Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00202660 Renewal 03/30/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)There is a wooden piece of framing above washer/dryer that was hanging off.Floors, walls, ceilings and other surfaces shall be in good repair. - Importance of Regulation o Floors, walls, ceilings and other surfaces shall be in good repair to ensure that the home is presentable and safe for the individual - Regulation Violated o There is a wooden piece of framing above washer/dryer that was hanging off. ¿ Fixing Violation o Property management was contacted to replace the framing around the washer and dryer. ¿ Prevent Future Violation o Acute established an email communication with the property manager that will allow for all direct communication. Acute staff will email all damages that need repair. ¿ Responsible Person o Program Specialist 04/29/2022 Implemented
6400.24There was no count on individual 1's Zolpidem 10mg, or Lorazepam 1mg. This is a controlled substance and needs to be counted under the controlled substances act of 1970The home shall comply with applicable Federal and State statutes and regulations and local ordinances.¿ Importance of Regulation o The home shall comply with applicable Federal and State statutes and regulations and local ordinances to ensure individual safety at all times ¿ Regulation Violated o There was no count on individual 1's Zolpidem 10mg, or Lorazepam 1mg. This is a controlled substance and needs to be counted under the controlled substances act of 1970 ¿ Fixing Violation o Immediately created a control substance count sheet for the individual¿s Lorazepam 1mg. Staff members are actively counting the Lorazepam per shift. ¿ Prevent Future Violation o To prevent future violations, Acute's lead staff (supervisor) will communicate directly with the pharmacy to identify each control substance medication every time there is a new prescription. ¿ Responsible Person o Director 04/01/2022 Implemented
SIN-00185599 Renewal 03/29/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144PRN Saline nose spray 0.65% was not present in home at time of inspection for Individual #4Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. 19-3 Valley Road Physical Site ¿ Regulation 6400. 144: ¿ Importance of Regulation o This regulation is critical for maintaining the health and safety of the individual. ¿ Regulation Violated o PRN Saline nose spray 0.65% was not present in home at time of inspection for Individual #4 ¿ Fix of Violation. ¿ Program specialists called the pharmacist who then delivered the PRN on 4/2/21. ¿ Responsible Person o Summer Kollie is responsible to prevent future violations. o Acute anticipated the resolution of this violation by 4/15/21 o Violation was resolved on 4/2/21 o Based on analysis of other individuals, there are no similar violations 04/02/2021 Implemented
SIN-00110719 Renewal 04/28/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)THE SELF ASSESSMENT WAS COMPLETED ON 10/01/2016 WHICH IS NOT WITHIN 3 TO 6 MONTHS PRIOR TO THE EXPIRATION DATE OF 09/29.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. WHO: Michael Addo, Director WHAT WILL BE CORRECTED: The self-assessment was completed Two (2) days late on10/1/2016 for 19 Valley Road, apt 3, Drexel Hill, PA 19026. WHEN: Target Date of completion was May 4, 2017. Specific Date of Completion was May 4, 2017 HOW: Fix the Violation, an immediate full self-assessment for 19 Valley Road, apt 3 Drexel Hill, PA 19026 was conducted on May 4, 2017. A copy of the assessment was placed in a centralize folder hosting all Acute¿s assessments in the office. PLAN TO PREVENT FUTURE OCCURRENCE: The Director will ensure that the self-assessment of each home that Acute operates is completed within 3 to 6 months prior to the expiration date of the certificate of compliance, in order to measure and record compliance with this chapter. The Director will maintain a calendar that tracks due dates for the self-assessment for each home that Acute operates. Once an assessment is completed for each home, a copy of the assessment will be filed in the home and in the head office. ATTACHMENT AND SUPPORTING DOCUMENTS Self-Assessment 05/04/2017 Implemented
6400.31(b)THERE WAS NO CURRENT COPY OF SIGNED RIGHTS IN INDIVIDUAL #1'S RECORD. Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. WHO: Gifty Quashigah, Program Specialist WHAT WILL BE CORRECTED: Individual¿s rights were signed upon admission into the program on 11/16/2015 but was not signed annually thereafter. WHEN: The target date of completion was May 5, 2017. HOW: Fix the Violation: The individual¿s legal guardian was immediately contacted and made aware of the individual¿s rights statements. The document was reviewed by the legal guardian, signed and dated for the year 2016. ACHD retained a signed copy of the individual¿s rights document in her folder. PLAN TO PREVENT FUTURE OCCURRENCE: The Program Specialist will ensure that this individual and all other individuals in the program upon admission, will have their rights statements reviewed, signed and dated and annually, thereafter, by the individual, or the individual parent(s), guardian or advocate to remain in compliance. This signed document will be filed in the individual¿s binder in the home as well as in the head office for record keeping. ATTACHMENT AND SUPPORTING DOCUMENTS Signed Individual's Rights 05/05/2017 Implemented
6400.141(c)(4)THE PHYSICAL EXAMINATION FOR INDIVIDUAL #1 DATED 08/03/2016 DID NOT INDICATE THAT A VISION OR HEARING SCREENING WAS COMPLETED. The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. WHO: Gifty Quashigah, Program Specialist WHAT WILL BE CORRECTED: The annual physical dated 08/16/16 which was completed for the individual, included vision and hearing, however, those sections of the form were not checked by the doctor to indicated that vision and hearing screening were completed. WHEN: The target date of completion was May 17, 2017. HOW: Fix the Violation, Individual¿s Primary doctor was contacted immediately, and the physical form was faxed over to the PCP at Pennsylvania Hospital for completion. It was filled out completely and faxed back to Acute. PLAN TO PREVENT FUTURE OCCURRENCE: The Program Specialist will ensure that every section of the annual physical form is filled out completely during annual physical examinations to remain in compliance. ATTACHMENT AND SUPPORTING DOCUMENTS Individual's completed physical examination. 05/17/2017 Implemented
6400.141(c)(14)THE PHYSICAL EXAMINATION FOR INDIVIDUAL #1 DATED 08/03/2016 DID NOT INCLUDE MEDICAL 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. WHO: Gifty Quashigah, Program Specialist WHAT WILL BE CORRECTED: The annual physical form dated 8/16/16 for individual was not completed to reflect medical information pertinent to diagnosis and treatment in case of emergency. WHEN: May 17, 2017 HOW: Fix the Violation; The incomplete annual physical form was resubmitted to the individual's PCP for completion. The section of the annual physical form indicating medical information pertinent to diagnosis and treatment in case of emergency was filled out and faxed over to Acute. PLAN TO PREVENT FUTURE OCCURRENCE: The Program Specialist will ensure that whenever annual physical examination is completed, the section of the form indicting medical information pertinent to diagnoses and treatment in case of emergency is filled out. The completed form will be kept in the individual's folder for record in order to remain in compliance. ATTACHMENT AND SUPPORTING DOCUMENTS Completed Annual Physical for individual 05/17/2017 Implemented
6400.181(e)(13)(iii)THE ASSESSMENT FOR INDIVIDUAL #1 DATED 04/08/2017 DID NOT INCLUDE PROGRESS AND GROWTH OVER THE LAST 365 DAYS IN THE AREA OF: ACTIVITIES FOR RESIDENTIAL LIVING. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. WHO: Gifty Quashigah, Program Specialist WHAT WILL BE CORRECTED: Individual¿s Progress over the last 365 calendar days and current level in activities of residential living were not evaluated in the assessment. WHEN: The target date of completion was May 05, 2017. HOW: Fix the Violation: The Program Specialist immediately revised the assessment to reflect level in activities of residential living. The individual continues to require full assistance from staff to complete her personal hygiene, cleaning and organizing her living space; as well as feeding and ambulating. The individual therefore, over the period of the assessment did not make progress in activities of residential living. PLAN TO PREVENT FUTURE OCCURRENCE: The Program Specialist will ensure that when assessments are written, level in activities of residential living will be adequately evaluated to reflect progress or lack of progress. ATTACHMENT AND SUPPORTING DOCUMENTS Updated Assessment indicating lack of progress under Activities of Residential Living. 05/05/2017 Implemented
6400.181(e)(13)(vii)THE ASSESSMENT FOR INDIVIDUAL #1 DATED 04/08/2017 DID NOT INCLUDE PROGRESS AND GROWTH OVER THE LAST 365 DAYS IN THE AREA OF: FINANCIAL INDEPENDENCE. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. WHO: Gifty Quashigah, Program Specialist WHAT WILL BE CORRECTED: Individual¿s Progress over the last 365 calendar days and current level in financial independence was not evaluated in the assessment. WHEN: The target date of completion was May 05, 2017. HOW: Fix the Violation: The Program Specialist immediately revised the assessment to reflect level in financial independence during the period of assessment. The individual continued to require full assistance from her representative payee through Advocacy Alliance to manage room and board payments at Acute as well as monthly spending allowance. The Individual had been observed to be throwing away cash (coins and notes) or attempting to ingest them when handed to her, demonstrating lack of concept in the use of money. The individual¿s staff continued to assist when purchases were made in the community, since she did not understand the use of money. She made no progress in financial independence. PLAN TO PREVENT FUTURE OCCURRENCE: The Program Specialist will ensure that when assessments are written, level in financial independence will be evaluated and stated to indicate progress made over the period of assessment or lack of progress. ATTACHMENT AND SUPPORTING DOCUMENTS Updated Assessment indicating lack of progress under Financial Independence. 05/05/2017 Implemented
6400.181(e)(13)(viii)THE ASSESSMENT FOR INDIVIDUAL #1 DATED 04/08/2017 DID NOT INCLUDE PROGRESS AND GROWTH OVER THE LAST 365 DAYS IN THE AREA OF: MANAGING PERSONAL PROPERTY.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. WHO: Gifty Quashigah, Program Specialist WHAT WILL BE CORRECTED: Individual¿s Progress over the last 365 calendar days and current level in managing personal property was not evaluated in the assessment. WHEN: The target date of completion was May 05, 2017. HOW: Fix the Violation: The Program Specialist immediately revised the assessment to reflect level in managing personal property during the period of assessment. The individual continued to require full assistance from her direct support staff, her family and advocate to manage her personal property during the period of assessment. She did not demonstrate the ability to acquire personal belongings, show accountability for her personal property or take responsibility for handling them without assistance. The Individual had been observed to be throwing personal belongings away, on the floor, ripping items apart and throwing them at her staff, causing damage to her personal belongings. The individual also attempted to ingest personal belongings as opposed to keeping them secure. Individual made minimum progress in managing personal property with verbal redirections from staff and was reported to maintain durations of up to one week with no incidents of property destruction during the period of assessment. PLAN TO PREVENT FUTURE OCCURRENCE: The Program Specialist will ensure that when assessments are written, level in managing personal property will be evaluated and stated to indicate progress made over the period of assessment or lack of progress. ATTACHMENT AND SUPPORTING DOCUMENTS Updated Assessment indicating minimum progress in managing personal property. 05/05/2017 Implemented
6400.183(3)THE GOAL OF COMMUNITY EXPLORING IN INDIVIDUAL #1's CURRENT ISP DOES NOT HAVE A METHOD OF EVALUATION OF PROGRESS TOWARDS THE GOAL. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome. WHO: Gifty Quashigah, Program Specialist WHAT WILL BE CORRECTED: The individual¿s ISP did not measure current status in relation to an outcome and method of evaluation used to determine progress toward the expected outcome. Therefore, Acute as the provider agency, is to establish a measure to determine status in relation to an outcome and method of evaluation to be used in making that determination in progress toward the expected outcome. WHEN: May 05, 2017 HOW: Fix the Violation; The Program Specialist immediately amended the sections of the daily progress note that indicated -- ISP outcome statements and ISP needed action(s) to show method of evaluation of progress towards the goal of community exploration. With that being established, all direct care staff are required daily to document the status of the individual before and after the needed action, and quantify level of participation to determine outcome in comparison to expected outcome. PLAN TO PREVENT FUTURE OCCURRENCE: The Program Specialist will ensure that whenever the individual¿s ISP dies not measure current status in relation to an outcome and method of evaluation used to determine progress toward the expected outcome, Acute as the provider agency, will set a measure to determine status in relation to an outcome and method of evaluation to be used in making that determination in progress toward the expected outcome. ATTACHMENT AND SUPPORTING DOCUMENTS Updated Progress Note 05/05/2017 Implemented
SIN-00093268 Renewal 04/22/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The first aid kit in the home did not contain scissors nor a thermometer. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. WHO: Fortune Quashigah, Associate Director, Acute, will be responsible for correcting the problem WHAT WILL BE CORRECTED: The first aid kit in the home did not contain scissors nor a thermometer. WHEN: Target Date of completion was 04/25/16. Specific Date of Completion was 04/25/16 HOW: To fix the violation, ACUTE immediately purchased a pair of scissors and a thermometer and placed them in the first aid kit at 19-3 Valley Road to complete the first aid kit according to THE program¿s requirement. Acute Management and direct care staff were re-oriented on First Aid Kit content ¿ Section 77 under DHS Chapter 6400. PLAN TO PREVENT FUTURE OCCURRENCE: The management team at Acute will ensure that whenever the company obtains a first aid kit, it will be inspected for completeness ¿ to include all needed items according to the guidelines of the program. Staff were also re-oriented on the importance of keeping first aid kit intact. Staff will replace all items used from the kit. A member of the management team and a lead staff/house supervisor will check first aid kit on a weekly basis to confirm that all required items are present for use when needed. ATTACHMENT AND SUPPORTING DOCUMENTS: Attachment In-House Training Attendance Sheet 2 Attachment V 640077 Reorientation Agenda Attachment VIII First Aid Kit 04/25/2016 Implemented
6400.112(a)A fire drill schedule is posted on a wall in the living room. Fire drills are announced. An unannounced fire drill shall be held at least once a month. WHO: Fortune Quashigah, Associate Director, Acute, will be responsible for correcting the problem WHAT WILL BE CORRECTED: A fire drill schedule is posted on a wall in the living room. Fire drills are announced WHEN: Target Date of completion was 04/25/16. Specific Date of Completion was 04/30/16 HOW: Acute staff immediately removed the fire drill schedule from the living room wall as it was in violation of the program¿s regulation. Management staff completely discarded the schedule so that staff and residents are unaware of future dates. None of the dates and times on the schedule posted are to be used for future drills. An in-house training was conducted informing staff of the violation of posting fire drill schedule. Staff was also informed that fire drills are to be unannounced and only one staff is going to be alerted 10 seconds prior to conducting a fire drill. PLAN TO PREVENT FUTURE OCCURRENCE: Members of the management team at Acute will ensure that all future fire drills be unannounced within 10 seconds of the drill. There will be no fire drill schedule posted in the home. In the future when a fire drill is to occur, a member of the management team will call the home and instruct staff to complete fire drill in 10 second after the call. In the event where there are two staff working on the shift, only the staff member who is instructed to conduct the fire drill will be aware 10 seconds prior to conducting the fire drill ATTACHMENT AND SUPPORTING DOCUMENTS: Attachment In-House Training Attendance Sheet 1 04/30/2016 Implemented
6400.151(a)Staff person #1 was hired on 1/30/16 and the physical exam was completed on 2/12/16. 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. WHO: Fortune Quashigah, Associate Director, Acute, will be responsible for correcting the problem WHAT WILL BE CORRECTED: Staff person #1was hired on 1/30/16 and the physical exam was completed on 2/12/16. WHEN: Target Date of completion was 04/29/16. Specific Date of Completion was 05/01/16. This includes reviewing all employees¿ records. HOW: To fix the violation, Acute Community Home Aid, implemented a mandatory requirement to obtain physical examination completed within a year prior to orientation or employment, from all newly hired staff who will come into direct contact with individuals or who will prepare or serve food. Thereafter, active staff will complete physical examination every 2 years. All current staff members whose physical examinations were conducted after their hire dates were identified and documented for corrective action. Management staff completed In-House Training on Staff¿s physical exam requirement¿ Section 151 under DHS Chapter 6400. PLAN TO PREVENT FUTURE OCCURRENCE: Acute will ensure that all newly hired staff will have their physical examination completed within 12 months prior to participating in orientation and being offered employment. The physical examination will be according to the guidelines of the program. To inforce this concept, a FingerCheck¿ system was purchased, including a Human Resource module. Once the physical exam document is submitted, this information will be uploaded into Acute new Human Resource Management system and attached to the appropriate employee profile. The system will be set to email Fortune Quashigah, Douglas Jones, Michael Addo, and the employee in question one month prior to the expiration date of the physical exam. The employee will be contacted directly by Fortune Quashigah to ensure a new physical form is being processed. The email will include specifics such as employee name, expiration date, and the document that will be expiring. The system includes a pre-screening component that allows for checklist to be attached to potential employees. Only employees who have passed a full check will be invited to orientation. If one of the check items is missing for any given employee, he/she will not be shortlisted for orientation. Management will continue to keep abreast with program bulletin for updates to the regulations and adhere to them in order to avoid violations in the future. Staff who fail to renew their physical exam will be removed from providing services or having any direct contact with individuals in the program. ATTACHMENT AND SUPPORTING DOCUMENTS: www.fingercheck.com Attachment III 6400151 (Signature In-House Training for Management) WHO: Fortune Quashigah, Associate Director, Acute, will be responsible for correcting the problem WHAT WILL BE CORRECTED: Staff person #3 was hired on 9/9/14 and the physical examination was completed on 11/3/15 WHEN: Target Date of completion was 04/29/16. Specific Date of Completion was 05/01/16 HOW: Staff #3 had completed a physical examination prior to hire date according to the guidelines of the program. However, during the inspection Staff #3 physical was not in the folder. The responsible staff located and placed it in the appropriate folder. Please see supporting document. Management staff completed In-House training on Staff Health ¿ Section 151 under DHS Chapter 6400. PLAN TO PREVENT FUTURE OCCURRENCE: Acute purchased a `Finger-Check¿ system, including the HR module that allows the company to enter employee documents and records. This system sends an automatic email to staff, 30 days or any day of choice prior to expiration of all documents. (www.fingercheck.com) ATTACHMENT AND SUPPORTING DOCUMENTS: Attachment In-House Training Attendance Sheet 1 Attachment III 6400151 Attachment VI GQ151 05/01/2016 Implemented
Article X.1007Staff #2 was hired on 1/30/16 and the criminal history record was completed on 2/7/16 Staff #3 was hired on 10/31/15 and the criminal history record was completed 8/15/14 . 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.WHO: Fortune Quashigah, Associate Director, Acute, will be responsible for correcting the problem WHAT WILL BE CORRECTED: Staff #2 was hired on 1/30/16 and the criminal history record was completed on 2/7/16 WHEN: Target Date of completion was 04/29/16. Specific Date of Completion was 04/29/16 HOW: Acute Community Home Aid Employment Background Check and Qualification Policy was immediately updated to include mandatory completion of criminal history record check of all newly hired staff within one-week prior to orientation or date of hire. All current staff members whose criminal history record checks were conducted after their hire dates were identified and documented for corrective action Management staff were oriented on Criminal History Record Check ¿ Section 21 under DHS Chapter 6400. The training highlighted the importance of conducting a timely background check and also provided insights on the safety of the individuals we support. PLAN TO PREVENT FUTURE OCCURRENCE: Acute will run criminal history record checks within a week prior to potential staff orientation to ensure compliance to the program¿s regulation. Utilizing our new Human Resource System, ¿FingerCheck¿, all potential employees will be associated with a checklist that Fortune Quashigah will follow. All items on the list must be completed before a potential employee can be invited to orientation. The shortlisted employees will be submitted to Michael Addo and Michael Addo will verify that every item on the checklist is provided before an individual is officially invited to orientation. ATTACHMENT AND SUPPORTING DOCUMENTS: www.fingercheck.com Attachment II 640021 Mgmt In-House Training Attachment VII Background Check Policy WHO: Fortune Quashigah, Associate Director, Acute, will be responsible for correcting the problem WHAT WILL BE CORRECTED: Staff #2 was hired on 2/1/15 and the criminal history record check was done on 2/15/15 WHEN: Target Date of completion was 04/29/16. Specific Date of Completion was 04/29/16 HOW: Staff #2 had completed a background check prior to hire date according to the guidelines of the program. However, during the inspection Staff #2 clearance was not in the folder. The responsible staff located and placed criminal background check clearance appropriate folder. Please see supporting document. To fix the violation in general, Acute Community Home Aid Employment Background Check and Qualification Policy was immediately updated to include mandatory completion of criminal history record check of all newly hired staff within one-week prior to orientation or date of hire. All current staff members whose criminal history record checks were conducted after their hire dates were identified for corrective action by Acute. Management staff completed In-House training on Criminal History Record Check ¿ Section 21 under DHS Chapter 6400. The training highlighted the importance of conducting a timely background check and also provided insights on the safety of the individuals we support. PLAN TO PREVENT FUTURE OCCURRENCE: Acute purchased a `Finger-Check¿ system, including the HR module, which allows the company to enter employee documents and training records. This system sends an automatic email to staff, 30 days or any day of choice prior to expiration of all documents. (www.fingercheck.com) Staff who fail to renew their Tuberculin test will be removed from providing services or having any direct contact with individuals in the program. To prevent future violations, Acute will run criminal history record checks of all newly hired staff prior to orientation to ensure compliance to the program¿s regulation. Staff who fail to renew their Tuberculin test will be removed from providing services or having any direct contact with individuals in the program. ATTACHMENT AND SUPPORTING DOCUMENTS Attachment II 640021 Attachment VII Background Check Policy Attachment IV DW21 04/29/2016 Implemented
SIN-00087774 Technical Assistance 12/28/2015 Compliant - Finalized