Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00228615 Renewal 07/31/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The second floor bathroom has a moderate dust buildup in the ceiling vent.Clean and sanitary conditions shall be maintained in the home. The DSPs on shift were immediately instructed to clean the bathroom and make sure the ceiling vent was clear of dust 7/31/2023 (see attached). 07/31/2023 Implemented
6400.67(b)The basement refrigerator is leaking water on the floor. Floors, walls, ceilings and other surfaces shall be free of hazards.The DSPs on shift were immediately instructed to clean the leaked water from the refrigerator in the basement after it was fully defrosted. Fridge was plugged back and there was no water leakage again effective 7/31/23 (see attached). 07/31/2023 Implemented
6400.82(f)There is no soap in the second floor bathroom.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. The DSPs on shift was immediately instructed to place a bar soap for washing hands in the bathroom on 7/31/23 (see attached). 07/31/2023 Implemented
6400.151(c)(2)Staff 1's record does not document a Tuberculin test. 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. Physical examination was completed for staff before hire with a checked section that reads ¿ No obvious signs of communicable diseases¿. 08/01/2023 Implemented
6400.151(c)(2)Individual 2's record does not document a Tuberculin test. 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. Going forward all physical examinations will be completed not greater than 1 year apart to include all information. Royal Home Care will also request for a complete physical examination using ODP standard form before admitting any individual for placement 08/01/2023 Implemented
6400.152(a)Staff 1's physical does not document that they are free from communicable diseases. If a staff person or volunteer has a serious communicable disease as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) or a medical problem which might interfere with the health, safety or well-being of the individuals, written authorization from a licensed physician is required for the person to be present at the home. The physical exam form was immediately taken to the doctor¿s office to fill out the section containing information pertinent to communicable diseases. 08/01/2023 Implemented
6400.163(f)individual 1's insulin medication was in the refrigerator in individual 1's bedroom unlocked.Prescription medications stored in a refrigerator shall be kept in an area or container that is locked.Individual¿s medication was immediately locked and kept in the refrigerator upstairs (see attached). The staff responsible for not locking the medications was immediately removed from the schedule and replaced by an experience staff pending medication administration training. The staff was retrained on 8/2/23 on medication administration foundation, procedure, and documentation by the agency¿s med trainer. 08/02/2023 Implemented
6400.163(f)individual 2 prescribed medication erythromycin benzoyl gel with directions to apply topically for folliculitis, is in the kitchen refrigerator in an unlocked container.Prescription medications stored in a refrigerator shall be kept in an area or container that is locked.Individual¿s medication was immediately locked and kept in the refrigerator upstairs (see attached). The staff responsible for not locking the medications was immediately removed from the schedule and replaced by an experience staff pending medication administration training. The staff was retrained on 8/2/23 on medication administration foundation, procedure, and documentation by the agency¿s med trainer. 08/02/2023 Implemented
SIN-00208323 Renewal 07/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The top of the refrigerator in the kitchen had substantial grease buildup resulting in it being brown and sticky.Clean and sanitary conditions shall be maintained in the home. The DSPs on shift were immediately instructed to clean the refrigerator in the kitchen and make sure it was clear of grease on 7/21/22. 07/21/2022 Implemented
6400.67(a)The following items in the home were in need of repair. - There was a handle broken in half on freezer in the kitchen. - There was a knob missing on the top drawer of a dresser - The area just above the rear exit had rust and paint peeling around the doorframe.Floors, walls, ceilings and other surfaces shall be in good repair. Royal Home Care maintenance contractor immediately replaced the broken handle on the freezer in the kitchen, the missing knob on the top drawer of a dresser and made sure the rear exit doorframe is free of rust and peeling paint by repainting it (see the attached). 07/26/2022 Implemented
6400.114(a)Two most recent physical exams for individual 4 were completed on 9/4/20 and 5/22/22. Greater than 1 year apart.If an individual or staff person smokes at the home, there shall be written smoking safety procedures. Going forward all physical examinations will be completed not greater than 1 year apart to include all information. Royal Home Care will also request for a complete physical examination using ODP standard form before admitting any individual for placement. Physical examination will be completed, signed, and dated by a licensed physician, certified nurse practitioner or licensed physician assistant. Royal Home Care nurse will audit the document to ensure that all required field are filled out. 07/26/2022 Implemented
6400.141(a)Most recent physical exams for individual 3 were completed on 2/8/21 and 4/28/22 -- Greater than 1 yearAn individual shall have a physical examination within 12 months prior to admission and annually thereafter. Going forward all physical examinations will be completed not greater than 1 year apart to include all information. Royal Home Care will also request for a complete physical examination using ODP standard form before admitting any individual for placement. Physical examination will be completed, signed, and dated by a licensed physician, certified nurse practitioner or licensed physician assistant. Royal Home Care nurse will audit the document to ensure that all required field are filled out. 07/26/2022 Implemented
6400.141(c)(14)The annual physical completed for individual 4 on 5/22/22 had the following section left blank: - Information pertinent to diagnosis in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The physical exam form was immediately taken to the doctor¿s office to fill out the section containing information pertinent to diagnosis in case of emergency. 07/26/2022 Implemented
6400.142(d)In the file of individual 4 there is no documentation of a dental exam that includes a cleaning. The dental appointments provided dated 12/15/21 and 6/16/22 were emergency appointments for tooth pain.The dental examination shall include teeth cleaning or checking gums and dentures. Individual was taken for an emergency dental appointment when he complained of toothache. He successfully completed the oral surgery per doctors¿ order. Individual 4 now has a dental hygiene plan per dentist¿s recommendation. He will brush and floss twice a day. 07/26/2022 Implemented
6400.142(g)There was no annual dental hygiene plan present in the file of individual 3.A dental hygiene plan shall be rewritten at least annually. Individual 3 now has a dental hygiene plan per dentist¿s recommendation. He will improve brushing and start flossing twice a day. 07/26/2022 Implemented
6400.142(g)There was no annual dental hygiene plan present in the file of individual 4.A dental hygiene plan shall be rewritten at least annually. Individual 4 now has a dental hygiene plan per dentist¿s recommendation. He will brush and floss twice a day. 07/26/2022 Implemented
6400.165(g)Individual 3 had a gap in his psychiatric medication reviews that was greater than 3 months from 7/28/21 to 1/12/22If 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.Individual #3 completed psychotropic med reviews via telehealth. The gap in date was because of doctor¿s availability due to covid-19 concerns. Going forward, the nurse, the program specialist, and the residential supervisor will ensure that all scheduled psychotropic med reviews are completed accordingly for all individuals. Supporting documents will be filed immediately after the visits in individual¿s medical book. 07/26/2022 Implemented
SIN-00190680 Renewal 07/26/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The electric outlet cover located in Individual #1 bedroom was missing which could cause an hazard.Floors, walls, ceilings and other surfaces shall be in good repair. The maintenance contractor immediately placed an electric outlet cover in individual #1 bedroom on 7/28/2021 to prevent hazard. 08/02/2021 Implemented
6400.71There were no emergency numbers near or on the telephones located in the office (basement) or in the kitchen.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 list of emergency telephone number was posted near the telephone located in the in the office (basement) immediately on 07/28/2021. 08/02/2021 Implemented
6400.141(c)(6)On the Annual Physical Examination Form for Individual #2, dated 9/4/20 the Tuberculin skin test was given 9/4/20 and the read date and results were omitted, left blank.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. Per agency's requirements, physical exam should include Tuberculin skin test which must be read and dated accordingly. Going forward physical examination will be completed including the date of tuberculin skin test in the result. 08/02/2021 Implemented
6400.141(c)(10)On the Annual Physical Examination Form for Individual #2 dated 9/4/20 the person free of communicable diseases was left blank.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. Physical exam should include Tuberculin skin test which must be read and dated accordingly. Going forward physical examination will be completed including the date of tuberculin skin test in the result 08/02/2021 Implemented
6400.18(i)The Incident Management Report with Discovery date 3/18/21 was not finalized with the required 30 days. The agency failed to request an extension to the Department in writing and provide the reason for the extension. Individual #3The 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.Program specialist was trained to finalize incident within 30 days or request for extension in writing if an incident if an incident will not be finalized on time. 08/04/2021 Implemented
6400.181(f)The program specialist did not provide the assessment to the individual plan team members at least 30 days prior to an individual plan ISP meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Program specialist was trained to provide assessment to the individual plan team members at least 30 days prior to an ISP plan meeting. 08/04/2021 Implemented
SIN-00170098 Renewal 01/31/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The floor vents throughout the home are bent and are in need of replacement. The bathroom shower head plate was found rusted. The 2nd floor closet door surface was found with a hole.Floors, walls, ceilings and other surfaces shall be in good repair. Royal Home maintenance contractor replaced the floor vent, bathroom shower head plate, and repaired the 2nd floor closet door surface on 02/10/2020. See attached pictures. Going forward, the residential director will carry out a monthly physical inspection of the homes and ensure that needed repairs are done in timely fashion. Training regarding 6400 compliance was completed with residential director on 02/11/2020. 02/10/2020 Implemented
6400.67(b)The dining room outlet cover was found cracked. Floors, walls, ceilings and other surfaces shall be free of hazards.Royal Home Maintenance contractor replaced dining room outlet cover on 02/10/2020. Going forward the residential director will carry out a monthly physical inspection of the homes. Training regarding 6400 compliance was completed with residential director on 02/11/2020. 02/10/2020 Implemented
6400.72(b)One bedroom was found empty. The closet door and frame are too small for the opening resulting with a gap exposing rusty nails. Screens, windows and doors shall be in good repair. Royal Home Maintenance contractor repaired closet door and frame and replaced nails on 02/10/2020. Going forward, the residential director will complete a monthly physical inspection. Training regarding 6400 compliance was completed with residential director on 02/11/2020. See attached picture. 02/10/2020 Implemented
6400.76(a)Individual # 1's bedroom had a chair peeling from its surface. Furniture and equipment shall be nonhazardous, clean and sturdy. Individual's chair was replaced on 02/03/20 by the maintenance contractor. Going forward Royal Home residential director will complete monthly physical site inspection and ensure that furniture is in good condition. Any furniture suffering from wear and tear will be replaced immediately. See picture. 02/03/2020 Implemented
SIN-00120566 Renewal 10/17/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The license of the home expired on 8/3/17 and the self assessmnet was completed on 5/18/17.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. On 12/15/2017, The site manager was trained by the program administrator who also reviewed 6400 regulation 15(a) and the deadline to complete the site's self-assessment. Going forward, the site manager under the supervision of the administrator will complete the self-assessment within 3 to 6 months prior to the expiration date of the agency's certificate of compliance. 12/15/2017 Implemented
SIN-00087294 Renewal 12/14/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(3)Individual # 2 needs assistance with managing money and the individual's record does not have receipts for purchases totally $15.00 or more. 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. Individual #2 is his own Rep Payee. Staff work closely to help him manage his money and make responsible financial decisions. Individual #2 has difficulty submitting receipts after each purchase. He is required to submit a receipt to RHC after every purchase. Individual #2 has expressed that he likes and prefers to shop with street vendors who do not provide receipts. Royal Home Care continues to encourage Individual #2 to shop at places and with people who will provide him receipts after every purchase. When Individual #2 receives any monies from RHC, he will sign off on a petty cash receipt. Individual # 2 annual assessment has been updated to reflect the following. Royal Home Care staff and Program Specialist will continue to encourage and educate Individual#2 on the importance of submitting receipts after every purchase. (Individuals who have the ability manage a certain amount of money shall have this amount identified in their individual support plans. The provider will ensure the individual signs a receipt for the amount of money, not to exceed the amount identified in the ISP, disbursed to the individual from the provider. DS08.03.16) 05/27/2016 Implemented
6400.112(e)The previous fire drill held during sleeping hours was on 01/16/2015 and the most recent fire drill held during sleeping hours was held on 08/11/2015.A fire drill shall be held during sleeping hours at least every 6 months. Royal Home Care¿s house manager, with the supervision of the administrator and Assistant director will ensure that fire drills held during sleeping hours are conducted at least once every six months. Most recent sleeping hours fire drill was conducted on 5/23/2016 at 2:00AM. Royal Home Care will continue this practice to ensure that the above noncompliance does not re occur. 05/27/2016 Implemented
6400.112(f)The fire drills records from December 2014 through December 2015 indicate the front door was used as the exit.Alternate exit routes shall be used during fire drills. Royal Home Care¿s house manager, with the supervision of the administrator and Assistant director will ensure that Alternate exit routes shall be used during fire drills. On the most recent fire drill conducted on 5/23/2016, the basement exit was utilized. Royal Home Care will continue this practice to ensure that the above noncompliance does not re occur. (Residential Staff will be retrained on the importance of utilizing alternate exit routes during monthly fire drill within 30 days of receipt of this plan DS 08.03.16) 05/27/2016 Implemented
6400.141(c)(4)Individual # 1's physical examination dated 08/26/2015 did not include a hearing screening.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. On Individual #1 physical exam dated 8/26/15 did not include a hearing screening, Individual #1 has an appointment for a hear evaluation 5/3/16 at 11:30 am, upon completion documentation will be submitted. Site Manager will complete monthly reviews to prevent non-compliance in individual health..(The program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days. A tracking system will be developed in order to ensure compliance with the timeframes outlined in the regulation DS 08.03.16) 05/03/2016 Implemented
6400.141(c)(14)Individual # 1's physical examination dated 08/26/2015 did not document medical 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. moving forward, Royal Home Care¿s nurse and house manager will review physicals and other medicinal documentation for all individuals after every appointment to ensure that Medical information pertinent to diagnosis and treatment in case of an emergency and all other relevant/required information is recorded.(The program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days DS 08.03.16) 05/27/2016 Implemented
6400.142(a)Individual # 1's previous dental examination was dated 10/03/2014 and the most recent dental examination was dated 11/30/2015.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. On 1/15/2016, Site Manager was trained by the Director on Individual Health 6400 regulations on completion of annual dental exams. Site Manager will complete quality assurance chart checks monthly to prevent medical appointments out of compliance.(The program director or designee will conduct a record review which will be completed within 30 days of receipt of this plan to identify any other individual records out of compliance. Any record found to be out of compliance will be corrected within 15 days. A tracking system will be developed in order to ensure compliance with the timeframes outlined in the regulation DS 08.03.16) 01/15/2016 Implemented
6400.181(f)Individual # 1's ISP meeting was held on 10/22/2015 and the annual assessment was sent to the SC and team members on 09/30/2015.(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). Royal Home Care¿s program specialist in collaboration with other team members will ensure that all individual assessments are sent 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. For most recent ISP meetings, Individual¿s updated ISP was forwarded to SC at least 30 calendar days prior to the ISP meeting. With the supervision of Royal Home Care¿s administrator and Assistant Director, Program Specialist will ensure that the above oversight does not re occur.(All program specialists will be retrained in their job duties and a record review of all individual served will be completed within 30 days of receipt of this plan. If an assessment was not sent to team members in accordance to the time frame, the program specialist will immediately send it. A tracking system will be developed to ensure assessments at being sent to team members according to the timeframes identified in the regulations DS 08/03/2016) 05/27/2016 Implemented
6400.186(a)Individual #1's 3 month ISP review documentation covering the period from 01/10/2015-04/10/2015 and 04/10/2015-07/10/2015 did not include a review medical, behavioral and financial services. Individual # 2's 3 month ISP review documentation covering the period from 04/28/2015-07/28/2015 did not report on the outcome "community integration" as identified in the ISP dated 04/28/2015 and did not include review medical or financial services. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. The program specialist responsible for the above violation no longer works for Royal Home Care. Royal Home Care has a new program specialist. As of 8/25/2015 new quarterly report template was developed to include a review medical, behavioral and financial services for all individuals. Template also reports on all outcomes as identified in every individual¿s ISP. All quarterly reports since the above date have included detailed reports on all outcomes as identified in all individual ISP¿s and includes a review medical, behavioral and financial services for all individuals. Royal Home Care¿s administrators and Assistant director will continue to monitor all reports to ensure that the above oversight does not re occur. 05/27/2016 Implemented
6400.186(b)Individual #1's 3 month ISP review documentation covering the period from 01/10/2015-04/10/2015 and 04/10/2015-07/10/2015 was not dated by the program specialist.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. The program specialist responsible for the above violation no longer works for Royal Home Care. Royal Home Care has a new program specialist. As of 8/25/2015 all quarterly reports have been signed by the program specialist and the respective individuals. All monthly reports are also signed by the program specialist. Royal Home Care¿s administrators and Assistant director will continue to monitor all reports to ensure that the above oversight does not re occur. 05/27/2016 Implemented
6400.188(c)Individual # 1 does not have a methodology or procedure developed to determine if progress is being made towards the outcomes identified in the ISP dated 01/10/2015. Individual # 2 does not have a methodology or procedure developed to determine if progress is being made towards the outcomes identified in the ISP dated 04/28/2015. The residential home shall provide services to the individual as specified in the individual's ISP. Royal Home Care's program specialist in conjunction with the house manager have developed measurable goals based on the outcomes identified in each individuals ISP. Data is collected every month to determine progress/lack thereof and documented in each individual's monthly and quarterly reports. Data is reviewed quarterly to determine if individuals have mastered measurable goals or if they need additional support making progress with their goals. Moving forward, Royal Home Care's Program specialist will file all data collected and attach them to monthly and quarterly reports. Royal Home Care¿s administrators and Assistant director will continue to monitor all reports to ensure that the above oversight does not re occur. 05/27/2016 Implemented
SIN-00090868 Unannounced Monitoring 11/30/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(d)Equaline mouthwash and cashmere mist deodorant which indicated to contact poison control if ingested was stored with water, ocean spray juice, brisk iced tea, horizon organic milk and assorted chip in the backroom of the basementPoisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.On 12/1/2015, Royal Home Care assistant Director and Program Specialist immediately purchased cabinets and shelves (Erected the shelves in the basement back room) to safely store all food items away from any potential poisonous substances. All Poison materials were locked in another cabinet stored in a separate area from the basement. House Manager conducts routine checks to ensure that all food materials and potential poisonous materials are not stored in the same area. (All staff will participate in training around poisonous and proper storage within 30 days of receipt of the plan of care. DS 4.6.16) 12/01/2015 Implemented
SIN-00086382 Unannounced Monitoring 09/21/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Palmolive Antibacterial soap, dial bar soap and Bruce floor cleaner, which indicated to contact poison control if ingested, were found unlocked in the cabinet above the sink in the basement. Not all of the Individuals residing in the home can safely handle poisonous materials.Poisonous materials shall be kept locked or made inaccessible to individuals. Royal Home Cares house manager, supervised by the Administrator and Assistant director, has assigned staff to sweep the home for hazardous/poisonous materials and secure them at the beginning and during all shifts. (There was a discrepancy in between the annual assessment and the ISP regarding the individuals ability in the home to safely use poisonous substances and the assessment was updated to reflect the following information: each individual in the home is capable of recognizing and using household cleaning materials and all individuals residing in the home will not ingest poisonous materials/substances DS 12/31/2015). However cleaning supplies and other poisonous materials will be kept locked in the home for safety reasons. 09/30/2015 Implemented
SIN-00086383 Unannounced Monitoring 08/10/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.213(11)Individual #1's annual assessment indicates the individual may or may not distinguish between safe and poisonous substances and the ISP indicates the individual can safely use and will not ingest poisonous substances. Individual #2's annual assessment indicates the individual may or may not distinguish between safe and poisonous substances and the ISP indicates the individual is aware and avoids poisonous substances. Individual #3's annual assessment indicates the individual may or may not distinguish between safe and poisonous substances and the ISP indicates the individual is will not ingest and can recognize poisonous substances. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. on 9/25/2015 Royal Home Care and Community Service Inc. program specialist updated the assessments for individual's 1, 2 and 3 to clearly define/state the individuals ability to distinguish between safe and poisonous substances. updated assessments were reviewed with all individuals and sent to their respective supports coordinators. Royal Home Care's Assistant Director, Program Specialist Trainer and Trainee will all review annual assessments and all updates made to the assessments to ensure content discrepancy and all other areas of the annual assessment are clearly defined. 09/25/2015 Implemented
SIN-00081772 Unannounced Monitoring 07/08/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.21(b)Staff A's date of hire was 06/18/2015 and the criminal background check was requested on 07/08/2015.The legal entity responsible for a facility or agency subject to licensure under Article X of the Public Welfare Code (62 P. S. § § 1001-1080) shall submit an application for a certificate of compliance prior to commencing operation of the facility or agency and may not commence operation until notified that a certificate of compliance will be issued.Royal Home care Human Resources will ensure that all personnel hired will have all clearances before their hire date. The assistant director of Royal Home care will supervise to ensure that such oversight does not repeat itself. 08/18/2015 Implemented
6400.181(e)(3)(iii)Individual # 1's annual assessment dated 05/20/2015 did not include skills in the area of personal adjustment. Individual # 2's annual assessment dated 05/20/2015 did not include skills in the area of personal adjustment. The individual's current level of performance and progress in the following areas: Personal adjustment. A new Program Specialist was hired on 08/11/2015 and trained on 08/10/2015. Program Specialist will revise assessments to include the current levels of performance in the areas of personal adjustment. The program specialist will update the individuals assessment to include information on the current levels of performance in the areas of personal adjustment by 8/18/2015. In the upcoming year all annual assessments will have the section of 6400.181(e)(3)(iii) on the current levels of performance in the areas of personal adjustment. (The Office Administrator will conduct annual reviews of assessments to ensure progress and growth is reflected in the assessment DS 11.15.15) 08/18/2015 Implemented
6400.181(e)(12)Individual # 1's annual assessment dated 05/20/2015 did not include recommendations for specific areas of training, programming and services. Individual # 2's annual assessment dated 05/20/2015 did not include recommendations for specific areas of training, programming and services. The assessment must include the following information: Recommendations for specific areas of training, programming and services. 6400.181(12) A new program was hired on 8/11/2015 and was trained on 08/10/2015. Program specialist will revise assessments to include the current levels of performance in the areas of recommendations for specific areas of training, programming and services. The program specialist will update the individuals assessment to include information on recommendations for specific areas of training, programming and services by 08/18/2015. In the upcoming year all annual assessments will have the section of 6400.181(12) Recommendations for specific areas of training, programming and services.(The Office Administrator will conduct annual reviews of assessments to ensure recommendations are included in the assessments DS 11.12.15) 08/18/2015 Implemented
6400.181(e)(13)(i)Individual #1's annual assessment dated 05/20/2015 did include progress and growth in the areas of health. Individual # 2's annual assessment dated 05/20/2015 did include progress and growth in the areas of health. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. A new program was hired on 8/11/2015. Program specialist will revise assessments to include the current levels of performance in the areas of Health. The program specialist will update the individuals assessment to include information on the individual's progress over the last 365 calendar days and current level in the following areas health by 8/18/2015 In the upcoming year all annual assessments will have the section of 6400.181(13)(i) individual's progress over the last 365 calendar days and current level in the area of health.(The Office Administrator will conduct annual reviews of assessments to ensure compliance regarding the assessment DS 11.12.15) 08/18/2015 Implemented
6400.181(e)(13)(ii)Individual #1's annual assessments dated 05/20/2015 did not include progress and growth in the areas of motor and communication. Individual #2's annual assessments dated 05/20/2015 did not include progress and growth in the areas of motor and communication. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. A new program was hired on 8/11/2015. Program specialist will revise assessments to include progress and growth in the area of motor and communication skills. The program specialist will update the individuals assessment to include information on the individual's progress over the last 365 calendar days and current levels in the areas of motor and communication skills on 08/18/2015. In the upcoming year all annual assessments will have the section 6400.181(13)(ii) individual's progress over the last 365 calendar days and current level in the areas of motor and communication skills.(The Office Administrator will conduct annual reviews of assessments to ensure compliance DS 11.12.15) 08/18/2015 Implemented
6400.181(e)(13)(iii)Individual #1's annual assessments dated 05/20/2015 did not include progress and growth in the areas of activities of residential living. Individual #2's annual assessments dated 05/20/2015 did not include progress and growth in the areas of activities of residential living. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. A new program was hired on 8/11/2015. Program specialist will revise assessments to include progress and growth in the area of Activities of residential living. The program specialist will update the individuals assessment to include information on the individual's progress over the last 365 calendar days and current levels in the areas Activities of residential living on 08/18/2015. In the upcoming year all annual assessments will have the section 6400.181(13)(iii) individual's progress over the last 365 calendar days and current level in the areas of Activities of residential living. (The Office Administrator will conduct annual reviews of assessments to ensure compliance DS 11.12.15) 08/18/2015 Implemented
6400.181(e)(13)(iv)Individual #1's annual assessments dated 05/20/2015 did not include progress and growth in the area personal adjustment. Individual #2's annual assessments dated 05/20/2015 did not include progress and growth in the area personal adjustment. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. A new program was hired on 8/11/2015. Program specialist will revise assessments to include in each individuals assessment progress and growth in the area of Personal adjustment. The program specialist will update the individuals' assessment to include information on the individual's progress over the last 365 calendar days and current levels in the areas personal adjustment on 08/18/2015. In the upcoming year all annual assessments will have the section 6400.181(13)(iii) individual's progress over the last 365 calendar days and current level in the areas of personal adjustment. (The Office Administrator will conduct annual reviews of assessments to ensure compliance DS 11.12.15) 08/18/2015 Implemented
6400.181(e)(13)(v)Individual #1's annual assessments dated 05/20/2015 did not include progress and growth in the area of socialization. Individual #2's annual assessments dated 05/20/2015 did not include progress and growth in the area of 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 new program was hired on 8/11/2015. Program specialist will revise assessments to include progress and growth in the area of Socialization. The program specialist will update the individuals¿ assessment to include information on the individual's progress over the last 365 calendar days and current levels in the areas of Socialization by 08/18/2015. In the upcoming year all annual assessments will have the section 6400.181(13)(iii) individual's progress over the last 365 calendar days and current level in the areas of Socialization.(The Office Administrator will conduct annual reviews of assessments to ensure compliance DS 11.12.15) 08/18/2015 Implemented
6400.181(e)(13)(vi)Individual #1's annual assessments dated 05/20/2015 did not include progress and growth in the area of recreation. Individual #2's annual assessments dated 05/20/2015 did not include progress and growth in the area of 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 new program was hired on 8/11/2015. Program specialist will revise assessments to include progress and growth in the area of recreation. The program specialist will update the individuals assessment to include information on the individual's progress over the last 365 calendar days and current levels in the areas of recreation by 08/18/2015. In the upcoming year all annual assessments will have the section 6400.181(13)(iii) individual's progress over the last 365 calendar days and current level in the areas of recreation.(The Office Administrator will conduct annual reviews of assessments to ensure compliance DS 11.12.15) 08/18/2015 Implemented
6400.181(e)(13)(vii)Individual #1's annual assessments dated 05/20/2015 did not include progress and growth in the area of financial independence. Individual #2's annual assessments dated 05/20/2015 did not include progress and growth in the area of financial independence. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. A new program was hired on 8/11/2015. Program specialist will revise assessments to include progress and growth in the areas of financial independence. The program specialist will update the individual's assessment to include information on the individual's progress over the last 365 calendar days and current levels in the areas of financial independence by 08/16/2015. In the upcoming year all annual assessments will have the section 6400.181(13)(iii) individual's progress over the last 365 calendar days and current level in the areas of financial independence.(The Office Administrator will conduct annual reviews of assessments to ensure compliance DS 11.12.15) 08/18/2015 Implemented
6400.181(e)(13)(viii)Individual #1's annual assessments dated 05/20/2015 did not include progress and growth in the area of managing personal property. Individual #2's annual assessments dated 05/20/2015 did not include progress and growth in the area of managing personal property. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. A new program was hired on 8/11/2015. Program specialist will revise assessments to include progress and growth in the areas of managing personal property. The program specialist will update the individuals¿ assessment to include information on the individual's progress over the last 365 calendar days and current levels in the areas of managing personal property by 08/18/2015. In the upcoming year all annual assessments will have the section 6400.181(13)(viii) individual's progress over the last 365 calendar days and current level in the areas of managing personal property.(The Office Administrator will conduct annual reviews of assessments to ensure compliance DS 11.12.15) 08/18/2015 Implemented
6400.181(e)(13)(ix)Individual #1's annual assessments dated 05/20/2015 did not include progress and growth in the area of community integration. Individual #2's annual assessments dated 05/20/2015 did not include progress and growth in the area of community integration. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.A new program was hired on 8/11/2015. Program specialist will revise assessments to include progress and growth in the areas of Community integration. The program specialist will update the individuals assessment to include information on the individual's progress over the last 365 calendar days and current levels in the areas of community integration by 08/18/2015. In the upcoming year all annual assessments will have the section 6400.181(13)(ix) individual's progress over the last 365 calendar days and current level in the areas of community integration.(The Office Administrator will conduct annual reviews of assessments to ensure compliance DS 11.12.15) 08/18/2015 Implemented
6400.181(e)(14)Individual #1's annual assessments dated 05/20/2015 did not include ability to swim. Individual #2's annual assessments dated 05/20/2015 did not include ability to swim. The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. A new program was hired on 8/11/2015. Program specialist will revise assessments to include the individual's ability to swim. The program specialist will update the individuals assessment to include information on the individuals ability to swim by 08/18/2015. In the upcoming year all annual assessments will have the section 6400.181(14) individual's ability to swim.(The Office Administrator will conduct annual reviews of assessments to ensure compliance DS 11.12.15) 08/18/2015 Implemented
6400.181(f)Individual # 3's ISP meeting date was 02/10/2015 and the annual assessment was dated 02/14/2015. Individual # 1's ISP meeting date was 06/11/2015 and the annual assessment was dated 05/20/2015. (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). A new program was hired on 8/11/2015. Program specialist will make the assessments available 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. The assistant director of Royal Home care will develop a tracking system to ensure compliance. The Assistant director will supervise program specialist to ensure the completion of this requirement. With the individuals in question, Royal Home program specialist will make assessments available to the SC by 08/30/2015. 08/30/2015 Implemented
SIN-00081757 Unannounced Monitoring 06/08/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.18(c)Individual # 1 is prescribed allergy relief to be taken daily. It was not administered on 05/01/15, 05/02/2015, 05/03/2015, 05/04/2015, 05/05/2015, and 05/06/2015. No incident report was filed. Individual # 2 is prescribed Clotrimazole-Betamethasone cream. The label indicates to apply 2x/day but the May and June MAR indicate it is administered at a PRN. No incident report was filed. The home shall orally notify the county mental retardation program of the county in which the home is located, the funding agency and the appropriate regional office of mental retardation, within 24 hours after abuse or suspected abuse of an individual or an incident requiring the services of a fire department or law enforcement agency occurs. Royal Home will retrained all staff in incident management. The Office Administrator will develop a tracking system to ensure all staff have been trained in incident management. Royal Home reported the medication error as an incident into HCSIS on 8/5/2015. Royal Home nurse will document weekly visitations, reviews of MAR and revisions of individual MAR. All documentation notes will be placed in each individual MAR DS 11.12.15 08/10/2015 Implemented
6400.76(a)Lint the size of a grapefruit was found in the dryer. Furniture and equipment shall be nonhazardous, clean and sturdy. Royal Home will retrain all staff on the 6400 regulations, health/safety of individuals served making sure every part of the home and all home equipment is kept clean and hazard free at all times within 30 days of receipt of this plan. Royal Home house manager will be responsible in making sure that the resident is clean and the individuals health and safety is put first. House manager will conduct checks weekly and document checks on a checklist DS 11.12.15. See attachments of dryer lint trap cleaned out and free debris. 08/10/2015 Implemented
6400.144Individual # 1 is prescribed Ibuprofen, one tablet every 8 hours as needed and it was not in the homeHealth 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. Royal Home as a provider will ensure that all individual medications will at all times be available in their home and staff will be retrained on administering medication and proper documentation. (The Office Administrator will develop a tracking system to ensure all staff are trained properly in medication administration DS11.12.15). Royal Home nurse will document weekly visitations and revisions of individual MAR. All documentation notes will be placed in each individual MAR. The nurse will be hired 6/18/2015. 08/10/2015 Implemented
6400.164(b)Individual # 1 was administered Symbicort 4.5 mcg on 05/29/2015 but the MAR was not initialed by the staff who administered the medication. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. Royal Home as a provider will ensure that all staff will be trained in administering and properly documenting medication administration by 8/10/2015. (The Office Administrator will develop a tracking system to ensure all staff are trained properly in medication administration. Royal Home nurse will document weekly visitations and revisions of individual MAR. All documentation notes will be placed in each individual MAR DS11.12/15) 08/10/2015 Implemented
6400.165Individual # 1 is prescribed allergy relief to be taken daily. It was not administered on 05/01/15, 05/02/2015, 05/03/2015, 05/04/2015, 05/05/2015, and 05/06/2015.Documentation of medication errors and follow-up action taken shall be kept. Royal Home as a provider will abide by the 6400 regulations relating to incident report management. In so doing, Royal Home will train all staff in administering medication and proper documentation, and reporting incident as it occurs. This training will be completed by 8/10/15. The Office Administrator will develop a tracking system to ensure all staff are trained properly in medication administration. Royal Home Care will also in a timely manner document and report all reportable incidents into HCSIS. Royal Home nurse will document weekly visitations, reviews of MAR and revisions of individual MAR. All documentation notes will be placed in each individual MAR. 08/10/2015 Implemented
6400.167(b)Indivdiual # 2 is prescribed Clotrimazole-Betamethasone cream. The label indicates to apply 2x/daily but the May and June MAR indicate it is administered as a PRN. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.Royal Home as a provider will ensure that all staff will be trained in administering and properly documenting medication administration. The Office Administrator will develop a tracking system to ensure all staff are trained properly in medication administration. Royal Home nurse will document weekly visitations, review of MAR and revisions of individual MAR. All documentation notes will reflect nurse signature on back of individual MAR. 08/10/2015 Implemented
SIN-00092553 Unannounced Monitoring 03/23/2016 Compliant - Finalized
SIN-00090573 Unannounced Monitoring 01/29/2016 Compliant - Finalized