Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00231117 Renewal 10/11/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(14)Individual #1's physical examination, completed on 07/24/23, did not address medical information pertinent to diagnosis in case of emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The agency reviewer (program specialist) will review the form upon return to ensure the section is completed. AC/CO 10/23/2023 Implemented
SIN-00212083 Renewal 09/28/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Direct Service Worker #2, date of hire 3/21/2022, had a Pennsylvania criminal history request completed 1/15/2020.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. 6400.21(a): Direct Service Worker #2 was a temporary staff used to cover a shift for 2 weeks due to immediate staffing need from 3/21/22 through 4/1/22. The part time HR representative received a PA criminal history completed 1/15/2020 from the staffing agency. In review, the HR representative requested an updated criminal history and was informed by the temporary staffing agency on initial contact on 3/1/22 that an update PA Criminal history would be forwarded by the start date of 3/21/22, however, HR representative did not follow up and the updated PA Criminal history was not received. The HR specialist did not run the criminal history check in anticipation of receiving this information. This was an oversight. 10/04/2022 Implemented
6400.141(c)(4)Individual #1 had a hearing screening completed 7/09/2021 and not again since.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. 6400.141(c)(4) Individual #1 had an annual physical on 7/11/2022. The PCP wrote on the form ¿unable to assess¿ and ¿follow up with a specialist¿ specifically because they do not assess for hearing in their office not because there were any hearing issues or deficiencies. The same PCP completed the same on the 6/2020 physical form. At that time, the program specialist made an appointment for 1/20/21, which was the first available from calling in 6/2020, due to COVID. There were no complaints, history or trauma that would have specified any hearing deficiencies. The audiologist completed a history, conducted an exam, reviewed the screening results as normal and stated that no further screenings were needed unless the individual was having issues. The individual has not complained of nor were any issues observed at the 7/11/2022 annual physical, therefore, no further screening had been scheduled. 10/04/2022 Implemented
6400.151(a)Direct Service Worker #3 had a physical examination completed 1/17/2020 and then again 2/04/2022. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. 6400.15(a) Direct Service worker #3 completed their physical on 1/17/20 and then again 2/4/22, which was out of compliance by 3 days per regulations. The DSW #3 was contacted beginning in the last week of November 2021 and provided with the agency paperwork. The DSW did not attempt to get their physical until after 1/1/22, during this time they developed car issues which prevented them from going timely. 01/24/2022 Implemented
6400.151(c)(2)Program Specialist #1 had a Tuberculin skin test read 1/18/2020 and then again 2/21/2022. Direct Service Worker #3 had a Tuberculin skin test read 1/17/2020 and then again 2/04/2022. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Program Specialist #1 had a TB skin test completed on 1/18/20 and then again on 2/21/22. The program specialist was hired on 3/4/20. They had a previous TB skin test completed on 1/18/20 and did not have another completed with their new hire physical 3/3/20. The HR specialist had made a note to remind the program specialist to complete their physical early to align both assessments, if possible, or complete their TB in 1/22, however, the HR specialist did not do so. Direct Care Service worker #3 has a TB skin test completed on 1/17/20 and then again on 2/4/22, which was out of compliance by 3 days per regulations. The DSW #3 was contacted beginning in the last week of November 2021 and provided with the agency paperwork. The DSW did not attempt to get their physical until after 1/1/22, during this time they developed car issues which prevented them from going timely. Per agency policy, the DSW #3 was advised that if the annual physical was not received by the extended deadline of 1/24/22, they would be taken off the schedule until compliance was met, further corrective action would be reviewed as necessary pending the DSW #3 action. DSW #3 was taken off the schedule until the physical was completed. The agency will continue to apply policy to ensure compliance for regulatory compliance. The agency will ensure that the house assessments are updated with this information along with the plan or correction/ corrective action as suggestion by the department licensing representative. 10/04/2022 Implemented
6400.163(d)During the inspection conducted 9/28/2022 a first aid kit was identified on top of the medication cabinet, in the dining room, unlocked and accessible. The first aid kit contained the following bottles of over the counter medications: Acetaminophen 500mg tablet, Ibuprofen 200mg tablet, and Antacid chews. Individual #1 and Individual #2 are assessed as unable to self-administer medications.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.During the onsite annual inspection on 9/28/22, the department licensing representative identified medication in the first aid kit, acetaminophen, ibuprofen, and antacids. These medications are not specifically for the individual, but rather for general house use as part of first aid. However, the medications in the first aid kit are listed on the individuals master PRN list. The master PRN list is specific written order that their PCP has signed off permitting for general usage for specific alignments such as heartburn, pain, fever etc. Therefore, if the individual experiences such alignments, then they staff can view the written order, call on call and document administration. All individuals, although not self-administering medication, are assessed to be safe around, not ingest, touch or are otherwise inappropriate with ¿poisons¿ which include medications. 09/28/2022 Implemented
SIN-00180214 Renewal 11/23/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)On 11/24/2020 there were dishwasher pods, of an unknown brand, located under the kitchen sink that were unlocked, unattended and accessible. There were several bottles of miscellaneous cleaners located in a plastic, 2-door utility cabinet in the basement that were unlocked, unattended, and accessible. Individual #1 is not assessed to be able to use or avoid poisonous materials.Poisonous materials shall be kept locked or made inaccessible to individuals. Cleaning products and bottles were appropriately labels in original containers or in containers appropriately marked according to the Materials Safety Data Sheet (MSDS). Individual #1's assessment was not correctly updated to reflect that they are able to properly reflect that they are able to safely be around and avoid poisonous materials. Therefore, these items are left unlocked as part of the least restrictive and safest supports. The assessment has been updated to reflect this and will be provided to the department as verification. AC/CO [Immediately, the CEO, or designee, shall train all staff on the definition of poisons and hazardous materials. The CEO, or designee, shall train the Program Specialist on the requirements of the Individual Assessment, as required by 6400.181(a)-(f). Documentation of the training shall be kept. The Program Specialist shall ensure that the Individual Assessment and the Individual Support Plan contain congruent information related to the individual's ability to use and/or avoid poisonous materials. If discrepancies between the Assessment and ISP exist, the Program Specialist shall inform the Plan Team Lead of the discrepancies. Documentation of these notifications shall by kept. DPOC by HDKP, HSLS on 1/11/2021]. 12/26/2020 Implemented
6400.141(c)(4)Individual #1 had a physical examination, dated 6/24/20; however, the physical examination did not include a vision or hearing screening. Both vision and hearing were marked "unable to complete".The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Individual #1 has his annual physical every June. His physician did not complete the vision and hearing screenings examination at this time because individual #1 refused. The physician did not see any deficiencies during his examination that suggested further follow up. However, the program specialist will schedule vision and hearing screenings by 1/31/2020 as some offices are operating different hours due to COVID. Afterwards, vision and hearing screenings will be as per the screening physician. This will be reviewed annually by the program specialist. AC/CO [Immediately, the CEO or designee, shall train all staff attending physical examinations on the requirements of the physical examination, as outlined in 6400.141(a)-(d). All staff shall be trained on the documentation requirements of appointments that are outside of the physical examination. Documentation of the trainings shall be kept. The CEO, or designee, shall conduct an audit of all individual physical examinations to ensure the documentation is completed and all required components of physical examinations are addressed, as required by 6400.141(c)(1-(15). Documentation of the audit shall be kept. Quarterly, for a period of at least one year, the CEO, or designee, shall conduct an audit of 25% of all individual physical examinations to ensure that all required information has been obtained. Documentation of the quarterly audits shall be kept. DPOC by HDKP, HSLS on 1/11/2021]. 12/26/2020 Implemented
6400.165(g)Individual #1 is prescribed medications to treat the symptoms of a psychiatric illness. Individual #1's psychiatric medication reviews dated 8/14/19, 10/10/19, and 12/18/19 do not list a diagnosis or purpose for the medications prescribed.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The psychiatrist did not complete the section of the form that indicated the purpose of the medication on these visits even after numerous requests from the office. Since the agency was not clear on whether or not this information could be documented by anyone other than the physician, it was not completed. Clarification from the department was received and the agency will now preprint this information on the form for the psychiatrist to review and sign. The psychiatrist office also created a standard form to assist providers with regulatory compliance. The program specialist will prepare, review and follow up with form completion for thoroughness and accuracy before submitting the form to the psychiatrist/ office and after receiving the form back. The CEO will also review forms quarterly for completion to ensure and maintain regulatory compliance AC/CO [Immediately, the CEO, or designee, shall train the Program Specialist on the requirements of psychiatric medications reviews, as required by 6400.165(g). Documentation of the training shall be kept. Immediately, and at least quarterly for a period of one year, the CEO, or designee, shall conduct an audit of all completed psychiatric medication reviews to ensure completion and all required information is captured. If information is missing, the CEO, or designee, shall request the missing information from the medical professional whom completed the psychiatric medication review. Documentation of these information request shall be kept. DPOC by HDKP, HSLS on 1/11/2021]. 11/24/2020 Implemented
SIN-00195578 Renewal 11/04/2021 Compliant - Finalized