Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00150579 Renewal 02/22/2019 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(c)Staff person # 1 did not complete 24 hours trainingProgram specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually.An excel sheet has been created that updates HR/book keeper when staff need their annual 24 hours of trainings. Annual training days and Relias trainings are used. CEO will ensure this is being done in order to maintain compliance. [Directed plan 7/2/19 Staff person #1 has received all trainings required. The program Specialist will audit all staff files to ensure that everyone has 24 hours of training for the training year.] 03/01/2019 Accepted
2380.36(d)Staff person #2 did not complete Intellectual Disabilities training.Program specialists and direct service workers shall have training in the areas of services for people with disabilities and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment.A new training curriculum has been created which includes Intellectual Disabilities training using Relias. The Program Specialist is responsible for this training during orientation and annually thereafter. CEO will ensure that this is done. [Directed plan 7/2/19 Staff person #2 completed Intellectual Disabilities training. The program Specialist will audit all staff files to ensure that everyone has Intellectual Disabilities training.] 05/01/2019 Accepted
2380.53(a)There were several cans of paint and a flammable combustible agent stored in an unlocked closetPoisonous materials shall be kept locked or made inaccessible to individuals, when not in use.A new locking door knob has been installed and is kept locked at all times. The CEO has overseen this. [Directed plan 7/2/19 A physical site check list will be created with all the 2380 physical site regulations. It will be used weekly to audit the facility to ensure compliance.] 03/01/2019 Accepted
2380.55(a)The individual's bathroom has a very pungent odor during the inspectionClean and sanitary conditions shall be maintained in the facility.The staff restroom is cleaned daily and deep cleaned weekly. Air freshener is kept locked but may be used by staff when necessary. [Directed plan 7/2/19 A physical site check list will be created with all the 2380 physical site regulations. It will be used weekly to audit the facility to ensure compliance.] 03/01/2019 Accepted
2380.85There were flammable and combustible materials stored in the unlocked closet near the hot water heater.Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.A new locking door knob has been installed on closet at program. CEO was responsible for the installation. The door will remind locked at all times. [Directed plan 7/2/19 A physical site check list will be created with all the 2380 physical site regulations. It will be used weekly to audit the facility to ensure compliance.] 03/01/2019 Accepted
2380.89(c)The fire drill forms for 1/28/19 and 12/12/18 did not include exit route used, and whether the alarm was operative.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm was operative.A new form has been created that lists the exit route and whether the smoke alarm was operative. The Supervisor will be responsible for this each month and file in office. [Directed plan 7/2/19 Emmaus will submit April, May, and June fire drills with exit routes, and alarm was operable to ODP. The supervisor will review all fire drills each month to ensure compliance, and if items are missing to ask staff that conducted the drill for the information.] 03/01/2019 Accepted
2380.91(a)Individual #3 did not have initial fire safety training.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.The Program Specialist will ensure that upon admission to program, a fire safety training will be conducted by a fire expert. Documentation will be kept on site and filed in permanent binder of each participant. [Directed plan 7/2/19 Individual #3 will have completed fire safety training. The program specialist will audit every individuals' files to ensure that fire safety training was completed.] 06/01/2019 Accepted
2380.111(c)(3)Individual #3's physical examination dated 4/6/18 did not include immunizations.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.An annual physical form containing section for immunizations will be used by all participants of program. CEO will ensure that this is completed. [Directed Plan 7/2/19 The physical form will be sent back to the individuals' family or provider to get updated with the current immunizations.] 03/01/2019 Accepted
2380.111(c)(4)Individual #3's physical examination dated 4/6/18 did not include Vision and Hearing.The physical examination shall include: Vision and hearing screening, as recommended by the physician.A new physical form containing a section for Vision and Hearing will be used. CEO will ensure that this is completed annually. [Directed plan 7/2/19 The physical form will be sent back to the individuals' family or provider to get updated with the current vision and hearing screenings.] 03/01/2019 Accepted
2380.111(c)(5)Individual #3's physical examination dated 4/6/18 did not include Tuberculin skin testing with negative results.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.An annual physical form denoting TB skin test was negative is being used. CEO will ensure that this is completed annually. [Directed plan 7/2/19 The physical form will be sent back to the individuals' family or provider to get updated with the current TB skin test with negative results.] 03/01/2019 Accepted
2380.111(c)(6)Individual #3's physical examination dated 4/6/18 did not include free of communicable disease.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.An annual physical form is now being used that contains this section, free of communicable disease. CEO will ensure that this is completed annually. [Directed plan 7/2/19 The physical form will be sent back to the individuals' family or provider to get updated with free of communicable disease.] 03/01/2019 Accepted
2380.111(c)(7)Individual #3's physical examination dated 4/6/18 did not include assessment of health maintenance needs.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.An annual physical form will be used that includes an assessment of the individual's health maintenance needs, medication regimen and the need for blood work. The CEO will ensure this is completed annually. [Directed plan 7/2/19 The physical form will be sent back to the individuals' family or provider to get updated with an assessment of health maintenance needs.] 03/01/2019 Accepted
2380.111(c)(8)Individual #3's physical examination dated 4/6/18 did not include physical limitations.The physical examination shall include: Physical limitations of the individual.An annual physical form including physical limitations is now being used in the program. CEO will ensure that this is completed annually. [Directed plan 7/2/19 The physical form will be sent back to the individuals' family or provider to get updated with physical limitations.] 03/01/2019 Accepted
2380.111(c)(9)Individual #3's physical examination dated 4/6/18 did not include allergies.The physical examination shall include: Allergies or contraindicated medication.An annual physical form will be used that has a section for allergies. The CEO will ensure that this is done annually for participants - including those with BOA Waivers. [Directed plan 7/2/19 The physical form will be sent back to the individuals' family or provider to get updated with allergies.] 03/01/2019 Accepted
2380.111(c)(10)Individual #3's physical examination dated 4/6/18 did not include information pertinent to diagnoses.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.A annual physical form will be used that includes information pertinent to diagnosis for all participants of the program and updated annually. The CEO will ensure that this is completed. [Directed plan 7/2/19 The physical form will be sent back to the individuals' family or provider to get updated with information pertinent to diagnoses.] 03/01/2019 Accepted
2380.111(c)(11)Individual #3's physical examination dated 4/6/18 did not include special diet instructions.The physical examination shall include: Special instructions for an individual's diet.An annual physical form that includes special diet instructions will be used for all participants at program. The CEO will ensure that this is done. [Directed plan 7/2/19 The physical form will be sent back to the individuals' family or provider to get updated with special diet instructions.] 05/01/2019 Accepted
2380.113(c)(2)Staff person#1's last recorded tuberculin skin testing with negative results was on 12/6/16, which is more than 2 years.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.Human Resource/Book keeper has created an Excel sheet that alerts her when physicals have expired and need a new physical and TB test. She will reach out to the employee. Failure to adhere to this policy will result in suspension from the schedule. CEO will oversee this. [Directed plan 7/2/19 Staff person #1 received their Tuberculin skin test with negative results. Human Resource /Book Keeper will audit all staff files to ensure that all staff have a TB test.] 03/01/2019 Accepted
2380.113(c)(2)Staff Person #2's physical examination dated 12/5/18 did not have record of a tuberculin skin testing with negative results.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.A physical form has been created that requires TB test and results to be recorded. The Human Resource/ Book keeper will ensure that this is done. [Directed plan 7/2/19 Staff person #1 received their Tuberculin skin test with negative results. Human Resource /Book Keeper will audit all staff files to ensure that all staff have a TB test.] 05/01/2019 Accepted
2380.121(e)Individual #2 had three Medications on site and CEO states medication was discontinued.Discontinued prescription medications shall be returned to the individual¿s family or residential program for proper disposal.The CEO will ensure that any discontinued medication is returned to the residential home or the family for proper disposal. [Directed plan 7/2/19 The CEO will audit all individuals' medications on a weekly basis to ensure discontinued medications are removed from the program.] 03/01/2019 Accepted
2380.124(a)Individual #4's February 2019 MARS did not indicate the full name of each person giving medication. CEO confirms the initials for Staff person # 4 and Staff person #2.A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered, and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication.Medicine Administrators have been trained to sign on each MAR in addition to initialing each time they administer medication. CEO will ensure this is completed. [Directed plan 7/2/19 The CEO will audit the MARS once a week to ensure that staff administering medications have their full name on the MAR.] 04/01/2019 Accepted
2380.128(d)Individual #2 medication Lamotrigine 150mg 3 tablets was administered by staff#3 and there was no documentation that the staff#3 had a medication practicum.A staff person who administers prescription medications or insulin injections to individuals shall complete the Medications Administration Course Practicum annually.CEO will ensure that records are kept proving certification for med administration and filed in each staff's personnel file. An Excel sheet will be created for annual training observations in order to keep their certifications up to date and current. [Directed plan 7/2/19 The CEO will audit the medication trainings of all staff to ensure they have current medication practicums.] 06/01/2019 Accepted
2380.173(1)(iii)Individual #1's Primary language not included in their record.Each individual¿s record must include the following information: Personal information including: The language or means of communication spoken or understood by the individual and the primary language used in the individual¿s natural home, if other than English.A new face sheet has been created that now includes participants' primary language. CEO will ensure that this is done upon admission. [Directed plan 7/2/19 Individual #1's primary language was included in the file. The program specialist will audit all individual files to ensure that their primary language is part of the record.] 05/01/2019 Accepted
2380.173(1)(v)Individual #1's Record did not include current dated photo.Each individual¿s record must include the following information: Personal information including: A current, dated photograph.All photos of participants have been updated and now include the date when photo was taken. The Supervisor has completed this and will update annually. The CEO will ensure that this is done. [Directed plan 7/2/19 The program specialist will audit the individual files once a month to ensure that photos are current.] 03/01/2019 Accepted
2380.177Individual #1's Records did not include Consent for release 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.A Consent for release of information has been created by Emmaus Home, sent to families and is filed in the participants' permanent binders. CEO will be responsible for this ensuring this is completed for each new admission. [Directed plan 7/2/19 The program specialist will audit the individual files once a month to ensure that consent for release of information is current.] 05/01/2019 Accepted
2380.181(a)Individual #1's record did not include an assessment.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 complete an initial assessment within sixty days upon admission - and annually after. The CEO will ensure that this is completed. [Directed plan 7/2/19 Individual #1 and #3 have an assessment completed in their record. The program Specialist will audit all individual files to ensure assessment are completed within the time frames.] 06/01/2019 Accepted
2380.181(a)Individual #3 was admitted on 10/17/18, and did not have an initial 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.Each new admission will receive an initial assessment within sixty days by the Program Specialist. This will be filed in the participant's permanent binder at the program. [Directed plan 7/2/19 Individual #1 and #3 have an assessment completed in their record. The program Specialist will audit all individual files to ensure assessment are completed within the time frames.] 06/01/2019 Accepted
2380.186(a)Individual #1's Record did not include quarterly reviews or signatures by program specialist.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 Program Specialist will review quarterly each participant's ISP and sign that she has reviewed the services and expected outcomes of the ISP. CEO will ensure that this is completed. [Directed plan 7/2/19 The program Specialist will audit all individual files to ensure quarterly reviews are completed within the time frames.] 04/01/2019 Accepted
2380.186(b)Individual #1's record did not include quarterly reviews or signatures by program specialist.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.Program Specialist will complete a quarterly review and sign it beginning first quarter of 2019. CEO will ensure that this is completed for every participant served. [Directed plan 7/2/19 The program Specialist will audit all individual files to ensure quarterly reviews are completed within the time frames.] 03/01/2019 Accepted
SIN-00124460 Initial review 11/08/2017 Compliant - Finalized