Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00203757 Renewal 04/07/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(d)Direct Service Professional #2, date of hire 03/08/19, did not receive re-certification in first aid, Heimlich techniques and cardio-pulmonary resuscitation. Direct Service Professional #2's first aid/CPR certificate expired November 30, 2021.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.Director will set up training for the staff with Staying Alive First Aid and CPR at the next available class date. 04/22/2022 Implemented
6400.51(a)(1)Direct Service Professional #3, date of hire 02/05/22, did not complete individual rights training until 03/22/22, exceeding the 30-day requirement.Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons.All Staff, prior to working alone with individuals and within 30 days of hire must complete the training orientation described in 6400.51(b). Direct Service Professional #3 was hired on February 5, 2022 and completed the training described in 6400.51(b) on March 23, 2022, 17 days after the deadline. [Staff Orientation and Training Chart received on 4/30/22 and reviewed on 5/4/22. DPOC by HDKP, HSLS, on 5/4/22]. 04/22/2022 Implemented
6400.52(c)(1)Chief Executive Officer (CEO) #1's annual training, for annual training year 1/1/2021 through 12/21/2021, did not include the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The CEO will train on PCP, Community integration, individual choice and supporting individuals to develop and maintain relationships via the ODP online training and will complete the training by April 28, 2022. [Certificate of training completion received 4/30/22 and reviewed 5/4/22. DPOC by HDKP, HSLS, on 5/4/22]. 04/22/2022 Implemented
6400.52(c)(2)CEO #1's annual training, for annual training year 1/1/2021 through 12/31/2021, did not include the prevention, detection and reporting of abuse, suspected abuse and alleged abuse.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 CEO will train on the prevention, detection, and reporting of abuse, suspected abuse and alleged abuse via the ODP online training and will complete the training by April 28, 2022. [Certificate of training completion, dated 4/29/22, received 4/30/22 and reviewed 5/4/22. DPOC by HDKP, HSLS, on 5/4/22]. 04/22/2022 Implemented
6400.52(c)(3)CEO #1's annual training, for annual training year 1/1/2021 through 12/31/2021, did not include individual rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.The CEO will train on individual rights via the ODP online training and will complete the training by April 28, 2022. [Certificate of training completion, dated 4/29/22, received 4/30/22 and reviewed 5/4/22. DPOC by HDKP, HSLS, on 5/4/22]. 04/22/2022 Implemented
6400.52(c)(4)CEO #1's annual training, for annual training year 1/1/2021 through 12/31/2021, did not include recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.The CEO will train on recognizing and reporting incidents via the ODP online training and will complete the training by April 28, 2022. [Certificate of training completion, dated 4/29/22, received 4/30/22 and reviewed 5/4/22. DPOC by HDKP, HSLS, on 5/4/22]. 04/22/2022 Implemented
SIN-00186031 Renewal 04/12/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The record for the fire drill completed on 5/26/2020 did not include the time of the drill or the amount of time it took for evacuation.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. Program director will ensure that 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. Program director has developed a tracking system/checklist to ensure fire drills will be conducted in a safe and timely manner and all equipment is operable. Individual and staff have been counseled on the importance of evacuating in a timely manner. Training was held on April 23,2021. 04/23/2021 Implemented
6400.112(d)Fire Drill held on 9/17/2020 had an evacuation time of 3 minutes and 47 seconds. The home does not have an extended evacuation time designated in writing by a fire safety expert within the previous 12 months. 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. Should fire drill be over the time limit, program director will complete a new fire drill with staff and individual. Individual and staff have been counseled on the importance of evacuation in a timely manner and cooperating with direction from staff members. After retraining April 23, 2021, fire expert completed a fire drill to ensure all policy and procedures were followed and individuals were able to get out safely within the timeframe 04/23/2021 Implemented
6400.112(e)There were no fire drills held during sleeping hours from January of 2020 through August of 2020.A fire drill shall be held during sleeping hours at least every 6 months. A fire drill was held on April 24, 2021 during sleeping hours and documentation was placed in Fire Drill Record Book. Individual and staff evacuated within the 2.5 minute timeframe. Staff and individual has been counseled on the importance of evacuation in a timely manner and during sleeping hours. 04/24/2021 Implemented
6400.112(h)Individual #1, date of admission 3/04/2013, refused to evacuate to the designated meeting place outside the home during the fire drill conducted on 6/27/2020. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.After retraining April 23, 2021 fire expert completed a fire drill to ensure all policy and procedures were followed and individuals were able to get out safely within the timeframe and designated meeting place. The Individual has been counseled on the importance of evacuating in a timely manner and cooperating with the direction from staff members. 04/23/2021 Implemented
6400.113(a)Individual #1, date of admission 3/04/2013, completed fire safety training by a fire safety expert on 3/04/2020, and then again on 3/25/2021. 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. Annual fire safety training was completed by fire expert John Ritter on April 23, 2021 via English verbal communication (blind) with individual upon initial admission and annually in general fire safety, evacuation procedures, responsibilities during a fire drills, the designated meeting place outside the building or within the fire safe area in the event of a actual fire and non-smoking policy. 04/23/2021 Implemented
6400.151(a)Direct Services Worker #1, date of hire 3/08/2019, had a physical examination completed 3/13/2019, and then again on 3/29/2021. 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. The Director will ensure that all staff will have a completed a physical prior to their date of hire. The compliance officer developed a checklist to include staff persons physical exam and Tuberculin testing to ensure all staff persons have a physical exam, free of communicable diseases and Tuberculin testing completed timely. Audited was completed on 04/23/2021. 04/23/2021 Implemented
6400.46(b)Direct Services Worker #1, date of hire 3/08/2019, completed fire safety training by a fire safety expert on 2/07/2020, and then again on 3/25/2021. Direct Services Worker #2, date of hire 6/18/2019, completed fire safety training by a fire safety expert on 2/07/2020, and then again on 3/25/2021. Program Specialist #3, date of hire 4/04/2016, completed fire safety training by a fire safety expert on 2/07/2020, and then again on 3/25/2021.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Annual fire safety training was completed by fire expert John Reiter on March 25, 2021 and again on April 23 2021, the training included 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, non-smoking policy, 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. At training the fire expert completed a fire drill to ensure all policy and procedures were followed and staff and individuals were able to get out safely within the timeframe. 04/23/2021 Implemented
SIN-00109241 Renewal 03/02/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(3)Direct Service Worker #1 physical examination completed 4/26/16 and the Direct Service Worker #2 physical examination completed 7/1/16 did not include a signed statement that the staff person is free of communicable diseases. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Sent a letter and form to the facility that performs the employee physical and TB test screening to include free of communicable diseases (see attached) Loving Care Center Inc. 1918 Paul Street Farrell, PA 16121 March 6, 2017 Corporate Health 295 N. Kerrwood Dr. #104 Hermitage, PA 16148 Gentlemen: Currently your facility performs pre-employment screening physical bundled with a TB test, please include the attached form which includes free of communicable diseases. Should you have any questions or concerns please feel free to call me. 878-202-4355. Thank you, Henry Sollenberger Loving Care Center, Inc Staff Physical Exam Name: ___________________ DOB: ____/____/_______ Age:______ Sex: M F SSN: _____-_____-_________ Post offer:______ (To be filled out by the physician and used in conjunction with the physician's Physical Examination Form) Mantoux Test: ________________ Results: _____________ Cleared for Work: __________________________________ Free of communicable diseases: ______________________ ___________________________________________________ ______________________ Physicians Signature [Direct Services Workers #1 and #2 had physical examinations updated to include a statement that the staff person is free of communicable disease on 3/7/17. Immediately, the program specialist shall review all staff persons physical examinations to ensure the physical examination has a signed statement that the staff person is free of communicable disease or specific precautions. Upon completion the CEO shall review all staff persons' physical examination documentation to ensure all required information is included. (AS 3/13/17)] 03/07/2017 Implemented
6400.186(e)The program specialist did not notify the plan team members of the option to decline the ISP review documentation for Individual #1. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. Sent a letter and form to the individual's team members of the option to decline the ISP review documentation. Loving Care Center Inc. 1918 Paul Street Farrell, PA 16121 (724)979-4229 March 6, 2017 To the members of the ISP Plan Team for: Dear Team Member: Every three months you are provided with a report of the participation and progress toward the Outcomes of the ISP for the individual named above residing with Loving Care Center, Inc. As per the Office of Developmental Programs regulation, you have the option of declining this ISP Review documentation. If you wish to decline the three (3) month review report, check ¿DECLINE¿ below. By checking ¿ACCEPT,¿ you will receive a copy of the three (3) month review documentation. Please sign, date, and mail this form back to me at the address above. Any questions or further clarification can be addressed by contacting me. If you decide to decline this information, you may at anytime choose to be placed back on the mailing list. Respectfully, Program Specialist Henry Sollenberger Cc: : Program Manager : SC Caseworker : Self DECLINE_______ ACCEPT_________ Signature: ___________________ Date______________ [On 3/6/17, Individual #1' plan team members were notified of the option to decline the ISP review documentation. At least annually, the program specialist shall review Individual #1's record to ensure all plan team members have been notified of the option to decline and documentation is kept. (AS 3/13/17)] 03/07/2017 Implemented
SIN-00088718 Renewal 01/20/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)An application for a Pennsylvania criminal history record check for Direct Service Workers #1, date of hire 10/2/15 was not submitted to the State Police until 1/19/16. An application for a Pennsylvania criminal history record check for Direct Service Workers #2, date of hire 10/22/15 was not submitted to the State Police until 12/10/15. Repeated Violation-1/8/15An 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. A training with the new HR person for all staff (full and part time) to discuss and review the importance of a Pennsylvania criminal history check that is submitted to the State Police within (5) working days after the person's date of hire. Provider will include Criminal history record checks as part of all new employee's orientation during the hiring process. This process will be maintained and monitored monthly or as needed by the new HR person. [Immediately, HR Director will develop and implement a new hire checklist to include required information including criminal history record checks to be maintained in each staff person's personnel file. HR Director will obtain required information including criminal history record checks and document of checklist and place in each staff person's personnel file. At least quarterly, CEO or program specialist will review all staff persons personnel file and checklist to ensure required information is completed timely including request for criminal history checks. Documentation of reviews shall be kept. (AS 4/4/16)] 02/29/2016 Implemented
6400.44(b)(10)Program Specialist #4 did not review, sign and date the monthly documentation of Individual #1's participation and progress toward outcomes from December 2014 through March 2015.The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of an individual's participation and progress toward outcomes.A training with the new HR person will be held for the Program specialist/director to discuss their responsibilities as a Program Specialist which includes reviewing, signing and dating the monthly documentation of the participation and progress toward individual's outcomes. This process will be maintained and monitored monthly by the new HR person. [The program specialist signed and dated the monthly documentation for Individual #1 from December 2015 to March 2016. Immediately, the Program Specialist/Director will develop and implement a checklist of all required information including the monthly documentation of an individual's participation and progress toward outcomes that is reviewed, signed and dated by the program specialist to be included in each individual's record. At least quarterly reviews of each Individual's record will be completed by the PS/Director. Documentation of reviews shall be kept on the checklist. (AS 4/7/16)] 02/29/2016 Implemented
6400.44(b)(14)Program specialist #4 did not provide the documentation of the ISP review dated August 2015 to October 2015 for Individual #1 to the plan team members.The program specialist shall be responsible for the following: Providing the documentation of the ISP review to the SC, as applicable, and plan team members as required under § 6400.186(d). A training will be held by the new HR person for Program specialist/director and Plan team members to discuss and review documentation of the Individual's Support Plan Review to the Support Coordinator. This process will be maintained and monitored monthly by the new HR person or as needed.[ISP review documentation for 9/24/15 to 12/23/15 was provide to the team members on 12/27/16. ISP review documentation for 12/23/15 to 3/23/16 was provide to the team members on 3/31/16. Immediately, the Program Specialist/Director will develop and implement a checklist of all required information including the providing the documentation of the ISP review to the SC, as applicable, and plan team members as required under § 6400.186(d) by the program specialist to be included in each individual's record. At least quarterly reviews of each Individual's record will be completed by the PS/Director. Documentation of reviews shall be kept on the checklist. (AS 4/7/16)] 02/29/2016 Implemented
6400.46(a)Direct Service Worker #1, date of hire 10/2/15, Direct Service Workers #2, date of hire 10/22/15 and Direct Service Worker #3, date of hire 2/17/15 did not receive orientation 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 until 1/18/16, 1/19/16 and 1/19/16; respectively.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. A training will be held by the new HR person for all staff (full and part time) Orientation will be review and discussed with staff concerning their responsibilities, daily operations and provider's policy and procedures of the home. This process will be maintained and monitored by the new HR person for all staff (full and part time) before working with Individual of the home or in their appointed positions.[Immediately, the Director will develop and implement a new hire checklist to include required trainings including 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 Director will complete the trainings with all staff persons within the required timeframes and document on checklist and place in each staff person's personnel file. At least quarterly, the Director will review all staff¿s personnel file and checklist to ensure required trainings are completed timely. Documentation of reviews shall be kept. (AS 4/7/16)] 02/29/2016 Implemented
6400.46(f)Direct Service Worker #1, date of hire 10/2/15, was not trained 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, 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.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. A training will be held by the new HR person for all staff (full and part time) to ensure staff knows how to respond to a fire at the home (smoke safety, evacuation, responsibilities of fire drills and designated meeting place) and how to operate fire safety devices (fire extinguishers, smoke detector, fire alarms, emergency lighting) and when to notify the fire department. This process will be maintained and monitored by the new HR person before any staff works with the individual of the home or their appointed positions. [Direct Service Worker #1 was trained in fire safety on 2/13/16. Immediately, the Director will develop and implement a new hire checklist to include required trainings including 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. to be maintained in each staff person's personnel file. The Director will complete the trainings with all staff persons within the required timeframes and document on checklist and place in each staff person's personnel file. At least quarterly, the Director will review all staff¿s personnel file and checklist to ensure required trainings are completed timely. Documentation of reviews shall be kept. (AS 4/7/16)] 02/29/2016 Implemented
6400.62(c)A unlabeled, clear, spray bottle containing a yellow liquid was located in the locked cabinet used for storing cleaning products/poisonous materials.Poisonous materials shall be stored in their original, labeled containers. A training with the House manager will be held for all staff (full and part time) to ensure that poisonous materials shall be stored in their original labeled containers. This process will be maintained and monitored each week by the House manager and will be added to Provider's policy and procedure manual.[At least monthly, the Director or designated staff person will complete a walk through of the home to ensure poisonous materials are stored in their original, labeled containers. Documentation of physical site checks shall be kept. (AS 4/6/16)] 02/29/2016 Implemented
6400.71The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the telephone in the kitchen.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. A training will be held by the Program specialist/director for all staff (full and part time) to ensure that a list of all Emergency telephone numbers (hospital, police, fire, ambulance and poison control center) shall be on the phone or by each phone in the home. This process will be maintained and monitored yearly by the program specialist/director or as needed. [At least quarterly, the Director or designated staff person will check all telephones in the home with an outside line to ensure required telephone numbers are on or by each telephone. Documentation of physical site checks shall be maintained. (AS 4/6/16)] 02/29/2016 Implemented
6400.81(i)The only window in Individual #1's bedroom did not have drapes, curtains, shades, blinds or shutters. bedroom.Bedroom windows shall have drapes, curtains, shades, blinds or shutters. The Provider applied for a waiver on February 10, 2016.[A waiver was granted on 2/26/16 for 55 PA.Code 6400.81i relating to individual bedrooms. The conditions of the waiver shall be maintained by the CEO. All current and future staff shall be trained on the waiver, documentation of trainings shall be maintained. (AS 4/4/16) 02/29/2016 Implemented
6400.141(c)(6)Individual #1's most recent Tuberculin skin testing by Mantoux method with negative results is dated 10/28/13.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. Provider will add to their admissions requirements that Individuals' must have a TB test by Mantoux (every two years) unless chest xray is required. A training for all staff (full and part time) by the Program specialist/director to review the new Admission requirements. Provider will include the new admission requirements in their policy and procedure manual. This process will be maintained and monitored by the Program specialist/director every (6) months or as needed. [Individual #1 had a Tuberculin skin test read on 2/17 with negative results on 2/17/16. CEO or designated staff person will review the individual's physical examinations prior to entering into the record to ensure all required information is present and will immediately obtain missing information. Documentation of reviews of all physical examinations shall be kept. (AS 4/4/16)] 02/12/2016 Implemented
6400.151(a)Direct Service Worker #1, date of hire 10/2/15, did not have a physical examination. Direct Service Worker #2, date of hire 10/22/15 had a physical examination completed on 11/10/15. 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. A training with the new HR person will be held with all staff (full and part time) to discuss staff physical examination. All direct care staff will have a physical exam 12 months prior to employment and every (2) years thereafter. Provider will include Staff physical examination as part of all new employees orientation during the hiring process. The new HR person will audit all current staff records and for direct care staff not in compliance with the 12 month/2 year period a physical examination will be scheduled and completed by Corporate Health. The new HR person will maintain and monitor every (6) months or as needed. [Direct Service Worker #1 had a physical examination completed on 10/13/15. Direct Service Worker #2 is no longer employed with the facility. Immediately, the Director will develop and implement a new hire checklist to include required information including physical examinations to be maintained in each staff person's personnel file. HR Director will obtain required information including completed physical examinations and document on checklist and place in each staff person's personnel file. At least quarterly, the Director will review all staff persons personnel file and checklist to ensure required information is completed timely including physical examinations. Documentation of reviews shall be kept. (AS 4/6/16)] 02/29/2016 Implemented
6400.151(c)(2)Direct Service Worker #2, date of hire 10/22/15, had a Tuberculin skin testing by Mantoux method with negative results read on 12/16/15. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. A training with the new HR person will be held with all staff (full and part time) to discuss Tuberculin skin testing by Mantoux method. All direct care staff will have a tuberculin skin test before working with individual and every (2) years thereafter. Provider will include Tuberculin skin testing as part of all new employee orientation during the hiring process. The new HR person will audit all direct care staff records and for direct care staff not in compliance, a TB test will be schedule with Corporate Health. This process will be maintained and monitored by the new HR person every (6) months or as needed.[Direct Service Worker #2 is no longer employed with the facility. Immediately, the Director will develop and implement a new hire checklist to include required information including physical examinations with Tuberculin skin testing to be maintained in each staff person's personnel file. HR Director will obtain required information including completed physical examinations with Tuberculin skin testing and document on checklist and place in each staff person's personnel file. At least quarterly, the Director will review all staff persons personnel file and checklist to ensure required information is completed timely including physical examinations. Documentation of reviews shall be kept. (AS 4/6/16)] 02/29/2016 Implemented
6400.151(c)(3)The physical examination completed on 11/10/15 for Direct Service Worker #2 does not include a signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. A training will be held by the new HR person with all staff (full and part time) to discuss direct care staff must be free of communicable disease. All direct care staff must include free of communicable diseases as part of their physical examination in order to prevent the spread of disease to individual. Provider will include free of communicable diseases as part of all new employee orientation during the hiring process. The new HR person will audit all current direct care staff records and for direct care staff not in compliance with free of communicable diseases, a Physical exam which will include free of communicable diseases will be scheduled with Corporate Health. This process will be maintained and monitored by the new HR person every (6) months or as needed. [Direct Service Worker #2 is no longer employed with the facility. Immediately, the Director will review all staff persons' current physical examination documentation to ensure all required information including addressing communicable disease and obtain missing information. The Director will immediately review all initial and annual staff physical examination documentation to ensure all required information is present and will obtain missing information prior to entering into each staff person personnel record. (AS 4/6/16)] 02/29/2016 Implemented
6400.161(b)A medication bottle containing 10mg tablets of Zyrtec Allergy medication was on top of the First Aid Kit located on the kitchen counter next to the sink. Individual #1 is not assessed to safely use or avoid toxic materials.Prescription and potentially toxic nonprescription medications shall be kept in an area or container that is locked, unless it is documented in each individual's assessment that each individual in the home can safely use or avoid toxic materials. A training with the Program specialist/director will be held for all staff (full and part time) on proper storage of medications both prescription and nonprescription medication will review Individual's assessment, include safely use or avoid toxic materials. The Program specialist/director will review, maintain and monitor the OTC chart (over the counter) non-prescription and the prescription medication chart every month. [Daily, the Director or designated staff person will complete a walk through of the home to ensure there are no prescription and potentially toxic nonprescription medications unlocked anywhere in the home. (AS 4/6/16)] 02/29/2016 Implemented
6400.163(c)The psychiatric medication reviews dated 1/15/15, 3/31/15, 6/24/15, 9/23/15, 11/6/15 and 1/11/16 for Individual #1 do not include the need to continue the medications. Repeated Violation-1/8/15 If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The Program specialist/director will train all staff (full and part time) to ensure that all medical forms are completely filled out and ensure the the "New" Psychiatrist Medical Form is used when medication is prescribed to treat diagnosed psychiatric illness. This form must be reviewed by a licensed physician every (3) months and must include the reason for prescribing the medication, the need to continue the medication and the necessary dosage. The "New" Psychiatrist Medication Form must be monitored, maintained and signed by both HR person and Program specialist this will be done every (3) months or as needed. [Immediately, the director will review all documentation completed by the licensed physician to ensure all required information is present and will obtain missing information from the physician. In addition, immediately the director will destroy "old" forms to ensure the aforementioned "new" form is used. (AS 4/6/16)] 02/29/2016 Implemented
6400.168(e)Documentation of the medication administration training course for the trainer was not kept. Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept.The new HR person will train all staff (full and part time) to ensure that Medication administration training documentation of the dates, locations of medication administration training for trainers and staff persons and the annual practicum for staff persons are kept in staff's personal file. Provider contacted Medication Administration Trainer Susan M. Oleyar for a copy of her certification. The new HR person will maintain and monitor every (6) months or as needed.[Immediately, the Director will develop and implement a procedure to maintain staff training documentation as required including medication administration training for staff and trains. At least quarterly, the Director will ensure required documentation of staff trainings is maintained. (AS 4/6/16)] 02/29/2016 Implemented
6400.181(e)(3)(i)Individual #1's assessment dated 4/8/15 did not include the individual's current level of performance and progress in the acquisition of functional skills.The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. A training with the Program specialist/director will be held for all staff (full and part time) to ensure that the individual's assessment must include current level of performance and progress in Acquisition of functional skills. This process will be maintained and monitored yearly by the program specialist/director or as needed.[Individual #1¿s assessment was updated 2/10/16 to include the individual's current level of performance and progress in the acquisition of functional skills. Immediately and at least quarterly, the program specialist will review Individual #1¿s assessment to ensure completion and accuracy and will update as required. Documentation of reviews and updates shall be kept. (AS 4/7/16)] 02/29/2016 Implemented
6400.181(e)(3)(iv)Individual #1's assessment dated 4/8/15 did not include the individual's current level of performance and progress in personal needs with or without assistance from others.The assessment must include the following information: The individual's current level of performance and progress in the following areas: Personal needs with or without assistance from others. A training with the Program specialist/director will be held for all staff (full and part time) to ensure that the individual's assessment must include current level of performance and progress in personal needs with or without assistance from others. This process will be maintained and monitored yearly by the program specialist/director or as needed.[Individual #1¿s assessment was updated 2/10/16 to include the individual's current level of performance and progress in personal needs with or without assistance from others. Immediately and at least quarterly, the program specialist will review Individual #1¿s assessment to ensure completion and accuracy and will update as required. Documentation of reviews and updates shall be kept. (AS 4/7/16)] 02/29/2016 Implemented
6400.181(e)(4)Individual #1's assessment dated 4/8/15 did not include the individual's needs for supervision. The assessment must include the following information: The individual's need for supervision. A training with the Program specialist/director will be held for all staff (full and part time) to ensure that the Individual's assessment must include the individual's need for supervision. This process will be maintained and monitored yearly by the program specialist/director or as needed.[Individual #1¿s assessment was updated 2/10/16 to include the individual's needs for supervision. Immediately and at least quarterly, the program specialist will review Individual #1¿s assessment to ensure completion and accuracy and will update as required. Documentation of reviews and updates shall be kept. (AS 4/7/16)] 02/29/2016 Implemented
6400.181(e)(9)Individual #1's assessment dated 4/8/15 did not include documentation of the individual's disability, including functional and medical limitations.The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. A training with the Program specialist/director will be held for all staff (full and part time) to ensure that the Individuals assessment must include the documentation of the individual's disability, including functional and medical limitations. This process will be maintained and monitored yearly by the Program specialist/director or as needed.[Individual #1¿s assessment was updated 2/10/16 to include the documentation of the individual's disability, including functional and medical limitations. Immediately and at least quarterly, the program specialist will review Individual #1¿s assessment to ensure completion and accuracy and will update as required. Documentation of reviews and updates shall be kept. (AS 4/7/16)] 02/29/2016 Implemented
6400.213(7)(ii)Individual #1's record did not include a copy of the invitation to the annual update meeting held on 7/13/15. Each individual's record must include the following information: A copy of the invitation to the annual update meeting. The documents had been removed from the Client's Clinical Manual prior to the inspection for training purposes and not returned for the inspection. The Program specialist/director will place a copy of the ISP invitation to the annual update ISP meeting in the Individual's records. The program specialist/director will maintain and monitor this every (6) months or as needed.[A copy of the invitation for Individual #1 with ARUD of 7/13/15 was placed in Individual #1 record. Immediately, the Program Specialist/Director will develop and implement a checklist of all required information including a copy of the invitation to be included in each individual's record. At least quarterly reviews of each Individual's record will be completed by the PS/Director to ensure all required information is present. Documentation of reviews shall be kept. (AS 4/4/16)] 02/29/2016 Implemented
6400.213(8)(ii)Individual #1's record did not include copy of the signature sheet for the annual update meeting on 7/13/15. Each individual's record must include the following information: A copy of the signature sheets for the annual update meeting. The documents had been removed from the Client's Clinical Manual prior to the inspection for training purposes and not returned for the inspection. The program specialist/director will place a copy of the signature sheet for the annual update ISP meeting in the individual's record. The Program specialist/director will maintain and monitor this every (6) months or as needed. [A copy of the signature sheet for annual update meeting held on 7/13/15 was placed in Individual #1's record. Immediately, the Program Specialist/Director will develop and implement a checklist of all required information including a copy of the signature sheet for the annual update meeting to be included in each individual's record. At least quarterly reviews of each Individual's record will be completed by the PS/Director to ensure all required information is present. Documentation of reviews shall be kept. (AS 4/4/16)] 02/29/2016 Implemented
6400.213(9)The ISP in Individual #1's record had an annual review meeting date of 6/27/14. Each individual's record must include the following information: A copy of the current ISP. The documents had been removed from the Client's Clinical Manual prior to the inspection for training purposes and not returned for the inspection. A training with the Program specialist/director will be held for all staff (full and part time) to review new ISP (1/04/2016) and ensure that the program specialist/director will place a copy the current ISP in the individual's records. The Program specialist/director will maintain and monitor this every (6) months or as needed.[ISP for Individual #1 with ARUD of 7/13/15 was placed in Individual #1 record. Immediately, the Program Specialist/Director will develop and implement a checklist of all required information including a copy of the current ISP to be included in each individual's record. At least quarterly reviews of each Individual's record will be completed by the PS/Director to ensure all required information is present. Documentation of reviews shall be kept. (AS 4/4/16)] 02/29/2016 Implemented
SIN-00078287 Unannounced Monitoring 04/29/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Direct Service Worker #1, date of hire 2/17/15 did not have a request for a Pennsylvania criminal history check until 2/28/15. 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 Director will ensure that all employees (including part-time and temporary staff) who will have direct contact with the individual of the home, will apply for a Pennsylvania criminal history record check and submit it to the State Police within 5 working days after the person's date of hire. [As per conversation with the Director on 10/5/15, the house manager reviews new hire checklist including background checks and completes and director reviews all documentation and prior to new employees beginning work at the home. (AS 10/5/15)] 06/26/2015 Implemented
6400.164(a)The March, 2015 medication log for Individual #1 did not include the person who administered the following prescription medications: Divalproex sod DR, 500mg at 9:00 PM on 3/17/15; Melatonin, 10mg at 11:00 PM 3/17/15; Risperidone, 1mg at 11:00 PM on 3/17/15; Zolpidem Tatrate, 10mg at 11:00 PM on 3/11/15 and 3/17/15, Erythomycin ointment at 8:00 PM on 3/11/15 and 3/16/15 and Ipatropium 0.06% spray at 9:00 PM on 3/17/15.A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. A meeting will be held for proper medication passing & proper documentation and the importance of documenting right after the dose. The Program Specialist will monitor this during weekly checks. Program Specialist will directly observe each staff person who administers medication weekly for one month and documentation will be recorded.[As per conversation with Director on 10/5/15, the Director/program specialist will complete medication train the trainer after 6 months of employment (November, 2015). New staff will receive Medication Training through a certified trainer. (AS 10/5/15) 06/26/2015 Implemented
Article X.1007Loving Care Center is required to maintain criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. 10225.101-10225.5102) and its regulations (6 Pa.Code Ch.15). CEO/Program Specialist #2, hired in 3/30/15 resides outside of Pennsylvania does not have a FBI check.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.The new director changed Loving Care Center Policy which requires the provider to maintain criminal history checks and hiring policy in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. 10225.101-10225.5102) and its regulations (6 Pa. Code CH.15). Provider submitted to department via email to ascharpf@pa.gov the FBI check in accordance with the Older Adult Protective Service Act.[As per conversation with the Director on 10/5/15, the house manager reviews new hire checklist including background checks and completes and director reviews all documentation and prior to new employees beginning work at the home. (AS 10/5/15)] 06/24/2015 Implemented
SIN-00066049 Renewal 01/15/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(c)The agency does not have a chief executive officer. According to staff interviews, Staff person #2 served as both the CEO and program specialist; however, s/he resigned from the positions during December, 2014. A chief executive officer shall have one of the following groups of qualifications: (1) A master's degree or above from an accredited college or university and 2 years work experience in administration or the human services field. (2) A bachelor's degree from an accredited college or university and 4 years work experience in administration or the human services field. [As per converation with the Board Treasurer on 6/181/5, by 7/1/15, s/he will submit to the department via email to ascharpf@pa.gov the qualifications of the CEO hired on 6/11/15. (AS 6/22/15)] 07/01/2015 Implemented
6400.44(a)The agency does not have a program specialist assigned to Individual #1. According to staff interviews, Staff person #2 served as both the CEO and program specialist; however, s/he resigned from the positions during December, 2014. A minimum of one program specialist shall be assigned for every 30 individuals. A program specialist shall be responsible for a maximum of 30 people, including people served in other types of services. As per converation with the Board Treasurer on 6/181/5, by 7/1/15, s/he will submit to the department via email to ascharpf@pa.gov the qualifications of the CEO hired on 6/11/15. (AS 6/22/15) 07/01/2015 Implemented
6400.46(d)Direct service worker #1 had 18 hours of training during the 2014 calendar training year.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. [CEO or designee will develope a tracking system to record all staff trainings and orientations for the training year. The tracking system will include the training source, content, dates, length of training. (AS 6/22/15)] 06/22/2015 Implemented
6400.46(e)Program Specialist #2, hired 2/4/14, was not trained in 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. 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. The new program specialist will have this training within the before 2/23/2015 [CEO or designee will ensure all new hires receive the required trainings within 30 calendar days after the day of initial employment or with 12 months prior to initial employment and will maintain a tracking system for required trainings. (AS 4/29/15)] 02/23/2015 Implemented
6400.68(b)The hot water temperature at the bathtub in the bathroom on the main level of the home measured 126.4 degrees Fahrenheit at 2:50 PM. Hot water temperatures in bathtubs and showers may not exceed 120°F. A water temperature chart was completed. The program manager will check the temperature in the bathroom daily and record. If it is above 120, staff will be responsible for adjusting it. The water temperature will be included on the monitoring tool that the program director will complete on a minimum of a monthly basis. 02/28/2015 Implemented
6400.74The interior stairs leading from the main level to the basement do not have a nonskid surface. Interior stairs and outside steps shall have a nonskid surface. Waiver approved by the department dated June 11, 2015 06/11/2015 Implemented
6400.80(a)At 2:00 PM, the outside walkway leading to the front door of the home was covered with 2-3 inches of snow. Outside walkways shall be free from ice, snow, obstructions and other hazards. High winds early in the day had put snow on the walkway by the door. We will hold a safety meeting to stress the need to conduct regular checks of the walk to ensure sidewalks are clean and travel into and out of the home is free of snow ice and things of the like. We will also add cleaning of outside walks to the job description. The walks will be reviewed by the program specialist. [CEO or Designee will monitor walkways at least daily to ensure walkways are free from ice, snow obstructions and other hazards. Updated job descriptions and safety meeting minutes will be submitted to the department to the attention of A. Scharpf. (AS 4/29/15)] 02/15/2015 Implemented
6400.82(e)The bathtub in the bathroom on the main level of the home did not have a nonslip surface or mat. Bathtubs and showers shall have a nonslip surface or mat. Waiver approved by the department dated June 11, 2015 06/11/2015 Implemented
6400.85(b)The swimming pool located in the back of the home has a deck that is level with the home and the top of swimming pool. The swimming pool is accessible to the Individual #1 through the unoccupied bedroom at the end of the hallway. An aboveground swimming pool that is under 4 feet in height shall be made inaccessible to individuals when the pool is not in use.Pictures of the pool showing the gate across the deck entrance to the pool. 06/11/2015 Implemented
6400.107At the time of inspection, there were portable space heaters being used in the lower level and a garage of the home. Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms. All portable heaters will be removed from loving care. A check for portable heaters will be added to the monitoring tool and will be checked on the monthly basis. All heaters have since been removed. 01/31/2015 Implemented
6400.141(c)(9)The physical examination, dated 10/29/14, did not include a prostate examination for Individual #1, date of birth 6/15/74.The physical examination shall include: A prostate examination for men 40 years of age or older. A new physical examination is scheduled for 3/11/2015. This exam will have a prostate exam. 03/11/2015 Implemented
6400.163(c)The psychiatric medication review documentation signed by the licensed physician on 10/13/14 does not include the need to continue the medication and the necessary dosage. The psychiatric review documentation signed by the licensed physician on 8/6/14 does not include the necessary dosage. Repeat Violation 12/30/13. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The program director and direct care staff will ensure that all medical forms are completely filled out and ensure that the correct form is used. The director will aslo review the medical chart one time per month. 02/28/2015 Implemented
6400.164(b)At 8:00 AM on 1/8/15, Divalproex SOD 500mg, Zyrtec 10mg, Perfect Multi vitamin, Vitamin D 400 units, Levothyroxine 50mcg, and Fluticasone prep 50mcg were administered to Individual #1. The name of the person administering the medications was not logged until 3:20 PM on 1/8/15. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. A meeting will be held on proper medicine passing and proper documentation and the importance of documenting right after the dose.The program specialist will monitor this during weekely checks. [Program Specialist will directly observe each staff person who administer medications at least weekly for 3 months and documentation will be kept and submitted to the department to the attention of A. Scharpf. (AS 4/29/15)] 02/28/2015 Implemented
6400.167(b)Individual #1 is prescribed Ambien 10mg tablet, take 1 tablet by mouth once daily at bedtime as needed for insomnia. From 1/1/15 to 1/7/15, Ambien 10mg was initialed as administered to Individual #1 on the medication administration record. There was no documentation as to the reason for administering the medication. Staff interviews revealed that the Ambien is given to Individual #1 every night and not on an as needed basis as prescribed. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.The Dr. in question has been visited during an appointment after the inspection and the label on the prescription will be changed to reflect a nightly dosage. The pharmacy will be contacted to denpense the medication again so the label can be correct.Director/Program Specialist will review the MAR on the weekly basis and when a new perscription is added or discontinued. 02/20/2015 Implemented
6400.171Boxes of pancake mix, rice, potato buds, stuffing mix and cornflake cereal were unsealed in the pantry cabinet in the kitchen of the home. Food shall be protected from contamination while being stored, prepared, transported and served. A meeting will be held with staff to discuss the issue of food safety. At the meeting a memo will be passed around containing the highlights of the meeting for a signature of all employees. Handouts will also be distributed to employees to keep. Clips and other proper containment measures will be discussed at the meeting to ensure everyone knows how to handle and store food. In addition the. Director/Program Specialist will add to the monitoring tool and check for proper food storage on a mimimum of a monthly basis. 02/28/2015 Implemented
6400.186(a)The most recent 3 month ISP review completed for Individual #1 was for the review period of 6/24/14 to 9/23/14. 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 new Director/Program Specialist updated quarterly review to include change in services provided. The Director/Program Specialist will ensure that the quarterly review will be completed at maximum intervals of three months and more frequently as the needs of the client change. A ¿due date¿ chart will be completed along with the use of reminders on the calendar will be used to ensure timely completion. The team members will receive the quarterly review upon completion and documentation will be provided on when it was sent. The quarterly will be reviewed with the individual and signed by both. 03/15/2015 Implemented
6400.186(b)The ISP review for Individual #1 for review the period of 6/24/14 to 9/23/14 is not signed by individual as reviewed. The ISP review for Individual #1 for the review period of 12/24/13 to 3/23/14 was not dated by the program specialist and individual upon review. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. 2. Director/Program Specialist will add specifically to the monitoring tool that the program specialist has signed and dated each quarterly review, the individual signed and dated, and documentation will be provided that it was sent to the team members on a minimum of a monthly basis. 03/15/2015 Implemented
SIN-00057880 Renewal 12/30/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment for this home was done on October 1, 2013, and the certificate of complinace expired on October 14, 2013.(a) The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. Provider has current and proper knowledge that all self assessments need to be completed 60 days before the certificate of compliance expires. This information has also been to the agency's Provider Monitoring book. [The provider will schedule future self inspections to be completed within the 3 to 6 month period prior to the expiration date on the license. (CHG 1/21/14)] 01/06/2014 Implemented
6400.46(f)Staff #1's date of hire was 3-26-13, and Staff #2 was hired on 3-13-13, but the staff-persons were not trained in the required topics until 9-28-13, which is after Staff #1 and Staff #2 had been working with the individual. (f) Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. Provider will include fire safety as a part of all new employees orientation during the hiring process. [Documentation of the above documents will clearly state the topics above for all orientation trainings. The Director will audit all current staff records and for any employees who have not received the required training in these topics, then training will be completed by 2/28/14. (CHG 1/21/14)] 01/14/2014 Implemented
6400.46(i)Staff#2's date of hire was on 3-13-13, but did not have first aid training completed until 9-28-13. (i) 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. Provider will include all first aid training within a 6 month time period from the date of hire for the new employee. [The director will audit all staff records to ensure that all program specialists, service workers and drivers of and aides in vehicles are trained in first aid, cpr and heimlich techniques. Any staff person found not to have the training completed within 6 months of hire will receive the training before working directly with any individuals. (CHG 1/21/14)] 01/14/2014 Implemented
6400.163(c)The three-month medication review for Individual #1, dated 11-11-13, did not address the need to continue Risperdal and Depakote. (c) If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Provider will make sure that when individual visits Psychiatrist the medical review form will be filled out completely and noted need to continue medication by the Psychiatrist. 01/13/2014 Implemented
6400.181(a)Individual #1's assessment was done on 5-28-13; however, his/her admission was on 3-4-13.(a) 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. Provider has current and proper knowledge of assessment limitations and will be filled 60 days after admission and within one year after admission. This process will need to be maintained yearly. 01/14/2014 Implemented
6400.213(1)(i)Individual #1's record did not include the individual's religious preference or next of kin. Each individual's record must include the following information: (1) 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. Provider has amended individuals record to show all information required and has placed each record in all available logs for the individual. 01/14/2014 Implemented
SIN-00240340 Renewal 03/12/2024 Compliant - Finalized
SIN-00221977 Renewal 03/30/2023 Compliant - Finalized
SIN-00170760 Renewal 02/11/2020 Compliant - Finalized
SIN-00150050 Renewal 02/14/2019 Compliant - Finalized
SIN-00129435 Renewal 02/21/2018 Compliant - Finalized
SIN-00042138 Initial review 10/04/2012 Compliant - Finalized