Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00234164 Renewal 11/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Direct Support Worker #1 was hired on 11/20/22. A Pennsylvania criminal history record was completed on 12/6/22.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. Although the application for PA criminal history check was submitted, it was not done timely as per regulation. Provider administration will ensure that all prospective employees will have an application for criminal history completed timely and within regulatory requirements of five working days of date of hire. 01/31/2024 Implemented
6400.165(g)Individual #1 is prescribed psychotropic medication. They had a three-month medication review completed by a licensed physician completed on 2/1/23, and then again on 6/29/23.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.Provider administration will ensure all future medication reviews for those individuals prescribed psychotropic medications are conducted at least every 3 months as required by regulation. 01/31/2024 Implemented
6400.181(f)Individual #1's most recent assessment completed on 2/2/23 was not sent to their individual plan team. An individual plan annual review meeting was held on 4/12/23.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Program specialist will make sure all assessments are submitted to the team members as per regulatory requirements. 01/31/2024 Implemented
SIN-00215600 Renewal 11/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency's Certificate of Compliance expiration date was 8/19/2022. The agency completed the self-assessment of the home on 11/28/2022.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. Self-assessments were completed, however not within a timely manner. CEO and Program Specialist will complete future self-assessments within the required timeframe of 3 to 6 months prior to expiration date of the certificate of compliance. CEO and Program Specialist will complete all self-assessments by 5/19/23 and will begin self-assessments no later than 3/1/23 to measure compliance with applicable regulations and correct any identified deficiencies. Violations will be identified, and written summaries of corrective actions taken will be documented. CEO and Program Specialist will review applicable regulations. 03/31/2023 Implemented
6400.15(c)Violations were identified by marking the "V" on the self-assessment; however, the agency did not identify the violations and complete a written summary of corrections made.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. Self-assessments were completed, however not within a timely manner. CEO and Program Specialist will complete future self-assessments within the required timeframe of 3 to 6 months prior to expiration date of the certificate of compliance. CEO and Program Specialist will complete all self-assessments by 5/19/23 and will begin self-assessments no later than 3/1/23 to measure compliance with applicable regulations and correct any identified deficiencies. Violations will be identified, and written summaries of corrective actions taken will be documented. CEO and program specialist will review applicable regulations. 03/01/2023 Implemented
6400.64(e)The trash receptacle, 24 inches high, in the laundry room of the home, did not have a lid.Trash receptacles over 18 inches high shall have lids. Trash receptacle replaced next day. Trash receptacle with lid was purchased for the laundry room and other receptacle thrown out. Staff were alerted to monitor all trash receptacles in the home for compliance that are 18 inches high and must have a lid. Staff will be responsible for monitoring on a weekly basis that all trash receptacles 18 inches high must have a lid and to alert house manager should an issue arise. Receptacles will be replaced immediately as needed. 03/01/2023 Implemented
6400.76(a)The inside of the microwave in the kitchen was delaminating and had several areas of what appeared to be rust. Furniture and equipment shall be nonhazardous, clean and sturdy. Microwave replaced next day. Staff was made aware of importance that all furniture and equipment shall be nonhazardous, clean and sturdy. 03/01/2023 Implemented
6400.82(e)The shower in the bathroom along the hallway in the first floor of the home did have a nonslip surface or mat. Bathtubs and showers shall have a nonslip surface or mat. Nonslip surface placed in shower next day. Staff made aware of importance of nonslip surface in all shoer areas of the home and to be in good condition at all times. Should staff discover any issues or concerns, house managers will be alerted. Replacements will be purchased immediately. House managers will utilize a monthly checklist to ensure compliance in the future. 03/01/2023 Implemented
6400.141(a)Individual #1's most recent physical examination was completed on 11/9/2021An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Physical examination was completed on 12/7/23. CEO and program specialist will conduct audit of all individuals' files for compliance purposes. Any issues/noncompliance identified during the audit will be immediately corrected. CEO will develop a checklist for continued monthly monitoring by CEO and program specialist of all individual files in order to maintain compliance in the future. All staff, especially house managers, will be trained on the importance of completing all areas of medical records/documentation at the time of examination. 03/01/2023 Implemented
6400.141(c)(1)Individual #1's most recent physical examination, completed 11/9/2021, did not include a review of previous medical history.The physical examination shall include: A review of previous medical history. CEO and program specialist will conduct audit of all individuals' files for compliance purposes. Any issues/noncompliance identified during the audit will be immediately corrected. CEO will develop a checklist for continued monthly monitoring by CEO and program specialist of all individual files in order to maintain compliance in the future. All staff, especially house managers, will be trained on the importance of completing all areas of medical records/documentation at the time of examination. 03/01/2023 Implemented
6400.141(c)(7)Individual #1's most recent hearing examination was completed on 11/9/2021.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. Physical examination done on 12/7/23 and included normal hearing evaluation. CEO and program specialist will conduct audit of all individuals' files for compliance purposes. Any issues/noncompliance identified during the audit will be immediately corrected. CEO will develop a checklist for continued monthly monitoring by CEO and program specialist of all individual files in order to maintain compliance in the future. All staff, especially house managers, will be trained on the importance of completing all areas of medical records/documentation at the time of examination. 03/01/2023 Implemented
6400.142(a)Individual #1 had a dental examination completed on 2/15/2021 and then again on 5/19/2022.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. CEO and program specialist will conduct audit of all individuals' files for compliance purposes. Any issues/noncompliance identified during the audit will be immediately corrected. CEO will develop a checklist for continued monthly monitoring by CEO and program specialist of all individual files in order to maintain compliance in the future. All staff, especially house managers, will be trained on the importance of completing all areas of medical records/documentation at the time of examination. 03/01/2023 Implemented
6400.214(b)Individual #1's most recent physical examination and dental examination are 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. Requirements for documentation to be kept in the home is corrected. All necessary documentation is currently in the home. Program specialist has included required document checklist to be utilized and referenced by staff and house managers to ensure compliance. CEO and program specialist to conduct monthly home inspections for continued compliance. Documentation to be updated as necessary. All staff, especially house managers, will be trained on appropriate regulations to ensure compliance. 03/01/2023 Implemented
6400.32(n)The cordless telephone is kept locked in the medication cart in the kitchen of the home restricting private access to Individual #1, Individual #2, and Individual #3. There are not restrictive procedure plans for the individuals residing in the home.An individual has the right to unrestricted and private access to telecommunications.Restrictive procedure plan is currently being developed by behavior specialist to be put in place. The restrictive procedure plan will include the prohibition or use of specific types of restrictive procedures, describe the circumstances in which the restrictive procedures may be used, staff who may authorize use of the restrictive procedures and a way in which monitoring will be conducted. CEO and program specialist will in the future audit files and monitor for necessity of restrictive procedures plan and ensure behavior specialist develops an appropriate plan and is implemented accordingly. 02/11/2023 Implemented
6400.52(a)(1)Chief Executive Officer #1 provides direct service. Chief Executive Officer #1 completed 12 hours of annual training.The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.CEO and any other staff person providing direct service to individuals will complete 24 hours of annual training.[Immediately, the CEO and any other staff who have not completed required trainings shall complete the required trainings. (DPOC by AES,HSLS on 2/8/2023)] 03/01/2023 Implemented
6400.52(c)(3)Chief Executive Officer #1's training for January 1, 2021 to December 31, 2021 training year, did not include Individual Rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.CEO will ensure that all staff that provides direct service to Indviduals will have 24 hours annual training and that training will encompass all required training topics. CEO and program specialist will utilize a checklist of required training topics for direct service workers and anyone providing direct service. Monthly audits will be conducted by CEO and program specialist to ensure compliance with applicable training requirements. 03/01/2023 Implemented
6400.52(c)(5)Chief Executive Officer #1's training for January 1, 2021 to December 31, 2021 training year, did not include the safe and appropriate use of behavior supports. Program Specialist #2 training for January 1, 2021 to 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.CEO will ensure that all staff that provides direct service to Indviduals will have 24 hours annual training and that training will encompass all required training topics. CEO and program specialist will utilize a checklist of required training topics for direct service workers and anyone providing direct service. Monthly audits will be conducted by CEO and program specialist to ensure compliance with applicable training requirements. 03/01/2023 Implemented
6400.52(c)(6)Chief Executive Officer #1 training for January 1, 2021 to December 31, 2021 training year, did not include implementation of the individual plan. Program Specialist #2 training for January 1, 2021 to December 31, 2021 training year, did not include implementation of the individual plan.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.CEO will ensure that all staff that provides direct service to Indviduals will have 24 hours annual training and that training will encompass all required training topics. CEO and program specialist will utilize a checklist of required training topics for direct service workers and anyone providing direct service. Monthly audits will be conducted by CEO and program specialist to ensure compliance with applicable training requirements. 03/01/2023 Implemented
6400.165(g)Individual #1's most recent review of medication prescribed to treat symptoms of a psychaitric illness was completed on 7/26/2022. [Repeated violation 12/20/21 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.Psychiatric review to be scheduled with psychiatrist which will include documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage. House manager will be responsible for ensuring all three-month reviews of all medications prescribed to treat psychiatric illness are completed filled out by psychiatrist at time of examination/evaluation. CEO and program specialist will then be responsible for performing monthly audits of all individual files for compliance in this area. 03/01/2023 Implemented
6400.192Chief Executive Officer #1 stated that the cordless telephone in the kitchen was being kept locked in the medicine cart due to Individual #2 making harassing calls to a previous staff member. Individual #2 does not have a restrictive procedure plan.The home shall develop and implement a written policy that defines the prohibition or use of specific types of restrictive procedures, describes the circumstances in which restrictive procedures may be used, the staff persons who may authorize the use of restrictive procedures and a mechanism to monitor and control the use of restrictive procedures.Restrictive procedure plan is currently being developed by behavior specialist to be put in place. The restrictive procedure plan will include the prohibition or use of specific types of restrictive procedures, describe the circumstances in which the restrictive procedures may be used, staff who may authorize use of the restrictive procedures and a way in which monitoring will be conducted. CEO and program specialist will in the future audit files and monitor for necessity of restrictive procedures plan and ensure behavior specialist develops an appropriate plan and is implemented accordingly. 02/11/2023 Implemented
SIN-00197904 Renewal 12/20/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)On 12/21/2021 at 10:15 AM, there were no screens in Individual #3's bedroom windows.Windows, including windows in doors, shall be securely screened when windows or doors are open. Screens were placed in windows in bedroom. Monthly monitoring will be done by house manager to ensure compliance with applicable regulation. 01/21/2022 Implemented
6400.81(k)(6)On 12/21/2021 at 10:15 AM, there was no mirror in Individual #2's bedroom.In bedrooms, each individual shall have the following: A mirror. Mirror placed in bedroom. In the future, house manager will be conducting monthly reviews/inspections of applicable regulations to ensure compliance. 01/21/2022 Implemented
6400.112(c)The written fire drill records for the fire drills conducted in 03/2021, 06/2021, and 07/2021 did not document the exact date of the month that the fire drill was held.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. Fire drill training will be conducted by CEO with all staff to review applicable regulations and maintain compliance. 01/21/2022 Implemented
6400.20(b)The home did not complete a trend analysis for the period from 1/1/2021 to 12/22/2021, therefore compliance was unable to be measured.The home shall review and analyze incidents and conduct and document a trend analysis at least every 3 months.Effective immediately, provider will conduct a quarterly review of incidents to complete trend analysis and then continue quarterly reviews in the future and document the review and results/findings. 01/31/2022 Implemented
6400.165(g)Individual #1 had a review of medications prescribed to treat symptoms of a psychiatric illness on 4/14/2021 and again on 8/13/2021.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.Provider will ensure documentation is obtained from all reviews of psychiatric medications quarterly. 01/31/2022 Implemented
SIN-00182297 Renewal 01/26/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The fire drill conducted on 10/9/19 had an evacuation time of 3:00 minutes. 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. All staff will be re-trained on the regulatory requirements of 6400.112(a)-(i). CEO will ensure training by all staff is complete and documented. In the future, new staff will be oriented/trained on fire safety requirements of 6400.112(a)-(i) and that all staff are trained at least annually to ensure compliance. In addition, each house manager will monitor fire drill records for compliance. Documentation of HM monitoring will be kept at each house and reviewed by CEO monthly. 02/26/2021 Implemented
SIN-00142802 Renewal 10/03/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(3)Individual #3's most recent had Diphtheria and Tetanus immunization was completed in June 2008.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. Individual #3's primary care physician has been notified and an appointment has been made for November 2018. In the future, CEO and Program Specialist with conduct a monthly review of individual files to ensure all immunizations are current. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure timely completion of individuals physical examination to include immunizations. Documentation of file audits shall be kept. (DPOC by AES, HSLS on 10/24/18)] 10/17/2018 Implemented
6400.142(c)The written record of Individual #1's dental examination, completed on 3/15/18 did not include the dentist's name.A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. Program Specialist will review all dental examination documents when received to ensure all required information is complete. If all required information is not included/complete, form will be returned to doctor for completion. [Immediately, the CEO shall educate the program specialist of the requirements of written records of dental examinations and the review process to ensure the written record of individuals' dental examination include all required information. (DPOC by AES, HSLS on 10/24/18)] 10/17/2018 Implemented
6400.163(c)Individual #1 had a review of medications to treat symptom of diagnosed psychiatric illness on 12/15/17 and then again on 4/11/18. Individual #2's review of medications to treat symptom of diagnosed psychiatric illness completed 4/19/18 did not include the necessary dosage of the medications. Individual #2's review of medications to treat symptom of diagnosed psychiatric illness completed 7/17/18 did not include the reason for prescribing the medication, the need to continue the medication and the necessary dosage of the medications. 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.Current form used for three month review of medication prescribed to treat symptoms of diagnosed psychiatric illness has been updated to include specific areas for medication, dosage and reason for the prescribed medication. Program Specialist will perform a check of each review when received to ensure all information required is complete. Form will be returned to doctor should any required information not be completed. [Documentation of the audits by the program specialist shall be kept. (DPOC by AES, HSLS on 10/24/18)] 10/17/2018 Implemented
6400.181(f)The program specialist provided Individual #1's assessment completed 3/5/18 to the SC and plan team members on 3/5/18 for an annual ISP meeting on 3/9/18. The program specialist provided Individual #2's assessment completed 2/23/18 to the SC and plan team members on 3/13/18 for an annual ISP meeting on 2/13/18.(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). Program Specialist has posted a calendar with each individual's assessment due date so that assessments will be submitted to SC at least 30 days prior to the annual ISP meeting as per regulation. CEO will conduct a quarterly review to ensure compliance. [Documentation of aforementioned quarterly reviews by the CEO shall be kept. (DPOC by AES, HSLS on 10/24/18)] 10/12/2018 Implemented
SIN-00122169 Renewal 10/11/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Direct Service worker #1 date of hire 8/8/17 had Pennsylvania criminal history record check completed 9/27/17.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. Original criminal record check was lost and we did not have the control number to get a copy. Program Specialist will review all staff records monthly to ensure that they contain all required documentations with emphasis on criminal background checks. [Immediately, the CEO or designee will develop and implement policies and procedures to ensure all staff persons have required criminal background checks completed, timely and records are kept and available for review upon request by the department. (AS 10/25/17)] 10/16/2017 Implemented
6400.33(f)Individual #2 and Individual #3 who are assessed safe with poisons materials and independent with daily hygiene do not have readily available access to their personal items, including shampoo, towels, razors and body wash which are stored in a locked closet in the bathroom in the hallway near the living room. The key to the locked closet is kept with the direct service workers. An individual has the right to receive, purchase, have and use personal property. Individual #2 and #3 have been given keys to closet where their hygiene products are kept. House Manager or designee will check daily to make sure that they have their keys and are able to access the closet. A staff meeting will be held on November 3, 2017 to review and discuss violations and plan of correction. [Immediately and at least annually as required, the CEO or designee shall educate Individual #2 and Individual #3 of their right to receive, purchase, have and use personal property and ensure they have readily available access to their personal property. Documentation of all trainings shall be kept. (AS 10/25/17)] 10/13/2017 Implemented
6400.44(b)(10)The Program Specialist #2 did not sign Individual #1's monthly documentation completed 8/2017. [Repeated violation 11/15/16 et al]The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of an individual'ss participation and progress toward outcomes.CEO will review Program Specialists monthly documentation to make sure that all monthly documentations are signed and dated. This will be done on a semi-monthly basis. [Immediately, the CEO shall educate Program specialist #2 of the job responsibilities as per 6400.44(b)(1)-(19)Documentation of training shall be kept. Documentation of CEO reviews shall be kept. (AS 10/25/17)] 10/23/2017 Implemented
6400.81(k)(6)Individual #1 did not have a mirror in his/her bedroom.In bedrooms, each individual shall have the following: A mirror. On the individuals ISP SIB (self injury behavior) is listed. However the ISP does not state that there should not be a mirror in her room. We have notified the SC that it is too dangerous for a mirror to be in this individuals room and have requested that it be documented in the ISP. A mirror has been placed in the individuals room until we can get it documented in the ISP. [Immediately and continuing at least quarterly, the CEO or designee shall complete an onsite check of all bedrooms in all community homes to ensure all bedrooms have all required items as per 6400.81(h)-(k)(1)-(6) including mirrors. At least quarterly, the program specialist shall review all individuals' ISPs as required and report changes to the SC and plan team members as applicable. (AS 10/25/17)] 10/24/2017 Implemented
6400.101The door to the storage area off the living room had a key lock mechanism on the storage area side preventing egress from the storage area when engaged.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The door knob was turned around to prevent any individual from locking self in the storage room so the egress is unobstructed. [Within 2 weeks of receipt of the plan of correction, all staff persons shall be educated that stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed and to monitor throughout the course of their daily duties. Immediately and at least quarterly, the CEO or designee shall completed an onsite check of all community homes to ensure stairways, halls, doorways, passageways and exits from rooms and from the building are unobstructed. (AS 10/25/17)] 10/13/2017 Implemented
6400.112(c)The written fire drill record for the fire drill held at 2:12PM in July 2017 did not include the complete date of the fire drill.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. Staff have been reminded of importance of documenting the date, as well as the 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. A staff meeting will be held on November 3, 2017 to review and discuss the violations and plan of correction. Program Specialist will review fire logs and document the review monthly. [Within 2 weeks of receipt of the plan of correction, all staff responsible for completing fire drills shall be educated in the requirements of conducting and documenting fire drill as per 6400.112(a)-(I). Documentation of trainings shall be kept. At least monthly for 3 months and then continuing at least quarterly, the CEO or designee shall review all fire drill records to ensure all fire drills are conducted and documented as required. (AS 10/25/17)] 10/24/2017 Implemented
SIN-00103509 Renewal 11/15/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The home's Certificate of Compliance expires on 8/19/17. The agency completed the self-assessment on 9/23/16.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. The program specialist will ensure that the self assessment is done 3-6 months prior to expiration of the certificate of compliance and submitted in the time frame.[Upon receipt of the Certificate of Compliance, the CEO will determine the time period to complete the self-assessment and will develop and implement a tracking system to ensure the agency completes the self-assessment for all community homes 3 to 6 months prior to the expiration date on the Certificate of Compliance. Within 30 days of receipt of the plan of correction, the CEO shall train all staff persons responsible for completion of self-assessment in the aforementioned tracking system. Prior to 3 months of the expiration date of the agency's certificate of compliance the CEO shall review all self-assessment to ensure timely and full completion. (AS 12/9/16)] 12/03/2016 Implemented
6400.44(b)(10)The program specialist did not sign and date Individual #1's January, 2016 monthly documentation of Individual #1's participation and progress toward outcomes.The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of an individual's participation and progress toward outcomes.The program specialist will review monthly, all progress notes and review all monthlys to ensure that they were done and signed correctly.[Immediately, the program specialist shall sign Individual#1's January 2016 monthly documentation. Immediately, the program specialist shall review all individual's monthly documentation for 2016 to ensure all are reviewed, signed and dated as required. Within 30 days of receipt of the plan of correction and at least annually thereafter, the CEO shall train the program specialist in the responsibilities of the position as per 6400.44.(b)(1)-(19). Documentation of the training shall be kept. At least quarterly for 1 year the CEO shall review all individuals' monthly documentation of the individual's participation and progress toward outcomes to ensure the program specialist has reviewed signed and dated as required. Documentation of reviews shall be kept. (AS 12/20/16)] 12/03/2016 Implemented
6400.103The home's written emergency evacuation procedures did not include individual responsibilities and an emergency shelter location.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. The program specialist has added to the procedure the individuals responsibilities and a shelter location. The program specialist will review all policies monthly to ensure all policies are correctly done and all information is correct. [Within 30 days of receipt of the plan of correction, all staff person shall be trained in the home's updated written emergency evacuation procedures. Documentation of training shall be kept. AS 12/16/16)] 12/03/2016 Implemented
6400.112(e)The home held 10 fire drills between 1/28/16 and 10/6/16. The only drill held during sleeping hours was on 9/3/16 at 1:45 AM.A fire drill shall be held during sleeping hours at least every 6 months. All staff has been informed that sleeping hours are 12am to 6am, not 11pm to 7am. The program specialist will review the fire drills monthly to ensure that sleeping drills are in the time frame. A staff meeting/training has been scheduled to go over .112 regulation on Dec 2, 2016.[Immediately, the CEO shall train all staff persons in the requirements of conducting and documenting fire drills as per 6400.112.(a)-(I) to ensure at least every 6 months a fire drill is held when individuals' living in the home are sleeping. Within 7 days after completion and documentation of fire drills, the program specialist shall review the fire drill documentation to ensure fire drills are being conducted and documented as required. At least quarterly for 6 months the CEO shall review all fire drill records to ensure fire drills are being conducted and documented as required. Documentation of all reviews shall be kept. (AS 12/16/16)] 12/03/2016 Implemented
6400.141(c)(3)The physical examination for Individual #2, completed on 1/12/16, did not include immunizations. [Repeated Violation-10/23/15]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. The program specialist will accompany the individual to their physical exam to ensure that the doctor has filled out all areas of the physical form is completed correctly. [Individual #2's physical examination was updated to address immunization. Immediately, the CEO shall train the program specialist in the required information in individuals' physical examinations as per 6400.141(c)(1)-(15). Documentation of trainings shall be kept. Immediately and upon completion, the program specialist shall review all individual's current physical examination to ensure all required information including immunizations is present and there are not required areas left blank and missing information is immediately obtained. Documentation of reviews shall be kept. (AS 12/16/16)] 12/03/2016 Implemented
6400.141(c)(9)The physical examination completed on 1/12/16 for Individual #2, date of birth 11/28/65 did not include a prostate examination.The physical examination shall include: A prostate examination for men 40 years of age or older. The program specialist will accompany the individuals to their physical exam to make sure all necessary test are done and all required areas on the form are completed before the appointment is over.[Individual #2 is scheduled for a prostate examination on January 3, 2107. Immediately, the CEO shall train the program specialist in the required information in individuals' physical examinations as per 6400.141(c)(1)-(15). Documentation of trainings shall be kept. Immediately and upon completion, the program specialist shall review all individual's current physical examination to ensure all required information is present and there are not required areas left blank and missing information is immediately obtained. Documentation of reviews shall be kept. (AS 12/16/16)] 12/03/2016 Implemented
6400.141(c)(11)The physical examination for Individual #2, completed on 1/12/16, did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work 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. The program specialist will accompany the individual to their physical exam to make sure that all areas of the form are completed correctly by the doctor before the appointment is over.[Individual #2's physical examination was updated to address health maintenance needs. Immediately, the CEO shall train the program specialist in the required information in individuals' physical examinations as per 6400.141(c)(1)-(15). Documentation of trainings shall be kept. Immediately and upon completion, the program specialist shall review all individual's current physical examination to ensure all required information is present and there are not required areas left blank and missing information is immediately obtained. Documentation of reviews shall be kept. (AS 12/20/16)] 12/02/2016 Implemented
6400.141(c)(12)The physical examination for Individual #1, completed on 3/7/16 did not include physical limitations of the individual.The physical examination shall include: Physical limitations of the individual. The program specialist will accompany the individual to their physical exam to ensure that all areas that are required are filled out by doctor before the appointment is over. [Individual #2's physical examination was updated to include physical limitations. Immediately, the CEO shall train the program specialist in the required information in individuals' physical examinations as per 6400.141(c)(1)-(15). Documentation of trainings shall be kept. Immediately and upon completion, the program specialist shall review all individual's current physical examination to ensure all required information is present and there are not required areas left blank and missing information is immediately obtained. Documentation of reviews shall be kept. (AS 12/20/16)] 12/03/2016 Implemented
6400.141(c)(14)The physical examination for Individual #1, completed on 3/7/16 did not include medical information pertinent to diagnosis and treatment in case of an emergency. Individual #2, completed on 1/12/16, did 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. The program specialist will accompany the individual to their physical exam to ensure that all areas of their physical form are filled out by the doctor before the appointment is over.[Individual #1's physical examination was updated to include medical information pertinent to diagnosis and treatment in case of an emergency. Individual #2's physical examination was updated to include medical information pertinent to diagnosis and treatment in case of an emergency. Immediately, the CEO shall train the program specialist in the required information in individuals' physical examinations as per 6400.141(c)(1)-(15). Documentation of trainings shall be kept. Immediately and upon completion, the program specialist shall review all individual's current physical examination to ensure all required information is present and there are not required areas left blank and missing information is immediately obtained. Documentation of reviews shall be kept. (AS 12/16/16)] 12/03/2016 Implemented
6400.145(1)The home's emergency medical plan did not list the hospital or source of health care that will be used in an emergency.The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. The program specialist has added the local hospital to the medical emergency plan. Any updates that are needed will be added and the program specialist will review all policies monthly to ensure that all required information has been added. [Within 30 days of receipt of the plan of correction, all staff person shall be trained in the home's updated emergency medical plan. Documentation of training shall be kept. AS 12/16/16)] 12/03/2016 Implemented
6400.163(c)Individual #1 is prescribed Divalproex for a mood disorder, Trazadone for depression and Ziprasidone for bi-polar disorder. Individual #1's review of medications completed 1/15/16 does not include the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Individual #1's review of medications completed 6/17/16 does not include the reason for prescribing the medications. Individual #1's review of medications completed 8/5/16 does not include the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Individual #1's review of medications completed 11/24/16 does not include the reason for prescribing the medication and the need to continue the medication. 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.Program specialist will accompany Individuals to their psych medication review appointment to ensure that all required paperwork that is needed is filled out by the doctor before the appointment is over. [Immediately, the CEO shall train the program specialist and all staff person responsible for assisting individuals with psychiatric medication reviews on the information required in psychiatric medication reviews as per 6400.163(c): the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Documentation of training shall be kept. The program specialist shall review all psychiatric medication reviews upon completion to ensure all required information is included and will obtaining missing information from the physician completing the review. At least quarterly, for 1 year the CEO shall review a 25% sample of psychiatric medication reviews to ensure completion with all required information. Documentation of all audits of psychiatric medication reviews shall be kept. (AS 12/16/16)] 12/03/2016 Implemented
6400.164(a)The medication logs for Individual #1 and Individual #2 were not signed by Direct Service Worker #1 who administered medication on 11/1/16, 11/2/16 and 11/14/16, Direct Service Worker #2 who administered medication on 11/4/16 and 11/8/16 and Direct Service Worker #3 who administered medication on 11/12/16 and 11/13/16. A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. A meeting has been scheduled for Dec 2, 2016 to go over regulation .164. Program specialist will review all signature pages monthly to make sure all staff has signed that administers medication. [Immediately and at least weekly for 3 months and monthly thereafter, the program specialist will review all medication logs to ensure all required documentation is included. Documentation of reviews shall be kept. Within 30 days of receipt of the plan of correction and continuing monthly if required documentation is not completed when medication logs are reviewed by the program specialist, all staff qualified to administer medication shall be trained in the requirements of medication administration documentation. Documentation of the trainings shall be kept. (AS 12/16/16)] 12/03/2016 Implemented
6400.181(e)(10)The assessment for Individual #2, completed on 10/11/16 did not include lifetime medical history. The assessment Individual #3, completed on 5/6/16 did not include lifetime medical history. [Repeated Violation-10/23/15]The assessment must include the following information: A lifetime medical history. There was a lifetime medical history but it was not acceptable. Program specialist is making a new form for the lifetime medical history to be added to the assessment and it will be updated by Dec 2, 2016 on all files.[Individual #2 and Individual #3 had a lifetime medical history completed. Within 30 days of receipt of the plan of correction and at least annually thereafter, the CEO shall train the program specialist on the required information to be included in individuals' assessments as per 6400.181(e)(1)-(14). Documentation of the trainings shall be kept. Immediately, the program specialist shall review all individuals' current assessments to ensure all required information is present including life time medical history. At least quarterly for 1 year the CEO shall review all individuals' assessment to ensure all required information is included and accurate. Documentation of reviews shall be kept. (AS 12/16/16)] 12/03/2016 Implemented
6400.212(a)The record for Individual #2 contained a Critical Revision ISP signature sheet for another Individual. A separate record shall be kept for each individual. The form has been removed and placed in its right file. Program specialist will review all files monthly to ensure that all forms are correctly placed. [Documentation of file reviews shall be kept. (AS 12/16/16)] 12/03/2016 Implemented
6400.213(1)(i)The records for Individual #2 and Individual #3 did not include the color of eyes. The record for Individual #3 did not include the religious affiliation.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.Eye color and religion has been added. Program specialist will make sure all areas of the intake is completed before the individual leaves. Program specialist will review all files monthly to ensure that all required forms are completed.[Individual #2's record was updated to include color of eyes. Individual #3's record was updated to include color of eyes and religious affiliation. Immediately and at least semi annually, all individuals' records will be reviewed to ensure all require personal information is included. Documentation of reviews shall be kept. (AS 12/16/16)] 12/03/2016 Implemented
SIN-00100177 Unannounced Monitoring 08/24/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Above the microwave in the kitchen, there was an area approximately six inches in diameter of small black spots in a light tan film which appeared to be mildew. Clean and sanitary conditions shall be maintained in the home. That area has been treated and the spot has not re-appeared. Staff will continue to monitor that area. [Immediately, the CEO shall develop and implement policies and procedures to ensure clean and sanitary conditions are maintained in all community homes to include daily staff cleaning duties and oversight monitoring at least weekly. Within 30 days or receipt of the plan of correction, all staff shall be trained on the policies and procedures to ensure clean and sanitary conditions are maintained in all community homes. (AS 12/9/16)] 09/12/2016 Implemented
6400.67(a)On the ceiling of the kitchen near the table, there were two areas approximately 24 inches by 36 inches that were that uneven, drooping and peeling. There was a large blue tarp on the roof of the home covering the section of home above the living room. There were areas of shallow dips in the roof near the driveway of the home. Floors, walls, ceilings and other surfaces shall be in good repair. A crew has been hired and doing the job now of replacing the roof with a new one.[Immediately, the CEO shall develop and implement policies and procedures to ensure floors, walls, ceilings and other surfaces are in good repair in all community homes to include at least weekly oversight monitoring and maintenance request procedures. Within 30 days or receipt of the plan of correction, all staff shall be trained on the policies and procedures to ensure clean and sanitary conditions are maintained in all community homes. (AS 12/9/16)] 09/12/2016 Implemented
6400.71The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the telephone in the kitchen 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. Staff will make sure that the emergency numbers are posted by the phones. The numbers were placed on site of the inspection and are still in place. [Immediately and at least quarterly, the program specialist shall audit all telephones with an outside line to ensure required telephone numbers are on or by the telephones and legible. All staff person shall check telephones to ensure all required numbers are on or by the telephones throughout the course of their daily duties. (AS 12/9/16)] 09/12/2016 Implemented
6400.82(f)At approximately 10:15 AM, the bathroom at the end of the side hallway 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.Staff will check all bathrooms on a regular basis to ensure that toilet paper and paper towels are stocked at all times. [Immediately, all staff person shall be trained on the items required in bathrooms and toilet area and the location of additional supplies. All staff shall ensure all required items are present and restock as necessary throughout the course of their daily duties. (AS 12/9/16)] 09/12/2016 Implemented
SIN-00086309 Renewal 10/23/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(g)The two most recent fire safety trainings for Direct Service Workers #1, #2 and #3 were completed on 6/1/2014 and 10/22/2015.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). The program specialist and CEO will make sure that all members of the staff are annually fire trained by an fire expert. The program specialist will have the date logged in the calendar when the annual is due and have the training scheduled prior to due date. The program specialist and CEO will quarterly go over staff trainings to make sure all trainings are being met by the scheduled dates. 01/10/2016 Implemented
6400.71The telephone number for the nearest fire department was not on or by the telephone in the living room/dining room 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. The program specialist has added the Fire departments phone number to the list of emergencies number which is located by each phone in the house. The program specialist will check daily to make sure that the numbers are displayed.[At least monthly physical site checks will be done by the Program Specialist to include required telephone numbers. Physical site checks will be documented and reviewed by the CEO. (AS 1/19/16)] 01/10/2016 Implemented
6400.141(c)(7)Individual #2's most recent gynecological examination including breast examination was completed 9/23/2014. Individual #2's date of birth is 12/30/83. There is no documentation from a licensed physician recommending no or less frequent gynecological examinations.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 program specialist will make sure that #2 individual's gynecological exam is scheduled annually. The program specialist will have all dates marked to when it is due and a exam will be scheduled prior to due date. The program specialist and CEO will review all appointments that need scheduled quarterly ake sure all get scheduled on time.[CEO will develop a tracking system as to when all individuals' appointments are due and schedule as needed to meet required time frames. Also, CEO will review all current and new physical examination documentation to ensure all required information is present and address as needed. (AS 1/19/16)] 01/10/2016 Implemented
6400.152(a)The physical examination documentation completed 4/23/15 for Direct Service Worker #4 reads Direct Service Worker #4 has a communicable disease requiring universal precautions. There is no written authorization from a licensed physician that Direct Service Worker #4 can be present in the home. If a staff person or volunteer has a serious communicable disease as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) or a medical problem which might interfere with the health, safety or well-being of the individuals, written authorization from a licensed physician is required for the person to be present at the home. I have received documentation from Direct service worker #4 doctor stating they are able to work. In the future the program specialist will review all physical when being received, if the communicable box is check I will notify the worker that a letter from their doctor is needed stating that they are able to work, in order for them to be able to start work.[CEO will immediately review all staff physical examinations to ensure all required information is present and address as needed. Going forward, CEO will review all staff physical examination documentation as submitted to ensure all required information is present and address as needed. (AS 1/19/16)] 01/10/2016 Implemented
6400.181(e)(10)Individual #1's most recent assessment, dated 6/2/2015, did not include a lifetime medical history.The assessment must include the following information: A lifetime medical history. The Program specialist has added an addendum to the assessment which includes the lifetime medical history for the individual. The program specialist will update the addendum annually. The program specialist and CEO will review all assessments quarterly to make sure the addendum is updated and added. 01/10/2016 Implemented
6400.181(f)Individual #1's most recent assessment, dated 6/2/2015, was not sent to the plan team members. Individual #2's most recent assessment, dated 12/12/14, was not sent to the plan team members.(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 program specialist will make sure that the individual's assessment will be sent to the team 30 prior to the ISP meeting. The program specialist has made a form for the team members to sign off on that they did receive the assessment 30 prior, that form will be placed in the individual's file. The program specialist ad CEO will review all files to make sure that the assessment was sent 30 prior.[PS and CEO will develop a tracking system to keep track of when assessment need to be sent and will review ISP invitation letters, ISPs and other documentation to ensure each individual's entire team receive assessments as required. (AS 1/19/16) 01/10/2016 Implemented
6400.186(b)Individual #1's 3 month ISP reviews, dated 3/24/15, 6/24/15, and 9/24/15, were not signed by Individual #1. Individual #2's 3 month ISP reviews, dated 6/3/15 and 9/3/15, were not signed by Individual #2.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. The program specialist has added the individual's signature to the 3-month isp form for the individual to sign. The program specialist and individual will review the 3-month isp review and both will sign off on it. The program specialist and CEO will review quarterly to make sure that both signatures are signed. 01/10/2016 Implemented
6400.186(d)Individual #1's 3 month ISP reviews, dated 3/24/15, 6/24/15, and 9/24/15, were not sent to plan team members. Individual #2's 3 month ISP reviews, dated 6/3/15 and 9/3/15, were not sent to 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. The program specialist made a form for the team members to sign off on if they would like a copy of the individual' 3 month review. The form after being signed will be placed in the individual's file. The program specialist and EO will review quarterly to ma sure that all 3 month reviews that were requested were sent to the team members. 01/10/2016 Implemented
6400.186(e)The program specialist did not notifying the plan team members of the option to decline ISP review documentation for Individual #1 and Individual #2. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. The program specialist has made a form with the option to decline to send to the team members , if the team members chooses to decline, the form with their signatures will be placed in the individual's file. The program specialist and CEO will review quarterly to make sure all documents have been sent and signed. 01/10/2016 Implemented
SIN-00070196 Renewal 10/06/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment prior to the expiration of the agency's certificate of compliance on 8/19/14.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. An self-assessment will be done by the agency within 3 to 6 months prior to the expiration date of the agency's certficate of compliance, to measure and record compliance with this chapter. [Self-assessment document will be completed by the CEO/designee within 30 days of reciept of the plan of correction and again within 3 to 6 months prior to the expiration date of the agency's certificate. (CHG 1/30/15)] 10/31/2014 Implemented
6400.21(c)The Pennsylvania criminal history checks were completed on 5/21/13 for Staff Person #1, date of hire 6/1/14 and Staff Person #2, date of hire 6/13/14. The Pennsylvania criminal history check was completed on 8/1/08 for Staff Person #3, date of hire 6/1/14.The Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person's date of hire. Criminal background checks will be done 1 year prior to hire date. As the day of inspection new background checks and will be submitted. [New criminal background checks were obtained for staff persons #1, #2, and #3. All staff persons records will be audited to ensure they contain a copy of the completed criminal background check that meets the regulatory requirements and requirements per OAPSA. (CHG 1/30/15)] 10/31/2014 Implemented
6400.65The bathroom in the hallway near the bedrooms did not have an operable window or mechanical ventilation.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. A screen has been install and the picture has been submitted 10/31/2014 Implemented
6400.72(b)The screen covering the window on the side of the home facing the parking area is torn and shredding. Screens, windows and doors shall be in good repair. The screen has been replaced and a picture will be submitted 10/31/2014 Implemented
6400.104The home did not notify the local fire department in writing of the address of the home and the exact location of the bedrooms of the individuals who need assistance evacuating in the event of an actual fire.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. The home notified the local fire departmeny on June 4th, a copy of the letter will be submitted [The fire department will be notified in writing in the future if the needs of the individuals who need assistance evacuating in the event of an actual fire change. (CHG 1/30/15)] 10/31/2014 Implemented
6400.141(c)(4)Individual #2's physical examination, dated 9/15/14, did not include a vision or hearing screening.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Staff will review the physical form before leaving the doctor's office to make sure all area's are filled in [Individual #2 had a vision and hearing screening. (CHG 1/30/15)] 10/31/2014 Implemented
6400.141(c)(11)Individual #1's physical examination dated 12/16/13 and Individual #2's physical examinations dated 9/15/14 did not include health maintenance needs. The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. We will be using an up-dated physical form which will include health maintenance needs [Individual #1's physician updated the physical examination form to address health maintenence needs. (CHG 1/30/15)] 10/31/2014 Implemented
6400.141(c)(14)Individual #1's physical examination dated 12/16/13 and Individual#2's physical examination dated 9/15/14 did 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. We will be using an up-dated physical form which contains information pertinent to diagnosis and treatment in case of emergency. [All individuals current physicals have been updated to include medical infromation pertinent to diagnosis and treatment in case of an emergency. (CHG 1/30/15)] 10/31/2014 Implemented
6400.142(f)Individual #1 does not have a written plan for dental hygiene.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. The individual has achieved dental hygiene independance which will be documented by his interdisciplinary team [All individuals records will be audited to ensure they contain the required documentation regarding dental hygiene. (CHG 1/30/15)] 10/31/2014 Implemented
6400.164(a)Lithium, 300 mg, take 2 capsules, 2 times per day, by mouth, prescribed for Individual #2, was administered on 10/6/14 at 8:00 PM; however, the medication administration record was not initialed as administered. 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. Staff will review the MAR after each initial medication pass to ensure all areas have been checked. [The CEO or designee will audit the MAR documentation once a week to ensure that the medication log is being initialled by staff promptly after a medication is administered. (CHG 1/30/15)] 10/31/2014 Implemented
6400.181(a)Individual #1 admitted on 5/19/14 did not have an initial assessment completed until 8/15/14. 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. The program specialist will have the assessment completed within the 60 calendar days. [Assessment was completed for Individual #1. All individual records will be audited to ensure they complete and timely assessments within 30 calendar days upon receipt of the plan of correction. (CHG 1/30/15)] 10/31/2014 Implemented
6400.181(e)(3)(iii)Individual #1's assessment dated 8/15/14 does not include personal adjustment.The individual's current level of performance and progress in the following areas: Personal adjustment. The program specialist will review the assessment when finished to make sure all areas are filled in. [Individual #1's assessment has been updated to include all required components. The CEO or designee will audit all assessments to ensure they contain the required information and were completed timely. (CHG 1/30/15)] 10/31/2014 Implemented
6400.181(e)(12)Individual #1's assessment dated 8/15/14 does not include recommendations.The assessment must include the following information: Recommendations for specific areas of training, programming and services. The Recommendation for specific areas of training , programming and services has been added and submitted. [Individual #1's assessment has been updated to include recommendations. All individuals assessments will be audited to ensure they contain the required components and have been completed timely. (CHG 1/30/15)] 10/31/2014 Implemented
6400.186(a)The program specialist did not complete a review of the monthly documentation of Individual #1's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. Individual #1's ISP Annual review update date is 6/24/15.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. The program specialist will complete an ISP review of the services and expected outcomes in the ISP specific to the residental home lincensed under this chapter with the individual every 3 months or more frequently if the individual's needs changewhich impactthe services as specified in the current ISP. 10/31/2014 Implemented
6400.186(e)The program specialist did not notify the plan team members of the option to decline the ISP review documentation for Individual #1. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. The program specialist will notify the plan team members of the option to decline the ISP review documentation.[Documentation of the notification/declination will be kept in the individual's record. (CHG 1/30/15)] 10/31/2014 Implemented
SIN-00163232 Renewal 09/25/2019 Compliant - Finalized