Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00235475 Renewal 12/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(a)During the 12/14/23 inspection, there was a drawer in the kitchen that was not functioning properly. The drawer was located on the lower portion of the cabinets, on the wall opposite of the appliances. The drawer was the last drawer on the right side of all the cabinets. The tracks for the drawer to slide on appeared to be missing so nothing stopped the drawer from falling out, once opened.Floors, walls, ceilings and other surfaces shall be in good repair.The Director of Programs will contact the Maintenance Coordinator to have the kitchen drawer repaired by 12/29/23. 12/29/2023 Implemented
2380.181(a)Individual #1 started attending the program on 7/26/23 and did not have an assessment completed until 9/27/23, outside the initial requirement time frame.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.The Director of Programs will review this regulation with the Program Specialists to ensure that they understand the necessity of meeting the required timeframes. The Program Specialists will develop a calendar with all assessment due dates for each individual on their caseload. 12/30/2023 Implemented
2380.181(f)Individual #2's 1/19/23 assessment was not sent to their communication specialist. Their annual individual support plan meeting was held on 2/21/23 and the communication specialist was present for the meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.The Program Specialists will review and update their current list of all team members for each individual on their caseload. The Program Specialists will develop a checklist of all team members to document when required paperwork (i.e.. assessments, letters, quarterly reports) are sent. 12/30/2023 Implemented
SIN-00217152 Renewal 02/13/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(b)The documentation provided for Staff #2's fire safety training completed on 1/7/22 and Staff #4's fire safety training completed on 12/19/22 were not signed by a trainer, indicating that they trained themselves on all the fire safety regulatory requirements.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Director of Programs will review the current annual fire safety forms and make revisions to the form for accuracy and clarification of who did the training by 3/17/23. 03/31/2023 Implemented
2380.37(a)All training content, certificates earned, and the training source were not provided during the 02/14/23 inspection for all Staff person #4 and Staff person #2 documented trainings. Their training records did not include the name of the staff, the training topic, the number of hours of training earned, nor the date completed.Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept.By 3/17/23, the Director of Programs will review the documentation & spreadsheets with the Training Coordinator to discuss revising how J&FC documents employee training throughout the year. 03/17/2023 Implemented
2380.39(c)(6)Staff person's #4 and #2 annual training records did not include in-person training on individual-specific plans and protocols and how to implement the individual plans.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.By 3/17/23, the Director of Programs & Program Specialist(s) will review the current process on annual training of individuals ISP's and/or special plans/protocols to make revisions to the process. 03/17/2023 Implemented
2380.129(a)REPEAT FROM 2/28/22 annual inspection: Staff person #4's medication administration training was completed on 04/01/21, and the annual medication administration training wasn't documented as being completed again until 04/09/22. However, Staff person #4's 04/09/22 medication training only had 1 of the 2 required Medication Administration Record (MAR) reviews and 1 out of the 2 required medication administration observations completed by 04/09/22.A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures and treatments as specified in § 2380.122 (relating to medication administration).By 3/17/23, the Director of Programs & Certified Medication Trainer will review the medication administration/trainer certification protocol to ensure J&FC is completing all reviews/observations within the required timeframes. 03/17/2023 Implemented
2380.183(c)Individual #1's annual Individual Support Plan (ISP) meeting was held on 11/10/22. The agency did not keep record of who was in attendance of the meeting.The list of persons who participated in the individual plan meeting shall be kept.By 3/17/23, the Program Specialist(s) will ask for a copy of the signature sheet during an in-person ISP meeting and/or complete a virtual meeting attendance form. 03/17/2023 Implemented
SIN-00200493 Renewal 02/28/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)Individual #3 is assessed to be unsafe around poisonous materials. There were items that contained a label to contact poison control center if ingested unlocked throughout the facility. Approximately 10 different cans of paint, of varying sizes, were unlocked and accessible in a closet next to one of the bathrooms, poisonous first aid cleaners were accessible via the key being stored in the same room as the first aid kit, and poisonous materials stored under bathroom sinks were accessible via the keys to unlock the cabinets being stored unlocked in the same bathroom.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.The mentioned keys have been moved from the first aid rooms and the mentioned bathroom and will be kept in a separate location of the program. The paint has also been moved into a locked closet. It is the responsibility of the program manager to ensure all poisonous materials are kept locked away and inaccessible to individuals who are not safe with poisons. 03/11/2022 Implemented
2380.113(c)(3)REPEAT from 3/15/21 annual inspection: Staff person #2's physical examination record did not indicate if they were free from communicable diseases or the precautions to take to prevent the spread of contagious diseases. The field was left blank and unchecked by the physician.The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in §  27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals.The HR department will review all completed physicals to ensure they are completed in their entirety. If they are not, they will send the form back to the doctor to request completion. It is the responsibility of the HR department to ensure the physicals are completed with all needed regulatory requirements. 03/15/2022 Implemented
2380.113(c)(4)Staff person #2's physical examination record did not indicate if they had any medical problems that would interfere with performing their job duties. The field was left blank and unchecked by the physician. Staff person #3's 4/20/21 physical examination record did not indicate if they had any medical problems that would interfere with performing their job duties. The field was left blank and unchecked by the physician.The physical examination shall include: Information of medical problems which might interfere with the safety or health of the individuals.The HR department will review all completed physicals to ensure they are completed in their entirety. If they are not, they will send the form back to the doctor to request completion. It is the responsibility of the HR department to ensure the physicals are completed with all needed regulatory requirements. 03/15/2022 Implemented
2380.181(e)(4)Individual #2's current, 5/7/2021 assessment doesn't include an appropriate assessment of their supervision needs. The assessment states, "the individual has limitations with safety skills awareness and should be supervised for safety, especially while out in the community," "needs supervision for safety", but that they "are able to be unsupervised for up to 5 minutes in the community". Their assessment also states the individual lacks safety awareness when in the community so they are supervised at all times except when in the restroom, "{the individual} would be safe to be unsupervised for up to 5 minutes," and "staff should ensure that they communicate with {the individual} of their whereabouts." According to the individual's individual plan, they would get into a vehicle with someone they didn't know, is vulnerable to victimization and needs supervision at all times.The assessment must include the following information: The individual¿s need for supervision.The individual's supervision statement and their supervision and community safety information in their assessment has been updated. It is the responsibility of the program specialists to ensure that all assessment information accurately reflects the needs of the individual. 03/15/2022 Implemented
2380.181(e)(5)Individual #1's current, 2/23/22 assessment doesn't indicate if they are or are not able to self-administer their medications. Their assessment states they have the ability to take medications with reminders and support but doesn't define what and how often the reminders and support are. The assessment does not indicate if they can recognize and distinguish their medications from others or know when their medication is to be taken.The assessment must include the following information: The individual¿s ability to self-administer medications.The assessment has been updated to clarify the individual's ability to self-administer meds. It is the responsibility of the program specialists to ensure the individual's ability to self-administer meds is being assessed using the guidelines of 121(e)(1)-(4). 03/08/2022 Implemented
2380.181(e)(13)(ii)Individual #1's current, 2/23/22 assessment does not include an assessment of their current level and progress, or regression in motor skills over the previous 365 days. Their 2021 and 2022 assessments both state that they have "maintained their motor skills which are still mostly within normal limits". However, Individual #1 fell in December 2021 when out in the community and sustained a dislocated finger and fractured left kneecap. During the 3/1/2022 onsite inspection, Individual #1 was ambulating extremely slowly, was unsteady on their feet, and appeared to have difficulty moving one foot in front of the other at a normal walking pace.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas:  Motor and communication skills.The individual's assessment has been updated to include more recent information on their motor skills. It is the responsibility of the program specialists to ensure the information in the assessment is current. 03/08/2022 Implemented
2380.181(e)(13)(vi)Individual #2's current, 5/7/21 assessment doesn't include a comprehensible assessment of their community integration skills and needs. The assessment states, "{the individual} has been on many outings this year," "they are cooperative when out in the community and really seem to enjoy getting out and about," "{the individual} has maintained in this area for the past year," and "{the individual} has not been on any outings since their last assessment" due to the pandemic.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration.The individual's assessment has been updated with accurate and current information for their community integration skills and needs. It is the responsibility of the program specialists to ensure the information in the assessment is current and accurate. 03/15/2022 Implemented
2380.39(c)(2)There are no records maintained that Staff persons #1-#3 received annual training in the prevention, detection and reporting of abuse, suspected abuse, alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The incident management training, which includes the prevention and detection of abuse, will be updated to include information on who is responsible for reporting and when. It is the responsibility of the training coordinator to ensure that staff are trained on these statutes. 03/15/2022 Implemented
2380.129(a)REPEAT from 3/15/21 annual inspection: Staff person #2 is administering medications to individuals at program. There are no records they completed and passed the Department's annual medication administration training course and its requirements annually. Their record included documentation that they completed the annual training on 2/15/2022, (but one of the required medication administration reviews {mars} wasn't completed until 2/16/22) but nothing annually prior to that. Staff person #2 has been administering medications over the previous year. The staff's previous medication training document submitted had a certification date of 2/16/18 by the medication trainer, included two observations in 2020 and 2021 and only one mar in 2020, the 2021 mar was left blank..A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures and treatments as specified in § 2380.122 (relating to medication administration).The tracking system has been revised to ensure that trainings are completed fully and on time by the med trainer. It is the responsibility of the medication trainers to ensure paperwork is complete and accurate. 03/15/2022 Implemented
2380.186Individual #1's fall plan and assessment state they are to use a walker when ambulating and staff are to encourage Individual #1 to use their walker if they notice the individual isn't using it. During the 3/1/2022 fire drill at the program, Individual #1 did not utilize their walker to evacuate the building and staff did not encourage the individual to use their walker to exit the building to walk to the meeting place. The meeting place was approximately 30 yards away from the program.The facility shall implement the individual plan, including revisions.The Walking Support Plan has been updated and staff have been trained on the updated plan. It is the responsibility of all staff to ensure that the plan is being followed so the individual remains safe. 03/15/2022 Implemented
SIN-00183988 Renewal 03/15/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.82There was a large, metal, outdoor, patio chair positioned partially in front of the far left egress door on the lower level. During the 3/16/21 physical site inspection of the building, the egress door would not open the entire way unless the chair was moved out of the way. When agency staff attempted to open the door on 3/16/21 it struck the chair and the chair was blocking the egress door.Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed.The chair was immediately moved to an area where it will not obstruct the door. Staff were reminded to be vigilant of where the patio furniture is located so it does not block any exits. Individuals were also reminded to keep the exits clear in case there would ever be an emergency. It is the responsibility of the program manager to ensure all exits are clear of obstructions. 03/19/2020 Implemented
2380.84The facility had the building inspected by a fire safety expert on 5/28/19 and not again until 3/10/2021. The facility did open for operation from August-November 2020. There are no records of attempts to have a fire safety expert inspect the building again until 3/10/21.The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.The quality assurance and compliance coordinator will be responsible for scheduling annual fire safety inspections. The quality assurance and compliance coordinator has created a notification in Google Calendars to inform them when the next fire safety inspection is due. 03/19/2021 Implemented
2380.90(a)One of the middle, lower level, egress doors did not contain an Exit sign that was legible. The door had a small sign bearing the word "exit" that was approximately 3 inches high by 8 inches long, placed directly above the door. However, there was a large hinge also directly above the door, blocking the exit sign from most angles.Signs bearing the word ``EXIT¿¿ in plain, legible letters shall be placed at exits.A larger Exit sign was created and placed above the door. It is the program manager's responsibility to ensure Exit signs are placed above all exits. See attachment #1. 03/17/2021 Implemented
2380.91(a)At the time of the 3/15/2021 inspection, there are no records maintained for the specific fire safety information the individuals received training on. The agency only had records via an individual sign in sheet, that fire safety training took place. Documentation of the trainer and content of training was not included in the individuals' records.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, 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 facility.The fire safety training curriculum has been outlined and documented in a new form. The form outlines the contents of the fire safety video and discussion. The video and discussion cover general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building, and smoking safety procedures for the individual in the facility that smokes. The signature sheet for individuals has also been updated to include the trainer and the content of the training. It is the responsibility of the program manager to ensure all individuals are trained in these areas upon admission to the facility and annually thereafter. See attachments #2 and #3. 03/24/2021 Implemented
2380.111(c)(3)Individual #1 started attending the program on 12/16/2019. Prior to attending the program, she had a physical examination completed on 4/16/2019. However, the physical examination record did not include documentation of her Tetanus or Tetanus and Diphtheria booster administered within the previous ten years. The agency had record that the individual signed a statement agreeing to obtain a Tetanus immunization on 12/13/2019. The agency did not have record of the completed immunization from the individual's physician's office.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.The program specialists are responsible for ensuring physical forms include all necessary information provided by 2380 regulations. The program has a physical form that includes all regulatory requirements that it sends to individuals and their family/caregivers before their physical examination is due. This form includes immunization information. If a physical form is returned to program without the necessary information, the program specialists will request the needed information from the individual's physician. Please see attachment #4. 03/19/2021 Implemented
2380.111(c)(4)Individual #1 started attending the program on 12/16/2019. Prior to attending the program, she had a physical examination completed on 4/16/2019. However, the physical examination record did not include a vision and hearing screening. The physical examination record did not have a field for this screening to be documented by the physician, nor did the physician indicate what the individual's most recent screenings were or if they were completed at the time of the 4/16/2019 physical examination.The physical examination shall include: Vision and hearing screening, as recommended by the physician.The program specialists are responsible for ensuring physical forms include all necessary information provided by 2380 regulations. The program has a physical form that includes all regulatory requirements that it sends to individuals and their family/caregivers before their physical examination is due. This form includes vision and hearing information. If a physical form is returned to program without the necessary information, the program specialists will request the needed information from the individual's physician. Please see attachment #4. 03/19/2021 Implemented
2380.111(c)(6)Individual #1 started attending the program on 12/16/2019. Prior to attending the program, she had a physical examination completed on 4/16/2019. However, the physical examination record did not include if the individual was free of communicable diseases or the precautions to be taken if the individual has a serious communicable disease to prevent the spread of the disease. The examination record did not have a field on the form for the physician to complete this, nor did the physician document this information.The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals.The program specialists are responsible for ensuring physical forms include all necessary information provided by 2380 regulations. The program has a physical form that includes all regulatory requirements that it sends to individuals and their family/caregivers before their physical examination is due. This form includes an area for the physician to mark if the individual is free from communicable diseases. If a physical form is returned to program without the necessary information, the program specialists will request the needed information from the individual's physician. Please see attachment #4. 03/19/2021 Implemented
2380.111(c)(7)Individual #1 started attending the program on 12/16/2019. Prior to attending the program, she had a physical examination completed on 4/16/2019. However, the physical examination record did not include an assessment of the individual's health maintenance needs or the need for blood work at recommended intervals. All fields on the physical examination record were left blank.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.The program specialists are responsible for ensuring physical forms include all necessary information provided by 2380 regulations. The program has a physical form that includes all regulatory requirements that it sends to individuals and their family/caregivers before their physical examination is due. This form includes health maintenance needs, medication regimen, and the need for bloodwork at recommended intervals. If a physical form is returned to program without the necessary information, the program specialists will request the needed information from the individual's physician. Please see attachment #4. 03/19/2021 Implemented
2380.111(c)(9)Individual #1 started attending the program on 12/16/2019. Prior to attending the program, she had a physical examination completed on 4/16/2019. However, the physical examination record did not include the individual's allergies or contraindicated medications. The physical examination record did not contain a field to include this information nor did the physician document this information on the examination record.The physical examination shall include: Allergies or contraindicated medication.The program specialists are responsible for ensuring physical forms include all necessary information provided by 2380 regulations. The program has a physical form that includes all regulatory requirements that it sends to individuals and their family/caregivers before their physical examination is due. This form includes allergies and contraindicated medication. If a physical form is returned to program without the necessary information, the program specialists will request the needed information from the individual's physician. Please see attachment #4. 03/19/2021 Implemented
2380.113(b)Staff person #3 did not have a licensed physician, certified nurse practitioner, or certified physician's assistant, complete, sign or date a physical examination record until 12/7/20. Staff person #3 has been working with individuals throughout this licensing review period from November 2019 to March 2021. Staff person #3's 12/14/18 physical examination record was completed by a medical assistant.The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant.The list of approved professionals that are required to complete, sign, and date physicals has been shared with Human Resources. Human Resources has shared the list with Wellspan Occupational Health so future physicals can be completed, signed, and dated by an approved professional. The human resource manager is responsible for ensuring a licensed physician, certified nurse practitioner, or certified physician's assistant completes the physical examination and request that this be done prior to the physical examination. 03/23/2021 Implemented
2380.113(c)(3)Staff person #3 did not have a signed statement by a licensed physician that she was free of communicable diseases, or documentation from a licensed physician that the staff has a serious communicable disease but is able to work in the facility if specific precautions are taken that will prevent the spread of the disease(s) to the individuals, until 12/7/20. She has been working with individual throughout this licensing review period from November 2019 until March 2021.The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in §  27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals.Human Resources has contacted Wellspan Occupational Health to inform them of the need to document if the employee is free of communicable diseases and if they aren't, what steps need to be taken to prevent the spread of the disease to individuals. The human resource manager is responsible for ensuring there is a signed statement by a licensed physician that the employee is free of communicable disease(s), or documentation that they have a disease(s), but are able to work safely in the facility if specific precautions are taken that will prevent the spread of the disease(s). The current form has an area for the physician to document this. If human resources receives a physical that does not have this information, they will call Wellspan to resolve the issue. 03/23/2021 Implemented
2380.171(b)(3)Individuals #1's and #2's records don't contain the name, address, and telephone number of the person able to give consent for emergency medical treatment.Emergency information for each individual shall include: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.The emergency medical consent contact was identified by the individual's team and has been documented on the individuals face sheet. All face sheets will be updated to include emergency medical consent contacts by April 2nd. The blank face sheet form that is used to create an individual's face sheet upon admission has been updated to include the emergency medical consent contact. The intake packet also has been updated to include the emergency medical consent contact. Please see attachment #5. 04/02/2021 Implemented
2380.173(1)(iv)Individual #1's record does not contain her religious affiliation. Her record states this is not known. However, her record does state that she understands what is said to her and can engage in conversation. She also lives with family who is interactive in her life and services. There are no records maintained that the agency, Jessica and Friends Community, attempted to ask the individual if she has a religious preference and/or what that is.Each individual¿s record must include the following information: Personal information including: Religious affiliation.The individual was asked by the program specialist about their religious affiliation. The individual has no affiliation, so the program specialist updated the face sheet to state "No Preference." All other files were checked to ensure religious affiliations were noted. The program specialists are responsible for obtaining this information upon an individual's admission to the program. Please see attachment #5. 03/17/2021 Implemented
2380.21(u)The Department issued updated, regulatory individuals' rights effective 2/3/2020. Individual #1 was not informed of her rights until 3/8/21. Individual #2 was not informed of his rights until 3/9/21. The rights reviewed with Individual #1 on 3/8/21 and Individual #2 on 3/9/21 do not include a review of the individual's rights defined in 2380.21(a), (b), (c), (d), (e), (f), (g), (n), (r), (s), and (t).The facility 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 facility and annually thereafter.The individual rights form has been updated to include all rights outlined by regulations. This form will be reviewed with all individuals upon admission to the facility and annually thereafter. It is the responsibility of the program specialists to ensure this is done. Please see attachment #6. 03/18/2021 Implemented
2380.129(a)The agency's, Jessica and Friends Community, medication trainers documented that Staff person #1 was certified via the Department's annual medication training, to administer medications on 1/7/2020 and again on 1/17/2021. The Department's annual medication administration training requires that the staff person have two medication administration (mar) reviews and two observations completed within the year in order to continue to be certified to administer medications. This was not completed annually for Staff person #1 as a medication trainer certified Staff person #1 on 1/7/2020 and not again until 1/17/2021. Additionally, Staff person #1 never had the required mar reviews or observations completed in 2021 prior to the staff's recertification date of 1/17/2021. At the time the agency's medication trainer indicated Staff person #1 was recertified to administer medications on 1/17/2021, Staff person #1 only had one out of the two required mars completed, and one out of the two required observations completed. The remaining mar and observation requirements weren't completed until 2/21/21; late.A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures and treatments as specified in § 2380.122 (relating to medication administration).The Executive Director of Operations has retrained the agency's medication administrators on the renewal requirements. Annuals will now be scheduled on the same day, each calendar year, and documents will be kept together. The medication trainers will be responsible for ensuring all renewal requirements are met and documents are kept together. 03/23/2021 Implemented
2380.129(d)There are no records maintained of the medication administration record (mar) reviews completed for Staff person #1's 1/7/2020 or 1/17/2021 annual medication administration trainings. The facility had record of the staff person's 2020 and 2021 practicum summaries, recording that two mar reviews were passed for each year's review, however, did not have record of the mar reviews. There are no records maintained of the mar review documents completed for Staff person #3's 2/16/2021 annual medication administration training. The facility had record of the staff person's 2/16/2021 practicum summary form, indicating two mar reviews were passed, but there are no records of the mar documentation indicating a date they were completed/passed.A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.The Executive Director of Operations has retrained the agency's medication administrators on record keeping for medication administration requirements. All training and renewal documents will be kept together for future reference. The medication trainers will be responsible for ensuring all renewal documentation is completed and specifically that 2 MAR reviews are completed and documented annually. 03/23/2021 Implemented
SIN-00160896 Renewal 11/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(b)There were two bottles of Ridz Odor Cleaner that were not in their original, labeled bottle.Poisonous materials shall be stored in their original, labeled containers.November 25th, 2019 - The label for the unlabeled bottle of Ridz Odor Cleaner was ordered on October 30th, 2019 and delivered and placed on the bottle on November 25th, 2019. Another label for the other unlabeled bottle, this one being Spray 9, was also ordered on October 30th, however, this label is on backorder. The unlabeled bottle has been removed from the program until the label gets delivered. Going forward, the program manager will be responsible for ensuring that all cleaning supplies are delivered to program with a label on them. 11/25/2019 Implemented
2380.173(1)(v)Individual #2 and #3 has a photo in the record, but it is not dated.Each individual¿s record must include the following information: Personal information including: A current, dated photograph.November 18th, 2019 - The photos for individuals #2 and #3 were dated and all files for all individuals were researched to ensure that all photos are dated. Going forward, the program specialists will be responsible for ensuring that all photos are dated when they are taken and placed in the individuals files. 11/18/2019 Implemented
2380.176(a)At the time of inspection, all the individual records were in an unlocked filing cabinet, with the cabinet doors open and the door to the office where they were being stored was also open and unlocked.Individual records shall be kept locked when they are unattended.November 18th, 2019 - The cabinet was locked and all staff were reminded that we are all responsible for ensuring all cabinets with individual records are kept locked whenever unattended. 11/18/2019 Implemented
2380.181(b)Individual #4 most recent physical dated 3/22/19 indicated in the "diet" section that food is to be "cut ··· to avoid choking". Individual's most recent Assessment dated 2/27/19 and finalized by signature on 3/25/19 indicates under the "functional Skills" section that the individual, "···takes appropriately sized bites and is not a choking risk". The information from the physical regarding the individual's diet was not updated in the most recent assessment nor was it added as an update or addendum to the most recent assessment. In the Amendment to the Lifetime Medical History updated on 10/02/2019, it still stated that the individual is, "···not a choking risk".If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have an assessment completed as required under this section.November 27th, 2019 - The PCP for individual #4 was contacted to discuss their most recent physical, due to the fact that they have not had any choking incidents or close calls at day program to this point. Individual #4 eats at an appropriate pace, does not overstuff their mouth, or exhibit any other risky eating habits. Before typing up a choking plan for this individual, we wanted to be sure that he was indeed a choking risk. We reached out to the PCP and they told us that the individual is not a choking risk and that an error was made on the physical. We requested that they put this in writing and they have faxed us a doctor's note stating that the individual is not a choking risk. Going forward, the program specialists will be responsible for checking all physicals and ensuring the ISP¿s, assessments, face sheets, and all other applicable paperwork is updated as needed. 11/27/2019 Implemented
SIN-00139093 Renewal 09/26/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(c)No documentation of fire alarms being checked monthly. Interconnected Fire system however independent fire alarms not being checked.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm was operative.Katrina Toomey, Program Manager, will be responsible for ensuring that the smoke detectors are checked monthly during or after the fire drills to make sure that they are operable. This information will be documented on the updated Fire Drill Record. The Fire Drill Record was updated immediately after the inspection was completed on 9/26/18. 09/26/2018 Implemented
SIN-00110688 Renewal 06/06/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(9)Individual #1's physical dated 7/11/16 stated no allergies. The ISP stated that they were allergic to Geodon. The physical examination shall include: Allergies or contraindicated medication.a. Katrina Toomey, Program Specialist b. The physical examination shall include allergies or contraindicated medications. c. The residential provider was contacted and they provided the updated/revised physical which includes the corrected information about the allergy on 6/7/17. (See Attachment #1)Katrina Toomey, Program Specialist, is responsible for ensuring that pertinent medical information regarding allergies is listed on the physical form. The physical form has been updated regarding this information for individual #1. Moving forward, when a new physical is received at the program, Katrina Toomey will make sure this information is included and that it matches what is stated in the individual's ISP. 06/20/2017 Implemented
2380.181(e)(13)(i)Individual #2's assessment dated 3/15/17 did not include progres over the last 365 calendar days and current level in health. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health.a. Katrina Toomey, Program Specialist. b. The annual assessment will include the individual¿s progress and growth in the area of socialization, recreation, and the ability to become integrated into her community. c. Program Specialist will indicate more details in each assessment regarding the individual¿s progress and growth. This is necessary even when the individual is new to our program so that we can use this information as a baseline for future assessments. This was completed on 6/7/17. (See attachment #2) 2. Katrina Toomey, Program Specialist, will be responsible for reviewing each section of the assessment, specifically the progress and growth in the areas of socialization, recreation, and the ability to become integrated into her community for individual #1. An updated assessment will be sent out that addresses the progress and growth which will be used as a baseline for future assessments. More details will be used in the review of the assessment. Katrina Toomey will ensure that future assessments will show more details in the areas of progress and growth in each section of the assessment where is it required specifically in the areas of socialization, recreation, and the individual¿s ability to become integrated into his or her community. 06/20/2017 Implemented
2380.181(e)(13)(ii)Individual #1's assessment dated 5/4/17 did not include progres over the last 365 calendar days and current level in motor and communication skills. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas:  Motor and communication skills.b. The annual assessment will include the individual¿s progress and growth in the areas of health, motor and communication skills, and personal adjustment. c. Program Specialist will indicate more details in each assessment regarding the individual¿s progress and growth. This was completed on 6/7/17. (See Attachment #3) 2. Katrina Toomey, Program Specialist, will be responsible for reviewing each section of the assessment, specifically the progress and growth in the areas of health, motor and communication skills, and personal adjustment for individual #2. An updated assessment will be sent out that addresses the progress and growth. More details will be used in the review of the assessment. Katrina Toomey will ensure that future assessments will show more details in the areas of progress and growth in each section of the assessment where is it required specifically in the areas of health, motor and communication skills, and personal adjustment. 06/20/2017 Implemented
2380.181(e)(13)(iii)Individual #2's assessment dated 3/15/17 did not include progres over the last 365 calendar days and current level in personal adjustment. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment. The annual assessment will include the individual¿s progress and growth in the areas of health, motor and communication skills, and personal adjustment. c. Program Specialist will indicate more details in each assessment regarding the individual¿s progress and growth. This was completed on 6/7/17. (See Attachment #3) 2. Katrina Toomey, Program Specialist, will be responsible for reviewing each section of the assessment, specifically the progress and growth in the areas of health, motor and communication skills, and personal adjustment for individual #2. An updated assessment will be sent out that addresses the progress and growth. More details will be used in the review of the assessment. Katrina Toomey will ensure that future assessments will show more details in the areas of progress and growth in each section of the assessment where is it required specifically in the areas of health, motor and communication skills, and personal adjustment. 06/20/2017 Implemented
2380.181(e)(13)(iv)Individual #1's assessment dated 5/4/17 and Individual #2's assessment dated 3/15/17 did not include progres over the last 365 calendar days and current level in socialization. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization. The annual assessment will include the individual¿s progress and growth in the areas of health, motor and communication skills, and personal adjustment. c. Program Specialist will indicate more details in each assessment regarding the individual¿s progress and growth. This was completed on 6/7/17. (See Attachment #3) 2. Katrina Toomey, Program Specialist, will be responsible for reviewing each section of the assessment, specifically the progress and growth in the areas of health, motor and communication skills, and personal adjustment for individual #2. An updated assessment will be sent out that addresses the progress and growth. More details will be used in the review of the assessment. Katrina Toomey will ensure that future assessments will show more details in the areas of progress and growth in each section of the assessment where is it required specifically in the areas of health, motor and communication skills, and personal adjustment. 06/20/2017 Implemented
2380.181(e)(13)(v)Individual #1's assessment dated 5/4/17 did not include progres over the last 365 calendar days and current level in recreation. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation. The annual assessment will include the individual¿s progress and growth in the areas of health, motor and communication skills, and personal adjustment. c. Program Specialist will indicate more details in each assessment regarding the individual¿s progress and growth. This was completed on 6/7/17. (See Attachment #3) 2. Katrina Toomey, Program Specialist, will be responsible for reviewing each section of the assessment, specifically the progress and growth in the areas of health, motor and communication skills, and personal adjustment for individual #2. An updated assessment will be sent out that addresses the progress and growth. More details will be used in the review of the assessment. Katrina Toomey will ensure that future assessments will show more details in the areas of progress and growth in each section of the assessment where is it required specifically in the areas of health, motor and communication skills, and personal adjustment. 06/20/2017 Implemented
2380.181(e)(13)(vi)Individual #1's assessment dated 5/4/17 did not include progres over the last 365 calendar days and current level in community-integration.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration. The annual assessment will include the individual¿s progress and growth in the areas of health, motor and communication skills, and personal adjustment. c. Program Specialist will indicate more details in each assessment regarding the individual¿s progress and growth. This was completed on 6/7/17. (See Attachment #3) 2. Katrina Toomey, Program Specialist, will be responsible for reviewing each section of the assessment, specifically the progress and growth in the areas of health, motor and communication skills, and personal adjustment for individual #2. An updated assessment will be sent out that addresses the progress and growth. More details will be used in the review of the assessment. Katrina Toomey will ensure that future assessments will show more details in the areas of progress and growth in each section of the assessment where is it required specifically in the areas of health, motor and communication skills, and personal adjustment. 06/20/2017 Implemented
2380.183(5)Individual #2's ISP did not include a SEEN plan. Individual is diagnosed with anxiety and depression and takes medication. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.a. Katrina Toomey b. Does each ISP, ISP Annual Update and ISP Revision include information regarding a protocol to address the social, emotional and environmental needs of the individual, if a medication is prescribed to treat symptoms of a diagnosed psychiatric illness? c. Program Specialist will provide a SEEN/Support Plan for individual #2 and any other individual that requires a psychotropic medication. This was completed on 6/7/17. (See Attachment #4) 2. Katrina Toomey, Program Specialist, will write a Support Plan and provide an Attachment to the Assessment for Individual #2 and any other individual that is taking a psychotropic medication. This plan addresses how staff at Jessica and Friends can best support our individuals that take these medications. As of 6/7/17 we have completed updating our current individuals¿ files that are taking psychotropic meds to include either a Support Plan via an Attachment to their Assessment or a Behavioral Support Plan. Moving forward, Katrina Toomey will make sure there is a SEEN/Support Plan for any new individual that starts our program that requires a psychotropic medication for any reason not just for individuals with negative behaviors that require a Behavioral Plan. 06/20/2017 Implemented
SIN-00094886 Renewal 05/31/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)REPEATED VIOLATION - 3/20/15 Clorox disinfectant wipes, Dawn soap, and hand sanitizer was stored in a poorly secured kitchen cabinet under the sink. The cabinet easily opened and poisons were accessible to individuals. Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Sara Kerns, Program Specialist, is responsible for ensuring that all poisonous substances are properly secured in locking cabinets. A new lock has been installed under the kitchen sink, making the soaps and other materials inaccessible to individuals. 06/30/2016 Implemented
2380.58(a)There is chipped paint and exposed wood on the toilet seat in the women's bathroom.Floors, walls, ceilings and other surfaces shall be in good repair.Sara Kerns, Program Specialist, is responsible for replacing surfaces that are not in good repair. A new toilet seat was installed on Monday. Moving forward, toilet seats will be replaced more frequently and will also be added to the monthly safety checklist. 06/27/2016 Implemented
2380.59(a)There is no hot water in the unisex bathroom or the men's bathroom. The facility shall have hot and cold running water under pressure in bathrooms and kitchen areas.Sara Kerns, Program Specialist, is responsible for making sure that there is hot and cold running water in all restrooms. A plumber was contacted and the water heater was repaired last week, as it needed a new heating element. Now all restrooms have hot and cold water. 06/23/2016 Implemented
2380.72(b)The side edge of the portable ramp, leading to the porch landing, is missing a piece of the siding exposing sharp edges. The outside of the building and the facility grounds shall be well maintained, in good repair and free from unsafe conditions.Sara Kerns, Program Specialist, is responsible for ensuring that the building and facility grounds are in good repair. The ramp has been replaced at the program and now has no damaged edges. The ramp is also a bit wider and longer, making the new ramp altogether better for our individuals. The ramp will be added to the safety checklist that is completed each month, to ensure that there are no damaged parts. 06/27/2016 Implemented
2380.111(c)(10)Individual #1's 2/29/16 physical exam and Individual #2's 4/26/16 physical exam does not include information pertinent to diagnosis and treatment in the event of an emergency. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Sara Kerns, Program Specialist, is responsible for ensuring that pertinent medical information regarding diagnosis and treatment in case of an emergency, is listed on the physical form. This information will include whether or not the person is verbal and has active seizures. The physical forms have been updated regarding this information. Moving forward, when a new physical is received at the program, Sara Kerns will make sure this information is included under the Medical Information section. 06/27/2016 Implemented
2380.173(5(ii)Individual #1's record did not include an invitation to the annual Individual Support Plan (ISP) meeting. Each individual¿s record must include the following information: A copy of the invitation to: The annual update meeting.Sara Kerns, Program Specialist, is responsible for obtaining a written invitation letter to the annual ISP meeting from the supports coordinator. A copy of Individual #1¿s ISP invitation letter has been sent to Sara Kerns and it is filed in that individual¿s book. Moving forward, Sara Kerns will check to make sure there is a copy of the letter on file prior to the person¿s meeting. 06/28/2016 Implemented
2380.176(a)REPEATED VIOLATION - 3/20/15 Individual records were stored in an unlocked bookshelf in the main program area. Individual records shall be kept locked when they are unattended.Sara Kerns, Program Specialist, is responsible for making sure that all of the individual records are kept locked when they are unattended. A locking cabinet was purchased and delivered to the program. The cabinet has been assembled and is currently in use to store the individual records at the program. 06/27/2016 Implemented
2380.177There were no written consents to release information for all individuals in the program.Written consent of the individual, or the individual's parent or guardian if the individual is incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.Sara Kerns, Program Specialist, is responsible for obtaining written consents for the release of information, including photographs, to persons not otherwise authorized to receive it. Sara Kerns has implemented new consent forms for use in the program, which addresses all of these areas. The new consent form covers all releases of information for the individual, not only doctor¿s physicals and photograph release forms. 06/29/2016 Implemented
2380.181(a)Individual #1 was admitted to the program on 1/4/16. An initial assessment was not completed until 3/14/16.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.Sara Kerns, Program Specialist, will complete initial assessments within 60 days of their start date into the program. The 15 day grace period does not apply to initial assessments. Sara Kerns will note on her spreadsheet, moving forward, to complete initial assessments within 60 days of the individual starting at the program. 06/29/2016 Implemented
2380.181(e)(12)Individual #1's 7/28/15 assessment and Individual #2's 3/14/16 assessment did not include recommendations for training, vocational programming, or competitive employment. The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.Sara Kerns, Program Specialist, will include more detail in the assessments regarding recommendations for vocational programming, training, or competitive employment, not only the potential to advance statements. Sara Kerns will elaborate more in regards to these areas on future assessments. An Addendum to the Assessment for Individual #2 will be written. Individual #1 will have an updated annual assessment in July, which will include more details in these areas. 06/29/2016 Implemented
2380.181(e)(13)(vi)Individual #2's 3/14/16 assessment does not include progress over the past year in community integration.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration.Sara Kerns, Program Specialist, will be responsible for collaborating with Individual #2, staff, and family in order to provide opportunities for community integration at least once per month. Sara Kerns has arranged for Individual #2 to go on her first outing on July 12. The trip will be to the mall, and additional staffing will be provided in the event of a seizure. Following the outing, the team will discuss how the outing went, and ways to continue community integration in a variety of settings for Individual #2. Because we will be taking Individual #2 on outings at least once per month, the assessment will indicate these details moving forward. Specifically, the assessment will address the progress made over the past year in community integration and the current level in community integration. 06/29/2016 Implemented
2380.183(1)Individual #2's Individual Support Plan (ISP) included a " new interest/seeing friends" outcome that ended on 3/4/16. The plan was not updated to include a new outcome.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Services provided to the individual and expected outcomes chosen by the individual and individual¿s plan team.Sara Kerns, Program Specialist, will contact the supports coordinator in order to update the outcome. Sara Kerns will review the ISP outcome dates at a minimum of quarterly, during the Quarterly ISP Reviews to make sure that the outcome dates are correct and email the supports coordinator of any changes. 06/29/2016 Implemented
2380.185(b)Individual #2's "new interest/seeing friends" outcome was not implemented between January and March of 2016. The ISP shall be implemented as written.Sara Kerns, Program Specialist, during the critical revision meeting prior to the individual starting at the program, will discuss outcomes with the team (supports coordinator, family, other providers). The outcome will be implemented on the start date in the program and tracked through progress notes. Individual #2¿s progress towards the ¿new interests/seeing friends¿ from January to March 2016 can be found in daily activity logs and in her Initial Team Meeting paperwork. 06/29/2016 Implemented
2380.186(c)(2)REPEATED VIOLATION - 3/20/15 Individual #1's 8/31/15, 10/22/15, 1/29/16, and 4/29/16 Individual Support Plan (ISP) reviews did not review the choking plan. The 10/22/15, 1/29/16, and 4/29/16 ISP reviews did not include a review of the social, emotional, environmental needs plan. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Sara Kerns, Program Specialist, will be responsible for reviewing each section of the ISP, specifically the choking plan and the SEEN plan for individual #1. An updated ISP review will be sent out that addresses the use of the choking plan and the SEEN plan. More details will be used in the review of the plans. Sara Kerns will meet with staff to ensure that documentation of any choking incidents and use of the SEEN plan will be completed in the case notes or daily logs. 06/28/2016 Implemented
2380.188(b)Individual #2 has not been provided opportunities and support to participate in community life since January of 2016.. Individual #2's 3/14/16 assessment indicated Individual #2 has not been out in the community because of his/her seizures and Individual #2 would require additional staffing to support him/herThe facility shall provide opportunities and support to the individual for participation in community life, including work opportunities.Sara Kerns, Program Specialist, will be responsible for collaborating with Individual #2, staff, and family in order to provide opportunities for community integration at least once per month. Sara Kerns has arranged for Individual #2 to go on her first outing on July 12. The trip will be to the mall, and additional staffing will be provided in the event of a seizure. Following the outing, the team will discuss how the outing went, and ways to continue community integration in a variety of settings for Individual #2. 06/29/2016 Implemented
SIN-00074104 Initial review 03/20/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(a)Staff #1 started working with individuals on 12/26/2014 and was not oriented to the daily operations of the facility until 12/29/2014. The facility shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals or in their appointed positions.The program specialist updated the orientation checklist to ensure that the first page is completed (orientation to daily operations) before new staff begin working with individuals 03/20/2015 Implemented
2380.53(a)Body Powder was unlocked in the program area. Hand Sanitizer was unlocked in the kitchen area. Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.The program specialist locked up body powder and hand sanitizer. The program specialist added to the monthly safety checklist to check labels which state contact poison control. 03/20/2015 Implemented
2380.173(9)Indiv #2 physical states a low fat diet; her ISP states low fat, low sugar, low sodium diet. Indiv #3 assessment states unsupervised time 5 minutes; ISP states unsupervised time for 15 minutes. Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.The program specialist has created a document to track ISP/Assessment information to ensure the ISP, assessment, and physicals contain the same content 05/12/2015 Implemented
2380.176(a)Indiv #1 changing directions were hanging on the wall in the program area. All individuals diet instructions were posted on the refrigerator. BSP's for all individuals were unlocked. Individual records shall be kept locked when they are unattended.The program specialist has removed all information regarding individuals care and personal information from public areas and they are now kept in locked areas 03/20/2015 Implemented
2380.181(e)(5)The ability to administer medications was not documented in the assessment for indiv #2. The assessment must include the following information: The individual¿s ability to self-administer medications.In the safety section of the assessment, the program specialist added an area to assess the individual's ability to self administer medication 05/21/2015 Implemented
2380.183(5)The SEEN Plan for indiv #3 does not include the psychiatric diagnosis and medication prescribed. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.The program specialist will edit all SEEN plans to include psychiatric diagnosis and medications prescribed. 05/13/2015 Implemented
2380.186(c)(2)SEEN Plan for indiv #2 was not reviewed on the 6/23/14 ISP Review. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.The program specialist will ensure to include information regarding the use of the SEEN plan in each quarterly review. The review of the SEEN plan will state frequency of plan use or if the plan did not have to be used. 06/15/2015 Implemented