| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
|
SIN-00235638
|
Renewal
|
10/13/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment is noted as being compliant, however, multiple areas were not compliant. For example, mammogram/gyn exam was noted as compliant and only men reside in the home, furnace inspection listed as compliant, however, the inspection has not been completed since 2/11/22, finally training records listed as compliant when not compliant as the staff member that was reviewed had not met the annual requirement of training for their position. | 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 CEO will complete the self-assessment accurately three to six months prior the expiration date of the agency's certificate of compliance. |
12/11/2023
| Implemented |
| 6400.22(g) | Financial review: July 26 charge to Individual 1 Car Barn for $65 indicates that he paid for five attendees, but there is no reimbursement notation (at least $26 for the other two individuals).
Financial reviews: August 16 charge to Train Collectors Museum for $40 indicates that Individual 1 paid for five attendees, but there is no reimbursement notation (at least $16 for the other two individuals).
August 28 charge to Asian Bento shows purchase of three meals, but there is no corresponding reimbursement notation.
September 5 charge to Hennings for purchase of two breakfast buffets, but there is no corresponding reimbursement notation.
September 11 charge to Hennings for purchase of three lunch buffets, but there is no corresponding reimbursement notation.
September 24 charge to the Gettysburg Nat'l Park for purchase of five admission ($245), but there is no corresponding reimbursement notation.
September 27 charge to Center City take out for $35.52 for the purchase of multiple food items, but there is no corresponding reimbursement notation.
All money for these items/purchases beyond the individual's portion must be reimbursed asap. | There may be no borrowing of the individual's personal funds by staff persons or by the home. | All purchases will be reimbursed to individual 1 in the amount of $364.03 from individual 2, the agency staff, and other resident. There will be no borrowing of individual 1 personal funds. |
12/18/2023
| Implemented |
| 6400.67(a) | There are brown stains on the ceiling of the dining room, which may indicate a water leak.
The edges of the counters in the kitchen are taped over with duct tape. These should be properly repaired or replaced. | Floors, walls, ceilings and other surfaces shall be in good repair. | The agency's maintenance contractor will replace all damaged ceiling tiles in the dining room along with replacing all counter tops in the kitchen. |
02/29/2024
| Implemented |
| 6400.72(b) | There is a window off the kitchen that has plastic and duct tape over it. This should be properly repaired or replaced ASAP to ensure proper temperatures in all rooms of the home. | Screens, windows and doors shall be in good repair. | The maintenance contractor assessed the hallway window and decided it will need to be replaced. Window is on order but can take up to 16 weeks to arrive. Once window arrives and weather permitting maintenance contractor will replace the existing window. |
03/30/2024
| Implemented |
| 6400.72(c) | The door lock at the end of the hallway just off of the kitchen does not catch. This should be repaired or replaced. | Outside doors shall have operable locks. | Maintenance contractor replaced doorknob on door at the end of the hallway. |
11/11/2023
| Implemented |
| 6400.106 | There was no annual furnace inspection found in the record. The last one was completed on 2/11/22. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| COO will ensure a yearly furnace inspection and cleaning will be done by a professional company, |
11/19/2023
| Implemented |
| 6400.112(c) | There was not a line included on the fire drill sheets to indicate if problems were encountered during the fire drills. | 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. | Wording was added to existing fire drill form asking of any problems to note. |
10/13/2023
| Implemented |
| 6400.141(c)(14) | For individual 1 and 2- Info pertinent to diagnosis on the current physical is blank; this section should provide at least minimal data on the individual's diagnoses and/or care in an emergent situation. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The emergency Section will be filled in at the next physical exam for individuals 1 and 2. |
02/29/2024
| Implemented |
| 6400.151(b) | For staff 1, physical exams for staff were signed, but not dated by the crnp or physician. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Wording has been added to the staff physical form to have the signature and date of either the physician, nurse practitioner, or physician assistant. |
10/13/2023
| Implemented |
| 6400.32(e) | The signed documentation and entry into the assessment, regarding Individual 1 and 2's obligations to pay for staff to accompany them to outings is a violation of their rights. This documentation, by its very nature, indicates that both individuals would be prohibited from going on outings if they were to refuse to pay for staff accompaniment. Additionally, the fact that there is legal guardianship for both individuals inherently declares them incompetent to make such decisions. Individual 1 and 2 must be reimbursed these charges. | An individual has the right to make choices and accept risks. | The agency will reimburse individual 1 and 2 for all staff purchases. Individual 1 will be reimbursed $85.00 for the months of Jan. 2023 - June 2023 (July - Sept. were reimbursed in violation 2) Indvidual 2 will be reimbursed $192.00 for months Jan 2023 - Sept. 2023. Agency started paying for staff purchases in Oct. 2023 to present so no reimbursements needed for those months. |
12/18/2023
| Implemented |
| 6400.52(a)(1) | There are 17.5 hours showing as being completed for multiple staff 2, 3, and 4. None of the staff reviewed completed the required annual training for their position. All the training sheets are the same and were not signed by the staff member making it difficult to determine if said trainings were conducted.
In addition, the staff member conducting training signed as an attendee and the trainer as well. Also, it could not be determined when the specific trainings were conducted date/time etc. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | COO will schedule training staff meetings; the Program Specialist will conduct the trainings required. The CEO will sign off on any trainings. |
02/01/2024
| Implemented |
| 6400.52(a)(3) | For staff 2- on 2/8/18, 17.5 hours of annual training completed in one day. however, this staff member signs the sheet as the trainer and attendee. | The following shall complete 24 hours of training related to job skills and knowledge each year: Program specialists. | The Program Specialist will complete 24 hr. annual trainings yearly. The CEO will sign off on any training forms and the COO will record in the employee file. |
02/01/2024
| Implemented |
| 6400.163(a) | For both individuals, there are several medications listed, and found in the medication bin, that do not have a pharmacy label (there are handwritten notations scribbled on the bottles). | 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 Nurse will make sure all medications shall be kept in their original containers. All prescribed medications shall have labels from the pharmacy. |
02/02/2024
| Implemented |
| 6400.163(b) | For both individuals, the medications are being placed in a container in advance of their determined administration timeline (multi-day pill box) | A prescription medication may not be removed from its original labeled container in advance of the scheduled administration, except for the purpose of packaging the medication for the individual to take with the individual to a community activity for administration the same day the medication is removed from its original container. | All medication will be kept in original labeled containers provided by the pharmacy. The weekly multi day dispensers will not be used any longer. |
02/02/2024
| Implemented |
| 6400.163(i) | Despite the declaration of individual 1 and 2's self-medicating status, their medications are not held in their bedrooms. | This section does not apply for an individual who self -administers medication and stores the medication in the individual's private bedroom or personal belongings. | Individuals 1 and 2 will no longer be self medicating . Their medications will be administered by certified staff or by the R-House nurse. |
03/31/2024
| Implemented |
| 6400.166(a)(1) | Individuals 1 and 2 are reported as self-medicating. However, the provided medication record (a bulleted list of the meds) does not meet the requirement of a standard medication record per the regulations. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Individual's name. | A medication record shall be kept for individuals receiving medications at R-House. |
02/29/2024
| Implemented |
| 6400.166(a)(2) | There is no log of the list of the individual 1 or 2's medications or who prescribed them. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | A medication log with the name of the medication and the name of the prescriber will be used by the house nurse or certified staff member when dispensing medications at R-House. |
02/29/2024
| Implemented |
| 6400.166(a)(14) | -The medication list for Individual 2 includes several that were discontinued (Flucatisone Nasal Spray that ended on 3/21, Prednisone 20mg tab that ended on 3/20, Amoxicillin 500mg tab that ended on 9/19). These must be removed upon the completion of the treatment timeline. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Duration of treatment, if applicable. | All discontinued medications are disposed of. A medication record will be used by the certified staff and or nurse when giving medications. discontinued medications will be noted on the log. A new pharmacy providing medication logs will be used. |
02/29/2024
| Implemented |
|
|
|
SIN-00213549
|
Renewal
|
10/17/2022
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | The home did not have up-to-date financial records for everyone that included all transactions made for or on behalf of the individuals. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | A bank ledger was created for all individuals to show debits and credits along with all receipts on 10/31/2022. |
10/31/2022
| Implemented |
| 6400.22(e)(3) | The home did not provide an accurate account of all expenses of a single purchase of $15 or more for the individuals. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | A bank ledger was created for all individuals to show debits and credits along with all receipts on any transactions over $15.00 on 10/31/2022. |
10/31/2022
| Implemented |
| 6400.64(a) | The ventilation vent in Individual's bathroom had bugs inside that must be cleaned. | Clean and sanitary conditions shall be maintained in the home. | The ventilation vent light was cleaned out by our maintenance contractor on 11/8/2022. |
11/06/2022
| Implemented |
| 6400.67(a) | The wall above the entry door when exiting Individual's #3 bedroom is cracked in multiple places and needs to be repaired.
In Individual's #2 bedroom the ceiling shows stains consistent with a leak, which needs to be repaired and painted.
The wall going down the basement has a hole in wall and is in need of repair. | Floors, walls, ceilings and other surfaces shall be in good repair. | In individual #3 room the cracks above the doorway were repaired by our maintenance contractor on 11/8/2022.
In individual #2 room the stains from a previous leak were repaired by our maintenance contractor on 11/15/2022.
The wall in need of repair going down the basement has been repaired. |
11/06/2022
| Implemented |
| 6400.72(b) | Four out of five of the windows in Individual's #1 bedroom will not remain open, they slam shut and need to repaired or replaced.
Window in Individual's #3 bathroom will not remain open, slams shut needs to be repaired or replaced.
The window in the Livingroom where the air conditioner was removed, the wood strip is missing exposing rusting nails. | Screens, windows and doors shall be in good repair. | All windows in individual 1 room as well as individual 3 bathroom has been assessed by our maintenance contractor on 11/15/2022 and was determined that all windows need to be replaced. Maintenance contractor ordered windows on 11/25/2022. We were informed by the window vendors that it could take up to 16 weeks for delivery. Once windows are delivered maintenance contractor will put them in by 3/30/2023. In the meantime, DSP staff will assist any individuals that need to use the windows to ensure their safety. |
03/30/2023
| Implemented |
| 6400.73(b) | In the garage area there is a missing portion of the railing (more than a 18 inch drop) and the area is frequent by the individuals who put out trash. This railing needs to be repaired. | Each porch that has over an 18-inch drop shall have a well-secured railing. | The missing portion of railing in the garage was repaired by our maintenance contractor on 11/8/2022 |
11/06/2022
| Implemented |
| 6400.76(a) | There was a rusted shower bar in individual's #2 bathroom and must be replaced. | Furniture and equipment shall be nonhazardous, clean and sturdy. | A new shower bar was purchased by COO/CFO and put up by DSP staff 10/30/2022. |
10/30/2022
| Implemented |
| 6400.113(a) | Fire safety training was not provided for individual #1 for the previous year, only the most recent training was late and conducted on10/7/22. | 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. | Due to COVID restrictions Chester Co. Fire Safety Training was not allowed into homes in 2021. They are our designated Fire Safety Training resource and will continue to be in the future. As a backup we will work with other agencies in the area and insurance risk management departments to ensure we get our individuals and staff the fire safety training required. All staff were trained in fire safety for 2022 on 10/7/2022. |
09/30/2023
| Implemented |
| 6400.141(a) | Individual #1 physical exams 12/28/20 and 2/3/22 provided, there was no physical exam provided for 2021. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Physical exams will be scheduled annually for individual #1 by the Program Specialist. It was identified that the physical for 2021 was not completed until 2/3/22 for Individual #1. Although it was completed, it was done late. |
02/06/2023
| Implemented |
| 6400.141(c)(6) | Individual #1 Tuberculin test was conducted 1/23/19 and 3/8/21, which was not within the required two-year timeframe. | 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. | It was identified that the TB for Individual 1 was completed, however it was late. Individuals #1 Tuberculin will be done at his physical exam in 2023. Individual 1 has his next TB scheduled for 2/6/23 at the time of his physical exam. This is ahead of the due date of March 8, 2023. |
02/06/2023
| Implemented |
| 6400.142(a) | It could not be determined when the last dental exam was completed as it was not found in the record at inspection. | 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. | The dental exam document was not located at the time of the inspection. Since then, the Program Specialist has located the dental form documentation and place it in the individuals' record. |
11/07/2022
| Implemented |
| 6400.142(g) | It could not be determined if individual's #1 and #2 had a dental hygiene plan that was written annually, as the plans dated 9/2/22 were the only plans provided at inspection | A dental hygiene plan shall be rewritten at least annually. | It was not able to be determined if a dental Hygiene plan was written annually for Individual 1 and 2 as documentation for 2021 was not located at the time of inspection. Since then, the Program Specialist has located the dental form documentation and place it in the individuals' record. |
09/02/2023
| Implemented |
| 6400.151(a) | The Program Specialist's annual physical exam was completed late. The previous exam was completed on 1/3/2020, next exam was completed on 6/20/2022, making it late by 5 months. | 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 COO will keep a monthly spreadsheet with staff physical exams due dates. Reminder notifications will go out to the respective staff 3 month, 2 months, and 1 month in advance. This method will help in keeping records in compliance. This spread sheet has been created and is in effect. |
01/01/2023
| Implemented |
| 6400.151(c)(2) | · The Program Specialist previous TB test was completed on 4/11/2019, and the test was completed on 6/20/2022. This exam was received late and not completed every 2 years. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | A review was conducted by the COO of all staff physical exam records to address any coming due exams and or TB test. Staff were notified who were coming due. |
01/01/2023
| Implemented |
| 6400.18(i) | 4 incidents were not closed and extensions were not filed or completed by due dates at the time of the inspections. The incidents reviewed were:
1. 8830543
2. 8908362
3. 8907604
4. 8907662 | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | The Programs Specialist with the help of the county point person has worked on the four incidents that were open and now three of the four incidents are closed. Only 8830543 is still open and is being worked on so that it will also be closed in two weeks by 12/9/2022 |
01/01/2023
| Implemented |
| 6400.46(b) | The program specialist (1) and the CEO (2) conducted the staff fire safety trainings, they were not trained by a Fire safety expert to conduct these trainings. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Due to COVID restrictions Chester Co. Fire Safety Training was not allowed into homes in 2021. They are our designated Fire Safety Training resource and will continue to be in the future. As a backup we will work with other agencies in the area and insurance risk management departments to ensure we get our individuals and staff the fire safety training required. All staff were trained in fire safety for 2022 on 10/7/2022. |
09/30/2023
| Implemented |
|
|
|
SIN-00194554
|
Renewal
|
10/20/2021
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff member #1's criminal history record check was completed (1/13/21) 9 days after the date of hire(1/4/21). | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. | The Office Manager will run a criminal history check before the point of hire |
11/15/2021
| Implemented |
| 6400.22(e)(3) | The actual receipts for single purchases exceeding $15 for check #2023 in the amount of $400 was not provided for individual#1. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | 1. Receipt for $400
a. The R-House Director is responsible client accounts
b. Receipts kept for client cash on hand spending
c. The director records client spending in the ledger and makes copies of the receipts over $15
2. $400 need receipts for documentation
3. target date 2/28/22
4.2/28/22 date the director will have new process for recording spending
the director will make sure there are more specific receipts for cash on hand use. |
11/15/2021
| Implemented |
| 6400.105 | There was a golf ball size lint found in the lint tray. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| Lint in the dryer trap
a. The DSP staff is responsible for cleaning the lint trap
b. The dryer lint trap will be cleaned after each use of the dryer.
c. the lint trap was cleaned by the DSP after each time the dryer is used starting 11/21/21
October 22 is the dated corrected. The lint trap was cleaned by DSP staff |
11/15/2021
| Implemented |
| 6400.112(a) | The unannounced fire drill for the month of September 2021 was not completed. | An unannounced fire drill shall be held at least once a month. | Missed September Fire Drill (whole house was sick with Covid)
a. The Director of R-House is responsible for conducting fire drills
b. Fire drills will be conducted monthly.
c. Fire drills will be conducted monthly as per regulations
2. September 2021 Fire Drill was missed for the entire house
3. The next month was October fire drill was completed on 10/28/21
4.each Month a fire drill will be completed by the end of each month |
11/15/2021
| Implemented |
| 6400.141(c)(9) | A current prostate exam was not completed for individual#1. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Late Prostate exam (late because the Primary Care Doctor decided the Urologist should do it instead of having it be done at the annual physical) Program Specialist will be responsible for correcting the problem
b. The Prostate exam was corrected by the program Specialist. The resident was taken to the appointment on October 22, 2021 where he had his prostate examined.
c. The prostate exam was completed by the urologist on October 22, 2021 See attachment #1
2. the Prostate exam was late. a review of the other prostate exams are in compliance.
3. Future Prostate exams will be made by the Program Specialist for the following years physical exam. The next years exams will be booked by 2/1/22
4. next year's physical will be done by Oct 12,2022 |
10/22/2021
| Implemented |
| 6400.142(c) | The follow up dental treatment recommended for individual#1 on 9/21/21, was not kept. | 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. | Missed follow-up dental appointment (due to illness)
a. the Program Specialist is responsible for making appointments and making sure individuals get to appointments
b. the missed appointment was made up. The resident was taken to the dentist on 11/11/21 by the Program Specialist.
The dental follow-up appointment was missed (due to illness)
the target date for the rescheduled appointment was 11/11/21 and it was kept and completed
11/11/21 was the target date and it was completed.
the Program Specialist took Individual 1 to the dentist on 11/11/21 |
11/11/2021
| Implemented |
| 6400.144 | The follow up dental services prescribed for individual#1 was not arranged or provided. | 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 dental exam will be completed. |
11/11/2021
| Implemented |
| 6400.181(a) | The annual assessment for individual#1 was not completed. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Assessment notification and discrepancies
a. Program Specialist is responsible for writing the yearly assessment
b. the assessment will be corrected
c. as per regulations an assessment will be sent out 30 days prior to the ISP
2. Assessment needs to be sent out 30 days prior to the ISP and needs to be signed by the individual
3. Target date the individual signed his assessment 10/21/22
4. Corrections on the assessment completed by 11/15/21
The Program Manager will complete the Assessment for each year |
11/15/2021
| Implemented |
|
|
|
SIN-00180679
|
Renewal
|
10/15/2020
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.34 | Licensing Representative was not permitted to gain access to the 3rd floor room (door locked) the agency provide no key during inspection. | The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients. | Correction Required: The facility or agency shall provide to the authorized agents of the Department full access to the agency or facility and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the dept to privately interview staff and clients.
POC:
The Plan is for the key to be onsite at all times and easily accessible to the Director and Office manager when needed.
A. Who: The R-house Office Manager and the R-House Director
B. The Office Manager has placed the key to the 3rd floor records room in the locked file cabinet #1 in the main office area. The CEO, has access at all times to the locked file cabinet.
C. Task was completed by 1/11/21.
D. The key will be kept in the locked file cabinet #1 for all future use. If someone needs to access the 3rd floor records room, they will request the key from the Office Manager or the Director.
E. All Management team members have been notified of the new location and procedure for obtaining the key to the 3rd floor records room. |
01/11/2021
| Implemented |
| 6400.21(b) | An FBI Clearance was not completed for Staff #1, it could not be determined if person resided out of state within the last 2 years. | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| Correction Required: If a prospective employee who will have direct contact with the individuals, resides outside this Commonwealth, an application for a Federal Bureau of Investigation FBI) Criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
POC:
The plan will be to update the R-House application and Interview process to include the question" Have you resided in the state of Pa for the past two years?"
A. Who: The Office Manager/HR and the DSP Supervisor/HR Assistant
B. The agency employee application will be corrected
C. This task was corrected on1/11/21. A new updated for hire application was updated.
D. The Office manager and the DSP supervisor have updated the employee for hire application and will include the question " have you resided in the state of Pa for the last two years and potential staff will be required to show proof of residency. If potential staff have lived outside of the state of Pa within the two years of being hired, they will have to have a FBI check done in addition to having a Pa criminal history check within 5 days after the person's hire date.
E. This is to replace the old Application and will be used for all future interviews. All Management team members and R-house staff have been informed of the new process. Attached is a picture of the new application. |
01/11/2021
| Implemented |
| 6400.22(e)(3) | There is no clear documentation of actual receipts or expense record of each individuals spending of purchases exceeding $15.00. There is no separate record of financial resources used that include amounts with deposits and withdraws clearly. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | Correction Required: If the home assumes responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation by actual receipt or expense record, of each single purchase exceeding $15.00 made on behalf of the individual carried out by or in conjunction with a staff person.
POC: The plan going forward is to have the receipts available from the last 6 months from the date of inspection.
A. who: The Director/Rep Payee for the individuals at R-House
B. In the future, the Director will have make sure all receipts from individual purchases and account logs are ready for review.
C. On 1/11/21 all receipts were current, organized and available to review along with all the individual account logs.
D. All staff and residents will be reminded to make sure all receipts over $15.00 are handed in timely so they can be recorded. Staff were filled in at the annual staff training meeting on 2/9/21. |
01/11/2021
| Implemented |
| 6400.72(b) | The window screen in Individual #1 bedroom was damaged (hole). | Screens, windows and doors shall be in good repair. | Correction required: Screens on windows and doors shall be in good repair.
POC: The plan will to have screen repaired for individual #1.
A. The maintenance person was notified about the need for the screen repair. In the future, window screens will be checked for any damage.
B. The window screen in the room of Individual #1
C. The window screen was repaired . The hole was patched up. date 1/11/21.
D. Attached is a picture of the repaired window screen. |
01/11/2021
| Implemented |
| 6400.111(a) | There was no operable 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. | Correction Required: There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic.
POC: A fire extinguisher with the minimum 2A has been placed in the attic above the apartment. target date and completed 1/18/21
A. Office Manager and Director
B. Office Manager will make sure a new extinguisher is purchased and put in the attic over the apartment.
C. In the future all floors including the basement and the Attic will have an operable 2-A rated fire extinguisher |
01/18/2021
| Implemented |
| 6400.141(c)(6) | Tuberculin skin test was not completed as required (agency states Individual #3 refused) no supporting documentation provided. | 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. | Correction Required: The physical exam 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.
POC: Individual #3 was not able to have a TB at the time of her physical because her physical was virtual due to the COVID-19 pandemic and Also Individual #3 doesn't like to be touched and most medical appointments especially invasive ones, need to be done under sedation. With the help of the behavior Specialist, the staff will continue to encourage individual #3 and will try to help her feel comfortable enough to allow someone to give her a TB test. Staff continue to follow and be trained on the behavior plan and the medical support plan and the letter from both the primary doctor. Any future refusals to get her TB will be noted on the physical form.
A. The Program Specialist, the Behavior Specialist , The DSP Supervisor and/or The Director
B. The letter from the doctor and the copy of the support plan and the letter from the Behavior specialist regarding invasive appointments will be available for review.
C. In the future Program Specialist or any staff taking individual #3 on appointments, will make sure all physical forms/medical forms will document when the individual refuses to take a TB test . Staff will continue to encourage Individual #3 to feel safe and comfortable enough to be able to get invasive medical test taken without the need of sedation. Target date for correction to be done 1/14/21.
D. All staff are trained on Individuals behavior plan/medical Support plans annually. Staff were retrained by the behavior specialist 12/8/20 and a follow up training was done on 2/9/21. |
01/14/2021
| Implemented |
| 6400.31(b) | A signed copy of rights for Individual #2 could not be found in individuals file, last dated rights was 1/16/19. | The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights. | Correction required: The home shall educate assist and provide the accommodation necessary for the individual to make choices and understand the individual rights.
POC: In the Future Individual #2 will be educated on their choices and rights annually.
A. The Program Specialist
B. The Program Specialist will educate, read and have Individual #2 sign their rights form. Target date to have corrected by 1/14/21.
C. The Program Specialist will annually educate individual #2 and all the individuals at the agency on their choices and rights. Individual #2 was educated on their rights on 10/15/20 and they signed their rights statement form. On 1/27/21 they were read their rights and choices statement form for the new year and it was signed on 1/27/21.
D. All staff will be educated on Individual choices and rights. Staff were trained on individual rights on 2/9/21. |
01/14/2021
| Implemented |
| 6400.31(b) | A signed copy of rights for Individual #3 could not be found in individuals file during inspection, last dated rights was signed on 1/16/19. | The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights. | Correction required: The home shall educate assist and provide the accommodation necessary for the individual to make choices and understand the individual rights.
POC: In the Future Individual #3 will be educated on their choices and rights annually.
A. The Program Specialist
B. The Program Specialist will educate, read and have Individual #3 sign their rights form. Target date to have corrected by 1/14/21.
C. The Program Specialist will annually educate individual #3 and all the individuals at the agency on their choices and rights. Individual #3 was educated on their rights on 10/15/20 and they signed their rights statement form. On 1/27/21 they were read their rights and choices statement form for the new year and it was signed on 1/27/21.
D. All staff will be educated on Individual choices and rights. Staff were trained on individual rights on 2/9/21. |
01/14/2021
| Implemented |
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SIN-00150599
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Renewal
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01/30/2019
|
Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(14) | On Individual #1 annual physical examination form Medical information pertinent to diagnosis and treatment in case of an emergency was omitted.
On Individual #2 annual physical examination form Medical information pertinent to diagnosis and treatment in case of an emergency was omitted. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Plan of Correction for Individual #1 and Individual #2 physical examination forms was corrected by the Program Specialist on 3/27/19 by sending the form to their Primary care Physician who reviewed the section that was not filled in. This section was the medical information pertinent to the diagnosis and treatment in case of an emergency. The doctor wrote "None" on both Barry and Larry's physical forms and initialed it. In the Future the Program specialist will make sure all the lines on the physicals forms are completely filled in by the physician at the time of the annual exams. No other action is required. |
03/27/2019
| Implemented |
| 6400.213(1)(i) | Individual #1 did not have a current, dated photograph.
Individual #2 did not have a current, dated photograph. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.
| The Plan of Correction will be to provide a current dated photo of Individual #1and Individual #2 on their Face Sheets. This correction was made by the Program Specialist. The Program Specialist reviewed the regulations regarding this matter and had the CEO of R-House sign off that this was completed. In the Future, The Program Specialist will make sure when the updated the data Face sheets for all individuals is being updated annually, that a current dated photo is included on the form. A new Face Sheet will be updated In April 2019. |
03/27/2019
| Implemented |
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SIN-00124000
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Renewal
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10/30/2017
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The hot water in the bathtub was 124°Fahrenheit. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | We called our plumber out to reset the water temperature to 120 degrees on the water heater. |
10/31/2017
| Implemented |
| 6400.151(a) | Staff person #1's date of hire was 2/13/17, and the physical exam was completed on 3/7/17. | 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. | We plan to follow the guidelines of 6400 regulations regarding new hires and having a physical 12 months prior to employment. |
11/01/2017
| Implemented |
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SIN-00093624
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Renewal
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04/28/2016
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(d) | Equate brand anti-bacterial hand soap and Dawn anti-bacterial dish soap were found stored with food in basement storage area. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | All poisonous materials were moved to a separate storage room away from any food. Food purchaser and Direct Care staff will ensure this will remain standard by checking the area after putting all groceries away on a weekly basis. [Program Specialist or other program designee will conduct weekly site inspections on an ongoing basis to ensure that poisonous materials are not stored with food items in the future. JG] All staff were trained on all of our violations that needed correcting and will be retrained at our yearly training meeting in January 2017.
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04/29/2016
| Implemented |
| 6400.105 | Flammable/combustible products WD40 and Clean Strip Brush Cleaner stored in in the basement in close proximity to the furnace. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
We will ensure all flammable, combustible and any equipment will remain stored and away from any heat source. Direct Care Night Shift staff will do a weekly check.All staff were trained on all of our violations that needed correcting and will be retrained at our yearly training meeting in January 2017.
| We will make sure all flammable, combustible, and any equipment will be removed and stored safely away from any heat source. All staff will check to make sure any flammable, combustible items are stored safely. [Program Specialist or other program designee will be responsible for weekly site inspections to ensure compliance with proper and safe storage of combustible materials. JG] |
07/20/2016
| Implemented |
| 6400.112(a) | It was reported through interviews that staff were informed ahead of time that fire drills would be held. | An unannounced fire drill shall be held at least once a month. | We now make sure our monthly fire drills are not announced to any staff or individuals. The CEO performs the fire drills. |
05/29/2016
| Implemented |
| 6400.141(c)(6) | Individual #1 was last tuberculin skin testing was 2/8/2014. | 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. | We will follow the refusal plan for medical appointments. The TB test will be done under sedation during yearly dental appointment. The CEO or Program Specialist assisted a direct care staff to take the individual to the appointment. |
09/30/2016
| Implemented |
| 6400.141(c)(11) | Individual #2's annual physical examination dated 6/23/2015 contained recommendations for health maintenance including blood work and labs. To date the recommendations have not been completed. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | We will make sure that all health maintenance needs and blood work will be done at physician's recommended intervals. Either Program Specialist or Direct Care Staff will take to appointments. At the end of any doctor appointment, the Staff will ensure they receive a hard copy of any blood prescriptions and any other health maintenance recommendations from the doctor; also, the doctor's office will send it electronically. The Program Specialist will set up a date for individual to get any test done and Direct Care staff will take them. [The program Specialist will routinely review the Individuals' records to ensure that all recommended health maintenance activities, screenings and appointments are scheduled and are completed within the required timeframe. JG] |
08/30/2016
| Implemented |
| 6400.143(a) | Individual #1's annual physical dated 4/15/15 documented her refusal for any medical tests and interventions that involve physical touching. The record did not contain a plan to address her refusals. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | The Behavioral Specialist, with input from our Program Specialist, created a medical refusal plan, which will be followed at all medical appointments. We will document each of the appointments in a daily log for the individuals. Each staff member will be given a copy of the medical refusal plan and will also be trained in the plan. [The Program Specialist or other program designee will monitor to ensure that the Medical Refusal Plan is being followed. JG] |
07/21/2016
| Implemented |
| 6400.151(c)(2) | Staff #2 last tuberculin skin testing was completed on 4/02/2012. | 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. | The employee received a TB test on 7/22/2016 (documentation provided). Going forward, we will make sure that all staff receives TB test via Mantoux method with negative results, if a positive a chest x-ray will be done and results will be recorded. At present time physicians are changing TB testing to blood draw with a more accurate result. The Program Specialist and Office Administrator will make sure all physical exams/TB testing via Mantoux or blood draw will be done at the time of physical exam. |
09/30/2016
| Implemented |
| 6400.181(c) | Annual assessment for Individual #1 did not state the source of the information used to write the assessment or how it was obtained.
Annual assessment for Individual #2 did not state the source of the information used to write the assessment or how it was obtained.
| The assessment shall be based on assessment instruments, interviews, progress notes and observations. | Source of information shall be added to the assessments, which shall include observation, daily logs, progress notes, interaction with individuals, and monthly/quarterly progress reports. The Program Specialist will make sure each assessments has been looked over and corrected during the annual renewal of assessments. |
07/21/2016
| Implemented |
| 6400.181(f) | Annual assessment for Individual #2 was not provided to team members 30 days prior to the ISP meeting. | The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| The Program Specialist will make sure each team member receives assessments to help in planning IPS's. Assessments will be given to each plan team member at least 30 days prior to ISP meeting by Program Specialist. A signature page will be signed by team member then returned to the Program Specialist to indicate receipt.
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11/30/2016
| Implemented |
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SIN-00078177
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Renewal
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04/17/2015
|
Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.111(a) | The upstairs fire extinguisher was not in the charged status. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | The fire extinguisher was recharged and certified. We have fire extinguishers check every year by main company. But, R-House staff will check extinguishers each month and document on chart. And any extinguisher that needs to be recharged will be done promptly. The Director created a check list to ensure that all fire extinguishers are checked monthly for all areas of the home. |
05/05/2015
| Implemented |
| 6400.151(a) | Staff #1's was hired on 7/1/14. The physcial examination for staff #1 was completed on 8/19/14.
Staff #2 was hired on 7/22/14 and did not have a physical examination.
| 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. | Staff #2's medical evaluation was completed on 5/5/15. Any new hired staff will have a physical prior to any contact with individuals. The Director developed a check list for all new staff hires to ensure that all the required documents and training to be completed in accordance with the regulations. The Director will review all new staff hire packets on their first day of hire to ensure the documents have been completed. [SW 5.11.15] |
05/05/2015
| Implemented |
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SIN-00056616
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Renewal
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02/10/2014
|
Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(e) | Sleep drills were not held every six months. There was a seven month gap between drils from June 24th 2013 to January 26th 2014. | (e) A fire drill shall be held during sleeping hours at least every 6 months.
| R-House will make sure that sleep fire drills are held every 6 month.
The Program Director will review the fire drills on a monthly basis to ensure that a sleeping drill is held within the requires 6 month period of time, starting 30 days within receipt of this Plan of Correction. |
02/20/2014
| Implemented |
| 6400.141(c)(9) | Individual #1's physical examination dated 7-17-13 did not include a prostrate examination. | (9) A prostate examination for men 40 years of age or older.
| We will make sure all male individuals have a prostate exam and if they did we will have proper documentation by reviewing the medical evaluation form on an annual basis.
The Program Director will develop a tracking document and track the dates of all required medical evaluations to ensure that the individuals receive the required anual evaluations, which includes the prostrate examination, starting within 30 days of receipt of this plan of correction. |
02/20/2014
| Implemented |
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SIN-00046457
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Renewal
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02/19/2013
|
Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.23 | The facility's grievance procedures do not assure do not assure an investigation will take place nor that a resolution will be achieved. | The home shall have written grievance procedures for individuals, individual's families, advocates and staff persons, that assure investigation and resolution of complaints.
| New policy written to include grievance investigations and resolutions |
01/15/2013
| Implemented |
| 6400.34(b) | The facilitys Civil Rights Procedures does not include a policy to inform individuals about the right to file complaints. | (b) The home shall develop and implement civil rights policies and procedures. | New policy for civil rights was written.
Other policies were resent to licensing agent.(didn't receive first copy) |
04/15/2013
| Implemented |
| 6400.103 | The facility's Emergency Evacuation Procedures do not include a means of transportation. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| Policy updated to include transportation, staffing and emergency shelter locations. |
04/15/2013
| Implemented |
| 6400.104 | The facility did not provide a written notification to the local fire department regarding the location of the individuals on site. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| A letter will be sent electronically via e-mail to fire station and printed out and kept in our records. |
04/15/2013
| Implemented |
| 6400.110(h) | The facility's inoperative fire alarm written plan did not include steps to patrol site for possible fire while the alarm was inoperative. | (h) There shall be a written procedure for fire safety monitoring in the event the smoke detector or fire alarm is inoperative.
| Updated policy to include monitoring of event of fire alarm inoperative |
04/15/2013
| Implemented |
| 6400.112(f) | Alternate exit routes drills of 10/28, 9/28, 8/31, and 7/30/12 were all front exits. | (f) Alternate exit routes shall be used during fire drills.
| When we have fire drills we will use alternative exits. Also will be documented on our fire drill form. |
02/28/2013
| Implemented |
| 6400.112(g) | Fire drills of 12/3, 11/29, 10/28, 9/28 were all in the 5pm hour. | (g) Fire drills shall be held on different days of the week and at different times of the day and night.
| We will have our fire drills at different times of the day and night. Also will be documented on our fire drill form. |
02/28/2013
| Implemented |
| 6400.142(a) | Individual #1 last dental was listed at 1/2/12. | (a) 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.
| We had to find a new dentist that would preform dental work under sedation. Individual will be going to Special Smiles. First appointment was in April. |
03/04/2013
| Implemented |
| 6400.143(a) | Individual #1 has refused Diphteria and Tetnus vacinations, Mammogram, and Gyn examinations. Agency needs better plan documentation of attemps at desensitization, counseling, positive approaches, etc. for this individual. | (a) If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record.
| Documentation of discussionstraining of health appointments and the necessity of said appointments will be documented in the individuals notebook and on monthly reports. A letter of deferral of gyn appointments will be received from the physician and kept in file. The letter will be received at the time of the annual physical exam. |
04/15/2013
| Implemented |
| 6400.181(a) | The assessment for individual #1 was over 1 yr. old. Last on record 11/14/11. | (a) 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.
| An assessment will be written 90 days prior to the end of ISP and 30 days prior to ISP renewal plan meeting. A plan was written but not in file at time of inspection. |
04/15/2013
| Implemented |
| 6400.181(e)(14) | Individual #2 did not have in his assessment documention of his ability concerning water safety. | (13) The individual's progress over the last 365 calendar days and current level in the following areas: (14) The individual's knowledge of water safety and ability to swim.
| The annual assessment will include water safety and the ability to swim |
04/15/2013
| Implemented |
| 6400.181(f) | The assessments for individuals #1 and #2 were not sent to the supports coordinator. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| The Program Specialist will electronically send annual assessment to the S.C. 30 days prior to the annual ISP meeting |
04/15/2013
| Implemented |
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