Inspection ID

Reason for Inspection

Inspection Date

Inspection Status

SIN-00240138

Unannounced Monitoring

02/21/2024

Non Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.80(a)	On 2/21/24 at 12:40PM, the outside deck and stairs at the rear 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 remnant of snow or ice that the inspectors observed. The stairs were tested and deemed safe and no longer a slip hazard.	02/21/2024	Implemented
6400.110(f)	In the physical development section of Individual #1's individual plan last updated on 1/17/24 reads, "[Individual #1] is deaf." In the fire safety section of the individual plan reads, "[Individual #1] does not need any verbal prompting or physical assistance to evacuate." Interviews reveal that Direct Service Workers need to wake up Individual #1 to evacuate the home for fire drills during sleeping hours. The smoke detectors and fire alarms are not equipped so the Individual #1 is alerted in the event of a fire during sleeping hours.	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.	This violation has been disputed and this is being discussed with [HSLS]. as our agency was in compliance with this regulation at the time of inspection.	04/10/2024	Not Implemented

SIN-00238147

Unannounced Monitoring

01/26/2024

Non Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.166(b)	Individual #1 is prescribed Ibuprofen 600mg with instructions to take one tablet by mouth every 8 hours for 5 days and to discontinue medication on 1/13/24. This medication was not initialed as administered for any of the days on the January 2024 medication record.	The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.	Client was given the medication as directed - but staff failed to sign the boxes on the MAR. Staff were made to correct their error. Management will continue to check the Medication Records and hold staff accountable for any errors. Staff were spoken to about the importance of the need for signatures and they were giving a write up for their error. The Record has been updated accordingly on the MAR	01/27/2024	Not Implemented

SIN-00236209

Unannounced Monitoring

12/11/2023

Non Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.214(b)	At 1:22PM, Individual #2's most current psychological evaluation, completed on 9/14/99 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 12/11 at the time of inspection, Individual #2 psychological evaluation was provided during the time of inspection.	12/11/2023	Not Implemented

SIN-00232838

Unannounced Monitoring

10/11/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.64(a)	On 10/11/23 at 11:16AM, there is dark colored substance that appears to be mold and/or mildew along the caulking, at the base of the inside and outside of the walk-in shower and along baseboards behind the sink in the bathroom.	Clean and sanitary conditions shall be maintained in the home.	To correct this violation, a work order was put in with the management company to have this addressed.	10/21/2023	Implemented
6400.67(a)	On 10/11/23 at 11:16AM, there was peeling paint from what appears to be water damage, on the ceiling above the shower stall. At 11:20AM, there was "bubbling" paint from what appears to be water damage, on the wall pillar to the right of the refrigerator in the kitchen of the home. In addition on the ceiling near the wall pillar, there was a light brown stain from what appears to be water damage.	Floors, walls, ceilings and other surfaces shall be in good repair.	To correct this violation, this issue was included on the same work order that was placed for the mold and mildew issue [55 PA Code Chapter 6400.64(a)].	10/12/2023	Implemented
6400.166(b)	Gabapentin 600mg tab prescribed to Individual #1 was not initialed as administered on 10/4/23 at 2:00PM. Eucerin cream prescribed to Individual #1 was not initialed as administered to Individual #1 on 9/30/23 at 8:00PM. (Repeat 4/28/23, 6/30/23, 8/23/23)	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, we scheduled a medication training on 10/22/23, this was to bring all of our new staff up to standard and also refresh the knowledge of some existing staff. Documenting and initialing medication administration was covered in the training. Staff were made aware of the importance of this step in the process and how it cannot be missed.	11/15/2023	Implemented

SIN-00232026

Unannounced Monitoring

09/22/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.22(d)(2)	House supervisor #2 stated that on 9/13/23, Individual #1 was taken to cash a check with a description, "3rd Thursday Spend" which was for $94.00. House Supervisor #2 stated that the money was given directly to Individual #2. The disbursement from this check was never logged on the financial ledger for Individual #1.	(2) Disbursements made to or for the individual.	To correct this violation a disbursement binder/log was created for Individual to document receipt of her monthly funds and her purchases with her funds. The ledger documents: 1. Date she receives her check; 2. What she purchases with her funds, the date of the purchase; 3. The remaining balance of her funds after her purchases.	10/09/2023	Implemented
6400.22(e)(1)	On 9/22/23 at 12:02PM, the following receipts were in Individual #1's financial binder: Wendys $10.58 on 9/18/23, Five Below 9/18/23 for $8.85, and Big Lots on 9/18/23 for $40.36. These withdrawals were not documented on the financial ledger for Individual #1.	If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals.	To correct this violation, all staff were advised to follow the procedures as outlined under the corrective action for violation 6400.22(d)(2). The are to keep track of receipts by placing them in the binder created to track Individual's purchases and the receipts are to be placed in the binder for the month, as proof of purchase.	10/11/2023	Implemented
6400.22(e)(3)	On 9/16/2023, Individual #1's financial ledger starting balance was at $90.00. On 9/16/23, $16.59 was spent from Individual #1's funds. The balance was indicated to be $73.41 after this expense. On 9/17/23, the financial ledger balance is $0, and there is not a record for the expenditure(s) for $73.41. On 9/16/23, Individual #1's "PEX Card" ledger shows an available balance of $100; however, Individual #1 was taken to Family Dollar the same day and there was a balance of $52.67 on the card and there is not a record for the expenditure(s) for the $47.33.	If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person.	To correct this violation, all funds given to Individual #1, or paid from Individual #1's personal funds, shall be documented in Individual #1's financial ledger at the time of the transaction. Receipts are required for ALL transactions and all receipts shall be confirmed with purchase and then documented maintained with DWs financial ledger.	10/11/2023	Implemented
6400.67(a)	On 9/22/23 at 1:13PM, Individual #1's bedroom ceiling has two areas of dark colored substance that appears to be mold and/or mildew and an area where the paint is bubbling. There is a shower in the bathroom on the second floor of the home directly above this area that appears to have caused this water damage.	Floors, walls, ceilings and other surfaces shall be in good repair.	To correct this violation a work order was submitted to the property manager to address what appeared to be mold, but it has not yet been confirmed. The removal is scheduled for the first week in November 2023.	10/30/2023	Implemented
6400.216(a)	On 9/22/23 at 11:00AM, Individual records including a blank medication record for October 2023 that lists all of Individual #1's current medications, a medication information sheet for Individual #1 regarding Metformin HCL ER 500mg Tab, a prescription copy for Individual #1's Ibuprofen 400mg tablet, Individual #1's positive behavior plan dated 7/11/23, a binder of behavioral incidents for Individual #1, daily progress reports for Individual #1, and Goal binders for Individual #1 and Individual #2 were unlocked and unattended in the staff office of the home. Direct Service Worker #1 was in the living room area of the home and the staff office on the other side of the home. On 9/22/23 at 1:23PM, Direct Service Worker #1 left Individual #1's financial documents and money unattended and unlocked on the dining room table of the home. During this time that Direct Service Worker #1 was in the restroom, Individual #1 went into the financial binders and obtained the money.	An individual's records shall be kept locked when unattended.	To correct this violation, Management consulted with Direct Service Worker #1 and advised and re-trained him to always keep office books in the office so that the door can be locked when unattended or going to the restroom. The Manager will continue to remind him and all staff that Individual records are NEVER to be left out in the open unattended, ESPECIALLY when going to the restroom. Direct Service Worker #1 is typically very mindful of the books, and I'm sure never expected Individual #1 would take money from her binder.	10/12/2023	Implemented
6400.18(b)(2)	Individual #1 was transported from the home to Emergency Department on 9/7/23 at 7:25PM by a direct care staff member. Individual #1's 8:00PM medications were not transported to the hospital with Individual #1 and subsequently the following prescribed medications were not administered: Diclofenac Sodium 1% gel, Senexon-S 8.6-50mg, Eucerin Cream, Gabapentin 600mg, Melatonin 3mg, Prazosin HCL 2mg, Benztropine MES 1mg, Divalproex ER 500mg, Clonazepam 1mg. This medication error was not reported in the Enterprise Incident Management System, 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 72 hours of discovery by a staff person: A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner.	To correct this violation, all medication errors from this incident will be reported in EIM within 24 hours of this POC. We will discuss with management so that they understand that they must ensure medications are taken with staff if/when they must take residents to an appointment or emergency facility, for times when the event or visit will overlap medication times.	10/30/2023	Implemented
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 # 9171943 from 2/20/23, ID # 9234985 from 6/10/23, ID # 9234444 from 6/15/23, ID # 9234406 from 6/19/23, ID # 9243912 from 7/6/23, ID # 9261014 from 8/8/23, ID # 9277904 from 8/20/23, and ID # 9267604 8/20/23. Individual #2 has the following open incidents with no extensions: ID # 9066593 from 8/2/22, ID # 9132250 from 12/6/22, ID # 9132248 from 12/6/22, ID # 9202965 from 4/18/23, ID # 9243271 from 7/5/23, ID # 9258931 from 7/15/23.	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.	To correct these incidents, all incidents have been extended, with the exception of four (4) incidents. We will request assistance with an extension of the remaining 4, as we have not been able to extend them through EIM. We are committed to finishing them all as soon as possible.	10/30/2023	Implemented
6400.166(a)(11)	Individual #1 is prescribed Divalproex Sodium ER 500 mg tab. Individual #1's September 2023 Medication Record reads, take 3 tablets by mouth at bedtime for mental health. The medication label instructs to take 3 tablets by mouth at bedtime for seizure prevention.	A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.	To correct this violation the MAR will be corrected to match the actual diagnosis or purpose as provided by the prescribing physician. Staff will be instructed to document the MAR EXACTLY as written on the medication label and the Supervisor will ensure that the MAR matches exactly as it is written on the label.	10/19/2023	Implemented
6400.166(b)	Diclofenac Sodium 1% gel was not initialed as administered to Individual #1 on 9/20/23 at 8:00AM. Gabapentin 600mg tab not initialed as administered to Individual #1 on 9/10/23 at 2:00PM. (Repeat 4/28/23, 6/30/23, 8/23/23)	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, Supervisor will monitor staff medication administration records throughout the week to ensure proper staff documentation of the medications administered for that day.	10/13/2023	Implemented
6400.167(a)(1)	Individual #1 was transported from the home to UPMC East Emergency Room on 9/7/23 at 7:25PM by a direct care staff member. Individual #1's 8:00PM medications were not transported to the hospital with Individual #1 and subsequently the following prescribed medications were not administered: Diclofenac Sodium 1% gel, Senexon-S 8.6-50mg, Eucerin Cream, Gabapentin 600mg, Melatonin 3mg, Prazosin HCL 2mg, Benztropine MES 1mg, Divalproex ER 500mg, Clonazepam 1mg.	Medication errors include the following: Failure to administer a medication.	To correct this noncompliance, staff will be re-trained to take resident's medications with them when going to a hospital or emergency facility or transported to an off-site facility.	10/12/2023	Implemented

SIN-00229837

Unannounced Monitoring

08/23/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.62(a)	At 11:35AM, the first aid kit contained multiple packets of acetaminophen and aspirin. The individuals 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.	The acetaminophen and aspirin were removed from the first aid kit at the site on the day it as discovered.	08/29/2023	Implemented
6400.72(a)	At 12:08PM, the magnetic "screen door" curtain, at the rear exit of the home leading from the kitchen, was torn approximately eight inches at the top.	Windows, including windows in doors, shall be securely screened when windows or doors are open.	The magnetic "screen door" curtain will be removed from the rear exit of the home leading from the kitchen to the back porch.	09/23/2023	Implemented
6400.76(c)	At 11:40AM, the seat cushions, on the five dining room chairs were sunken in approximately three inches. In additon, two of the seat cusions had tears between one and four inches.	Furniture shall be comfortable and home-like.	Replacement chairs will be delivered to the site on or before 9/9/2023.	09/09/2023	Implemented
6400.163(a)	At 11:46AM, Individual #1's prescribed Eucerin Cream was not kept in the original labeled container from the pharmacy.	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, Staff took the label off the plastic bag and attached the label to the jar during the inspection. The label is now on the jar where it belongs.	08/23/2023	Implemented

SIN-00228473

Unannounced Monitoring

07/27/2023

Non Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.18(a)(4)	On 7/22/2023, the Chief Executive Officer #1 became aware of incident of Individual-to-Individual abuse. The incident was not reported through the Enterprise Incident Management System, the Department's information management system until 7/26/23.	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.	On 7/22/2023, the CEO was made aware of the Incident to incident abuse. Regrettably the CEO thought a newly trained employee was inputting the Incident and did not put the incident into the EIM System. Upon discovery of this mistake, the CEO immediately put the incident in EIM. The CEO will ensure that there have not been any additional unreported incidents on all of the sites and that staff are being careful to report incidents in a timely manner.	07/26/2023	Not Implemented
6400.18(a)(5)	On 7/15/2023, Operations Manager #2 reported to Chief Executive Officer #1, that Individual #1 was without supervision in the home, from 4:00PM to 6:00PM, on the same day, 7/15/2023. Individual #1's Individual Plan, last updated on 5/31/23, states, in the Home Supervision Section that Individual #1 is supervised 24 hours a day and reads, "[Individual #1] is supervised at all times." As of 7/27/2023, the incident of neglect was not reported 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: Neglect.	On 7/15/2023, the CEO was made aware by Operations Manager #2 that Individual #1 was without supervision in the home for 2 hours. Unfortunately, the CEO failed to put the incident into EIM in a timely manner. To correct this violation, the CEO put this incident into the EIM system immediately upon discovery of their oversight.	08/15/2023	Not Implemented

SIN-00227272

Unannounced Monitoring

06/30/2023

Non Compliant - Finalized

SIN-00220293

Renewal

03/07/2023

Non Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.112(c)	The written fire drill record for the fire drills held on 1/16/23 and 2/28/23 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.	Not all smoke detectors on site were operable at the time of inspection. To address this issue while waiting for repair/replacement of the smoke detectors, the 'Inoperable Smoke Detector Policy' was utilized. Because this was a new issue and new process the question was answered incorrectly. To correct this violation all staff who facilitate Fire Drills were retrained on fire drill records and documentation and all now understand that when a smoke detector is not functioning, the correct response is 'NON-OPERABLE' and not "Not Applicable". The Operations Manager audited all completed fire drill forms on sites to ensure correct documentation and compliance.	03/25/2023	Not Implemented
6400.141(a)	Individual #1, date of admission on 7/1/21, had an initial physical examination completed 8/4/22.	An individual shall have a physical examination within 12 months prior to admission and annually thereafter.	Individual #1's date of admission on 7/1/2021, but the physical presented for licensing was out of compliance. It was later discovered that Individual #1 did have a physical prior to 8/4/2022 but the documentation was not located until after the licensing review. To correct this violation the physical was placed in Individual #1's Licensing binder and updated on Individual #1's medical records. All Files and documents for Individual #1 was checked and reviewed for any missing documents. No additional discrepancies or missing documents were discovered. The Operations Manager and Administrative Assistant will check all paperwork to ensure the correct documents are filed in the correct licensing Binders.	04/26/2023	Implemented
6400.142(a)	Individual #2 had a dental examination completed on 8/9/21 and then again on 10/13/22.	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 #2 had a dental examination on 8/9/21 and again on 10/13/22 - 43 days out of compliance. To correct this violation, Individual #2 has a dental appointment scheduled on 10/12/2023, which is in compliance. With the implementation of the new tracking system, all required dental appoints for Individual #2 will be compliant. The Operations Manager will review and track all dental appointments to ensure dental appointments are scheduled within 365 days of the previous dental appointment.	04/14/2023	Implemented
6400.34(a)	Individual #1 was informed of individual rights on 1/22/22 and then again on 2/27/23. Individual #2 was informed of individual rights on 1/15/22 and then again on 2/27/23.	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
6400.181(f)	The program specialist did not provide Individual #1's assessment, completed 8/1/22 to the plan team members at least 30 calendar days prior to individual #1's plan team meeting on 8/3/22.	The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.	Individual #1's plan team did not have a copy of the assessment at least 30 calendar days prior to an Individual Meeting. To correct this violation the Program Specialist will provide an Annual Assessment to Individual #1s plan team at least 30 calendar days prior to an Individual's plan meeting for the 2024 Plan Team meeting. The Program Specialist and Operations Manager will work together to complete Individual #1's Annual Assessments and provide it to the plan team at least 30 calendar days prior to an Individual Meeting in 2024. The Program Specialist and Operations Manager will review all Individual's Annual Assessment dates to ensure that all Individuals are in or will be in compliance, and that all plan team members have or will have a copy at least 30 calendar days prior to an Individual's Meeting.	04/26/2023	Implemented
6400.182(c)	Individual #1's annual assessment, completed on 3/1/23 indicates that Individual #1 independently responds to a fire alarm and evacuates in two and a half minutes and is independent for sensing and moving away from heat sources. In the Health and Safety section of the Individual #1's Individual Plan, last updated 8/8/22, reads "[Individual #1] would need assistance to evacuate if a fire were to occur and [Individual #1] is not aware of heat sources."	The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.	Individual #1's annual assessment dated 3/1/2023 relevant to fire alarms, evacuations and awareness of heat sources in Individual #1's annual assessment dated 8/8/2022, was not correct. The Assessment completed on 3/1/2023 is correct.To avoid this violation in the future, the Assessment document will be reviewed more thoroughly to catch any missing or incorrect information. Because this #1 is capable of responding to a fire alarm and can evacuate within two and a half minutes and is independent for sensing and moving away from heat sources. The Program Specialist will review all Assessments for any errors prior to delivery to the Plan Team. The P.S. will make every attempt to catch mistakes before the final copy is delivered to the Plan Team.	04/26/2023	Not Implemented
6400.195(b)	The current behavioral support plan being utilized for Individual #2 was developed on 9/24/17 and has not been revised since 12/12/17.	The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews.	To correct this violation, a meeting with The Behavioral Specialist has been requested. The upcoming meeting date will set as the date to be used to schedule the next meeting within 6 months from the date of the soon to be scheduled appointment.The Operations Manager and Program Specialist will be responsible for scheduling reviews and/or revisions every 6 months.	04/24/2023	Not Implemented

SIN-00218994

Unannounced Monitoring

02/10/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.171	On 2/10/23 at 10:26AM, there was what appeared to be leftover pizza partially covered by aluminum foil on a plate in the refrigerator in the kitchen of the home.	Food shall be protected from contamination while being stored, prepared, transported and served.	To correct this violation, the leftover pizza was thrown away because it was not properly stored and to prevent possible food-born illnesses because it was not properly protected from contamination while being stored. A food storage training will be given to all staff and staff will be trained to check daily, any left-over food to ensure protection from contamination.	02/19/2023	Implemented
6400.32(m)	On 2/10/23 at 9:54AM, the home's mailbox was locked and unable to be opened without a key. The only key to the mailbox is kept in the possession of Chief Executive Officer #1; thus, restricting access to Individual #1 and Individual #2 to their delivered mail.	An individual has the right to unrestricted access to send and receive mail and other forms of communications, unopened and unread by others, including the right to share contact information with whom the individual chooses.	To correct this violation, a key was made for the residents at this location and all residents received a key on 2/14/2023. Individual #1 and Individual #2 now have mailbox keys and access to the mailboxes.	03/03/2023	Implemented

SIN-00218616

Unannounced Monitoring

02/02/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.72(a)	On 2/2/23 at 12:59PM, an ethernet cable was observed to be running from the inside wall of Individual #1's bedroom, leading through the screen and then out the only window of her bedroom to the outside. This same wire re-enters the home's lower level through the dining room window. The ethernet cable creates approximately a ½" gap in both the screen and window of Individual #1's bedroom and the dining room window.	Windows, including windows in doors, shall be securely screened when windows or doors are open.	To Correct this violation, the cable company was contacted on 2/2/2023 for immediate remediation of the ethernet cable inside Individual #1's bedroom. An appointment was scheduled for 2/4/2023. The cable representative arrived on 2/4/2023 but did not correct the ethernet cable problem, Comcast was contacted and no explanation for not repairing was provided. A second appointment was scheduled for 2/10/2023, at which time the ethernet cable was properly installed. The ethernet cable cords were checked for proper installation at all other sites, and all other sites had cable cords that were installed correctly.	02/17/2023	Implemented

SIN-00216419

Unannounced Monitoring

12/02/2022

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.67(a)	On 12/2/22 at 2:04PM, there was not a shower head in the shower in the bathroom on the 2nd floor of the home. There was pipe protruding from the shower wall. Client Care Manager #1 stated that the shower head has been broke for about one month.	Floors, walls, ceilings and other surfaces shall be in good repair.	To correct the non-compliance, a new shower head was requested of the property manager, to date they have not installed a new shower head. to protect the Individual #1, she is taking her baths and showers in the first floor bathroom with a full tub and functional shower.	01/15/2023	Implemented
6400.74	On 12/2/22 at 1:30PM, the eight outside steps leading from the deck to the ground in the rear of the home did not have a nonskid surface.	Interior stairs and outside steps shall have a nonskid surface.	On 12/9/2022, the Client Care Manager placed a non-slip, non-skid tape on the front and rear steps at site 1905.	12/09/2022	Implemented

SIN-00214028

Unannounced Monitoring

10/24/2022

Non Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.68(b)	At 12:39PM, the hot water temperature at the sink in the bathroom on the second floor of the home measured at 123.4 degrees Fahrenheit.	Hot water temperatures in bathtubs and showers may not exceed 120°F.	To correct this violation, staff lowered the water temperature during the inspection. Staff checked Water temperature an hour later and found the water temperature was safely under 120f. To avoid a repeat violation, staff will measure water temperatures at least weekly effective immediately to ensure water temperatures do not exceed 120f.	11/30/2022	Not Implemented
6400.71	The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the cordless telephones in 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.	To correct this violation, a list will be placed on the handheld unit of the phone, the list will include the nearest hospital, police department, fire department , ambulance and poison control center on the cordless telephone. Management and staff will check the phones monthly at all sites to ensure this information is present, legible and easily accessible.	11/30/2022	Not Implemented
6400.76(a)	There was a knob missing from the door of the wardrobe closet in Individual #3's bedroom leaving a metal bolt protruding, approximately 3/4 of an inch, posing a laceration hazard.	Furniture and equipment shall be nonhazardous, clean and sturdy.	To correct this violation, the protruding screw was removed on the day of the inspection. The Program Specialist inspected that piece and all of the furniture in the bedroom for similar or other safety issue and all will check all sites to ensure safe, non-hazardous, clean and study furniture on all sites for all residents.	11/30/2022	Not Implemented
6400.81(i)	The window in Individual #1's bedroom did not have drapes, curtains, shades, blinds or shutters.	Bedroom windows shall have drapes, curtains, shades, blinds or shutters.	To correct this violation, #1's bedroom will have curtains installed with a springing rod for easy removal. This will make it easier and safer to pull down and re-hang. Resident will be supported with the request not to pull the curtains down when upset. Spring rods will be a safer option for easy removal and replacement when needed. The Program Specialist will check all bedrooms at all sites to ensure curtains, shades, blinds and/or shutters are properly hung in all resident's bedrooms.	11/30/2022	Not Implemented
6400.101	At 12:58PM, there was a turn lock mechanism on the kitchen side of the door between the kitchen and the basement posing an obstructed egress from the basement when engaged.	Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.	To correct this violation this door knob will be replaced with a knob that does has a lock and key so one cannot get locked in the basement. The basement should be easily accessible and safe for everyone and we want no to ever get locked in the basement. All doors will be checked at all sites to ensure unobstructed egress for doors and basements one cannot get out of safely.	11/30/2022	Not Implemented
6400.216(a)	The unlocked wardrobe closet in Individual #3's bedroom contained individual records including Individual #2's medication list.	An individual's records shall be kept locked when unattended.	To correct this violation all records were immediately removed from Individual #3's bedroom and locked in a safe secure location. All closets on site were checked for Individual records, and no additional individual records were found on site. To ensure compliance all sites will be check for Individual records that are not securely locked.	11/30/2022	Implemented
6400.32(r)	The agency has not provided Individual #1 the right to lock Individual #1's bedroom door. The agency has not provided Individual #2 the right to lock Individual #2's bedroom door.	An individual has the right to lock the individual's bedroom door.	To correct this violation, Individual #1 and Individual #2 will be asked if they want a key to lock their bedroom door. If they say "Yes", a key or a locking mechanism will be made available to lock their bedroom doors. If they say "No", they will be given a declination letter to sign stating they have declined a key to their bedroom door. The Program Specialist will ask all of the HCS residents if they want a key or locking mechanism to lock and unlock their bedroom door.	11/30/2022	Not Implemented

SIN-00207498

Renewal

06/22/2022

Non Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.106	The furnace was not inspected and cleaned. [Repeated violation, 7/7/21 et al]	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.	The furnace was inspected on June 22, 2022. A copy of the furnace inspection will be forwarded under separate email.	08/07/2022	Implemented
6400.112(f)	The front door was used as the exit route in all fire drills from 7/4/21 to 6/11/22. The home has more than one exit.	Alternate exit routes shall be used during fire drills.	From 7/21-6/22, the front door was used as an exit for all fire drills when the home had more than one exit. To correct this violation, the operations manager conducted a fire drill on July 1, 2022 using a different exit and will continue to alternate exits throughout the calendar year.	07/01/2022	Implemented
6400.141(c)(3)	Individual #1's physical examination, completed 1/24/22 does 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 immunizations will be included on the physical examination form for Individual #1 and will be included on all annual physical forms going forward. The Program Specialist will review every residents' 2022 annual physical and will attach their immunization records to the form in preparation for their annual physical exam.	08/15/2022	Not Implemented
6400.141(c)(8)	The physical examination, completed 1/24/22 for Individual #1, age 52, does not include 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 this violation, Program Specialist will contact Individual #1's PCP to get a copy of the last 2021 mammogram of record. Based upon the information from the PCI, the Program Specialist will schedule the first available mammogram date available for Individual #1 if needed or get copy of the latest mammogram to measure compliance. The Program Specialist will review all female Individual's records to ensure mammograms have been completed within compliance or one will be scheduled according to the age and last mammogram of the resident in 2022 to establish compliance.	08/15/2022	Not Implemented
6400.141(c)(11)	Individual #1's physical examination, completed 1/24/22 does not include an assessment of the individual's health maintenance needs, medication regimen, and the need for bloodwork at recommended intervals.	The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.	To correct this violation Program Specialist will contact Individual #1's PCP to get an update on health maintenance needs, medication regime and the need for bloodwork. Program Specialist will review all Resident's medical examination forms to ensure this information is documented on the examination form of their most recent examination.	08/15/2022	Not Implemented
6400.141(c)(14)	Individual #1's physical examination, completed 1/24/22 does not include medical information pertinent to diagnosis and treatment in case of an emergency.	The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.	To correct this violation, Program Specialist will contact Individual #1's PCP for medical information pertinent to diagnosis and treatment in case of an emergency. Program Specialist and/or the Operations Manager will review all agency Individual's medical examination forms to ensure that medical information pertinent to diagnosis and treatment in case of an emergency, is a filled out on all Individuals medical examination forms.	08/15/2022	Not Implemented
6400.143(a)	Individual #1 refused a physical examination on 7/7/21. Individual #1's record does not include documentation of the continued attempts to educate the individual about the need for health care.	If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record.	To correct this violation, a training will be documented to highlight the the value of Individual #1's health care and why it is important for her to go to her medical appointments. The Client Care Manager will create and conduct the training about health care to educate Individual #1 and all residents about the need for health. cfre. via pictures, gestures and sign language to help Individual #1 understand the benefits of attending her medical appointments for her health and safety. The Client Care Manager will communicate the need for medical and dental health care to Individual #1.	08/15/2022	Not Implemented
6400.181(e)(1)	Individual #1's assessment, completed 1/15/22 does not include the strengths and needs of the individual.	The assessment must include the following information: Functional strengths, needs and preferences of the individual.	The Program Specialist (PS) will include strengths, needs and preferences of Individuals on the annual Assessment form for Individual #1 going forward on all future assessments. PS will review all Individuals' assessments to ensure functional strengths, needs and preferences of the Individual is included for upcoming Assessments due in 2022.	08/15/2022	Not Implemented
6400.181(e)(2)	Individual #1's assessment, completed 1/15/22 does 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, the Program Specialist included likes, dislikes and interests of the Individual on the assessment form. Program specialist will review all agency Individual's assessments to ensure likes, dislikes and interests of the Individual are included on their forms. Assessments without this information will be revised to include the likes, dislikes and interests of the Individual on the form.	08/15/2022	Not Implemented
6400.181(e)(10)	Individual #1's assessment, completed 1/15/22 does not include a lifetime medical history.	The assessment must include the following information: A lifetime medical history.	To correct this violation the Program Specialist (PS) will add the lifetime medical history of Individual #1 on the Assessment form for 2022, and for every annual review thereafter. PS will review all Providers Individuals' Annual Assessments to ensure the lifetime medical history of the individual is included in the Annual Assessment in a timely manner.	08/15/2022	Not Implemented
6400.181(e)(11)	Individual #1's assessment, completed 1/15/22 does not include psychological evaluations.	The assessment must include the following information: Psychological evaluations, if applicable.	To correct this violation, the Program Specialist (PS) will attached a copy of the psychological evaluation form for Individual #1 on all future Annual Assessment document for annual review. The Program Specialist will ensure that all psychological evaluations for all Agency Individuals will be included as an attachment to the Annual Assessment document in a timely manner. PS will review all Individuals' Annual Assessments to ensure a copy of the psychological evaluation for Providers' Individuals is included with their Annual Assessment in a timely manner.	08/30/2022	Not Implemented
6400.181(e)(13)(viii)	Individual #1's assessment, completed 1/15/22 does not include the individual's progress over the lase 365 calendar days and current level in managing personal property.	The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property.	To correct this violation, the Program Specialist will include a 365 day progress report and their current level of personal property management as an attachment to their Assessment forms. The Program Specialist will review all of the agency's Individuals Assessments to ensure it includes progress for the individual over the last 365 days and their ability to manage personal property.	08/15/2022	Not Implemented
6400.50(a)	Direct Service Worker #1's orientation does not include the completion date for the job-related knowledge and skills of individual plan training.	Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.	To correct this violation, Human Resources (HR) will contact DSW #1 to confirm the date of completion of the training "Job related knowledge and skills of individual' and that the trainings are signed and dated. If training has not been completed, HR will reschedule the training for DSW #1 within 7 days of the inquiry.	08/15/2022	Not Implemented
6400.51(b)(5)	Direct Service Worker #1's orientation does not include the job-related knowledge and skills of behavior supports training.	The orientation must encompass the following areas: Job-related knowledge and skills.	To correct this violation, Human Resources (HR) will contact DSW #1 and schedule the training "Job related knowledge and skills" training within 7 days of this submission. HR will confirm completion when the training is confirmed signed and dated. HR will review all employee records to ensure 'job-related knowledge' and 'skills of Individual plan' training , is included in the training curriculum.	08/15/2022	Not Implemented
6400.165(g)	Individual #1 is prescribed medication to treat symptoms of a psychiatric illness. There are not reviews of the medications by a licensed physician.	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 (PS) will get documentation for 3 month reviews for psychiatric medications prescribed for Individual #1. 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.	08/15/2022	Not Implemented
6400.181(f)	The program specialist did not provide Individual #1's assessment, completed 1/15/22 to the individual plan team members at least 30 calendar days prior to the individual annual plan meeting on 1/21/22.	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 annual Individual plan meeting date. Program Specialist (PS) will email or mail the Assessment at least 31-60 days before the annual 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
6400.183(c)	A list of persons who participated in Individual #1's individual plan meeting on 1/15/22 was not kept.	The list of persons who participated in the individual plan meeting shall be kept.	To correct this violation, Program Specialist will scan the ISP plan meeting list to HR for storage in the electronic central files for licensing documentation. The electronic central file will be managed by the Human Resource Manager. HR will scan the Individual plan meeting documents, Assessments and all licensing documentation in the central files.	08/15/2022	Not Implemented

SIN-00189890

Renewal

07/07/2021

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.15(a)	The agency did not complete a self-assessment 7of 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 6/16/21.	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
6400.106	The furnace for the home was inspected and cleaned on 1/24/2020, and then again on 2/19/2021.	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.	To correct this violation, two furnace cleanings will be scheduled for the next three (3) years, twice per year to check both the heating and cooling system and ensure compliance with 6400.106.	07/30/2021	Implemented
6400.141(a)	Individual #1's most recent physical examination is dated 5/6/2019.	An individual shall have a physical examination within 12 months prior to admission and annually thereafter.	Individual #1 was not able to get an annual physical in 2020 due to COVID. To Correct this violation, we have contacted Individual #1's guardian to get a copy of her 2021 annual physical. Because Individual #1 is not a waiver resident and Harmony Care Services does not take her to her medical appointments, her court appointment guardian is the only person who takes Individual #1 to her medical appointments. Our challenge is getting medical appointments scheduled within 6400 regulations guidelines and proper documentation since only her guardian communicates with her Medical doctors and takes Individual #1 to all of her medical appointments. We provide the forms and documentation but it is a challenge getting them returned in a timely manner. [Individual #1 physical examination, dated 5/18/21, verified on 9/8/2021. DPOC by HDKP, HSLS, on 9/8/2021].	07/30/2021	Implemented
6400.181(a)	Individual #1's most recent assessment was completed on 4/5/2019.	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.	To correct this violation, the 2020 and 2021 Assessments were placed in the Individual's annual binder on July 14, 2021. [Individual #1 Assessment for 2020, dated 4/1/2020, and 2021, dated 3/31/2021, verified on 9/8/2021. Documentation of record reviews by CEO shall be documented. Documentation shall be kept. DPCO by HDKP, HSLS, on 9/8/2021].	07/14/2021	Implemented
6400.163(h)	Individual #1 was prescribed Bacitracin ointment on 6/22/2021, with the instructions "apply topically for 7 days;" however, the medication remained with the current medications on 7/8/2021.	Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.	To prevent a repeat violation, HCS will re-train staff on medication documentation with an emphasis on discontinuation of prescription medications. [Training for medication documentation and disposal, dated 7/30/2021, verified on 9/8/2021. Weekly and monthly reviews of medication verified on 9/8/2021. DPOC by HDKP, HSLS, on 9/8/2021].	07/30/2021	Implemented

SIN-00174979

Renewal

08/06/2020

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.141(a)	The most recent physical examination for Individual #1 was completed 2/26/19.	An individual shall have a physical examination within 12 months prior to admission and annually thereafter.	To correct this violation, Individual #1 completed her physical examination on August 21, 2020. It was scheduled for June 12, 2020, but Individual #1 refused to leave the house for the appointment. To prevent this violation from ever occurring again, the new Program Specialist is making contact with Individual #1's PCP, get familiar with Individual #1's medical issues and concerns and establish a relationship with her health care provider. He will also schedule all Annual physicals when they leave an annual Physical to ensure the date is within 365 days of the previous year's physical. The P.S. and House Manager will review he medication regime with the PCP and discuss Individual #1's healthcare needs in more detail with her PCP. Most significant is the the P.S.', concern for Individual #1 has given her incentive to be more concerned about herself. Since the P.S. has begun working with her, she has not refused any appointments. I have asked the Program Specialist, House Manager and Compliance Officer to prepare a bi-annual training to discuss healthcare maintenance, medical appointments, medical documentation and expectations for Residential health care, to include compliance issues and what compliance means for staff, residents and the agency. This training will become one of HCS's annual trainings.	08/21/2020	Implemented
6400.141(c)(6)	The most recent Tuberculin skin test for Individual #1 was completed 7/21/18. (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 completed her TB skin test on August 18, 2020 and it was read on August 20, 2020. The original TB test was scheduled for June 12, 2020, during her scheduled annual physical, but Individual #1 refused to leave the house to go to the appointment and a new appointment was not rescheduled by the then Program Specialist and it was not followed up by the House Supervisor. To prevent this repeat violation, the company Program Specialist and House Supervisor was relieved of their duties for not do their jobs effectively and putting our residents health and safety at risk. In addition to hiring a new Program Specialist and a new House Manager, HCS hired a Compliance Officer to ensure this violation never happens again. To ensure compliance moving forward, the new Program Specialist, who is fluent in ASL, has ensured HCS that all medical and health maintenance appointments will be scheduled and and in compliance within the required timeframe. The P.S. has encouraged Individual #1 to take more interest in her health and well being and she is responding well to his support by going to her medical appoints that have been scheduled this month, evidenced by her getting her TB Test this month without resistance. The new Program Specialist is also scheduling all of her upcoming medical appointments and will continue to work with Individual #1 and her staff to ensure they all understands the value and importance of keeping her appointments when they are scheduled and involving her in her healthcare as appointments are scheduled. The Program, specialist will continue to work with staff to ensure they prepare her in advance for upcoming medical appointments. It appears that the more she is included in her health care plan, the more likely she will participate.	08/21/2020	Implemented
6400.165(g)	Individual #1 is prescribed divalproex sodium DR 500mg and clonazepam 1mg to treat symptoms of anxiety and depression. There was not a review by a licensed physician of the medications prescribed to treat symptoms of Individual #1's psychiatric illness. (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.	A request for a review of the psychiatric medications divalproex sodium DR 500mg and clonazepam 1mg for Individual #1 is pending review by her psychiatrist. We will forward it the medication review to our monitor upon receipt. To prevent this repeat violation, we will follow the new three layer protocol we have set in place for all psychiatric medication reviews. Psychiatric medication forms for Individual #1 shall be faxed prior to a telephone appointment or hand delivered to the doctor for on-site appointments. The review form will include the reason for prescribing the medication, the need to continue the medication and the necessary dosage. To correct and eliminate this violation going forward, the Program Specialist will review the medication review and examination form after the Dr. visit or phone call to ensure that both forms are completed in their entirety. The House Manager will provide a second review when making a copy and putting the med review in Individual #1's Licensing Binder. The Compliance officer will provide the third and final review on a monthly basis to ensure compliance. We have now a strong team and efficient team of Managers in place who have been working together diligently to improve the process and procedures necessary to prevent this repeat violation. The process begins with the Program Specialist (P.S.) who will schedule the Psychiatric Reviews for the Residents and review the Med Review form with staff who will take Individual #1 to the appointment. The P.S. will review the forms upon return to ensure a completed documentation or it will not be accepted and staff will be required to return to the doctors office to finish their job. On a monthly basis, the Compliance Officer, will review all medical review documentation to ensure that all exam forms are filled out completely and residents who are prescribed psychiatric medications have gotten their medications reviewed and documented properly by their Psychiatrist.	08/25/2020	Implemented

SIN-00170947

Renewal

02/04/2020

Non Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.112(e)	A fire drill has not been held during sleeping hours. The home became occupied in July 2019.	A fire drill shall be held during sleeping hours at least every 6 months.	On February 5, 2020, a sleeping hour fire drill was conducted at the home. The House Manager will monitor monthly fire drills and schedule the fire drills randomly throughout year, for this site. Two sleeping hour fire drills will be scheduled within 6 months of each other for compliance. The House Manager will monitor the monthly fire drills for this site and ensure, by the 21st of each month, that there is at least 1 sleeping hours fire drill at least every 6 months. [Documentation of the fire drill held on 2/5/20 at 2:50AM was submitted to the Department. Documentation of the audits of fire drill records shall be kept. (DPOC by AES,HSLS on 4/17/20)]	02/05/2020	Implemented
6400.141(c)(6)	Individual #1 has not had Tuberculin testing. (repeat violation 4/5/19)	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 got a TB exam in 2019 and the exam was not collected by staff who was the House Manager at that time; a copy has been requested for her records and the Program Specialist will have a copy of the TB Test from the Guardian by 3/27/20. A meeting has been requested with the Guardian and Trustee about Harmony Care Services assisting with the management of the medical appointments for Individual #1. The Guardian currently manages all medical appointments. The Program Specialist will continue to monitor the medical exams by developing a spreadsheet for all medical appointments for Individual #1 and this will be shared with the a Guardian for timely appointments. The Program Specialist will monitor this Tuberculin skin tests for Individual #1. [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
6400.141(c)(7)	Individual #1, date of birth 2/28/98 has not had a gynecological examination.	The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations.	On February 7, 2020, the CEO contacted the legal Guardian for Individual #1 for a revised copy of the Gynecological Examination. CEO explained the requirements for meeting all of the medical examination standards required by a licensed residential facility and that Individual #1 must meet these standards as a resident of Harmony Care Services.Harmony Care Services will schedule a meeting with the Guardian and Trustee to discuss their options for assisting with medical appointments for Individual #1. The meeting will be held on or before 3/27/2020. The Program Specialist will monitor gynecological examinations for timely scheduling. [As soon as possible, Individual #1 shall have a physical examination to include a gynecological examination including a breast examination unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. 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 a gynecological examination including a breast examination and a Pap test as required. 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
6400.141(c)(14)	The physical examination for Individual #1, completed 5/6/19 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.	On February 11, the Individuals physical exam form was updated, corrected and returned to Individual #1 Binder. Individual #1's annual physicals and medical examinations will be monitored by the Program Specialist in 2020. The Program Specialist will ensure that all medical information pertinent to diagnosis and treatment in case of an emergency is reviewed and documented on the examination form. The Program Specialist will review medical examination forms on the 1st of every month, to ensure medical information pertinent to diagnosis is documented. If this section is not completed, the staff responsible for the medical visit will be retrained by the Residential Supervisor for thorough medical examination paperwork.The House Manager and will monitor the medical exam forms when Staff returns from the appointment. The Residential Supervisor will monitor examination forms monthly.[On January 23, 2020, Individual #1 had a review of medications prescribed to treat symptoms of a diagnosed psychiatric illness. The documentation included a section that read "medical information pertinent to diagnosis treatment, in case of emergency." This requirement is to be included as part of the physical examinations. Immediately, the CEO or designee shall audit physical examination documentation to ensure required information is part of the physical examination documentation as per 6400.141c1-15. within one week of review of physical examination form, the CEO or designee shall educate all staff persons on the requirements of individuals' physical examinations and the health needs and services of each individual. Documentation of the trainings shall be kept. Upon completion, a designated staff person educated in the requirements of individuals' physical examination requirements shall audit all individuals current physical examinations to ensure all required information is included and there is not any required information left blank and that all health services are being arranged and provided for all individuals. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 4/17/20)]	02/11/2020	Not Implemented
6400.151(c)(2)	Chief Executive Officer #1 had a Tuberculin skin testing completed 3/20/18. There is no previous Tuberculin testing; therefore, compliance could not be measured.	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.	On February 8, 2020, the previous TB exam for CEO #1 was placed in their Employee Binder. On February 16, 2020, the CEO began working with a Compliance Consultant to assist with the development of a record keeping and documentation system for Employee records, to include Tuberculin skin testing. The Consultant will review employee records and will work with Human Resource Specialist Manager to for records management training. On the first day of every month, the Human Resource Specialist will contact staff about TB skin tests flagged by the Consultants as coming due for that month. The Human Resource Manager will contact the employee and the employee will schedule and confirm a date for the TB exam within 24 hours of discovery. The House Manager will monitor missing or flagged Tuberculin skin test. [Chief Executive Officer #1 had a tuberculin testing placed 3/20/20, but failed to have the testing read/completed. Chief Executive Officer #1 had tuberculin testing completed on 4/9/20 (read). Immediately and upon hire, the CEO or designee shall educated the HR Manager and house manager on their responsibilities to ensure all staff persons have physical examinations completed, timely, with all required information including tuberculin skin testing. (DPOC by AES,HSLS on 4/17/20)]	03/26/2020	Not Implemented
6400.34(a)	Individual #1 had a signed statement acknowledging being informed and explained individual rights on 1/1/20, there was no previously signed statement; therefore, compliance cannot be measured. Individual #2 had a signed statement acknowledging being informed and explained individual rights on 1/3/20, there was no previously signed statement; therefore, compliance cannot be measured.	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 signed 2019 statement acknowledging being informed and explained individual rights was placed in Individual #1's Licensing binder, it was completed on 1/3/2020, but removed by mistake when preparing the new binders. Individual #2 had an Individual Rights form with a signature page on the back for multiple years and January 1, 2020 was on that form at the time of the review - I can see how it was missed. To prevent this violation, HCS will use the single signature Individuals Rights Form so that each year is separate and there will be no room for oversight or error. The Individual Rights Documentation will be monitored and updated by the Program Specialist annually, during the first week of January, every year using the single sign form. The Program Specialist will monitor the Individual Rights statement. [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)]	02/05/2020	Not Implemented
6400.165(g)	The most recent review of medications prescribed to treat symptoms of a psychiatric illness for Individual #1 was completed 4/10/19. The most recent review of medications prescribed to treat symptoms of a psychiatric illness for Individual #2 was completed 9/26/19.	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.	February 5, 2020 - The Program Specialist contacted the Dr's office and confirmed that no appointment was made for Individual #1 after 9/26/2019. The Program Specialist will work with Individual #1's Guardian, who is responsible for medical and psychiatric appointments to ensure timely scheduling of Psychiatric appointments and attempt to get an appointment scheduled before March 27, 2020. The Program Specialist (PS) will created a spreadsheet to manage medical appointments for Individual #1 for 2020. The CEO will meet with the Guardian and Trustee to discuss a better process for managing Individual #1's medical appointments. HCS will offer to work with the Guardian to ensure timely scheduling all Individual #1's medical examinations. When appointments are scheduled, they will be posted in the Staff Office and the resident's calendar on a monthly basis and staff will have Individual #1 ready for the appointments with the Guardian. The Program Specialist will monitor Individual #1's medical appointments on the 1st of the month.[On January 23, 2020, Individual #1 had a review of medications for treatment of a psychiatric illnesses. the next appointment according to the documentation is scheduled for 5/27/21 at 12:00PM which is beyond the required 3 months. On 4/10/20, Individual #2 had a review of medications for treatment of a psychiatric illnesses. Immediately, the CEO or designee shall develop and implement a tracking, scheduling and monitoring system to ensure all individuals have medication reviews completed, timely, with required information. Immediately, upon completion of medication reviews, a designated staff person qualified to administer medications shall audit the medication review documentation to ensure all individuals are being administered as prescribed. Documentation of the audits shall be kept. Prior to assisting individuals with medication reviews, the CEO or designee shall train all staff person responsible for ensuring medication reviews are completed and medications are administered as prescribed of the aforementioned tracking, scheduling and monitoring procedures and their responsibilities. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 4/17/20)]	03/27/2020	Not Implemented

SIN-00161976

Unannounced Monitoring

08/29/2019

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.68(b)	At 3:10PM, the hot water temperature at the bathtub in the bathroom between the Individual's bedroom and staff office on the first floor of the home measured at 138.3°F.	Hot water temperatures in bathtubs and showers may not exceed 120°F.	The water temperature in the bathtub in the bathroom on the first floor measured 138.3F by the Inspector's thermometer and 110.F by the Harmony Care Services thermometer, which was measure weekly at that temperature. It was inconclusive as to why there was such a huge discrepancy between the two thermometers at the same time. However, Harmony Care Services, thermometer consistently registered at 110.F by the records presented at the time of inspection. The temperature was lowered on 8/29/2019, and re-tested on 8/20/2019 and it was ______.To manage the hot water temperature in bathtubs and showers, HCS Staff will continue to monitor the water temperatures weekly for the next four weeks and bi-weekly for the next 5-8 weeks and monthly starting after the 9th week (third month) and monthly thereafter. The Manager will document they checked the temperature on a monthly basis by signing the temperature log monthly. [Agency reports the hot water temperature on 8/30/19 measured 110.5°F. (AES,HSLS on 9/26/19)]	08/29/2019	Implemented
6400.76(a)	The bathtub drain in the bathroom between the bedroom and staff office was clogged causing several inches of hot water to remain in the bathtub when the hot water was run to measure compliance with the temperature.	Furniture and equipment shall be nonhazardous, clean and sturdy.	The bathtub drain was clogged with hair and upon discovery Staff cleaned the clogged drain by pulling out the hair clogging the drain. Once hair was removed the drain functioned properly.The other drains throughout the house were checked and were not clogged.Staff will check all drains in the house weekly to remove any hair or debris that could potentially clog the drain. The House Manager will check the drains monthly to ensure the tub is nonhazardous, clean and unclogged. [Immediately, the CEO or designee shall educate all staff person working in community homes on the procedures to ensure all furniture and equipment are nonhazardous, clean and sturdy at all times. At least monthly, the CEO or designee shall complete an onsite audit of all community homes to ensure furniture and equipment are nonhazardous, clean and sturdy. Documentation of the audits of the homes shall be kept. (DPOC by AES,HSLS on 9/26/19)]	08/29/2019	Implemented

SIN-00143020

Renewal

10/02/2018

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC 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 Self-Assessment for 1905 Penn Avenue, Pgh., PA 15221 was completed on 9/30/18. The Self-Assessment for 800 Penn Center Blvd, Pgh. 15235 and 509 Penn Center Blvd, #509, Pgh 15235, was completed on this date also.The Program Administrator will set a calendar reminder 6 months prior to the expiration of the Agency's Certificate of Compliance. The Reminder will set the start date to complete and submit the Self-Assessment to Licensing within 60 days of the calendar reminder. A copy of the Self-Assessment will be sent to the CEO and House Managers. Self-Assessments will be monitored by the Agency Program Administrator.[Documentation of audits of the completed self-assessments by the CEO shall be kept. (DPOC by AES,HSLS on 10/25/18)]	10/12/2018	Implemented

SIN-00137694

Unannounced Monitoring

07/03/2018

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.68(b)	The hot water temperature at the bathtub of the bathroom located off the hallway of the main floor of the home measured 125.4°F at 1:20PM on 7/3/18.	Hot water temperatures in bathtubs and showers may not exceed 120°F.	To correct this violation, the hot water temperature was adjusted not to exceed 120 F on July 9th. To prevent a repeat violation, the hot water temperature will be tested and recorded monthly to remain in compliance with 55 PA Code Chapter 6400 6400.68(b). Each site has an ODP Regulation thermometer that shall be used to measure the bathroom bathtub hot water on a monthly basis. This will be the responsibility of the House Manager to test and document the temperature and it will be the responsibility of the Operations Manager to monitor the documentation of the House Manager. [Immediately and prior to anyone moving in to the home and continuing at least weekly for 1 month and then continuing monthly, a designated trained staff person shall measure the hot water temperature at all bathtubs and showers at all community homes to ensure the hot water temperatures in bathtubs and showers does not exceed 120°F. Documentation of the temperatures, times and locations shall be kept and reviewed by a designated management staff person. (DPOC by AES,HSLS on 8/20/18)]	07/09/2018	Implemented
6400.77(a)	The home did not have a first aid kit.	A home shall have a first aid kit.	A first aid kit was purchased for site 1905 months before the inspection, which was why the CEO's first response was "yes", when Rebecca asked if there was a first aid kit for the site. The first aid kit is always one of the first items the CEO purchases for a new site, because her first violation was the first aid kit (tweezers) in 2015 and from then on, a first aid kit with tweezers is the first item she purchases for a site - so instintctiny she said yes, there was a First Aid kit for that site, However, because she did not see it, she told the inspectors to put a "no", because it wasn't there at the time, and she did not want to lie, but she knew she had one for the site. This was an unfortunate oversight that was immediately corrected on July 3rd, immediately after the inspection. To prevent a repeat violation moving forward, the new policy, when ordering First Aid kits on-line, is to have them delivered directly to the site and not to the administrative office, as was the case in this incident. [The first aid kit was placed in the home on 7/3/18 by the CEO. Upon opening new homes and at least monthly, a designated management staff check all first aid kits to ensure a first aid kit is available and contains all required items and extra supplies are available if needed. (DPOC by AES,HSLS on 8/20/18)]	07/03/2018	Implemented
6400.110(b)	The smoke detector located in the second floor hallway was 16 feet and 5 inches from the bedroom located at the end of the hallway.	There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door.	To correct this violation, the smoke detector located in the hallway will be moved within 15 feet of each individual and staff bedroom door. The corrective action began on July 3, new,interconnected smoke detectors were order, an electrician was hired on July 15 and the installation will occur during the week of July 23. To prevent a repeat violation, HCS Maintenance Manager will have the installer mark the intended installation location to confirm that it meets 55 PA Code Chapter 6400.110(b) with an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door before installation, and will measure the location upon completion of the installation to make sure there were no changes to the installation location. [Immediately, prior to opening homes and at least monthly, a designated staff person trained in fire alarms and smoke detectors as per 6400.110(a)-(h) shall test all smoke detectors and fire alarms in all community homes to ensure correct location and operability. Documentation of the checks shall be kept. (DPOC by AES,HSLS on 8/20/18)]	07/31/2018	Implemented
6400.110(e)	The home which has 3 floors did not have interconnected smoke detectors.	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, interconnected smoke detectors were purchased on July 3, the CEO met with the electrician on July 16 and installation is scheduled for July 23. The installation will be completed on or before July 31, 2018, before any occupants move into the home. To prevent a repeat violation, we will always order "inter-connected smoke detectors, regardless of whether it is a multi-floor or multi-room residence, all smoke detectors installed at a Harmony Care Services' site will be interconnected smoke detectors.[Immediately, prior to opening homes and at least monthly, a designated staff person trained in fire alarms and smoke detectors as per 6400.110(a)-(h) shall test all smoke detectors and fire alarms in all community homes to ensure correct location and operability. Documentation of the checks shall be kept. (DPOC by AES,HSLS on 8/20/18)]	07/31/2018	Implemented

SIN-00242389

Unannounced Monitoring

04/04/2024

Compliant - Finalized

SIN-00234464

Unannounced Monitoring

11/14/2023

Compliant - Finalized

SIN-00173284

Unannounced Monitoring

06/04/2020

Compliant - Finalized

SIN-00164551

Unannounced Monitoring

10/11/2019

Compliant - Finalized

SIN-00154598

Renewal

04/05/2019

Compliant - Finalized