| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
|
SIN-00223739
|
Renewal
|
04/14/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.63(a) | Hot water in the kitchen sink reached 128 degrees. Hot water in the upstairs bathroom sink reached 127 degrees. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | The hot water temperature was decreased by CEO (see photo). This home owned and Operated by the KFE CEO. on April 18, 2023 at the staff meeting informed all staff of the citations and plans of action. It was reiterated to staff that water temperatures need to be checked and documented daily in Therap (electronic communication system). Therap is monitored daily by the Program Specialist and CEO. |
06/12/2023
| Implemented |
| 6400.67(b) | A door of a large wooden cabinet in the basement is broken at its hinges and held in place by its latch. When unlatched, the door falls almost completely off of the cabinet frame. Also, the mirror in Individual 2's bedroom is cracked and bent. | Floors, walls, ceilings and other surfaces shall be free of hazards. | KFE CEO held a staff meeting on April 18, 2023 to address the compliance and safety of the home. During the meeting it was discussed floors, doors, cabinets, walls, ceilings and other surfaces must be free of hazards, specifically ensuring all mirrors are functional and operable; free of cracks as well as all cabinets being in working condition. The mirror has been replaced by the Program Specialist on April 19, 2023. The cabinet door has been repaired. |
04/19/2023
| Implemented |
| 6400.68(b) | The hot water in the upstairs bathroom shower reached 127 degrees. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The hot water temperature was decreased by CEO (see photo). This home owned and Operated by the KFE CEO. on April 18, 2023 at the staff meeting informed all staff of the citations and plans of action. It was reiterated to staff that water temperatures need to be checked and documented daily in Therap (electronic communication system). Therap is monitored daily by the Program Specialist and CEO. |
06/12/2023
| Implemented |
| 6400.82(f) | There was no soap in the basement bathroom. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Soap has been placed in the basement bathroom effective April 15,2 023 |
04/15/2023
| Implemented |
| 6400.111(c) | The kitchen has no fire extinguisher. The nearest fire extinguisher was at the top of the stairs leading to the basement, with a door separating the two spaces. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | The CEO moved the fire extinguisher in the kitchen (see attached photo). On April 18, 2023 The Administrators of KFE met with the direct care staff and site supervisors regarding the result of the inspection including the importance of ensuring that there is a 2A-10BC fire extinguisher in each kitchen at all times. |
04/14/2023
| Implemented |
| 6400.141(c)(6) | The physical form on February 22, 2023, indicated no lab results were provided regarding individual 3's Tuberculosis results on the physical form the date given 2/14/2022 and read date 2/16/2022. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | On April 17, 2023 Individual #3 obtained a copy of the Tuberculin Skin Test results from 2/14/22 date administered and read on 2/16/22 (See attached) |
04/17/2023
| Implemented |
| 6400.143(a) | On January 1, 2023, Individual 2 was scheduled a dental appointment. Staff did not indicate that individual 2 refused the appointment, and rescheduled dental appointments on March 28, 2023. | 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. | The CEO met with all administrative and direct care employees on April 18, 2023 regarding the result of the inspection including the plan of correction to ensure all appointment refusals are accurately documented and stored. |
04/18/2023
| Implemented |
| 6400.144 | Individual 2 does not have an adequate supply of their PRN ibuprofen. The order indicates 2 -- 3 pills are to be taken as needed every 6 hours for headache; there was only one pill in the bottle. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| The Program Specialist contacted the pharmacy on April 15, 2023. The PRN ibuprofen was refilled (see attached). |
04/15/2023
| Implemented |
| 6400.165(g) | Quarterly psychotropic review for individual 3 was completed on July 18, 2022, and November 14, 2022. Psychotropic reviews are to be completed every three months. | 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. | KFE Program Specialist obtained the 90-day psychotropic reviews for every quarter after November 2022 (Feb 2023, and May 2023) from the psychiatrist (see attached) |
05/01/2023
| Implemented |
| 6400.181(b) | The assessment dated January 2, 2023, stated individual 2 was not working. However, documentation was provided to license representative to verify missed doctor's appointment on January 4, 2023, because individual 2 had to work. Assessment needs to be consistent with day-to-day activities. | 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. | The assessment was updated to include that the individual was working by the Program Specialist on 4/15/2023 (see updated assessment) |
04/15/2023
| Implemented |
|
|
|
SIN-00203727
|
Renewal
|
04/11/2022
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(b) | Staff #1 member resided in New Jersey within two years prior to their date of hire, 1/6/22. While a Pennsylvania criminal background check was requested 12/2/21, but an FBI background check was not requested within 5 days of hire, as documentation was not provided. | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| Staff #1 has obtained a FBI clearance on April 4, 2022 and processed in accordance with the Child Protective Services; however it was not through the Department of Aging for older adults (see attached). Staff #1 applied for the FBI check on May 18, 2022 (see attached receipt). |
05/18/2022
| Implemented |
| 6400.68(b) | The water temperature was measured at 127.7°F in the upstairs bathroom. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | On April 12, 2022, The water temperature was rechecked and it did not exceed 120 degrees Fahrenheit this was submitted but the CEO to the inspector via email. A sign was made and posted in all homes to remind staff to check water temperature daily including steps to take if temperature exceeds 120 degrees (see attached posting). |
04/14/2022
| Implemented |
| 6400.112(d) | The Fire Drills dated 3/7/22, 2/07/22, 1/16/22, 8/18/21 and 4/21/21 all exceeded the 2 ½ minutes allotted, no other drill was conducted during the month. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | All staff were retrained on proper documentation of fire drills on April 27, 2022 (See attached training sign in sheet). The Fire Drill was conducted on April 19, 2022 at 5pm ; the fire drill does not exceed the allotted 2 1/2 minutes to evacuate. |
04/27/2022
| Implemented |
| 6400.141(c)(11) | Individual #3, 4/7/22 physical does not contain a record of any considerations regarding health maintenance needs. | 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. | Individual #3 Physical Form was updated to include information regarding health maintenance needs by the physician on April 14, 2022 (see attached physical form). During the meeting on April 14, 2022 the CEO reviewed with the Site Supervisors and Program Specialist on completing all forms in their entirety. Including steps to take when information is missing (see attached Agenda, and persons in attendance). |
04/14/2022
| Implemented |
| 6400.141(c)(14) | Individual #3, 4/7/22 physical does not contain information pertinent to diagnosis in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #3 Physical Form was updated to include information pertinent to diagnosis in case of emergency (see attached physical form). During the meeting on April 14, 2022 the CEO reviewed with the Site Supervisors and Program Specialist on completing all forms in their entirety. Including steps to take when information is missing (see attached Agenda, and persons in attendance). |
04/14/2022
| Implemented |
| 6400.151(a) | Agency records do not contain a physical for staff member #1 from within a year prior to their hire date of 1/6/22. The physical on file is dated 1/31/22. | 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. | Staff #1 date of hire is 1/31/22. The date of hire was incorrect on the New Hire Checklist. The date of 1/6/22 was the date offer was made and the employee came to complete paperwork. All corresponding documents in Staff #1 file shows on or after 1/31/22 regarding training and any other official employment documents. The agency immediately corrected the New Hire Checklist to reflect the updated changes. |
04/14/2022
| Implemented |
| 6400.181(e)(10) | Individual #3's file did not contain a lifetime medical document, as it was not provided. | The assessment must include the following information: A lifetime medical history. | Individual #3 Lifetime Medical History was completed by the Program Specialist on May 9, 2022 (see attached). The Lifetime Medical History was reviewed by the CEO and then after approval was sent to the Supports Coordinator via email on May 21, 2022 (see email confirmation). |
05/21/2022
| Implemented |
| 6400.181(e)(13)(ii) | Individual #3, 3/22/22 assessment does not capture the individual's health progress over the past 365 calendar days. | 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 annual assessment was updated during the audit to include Individual #3 health progress for the past 365 calendar days (see attachment). |
04/14/2022
| Implemented |
| 6400.181(e)(14) | Individual #3, 3/22/22 assessment does not address his ability to swim or safety around water. Prior to the end of the inspection, the agency submitted an updated assessment that includes this information. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | The assessment for Individual #3 was update prior to the end of the inspection to include the individuals ability to swim or safety around water as per 6400.181 (e) (14). |
04/14/2022
| Implemented |
| 6400.181(f) | Individual #3'3 2/25/21 assessment was not shared with his team within 30 days of his 1/25/22 ISP meeting as documentation was not provided. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | On April 13, 2022 KFE has created a checklist for the annual assessment to ensure that it is submitted prior to the annual review ISP Meeting. The checklist was reviewed with all administrative employees on April 14, 2022 to ensure the the Assessment is completed onetime, send to all parties onetime and filed away properly. |
04/14/2022
| Implemented |
|
|
|
SIN-00186487
|
Renewal
|
04/07/2021
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | The filter located in the dryer was not free of hazard, there was a golf ball size lint within the filter. | Floors, walls, ceilings and other surfaces shall be free of hazards. | KFE CEO held a staff meeting on April 26, 2021 and April 27, 2021 with all employees to address the compliance and safety of the home. During the meeting it was discussed floors, walls, ceilings and other surfaces must be free of hazards, specifically ensuring that the dryer filter is checked and lint and any other hazards are to be removed immediately after each laundry cycle. |
04/27/2021
| Implemented |
| 6400.71 | There were no emergency telephone numbers located on or near the telephone in the living room. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| KFE Program Specialist updated all emergency telephone numbers for each home supported by KFE on April 29, 2021 and placed them near the telephone in each residence. |
04/29/2021
| Implemented |
| 6400.77(b) | The First Aid Kit did not contain Scissors, Tweezers, tape or antiseptic. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | KFE¿s CEO purchased scissors, tweezers, tape and antiseptic for the First Aid Kid on April 15, 2021. KFE¿s CEO checked each residence first aid kit to ensure all First Aid Kit¿s had the required items as per 6400.77 (b). During the staff meeting held on April 15, 2021. KFE addressed with all employees their job responsibilities including the importance of documenting any missing items in the first aid kit on the Physical Site Inspection Form. |
04/15/2021
| Implemented |
| 6400.77(c) | There was no First Aid Manual in the First Aid Kit at time of inspection. | A first aid manual shall be kept with the first aid kit. | FE CEO purchased and added a new first aid manual to each home on April 15, 2021. (see photo) |
04/15/2021
| Implemented |
| 6400.113(c) | It cannot be determined that individual #3 has received fire safety training, as records of that training were not provided at time of inspection. | A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept. | Fire safety training will be held on May 27, 2021 for all individual¿s receiving residential services from our organization. |
05/27/2021
| Implemented |
| 6400.141(a) | It cannot be determined that individual #3 has had a physical exam within the past year. The most recent physical observed at point of inspection was from 2018. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #3 Annual physical exam was completed on 3/23/21. (see attached) |
03/23/2021
| Implemented |
| 6400.142(a) | It cannot be determined that individual #3 received a routine dental exam within the past year, as dental documentation was not provided at time of inspection. | 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. | Individual #3 dental exam was completed 12/3/20 however dental exam form was not completed. We have attached a visit summary report obtained from the dental visit. (see attached) |
12/03/2020
| Implemented |
| 6400.142(f) | It cannot be determined that individual #3 has a dental hygiene plan, as one was not provided at time of inspection. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Individual #3 dental hygiene plan was created and reviewed with the individual on 4/25/21. (See attached). |
04/25/2021
| Implemented |
| 6400.151(a) | It could not be determined a physical examination was completed signed and dated by a licensed physician at time of inspection for Staff #2, Staff #3 and Staff #4. | 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. | KFE did not properly submit all relevant documentation during inspection. Staff #2 physical examination was completed on 11/23/20. Staff #3 while no longer employed and was not employed at the time of inspection received their physical examination on 1/18/21 (see attached), Staff #4 physical examination dated for 3/18/21 (see attached). |
04/12/2021
| Implemented |
| 6400.181(a) | It cannot be determined that individual #3 has been assessed by the agency annually as assessment documentation was not provided at time of inspection. | 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. | KFE will ensure that each individual maintain an annual assessment as per regulations |
05/26/2021
| Implemented |
| 6400.183(2) | It cannot be determined that individual #3, individual plan was developed by an interdisciplinary team, as records regarding his plan and plan meeting were not provided at time of inspection. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Services provided to the individual to increase community involvement, including volunteer or civic-minded opportunities and membership in National or local organizations as required under § 6400.188 (relating to provider services). | Individual #3 participated in the development of their ISP meeting. See attached ISP signature sheet dated for 10/28/2020. (see attached) |
04/12/2021
| Implemented |
| 6400.217 | It cannot be determined that individual #3 records contain a signed consent for the release of information, as one was not provided at point of inspection. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Individual #3 signed consent for the release of information on 4/21/21.(see attached) |
04/21/2021
| Implemented |
| 6400.31(b) | It cannot be determined when the agency provided individual #3 education about his rights, as his individual rights documentation observed at time of inspection was undated. | The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights. | Individual #3 was educated about their individual rights on 4/21/21. See attached documentation. (see attached). |
04/21/2021
| Implemented |
| 6400.46(a) | Staff #3 and Staff #4 were not trained annually in general fire safety. No verification was provided at time of inspection. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | All employees of King Family Enterprise has been scheduled for Fire Safety training to be conducted to Thursday, May 27, 2021. We will submit the certificates as soon as they are obtained by the Fire Safety Instructor through Tri State |
04/10/2021
| Implemented |
| 6400.46(b) | It could not be determined who is the Fire safety training expert that conducted the training. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Fire Safety Expert documentation was submitted to KFE on May 26, 2021 through Tai-State. (see attached) |
04/10/2021
| Implemented |
| 6400.46(d) | Program specialists Staff # 02 direct service workers Staff #3, Staff #4) was not trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer. Agency has not provided this verification at time of inspection. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | KFE did not submit First Aid/CPR documentation for employees in sample. Staff #2 CPR certificate is dated for November 25th, 2019 (see attached), Staff #3 who is no longer employed CPR and First AID Training is dated for 1/30/21 (see attached), Staff #4 CPR certificate is dated for 3/15/21 (see attached) all which expires within 2 years. However, as per the regulation the training should occur annually. KFE staff is scheduled for annual CPR training on June 14, 2021 |
04/12/2021
| Implemented |
| 6400.161(c) | The agency is not providing or arranging assistive technology to Individual #3 in self-administer medications. Individual is refusing to take medication and no written record is being utilized to monitor such activity. | The home shall provide or arrange for assistive technology to assist the individual to self-administer medications. | KFE Trained Staff on their responsibility of supporting an individual that Self-Administer medication 4/14/21 (see attachment). KFE also met with the individuals at 9th street to discuss the importance of taking their medication. |
04/14/2021
| Implemented |
| 6400.163(d) | The prescription medications of the individuals #3 was not kept in an area or container that was locked. The closet door nor the medication box had a lock. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | KFE moved the medication of individual #3 out of the closet and stored the medication in a metal cabinet with a lock on 4/8/21. |
04/08/2021
| Implemented |
| 6400.165(a) | Medication Anti-Diarrheal & Anti Gas was found in Individual #3 med box, this medication was not on the MAR and no prescription could be located. | A prescription medication shall be prescribed in writing by an authorized prescriber. | KFE completed an evaluation of all prescribed medication and compared it with the MAR. Any meds that were not prescribed were immediately removed on 4/8/21. |
04/08/2021
| Implemented |
| 6400.165(b) | A prescription order shall be kept current. The medication Senna Tabs expired on 01/2021 and medication Linzess Caps expired on 10/06/20. For Individual #3 | A prescription order shall be kept current. | KFE removed all expired medication on 4/8/21 |
04/08/1921
| Implemented |
| 6400.165(c) | Medication Linzess Caps 290mg, is not being administered as prescribed. Staff is not logging when medication is being given and/or administered. (It could not be determined at time of inspection if Individual #3 is self- administering). | A prescription medication shall be administered as prescribed. | KFE retrained staff on 4/14/21 on medication administration and documentation. |
04/14/2021
| Implemented |
| 6400.166(a)(16) | Individual #3 is refusing to take prescribed medication (Linzess, Senna), the agency is not documenting on the medication record or reporting the incident to prescriber. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Side effects of the medication, if applicable. | KFE discuss why taking medication is important and retrained staff on the procedure of documenting a refusal in the MAR |
04/14/2021
| Implemented |
| 6400.213(1)(i) | Individual #3 individual record does not include his religious affiliation, race, Social Security number, or next of kin. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Individual #3 face sheet was updated on 4/30/21 to include his religious affiliation, race, Social Security Number, or next of kin by the Program Specialist. All individuals supported by KFE face sheets were reviewed and updated to reflect all requirements as per 6400.213 (1) (i) by the Program Specialist. (see attached) |
04/30/2021
| Implemented |
|
|
|
SIN-00158876
|
Renewal
|
07/10/2019
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | There was dirt buildup on the kitchen floor at the stove and on the hood of the stove.. | Clean and sanitary conditions shall be maintained in the home. | King Family Enterprise (KFE) reviewed the dirt buildup on the kitchen floor at the stove and hood of the stove. KFE will ensure that Clean and sanitary conditions shall be maintained in the home according to 6400.64(a). Moving forward Kiayanna Bing (Lead Staff) will complete a 6400 Self Inspection scoresheet on the Physical Site every 6 months. Any area where a violation is found Kiayanna will immediately submit a work order form into the HR Department .
6400.64 (a)
(a) There may not be evidence of infestation of insects or rodents in the home. |
07/26/2019
| Implemented |
| 6400.64(b) | There was evidence of infestation of insects in the home. The basement window bay had dead and living flies. | There may not be evidence of infestation of insects or rodents in the home. | King Family Enterprise (KFE) reviewed the evidence of infestation of insects in the home and basement window KFE will ensure that there may not be evidence of infestation of insects or rodents in the home. according to 6400.64(b). Moving forward Kiayanna Bing (Lead Staff) will complete a 6400 Self Inspection scoresheet on the Physical Site every 6 months. Any area where a violation is found Kiayanna will immediately report it to Erika Murchison (Administrative Assistant).
6400.64
(b) There may not be evidence of infestation of insects or rodents in the home. |
07/15/2019
| Implemented |
| 6400.64(f) | Outside trash cans in front of home did not have lids. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | King Family Enterprise (KFE) reviewed the outside trash cans in front of home and will ensure that the Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.according to 6400.64(f). Moving forward Kiayanna Bing (Lead Staff) will complete a 6400 Self Inspection scoresheet on the Physical Site every 6 months. Any area where a violation is found Kiayanna will complete a work order form (Administrative Assistant).
6400. 64(f)
(f) Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. |
07/24/2019
| Implemented |
| 6400.66 | The outside front door light switch was not working.
There was no light going down the basement steps, no light at the basement exit, no light in the basement washing area, and no light in the basement bathroom. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| King Family Enterprise (KFE) reviewed the outside front door light switch that was not working. KFE made the necessary repairs and will ensure that Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents according to 6400.66. Moving forward Kiayanna Bing (Lead Staff) will complete a 6400 Self Inspection scoresheet on the Physical Site every 6 months. Any area where a violation is found Kiayanna will complete a work order request form to the HR Department.
6400. 66
Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. |
07/15/2019
| Implemented |
| 6400.67(a) | The ceiling light fixture was not in good repair. | Floors, walls, ceilings and other surfaces shall be in good repair. | King Family Enterprise (KFE) reviewed the ceiling light fixture and will ensure that Floors, walls, ceilings and other surfaces shall be in good repair according to 6400.73(a). Moving forward Kiayanna Bing (Lead Staff) will complete a 6400 Self Inspection scoresheet on the Physical Site every 6 months. Any area where a violation is found Kiayanna will immediately report it to Erika Murchison (Administrative Assistant).
6400. 67(a)
(a) Floors, walls, ceilings and other surfaces shall be in good repair. |
07/15/2019
| Implemented |
| 6400.73(a) | The handrail leading down the basement stairs was not secure. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | King Family Enterprise (KFE) reviewed the handrail leading down the basement stairs. KFE replaced the handrail and will ensure that each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail according to 6400.73(a). Moving forward Kiayanna Bing (Lead Staff) will complete a 6400 Self Inspection scoresheet on the Physical Site every 6 months. Any area where a violation is found Kiayanna will complete a work order request form to the HR Department.
6400. 73(a)
(a) Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. |
07/15/2019
| Implemented |
| 6400.76(a) | Individual #1's bedroom center window blind was damaged. | Furniture and equipment shall be nonhazardous, clean and sturdy. | King Family Enterprise (KFE) reviewed Individuals Bedroom #1 which had the center window blind damaged. KFE repaired the damaged blind and will ensure that each room contains Furniture and equipment shall be nonhazardous, clean and sturdy according to 6400.76(a) and moving forward Kiayanna Bing (Lead Staff) will complete a 6400 Self Inspection scoresheet on each consumers room every 6 months. Any area where a violation is found Kiayanna will immediately report it to Erika Murchison (Administrative Assistant).
6400. 76(a)
(a) Furniture and equipment shall be nonhazardous, clean and sturdy. |
08/26/2019
| Implemented |
| 6400.77(b) | There was no antiseptic found in the first aid kit. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | King Family Enterprise (KFE) reviewed and updated the First Aid Kits that did not have the antiseptic. KFE will ensure that each First Aid Kit will contain the required material according to 6400.77(b) and moving forward Kiayanna Bing (Lead Staff) will complete a 6400 Self Inspection scoresheet every 6 months. Any area where a violation is found Kiayanna will complete a Work Order Form and submit it to management asap.
6400.77(b)
(b) A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. |
07/24/2019
| Implemented |
| 6400.81(i) | The vacant bedroom #2 did not have drapes, curtains, or blinds. | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. | King Family Enterprise (KFE) reviewed Bedroom #2 which did not have drapes, curtains or blinds. Bedroom #2 have been updated. KFE will ensure that each room includes drapes, curtains, and shutters according to 6400.81(i) and moving forward Kiayanna Bing (Lead Staff) will complete a 6400 Self Inspection scoresheet on each consumers room every 6 months. Any area where a violation is found Kiayanna will complete a Work Order Form asap.
6400. 81(i)
(i) Bedroom windows shall have drapes, curtains, shades, blinds or shutters. |
08/26/2019
| Implemented |
| 6400.81(k)(3) | The vacant bedroom #2 did not have bedding, pillows, linens and blankets. | In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season. | King Family Enterprise (KFE) reviewed Bedroom #2 which did not have bedding, pillows, linens and blankets. Bedroom #2 now has bedding, pillows, linens and blankets according to 6400.81(k)(3) and moving forward Kiayanna Bing (Lead Staff) will complete a 6400 Self Inspection Guide every 6 months. Any area where a violation is found. KIayanna will immediately report it to Jeffrey King Sr (President).
6400. 81(k((3)
(k) In bedrooms, each individual shall have the following:
(1) A bed of size appropriate to the needs of the individual. Cots and portable beds are not permitted. Bunkbeds are not permitted for individuals 18 years of age or older.
(2) A clean, comfortable mattress and solid foundation.
(3) Bedding, including pillow, linens and blankets appropriate for the season.
(4) A chest of drawers.
(5) Closet or wardrobe space with clothing racks and shelves accessible to the individual.
(6) A mirror. |
08/20/2019
| Implemented |
| 6400.81(k)(4) | The vacant Bedroom #2 did not have a chest of drawers. | In bedrooms, each individual shall have the following: A chest of drawers. | King Family Enterprise (KFE) reviewed Bedroom #2 which did not have the chest of drawers. Bedroom #2 now has a chest of drawers according to 6400.81(k)(4) and moving forward Kiayanna Bing (Lead Staff) will complete a 6400 Self Inspection Guide every 6 months. Any area where a violation is found. Kiayanna will complete a work order form asap.
6400. 81(k((4)
(k) In bedrooms, each individual shall have the following:
(4) A chest of drawers. |
08/20/2019
| Implemented |
| 6400.110(e) | The third floor smoke detectors were not interconnected. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | King Family Enterprise (KFE) had the third floor smoke detectors checked and they are now interconnected with the 1st and 2nd floor smoke detectors according to 6400.110(e). Moving forward Kiayanna Bing (Lead Staff) will ensure that the smoke detectors are interconnected during each monthly Fire Drill. If she finds that there is a problem she will fill out a work order form and submit it to Jeffrey King Sr (President). Jeffrey King Sr will have the problem reviewed by a professional asap.
6400.110(e)
(e) If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. |
07/15/2019
| Implemented |
| 6400.112(a) | There was no record or documentation found that a fire drill was conducted 12/2018. | An unannounced fire drill shall be held at least once a month. | King Family Enterprise (KFE) reviewed the Fire Drill that was not conducted on 12/18 and going forward KFE will ensure that a Fire Drill is conducted at least once a month according to 6400 112(a). In addition Erika Murchison (Administrative Assistant) will schedule a specific date for the Fire Drill each month. This will be included on the Calendar with the Staff Shift Schedule. Kiayanna Bing (Lead Staff) will confirm that the Fire Drill has been conducted on the selected date.
(a) An unannounced fire drill shall be held at least once a month. |
08/26/2019
| Implemented |
|
|
|
SIN-00132608
|
Renewal
|
03/23/2018
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | Individual #1's record did not contain a current signed copy of the individual's rights. | Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | King Family Enterprise reviewed the Civil Rights with Individual #1 and going forward KFE will ensure that each individual is aware of their Civil rights according to 6400.34. Civil rights.
(a) An individual may not be discriminated against because of race, color, religious creed, disability, handicap, ancestry, national origin, age or sex.
(b) The home shall develop and implement civil rights policies and procedures. Civil rights policies and procedures shall include the following:
(1) Nondiscrimination in the provision of services, admissions, placement, use of the home, referrals and communication with non-English speaking and nonverbal individuals.
(2) Physical accessibility and accommodations for individuals with physical disabilities.
(3) The opportunity to lodge civil rights complaints.
(4) Informing individuals of their right to register civil rights complaints. |
04/02/2018
| Implemented |
| 6400.62(a) | There was an unlocked cabinet by the back door that contained mothballs, lighter fluid and Deck Wash.
There were cleaning wipes stored under the kitchen sink in an unlocked cabinet.
Individual #1's bedroom has many hygiene chemicals that are unlocked while individual #2 is unable to differentiate between poisons and ingestible items. | Poisonous materials shall be kept locked or made inaccessible to individuals. | King Family Enterprise placed a lock on each cabinet door with chemicals and stored away all poisonous material according to 6400.62. Poisons.
(a) Poisonous materials shall be kept locked or made inaccessible to individuals.
(b) Poisonous materials may be kept unlocked if all individuals living in the home are able to safely use or avoid poisonous materials. Documentation of each individual¿s ability to safely use or avoid poisonous materials shall be in each individual¿s assessment.
(c) Poisonous materials shall be stored in their original, labeled containers.
(d) Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. In addition, KFE believes that there are no safety concerns with individual #2¿s ability to safely handle and be around poisons and as a result the ISP was updated in the (Safety Precaution) section of the ISP. |
04/03/2018
| Implemented |
| 6400.104 | There was no record of notification being sent to the local fire department. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| King Family Enterprise notified the local fire department in writing and will ensure that a record is kept on file according to 6400.104. Notification to local fire department.
The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. |
03/27/2018
| Implemented |
| 6400.141(c)(14) | Individual #2's annual physical dated 12/20/17 did not include information pertinent to diagnosis in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | King Family Enterprise will ensure that the physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. |
05/18/2018
| Implemented |
| 6400.181(a) | Individual #2 did not have a current assessment. | 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. | King Family Enterprise shall ensure that 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. |
05/10/2018
| Implemented |
| 6400.181(a) | Individual #1's record did not contain a current assessment. | 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. | King Family Enterprise will ensure that 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. |
05/03/2018
| Implemented |
| 6400.185(a) | Individual #2's ISP dated 4/25/17 was not implemented by the start date. | The ISP shall be implemented by the ISP's start date. | King Family Enterprise will ensure that the ISP shall be implemented by the ISP's start date. |
04/01/2018
| Implemented |
| 6400.185(a) | There was no indication that individual #1's ISP was implemented by the start date. | The ISP shall be implemented by the ISP's start date. | King Family Enterprise will ensure that the ISP shall be implemented by the ISP's start date. |
04/01/2018
| Implemented |
| 6400.186(a) | individual #1's record did not contain 90 day reviews of the ISP dated 12/29/17. (This is a repeat violation from 3/16/17) | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | King Family Enterprise will ensure that The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impacts the services as specified in the current ISP. |
04/21/2018
| Implemented |
| 6400.186(a) | Individual #2's record did not contain any 90 day ISP reviews. (This is a repeat violation from 3/16/17) | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | King Family Enterprise will ensure that The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impacts the services as specified in the current ISP. |
05/07/2018
| Implemented |
| 6400.186(c)(1) | Individual #1's record did not contain monthly reviews. (This is a repeat violation from 3/16/17) | The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. | King Family Enterprise will ensure that the ISP review will include the following:
A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. |
04/14/2018
| Implemented |
| 6400.186(c)(1) | Individual #2's record did not contain any monthly reviews of the ISP. (This is a repeat violation from 3/16/17) | The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. | King Family Enterprise will ensure that The ISP review will include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. |
04/30/2018
| Implemented |
|
|
|
SIN-00112217
|
Renewal
|
03/16/2017
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | Individual #1 had signed the rights statement but it was not dated. | Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | The Director had the individual sign the rights statement and the Administrator Assistant will keep records of the document and make sure each individual has the statement signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. |
06/12/2017
| Implemented |
| 6400.46(c) | The CEO had only 16 hrs of documented trainng during the past training year. | The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually. | The CEO completed 24 hrs of training and going forward The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually. |
03/13/2017
| Implemented |
| 6400.46(f) | Staff # 1 did not have inital fire safety training. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Staff #1 completed the initial first aid training. KFE will require that the Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home, shall be trained before working with individuals in first aid techniques.[KFE will have staff #1 trained in fire safety by the fire safety expert and submit documentation of training by 8/28/17. KFE will audit all new employees hired in 2017 and annually thereafter to ensure all employees receive adequate fire safety training.R.G. 8/14/17] |
03/30/2017
| Implemented |
| 6400.46(h) | Staff #1 did not have initial first aid training. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home, shall be trained before working with individuals in first aid techniques. | Staff #1 completed the initial first aid training. KFE will require that the Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home, shall be trained before working with individuals in first aid techniques. |
03/30/2017
| Implemented |
| 6400.46(i) | Staff #1 did not have training in FirstAid/CPR and Heimlich. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Staff #1 completed the Traiing for FirstAid/CPR and Heimlich. The Program Specialist for KFE will require that direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. |
12/27/2016
| Implemented |
| 6400.112(a) | Fire drills documentation were missing for 11/16 and 12/16. | An unannounced fire drill shall be held at least once a month. | The Fire Drill documentation was updated and moving forward a written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept. |
04/28/2017
| Implemented |
| 6400.112(e) | The sleep drill for 11/16 was missing. | A fire drill shall be held during sleeping hours at least every 6 months. | KFE will perform A fire drill shall be held during sleeping hours at least every 6 months. |
06/22/2017
| Implemented |
| 6400.113(c) | Documentation of fire safety training was missing for individual #1. | A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept. | The fire safety training was completed and updated in the assessment. Moving forward A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept. |
04/28/2017
| Implemented |
| 6400.141(c)(6) | Individual #1's TB test was more than 2 yrs apart, 12/31/16 and 5/20/14. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The Program Specialist file the document with the TB results for individual #1 and will follow the requirement that The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. |
04/28/2017
| Implemented |
| 6400.141(c)(10) | The individual # 2's physical exam dated 2/17/16 did not evaluate need for communicable disease precautions. | 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. | The Program Specialist updated the information for individual #2 regarding communicable disease precautions. Moving forward 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. |
05/31/2017
| Implemented |
| 6400.142(a) | Individual # 1 did not have documentation of a dental exam. | 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. | The KFE Program Specialist added the dental document for individual #1 and will maintain the policy that 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. |
06/19/2017
| Implemented |
| 6400.142(a) | Indvidual #1 and #2 did not have on file a record of their dental exam. | 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. | The KFE Program Specialist added the dental document for individual #1 & #2 and will maintain the policy that 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. |
06/19/2017
| Implemented |
| 6400.181(d) | The assessmet was not dated or signed by the program specialist. | The program specialist shall sign and date the assessment. | The Program Specialist signed and dated the assessment and will do so go forward. |
06/21/2017
| Implemented |
| 6400.181(e)(4) | The assessment did not document individual #1's supervision level and unsupervised time. | The assessment must include the following information: The individual's need for supervision.
| The Program Special updated the assessment with the details concerning the supervision level for individual # 1 |
06/21/2017
| Implemented |
| 6400.181(e)(5) | Individual #1's assessment did not evaluate his ability to self-administer medication. | The assessment must include the following information: The individual's ability to self-administer medications. | The KFE Program Specialist has updated the assessment for individual #1 and moving forward he will maintain records of the individual's ability to self-administer medications. |
06/21/2017
| Implemented |
| 6400.181(e)(5) | Individual #2's undated assessment did not record his ability to self-administer medications. | The assessment must include the following information: The individual's ability to self-administer medications. | The Program Specialist has updated the ability to self-administer medications and will maintain this record moving forward. |
06/21/2017
| Implemented |
| 6400.181(e)(8) | The assessment for individual #2 did not assess his ability to evacuate in case of a fire. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | The KFE Program Special has updated the information stating that individual #2 is able to evacuate in case of a fire. In addition to keeping records for future updates to the assessment. |
06/19/2017
| Implemented |
| 6400.181(e)(10) | Individual #1 did not have a lifetime medical history as part of his assessment. | The assessment must include the following information: A lifetime medical history. | The Program Specialist updated the lifetime medical history information for individual # 1 and moving forward it will be added to the assessment. |
06/21/2017
| Implemented |
| 6400.181(e)(13)(i) | The assessments for individuals #1 and #2 did not indicate progress and growth in the area of health. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| The Program Specialist added the progress and growth in the area of health to the assessment for individuals 1 and 2. Then moving forward the Program Specialist will had this to the assessment over the previous 365 days. |
06/21/2017
| Implemented |
| 6400.181(e)(13)(vii) | The assesment for individuals #1 and #2 did not indicate progress and growth in the field of financial independence. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| The Program Specialist updated the section which indicates the progress and growth in the field of financial independence. Moving forward it will be included in the assessment of each individual. |
06/19/2017
| Implemented |
| 6400.181(e)(14) | The assessment for individuals #1 and #2 did not indicate progress and growth in the knowledge of water safety/swimming. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | The KFE Program Specialist updated the assessment with the indicated progress and growth in the knowledge of water safety/swimming. We will also update the information in all assessments moving forward. |
06/20/2017
| Implemented |
| 6400.181(f) | Documentation that the assessment for individual #2 was sent to the sc 30 days before the annual meeting was not available. | (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 KFE Program Specialist will follow the ODP requirements that the (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). |
06/21/2017
| Implemented |
| 6400.186(a) | Two quarterlies for individual #1 were missing from the record for the period of 10/25/15-1/25/16 and 1/26/16 -4/25/16. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | The program specialist of KFE completed the two missing quarters and shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. |
04/30/2017
| Implemented |
| 6400.186(b) | The quarterly for June-August, 2016 was not signed and dated and the next quarterly for Oct.-Dec., 2016 was not dated. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP and going forward each assessment will be signed. |
06/21/2017
| Implemented |
| 6400.186(c)(1) | The monhly ISP reviews were missing from individualls #1 and #2 records. | The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. | The Program Specialist completed the monthly ISP reviews and he maintain that The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. |
06/30/2017
| Implemented |
| 6400.213(1)(i) | No idenifying marks or religious affiliation or individual #1 was noted in the record. | 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. | The Administrator Assistant updated the Personal Information for the individual and going forward the Admin Assistant will make sure 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. |
04/03/2017
| Implemented |
|
|
|
SIN-00093625
|
Renewal
|
03/29/2016
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff #4 did not have a criminal history clearance on file. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| The King Family Enterprise (KFE) will require that a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the home who will have direct contact with individuals, including part-time and temporary staff, who will have direct contact with individuals, [PRIOR TO THE DATE OF HIRE, PER OLDER ADULT PROTECTIVE SERVICES ACT (OAPSA) GUIDELINES. JG 3/07/17] This will be the responsibility of the Program Specialist. |
10/05/2016
| Implemented |
| 6400.22(e)(1) | Individual #1's record did not have a financial record for the period of December 2015 through February 2016. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | If KFE assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. (Program Designee will be responsible to monitor the financial records to ensure that there is no mishandling of individual funds. JG 3/07/17} |
10/05/2016
| Implemented |
| 6400.22(e)(3) | The provider failed to obtain receipt(s) for monetary disbursement(s) of $15.00 or more for Individuals #2 and #3.
| If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by receipt or expense record, of each purchase exceeding $15 made on behalf of the individual by or with a staff person. | KFE will require that If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by receipt or expense record, of each purchase exceeding 15 dollars made on behalf of the individual by or with a staff person. This will be the responsibility of the CFO who will monitor financial records to ensure compliance. |
10/05/2016
| Implemented |
| 6400.31(b) | Individual #1's record does not include a signed copy of the Individual's Rights.
Individual #2's record does not include a signed copy of the Individual's Rights.
Individual #3's record does not include a signed copy of the Individual's Rights.
| Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | KFE will require a Statements signed and dated by the individual,individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. This is the responsibility of the Administrative Assistant. [The Program Director will conduct bi-annual reviews of all of the Individuals records to ensure a copy of the Rights are completed annually by all participants, starting immediately. SW 3.8.17] |
10/07/2016
| Implemented |
| 6400.46(a) | Staff #6 did not receive orientation before working with individuals. | The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. | The King Family Enterprise will require that every staff person receive training relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. This will be the responsibility of the Program Specialist (Jeffrey King Sr.).[The Program Director will audit all staff files to ensure all staff have received orientation to each individuals needs, the homes policies/procedures and their specific job responsibilities, immediately. The Program Director will review all newly hired staff files within 30 days of hire to ensure that the staff have received the required training, starting immediately. SW 3.8.17] |
10/05/2016
| Implemented |
| 6400.46(c) | Staff #3 (CEO) did not receive the required 24 hours of annual training. | The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually. | KFE will require that the CEO shall have at least 24 hours of training relevant to human services or administration annually. This will be the responsibility of the Program Specialist. [The CEO will complete the 24 hours of training for 2017 plus any hours of training missed during the 2016 training year by 12/31/17. SW 3.8.17] |
10/31/2016
| Implemented |
| 6400.46(d) | Staff #4 did not receive 24 hours of annual training.
Staff #5 did not receive 24 hours of annual training.
Staff #6 did not receive 24 hours of annual training.
| Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. | KFE will require that the program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. This is the responsibility of the Program Specialist. [Program Designee will monitor employee training hours quarterly to ensure compliance. Staff with missing training hours for 2016 will complete the number of hours missing during the 2017 training year in addition to the 24 hours required annually by 12/31/17.JG 3/07/17] |
10/31/2016
| Implemented |
| 6400.46(e) | Staff #3 did not receive training in the areas of Intellectual Disabilities and program planning and implementation, within 30 calendar days after the day of initial employment, or within 12 months prior to initial employment. | Program specialists and direct service workers shall have training in the areas of mental retardation, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. | KFE will require that program specialists and direct service workers shall have training in the areas of Intellectual Disabilities, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. This is the responsible of the Program Specialist [who will conduct a bi-annual audit of all staff training records starting immediately. SW 3.8.17] |
10/28/2016
| Implemented |
| 6400.46(f) | Staff #1 was not trained in fire safety.
Staff #2 was not trained in fire safety.
Staff #3 was not trained in fire safety.
Staff #4 was not trained in fire safety.
Staff #5 was not trained in fire safety.
Staff #6 was not trained in fire safety.
| Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | The King Family Enterprise will require that the program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department. This is the responsibility of the Program Specialist.[All staff of the home will be trained immediately in fire safety. The Program Director will conduct bi-annual audits of all staff training starting immediately. SW 3.8.17] |
10/31/2016
| Implemented |
| 6400.46(j) | Staff #3's employee file did not contain a record of trainings.
Staff #4's employee file did not contain a record of 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. | KFE will require that the 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. This will be maintained by the Administrative Assistant. [Program Designee will monitor employee files quarterly to ensure that there is a record of trainings and the employee has the required number of training hours. |
10/05/2016
| Implemented |
| 6400.112(c) | No documentation of fire drills was available onsite. | 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 or smoke detector was operative. | KFE will keep 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 or smoke detector was operative. This will be the responsibility of the Residence Supervisor. [Program Designee will review the fire drill documentation monthly to ensure compliance and maintain documentation for review by Department staff upon request. JG 3/07/17] |
10/05/2016
| Implemented |
| 6400.112(f) | Individuals evacuate through the front door of the residence only even though there is at least one other alternate exit from the residence. | Alternate exit routes shall be used during fire drills. | Alternate exit routes will be used during fire drills and documented each month. This will be the responsibility of the Residence Supervisor. [Program Designee will review the fire drill records monthly to ensure compliance. JG 3/07/17] |
10/05/2016
| Implemented |
| 6400.113(a) | Individual #1 did not receive fire safety training upon admission.
Individual #2 did not receive fire safety training upon admission.
Individual #3 did not receive fire safety training upon admission.
| 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. | KFE will make sure that each 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. Individual #1 is no longer with the KFE Residence. The Program Specialist will confirm that each individual received the required Fire and Safety Training.[The Program Director will audit all of the Individuals records bi-annually to ensure fire safety training has been completed. SW 3.8.17] |
05/16/2016
| Implemented |
| 6400.141(a) | Individual #1 did not have a Physical Examination prior to the individual's admission date of 11/18/2015. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | KFE will require that an individual have a physical examination within 12 months prior to admission and annually thereafter. The Administrative Assistant will be responsible for maintaining files which will includes the annual physical. [The Program Director will conduct bi-annual audit of all Individual records to ensure that a physical was conducted prior to admission and annually thereafter, starting immediately. SW 3.8.17] |
10/05/2016
| Implemented |
| 6400.141(c)(4) | Individual #3's annual Physical Examination dated 12/07/2015 recommended further vision screening which did not occur. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | KFE will require that the physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Individual #3 has an eye exam scheduled for 10/28/16. [Any follow-up care, tests or treatment ordered by the practitioner. JG 3/07/17] |
10/28/2016
| Implemented |
| 6400.141(c)(10) | Individual #1's Physical Examination dated 3/09/2016 did not document if the individual is free of communicable disease.
Individual #2's Physical Examination dated 2/17/2014 did not document if the individual is free of 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. | KFE will required that 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. KFE hired a new Administrative Assistant that will monitor the documentation for each individual profile. [The Program Director will conduct bi-annual audits of all Individuals records to ensure physical examinations are completed, starting immediately. SW 3.8.17] |
10/05/2016
| Implemented |
| 6400.141(c)(15) | Individual #3's Physical Examination dated 12/07/2015 did not document special diet instructions. | The physical examination shall include: Special instructions for the individual's diet. | KFE will require that the physical examination shall include: Special instructions for the individual's diet. [KFE staff who accompany individuals to physical examination appointments will be sure to have practitioner complete ALL AREAS OF THE PHYSICAL EXAM FORM/LEAVE NO BLANKS. Program Designee will review physical exam forms after completion to ensure that they are completed thoroughly. JG 3/07/17] The Administrative Assistant will maintain records and confirm that this is prevented with future individuals at the KFE Residence. |
10/28/2016
| Implemented |
| 6400.143(a) | Individual #1 refused medication on two occasions (9/01/15 and 9/10/15); and there was no documented desensitization plan. | 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. | KFE will train staff that 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. [in addition, a Program Designee will be responsible to write a Desensitization Plan to address the individual's continued refusal of medical exams or treatment. JG 3/07/17] |
10/05/2016
| Implemented |
| 6400.151(a) | Staff #4's employee file does not contain a current Physical Examination.
Staff #6's employee file does not contain a current Physical Examination.
| 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. | KFE will require all staff who come into direct contact with individuals or who prepare or serve food, including temporary, substitute and volunteer staff, to have a physical examination within 12 months prior to employment and every 2 years thereafter. KFE will go through each staff's record and confirm their physical dates are compliant. [Going forward, a Program Designee will monitor employee files on an ongoing basis to ensure compliance. JG 3/07/17] |
10/05/2016
| Implemented |
| 6400.181(a) | Individual #1's record did not include an assessment.
Individual #2's record did not include an assessment.
Individual #3's record did not include an assessment.
| 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. | KFE will make sure that 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 will include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. This will be monitored by the Program Specialist [to ensure compliance. JG 3/07/17] |
10/28/2016
| Implemented |
| 6400.184(a)(1)(ii) | Individual#3's ISP meeting dated 8/31/2015 was not attended by the Program Specialist. | A plan team must include as its members the following: A program specialist or family living specialist, as applicable, from each provider delivering a service to the individual. | The Program Specialist will attend the ISP meeting of each individual. We understand that a plan team must include as its members the following: A program specialist from each provider delivering a service to the individual. The Program Director will provide training to the Program Specialist on the importance of attending ISP meetings within 30 days of receipt of this plan of correction. SW 3.8.17] |
10/04/2016
| Implemented |
| 6400.186(a) | Individual #1's record did not include 3 month ISP review documentation.
Individual #2's record did not include 3 month ISP review documentation.
Individual #3's record did not include 3 month ISP review documentation.
| The Program Specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | KFE's program specialist shall complete an ISP review of the services and expected outcomes in the ISP with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. There will also be meetings set monthly between the Assistant Director and the Program Specialist to review services and expected outcomes.[The Program Director will conduct a training to the Program Specialist and Assistant Director on the importance of the 3 month ISP reviews, within 10 days of receipt of this plan of correction. The Program Director will conduct bi-annual audits of all Individual records to ensure that 3 month ISP reviews are being conducted for all Individuals of the home, starting immediately. SW 3.8.17] |
10/03/2016
| Implemented |
| 6400.186(c)(1) | Individual #1's record did not include monthly documentation.
Individual #2's record did not include monthly documentation.
Individual #3's record did not include monthly documentation.
| The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. | The King Family Enterprise will implement an ISP review process which will include the following: A review of the monthly documentation of an individual's participation and progress toward the ISP outcomes. The Program Specialist will be responsible for writing the monthly review. The information will be used to develop the quarterly review. [The Program Director will conduct a training for the Program Specialist on the importance of conducting a monthly reviews to ensure the outcomes are documented, within 10 days of receipt of this plan of correction. SW 3.8.17] |
06/01/2016
| Implemented |
| 6400.211(b)(1) | Individual #1's record did not include emergency contact information.
Individual #2's record did not include emergency contact information.
Individual #3's record did not include emergency contact information.
| Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. | KFE created a document that will be used for current individuals and incoming new individuals which will include emergency contact information including the name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. [A Program Designee will be responsible to review individual records upon admission and quarterly to ensure that all necessary information is present and up-to-date. JG 3/07/17] |
09/17/2015
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include hair color and identifying marks.
Individual #3's record did not include hair color and identifying marks.
Individual #2's record did not include hair color, eye color and identifying marks.
Individual #1's record did not include religious affiliation.
Individual #2's record did not include religious affiliation.
Individual #3's record did not include religious affiliation.
Individual #1's record did not include next of kin.
Individual #2's record did not include next of kin.
Individual #3's record did not include next of kin.
Individual #2's record did not include a current, dated photograph.
| 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. | KFE created a document that will be used for current individuals and every new individual that comes into the residence. It will [contain demographic information such as] hair color, eye color and identifying marks, religious affiliation, next of kin, and a current, dated photograph. Personal information including: name, sex, admission date, birthdate, social security number, primary language, race, height and weight. [The Program Designee will be responsible to monitor that the information is contained in the record, and updated as needed. JG 3/07/17] |
09/17/2015
| Implemented |
| 6400.217 | Individual #1's record does not include a written consent for Release of Information form.
Individual #2's record does not include a written consent for Release of Information form.
Individual #3's record does not include a written consent for Release of Information form.
| Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| KFE will maintain a signed document from each individual that will give consent to release of information. This will be kept on file with their personal profile. [The Program Designee will review individual records to ensure that all required documents are present in the file. JG 3/07/17] |
10/04/2016
| Implemented |
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SIN-00081487
|
Initial review
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04/28/2015
|
Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.111(f) | The fire extinguishers in the basement, kitchen, and second level did not have an inspection tag. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | The King Family Enterprise will have Fire Extinguishers checked annually by a fire safety expert. This will be monitored by the Residence Supervisor (Jeffrey King JR). Staff will be required to notify the Residence Supervisor of any noticeable damages to the Fire Extinguishers. Any damage to the Extinguishers will be addressed ASAP by the Residence Supervisor.
(The residential supervisor will keep a tracking system to ensure all extinguishers are inspected annually. The residential supervisor will contact the fire safety expert 3 months prior to expiration to schedule the inspection of the extinguishers. AH 9.23.15) |
09/04/2015
| Implemented |
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