| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency's certification of compliance expired on 8/20/16. The agency did not complete a self-assessment of the home until 9/6/16. | 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. Who- Program Specialist and CEO
B. What- The agency will complete a self-assessment of each home the agency operates serving eight or fewer individuals, 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
C. When and How- the CEO has created reminders on the agency¿s google calendar to ensure proper completion of the self-assessment packet. The CEO has scheduled a training for the completion of the assessment prior to the assessment packet due date in March of 2017.
To be sent by 11/18/2016 for corrective proof:
- Due dates listed on google calendar
- Training proof provided to managers on completion of assessment packet. |
11/18/2016
| Implemented |
| 6400.15(c) | The self-assessment completed on 9/6/16 did not include a written summary of the violations or corrections made. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| A. Who- Program Specialist, CEO, House Managers
B. What- A copy of the agency¿s self-assessment results and written summary of corrections made shall be kept by the agency for at least one year.
C. When and How- House managers and program specialist will be retrained on the completion of self-assessment packets to ensure proper completion. Training will be provided a month prior to the March 2017 completion of agency self-assessment packets. Managers will keep self-assessment packets in the home and comment on completion of corrections made.
To be sent by 11/18/2016 for corrective proof:
- Training materials on completion of agency self-assessment packet. |
11/18/2016
| Implemented |
| 6400.21(a) | REPEAT from 6/29/15 annual inspection: Staff #1's date of hire was 10/1/15 and his/her Pennsylvania State Police criminal history record check wasn't completed until 10/7/15. - Staff #2's date of hire was 6/23/15 and his/her criminal histroy record check wasn't completed until 8/27/15. - Staff #3's date of hire was 12/8/15 and he/she had a Pennsylvania criminal history record check completed on 11/13/15. However the request was under review for control. At the time of licensing on 9/27/16, there wasn't a finalized criminal history record check for Staff #3. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes 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.
| A. Who ¿ HCA Corporate Office
B. What ¿ Ensure all newly hired staff have completed a criminal background check within five working days of date of hire.
C. When and How ¿ Staff 1¿s criminal background was run on time, but no follow-up occurred to obtain the dispensation that was under review. HCA Corporate Office will follow new policy regarding following up on criminal background checks that come back Under Review.
To be sent by 11/18/2016 for corrective proof:
- Dispensation for Staff 1. Per Peake v. Commonwealth of Pennsylvania, et al., M.D. 2015, we have decided to keep Staff 1 because the violations were non-violent in nature and they occurred many years ago.
- Policy regarding following up on criminal background checks that come back Under Review. |
11/18/2016
| Implemented |
| 6400.22(d)(1) | The residential provider did not keep an up-to-date financial record for Individual #1. | 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. Who- House Managers, DSPs, Program Specialist, CEO
B. What- The home will keep an up-to-date financial and property record that includes the following: Personal possessions and funds received by or deposited within the home.
C. When and How- The financial tracking has been updated as of 10/2/2016 and have been distributed to the team to reflect an up-to-date financial and property tracking. Staff including but not limited to House Managers and DSPs have been trained on the updated financial tracking form and have implemented the new system within the home. House managers will oversee proper completion of the up to date financial tracking for all individuals.
To be sent by 11/18/2016 for corrective proof:
- Updated financial tracking form
- Training provided to staff on updated financials. |
11/18/2016
| Implemented |
| 6400.67(a) | There was approximately a 10 inch unpainted surface area above the fireplace mantle. The unfinished surface apeared to be spackling material covering up 3 holes. | Floors, walls, ceilings and other surfaces shall be in good repair. | A. Who- House Managers and DSPs
B. What- House managers will ensure that floors, walls, ceilings, and other surfaces are in good repair.
C. How and When- House managers and DSPs will report on the daily crossover any maintenance needs or repairs in the home. Maintenance will be called as needed to correct. Staff will report any needed repairs to the executive team to ensure that all repairs are addressed accordingly.
To be sent by 11/18/2016 for corrective proof:
- Completed daily crossovers by DSPs and House Managers
- Proof of training on daily crossovers and repair expectations. |
11/18/2016
| Implemented |
| 6400.144 | Individual #1 had a doctor's order to check his/her blood sugar 3 times per day. According to blood sugar logs, his/her blood sugar was not tested and recorded on 7/22/16 at 8am and 7/29/16 at 4pm. According to the blood sugar log, there weren't test strips at the home at 4pm on 7/29/16. | 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.
| A. Who- House Managers, Direct Support Staff, Program Specialist, CEO
B. What- Health services such as medical, nursing, pharmaceutical, dental, dietary, and psychological services that are planned or prescribed for the individual shall be arranged or provided for.
C. When and How- Blood sugar tracking has been updated as of 11/9/2016 and includes information pertaining to the protocol set in place by the Endocrinologist. Staff have been trained on the new protocol and completion of the blood sugar tracking form. DSPs and House Managers will ensure proper completion of the blood sugar tracking form as described in the offered training.
To be sent by 11/18/2016 for proof of corrective action:
- Updated and completed blood sugar tracking form.
- Updated blood sugar protocol
- Training provided to staff on updated blood sugar tracking and diabetes protocol. |
11/18/2016
| Implemented |
| 6400.151(a) | Staff #4 had a physical exam completed on 7/29/14 and not again until 8/26/16, outside of the 2 year time frame. | 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. | A. Who ¿ HCA Corporate Office
B. What ¿ Ensure staff have completed a physical examination every two years.
C. When and How ¿ Staff records will be reviewed monthly to see which staff will be requiring a physical for the following month. Arrangements will be made by the HCA Corporate Office for the staff to complete their physical within the two-year time frame.
To be sent by 11/18/2016 for corrective proof:
- Policy regarding staff physicals and the monthly review of records to ensure compliance with the two-year time frame. |
11/18/2016
| Implemented |
| 6400.164(a) | The over the counter medication logs for Individual #1 did not contain the strength of medicine prescribed, the dosage given, and the time of administration. The following dates were noted to be when this occurred; 6/11/16, 5/7/16, 5/6/16, 5/5/16, 5/4/16, 5/3/16, 5/2/16, 11/8/15, 11/4/15. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | A. Who- House Managers, Direct Support Professionals, Program Specialist, CEO
B. What- The OTC medication log includes the following information; medication prescribed, dosage, time and date (including insulin) were administered, and the name of the individual administering the medication or insulin is kept on record for all individuals who are not self-medicating.
C. When and How- OTC medication log has been updated and distributed to the team. OTC medication log includes; name of medication, dosage, time and date administered, and staff signature for administration. Staff including managers and the program specialist have been trained on the updated OTC log as of 11/9/2016.
To be sent by 11/18/2016 for corrective proof:
- Updated OTC Medication Log
- Meeting agenda and sign in for training on updated OTC medication log. |
11/18/2016
| Implemented |
| 6400.181(d) | The assessment completed on 4/15/16 for Individual #1 did not include a written signature and date from the program specialist. The signature and dated was electronically prepopulated from an unsecure system. | The program specialist shall sign and date the assessment. | A. Who- Program Specialist
B. What- The program specialist will sign and date all completed assessments.
C. When and How- The program specialist will ensure that all assessments are signed and dated once they have been completed by the program specialist and printed to be filed and sent to the support team. The program specialist and individual will sign off on the assessment upon review of all assessment content.
To be sent by 11.18.2016 for corrective proof:
- Program Specialist signature on completed annual assessment. |
11/18/2016
| Implemented |
| 6400.181(e)(3)(ii) | The assessment completed on 4/15/16 for Individual #1 did not include his/her current level of communication skills. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. | A. Program Specialist and CEO
B. What- The assessment will include the individual¿s current level of performance and progress in the area of communication.
C. When and How- The assessment has been updated to include the current level of performance and progress in the area of communication as of 10/2/2016. The updated assessment has been presented and reviewed with the program specialist and trained on on 10/2/2016.
To be sent by 11.18.2016 for corrective proof:
- Updated assessment including the current level of performance and progress in the area of communication.
- Completed assessment with the communication section completed in its entirety including current level of performance and progress.
- Training on assessment completion by Program Specialist |
11/18/2016
| Implemented |
| 6400.181(e)(4) | The assessment completed on 4/15/16 for Individual #1 did not include his/her need for supervision. | The assessment must include the following information: The individual's need for supervision.
| A. Who- Program Specialist and CEO
B. What- The assessment will include the individual¿s need for supervision
C. When and How- The assessment has been updated as of 10/2/2016 to include individual¿s supervision needs and comments on the supervision levels. The program specialist has been trained on the updated assessment and will ensure all assessments include the individual¿s supervision needs and comments on the supervision level.
To be sent by 11.18.2016 for correct proof:
- Updated assessment including the supervision needs of the individual and comments the supervision levels.
- Completed assessment for an individual that includes the supervision needs and comments on the supervision level.
- Training on assessment completion by Program Specialist on 10/2/2016. |
11/18/2016
| Implemented |
| 6400.181(e)(9) | The assessment completed on 4/15/16 for Individual #1 did not include his/her disability, including functional and medical limitations. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | A. Who- Program Specialist
B. What- All assessments will include documentation of the individual¿s disability including functional and medical limitations.
C. How and When- The assessment has been updated as of 10/2/2016 to include comments on the individual¿s disability including functional and medical limitations. The program specialist has been trained on the new assessment template and will ensure that all individual annual assessment include documentation of the individual¿s disability including functional and medical limitations.
To be sent by 11/18/2016 for corrective proof:
- Updated assessment including documentation of the individual¿s disability including functional and medical limitations.
- Completed assessment for an individual that includes comments on the individual¿s disability including functional and medical limitations.
- Training provided to the Program Specialist on 10/2/2016 on updated assessment and completion. |
11/18/2016
| Implemented |
| 6400.181(e)(10) | The assessment completed on 4/15/16 for Individual #1 did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | A. Who- Program Specialist
B. What- The assessment includes a lifetime medical history
C. When and How- The annual assessment has been updated as of 10/2/2016 to include comments on the individual¿s lifetime medical history. The program specialist has been trained on the new assessment and completion of the updated assessment. The program specialist will ensure that this section of the assessment is completed for all individuals by commenting on their lifetime medical history.
To be sent by 11/18/2016 for corrective proof:
- Updated assessment that includes a section to comment on the lifetime medical history of the individual.
- Completed assessment for an individual by the program specialist that includes comments on the lifetime medical history.
- Training provided to the program specialist on 10/2/2016 on updated assessment and completion. |
11/18/2016
| Implemented |
| 6400.181(e)(13)(v) | The assessment completed on 4/15/16 for Individual #1 did not include progress in socialization. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | A. Who- Program Specialist
B. What- The assessment will include progress over the last 365 calendar days and current levels in the following areas: Socialization.
C. When and How- The annual assessment has been updated as of 10/2/2016 to include progress and comments on the current level in the area of socialization. The program specialist has been trained on the updated annual assessment and completion of the assessment. The program specialist will ensure that the area of socialization is commented on in regards to the progress over the last 365 calendar days and the current levels in the area of communication.
To be sent by 11/18/2016 for corrective proof:
- Updated assessment that includes a section for progress and comments on current levels in the area of socialization.
- Completed assessment for an individual in which the program specialist has commented on the progress over the last 365 calendar days and current levels in the area of socialization.
- Training provided to the program specialist on 10/2/2016 on updated assessment and completion. |
11/18/2016
| Implemented |
| 6400.181(e)(13)(vi) | REPEAT from 6/29/15 annual inspection: The assessment completed on 4/15/16 for Individual #1 did not include progress in recreation. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | A. Who- Program Specialist
B. What- The assessment includes the individual¿s progress over the last 365 calendar days and current levels in the area of recreation.
C. When and How- The annual assessment has been updated as of 10/2/2016 to include comments on progress and current levels in the area of recreation. The program specialist has been trained on the new assessment and completion as of 10/2/2016. The program specialist will ensure that all assessments for individuals includes comments on the progress over the last 365 calendar days and current levels in the area of recreation.
To be sent by 11/18/2016 for corrective proof:
- Updated annual assessment that includes comments on progress over the last 365 calendar days and current levels in the area of recreation.
- Completed assessment for an individual that includes the information regarding recreation.
- Training provided to the Program Specialist on 10/2/2016 that reviewed updated assessment and completion of annual assessments. |
11/18/2016
| Implemented |
| 6400.186(b) | The Individual Support Plan (ISP) reviews for Individual #1 completed on 7/8/16, 4/6/16, and 1/6/16 did not include a written signature and date. The signature and date was electronically prepopulated from an unsecure system. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | A. Who- Program Specialist
B. What- The ISP will be reviewed, signed, and dated by the program specialist within 30 days of the ISP update date.
C. When and How- The program specialist will visit all homes when a new ISP has been issued, updated, and printed. The program specialist will visit the homes to review the ISP and sign off as well as date the updated ISP.
To be sent by 11/18/2016 for corrective proof:
- ISP signature pages signed and dated by HCA Program Specialist |
11/18/2016
| Implemented |
| 6400.213(11) | The assessment completed on 4/15/16 for Individual #1 indicated under supervision needs for home and community, "24." Individual #1's Individual Support Plan (ISP) updated on 7/6/16 indicated that he/she needs 24 hour supervision at home but may be left unsupervised for 15 minutes when staff walk the dog. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | A. Who- Program Specialist and House Managers
B. What- All ISP discrepancies will be reported to the county support coordinator so the ISP can be revised accordingly.
C. When and How- The Program Specialist and House Manager will review all ISPs on the 1st of every month, or when a new ISP is distributed by the county. The Program Specialist and House Managers will review the ISP in full and report any discrepancies to the county Support Coordinator within two days of the review or receipt of new ISP. Training and expectations for ISP reviews will be provided to the Program Specialist and House Managers by 11/18/2016.
To be sent by 11/18/2016 for corrective proof:
- E mails sent to support coordinators will all ISP discrepancies
- Updated ISPs where discrepancies have been addressed and fixed
- Proof of training on 6400 regs and ISP |
11/18/2016
| Implemented |
| Article X.1007 | REPEAT from 6/29/15 annual inspection: Hoffman Care Associates is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 ¿ 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff #1 was hired on 10/1/15; the criminal history check was requested on 10/7/15. Staff #2 was hired on 6/23/15; the criminal history check was requested on 8/27/15. Staff #3 was hired on 12/8/15; at the time of licensing on 9/27/15 results from his/her criminal history check were not obtained by the agency. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | A. Who ¿ HCA Corporate Office
B. What ¿ Ensure all newly hired staff have completed a criminal background check within five working days of date of hire.
C. When and How ¿ Staff 1¿s criminal check was run on the fifth business day after hire. HCA Corporate Office will follow new policy regarding following up on criminal background checks that come back Under Review.
To be sent by 11/18/2016 for corrective proof:
- Dispensation for Staff 1. Per Peake v. Commonwealth of Pennsylvania, et al., M.D. 2015, we have decided to keep Staff 1 because the violations were non-violent in nature and they occurred many years ago.
- Policy regarding following up on criminal background checks that come back Under Review. |
11/18/2016
| Implemented |