Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00233485 Renewal 11/07/2023 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16Individual #1 is 71 years old and diagnosed with OCD, Depression, anxiety, mild ID, open angle glaucoma, hypertriglyceridemia, hypertension, tinnitus, eczema, onychomycosis, presbyopia, hypertrophic nails, and impetigo. Individual #1 has been in the care of Hoffman Care Associates since 10/1/13. Per individual #1's ISP, the individual needs assistance with budgeting, money management, and keeping their money safe. The individual requires a representative payee due to poor financial understanding. Individual #1 has had HCA as their Rep Payee since admittance to the program on 10/1/13. Hoffman Care Associates (HCA) Financial policy states that HCA has in the past offered to provide Rep Payee services however no longer provides these services for incoming clients. They will continue to provide services for current clients who are already utilizing HCA for Rep Payee services. HCA reports individual #1's Rep Payee, staff #6, is no longer an employee of the agency. The date of actual separation is unknown (this was requested at time of inspection and again on 11/13/23). The current rep payee remains affiliated with the Agency however by being married to the Agency Owner. There is no documentation that upon the rep payee's "separation" from HCA that individual #1 was offered a new Rep Payee either within HCA or with an outside agency. In review of the Representative Payee checking account there were several questionable withdrawals/deposits/purchases noted. The provider nor the Representative Payee have been keeping any receipts for this account and were unable to account for the questionable transactions during the inspection. In review of the bank statements the following information was discovered: Statement ending 1/13/23: Balance: $13909.77 Purchases: $198.83: Questionable Purchases Statement ending 2/14/23: Balance: $4296.62 Withdrawals: $11,000: Questionable Withdrawals Statement ending 3/14/23: Balance: $10,754.42 Deposits: $5,000-Questionable Deposits Statement ending 4/14/23: Balance: $12,445.66 Statement ending 5/12/23: Balance: $2544.24 Purchases: $10,401.85 (includes check # 248, 250) (Questionable Purchases) Statement ending 6/14/23: Balance: $4051.79 Statement ending 7/14/23: Balance: $3346.89 Purchases: $2190.60 (includes check # 245, 246) (Questionable Purchases) Statement ending 8/14/23: Balance: $2265.90 Purchases: $2684.10 (Questionable Purchases) Statement ending 9/14/23: Balance: $901.82 Purchases: $2948.83 (Questionable Purchases) Statement ending 10/13/23: Balance: $4868.60 Withdrawals: $3000 (Questionable Withdrawals) Purchases: $7340.01 (includes check # 256) (Questionable Purchases) Deposits: $12, 517.67 (Questionable Deposits) The evidence presented suggests potential financial exploitation of Individual #1. The questionable withdrawals, purchases, and lack of documentation for these transactions raise concerns about the misuse of funds intended for the individual's benefit. Additionally, the unclear circumstances surrounding the separation of the original representative payee, who is married to the agency owner, may indicate a conflict of interest.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.A thorough investigation will be completed to gather information regarding the misuse of Individual #1's funds. Hoffman Care will reimburse Individual #1 for the total amount of money that was spent by the rep payee. The rep payee will immediately have no access to Individual #1's bank account. The CEO will be responsible in overseeing the account while Hoffman Care works on obtaining a new independent third party as the rep payee for Individual #1. The CEO will notify law enforcement of the misuse of Individual #1's personal funds and collaborate with law enforcement as needed. Moving forward no employees of Hoffman Care will serve as the rep payee for any of the individuals in their care. The CEO will develop a comprehensive code of conduct and enforce consequences for any staff found engaging in unethical behavior. All staff will be trained on the code of conduct. 12/29/2023 Accepted
6400.22(d)(1)(Repeat from 1/3/23) At time of the inspection, individual #1's financial log was not correct. The log noted that the beginning October 2023 balance was $2568.79, however the ending balance for September 2023 was recorded as $2518.77 (discrepancy of $50.02). There was a miscalculation on September's ledger as well -- on 9/29/23 balance was $2516.66, a purchase was made at target for $10.58 -- the balance should have been $2506.08, ledger incorrectly identifies balance as $2520.58.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. Manager has been retrained on ensuring all purchases are documented accordingly. 11/15/2023 Accepted
6400.151(a)Staff person #2 was hired on 4/7/22. The physical was not completed until 12/1/22. No other physical form was available in staff's chart. 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 member #2 went to Concentra for a physical on 11/16/2023. 11/16/2023 Accepted
6400.151(b)Staff #2's physical form, dated 12/1/22, was signed by the physician but not dated by the physician. The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. Staff member #2 went to Concentra for a physical on 11/16/2023 and the form was signed and dated. 11/16/2023 Accepted
6400.151(c)(2)(Repeat from 10/19/22) Staff #2, was hired 4/7/22. The TB chest xray was not completed until 12/1/22. No other TB test results available in staff's chart. 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. Staff member #2 had a TB test performed on 11/16/2023 at Concentra. Staff member had a chest x-ray performed. 11/16/2023 Accepted
6400.18(g)For individual #1 an incident of exploitation/misuse of funds was discovered on 9/25/23. This was reported in EIM within the 24hr timeframe on 9/26/23. The provider did not initiate an investigation at that time due to a conflict of interest. The incident report notes the provider is attempting to locate another CI. At the time of inspection, 11/7/23-11/9/23, the incident investigation has still not been initiated. Per staff #5, Lancaster BHDS was contacted to complete this investigation but not until 11/7/23.The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person.HCA will contact another provider, CSG, that can be contracted if a conflict of interest arises in the future. HCA is also trying to identify another staff member without familial ties to management, or the spouse/partner of management, to become a Certified Investigator. 11/10/2023 Accepted
6400.34(a)Individual #1 rights were reviewed on 10/31/23. Missing from the signed Rights documents was Rights-31a-g, 33 a & b, and 32i.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.Civil Rights form has been updated to reflect and include all rights listed in the 6400 regulations. New forms have been reviewed with all clients. 11/09/2023 Accepted
6400.207(4)(I)At the time of the inspection, individual #1 was prescribed Lorazepam 0.5mg as needed to treat anxiety at the 9/20/23 psychiatric medication review appointment. There is not a clear description of the explicit psychiatric symptoms of the mental illness provided by the physician or clear parameters of when this medication should be given. The SEEN plan does not address the use of this medication either. The individual received this medication on 11/1/23, MAR in the home was not signed/authorized by the CEO.A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition.House manager has initiated contact with individuals doctor to clarify use of PRN medication. Doctor requested in-person appointment to discuss. Appointment is scheduled for 11/29. Until then, medication will not be administered to the client. 11/15/2023 Accepted
SIN-00202761 Renewal 03/08/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)REPEAT from 1/4/2021 annual inspection: At the time of the 3/10/22 onsite inspection, the first aid kit was not equipped with scissors. 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. Scissors have been added to the first aid kit 05/04/2022 Implemented
6400.104The most recent letter to the local fire department, dated 9/20/21, only indicates that one resident, Individual #2, is in the home and may need assistance. There are two individuals who reside in the home and the letter isn't clear as where Individual #2's bedroom is located.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. Fire letter has been updated to clarify where BOTH individuals bedrooms are and resent to the fire department. 05/09/2022 Implemented
6400.141(c)(9)Neither a prostate exam nor a Prostate-Specific Antigen (PSA) test was conducted for Individual #1 at their 6/2/21 physical examination appointment.The physical examination shall include: A prostate examination for men 40 years of age or older. PCP has completed this portion of the annual physical to explain why a prostate exam was not completed. 04/11/2022 Implemented
6400.141(c)(14)Individual #1's 6/2/2021 physical examination record did not include information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. PCP has completed this information on the physical examination. 05/02/2022 Not Implemented
6400.46(d)Staff person #2 was trained by the National CPR Foundation in first aid, CPR, AED on 11/28/18 and not again until 1/5/2021, outside the 2-year certification window described on their certificate.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.Staff #2 will redo First Aid/CPR training. 05/27/2022 Implemented
6400.51(b)(5)Staff persons #1 and #2 have worked directly and independently with Individual #1 over the previous year. There are no records maintained that Staff person #1 was oriented to Individual #1's individual-specific plans, protocols, health needs, services, behavior support plans, financial management skills, food and dietary needs, etc. Additionally, there are no records that any individual-specific trainings included an in-person training component.The orientation must encompass the following areas: Job-related knowledge and skills.Staffs #1 and #2 will redo orientation, which will also include an in-person component. 05/27/2022 Implemented
6400.52(a)(1)Staff person #1 has worked directly with Individual #1 over the previous year. There are no records maintained that Staff person #1 received any training hours during the agency's annual training year from 7/1/2020-6/30/2021. Staff person #3 only completed 21 hours of annual training within the annual training year.The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.Staffs #1 and # are back on track with two hours of training per month. 05/27/2022 Not Implemented
6400.52(c)(2)Staff person #3's annual training did not include all of the required elements defined in 6400.52(c)(2).The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.Staff #3's training for the rest of the year will be sure to include the required components. 05/27/2022 Implemented
6400.165(g)Individual #1's 9/3/2021 review of their psychotropic medications does not include the diagnosis or reason for prescribing the psychotropic medications. The review stated the medication was prescribed for "HTN", which is the medical abbreviation for "hypertension" and not the reason for Individual #1's medication prescribed to treat a psychiatric illness.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Appointment forms have been updated to include a spot for physician to complete including reason for prescribing the medication. 05/02/2022 Implemented
6400.166(b)During the 3/10/22 onsite inspection, it was discovered that the date and time of medication administration, and the name and initials of the staff person who administered Individual #1's morning medications on 3/10/22 was not recorded at the time of administration.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Write up was completed for staff member who had not immediately signed off on MARs following medication administration to client. Staff was retrained on MAR protocol. 03/21/2022 Implemented
6400.169(a)Staff person #2 was documented that they were certified via the Department's annual medication administration training course on 8/28/2020 and not again until 9/2/2021, outside the annual time frame requirements. There are no records maintained that additional medication training was completed for Staff person #2 due to their late medication recertification. According to the course, only one mar was completed by 8/28/2021, so an additional two mars were required to recertify the staff.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).Staff #2 will undergo the required additional medication training. 05/27/2022 Implemented
SIN-00181523 Unannounced Monitoring 01/04/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The Self-Assessment was completed, but not dated, so the date of completion is unknown.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. All individual Self-Assessments will be checked by CEO upon completion to ensure all information has been entered, including the date, and is accurate in reflecting the individual and home. CEO will ensure these self-assessments are completed 3-6 months prior to the expiration date of the agencies certificate of compliance. 01/15/2021 Implemented
SIN-00160895 Renewal 09/17/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The cordless phone in the living room, beside the TV, did not contain emergency numbers.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. A. What was the Issue/Violation- House 605 Crestwyck Circle did not have Emergency Phone numbers listed by the living room phone. B. Who is Responsible for Making these Corrections: House Manager, Program Specialist C. What action should have been taken/addressed- Telephone numbers of the nearest hospital, police department, fire department, ambulance, and poison control center shall be on or by each telephone in the home with an outside line. D. When/How will the violation/issue be addressed- House Manager will place Emergency phone numbers at all phones in the home as well as on the back of all cordless phones. E. Proof of Materials/Information to be Reviewed- Picture attached of phones with emergency numbers. 09/23/2019 Implemented
6400.80(b)The Left window shutter is falling off. There are 2 screws, one on each side of the shutter on the top, middle and bottom that hold it to the siding of the home. The 2 screws on the top and middle are detached from the home siding and the shutter is falling off. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.A. What was the Issue/Violation- House 605 Crestwyck Circle had an outside shutter that was off of the hinges on the back bedroom window. B. Who is Responsible for Making these Corrections: House Manager, Program Specialist C. What action should have been taken/addressed- The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. D. When/How will the violation/issue be addressed- House Manager will put in a maintenance request to the apartment complex to have the shutter secured into the side of the apartment. E. Proof of Materials/Information to be Reviewed- Picture of fixed shutter as well as initial maintenance request to complex. 09/23/2019 Implemented
SIN-00217087 Unannounced Monitoring 01/03/2023 Compliant - Finalized
SIN-00177767 Renewal 04/05/2021 Compliant - Finalized