Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00222366 Renewal 03/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill conducted at 8:11AM on 7/20/2022 did not indicate the time it took to evacuate. This section was left blank.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The Residential Team Lead Supervisor (RTLS) will re-train the Direct Support Supervisors (DSS) and Direct Support Mentors (DSM) on the ODP Fire Drill 6400.112a-112h regulations and the Provider's policy on Fire Drills. The training will review the requirements and importance of completing the monthly fire drills at each service location and the current Fire Drill forms used to document results including the time it took to evacuate and ensuring that all sections of the form are completed and accurate for each Fire Drill conducted. 04/25/2023 Implemented
SIN-00204197 Renewal 04/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(a)Individual #1, date of admission 8-28-21 had an initial assessment completed on 11-31-21. [Repeated Violation 5/4/21 et al.] Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The provider held a training on 5/4/22 in which intake requirements and time frames were addressed. The intake form was separated by time frame and a signature line was added to the bottom of every page with instructions to send the form to the regional Director for review after each interval. 05/13/2022 Implemented
6400.34(a)Individual #1 was informed of individual rights on 1-7-21, and then again on 2-11-22. [Repeated Violation 5/4/21 et al.]The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.A residential Due Date Calendar has been created in which due dates are added to the calendar that Managers accept onto their calendar, due dates are set prior to the deadline. Individual Rights has been set on the calendar for January 4th 2023, with due stipulation of January 20, 2023. Training occurred on 5/4/22 which included the program specialist and members of the management team. This training was related to due date requirements for 6400 regulations, time management and calendar training. Training occurred on 5-13-22 related to the new process for cross checking the calendar and printing reminders to send out weekly. 05/13/2022 Implemented
6400.181(f)The program specialist provided Individual #1's assessment, completed 11-31-21 to the individual plan team members on 12-27-21 for the annual individual plan meeting on 12-17-21. [Repeated Violation 5/4/21 et al.]The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.A residential Due Date Calendar has been created in which due dates are added to the calendar that Managers accept onto their calendar, due dates are set prior to the deadline. Individual Rights has been set on the calendar for October 21, 2022, with due stipulation of November 15, 2022. Training occurred on 5/4/22 which included the program specialist and members of the management team. This training was related to due date requirements for 6400 regulations, time management and calendar training. Training occurred on 5-13-22 related to the new process for cross checking the calendar and printing reminders to send out weekly. 05/13/2022 Implemented
SIN-00187285 Renewal 05/04/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment of the home.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. A self-assessment will be completed for each home Between April 1st and July 30th, annually. Prior to the self-assessment being printed for use, the IDD Administrator will check the ODP website for the most current version and supply it to his House Coordinators and Program Specialist to complete the site parts of the assessment. The Program Specialist, Program Director and Program Manager will receive training on how to complete a self-assessment on 6/24/21 from 10am-3pm from the Regional Director. The Program Manager will review and advise House Coordinator and Assistant Program Directors on how to properly fill out the form on 06/29/21 during the weekly managers meeting. The Self Assessments will be completed on 6/30/21. 06/30/2021 Implemented
6400.77(b)The home's first aid kit does not include antiseptic. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. On 5/20/21 the first aid checklist was updated to include antiseptic. Antiseptic put into the 1st aid supply kit on 5/20/21. The House Coordinator completed the revised First Aid Checklist for June noting that it included antiseptic. 06/10/2021 Implemented
6400.112(c)The written fire drill records for the monthly fire drills held from 12/2020 through 3/2021 did not included the exit routes used.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The provider has included in manager training that two categories are to be included in fire drills moving forward. 1. The route of escape. 2. The meeting location area. on 5/25/21. The Fire Drills from May and June had the exit route and meeting area, but was not specifically defined. The provider add " exit route used" to the form. On 6/17/21 a fire drill was conducted on this site, on 6/21/21 the site administrator filled out the correct form using the data from the 6/17/21 fire drill and signed off on it. 06/21/2021 Implemented
6400.151(a)Direct Service Worker #1 had a physical examination on 2/15/2018 and then again on 3/4/2020. 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. The provider will inform individuals of the expiration date of the physical by email also notifying them that failure to renew their physical by the expiration date will result in suspension until the requirements of the position are met. On 6/23/21 the Regional Director advised the HR/Training coordinator to add the follow clause to the form email that the HR/Training coordinator sends out to staff who are due for the annual physical : "Your current physical will expire on, (add date), if you fail to renew your required physical, you will be suspended from working until you can meet the requirements of the job and possibly further disciplinary action up to and including termination." When individuals complete their annual Physical they send the paperwork to the HR/Training Coordinator, the HR/Training Coordinator enters that information into our HR Tracking system on line. Monthly, the HR/Training Coordinator prints a report from that system and uses it to inform people whose renewal date is less than 90 days away, that they are due for renewal by email. On 6/23/21 the Regional Director advised the HR/Training Coordinator that individuals who did not renew by the expiration date must be suspended until the are back in compliance. 06/23/2021 Implemented
6400.46(b)Direct Service Worker #1 was trained in fire safety on 4/2/2019 and then again on 8/26/2020.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).The provider will provide fire safety training every six months. The most recent fire safety training was on March 9, 2021 Another fire safety training will be conducted on 6/30/21 during the weekly staff meeting. 06/30/2021 Implemented
SIN-00167569 Renewal 12/11/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101The bathroom along the hallway on the second floor of the home was locked with a pad lock requiring a key to unlock preventing egress when engaged.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. 1. The maintenance department removed the padlock and change the lock with the ability to open from the inside (12/12/19) 2. Maintenance will do monthly checks to ensure that no doors have padlocks on them. [Immediately, the CEO or designee shall educate all staff persons that stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed and to monitor for obstructions throughout the course of their daily duties. Documentation of the aforementioned monthly site checks shall be kept. (DPOC by AES,HSLS on 12/24/19)] 12/12/2019 Implemented
SIN-00147377 Renewal 12/18/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment of the home.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. The agency will use the correct self-assessment form during the months we are to conduct the self-assessment. (The incorrect form was used). The Vice President reviewed the correct form with the Program Specialist, Program Director, and Operations Director on 12/17/18 during the audit after finding out that the incorrect self-assessment form was used. The Program Specialist copied 7 correct self-assessment forms to prepare to do the self-assessments for each license homes which is due between April and July of 2019 on 12/18/19 after the audit ended and showed it to the Vice President before she flew back to Glenside. The Program Specialist also added on the google calendar as well as a visual calendar in the office to remind her that the inspection is due. Assistant Office Manager also added to her outlook calendar as April 1, 2019 as a reminder send the team e-mail letting them know that the residential team needs to start to work on the self-assessments for each license homes. The Operations Director will be responsible to check the ODP website to ensure that the program is using the correct self-assessment forms 1 month prior to the start of the beginning quarter. To ensure that the correct forms are completed, the Operations Director will check the forms again in April when the program specialist begins to work with the Program Director on the self-assessment form. May of 2019, the Vice President added to her white board and calendar reminder on outlook to inquire the self-assessments to review to ensure the correct forms were utilized so there is ample time to redo the assessment if the incorrect form was used. 01/11/2019 Implemented
6400.31(b)Individual #2 signed and dated a statement acknowledging receipt of the information on rights on 4/8/17, and then again on 5/15/18.Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. The Program Specialist will create a calendar of then the due dates of the form ¿a statement acknowledging recipient of information on rights¿ for each individual. The Vice President added in the `annual paperwork¿ section in the ¿annual paperwork to the existing CLA audit form on 1/7/19. The new row added ¿Individual Rights¿ with last one done and newest one done. The Vice President will train the Operations Director on the new section and how to do an audit to ensure that the individual rights were reviewed in a timely manner. The Vice President will submit an updated CLA audit tool based on this POC including the Individual Rights due dates. 01/16/2019 Implemented
6400.141(a)Individual #1 had a physical examination on 7/28/17, and then again on 10/29/18.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The Program will ensure that the annual physical examination does not pass the date of the last physical examination by referring to the existing Google calendar. After the appointment, the Program Specialist or the Operations Director will add the due date of the next appointment based on the last appointment on the Google calendar. The Operations Director and Program Specialist will review the Google Calendar during their bi-weekly supervision meeting to review upcoming appointments within the next 2 months and determine if an appointment has been made. The Operations Director will utilize our existing CLA audit tool that has a column indicating: Types of appointments, Previous year appointment date, and add the date of the appointment after the appointment took place and determine if the appointment was on time or not. The Quality Assurance Department will conduct random chart audits on the individual receiving our services. The Vice President gave the Quality Assurance team copy of our existing CLA audit tool on 1/7/19. The Quality Assurance department will send the team a summary of their findings based on the audit including the timeliness of the annual appointment dates. 01/16/2019 Implemented
6400.163(c)The reviews of medications prescribed to treat symptoms of a diagnosed psychiatric illness, dated 9/12/18, 10/10/18, and 12/5/18, completed for Individual #1 did not include necessary dosages of prescribed medications. 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.The Program Specialist and the Blended Case Manager take the individuals to the appointment and the individual¿s medication log from our Electronic Medical Record will be printed out to bring to the appointment for the psychiatrist to review and sign and date the form if there are no changes. If there are changes in medication and dose, the psychiatrist will write a note on the form and sign as well as date the form. Upon receiving the summary of the appointment in the mail, the residential care coordinator will attach the signed medication log along with the summary under our attachment section in the electronic medical record. The Vice President will update the current CLA audit tool to add a section to the Psychiatric note ¿ ¿Information about medication and dosage included?¿ and train the Operations Director about the new addition on the audit tool. The Operations Director will be responsible to conduct monthly chart audits using the CLA audit tool which will include reviewing psychiatric summaries and adding ¿yes or no¿ to the column ¿information about medication and dosage included?¿ 01/16/2019 Implemented
6400.186(d)The Program Specialist did not provide Individual #1's ISP review documentation, end dated 5/6/18 to the plan team members.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. The Program Specialist will provide ISP Review documentation to the team members in a timely manner (30 days prior to the ISP review meeting). The Operations Director is included in the e-mail thus the Operations Director will review the timeliness of the information sent out. The Operations Director will develop a checklist of the areas of improvement based on this plan of correction and establish a bi-weekly supervision meeting with the Program Specialist and discuss the status of areas of improvement including sending documents in a timely manner. The supervision meetings shall be documented and signed by the Program Specialist and the Operations Director. 01/14/2019 Implemented
SIN-00127934 Renewal 01/16/2018 Compliant - Finalized