Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00237386 Renewal 01/22/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)Individual #7 had a Physical Examination form completed on 7/28/22 and not again until 09/28/23, outside of the annual timeframe.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.To fix the immediate issue HSF Administrative Director will modify our tracking spreadsheet by simplifying the amount of information contained on the spreadsheet. Conditional formatting will be added to identify by color coded cells physicals due within 90 days to easily identify individuals who are coming due. The new spreadsheet will also have a column with conditional formatting to identify individuals who's physical is due within 30 days. This will be completed by 2/16/24. HSF Administrator will notify Individuals as well as their team in writing that they must have their physical completed on time or be temporarily suspended until it is complete (90-day notice letter). 30 days before the due date, an email reminder will be sent out to the team to notify them again of the upcoming due date. HSF Administrator will also call the individual's provider/caregiver to find out the date of the scheduled appointment, if the date has not yet been provided to us. HSF Administrator will be responsible for sending a suspension letter the day before the physical is due, if we have not yet received it. 02/16/2024 Implemented
2380.111(b)Individual #2's most recent TB test read on 5/3/23 does not document who read the test. It is not signed.111d-Immunizations, vision and hearing screening and tuberculin skin testing may be completed, signed and dated by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.To fix the immediate issue, we will have Individual #2's medical provider fill out the incomplete section of the TB test document. 02/02/2024 Implemented
2380.113(c)(2)Individual #4 had a TB test read on 6/9/21 and not again until 10/5/23, outside of the every two year requirement.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the 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, certified nurse practitioner or certified physician's assistant.To fix the immediate issue HSF Administrative Director will modify our tracking spreadsheet by simplifying the amount of information contained on the spreadsheet. Conditional formatting will be added to identify by color coded cells TB tests due within 90 days to easily identify growers who are coming due. The new spreadsheet will also have a column with conditional formatting to identify individuals whose TB is due within 30 days. This will be completed by 2/16/24. HSF Administrator will notify Individuals as well as their team in writing that they must have their TB test completed on time or be temporarily suspended until it is complete (90-day notice letter). 30 days before the due date, an email reminder will be sent out to the team to notify them again of the upcoming due date. HSF Administrator will also call the individual's provider/caregiver to find out the date of the scheduled appointment, if the date has not yet been provided to us. HSF administrator will be responsible for sending a suspension letter the day before the TB test is due, if we have not yet received it. 02/16/2024 Implemented
2380.172(a)Individual #3's record contained an annual physical for Individual #8.A separate record shall be kept for each individual.To fix the immediate issue, we returned the misfiled page to Individual #8's record book on 1/23/24. 02/09/2024 Implemented
2380.181(e)(7)Individual #4's 07/19/23 Annual Assessment completed on 7/19/23 does not specify if the individual can move away from heat sources "quickly". Individual #7's Annual Assessment completed on 11/2/23 does not specify if Individual #7 can move away from heat sources "quickly".The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.To fix the immediate issue, the annual assessments for Individual #4 and Individual #7 were updated by HSF Program Specialists to include whether they can or cannot move away from heat sources quickly. These updated assessments were sent out to the Individual teams as an addendum on 2/1/24 and 1/29/24 respectively. 02/23/2024 Implemented
SIN-00201654 Renewal 03/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.59(a)The water temperature at the time of the inspection on 3/15/22 was only 91.7 degrees. The minimum allowable hot water temperature is 95 degrees with a 2-degree differential.The facility shall have hot and cold running water under pressure in bathrooms and kitchen areas.To immediately resolve the issue, the water temperature on the water heater was turned up to 100 degrees on 3/15/22. The water was tested with a digital thermometer on that date and did test at 100 degrees. 03/25/2022 Implemented
2380.111(c)(4)Individual # 3 had an annual physical on 8/25/20 and 9/7/21. Neither of the completed annual physical examinations included a hearing or vision screening. Individual #4 had an annual physical completed on 2/25/21 and again on 3/1/22. Neither of the completed physical examinations included a hearing screening. Individual #5 had an annual physical examination completed in August 2021. Individual #5's vision was not screened at that physical examination. Individual #6 had an annual physical completed on 5/13/19 and 6/14/21. Neither of the completed physical examinations included a vision or hearing screening.The physical examination shall include: Vision and hearing screening, as recommended by the physician.To address the immediate issue, HSF's Program Specialists will review annual physical examinations for our program participants to identify if any other individuals have had a portion of their examination deferred. For any individuals identified, our Program Specialists will contact their family/residential provider to obtain valid documentation as to why the portion of the examination was deferred. Contact will be made for any individuals identified by 4/1/22. For any who are unable to provide valid documentation, we will require them to have the screening conducted by a medical professional. Services will be suspended for any individuals who do not return their documentation by this date. 04/01/2022 Implemented
2380.111(c)(11)Individual #4's most current TB test completed on 2/25/21 is not signed by an RN/LPN/MD/CNP/PA-C.111d-Immunizations, vision and hearing screening and tuberculin skin testing may be completed, signed and dated by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.To address the immediate issue, we will review all incoming Physicals and TB tests for Growers and Staff to ensure they have been signed and dated by an appropriate medical professional. Please see Attachment 6 as a demonstration that we are reviewing these documents to ensure that they are in compliance with this regulation. 03/25/2022 Implemented
2380.111(c)(11)Individual #5's most recent annual physical completed in August 2021 did not identify the individual's dietary instructions. This section was left blank.The physical examination shall include: Special instructions for an individual's diet.To address the immediate issue, HSF's Program Specialists will review the annual physical examinations for our program participants to identify if any parts of the individual physical have been left blank. For any individuals identified, our Program Director or Med Trainer will contact the appropriate team member for revision by the individual's doctor. Contact will be made for any individuals identified by 4/1/22. Services will be suspended for any individuals who do not return their documentation by this date. 04/01/2022 Implemented
2380.181(a)Individual #2's had an assessment completed on 2/25/21 and not again since, outside of the annual timeframe. Individual #3 had an assessment completed on 11/13/20 and not again until 12/15/21, outside of the annual timeframe. Individual #6 stopped attending this day program in March 2020 and returned to this day program on 7/7/21. Per ODP announcement 21-016 and the PAR meeting conducted on 7/15/21, any individual returning to day programming after 7/1/21 was to be considered a new admission. As of the 3/15/22 inspection, Individual #6 has not had a 60-day assessment completed.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.To address the immediate issue, the Program Specialist will complete and distribute the 60-day assessment to the ISP team for individual #6. This assessment will be completed and sent out by 3/25/22. See Attachment 8, documenting the completion and distribution of the 60-day assessment. The annual assessment for Individual #2 was completed and sent outside the annual time frame. Documentation that the assessment was completed and sent to the team can be found in Attachment 9. 03/25/2022 Implemented
2380.181(e)(10)Individual #5's most recent annual assessment completed on 9/21/21 did not include their lifetime medical history.The assessment must include the following information: A lifetime medical history.To address the immediate issue, we made contact with the residential provider for individual #5 again on 3/24/22 to get an updated copy of the LMH. Upon receiving the LMH, our Lead Program Specialist re-sent the assessment to the ISP team with the psychological evaluation and LMH attached. Please see Attachment 11 for documentation that these items have been distributed to the ISP team. 03/25/2022 Implemented
2380.21(u)Individual #3's rights were reviewed with them on 9/14/20 and not again until 10/8/21, outside of the annual timeframe.The facility 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 facility and annually thereafter.To address the immediate issue, our Program Specialists reviewed the ISP books of all current Growers to ensure all individuals have had their rights reviewed within the annual time frame. Program Specialists identified the individual who is due first for this year's annual cycle. See Attachment 1 for demonstration of compliance with this regulation 03/25/2022 Implemented
2380.36(c)Staff person #3 was CPR/First Aid trained on 7/31/18 and not again until 9/29/21; outside of the biannual timeframe.There shall be at least 1 staff person for every 18 individuals, with a minimum of 2 staff persons present at the facility at all times who have been trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation within the past year. If a staff person has formal certification from a hospital or other recognized health care organization that is valid for more than 1 year, the training is acceptable for the length of time on the certification.To address the immediate issue, our Administrative Assistant will review the personnel files for all staff to identify if any staff members are coming due for retraining. Our next CPR/FA training is scheduled on 4/5/22. 04/05/2022 Implemented
2380.182(c)No ISP team meeting was held for Individual #6 in 2021 to accurately complete an annual ISP review.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.To address the immediate issue, we confirmed with the Supports Coordinator for individual #6 that a meeting was not held. Program Specialists also inquired about scheduling an ISP meeting for 2022. The meeting has been scheduled and we have received an invitation letter. Please see Attachment 13 for this documentation. Additionally, our Program Specialists will be retrained on 2380.182 regulations. Please see Attachment 14 for documentation of this training. Program Specialists will review each individual's file to ensure that we have documentation that a meeting was held during 2021. If documentation is missing for any individuals, our Program Specialists will reach out to the individual's Supports Coordinator to confirm that a meeting was held and to receive any missing documentation. Files will be reviewed, and contact will be made by 4/1/22. 04/01/2022 Implemented
2380.183(a)(1)Individual #5's ISP team meeting was held on 11/18/21. Individual #5 was not in attendance of the ISP Team Meeting.The individual plan shall be developed by an interdisciplinary team, including the following: The individual.To address the immediate issue, our Lead Program Specialist reached out to Individual #5's supports coordinator for documentation on who was invited to the ISP meeting. No staff members from Hope Springs Farm attended the ISP meeting, because we did not receive an invitation. Individual #5 was in our care the day of the meeting. He was not able to attend the meeting because we were not aware that a meeting had been scheduled. We will retrain all HSF Program Specialists on the 2380.183 regulations so they can ensure all required meeting participants are present. All program specialists will be retrained by 4/1/22. See Attachment 16 for documentation of this training. Program Specialists will populate the "Grower ISP Meeting Tracker" spreadsheet by 4/1/22 to identify if any other meetings had been missed. If any additional individuals are identified, Program Specialists will reach out to the Supports Coordinator for documentation by 4/1/22. Reference Attachment 15 for the spreadsheet. 04/01/2022 Implemented
2380.183(a)(3)Individual #4's ISP team meeting was held on 1/5/22. There was no member of direct care staff that participated in the meeting. Individual #5's ISP team meeting was held on 11/18/21. There was no member of the direct care staff that participated in the meeting.The individual plan shall be developed by an interdisciplinary team, including the following: The individual's direct care staff persons.To address the immediate issue, we will retrain all Program Specialists on 2380.183 regulations and the procedures in place at the farm, specifically the expectation that two staff members will represent the farm at an ISP meeting (a Program Specialist and a Direct Support Professional).This retraining will be completed by 3/25/22. See Attachment 16. Additionally, we will retrain DSP staff members on the expectation for a direct care staff to attend the ISP meeting during our weekly staff meeting on 3/28/22. 03/28/2022 Implemented
SIN-00201947 Unannounced Monitoring 03/14/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34During the inspection completed on 3/14/22, Hopes Spring Farm (HSF) denied ODP the request of making copies of requested documents. Staff #1 advised ODP that all requested documents must be sent to their legal team and then HSF's legal team will provide the documents to ODP. Not allowing ODP to receive documents on demand and instead filtering requested documents through their legal team has created a delay and violates this regulation.The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients.On 3/14/22 Staff #1 was instructed by the Property Owner/Board President that any requested documentation must be sent to ODP by her lawyer. Additionally, our Verizon Internet service was down until after 3:00 PM on that day, which delayed our ability to send over the documents. To address the immediate issue, Staff #1 and the Property Owner/Board President will be retrained on the 20.31-20.34 regulations related to inspections. See Attachment 1 for the training documentation. Hope Springs Farm will provide full access of the facility and its records will be granted to any authorized agents of the Department, including the opportunity to privately interview staff and clients. 03/24/2022 Implemented
2380.26Article X - 1016. Right to enter and inspect: For the purpose of determining the suitability of the applicants and of the premises or whether or not any premises in fact qualifies as a facility as defined in section 1001 of this act or the continuing conformity of the licensees to this act and to the applicable regulations of the department, any authorized agent of the department shall have the right to enter, visit and inspect any facility licensed or requiring a license under this act and shall have full and free access to the records of the facility and to the individuals therein and full opportunity to interview, inspect or examine such individuals. During the inspection completed on 3/14/22, ODP was denied copies of requested documents and was advised by staff #1 that all requested documents needed to be sent to their legal team who will then provide the documents to ODP. Not providing documents at the time of request on 3/14/22 is creating a delay of full and free access to the records of the facility and is a violation of said regulation.The facility shall comply with applicable Federal and State statutes and regulations and local ordinances.On 3/14/22 Staff #1 was instructed by the Property Owner/Board President that any requested documentation must be sent to ODP by her lawyer. Additionally, our Verizon Internet service was down until after 3:00 PM on that day, which delayed our ability to send over the documents. To address the immediate issue, Staff #1 and the Property Owner/Board President will be retrained on the 2380.26 regulations, specifically 62 P.S. § 1016 (Article X of the Public Welfare Code) See Attachment 3 for the training documentation. Hope Springs Farm will provide full access to the facility and its records to any authorized agents of the Department, including the opportunity to privately interview staff and clients. 03/24/2022 Implemented
SIN-00186605 Renewal 04/26/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.57(b)(1)On 2/5/21 Staff person #1 changed positions to become the CEO. The department was not notified of this change. Staff person #1 was instructed during the annual inspection to notify the department of the change in CEO.A certificate of compliance is void without notice if there is a change in the ownership of the legal entity of the facility or agency. A transfer of stock of a corporation does not, for purposes of this chapter, constitute a change of ownership of a legal entity.To address the immediate issue, staff Person #1 made contact via email to RA-odplicensing@pa.gov as well as two ODP direct contacts to notify the department of the change in CEO. Confirmation was given on 4/29/2021 that the correspondence was received and that the changes have been made. 04/28/2021 Implemented
2380.126(a)(11)The MARs ( medication administration record) for the months November 2020, March 2021, April 2021 did not contain the purpose of the medication (Quetiapine Fumarate 50 mg tab) for Individual # 4 .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 fix the immediate issue we updated the MAR for individual #4 on 4/28/2021 to include the purpose of the Quetiapine Fumarate 50mg tablets. To ensure immediate agency wide compliance the Medication Administration Trainers reviewed all of our MARs for the month of April and the upcoming month of May. The MARs were updated to include the purpose of the medication. This was completed on 4/28/2021. 04/28/2021 Implemented
2380.181(f)The 1/20/21 annual Assessment for Individual #1 was not sent out to the team members until 4/26/2021. The 2/3/21 annual assessment for Individual #2 was not sent out to team members until 4/26/21. The 3/17/21 assessment for Individual #4 was not sent to the team members until 4/26/21. The following assessments were not sent out to the team members at least 30 calendar days prior to the Individuals plan meeting,The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.To fix the immediate issue we sent out the annual assessment for individual #1, #2, and #4 on 4/26/2021. Our Lead Program Specialist then sent out any other assessments that were not yet sent. To ensure immediate agency wide compliance, we modified our existing policy requiring the Program Director to review the assessment before it can be sent. The duration of our facility closure (11/2020-3/2021) created a backlog of reports that needed to be reviewed. The modified policy allows Program Specialists to conduct a peer review of finished assessments. After the assessment has been reviewed by another Program Specialist, the assessment can be sent out. Program Specialists were trained on 5/5/2021 on what the Program Director looks for when reviewing assessments. 04/26/2021 Implemented
SIN-00161465 Renewal 11/04/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(a)The annual physical for individual #2 was completed on 11/02/17 and not again until 12/24/2018, which exceeds the one year and 15-day grace allowed by regulations.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.To fix the immediate issue we have redesigned our tracking spreadsheet to automatically identify by color coded cells, physicals within 90 days to more easily identify growers who are coming due within 90 days. The Administration Director will notify them as well as their team in writing that they must have their physical completed on time or be temporarily suspended until it is complete. This is a continuation of our successful corrective action plan from initiated January 2019. To ensure agency wide compliance the Administrative department will review all physicals to be sure they all have three initials by 11/22/19, and we will continue our successful process initiated in January 2019 of sending notification to individuals whose physicals are coming due within 90 days, and temporarily suspending individuals who do not meet the annual requirements. To fix the issue with all individuals and to raise the level of attention to the issue all physical due dates are reviewed as part of the Weekly Directors meetings to ensure the physicals are being completed on time. The Administrative Director will continue to keep track of the dates in the spreadsheet to identify physicals that are coming due and issue the letters, and the ED will be ultimately responsible for all the physicals completed in a timely manner as the lead for the Directors meetings. AD will sign the suspension letters approved by the ED. 11/22/2019 Implemented
2380.111(c)(6)Most recent physical dated 11/09/2018 for individual #1 does not indicate if the individual is free from communicable diseases. This part of the form was left blank.The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals.To fix the immediate issue the Administrative Director will contact the physician to complete the missing information by 11/22/19; corrected physical by 12/20/19 To ensure agency wide compliance the Administrative department will review all physicals to be sure they all have three initials by 11/22/19, and we will continue our successful process initiated on 12/31/18, requiring 3 directors to review all physicals for missing information. Described below. To ensure this does not happen again, we will continue our successful process initiated on 12/31/18. We consider this process successful because no discrepancies were noted on individual records after the process was put into place. Since this discrepancy existed after the last site inspection and prior to the execution of our CAP on 12/31/18, requiring 3 directors to review all physicals for missing information. The OD and AD will continue to review all the physicals for missing information and the ED will also continue to review all the physicals to be sure the physicals are complete and the OD/AD reviews are effective. Individual physicals will be tracked by the Administrative Director and status reviewed at Weekly Compliance meetings. 12/20/2019 Implemented
2380.173(1)(ii)Identifying marks for individual # 5 was left blank. Provider should indicate "N/A" or "none" if there aren't any.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.To fix the immediate issue the individual¿s family was contacted and the information sheet was updated, 11/8/19; To ensure immediate agency wide compliance the Administrative department will review all individual¿s ISP books, by 12/6/19. Also, all Program Specialists will be retrained on the record review checklist, so that this item will be verified during every quarterly ISP review. To fix the issue in the future and to raise the level of attention to the issue all Program Specialists will be retrained on the record review checklist, so that it will be verified during every quarterly ISP review. Training will be completed by 12/13/19; Training sign in sheets. 12/13/2019 Implemented
2380.36(b)Staff #3 hired 10/9/17 had fire safety training on 10/09/17 and not again until 11/28/18.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).To fix the immediate problem, staff member was identified and retrained by a fire safety expert on 10/11/19. To ensure agency wide compliance the Administrative Director will review all staff records by 11/15/19 for Fire safety training completion in time. Also, we have redesigned our tracking spreadsheet to identify by color coded cells annual requirements including fire safety, at 65 days prior to the last annual training date, so that it can be completed in the 11th month; 11/15/19. To fix the issue with all future staff training all Fire Safety and CPR/First Aid requirements will revert to an 11-month training cycle. We will also continue the successful process of Administrative Director tracking all annual training requirements and reporting at compliance meeting. To ensure we are meeting the annual requirements, staff members will be temporarily suspended from working with individuals until all annual training requirements are met. 11/22/2019 Implemented
SIN-00141516 Renewal 11/13/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.16Individual #5 had three seizures on 10/22/18, at 11:55am, 12:00pm, and 12:13pm, each with recorded durations less than five minutes. Following the last recorded seizure Individual was drowsy, confused and unresponsive for ten minutes and individual's breathing became difficult. Farm of Hope Staff contacted the Individual's residential supervisor, who instructed them to call 911. The Individual was transported from Farm of Hope to Penn State Milton S. Hershey Medical Center by ambulance. Penn State Milton S. Hershey Medical Center discharge instructions from 10/22/18 4:33pm state that the individual should return to the Emergency Department for loss of consciousness, intractable vomiting, altered mental status, seizures, or any new, worsening, or concerning symptoms. 10/24/18 at 11:14am, individual began having another seizure and went back to the Emergency Department. Farm of Hope Staff waited until the seizure lasted for 5 minutes before calling 911. The discharge paperwork for the Individual from the 10/22/18 Emergency Department visit states that the Individual should return to the Emergency Department for any seizure, it does not state a length of observed seizure duration to wait before seeking medical attention. The record does not contain discharge paperwork from the 10/24/18 Emergency Department visit. 09/19/18 Seizure training log for Epilepsy Fact Sheet and Seizure Observation Record (page 3) heading "When to call 911" states that an ambulance should be called if the seizure lasts longer than 5 minutes or one seizure immediately follows another. It also states that an ambulance should be called if the person does not resume normal breathing after the seizure ends. Individual had three successive seizures and was unresponsive for 10 minutes following the last recorded seizure. Staff did not follow two written protocol from the training.This applies to abuse occurring at the facility. Actions of one individual to another individual including rape, sexual molestation, sexual exploitation, and intentional actions causing physical injury that require medical attention by medical personnel at a medical facility are considered abuse. Relating to improper use of restraints, this regulation should be cited if there is serious or widespread use of restraints without following the requirements of this chapter. Otherwise, the specific section(s) of 151-165 should be cited. Record as non-compliance if there is any founded evidence of abuse since the previous annual licensing inspection for which appropriate corrective action was not taken. If appropriate corrective action was taken, non compliance should not be cited. If a report of abuse is investigated and determined to be unfounded, record as compliance. If a report of abuse is still under investigation at the time of the inspection, record as noncompliance on the LIS and score sheet. At the conclusion of the investigation, withdraw the non-compliance if the abuse is determined to be unfounded or if appropriate corrective action was taken. Source: Site Records Interview To fix the immediate issue we have initiated and completed the investigation of Neglect and it was confirmed. 11/99/18; IDD# 8 The staff member target was counseled and immediately retrained, 11/99/18; training sheet and content We have asked for and received a revised seizure protocol from the individual's physician; 11/99/18; doctor's notes To ensure agency wide compliance we have completed retraining of the directors, point persons and the supervisors on 11/15/18, then completed the training of all the DSP staff on 11/16/18 of the general seizure protocols that should have been used instead of only relying on only the doctor's written protocol; sign in sheets and content To ensure this does not happen again we have scheduled to have the South Central HCQU retrain all the direct support staff including the supervisors, PPs and Directors on the seizure protocols that apply in ALL situations: scheduled for 1/9/2019; sign in sheet and content Also direct support staff, PPs, Supervisors and Directors will be trained on the general seizure protocols used to determine when to call for emergency help every 6 months; 5/31/19 sign in sheets and content. Correction Date:(required) 5/31/19 Implemented
2380.21(a)Individual #3 had a 2/12/18 unhealthy lunches protocol that indicated that when Individual #3 comes to the program, staff look at the lunch and if its not appropriate, Individual #3 will be asked to take some things out and send home with residential staff. If Individual #3 refused to give any part of the lunch to staff, Individual #3 will be sent home. Rights violation, as Individual #3 does not have a restrictive procedure for this protocol.An individual may not be discriminated against because of race, color, religious creed, disability, handicap, ancestry, national origin, age or sex.To fix the immediate issue we have revoked the protocol to have the individual show us his lunch; 11/99/18; email revoking the protocol To ensure agency wide compliance the Program Director (senior PS) and the Operations Director will review all current SEEN plans for any restrictive language. All SEEN Plans with any discrepancies will be identified to the ED and addendums prepared and sent to the support teams as they are resolved. 3/29/19; Checklist for all Growers plans When the comprehensive review is complete the Senior PS will train the other PS's to identify this type of discrepancy in the SEEN plan. 4/19/19; training sign in sheet and content To ensure this does not happen again, the OD will review all Assessments and SEEN Plans as they are prepared for the annual ISP meetings. The ED will also review all the Assessments and SEEN Plans as they are prepared during the next three months to be sure the PS's are providing a consistent message to the support team and the OD reviews are effective; 3/29/19; Assessment front page with OD and ED initials Correction Date:(required) 4/19/19 Implemented
2380.36(a)Staff #2 DOH is 9/5/18 and first contact with individuals was on 9/5/18. Staff #2 did not have training on policy and procedures until 9/6/18, orientation to the facility/daily operation until 9/13/18, and job description until 9/18/18.The facility shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals or in their appointed positions.Staff #2; To fix the immediate issue we have clarified the Initial Orientation Training Plan to show that staff cannot work with or shadow individuals until all of Part I is complete; includes policy and procedures, orientation to the facility/daily operation, and job description. 11/99/18; IO Training plan To ensure agency wide compliance all Directors and supervisors will be trained on this requirement so that new staff don't work with Growers before all the requirements of Part I are completed. 12/31/18; training sheets and content To fix the issue for all future staff, the AD must sign off that Part I is complete before the staff reports to their supervisor and OD for assignment to shadow with other staff. 3/29/19; new staff IO training plan Correction Date:(required) 3/29/19 Docs; new IO Training Plan 2019 Implemented
2380.36(e)REPEAT from 10/13/17 annual inspection: Staff #2 had first contact with individuals on 9/5/18 and received fire safety training on 9/6/18. Staff #3 had fire safety training 10/16/17 and not again until 11/6/18. Staff #1 had fire safety training 06/29/17 and not again until 08/05/18.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.Staff #2; To fix the immediate issue we have clarified the Initial Orientation Training Plan to show that staff cannot work with or shadow individuals until all of Part I is complete; includes initial Fire Safety Training. 11/99/18; IO Training plan To ensure agency wide compliance all Directors and supervisors will be trained on this requirement so that new staff don't work with Growers before all the requirements are completed. 12/31/18; training sheets and content To fix the issue for all future staff, the AD must sign off that Part I is complete before the staff reports to their supervisor and OD for assignment to shadow with other staff. 3/29/19; new staff IO training plan Staff #3 & #4; To fix the immediate issue we have engaged a local fire safety training company to provide this annual training. 12/99/18 sign in sheets To ensure agency wide compliance all staff records were reviewed and a schedule created for annual fire safety training; 11/99/18; ED notes To fix the issue with all future staff and to raise the level of attention to the issue all annual training due dates are reviewed as part of the Weekly Directors meetings to ensure the training is being completed on time. The Program Director (Senior PS) and the Operations Director will make sure we have sufficient staffing to handle the Grower support ratios, the ED will keep track of the dates in the spreadsheet to identify staff trainings that are coming due. Meetings started 11/23/18; directors meeting notes Correction Date:(required) 3/29/19 Implemented
2380.36(f)The agency is not using an approved fire safety expert to conduct their fire safety trainings annually. They are using college of direct support website for fire safety training. Staff #1 and Staff #5 did not receive annual fire safety training by a fire safety expert.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f).To fix the immediate issue Staff #1 & #5 will be trained by a Fire Safety Expert, we have engaged a local fire safety training company to provide this annual training. 1/31/19; training sign in sheets To ensure agency wide compliance we will retrain all staff who were trained using the CDS Elsevier system for their annual requirements using our local fire safety training company; 1/31/19; training sign in sheets and content To fix the issue with all future staff training we will contract the local fire safety training company for all annual fire safety training. We have also asked ODP to reconsider allowing the use of the CDS Elsevier system content to serve for annual fire safety training. 1/31/19; emails to CLEMSafe and ODP Correction Date:(required) 1/31/19 Implemented
2380.59(c)Coliform water test were late- test conducted 3/8/18 and not again until 6/27/18.A facility that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept.To fix the immediate issue we called the inspection company and scheduled the next inspection for the week of December 17, 2018; the test has been confirmed scheduled for 12/18/18; 12/31/18; test results To ensure agency wide compliance the Directors will be trained on the process to confirm the testing schedule date with the company; 12/21/18; training sign content To fix the issue for future inspections the AD will call to confirm the testing date 30 days prior to the due date so that we coordinate these inspections with the vendor to be on or before the due date. These dates will be monitored in the Directors meeting minutes. 3/29/19; next test results Correction Date:(required) 3/29/19 Implemented
2380.89(g)REPEAT from 10/13/17 annual inspection: 11/9/18 fire drill log indicated Individual #1 did not evacuate to the designated meeting place. 6/20/18 fire drill log indicated Individual #1 did not evacuate to the designated meeting place.Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.To fix the immediate issue we completed another fire drill for November and all individuals evacuated and meet at the meeting place successfully; 11/99/18; second fire drill To ensure agency wide compliance all Directors and Supervisors will be retrained on the requirements of the Fire Drill Evacuation procedures that require Individuals who do not evacuate on time or do not go to the meeting place to receive additional training and another fire drill conducted that month. 12/31/18; training sheet and contents To fix the issue for all future fire drills, a third Director (AD) will initial the section of the fire drill record that shows the individuals evacuating and going to the meeting place, so that another drill can be scheduled if needed. This will be accomplished for the next three monthly fire drills to be sure all discrepancies are caught, retrained and drills rescheduled.; 3/29/19; fire drill records with AD initials Correction Date:(required) 3/29/19 Implemented
2380.111(c)(10)REPEAT from 10/13/17 annual inspection: Individual #3 12/22/17 physical was blank for info pertaining 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 fix the immediate issue the Administrative Director will contact the physician to complete the missing information; 12/31/18; corrected physical The AD will then provide the updated status to the residential team and the SC to update the ISP as necessary; 12/31/18; ISP update request To ensure agency wide compliance the AD will review all the physicals for missing information and all discrepancies will be identified to the ED and ISP Update requests will be prepared and sent to the SCs as needed. 3/29/19; Checklist for all Growers plans Individual physicals with blank information will be tracked by the Executive Director and status reviewed at the Weekly Directors meetings To ensure this does not happen again, the OD and AD will continue to review all the physicals for missing information and the ED will also review all the physicals during the next three months to be sure the physicals are complete and the OD/AD reviews are effective; 3/29/19; physical front page with 3 sets of initials Correction Date:(required) 3/29/19 Implemented
2380.113(a)REPEAT from 10/13/17 annual inspection: Staff #1 physical late, completed 07/22/16 and not again until 09/08/18.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.To fix the immediate issue we have redesigned tracking spreadsheet to more easily identify staff members who are coming due within 90 Days. The Administration Director will notify them as well as their immediate supervisor in writing that they must have their physical completed on time of be temporarily suspended until it is complete. 12/10/18; new spreadsheet and letter To ensure agency wide compliance we will retrain all direct support staff on the requirement and the 90 day letter and possible suspension policy. 12/21/18, training sign in and content To fix the issue with all future staff and to raise the level of attention to the issue all physical due dates are reviewed as part of the Weekly Directors meetings to ensure the physicals are being completed on time. The Administrative Director will keep track of the dates in the spreadsheet to identify staff physicals that are coming due and issue the letters, and the ED will be ultimately responsible for all the physicals completed in a timely manner as the lead for the Directors meetings. Meetings started 11/23/18; copy of directors meetings notes Correction Date:(required) 12/21/18 Implemented
2380.113(c)(2)REPEAT from 10/13/17 annual inspection: Staff #1 tuberculin skin test completed 07/30/15 and not again until 11/03/17.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the 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, certified nurse practitioner or certified physician's assistant.To fix the immediate issue we have redesigned tracking spreadsheet to more easily identify staff members who are coming due within 90 Days. The Administration Director will notify them as well as their immediate supervisor in writing, that they must have their TB Test completed on time of be temporarily suspended until it is complete. 12/10/18; new spreadsheet and letter To ensure agency wide compliance we will retrain all direct support staff on the requirement and the 90 day letter and possible suspension policy. 12/21/18, training sign in and content To fix the issue with all future staff and to raise the level of attention to the issue all TB Test due dates are reviewed as part of the Weekly Directors meetings to ensure the TB Tests are being completed on time. The Administrative Director will keep track of the dates in the spreadsheet to identify staff TB tests that are coming due and issue the letters, and the ED will be ultimately responsible for all the TB tests completed in a timely manner as the lead for the Directors meetings. Meetings started 11/23/18; copy of directors meetings notes Correction Date:(required) 12/21/18 We have redesigned tracking spreadsheet to more easily identify staff members who are coming due within 90 Days to notify them in writing, and it will be tracked and discussed at the Weekly Directors meetings. Implemented
2380.173(9)Individual #3 ISP states individual is encouraged to limit sodium intake and carbs, make healthy choices due to high cholesterol, was prescribed a low cholesterol diet at 12/17/15 physical, encouraged not to overuse condiments, encouraged to limit milk/cheese as individual may develop diarrhea when consuming too many dairy products. Individual #3 12/22/17 physical indicated to follow a high fiber diet (high in fruits and vegetables), then the lifetime medical history attached to the physical indicated to follow a low cholesterol, low salt, low fat diet. Individual #3 ISP lists allergies to ceftin and cefaclor drugs. 12/22/17 physical had allergies to cefzil and cefaclor, cephalosporins for allergies. 10/22/18 assessment also included allergies to seasonal that wasn't anywhere else throughout the record. Individual #4- content discrepancy: ·ISP diabetic diet, Physical exam: low carb diet. ·ISP states individual needs supervision with poisons and receives assistance while using them. Assessment indicated safe to use poisons.Each individual's record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.To fix the immediate problems we will: Individual #3 - Identify the discrepancy between the ISP -- Physical -- Lifetime Medical History (LMH) to the SC; 12/21/18; ISP Update request and email. The PD will review individual #3 medical and dietary needs with the residential team and determine the correct needs and allergies; 1/31/19; PD report to Directors meeting Then request the SC make the necessary correction to his ISP and request the residential team provide corrections to the Farm to reflect a consistent message. 1/31/19; ISP Update request and email Individual #4 - The PD will review individual #4 medical and dietary needs along with the individuals ability to be safe around poisons, with the family and physician to determine the correct needs; 1/31/19; PD report to Directors meeting Then request the SC make the necessary correction to the ISP to reflect a consistent message of the medical/dietary needs,. 1/31/19; ISP Update request and email If the ISP is correct about the poisons the Farm will issue an addendum to the assessment, if the ISP is incorrect we will include this in the request to the SC to update the ISP; 1/31/19; ISP Update request and email or addendum and email Individual #5 -- assign the OD (also the med trainer) to review the individual's medications list to determine if the PRN for seizures is necessary, 12/21/18; report to Directors meeting If the ISP is correct the Farm will request a corrected list of medications and PRN's from the residential team, if the ISP is incorrect we will request the SC update the ISP; 1/31/19; ISP Update/Meds List update request and email To ensure agency wide compliance the Program Director (senior PS) and the Operations Director will review all current physicals with the ISPs All discrepancies will be identified to the ED and addendums to the ISP Quarterly reports prepared and sent to the support teams, and ISP Update requests also prepared and sent to the SCs as they are resolved. 3/29/19; Checklist for all Growers plans When the comprehensive review is complete the Senior PS will train the other PS's to identify this type of discrepancy in the assessments. 4/19/19; training sign in sheet and content To ensure this does not happen again, the OD review of the ISP Quarterly reports will include reviewing the physicals for the next three months to ensure all PSs and OD as well as the Administrative Director (AD) can identify and correct this discrepancy appropriately; 3/29/19; Quarterly reports with ED initials Implemented
2380.181(e)(3)(iii)Individual #3 10/22/18 assessment does not identify the amount of behaviors/physical aggression/verbal aggression/property destruction Individual #3 displays. Individual #3 also has inappropriate touching/kissing/refusals/stealing that are not addressed in assessment or in SEEN plan.The assessment must include the following information: The individual's current level of performance and progress in the following areas:  Personal adjustment.To fix the immediate issue we have assigned the senior PS (Colby Z) to carefully review the daily service notes, monthly progress notes, and the Farm assessment, as well as the Farm SEEN plan to align all the documents to create a more consistent behavior picture. Assigned 12/13/18 (Directors meeting notes 12/13/18) to be completed by 1/31/19; report from PD to Directors meeting To ensure agency wide compliance the Program Director (senior PS) and the Operations Director will review all current assessments and SEEN plans for inconsistencies in the behavior assessment and assessment of the individual's progress. All assessments/SEEN Plans with any inconsistencies will be identified to the ED and addendums prepared and sent to the support teams as they are resolved. 3/29/19; Checklist for all Growers plans When the comprehensive review is complete the Senior PS will train the other PS's to identify this type of discrepancy in the assessments. 4/19/19; training sign in sheet and content To ensure this does not happen again, the OD (Lori L) will review all Assessments and SEEN Plans as they are prepared for the annual ISP meetings. The ED will also review all the Assessments and SEEN Plans as they are prepared during the next three months to be sure the PS's are providing a consistent message to the support team and the OD reviews are effective; 3/29/19; Assessment front page with OD and ED initials Correction Date:(required) 4/19/19 Implemented
2380.181(e)(5)Individual #3 10/22/18 assessment did not include the individual's ability to self-administer medications.The assessment must include the following information: The individual's ability to self-administer medications.To fix the immediate issue we have reviewed the individual's records and determined he is not able to self-administer medications and will issue an addendum to the individual's assessment; 12/31/18; addendum and email to team To ensure agency wide compliance the Program Director (senior PS) and the Operations Director will review all current assessments and SEEN plans for inconsistencies in the assessment of the individual's ability to self-administer medications. All assessments/SEEN Plans with any discrepancies will be identified to the ED and addendums prepared and sent to the support teams as they are resolved. 3/29/19; Checklist for all Growers plans When the comprehensive review is complete the Senior PS will train the other PS's to identify this type of discrepancy in the assessments. 4/19/19; training sign in sheet and content To ensure this does not happen again, the OD (Lori L) will review all Assessments and SEEN Plans as they are prepared for the annual ISP meetings. The ED will also review all the Assessments and SEEN Plans as they are prepared during the next three months to be sure the PS's are providing a consistent message to the support team and the OD reviews are effective; 3/29/19; Assessment front page with OD and ED initials Correction Date:(required) 4/19/19 Implemented
2380.181(e)(5)Individual #3 10/22/18 assessment doesn't include ability to self administer medications. Assessment states needs to improve, doesn't know name or when takes medications. Individual #6 assessment does not indicate ability to self-administer medications.The assessment must include the following information: The individual's ability to self-administer medications.To fix the immediate issue we have reviewed the individual's records and determined he is not able to self-administer medications and will issue an addendum to the individual's assessment; 12/31/18; addendum and email to team To ensure agency wide compliance the Program Director (senior PS) and the Operations Director will review all current assessments and SEEN plans for inconsistencies in the assessment of the individual's ability to self-administer medications. All assessments/SEEN Plans with any discrepancies will be identified to the ED and addendums prepared and sent to the support teams as they are resolved. 3/29/19; Checklist for all Growers plans When the comprehensive review is complete the Senior PS will train the other PS's to identify this type of discrepancy in the assessments. 4/19/19; training sign in sheet and content To ensure this does not happen again, the OD (Lori L) will review all Assessments and SEEN Plans as they are prepared for the annual ISP meetings. The ED will also review all the Assessments and SEEN Plans as they are prepared during the next three months to be sure the PS's are providing a consistent message to the support team and the OD reviews are effective; 3/29/19; Assessment front page with OD and ED initials Correction Date:(required) 4/19/19 Implemented
2380.183(5)Individual #3 ISP does not include ways to address behaviors in assessment because the behaviors are not even in the SEEN plan. The ISP does not include the SEEN plan that program uses. The ISP includes the restrictive plan, however, staff said the restrictive plan isn't used at day program. ISP for Individual #3 needs to include the need for 1:1 staff in the community.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.To fix the immediate issue we have assigned the senior PS (Colby Z) to carefully review the ISP behavior section, residential restrictive plan, the Farm assessment, and the Farm SEEN plan to align all the documents to create a more consistent behavior planning. Assigned 12/13/18 (Directors meeting notes 12/13/18) to be completed by 1/31/19. Assessment addendum, SEEn Plan, ISP update and email When the farm SEEN plan is validated the OD will send to the SC for inclusion in the ISP: 1/31/19 When the comprehensive review is complete the Senior PS will train the other PS's to identify this type of discrepancy in the plans. 2/22/19 To ensure this does not happen again, the OD (Lori L) will review all Assessments and SEEN Plans as they are prepared for the annual ISP meetings. For the next three months the ED will also review all the Assessments and SEEN Plans as they are prepared to be sure the PS's are providing a consistent message to the support team and the OD reviews are effective; 3/29/19 To fix the immediate issue we have issued an ISP Update request to the SC to add more language to the Health and Safety section/Reason for intensive staffing subsection to clarify the need for 1:1 staffing in the community: "···REQUIRES ONE ON ONE STAFFING TO ENSURE THE SAFETY OF THE OTHER GROWERS. ONE ON ONE STAFFING WILL REDIRECT RICHARD WHEN HE IS AGITATED AND PROVIDE HIM WITH THE OPPORTUNITY TO GO TO A QUIET PLACE UNTIL HE IS ABLE TO CONTROL HIS ANGER AND EMOTIONS. ONE ON ONE STAFFING WILL PROVIDE A MORE STRUCTURED ENVIRONMENT AND MORE CONSISTENCY WITH HIS STAFFING." This language is then consistent with the language in the Health and Safety section/Supervision Care Needs subsection; 12/14/18 Since this issue was not identified in the most recent ISP review, all Program Specialists and Directors will be trained by ED on this issue raised by the inspection team so they can identify it in future ISP reviews. 12/21/18 To ensure these violations don't occur again, the ED will review all the ISP Update Requests submitted to the SCs to make sure the OD and PS's understand the issue addressed here. As of 12/13/18 the email to the SC's containing the ISP Update Request have been added to the Quarterly package for ED review; Quarterly package and emails Correction Date:(required) 3/29/19 Docs: directors meeting notes 2018 12 13 assigning Colby, ISP Update Request of 12/14/18, email to SC for ISP updates Implemented
2380.186(a)REPEAT from 10/13/17 annual inspection: --Individual #3 ISP review completed on 9/7/18 was reviewing the time period from 5/14/18-8/12/18; late. 5/23/18 ISP review, reviewed 2/19/18-5/13/18 time period; late. --Individual #2 ISP review covering period 6/18/18-9/16/18, completed on 10/9/18; late. --Individual #4 ISP review that reviewed the time period from 5/21/18-8/19/18 wasn't completed until 9/11/18, 11/20/17- 2/18/18 review period wasn't completed on 3/12/18, 8/21/17-11/19/17 review period was completed on 12/5/17; late.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impact the services as specified in the current ISP.To fix the immediate issue we revised the tracking spreadsheet to more clearly identify the due date within 15 days of the end of the report period. 11/16/18 All Program Specialists and Directors were trained on the new spreadsheet and the deadlines for completion 15 days after the end of the period. 11/30/18 As of 12/6/18 all the Directors meeting notes show there were no more late reports. To fix the issue with all future reports and to raise the level of attention to the issue all Quarterly report due dates are reviewed as part of the Weekly Directors meetings to ensure the reports are being completed on time. The Program Director (Senior PS) and the Operations Director will make sure we have sufficient staffing to complete the reports coming due, the Administrative Director will keep track of the dates in the spreadsheet to identify reports that are coming due, and the ED will be ultimately responsible for all the reports completed in a timely manner as the lead for the Directors meetings. Meetings started 11/23/18 Correction Date:(required) 12/6/18 Implemented
SIN-00121452 Renewal 10/13/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(e)REPEATED VIOLATION - 9/13/16. Staff #1's 10/19/16 fire safety training was completed late. The previous fire safety training was completed on 9/9/15.Program specialists and direct service workers shall be trained before working with individuals in general firesafety, evacuation procedures, responsi-bilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.Staff #1 has completed annual Fire safety training on October 16, 2017 before the 12 month deadline for this year of October 19, 2017. The Executive Director has contracted with fire safety training company and will schedule by November 1 2017 another session. For long-term compliance ED will schedule at least two sessions each year in order to ensure none of the staff go beyond their annual requirement. Next class will be scheduled for first week of February 2018. 11/01/2017 Implemented
2380.89(a)REPEATED VIOLATION- 9/13/16. A fire drill was not completed in July of 2017.An unannounced fire drill shall be held at least once a month.The Executive Director will update the Fire Safety Procedures policy by November 1 2017, to have a Director execute, monitor and document an unannounced fire drill before the 10th of every month, and the ED will approve all the fire drill forms. Directors and staff will be retrained on the new procedures before December 8 2017. 12/08/2017 Implemented
2380.89(g)The fire drill logs for the year did not indicate if all individuals met at the designated meeting place. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.The Executive Director will redesign the Fire Drill Form before December 1 2017 to capture if all the Growers evacuated to the designated meeting place, or which of them did not and what we will do. Directors and staff will be retrained on the new form before December 8 2017. 12/08/2017 Implemented
2380.91(a)REPEATED VIOLATION- 9/13/16. Individual #1 was admitted to the program on 5/5/17. Initial fire safety training was completed on 7/7/17. Individual #4 was admitted to the program on 7/14/17. Initial fire safety was not completed until 8/9/17.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility. PLAN OF CORRECTION: The Executive Director will update the Fire Safety Procedures policy by November 1 2017, to state all Growers will receive their fire safety training on their first day at the Farm. Directors and staff will be retrained on the new procedures before December 8 2017. 12/08/2017 Implemented
2380.111(a)Individual #2's most recent physical exam was completed on 5/26/16. Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.The Executive Director will update the policy manual Appendix 8, Quarterly ISP Review Procedures to include a new policy for to ensure Growers (Family or residential staff) have sufficient time to make the appointment and have the physical done before their annual date. The Directors Supervisors and Staff will be retrained on this update by Friday November 10, 2017, and The Exec. Dir. will update the Policy and Procedure Manual, and distribute to all staff before December 1, 2017. The new policy will state that the Program Specialist will identify any physicals and TB Tests coming due, and the Administrative Director will monitor the due dates for all Growers and issue a ¿90 Day Notice¿ to the Growers and their Family or residential staff. Growers will be required to provide the appointment date to the directors for approval within 45 days. If no appoint has been made at that time the OD and ED can consider appropriate corrective action. 12/01/2017 Implemented
2380.111(c)(1)REPEATED VIOLATION - 9/13/16. Individual #1's 4/3/17 physical exam, Individual #3's 7/28/17 physical exam, and Indivdiual #4's 5/16/17 physical exam did not include a medical history.The physical examination shall include: A review of previous medical history.The Executive Director will update the policy manual Appendix 8, Quarterly ISP Review Procedures to include a new policy for all Grower physicals that come in will be reviewed by two Directors. The Quarterly ISP Review Checklist will instruct Program Specialists to make sure there are two sets of Directors initials on the physicals. The Directors Supervisors and Staff will be retrained on this update by Friday November 10, 2017, and The Exec. Dir. will update the Policy and Procedure Manual, and distribute to all staff before December 1, 2017. The new policy will state that all Grower physicals that come in will be reviewed by two Directors and all discrepancies corrected before they are filed; the Program Specialist will identify any physicals that do not have the two Directors initials and they will be reviewed and missing medical histories corrected immediately. A review of all Growers physicals will be completed by Friday November 3 2017 to ensure no other violations exist, all corrections will be completed by Friday December 15, 2017. 12/15/2017 Implemented
2380.111(c)(3)Individual #1's tetanus and deptheria immunization was last completed on 5/17/07. The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.The Executive Director will update the policy manual Appendix 8, Quarterly ISP Review Procedures to include a new policy for all Grower physicals that come in will be reviewed by two Directors. The Quarterly ISP Review Checklist will instruct Program Specialists to make sure there are two sets of Directors initials on the physicals. The Directors Supervisors and Staff will be retrained on this update by Friday November 10, 2017, and The Exec. Dir. will update the Policy and Procedure Manual, and distribute to all staff before December 1, 2017. The new policy will state that all Grower physicals that come in will be reviewed by two Directors and all discrepancies corrected before they are filed; the Program Specialist will identify any physicals that do not have the two Directors initials and they will be reviewed immediately. A review of all Growers physicals will be completed by Friday November 3 2017 to ensure no other violations exist, all corrections will be completed by Friday December 15, 2017. 12/15/2017 Implemented
2380.111(c)(5)Individual #5's most recent tuberculin skin test was completed on 7/3/15.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.The Executive Director will update the policy manual Appendix 8, Quarterly ISP Review Procedures to include a new policy for to ensure Growers (Family or residential staff) have sufficient time to make the appointment and have the TB Test done before their annual date. The Directors Supervisors and Staff will be retrained on this update by Friday November 10, 2017, and The Exec. Dir. will update the Policy and Procedure Manual, and distribute to all staff before December 1, 2017. The new policy will state that the Program Specialist will identify any physicals and TB Tests coming due, and the Administrative Director will monitor the due dates for all Growers and issue a ¿90 Day Notice¿ to the Growers and their Family or residential staff. Growers will be required to provide the appointment date to the directors for approval within 45 days. If no appoint has been made at that time the OD and ED can consider appropriate corrective action. 12/01/2017 Implemented
2380.111(c)(10)REPEATED VIOLATION - 9/13/16. Individual #4's 5/16/17 physical exam 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 Executive Director will update the policy manual Appendix 8, Quarterly ISP Review Procedures to include a new policy for all Grower physicals that come in will be reviewed by two Directors. The Quarterly ISP Review Checklist will instruct Program Specialists to make sure there are two sets of Directors initials on the physicals. The Directors Supervisors and Staff will be retrained on this update by Friday November 10, 2017, and The Exec. Dir. will update the Policy and Procedure Manual, and distribute to all staff before December 1, 2017. The new policy will state that all Grower physicals that come in will be reviewed by two Directors and all discrepancies corrected before they are filed; the Program Specialist will identify any physicals that do not have the two Directors initials and they will be reviewed immediately. A review of all Growers physicals will be completed by Friday November 3 2017 to ensure no other violations exist, all corrections will be completed by Friday December 15, 2017. 12/15/2017 Implemented
2380.113(a)Staff #1's 9/12/16 physical exam was completed late. The previous physical exam was completed on 8/10/14.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.The Executive Director will update the policy manual to include a new policy for to ensure staff members have sufficient time to make the appointment and have the physical done before their annual date. The Directors Supervisors and Staff will be retrained on this update by Friday November 10, 2017, and The Exec. Dir. will update the Policy and Procedure Manual, and distribute to all staff before December 1, 2017. The new policy will state that the Administrative Director will monitor the due dates for all staff and issue a ¿90 Day Notice¿ to the staff member and their supervisor. Staff will be required to provide the appointment date to their supervisor for approval within 45 days. If no appoint has been made at that time the OD and ED can consider appropriate corrective action. 12/01/2017 Implemented
2380.113(c)(2)Staff #1's 9/12/16 tuberculin (TB) skin test was completed late. The last TB test was completed on 8/12/14.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the 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, certified nurse practitioner or certified physician's assistant.The Executive Director will update the policy manual to include a new policy for to ensure staff members have sufficient time to make the appointment and have the TB Testing done before their annual date. The Directors Supervisors and Staff will be retrained on this update by Friday November 10, 2017, and The Exec. Dir. will update the Policy and Procedure Manual, and distribute to all staff before December 1, 2017. The new policy will state that the Administrative Director will monitor the due dates for all staff and issue a ¿90 Day Notice¿ to the staff member and their supervisor. Staff will be required to provide the appointment date for the TB Test as well as the follow up to have the test read to their supervisor for approval within 45 days. If no appoint has been made at that time the OD and ED can consider appropriate corrective action. 12/01/2017 Implemented
2380.181(a)Individual #1 was admitted to the program on 5/5/17. An initial assessment was completed on 7/17/17. Individual #4 was admitted to the program on 7/14/17. An initial assessment was completed on 9/28/17.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.The Program Specialist will establish the due date for this initial assessment upon admission of all new Growers and the Operations Director will review the progress of the assessment during these 60 days. The Executive Director will review and ensure the completion of the initial assessment within the required time line. Program Specialists and Directors will be retrained by the Exec. Dir by Friday November 3, 2017 on this requirement. A review of all Growers records admitted since July 1 2017 will be completed by Friday November 3 2017 to ensure no other initial assessments are late, all corrections will be completed by Friday November 10, 2017. 11/10/2017 Implemented
2380.181(e)(8)Individual #2's 7/10/17 assessment did not include his/her ability to evacuate in the event of a fire.The assessment must include the following information: The individual¿s ability to evacuate in the event of a fire.The Exec. Dir will update the Assessment Template and instructions by Friday October 20, 2017 to instruct the Program Specialists to document this area as a ¿Can or Cannot¿ standard instead of documenting their training and knowledge. The standard must have been demonstrated during their initial training/annual or monthly fire drills. All Program Specialists and Directors will be retrained on this requirement by Friday November 3, 2017. A review of all Growers assessments completed after July 1, 2017 will be completed by Friday November 3 2017 to ensure no other violations exist, all corrections will be completed by Friday November 10, 2017. 11/10/2017 Implemented
2380.181(e)(10)REPEATED VIOLATION - 9/13/16. Individual #1's, #2's, #3, #4, and #5's current assessment did not include a lifetime medical history. The assessment must include the following information: A lifetime medical history.The Exec. Dir will update the Assessment Template and instructions by Friday October 20, 2017 to eliminate the confusion for this requirement and instruct the Program Specialists to copy and attach the LMH provided by the residential provider with the physical, or create one and attach it. All Program Specialists and Directors will be retrained on this requirement by Friday November 3, 2017. A review of all Growers assessments will be completed by Friday November 3 2017 to ensure no other violations exist, all corrections will be completed by Friday December 15, 2017. 12/15/2017 Implemented
2380.181(e)(12)Individual #1's 7/17/17 assessment and Individual #2's 7/10/17 assessment did not include recommendations for training, vocational programming, or competitive employment.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.The Exec. Dir will update the Assessment Template and instructions by Friday October 20, 2017 to eliminate the confusion for this requirement and instruct the Program Specialists to make recommendations for specific areas of training, vocational programming and competitive community-integrated employment instead of listing their current capabilities. All Program Specialists and Directors will be retrained on this requirement by Friday November 3, 2017. A review of all Growers assessments completed after July 1, 2017 will be completed by Friday November 3 2017 to ensure no other violations exist, all corrections will be completed by Friday November 10, 2017. 11/10/2017 Implemented
2380.183(7)(i)Individual #1's Individual Support Plan (ISP) did not include his/her potential to advance in vocational programming.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming.The Exec. Dir. will update by October 23, 2017, the ISP Quarterly Review Template and Checklist with specific sections to review the individual¿s potential to advance in Vocational programming. Program Specialists will now enter their review of this section in the ISP Quarterly Review Report, and the ¿Director¿s Review¿ will ensure it has been completed each time. The program Specialists and Directors will be retrained on this update on Tuesday October 24, 2017, and The Exec. Dir. will update the Policy and Procedure Manual, Appendix 8; Quarterly ISP Review Procedures and distribute to all staff before December 1, 2017. To ensure long-term compliance, the ISP Quarterly Review Checklist will be updated to review the individual¿s potential to advance in Vocational programming, and Program Specialists and Directors will be retrained before December 1, 2017. All Grower records will be reviewed by Program Specialists and Directors, and since this correction will be part of the new ISP Quarterly review process, all the records will have been reviewed and corrected with new quarterly review reports by 1 February 2018. 02/01/2018 Implemented
2380.183(7)(iii)Individual #1's Individual Support Plan (ISP) did not include his/her potential to advance in competitive employment.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following:  Competitive community-integrated employment.The Exec. Dir. will update by October 23, 2017, the ISP Quarterly Review Template and Checklist with specific sections to review the individual¿s potential to advance in Competitive community-integrated employment. Program Specialists will now enter their review of this section in the ISP Quarterly Review Report, and the ¿Director¿s Review¿ will ensure it has been completed each time. The program Specialists and Directors will be retrained on this update on Tuesday October 24, 2017, and The Exec. Dir. will update the Policy and Procedure Manual, Appendix 8; Quarterly ISP Review Procedures and distribute to all staff before December 1, 2017. To ensure long-term compliance, the ISP Quarterly Review Checklist will be updated to review the individual¿s potential to advance in Competitive community-integrated employment, and Program Specialists and Directors will be retrained before December 1, 2017. All Grower records will be reviewed by Program Specialists and Directors, and since this correction will be part of the new ISP Quarterly review process, all the records will have been reviewed and corrected with new quarterly review reports by 1 February 2018. 02/01/2018 Implemented
2380.186(a)REPEATED VIOLATION- 9/13/16. Individual #2's Individual Supprt Plan (ISP) review covering the period of time between 5/1/17 and 8/6/17 was not completed until 8/31/17. The ISP review covering the period of time between 11/7/16 and 2/5/17 was not completed until 2/28/17. Individual #3's 6/1/17 ISP review was completed late. The previous was completed on 2/16/17. Individual #5's 7/19/17 ISP review was completed late. The previous review was completed on 3/23/17.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.The Exec. Dir. will update by October 23, 2017, the ISP Quarterly Review Template and Checklist with specific instructions to ensure the quarterly review is completed (signed by PS and Individual) within 15 days of the 3 month deadline. An inventory will be done by Friday October 27, 2017 to capture the completed dates of the last quarterly reports for all the Growers and we will restructure our priority board to ensure they are completed on time. The program Specialists and Directors will be retrained on this update on Tuesday October 24, 2017, and The Exec. Dir. will update the Policy and Procedure Manual, Appendix 8; Quarterly ISP Review Procedures and distribute to all staff before December 1, 2017. To ensure long-term compliance, the ISP Quarterly Review Checklist will be updated to cover all the relevant sections and information we need to review, and Program Specialists and Directors will be retrained on their responsibilities before December 1, 2017. All Grower records will be reviewed by Program Specialists and Directors, and since this correction will be part of the new ISP Quarterly review process, all the records will have been reviewed and corrected with new quarterly review reports by 1 February 2018. 02/01/2018 Implemented
2380.186(c)(2)Individual #1's Individual Support Plan reviews did not include a review of his/her enhanced supervision needs or the plan to reduce the enhanced supervision. Individual #2's Individual Support Plan reviews did not icnlude a review of his/her social, emotional, environmental needs plan. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.The Exec. Dir. will update by October 23, 2017, the ISP Quarterly Review Template and Checklist with specific sections to review the enhanced supervision needs or the plan to reduce the enhanced supervision, and the social, emotional, environmental needs plan. Program Specialists will now enter their review of these sections in the ISP Quarterly Review Report, and the ¿Director¿s Review¿ will ensure they have been completed each time. The program Specialists and Directors will be retrained on this update on Tuesday October 24, 2017, and The Exec. Dir. will update the Policy and Procedure Manual, Appendix 8; Quarterly ISP Review Procedures and distribute to all staff before December 1, 2017. To ensure long-term compliance, the ISP Quarterly Review Checklist will be updated to review enhanced supervision needs, and SEEN plans, and Program Specialists and Directors will be retrained before December 1, 2017. All Grower records will be reviewed by Program Specialists and Directors, and since this correction will be part of the new ISP Quarterly review process, all the records will have been reviewed and corrected with new quarterly review reports by 1 February 2018. 02/01/2018 Implemented
Article X.1007Farm of Hope is required to maintain criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 ¿ 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff #2, #3 and #4 were hired on 9/11/17. Criminal history checks were completed on 9/12/17.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.The Executive Director will update the policy manual to get the criminal background checks required under the OAPSA prior to issuing the hiring offer letter. If a FBI criminal history check is required the prospective employee must provide a copy of the application for the criminal history check prior to their start date. The Directors and Supervisors will be retrained on this update by Friday November 10, 2017, and The Exec. Dir. will update the Policy and Procedure Manual, and distribute to all staff before December 1, 2017. 12/01/2017 Implemented
SIN-00101270 Renewal 09/12/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(e)Fire safety training for staff #1 was last completed on 09/09/15. Fire safety training was due by 09/09/16.Program specialists and direct service workers shall be trained before working with individuals in general firesafety, evacuation procedures, responsi-bilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.All annual training requirements will be updated to state the requirement from the LII ¿Time Lines¿ section that there is no grace period for training items listed in § 2380.36. Staff Training. We have obtained credentials for one of our staff members as a Fire Safety Expert to conduct the training, and we have contacted a local commercial safety training company so that we don¿t miss this requirement in the future. 10/31/2016 Implemented
2380.58(a)There is a hole in wall under the sink in the green bathroom. Floors, walls, ceilings and other surfaces shall be in good repair.The hole in wall under the sink in the green bathroom was patched and plastered. 09/16/2016 Implemented
2380.62Emergency phone numbers are not posted on or near the telephone. They are posted on the wall around corner of the phone.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line.Emergency number sheets will be moved to be closer to each phone station (3) in the facility, and stickers will be put on each handset (5). 10/14/2016 Implemented
2380.72(a)The hand railing outside the main entrance was loose and moved approximately 4 inches when held. Outside walkways shall be free from ice, snow, obstructions and other hazards.The hand railing was secured and an additional cross brace was added to strengthen the support. 09/16/2016 Implemented
2380.89(a)A 12/2015 fire drill did not occur.An unannounced fire drill shall be held at least once a month.Fire drills will be set up to be conducted during the first 15 days of every month, so that if there are any events that conflict with the fire drill there will still be time to reschedule and not miss any monthly fire drill. The Program or Executive Director will be required to sign the fire drill to ensure it was done properly and on time. 10/20/2016 Implemented
2380.91(a)Individual #7 DOA to program was 02/9/16. Record indicates that the first fire safety training occurred on 06/07/16. Fire Safety training upon initial admission did not occur. Individual #4 DOA to program was11/23/15. Record indicates that the first fire safety training occurred on 01/20/16. Fire safety training upon initial admission did not occur. Individual #6 did not receive fire safety training upon DOA 03/28/16. Her first fire safety training occurred on 05/23/16. An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility.A New Participant in processing checklist is being created to make sure we train all individuals within the first 30 days after their date of admission. 11/30/2016 Implemented
2380.111(c)(1)Individual #7's 02/05/16 physical examination form did not indicate that the lifetime medical history summary was reviewed; the area for response was not checked Yes or No, it was left blank. The physical examination shall include: A review of previous medical history.A New Participant in processing checklist is being created to make sure we get this life time medical history, or we record all our efforts to obtain it. We are also revising our physical assessment form to make it easier to identify missing or blank items on the form. 11/30/2016 Implemented
2380.111(c)(10)Individual #7's 02/05/16 physical exam does not include information pertinent to diagnosis and treatment in case of emergency. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.A New Participant in processing checklist is being created to make sure we get the appropriate medical history, or we record all our efforts to obtain it. We are also revising our physical assessment form to make it easier to identify missing or blank items on the form. 11/30/2016 Implemented
2380.113(c)(3)Staff #1's physical exam dated 12/16/14 states ¿yes¿ to the question ¿ does this individual have a communicable diseases. This staff does not have a communicable disease per management. The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in §  27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals.This staff member received an updated physical that states she does not have any communicable diseases. All staff members¿ physical exam records have been reviewed for similar discrepancies, and any found were corrected. 09/22/2016 Implemented
2380.124(b)Individual #5's medication log for Diazepam 5 mg QD at1 pm taken for agitation was left blank on 08/31/16 (please note she did not attend program on this date.)The information specified in subsection (a) shall be logged immediately after each individual¿s dose of medication.The ¿Steps to Medication Administration¿ will be updated to include a final step to review all individuals records one more time and annotate MAR¿s for individuals who are not at the program that day with an ¿A¿ for away, before they complete their medications administration session. All medications administration staff will be retrained/remediated on the procedure. 10/31/2016 Implemented
2380.173(9)Indiviual #6's ISP updated 08/01/16 states that she can be out of staff's line of sight for up to 15 minutes as long as staff know where she is and what she is doing. She is also able to go into the main building to use the bathroom without anyone being present. Her aseessment dated 05/31/16 states she needs 1:5 support and is able to walk from one part of the farm to another. Indiviual #5's assessment dated 02/15/16 does not state she needs any adaptive equipment. Her ISP updated 07/18/16 and physical dated 04/18/16 indicate that she uses weighted utensils and a cup with a straw. Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.Our training on the ISP content review will be updated to reflect the items noted in the assessments and will be more comprehensive (and include these examples) and all staff who do the reviews will be retrained. 11/30/2016 Implemented
2380.181(e)(4)Individual #7's assessment dated 03/31/16 does not indicate her need for supervision both at the facility and in the community. Area on the assessment was left blank. The assessment must include the following information: The individual¿s need for supervision.The individual assessment template is being revised so that the individual¿s need for supervision cannot be left blank. 11/30/2016 Implemented
2380.181(e)(5)Individual #3's 07/29/16 assessment does not state his ability to self-administer medication. Individual #7's 03/31/16 assessment does not specify her ability to self-administer medication nor includes progress towards self-medication. Also, her ISP 06/28/16 review and 08/9/16 update states she self-medicates the medications Zoloft, Claritin and Nasacort. The assessment must include the following information: The individual¿s ability to self-administer medications.The individual assessment template is being revised so that the individual¿s ability to self-administer medications cannot be left blank. 11/30/2016 Implemented
2380.181(e)(7)Individual #4's 01/19/16 assessment does not state her ability to sense and move away from heat sources quickly. It simply states that it is unclear if she would touch a hot surface or not.The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.The individual assessment template is being revised so that the individual¿s ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated cannot be left blank. 11/30/2016 Implemented
2380.181(e)(10)Individual #1's 07/29/16 assessment does not include a Lifetime Medical History Individual #7's 03/31/16 assessment did not include a lifetime medical history. Individual #4's 01/19/16 assessment did not include a lifetime medical history. Individual #6's 05/31/16 assessment did not include a lifetime medical history. Individual #5's 02/15/16 assessment did not include a lifetime medical history.The assessment must include the following information: A lifetime medical history.The individual assessment template is being revised so that the individual¿s life time medical history is always included, and any that are missing we will record all our efforts to obtain them. 11/30/2016 Implemented
2380.183(5)Individual #3 takes psychotropic medications. There is no SEEN plan in place. Individual #7 takes psychotropic medications. There is no SEEN plan in place. Individual #4 takes psychotropic medications. There is no SEEN plan in place. Individual #5 takes psychotropic medications. There is no SEEN plan in place. The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.All individuals taking psychotropic drugs will have a SEEN plan developed to address the social, emotional and environmental needs of the individual. 12/30/2016 Implemented
2380.186(e)Indiviual #6's assessment did not include the option to decline offer to her mother. The program specialist shall notify the plan team members of the option to decline the ISP review documentation.Individual Assessment templates and ISP Review reports have been updated to include the notification to all team members that they have the right to decline the ISP review documentation. 09/28/2016 Implemented
SIN-00079315 Renewal 09/17/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(6)Individual #2 physica dated 7/13/15 and individual #3's physical dated 12/15/15 did not list if they were free of communicable diseases. The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals.1. The Program Specialist contacted the residential Program Director and Physician to get an update to this inconsistency. a. Completed 9/25/2015, Attachment D.1.a. 2. We have created a new ISP Quarterly Review process that will catch these inconsistencies and correct them at each ISP Quarterly and Annual review. a. Completed 9/29/2015, Attachment A.2.a., page 6. 3. Senior Staff (who have been previously trained to compile the ISP Quarterly Review Report), Program Directors, and Program Specialists will be trained by the Executive Director on the new ISP Quarterly Review process before 10/30/2015. 09/29/2015 Implemented
2380.111(c)(7)Individual #2's physcial dated 7/13/15 did not include an assessment for health maintenance. 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.1. The Program Specialist contacted the residential Program Director and Physician to get an update to this inconsistency. a. Completed 9/25/2015, Attachment D.1.a. 2. We have created a new ISP Quarterly Review process that will catch these inconsistencies and correct them at each ISP Quarterly and Annual review. a. Completed 9/29/2015, Attachment A.2.a., page 6. 3. Senior Staff (who have been previously trained to compile the ISP Quarterly Review Report), Program Directors, and Program Specialists will be trained by the Executive Director on the new ISP Quarterly Review process before 10/30/2015. 09/29/2015 Implemented
2380.111(c)(8)Individual #2's physcial dated 7/13/15 did not include physical limitations of the individual. The physical examination shall include: Physical limitations of the individual.1. The Program Specialist contacted the residential Program Director and Physician to get an update to this inconsistency. a. Completed 9/25/2015, Attachment D.1.a. 2. We have created a new ISP Quarterly Review process that will catch these inconsistencies and correct them at each ISP Quarterly and Annual review. a. Completed 9/29/2015, Attachment A.2.a., page 6. 3. Senior Staff (who have been previously trained to compile the ISP Quarterly Review Report), Program Directors, and Program Specialists will be trained by the Executive Director on the new ISP Quarterly Review process before 10/30/2015. 09/29/2015 Implemented
2380.111(c)(10)Individual #2's physcial dated 7/13/15 did not include emergency information. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.1. The Program Specialist contacted the residential Program Director and Physician to get an update to this inconsistency. a. Completed 9/25/2015, Attachment D.1.a. 2. We have created a new ISP Quarterly Review process that will catch these inconsistencies and correct them at each ISP Quarterly and Annual review. a. Completed 9/29/2015, Attachment A.2.a., page 6. 3. Senior Staff (who have been previously trained to compile the ISP Quarterly Review Report), Program Directors, and Program Specialists will be trained by the Executive Director on the new ISP Quarterly Review process before 10/30/2015. 09/29/2015 Implemented
2380.111(c)(11)Individual #2's physcial dated 7/13/15 and Individual #3's physcial dated 12/15/14 did not inlcude diet instructions.The physical examination shall include: Special instructions for an individual's diet.1. The Program Specialist contacted the residential Program Director and Physician to get an update to this inconsistency. a. Completed 9/25/2015, Attachment D.1.a. 2. We have created a new ISP Quarterly Review process that will catch these inconsistencies and correct them at each ISP Quarterly and Annual review. a. Completed 9/29/2015, Attachment A.2.a., page 6. 3. Senior Staff (who have been previously trained to compile the ISP Quarterly Review Report), Program Directors, and Program Specialists will be trained by the Executive Director on the new ISP Quarterly Review process before 10/30/2015. 09/29/2015 Implemented
2380.177Individual #1, #2, and #3 did not have in their record release of information. Written consent of the individual, or the individual's parent or guardian if the individual is incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.1. We have created a new CONSENT TO RELEASE INFORMATION form for all Growers to sign. a. Copy of CONSENT TO RELEASE INFORMATION form now in use, signed by Individuals #2 and #3. Completed 9/28/2015, Attachment C.1.a. 2. We have created a check list to ensure all current Growers have this signed and on file with Farm of Hope Inc. a. Program Directors and Program Specialists will contact all current the Growers and their family/guardians to get the new form signed and filed in their ISP books. o Started 9/23/2015, Expected Completion 10/16/2015 b. Copy of the checklist we are using to ensure all our current Growers get the new consent form. Attachment C.2.a. 3. We have created an Intake Record Checklist for Program Directors and Program Specialists to ensure we have all the required documents prior to the Growers start date. a. We have used the checklist with a potential Grower prior to their start date. o Completed 9/28/2015, Attachment C.3.a. b. Program Directors and Program Specialists will be trained by the Executive Director on the Checklist, intake process and forms to ensure all required information is returned prior to Growers start date. Estimated Completion of training: 10/16/2015 09/28/2015 Implemented
2380.181(e)(13)(iv)Individual #1's assessment did not have progress over the last 365 calendar days and current level in socialization. The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.1. Program specialist has added socialization progress notes to the assessment for individual #1. a. Completed 9/17/2015, Attachment B.1.a. 2. The annual assessment questionnaire and template has been updated to include progress notes for the socialization section. The new assessment was used with a new Grower a. Completed 9/30/2015, Attachment B.2.a. 3. Program Specialists will train (self-discussion and practice) on the new assessment questionnaire and template before 10/30/2015. 09/30/2015 Implemented
2380.186(d)Individual #3's ISP review was not sent to team within 30 calendar days. ISP review was completed on 6/2/2015 and not sent out to team until 9/17/2015.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.1. Each ISP Quarterly Review will now include the Executive Director¿s Review to be conducted within 30 calendar days after the ISP Review is completed. a. The Executive Director¿s Review includes ensuring the ISP Quarterly Review Report is sent to the plan team within 30 days. 2. The new Executive Director¿s Review of the ISP Quarterly Review process has been used for a current Grower. a. Completed 9/29/2015, Attachment A.2.a. page 4 3. Senior Staff (who have been previously trained to compile the ISP Quarterly Review Report), Program Directors, and Program Specialists will be trained by the Executive Director on the new ISP Quarterly Review process before 10/30/2015. 09/29/2015 Implemented
SIN-00066204 Initial review 09/16/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(a)The carpet in the living area of the facility is covered in dark stains. The tile in the rest of the facility is covered with dark stains, paint splatters and hay.Floors, walls, ceilings and other surfaces shall be in good repair.Transcribed from paper LIS by A. Knaus Martin Flooring will remove carpet, install new vinyl flooring, commercially clean, wax, polish tiled floor. Work will be done September 18 & 19, 2014. 09/18/2014 Implemented
2380.59(b)The water temperature taken from the men's bathroom was 122.2 degrees.Hot water temperatures in areas accessible to individuals may not exceed 120°F.  Implemented
2380.72(b)The handrail on the ramp leading to the entrance door of the program was not sturdy. It wobbled back and forth and presented a hazard to individuals with mobility needs.The outside of the building and the facility grounds shall be well maintained, in good repair and free from unsafe conditions.Transcribed from paper LIS by A. Knaus The railing on the ramp has been secured so that it does not wobble back and forth on Sunday, August 31, 2014 by Brian Sweger. We will periodically check to make sure it stays tight. 09/18/2014 Implemented
SIN-00069332 Initial review 08/29/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.58(a)The carpet in the living area of the facility is covered in dark stains. The tile in the rest of the facility is covered with dark stains, paint splatter, and hay. Floors, walls, ceilings and other surfaces shall be in good repair.Martin Flooring will: 1. Remove carpet 2. Install new vinyl flooring 3. Commercially clena, wax and polish tile floors Work will be done September 18 & 19, 2014 Implemented
2380.59(b)The water temperature taken from the men's bathroom was 122.2 degrees. Hot water temperatures in areas accessible to individuals may not exceed 120°F.Maintenance person, BS, turned the temperature on the hot water heater down to 120 degrees. This was done on Friday, August 29, 2014. Will conduct periodic checks of temperature. Implemented
2380.72(b)The handrail on the ramp leading to the entrance door of the program was not sturdy. The handrail wobbled back and forth and presented a hazard to individuals with mobility needs. The outside of the building and the facility grounds shall be well maintained, in good repair and free from unsafe conditions.The railing on the ramp has been secured so that it does not wobble back and forthe on Sunday, August 31, 2014 by Maintenance person, BS. We will periodically check to make sure it stays tight. Implemented
SIN-00219731 Renewal 02/27/2023 Compliant - Finalized