Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00240128 Unannounced Monitoring 02/21/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16On 2/21/24 at 10:22AM, while conducting an interview in an Individual's bedroom on the second floor of the home, the Licensing Representative heard a loud sound. Upon exiting the room, the Licensing Representative observed through the ajar door, that Individual #2 was undressed and wet on the bathroom floor from apparently falling from the shower. The water in the shower remained on. Direct Service Worker #1 was summoned from the kitchen on the first floor of the home where she was washing dishes in the kitchen, to attend to Individual #2. In the ability to bathe self-section of Individual #2's current assessment, completed 12/22/23, assess Individual #2 to be unable to set the water temperature, requires physical hand to hand assistance, requires verbal prompting to rinse soap, measure shampoo, wash hair, and dry off. In the supervision section of this assessment, Individual #2 requires verbal prompting while in the bathroom using the toilet, bathtub, and shower. In the ability to be left unsupervised section of this assessment, indicates that Individual #2 is not able to be left unsupervised in the home.Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.During the time of this alleged incident there was an inspection taking place at our site. My staff was told that the inspectors were going upstairs in the home to conduct a private interview with one of the residents. At the time she was downstairs with individual 2. Individual 2 went upstairs to get ready and decide to take a shower. Out of respect for the inspectors and what they understood of the inspection process, the staff that was working was under the impression they needed to remain downstairs while they were interviewing the other individual upstairs. When other staff arrived during this time - it was communicated to them by this staff that they needed to wait downstairs while they were upstairs. Which makes this an extraordinary situation, because under normal conditions (no interview being conducted on the second floor) my staff would have been upstairs checking on Individual #2 in this scenario. Individual #2 is a not a waiver client of the state. When she moved to this site, we had to get her records up to date to be in compliance with 6400 regs. Part of this was updating her assessments and ISP. Individual # 2 has been bathing herself for years (she does not like to be touched), staff only checks on the individual to see if they need assistance. Our Program specialist who was updating individual #2 paperwork is newer to our agency and was not aware of the previous assessment of individual #2. They mistakenly put down that individual #2 needs assistance bathing and toileting. An email was sent to the inspector who conducted this inspection to present this mistake to him and the correction as well as what was already shown in the system which is the individual is able to bathe themselves. 02/21/2024 Not Implemented
6400.62(a)On 2/21/24 at 10:41AM, a twelve ounce bottle of Shark VACMOP floor cleaner was unlocked and accessible under the vanity in the ensuite bathroom of Individual #2's bedroom. Individual #2's most recent assessment completed, 12/22/23, has Individual #2 assessed as unable to use or avoid poisonous materials. [Repeated violation 4/28/23]Poisonous materials shall be kept locked or made inaccessible to individuals. On 2-21-24, the product in question was immediately removed and properly stored. Next - staff were retrained through direct instruction from our Residential Site Coordinator. They were reminded that all products considered poisonous/Toxic and harmful to our clients are to be stored and locked according to our procedures. 02/21/2024 Not Implemented
6400.64(b)On 2/21/24, Interviews reveal that there is a rat issue in the home, a rat has been observed coming from behind the stove in the kitchen, behind the microwave and in the basement, and exterminators have been to the home. There is an eight-inch by eight-inch hole behind the microwave in the kitchen of the home. At 10:08AM, a rodent sticky pad with a dollop of peanut butter in the center was atop a cabinet above the stove in the kitchen of the home. At 12:02PM, Greenix rodent trap boxes were outside near the side and rear doors of the home. In addition, there was multiple discarded items to include but not limited to discarded food wrappers, aluminum foil, and empty plastic bottles strewn across the ground under the rear deck of the home.There may not be evidence of infestation of insects or rodents in the home. As stated in the correction required section - there was no evidence of rat(s) at the time of inspection because this issue had been addressed. This violation was based on the hour long interview conducted with individual 2, inspectors stated that "if not for the interview we would not have know about the rats." The was one rodent seen in the home that was caught by an exterminator weeks prior to the licensing inspection. Staff explained that this issue to the inspectors at the time of inspection that the issue had been addressed and we were not in violation. Additionally a detailed email was sent to the inspector at their request. This email included documentation detailing preventive treatment measures as well as the subsequent actions that we had taken to address the rat that was seen on the premises immediately. 02/21/2024 Implemented
6400.67(a)On 2/21/24 at 10:34AM, there are numerous cracks in the walls of Individual #1's bedroom.Floors, walls, ceilings and other surfaces shall be in good repair. On 3/10 the cracks that were noted and brought to our attention were fixed and properly sealed. 03/11/2024 Implemented
6400.80(a)On 2/21/24 at 12:01PM, the outside deck at the rear egress of the home had areas that were covered in snow and ice posing a slipping and falling hazard. Outside walkways shall be free from ice, snow, obstructions and other hazards. On 2-21-24 immediately following the inspection staff were instructed to clear up any remnance of snow or ice that the inspectors observed. 02/21/2024 Implemented
6400.214(b)On 2/21/24, a complete current assessment for Individual #1 was not being kept in the home. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. On 3/11/24 the most current copies of the assessment for individual 1 was updated and in the home. The rest of the binder was checked by the Program Specialist and all required documentation was in place. 03/12/2024 Implemented
6400.165(c)Individual #1 is prescribed Xulane 150-35 mcg/24hr with instruction to, "Apply 1 patch topically onto skin weekly for 3 weeks, then 1 week off for birth control." Individual #1's February 2024 Medication Administration Records documents a patch administered at 8:00AM on 2/9/24 and not again as of 2/21/24. House Supervisor #1, she stated that she thought the patch was to be applied one time and left on for a three-week period and then one week off.A prescription medication shall be administered as prescribed.On 2/21/24 - the HCS Admin staff immediately called the pharmacy to get confirmation on the correct way to remedy this medication issue safely. Staff were then retrained through direct management to staff instruction with clear directives on how to administer individual #1 prescribed Xulane 150-35 mcg/24hr patch. once weekly for 3 weeks and then 1 week off and then repeat. We have also followed the inspectors direction on how to document this on the individuals MAR so that it is clear and will prevent errors. 02/21/2024 Implemented
SIN-00238136 Unannounced Monitoring 01/26/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(13)Individual #1 is prescribed Xulane 150-35 MCG/24HR PTWK, with instructions to apply 1 patch topically onto skin weekly for 3 weeks, then 1 week off for birth control. Individual #1's January 2024 medication record for this medication was documented with check marks daily for three weeks. The administration days and times of were not documented with the name and initials of the person administering this medication. Individual #2 is prescribed Sertraline HCL 100mg with instructions to take 1 ½ tablets by mouth daily, Zovia 1-35 mc-mcg with instructions to take 1 tablet by mouth once daily, Carbamazepine ER 300mg cap with instructions to take 1 capsule by mouth two times a day, Calcium 600-Vit D3 400 Tab with instructions to take 1 tablet by mouth two time a day, Divalproex SOD DR 500mg Tab with instructions to take 1 tablet by mouth 3 times a day was not initialed as administered at 8:00AM on 1/1/24 through 1/7/24 and 1/9/24 through 1/23/24. Individual #2 is prescribed Divalproex SOD DR 500mg Tab with instructions to take 1 tablet by mouth 3 times a day was not initialed as administered at 4:00PM on 1/1/24 through 1/22/24. Individual #2 is prescribed Carbamazepine ER 300mg cap with instructions to take 1 capsule by mouth two times a day, Calcium 600-Vit D3 400 Tab with instructions to take 1 tablet by mouth two time a day, Divalproex SOD DR 500mg Tab with instructions to take 1 tablet by mouth 3 times a day was not initialed as administered at 8:00PM on 1/1/24 through 1/22/24. Individual #2 is prescribed Risperidone 3mg tablet with instructions to take ½ tablet by mouth twice daily and to discontinue medication on 1/23/24. On the January 2024 medication record, Risperidone 3mg was not initialed as administered at 8:00AM or 8:00PM from 1/1/24 through 1/23/24.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.Individual #1's birth control patch was being done with checkmarks as stated, as per the inspector we were advised that in place of checkmarks the staff who is administering the patch is to initial, write full name, time and date when it is being put on the individual and then in 3 weeks when it comes off as prescribed staff are to initial, write name, and the time and date that it comes off, and then repeat after a week when it is time to administer the new patch as prescribed. signatures for individual #2's medication - there was a new MAR being used at the time of inspection which did not have the initials mentioned - this was due to an increase in their medication to 4mg and there was no place to make that adjustment on the current MAR that was being used. Management informed the pharmacy and the pharmacy had to make a new MAR because they did not update it correctly. When we got the new MAR - the staff began using it but did not update the previous dates that were signed on the old MAR and instead they just continued on from the date they received the new MAR. They were informed by management that this needed to be updated to reflect all the signatures and dates on the previous (old) MAR, and it was not done at the time of inspection. Each staff member was written up for not updating the MAR as they were instructed to do so. The previous (old) MAR was presented to the inspector to show that these were in fact signed for and not neglected, and the new MAR was properly updated to have complete records documented in one place. 01/31/2024 Not Implemented
SIN-00236208 Unannounced Monitoring 12/11/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(f)At 10:00AM, there was ten outdoor black trash bags containing disgarded items lined up in the grass next to the sidewalk. There were three outdoor trash receptacles next to the bags; however, two of the trash receptacles were not able to be closed due to garbage bags overflowing and protruding from the top of the receptacle. In addition, there was additional loose disgarded items on the ground in this area including cardboard boxes, a steam cleaner, and a piece of drywall that was attached to a wood framing.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The black trash bags and other bulk items that were out and noted at the time of the inspection were there only because they were placed for bulk pick up by the town sanitation department. The items were picked up within the next few days during bulk pick up. This site had been vacant since August prior to the Individuals who now reside at this location moving in during the middle to end of November, and prior to them moving in HCS had repairs and renovations done on the site to get it ready. This violation was due to extraordinary circumstance because HCS does regularly manage our trash in accordance with the 6400 regulations and kept in closed receptacles. 12/15/2023 Implemented
6400.71At 10:14AM, the telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the cordless telephone on the first floor of the home.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. On 12/11/23 The phone numbers for the hospital, police department, fire department, ambulance and poison control center were placed visibly by the first floor phone in the site - where they can easily be located and utilized if necessary. 12/11/2023 Implemented
6400.113(a)Individual #2, date of admission 11/30/23 was not been instructed in fire safety 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. It is important to note that Individual #2 was a non-waiver client who moved into a licensed site of ours at the end of November. Our management team, program specialist and Residential Site coordinator have been working to get Individual #2 records compliant with the state regulations which we know is a requirement. At the time of inspection we were still in the process of doing this and getting what is required into her records/binder. 01/15/2024 Implemented
6400.141(c)(4)Individual #2's physical examination, completed on 7/31/23 did not include a hearing screening.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. HCS administrator advised individual #2's guardian that a health screening was required and requested that one be arranged at their next PCP appointment where a physical is required so that we can have that record. 01/15/2024 Implemented
6400.141(c)(7)Individual #2's most recent gynecological examination was completed on 11/30/20. [Repeat 3/7/23]The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. The 11/30 record for indiviudal #2 was the most recent record HCS had to show because at that time they were living at a different licensed site of HCS and we were maintaining their records in accordance with the 6400 regs. HCS program specialist and Administrator are working with individual #2's guardian to get their most recent records so that they can be put into their binder on site. 01/15/2024 Not Implemented
6400.141(c)(11)Individual #2's physical examination, completed on 7/31/23 did not include health maintenance needs, medication regimen, and the need for bloodwork at recommended intervals. This section was left blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. It is important to note that Individual #2 was a non-waiver client who's appointments are managed by their Guardian prior to them moving in. HCS administrator will advise individual #2's guardian that An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals - is something that will need to be addressed at their next PCP appointment where a physical is required so that we can have that record. 01/15/2024 Not Implemented
6400.141(c)(14)Individual #2's physical examination, completed 7/31/23 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. It is important to note that Individual #2 was a non-waiver client who's appointments are managed by their Guardian prior to them moving in. HCS administrator will advise individual #2's guardian that medical information pertinent to diagnosis and treatment is something that will need to be addressed by their physician at their next PCP appointment where a physical is required so that we can have that record. 01/15/2024 Not Implemented
6400.214(a)At 11:25AM, Individual #1's current dated photograph was not being kept in the home.Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home.on 12/12 an updated photograph was dated and added to Individual #2's binder to bring that matter to compliance within the regulations. 12/12/2023 Implemented
6400.214(b)At 11:26AM, Individual #1's current assessment and individual plan were not being kept in the home. At 11:41AM, Individual #2's individual plan and psychological examination were not being kept in the home.The most current copies of record information required in § 6400.213(2)-(8) shall be kept at the residential home.HCS Program Specialist will check to ensure we have the most current copies of each individuals plan and Individual #1's assessment, and then place them in the home to maintain compliance with this regulation. 01/15/2024 Not Implemented
6400.18(a)(9)On 10/21/2023, Individual #1 along with an agency staff person were involved in a motor vehicle accident. Individual #1 was transported to the Emergency Department of a local hospital. Individual #1 was diagnosed with a lumbar strain and an acute cervical strain. The agency did not report the incident through the Enterprise Incident Management System, the Department's information management system.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Injury requiring treatment beyond first aid. This incident will be handled as follows - an extension was requested to address this incident in EIM. Our certified investigator will work with staff to get all pertinent information and will input this into EIM. 01/15/2024 Not Implemented
6400.24On October 3, 2022, the agency was issued sanctions under Pennsylvania Code Title 55 Chapter 6100 regulations: Services for Individuals with an intellectual disability or autism. The sanctions included an ongoing ban on serving new individuals. On November 30, 2023, the agency admitted a new individual.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.This violation is misrepresenting the facts - This was not a newly admitted individual per HCS understanding. Individual #2 has been a client with HCS since 2019 - and has lived in our 1905 site, then moved to another site of ours, and on 11.30 moved into their current site. So given the language that was provided to us, moving individual #2 into the current site was not in violation of the referenced sanction we received. 12/11/2023 Implemented
6400.32(r)(1)At 10:26AM, Individual #2's bedroom door has a keyed lock. Individual #2 does not have a key to utilize the bedroom door lock. Individual #2 has not been given the right to lock and unlock the Individual #2's bedroom door.Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.It is important to note that Individual #2 is a non-waiver client, and their guardian does not want Individual #2 to lock their door. We have spoken to them about this regulation and are awaiting a decision. 01/15/2024 Not Implemented
6400.34(a)Individual #2, date of admission 11/30/23 has not been informed and explained individual rights. [Repeat 3/7/23]The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Individual #2 and their guardian will be informed of individual rights and the process to report a rights violation. 01/15/2024 Implemented
6400.165(g)Individual #2 had a psychiatric medication review completed on 7/1/23 and then again on 11/21/23. [Repeat 3/7/23]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.HCS admin will inform individual #2's guardian of the process when a medication is prescribed to treat symptoms of a psychiatric illness, and work with them to have this process followed to ensure compliance. 01/15/2024 Not Implemented
6400.213(1)(i)The photograph in Individual #2's record was dated 1/3/2019.Each individual's record must include the following information: (vi) A current, dated photograph.On 12/12 A current dated photograph was added to individual #2's binder. 12/12/2023 Implemented
SIN-00234463 Unannounced Monitoring 11/14/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(e)On 11/14/23 at 10:22AM, the smoke detectors, on each of the three stories of the home, were not interconnected [Repeated violation 8/23/23].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. To correct this violation we will replace the one defective detector and regularly check them to ensure they are in sync. 11/30/2023 Implemented
SIN-00231995 Unannounced Monitoring 09/22/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.18(i)The home has not finalized the following incident reports through the Enterprise Incident Management System, the Department's information management system or notified the Department in writing that an extension is necessary and the reason for the extension: ID # 9220338 from 4/9/2023, ID# 9199715 from 4/13/2023, ID# 9199714 from 4/13/2023, ID# 9227789 from 5/31/2023, ID# 9264496 from 8/7/2023, and ID# 9265275 from 8/16/2023.The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension.This will be handled as follows, HCS CI has submitted an extension to complete these incidents through the Enterprise Incident Management System (EIM). They will then gather information to complete these incidents in order to close them each out in EIM. 02/15/2024 Not Implemented
SIN-00229832 Unannounced Monitoring 08/23/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)At 11:35AM, the first aid kit contained multiple packets of acetaminophen and aspirin. The individuals in residing in the home are not assessed to self-medicate and are not assessed safe with poisonous materials.Poisonous materials shall be kept locked or made inaccessible to individuals. To correct this violation the acetaminophen and aspirin was immediately removed from the first aid kit and properly disposed of by the Team Lead while the inspectors was still on site. Team Lead will speak with all staff at this site to ensure they understand the seriousness of this violation and to ensure they will always make sure that the first aid kits are locked and made inaccessible for the individuals who cannot self-medicate and not assessed safe with poisonous materials. They will also ensure there are no medications or poisonous materials in the First Aid Kits. 08/29/2023 Implemented
6400.110(a)At 11:03AM, the smoke detector in the basement of the home was not operable. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. The smoke detector in the basement was fixed on August 29 and is now operational and functioning correctly as an interconnected smoke detector. 08/29/2023 Implemented
6400.110(e)At 11:02AM, the smoke detector on the first floor was operable; however' was not interconnected to the other two floors of the home. At 11:04AM, the smoke detector on the second floor of the home was operable; however, was not interconnected to the other two floors of the home.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. To correct this violation, all smoke detectors on each floor were re-connected and tested on August 29, 2023. All smoke detectors were tested and found to be audible throughout the home. Team Lead will check the site weekly to ensure the smoke detectors are functioning properly as interconnected. Between August 22 and August 29, the site utilized the manual smoke detector check-up until the detectors were repaired on 8/29/23. 08/29/2023 Implemented
6400.163(a)At 10:34AM, one Clonazepam tablet and two Acetaminophen tablets prescribed to Individual #1 were removed from the original labeled container from the pharmacy and were inside a small plastic storage container with "4PM" handwritten in black marker on a piece of masking tape on the container.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.To correct this violation the medication label on the bag was removed and placed on the original medication container upon discovery on the same day. Management and Staff Nurse will check medications on a regular basis to ensure all medications have their correct medication prescription label on the original container upon arrival from the pharmacy. Staff Nurse will contact the pharmacy immediately if the prescription label is not placed on the container and they will request they correct this mistake, by either send new medication with the prescription label or they send a prescription label that can be placed on the medication before staff begin to administer the medication. 08/23/2023 Implemented
6400.163(b)At 10:34AM, one clonazepam tablet and two acetaminophen tablets prescribed to Individual #1 were removed from the original labeled container from the pharmacy and were inside a small plastic container with "4PM" handwritten in black marker on a piece of masking tape on the container. Two empty zip lock bags were found. One zip lock bag was labeled "Sunday 8am" and the other "Sunday 8pm" in black marker. There was another small container which was empty with "8pm" handwritten in black marker on a piece of masking tape on the container.A prescription medication may not be removed from its original labeled container in advance of the scheduled administration, except for the purpose of packaging the medication for the individual to take with the individual to a community activity for administration the same day the medication is removed from its original container.To correct this violation, a medication training is scheduled for September 9th for all staff requiring medication training. Training will include proper medication passing procedure, including only removing medication from their original containers at the time the medication is scheduled to be passed. For all staff currently medication trained, a Medication Memo will be distributed, reminding med trained staff that a prescription medication cannot be removed from its original labeled container in advance of the scheduled administration. 09/09/2023 Implemented
6400.166(b)At 10:34AM, one Clonazepam tablet and two Acetaminophen tablets prescribed to Individual #1 were removed from the original labeled container from the pharmacy and were inside a small plastic storage container with "4PM" handwritten in black marker on a piece of masking tape on the container. Direct Service Worker #1 stated that the Clonazepam and Acetaminophen tablets were not administered at 4:00PM on 8/22/23. Direct Service Worker #1 is the staff member that did not administer the 4:00PM medication to Individual #1. Individual #1's August 2023 Medication Administration Record was initialed as being administered on 8/22/23 at 4:00PM by Direct Service Worker #1. [Repeat violation 4/28/23 and 6/30/23]The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.To correct this violation, DSW #1 was written up for this violation and will be attending the September 9, 2023, medication training to be re-trained for proper medication administration. 09/09/2023 Not Implemented
6400.167(a)(1)At 10:34AM, one Clonazepam tablet and two Acetaminophen tablets prescribed to Individual #1 were removed from the original labeled container from the pharmacy and were inside a small plastic storage container with "4PM" handwritten in black marker on a piece of masking tape on the container. Direct Service Worker #1 stated that the Clonazepam and Acetaminophen tablets were not administered at 4:00PM on 8/22/23. Direct Service Worker #1 is the staff member that did not administer the 4:00PM medication to Individual #1.Medication errors include the following: Failure to administer a medication.To correct this violation, DSW #1 was written up for failure to administer a medication. To correct the failure to administer a medication, DSW #1 will be attending the September 9, 2023, medication training to be re-trained for proper medication administration. 09/09/2023 Not Implemented
SIN-00227269 Unannounced Monitoring 06/30/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(a)The top step, from the wooden deck in the rear of the home, has a nonskid strip that is peeling away from the wood and hanging approximately three inches below the step, posing a tripping, and falling hazard. As per Individual #1's Individual plan, updated 6/21/2023; "[Individual #1] has a diagnosis of cerebral palsy. As a result, [Individual #1] walks with an unsteady gait." Outside walkways shall be free from ice, snow, obstructions and other hazards. To correct this violation, the non-skid strip on the top step was replaced on July 16, 2023. Additionally, we have replaced all existing non-skid tape in all areas at all sites with new non-skid tape where needed. 07/16/2023 Implemented
6400.165(c)Individual #1 is prescribed Levonor-Est Estra 0.15-0.03, take 1 tablet by mouth every day (skip placebo tablets) for menses. From 5/21/23 through 5/31/23, the agency administered this medication to Individual #1. From 6/1/23 through 6/12/23, Individual #1 was administered this medication while inpatient at the hospital. From 6/13/23 through 6/17/23 this medication was administered by the agency. The seven days of placebo tablets were not skipped as prescribed. Ketoconazole 2% shampoo, apply topically to affected area twice a week for scalp flaking/rash, prescribed to Individual #1, was administered on 6/23/23 and then again on 6/30/23. [Repeat 4/28/23]A prescription medication shall be administered as prescribed.We have restructured our process and added an additional level of oversight to ensure efficient, consistent medication administration for Individual #1 and all agency Individuals. Following this inspection, we hired an experienced Program Specialist who will ensure that medications administered on site, and in medical facilities when a resident is admitted, are properly accounted for and properly administered. DSP will ensure that the prescription matches what was prescribed. Medications will be checked when delivered and when returning home from a medical facility by our on-staff Licensed Nurse, who will be at all sites weekly to review the MAR and Medications to ensure compliance. We will retrain staff on administering "placebo pills" for Individual #1 on or before August 8, 2023. The Program Specialist and Operations Manager will review all MARs at all site locations for compliance. 07/19/2023 Not Implemented
6400.166(b)Vitamin D3 50mcg., take 1 tablet by mouth every day for supplement, prescribed to Individual #1 was not initialed as administered on 6/26/23 and 6/27/23. [Repeat 4/28/23]The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.We have been in the process of reworking our process and oversight for medications. Following this inspection. We hired an experienced Program Specialist to work with the Operations Manager to ensure that medication management is improved agency wide. All HCS staff were or are being retrained to ensure that they understand that medications administration is a Priority at Harmony Care Services. Trainings include passing medications on time, following all steps of the medication pass process, and always remembering to initial the MAR upon completion of a medication pass, which should be the the outcome of a successful medication pass. This issue is currently under review to analyze the problems and find effective solutions to significantly reduce and hopefully eliminate this violation. 08/08/2023 Not Implemented
SIN-00224018 Unannounced Monitoring 04/28/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16On 4/9/23 at approximately 9:00PM, Direct Service Worker #2 reported that Individual #1 slipped and fell in the kitchen. Direct Service Worker #2 admittedly did not hear Individual #1 approach the kitchen or witness Individual #1 falling. Direct Service Worker #2 evaluated Individual #1 for injuries using a "body chart" and the following injuries were notated, a "busted lip", a "mark on the arm from fall", and "... bruising to back of legs." On 4/13/2023, Individual #1's mother took Individual #1 to a scheduled dental appointment for extraction of the first and second molars. During this dental appointment, the dentist observed that the two central (front) teeth were loose, and extraction was completed on all four teeth. Following the dental appointment, Individual #1's mother transported Individual #1 to the community home. While assisting Individual #1 with changing her clothes, Individual #1's mother discovered that Individual #1 had bruising on her left leg, chest, left elbow, and feet; abrasions on her right ankle and abdomen, a swollen left ankle, a thin red mark, approximately 5 inches in length, extending across the middle of her neck, and a laceration on Individual #1's upper lip. Individual #1's mother proceeded with Individual #1 to the Emergency Department at UPMC Presbyterian Hospital where Individual #1 was administered medication for pain and anxiety and X-rays of both ankles and feet and left elbow were taken. From 4/9/23 to 4/13/23, the agency neglected to secure care healthcare for Individual #1's injuries, investigate an unexplained and unwitnessed injury requiring treatment beyond first aid; thus, resulting in additional pain, trauma, and medical and dental care for Individual #1.Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.To correct this violation, Mandatory Training on the correct way to Identifying and report Abuse will be scheduled and documented for all staff, at all sites at least annually, and as needed. the Immediate reporting of abuse and injury will be included in the training. A report to the manager immediately upon discovery will be required and training to enforce the need for immediate transport to an Urgent Care or Emergency Room Facility for examination of an injured will be included in the training. Any employee found negligent in following the mandated policy Incident Management will face disciplinary action that can result in a written warnings up to and/or including termination. 06/15/2023 Not Implemented
6400.62(a)On 4/28/23 at 11:53AM, a 19 ounce aerosol can of Lysol disinfectant spray was unlocked and unattended on a shelf between the kitchen and living room. [Repeat 10/24/22]Poisonous materials shall be kept locked or made inaccessible to individuals. To correct this violation, the Lysol spray was put away into the locked box that holds poisonous materials. Direct Service Worker on duty was instructed and retrained to always return poisonous materials to the Poisonous Material lock box. This site and all sites will be checked every day, several times per day for poisonous materials by staff and management daily for any poisonous materials that may have been left out in inappropriate places in the homes. Managers will check all sites for poisonous materials on a daily basis as standard operating procedure. 06/15/2023 Not Implemented
6400.67(a)The metal tack strip, on the floor between the hallway and the kitchen, was not securely tacked in place posing a trip and fall hazard. The loose tack strip exposed sharp and jagged edges of the flooring posing a laceration hazard. [Repeat 2/2/23]Floors, walls, ceilings and other surfaces shall be in good repair. The metal tack strip was replaced on May 1, 2023 and securely tacked in place. All floors, walls, ceilings and other surfaces at all sites will be checked for needed repair daily as part of general facility maintenance. 05/30/2023 Not Implemented
6400.144On 11/1/22, Individual #1 was prescribed a mechanical soft diet. On 4/28/23 at 12:05PM, a Department Licensing Representative witnessed Direct Service Worker #1 prepared and serve Individual #1, a plate of food containing a breaded chicken patty sandwich cut in approximately one-inch to two-inch pieces and whole tater tots. As per Indvidual #1's Individual plan updated 2/8/2023, "[Individual #1] has been identified as a choke risk."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. To correct this violation: - A Staff meeting was held 5/09/23, via zoom, to review Mechanical Diets with all staff; - Individual #1's doctor changed the Prescription to a level 6 Mechanical diet; - All staff were updated on the changes to the Level 6 Mechanical diet for Individual #1; - A binder was placed onsite with all information on Mechanical Diet/ Level 6, for hands on reference; - Managers will monitor staff during food prep for Individual #1 when on site; Managers will monitor all sites on a regular basis, for any health services that could be beneficial to the Individuals served by the Agency. 06/15/2023 Not Implemented
6400.18(a)(4)On 4/9/23, the home became aware of a suspected incident of physical abuse for Individual #1. The agency did not report the incident in the Department's information management system until 4/14/23.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Abuse, including abuse to a individual by another client. The incident was reported as a slip and fall that occurred while staff was mopping the kitchen floor, and because of the incorrect information provided, the incident was not reported within 24 hours as required by Department. To correct this violation, HCS Policy has been revised to require that any Individual involved in an alleged incident or accident or suspected physical abuse shall be taken to an Urgent Care Facility or the Emergency Room for a professional medical to diagnosis immediately upon discovery by Staff on duty. This policy will be implemented at all sites to ensure that incidents are reported as required and within compliance as required under Regulation 6400.18(a)(4). All agency sites will be trained on Abuse and Incident Management during the 2023 Training Year. 06/15/2023 Not Implemented
6400.18(g)On 4/9/23, the home became aware of a suspected incident of physical abuse. The home did not initiate an investigation until 4/14/23.The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person.The Incident was not identified as a suspected incident of physical abuse when first reported, which resulted in failure to initiate an investigation within 24 hours of discovery by a staff person. To correct this violation the agency policy has been revised to require that any incident - major or minor - must be taken IMMEDIATELY to an Urgent Care Facility or the Emergency Room and to initiate an investigation within 24 hours of discovery. This change in policy all require all incidents be reported within 24 hours of discovery by a staff person to ensure compliance. 06/15/2023 Not Implemented
6400.165(c)Individual #1 is prescribed Ibuprofen 600mg tab, take 1 tablet by mouth every 6 hours as needed for mild pain for up to 7 days. Individual #1 was administered the Ibuprofen from 4/13/2023 to 4/23/2023, 10 days. Individual #1 is prescribed Levonor E Estrad 0.15-0.03 take 1 tablet by mouth every day (skip placebo) for menses. The placebo was skipped from 4/18/23 to 4/21/2023 then the medication resumed to be administered on 4/22/23. The placebo was skipped for 4 days rather than the prescribed 7 days.A prescription medication shall be administered as prescribed.Due to our previous Med Trainer's inconsistencies with our medication administration needs, HCS made the decision to conduct Medication Administration retraining for the entire company. The decision was made to ensure uniform consistency with medication administration and to ensure all prescription medications are administered as prescribed. The plan of correction included Medication Trainings held for the entire agency on 4/18/23, 4/20/23, 4/22/23, and 4/25/23. Medication Observations are in progress and will continue until all trained staff have been med observed as per med training and compliance requirements. Medication Training is a high priority for all sites throughout the year for all staff and new hires on an ongoing basis. 06/15/2023 Not Implemented
6400.166(b)Ear drops 6.5%, instill 5 drops into each ear once a week for ear wax, prescribed to Individual #1 was not initialed as administered on 4/28/23 at 11:27AM. The ear drops were most recently administered to Individual #1 on 4/21/23 at 8:00AM. Levonor-Eth Estra 0.15-0.03, take 1 tablet by mouth every day (skip placebo) for menses, was not initialed as administered on 3/27/23.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Due to our previous trainer's inconsistencies with our medication administration needs, we had the entire company re-trained on Medication Administration, with the objective of uniform consistency within our staff, and quality medication administration as an agency. Medication trainings were held on 4/18/23, 4/20/23, 4/22/23, and 4/25/23, for all Agency staff on the importance of proper documentation, including initials where required on MAR documentation. Training objectives included uniform consistency, quality medication administration, and proper and complete documentation, which includes recorded initials for administered medications. All Direct Support Workers at all sites have been or will be trained on proper medication documentation, which includes current staff and newly hired staff this month, on-going and as needed throughout the year. 06/15/2023 Not Implemented
SIN-00220291 Renewal 03/07/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill records for the fire drills held on 11/11/22, 12/7/22, 1/23/23 indicated that not all smoke detectors and strobes were operable; however, the "problems encountered" sections were marked "not applicable."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. March 15, 2023 - Managers, who do the Fire Drills, were re-trained on the PA ODP 'Inoperable Smoke Detector Policy'. The training was successfully completed and staff now understand that "NON-OPERABLE" is the correct answer even while following the 'Inoperable Smoke Detector Policy'. All staff will be trained on the 'Inoperable Smoke Detector Policy' at all sites to reinforce the importance and the purpose of the "Inoperable smoke detector policy". The Operations Manager will audit all completed fire drill forms on a monthly basis monitor scheduled annually and as needed for new employees and managers. 04/26/2023 Not Implemented
6400.112(e)A fire drill was held during sleeping hours on 5/19/22 and then not again until 2/18/23.A fire drill shall be held during sleeping hours at least every 6 months. On or before April 7, 2023, a fire drill during sleeping hours will be scheduled at each site to correct the violation of the sleeping hours fire drill not being scheduled within 6 months.The Operations Manager and Residential Supervisor will ensure that an overnight fire drill on or before August 18, 2023 has been scheduled. Fire Drill records will be monitored by the Operations Manager and/or the Residential Supervisor or before the 30th of each month. 04/26/2023 Not Implemented
6400.141(c)(3)Individual #1 most recently received the Tdap (Tetanus, Diphtheria, and Pertussis) immunization on 02/16/11. Tdap booster shots are recommended by the Unites States Public Health Service, Center for Disease Control every 10 years.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. By March 30, the Residential Supervisor will have a scheduled Tdap booster for the earliest appointment date opportunity available for Individual #1. The Tdap immunization will be included in the agency's electronic medical appointment tracking system (MATS) for continued compliance with the next 10 years of the 2023 booster shot. The Operations Manager will review all Individuals Tdap booster shot records. 04/26/2023 Not Implemented
6400.141(c)(6)Individual #1 most recently had a tuberculin skin test completed on 08/10/22. There was not documentation of the previous tuberculin skin test; therefore, complaince could not be measured.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. In March or 2023, Individual #1's, 8/10/2022 TB Test was presented during inspection, but there was no record of a 2021 TB test. After the Inspection was completed, Individual #1's 2021 TB Test, was located, with a date of 11/1/2021, which was compliant within 2 years of her 8/10/2022 TB Test. All TB Records for all HCS Individuals will be reviewed by the Operations Manager for compliance or to schedule a TB test for those needing a TB test date within 03/30/2023 Not Implemented
6400.141(c)(7)Individual #1 had a gynecological examination, completed on 01/11/22 and then again on 03/03/23.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. On or before April 15, 2023, HCS will request an exemption for Individual #1, for the annual gynecological exams, pap tests and breast examinations, requesting none or less frequent gynecological examinations, breast exams and pap tests until Individual #1 is 40 years of age, and then every 5 years thereafter. Until a final decision has been made for an exemption, Operations Manager will ensure a gynecological exams pap test and breast examination will be scheduled on or before March 3, 2024. All female residents 18 years of age or older will be monitored and tracked for scheduled annual gynecological exams, pap tests and breast examinations to ensure compliance 365 days within their previous annual exam(s). 04/26/2023 Implemented
6400.142(a)Individual #1 had a dental examination, completed on 10/06/21 and then again on 01/31/23.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. To correct this violation, Individual #1 will have a dental examination scheduled on or before January 31, 2024, and then within 365 days of the previous appointments thereafter. To ensure compliance with this requirement , all Individual's dental and medical records will be checked for recent or scheduled dental appointments. If one is not scheduled, an appointment will be scheduled within 365 days of the previously scheduled dental appointment. The Operations Manager will review all Individual's Dental Appointments scheduled in 2022 to ensure appointments are scheduled within compliance for 2023 and 2024. 04/26/2023 Implemented
6400.151(a)Direct Service Worker #1, date of hire 01/16/23, had an initial physical examination completed on 01/18/23. 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. Direct Service Worker #1 was hired on 1/16/2023 and completed her physical examination on 1/18/2023. DSW #1 began working on 1/18/2023 before the results of the TB test was available, putting the Individual in a possible compromised situation. To correct this violation HCS will not place any employee on site with Individuals until the results of TB Test are reviewed and confirmed compliant. Once a negative result is confirmed, newly hired employees can come into direct contact with the Individuals on site. The Operations Manager will monitor the date new employees are compliant to come in contact with HCS Individuals. 03/30/2023 Implemented
6400.151(c)(2)Program Specialist #1 had a tuberculin skin test completed on 04/09/20 and then again on 06/27/22. 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. Program Specialist failed to get a TB Test completed as required for compliance. to correct his violation, the Program Specialist will ensure that a TB test is scheduled on or before 6/27/2024. The P.S. will work with the Operations Manager to ensure compliance is met regarding TB Tests on 2024. The 6/27/2022 TB Test will be tracked on the electronic health records system to ensure compliance in 2024 with the 2024 TB Test. The Operations Manager will track TB Tests for the Program Specialist. 04/26/2023 Implemented
6400.181(e)(13)(i)On 11/01/22, Individual #1's physician prescribed Individual #1 a mechanical soft diet. Individual #1's assessment, completed 02/16/23, was not updated to include Individual #1's prescribed diet. Individual #1's assessment, completed 02/16/23 indicate Individual #1's food must be cut into small dime-sized pieces.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. On 11/01/2022, Individual #1 was prescribed a mechanical soft diet that was not updated in the Annual Assessment completed on 2/16/23. To correct this violation the Program Specialist will document and update the diet change in Individual #1's assessment on or before March 30, 2023. The Program Specialist will document and update all changes to the diet of Individual #1 at the time of the change.The Program Specialist and Operations Manager will monitor all changes needing updated in all HCS Individual's Assessments to ensure compliance with current, updated and new information for all HCS Individuals. 04/26/2023 Not Implemented
6400.20(b)The home is not reviewing and analyzing incidents and conducting and documenting a trend analysis for at least the prior year.The home shall review and analyze incidents and conduct and document a trend analysis at least every 3 months.The home is not reviewing and analyzing incidents and trend analysis. Starting in April 2023, the home will review and analyze incidents and trend analysis at all sites and then every three months thereafter to document incident trends that have occurred since January 2023. Every three months thereafter the teams will review Incidents to develop a plan to reduce and eliminate the incidents and trends that are occurring on sites. The team will include staff who work at each site, the Operations Manager, Residential Supervisor and Client Care Manager .The Operations Manager will schedule and manage the incidents and trend analysis. 04/26/2023 Not Implemented
6400.34(a)Individual #1 was informed of individual rights on 01/14/22 and then again on 02/27/23.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.The Program Specialist failed to inform Individual # 1 of their Individual Rights and the process to report a rights violation in January, which is the month assigned for this annual review. Individual #1 was not informed of their Individual Rights until February 27, 2023, because the Program Specialist was on leave of absence. To correct this violation the Program Specialist will schedule a training with the Operations Manager, Residential Supervisor and Client Care Manager on how to review with Individual #1, their Individual Rights and the process to report a rights violation if the Program Specialist is not available. The Program Specialist reviewed all Individual files to ensure their 2023 Individual Rights document was reviewed with them and placed in their files. 04/26/2023 Implemented
6400.52(c)(1)Program Specialist #1's training for training year from January 1, 2022, to December 31, 2022, 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 Program Specialist failed to complete the required trainings for training year 1/1/2022 - 12/31/022, including Person Centered Practices, Community Integration, Individual Choice and Supporting Individuals to develop and maintain Relationships. To correct this violation, Harmony Care Services' Human Resource Manager will ensure that all required trainings for the Program Specialist are completed between January 2023 - December 2023 and every year thereafter.Training records will be documented and maintained in HCS' electronic files and a copy will be placed in the Program Specialist file and reviewed by the Human Resource Manager at the end of each quarter. Annual Training records for the Program Specialist will be monitored by the Human Resource Manager and the HR Manager will assign quarterly trainings for completion and follow-up until they are completed for that quarter to ensure compliance by December 15th of every year. The HR Manager will review and monitor training records for the Program Specialist and a copy of all Trainings will be maintained electronically and in the P.S.' employment file. 04/26/2023 Not Implemented
6400.52(c)(3)Program Specialist #1's training for training year from January 1, 2022, to December 31, 2022, did not include Individual Rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.To correct this violation, Harmony Care Services' Human Resource Manager will ensure that the Individual Rights training for the Program Specialist is completed between January 2023 - December 2023 and every year thereafter.Training records will be documented and maintained in HCS' electronic files and a copy will be placed in the Program Specialist file and reviewed by the Human Resource Manager at the end of each quarter. Annual Training records for the Program Specialist will be monitored by the Human Resource Manager and the HR Manager will assign quarterly trainings for completion and follow-up until they are completed for that quarter to ensure compliance by December 15th of every year. The HR Manager will review and monitor training records for the Program Specialist and a copy of all Trainings will be maintained electronically and in the P.S.' employment file. 04/26/2023 Implemented
6400.52(c)(4)Program Specialist #1's training for training year from January 1, 2022, to December 31, 2022, 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.To correct this violation, Harmony Care Services' Human Resource Manager will ensure that Recognizing and Reporting Incidents training for the Program Specialist is completed between January 2023 - December 2023 and every year thereafter.Training records will be documented and maintained in HCS' electronic files and a copy will be placed in the Program Specialist file and reviewed by the Human Resource Manager at the end of each quarter. Annual Training records for the Program Specialist will be monitored by the Human Resource Manager and the HR Manager will assign quarterly trainings for completion and follow-up until they are completed for that quarter to ensure compliance by December 15th of every year. The HR Manager will review and monitor training records for the Program Specialist and a copy of all Trainings will be maintained electronically and in the P.S.' employment file. 04/26/2023 Implemented
6400.52(c)(6)Program Specialist #1's training for training year from January 1, 2022, to December 31, 2022, did not include Implementation of the individual plan if the person works directly with an individual.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.The Program Specialist failed to complete the required trainings for training year 1/1/2022 - 12/31/022, including Implementation of the Individual Plan if the person works directly with an Individual.To correct this violation, Harmony Care Services' Human Resource Manager will ensure that all required trainings for the Program Specialist are completed between January 2023 - December 2023 and annually every year thereafter. Training records will be documented and maintained in HCS' electronic files and a copy will be placed in the Program Specialist file and reviewed by the Human Resource Manager at the end of each quarter. Annual Training records for the Program Specialist will be monitored by the Human Resource Manager and the HR Manager will assign quarterly trainings for completion and follow-up until they are completed for that quarter to ensure compliance by December 15th of every year. The HR Manager will review and monitor training records for the Program Specialist and a copy of all Trainings will be maintained electronically and in the P.S.' employment file. 04/26/2023 Not Implemented
6400.165(g)Individual #1 is prescribed medications to treat Mood Disorder and Anxiety Disorder. Individual #1 had a Psychiatric medication review on 04/28/22, and then again on 03/02/23.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.Individual #1 is prescribed medications to treat Mood Disorder and Anxiety Disorder but the documentation and reason for prescribing the medication was not documented.Individual #1's physician reviews the medication at least every three months but the request for documentation of the review and reasons for prescribing has not been consistent, nor compliant. Operations Manager will continue to provide the form for documentation, and will continue to follow-up for the form provided for review, for update and signature of the doctor for the quarterly psychiatric medication review. Operations Manager and Program Specialist will ensure documentation is provided on schedule in 2023-2024. 04/26/2023 Implemented
6400.182(c)On 11/01/22, Individual #1's physician prescribed Individual #1 a mechanical soft diet. Individual #1's Individual Plan, last updated 02/08/23 was not updated to include Individual #1's prescribed diet. Individual #1's Individual Plan, last updated 02/08/23 indicate Individual #1's food must be cut into small dime-sized pieces.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.Individual # 1 was prescribed a mechanical soft diet on 11/1/2022, and it was not updated in Individual #1's Assessment updated on 2/8/2023. To correct this violation the Program Specialist will inform the Supports Coordinator of the mechanical soft diet change made on 11/1/2022, for inclusion in Individual #1's Individual Plan. The Assessment will be updated and sent to the P.S. on or before 4/1/2023.The Program Specialist and Operations Manager will review the Assessment for any additional updates or corrections and will provide changes and updated information to the Supports Coordinator for revision in the Individual Plan. 04/26/2023 Not Implemented
SIN-00218615 Unannounced Monitoring 02/02/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)On 2/2/23 at 11:13 AM, there was a hole approximately three inches by two inches in the wall near the sink in the bathroom on the second floor of the home. In addition, there were coaxial cables visible inside this hole in the wall. On 2/2/23 at 11:23AM, there was a hole approximately three inches by three inches at the base of the wall in the kitchen of the home, where the ventilation cover was detached from the ventilation duct.Floors, walls, ceilings and other surfaces shall be in good repair. To correct this violation, a repairman was contacted on 2/3/2023 to come onsite to correct the hole in the bathroom wall near the sink and the 3x3 hole at the base of the wall in the kitchen caused the the displacement of the ventilation duct. An appointment was scheduled for repair on 2/9/2023, but unfortunately the repairman's father passed away before the scheduled appointment and the repair had to be rescheduled. Both holes have been safely covered until the repair can be completed. The walls at this site and all sites were checked for holes in floors, walls, ceilings and other surfaces at all of the HCS residents. No visible holes were discovered at any of the other sites. 02/24/2023 Implemented
6400.72(a)On 2/2/23 at 11:20 AM, there was not a screen in the window near the landing on the steps leading to the second floor of the home.Windows, including windows in doors, shall be securely screened when windows or doors are open. The removable screen was taken out of the window at the end of fall season. The screen is removed from the window during the winter season and the screen is removed. To ensure the windows are in compliance when opened, a permanent screen will be installed in the window before spring season 2023. The window will not be opened without a screen before the installation of the permanent screen. The Operations Manager will ensure that all windows that are opened will have secure, permanent screens installed and they will be checked monthly for repairs, tears and maintenance needs. All windows at all sights that are opened will be checked for permanent screens installed in the windows and checked for functionality on a seasonal/monthly basis. 02/28/2023 Implemented
6400.80(a)On 2/2/23 at 10:59AM, the rear exit of the homes fire evacuation route that leads across the decking was observed to be covered in snow. Outside walkways shall be free from ice, snow, obstructions and other hazards. The correct this violation, the snow removal service provider was contacted and reminded to remove snow in the rear of all properties as needed when they are on site to remove snow from the front of the properties. The snow removal service provider, when on site to remove snow, will check all areas of the property for snow removal needs, especially fire evacuation routes. Snow removal needs will be checked on snowy days at all sites by the snow removal service provider when snow falls. And snow removal services will be provided on snowy days. 02/04/2023 Implemented
6400.81(k)(2)On 2/2/23 at 11:16AM, the middle area of Individual #1's mattress was sagging approximately two to four inches.In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. To correct this violation, the sagging mattress issue had already been identified and corrected several days before the on-site inspection. Staff had identified the problem on January 28, 2023 and a bed was ordered on January 30th. A new frame for the new mattress will also be purchased for the new bed with a delivery date expected on or before March 1, 2023. This sagging mattress had already been identified and needing replaced several days before inspection and a new mattress had already been ordered. The problem was identified on January 28, 2023 and a bed was ordered on January 29th, 2023. A delivery date was not provided but the replacement is expected before the end of the month. All mattresses for all residents were checked for cleanliness, comfort and a solid foundation by the Operations Manager and Residential Supervisor. Mattresses will be checked regularly when the sheets are changed. 03/01/2023 Implemented
6400.110(e)On 2/2/23 at 11:32AM, the smoke detector on each of the three floors of the home 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. To correct this violation, ABCO Fire Services reviewed the interconnected smoke detectors at 8533 Frankstown Road and 1905 Penn Avenue on Wednesday, February 7, 2023. A proposal by ABCO will be available to determine if HCS will choose to replace or repair the current interconnected smoke detector system. Blue tooth smoke detectors were also recommended and will reviewed as well. The maintain compliance all smoke detectors will be checked at all HCS sites for proper functionality with immediate replacement of malfunctioning smoke detectors on a monthly basis, with regular month fire drills. This will ensure all smoke detectors on site are operable. 03/01/2023 Implemented
SIN-00216164 Unannounced Monitoring 12/02/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(f)On 12/2/22 at 11:08 AM, there was 3 outdoor trash receptacles next to the exit door at the side of the home. Two of the receptacles' lids were not fully closed due to garbage bags protruding from the top. The third can did not have a lid. On the ground, around the trash receptacles, among a pile of dried leaves, there was various food wrappings including pieces of aluminum foil, Styrofoam bowls with remnants of what appeared to be dried up spaghetti sauce and chewing gum package. In addition, there were soiled latex gloves on the sidewalk in this same area. [Repeated violation]Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.To correct this violation the trash was collected around the cans and the property on the day of inspection. Staff was retrained on trash maintenance and how to avoid rodents with good trash management. Team Lead monitors the trash cans weekly when on site. 01/15/2023 Implemented
6400.67(a)On 12/2/22 at 11:01AM, there was not a toilet seat on the toilet in the bathroom on the 3rd floor of the home. The toilet seat was leaning up against the wall next to the toilet.Floors, walls, ceilings and other surfaces shall be in good repair. The toilet seat at 8533 was corrected on the day of inspection, but a brand new toilet seat was purchased the same day and installed to replace the one attached while Inspectors were on site. Staff on site was trained on site that day by the Client Care Manager, about making certain that when a toilet has any malfunction, they are to contact the Team Leads and Operations Manager immediately and they are to document the date and time of contacting the Operations Manager for repair in the daily site log. 12/02/2022 Not Implemented
6400.68(b)On 12/2/22 at 11:01AM, the hot water temperature at the bathtub in the bathroom on the 3rd floor of the home measured 125.4 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. The hot water temperature on the 3rd floor bathroom bathtub was adjusted and is now reading between 113-115 degree Fahrenheit at site 8533. The temperatures read on 12/30/22 was 114.4 12/30/2022 Implemented
6400.81(k)(6)On 12/2/22 at 10:41AM, Individual #1's bedroom did not have a mirror.In bedrooms, each individual shall have the following: A mirror. To correct this violation, a mirror was placed in Individual #1's bedroom on 12/2/2022. 12/02/2022 Implemented
6400.82(f)On 12/2/22 at 11:15AM. the bathroom in the basement of the home did not have paper or cloth towels.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. To correct this violation, paper towels were placed in the bathroom on 12/2/2022 and extra supply was placed in the cupboard in that bathroom. 12/02/2022 Implemented
6400.101On 12/2/22 at 10:13AM, the sliding glass door in the dining room had a wooden dowel rod between the door and the trim of the door obstructing the egress to the outside of the home.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. To correct this violation, the dowel rod was removed at the time of inspection and has never been placed their again since the inspection. 12/02/2022 Implemented
6400.110(a)The home has a basement, first floor and second floor. On 12/2/22 at 10:42, there was not an operable smoke detector on the first floor of the home. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. To correct this violation, battery operated smoke detectors were installed on each floor as a backup plan for inoperable interconnected smoke detectors. The new inter-connected smoke detectors were installed over the next two days after the inspection. The inoperable smoke detector policy and protocol was implemented on the day of the inspection, while the interconnected detectors were not installed. Staff checked each floor every hour until the detectors were installed on 12/3/2022 and 12/4/2022. 12/04/2022 Not Implemented
6400.110(c)The home has a basement, first floor and second floor. On 12/2/22 at 10:42, the smoke detectors in the basement and on the second floor of the home were not in common areas or hallways.The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. To correct this violation, smoke detectors were installed in the basement and on the second floor of the home the weekend of the site inspection. 12/04/2022 Not Implemented
6400.110(h)On 12/2/22, between 11:10AM and 11:15AM, Client Care Manager #3, Direct Service Worker #1 and Direct Service Worker #2 were not aware of an inoperable smoke detector policy to implement when the smoke detectors in the home was not fully operational. There shall be a written procedure for fire safety monitoring in the event the smoke detector or fire alarm is inoperative.To correct this violation, the inoperable smoke detector policy was explained to the Client Care Manager, DSP #1 and DSP #2, and all other staff members at this site on 12/2/2022. All staff implemented the policy and documented the fire-safety monitoring policy after their training on 12/2/2022. 12/03/2022 Implemented
6400.32(r)(1)The agency has not provided Individual #1 the right to lock Individual #1's bedroom door.Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.To correct this non-compliance, Individual #1was provided with a new door knob with a lock and key on 12/12/2022. Individual #1 signed a form confirming she has received the key to her bedroom door. A second key was put on the House Keys chain and a third spare key was placed in office file cabinet. 12/12/2022 Implemented
6400.32(r)(4)On 12/2/22 at 10:40AM, Individual #1's bedroom door was equipped with a key locking mechanism. Individual #1 does not have access to a key for the door. Direct Service Worker #1 and Direct Service Worker #2 also do not have access to a key to gain immediate access.The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency.To correct this violation, Individual #1was provided with a new door knob with a lock and key on 12/12/2022. A second key was put on the House Key chain and a third spare key was placed in office file cabinet. Direct Service worker #1 and Direct Service Worker #2 now have access to Individual #1's bedroom for immediate access by using the key on the house key chain or the spare key placed in the file cabinet in the office. 12/12/2022 Implemented
SIN-00214020 Unannounced Monitoring 10/24/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)At 10:42AM, the following poisonous materials were unlocked and accessible in the unlocked laundry room in the home: Comet with Bleach, Woolite Carpet Cleaner, Windex window cleaner, Resolve carpet cleaner, and a bottle of Drano. Individual #1 is not assessed to be safe around poisonous materials.Poisonous materials shall be kept locked or made inaccessible to individuals. To correct this violation all laundry products were immediately removed from the laundry room and placed in the locked office. Staff was advised not to leave any laundry products in the laundry room. All HCS Staff will ensure that all sites with an Individual not assessed safe around poisonous materials will ensure that poisonous materials are locked up at those sites. 11/30/2022 Implemented
6400.64(e)The trash receptacle, measuring 22 inches in height, in the laundry room in the basement of the home, did not have a lid.Trash receptacles over 18 inches high shall have lids. To correct this violation a trash receptacle with a lid was placed in the laundry room. All trash cans were checked for lids at this site and other sites to ensure compliance with 6400.64(e). 11/30/2022 Implemented
6400.64(f)The uncovered outside trash receptacle, was on laying on its side in the driveway of the home, with a multitude of discarded items including soiled rubber gloves, fast food containers, plastic water bottles, various plastic bags, dispersed throughout the driveway of the home.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.To correct this violation all garbage was collected and bagged up for trash collection that evening. Staff was reminded and re-trained on the policy and procedure "No garbage in any trash can without a lid" procedure by the Manager. 11/30/2022 Not Implemented
6400.105The lint trap of the dryer in the basement of the home was entirely coated in a layer of lint.Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. To correct this violation, the lint was removed from the trap. Staff was informed and retrained on laundry room maintenance highlighting the danger of not removing lint from the lint trap. The site manager was instructed to check the dryer lint trap during weekly site checks at all locations where a dryer is on site. 11/30/2022 Implemented
6400.110(c)The home has four floors. At 10:42AM, the interconnected smoke detectors on the second floor of the home were not in common areas or hallways.The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. To correct this violation all interconnected smoke detectors at this site we be checked and replaced as needed. On the day of a site fire drill Management staff will check all smoke detectors for chirping or battery needs. 11/30/2022 Not Implemented
6400.32(r)(1)The agency has not provided Individual #1 the right to lock Individual #1's bedroom door.Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.To correct this non-compliance, Individual #1 was asked if she wanted to have a key or any other method to lock or unlock her door she said no. HCS will provide a declination letter for Individual#1 to sign, and it will be placed in her residential binder. HCS will review with all residents their right to lock their bedroom door and give them all the option to have a key or entry mechanism to their bedrooms if they want one. 11/30/2022 Not Implemented
SIN-00207496 Renewal 06/22/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)A bottle of Head & Shoulders dry scalp 2 in1 shampoo conditioner with warning instruction to contact poison control if ingested was unlocked and accessible in the bathroom on the second floor of home. Individual #2 is not assessed safe with poisonous materials.Poisonous materials shall be kept locked or made inaccessible to individuals. To correct this violation the bottle of head & shoulders was immediately removed from the bathroom and discarded. Individual #2 is assessed not safe with poisonous materials, therefore HCS will not purchase personal care products with 'contact poison control' warning labels; 08/10/2022 Not Implemented
6400.112(f)The front door was used as an exit for all fire drills held from 7/7/21 through 6/2/22. The home has more than one exit.Alternate exit routes shall be used during fire drills. The front door was used as an exit for all fire drills when the home had more than one exit. The operations manager immediately changed the fire drill schedule to ensure a different exit was used at the home in July 2022. 07/31/2022 Implemented
6400.141(a)Individual #1 does not have a physical examination. Individual #2 had a physical examination completed on 4/17/20 and then again 10/26/21. [Repeated violation, 7/7/21 et al]An individual shall have a physical examination within 12 months prior to admission and annually thereafter. To correct his violation Individual #1 completed a physical examination on 8/4/2022.The Program Specialist will schedule an annual physical for Individual # 2 on or before 10/26/2022; Operations Manager will check that a physical examination was completed within 12 months prior to admission and annually thereafter, to ensure their annual physical is scheduled and completed within compliance. 08/15/2022 Not Implemented
6400.141(c)(5)Individual #2's physical examination, 10/26/21 did not include immunizations.The physical examination shall include: Immunizations and screening tests for individuals 17 years of age or younger, as recommended by the Standards of Child Health Care of the American Academy of Pediatrics, Post Office Box 1034, Evanston, Illinois 60204. To correct this violation, the 2022 physical examination scheduled for Individual #2 will include immunizations. Program Specialist will ensure that all remaining 2022 physicals for agency's Individuals will include Immunizations on the physical examination form. 08/15/2022 Not Implemented
6400.141(c)(6)Individual #2's most recent tuberculin skin testing was completed on 4/19/20. [Repeated violation, 7/7/21 et al]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. To correct this violation, Individual #2 is scheduled for a TB test on or before 8/10/2022. 08/15/2022 Not Implemented
6400.151(c)(2)Program Specialist #1 does not have a completed Tuberculin testing. 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. To correct this violation, Program Specialist completed a TB test with negative results on July 25, 2022. 07/25/2022 Implemented
6400.181(d)The program specialist did not sign Individual #1's assessment completed 8/15/21.The program specialist shall sign and date the assessment. To correct this violation, the Program Specialist and the Operations Manager, as the second set of eyes, will review all assessments to insure the document is signed and dated. -Program Specialist and Operations Manager will insure that all subsequent 2022 Assessment signature lines is signed and dated before sending it to other team members. 08/15/2022 Not Implemented
6400.181(e)(1)Individual #1's assessment, completed 8/15/21 did not include the strengths and needs of the individual. Individual #2's assessment, completed 1/14/22 did not include the strengths, needs, and preferences of the individual. The assessment must include the following information: Functional strengths, needs and preferences of the individual. Program Specialist (PS) included strengths, needs and preferences of Individual #1's 2022 Assessment. PS will include the strengths, needs and preferences for Individual #2 's 2022 annual assessment in a timely manner. Operations Manager will review and ensure completed and signed documentation. 08/15/2022 Not Implemented
6400.181(e)(2)Individual #1's assessment, completed 8/15/21 did not include the dislikes and interests of the individual. Individual #2's assessment completed, 1/14/22 did not include the likes, dislikes, and interests of the individual.The assessment must include the following information: The likes, dislikes and interest of the individual. To correct this violation, Program Specialist will include likes, dislikes and interests of Individual #1 and Individual #2's assessment will include likes, dislikes and interests on the 2023 assessment because of the plan to revise the Assessment document. Program specialist will review all agency Individual's assessments to ensure likes, dislikes and interests of the Individual are included. 08/15/2022 Not Implemented
6400.181(e)(10)Individual #1's assessment, completed 8/15/21 did not a lifetime medical history. Individual #2's assessment completed, 1/14/22 did not include the a lifetime medical history.The assessment must include the following information: A lifetime medical history. To correct this violation the Program Specialist included the lifetime medical history of Individual #1 and will include the lifetime medical history for Individual #2's 2023 assessment because the assessment form is being revised to include a lifetime medical history all on the same form. The PS will review all agency Individual's assessment forms to update it include the lifetime medical history section. 08/15/2022 Not Implemented
6400.52(c)(5)Program Specialist #1's annual training for training year, January 1, 2021 through December 31, 2021 training year did not include the safe and appropriate use of behavior supports.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.To correct this violation, Program Specialist (PS) will complete the training "Safe and appropriate use of Behavior Supports" within 3 business days to ensure training record is in compliance for a Program Specialist. PS will forward "Safe and appropriate use of Behavior Supports" training certificate and all training certificates to HR for scan into the electronic records for training compliance & documentation. Human Resource Manager will scan and file training certificate in electronic file system to maintain in compliance with PS training curriculum. 08/10/2022 Not Implemented
6400.52(c)(6)Program Specialist #1 did not complete the implementation of the individual plan training requirement during the January 1st through December 31st training year..The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.To correct this violation, Program Specialist (PS) will complete the training "Implementation of the Individual Plan" within 5 days to ensure Program Specialist training record is in compliance. HR will scan and file PS training records and will follow the create a PS check-list training records check-list to maintain compliance with PS training curriculum. HR will scan and file PS training records and will follow the create a PS check-list training records check-list to maintain compliance with PS training curriculum. PS will forward "Implementation of the Individual Plan" training certificate and all PS training certificates to HR for scan into the electronic records for training compliance documentation." 08/10/2022 Not Implemented
6400.165(g)There was not documentation for the reviews of psychiatric medications completed on 7/29/21, 10/14/21, 3/3/22, and 4/28/22 for Individual #2.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.To correct this violation the Program Specialist will get documentation for 3 month reviews for psychiatric medications prescribed for Individual #2 from 7/21 through 4/22. The PS will review all site records for Individuals under the care of a physician treating symptoms for a psychiatric illness to ensure documentation for medication is on file and documented in a timely manner. 08/30/2022 Not Implemented
6400.181(f)The program specialist did not provide Individual #1's assessment completed 8/15/21 to the individual plan team members. The program specialist did not provide Individual #2's assessment completed, 1/14/22 to the individual plan team members.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.To correct this violation, Program Specialist will confirm and document the annual ISP meeting date with the Supports Coordinator at least 45 to 90 days prior to the previous year's meeting date. Program Specialist (PS) will email or mail the Assessment at least 31-60 days before the Plan meeting, to ensure the Assessment is received at least 30 calendar days prior to the meeting. The mail date will be documented on a check-off sheet to ensure timely delivery of the Assessment and maintained by the Program Specialist and confirmed by the Operations Manager. 08/05/2022 Not Implemented
SIN-00189888 Renewal 07/07/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment of the home within 3 to 6 months prior to the expiration date of the agency's Certificate of Compliance, expiration date 8/18/21. The self-assessment for the home was completed on 6/25/21.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. Reminders to "Start the Annual Site Assessments" were set on the iPhone calendar of the CEO, COO, and Program Manager for 12 noon on December 1st & 15th, January 1st & 15th and February 1st & 15th to ensure that the Annual Self-Assessments are started in January and completed by March for submission on on or before March 30th of every year. 07/30/2021 Implemented
6400.21(a)Direct Services Worker #1, date of hire 9/1/2020, had a Pennsylvania criminal background check requested on 4/9/2019.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. To prevent a future violation of 6400.21(a), Harmony Care Services will not inquire about previous criminal background checks. Harmony Care will always run it's own Criminal background check BEFORE an offer of employment. Once a clean criminal background check is presented , HR will give approval to move forward with the candidate. 07/30/2021 Implemented
6400.141(a)Individual #1's most recent physical examination is dated 4/17/2020.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual #1 had an annual Physical on September 9, 2020. The problem is that it was not placed in the Licensing Binder after the appointment. To Correct this violation, the September 2020 Physical was placed in Individual #1's licensing Binder. [Individual #1 physical examination, dated 9/9/2020 verified on 9/8/2021. Training for staff related to medical documentation, dated 7/30/2021, verified on 9/8/2021. DPOC by HDKP, HSLS, on 9/8/2021]. 07/30/2021 Implemented
6400.141(c)(6)Individual #1 has no documentation of a tuberculin evaluation [Repeat violation 8/6/2020, et. al.].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. Individual #1 will be taken to get a TB test on or before August 7, 2021. This date will set the baseline for her testing every 2 years. [Training for staff related to medical documentation, dated 7/30/2021, verified on 9/8/2021. DPOC by HDKP, HSLS, on 9/8/2021]. 08/07/0202 Implemented
6400.142(a)Individual #1 has no documentation dental examination performed by a licensed dentist.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 #1's last dental appointment was in February of 2020 at Pitt University's Special Needs Dental Clinic, this was before she became a resident of Harmony Care Services. Due to COVID she was unable to get an appointment in August of 2020 and is still on the waiting list for her next dental appointment. [Training for staff related to medical documentation and timeliness, dated 7/30/2021, verified on 9/8/2021. As of 9/8/2021, documentation of scheduled dental appointment for Individual #1 has not been provided. DPOC by HDKP, HSLS, on 9/8/2021]. Individual #1 goes to this facility because she must be sedated for her dental appointments. 08/21/2021 Implemented
SIN-00174977 Renewal 08/06/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(6)There was not documentation of the results of Individual #1's Tuberculin skin test administered 1/30/20; therefore, compliance could not be measured. (Repeat violation 2/4/20 et al)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. To correct this violation, Individual #1 was taken to Med Express for a TB test on August 18, 2020 and the results were read and documented on 8/21/2020. To prevent this repeat violation, our Program Specialist is developing a 'live' spreadsheet that He, the House Manager, and the Compliance Officer can access and update as new information, appointments and information becomes available. As a team, with 3 layers of of check and balance review, this will ensure 100% compliance and scheduling for TB Test for Individual #1. In addition to the three levels of review (Program Specialist, House Manager, Compliance Officer), compliance training for healthcare and medical appointments will be added to HCS's annual training schedule to emphasize and train all staff on the importance of medical and healthcare maintenance for our residents. The objective is to empower our staff to have a heightened sense of concern and awareness for healthcare compliance as it applies to the Individuals we support. 08/06/2020 Implemented
6400.32(d)The Office of Developmental Programs requires that staff who provide direct services wear a mask that covers the nose and mouth during the entirety of service provision. At 10:36AM on 8/7/20 Direct Service Worker #1 was not wearing a facemask and Chief Executive Officer #2 was wearing a face shield. Failure to wear masks is undignified and disrespectful in that it creates a risk of transmitting the COVID-19 virus from staff to individuals.An individual shall be treated with dignity and respect.At the onset of the COVID Pandemic, all of our staff were trained using CDC and the Dept of Human Services required trainings. Staff was trained and re-trained about the requirement to wear a masks at all sights, from the beginning of the Pandemic. We conducted trainings during staff meetings and on-line trainings. Unfortunately Staff #1 chose to disregard the policy, despite our numerous trainings and put Individual #1 at risk by not wearing a face mask. We do not know if this was consistent, but given the fact that she did to have it on while during our licensing review, it was very probable that there was a blatant disregard for the training, warnings and heath risks. To correct this most serious violation, health risk and disregard for the dignity and respect of Individual #1, DCStaff #1 was relieved her of her duties and is no longer an employee of Harmony Care Services. HCS message is very clear - if you do not treat our residents with dignity and respect at all times- and especially during a Pandemic - you will not be employed at Harmony Care Services. 08/07/2020 Implemented
6400.165(g)Individual #1 is diagnosed with intermittent explosive disorder and anxiety. The review of medications prescribed to treat symptoms of a psychiatric illness completed on 7/8/20 for Individual #1 does not include the reason for prescribing the medications. The review of medications prescribed to treat symptoms of a psychiatric illness completed on 5/4/20 for Individual #1 does not include the reason for prescribing the medication, the need to continue the medication and the necessary dosage.. (Repeat violation 2/4/20 et al)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.Due to the COVID Pandemic, the Individual #1's Psychiatric appointments and medication reviews were done by telephone at the request of her Dr. The psychiatric appointment scheduled on 7/8/20 was scheduled, but her staff was not informed by the Program Specialist. Staff and Individual #1 entered the house, the phone was ringing and the Dr. was on the line to their surprise. The Doctor had the wrong forms for the Medication review and that is why it did to have the required information. To correct this violation, the correct forms were forwarded to the Dr., who reviewed the medications and completed the Medication Review form for his patient. To prevent this repeat violation, the new Program Specialist has committed to providing a schedule of Medication review dates in advance for scheduled appointments. Staff will be provided with the appropriate documentation in advance of the review and the Dr. will have received the Med Review and exam forms in advance of the appointment if it is on the phone, otherwise staff will take the appropriate forms to the on-site appointment. After the appointment, the Program Specialist (P.S.) will review the completed medical forms to ensure proper documentation or require staff get the necessary corrections completed. The House Manager will provide a second review when they make copies and put the forms in Individual #1's Binder. On a monthly basis, the Compliance Officer will provide a third and final review of the Psychiatric exam and medication review forms for compliance. This process will become the three (3) level review process that will ensure proper documentation for Psychiatric appointments and medication reviews. 08/21/2020 Implemented
SIN-00170945 Renewal 02/04/2020 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The hot water temperature at bathtub in bathroom at the top of the stairs on the second floor of the home measured 126.1 degrees Fahrenheit at 11:34AM. (Repeat violation 8/29/19) Hot water temperatures in bathtubs and showers may not exceed 120°F. On February 5, 2020, the hot water temperature was re-adjusted below 120F during when it was discovered that the water temperature exceeded 120F. It was tested four (4) times after re-adjustment and did not exceed 120F. The water temperature is monitored daily and registered under 120F up to the day of inspection, as per the House Manager and house fire drill records. Staff will continue to personally monitor and regulate the water temperature daily for Individual #1, who cannot regulate their own temperature and will not get into the tub or shower without staff support.The water TEMPERATURE will be monitored by the House Manager. The water temperature RECORDS will be monitored by the Program Specialist. [On 4/17/20, the hot water temperature at the bathtub was 118.4 Fahrenheit. On 4/17/20, the hot water temperature at 800 Penn Center Blvd. Pgh PA. measured 124.8 and 123.6. Immediately, the CEO or designee shall develop and implement a hot water temperature tracking document to include: day and time of measurement, location of measurement, name of staff person measuring and the temperature of the hot water. At least weekly, a designated staff person educated in measuring accurate hot water temperature, completing aforementioned documentation and the requirements of hot water temperature and the procedures to correct water temperature exceeding 120°F. At least monthly, the CEO or designee shall audit the aforementioned documentation to ensure accurate completion and that the hot water temperature does not exceed 120°F. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 4/17/20)] 02/05/2020 Not Implemented
6400.106The home had a furnace inspection completed 11/1/18 and then again 1/24/20.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. On March 5, 2019, the home had a furnace inspection completed by The Sullivan Company. The documentation was not in the new binder, but it was presented on February 5, 2020 during Inspection. The CEO checked that the furnace inspections for the other homes were placed in the Fire Drill Binders. Every January, on or before January 21st of every year, The CEO will schedule a furnace inspection and the documentation will be placed in the fire drill binders for easy access. The House Manager will ensure that all Furnace Inspection documentation is placed in the Fire Drill Binder when presented by the Inspection Company. Furnace Inspections will be monitored by the CEO. [At least quarterly for 1 year, the CEO shall audit the documentation of the furnace inspection and cleaning to ensure documentation is available upon request by the Department. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 4/17/20)] 02/05/2020 Implemented
6400.112(c)The written fire drill records for the fire drills held on 5/13/19 and 7/17/19 did not include the amount of time it took for evacuation of the home.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. On February 5, 2020, an overnight fire drill was scheduled at this site. This fire drill time was documented and under 2.5 minutes. The CEO reviewed the fire drill process with staff and discovered that one staff person was forgetting to document the evacuation times. Although this staff person no longer works for HCS, they were retrained on proper Fire Drill documentation and attention to documentation detail, which is the most important part of the drill. The CEO checked other fire drill records and did not find any additional missing fire drill times or information. On the first day of every month the House Manager will set up unannounced fire drills for the month and check each drill to ensure that evacuation times are documented and that the times are within compliance guidelines of 2.5 minutes. On the 21st of every month the Program Specialist will review each sites Fire Drill Records with the House Manager to ensure that a fire drill is or has been scheduled for all sites on or before the 30th of every month. [At least quarterly for 1 year, the CEO or designated management staff person shall audit all fire drill records to ensure fire drills are held and documented as required. Documentation of aforementioned audits of all fire drill records shall be kept.(DPOC by AES,HSLS on 4/17/20)] 02/05/2020 Implemented
6400.112(d)The fire drill held on 8/30/19 had an evacuation time of 2 minutes and 38 seconds. The fire drill held on 9/29/19 had an evacuation time of 3 minutes and 16 seconds. The home does not have an extended evacuation time. 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. On February 6, 2020, a fire drill was conducted at the site and evacuation time was under 2.5 minutes. The safe place was changed at the suggestion of the fire official who explained that the porch or back yard was an appropriate safe place for evacuation. Prior to that change, staff was evacuating to the next door neighbor's home. Staff was re-trained on the new safe place evacuation location; evacuation times are now in compliance. The CEO checked the designated safe-places at the other sites and found that one other location was also evacuating further than required for a safe place. Since the newly assigned safe places have been established, evacuation times have all been under 2 minutes. During the first week of every month, the House Manager shall privately schedule the unannounced fire drills for that month. On the appointed time, scheduled drills, will be unannounced to staff on site as per the House Manager's monthly schedule. A minimum of two drills every 6 months will be scheduled during sleeping hours. On the 21st of every month the Program Specialist will review each site¿s Fire Drill Records and ensure that a fire drill is or has been scheduled for all sites on or before the 30th of every month. They will look for the overnight drills, evacuation times and complete paperwork. The House Manager will be responsible for monitoring evacuation times during monthly fire drills. [Immediately/as soon as possible (due to COVID-19) the CEO shall ensure the designate meeting place is a fire safe area by a fire safety expert and/or documentation. Documentation of the fire safe area shall be maintained. Documentation of aforementioned audits of fire drills shall be kept. (DPOC by AES,HSLS on 4/17/20)] 02/06/2020 Not Implemented
6400.141(c)(3)Individual #1 does not have a Tetanus or Diphtheria immunization.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. On February 5, 2020, CEO #1 spoke to the Supports Coordinator of Individual #1 to discuss the ongoing issue regarding non-compliance with the Tetanus/Diphtheria Immunization requirements for Residents due to the parent¿s objections for religious reasons. CEO #1 confirmed that this is the only non-compliance objector of the tetanus/diphtheria shot within the agency. The Parents, who object to this specific immunization, talked about becoming guardian, but as of 3/28.2020 have not become Guardian. On March 25, 2020, in the presence of a witness, the CEO will move forward to ask Individual #1 if they do or do not does want to have the Tetanus /Diptheria immunization shot, if the parents are not guardians by that date. The wishes of Individual #1, to have or not have the Tetanus/Diptheria immunization will be honored with the support of the Supports Coordinator.Tetanus/Diphtheria Immunizations will be monitored by the Program Specialist. [Immediately/as soon as possible (due to COVID-19), Individual #1 shall immunizations as recommended by the United States Public Health Service, CDC, Atlanta Georgia 30333. Upon a refusal of treatment, the CEO or designee shall implement refusal of treatment requirements as per 6400.143a and 143b. Immediately, the CEO or designee shall develop and implement a tracking and auditing system to ensure timely completion of physical examinations with required information including immunizations and screenings. At least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking system to ensure timely completion of required information. Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff person responsible for supporting individual in physical examinations of the required information and the tracking system (as needed) to ensure timely completion of physical examination with required information. Documentation of trainings shall be kept. (DPOC by AES,HSLS on 4/17/20)] 03/27/2020 Not Implemented
6400.171There was an unsealed bag containing fish in the freezer in the kitchen.Food shall be protected from contamination while being stored, prepared, transported and served. On February 5, 2020, the unsealed bag of fish was discarded due to improper storage. All other freezer and refrigerator items were checked for proper storage and correct dates. Staff will be re-trained on proper food storage and maintenance during the March 2020 house meeting. On the first and last day of every week, the House Manager will check the freezer for proper food storage, dates and maintenance. Food storage and maintenance will be monitored by the House Manager. [On 2/6/20, one staff person was educated on food safety. On 4/16/20, the additional staff persons were educated on food safety. (DPOC by AES,HSLS on 4/17/20)] 03/27/2020 Implemented
6400.34(a)Individual #1 was most recently informed and explained individual rights on 1/1/2019.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.On February 5, 2020, the 2020 Individual Rights document was placed in Individual #1¿s licensing binder. Annually, on or before the 3rd of every January, Individual Rights will be reviewed with all Individuals at all sites. The Program Specialist will ensure that the current and previous year Individual rights forms will be in the licensing binders at all times when the documents are signed by the Individuals during the first week of January. Annually between January 1-3, the Program Specialist will meet with all Harmony Care Services Individuals to review Individual Rights, get them signed and placed in their Licensing Binders. [Immediately, the CEO or designee shall update the individual rights notification documentation to include the revised individual rights as updated February 3, 2020 per 6400.32a-32v. Within 10 days of receipt of the plan of correction and annually thereafter, the CEO or designee shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual. Documentation shall be kept. Within 30 days of receipt of the plan of correction, upon hire and at least annually, the CEO or designee shall educate all staff persons on individual rights and the agency's process to educate, assist and proved the accommodation necessary for the individuals to make choices and understand the individual rights. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 4/17/20)] 03/27/2020 Not Implemented
6400.162(a)Direct Service Worker #1 had medication administration training conducted on 2/25/18 and then again 5/11/19. Direct Service Worker #1 administered medications to Individual #1 on 3/10/19, 3/17/19, 3/23/19, and 3/24/19.A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication.Harmony Care Services (HCS) lost the only Medication Trainer we knew and used in 2019 due to illness and an expired certification. This was the only trainer we knew and in that moment HCS understood the value of on staff Medication Trainers. When training dates become available in 2020, Harmony Care Services will support up to two Direct Support Workers to become Medication Trainers for the Agency, one deaf and one hearing trainer will be selected. Every year thereafter, one new trainer will be selected to become a Medication Trainer in that fiscal year. Harmony Care Services is negotiating with a Compliance Consultant from the AMA Company to work with HCS and our Program Specialist to develop and successfully manage the Medication Certification process for the company. During the first week in January of every year, all medication training records will be reviewed by the Program Specialist and Compliance Consultant. Staff will be notified of their Annual Medication Training/Recertification date on or before January 15th.The Program Specialist will monitor the Medication Certification and Training process [Direct Service Worker #1 was recertified in medication administration on 1/20/20. Immediately, the CEO or designee shall audit all staff person qualifications for medication administration to ensure all qualifications/trainings are up to date and develop a tracking system to ensure staff qualifications are kept up to date. At least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking system and medication qualification/training documentation to ensure medication is administered by staff persons who are certified to administer medication. (DPOC by AES,HSLS on 4/17/20)] 03/27/2020 Not Implemented
6400.165(g)The most recent review of medications prescribed to treat symptoms of a psychiatric illness for Individual #1 was on 9/20/19.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.On February 5, 2020, after confirming with the Doctor's office that no appointments were scheduled for Individual #1 after 9/20/19, the Program Specialist scheduled an appointment for March 3, 2020. The Program specialist reviewed appointments with the doctor¿s office and confirmed that all other 2019 psychiatric appointments were within compliance and medications were reviewed and sign by the physician. To prevent future missed medical appointments, the Program Specialist (PS) will create a spreadsheet outlining all psychiatric medical appointments for Individual #1. Program Specialist will post Individual #1's Psychiatric Medical Appointments in the Staff Office and will confirm with staff when appointments come due to ensure compliance is within 90 days and transportation and staff support is scheduled. The Program Specialist will monitor medical psychiatric appointments on a monthly basis on the 1st of the month for Individual #1. The PS will confirm appointments are completed and file the paperwork in Individual #1¿s binder and a copy will be forwarded to the Administrative office to archives and ensure a copy is [Individual #1 had a review of medication on 3/18/20. The medication review did not include the reason for prescribing the medications. Immediately, the CEO or designee shall review documentation used for psychiatric medication reviews and update as needed to ensure required information is present. Immediately, the CEO or designee shall educate all staff person responsible for supporting individuals with medications reviews of the requirement. Upon completion, a designee educated on medication reviews and certified to administer medication shall audit the documentation to ensure timely completion with required information and that individuals are administered medications as prescribed. (DPOC by AES,HSLS on 4/17/20)] 03/03/2020 Not Implemented
SIN-00164546 Unannounced Monitoring 10/11/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)At 11:50AM, an unmarked spray bottle containing a blue liquid was in the unlocked closet in the hallway on the second floor of the home.Poisonous materials shall be stored in their original, labeled containers. To correct our non-compliance, the blue liquid in the unmarked bottle, which was Windex, was immediately removed from the home. To prevent a repeat violation, the House Manager was trained on the policy that all poisonous materials shall be stored in their original labeled container. All staff was retrained that all products purchased for the homes shall be kept in their original, tabled containers and that if they ever find an unmarked bottle of anything, they are to immediately identify the material, report it to the House Manager, and immediately remove it from the home. 10/11/2019 Implemented
6400.151(a)Direct Service Worker #1, date of hire 9/5/19, did not have a physical examination. (Repeat violation 4/5/19) 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. To Correct this violation, on 10/22/19, the person who facilitated the hiring process for Direct Service Worker #1, was re-trained on the correct Physical form to use when interviewing and/or hiring new staff. Direct Service Worker # 1 did have a physical within 12 months prior to employment at Harmony Care Services, but it was on the wrong form; she was asked to have her physical information transferred from the MedExpress form to the HCS physical form so that it is easily identifiable as compliant with 55 PA Code 6400.151 (a). [Immediately, upon hire and at least quarterly for 1 year, the CEO or designee shall audit all staff persons' current physical examinations to ensure timely completion with all required information. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 10/31/19)] 10/22/2019 Implemented
SIN-00161971 Unannounced Monitoring 08/29/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(b)(3)Direct Service Worker #1, date of hire 8/26/19, was the only staff person providing supervision to the two individuals living in the home from 7:00 AM to 9:00 AM, on 8/29/19. Direct Service Worker #1 has not been trained in the required areas for orientation, fire safety, first aid and intellectual disabilities.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. Direct Service Worker #1 received training in the required areas of orientation for intellectual disabilities on August 24, 2019 during her orientation, however staff failed to show the fire safety training video during this orientation because it was not on site. The HCS orientation process includes a fire safety video during every orientation for all new staff prior to working with HCS Individuals. Direct Service Worker #1 was also on site without a manager from 7a-9a on 8/29/19, which is a violation of the CEO's policy for new employees. The Manager was given a verbal warning for this violation on 8/29/2019, and will be monitored for this violation with all new hires for the balance of 2019.To prevent a repeat violation, HCS's CPR/First Aid trainer conducted a CPR/first aid class for Direct Service Worker #1 on 8/30/2019 and DSWorker #1 watched the Fire Safety video on August 30, 2019, after CPR Training. The staff who failed to follow procedure was re-trained on the new hire process on 8/29/2019. The fire safety video was placed on site on 8/30/2019 and the House Manager will review the New Hire Orientation records for PA 6400 (46)a compliance and must get approval from the CEO prior to scheduling new staff for the balance of 2019. It is the House Manager's responsibility to review the new employee file for compliance and get approval from the CEO for scheduling new staff before putting a new employee on the schedule . The Quality Manager will monitor new employee files for 6400 compliance on or before the 30th of every month. 08/30/2019 Implemented
6400.76(a)The toilet seat on the toilet in the bathroom in the basement of the home was loose and was able to slide approximately one inch off either side of the toilet posing a falling risk. Furniture and equipment shall be nonhazardous, clean and sturdy. The staff toilet seat in the lower level of the home was repaired on 8/30/2019. Harmony Care Services has on-site maintenance who was called immediately upon discovery. This toilet seat issue was not reported prior to this inspection, but once reported it was repaired immediately. This toilet seat is used by staff only, not the residents who have two toilets on the second floor for their use. The House Manager was reminded and retrained to report needed repairs for all bathrooms in the home, not just bathrooms used for residents. To prevent a repeat violation, the House Manager will check all bathroom facilities on a weekly basis and report to the maintenance man any issues discovered for all bathrooms in the home. 08/30/2019 Implemented
6400.46(a)Direct Service Worker #1, date of hire 8/26/19 and Direct Service Worker #2, date of hire July 2019, were not trained in general fire safety training before working with the Individuals. [repeat violation-4/5/19]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.Direct Service Worker #1 and Direct Service Worker #2 received fire safety training on 8/30/2019. To correct this violation, DSW #1 and DSW #2 was shown the fire safety video, which is standard procedure for HCS New Employee Orientations. The staff conducting the orientations was re-trained on both the HCS new hire Policy and procedures and Pa Code 6400.46(a) for general fire safety. To prevent a repeat violation, the CEO hired a HR manager whose responsibility will be to conduct all new hire orientations according to 55 PA Code 6400.46 regulations, effective, 8/30/2018. The CEO hired a Quality Manager on 9/13/2019 to ensure that all general fire safety training is completed, documented and in on-site training binders before working with Individuals. The House Manager will review all new hire orientation documentation with the Human Resource Manager for compliance with PA 6400.46(a) before getting approval from the CEO to place the new staff on the schedule. The Quality Manager will be responsible for monitoring new hire documentation procedures are being followed and that orientation records on or before the 30th of each month. 08/30/2019 Implemented
6400.46(c)Direct Service Worker #1, date of hire 8/26/19, and Direct Service Worker #2, date of hire July 2019 were not trained in first aid techniques before working with the individuals. [repeat violation-4/5/19]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.Direct Service Worker #1 and Direct Service Worker #2 were trained in First Aid Techniques on August 30, 2019. The Staff who interviewed and hired staff failed to provide the First Aid Techniques. This staff was retrained on the New Hire Process on August 29, 2019, by the CEO. First Aid technique training was provided to both Direct Service Worker #1 and Direct Service Worker #2, on August 30, 2019. To correct this violation, Harmony Care Services will have all employee orientation records on site for easy access, and all New Hires will have first aid technique training during their orientation week and before working with Individuals, with proof documented in their new employee file. The House Manager will monitor new hire records on a weekly basis, to ensure First Aid Technique training is completed and documented before working with the Individuals. The Quality Manager will monitor new hire orientation binders for compliance with PA 6400.46 (c) on or before the 30th of each Month. 08/30/2019 Implemented
6400.51(a)(3)Direct Service Worker #1, date of hire 8/26/19, and Direct Service Worker #2, date of hire July 2019 did not complete orientation prior to working alone with the individuals.Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons.Direct Service Worker #1 and Direct Service Worker #2, had an orientation on August 24 and Direct Service Worker #2 in July, both had orientations prior to working alone with the Individuals. The issue was that the records were not on site, they are kept in the HCS Administrative office with the other personnel records. On 9/11/2019, DSW #1 and #2 was retrained on all new HCS forms, including the Orientation forms, so they know and understand when asked about their orientation and the process and procedure. To prevent a repeat violation, all Personnel Binders are being reviewed and copies of the Orientation and Training records will me made available and placed in a binder to be kept on site for easy access and review. This is a major project, therefore, our target date for completion is 9/29/2019.The Program Specialist will monitor new personnel files weekly and the Quality Manager will monitor personnel files on site on a monthly basis on or before the 30th of each month and will report their findings to the CEO. 09/11/2019 Implemented
6400.166(b)Pradaxa 50mg, 1 capsule by mouth 2 times per day; Tamsulosin 4mg, 1 capsule by mouth every day; Ranitidine 150mg, 1 tablet by mouth every evening; DOK 100 mg, 1 tablet by mouth every day; Aripiprazole 20 mg, 1 tablet, by mouth every day, prescribed to Individual #1 were not documented as administered on 8/6/19, 8/7/19 and 8/8/19 at 5:00PM. Atorrastain 40 mg, 1 tablet by mouth at bedtime prescribed to Individual #1 was not documented as administered on 8/6/19, 8/7/19 and 8/8/19 at 8:00PM. Citalopram 40 mg, 1 tablet by mouth every day; Janumet XR 50-1000mg, 1 tablet, by mouth every day; Pioglitazone 15 mg, 1 tablet by mouth every day; Levonthyroxine 112mcg, 1 tablet by mouth every day; Lisinopril 10 mg, 1 tablet by mouth every day; Metoprolpol ER 25 mg, 1 tablet by mouth every day prescribed to Individual #1 were not documented as administered on 8/12/19 at 8:00AM. Cefuroxine 500 mg, 1 tablet by mouth 2 times per day prescribed to Individual #1 was not documented as administered on 8/26/19, 8/27/19, 8/28/19 and 8/29/19 at 8:00 AM. Calcium Carb/Cholecal 600 mg/200 Unit, 1 tablet by mouth 2 times per day; Sertraline HCL 100 mg, 1 and ½ tablets by mouth every day; QC Essentials PO Tab, 1 tablet by mouth every day; Clonazepam 2 Mg, 1 tablet by mouth 2 times per day prescribed to Individual #2 were not documented as administered on 08/10/19 at 8:00AM. Divalproex Sodium DR 250 mg, 1 tablet by mouth 2 times per day prescribed to Individual #2 was not documented as administered on 7/27/19 at 8:00PM. Clonazepam 2 mg, 1 tablet by mouth 2 times per day prescribed to Individual #2 was not documented as administered on 06/17/19, 06/19/19, 06/20/19, 06/21/19 at 8:00AM. Divalproex Sodium DR 250 EC, 1 tablet by mouth every morning and 2 tablets by mouth at bedtime prescribed to Individual #2 was not documented as administered on 06/17/19 and 06/21/19 at 8:00AM.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.On September 2, 2019, The newly hired Program Specialist reviewed all medication documentation at all HCS Houses and found no additional missed records. The Program Specialist had a training on 9/11/2019 with all HCS staff to review the new medication documentation records. A check and balance procedure of Manager signatures on the MAR and Medication logs was implemented to ensure daily monitoring. A Quality Manager position was created to review all medication paperwork on a regular schedule and the position was filled on 9/13/2019. After the Quality Manager begins working at HCS this month (September), the Quality Manager will begin regularly scheduled reviews of all medication documentation in all HCS homes a minimum of 3 times per week and the house manager will be monitoring the records daily. The medication records will be monitored by the House Manager daily as long as they are House Manager, the Quality Manager will review medication records on a weekly basis for 60 days and on a monthly basis, on or before the 30th of each month thereafter. 09/11/2019 Implemented
SIN-00154596 Renewal 04/05/2019 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(b)Individual #1, date of admission 11/14/18, initially signed and dated acknowledging receipt of the information on individual rights on 1/1/19.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. Individual #1 had an initial Individual Rights signed on 11/14/2018, upon admission. The 1/1/19 Rights was her second Rights Form, the first Individual Rights form was signed on 11/14/2018 is filed in her Guardian's law offices in Individual #1's personal records. Individual #1 is on an Annual calendar basis January - December, not the DHS July1-June 30 fiscal year calendar. [On 6/13/19, a copy of the aforementioned rights was not available for review. Immediately, upon admission and continuing at least annually for 1 year, the CEO or designee shall audit all individuals' record to ensure individuals are informed of individual rights timely and statements are signed and dated by the individual, the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept and available for review upon request by the Department. (DPOC by AES,HSLS on 6/18/19)] 04/08/2019 Not Implemented
6400.46(d)Direct Service Worker #1 had 22.5 hours of training for the training year of 1/1/18 to 12/31/18. (Repeat violation 10/2/18 et al)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. Direct Service Worker #1 had 24.5 hours of training in 2018, because she completed 2 hours of Medication Training on 10/14/18 and that training was not included in her 2018 Training Records. To prevent a repeat violation, the documentation of Training Hours will be managed by the Program Administrator and House Managers to ensure that all staff training hours are accounted for and that their annual training records are clearly and easily available. [On 6/13/19, Direct Service Worker #1 had only 16 hours of training documentation for the 2018 upon request by the Department. Immediately, the CEO or designee shall develop and implement an initial and annual training plan and training record keeping system to ensure all staff persons complete training as require and documentation is available upon request by the Department. (DPOC by AES,HSLS on 6/18/19)] 04/08/2019 Not Implemented
6400.46(f)The most recent fire safety training for Direct Service Worker #1 was completed 3/5/18.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. Direct Service Worker #1 completed fire safety training was completed on 4/7/2019 after missing the March training due to illness. This DSW has always been in compliance with Fire Safety Training and would have attended the March training. To correct the violation, DSW #1 took the Fire Safety Training on 4/7/2019. [On 6/13/19, Direct Service Worker #1 had fire safety training completed 4/7/19 and documentation available for review by the Department. Immediately, the CEO or designee shall develop and implement an initial and annual training plan and training record keeping system to ensure all staff persons complete training as require and documentation is available upon request by the Department. Immediately and continuing at least quarterly, the CEO or designee shall audit all staff persons training record to ensure timely fire safety training. (DPOC by AES,HSLS on 6/18/19)] 04/07/2019 Implemented
6400.65The en suite bathroom of the bedroom located to the right of the stairs on the second floor of the home did not have mechanical ventilation or operable window. The window in the bathroom was nailed shut.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. The window in the bathroom was not nailed shut, the bathroom was recently painted and the paint prevented the window from opening during inspection. Staff was able to remove the dried paint and open the window. A photo was sent to [the Department] and the monitors showing the window open on 4/6/2019. [On 6/13/19, the window was operable. At least monthly, a designated staff person educated in the requirements of the physical site 6400 regulations shall completed an onsite visit to all community homes to ensure living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms are ventilated by at least one operable window or by mechanical ventilation. Documentation of the onsite visits shall be kept. (DPOC by AES,HSLS on 6/18/19)] 04/05/2019 Implemented
6400.71The telephone number of the nearest hospital was not on or by the telephone in the living room of the home.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. The telephone number for the hospital was added on 4/08/2019. It is and has always been the practice of Harmony Care Services to include the nearest hospital on each telephone the home. To prevent a repeat violation, the House Manager will check that all phone numbers on all HCS phones and document on the daily residential checklist. [On 6/13/19, the telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were on or by each telephone in the home with an outside line. [DPOC by AES,HSLS on 6/18/19)] 04/08/2019 Implemented
6400.113(a)Individual #1, date of admission 11/14/18, had initial fire safety training completed 3/5/19. The most recent fire safety training for Individual #2 was completed 3/5/18. 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. Individual #1 had initial fire training during her Orientation on 11/14/2018. Individual #2 had fire safety training on 4/6/2019 and submitted to [the Department] on 4/7/2019. To prevent a repeat violation, all documentation will be placed in the Resident's binders upon receipt. [Immediately, the CEO or designee shall develop and implement an initial and annual training plan and training record keeping system to ensure all individuals complete training as require and documentation is available upon request by the Department. (DPOC by AES,HSLS on 6/18/19)] 04/06/2019 Implemented
6400.141(a)Individual #1, date of admission 11/14/18, did not have a physical examination. (Repeat violation 10/2/18 et al)An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual #1 had a physical examination on May 6, 2019. Individual #1 is a non-SCO, non-consolidated, non-base waiver resident. Individual #1's Guardian is responsible for all medical care and now understand the Physical Examination and documentation requirements for residents of licensed facilities. They have been very cooperative. The first available appointment for a Physical was May 5, 2019, which was successfully completed. To prevent a repeat violation, this date will become the baseline date for annual physicals for Individual #1, who will receive all required examinations required by PA Code 6400 regulations. [Immediately, the CEO or designee shall develop and implement a tracking and scheduling system to ensure all individuals have physical examinations completed, timely. At least monthly, a designated staff person shall audit and update the aforementioned tracking system. (DPOC by AES,HSLS on 6/18/19)] 05/06/2019 Implemented
6400.141(c)(6)Individual #1, date of admission 11/14/18, did not have a Tuberculin skin test. (Repeat violation 10/2/18 et al)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. Individual #1 is a non-SCO, non-consolidated, non-base waiver resident. Individual #1's Guardian is responsible for her medical care and Harmony Care Services, has explained the documentation requirements for residents of licensed facilities and has been very cooperative. The first available appointment for the TB test was May 5, 2019, which was found negative. To prevent a repeat violation, this date will become the baseline date for TB testing for Individual #1, who will receive all required tests and physical examinations required by PA Code 6400 regulations. [On 6/13/19, documentation of the Individual #1's tuberculin skin testing was not available upon request by the Department. Immediately, the CEO or designee shall develop and implement a tracking and scheduling system to ensure all individuals have physical examinations completed with all required information including tuberculin skin testing, timely. At least monthly, a designated staff person shall audit and update the aforementioned tracking system. (DPOC by AES,HSLS on 6/18/19)] 05/06/2019 Not Implemented
6400.151(a)The most recent physical examination for Direct Service Worker #1 was completed 3/6/15. 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. Direct Service Worker #1's most recent physical examination was on 12/20/2018. To Prevent a repeat violation, we have made several changes to our record retention system, and we have place the Office Manager in charge of tracking employee physicals, TB Tests, CPR/First Aid and Medication Training records. [The aforementioned physical examination for DSW #1 on 12/20/18 was not available upon request by the Department on 6/13/18. Newly hired Direct service workers had physical examinations completed, timely. Immediately, the CEO or designee shall develop and implement record keeping system to ensure all staff persons have physical examinations completed, timely and documentation is available upon request by the Department. Immediately and continuing at least quarterly, the CEO or designee shall audit all staff persons two most physical examinations to ensure completion, timely. (DPOC by AES,HSLS on 6/18/19)] 04/08/2019 Implemented
6400.168(a)The most recent medication administration training for Direct Service Worker #1 was completed 3/27/17. Chief Executive Officer #2 indicated that Direct Service Worker #1 administers medication on a regular basis. In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. Both the Direct Service Worker #1 and Chief Executive Officer #2 were re-certified to pass medications on 10/14/2018 and 5/4/2019. Direct Service Worker #1 worked the overnight shift until 2018, when she began working the 3p-11p evening shift, which required her to pass medications. To Prevent a repeat violation all medical training records will be maintained by the Office Manager who will ensure all required medical training paperwork is placed in employee files. [At least quarterly for 1 year, the CEO or designee shall audit all staff persons medication administration training to ensure completion and the training documentation is available upon request by the Department. (DPOC by AES,HSLS on 6/18/19)] 04/15/2019 Implemented
6400.181(a)Individual #1, date of admission 11/14/18, had an initial assessment completed 4/5/19. 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. Individual #1 neither a Consolidated nor Base waiver Individual, she is a non-SCO resident. PA 6400 regulations did not state that an assessment was required for a non-SCO resident, and for that reason, Individual #1 did to have an initial assessment completed within 60 calendar days after admission. To prevent a repeat violation, all residents, whether SCO or non-SCO residents, shall have an initial assessment within within 1 year prior to or 60 calendar days after admission and updated annually thereafter.[Immediately, the CEO or designee shall educate the program specialist of the responsibilities of the program specialist's position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. At least quarterly for 1 year, the CEO or designated management staff person shall audit all individuals' current assessment to ensure completion, timely. (DPOC by AES,HSLS on 6/18/19)] 04/05/2019 Implemented
6400.181(f)The program specialist did not provided the assessment dated 1/15/19 for Individual #2 to the plan team members for the ISP meeting on 1/29/19. (Repeat violation 10/2/18 et al)(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 Assessment was emailed to the plan team and a copy was forwarded to [the Department]. To prevent a repeat violation a copy of the email notification will be maintained in the Residential Binder.[Immediately, the CEO or designee shall educate the program specialist of the responsibilities of the program specialist's position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. At least quarterly for 1 year, the CEO or designated management staff person shall audit correspondence documentation to ensure the program specialist has provided all individuals' current assessment to the plan team member, timely. (DPOC by AES,HSLS on 6/18/19)] 04/12/2019 Implemented
6400.186(d)The program specialist did not provide the ISP review dated 3/1/19 for Individual #2 to the plan team members.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. Plan team information was provided to the team on 3/14/2019, copies were submitted to [the Department] on 4/12/2019. To Prevent this repeat violation, copies of the signed delivery method will be maintained in the Residential Binders. [Immediately, the CEO or designee shall educate the program specialist of the responsibilities of the program specialist's position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. At least quarterly for 1 year, the CEO or designated management staff person shall audit correspondence documentation to ensure the program specialist has provided all individuals' ISP review documentation as required to the plan team member, timely. (DPOC by AES,HSLS on 6/18/19)] 04/12/2019 Implemented
SIN-00148745 Unannounced Monitoring 01/17/2019 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34At approximately 10:00AM, while completing an unannounced inspection, the Department requested Individual #2's written record. Individual #2's written record was not available upon request or provided by the agency during the length inspection.The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients.Individual #2 is not receiving services through an SCO and did not arrive at Harmony Care Services with records. Harmony Care Services' Program Specialist, Myra Powell, is Plan Lead and she will have an Initial ISP for Individual #2 available on or before 2/10/2019, within 90 calendar days of Individual #2's date of admission, which was November 12, 2018. A copy of the ISP will be forwarded to your attention as authorized agents of the Department, immediately upon completion. [An ISP was completed for Individual #2 on 1/11/19. Immediately, the program specialist shall review regulatory requirement 6400.213(1)-(14) Content of records to ensure all required information is included in Individual #2's record and available for review upon request by the Department. Immediately and continuing at least quarterly for 1 year, the CEO or designee shall audit all individuals' records to ensure all required information is included and available for review upon request by the Department. Documentation of all audits of individuals' records shall be kept. (DPOC by AES,HSLS on 3/5/19) 02/10/2019 Not Implemented
6400.68(b)The hot water temperature at the bathtub in the bathroom located on the second floor of the home measured 124.3 degrees Fahrenheit at 9:45AM. Hot water temperatures in bathtubs and showers may not exceed 120°F. The water temperature was corrected before the end of the unannounced review on 1/17/19; the temperature was corrected to under 120F. The bathroom is under construction for renovations and the water will be monitored daily by staff until completion. To correct this violation and prevent repeat violations, staff will monitor and document the temperature weekly. [Immediately, the CEO or designee shall train all staff persons responsible for measuring hot water temperature of the procedures of measuring, reporting, adjusting and documenting hot water temperature to ensure the hot water temperatures in bathtubs and showers do not exceed 120°F. At monthly for 6 months, the CEO or designee shall audit all documentation of measurements to ensure the hot water temperatures in bathtubs and showers do not exceed 120°F. Documentation of audits shall be kept. (DPOC by AES,HSLS on 3/5/19)] 01/17/2019 Not Implemented
6400.163(c)The most recent psychiatric medication review for Individual #1 was completed 9/19/18. 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.Individual #1 will see a Psychiatrist on January 24, 2019, at Mercy Behavioral Services for an assessment and psychiatric medicine review. We will submit Individual #1's psychiatric medication review to your attention as our our POC on that date. To prevent repeat violations, we will request to schedule Individual #1's psych appointments for the entire year at the 1/24/19 meeting to ensure compliance with 55 PA Code 6400.163(c) - timely completion of Psychiatric Medication Reviews. The appointments will be posted on the HCS Master Calendar and monitored monthly by the Program Specialist, Myra Powell. [Individual #1 had a medication review on February 5, 2019. Immediately, the CEO or designee shall develop and implement policies and procedures to ensure psychiatric medication review are completed, timely, with all required information. Within 2 weeks of receipt of the plan of correction, the CEO or designee shall educate all staff person responsible for ensuring that psychiatric medications review are completed timely of the aforementioned policies and procedures. Documentation of the trainings shall be kept. At least quarterly for 1 year, the CEO or designee shall audit all psychiatric medication reviews to ensure timely completion with all required information. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 3/5/19)] 01/24/2019 Not Implemented
6400.214(b)The current copies of the record information for individual #2 required in 6400.213(2)-(14) was not kept at the home. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. Individual #2 is not receiving services through an SCO and did not arrive at Harmony Care Services with records. Harmony Care Services' Program Specialist, Myra Powell, is Plan Lead and will have an Initial ISP for Individual #2 available on or before 2/10/2019, within 90 calendar days of Individual #2's date of admission, November 12, 2018. A copy of the ISP will be forwarded to your attention as an authorized agent immediately upon completion. A copy will be kept at the residential home. [An ISP was completed for Individual #2 on 1/11/19. Immediately, the program specialist shall review regulatory requirement 6400.213(1)-(14) Content of records and 6400.214(b) to ensure all required information is included in Individual #2's record and available for review upon request by the Department and required record information is available at the home. Immediately and continuing at least quarterly for 1 year, the CEO or designee shall audit all individuals' records at the home to ensure all required information is included and available for review upon request by the Department. Documentation of all audits of individuals' records shall be kept. (DPOC by AES,HSLS on 3/5/19) 02/10/2019 Not Implemented
SIN-00143018 Renewal 10/02/2018 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency completed a self-assessment of the home on 9/30/18. The agency's certificate of compliance expires on 11/14/18.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. September 30, 2018 - The CEO completed the Self-Assessment for 8533 Frankstown Road, 800 Penn Center Blvd and 1905 Penn Avenue on 9/30/18. To correct this violation, House Managers will complete the Self-Assessments within 3 to 6 months prior to the expiration date of the Agency's certificate of compliance.The Program Administrator and House Managers will set calendar reminders at 180 and 45 days prior the expiration of the Agency's Certificate of Compliance.The House Manager will deliver the Self-Assessments to the Program Administrator by mail, email or hand delivered no later than 45 days for final review prior to the expiration of the agency's certificate of compliance. The Program Administrator will deliver the Self-Assessment to Licensing by email within 5 days of review of the assessment.Self-Assessments will be monitored by the Program Administrator.[Documentation of audits of the completed self-assessments by the CEO shall be kept. (DPOC by AES,HSLS on 10/25/18)] 10/19/2018 Implemented
6400.21(a)Direct Service Worker #2 date of hire 7/28/18 did not have a Pennsylvania criminal background check completed. (repeat violation 3/13/18 et al)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. October 5, 2018, the criminal background check for Direct Service Worker #2 was completed.To eliminate this repeat violation, personnel files for all employees were reviewed by the executive assistant on October 3, 2018, for any additional missing background check records.The executive assistant will completed background checks immediately after the first interview and before the second interview and/or new hire orientation.Criminal background records will be monitored by the Program Administrator.[Immediately, upon hire and continuing at least quarterly for 1 year, the CEO or designee shall audit all staff person criminal background checks to ensure completion as required, timely. Documentation of audits shall be kept. (DPOC by AES,HSLS on 10/25/18)] 10/05/2018 Not Implemented
6400.46(i)The most recent First Aid and cardio-pulmonary resuscitation training for Direct Service Worker #1 was completed 8/16/16. (repeat violation 3/13/18 et al)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. The First Aid/CPR training for Direct Service Worker #1 was completed on 8/18, within 2 years of expiration of First Aid/CPR Certification.All other Employee First Aid/CPR training records were reviewed for compliance and were in good standing or corrected on or before 10/5/2018.The First Aid/CPR training records will be reviewed annually in January to confirm certification compliance with 6400. 46 (I) and will be monitored by the Program Administrator and executive assistant. 10/05/2018 Not Implemented
6400.141(c)(3)The physical examination for Individual #1 completed 8/28/18 did not include Immunizations. There was a hand written note from the parents of Individual #1 indicating they did not want immunizations but they are not the legal guardians for Individual #1.(repeat violation 3/13/18 et al)The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. October 10, 2018. - Deborah Perry, CEO met with the parents of Individual #1, to discuss the immunization requirements for their daughter under a Consolidated Waiver.The parents agreed to seek legal guardianship for their daughter, Individual #1, and agreed to pursue the legal matter within the next 30-60 days.The CEO and Program Administrator will monitor the progress of securing Individual #1 legal guardianship documentation.[Within 30 days, Individual #1's plan team members along with Individual #1's physician shall develop a plan in the best interest of Individual #1's health to have medical treatment provided. Documentation of notes from correspondence with plan team members and Individual #1's physician shall be kept. (DPOC by AES,HSLS on 10/25/18)] 10/10/2018 Not Implemented
6400.141(c)(4)The physical examination for Individual #2 completed 2/12/18 did not include a vision screening.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. October 11, 2018 - Individual #2, had a vision screening by a physician.All other HCS resident's records were reviewed for vision screening examinations recommended by their physician and all were in compliance. Every January 1 through January 31, all vision, hearing other required annual screenings for Individual #2 and all other HCS residents will be reviewed for compliance with physician recommendations.Vision screenings will be monitored by the Program Administrator.[Immediately and upon completion, the CEO or designee shall audit all individuals' current physical examinations to ensure all required information is included and health care and services are provided as order. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 10/25/18)] 10/11/2018 Not Implemented
6400.141(c)(7)Individual #1, date of admission 10/2/17 has not had a gynecological examination.(repeat violation 3/13/18 et al)The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. October 24, 2018 - Individual #1 has a gynecological examination scheduled on 10/24/2018. This examination will establish the baseline for Individual #1. The previous gynecological exam in 2017, completed by the Merakay DDTT team before Individual #1's waiver funding, the DDTT team reported they had no documentation of record for the 2017 gynecological examination for Individual #1. Examination records of all of HCS's female Individuals were reviewed for gynecological examination compliance with PA 6400.141(c) (7) and all are compliant.All female residents of HCS shall have an annual gynecological examination, unless their licensed physician recommends none or less frequent gynecological examinations. Gynecological examinations will be monitored by the Program Administrator.[Immediately and upon completion, the CEO or designee shall audit all individuals' current physical examinations to ensure all required information is included and health care and services are provided as order. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 10/25/18)] 10/24/2018 Not Implemented
6400.141(c)(13)The physical examination for Individual #2 completed 2/12/18 did not include allergies. This section was left blank.The physical examination shall include: Allergies or contraindicated medications.October 19, 2018 - An attachment was added to Individual #2's physical examination, dated 2/12/18, to include allergy information.All Individual's residing in Harmony Care Services sites will have allergy information included as an attachment to the examination records/form if the doctor does not include allergy information on their after visit paperwork.Allergy information and all information documented on the HCS examination forms will be monitored by the Program Administrator. [Immediately and upon completion, the CEO or designee shall audit all individuals' current physical examinations to ensure all required information is included and health care and services are provided as order. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 10/25/18)] 10/19/2018 Not Implemented
6400.142(a)Individual #1 date of admission 10/2/17 has not had a dental examination.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. October 16, 2018 - Individual #1 had a dental examination on 4/4/2018, with her mother and her Merakay DDTTeam, but the DDTT team did not have documentation for the dental examination. HCS will contact the dentist used by the DDTT team to request documentation of the dental exam on or before 10/27/18.A Dental appointment for Individual #1 was scheduled and completed on October 16, 2018, with satisfactory results.Dental examinations and all medical examination dates will be scheduled and completed by the HCS nurse and/or House Manager, for scheduling every six months in compliance with PA 6400.142 (a). Dental examinations will be monitored by the Program Administrator. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure completion of dental examinations for all individuals, timely. (DPOC by AES,HSLS on 10/25/18)] 10/16/2018 Not Implemented
6400.163(c)The psychiatric medication reviews for Individual #1 completed 9/19/18 and 8/23/18 did not include need to continue medications. Individual #1 had a psychiatric medication review completed 11/30/17 and then again 8/23/18. The psychiatric medication reviews for Individual #2 completed 9/18/18 did not include necessary medication dosages, reason for prescribing, or need to continue the medications. The psychiatric medication reviews for Individual #2 completed 5/16/18 and 4/27/18 did not include need to continue the medications. The psychiatric medication review for Individual #2 completed 1/26/18 did not include need to continue or reason for prescribing the medications.(repeat violation 3/13/18 et al) 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.October 17, 2018 - The Psychiatric reviews for Individual #1, dated 9/19/18 and 8/23/18 was hand delivered to Dr. Mahmood Usman, Individual #1's Psychiatrist, on 10/17/18, and completed on 10/17/18.All HCS Psych Review forms must include reasons for prescribing the medications, the need to continue the medications and the necessary dosages, signed and dated by the Psychiatrist. Psychiatric Medication Review documentation will be monitored by the Program Administrator.[Individual #2 had Psychiatric medication reviews completed with all required information on 1/26/18, 4/27/18, 5/16/18, 9/18/18. Immediately, the CEO shall educate all staff person responsible for ensuring the psychiatric medication reviews for all individuals are completed with all required information of the requirements as per 163c. Upon completion, a trained staff person who is also certified to administer medications shall audit all individuals' psychiatric medication review documentation to ensure completion with all required information and that individuals are administered medications as prescribed. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 10/25/18)] 10/17/2018 Not Implemented
6400.181(e)(1)The assessment for Individual #1 completed 9/1/18 did not include strengths or preferences. The assessment for Individual #2 completed 1/28/18 did not include strengths or preferences. The assessment must include the following information: Functional strengths, needs and preferences of the individual. October 7, 2018 - The Assessment for Individual #1, completed on 9/1/18, and Individual #2, completed on 1/28/18, was revised and updated to include strengths and preferences and attached as an addendum. Assessments for all other Harmony Care Services Residents were revised and updated on 10/7/2018 to include strengths and preferences.Strengths and Preferences will be included on all Initial and annual Individual Assessments.The Program Administrator will monitor Individual Assessments.[Upon completed or revision for at least 1 year, the CEO or designee shall audit all individuals' current assessments to ensure all required information is included. Immediately, the CEO or designee shall educate all staff persons in the requirements of individuals' assessments as per 6400.181e(1)-(14) and the content of the health and safety needs relevant to each individual. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 10/25/18)] 10/07/2018 Not Implemented
6400.181(e)(2)The assessment for Individual #1 completed 9/1/18 did not include likes, dislikes or interests. The assessment for Individual #2 completed 1/28/18 did not include likes, dislikes or interests.The assessment must include the following information: The likes, dislikes and interest of the individual. October 7, 2018 - The Assessment for Individual #1, completed on 9/1/18, and Individual #2, completed on 1/28/18, was revised and updated to included likes, dislikes and interests of the Individual. It was added as an addendum to the Assessments dated 9/1/18 and 1/28/2018.Assessments for all other Harmony Care Services Residents were revised and updated on 10/7/2018, to include likes, dislikes and Interests of the Individual. Likes, dislikes and Interests of the Individual will be included on all initial and annual Harmony Care Services Assessments. The Program Administrator will monitor Individual Assessments.[Upon completed or revision for at least 1 year, the CEO or designee shall audit all individuals' current assessments to ensure all required information is included. Immediately, the CEO or designee shall educate all staff persons in the requirements of individuals' assessments as per 6400.181e(1)-(14) and the content of the health and safety needs relevant to each individual. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 10/25/18)] 10/07/2018 Not Implemented
6400.181(e)(10)The assessment for Individual #2 completed 1/28/18 did not include a lifetime medical history.The assessment must include the following information: A lifetime medical history. October 16, 2018 - The Assessment for Individual #2 did not have a Lifetime medical history because it either does not exist or has never been documented for public record. Harmony Care Services began collecting information on 10/16/18, and will make every effort to collect medical history for Individual #2, with a target date for completion on or before November 9, 2018.All HCS Individual's Assessments must include a lifetim[Upon completed or revision for at least 1 year, the CEO or designee shall audit all individuals' current assessments to ensure all required information is included. Immediately, the CEO or designee shall educate all staff persons in the requirements of individuals' assessments as per 6400.181e(1)-(14) and the content of the health and safety needs relevant to each individual. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 10/25/18)]e medical history. The Program Administrator will monitor documentation of lifetime medical history. 10/19/2018 Not Implemented
6400.183(5)Individual #2, who is prescribed medications to treat symptoms of a diagnosed psychiatric illness did not have a social, emotional, and environmental plan.The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. October 4, 2018 - The Acting Program Specialist developed a Social, Emotional and Environmental Plan to address these needs of Individual #2.The S.E.E.P. plan for Individual#2 will be reviewed and updated as the social, emotional and environmental needs of Individual #2 changes. Review of Individual S.E.E.P. plans will be required reading/training for all HCS Direct Care Staff before supporting the Individual.S.E.E.P plans will be monitored by the Program Administrator. [Immediately and continuing at least quarterly, the program specialist shall audit all individuals' ISPs to ensure all individuals ISPs to ensure if a medication has been prescribed to treat symptoms of a diagnosed psychiatric illness the ISP, including updates and revisions include a protocol to address the social, emotional and environmental needs of the individual and will request ISP updates and revisions as needed. Documentation of all audits shall be kept.(DPOC by AES,HSLS on 10/25/18)] 10/04/2018 Not Implemented
SIN-00137687 Unannounced Monitoring 07/03/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.164(b)The medication administration record for Individual #1 was not initialed on 7/1/18 and 7/2/18 at 8:00 pm for Risperidone 4mg, 7/1/18 at 8:00 pm for Os-cal 500+D, and 7/1/18 at 3:00 pm and 8:00pm for Clonazepam 2mg. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. To correct this violation, staff responsible for this violation was coached, reviewed and re-trained on proper medication documentation. To prevent a repeat violation, we will schedule random medication refresher courses on a quarterly basis to test staff's knowledge and reduce documentation violations. The House Manager and Nurse have set up a check and balance system to monitor the MARS in the morning and in the evening on a daily basis to prevent repeated violations and establish compliance with 55 PA Code Chapter 6400.164 (b). [At least weekly, a designated staff persons certified to administer medication shall audit all individual current medication administration record, medications and doctors orders to ensure all individuals are administered medications as prescribed and documented as required. Documentation of audits and aforementioned quarterly trainings shall be kept. (DPOC by AES,HSLS on 8/20/18)] 07/09/2018 Implemented
6400.186(a)The program specialist completed the most recent ISP review for Individual #1 on 1/15/18. The program specialist has not completed an ISP review for Individual #2 date of admission 1/6/18.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. An ISP review was completed for Individual #2 on April 5 and July 5th. To correct this violation the ISP April 5, 2018 ISP review for Individual #2 was put into their licensing binder, as was the ISP Review for July 2018. To correct this violation, and remain in compliance with 55 PA Code 6400.186(a) a copy of the April and July ISP Review was placed on site in Individual #2's licensing binder and it will be the responsibility of the Program Specialist to ensure all ISP records are maintained on site and the original will be maintained in the Administrative Office. [At least quarterly for 1 year the CEO shall review all individual records to ensure the program specialist completed ISP reviews for all individuals, timely. (DPOC by AES,HSLS on 8/20/18)] 07/06/2018 Implemented
6400.186(c)(1)The most recent monthly review documentation for Individual #1 and Individual #2 was completed March 2018.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. To correct this violation, the monthly reviews for Individual #1 and Individual #2 were returned to their licensing binders as required under 55 PA Code Chapter 6400.186(c)(1); all of our records were being reviewed, revised and/or restructured to establish compliance and prevent repeat violations. The Program Specialist and CEO will be responsible for all ISP records and documentation maintain compliance with 55 PA Code Chapter 6400.186(c)(1). [At least quarterly for one year, the CEO shall review the all individuals' records to ensure ISP reviews are completed timely with the required monthly documentation. (DPOC by AES,HSLS on 8/20/18)] 08/03/2018 Implemented
6400.213(9)The record for Individual #2 did not include a copy of the current ISP. Each individual's record must include the following information: A copy of the current ISP. To correct this violation, the ISP was replaced in the Individual's records. There was a copy in the Binder, but it was used to make copies during a training and staff failed to returned it to it's place. To prevent a repeat violation, staff was re-trained and corrected as to the importance of the ISP and being mindful to return information to it's correct place. To remain in compliance with 55 PA Code Chapter 6400.213(9), a copy of the current ISP will always be in each individual's records and it will be the responsibility of the Program Specialist and House Manager to ensure that an ISP is always in each Individual's records on a monthly basis when the Monthly reviews are completed. [Immediately, the CEO shall educate the Program specialist and the house manager of the required information in individuals records as per 6400.213(1)-(14). Documentation of the training shall be kept. (DPOC by AES,HSLS on 8/20/18)] 07/09/2018 Implemented
SIN-00133180 Unannounced Monitoring 04/13/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.161(b)At 11:32AM, Nystatin 100,000 units/GM powder prescribed for Individual #1 was unlocked and accessible on top of the dresser in Individual #1's bedroom. 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. To correct this non-compliance the medication was immediately removed from the bedroom and locked in the locked file cabinet on the day this violation was discovered. To avoid this issue moving forward All staff will be re-trained in the policies and procedures of proper Medication storage and safety precautions on April 24 and April 26, 2018. The House Manager will be charged with monitoring all medication storage on a daily basis and the Compliance Officer will do unannounced visits to each site to review that medical records and storage procedures are in compliance with PA Code 6400.161(b). [Documentation of the trainings shall be kept. (AS 4/30/18)] 04/13/2018 Implemented
6400.164(a)Nystatin 100,000 Units/GM powder to be applied topically three times a day on rash prescribed for Individual #1 on 4/9/18 was not listed on Individual #1's April 2018 medication log.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. To address this non-compliance the MARs record for Individual #1 was updated on 4/14/2018 to include the Nystatin 100,00 Units/GM powder. To correct this moving forward all staff are being re-trained in Medication procedures and policy on April 24 and April 26, 2018. The House Manager will check MARs records weekly and The Compliance Officer will check MARs records monthly to remain in compliance with PA Code 6400.164(a).[Immediately, and continuing at least weekly for 2 months and then continuing monthly, the CEO or designee trained in medication administration shall review all individuals' medications, medication administration records and doctors' orders to ensure all individuals are administered medications as prescribed and documented as required. Documentation of audits shall be kept. (AS 4/30/18)] 04/14/2018 Implemented
SIN-00130997 Renewal 03/13/2018 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Direct Service Worker #1, date of hire 6/7/17, had a Pennsylvania criminal history record check completed 7/10/17. Direct Service Worker #4, date of hire 10/1/17, had a Pennsylvania criminal history record check completed 10/10/17.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. To Correct our non-compliance, Harmony Care Services will conduct a criminal background check on the day of the employee candidate's second interview to eliminate the possibility of another 5- day violation. To alleviate this issue moving forward, HCS will update the Employment Policy to include criminal background checks be conducted on the date of the second interview to meet the standards of compliance with PA Code 6400.21(a). [Immediately, upon hire and at least quarterly for 1 year, the CEO shall audit all staff person's records to ensure all employees who have direct contact with individual have a criminal backgrounds checks as required and documentation is kept and available upon request by the Department. Documentation of audits shall be kept. (AS 4/27/18)] 03/15/2018 Implemented
6400.31(b)Individual #1, date of admission 10/2/17, had a statement acknowledging receipt of the information on rights signed 3/13/18. Individual #2, date of admission 1/6/18, had a statement acknowledging receipt of the information on rights signed 3/11/18.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. To Correct our non-compliance, Harmony Care Services will update the New Resident Orientation to include the signing and dating of the receipt, review, and acknowledgement of the information on rights of the Individual on the day of Admission. Documentation will be maintained in the Administrative office and Individuals Licensing Binder. To alleviate this issue moving forward, HCS will update the New Resident Orientation to include the signing and dating of the Indiviual Rights document on the date of admission. The Annual Licensing Review Checklist will include a line item for checking that the Individual Rights form was signed and dated by the Individual in accordance with PA Code 6400.31(b). [Immediately, the CEO shall develop and implement a tracking system to ensure all individuals are informed of individual rights and sign and date acknowledging the receipt of the information on rights, timely and documentation is maintained. At least quarterly, the CEO shall audit the aforementioned tracking system to ensure all individuals are informed of individual rights and sign and date acknowledging the receipt of the information on rights, timely. Documentation of the audits shall be kept. (AS 4/27/18)] 03/28/2018 Implemented
6400.46(a)The home did not provide orientation for Direct Service Worker #1, date of hire 6/7/17. The home did not provide orientation for Direct Service Worker #2, date of hire 8/10/17.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. To correct our non-compliance, Harmony Care Service will update the New Hire Orientation Packet to include documentation that an Orientation was provided to staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals in their appointed positions. To Alleviate this issue moving forward, The signed and dated Orientation Document will be included in both the Licensing Binder and Personnel File of the Direct Service Worker. Verification of the Direct Service Worker's Orientation documentation will be included as a line item on the Annual Licensing Review Checklist (ALRC). These correction update will ensure that the signed/dated Orientation form is available for review and meets compliance standards in accordance with PA Code 6400.46(a). [On 4/13/18, orientation for Direct Service Workers #1 and #2 was not available upon request by the Department. Immediately, the CEO shall audit Direct Service Worker #3's staff file to ensure completion of orientation as required and documentation is maintained and available for review upon request from the Department. Immediately, upon hire and continuing at least quarterly for 1 year, the CEO shall audit staff files to ensure all staff persons have completed orientation as required and documentation is maintained and available for review upon request by the Department. (AS 4/27/18)] 03/28/2018 Not Implemented
6400.46(d)Program Specialist #3 had no record of training relevant to human services during the training year of 1/1/17 to 12/31/17. (Repeat Violation 3/32/17 et. al)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. To correct our non-compliance, the Training Record indicating 24 Hours of Training, was placed in the Program Specialist's Employee Records and Personnel Files. To alleviate this issue moving forward, the Training Records for the Program Specialist and all HCS Employees will be maintained in their Employee Records and Personnel File for easy access and review. HCS has created a Training Department and hired an on-staff trainer to manage the training records and files for employees of Harmony Care Service to eliminate this issue moving forward and remain in compliance with PA code 6400.46(d). [On 4/13/18, record of training for Direct Service Worker #1 was not available upon request by the Department. Immediately, the CEO shall audit Direct Service Worker #1's staff file to ensure the record of training is maintained and available for review upon request from the Department. Immediately, upon hire and continuing at least quarterly for 1 year, the CEO shall audit staff files to ensure all staff persons have completed orientation as required and documentation is maintained and available for review upon request by the Department. (AS 4/27/18)] 03/28/2018 Not Implemented
6400.46(e)Direct Service Worker #1, date of hire 6/7/17, did not have training in the areas of intellectual disability, the principles of normalization, rights and program planning and implementation. Direct Service Worker #2, date of hire 8/10/17, did not have training in the areas of intellectual disability, the principles of normalization, rights and program planning and implementation.Program specialists and direct service workers shall have training in the areas of intellectual disability, 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. To correct our non-compliance, the Harmony Care Service CEO will update the New Employee Orientation Packet to include training in the areas of Intellectual Disability, The Principles of Normalization, and Rights and Program Planning and Implementation. To Alleviate this issue moving forward, the orientation form will be signed and dated and will include documentation of training in the areas of Intellectual Disability, The Principles of Normalization, Rights and Program Planning and Implementation. Documentation of these trainings will be maintained in the DSWs Personnel File. A signed/dated document of the Orientation Training will be included as a line item under the Training section of the Annual Licensing Checklist to ensure compliance in accordance with PA Code 6400.46(e), [On 4/13/18, required training documentation for Direct Service Workers #1 and #2 was not available upon request by the Department. Immediately, the CEO shall train Direct Service Workers #1 and #2 in the areas of intellectual disability, the principles of normalization, rights and program planning and implementation and ensure training documentation is maintained and available for review upon request from the Department. Immediately, within 30 days after the day of initial employment and continuing at least quarterly for 1 year, the CEO shall audit staff files to ensure all staff persons have completed trainings as required and documentation is maintained and available for review upon request by the Department. (AS 4/27/18)] 03/28/2018 Not Implemented
6400.46(f)Direct Service Worker #2, date of hire 8/10/17 did not have fire safety training before working with individuals.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. To correct our non-compliance, the Harmony Care Service Manager will include Direct Service Worker #2's Fire Safety Training documentation in their Employee File and Personnel Records. To Alleviate this issue moving forward, the Annual Licensing Review Checklist will be revised to include a line item check for review of the signed/dated documentation of fire training during Orientation by the Manager, which includes general fire safety, evacuation procedures, reponsibitly during fire drills, the designated meeting place outside the building or within the fires safe area in the even of an actual fire, smoking safety procedures if individuals of staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms and notifications of the local fire departments as soon as possible after a fire is discovered. Documentation of this training will be maintained in the DSW's Personnel Records and Employee Files to ensure proper fire training and compliance in accordance with PA Code 6400.46(f). [On 4/13/18, required training documentation for Direct Service Workers #2 was not available upon request by the Department. Immediately, the CEO shall train Direct Service Workers #2 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 and ensure training documentation is maintained and available for review upon request from the Department. Immediately, within 30 days after the day of initial employment and continuing at least quarterly for 1 year, the CEO shall audit staff files to ensure all staff persons have completed trainings as required and documentation is maintained and available for review upon request by the Department. (AS 4/27/18)] 03/28/2018 Not Implemented
6400.46(g)Program Specialist #3, date of hire 7/1/14, did not have fire safety training.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). To correct our non-compliance, Harmony Care Service's Program Specialist will maintain a copy of all Fire Safety Trainings in their Employee File and Personnel Records. To alleviate this issue moving forward, the CEO will update the Annual Licensing Review Checklist to include a check on the Annual Fire Training records of the Program Specialist and all Staff and Residents. A copy of the signed and dated Annual Fire Safety Training by a fire safety expert in the training areas specified in subsection (f) will be maintained in the Program Specialist's Employee File in accordance with PA Code 6400.46(g). [On 4/13/18, required training documentation for Program Specialist #3 was not available upon request by the Department. Immediately, the Program Specialist #3 shall be trained by a fire safety expert 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 and ensure training documentation is maintained and available for review upon request from the Department. Immediately, within 30 days after the day of initial employment and continuing at least quarterly for 1 year, the CEO shall audit staff files to ensure all staff persons have completed trainings as required and documentation is maintained and available for review upon request by the Department. (AS 4/27/18)] 03/28/2018 Not Implemented
6400.46(i)Direct Service Worker #1, date of hire 6/7/17, did not have training in first aid, Heimlich techniques and cardio-pulmonary resuscitation. Direct Service Worker #2, date of hire 8/10/17, did not have training in first aid, Heimlich techniques and cardio-pulmonary resuscitation. Program Specialist #3, date of hire 7/1/14, had training in first aid, Heimlich techniques and cardio-pulmonary resuscitation that expired 4/22/17. (Repeat Violation 3/23/17 et. al)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. To correct our non-compliance, a copy of the Program Specialist #3 current CPR/First Aid card was placed in their Employee File and Personnel Records. DSW #1 and #2 will be scheduled for a CPR/First Aid training within 14 days of Correction Date. Harmony Care Service will update the Annual Licensing Review Checklist to include a line item to check for Training in first aid, Heimlich techniques and cardio-pulmonary resuscitation (CPR) for Program Specialists, Direct Service Workers, Drivers and Aides in vehicles within 6 months after the day of initial employment and annually thereafter by a hospital or other recognized health care organization.. A copy of the CPR Card or Proof of training will be maintained in the Program Specialist's, Direct Care Worker, Drivers and Drivers Aide's Personnel File. and Employee Record. Documentation of first aid, Heimlich techniques and cardio-pulmonary resuscitation (CPR) training will be included as a line item under the Training section of the Annual Licensing Checklist to ensure compliance in accordance with PA Code 6400.46(i). [Program Specialist/CEO #3 had CPR/FA training completed 4/11/17, valid for 2 years. Immediately, within 6 months after the day of initial employment and continuing at least quarterly for 1 year, the CEO shall audit staff files to ensure all staff persons have completed trainings as required and documentation is maintained and available for review upon request by the Department. (AS 4/27/18)] 03/28/2018 Not Implemented
6400.68(b)On 3/13/18 at 2:46PM the hot water temperature at the bathtub located in the bathroom off the hallway on the second floor of the home measured 146.1°F. Hot water temperatures in bathtubs and showers may not exceed 120°F. To Correct our non-compliance, Harmony Care Services immediately called their maintenance worker upon discovery of the violation. Within the hour the hot water temperature was adjusted down to 108.F during the second read of the bathtub water located in the bathroom off the hallway on the second floor of the home. To alleviate this issue moving forward, HCS purchased an Extech Waterproof thermometer for all HCS sites and staff was trained by the CEO on the proper procedure used to check the hot water temperature in the bathtub on a monthly basis at all HCS sites in accordance with PA Code 6400.68(b). [On 4/13/18, at 11:38AM, the hot water temperature at the bathtub measured 104.9°F. At least weekly for 3 months and continuing at least monthly, the CEO or designee shall measure the hot water temperature at all bathtubs and showers in all community homes to ensure the hot water temperature does not exceed 120°F. Documentation of measurements shall be kept. (AS 4/27/18)] 03/28/2018 Implemented
6400.107There was a portable space heater in the laundry room located in the basement 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. To Correct our non-compliance, the portable space heater, which was the property of the construction contractor working in the building, was removed out of the building immediately upon discovery, as witnessed by the Licensing Auditor who documented the violation. To alleviate this issue moving forward, HCS will inform all contractors prior to working on HCS premises, that portable space heaters are not permitted on the premises of Harmony Care Services, including staff rooms, in accordance with PA Code 6400.107. [On 4/13/18, the space heater in the laundry room was not present; however, there were two space heaters in the closet in the basement of the home. Immediately, the CEO or designee shall complete an onsite walk through of all areas of all community homes and remove all space heaters including the space heaters in the closed in the basement of the home. Within 30 days of receipt of the plan of correction, the CEO shall educate all staff persons working in community homes that portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms. At least quarterly, the CEO or designee shall complete an onsite walk through of all community homes to ensure there are not any portable space heaters, defined as heaters that are not permanently mounted or installed, in any room including staff rooms. (AS 4/27/18)] 03/28/2018 Not Implemented
6400.112(c)The written fire drill record for the fire drills held on 7/10/17 and 2/20/18 did not indicate AM or PM for the time the fire drill was held. (Repeat Violation 3/23/17 et. al).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. To Correct our non-compliance, the Fire Drill Form was redesigned to include an AM or PM time designation for every documented fire drill. Staff will be retrained on correct procedures for filling out the Monthly Fire Drill form within 30 days of date of Correction. To alleviate this issue moving forward, Staff will use the updated Fire Drill Form and all staff will be re-trained within 30 days of the date of correction on the correct way to complete the Fire Drill Form in compliance with Pa Code 6400.112(c)..[Within 30 days of receipt of the plan of correction, the CEO shall train all staff persons responsible for completing and documenting unannounced fire drills in the requirements of fire drills as per 6400.112(a)-(I). Documentation of trainings shall be kept. Within 5 days of completion of the a fire drill, the CEO shall audit the fire drill record to ensure fire drills are held and documented as required. Documentation of the audits shall be kept. (AS 4/27/18)] 03/28/2018 Not Implemented
6400.112(d)The fire drill held on 2/20/18 had an evacuation time of 5 minutes and 31 seconds. 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. To Correct our non-compliance, additional fire training will be provided to help any Individual unable to evacuate within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. To alleviate this issue moving forward, there will be 1 additional fire drill training per year for individuals unable to evacuate within 2 1/2 minutes or within the period of time specified in writing by a fire safety expert. HCS will also review a different fire safe location with the Penn Hills Fire Marshall to determine a designated Safe place that can be reached within 2 1/2 minutes by a fire safety expert, not an employee of Harmony Care Services, to ensure compliance with PA Code 6400.112(d). [Within 5 days of receipt of the plan of correction and continue until all individual evacuate within the required time, the CEO shall observe a fire drill to ensure all Individuals' at all community homes evacuate the entire building with 2 1/2 minutes. Additional fire safety training shall immediately be provided by the CEO if all individuals' at all community homes do not evacuate timely. Within 30 days of receipt of the plan of correction, the CEO shall train all staff persons responsible for completing and documenting unannounced fire drills in the requirements of fire drills as per 6400.112(a)-(I). Documentation of trainings shall be kept. Within 5 days of completion of the a fire drill, the CEO shall audit the fire drill record to ensure fire drills are held and documented as required. Documentation of the audits shall be kept. (AS 4/27/18)] 03/28/2018 Not Implemented
6400.112(e)There was not fire drill held during sleeping hours between 7/10/17 and 2/20/18. (Repeat Violation 3/28/16 and 3/23/17 et. al)A fire drill shall be held during sleeping hours at least every 6 months. To Correct our non-compliance, a twelve-month fire drill schedule was created by the CEO and will be managed as scheduled by the CEO over a twelve (12) month period, which includes a fire drill during sleeping hours within 30 days of the correction date and again, at least six months from that date and at least every 6 months moving forward. To alleviate this issue moving forward, the CEO will continue to manage the fire drill schedule in compliance with code 6400.112(e). The Annual Licensing Review Checklist will be updated to include a line item to confirm documentation of two sleeping hour fire drills at least every 6 months and staff will be retrained to understand the importance of sleeping hour fire drills by the CEO within 30 days of the date of correction. [Within 30 days of receipt of the plan of correction, the CEO shall train all staff persons responsible for completing and documenting unannounced fire drills in the requirements of fire drills as per 6400.112(a)-(I). Documentation of trainings shall be kept. Within 5 days of completion of the a fire drill, the CEO shall audit the fire drill record to ensure fire drills are held and documented as required. Documentation of the audits shall be kept. (AS 4/27/18)] 03/28/2018 Not Implemented
6400.113(a)Individual #1, date of admission 10/2/17, had fire safety training completed 3/5/18 there was no record of previous trainings so compliance could not be measured. Individual #2, date of admission 1/6/18, had fire safety training completed 3/5/18 there was no record of previous trainings so compliance could not be measured. (Repeat Violation 3/28/16 and 3/23/17 et. al) 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. To Correct our non-compliance, Harmony Care Services' Manager will update and include fire safety training during New Residents Orientation, upon initial admission and then annually thereafter. To alleviate this issue moving forward, during the New Resident Training and Orientation, the Manager will include 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, to meet the compliance standards in accordance with PA Code 6400.113(a).[Immediately and continuing at least quarterly, the CEO shall audit fire safety training records for the past 2 trainings to ensure fire safety training was completed, timely and documentation is maintained and available for review up on request by the Department. Documentation of audits shall be kept. (AS 4/27/18)] 03/28/2018 Not Implemented
6400.141(a)Individual #2, date of admission 1/6/18, had a physical examination completed 2/12/18.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. To Correct our non-compliance, the Harmony Care Services' Residential Admission policy shall be revised to include and require that all Individuals shall have copy of a physical examination within 12 months prior to their admission date and annually thereafter. Individuals will not be admitted into HCS without a current physical examination and TB Test, dated 12 months prior to admission. To alleviate this issue moving forward, the Harmony Care Services Residential Admission Policy will be revised in accordance with PA Code 6400.141(a). The Compliance Officer will review all New Resident documentation prior to Admission to verify a copy of their current Physical and TB Text in accordance with PA Code 6400.141(a). [Immediately, upon admission and at least quarterly for 1 year, the CEO shall audits all individuals' records to ensure the most recent physical examination(s) are kept in the individuals' records and available for review upon request by the Department. Documentation of audits shall be kept. (AS 4/27/18)] 03/28/2018 Not Implemented
6400.141(c)(3)The physical examination dated 1/25/18 for Individual #1 did not include immunizations, this section was left blank. The physical examination dated 2/12/18 for Individual #2 did not include immunizations, this section was left blank. (Repeat Violation 3/23/17 et. al)The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. To correct our non-compliance, Harmony Care Services hired a Compliance Officer who will review medical violations and will review and retrain staff on medical examination and documentation, including immunizations, when taking Individuals to their medical appointments. To alleviate this issue moving forward the Compliance Officer will develop a process and procedure to eliminate this violation in accordance with code 6400.141(c)(3) and will revisit and review this information with staff on an annual basis and review all Individual's examination records on a Quarterly basis. [Immediately, the CEO shall contact medical professional to ensure Individual #1 and Individual #2 have a physical examinations completed to include immunizations. Immediately, the CEO and Compliance officer shall review the agency medical form to ensure all required information as per 141(c)(1)-(15) is part of the form for the medical professional to address. Upon completion, the CEO and compliance officer shall audit the physical form completed by the medical professional to ensure all required information is included and there are not any required areas left blank and orders are followed for the health and safety of the individual. Documentation of the audits shall be kept. (AS 4/27/18)] 03/28/2018 Not Implemented
6400.141(c)(6)Individual #1, date of admission 10/2/17, had a Tuberculin skin test completed 1/27/18. Individual #2, date of admission 1/6/18, did not have a Tuberculin skin test.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. To Correct our non-compliance, the Harmony Care Services' Residential Admission policy for Individuals shall be revised to include and require that all Individuals shall have copy of a Physical Examination and TB Test within 12 months prior to their admission date and then annually and bi-annually respectively, thereafter. To alleviate this issue moving forward, Individuals will not be admitted into HCS without a current physical examination and TB Test, dated 12 months prior to admission. The Harmony Care Services Residential Admission Policy will be revised to include a current physical and TB Test in accordance with PA Code 6400.141(a) prior to admission. The Compliance Officer will review all New Individual Resident's documentation prior to their admission date to verify copies of their current Physical and TB Test in accordance with PA Code 6400.141(a). [Immediately, the CEO shall contact medical professional to ensure Individual #2 have a physical examinations completed to include Tuberculin skin test . Immediately, the CEO and Compliance officer shall review the agency medical form to ensure all required information as per 141(c)(1)-(15) is part of the form for the medical professional to address. Upon completion, the CEO and compliance officer shall audit the physical form completed by the medical professional to ensure all required information is included and there are not any required areas left blank and orders are followed for the health and safety of the individual. Documentation of the audits shall be kept. (AS 4/27/18)] 03/28/2017 Not Implemented
6400.141(c)(7)Individual #1, date of birth 10/13/80, did not have a gynecological examination. Individual #2, date of birth 5/28/70, did not have a gynecological examination. (Repeat Violation 3/28/16 and 3/23/17 et. al)The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. To correct our non-compliance, Harmony Care Services will require a gynecological examination, including a breast examination and a Pap test, unless we have documentation from a licensed physician recommending no or less frequent gynecological examinations, on the date of admission. To alleviate this issue moving forward, HCS will require a gynecological examination, including a breast examination and a Pap test and all other required examinations for New Residents on the date of Admission. These documents will be used as the start date for scheduling of all subsequent medical appointments in accordance with code 6400.141(c)(7). The Compliance Officer will review all New Individual Resident's documentation prior to their admission date to verify copies of their current gynecological examination in accordance with PA Code 6400.141(c)(7). [Immediately, the CEO shall contact medical professional to ensure Individual #1 and Individual #2 have physical examinations completed to include gynecological examinations. Immediately, the CEO and Compliance officer shall review the agency medical form to ensure all required information as per 141(c)(1)-(15) is part of the form for the medical professional to address. Upon completion, the CEO and compliance officer shall audit the physical form completed by the medical professional to ensure all required information is included and there are not any required areas left blank and orders are followed for the health and safety of the individual. Documentation of the audits shall be kept. (AS 4/27/18)] 03/28/2018 Not Implemented
6400.141(c)(8)Individual #2, date of birth 5/28/70, did not have a mammogram.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. To correct our non-compliance, Harmony Care Services will require a mammogram for women at least every 2 years for women 40 through 49 years of age and at leasgt every year for women 50 years of age or older, unless we have documentation from a licensed physician recommending none or less frequent mammograms, on the date of admission. To alleviate this issue moving forward, HCS will require a mammogram for New Residents on the date of Admission. This document will be used as the start date for scheduling of all subsequent medical appointments in accordance with code 6400.141(c)(8). The Compliance Officer will review all New Individual Resident's documentation prior to their admission date to verify copies of their current mammogram in accordance with PA Code 6400.141(c)(8). [Immediately, the CEO shall contact medical professional to ensure Individual #1 has a physical examination completed to include mammogram. Immediately, the CEO and Compliance officer shall review the agency medical form to ensure all required information as per 141(c)(1)-(15) is part of the form for the medical professional to address. Upon completion, the CEO and compliance officer shall audit the physical form completed by the medical professional to ensure all required information is included and there are not any required areas left blank and orders are followed for the health and safety of the individual. Documentation of the audits shall be kept. (AS 4/27/18)] 03/28/2018 Not Implemented
6400.141(c)(11)The physical examination dated 1/25/18 for Individual #1 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section was left blank. (Repeat Violation 3/28/16 and 3/23/17 et. al)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. To correct our non-compliance, Harmony Care Services hired a Compliance Officer who will review medical violations and retrain staff on medical examination and documentation, including an assessment of the individual's health and maintenance needs, medication regimen and the need for blood work at recommended intervals, when taking Individuals to their medical appointments. To alleviate this issue moving forward the Compliance Officer will develop a process and procedure to eliminate this violation in accordance with code 6400.141(c)(11) and will review and retrain this information to meet the compliance standards in accordance with Pa Code 6400.141(c)(11) [Immediately, the CEO shall contact medical professional to ensure Individual #1 has a physical examination completed to include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Immediately, the CEO and Compliance officer shall review the agency medical form to ensure all required information as per 141(c)(1)-(15) is part of the form for the medical professional to address. Upon completion, the CEO and compliance officer shall audit the physical form completed by the medical professional to ensure all required information is included and there are not any required areas left blank and orders are followed for the health and safety of the individual. Documentation of the audits shall be kept. (AS 4/27/18)] 03/28/2018 Not Implemented
6400.141(c)(13)The physical examination dated 2/12/18 for Individual #2 did not include allergies or contraindicated medications. This section was left blank.The physical examination shall include: Allergies or contraindicated medications.To correct our non-compliance, Harmony Care Services hired a Compliance Officer who will review medical violations and will review and retrain staff on medical examination and documentation, including allergies or contraindicated medications, when taking Individuals to their medical appointments. To alleviate this issue moving forward the Compliance Officer will develop a process and procedure to eliminate this violation in accordance with code 6400.141(c)(13), and will revisit and review this information with staff on an annual basis and review all Individual's examination records on a Quarterly basis to meet the compliance standards for PA Code 6400.141(c)(13). [Immediately, the CEO shall contact medical professional to ensure Individual #2 has physical examinations completed to include allergies or contraindicated medications. Immediately, the CEO and Compliance officer shall review the agency medical form to ensure all required information as per 141(c)(1)-(15) is part of the form for the medical professional to address. Upon completion, the CEO and compliance officer shall audit the physical form completed by the medical professional to ensure all required information is included and there are not any required areas left blank and orders are followed for the health and safety of the individual. Documentation of the audits shall be kept. (AS 4/27/18)] 03/28/2018 Not Implemented
6400.141(c)(14)The physical examination dated 1/25/18 for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of an emergency. The physical examination dated 2/12/18 for Individual #2 did not include medical information pertinent to diagnosis and treatment in case of an emergency. (Repeat Violation 3/28/16 and 3/23/17 et. al)The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. To correct our non-compliance Harmony Care Services will use an Annual Physical form that will include a section stating the medical information pertinent to diagnosis AND treatment in case of an emergency, in the annual physical document. This document will be used for both Individual #1 and Individual #2 in accordance with code 6400.141(c)(14). To alleviate this issue moving forward, the annual physical form used by all Harmony Care Service's Individuals will include medical information pertinent to diagnosis and treatment in case of an emergency to ensure compliance with PA Code 6400.141(c)(14). [Immediately, the CEO shall contact medical professional to ensure Individual #1 and Individual #2 has physical examinations completed to include medical information pertinent to diagnosis and treatment in case of an emergency. Immediately, the CEO and Compliance officer shall review the agency medical form to ensure all required information as per 141(c)(1)-(15) is part of the form for the medical professional to address. Upon completion, the CEO and compliance officer shall audit the physical form completed by the medical professional to ensure all required information is included and there are not any required areas left blank and orders are followed for the health and safety of the individual. Documentation of the audits shall be kept. (AS 4/27/18)] 03/28/2018 Not Implemented
6400.151(a)Direct Service Worker #1, date of hire 6/7/17, did not have a physical examination. Direct Service Worker #2, date of hire 8/10/17, did not have a physical examination. Program Specialist #3, date of hire 7/1/14, had a physical examination completed 4/1/15. (Repeat Violation 3/28/16 and 3/23/17 et. al) 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. To Correct our non-compliance, Program Specialist #3 had a Physical and TB Test completed on 3/19/18. The new hire policy will be updated to include that all newly hired employees will be required to bring a current physical and TB, taken within 12 months prior to employment, to their HCS New Hire Orientation prior to employment. To alleviate this issue moving forward, Harmony Care Services will change their policy to require proof of current Physical and TB Test at their Orientation prior to employment, in accordance with PA Code 6400.151(a). All new hires shall attend New Employee Orientation prior to employment with Harmony Care Services. [Immediately, upon completion and at least semiannually, the CEO or designee shall review all staff records to ensure all staff persons have a current physical examination. Immediately, all staff persons including Direct Service Workers #1 and #2 and Program specialist #3 without a current physical examination in their file shall not work in the community homes with individuals until a current physical examination is completed and the documentation is maintained and available for review upon request from the Department. Documentation of audits shall be kept. (AS 4/27/18)] 03/28/2018 Not Implemented
6400.151(c)(2)Program Specialist #3, date of hire 7/1/14, had a Tuberculin skin test completed 4/3/15. 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. To correct our non-compliance, the Program Specialist had a TB test on 3/19/18 by Mantoux method with negative results, and will schedule a TB Test every 2 years thereafter. To alleviate this issue moving forward, all new hires shall be required to attend New Employee Orientation prior to employment with Harmony Care Services. The new hire policy will be updated to include that all Program Specialists, CEO and all newly hired employees will be required to bring a current physical and TB test, taken within 12 months prior to employment, to their HCS New Hire Orientation prior to employment, in accordance with PA Code 6400.151(a).[Immediately, upon completion and at least semiannually, the CEO or designee shall review all staff records to ensure all staff persons have a current physical examination including Tuberculin testing. Immediately, all staff persons without a current physical examination including Tuberculin testing documentation in their file shall not work in the community homes with individuals until a current physical examination is completed and the documentation is maintained and available for review upon request from the Department. Documentation of audits shall be kept. (AS 4/27/18)] 03/28/2018 Implemented
6400.163(c)The most recent psychiatric medication review for Individual #1 was completed 11/11/17. (Repeat Violation 3/28/16 and 3/23/17 et. al) 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.To Correct this non-compliance, Harmony Care Services hired a Compliance Officer to monitor all signed and dated medical forms to ensure compliance under PA Code 6400.163(c). To alleviate this issue moving forward, the Compliance Officer will train all Direct Care Workers on medical form documentation and training on how to prepare for Medical appoints for the purpose of securing properly completed forms and documents in accordance t with Pa Code 6400.163(c).[Aforementioned training shall be completed within 30 days of receipt of the plan of correction and prior to supporting Individuals' in appointments for psychiatric medication reviews. Documentation of training shall be kept. Immediately and upon completion, at least 2 designated staff person certified to administer medication and trained in the requirements of psychiatric medication reviews, shall audit all individuals' psychiatric medication reviews to ensure all required information is included and individuals' are administered medications as prescribed. Documentation of audits shall be kept. (AS 4/27/18)] 03/28/2018 Not Implemented
6400.164(b)Os Cal 500+D prescribed for Individual #1 was not initialed as administered on 3/4/18 and 3/6/18 at 8:00 PM. Clanazepam 2 mg and Respiridone 4mg prescribed for Individual #1 was not initialed as administered on 3/4/18 at 8:00 PM. (Repeat Violation 3/23/17 et. al). The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. To Correct our non-compliance, the Direct Care Worker who passed the medication was re-trained by the agency Nurse in proper procedures for passing of medications and the logging in of information immediately after individual #1's dose of medications specifically, and for all other Individual's medications in general, as specified in subsection (a). To alleviate this issue moving forward, the staff nurse will monitor all new medication trained staff for 30 days, on a weekly basis to ensure proper procedures for passing medications in accordance with PA Code 6400.164(b). [Immediately, and continuing at least weekly for 2 months and then continuing monthly, the CEO or designee trained in medication administration shall review all individuals' medications, medication administration records and doctors' orders to ensure all individuals are administered medications as prescribed and documented as required. Documentation of audits shall be kept. (AS 4/17/18)] 03/28/2018 Not Implemented
6400.186(b)The ISP review for Individual #1 for the review period of 10/2/17 to 1/15/18 was not signed by the individual.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. To correct our non-compliance, Harmony Care Services' Program Specialist will have Individual #1 sign and date the ISP Review Signature Sheets for the review period, 10/2/17 to 1/15/18, in accordance with 6400.186(b). To alleviate this issue moving forward, a new Program Specialist will be hired within thirty days of the Correction Date. Upon hire, The Program Specialist will ensure that that All HCS Individuals shall sign and date their monthly ISP Review signature page upon review of their ISP, in accordance with PA code 6400.186(b). [Immediately, the program specialist shall review the IPS review for Individual #1 for the review period of 10/2/17 to 1/15/18 and Individual shall sign. Upon hire, the CEO shall train the program specialist of the responsibilities of the program specialist position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. Within 30 days of the receipt of the plan of correction, the CEO and program specialist shall develop and implement a tracking system to ensure the program specialist completes job duties, timely. At least quarterly for 1 year, the CEO shall audit all individuals' ISP reviews and correspondence documentation to plan team members to ensure the program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. Documentation of audits shall be kept. (AS 4/27/18)] 03/28/2018 Not Implemented
6400.186(d)The program specialist provided ISP review documentation for Individual #1 for the review period of 10/2/17 to 1/15/18 to the plan team members on 3/12/18. (Repeat Violation 3/23/17 et. al)The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. To correct our non-compliance, Harmony Care Services has placed an advertisement on Indeed in search of a new Program Specialist whose sole purpose is to bring the company into monthly, quarterly and annual compliance for ISP/ Program management and requirements in accordance with PA Code 6400.186(d) specifically and PA Codes 6400.181 - 190 in general. To alleviate this issue moving forward, the New Program Specialist will ensure that that the plan team receives copies of Individual #1's ISP Review documentation on schedule in accordance with PA Code 6400.186(d). [Upon hire, the CEO shall train the program specialist of the responsibilities of the program specialist position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. Within 30 days of the receipt of the plan of correction, the CEO and program specialist shall develop and implement a tracking system to ensure the program specialist completes job duties, timely. At least quarterly for 1 year, the CEO shall audit all individuals' ISP reviews and correspondence documentation to plan team members to ensure the program specialist provided all individuals' ISP reviews to plan team members as required, timely. Documentation of audits shall be kept. (AS 4/27/18)] 03/28/2018 Not Implemented
6400.213(1)(i)There was not a date on the photograph in the record for Individual #1 and Individual #2. The record for individual #1 did not include identifying marks.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. To Correct our non-compliance, Harmony Care Services Manager shall include an updated photograph of Inivdiual 1 and Indiviual #2 with a date on the photograph. To alleviate this issue moving forward, all photographs used for the Records of Individuals shall be dated and shall include identifying marks; in the event there are no visible identifying marks the question shall not be left blank, it shall indicate - NONE. [On 4/13/18, Individual #2 had a dated photograph. Immediately, the CEO shall include a dated photograph and identify marks in Individual #1's record. Immediately, the CEO or designee will audit all individuals' records to ensure the records for all individuals' including Individual #1 have the signature sheets for current annual meetings. Within 30 days of receipt of the plan of correction, the CEO shall educate the program specialist and the compliance officer as to the required content of all individuals' records as per 6400.213(1)-(14). Documentation of the trainings shall be kept. At least quarterly, the CEO or designee shall audit all individuals' records to ensure all required content is included. Documentation of audits shall be kept. (AS 4/27/18)] 03/28/2018 Not Implemented
SIN-00112275 Renewal 03/23/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment.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. To correct the violation, Harmony Care Services will complete a self assessment of home 0004 and 0005 for this licensing year by 05/04/2017. To prevent a repeat violation, HCS will mark on the Master Calendar, and the Calendar of the CEO, the dates of September 1 and September 15 with a reminder to complete self-assessment for certificate of compliance. On December 1 and December 15 of each year, the reminder will highlight was the self-assessment completed on schedule, to ensure that within that 3-6 month time period, the Self -Assessment was completed to maintain that the Certificate of Compliance was completed within 3-6 months prior to the expiration date of HCS's certificate of compliance, to measure and record compliance.[Prior to 3 months before the expiration of the Certificate of Compliance, the CEO shall review all self-assessments to ensure timely and accurate completion. (AS 5/22/17)] 05/04/2017 Implemented
6400.46(d)Program Specialist #1 had 22.5 hours of training relevant to human services during the training year of 1/1/16 to 12/31/16.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. To correct the violation, The Program Specialist will complete the required remaining hours for 2016 by 05/04/2017. To avoid a repeat violation, the House Manager will track the credit hours for the Program Specialist and Direct Service Workers who are employed for more than 40 hours per month to ensure their 24 hours of training relevant to human services are met. The Operations Manager will follow-up at least Quarterly, to review where all employees and staff are with training hours for the year and support the House Manager in tracking the 24 hours of required training relevant to human services.[Documentation of reviews of tracking of training by the House managers and Operations manager shall be kept. (AS 5/24/17)] 05/04/2017 Implemented
6400.110(f)Individual #1, date of admission 11/14/16 is deaf. On 3/23/17, the smoke detector and fire alarm system in the home were not equipped so the Individual #1 would be alerted in the event of a fire. If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. The Plan of Correction took place on 04/01/2017. Strobe light smoke detectors and fire alarms were installed on all floors, bathrooms and bedrooms at site 0004, 8533 Frankstown Road making it possible for each person with a hearing impairment will be alerted in the event of a fire. Harmony Care Service will equip all residential sites supporting people with a hearing impairment with strobe light smoke detectors and fire alarm equipment. The Only exception would be if the Individual's doctor has identified that a Smoke Detector/Fire Alarm with strobe lighting is known to trigger an epileptic incident for the Individual. . [Not acceptable (AS 5/24/16) CEO shall ensure all individuals with hearing impairment are alerted in the event of a fire as required. Immediately and continuing at least monthly all smoke detectors and fire alarms including those equipped so that individuals¿ with hearing impairment shall be tested to ensure they are in working order. (AS 5/24/17)] 05/04/2017 Implemented
6400.112(a)Individual #1 date of admission 11/14/16. On 3/23/17, the only unannounced fire drill held was on 3/9/17. (Repeated Violation 3/28/16) An unannounced fire drill shall be held at least once a month. To correct this violation, the Harmony Care Services (HCS) House Manager will create a quarterly fire drill schedule for each site and maintain the information in a private, confidential location at Harmony Care Services by 05/04/2017. To prevent this violation, Harmony Care Services will assign the responsibility of Fire Drills to the House Manager (HM). The HM will maintain a private and confidential schedule for fire drills and will coordinate all unannounced fire drill activity at sites 0004 and 0005. The HM will maintain one binder with documentation of Monthly Fire Drills for all sites. It will include two Overnight Fire Drills per site; the Annual Fire Training records and signature page; employee initial fire training and the Initial Fire Training Records for new Individuals including the training records and signature pages.[Within 30 days of receipt of the plan of correction, the operations manager shall train all staff person responsible for conducting fire drill on the requirement for conducting and documenting fire drills as per 6400.112(a)-(I). Documentation of trainings shall be kept. (AS 5/24/17)] 05/04/2017 Implemented
6400.113(a)Individual #1 date of admission 11/14/16 had initial fire safety training 11/26/16.(Repeated Violation 3/28/16) 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. The Plan of Correction for this violation is to include the initial fire safety training in the orientation presented on the move-in day of the Individual. It will be the responsibility of the House Manager to review the initial fire safety training on move-in day when they conduct the orientation.To prevent a repeat violation, Harmony Care Services will implement a new policy that will require scheduling an orientation at least one week before the move-in date. The orientation will include the initial fire safety training. It will be the responsibility of the House Manager to schedule the orientation at least one week before the move-in, start date. [CEO shall be present on the move in day of all individuals to ensure the individual is instructed in fire safety for the health and safety of each individual. CEO shall develop and implement a tracking system to ensure all individuals are 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. Documentation of the trainings shall be kept. (AS 5/24/17)] 05/04/2017 Implemented
6400.141(c)(3)The physical examinations completed 3/14/17 for Individual #1 did not include immunizations.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. To correct this violation, the immunization records for Individual 1 will be included with the 03/14/2017 physical examination by 05/04/2017 to become part of the annual physical medical review. To prevent a repeat violation, the agency medical records coordinator will maintain a copy of immunization records of each Individual and a copy will be available in the Medication Binder. The immunization records will be presented to the doctor during the annual physical. The immunization records will be included on that day with the physical examination records and will become part of the permanent annual physical examination record for that year. [A record of Individual #1's immunization was obtained form the physician on 5/2/17. Within 30 days of the receipt of the plan of correction, the CEO shall training medical records coordinator of the required information for individuals' physical examination as per 6400.141(c)(1)-(15). Documentation of the training shall be kept. Immediately, and upon completion the medical records coordinator shall review all individuals' current physical examinations to ensure all required information is included and there are not required areas left blank. (AS 5/24/17)] 05/04/2017 Implemented
6400.141(c)(11)The physical examination completed 3/14/17 for Individual #1 did not include health maintenance information. The section was blank. (Repeated Violation 3/28/16)The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The Plan of Correction for this violation is to contact the doctor's office and request they complete the health maintenance information. When the information is received, it will be added to the 03/14/2017 physical examination records for Individual 1. The doctor's office will be contacted by 05/04/2017 by the medical records coordinator for Harmony Care Services.To prevent a repeat violation, Harmony Care Services will re-train all staff on compliance regarding complete physical examination information. The training will review the specific information required for every medical appointment and discuss the most effective ways to get the required information from busy medical offices. [Individual #1's physical examination was updated to include health maintenance information. Immediately and after completion the CEO will review all individuals' physical examination documentation to ensure all required information is included and there are not areas of required information left blank for the health and safety of the individuals. Documentation of reviews shall be kept. (AS 6/2/17)] 05/04/2017 Implemented
6400.141(c)(14)The physical examination completed 3/14/17 for Individual #1 did not include medical information pertinent to diagnosis in case of emergency. (Repeated Violation 3/28/16) The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The Plan of Correction for this violation is to request the information from the doctor's office and upon receipt of that information include it in the 03/14/2017 physical examination records for Individual 1. The request for information will be made by 05/04/2017.To prevent a repeat violation, Harmony Care Services will hold a compliance training for physical examination records information. The training will review the specific information required for every medical appointment and review the most effective ways to get the required information from busy medical offices. The Medical Records Coordinator will check with staff who are taking the Individual to the examination to ensure they understand all of the information they are required to verify before they leave the doctor's office.[Individual #1's physical examination was updated to include medical information pertinent to diagnosis and treatment in case of an emergency. Immediately and after completion the CEO will review all individuals' physical examination documentation to ensure all required information is included and there are not areas of required information left blank for the health and safety of the individuals. Documentation of reviews shall be kept. (AS 6/2/17)] 05/04/2017 Implemented
6400.211(a)The emergency information for Individual #1 was not easily accessible at the home.Emergency information for an individual shall be easily accessible at the home. The Plan of Correction for this violation was to move the Emergency Information for Individual 1 into his Licensing Binder by 05/04/2017, making it easily accessible at home. To prevent a repeat violation, Emergency Information will be maintained in all Individual Residential Binders to make it easily accessible at the home. [Immediately, the CEO will move all individuals emergency information as stated above and all staff persons working in the home will be educated on the location. (AS 5/24/16)] 05/04/2017 Implemented
6400.213(1)(i)The record for Individual #1 did not include color of hair.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.Our Plan of Correction for this violation is to add "color of hair" on the records for Individual 1 by 05/04/2017. To prevent a repeat violation, the House Manager will review Individual's records every January to check for any changes or required updated information and to make certain all required information is included in the records. [Immediately, the CEO shall train the program specialist and house manager on what each individual record must include as per 6400.213(1)-(14). Documentation of the training shall be kept. Within 30 days of receipt of the plan of correction, the program specialist and/or house manager shall review all individuals' records to ensure all required information is included. (AS 5/24/17)] 05/04/2017 Implemented
6400.217Written consent for the release information including photographs, to persons not otherwise authorized to receive it was not obtained from Individual #1.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. To Correct the Violation, Harmony Care Services (HCS) will obtain from Individual 1 by 05/04/2017, written consent for the release of information, including photographs to persons not otherwise authorized to receive it.To prevent a repeat violation, Harmony Care Services will have the consent for the release of information document signed by the Individual on move-in day or at their orientation which will be scheduled at least one week before move in day. The House Manager will coordinate the orientation and verify the signed record of written consent for the release of information for all new residents at least one week before moving into a Harmony Care Services site. 05/04/2017 Implemented
SIN-00092610 Renewal 03/28/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(c)The Chief Executive Officer #1 did not have the qualifications available for review; therefore, compliance could not be measured. 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. The Chief Executive Officer has available a BS in Business Management and four (4) years of experience in administration. Documentation will be provided with the submission of the plan of correction. [Prior to hire the CEO will review the require qualifications for each position and maintain credentials in staff records for review. (AS 7/18/16)] 05/21/2016 Implemented
6400.71The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center located in the dining area. 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. Harmony Care Services, LLC, created a sheet of Avery Labels with the telephone number of Penn Hill's nearest hospital, police department, fire department, ambulance and poison control center and placed a label on the telephone in the dining area on April 2, 2016. HCS will monitor the label monthly for wear and tear and replace worn labels as needed. As additional telephones are added in the home these labels will be added to each additional telephone and monitored monthly for wear and tear and replaced as needed. [Telephone label with required telephone numbers was submitted to the Department on 7/19/16. CEO/Program specialist will be responsible for aforementioned monitorings. Documentation of monitorings shall be kept. (AS 7/18/16)] 05/21/2016 Implemented
6400.110(e)The home has four stories including a basement and attic. The home does not have at least one smoke detector on each floor that is interconnected and audible throughout the home or an automatic fire alarms system that is audible throughout the home. 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. Harmony Care Services, LLC, (HCS) purchased four (4) interconnected Kidde RF-SM-DC wireless smoke detectors for 8533 Frankstown Road on March 28, 2016 and installed them on April 2, 2016. It will be the policy of HCS to install interconnected wireless smoke detectors in any HCS home with multiple levels, a basement and attic. [Starting within a week of receipt of the plan of corrections, at least weekly for 4 weeks and then at least monthly, CEO or designated staff person will engage the system to ensure interconnected smoke detectors are in proper working order and audible throughout the home. Documentation of testing shall be kept. (AS 7/18/16)] 05/22/2016 Implemented
SIN-00173282 Unannounced Monitoring 06/04/2020 Compliant - Finalized