Inspection ID

Reason for Inspection

Inspection Date

Inspection Status

SIN-00221190

Unannounced Monitoring

02/01/2023

Non Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.16	Individual #1 is 80-years old and has resided with Human Achievement Program since 9/15/89. Individual #1 has the following diagnosis: severe IDD, cerebral palsy, limited speech, unsteady gait, hypertension, elevated cholesterol, constipation, spastic quadriplegia, hyper-reflexive joints, bilateral cavus deficiencies on both feet, mild pan colonic diverticulosis, notal sigmoid polyp removed in October 2005, hypothyroidism, osteopenia, mild degenerative changes in thoracic spine, compound myopic astigmatism with presbyopia in both eyes, vitreous floater in the left eye, posterior vitreous detachment of left eye, excess cerumen build-up, moderate-severe hearing loss, blepharitis, strabismus, alternating exotropia, constant esotropia, cataracts, mild anemia, osteoarthritis, enlarged prostate with benign prostatic hyperplasia, persistent vascular disease, and incontinence. When Individual #1 is not in bed, they utilize a wheelchair for ambulation. During the inspection initiated on 2/1/23 it was discovered that Human Achievement Program had multiple systematic failures of not pursuing medical treatment for Individual #1 in a timely manner, not following through with doctor's recommendations and/or treatments, rights violations, failure to document medication administrations, failure to administer prescribed medications, lack of training, lack of medication administration training, administering treatments to the individual without a doctor's recommendations, and changing the administration of the medication without a doctor's order; all of which created conditions conducive to serious injury .	Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.	The electronic MAR has been reconfigured to provide for the documentation of administration of approved OTC products. All staff have been trained in the proper documentation of OTC administration. Attachment A, Attachment B Staff have received information from HCQU regarding Pressure Injury causes, detection and reporting requirements in response to the presence of pressure injuries. Attachment D The Provider secured the services of a Certified Medication Trainer from another agency. Staff#3 has been retrained in the medication administration training. An additional Practicum Observer has completed training. The Practicum Observer is trained to conduct all required observations and document them appropriately on the proper forms.	03/31/2023	Not Implemented
6400.62(a)	At the time of the inspection, the accessible cabinet that contained all the poisons in the laundry area was left unlocked. In the cabinet it contained laundry detergent, fabric softener, and bathroom cleaning products. In the bathroom sitting on the sink was a bottle of witch hazel dated 7/17/19, left unattended.	Poisonous materials shall be kept locked or made inaccessible to individuals.	The lock on the cabinet was repaired. All employees were instructed to keep their personal possessions including but not limited to poisonous materials outside of the home or to always secure them within a locked area of the home when unattended.	03/31/2023	Implemented
6400.144	Daily staff notes in the month of November 2022 documented that staff noticed Individual #1 had 3 open sores and redness in the groin area. Staff were reportedly applying a barrier cream, Bacitracin. These medication administrations were not documented on the November MAR's. The November Service Notes also documented that Individual #1 had expressed pain and being uncomfortable daily when staff would try to reposition the individual. Medical treatment was not sought until Individual #1 went by ambulance to the hospital on 11/30/22. During that ER visit, Individual #1 was diagnosed with a UTI and Covid. There was no discussion about the wounds. The December 2022 Daily Services Notes documented that Individual #1 had a sore on their heel and a small open wound to the scrotum. Staff were reportedly applying barrier cream to Individual #1's scrotum. On 12/30/22, Individual #1 was having difficulty sitting up. Staff continued applying barrier cream to the small open wound near the scrotum. No medical treatment was sought & none of the treatments or medications used were documented on the December's MAR's. The January 2023 Daily Service Notes documented that Individual #1 has a standing order from 11/16/22 to have their urine tested any time they exhibited symptoms of a UTI. On 1/3/23, Individual #1 was exhibiting symptoms of a UTI and gave a urine sample. On 1/6/23, Individual #1 was diagnosed with a UTI. Individual #1 was not prescribed any medication to treat the UTI, because the UTI was documented as "antibiotic resistant." The individual received no treatment, and symptoms worsened as time went on. Throughout the month, Individual #1 continued to exhibit symptoms of not feeling well. Staff continued to document seeing open wounds on Individual #1. In January 2023, it was noted that Individual #1's urine had a very strong odor and had burnt some of Individual #1's skin. Staff applied a honey bandage to Individual #1's tailbone and applied barrier cream after cleaning with saline solution and repositioning. Nothing was documented on the MAR's. The physician was not notified. There was no prescription for the honey bandages, and they reportedly belonged to another individual who had previously lived in the home. In addition, Staff #5 used a condom catheter on Individual #1. This was not documented on the MAR and no documentation was provided that staff were trained on the use of condom catheters. Staff #5 found it difficult for Individual #1 to take their medications. Staff #5 crushed the medications and put them in a smoothie. Individual #1 drank about 3/4 of the smoothie. There was no documentation that the prescribing physician was notified about crushing Individual #1's medications and the Individual not receiving all of it. Individual #1 had a doctor's appointment on 1/12/23 with their CRNP. This was a follow up to an ER visit that took place on 11/30/22. During this appointment it was documented that Individual #1 had a pressure injury of the sacral region stage 2. They also had pressure sores developed on their right hip, left hip, and sacrum. The doctor wrote on the note- "Aides were not trained properly for wound dressing & management." The doctor directed staff to cleanse the wound with a wound cleanser, pat dry, apply a thin film of Baza cream, and cover with a gentle border. Individual #1 was to return by 2/9/23 for follow-up, but was admitted to the hospital, before follow-up could occur. A prescription for Baza Cream (Zinc Oxide) was called into the pharmacy. However, it was never picked up and at the time of the inspection, the Baza Cream was not available in the home. According to the daily service notes, staff have been applying a barrier cream, Calmoseptine, for months and this had not been documented on the MAR's. No information was able to be seen on the Calmoseptine cream label since it had worn away. On 1/19/23, Individual #1 had to be transported by ambulance after becoming lethargic & less alert. They were admitted and diagnosed with an acute UTI, pressure wounds, a small to medium right pleural effusion, and sepsis. Individual #1 was started on an IV and antibiotics. On 1/20/23, Individual #1 was still in the hospital and required debridement of the left hip from the pressure injury. On 1/24/23, required debridement of right hip wound. While in the hospital, Individual #1 refused to eat and was diagnosed with failure to thrive. Individual #1 was given a Peg Tube. On 2/24/23, Individual #1 was discharged to a Select Specialized Long-Term-Care Facility.	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 electronic MAR has been reconfigured to provide for the documentation of administration of approved OTC products. All staff have been trained in the proper documentation of OTC administration. Attachments A and B On 1/12/23 the provider informed the PCP of the situation and requested that the PCP initiate contact with the Urologist to pursue treatment as the provider's attempts to do so were not effective. Individual #1 was taken to the ER and subsequently admitted where they received wound care and antibiotic treatment for the UTI.	03/31/2023	Not Implemented
6400.32(c)	On 11/30/22, Individual #1, who is non-verbal, went unaccompanied to the ER by ambulance. Individual #1 remained at the ER approximately 5 hours, alone. Individual #1 returned home unannounced via ambulance on 12/1/22 at 5am. Staff didn't receive discharge paperwork from the EMT's, giving directions on Individual #1's aftercare.	An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.	Administrative staff have been assigned to be available for emergency room support in the event that other staff are not available.	03/31/2023	Implemented
6400.44(b)(4)	Per Individual #1's ISP completed 10/23/22, they are to be within the community multiple times a month. The program specialist shall be responsible for the following: Supporting the integration of individuals in the community. Individual #1 had only been documented as being in the community 4 times since November 2022 to January 19, 2023. Individual #1's community involvement was only doctor's appointments or ER visits. There was no documentation that Individual #1 was asked if they wanted to go into the community.	The program specialist shall be responsible for the following: Supporting the integration of individuals in the community.	Staff have been instructed to include a statement in the comment section of the community activity data collection that indicates that the individual was asked if they would like to go into the community as well as if they were not feeling well. Attachment G	03/31/2023	Implemented
6400.50(b)	Staff #4 confirmed that HAP doesn't keep records for their staff of the 4 observations completed or the handwashing and gloving completed for the medication administration training. Staff #4 indicated they were completed by recording them on the initial student exam summary sheet, but records weren't included in the packet. Hap staff were unable to locate the packet with the information in the training record.	The home shall keep a training record for each person trained.	The Provider secured the services of a Certified Medication Trainer from another agency. An additional Practicum Observer has completed training.	03/31/2023	Implemented
6400.52(c)(6)	Following the 1/12/23 appointment with Individual #1's primary care physician, Individual #1 was to receive wound care for their pressure injuries. Staff were not trained in wound care for individual #1 that was prescribed on 1/12/23.	The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.	Staff have received information from HCQU regarding Pressure Injury causes, detection and reporting requirements in response to the presence of pressure injuries. Attachment D. Any future occurrences will be immediately referred to the PCP for treatment and referral to wound care specialists. In the event of a delay in obtaining the services of the PCP and/or Wound Care Center, or if the condition does not improve within the time parameters indicated by the treating physician, Individuals will be taken to the ER for immediate treatment.	03/31/2023	Not Implemented
6400.162(a)	There was no record of the 4 observations completed or the handwashing and gloving completed for Staff #5. Staff #65was administering medications. Staff #3 completed the annual medication administration training on 10/23/21 and not again until 2/13/23. Staff #3 continued to administer medication to Individual #1 from 10/23/22 through 1/19/23.	A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication.	The Provider secured the services of a Certified Medication Trainer from another agency. Staff#3 has been retrained in the medication administration training. An additional Practicum Observer has completed training.	03/31/2023	Not Implemented
6400.163(a)	On 1/7/23, the staff note written by Staff #5 stated that they found it difficult for Individual #1 to take their medications. Staff #5 crushed the medications and put them in a smoothie. Individual #1 drank about 3/4 of it. There is no documentation from the physician that Individual #1's medication could be crushed. Individual #1 did not receive all the medication as Staff #5 indicated Individual #1 only drank about ¾ of the smoothie. There is no documentation that Staff notified the physician regarding the crushing of the medications or that they individual did not take all their prescribed medications.	Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.	The pharmacy has provided the Provider with a list of medications that may be crushed for administration. Staff have been instructed to not crush any medication that does not appear on the list. Attachment H.	03/31/2023	Implemented
6400.163(h)	Individual #1 was prescribed Naproxen 500mg for pain. At the time of the inspection, there was a bottle of naproxen 500mg available at the home that had expired on 8/9/22.	Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.	The medication was removed from the home.	03/31/2023	Not Implemented
6400.165(a)	On 1/5/23, Staff #5 noted that Individual #1's urine had burnt some of their skin. Staff #5 applied a honey bandage to the tailbone and applied barrier cream after cleaning the wound with a saline solution and repositioning the individual. There is no prescription for honey bandages to be applied to Individual #1 and they are not on the approved over-the-counter medication list for Individual #1.	A prescription medication shall be prescribed in writing by an authorized prescriber.	The electronic MAR has been reconfigured to provide for the documentation of administration of approved OTC products. All staff have been trained in the proper documentation of OTC administration. Attachments A and B	03/31/2023	Not Implemented
6400.165(b)	In January 2023, it was noted that Individual #1's urine had a very strong odor and had burnt some of Individual #1's skin. Staff applied a honey bandage to Individual #1's tailbone and applied barrier cream after cleaning with saline solution and repositioning. Staff had been applying Calmoseptine, as opposed to Baza Cream. Nothing was documented on the MAR's. The physician was not notified. There was no prescription for the honey bandages.	A prescription order shall be kept current.	The electronic MAR has been reconfigured to provide for the documentation of administration of approved OTC products. All staff have been trained in the proper documentation of OTC administration. Attachments A and B	03/31/2023	Not Implemented
6400.165(c)	On 1/7/23, Staff #5 found it difficult for Individual #1 to take their medications. Staff #5 crushed the medications and put them in a smoothie. Individual #1 drank about 3/4 of the smoothie. There was no documentation that the prescribing physician was notified about crushing Individual #1's medications and the Individual not receiving all of it. Staff #5 did not document which medications were crushed.	A prescription medication shall be administered as prescribed.	The pharmacy has provided the Provider with a list of medications that may be crushed for administration. Staff have been instructed to not crush any medication that does not appear on the list. Attachment H	03/31/2023	Not Implemented
6400.167(a)(1)	On 1/12/23, a prescription for Baza Cream (Zinc Oxide) was called into the pharmacy. However, it was never picked up and at the time of the inspection, the Baza Cream was not available in the home. Individual #1 did not receive the Baza Cream (Zinc Oxide) as prescribed.	Medication errors include the following: Failure to administer a medication.	Individual #1 was taken to the ER and subsequently admitted where they received wound care and antibiotic treatment for the UTI.	03/31/2023	Implemented
6400.167(a)(1)	On 1/7/23, the staff note written by Staff #5 stated that they found it difficult for Individual #1 to take their medications. Staff #5 crushed the medications and put them in a smoothie. Individual #1 drank about 3/4 of it. There is no documentation from the physician that Individual #1's medication could be crushed. Individual #1 did not receive all the medication as Staff #5 indicated Individual #1 only drank about ¾ of the smoothie. There is no documentation that Staff notified the physician regarding the crushing of the medications or that they individual did not take all their prescribed medications.	Medication errors include the following: Failure to administer a medication.	The pharmacy has provided the Provider with a list of medications that may be crushed for administration. Staff have been instructed to not crush any medication that does not appear on the list. Attachment H	03/31/2023	Implemented
6400.167(a)(5)	In January 2023, it was noted that Individual #1's urine had a very strong odor and had burnt some of Individual #1's skin. Staff applied a honey bandage to Individual #1's tailbone and applied barrier cream after cleaning with saline solution and repositioning. The honey bandages were left in the home by hospice for an individual that had previously resided there. Nothing was documented on the MAR's. The physician was not notified. There was no prescription for the honey bandages, and they reportedly belonged to another individual who had previously lived in the home.	Medication errors include the following: Administration to the wrong person.	The electronic MAR has been reconfigured to provide for the documentation of administration of approved OTC products. All staff have been trained in the proper documentation of OTC administration. Attachments A and B	03/31/2023	Not Implemented

SIN-00195015

Renewal

11/09/2021

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.61(a)	The front entrance to the home has a wooden porch which has movable metal ramps instead of a permanent ramp. One individual within the home is confined to a wheelchair.	A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs.	The home is equipped with a permanent ramp from the parking area to the rear entrances of the building. A comparable ramp is being designed for the from of the home as well.	11/29/2021	Implemented
6400.64(a)	A package of Turkey breast which was dated 10/10/19 was found in the kitchen freezer. A package of Chicken drumsticks with the date of June 28, 2019 was found in the kitchen freezer.	Clean and sanitary conditions shall be maintained in the home.	The poultry items was removed and discarded from the home. The contents of all freezers were examined and compared with the recommended expiration dates as published by the Department of Health and removed as appropriate.	11/15/2021	Implemented
6400.103	The emergency evacuation plan for the home does not include individual responsibilities.	There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.	The Emergency evacuation procedures for this home has been amended by the Executive Director to include Individual responsibilities. Attachment I.	12/03/2021	Implemented
6400.181(e)(4)	The ISP states Individual # 1 must be monitored in the bathroom due to clogging the toilet and excessive flushing. The assessment 5/1/21 does not mention this. The ISP also mentions she must not have or be around soda cans because she may eat the tab or flush it down the toilet. The assessment does not mention this. ISP states Individual # 1 must be monitored in the shower due to a seizure disorder. The assessment does not mention this. ISP states arms length super in the community; assessment does not state this.	The assessment must include the following information: The individual's need for supervision.	On 11/15/2021 the Program Specialist created an addendum to Individual (DD) Assessment and sent to the team. Attachment J2. Amended information is included in the Home and community section of her Assessment as part of her Strength/Need Summary. Areas addressed include monitoring in shower due to seizure disorder, clogging toilet, excessive flushing and monitoring around soda cans and tabs. Attachment J1.	11/15/2021	Implemented
6400.165(f)	Individual # 1 takes psychotropic medications and she does not have a SEEN plan in place.	If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.	On 11/15/2021 a SEEN plan was added as an addendum to individual (DD). A copy of the SEEN plan was sent to the team and her supports coordinator amended the ISP to include the same information. Attachment K	11/15/2021	Implemented
6400.185(1)	The ISP dated 10/21/21 states Individual # 1 can swim; however, it does not state what type of of supervision is required.The ISP supervision states 1:3 staff supervision at home; but not monitored in bedroom. It does not state if any checks are done while she is in the bedroom.	The individual plan, including revisions, must include the following: The individual's strengths, functional abilities and service needs.	The Program Specialist reviewed the Assessment and ISP for individual (DD) to ensure the information was the same in both places. The Program Specialist created an addendum to the assessment under the Danger and Safety page, Section (G): Water/swimming/bathing and changes were noted in bold letters. Amendments were also created for 1:3 supervision under the Home and Community Supervision in the Strength/ Needs Summary portion of o include the amended assessment. These changes were also noted in bold print. Changes sent to the supports coordinator on 11/15/2021 and she updated Individual (DD) ISP to reflect the changes emailed to her. The SC responded on 11/15/21 that she completed the updates to the ISP. The Program Specialist reviewed and confirmed the changes to the ISP on 11/16/2021. Attachment J1 and J2	11/16/2021	Implemented

SIN-00121463

Renewal

11/07/2017

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.15(a)	The agency did not complete a self-assessment of the home. Their certificate of compliance expired on 9/15/17.	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.	6400.15(a) The agency completed the self assessment in February 2017 and August 2017. The agency shall complete a self assessment of all locations after April 1, 2018 and before April 30, 2018 which shall be within 3 to 6 months of the expiration of the current license ( 9/15/18). Executive Director was retrained on regulations noting specific due dates of self assessment. ED has placed the correct date of April 2018 for the next self assessment phase using a calendar/Microsoft outlook. Completed 11/10/2017.	11/10/2017	Implemented
6400.20	Individual #1 fell on 9/13/17 while in residential care which required a visit to an urgent care center for xrays. The agency did not complete an incident report or maintain a record of the incident. Individual #1 was seen at patient first on 1/18/17 for, quote, unspecified convulsions, instructions: seizure, end quote. The home did not have a record of this seizure and/or seizure activities that required medical attention.	The home shall maintain a record of individual illnesses, seizures, acute emotional traumas and accidents requiring medical attention but not inpatient hospitalization, that occur at the home.	6400.20 Staff failed to realize the significance of regulation 6400.20 and the importance of reporting an incident to HCSIS which was treatment beyond First Aid. This person was retrained on this regulation and HCSIS Incident Management to understand the importance of record keeping and documentation.11/10/2017	11/10/2017	Implemented
6400.22(d)(2)	Individual #1 had a receipt for the amount of $7.69 to Chick-fil-A on 6/12/17. Individual #1's financial log indicated that $7.68 was spent at Chick-fil-A on 6/12/17. Individual #1's financial record has been a penny off since then.	(2) Disbursements made to or for the individual.	6400.22(d)(2) The Administrative assistant and HC failed to document that a record of a receipt was $.01 off and therefore the monies would indicate this in the balance. Admin and HC were retrained on the significance of proper documentation and comparing receipts to ledgers entries. HC¿s are now checking ledgers along with Admin to compare receipts and entries twice monthly to insure accuracy. Errors in transcribing receipt amounts shall be documented on the ledger and balances adjusted accordingly. It is noted that that all funds for this individual were accounted for as his actual cash balance was correct. 12/7/17 All other financial records were reviewed and corrected if needed.	12/07/2017	Implemented
6400.112(c)	The smoke detector in the attic is not checked every month. There is not proper flooring in the attic to allow staff to access the smoke detector. Staff at the home indicated they do not check the attic smoke detector every month.	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.	6400.112(c) The smoke detector in the attic was found to be operable during each fire drill as it can be heard throughout the home. The detector has been relocated to the entrance of the attic to allow staff access to push the test button. The provider chooses not to implement the recommendation of the licensing representative that the attic be sealed and therefore not subject to this requirement. Staff have been retrained to made aware that all interconnected detectors must be manually tested individually rather than just heard. Email sent to maintenance and confirmed 12-6-17.	12/06/2017	Implemented
6400.113(a)	REPEAT from 10/3/16 renewal inspection: Individual #1 had fire safety training on 5/7/16 and not again until 7/25/17. The agency indicated that there was a period of time where Individual #1 was out of their services, however he/she returned prior to 5/7/17 when his/her fire safety training was due.	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.	6400.113(a) Executive Director failed to note that this person was in a different health care facility at the time of the Annual training dates for the company. When the individual returned to HAP, ED should have had the noted information in her files to indicate this person required training in May of 2017 as an annual training on fire safety. ED has been retrained on this regulation to signify dates of ¿annual¿. 11/10/2017	11/10/2017	Implemented
6400.141(c)(12)	Indvidual #1's 4/14/17 physical examination form indicated no for physical limitations. However his/her Individual Support Plan (ISP) indicated, in quotes, he/she had issues with an unsteady gait when he/she walks. He/She has difficulty with stairs and has been known to crawl up stairs for fear of falling. He/She may need personal support when walking up stairs or uneven terrain due to balance concerns or pain in knees, end quote.	The physical examination shall include: Physical limitations of the individual.	6400.141(c)(12) House Coordinator and Program Specialist did not compare annual physical and Lifetime medical history to ISP. The importance of comparing the information for this regulation would help the team maintain accurate and up to date information on the person. HC and PS have been retrained on the regulation and have notified the SC to make a critical revision to the ISP for the individual so the team has proper documentation. 12/13/17. Moving forward, an Individual ISP has been completed to reflect up to date and proper information for that Individual. 12/4/17	12/04/2017	Implemented
6400.142(c)	A written record of Individual #1's dental examinations from the fall of 2016 until present, 11/7/17, were not kept by the agency. When the annual licensing was conducted on 11/7/17, the agency had Individual #1's dental records faxed to the agency for review.	A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept.	6400.142(c) House Coordinator did have dental appointments for the individual but failed to review the forms and note the lack of documentation on the report. HC and staff were retrained on the significance of proper reporting of all medical appointments to include documentation of services. 11/10/2017 The Program Director will monitor all required medical appointments to insure proper documentation is maintained in the record.	11/10/2017	Implemented
6400.144	Individual #1 had a dental examination and cleaning completed on 9/30/16 with a dentist recommended 6 month recall. He/she did not have a dental examination that included a cleaning until 9/18/17. Individual #1 was seen at patient first on 7/27/17 with a diagnosis of pneumonia. According to the patient first appointment summary form, Individual #1 was to be seen by his/her family physician at Pinnacle Health in Camp hill on 7/30/17 for follow up. Individual #1 was never seen by his/her family physician at Pinnacle Health. Individual #1 fell on 9/13/17 which resulted in a contusion of his/her shoulder. According to the patient first appointment summary form on 9/13/17. Individual #1 was to ice his/her shoulder for 15 minutes on and 15 minutes off. There was no documentation to indicate the ice treatment occurred.	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.	6400.144 House Coordinator failed to document a phone call received by the dentist office canceling the appointment and left the record blank. HC was retrained in this area to understand the importance of proper documentation and cancellations for an individual record. New communication forms and telephone contact sheets have been implemented and is used by all HC/PD in the company. 12/7/17	12/07/2017	Implemented
6400.163(c)	Individual #1 is prescribed psychotropic medications for Anxiety and Depression. Individual #1 did not have a medication review by a licensed physician for the past year. There also was no documentation of medication reviews in Individual #1's	If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.	6400.163(c) House Coordinator made appointments with the prescribing physician which was the PCP. House Coordinator and Resident Advisors failed to recognize that the medical forms were not completed properly to signify a diagnosis and outcome of each visit. HS and RA¿s were retrained on this regulation,6400.163(c) so they can understand the significance of the rule itself and the importance of documentation when individual health is being reviewed and/or treated. 11/10/2017 reviewed with staff and 11/14/17 individual had medical appointment with PCP to review meds.	11/14/2017	Implemented
6400.164(a)	REPEAT from 10/3/16 and 9/29/15 annual inspections: Individual #1 was prescribed Tamsulosin, .4mg take 1 capsule by mouth 1 hour after breakfast and 1 hour after evening meal. He/She was also prescribed Trazodone 100mg once daily after a meal. His/Her November, October, September, August and July 2017 medication logs indicated he/she was to take Tamsulosin .4mg take 1 tablet by mouth daily. Individual #1's medication logs for the past year indicated he/she was to take Trazodone 100mg take 1 tablet, but did not indicate the frequency.	A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication.	6400.164(a) House Coordinator did not review prescriptions and medical information given by doctor for Tamsulosin and Trazodone. HC was retrained on this regulation to understand the importance of following directions set forth by medical field and significance of administering medications as they are prescribed. Medication log was corrected and compared to label on scripts and read by HC and Resident advisors prior to administration 12/01/2017. House Coordinators and Program Director have been trained in completing a chart/checklist to compare these labels and logs once per month when medications are picked up using the 5 rights each person has for medication administration. Training completed and documented 11/9/17and 12/8/17. All other current medication logs have been reviewed and corrected as needed.	12/08/2017	Implemented
6400.181(e)(2)	Individual #1's 1/13/17 assessment did not include likes, dislikes and interests. This information was not completed until 2/21/17 and the agency did not have documentation that this information was completed with the 1/13/17 assessment.	The assessment must include the following information: The likes, dislikes and interest of the individual.	181(e)(2) Does each assessment include the like/dislike and interests of the individual? Program specialist followed the previous years of procedures when completing ISP/assessment information. The PS updated his/her likes/dislikes, interests, specific areas of training, lifetime medical histories, disability to include functional and medical limitations with the Individual signing on the day of the ISP, replacing the original documents. Moving forward the agency will maintain the aforementioned documents originally submitted with the assessments in the record and continue to provide the team with updated materials and documents for ISP meetings. These materials will be kept with the original assessment as an amendment to the documents. PS was retrained on regulations on 12/01/2017. Procedure put in place on 12/04/2017.	12/04/2017	Implemented
6400.181(e)(9)	Individual #1's 1/13/17 assessment did not include documentation of disability including functional and medical limitations. This information was not completed until 2/21/17 and the agency did not have documentation that this information was completed with the 1/13/17 assessment.	The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations.	181(e)(9) Does each assessment include the individuals disability, including functional and medical limitations? Program specialist followed the previous years of procedures when completing ISP/assessment information. The PS updated his/her likes/dislikes, interests, specific areas of training, lifetime medical histories, disability to include functional and medical limitations with the Individual signing on the day of the ISP, replacing the original documents. Moving forward the agency will maintain the aforementioned documents originally submitted with the assessments in the record and continue to provide the team with updated materials and documents for ISP meetings. These materials will be kept with the original assessment as an amendment to the documents. PS was retrained on regulations on 12/01/2017. Procedure put in place on 12/04/2017.	12/04/2017	Implemented
6400.181(e)(10)	Individual #1's 1/13/17 assessment did not include a lifetime medical history. This information was not completed until 2/21/17 and the agency did not have documentation that this information was completed with the 1/13/17 assessment.	The assessment must include the following information: A lifetime medical history.	181(e)(10) Does each assessment include a lifetime medical history? Program specialist followed the previous years of procedures when completing ISP/assessment information. The PS updated his/her likes/dislikes, interests, specific areas of training, lifetime medical histories, disability to include functional and medical limitations with the Individual signing on the day of the ISP, replacing the original documents. Moving forward the agency will maintain the aforementioned documents originally submitted with the assessments in the record and continue to provide the team with updated materials and documents for ISP meetings. These materials will be kept with the original assessment as an amendment to the documents. PS was retrained on regulations on 12/01/2017. Procedure put in place on 12/04/2017.	12/04/2017	Implemented
6400.181(e)(12)	Individual #1's 1/13/17 assessment did not include recommendations for specific areas of training, programming and services. This information was not completed until 2/21/17 and the agency did not have documentation that this information was completed with the 1/13/17 assessment.	The assessment must include the following information: Recommendations for specific areas of training, programming and services.	181(e)(12) Does each assessment include recommendations for specific areas of training, programming, and services? Program specialist followed the previous years of procedures when completing ISP/assessment information. The PS updated his/her likes/dislikes, interests, specific areas of training, lifetime medical histories, disability to include functional and medical limitations with the Individual signing on the day of the IS, replacing the original documents. Moving forward the agency will maintain the aforementioned documents originally submitted with the assessments in the record and continue to provide the team with updated materials and documents for ISP meetings. These materials will be kept with the original assessment as an amendment to the documents. PS was retrained on regulations on 12/01/2017. Procedure put in place on 12/04/2017.	12/04/2017	Implemented
6400.186(c)(2)	REPEAT from 10/3/16 renewal inspection: Individual #1's Individual Support Plan (ISP) reviews did not review his/her behaviors, behavior support plan or communication support for the prior three months. According to behavior data tracking logs he/she had many recorded behaviors that were not indicated on his/her ISP reviews.	The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter.	6400.186(c)(2) PS did not review forms for Behavior support and include them on his Quarterly reviews. PS was retrained on regulation #186 c 2 and understands significance of review. Moving forward, an individual who receives Behavior support shall have his review completed to include the significance of this regulation noting the recorded behaviors. 11-21-17.	11/21/2017	Implemented
6400.213(1)(i)	Individual #1's record did not include (ii) his/her identifying marks. The field was blank.	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.	6400.213(1)(i) House Coordinator noted that Individual did not have any markings at all, however did not recognize the importance of marking ¿None¿ in their individual record as a means of documentation for the team to share/use. HC was retrained on this requirement, information was updated. 12/6/17. All other records where checked to ensure proper documentation.	12/06/2017	Implemented
6400.213(11)	Individual #1's 4/14/17 physical examination form indicated he/she was to follow a healthy diet with increased fruits and vegetables and lean meats. His/Her 4/14/17 physical exam form also indicated he/she should follow a diabetic-low sugar diet. His/Her Individual Support Plan (ISP) indicated he/she should follow a low sugar, low sodium diabetic diet. His/Her ISP indicated he/she needs assistance with toileting. He/She may not wipe after a bowel movement. He/She needs 1:1 assistance with bathing, showing and toileting. However his/her 1/13/17 assessment indicated he/she was independent with toileting. On 1/18/17 Individual #1 was seen by a medical professional and according to the medical documentation from that appointment, he/she had diagnosis: unspecified convulsions, instructions: seizure. Individual #1's ISP, assessment, lifetime medical history forms and physical did not indicate this diagnosis or incident that occurred.	Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186.	6400.213(11) House Coordinator and Program Specialist did not compare notes from PCP regarding diet, unspecified convulsions and compare the notes of the assessment to the ISP. HC and PS have been retrained on this regulation and have been in contact with the PCP to clarify information. They also requested a critical revision to the ISP via e-mail to SC to clarify diet, bowel habits and personal hygiene and that there is no seizure disorder. Content discrepancy noted on forms. Email sent 12/07/2017 and 12/13/17.	12/13/2017	Implemented
6400.215(a)	Individual #1's daily behavior support data tracking is not kept in his/her record at the home or at the agency. The agency gives Individual #1's behavior data tracking to his/her behavior specialist who works for another agency.	Information in the individual's record shall be kept for at least 4 years or until any audit or litigation is resolved.	215(a) Information was not kept by House Coordinator and recorded in main file. Behavior therapist maintained records in her office. HC/Program Director was retrained on this regulation and is now scanning the behavior data once monthly to the Program Specialist, emailing the information to the Behavior therapist, and maintaining the information in the main record of the Individual in order to maintain compliance for the team. 12/1/17	12/01/2017	Implemented

SIN-00086093

Renewal

09/29/2015

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.111(a)	There was no fire extinguisher located in the attic.	There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic.			Implemented
6400.183(7)(iii)	No potential to advance in vocational programming and competitive employment for indiv #1.	The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming.	Attached copy of assessment from January 2015 contains statement regarding individual's desire for vocational programming. attachment #1	11/17/2015	Implemented

SIN-00211015

Renewal

09/12/2022

Compliant - Finalized

SIN-00160836

Renewal

10/08/2019

Compliant - Finalized

SIN-00101843

Renewal

10/03/2016

Compliant - Finalized

SIN-00069339

Renewal

07/08/2014

Compliant - Finalized