Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00186768 Renewal 04/20/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(b)The agency completed self-assessment inspections on 12/16/20 and 03/16/21 but did not use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.1. On 4/22/2020¿s Team Meeting, CEO decided that agency will conduct self-inspection to all houses except Logan Ferry using Self-Inspection in Appendix in RCG. On 4/23/2021, CEO, CCO, Program Specialist, QA/CO, and Health/IDD Manager met to go over each section of the RCG and Self-Inspection. Team learned that they are more items added. However, we gladly have documentations from 2019 pertaining to individual rights. 2. Self-inspection using new tools were completed: a. On 4/30/2021 at Dorothy House and Greenfield House b. On 5/1/2021 at Green Tree House and Highland House c. On 5/2/2021 at Braun House, Delmont House, and Rubco House 3. On 5/3/2021, during team meeting, was the finalization of Self-Assessment Completion. CCO will submit the completed self-inspection on 5/7/2021 4. CCO will submit all the meeting signature sign-in sheets and meeting minutes on 5/7/2021. 05/07/2021 Implemented
SIN-00172623 Renewal 03/12/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)On 3/13/20, at 11:45AM, an Agent of the Department witnessed a snake entering a twelve inch high by one and a half inch wide crack in the wall before the entrance to the fruit cellar in the basement of the home.Floors, walls, ceilings and other surfaces shall be in good repair. 1. CEO reported on 3/16/2020, that Rubco¿s landlord had started fixing the hole in the cellar. CEO sent the pictures of before and after the wall is repaired on 3/16/2020. The final picture of the repainted wall was sent on 3/27/2020. CCO is going to submit the before and after pictures on 3/30/2020. 2. On 3/20/2020, CCO added addendum to the Monthly House Inspection to ensure that all house supervisors check all surfaces in all parts of the houses including. House Supervisor will acknowledge the addendum. The revised forms and acknowledgement were sent to the house supervisors. All house supervisors are expected to complete March monthly house inspection by 3/30/2020. CCO will submit the signed acknowledgment and monthly house inspection by 4/3/2020. 3. QA/CO during her inspection to the houses, will ensure to check there is no cracks/holes on the floors, walls, ceilings, and other surfaces, in all rooms in the house, including cellar and attic. Due to social distancing and Governor Wolf¿s stay-at-home order effective Monday, March 23rd in Allegheny County, QA/CO¿s visits to the houses have been suspended until further notice. Monthly House Inspection will only be signed by House Supervisor. All admin staff currently WFH. Only staff with clearance could access headquarters. Headquarters has been used as a place to drop off groceries to be disinfected (wiped off) before they are delivered to the houses. As soon as Covid-19 is contained, QA/CO will continue her biweekly inspection to the houses. 04/03/2020 Implemented
SIN-00134134 Renewal 05/02/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.186(a)The program specialist completed an ISP review for the period 3/1/17-5/30/17 on 7/14/17.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. 1. Former Program Specialist completed ISP review, without the knowledge that individuals' signatures will need to follow 15 day grace period. Current Program Specialist created checklist and posted the deadline of individual's signature in the outlook. The checklist and outlook reminder will be shared with CEO, CCO, and CO/QA. CCO will submit the checklist and outlook calendar reminder on 5/10/2018 2. On 5/7/2018 Program Specialist was assigned to attend ODP training on ISP Checklist. Program Specialist ISP training certificates will be submitted on 5/10/2018. 3. CCO revised the ISP Plans and Procedures on 5/7/2018. CEO, Program Specialist, QA/CO, Participant Coordinator signed and acknowledged plans and procedures. CCO will submit the revised and signed ISP Plans and Procedures on 5/10/2018. 4. Agency put violation on 6400.186 (a) on the agenda for 6/12/2018 Assessment Team meeting. The meeting agenda, minutes, and timesheet for 6/12/18 meeting will be submitted on 6/14/2018. The outlook reminder and agenda for the meeting on 6/12/2018 will be submitted by 5/10/2018. 05/10/2018 Implemented
SIN-00114304 Renewal 05/17/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(c)The home had coliform water tests completed 7/21/16 and then again on 10/27/16 and on 1/25/17 and then again on 5/2/17.A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept.The QA Coordinator removed the annual expected water test dates from the Compliance calendar and entered the exact date of the water test for the one residential house. The QA Coordinator entered a due date and a 30 day warning date into the calendar for the upcoming water test. The QAC invited the Director to the 30 day warning calendar event by email. The QAC will email the Director at the 30 day warning date about the upcoming due date for a water test at the one residential house. The QAC will follow up with the Director by email within 14 days to get a confirmation that the water test appointment has been made. The QAC will follow up with the Director to receive a copy of the inspection for the QA binder. The QAC will enter the new test date, the quarterly due date and the 30 day warning date into the Compliance calendar and invite the Director to the 30 day warning date. 06/16/2017 Implemented
6400.106The furnace in the home was inspected and cleaned on 3/4/16 and then again 4/20/17.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The QA Coordinator removed the annual expected furnace inspection dates in the Compliance calendar and entered the exact date of the furnace inspections for all residential houses. The QA Coordinator entered due dates and 30 day warning dates into the calendar for all upcoming furnace inspections. The QAC invited the Director to the 30 day warning calendar events by email. The QAC will email the Director at the 30 day warning date about the upcoming due date for a furnace inspection at a specific house. The QAC will follow up with the Director by email within 14 days to get a confirmation that the inspection appointment has been made. The QAC will follow up with the Director to receive a copy of the inspection for the QA binder. The QAC will enter the new inspection date, the annual due date and the 30 day warning date into the Compliance calendar and invite the Director to the 30 day warning date. 06/16/2017 Implemented
6400.163(c)The psychiatric medication reviews for Individual #1 were completed on 10/6/16 and then again 1/19/17. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The Participant Coordinator contacted the psychiatrist's office and requested a letter from the doctor signifying that the 1/19/2017 appointment was what was available. The Participant Coordinator spoke with the doctor's appointment scheduler who said that they had a standard letter, she would get the doctor to sign, and would fax it to the TLHHC office. After two weeks, the PC contacted the appointment scheduler and was informed that the doctor had decided to not sign. The PC thought that the grace period for psychiatric med review appointments was 14 days and that the 1/19/2017 appointment was within the grace period. The PC was informed by the inspectors that the grace period was 5 days. The PC updated her appointment tracker spreadsheet to include a new column that calculated the due date for the next three month psych med review when she entered the current appointment date. A copy of the updated tracker spreadsheet will be placed in the 6400 inspection binder under POC. The PC will send a quarterly email report of the psychiatric appointment dates for the entire 6400 program participants for the next 9 months (until 3/2018) to the Programs Specialist and Director to ensure compliance. 06/16/2017 Implemented
SIN-00092322 Renewal 04/01/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(9)The physical examination, completed on 2/1/16, for Individual #1 date of birth 9/18/1974 does not include a prostate examination.The physical examination shall include: A prostate examination for men 40 years of age or older. Participant Coordinator updated the initial Participant Checklist to include prostate exam. Participant Coordinator will check that male individuals at/over the age of 40 that are accepted to the residential program have an initial exam. Participant Coordinator will monitor all male participants over the age of 40 in the residential program and schedule a prostate exam on an annual basis. The Participant Coordinator will email a monthly report of upcoming required medical appointments and previous month¿s completed medical appointments to the Director. The Participant Coordinator scheduled a prostate examination for individual 1 for 4/26/2016. A copy of the updated Participant Checklist and the prostate examination will be filed at the office in a 2016 POC folder by 4/30/2016.[Immediately, the program specialist will review all individuals' current physical examinations to ensure all required information is included in the physical examination and will immediately obtain missing information. Prior to entering into the individual's record physical examination documentation will be reviewed by the program specialist to ensure all required information is included in the physical examination and will immediately obtain missing information. At least quarterly for 1 year, the CEO will review a 25% sample of all individual physical examination to ensure all required information is included in the physical examination and will immediately obtain missing information. Documentation of all reviews shall be kept. (AS 5/26/16)] 04/30/2016 Implemented
6400.141(c)(12)The physical examination, completed on 2/1/16, for Individual #1's does not include the physical limitations of the individual.The physical examination shall include: Physical limitations of the individual. The Participant Coordinator will review all completed physical forms for completeness. The Participant Coordinator will check that the doctor has completed all sections of the form. If the doctor did not complete, the Participant Coordinator will contact the doctor¿s office, fax over the incomplete form, monitor for a return fax, contact again if necessary, and receive the completed form. The Participant Coordinator will send the form to the House Supervisor to be placed in the individual¿s book. The Training Coordinator enrolled all residential staff in the on-line Relias training ¿Medical Appointment Checklist,¿ to be completed by 4/30/2016.[Individual #1's physical examination completed on 2/1/6 was updated on 4/26/16 to include physical limitation. Immediately, the program specialist will review all individuals' current physical examinations to ensure all required information is included in the physical examination and will immediately obtain missing information. Prior to entering into the individual's record physical examination documentation will be reviewed by the program specialist to ensure all required information is included in the physical examination and will immediately obtain missing information. At least quarterly for 1 year, the CEO will review a 25% sample of all individual physical examination to ensure all required information is included in the physical examination and will immediately obtain missing information. Documentation of all reviews shall be kept. (AS 5/26/16)] 04/30/2016 Implemented
SIN-00078151 Renewal 04/09/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There was a strong odor of urine in the bedroom on the first floor of the home.Clean and sanitary conditions shall be maintained in the home. 1. On 4/10/2015, the CEO assigned Compliance Officer (CO) to create Cleanliness and Sanitary Policy to be trained to Rubco Staff. The policy was trained and signed by staff. The latest signature was on 5/18/2015. CO will submit the signed policy by staff on 5/29/2015 2. On 4/13/2015, CO reviewed and updated the house supervisor's job description. Update emphasized on the role of house supervisor in monitoring the maintenance of day-to-day housekeeping. In Parallel, a Monitoring Checklist and Quality Assurance Manager's job description were created as agency internal monitoring tool. The job description was signed by house supervisors and Quality Assurance Manager (QAM) on 5/1/2015. CO will submit the updated job description signed by house supervisor and QAM on 5/29/2015. House supervisor's job title is Senior Home Support Specialist (SHSS) 3. On 4/15/2015, CO created standardized housekeeping schedule, displaying daily, weekly, and monthly staff's housekeeping schedule. SHSSs customized the calendar as needed. CO will submit the housekeeping schedule on 5/29/2015 4. CO updated Inspection checklist on 4/10/2015, adding 6400.64(a) for checking cleanliness and sanitary condition of the house. QAM will conduct monthly inspection with house supervisor. SHSS and QAM conducted May Inspection on May 5, 12, and 19. CO will submit the completed and signed updated House Inspection Checklist on 5/29/2015 5. CO put violation on 6400.64 (a) on the agenda for Assessment Meeting on 5/14/2015. CEO went over the role of QAM as a part of agency's monitoring system to prevent the recurrence of noncompliance. CO will submit the meeting agenda, and sign-in sheet on 5/29/2015. [The clean and sanitary policy contains a schedule for trash removal due to the odor in bedroom being determined to be caused by soiled adult briefs in the trash receptacle. (AS 6/10/15)] 05/30/2015 Implemented
6400.163(c)The psychiatric medication reviews by a licensed physician for Individual #1 were completed on 5/1/14 and 8/23/14. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.1. On 4/13/2015 Quality Assurance Officer (QAO) assigned QAM to monitor medical appointment schedule for individuals based on the Monitoring Checklist. CO will submit the monitoring checklist on 5/29/2015. 2. Agency will continue implementing the medical appointment tracking utilizing Therap web application and outlook reminder which started on 12/1/2015. Participant Coordinator (PC) will record and schedule appointments in Therap web application, allowing the auto-creation of medical appointment calendar. In addition, PC will utilize shared outlook calendar reminders for Doctor Appointment and Refill. CO will submit the screenshots of the progress of agency medical appointment monitoring tool using database, outlook calendar, and Therap Web Application on 5/29/2015 3. In the event individual was/is not able to be seen due to conflicted physician's schedule, PC will email QAO and CO. CO will send an email notification to the Licensing Administrator followed by a phone call, requesting confirmation stating that agency has no control to prevent the noncompliance. CO will submit updated PC's job description on 5/29/2015 4. QAO assigned QAM to conduct medical appointment monitoring using Monitoring Checklist. QAM will submit weekly medical appointment report to QAO and CO. CO will submit a sample weekly Medical Appointment Report and Monitoring Checklist on 5/29/2015. 5. CO put violation on 6400.64 (a) on the agenda for Assessment Meeting on 5/14/2015. CEO went over the role of QAM as a part of agency's monitoring system to prevent the recurrence of noncompliance. CO will submit the meeting agenda, and sign-in sheet on 5/29/2015. 05/30/2015 Implemented
6400.181(e)(7)The assessment dated 1/21/15 for Individual #2 did not include the individual's knowledge of the danger of heat sources and the ability to sense and move away quickly form heat sources which exceed 120 degrees Fahrenheit. The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. 1. Program Specialist completed the Annual Assessment on 1/2/2015. However, PS failed to transcribed heat source part assessment in the Annual Assessment. On 4/13/2015 Quality Assurance Officer (QAO) assigned Program Specialist (PS) to complete the assessment on individual #2's knowledge of the danger of heat sources. CO will submit completed annual assessment for Individual's #2 on 5/29/2015. 2. CO created Individual Assessment Policy and Procedures and Individual Assessment Checklist: a. CO will create an Individual Assessment Checklist. b. QAM will maintain annual list of individuals' assessment due dates and place them in the outlook calendar with a reminder set for 2 weeks. c. QAM will notify PS by email if due date is approaching with a cc to CEO/QAO, Director, and CO. d. PS will hand over the completed individual's assessment to QAM to be placed in the individual's binder. e. QAM will consult the assessment with the checklist and notify the results to the PS. f. QAM will email a report to the CEO/QAO and Director of Support Services with a cc to CO once the individual's assessment has been placed in individual's binder CO will submit the policy, checklist, and signed-in training on 5/29/2015 3. CO put violation on 6400.181. ( e)(7) on the agenda for Assessment Meeting on 5/14/2015. CEO went over the role of QAM as a part of agency's monitoring system to prevent the recurrence of noncompliance. CO will submit the meeting agenda, and sign-in sheet on 5/29/2015. 05/30/2015 Implemented
6400.186(b)The three month review of the ISP for Individual #2 completed on 1/14/15 was not signed by the program specialist.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. 1. Program Specialist (PS) signed the Monthly Review while the inspectors were still on site on 4/10/2015. CO will submit signed Monthly Review for Individual's #2 on 5/29/2015. 2. Compliance Officer created ISP Plans and Procedure: a. PS will coordinate with Quality Assurance Manager on monitoring attendance and participation in the ISP, ISP Annual Update, and ISP Revision meeting. b. QAM will maintain the ISP information in the database, and schedule the upcoming meetings and ISP reviews in the outlook calendar with a reminder set for 2 weeks before the 30-day limit for providing the ISP Review documentations. c. QAM will notify PS by email if due date is approaching with a cc to CEO/QAO, Director of Support Services, and CO. d. PS will email ISP Review documentation to SC with a cc to CEO, Director of Support Services, and CO. e. PS will hand over the completed documentation to QAM to be placed in the individual binder. f. QAM will check if the review has been signed by Program Specialist. g. QAM will email a report to the CEO/QAO and Director of Support Services with a cc to CO once the completed documentation has been placed in the individual's binder. CO will submit the plans and procedures and sign-in training on 5/29/2015 3. CO put violation on 6400.186(b) on the agenda for Assessment Meeting on 5/14/2015. CEO went over the role of QAM as a part of agency's monitoring system to prevent the recurrence of noncompliance. CO will submit the meeting agenda, and sign-in sheet on 5/29/2015. 05/30/2015 Implemented
SIN-00060522 Renewal 04/25/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)On April 23, 2014, the water temperature in the bathtub measured 125 Degrees Fahrenheit at 12:20PM.(b) Hot water temperatures in bathtubs and showers may not exceed 120°F. 1. Director of Support Services assigned Field Supervisor to purchase a new thermometer on 4/30/14. 2. House Supervisor will adjust the temperature in the bathtubs and showers, and submit the pictures on 5/1/14. 3. Compliance Office wrote a policy on procedure on how to check water temperatures. Program Specialist on 4/30/14 assigned staff to read and sign the policy, and post laminated instruction in the bathroom. House Supervisor will take pictures of the posted instruction and scanned sign in sheet on 5/1/14. 4. Compliance Officer modified the monthly assessment checklist by including water temperature. Program Specialist and House Supervisor will conduct monthly checking on 5/1/14. Director of Support Services will monitor the implementation of the assessment. 5. Agency put violation on 6400.68(b) on the agenda for 5/7/14 Assessment Team meeting. 05/08/2014 Implemented
6400.68(c)The home which is not connected to a public water system opened on 4/29/13. Individuals have resided in the home since May, 2013. A coliform water test by a Department of Environmental Resources' certified laboratory was not completed until 2/26/14.(c) A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources' certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept. 1. Director of Support Services contacted Microbac Laboratories, Inc., to schedule water testing for the next three-month period of 5/5/2014, 8/4/2014, and 11/3/2014. 2. Compliance Officer placed the schedule dates on the outlook calendar for reminder on 4/29/14. 05/08/2014 Implemented
6400.164(b)On 4/21/14, Individual #1 received Diphenoxylate/Atropine at 8:00PM. The medication administration record was not initialed as given. Individual #1 is prescribed Mypirocin 2% ointment to be applied topically twice daily; on 4/4/13 and 4/15/14 the medication was not initialed as given. (b) The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. 1. Director of Support Services assigned Program Specialist on 4/24/14 to investigate the missing initial. Program Specialist had assigned identified Staff #1 and Staff #2 to initial the dates on 4/29/14. 2. Agency started providing training on Drug, Alcohol, and Medication Policy on 3/26/2014 through Care2Learn. Medication Log is included in the policy. Program Specialist on 4/30/14 assigned staff to read and sign the Medication Log policy and post the laminated instruction on MARs Binder. House Supervisor will take pictures of the posted instruction and scanned sign in sheet on 5/1/14. 3. Compliance Officer modified the monthly assessment checklist by including 6400.164(b). Program Specialist and House Supervisor will conduct monthly checking on 5/1/14. Director of Support Services will monitor the implementation of the assessment. 4. Agency put violation on 6400.164(b) on the agenda for 5/7/14 Assessment Team meeting. 05/08/2014 Implemented
6400.181(e)(6)The assessment dated 8/29/13 for Individual #2 did not include the ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. Program Specialist on 4/29/14 modified the assessment that has included the information on the individuals' ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. 05/08/2014 Implemented
SIN-00054829 Renewal 10/07/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment of the home, dated 5/13/13 and 5/14/13, did not assess the following sections: Individual Health and Plan Review/ Plan Revisions.(a) The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. The agency assigned Compliance Officer to create Assessment Team. Assessment Team will consist of House Inspector, Admission Officer, Director of Human Resources, Program Specialist, Training Managers, and Data Specialist, House Inspector, and House Supervisors. Compliance Officer will assign Assessment Team to conduct general assessment on the first week of March and September to measure and record compliance with Chapter 6400. Team is divided into four (40) sub teams. Team 1 will assess the General Requirements and Individual Rights. Team 2 will assess Staffing, Individual Health, and Staff Health. Team3 will assess Physical Site and Fire Safety. Team 4 will inspect Medication, Nutrition, Assessment, Development of Plan, Plan Content, Participation in Plan Development, Implementation of the Plan, Plan Review and Plan Revision, Copies of the Plan, Provider Services, and Individuals Records. On the first week of April and October, Sub Team will report to the Compliance Officer, submitting finding on non-compliance along with a corrective action plan to address the finding and will include target date. Compliance Officer will report to the CEO. CEO will assign Compliance Officer to monitor the correction progress. CEO, Compliance Officer, and Assessment Team will meet to identify and prevent recurrence of non-compliance. Agency submitted the Implementation Plan for the Assessment Team and completed Self-Assessment. 10/21/2013 Implemented
6400.21(a)Staff Person #2s criminal history check requested 4/18/13 contained a prohibitive offense in accordance with the Older Adult Protective Services Act (35 P.S. § 10225.101¿10225.5102) and 6 Pa.Code Chapter 15 (relating to protective services for older adults). Staff Person #1s date of hire at the facility was on 4/23/13 and s/he worked at the home with individuals unsupervised through 10/7/13. Repeat Violation 7/13/12 (a) An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. The agency has dismissed Staff #2 from residential assignment. Human Resources Director will monitor that PA criminal check is done in a timely manner and will consult the record with Older Adult Protective Services Act (35 P.S. & 10225.1012100225.5102) and 6 PA Code Chapter 15. To prevent recurrence, agency modified application checklist to monitor applicant¿s criminal history. CEO assigns Compliance Officer to conduct monthly monitoring Agency submitted TLHHC Employee Manual ¿ Policy and Procedures. Page 5-6: Criminal Background Check, Staff dismissal notice, and modified checklist. [All Criminal History Checks will be completed with results received and approved before a staff person is hired. The Providers policies and procedures will be amended to include the aforementioned addition by 12/1/13. All current staff members Criminal History Record Checks will be reviewed to ensure that they contain no prohibitive offenses in accordance with the Older Adult Protective Services Act and Act 13 immediately. All administrative staff that plays a role in the hiring process will complete the Department of Aging Abuse and Criminal History Check Training by 12/15/13 which can be found at http://www.portal.state.pa.us/portal/server.pt/community/self_study_course/18031 . Documentation shall be kept. (CHG 11/6/13)] 10/21/2013 Implemented
6400.33(e)The first floor bathroom did not have curtains on the window for privacy. (e) An individual has the right to privacy in bedrooms, bathrooms and during personal care. Agency recognizes individual right to privacy, and placed curtains on the window of the first floor bathroom. Agency submitted photo of window with curtains is attached 10/21/2013 Implemented
6400.46(f)Staff #1 was not trained in general fire safety before working with individuals. The initial date of fire safety was 9/12/13. The date of hire for Staff #1 was 6/11/13.(f) Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. Agency provides General Fire Safety training as a part of orientation to new hires. Staff #1 was hired as a habilitation aide. Agency modified Applicant/Employee Transfer Checklist to ensure that before Scheduling Officer assigns new hires and/or current employee transfers as residential staff, s/he will need to receive confirmation from the Training Manager that they have been trained in general safety training, evacuation procedures, responsibilities during fire drills, the designated meeting place, smoking safety procedure, the use of fire extinguishers, smoke detectors, and fire alarms, and notification of the local fire department. Agency submitted modified checklist. 10/21/2013 Implemented
6400.66The two basement exits at the rear of the home did not have lighting to ensure safety.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. To ensure safety and to avoid accidents, Agency will place lighting at the two basement exits at the rear of the home. Agency will submit the pictures on 11/11/13. [A physical site checklist will be developed that include checking lighting to assure safety and to avoid accidents. The Program Specialist will complete the physical site checklist monthly and forward the checklist for review to the Director. The Director will review the checklists monthly and ensure appropriate and immediate action has been taken to mitigate the safety hazards. All staff members will be educated on the procedures to be followed if a lighting/safety hazard or repair is needed in one of the community homes by 12/15/13. Documentation shall be kept. (CHG 11/6/13)] 10/21/2013 Implemented
6400.67(a)1. The bedrooms of Individual #1 and Individual #2 had cracked plaster throughout the ceilings. 2. The plaster of the bedroom wall of Individual #1 was cracked approximately 2 ½ ` by 10 ¿. 3. The first floor bathroom had a hole in the wall near the toilet approximately 4¿ by 3¿. (a) Floors, walls, ceilings and other surfaces shall be in good repair. To ensure floors, walls, ceilings and other surfaces shall be in good repair, agency will perform repair of the cracked plaster throughout ceilings in the bedroom Individual # 1 and #2, crack on the bedroom wall Individual #1, and the hole near the toilet in the first floor bathroom. Agency will submit the pictures of the repaired bedroom ceilings, the plaster on the bedroom wall, and the hole in the wall near the toilet on 11/19/13 [A physical site checklist will be developed that includes the presence of cracks or holes in floors, walls, ceilings and other surfaces. The Program Specialist will complete the physical site checklist monthly and forward the checklist for review to the Director. The Director will review the checklists monthly and ensure appropriate and immediate action has been taken that are needed for repairs. All staff members will be educated on the procedures to be followed if a lighting/safety hazard or repair is needed in one of the community homes by 12/15/13. Documentation shall be kept. (CHG 11/6/13)] 10/21/2013 Implemented
6400.77(b)The first aid kit did not contain sterile gauze pads. Repeat Violation - 7/13/12(b) 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. 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. Agency placed sterile gauze pads. Agency submitted the photo of first aid kit with sterile gauze pad. 10/21/2013 Implemented
6400.1011. The fruit cellar basement exit has an eyehook latch on the outside of the door preventing egress. 2. The bedroom door of Individual #2 had a skeleton key lock preventing egress. 3. The second floor storage room was locked from the outside with a padlock preventing egress. Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Agency will remove the eyehook latch in the fruit cellar basement exit, put caulking in the skeleton key on the bedroom door of Individual #2, and replace outside padlock on the second floor storage room with locking mechanism that allows egress. Agency will submit the pictures of the repairs on 11/11/13. [The Program Specialists and House Managers will perform an inspection of all locks and latches throughout each individual home and document the results by 12/1/13. Concerns regarding entrapment hazards will be documented. The Director will review the documentation of the inspections and remove all locks and latches identified to be a potential entrapment hazard by 12/15/13. All staff persons will be educated on the potential entrapment hazards created by locks and latches in the homes and the related safety concerns by 12/31/13. (CHG 11/6/13)] 10/21/2013 Implemented
SIN-00241795 Renewal 03/27/2024 Compliant - Finalized
SIN-00222913 Renewal 04/11/2023 Compliant - Finalized
SIN-00153958 Renewal 04/23/2019 Compliant - Finalized
SIN-00051303 Initial review 07/02/2013 Compliant - Finalized