates along with annual immuization dates in agency database to ensure continued compliance. 12/09/2019 Not Implemented
6400.141(c)(6)The Tuberculosis test was last completed on 11/19/18 but was never read with negative results. The date is unknown date for the prior negative Tuberculosis reading in order to measure two year compliance.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. The Tuberculosis test was last completed on 11/19/18 but was never read with negative results. The date is unknown date for the prior negative Tuberculosis reading in order to measure two year compliance. Individual 1 completed tb appointment on 12/9/2019 and will have results read on 12/11/2019. Program specialist will track annual physical dates along with tb testing dates in agency database to ensure continued compliance. 12/09/2019 Not Implemented
6400.141(c)(10)Communicable disease was left blank on the physical dated 4/23/19, unknown if individual 1 is free of communicable diseaseThe physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. Communicable disease was left blank on the physical dated 4/23/19, unknown if individual 1 is free of communicable disease. Physical paperwork for individual 1 was faxed to doctors office to be corrected to include the communicable disease section. Paperwork will be picked up on 12/11/2019 Program specialist will review all physical paperwork when submitted to ensure its fully completed. 12/09/2019 Not Accepted
6400.142(a)Dental exam for individual 1 was not completed annually, 4/9/18 was last completed exam.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. Dental exam for individual 1 was not completed annually, 4/9/18 was last completed exam. Annual dental exam has been scheduled and was completed on 11/4/2019 . Program Specialist will track annual dates in the agency database to ensure continual compliance 11/04/2019 Not Accepted
6400.144The following medication prescribed to individual 1 was not available at the time of physical site inspection: Drysol Solution, Mederma Ag Facial Toner, Motrin, and the individual's Ventolin Inhaler The most recent Vision exam dated 11/1/2018 stated from physician that a follow up appointment is requested in 6 months. As of 10/31/2019 no follow up exam has been scheduled for individual 1.Health 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. The following medication prescribed to individual 1 was not available at the time of physical site inspection: Drysol Solution, Mederma Ag Facial Toner, Motrin, and the individual's Ventolin Inhaler The most recent Vision exam dated 11/1/2018 stated from physician that a follow up appointment is requested in 6 months. As of 10/31/2019 no follow up exam has been scheduled for individual 1. All missing medication have been refilled and placed on site for prescribed administration. Incident reports will be entered into EIM for missing medication. Vision exam was completed 11/7/2019 . House managers will complete full med checks during site visits while completing environmental checks weekly at the site.House managers will schedule all follow up appointments per doctors request. 11/08/2019 Not Implemented
6400.168(d)Staff 1 does not have a current annual medication certification. The last annual practicum was completed on March 2016. Documentation of medication training that is more up to date was not been received and kept.A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. Staff 1 does not have a current annual medication certification. The last annual practicum was completed on March 2016. Documentation of medication training that is more up to date was not been received and kept. Staff have been retrained on medication administration and received 4 aberrations to be certified. All staff are being retrained in medication administration. Practicum observers will complete annual certification process to ensure continued compliance in medication administration for staff. 12/06/2019 Not Accepted
6400.181(a)Assessment for individual 1 was not completed annually, 2/22/18 was previous assessment, the current assessment was updated, completed and dated late on 6/22/19. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Assessment for individual 1 was not completed annually, 2/22/18 was previous assessment, the current assessment was updated, completed and dated late on 6/22/19. Program specialist training is scheduled for 12/10/2019 to review regulatory requirements for individual reports and documentation. Program Specialist will track annual dates of required documentation in a agency database to ensure annual dates remain in compliance . 12/09/2019 Not Accepted
6400.181(e)(7)Knowledge of heat sources other than water temperature regulation was not discussed in individual 1's assessment dated 6/22/19The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. Knowledge of heat sources other than water temperature regulation was not discussed in individual 1's assessment dated 6/22/19. Program Specialist updated individual 1's assessment to reflect knowledge of heat sources other than water temperature regulation. Program specialist training is scheduled for 12/10/2019 to review regulatory requirements for individual reports and documentation. 12/10/2019 Not Accepted
6400.183(5)There was no protocol to address the SEEP (social, environmental and emotional protocol of psychotropic medication haloperidol and benztropine medication currently prescribed for individual 1.The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. There was no protocol to address the SEEP (social, environmental and emotional protocol of psychotropic medication haloperidol and benztropine medication currently prescribed for individual 1. Program specialist developed a SEEP plan for individual 1 and included it in their file and shared it with the sc. The SEEP plan will be updated annually at the same time of the annual assessment by program specialist. 12/09/2019 Not Implemented
6400.163(d)There were packs of aspirin in the first aid kit which was unlocked in a closet, accessible to individuals in the home. The individual can not self medicate.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.There were packs of aspirin in the first aid kit which was unlocked in a closet, accessible to individuals in the home. The individual can not self medicate. The first aid kit was checked and the aspirin was removed and disposed of. House managers will complete checks of the first aid kits during site checks while completing environmental checks weekly to ensure the required regulatory items are present in the first aid kit. 10/31/2019 Not Implemented
6400.165(g)The 3 month review for psychotropic medications benztropine and haloperidol was not completed timely, the last review was dated on 1/23/19 and it was filled out incompletely.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.The 3 month review for psychotropic medications benztropine and haloperidol was not completed timely, the last review was dated on 1/23/19 and it was filled out incompletely. Individual 1 90 day review has been scheduled. Program specialist will track 90 day appointment dates and ensure that the appointments are scheduled and paperwork is turned in and filed. Programs specialist will update the agency database with appointment follow up dates and request. 12/09/2019 Not Accepted
6400.166(b)The following medication was not recorded in the medication record at the time the medication was administered for individual 1: Cogentin .5 mgs was not signed for on 10/4/19; Desyrel 50 mg 8pm was not signed for on 10/4/19; Drysol Solution 8pm mgs was not signed for the entire month of October 2019; Mederma Ag Facial Toner was not signed for after 10/6/19 for the rest of the month; Nizaral 2% cream was not signed for on 10/4/19, 10/25, 10/26, 10/27, 10/28, and 10/29/19; Xalantan Eye Drops was not signed for on 10/1/19 and 10/2/19; Lachydrin 12 % cream 8 am was not signed for on 10/26, 10/27, 10/28, 10/30/19; During the month of October, only one staff placed their signature and initials on the back of the medication record to show who they were. Several other staff who initialed the front of the record did not indicate their names on the back.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The following medication was not recorded in the medication record at the time the medication was administered for individual 1: Cogentin .5 mgs was not signed for on 10/4/19; Desyrel 50 mg 8pm was not signed for on 10/4/19; Drysol Solution 8pm mgs was not signed for the entire month of October 2019; Mederma Ag Facial Toner was not signed for after 10/6/19 for the rest of the month; Nizaral 2% cream was not signed for on 10/4/19, 10/25, 10/26, 10/27, 10/28, and 10/29/19; Xalantan Eye Drops was not signed for on 10/1/19 and 10/2/19; Lachydrin 12 % cream 8 am was not signed for on 10/26, 10/27, 10/28, 10/30/19; During the month of October, only one staff placed their signature and initials on the back of the medication record to show who they were. Several other staff who initialed the front of the record did not indicate their names on the back. Staff have been identified and will be held accountable for not documenting correctly. Staff have been retrained on medication administration and certified to administer medication. Practicum observers will complete annual certification process to ensure continual compliance. 12/09/2019 Not Accepted
SIN-00150069 Renewal 02/04/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)There was no documentation to show that a self-assessment was done 3-6 months prior to the license expiration.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. a) The Program Director will ensure the completion of a self-assessment of each home the agency operates serving eight or fewer individuals, within 3to 6 months prior to expiration date of the agency's certificate of compliance. b) The licensing inspection instrument for the community homes for individuals with an intellectual disability regulations to measure and record compliance. c) The Program Director shall maintain copy of the agency's self-assessment results and a written summary of at least 1 year. 04/01/2019 Implemented
6400.46(e)Staff person #1 was hired on 5/12/18 but completed ID training on 7/9/18 which is past 30 calendar days after the initial day of employment.Program specialists and direct service workers shall have training in the areas of intellectual disability, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. a) All new hires will attend administrative new hire training prior to working with the individuals. b) New hires who are permitted to forgo the administrative new hire training will participate in the IDS training plan no than 3 weeks after the date of hire. c) Training is tracked by Quality Assurance to ensure compliance in this area. d) Staff that have been identified without training within 21 days of the their start date, will be remove from the working schedule until all required trainings have been completed. 03/31/2019 Implemented
6400.112(a)The fire drill record was missing for September 2018 An unannounced fire drill shall be held at least once a month. Fire drills at each will be : Recorded including date, time, time required for evacuation, and number of persons taking part upon completion of each fire drill. a) The Site Manager will sign each drill verifying the completion of all required fields. b) The Program Director shall ensure that fire drills are reviewed at the weekly core team meeting. c) QA will review all fire drills monthly to ensure accuracy and completion of all required documentation. 02/28/2019 Implemented
6400.112(e)The only sleep fire drill for 2018 was completed on 3/31/2018.A fire drill shall be held during sleeping hours at least every 6 months. A fire drill shall be held during sleep hours at least every 6 months. a) The monthly fire drill report will have prompts to state the exact month the sleeping drill takes place throughout the calendar year. b) The Site Manager will sign each drill verifying the completion of all required fields. c) The Program Director shall ensure the fire drills are reviewed at the weekly core team meeting. d) QA will review all fire drills monthly to ensure accuracy and completion of all required documentation. 02/28/2019 Implemented
6400.141(c)(6)There was no clear documentation of the date the Tuberculin shot was administered and read. Date of administration was 12/18/17 and date read was 12/20/18 for individual #1.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. a) The program will track annual physicals by date for each staff employed under the 6400 regulations via spreadsheet review on a monthly basis; to ensure regulatory compliance. b) A new hire file review will take place 7 days after the date of hire to ensure all required regulatory documentation (physicals) is present by Human Resources. Each staff member out of compliance will be removed from the schedule until the records reflect compliance 03/31/2019 Implemented
6400.151(a)There was no documentation to show that staff person #1 completed a physical exam. 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. a) A new hire file review will take place 7 days after the date of hire to ensure all required regulatory documentation (physicals) is present by Human Resources. Each potential staff member out of compliance will be unable to start working until the records reflect compliance. b) The program will track annual physicals by date for each staff employed under the 6400 regulations via spreadsheet review on a monthly basis to ensure regulatory compliance. 03/31/2019 Implemented
6400.151(c)(2)There was no documentation to show that staff person #1 completed a Tuberculin screening. 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. a) The program will track annual physicals by date for each staff employed under the 6400 regulations via spreadsheet review on a monthly basis; to ensure regulatory compliance. b) A new hire file review will take place 7 days after the date of hire to ensure all required regulatory documentation (physicals) is present by Human Resources. Each staff member out of compliance will be removed from the schedule until the records reflect compliance 03/31/2019 Implemented
6400.186(a)There was no documentation to show that Individual #1's ISP dated 4/12/18 was reviewed every three months.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. ISP's shall be reviewed every 3 months or more with the consumer: a) Program Specialist will ensure the completion of a documented quarterly review of the individual' progress. b) Quality Assurance will complete quarterly audits to ensure the documentation in each client file meets the regulatory requirements. c) The Program Director will meet with the Program Specialist monthly to evaluate the completion of the required documentation 04/06/2019 Implemented
6400.213(1)(i)Individual #1's record did not include eye color and hair color.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. The Client's face sheet will possess all of the required information listed under 6400.213(1) (i). The Program Specialist will update the client face sheet & emergency packet including the following information: a. Client name b. sex c. date of birth d. social security number e. language or means of communication f. race/ethnicity g. height h. weight i. eye color j.hair color k. religious affiliation l. any scars or marks m. next of kin n. dated photograph o. list of physicians and contact information p. current list of medication Quality Assurance will complete quarterly audits to ensure the documentation in each client file meets the regulatory requirements The Program Director will meet with the Program Specialist monthly to evaluate the completion of the required documentation. 03/31/2019 Implemented
6400.213(1)(i)Individual #1's file did not include religious affiliation.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. The Client's face sheet will possess all of the required information listed under 6400.213(1) (i). The Program Specialist will update the client face sheet & emergency packet including the following information: a. Client name b. sex c. date of birth d. social security number e. language or means of communication f. race/ethnicity g. height h. weight i. eye color j.hair color k. religious affiliation l. any scars or marks m. next of kin n. dated photograph o. list of physicians and contact information p. current list of medication Quality Assurance will complete quarterly audits to ensure the documentation in each client file meets the regulatory requirements The Program Director will meet with the Program Specialist monthly to evaluate the completion of the required documentation. 03/31/2019 Implemented
SIN-00126780 Renewal 10/03/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(c)Staff #1 does not meet the qualifications required for the position of Program Specialist. Staff #1 did not have the 2 years of experience working directly with persons with intellectual disabilities required for a person possessing a Bachelor's Degree. A program specialist shall have one of the following groups of qualifications: (1) A master's degree or above from an accredited college or university and 1 year work experience working directly with persons with intellectual disability. (2) A bachelor's degree from an accredited college or university and 2 years work experience working directly with persons with intellectual disability. (3) An associate's degree or 60 credit hours from an accredited college or university and 4 years work experience working directly with persons with intellectual disability.Upon review of program specialist's experience, Staff #1 did not meet the qualifications required for the position of Program Specialist prior to employment. Staff #1 did not have the 2 years of experience working directly with persons with intellectual disabilities required for a person possessing a Bachelor's Degree prior to employment. Staff #1 was hired on 9/14/2015. The individual now has 2 years and 5 month experience working with individuals with intellectual disability. Staff # 1 also has a bachelor¿s degree from accredited college or university. Volunteers of America Delaware Valley will ensure to comply with all program specialist qualifications as provided by Chapter 6400.44(c) regulations. 10/01/2017 Implemented
6400.46(h)Staff #1's most recent First Aid training occurred on 9/15/15.Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home, shall be trained before working with individuals in first aid techniques. Volunteers of America Delaware Valley, Intellectual Disabilities Services program requires all employees to fulfill training requirements per policy and procedures. CPR/First Aid/AED Life Safety training is a mandated requirement from our agency and funding source. Upon review, staff member # 1 was found non-complaint. The immediate supervisor has been tasked to provide the employee with the proper CPR/First Aid/AED Life Safety training. Staff member #1 has fulfilled their training compliance on 10/4/2017. In addition, a tracking system has been implemented to ensure continued compliance of all program mandated trainings. This training tracking system will be reviewed quarterly by the Quality Assurance Coordinator. Please see attachment:6400 CAP HR Items 10/04/2017 Implemented
6400.46(i)Staff #1's most recent CPR/Heimlich training occurred on 9/15/15.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. Volunteers of America Delaware Valley, Intellectual Disabilities Services program requires all employees to fulfill training requirements per policy and procedures. CPR/First Aid/AED Life Safety training is a mandated requirement from our agency and funding source. Upon review, staff member # 1 was found non-complaint. The immediate supervisor has been tasked to provide the employee with the proper CPR/First Aid/AED Life Safety training. Staff member #1 has fulfilled their training compliance on 10/4/2017. In addition, a tracking system has been implemented to ensure continued compliance of all program mandated trainings. This training tracking system will be reviewed quarterly by the Quality Assurance Coordinator.Please see attachment:6400 CAP HR Items 10/04/2017 Implemented
6400.64(a)Individual #1's bathroom shower had a substance consistent with mildew on the grout and shower tiles.Clean and sanitary conditions shall be maintained in the home. It is the policy of Volunteers of America Delaware Valley that all sites remain clean and clutter free at all times. Following the inspection the bathroom shower have been cleaned and cleared of all mildew. Health and Safety check are completed on a monthly basis to monitor the cleanliness of each home. Please see attachment: Blvd bathroom. It is the expectation that all sites maintain clean and sanitary conditions within the home at all times. Volunteers of America Delaware Valley will ensure the upkeep of personal living areas and housekeeping related task. All sites shall remain in good repair and free of hazards. 10/09/2017 Implemented
6400.67(a)A kitchen cabinet drawer was missing.Floors, walls, ceilings and other surfaces shall be in good repair. A work order was entered for Volunteers of America Delaware Valley maintenance to fix the broken drawer. The work order was completed on January 26, 2018. Please see attachment 3. It is the expectation that all sites maintain clean and sanitary conditions within the home at all times. Volunteers of America Delaware Valley will ensure the upkeep of personal living areas and housekeeping related task. All sites shall remain in good repair and free of hazards. 01/26/2018 Implemented
6400.81(k)(1)Individual #2's bedframe was broken.In bedrooms, each individual shall have the following: A bed of size appropriate to the needs of the individual. Cots and portable beds are not permitted. Bunkbeds are not permitted for individuals 18 years of age or older. It is the expectation that all sites maintain clean and sanitary conditions within the home at all times. Volunteers of America Delaware Valley will ensure the upkeep of personal living areas and housekeeping related task. All sites shall remain in good repair and free of hazards. The bedroom frame has since been removed from the property and discarded. The room has been furnished with a new bedroom set which includes a headboard, footboard, dresser and mirror. Please see attachment: Blvd Room Photo. 11/30/2017 Implemented
6400.151(a)Staff #1's most recent physical examination occurred on 7/20/15. 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. It is the policy of Volunteers of America Delaware Valley, Intellectual Disabilities Services, that all staff provides written physical examination and tuberculosis screening documentation by a licensed physician. The examination must indicate the individual is free from other communicable diseases and has no other contagious diseases or medical problems. Upon inspection, records indicate staff #1 failed to have documented full medical clearance on file. Staff member# 1 provided documentation verifying compliance effective October 18, 2017. The documentation provided shows proof of a current physical examination with results from a tuberculin skin test. Human resources have implemented an annual check of health screening compliance based on each staff's anniversary date. Please see attachment: 6400 CAP HR Items 10/18/2017 Implemented
6400.151(c)(2)Staff #1's most recent TB test occurred on 9/04/15. 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. It is the policy of Volunteers of America Delaware Valley, Intellectual Disabilities Services, that all staff provides written physical examination and tuberculosis screening documentation by a licensed physician. The examination must indicate the individual is free from other communicable diseases and has no other contagious diseases or medical problems. Upon inspection, records indicate staff #1 failed to have documented full medical clearance on file. Staff member# 1 provided documentation verifying compliance effective October 18, 2017. The documentation provided shows proof of a current physical examination with results from a tuberculin skin test. Human resources have implemented an annual check of health screening compliance based on each staff's anniversary date. Please see attachment: 6400 CAP HR Items 10/18/2017 Implemented
SIN-00096488 Renewal 07/11/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment was not completed 3 to 6 months before the expiration of the license. The self-assessment was completed on 3/18/16The 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. In an effort to measure and record compliance, Volunteers of America will complete a self assessment of each home, within 3 to 6 months of the expiration date of our certificate of compliance. A copy of our self assessment results with a written summary of corrections made will be kept on record for at least one year. Volunteers of America Delaware Valley Intellectual Disabilities Services¿ self assessments are complete to date, and are in compliance with the 3 to 6 months requirement. 11/21/2016 Implemented
SIN-00047352 Renewal 03/21/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.18(b)The provider's Unusual Incident policy did not include any procedure on prevention.(b) Written policies and procedures on the prevention, reporting, investigation and management of unusual incidents shall be developed and kept at the home. The provider has updated the unusual incident policy to include procedure on prevention. Effective 5/1/13 . All employees will be trained on the policy and the QE Director will minitor complicnce. 04/01/2013 Implemented
6400.44(b)(1)The program specialist was not informed of the position¿s responsibilities. (b) The program specialist shall be responsible for the following: (1) Coordinating and completing assessments. The provider has updated org chart and job description for the Program Coordinator who is responsible for coordinating and completing assessments. The program specialist has been informed of the position's responsibilities. 04/01/2013 Implemented
6400.46(g)Staff #1 received fire safety training on 12/5/12, but was not trained by a fire safety expert. (g) Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). Provider will ensure that all staff are trained annually by a fire safety expert in the training areas specified in subsection (f). Training was completed by the Phila Fire Dept. on 4/15/13. The QE Director will minitor the training system. 04/15/2013 Implemented
6400.103The provider's Emergency Evacuation Procedure did not include a means of transportation or an emergency shelter location. There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. Provider has updated all related polices, a means of transportation and emergency shelter location as been added to the policies. Effective 5/1/13 . All employees will be trained on the policy and the QE Director will minitor complicnce. 04/01/2013 Implemented
6400.143(a)Individual #1 refused a prostate exam on 2/27/13; there was no refusal plan developed.(a) If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. Provider will ensure that all consumers that refuses medical or dental appointments, that there is a refusal plan developed. A refusal plan was developed for Individual # 1 and a follow up prostate exam is scheduled for August 27, 2013. 04/01/2013 Implemented
6400.145(1)The provider's written Emergency Medical Plan did not include a hospital or source of health care to be used in an emergency. The home shall have a written emergency medical plan listing the following: (1) The hospital or source of health care that will be used in an emergency. Provider has updated all related polices, as it relates to the Emergency Medical Plan. Hospitals that are in close proximity to our homes have been identified and added to the policy. Effective 5/1/13 . All employees will be trained on the policy and the QE Director will minitor complicnce. 04/01/2013 Implemented
6400.151(c)(2)Employee #1's annual physical dated 7/30/11, did not include tuberculin screening.(2) 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. Provider will ensure that all staff will have a physical examination within 12 months prior to employment and every 2 years thereafter. The examination will include a screening for tuberculosis and other communicable diseases, a statement from the physician that the staff member has no contagious diseases, and information on any medical problems which might interfere with the health of the clients. A physical dated 8/2/11 indicates that employee #1 had TB screening with negative results. 04/30/2013 Implemented
6400.168(d)Staff #1's annual Medication Administration Practicum dated 12/5/12 was completed by Staff #2 who is a Medication Administration Practicum Observer who was not trained as required by the Department¿s Training Curriculum¿s criteria. (d) A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. Provider will ensure that all staff that administers prescription medicaiton and insulin injections to an individual shall complete and pass the Medication Administration Course Practicum annually. All staff that administer medication was retrained on March 27-28. All Pracicum Observers were retrained on April 15, 2013. The QE Director will monitor this system. 04/15/2013 Implemented
6400.192The provider's Restrictive Procedures did not include information on who may authorize the use of restrictive procedures, or mechanisms to monitor and control the use; nor did it include a process for the individual or family to review the use. A written policy that defines the prohibition or use of specific types of restrictive procedures, describes the circumstances in which restrictive procedures may be used, the persons who may authorize the use of restrictive procedures, a mechanism to monitor and control the use of restrictive procedures and a process for the individual and family to review the use of restrictive procedures shall be kept at the home. The provider as updated all policies as it relates to restrictive procedures plan. Effective 5/1/13 . All employees will be trained on the policy and the QE Director will minitor complicnce. 04/01/2013 Implemented
SIN-00222638 Renewal 04/05/2023 Compliant - Finalized
SIN-00084792 Renewal 03/25/2015 Compliant - Finalized
SIN-00061827 Renewal 03/03/2014 Compliant - Finalized