Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00222640 Renewal 04/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The bathroom ceiling has water damage (paint peeling) that needs repair.Floors, walls, ceilings and other surfaces shall be in good repair. The bathroom ceiling has water damage (paint peeling) that needs repair.Floors, walls, ceilings and other surfaces shall be in good repair.Staff reported the needed repairs to the Leasing office on March 20th. A walkthrough with the Facilities Manager on March 30th, and he stated the office will reach out to schedule the repairs. All reported repairs were completed between April 3rd -April 17th.A picture was taken once completed and will be submitted in the supporting documentation email. House managers will check the condition of the sites appliances during site checks while completing environmental checks weekly for the site. House Managers will report any discovered needed repairs to the leasing office and schedule a repair appointment. Staff received additional on-site orientation training on regulation requirements regarding site conditions on 4/11/23. 04/18/2023 Implemented
6400.70The phones in the home are inoperable. The staff contacted the office to ascertain a backup phone to be delivered today until they can have Comcast come out and investigate the situation.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. The phones in the home are inoperable. The staff contacted the office to ascertain a backup phone to be delivered today until they can have Comcast come out and investigate the situation. A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. An appointment was scheduled with Verizon on 4/3/23 for phone line repair on 4/4/23 at 3:00pm. IT placed company cell phones at the site as a means of a temporary phone line until the phone line was repaired the following day. .A picture was taken by IT of the company cell phone placed on site and will be submitted in the supporting documentation email. House managers will check all phones within the sites during site checks while completing environmental checks weekly for the site. House Managers will report any discovered needed repairs to the responsible repairing entity and schedule a repair appointment. Staff received additional on-site orientation training on regulation requirements regarding site conditions on 4/11/23. 04/04/2023 Implemented
SIN-00203234 Renewal 04/05/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)Individual 3's last Annual Physical Examination was conducted on 10/09/2020, their current physical was not completed until 11/02/2021 rendering the physical not completed annually.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual 3's last Annual Physical Examination was conducted on 10/09/2020, their current physical was not completed until 11/02/2021 rendering the physical not completed annually. Individual #3 primary physician due to covid -19 was only completing tele health during the time the physical was to be renewed and the office did not give a physical appointment until November. Documentation from the doctors office of scheduling perimeters has been included in the supporting documentation.Program specialist will track annual appointments in a spreadsheet that will be updated quarterly when the Program Specialist completes their quarterly reports. The nurse will schedule all medical appointments and will review all medical appointment documentation to ensure the forms are properly filled out prior to filing in individuals medical charts. The Department Director will audit the program charts quarterly to ensure all required documentation is present, accurate, and completed correctly. Any items found to need follow up will assigned to the Program Specialist to complete with a 5 day turn around resubmission to the Department Director prior to filing in the program charts. 04/22/2022 Implemented
6400.141(c)(10)The Annual Physical Examination Form dated 11/02/2021 indicates that Individual 3 is NOT free of communicable diseases. The agency did not provide specific precautions to prevent the spread of disease.The 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. The Annual Physical Examination Form dated 11/02/2021 indicates that Individual 3 is NOT free of communicable diseases. The agency did not provide specific precautions to prevent the spread of disease. Individual 3's annual physical examination form has been corrected on 4/7/22 to reflect that he is free of communicable diseases.The nurse will schedule all medical appointments and will review all medical appointment documentation to ensure the forms are properly filled out prior to filing in individuals medical charts. The Department Director will audit the program charts quarterly to ensure all required documentation is present, accurate, and completed correctly. Any items found to need follow up will assigned to the Program Specialist to complete with a 5 day turn around resubmission to the Department Director prior to filing in the program charts. 04/08/2022 Implemented
6400.142(e)Although Individual 3 is being seen annually for dental services the agency is not following up treatment recommended by the Physician. They were scheduled for a follow-up on June 10, 2021, at 12:00pm and this appointment was never made or attended, they did not return to the dentist until 03/09/2022.Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed.Although Individual 3 is being seen annually for dental services the agency is not following up treatment recommended by the Physician. They were scheduled for a follow-up on June 10, 2021, at 12:00pm and this appointment was never made or attended, they did not return to the dentist until 03/09/2022. Individual #3 completed annual dental on 3/9/22 and follow up to the annual is scheduled for 8/23.The nurse will schedule all medical appointments and will review all medical appointment documentation to ensure the forms are properly filled out prior to filing in individuals medical charts. The Department Director will audit the program charts quarterly to ensure all required documentation is present, accurate, and completed correctly. Any items found to need follow up will assigned to the Program Specialist to complete with a 5 day turn around resubmission to the Department Director prior to filing in the program charts. 04/08/2022 Implemented
SIN-00200516 Unannounced Monitoring 02/18/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)The red recliner located in the vacant bedroom, currently used as an informal office area was damaged, the left arm was loose and was not sturdy if sat on. Furniture and equipment shall be nonhazardous, clean and sturdy. The red recliner located in the vacant bedroom, currently used as an informal office area was damaged, the left arm was loose and was not sturdy if sat on. Staff spoke with AR about disposing of his old recliner being stored in the staff office. AR agreed that it could be thrown out due to the inspectors pointing out it should be disposed of. Staff disposed of the chair on 2/18/22 after AR agreed to let them dispose of the chair. 02/18/2022 Implemented
SIN-00192837 Renewal 09/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(9)Individual 1's most recent prostate exam was conducted on 06/20/2019 per the individual's latest annual physical examination, dated 10/09/2020. Evidence of a more recent prostate exam was not found within the individual record at time of inspection.The physical examination shall include: A prostate examination for men 40 years of age or older. Individual 1's most recent prostate exam was conducted on 06/20/2019 per the individual's latest annual physical examination, dated 10/09/2020. Evidence of a more recent prostate exam was not found within the individual record at time of inspectionThe physical examination shall include: A prostate examination for men 40 years of age or older. A prostate exam was refused by Individual #1 during the appointment. Proper documentation of the refusal was inside of the program reports but a refusal medical form was not attached to the physical. A refusal medical form for the prostate exam has been attached stating that on 10/9/2020 the individual refused a prostate exam. 09/30/2021 Implemented
6400.141(c)(10)Individual 1's latest Annual Physical Exam, dated 10/09/2020, does not specify whether or not the individual is free from communicable disease. Both the "yes" and "no" boxes next to the question "Is the person free of communicable diseases?" on the form are blank, as is the fillable line accompanying the question. It cannot be reasonably determined whether Individual 1 is free from communicable disease and, if not, what precautions---if any---should be taken to prevent the spread of disease to other individuals.The 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. Individual 1's latest Annual Physical Exam, dated 10/09/2020, does not specify whether or not the individual is free from communicable disease. Both the "yes" and "no" boxes next to the question "Is the person free of communicable diseases?" on the form are blank, as is the fillable line accompanying the question. It cannot be reasonably determined whether Individual 1 is free from communicable disease and, if not, what precautions---if any---should be taken to prevent the spread of disease to other individualsThe 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.Physical form was sent to primary for information to be updated in regard to being free of communicable diseases. Program specialist will track annual appointments and will review all medical appointment documentation to ensure the forms are properly filled out prior to filing in individuals¿ medical charts. 09/03/2021 Implemented
6400.184(c)Individual 1's record did not contain a list of the participants who attended the most recent Individual Plan Meeting, which occurred on 11/24/2020. A plan team member who attends a meeting under subsection (b) shall sign and date the signature sheet.Individual 1's record did not contain a list of the participants who attended the most recent Individual Plan Meeting, which occurred on 11/24/2020, A plan team member who attends a meeting under subsection (b) shall sign and date the signature sheet.Even though the ISP meeting was completed virtually the agency's Program Specialist should have included a confirmation email of everyone stating they were attending and scanning a sign in sheet foe each participant to sign and send back to theProgram Specialist. Moving forward all virtual ISP will need a confirmation email from each participant that is attending. The Program Specialist will then scan a sign in sheet to each participant to sign and scan back to the Program Specialist following the completion of the virtual ISP meeting . 09/22/2021 Implemented
6400.34(a)The Individual Rights Packet and Consent forms that were reviewed with and signed by Individual 1 on 01/04/2021 do not enumerate all of the Rights of the Individual covered under 55 Pa. Code Chapter 6400 regulations. Specifically, information relating to the Individual Rights included in the following sections of 55 Pa. Code Chapter 6400 was not present on the documents issued by the provider: 32(h), 32(r), 32(s), and 32(t). It cannot be reasonably determined whether the provider informed Individual 1 of these rights annually as required.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.The Individual Rights Packet and Consent forms that were reviewed with and signed by Individual 1 on 01/04/2021 do not enumerate all of the Rights of the Individual covered under 55 Pa. Code Chapter 6400 regulations. Specifically, information relating to the Individual Rights included in the following sections of 55 Pa. Code Chapter 6400 was not present on the documents issued by the provider: 32(h), 32(r), 32(s), and 32(t). It cannot be reasonably determined whether the provider informed Individual 1 of these rights annually as requiredThe 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 full consent packet including review of the individual rights was submitted on 9/1/21 during inspection. The consent packet including the same wording was submitted for all of the chosen individuals for review which no other consent packet was cited as not fulfilling this requirement. All of the other consent packets submitted that day were found compliant which were the same exact consent packet submitted for individual #1. The consent packet is included in the supporting documentation email for another review, Individual #1 consent had been reviewed during the yearly pop up visits and was found to be compliant. Comparing the consent packet contents to the requirements in the regulations all of the individual rights were included inside of the packet signed on 1/4/21. 09/01/2021 Implemented
6400.181(f)There is no documentation present within Individual 1's Individual Record that establishes that a copy of the Individual Assessment, dated 10/23/2020, was provided to the members of the individual plan team at least 30 days prior to the Individual Plan Meeting, which occurred on 11/24/2020The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.There is no documentation present within Individual 1's Individual Record that establishes that a copy of the Individual Assessment, dated 10/23/2020, was provided to the members of the individual plan team at least 30 days prior to the Individual Plan Meeting, which occurred on 11/24/2020The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. A copy of the email showing submission of 30 day prior to ISP was included in the 9/1/21 upload to the states dropbox. Documentation was submitted and provided during the inspection as requested a screen shot of the dropbox submission confirmation with time and date will be included in supporting documentaion n email along with the original scan in email to submit which shows the contents of the scan and the time and date it was scanned and upload. 09/01/2021 Implemented
SIN-00191149 Unannounced Monitoring 07/28/2021 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The bathroom shower had substances consistent with dirt and mildew built up on the inside of the tub. The non slip was also worn and dirty.Clean and sanitary conditions shall be maintained in the home. The bathroom shower had substances consistent with dirt and mildew built up on the inside of the tub. The non slip was also worn and dirty. Site staff clean the bathroom immediately and a new bathmat was purchased and placed in the bathroom the same day. 07/28/2021 Implemented
6400.68(b)The water temperature in the tub of the main bathroom measured at 125.2 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. The water temperature in the tub of the main bathroom measured at 125.2 degrees Fahrenheit.The water temperature was turned down on 7/28/2021 and read 119 degrees. The water was tested again on 7/29/2021 and read 120 degrees. House managers will check the water temperature during site checks weekly. 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. 07/28/2021 Implemented
6400.142(g)Dental hygiene plan was last updated 3/2/2020 for individual 1. More than one year has lapsed since last plan.A dental hygiene plan shall be rewritten at least annually. Dental hygiene plan was last updated 3/2/2020 for individual 1. More than one year has lapsed since last plan. The Program Specialist completed the new Dental Plan and placed it in the program chart. Program Specialist will track plans to ensure that they are completing them annually so that dates of completion remain in compliance at all times . Program Director will audit charts monthly to ensure that the plans are in compliance. 07/29/2021 Implemented
6400.144Medication to be taken as needed was not available on site during the medication review for individual 1. The following medication was found in the medication box but was expired. Tylenol 325 mg tablet expired on 4/30/2021, Ocean Nasal Spray .65% concentration was expired on 4/23/2021, and Ventolin HFA 90mcg to be taken as needed expired on 7/6/21. The medication as needed was not available immediately should the individual need it. Tinactin 1% spray was sprayed in individual 1's shoes daily except on 7/25/2021. The medication record instructs spraying the individuals shoes only on Tuesdays and Fridays.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 2, 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)Documentation was not provided that the assessment dated 10/23/2020 for individual 1 was sent out to the plan team at least 30 days prior to the team 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.Documentation was not provided that the assessment dated 10/23/2020 for individual 1 was sent out to the plan team at least 30 days prior to the team meeting.Dates will be tracked so that assessments go out to SC providers a month prior to the annual review date. Program specialist received training on 8/10 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-00176382 Unannounced Monitoring 08/20/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The cabinet located in the kitchen under the sink was broken and not in good repair.Floors, walls, ceilings and other surfaces shall be in good repair. The cabinet located in the kitchen under the sink was broken and not in good repair. Kitchen cabinet was fixed by the apartment complex on 9/21/2020. House Managers will complete site checks twice weekly and the environmental check paperwork will be turned into the Program Director. The Program Director will review the documentation and will follow up on items that need to be addressed until it is corrected. 09/21/2020 Implemented
6400.165(b)For individual #01, the medication PHENERGAN W/MD Syrup was not located in the individual's medication container but on the (MAR) Medicine Administration Record which is used for documenting administered medication(s).A prescription order shall be kept current.For individual #01, the medication PHENERGAN W/MD Syrup was not located in the individual's medication container but on the (MAR) Medicine Administration Record which is used for documenting administered medication. PHENERGAN W/MD Syrup was refilled and delivered by the pharmacy. The medication was placed inside of Individual #1's medication container. House Managers will complete full medication checks during site visits twice weekly during environmental checks. The results of the medication checks will be turned in to the Program Director for review and follow up on items that need to be addressed until they are completed. 08/24/2020 Implemented
SIN-00171641 Unannounced Monitoring 02/20/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)Information pertinent to diagnoses in case of emergency was left blank on physical dated 11/12/19 for individual 1.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Information pertinent to diagnoses in case of emergency was left blank on physical dated 11/12/19 for individual 1.The Physical form was taken to the primary during an appointment on 3/12/2020 for information to be updated in regards to information pertinent to diagnoses in case of emergency .Once physical paperwork is submitted the Program specialist will track annual appointments and will review all medical appointment documentation to ensure the forms are properly filled out prior to filing in individuals¿ medical charts. 03/12/2020 Implemented
6400.186The Individual plan was not implemented as written, The most recent individual plan as of the date of review, noted individual 1 does not self medicate. However, individual is currently self medicating per February 2020 Medication administration record. The Assessment dated 12/23/19 also stated individual does not self medicate but it is a foreseeable goal.The home shall implement the individual plan, including revisions.The Individual plan was not implemented as written, The most recent individual plan as of the date of review, noted individual 1 does not self medicate. However, individual is currently self medicating per February 2020 Medication administration record. The Assessment dated 12/23/19 also stated individual does not self medicate but it is a foreseeable goal. Team agreement on 3/10/20 is that individual 1 will stop self medicating until he completes the class again and is observed to ensure that he is able to properly self medicate. A one on one session for individual 1 has been scheduled for April 2nd and 3rd. Individual 1's assessment has been updated and his SC will updated his ISP as well. 03/10/2020 Implemented
SIN-00169669 Unannounced Monitoring 01/17/2020 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The Water temperature measured at 124.5 degrees Fahrenheit in the main bathroom. Hot water temperatures in bathtubs and showers may not exceed 120°F. The Water temperature measured at 124.5 degrees Fahrenheit in the main bathroom.he water temperature was turned down on 1/23/2020 and read 119 degrees. The water was tested again on 1/31/2020 and read 117.1 degrees. House managers will check the water temperature during site checks weekly. 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. ( All reference items will be labeled POC 2 ) 01/23/2020 Implemented
6400.82(f)There was no hand cloth or paper towel found in the main bathroom during physical site monitoring.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. There was no hand cloth or paper towel found in the main bathroom during physical site monitoring. On 1/17/2020 the house manager purchased paper towels and placed them in the bathroom on the paper towel holder. The last site check was completed on 1/31/2020 and there were paper towels at each sink within the home. House managers will check the water temperature during site checks weekly. 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. ( All reference items will be labeled POC 2 ) 01/17/2020 Submitted
6400.142(a)There was no current annual dental exam for the year 2019 found in individual 1's record at the time of review. 10/8/18 was the last recorded appointment.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. There was no current annual dental exam for the year 2019 found in individual 1's record at the time of review. 10/8/18 was the last recorded appointment. Appointment was scheduled for 1/14/2020 for annual dental appointment, however Individual #1 refused to attend the appointment in order for the annual to be completed. Another appointment is scheduled for 2/18/2020. If Individual #1 refuses again the team will develop a desensitization plan. Program Specialist will track annual required medical appointments within an agency database to ensure proper tracking of appointments within the regulated timeframe. Program Specialists will send out alerts a month prior to the expiration date to all house managers. Confirmation of the completed appointment will be completed by the program specialist to ensure that the physical form has been filled out correctly prior to being filed in individuals¿ medical chart. ( All reference items will be labeled POC 2 ) 01/31/2020 Submitted
6400.181(d)The assessment completed in 2019 was not dated by the program specialist. It was unable to be determined if assessment was completed annually as a result.The program specialist shall sign and date the assessment. The assessment completed in 2019 was not dated by the program specialist. It was unable to be determined if assessment was completed annually as a result. Individual #1 current program specialist started on 8/5/2019 and completed the current assessment on file in November 2019 that was reviewed during inspection. Program Specialist received training on how to properly complete the annual assessment. Dates 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. 01/17/2020 Submitted
6400.165(g)The psychotropic medications were not reviewed every 90 days in 2019 for individual 1. The only documented dates in 2019 were 8/5/19 and 12/5/19 *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 psychotropic medications were not reviewed every 90 days in 2019 for individual 1. The only documented dates in 2019 were 8/5/19 and 12/5/19 * Next 90 day appointment is on 2/27/2020 at noon for Individual #1.Program Specialist received training on 12/18/2019 on how to properly schedule 90 day appointments within the required time frame . Program specialist will complete paperwork two days prior to the appointment for Program Director to review and return with approval. Program Specialist will attend all 90 appointments with individuals to ensure proper completion of the appointment. 01/17/2020 Submitted
6400.166(b)Upon review of the medication administration record and blister packs, all of individual 1's 8pm prescribed dosages on 1/5/2020 were not logged in the Medication administration record immediately after use and left blank. The blister packs matched with the day dispensed so medication was administered but not logged. The following medication was not logged: Astelin 137mcg nasal spray, Cogentin 1mg tablet , Depakote 250mg and 500mg , fish oil 1000mg , and glucphage 500 mg tablet. Risperdal 3mg tablet on 1/5/2020 but also on 1/4/2020 was not logged immediately after 8pm dosage.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Upon review of the medication administration record and blister packs, all of individual 1's 8pm prescribed dosages on 1/5/2020 were not logged in the Medication administration record immediately after use and left blank. The blister packs matched with the day dispensed so medication was administered but not logged. The following medication was not logged: Astelin 137mcg nasal spray, Cogentin 1mg tablet , Depakote 250mg and 500mg , fish oil 1000mg , and glucphage 500 mg tablet. Risperdal 3mg tablet on 1/5/2020 but also on 1/4/2020 was not logged immediately after 8pm dosage. Staff were identified and held accountable for not properly documenting medication administration on the MAR. Staff received medication administration training along with 4 observations to be officially certified to give medication. Program director will ensure that all staff have completed the medication administration course within 30 days of hire. Department administrative staff will track all staff certification dates for annual recertification requirements. Alerts will go out to practicum observers a month prior to needed deadline to complete MAR reviews and observations. Staff have been trained that they must sign the back of each MAR they initial for medication administration to provide proper identification of the staff administering medication 01/17/2020 Submitted
SIN-00165363 Renewal 10/30/2019 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(f)There was no record of initial or annual fire safety training for Staff #1 since listed date of hire on 7/9/2018.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. There was no record of initial or annual fire safety training for Staff #1 since listed date of hire on 7/9/2018. Staff received fire safety training on 11/19/2019. Fire safety training has been added to initial orientation training week. Annual fire safety training will be scheduled with the Philadelphia Fire Marshall yearly with the projected month of November. 11/19/2019 Not Implemented
6400.62(d)A can of Raid roach killer was found in pantry with cookies, chips and other food items during inspection..Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.A can of Raid roach killer was found in pantry with cookies, chips and other food items during inspection. The can of raid was removed from the pantry and was disposed of. Staff received additional on site orientation training to review regulation requirements for storing of poisonous material. The leasing company will have extermination services out to the site on 12/11/2019. House managers will check that poisonous materials are stored separately from food items during their site checks while completing environmental checks weekly. 11/06/2019 Not Implemented
6400.64(a)The dining table had sticky substance consistent with syrup on the surface. Individual #2's bedroom rug was soiled and the wall next to the closet was stained with an unknown brown substanceClean and sanitary conditions shall be maintained in the home. The dining table had sticky substance consistent with syrup on the surface. Individual #2's bedroom rug was soiled and the wall next to the closet was stained with an unknown brown substance The dining table was thoroughly cleaned of sticky substance. The rug was cleaned and a slip proof area rug was placed since the stain would not come up. The wall was wiped cleaned of unknown brown substance. House manager will check for site cleanliness during site checks while completing environmental checks weekly. Staff received additional on site orientation training on regulation requirements in regards to site cleanliness. 12/09/2019 Not Implemented
6400.71Emergency telephone numbers were not posted at phone or nearby in the living room area where the phone was located.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. Emergency telephone numbers were not posted at phone or nearby in the living room area where the phone was located. Emergency telephone numbers were posted next to the telephone in the living room. House managers will ensure the list of emergency numbers are always posted near each telephone during site checks while completing environmental checks weekly. 12/06/2019 Implemented
6400.76(a)Three dining room chairs were torn at the fabric, worn and were in bad condition at the time of physical site inspection. Furniture and equipment shall be nonhazardous, clean and sturdy. Three dining room chairs were torn at the fabric, worn and were in bad condition at the time of physical site inspection. A new table and chairs set was purchased for the site on 12/6/2019 and will be delivered on 12/11/2019. 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 to review regulation requirements in regards to furniture conditions for the site. 12/11/2019 Not Implemented
6400.169(a)Medication administration training was not completed for staff #1. Medication administration certification was last completed on 8/17/2018. Documentation of training was incomplete and Staff #1 was administering medication since the certification expiration.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).Medication administration training was not completed for staff #1. Medication administration certification was last completed on 8/17/2018. Documentation of training was incomplete and Staff #1 was administering medication since the certification expiration. Staff received medication administration training along with 4 observations to be officially certified to give medication. All staff are being retrained and properly certified to administer medication. Staff will receive medication training during their initial orientation training period. Annual recertifications will be completed by practicum observers per regulation guidelines to ensure staff remain properly certified to administer medication. 12/09/2019 Not Implemented
6400.169(d)The documentation of current medication administration training was not kept for staff #1. Most recent certification provided was on 8/17/18. The expiration of certification was on 8/17/19 and no record exists of recertification or annual practicum.A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.The documentation of current medication administration training was not kept for staff #1. Most recent certification provided was on 8/17/18. The expiration of certification was on 8/17/19 and no record exists of recertification or annual practicum. Staff received medication administration training along with 4 observations to be officially certified to give medication. All staff are being retrained and properly certified to administer medication. Staff will receive medication training during their initial orientation training period. Annual recertifications will be completed by practicum observers per regulation guidelines to ensure staff remain properly certified to administer medication. 12/09/2019 Not Implemented
SIN-00150072 Renewal 02/04/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71There were no emergency telephone numbers listed near or on the telephone located in the living room.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 emergency phone numbers shall be placed near or above each phone in the home. The numbers will include but not limited to the contact information for the nearest hospital, police department and poison control center. a) Staff will ensure to check daily via the chore list. b) The Site Manager has an obligation to review the chore list weekly and evaluate the home. c) The Site Manager will ensure the completion of the environmental health and safety check list monthly for continuity. d) The Site Manager will immediately post the emergency phone that will include but is not limited to the nearest hospital, police department, fire department, ambulance and poison control. 02/06/2019 Implemented
6400.76(a)In individual #1's bedroom, the dresser was missing the knobs. Furniture and equipment shall be nonhazardous, clean and sturdy. a) Staff will ensure to check daily for non hazardous, clean and sturdy furniture and equipment via the chore list and report repairs or replacements needed. b) The Site Manager has an obligation to review the chore list weekly and evaluate the home. c) The Site Manager will ensure the completion of the environmental health and safety checklist monthly for continuity. d) The Site Manager will ensure that work orders are entered to ensure the replacement or repairs of furniture and equipment timely via the chore list. e) The Program Director shall ensure to review site needs at the weekly core team meeting. 03/31/2019 Implemented
6400.112(a)The September 2018 fire drill was not found in the records. 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 fire drill record for 2006 A N. John Russell Circle had no sleep drills for the 2018 calendar year.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. 03/05/2019 Implemented
SIN-00061992 Renewal 03/03/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment was completed on 2/13/14.(a) 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.   05/20/2014 Implemented
6400.62(d)Can of lighter fluid was found mixed-in with food items in the kitchen closet.(d) Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.   05/20/2014 Implemented
SIN-00047356 Renewal 03/21/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(g)Staff #2 received fire safety training on 12/12/12, 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 Phila Fire Dept. on 4/15/13. The QE director will ensure that the training requiments are implimented. 04/15/2013 Implemented
6400.168(d)Staff #2's annual Medication Administration Practicum dated 11/20/12 was completed by Staff # 3 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 be responsible for minitoring the training system. 04/15/2013 Implemented
SIN-00123365 Renewal 10/03/2017 Compliant - Finalized
SIN-00096491 Renewal 07/11/2016 Compliant - Finalized