| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
|
SIN-00240173
|
Renewal
|
02/15/2024
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.34 | There is a small storage closet located behind the individual's dresser in the second-floor bedroom that is secured with a combination lock. Staff did not have the combination to the lock so that licensing representative could see in the closet. | 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. | Maintenance removed the lock was removed, and Program Specialist replaced combination lock with a key lock. The key is stored in the office within the home. |
03/21/2024
| Implemented |
| 6400.65 | The exhaust fan in the second-floor bathroom did not work at the time of inspection and was covered with significant dirt buildup. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| The exhaust fan has been cleaned; however the maintenance man will have it fixed by 03/29/24. |
02/16/2024
| Implemented |
| 6400.104 | Fire department notice does not provide specific information (i.e. floor plan) of the individuals' bedrooms. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| COO revised and re-sent letters to local fire departments. Revised letters will be sent via email attachment with other supporting documentation. |
02/16/2024
| Implemented |
|
|
|
SIN-00220480
|
Renewal
|
02/15/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(c) | The provided criminal background check for staff 2 was completed more than four years after the indicated DOH | The Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person¿s date of hire.
| Criminal history clearance was processed for staff #2 (attached). |
| Implemented |
| 6400.64(a) | Second Floor bathroom has black substance consistent with mold or dirt underneath non-skid flower circles located inside of tub | Clean and sanitary conditions shall be maintained in the home. | House manager instructed direct support staff to clean second floor bathtub. Non-skid bath mat was placed in bathtub (photo attached). |
02/16/2023
| Implemented |
| 6400.66 | There is no light fixture at exterior exit leading to driveway | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| An electrician installed a motion-sensor light fixture over the basement exit door. Photos are attached. |
03/01/2023
| Implemented |
| 6400.110(e) | Home is three levels and smoke detectors are not interconnected. The smoke detector on the third floor is interconnected | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | Homes have hardwired, interconnected smoke detectors and separate carbon monoxide detectors. Video demonstrating interconnected smoke detectors being activated is attached. |
02/15/2023
| Implemented |
| 6400.112(e) | Only one sleep drill was held for Cricket Ln in November 2022 | A fire drill shall be held during sleeping hours at least every 6 months. | An overnight fire drill was held on 3/5/23 in advance of scheduled overnight drill (attached). |
03/25/2023
| Implemented |
| 6400.52(a)(1) | The provided training data for staff 2 indicates only 14 of the required 24 hours of annual training were completed | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Staff #2 has been on leave of absence since March 2023. Staff will complete annual required trainings upon return to work in June and will have them completed by 7/31/23 |
07/31/2023
| Implemented |
|
|
|
SIN-00200460
|
Renewal
|
02/22/2022
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(1) | Upon arrival at the home, licensing representative observed staff #1 not wearing a facemask, per Aegis covid policy. This staff had to leave the home to retrieve the face mask out of their vehicle. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | Staff was not wearing a mask according to agency COVID policy. Masks were not easily accessible in the home. All staff were notified of Aegis¿ current COVID masking policy, stating that masks are required while working in the home. This policy was re-posted in the homes as well. All staff have been provided reusable masks, and disposable masks were placed in the homes for use by staff and individuals. Postings and mask supplies to be emailed to licensing for review (attachment: Cricket_masks) |
03/31/2022
| Implemented |
| 6400.64(f) | The outside trash receptacle was overflowing with trash and could not be closed properly. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | Outdoor trash cans were overflowing, and lid could not be closed at the time of inspection. Trash was put out for collection at the following collection day 2/24/22. |
02/26/2022
| Implemented |
| 6400.66 | The light on the side exit of the home is inoperable.
The light at the top of the stairs leading to the second floor of the home is inoperable. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The lights on the side exit of the home and the 2nd floor landing were not operable at the time of inspection. Light bulbs were replaced on 2/25/22, and photo to be emailed to licensing for review. (attachment Cricket_lights) |
03/31/2022
| Implemented |
| 6400.77(b) | The first aid kit was missing tape. [REPEATED NON-COMPLIANCE 1/26/21] | 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. | First aid kit was not complete in its contents at the time of inspection ¿ tape was missing. First aid kit was restocked with required item ¿ tape on 2/22/22. Photo of first aid kit to be emailed to licensing (attachment: Cricket_first_aid_kit) |
03/31/2022
| Implemented |
| 6400.111(f) | The basement fire extinguisher has not been inspected annually. It was last inspected in January 2021. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | Fire extinguisher in basement did not have current inspection tag. Fire extinguisher inspection company inspected all extinguishers on 12/8/21. Whether or not they forgot to tag this extinguisher is unknown. Provider called inspection company to come out and tag fire extinguisher. (attachment: Cricket_fire_extinguisher_tag) |
02/25/2022
| Implemented |
| 6400.114(b) | Aegis smoking policy states that the designated smoking area outside the home will be cleaned daily to prevent fires, however licensing representative observed several dozen cigarette butts around the homes perimeter in the front yard, side yard, area between the bushes and in the cracks between the cement sidewalk paths, indicating the designated smoking area is not being enforced and that the area is not cleaned daily. | Written smoking safety procedures shall be followed. | Agency smoking policy was not followed. Cigarette butts were scattered over the side yard and walk way. Cigarette butts were cleaned up by staff and individual #1 on 2/25/22 (attachment: Cricket_yard_walkway). A second metal outdoor ashtray was purchased and delivered to home for individual to use. (attachment: Cricket_ashtray) COO reviewed with staff and individual #1 where it is safe to smoke on the property and how and when to clean the ashtray & cigarette butts on 2/25/22. |
03/31/2022
| Implemented |
| 6400.144 | It can not be determined if individual #2 was administered their prescribed medication clonazepam/klonopin .5 mg on 2/22/22, as it was not signed out for not listed on the controlled drug dispensing form with a daily count for that day.
It can not be determined if individual #1 prescribed medication, prilosex/omeprazole cap 20 mg was administered on 2/23/22 at 6 am, as the medication administration record was blank for this dosage.
Individual #1 prescribed medications Flovent hfa/aer 44 mcg with instructions to inhale 2 puffs daily at 8 am and again at 8 pm was not in the home. This medication was being signed as being given at 8 am on the medication administration record. The 8 pm dosage had not been signed out as being given from the beginning of February 2022 through the date of the inspection on 2/23/22.
Individual #2 prescribed medication clonazepam tab .5 mg is listed on the MAR for a daily dosage as well as PRN. The blister pack being given daily has a PRN yellow label across the front and does not mention the daily dosage. It cannot be determined what the current prescription order is and if this medication is being administered properly.
Individual # 1 had medication loratadine/Claritin 10 mg tab PRN, with a prescription label dispensed to them in the medication box that was not listed on the MAR.
Individual # 2 prescribed PRN medications benzonatate cap 100 mg, clonazepam tab .5 mg and eye itch relief drops/izaditor .025% were not present in the home.
Individual # 1 prescribed PRN's albuterol aer hfa 90 mcg not present in home. | Health 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.
| Medication trainer spoke with staff #1 regarding administration of individual #2¿s clonazepam on 2/22/22; individual #1's omeprazole. Staff said they were administered. Med trainer reviewed cycle and PRN MAR documentation with staff #1 on 2/24/22. All PRN medications for individual #1 and #2, individual #2's clonazepam; individual #1's flovent were ordered and delivered between 2/28 and 3/7. Med trainer contacted pharmacy to have individual #1's loratadine added to the MAR. |
03/31/2022
| Implemented |
| 6400.163(h) | Individual #2 had prescribed PRN medication present in the home that were expired. These medication are acetamin tab 500 mg--expired 7/27/21, clonidine tab .1 mg--expired 3/9/21, ibuprofen tab 800 mg--expired 7/25/21 and nIndividual #2 had prescribed PRN medication present in the home that were expired. These medication are acetamin tab 500 mg--expired 7/27/21, clonidine tab .1 mg--expired 3/9/21, ibuprofen tab 800 mg--expired 7/25/21 and naproxen sod. tab 550 mg--expired 4/22/21.aproxen sod. tab 550 mg--expired 4/22/21. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | PRN medications for individual #2 were in the home and were expired. These medications were immediately removed from the home and destroyed by using the pharmacy-provided Rx Destroyer. COO contacted pharmacy for new PRNs to be delivered. Medications were delivered between 2/28/22 and 3/7/22. |
03/31/2022
| Implemented |
| 6400.166(a)(13) | Individual #1 prescribed medication, risperidone tab 2 mg was administered but not signed out for on 2/22/22.
Staff# 1 stated that they administered individual #1 PRN medication nicotine gum 2 mg, however this medication was not signed out for on the MAR as being given. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Staff had not signed the MAR for individual #1 for two medications ¿ a cycle medication and a PRN. Med trainer spoke with staff #1 regarding these medications. Staff #1 stated they were given. Med trainer reviewed documenting administration on the MAR with staff #1 on 2/24/22 |
03/31/2022
| Implemented |
| 6400.169(a) | Staff #'s 1-12 have been administering medication in Aegis' home per the medication administration record without them having completed both the medication administration courses and the course renewal requirements. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Staff administering medication did not have documentation of their training in their file at the time of inspection. Those staff stopped administering medication until documentation was emailed and provided to licensing. In the interim, provider contracted with an RN to assist with medication. RN's information provided to licensing on 2/28/22. |
04/01/2022
| Implemented |
|
|
|
SIN-00183406
|
Renewal
|
01/26/2021
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | The application for a PA Criminal history record was not submitted to the State Police for employee Staff #4 who was hired on 5/11/2020.
The application for a PA Criminal history record was not submitted to the State Police for employee Staff #5 who was hired on 9/03/2020.
The application for a PA Criminal history record was not submitted to the State Police for employee #3 who was hired on 10/28/2020.
The application for a PA Criminal history record was submitted to the State Police on 10/20/2020. Staff person #6 was hired 10/12/20 the check was completed late after the 5 working days of employment. | 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.
| Application for PA criminal history was not submitted to state police for staff #3, 4 and 5. Application for PA criminal history for staff # 6 was submitted after the 5 days of employment. PA state police history for staff # 3 and 5 were emailed for review. Staff#4 is no longer employed with provider. |
03/30/2021
| Implemented |
| 6400.21(b) | The agency failed to complete a Federal Bureau of Investigation criminal history record check within 5 working days after hiring staff #3 on 10/28/20. No verification was submitted during inspection to determine if staff #3 resided outside the Commonwealth. | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| Staff #3 did not have an FBI criminal history record check within 5 days of hire, and verification of residency was submitted during inspection. Staff #3's Pennsylvania driver's license was emailed for review. |
08/23/2021
| Implemented |
| 6400.22(d)(1) | The agency failed to keep an up-to-date financial and property record for each individual, the statements provided were incomplete and the ledger did not clearly show disbursements made to or for the individuals including and up to funds received by or deposited with the home. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | An up-to-date financial record for each individual was incomplete. Bank statements showing disbursements to individuals, payments made for individuals for room and board, medical and pharmacy bills were emailed for review. |
08/23/2021
| Implemented |
| 6400.22(e)(3) | The agency assumed the responsibility of maintaining the individual's financial resources but failed to provide actual receipt or expense records of purchases greater than $15.00 for each individual. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | The agency did not provide actual receipts or expense records for purchases greater than $15 for each individual. Receipts, copies of canceled checks, and invoices for online purchases were emailed for review. |
08/23/2021
| Implemented |
| 6400.44(c) | The agency failed to provide the Program Specialist Staff #1 qualifications. | A program specialist shall have one of the following groups of qualifications: (1) A master's degree or above from an accredited college or university and 1 year work experience working directly with persons with intellectual disability. (2) A bachelor's degree from an accredited college or university and 2 years work experience working directly with persons with intellectual disability. (3) An associate's degree or 60 credit hours from an accredited college or university and 4 years work experience working directly with persons with intellectual disability. | The program specialist's qualifications were not provided at time of inspection. Program specialist's degree and resume were emailed for review. |
08/23/2021
| Implemented |
| 6400.73(a) | There were wheelchair accessible ramps outside of the home which did not have rails on either side of them. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | The wheelchair accessible ramps outside the home did not have railings as required. Railings were installed and photos were emailed for review. |
02/16/2021
| Implemented |
| 6400.77(b) | There were no scissors in the first aid kit. | 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. | There were no scissors in the first aid kit. Scissors were purchased and placed in the first aid kit. Photos of the first aid kit were emailed for review. |
01/28/2021
| Implemented |
| 6400.151(b) | The Physical Examination Form for Staff #1 dated 3/27/19 did not contain the date the physician completed the Staff Physical Examination form. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | The physical exam for for staff#1 did not contain the date the physician completed the staff physical exam. Staff #1 was unable to obtain a date on the signature line for that physical from the provider. |
05/03/2021
| Implemented |
| 6400.151(c)(3) | The initial Physical assessment for staff #3 dated 10/22/2020, did not indicate if the staff person was free of communicable diseases (this portion was left blank). | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | The initial physical assessment for staff #3 did not indicate if the staff person was free of communicable diseases. Staff #3 was asked to contact the provider to complete the form or obtain a new physical exam. |
08/23/2021
| Implemented |
| 6400.46(a) | Direct service worker Staff #3 was not trained before working with individuals in general fire safety. DSW was hired on 10/28/2020 and wasn't trained until 1/20/2021. | 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 home, 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. | Direct support staff was not trained in general fire safety prior to working with individuals. Due to COVID-19, our fire safety provider was not providing trainings. When we secured an online alternative, fire safety training was held for staff. |
01/20/2021
| Implemented |
| 6400.46(c) | Program Specialist Staff #1 has no annual (current) First Aid (CPR) certification. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques. | Program specialist staff #1 had no annual First Aid/CPR certification. Program specialist completed First Aid/CPR training on 1/10/2020. Certification expires 1/10/22. Certificate was emailed for review. |
02/01/2021
| Implemented |
| 6400.52(a)(1) | Direct service worker Staff #2 did not complete 24 hours of training related to the job skills. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Direct support staff did not complete 24 hours of training related to job skills. Due to COVID-19, scheduled trainings were canceled. During 2020, trainings for staff were internal, virtual and centered on COVID-19: prevention, PPE, enhanced cleaning, screening procedures, procedures for COVID+ individuals and staff. |
02/01/2021
| Implemented |
| 6400.52(a)(3) | The program specialist Staff #1 did not complete 24 hours of training related to the job skills. | The following shall complete 24 hours of training related to job skills and knowledge each year: Program specialists. | Program specialist did not complete 24 hours of training related to job skills. Due to COVID-19, scheduled trainings were canceled. During 2020, trainings for staff were internal, virtual and centered on COVID-19: prevention, PPE, enhanced cleaning, screening procedures, procedures for COVID+ individuals and staff. Regular trainings resumed in 2021. |
02/01/2021
| Implemented |
| 6400.162(b)(2)(i) | Records of Medication Training for Direct service worker Staff #2 was not completed/provided at time of inspection. | A prescription medication that is not self-administered shall be administered by one of the following: A person who has completed the medication administration course requirements as specified in § 6400.168 (relating to medication administration training) for the administration of the following: Oral medications. | Records of medication training for direct service worker #2 was not completed/provided at time of inspection. Staff #2's medication training records were emailed for review. |
02/01/2021
| Implemented |
| 6400.162(b)(2)(i) | Records of Medication Training for Direct service worker Staff #3 was not completed/provided at time of inspection. | A prescription medication that is not self-administered shall be administered by one of the following: A person who has completed the medication administration course requirements as specified in § 6400.168 (relating to medication administration training) for the administration of the following: Oral medications. | Records of Medication Administration training for direct support staff #3 were not completed/provided at time of inspection. Staff #3 is undergoing medication administration training. |
09/03/2021
| Implemented |
|
|
|
SIN-00154806
|
Renewal
|
04/25/2019
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | The back outside light was inoperable | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The light bulb over back door was replaced (photos supplied via email). Moving forward, the House Manager will be responsible for monitoring and ensuring all lights in houses are in working order and will submit requests for repair or replacement to the COO as needed. |
04/26/2019
| Implemented |
| 6400.67(a) | The left kitchen cabinet drawer was missing its knob | Floors, walls, ceilings and other surfaces shall be in good repair. | A new knob was installed onto the cabinet (photo supplied via email). Moving forward, all knobs and handles in the houses will be checked by the House Manager and requests to fix or replace will be submitted to the COO. |
04/26/2019
| Implemented |
| 6400.112(h) | All fire drill records did not document 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. | A section for the meeting place at each house was added to the fire drill record (supplied via email.) Moving forward, the meeting place will be completed with all other information on fire drill record. |
04/26/2019
| Implemented |
|
|
|
SIN-00128050
|
Renewal
|
01/19/2018
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | Individual #1's record did not include documentation of Individual rights. | 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. | Documentation of individual's rights were placed in record on 1/24/18 (attachment 6). To ensure that documentation is present during inspection, duplicate copies of records will be made and kept in the main office where inspections take place, and on site in the home. Program Manager will be responsible for placing documentation in both locations. COO and Program Specialist will conduct periodic checks to ensure documentation is present at both locations. |
01/24/2018
| Implemented |
| 6400.111(a) | The fire extinguisher in the basement was not fucntional as indicated by the arrow on red. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | The fire extinguisher was taken to its certifying company, Philadelphia & Pennsylvania Fire Protection, recharged, and replaced (attachment 3). Original certificate also attached (attachment 4). A procedure was implemented that includes checking all fire extinguishers monthly (attachment 5). Staff conducting fire drills will check all fire extinguishers in house. House Manager will verify fire extinguisher reports are complete and accurate. House Manager will submit forms to Program Manager. Staff were trained and procedure was tested in February. Procedure was implemented in March. |
06/22/2018
| Implemented |
| 6400.113(a) | Individual #1's record did not include documentation of Fire Safety Training. | An individual, including an individual 17 years of age or younger, 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 home. | Fire Safety Training documentation was placed in record on 1/24/18 (attachment 2). To ensure that documentation is present during inspection, duplicate copies of records will be made and kept in the main office where inspections take place, and on site in the home. Program Manager will be responsible for placing documentation in both locations. COO and Program Specialist will conduct periodic checks to ensure documentation is at both locations. |
01/24/2018
| Implemented |
| 6400.186(b) | Individual #1's Individual Support Plan 3 months review dated 12/19/17 was not signed by the program specialist. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Program Specialist and individual signed the ISP 3 month review on 1/24/18 (attachment 1). Program Specialist is responsible for obtaining signatures on ISP reviews. Program Manager will ensure that 3-month reviews are signed by both Program Specialist and individual by reviewing individuals¿ records quarterly. |
01/24/1918
| Implemented |
|
|
|
SIN-00109765
|
Renewal
|
01/25/2017
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | Self-assessment dated 6/28/16. It was not completed 3 to 6 months prior to the expiraton of the document on 7/29/16. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| A schedule of licensing deadline dates was created and will be used in future licensing procedures to ensure deadlines are met. |
01/30/2017
| Implemented |
| 6400.62(a) | Ajax super degreaser was found in an unlocked kitchen cabinet. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Temporary locks were purchased for under sink cabinets and first aid cabinets. Permanent magnet locks were purchased and installed. Photo documentation was sent to Walter Szott on 2/1 and 2/4/17 |
01/27/2017
| Implemented |
| 6400.62(d) | Hand sanitizer with content 70% ethyl alcohol with notation to call poison control was found in unlocked over-rfrigerator cabinet, | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | Hand sanitizer was moved to locked cabinet. Photo documentation was sent to Walter Szott |
01/25/2017
| Implemented |
| 6400.68(b) | The hot water temperature was tested at 126.1 | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Hot water heater was turned down. Thermometer was purchased and water temperature is tested monthly to ensure compliance with proper temperature. |
01/25/2017
| Implemented |
| 6400.81(k)(6) | Individual #1's bedroom did not have a mirror. | In bedrooms, each individual shall have the following: A mirror. | Mirror was installed in individual #1's bedroom on 01/27/2017 and photo documentation was sent to Walter Szott on 02/01/2017. |
01/27/2017
| Implemented |
| 6400.112(d) | Individual #2 did not evacuate the home in 2.5 minutes on 8/17/16 and 12/20/16. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Moving forward, if individuals do not successfully complete fire drills, repeat fire drills will be held during the month until individuals can successfully evacuate building in less than 2.5 minutes. Unsuccessful fire drills will be used as practice and learning tools for future fire drills. |
01/27/2017
| Implemented |
| 6400.112(e) | The fire drills dated 3/11/16 and 12/20/16 were sleep drills 9 months apart. | A fire drill shall be held during sleeping hours at least every 6 months. | A schedule of fire drills has been posted at each house and will be monitored for compliance by the program manager. |
01/27/2017
| Implemented |
| 6400.141(c)(10) | The physical dated 2/9/16 did not evaluate communicable disease precautions. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Staff will ensure that every section of physical form is completed and all issues are addressed accurately. Program Manager will follow up on completion of form. |
02/14/2017
| Implemented |
| 6400.141(c)(12) | The physical dated 2/9/16 did not evluate physical limitations. | The physical examination shall include: Physical limitations of the individual. | Staff will ensure that every section of physical form is completed and all issues are addressed accurately. Program Manager will follow up on completion of form. |
02/14/2017
| Implemented |
| 6400.141(c)(14) | Information pertinent to diagnosis in case of emergency was not avaiable in the physical. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Staff will ensure that every section of physical form is completed and all issues are addressed accurately. Program Manager will follow up on completion of form. |
02/14/2017
| Implemented |
| 6400.141(c)(15) | The physical did not list diet instructions for individual #2. | The physical examination shall include:Special instructions for the individual's diet. | Staff will ensure that every section of physical form is completed and all issues are addressed accurately. Program Manager will follow up on completion of form. |
02/14/2017
| Implemented |
| 6400.181(e)(10) | Individual #2's record did not include lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Lifetime medical history was updated after PCP visit 2/14/17. It was sent to Walter Szott. Moving forward, all individuals' lifetime medical histories will be completed upon move-in, and updated annually thereafter. Updated lifetime medical histories will be kept in individual's Program Book. |
02/14/2017
| Implemented |
| 6400.213(1)(i) | Individual #2 did not include weight, height, race, hair color, eye color or identifying marks in thr record. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | The "face sheet" was completed including the required information and placed in the individual's record. "Face sheets" will be included in admission packet moving forward to ensure completion and compliance. |
01/26/2017
| Implemented |
| 6400.217 | Individual #2's record did not contain a consent for release of information. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Written consent for the release of information was obtained by the individual and her mother and placed in the individual's file. Release of information consents will be included in the admission packet moving forward. |
01/30/2017
| Implemented |
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SIN-00084275
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Renewal
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10/16/2015
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.73(a) | The exterior basement exit has nine steps and no attached handrail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | 55 PA Code 6400.73(a)
Each ramp, interior stairway, and outside/exterior steps, exceeding two steps, shall have a well-secured handrail.
10/19/2015
PLAN of CORRECTION: The handrail was installed on 10/23/2015. Photo of handrail submitted
Handrail was re-attached to exterior basement stairwell. To ensure handrails remain in place and in secure working order, quarterly inspections of handrails will be conducted by CEO. In addition, quarterly inspections of each home will be conducted by program designee to ensure any repairs or areas of non-compliance with the physical site are documented and repaired (dd 12/8/15). Any repairs or replacements found to be needed will be completed within a ten working days (dd 12/8/15). A record of maintenance, repair and/or replacement will be kept on file. |
10/19/2015
| Implemented |
| 6400.77(b) | The thermometer is missing from the first aid kit. | 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. | 10/24/15
55 PA Code Chapter 6400.77(b)
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. Two thermometers were purchased on 10/20/15. One was placed in the first aid kit, the second was placed as a back-up in the home storage closet.
PLAN of CORRECTION
Two thermometers were purchased, one placed in first aid kit, and the second, stored as a back up.
To ensure that no item is missing from the first aid kit, the following procedure has been enacted, and will be followed and monitored. Monthly, each first aid kit will be inventoried for the above-listed items. A check list will be maintained and signed (initialed) by Direct Support staff. If any items are found to be low in inventory, they will be replaced before they run out. To ensure that no items run out in between inventories, a complete back up first aid kit will be kept in the storage closet in the office. As items need to be replaced, Direct Support staff will replenish the first aid kit in use. Also, the CEO will purchase additional first aid kid items as needed and add them to the first aid kit and/or the back up supply.
The inventory sheet will be randomly monitored by the CEO to ensure inventories are being completed and supplies are being re-stocked.
Inventory check list will include the following information (copy available):
Date of Inventory
Initials of staff doing inventory
(after each item): Item in Stock (check), Item low (check), Item missing (check)
Antiseptic
Bandages
Gauze Pads
Thermometers
Tweezers
Tape
Scissors
Syrup of Ipecac
Date items replenished
Initials of Staff who restocked first aid kit
Date inventory and first aid supplies checked by CEO
CEO initials |
10/24/2015
| Implemented |
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SIN-00065985
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Initial review
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07/29/2014
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.111(a) | Upon initial inspection (7-29-14) there was no fire extinguisher located in the basement. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | An operable fire extinguisher was purchased and installed in the basement on the date of inspection (7/29/2014), and photographs of said extinguisher were sent to the inspector. In the future all homes will be monitored monthly to ensure that a fire extinguisher is located on all levels of the home by Felix Okolo. |
07/29/2014
| Implemented |
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