Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
SIN-00232587
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Renewal
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09/26/2023
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Compliant - Finalized
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Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.151(a) | Direct Service Worker #1, date of hire 1/13/23, had a physical examination completed 1/16/23. Direct Service Worker #2 had physical examinations completed 8/4/21 and then again 9/20/23. | 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. | Direct Service Worker #1 did have a physical exam on 1/13/23, the doctor did not sign the physical until 1/16/23 when Training coordinator asked for it to sent over via fax. Training Coordinator will utilize a new system called on target to keep certification dates up to date. This will assist with knowing when all staff physicals and Mantoux dates are up for renewal. A letter will be sent to the staff 6 months and 3 months prior to date. The system will be able to send a direct message through on target to the staff with this information. The system is still being impemanted and certifications are being entered by Training Coordinator. |
10/30/2023
| Implemented |
6400.151(c)(2) | Direct Service Worker #2 had Tuberculin skin testing by Mantoux method completed 8/2/21 and then again 9/22/23. | 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. | Training Coordinator will utilize a new system called on target to keep certification dates up to date. This will assist with knowing when all staff physicals and Mantoux dates are up for renewal. A letter will be sent to the staff 6 months and 3 months prior to date. The system will be able to send a direct message through on target to the staff with this information. The system is still being impemanted and certifications are being entered by Training Coordinator. |
11/30/2023
| Implemented |
6400.46(d) | Documentation regarding Direct Service Worker #2 training in first aid, Heimlich techniques and cardio-pulmonary resuscitation was not provided. Therefore, compliance could not be measured. | 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 training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | The On target system will have all information related to staff certifications entered into it including CPR/First Aid/Heimlich information for each staff. It will send a reminder for the renewal date 6 months then 3 months prior to renewal date. Staff will not be able to be scheduled or work directly with a client if this certification is not completed by the renewal date and the staff will be suspended until it is completed. DSW #2 did receive CPR Training on 9-29-23. |
11/30/2023
| Implemented |
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SIN-00213175
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Renewal
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10/13/2022
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Compliant - Finalized
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Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.141(a) | Individual #1 had a physical examination compelted on 6-2-21, and then again on 6-27-22. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Program specialist will create a spreadsheet with all scheduled current physical dates, as well as renewal due dates to ensure a timely exam and for 2022-2023 to meet compliance. Program Specialist will call 6 months prior to annual date to schedule renewal physical date to ensure it is compliant. Once scheduled Program Specialist place the renewal date on the company calendar. |
12/26/2022
| Implemented |
6400.141(c)(6) | Individual #1 had a Tuberculin skin test completed on 2-14-20, and then again on 6-29-22. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Mantoux date and renewal date will be listed on a spreadsheet created by Program Specialist along with all current physical dates with renewal dates to ensure compliance. Once scheduled Program Specialist place the renewal date on the company calendar. |
12/26/2022
| Implemented |
6400.32(r) | The agency has not provided Individual #1 the right to lock Individual #1's bedroom door. The agency has not provided Individual #2 the right to lock Individual #2's bedroom door. | An individual has the right to lock the individual's bedroom door. | Individual #1 signed a declination form on 10/14/2022 declining a locking mechanism on their bedroom door.
Individual #2's Legal guardian signed a declination form on 10/14/2022 declining a locking mechanism on their bedroom door. |
10/14/2022
| Implemented |
6400.181(f) | The program specialist provided Individual #1's annual assessment, completed on 3-17-22 to the plan team members on 3-17-22 for an annual individual plan meeting on 3-10-22. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Individual's Assessment Date needs to be pushed back to ensure Assessment is sent to Program Specialist 30 days prior to ISP Date. Individuals new assessment date will be 1/31/2023 to ensure that the Assessment is sent by 2/10/2023 to the Program Specialist which is 30 days prior to his ISP meeting date of 3/10/2023. Spreadsheet of Individuals assessment dates will be updated to meet these requirements. |
10/28/2022
| Implemented |
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SIN-00196455
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Renewal
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11/16/2021
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Compliant - Finalized
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Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.46(b) | Direct Service Worker #2, date of hire 10/29/13, completed annual fire safety training on 06/24/21 but did not have fire safety training in 2020. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Program Specialist will check Fire Safety qualifications of all DSP's working in the home and place the due date on the calendar to alert the Program Specialist that it is due. A reminder will be sent to the DSP at least a week in advance so they are aware that it is due and will not be missed. |
12/03/2021
| Implemented |
6400.52(c)(2) | CEO #1's Annual Training did not encompass the prevention, detection and reporting of abuse, suspected abuse and alleged abuse for the annual training year dated 7/1/2020 through 6/30/2021. | 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. | CEO did complete the necessary training, it was done past the 6/30/21 deadline. Training qualifications are checked quarterly by the Office Manager and reminders are sent out to remind staff what training needs completed. |
12/03/2021
| Implemented |
6400.52(c)(3) | CEO #1's Annual Training did not encompass Individual Rights for the annual training year dated 7/1/2020 through 6/30/2021. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | CEO did complete the necessary training; it was done past the 6/30/21 deadline. Training qualifications are checked quarterly by the Office Manager and reminders are sent out to remind staff what training needs completed. |
12/03/2021
| Implemented |
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SIN-00180975
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Renewal
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12/10/2020
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Compliant - Finalized
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Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.151(a) | Direct Service Worker #1, date of hire 7/28/20, had initial physical examination completed on 12/09/20. | 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. | As soon as PHS noticed that DSP #1 did not have a Physical, one was immediately scheduled and completed on 12/9/2020 at 8:45a by Corporate Health who PHS uses to complete DSP's Physical's and Mantoux's. Residential Director is responsible for reviewing and ensuring Physical qualifications are met and kept up to date. A spread sheet is utilized for this process along with calendar reminders. [Prior to hire and at least quarterly for 1 year, the CEO or designee shall audit new staff persons' physical examinations and aforementioned tracking system to ensure all staff person have physical examinations completed, timely. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 12/30/20)] |
12/09/2020
| Implemented |
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