Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00229715 Unannounced Monitoring 08/08/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)During the inspection conducted on 8/08/2023, it was observed that Individual #1's wooden headboard was not sturdy and was able to sway approximately three inches back and forth. The bolts attached from the bed frame to the headboard were loose and several bolts were missing. Furniture and equipment shall be nonhazardous, clean and sturdy. on 8/9/2023, Individual #1's headboard was secured to the wall by HNA's contractor. 0n 8/14/2023 , the staff were retrained on how to complete the Maintenace Request form where the form is located and the process of submitting the form to the House Manager . 08/28/2023 Implemented
6400.18(a)(9)Individual #1, date of admission 5/18/2018, was seen at MedExpress on 7/10/2023 and was diagnosed with two fractured toes on her right foot. As of 8/08/2023, this incident was not reported through the Department's information management system or on a form specified by the department. This exceeds the 24-hour reporting requirement.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Injury requiring treatment beyond first aid. On 8/9/2023 the Program Specialist/Incident Manager submitted in the Departments Information Management System the report on this incident. On 8/9/2023 the house staff was retrained on the incident reporting , the incident reporting form, the location of the form and the immediate reporting of the incident to management. 08/31/2023 Implemented
6400.18(h)(6)Individual #1 was taken to MedExpress on 7/10/2023 and was diagnosed with two fractured toes on their right foot. Staff are unaware of how this injury occurred. As of 8/08/2023, an investigation of the incident was not conducted by a Department-certified incident investigator.A Department-certified incident investigator shall conduct the investigation of the following incidents: Injury requiring treatment beyond first aid as a result of an accidental or unexplained injury or an injury caused by a staff person, another individual or during the use of a restraint.On 8/9/2023 the incident was reported in the incident management system, and the certified investigator began his investigation. On 8/9/2023 the Program Specialist/ Incident manager was retrained on the on the incent management process and timelines. On 8/9/2023 , the house staff was retrained on the incident reporting , the incident reporting form, the location of the form and the immediate reporting of the incident to management. 08/31/2023 Implemented
6400.162(c)(3)Individual #1 is being prescribed 10 medications that are not being prepared as ordered by the prescriber. This includes, but is not limited to: Duloxetine HCL DR 60 Mg Cap - Take 1 capsule by mouth daily for pain/depression, Meloxicam 7.5 MG Tablet - Take 1 tablet by mouth 2 times a day with meals for pain and inflammation, and Acetaminophen 325 MG tablet - Take 1 to 2 tablets by mouth every 6 ours as need for pain, mild (1-3) or fever. These medications are being crushed and put into applesauce or yogurt prior to being administered to Individual #1.Medication administration includes the following activities, based on the needs of the individual: Prepare the medication as ordered by the prescriber.On 8/8/2023 the Pharmacy was notified of the incorrect labels. The corrected labels were printed by the pharmacy, delivered and applied on 8/9/2023. The house manager was retrained to inspect each refilled medication label for accuracy prior to putting the medication into the rotation. 08/31/2023 Implemented
6400.166(b)Individual #1 is prescribed the following medication: Neomycin-Polymyxin-HC Ear Solution - Place 2 drops (10 ml) in each ear on Mondays at 8 AM. This was documented as administered on Sunday, 8/06/2023 at 8:00 AM and Monday, 8/07/2023 at 8:00 AM. This was a documentation error and was only administered on Monday, 8/07/2023 at 8:00 AM.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.On 8/8/2023 the Medication Administrator was retrained by the Practicum Observer on the process set forth by HNA when a documentation error occurs. 08/29/2023 Implemented
SIN-00227998 Renewal 07/20/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.34(a)Individual #1 was informed and explained individual rights and the process to report a rights violation on 01/01/22 and then again on 01/04/23.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.The home shall inform and explain individual rights and the process to report a rights violation to the individual and persons designated by the individual, upon admission to the home and annually thereafter. On 7/24/2023 the House Managers compiled a list of all residents and the 2023 date of the individual rights review and signature. The individual rights will be administered to the residents 365 days from the 2023 administration of the individual rights with no grace period. 07/31/2023 Implemented
SIN-00209776 Renewal 08/02/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(8)Individual #1 completed a mammogram on 7/1/21, and then again on 7/21/22, exceeding the annual requirement. Individual #1 is 50 years of age or older.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. Staff will schedule the annual mammogram at the time of completion of the current annual mammogram, to be compliant with the 380- days period. Annual appointments are entered into the electronic medical record (EMR). [Training form, dated 9/19/22, on the requirements of mammogram examinations was received on 9/23/22 and reviewed 9/28/22. Monthly appointment audit template for House manager and Quarterly appointment audit template for Program Specialist received on 9/23/22 and reviewed 9/28/22. DPOC by HDKP, HSLS, on 9/28/22]. 09/30/2022 Implemented
6400.142(a)Individual #1 had a dental examination on 11/19/20, and then again on 12/10/21, exceeding the annual requirement. Individual #2 had a dental examination on 2/23/21, and then again on 7/28/22, exceeding the annual requirement.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. Staff will schedule next annual dental exam at the time of completion of the current annual dental exam, to be compliant and within the 380-day period. The annual appointments are put into the electronic medical record (EMR). [Training form, dated 9/20/22, on the requirements of dental examinations was received on 9/23/22 and reviewed 9/28/22. Monthly appointment audit template for House manager and Quarterly appointment audit template for Program Specialist received on 9/23/22 and reviewed 9/28/22. DPOC by HDKP, HSLS, on 9/28/22]. 09/30/2022 Implemented
6400.52(c)(5)Program Specialist #1 did not complete the annual training topic for the training year 7/1/21 through 6/30/22: The safe and appropriate use of behavior supports.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.The Program Specialist will develop a profile for each resident to encompass the specific needs of the individual and practices necessary to assure the person's health, safety and welfare. This profile will be used in conjunction with the Skills assessment, Individual Support Plan and included in the Residential annual Training as well a new hire orientation. [Individual profiles received on 9/23/22 and reviewed 9/28/22. Training form, dated 9/21/22, on the requirement that annual training must include Safe and Appropriate use of behavior supports was received on 9/23/22 and reviewed on 9/28/22. DPOC by HDKP, HSLS, on 9/28/22]. 09/30/2022 Implemented
6400.52(c)(6)Program Specialist #1 did not complete the annual training topic for the training year 7/1/21 through 6/30/22: Implementation of the individual plan.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.The Program Specialist will develop a profile for each resident to encompass the specific needs of the individual and practices necessary to assure the implementation of the individual plan This profile will be used in conjunction with the Skills assessment, Individual Support Plan and included in the Residential annual Training as well a new hire orientation. [Individual profiles received on 9/23/22 and reviewed 9/28/22. Training form, dated 9/21/22, on the requirement that annual training must include Implementation of the Individual Plan was received on 9/23/22 and reviewed on 9/28/22. DPOC by HDKP, HSLS, on 9/28/22]. 09/30/2022 Implemented
6400.165(g)Individual #1 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness. Individual #1 had a psychiatric medication review completed on 11/19/21, and then again on 3/7/22, exceeding the 3-month requirement. Individual #1 had a psychiatric medication review completed on 3/1/22 and then again on 6/30/22, exceeding the 3-month requirement.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.90-day medication check will be scheduled at the conclusion of the Zoom or face to face appointment to remain compliant. Should the practitioner not be available a different practitioner will be requested to remain in compliance. [Training form, dated 9/19/22, on the requirements of psychiatric medication reviews was received on 9/23/22 and reviewed 9/28/22. Monthly appointment audit template for House manager and Quarterly appointment audit template for Program Specialist received on 9/23/22 and reviewed 9/28/22. DPOC by HDKP, HSLS, on 9/28/22]. 09/30/2022 Implemented
6400.169(a)Program Specialist #1 completed the Modified Medication Administration course on 10/2/2020; however, the agency did not provide documentation of training from the provider on the use of the provider's medication record for documenting the administration of medication, documentation of four (4) observations of Program Specialist #1 administering medications by a Certified Medication Administration Trainer or a Qualified Practicum Observer, and documentation of Program Specialist #1 observed applying proper handwashing and gloving techniques in accordance with ODP Announcement 20-114 regarding initial training. Additionally, the agency did not provide documentation of Annual Practicum requirements or completion of the Standard Medication Administration Course by 10/2/2021, exceeding the annual requirement. The agency did not provide documentation of four (4) observations of Program Specialist #1 administering medication by a Certified Medication Administration Trainer or a Qualified Practicum Observer and the agency did not provide documentation of four (4) Medication Record Reviews for Program Specialist #1 by a Certified Medication Administration Trainer or a Qualified Practicum Observer in accordance with ODP Announcement 20-114 [Repeat violation 8/26/21, et. al.].A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).The Program Specialist will be taking the standard medication administration course when the student platform opens September 2022. At this time the Program Specialist is not passing medications. 10/15/2022 Implemented
SIN-00176968 Renewal 09/29/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)Individual #1and Individual #2 received general fire safety training on 3/4/19 and then again on 7/2/2020. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. 6400.113(a) - Individuals will be instructed upon admission and reinstructed annually on general fire safety. HNA will develop a policy and procedure to ensure "Fire Safety" training, evacuation procedures, responsibilities during fire drills, the designated meeting place outside of the building or within the fire safe area in the event of an actual fire will be completed on a biannual schedule. Staff will be trained on the new fire safety training policy and a schedule will be kept in the 'Fire Safety Manual". This correction will be made by November 13, 2020 [At least quarterly for one year, the CEO or designee will audit all individuals' records to ensure that individuals receive fire safety training upon admission and annually thereafter. Documentation off all trainings and audits shall be kept. (DPOC by RM, HSLS on 1/7/2021)] 11/13/2020 Implemented
6400.141(a)Individual #1 had physical examinations completed on 5/2/19 and then again on 9/14/2020. Individual #2 had physical examinations completed on 5/10/19 and then again on 7/20/20.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. 6400.41(a) An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Due to the COVID-19 Pandemic, the individual's Primary Care Physicians were not accepting in person appointments until the yellow phase was lifted on June 5, 2020. At this time we accepted the first available appointments . ODP chapter 55 Pa code 6400 at-a-glance reopening guide states " For service locations in green phase counties, provider must resume the following activities that are suspended in red and yellow phase counties within 30 days of county designation as green: 1. Annual individual physical examinations and biennial staff physical examinations should be scheduled for the first available date." This Guidance was issued on 6/10/2020 by the Office Of Developmental Programs, Regulatory suspensions for Ch. 55 PA Code 2380, 2390, 6100, 6400, 6500. HNA has follows an appointment schedule for each individual to remain compliant . The staff will be trained on the proper way to document the inability to obtain medical appointments during a pandemic or crisis should we again be governed by closures. This training will be completed by November 13, 2020.[At least quarterly for one year, the CEO or designee will audit all individuals' records to ensure a physical examination is conducted annually. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 1/7/2021)] 11/13/2020 Implemented
6400.141(c)(7)Individual #1's record contains a statement that is not signed or dated, "[Individual #1] has never had a gynecological exam due to family and her PCP's decision that it might traumatize her." Individual #1's physical examination completed on 9/14/2020, in the section labeled "genitals" it states "deferred". Individual #2 had a gynecological examination including a breast examination and a Pap test on 1/4/19 and then again on 3/13/2020. [Repeat violation 5/31/19]The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. 6400.141(c)(7)The physical examination shall include a gynecological examination including a breast examination and a PAP test for women 18 years of age or older, unless there is documentation from a licensed physician . Individual#1 has a Legal guardian which is her sister. On 5/29/2020 , her guardian wrote a letter stating she declines cervical screening for individual #1. The House Manager will ask Individual #1 to go to a quiet area of the house where she will talk to individual #1 about the health benefits of getting a gynecological exam, one time monthly. The house manager will document individual#1's response and the date she spoke to Individual #1. The program Specialist reviews The Desensitization Plan biannually with individual #1 . The desensitization plan used by the program specialist will be revised and continue to review with individual #1 biannually. On 6/24/2019 individual #2's gynecologist documented a PAP and HPV testing was done on 6/24/2019 . current guidelines state a pap is no longer needed after age 65 as long as patient has had regular screening and no abnormal pap smears. since individual #2 had no pap smears results at UPMC recommendation is pap repeated in 3-5 years per guidelines. Individual #2 will return for a pap in 2022.[Immediately, the CEO or designated management staff will develop a system to track all individual gynecological examinations to ensure they are completed annually or per doctor recommendation. Quarterly for at least one year, the CEO or designee will audit all individual records to ensure gynecological examinations are completed per the required time frames. Immediately, the CEO or designated management staff will train all staff responsible for completing and scheduling medical appointments on the requirements of 6400.141c7. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 1/7/2021)] 11/13/2020 Implemented
6400.141(c)(8)Individual #1, date of birth 5/31/66, had a mammogram on 11/9/18 and then again on 12/31/19. Individual #2, date of birth 5/15/50, had a mammogram on 5/20/19 and then again on 6/29/2020.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. 6400.141(c)(8) The physical examination shall include a mammogram for women under the age of 50 at least every 2 years and at least every year for women over the age of 50. Individual #1 had her first mammogram on 11/9/2018 , which a desensitization plan was used. on 11/12/2019 individual #1 refused the mammogram and her appointment canceled. The desensitization plan was re-instituted and her appointment was rescheduled for 12/31/2019. HNA uses an individual appointment schedule to remain in compliant. Individual #2 received a mammogram on 5/20/2019 and again 6/29/2020, Due to the COVID-19 Pandemic mammograms were done emergent during the red and yellow phases. On 6/5/2020 we entered the green phase and the first available appointment was scheduled. The ODP's reopening plan states once in the green phase counties have 30 days to resume activities and schedule first available appointments. Staff will be retrained to follow the guidelines for mammograms to remain in compliance with the regulations.[At least quarterly for one year, the CEO or designee will audit all individuals' records to ensure mammograms are completed per the required regulatory time frames. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 1/7/2021)] 11/13/2020 Implemented
6400.141(c)(10)Individual #2's physical examination completed on 7/20/2020 did not include a statement regarding communicable disease.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. 6400.141(c)(10) the physical examination shall include a statement free from contagious diseases. Individual #2 physical examination was done on 7/2/2020 not 7/20/2020 as cited. The physician's medical form is checked individual is free of contagious diseases. Staff will be trained to review all medical forms prior to leaving physicians office to ensure that all information is accurate and there are no blank spaces.[Immediately, the CEO or designated management staff will update physical examination form to ensure the contagious disease statement can be clearly understood and all staff will be trained on the new form. At least quarterly for one year, the CEO or designee will audit all individuals' records to ensure physical examinations are complete and accurate. Documentation of all audits and trainings shall be kept. (DPOC by RM, HSLS on 1/7/2021)] 11/13/2020 Implemented
6400.141(c)(11)Individual #2's physical examination completed on 7/20/2020 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. 6400.141(c)(11) The physical examination shall include an assessment of the individual's health maintenance needs, medication regimen and the need for bloodwork. The physical examination was completed on 7/2/2020 , not 7/20/2020. The examination reflects a plan from the Physician addressing each diagnosis , the continuation of the medication and required plan for follow up and bloodwork. Staff will be retrained on reviewing paperwork before leaving the physicians office to ensure that all information is accurate and no spaces are left blank. [At least quarterly for one year, the CEO or designee will audit all individuals' records to ensure physical examinations are complete and accurate. Documentation of all audits and trainings shall be kept. (DPOC by RM, HSLS on 1/7/2021)] 11/13/2020 Implemented
6400.141(c)(12)Individual #2's physical examination completed on 7/20/2020 did not include physical limitations of the individual.The physical examination shall include: Physical limitations of the individual. 6400.141(c)(12) The physical examination shall include physical limitations of the individual. Individual #2 's physical examination was completed on 7/2/2020 not 7/20/2020. The physician documented individual #2 is encouraged to use her walker at home , no acute concerns. Staff will be trained to review all documentation received prior to leaving the physician's office to ensure all information has been recorded correctly and all blanks are filled in on the forms.[At least quarterly for one year, the CEO or designee will audit all individuals' records to ensure physical examinations are complete and accurate. Documentation of all audits and trainings shall be kept. (DPOC by RM, HSLS on 1/7/2021)] 11/13/2020 Implemented
6400.141(c)(14)Individual #2's physical examination completed on 7/20/2020 did not include 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. 6400.141.(c)(14) The physical examination shall include medical information pertinent to diagnosis and treatment in case of an emergency. Physician will be contacted to revise the physical form to reflect medical information pertinent to to diagnosis and treatment in case of emergency. HNA staff used an outdated physical form for Individual #2's physical. All copies of the outdated form were destroyed and the updated forms were distributed to staff. Staff will be trained on the new forms.[At least quarterly for one year, the CEO or designee will audit all individuals' records to ensure physical examinations are complete and accurate. Documentation of all audits and trainings shall be kept. (DPOC by RM, HSLS on 1/7/2021)] 11/13/2020 Implemented
6400.141(c)(15)Individual #2's physical examination completed on 7/20/2020 did not include special instructions for the individual's diet.The physical examination shall include:Special instructions for the individual's diet. 6400.141(c)(15) The physical examination shall include ; Special instructions for the individual's diet. Individual's physical examination was completed on 7/2/2020 not 7/20/2020. The physician documented healthy diet and weight loss encouraged. The physician will be contacted to elaborate on his recommendations for a healthy diet.. Staff will be trained on 6400.141(c)(15) and the need to review the dietary information on the physical prior to leaving the physicians office to ensure that the dietary information is correct.[At least quarterly for one year, the CEO or designee will audit all individuals' records to ensure physical examinations are complete and accurate. Documentation of all audits and trainings shall be kept. (DPOC by RM, HSLS on 1/7/2021)] 11/13/2020 Implemented
6400.165(g)Individual #2 is prescribed Sertaline, 100 mg-one time per day for depression and Olanzapine, 5mg-one time per day for Bi-Polar. The review of medications prescribed to treat symptoms of a psychiatric illness completed on 6/26/2020 does not include the medication, necessary dosages, the reason for prescribing and need to continue the medications. The review of medications prescribed to treat symptoms of a psychiatric illness completed on 8/28/2020 does not include does not include the reason for prescribing or the need to continue the medications. [Repeat violation 5/31/19; previously 6400.163 (c)]If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.6400.165(g) if a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes reason for prescribing, the need to continue and the dosage. Individual #2 was seen via facetime for her psychiatric examinations on 6/26/2020 and 8/28/2020. No in person visits were being done during this time period. The staff documented , the review of medications with the physician as well as no medication changes for this visit. The after visit summary was printed from UPMC's website as verification to the visit. The staff will be trained on all necessary information that needs to be documented for psychiatric visits that comply with 55PA Code Chapter 6400.165(g) whether it is an in person visit or a tele-visit.[At least quarterly for one year, the CEO or designee will audit all individuals' records to ensure psychiatric medications reviews are complete and accurate. Documentation of all audits and trainings shall be kept. (DPOC by RM, HSLS on 1/7/2021)] 11/13/2020 Implemented
6400.181(f)Individual #1's assessment completed on 10/1/19 was not provided to the individual plan team members. [Repeat violation 5/31/19]The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.6400.181(f) The program specialist shall provide the assessment to the individual plan team members at least 30 calendar day prior to an individual plan meeting. All ISP Gathering Information was supplied to the team members on 10/1/2020. Per the ISP invitation dated August 22, 2019, Jessica Hunter, SC, requested that all gathering information be submitted at least two weeks prior to the ISP Meeting scheduled for October 16, 2019. For future meetings, The Program Specialist will submit the assessment to the team members at least 30 days before the ISP Meeting regardless of what the timeline requested by the Supports Coordinator.[Immediately, the CEO or designated management staff will train the program specialist on the requirement of 6400.181f. At least quarterly for one year, the CEO or designee will audit all correspondence documentation to ensure all individuals plan team members are provided the assessment timely. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 1/7/2021)] 11/13/2020 Implemented
6400.213(7)The record for Individual #2, date of admission 11/2/17, did not include an invitation or signature page from the most recent annual ISP review meeting.Each individual's record must include the following information: Individual plan documents as required by this chapter.6400.213(7) each individual record must include an invitation or signature page from the most recent annual ISP meeting. The annual ISP was conducted by phone individually . An email dated 6/30/2020 was received stating the SC will be contacting the team individually to obtain the annual updates to complete the ISP. On 10/29/2020 a request for the signature page was made to the SC . The SC's response was the ISP paperwork was submitted to her office a few weeks ago . It might take longer to receive it since we have limited staff in the office to mail it out. The Program Specialist will request a copy of the invitation letter if it is not sent in a timely manner after the the ISP meeting is scheduled. The Program Specialist will request a copy of the signature page at the ISP meeting if held in person. If the meeting is conducted via telephone or virtually, the Program Specialist will request an email copy of the signature page prior to concluding the meeting.[Immediately, the CEO or designated management staff will train the program specialist on the requirement of 6400.213(7). At least quarterly for one year, the CEO or designee will audit all ISP documentation to ensure all individuals have received the ISP invitation and signature page or a written request for the documentation has been made. (DPOC by RM, HSLS on 1/7/2021)] 11/13/2020 Implemented
SIN-00156093 Renewal 05/31/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency completed a self-assessment of the home on 4/22/19. The agencies certificate of compliance expires 6/22/19.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. Regulation 6400.15(a): The Agency did complete an assessment on April 22, 2019 which was within 3 months prior to the expiration of the agency's Certificate of Compliance, expiration date June 22, 2019. The self-assessment that was completed was on the wrong form, which invalidated our compliance to regulation 6400.15(a). The Program Specialist and Compliance Coordinator reviewed the provisions of regulation 6400.15(a) and (b)., immediately following the licensing exit interview on May 31, 2019. The correct licensing inspection instrument was obtained and completed on June 3, 2019 by the Compliance Coordinator. The Program Specialist and the Compliance Coordinator are responsible for submitting the correct form within 3 to 6 months prior to the expiration of the agency's certificate of compliance. The date for submitting the LII will be added to the calendar of annual compliance dates which is kept by the Compliance Coordinator. [Immediately, the CEO and program specialist shall review the regulation 6400.15a and the agency's current certificate of compliance and develop a tracking system to ensure the self-assessment for each home is completed between 3 and 6 months prior to the expiration date of the certificate of compliance, not within 3 months as stated above in the plan of corrections. Prior to 3 months of the expiration of the current certificate of compliance, the CEO shall audit all self-assessments to ensure timely and full completion of each self-assessment for each community home. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 6/28/2019)] 06/03/2019 Implemented
6400.15(b)The agency did not use the Department's licensing inspection instrument for the self-assessment completed on 4/22/19.The agency shall use the Department's licensing inspection instrument for the community homes for people with intellectual disability regulations to measure and record compliance. Regulation number 6400.15 (b); The Agency did not use the correct form for the self-assessment for each home it operates. The correct form was obtained from the Licensing Inspectors on May 31, 2019. The Program Specialist and the Compliance Coordinator reviewed the provision of 6400.15(b) which requires that the agency use the Department's licensing inspection instrument for community home regulations to measure and record compliance immediately after licensing exit interview. The Compliance Coordinator completed the self assessment forms on June 3, 2019. The program Specialist and Compliance Coordinator will be responsible for submitting the correct forms annually within 3 to 6 months prior to the expiration of the agency's certificate of compliance. [Prior to completion, the CEO or designee shall utilize the Department's website or other means to ensure the most current Department's licensing inspection instrument is used when completing the required self-assessments for each home. (DPOC by AES,HSLS on 6/2819)] 06/03/2019 Implemented
6400.44(c)Program Specialist #1 date of hire 5/31/18 does not meet the qualifications necessary to be a program specialist. A program specialist shall have one of the following groups of qualifications: (1) A master's degree or above from an accredited college or university and 1 year work experience working directly with persons with intellectual disability. (2) A bachelor's degree from an accredited college or university and 2 years work experience working directly with persons with intellectual disability. (3) An associate's degree or 60 credit hours from an accredited college or university and 4 years work experience working directly with persons with intellectual disability.6400.44(c): The Program Specialist shall meet the necessary requirements to be a program specialist. New Program Specialist has a degree of Associate of Applied Science in Business Management and over 20 years experience working with individuals with IDD. Experience began as a Direct Care Worker, promoted to Program Specialist, then Program Director and finally Program Administrator overseeing 5 Program Directors. The Program Specialist will work in conjunction with the Compliance Coordinator to ensure that all aspects of the 6400 regulations are met. [Copies of diploma and resume for new program specialist provided to the Department. Prior to hire, the CEO or designee shall review qualification documentation to ensure the program specialist has the qualifications required for the program specialist position. Documentation of qualifications shall be kept and available for review upon request by the Department. (DPOC by AES, HSLS on 6/28/19)] 06/17/2019 Implemented
6400.112(e)A fire drill was not held during sleeping hours between 8/28/18 and 5/21/19.A fire drill shall be held during sleeping hours at least every 6 months. The Compliance Coordinator reviewed all provisions of 6400.112(e) on June 17,2019. The HM was retrained on the provision of 6400.112 and received a written copy to place in the fire books along with the written schedule for conducting fire drills. The schedule requires a sleep hour fire drill will be done quarterly, beginning July 1 2019. Fire drills will be reviewed quarterly by the compliance Coordinator and the program specialist to ensure that all provisions of 6400.112 are being adhered to. [An unannounced fire drill during sleeping hours shall be held by November 2019. Documentation of audits by the program specialist and compliance coordinator of fire drill records shall be kept to ensure fire drills are held and documented as required and to ensure all fire drill are unannounced and the aforementioned "schedule" is not provided to staff person and individuals participating in fire drill. (DPOC by AES,HSLS on 6/28/19)] 06/17/2019 Implemented
6400.141(c)(7)Individual #1 date of admission 11/2/17 did not have a Gynecological examination.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. The Compliance Coordinator reviewed all provisions of 6400.141(c)(7) on June 24,2019. Individual #1 had a PAP smear on June 24, 2019 and at that time the CRNP gave her recommendation as well as the American College of Obstetrics and Gynecology. Current guidelines state paps are no longer needed after age 65( as long as the patient has had regular screening and no abnormal pap smears). Since, Individual #1's health system does not have any pap results, Individual #! will repeat a pap in 3- 5 years. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure timely completion of individuals' physical examinations and follow up appointments. At least monthly, the CEO or designee shall audit the tracking system to ensure all individuals have physical examinations and follow up appointments completed timely and as recommended by physicians to ensure the health and safety of the individuals. Documentation of audits shall be kept. (DPOC by AES, HSLS on 6/28/19)] 06/24/2019 Implemented
6400.141(c)(14)The physical examination dated 5/15/19 for Individual #2 does not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The Compliance Coordinator reviewed all provisions of 6400.141(c)(14) on June 17,2019. The HM was retrained on the provisions of 6400.141(c)(14), . The HM will ensure completeness of the HNA Physical form allowing no blanks on the form prior to leaving the physician office. The Compliance Coordinator will review the Physical form post appointment in adherence to provision 6400.141(c)(14). [Immediately, the CEO or designee shall obtain the missing information for Individual #2's current physical examination. Documentation of audits of all individuals' physical examinations shall be kept. (DPOC by AES,HSLS on 6/28/19)] 06/17/2019 Implemented
6400.143(a)On 5/8/18, Individual #2 declined a gynecological examination. There is not documentation of continued attempts to educate the individual about the need for health care.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. 6400.143(a) individual #2 declined a gynecological examination on 5/8/18. The Program Specialist wrote a desensitization plan for individual #2 that explains the need to have regular gynecological exams. . The House Manager will implement the plan; she will talk privately to individual #2 one time a month about the need for gynecological exams. She will document the date and individual #2's response monthly. The Program Specialist and the Compliance Coordinator will review the monthly documentation and make changes to the plan as needed. [Documentation of the audits shall be kept. (DPOC by AES,HSLS on 6/26/19)] 06/14/2019 Implemented
6400.151(c)(3)The physical examination for Direct Service Worker #2 completed 2/16/18 does not indicate the staff person is free of communicable diseases. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. The Compliance Coordinator reviewed all provisions of 6400.151(c)(3) on June 17, 2019. All staff requiring a physical exam and choose to have the exam done by their PCP will be required to have their physician review HNA's physical form and sign off the form which states the staff is "free from communicable diseases. prior to working in the residential homes. Beginning July 1, 2019 all physical forms will be reviewed by the Program Specialist and the Compliance Coordinator prior to the staff working to ensure compliance to provision 6400.151(c)(3). [Documentation of audits of staff physical examinations shall be kept. (DPOC by AES,HSLS on 6/28/19)] 06/17/2019 Implemented
6400.163(c)The reviews of medications prescribed to treat symptoms of a psychiatric illness for Individual #1, dated 10/12/18 and 7/6/18 did not include reason for prescribing the medication. 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 Compliance Coordinator reviewed all provisions of 6400.163 (c) on June 17, 2019. The House Manager and House Supervisor were retrained on provisions of 6400.163 (c). to assure the Psychiatric Physician completes the HNA Psychiatric visit form documenting the reason medications is prescribed , dosage, and need to continue medications. Compliance Coordinator will review Psychiatric visit every three months after the psychiatric appointment.. [Documentation of the audits shall be kept. (DPOC by AES,HSLS on 6/28/19)] 06/17/2019 Implemented
6400.181(a)The current assessment for Individual #1 does not have the full a date of completion only has June 2018. There is not previous assessment in the record; therefore compliance cannot be measured. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The Compliance Coordinator and Program Specialist reviewed all provisions of 6400.181(a) on June 17, 2019. At Licensing ,June 1, 2018 . Home Not Alone was cited on the assessment , "assessment was not completed". Assessment was submitted and approved. Licensing 5/31/2019 it was found that the assessment lacked an exact date (6/18). Assessment was corrected 6/1/2018. The compliance Coordinator and Program Specialist will review assessment dates to include month, day and year every 6 months to remain in compliance to provision 6400.181(a).beginning on July 1, 2019. [Documentation of audits of individuals' assessments shall be kept. Immediately, the CEO or designee shall develop a tracking system to ensure the program specialist completed all individuals' assessments, timely and maintains and ensures at least the 2 most recent individuals' assessment are available for review upon request by the Department. (DPOC by AED,HSLS on 6/28/19)] 06/17/2019 Implemented
6400.181(b)The assessment from June 2018 for Individual #1 was not dated by the program specialist.If the program specialist is making a recommendation to revise a service or outcome in the ISP as provided under § 6400.186(c)(4) (relating to ISP review and revision), the individual shall have an assessment completed as required under this section. 6400.181(b): The assessment from June 2018 for individual #1 was not dated by the program specialist. The Program Specialist and the Compliance Coordinator reviewed 6400.181(b) immediately after the licensing exit interview May 31, 2019. The Program Specialist added the assessment date June 1, 2018. Individual #1's new assessment was completed on June 10, 2019, signed by the Program Specialist and sent to the SC. The Program Specialist and Compliance Coordinator will review assessments every 6 months to ensure that assessments remain accurate and that compliance is met. The Program Specialist will update assessments if individual's needs change and a copy will be mailed to the SC. [Documentation of audits of individuals' assessments shall be kept. Immediately, the CEO or designee shall develop a tracking system to ensure the program specialist completed all individuals' assessments, timely and with the full date of completion and maintains and ensures at least the 2 most recent individuals' assessment are available for review upon request by the Department. (DPOC by AED,HSLS on 6/28/19)] 06/14/2019 Implemented
6400.181(f)There was not documentation to show that the program specialist provided the assessment completed June 2018 for Individual #1 to the plan team for the ISP meeting on 7/9/18. There was not documentation to show that the program specialist provided the assessment completed 6/21/18 for Individual #2 to the plan team for the ISP meeting on 10/11/18.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). The program Specialist reviewed all provisions of 6400.181(f) on June 17, 2019.The program Specialist was retrained on the provision 6400.181. The Program Specialist and Compliance Coordinator developed a cover letter to be sent with all assessments and quarterly reviews to the team. A copy will be kept in individual #1 and #2's charts as documentation of date sent and to whom. The Compliance Coordinator will review all correspondence to assure provision 6400.181 (f) are adhered to. [Individual #1 and Individual #2's Assessments completed June 10, 2019 were provided to the plan team members on 6/12/19. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 6/28/19)] 06/17/2019 Implemented
6400.186(b)The ISP review dated March 2019 for Individual #1 was not signed or dated by the Program specialist or the individual.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. 6400.186(b): The ISP for individual ##1 was not signed or dated by the Program Specialist or the individual. Regulation 186(b) was reviewed by the Program Specialist and the Compliance Coordinator. The Program Specialist will sign the ISP review prior to meeting with the individual to review the document. The Program Specialist will obtain the individual's signature prior to sending ISP review to SC and Team Members. A quarterly review of individuals chart will be completed by the Program Specialist and Compliance Coordinator. [Documentation of audits of individuals' records shall be kept. (DPOC by AES,HSLS on 6/28/19)] 06/17/2019 Implemented
6400.186(d)The program specialist did not provide the ISP reviews for Individual #1 completed 6/29/18, 9/28/18, and 12/31/18 to the plan team members. The program specialist did not provide the ISP reviews for Individual #2 completed 3/29/19, 12/31/18, 9/28/18, and 6/29/18 to the plan team members.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. 6400.186(d) The Program Specialist did not provide documentation to support the ISP reviews for individual #1 were sent to the SC and Team members for 6/29/18, 9/28/18 and 12/31/18, also for individual #2 for 3/29/19, 12/31/18, 9/28/18 and 6/29/18. The Program Specialist and the Compliance Coordinator reviewed the provisions of Regulation 6400.186(d) and developed a form that will be enclosed with the reviews that are sent to the SC's and team members. The form states who is receiving the review, the date of the review and the date it was mailed. A copy of the form will be kept with the individual's ISP review in their permanent file. A quarterly review of the files will be completed by the Program Specialist and the Compliance Coordinator. [Documentation of audits of individuals' records shall be kept. (DPOC by AES,HSLS on 6/28/19)] 06/17/2019 Implemented
SIN-00136313 Renewal 06/01/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(a)On 3/21/18, Direct Service Worker #4 caused a brush burn on Individual #1's right arm while changing Individual #1. Individual #1's family removed Individual #1 from the home in part as result of the incident.An individual may not be neglected, abused, mistreated or subjected to corporal punishment. Direct Service Worker #4 was removed from the home after the incident with Individual #1. HNA cannot find any evidence that the family wanted individual #1 removed from the home; however, HNA did send a 30 day termination notice to individual #1's family and Supports Coordinator on March 22, 2018. Staff was retrained in neglect, abuse, mistreatment and corporal punishment. Program Specialist will have quarterly trainings on abuse and neglect with staff. [On 6/29/18, house managers and direct service workers were trained on abuse and neglect prevention. Upon hire and continuing at least annually, all staff person shall be trained on individual rights including; an individual may not be neglected, abused, mistreated or subjected to corporal punishment to include types of abuse, abuse prevention and reporting abuse. Documentation of all trainings shall be kept. (AS 7/26/18)] 06/29/2018 Implemented
6400.101The home had child safety locks on the door knobs on the door in the dining room leading to the basement obstructing egress from the basement to the outside and the door in the right side kitchen obstructing egress to the outside balcony and the backyard.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Child Safety door knob covers were remove from the basement door and the kitchen door on 6/1/18. Corrective Action: Program Specialist , House Manager and staff retrained on regulation 6400.101 . [On 7/20/18, stairways, halls, doorways, passageways and exits from rooms and from the building were found to be unobstructed. Immediately, upon hire and continuing at least annually, the CEO or designee shall educate all staff person working in community homes that stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed and to monitor throughout the course of their daily duties. Documentation of training shall be kept. (AS 7/26/18)]. 07/06/2018 Implemented
6400.106The furnace inspection of the home was completed 2/1/17 then again 3/18/18.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. 1. The program Specialist will develop a calendar for inspections. 2. The Program Specialist and House manager will be retrained on regulation 6400.106 [At least quarterly for 1 year, the CEO shall audit the aforementioned tracking system and documentation of past and current furnace inspections and cleaning to ensure completion, timely. Documentation of aforementioned training shall be kept. (AS 7/26/18)] 07/06/2018 Implemented
6400.151(a)Direct Service Worker #2, date of hire 5/18/18, had a physical examination completed 5/21/18. 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. DSP #2 did not have physical completed until 5/21/2018. DSP #2 filled in at the site due to a staffing emergency. The staff worked for Home Not Alone as a companion aid prior to working at Bryant. She was initially a temporary fill in staff at Bryant ,and she agreed to stay at Bryant. Home Not Alone scheduled her physical exam at the doctor's first available date 5/21/18. Home Not Alone has created a policy for rehired employees and transferred employees. All office staff have been trained on the policy for rehires and transfers. [Agency has developed new hire and transfer staff policies including initial staff physical examination timeliness. Recently hired staff person had initial physical examination completed prior to employment. Immediately, the CEO or designee shall develop and implement a tracking system of staff person physical examinations to ensure timely completion of all staff persons physical examinations. At least quarterly, the CEO or designee shall audit the aforementioned tracking system and a 10% sample staff person past and current physical examination to ensure timely completion of all staff persons physical examinations. Documentation of audits shall be kept. (AS 7/26/18)] 06/28/2018 Implemented
6400.168(d)In April 2018, Program Specialist #3 instructed direct service workers, who were not certified to administer medications, to administer medications to Individual #1 and document initials of other direct service workers who were certified to administer medication when the direct service workers were not available to administer the medication.A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. Program Specialist #3 has been terminated for directing staff to pass medications even though they were not trained in medication administration and for directing staff to forge another staff's initials on the MAR. Staff have been trained and certified in Medication administration. The Medication Administration Trainers train new staff prior to allowing them to pass medications. Medication Administration Trainers will track all staff who administer medication to ensure they remain in compliance with the regulations. [Staff persons who administer medication have current documentation of medication administration training. Individual #2's current medication record showed staff persons certified to administer medications were administering Individual #1's medications. Prior to initially administering medications and continuing at least quarterly for 1 year, the CEO or designee shall audit staff person's medication administration training to ensure only staff persons certified to administer medication are administering medication. Documentation of audits shall be kept. (AS 7/26/18)] 06/29/2018 Implemented
6400.213(1)(i)Individual #2's records did not include the religious affiliation.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. Individual #2 did not have religious affiliation on her personal information. Religion was added to her personal information. Program Specialist will review individual records quarterly to ensure compliance. [Individual #2's record was updated to included religious affiliation. Immediately, the CEO shall educate all staff persons of the required personal information to be included in all individuals' records as per 6400.213(1)-(14). Documentation of the training shall be kept. Immediately, upon admission and continuing at least quarterly, a designated trained staff person shall audit all individuals' records to ensure all required information is included. Documentation of the audits shall be kept. (AS 7/26/18)] 06/29/2018 Implemented
SIN-00117456 Renewal 06/29/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(j)Records of orientation and training for Direct Service Worker #1, Direct Service Worker #2, and Direct Service Worker #3 did not include the dates and lengths of the trainings.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.Corrective Action: Records of orientation and training for Direct Service Worker #1, Direct Service Worker #2, and Direct Service Worker #3 were revised on 7/5/2017 to include the dates and lengths of the training and added to staff files. (see attached) Plan to ensure continued compliance: Coordinator revised the Orientation/Training form on 6/30/2017 to include a blank space to document for lengths of training (see attached). Training on proper completion of the new Orientation/Training form record was completed with House Manager on 6/30/2017 (see attached) Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept on file, The Program Specialist and the house Manager are responsible for quarterly staff person file reviews in order to maintain compliance in training/ orientation requirements. Documentation of compliance will be noted at the agency Quality Improvement meetings that are held quarterly. 08/20/2017 Implemented
6400.151(c)(3)Direct Service Worker #2's physical examination, completed 5/19/17, did not include a signed statement that the staff person is free of communicable diseases. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Corrective Action: An addendum to the current non-compliant physical form was completed by physician on 6/30/2017. The addendum was added to DSW file. Addendum is attached. Plan to ensure continued compliance: The Agency Director has directed the Staff Interviewer and the receptionist to utilize the Agency updated physical form which includes the information that the ¿staff person is free of communicable disease¿ (see Attached). On 6/30/2017 the Receptionist has also phoned the Agency¿s physician¿s staff to inform them that only an HNA Physical form should be completed and they should not deviate from this requirement in order to maintain compliance. Receptionist and Program Specialist was trained on ensuring current staff and the agency physician use the agency physical form, training completed on 6/30/2017. Training record attached. In the event that a Direct Support Worker has a current physical from another physician without a Free from communicable disease statement, a Bi-annual Communicable Disease Statement form will be completed by the physician who completed the new staff's original physical (see attached form) Program specialist will continue to be responsible for reviewing staff person¿s files to ensure that the physical exam form includes all required information in order to maintain ongoing compliance. 08/20/0217 Implemented