| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
|
SIN-00193023
|
Renewal
|
09/21/2021
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | Both egresses leading from the enclosed back porch to the backyard did not possess exterior lighting at the time of the inspection. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps, and fire escapes shall be lighted to assure safety and to avoid accidents.
VIOLATION: Both egresses leading from the enclosed back porch to the backyard did not possess exterior lighting at the time of the inspection.
WHY THE REGULATION IS IMPORTANT: This regulation is important because it ensures a rapid evacuation in the event of an emergency and minimizes the risk of falls or other injuries due to inadequate illumination. It is important that all individuals can use these lights during an emergency to evacuate safely.
WHY THE VIOLATION OCCURRED: There was no lighting right above the doors because there were other security lights on the same sides of the house. Therefore, it was assumed by Ideal Services facilities staff that the one light on those sides would suffice.
IMMEDIATE SOLUTION: As an immediate remediation for the problem, extra lights had been installed right above the doors since it was detected. Pictures of the lighted doorways are attached as Attachment #1. |
10/14/2021
| Implemented |
| 6400.141(a) | Individual #1 received an annual physical exam on 6/9/2020 and not again until 8/18/2021. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | (a) An individual shall have a physical examination within 12 months prior to admission and annually thereafter.
VIOLATION: Individual #1 received an annual physical examination on 6/9/2020, but did not get another one again until 8/18/2021. This was 39 days late, or 24 days after the grace period expired.
WHY THE REGULATION IS IMPORTANT: This regulation is important because accurate medical information is essential to develop accurate assessments and individual plans. It ensures that individuals medical needs will be met, and that proper care is provided. This would also help the residential homes know that the individuals medical and health needs are still being met.
WHY THE VIOLATION OCCURRED: The violation occurred because the clinic was not scheduling in-person visits for the longest time, due to the COVID-19 pandemic social isolation restriction as a preventive for the spread. Coupled with the fact that Individual #1 was not able to tolerate mask wearing, the clinic would not schedule him when they eventually opened for in-person visits. When they did schedule him, it was already past the deadline.
IMMEDIATE SOLUTION: There is no immediate remediation for the problem. Unfortunately, in retrospect, it cannot be fixed. |
10/14/2021
| Implemented |
| 6400.141(c)(6) | Individual #1 received Tuberculin skin testing by Mantoux method on 5/23/2018 and did not receive testing again until 6/29/2020. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter.
(c) The physical examination shall include:
(6) Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted.
VIOLATION: Individual #1 received Tuberculin skin testing by Mantoux methos on 5/23/2018, and did not receive testing again util 6/29/2020. This was five weeks late.
WHY THE REGULATION IS IMPORTANT: This regulation is important because accurate medical information is essential to develop accurate assessments and individual plans. It ensures that individuals¿ medical needs will be met, and that proper care is provided in the event of an emergency and at all times. It is also important to ensure that the individual is free of communicable diseases.
WHY THE VIOLATION OCCURRED: The violation occurred because the clinic did not schedule Individual #1 for his TB testing because he could not tolerate mask wearing. It could not be done through a remote visit.
IMMEDIATE SOLUTION: There is no immediate remediation for the problem. Unfortunately, in retrospect, it cannot be fixed. |
10/14/2021
| Implemented |
| 6400.141(c)(10) | Individual #1 physical exam completed on 8/18/2021 does not identify if the Individual is free from communicable diseases. | 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. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter.
(c) The physical examination shall include:
(10) Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals.
VIOLATION: Individual #1 physical examination completed on 8/18/2021 does not identify if the individual is free from communicable diseases.
WHY THE REGULATION IS IMPORTANT: This regulation is important because accurate medical information is essential to help the residential staff to seek necessary treatment for the individual if it was needed. Also, this will protect the other individuals and staff from being exposed, and contracting communicable diseases, if it was detected early. Overall, individuals medical needs will be met, and proper care will be provided at all times.
WHY THE VIOLATION OCCURRED: The violation occurred because the provider deferred checking that box while she waited for the result of the TB test which was scheduled. However, the residential staff discovered that Individual #1 had a TB test result that was still valid. Checking of the box was inadvertently omitted after that.
IMMEDIATE SOLUTION: This error was corrected on the first day of the inspection, 09/21/2021. The report was sent back to the doctor¿s office for the doctors review, and it was corrected promptly. |
10/14/2021
| Implemented |
| 6400.183(a)(3) | ISP meeting held on 9/23/2020 for Individual #1 did not include a member of direct care staff. | The individual plan shall be developed by an interdisciplinary team, including the following: The individual's direct care staff persons. | (a) The individual plan shall be developed by an interdisciplinary team, including the following:
(3) The individuals direct service workers.
VIOLATION: ISP Meeting held on 9/23/2020 for Individual #1 did not include a member of his direct care staff.
WHY THE REGULATION IS IMPORTANT: This regulation is important because it ensures that the Individual Plan is person-centered, individual-driven, and fully understood by all of the individual¿s natural and formal supports.
WHY THE VIOLATION OCCURRED: The violation occurred because the provider followed the guidance from the Regulatory Compliance Guide states that:
Individual Plan teams do not need to include all of the persons listed in 6400.183(a)(1)-(4).
Secondly, § 6400.183(b) ¿ At least three members of the individual plan team, in addition to the individual and persons designated by the individual, shall be present at a meeting at which the individual plan is developed or revised.
Nowhere in the Chapter 6400 Regulation or its Regulatory Compliance Guide does it state categorically that the attendance of a direct care staff is obligatory.
IMMEDIATE SOLUTION: There is no immediate remediation for the problem. Unfortunately, in retrospect, it cannot be fixed. |
10/14/2021
| Implemented |
|
|
|
SIN-00177769
|
Renewal
|
10/13/2020
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | Palmolive which stated to call poison control was in a plastic bottle which was not the orginal container at the time of the inspection. | Poisonous materials shall be stored in their original, labeled containers. | Poisonous materials shall be stored in their original, labeled containers.
"Poisonous materials" include any item labeled "seek medical attention if swallowed" or "contact Poison Control Center if swallowed."
Storing them properly minimizes the possibility that an individual or staff person will be harmed by exposure to or consumption of poisonous materials.
When an individual ingests, or is unduly exposed to hazardous materials, it can lead to injury or even death.
There is Palmolive soap in a soap dispenser which is not the original container of the detergent.
Palmolive dish detergent is considered as potentially toxic.
Having it in a container that is not the original container is a violation of a safety policy. - 55 PA Code Chapter 6400.62(c)
Staff poured the Palmolive soap into a soap dispenser so as to make it easier to use. The goal was to be able to pump it out more easily. However, the safety component of it was ignored.
That was an error that was not well thought through.
One of the individuals in the home has been assessed as unable to safely use poisonous materials in his Assessment and Individual Plan. Therefore, to forestall the possibility of his being exposed to poison, the dish detergent has to be in its original container.
To correct this immediately, the soap dispenser has been replaced with dish detergent in its original container.
Secondly, the soap dispenser was removed from the home.
All staff in the home attended a Post-Inspection Meeting at which the importance of the regulation was reviewed and emphasized.
This Training will be included as a component in the Orientation Training so that all staff will be aware of the importance of this safety regulation right from the word go. Training Notes are attached as Attachment #5.
The Program Specialist will inspect the homes periodically to ensure compliance. |
11/07/2020
| Implemented |
| 6400.67(b) | There was a golf ball size amount of lint in the dryer at the time of inspection. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Floors, walls, ceilings and other surfaces shall be free of hazards.
Lint is a fire hazard. Statistics show that dryers are the cause of more than 20,000 household fires every year, totaling millions of dollars in damage. (Source: The Spruce - https://www.thespruce.com/dryer-vent-lint-fire-hazard-).
The regulation is important because fire outbreaks may occur if the staff continue to leave lint in the dryer. Diligently removing lint from dyers will prevent incidents of fire outbreaks in the home. This will ensure safety for both the individuals and staff.
There was a golf-ball sized of lint in the clothes dryer on the morning of the inspection.
Definitely, a staff who finished doing laundry failed to remove the lint from the laundry.
Immediately, two reminders are placed around the dryer Picture is Attachment #6.
A big one (letter size) placed on the wall behind the machine.
A smaller strip (in yellow fluorescent color) is placed on top of each machine.
These will serve as reminders for each staff when they finish laundry.
Staff were called for a post-inspection briefing, and they were informed that this could be a source of fire, if it continues.
A training was done to have a more in-depth training on
The Importance of Removing Dryer Lint¿ (see Attachment #7)
This training will be incorporated as part of the Orientation Training henceforth.
Each Home Supervisor is tasked with the role of checking for lint in the dryers in their home every day. This way, if there is a staff who is not completing that task, it will be detected quickly, and they will be brought to book promptly.
The Program Specialist will inspect the homes periodically to ensure compliance. The inspections may be either scheduled or impromptu. |
11/07/2020
| Implemented |
| 6400.183(3) | Individual #1's ISP meeting on 8/19/2020 did not have a direct care worker present. | 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. | The individual plan shall be developed by an interdisciplinary team, including the following:
(3) The individual's direct service workers.
This regulation is important because having a full interdisciplinary team which includes the individual's direct care staff, ensures that both the individual's natural and formal supports are able to contribute their own perspective in order to improve the planning process.
An interdisciplinary approach can offer a more comprehensive and holistic approach that will improve the individual¿s outcomes and levels of satisfaction. It gives the process an access to an entire team of experts for planning and accessing supports. When the entire team works collaboratively with a common purpose, it results in improved outcomes, improved efficiency, and increased satisfaction for the individual.
The Direct Care Worker, given fact that they work closely with the individual on a regular basis, is able to offer first-hand information that reflects the individuals preferences and ensure the individuals health, safety, and well-being. This enhances a person-centered approach which ultimately improves service coordination. An interdisciplinary team is more likely to come up with more creative avenues for service implementation.
A Direct Care Worker was not present at the Individuals ISP meeting of 8/19/20.
That was an oversight.
There is not much that can be done to rectify this immediately.
To prevent this from happening in the future, the Program Specialist will start including at least one Direct Care staff in the meetings. |
11/07/2020
| Implemented |
| 6400.62(b) | Palmolive which stated to call poison control was left unlocked in the kitchen at the time of the inspection. | Poisonous materials may be kept unlocked if all individuals living in the home are able to safely use or avoid poisonous materials. Documentation of each individual's ability to safely use or avoid poisonous materials shall be in each individual's assessment. | Poisonous materials may be kept unlocked if all individuals living in the home are able to safely use or avoid poisonous materials. Documentation of each individuals ability to safely use or avoid poisonous materials shall be in each individuals assessment.
Poisonous materials include any item labeled ¿seek medical attention if swallowed or contact Poison Control Center if swallowed.
Storing it properly minimizes the possibility that an individual will be harmed by exposure to or consumption of poisonous materials.
The Palmolive soap was left on the kitchen sink, not locked up in a secure cabinet. This was an error that was not well thought out.
One of the individuals in the home is not able to safely use or avoid poisonous materials. This is documented in his Assessment and Individual Support Plan.
This is a violation because Palmolive dish detergent is considered to be potentially toxic (considered as poisonous).
Leaving it not locked up will make it accessible to the individual, and it will have severe consequences if he was able to ingest it. This is therefore, a violation of the safety policy.
This is a violation of the Safety Precaution in the individuals Support Plan (ISP) and assessment.
Staff left the Palmolive soap on the kitchen sink so as to make it easier to reach when it is needed.
To correct this immediately, the Palmolive soap has been placed in a locked cabinet.
All staff in the home attended a Post-Inspection Meeting at which the importance of this regulation was reviewed and emphasized.
This safety aspect will be included as a component in the Orientation Training so that all staff will be aware of the importance of this safety regulation from the get go.
Training Notes are attached as Attachment #5.
The Program Specialist will enforce this safety regulation by inspecting each home at periodic intervals ¿ scheduled and unannounced. |
11/07/2020
| Implemented |
| 6400.166(a)(3) | Individual #1's MAR did not list drug allergies. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Drug allergies. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered:
(3) Drug allergies.
This regulation is important because consistent and comprehensive recording of drug allergy status is important to ensure that all patients with confirmed or suspected drug allergy have a full and accurate record of this in their electronic medical record. Accurate recording of drug allergy status will prevent the prescription and administration of drugs inducing allergic reactions and will improve patient safety. Providing this information could help avoid patients with known allergies wrongly receiving drugs that could endanger their health.
The individual¿s drug allergy status was not documented in her electronic medical record.
This error occurred because the MAR was not reviewed by the agencys Nursing Staff. After the IT Staff had input the basic information, the Clinical staff members did not review it.
To correct this immediately, all MARs have been updated to include all necessary information, including Drug Allergies (current MAR attached as Attachment #).
This was reviewed with all staff at the post-inspection briefing.
All certified medication administration staff have been informed to look out for this information in all MARs.
To prevent this from happening in the future, a multi-level system of verification has been put in place:
After IT has input all the medications information in the electronic system, it will be reviewed by:
1. The Nursing Supervisor
2. The Director of Nursing Services
This way, all possible errors will be captured and corrected immediately.
The Program Specialist shall be responsible for providing oversight in this area. |
11/07/2020
| Implemented |
| 6400.166(a)(11) | Individual #1's MAR did not list diagnosis for the medication prescribed. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered:
(11) Diagnosis or purpose for the medication, including pro re nata.
This regulation is important because having comprehensive information on an MAR will reduce the potentials for medication errors. Therefore, all medications need to be reconciled to reflect correct medication names, dosages, and the purpose of the medication (diagnosis for which it is used). This process of medication reconciliation will significantly decrease or eliminate medication errors, and thereby increase patient safety. Medication reconciliation is an important element of safe medication administration.
The diagnosis or purpose for each of the individuals medications was not listed in her electronic medical record.
This error occurred because the MAR was not reviewed by the agencys Nursing staff and the Program Specialist. After the IT Staff had input the basic information, the Clinical staff did not review it.
To correct this immediately, all MARs have been updated to include all necessary information, including the diagnosis for each medication (current MAR attached as Attachment #8).
This was reviewed with all staff at the post-inspection briefing.
All certified medication administration staff have been informed to look out for this information in all MARs.
To prevent this from happening in the future, a multi-level system of verification has been put in place:
After IT has input all the medications information in the electronic system, it will be reviewed by:
1. The Nursing Supervisor
2. The Director of Nursing Services
This way, all possible errors will be captured and corrected immediately.
The Program Specialist shall be responsible for providing oversight in this area. |
11/07/2020
| Implemented |
| 6400.181(f) | Individual #1 assessment dated 3/30/20 was not sent to the ISP team. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.
The importance of this regulation cannot be overstated. Assessments are essential to maximizing personal growth and development, the persons ability to self-direct through choice and control over decisions affecting them directly while protecting the health and safety of the individual.
Assessments are the foundation for many of the requirements of the residential program. Regulation requires that assessments are completed in a timely fashion and that notification of assessment results are provided to individual plan team member at least 30 calendar days prior to an individual plan meeting. This is important because the assessment would have reflected all changes in the past year which would be relevant to the annual individual plan review.
The individuals assessment dated 3/30/2020 was not provided to the plan team members at least 30 calendar days prior to the individual plan meeting.
The Program Specialist had sent all of the individuals Quarterly Reviews to the Plan Team members. The contents of those are a quarterly breakdown of the Annual Assessment (e-mail cover letter attached as Attachment #9). So, somehow, the team got the needed information. However, this does not preclude sending the Annual Assessment. The only explanation for this lapse is that it was an oversight on the part of the Program Specialist.
To correct this immediately, the Assessment has been sent (e-mail cover letter attached as Attachment #12).
To prevent this type of error in the future, the Program Specialist shall send the assessment as soon as they are completed or 30 days before an individual plan meeting.
The CEO will supervise the Program Specialist to ensure that this is accomplished in a timely fashion. |
11/07/2020
| Implemented |
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|
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SIN-00158704
|
Renewal
|
07/02/2019
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Poisons were found unlocked under Individual # 1's bathroom sink including Fresh Linen Scent Great Value disinfectant spray, Clorox disinfecting wipes and CLorox clinging bleach toilet cleaner. Clorox Toilet Cleaner was left on the floor to the right of toilet in the basement bathroom unlocked. Pine Sol Multi Surface cleaner 100 oz, Members mark disinfecting wipes, Scrubbing bubbles bath cleaner, a 4 pack of Lysol disinfecting spray and a 4 pack of comet with bleach were unlocked in the laundry room. | Poisonous materials shall be kept locked or made inaccessible to individuals. | This is a violation. It occurred because the doors leading to the laundry room were unlocked at that time in order to provide access to the laundry room.
To fix the violation immediately, it is being enforced that the two doors be kept locked at all times. The first door is the one that leads directly into the laundry. The second door is the one that leads into the basement.
To prevent future occurrences of this violation, these doors will remain locked at all times, except when staff needs to gain entrance into the laundry. In addition, a locked cabinet has been provided to keep all the poisonous materials locked and inaccessible to individuals. The Program Supervisor shall ensure that all Direct Care Staff with the plan. The Residential Director shall provide overall oversight. |
08/15/2019
| Implemented |
| 6400.62(c) | A spray bottle labeled Floor Cleaner was located on laundry room shelf. The contents of the bottle were not in the original container. | Poisonous materials shall be stored in their original, labeled containers. | This is a violation. It occurred because a Direct Care Staff mixed a cleaning substance and failed to dispose of the unused portion.
To fix this problem right away, the contents of the spray bottle had been discarded and the spray bottle had been thrown away.
To prevent a future occurrence, the agency will no longer use products that have to be mixed into spray bottles. All cleaning products will be ones purchased and usable straight out of their original containers.
The Program Supervisor shall be responsible for purchasing products that will not need to mixed into spray bottles. All spray bottles in the home have been gotten rid of.
The Program Supervisor shall enforce this method, and the Residential Director shall provide oversight. |
08/16/2019
| Implemented |
| 6400.64(a) | There is brown splatter residue on the ceiling of the kitchen above the counter to the right of the stove. The splatter extends 3 feet on ceiling. | Clean and sanitary conditions shall be maintained in the home. | This is a violation. It was overlooked by the residential staff.
To fix the problem immediately, the splatter spots have been painted.
To avoid a future reoccurrence of this sort of violation, every blemish shall be treated as important and restored immediately. The Direct Care Staff will have to ensure an effective use of the Walk-Through form (Attachment #6), coupled with a good response system. The Program Supervisor will be responsible for acting on reports from the Direct Care Workers. The Program Supervisor shall carry out a weekly walk-through of each home too. The Program Supervisor shall forward all Work Orders to the maintenance officer. The Residential Director shall offer overall lead for this process. |
08/16/2019
| Implemented |
| 6400.67(a) | Individual # 2's Bathroom Vanity mirror is cracked. | Floors, walls, ceilings and other surfaces shall be in good repair. | This is a violation. It was recently cracked.
To fix the violation immediately, a new vanity mirror has been installed to replace the old one - Picture attached as Attachment #8.
To prevent future violations of this type, Direct Care Staff will have to meticulously complete the Walk-Through Checklist and promptly report all things that are in a state of disrepair. The Residential Supervisor is responsible for responding swiftly by sending a Work Order to the Maintenance Office. The Residential Director shall provide oversight for this aspect. |
08/16/2019
| Implemented |
| 6400.67(b) | The second wooden board of the step from the door of the rear sun room is not secured. When stepping onto the board, it lowered by approximately 2 inches. This is a tripping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | For safety reasons, this is a violation.
To fix the problem immediately, the wooden board has been removed and replaced with a concrete step. And the concrete step has a non-slippery and non-skid surface - picture as Attachment #7.
The agency's maintenance officer will carry out periodic walk throughs to ensure that every inch of the home is checked. The Residential Supervisor will provide oversight. |
08/16/2019
| Implemented |
| 6400.72(b) | The screen door which leads outside of the kitchen does not have a functioning door handle. The screen door Handle does not unlock. Individual # 2's bifold closet door does not open well as the bottom of the door sticks to the carpet. | Screens, windows and doors shall be in good repair. | This violation occurred because the screen door handle was actually locked at the time of the inspection. It was locked because it was never used. The door was deliberately never used because there are two other useable exits/entrances to the home. The exit was designated to be never used.
To fix the problem immediately, the door handle has been unlocked. In an attempt to repair or replace it, it was discovered that we only needed to unlock the latch. It is working perfectly now.
The closet door in Individual #2's bedroom has been repaired. It now opens well and does not stick to the carpet.
To prevent future occurrences of these violations, Direct Care Staff will be expected to include these doors (and all doors) in their Walk-Through Check - Walk Through List attached as Attachment #6. The Program Supervisor will review the Walk-Through inventory weekly and address all concerns noted. The Residential Director will also carry out periodic checks on all physical facilities. |
08/16/2019
| Implemented |
| 6400.74 | The wooden step outside of the rear sun room does not have a non skid surface. | Interior stairs and outside steps shall have a nonskid surface.
| This regulation is important for the safety of the individuals and the staff.
The violation occurred because the agency maintenance assessed the step safe and non-slippery. Through the different seasons in the last year-and-a-half, it had remained non-slippery and non-skid when wet.
To fix the violation right away, the wooden step has been removed, and replaced with a concrete step with a non-skid surface - picture attached as Attachment #7.
For future compliance, the agency's maintenance officer shall ensure that surfaces in the homes are safe. The Residential Director will provide oversight. |
08/15/2019
| Implemented |
| 6400.80(b) | There were three piles of hedge clippings on the lawn in front of hedges in the front lawn. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | There were three piles of hedge clippings on the front lawn. This is a violation.
The violation occurred because the landscaping work was still ongoing. The landscaping guy trimmed the hedges and piled them up. Reportedly, he took a break before hauling away the clippings.
To fix the violation, the hedge clippings were removed immediately.
To prevent future violations, the agency has requested that the landscaping man starts his job and completed it before taking a break. The Residential Supervisor will provide supervision to ensure compliance. |
08/15/2019
| Implemented |
| 6400.110(a) | The attic does not have a smoke detector. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | This is a violation because an attic is expected to have a smoke detector.
This regulation was violated owing to an erroneous understanding of spaces that were considered as a floor.
To fix the problem, the space has been rendered inaccessible to individuals and staff. It has been screwed up and shut off so that no one is able to access it.
This will prevent future violations of this regulation.
The agency's maintenance department will be responsible for ensuring that the space stays inaccessible. The Residential Supervisor will provide oversight. |
08/15/2019
| Implemented |
| 6400.111(a) | The attic does not have an operable fire extinguisher | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | The agency did not consider this a violation because the Licensing Inspection Instrument for Community Homes gave further clarification on this regulation. And it states: "If no individuals or staff persons have access to a floor (except of course to test the smoke detector); no extinguisher is required on that floor. If people use the floor even for storage, an extinguisher is required."
The attic in this home is not a living space, neither was it used for the storage of anything. It was never accessed for anything by either individuals or staff.
To fix the citation right away, however, the access has been securely screwed up. This will prevent anyone from accessing it for anything.
To prevent future violations, the agency's maintenance will ensure that the access is always securely fastened up. The Program Supervisor will ensure that maintenance keeps it screwed up. |
08/15/2019
| Implemented |
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|
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SIN-00138512
|
Renewal
|
07/24/2018
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | Floor cleaner (Pine Sol) stored in unlabeled spray bottle. | Poisonous materials shall be stored in their original, labeled containers. | Poisonous materials shall be stored in their original, labeled containers.
1. This regulation is important because it protects people from being harmed by poisonous materials which might be mistaken for other substances when they are not in their original container.
2. There was diluted Lysol which was stored in an unlabeled spray bottle.
3. This was an oversight that was not in adherence to the regulation.
4. As an immediate fix:
The content of the spray bottle has been discarded.
5. To prevent this sort of error in the future:
a. Small amounts needed for each cleaning job will be diluted for one-time use.
b. Any unused portion will be discarded after each cleaning job.
c. Spray bottles shall be rinsed off and stored empty.
d. Staff will be retrained on this policy.
e. The Program Specialist shall check the water temperature on a periodic basis.
f. The Residential Director will provide oversight for the Program Specialist to ensure compliance. |
08/23/2018
| Implemented |
| 6400.68(b) | Hot water temperature was measured at 128.4 degrees F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | Hot water temperatures in bathtubs and showers may not exceed 120°F.
1. This regulation is important because it protects people from accidental scalding which could lead to serious injury or death.
2. The shower¿s water temperature in individual #1¿s bathroom was 128.4 degrees F.
3. There is no anti-scald protective device on the shower or water heater.
4. As an immediate fix:
The water heater was reset to 110 degrees F. A pipe thermometer was installed (picture included as Attachment #10A). This calibrated device will enable staff in the home get accurate measurements of the water temperature and ensure it does not exceed 120 degrees F. All Staff have been trained on the new procedure to prevent excessive water temperature.
5. To prevent this problem in the future, Ideal Services will do the following:
a. Ideal Services will follow a Water Temperature Policy and Procedure (recently developed and attached as Attachment #10B).
b. The Residential Director will train all Direct Care Staff on the procedure for checking water temperature.
c. ISG¿s Policy on Water Temperature has been amended to include the steps that will be taken to ensure compliance with the regulation. |
08/23/2018
| Implemented |
| 6400.73(a) | No handrail was present on the side exit (driveway) steps. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail.
1. This regulation is important because it protects individuals from falls which could lead to serious injury or death.
2. The three-step side entrance to the kitchen did not have hand rails.
3. The lowest step was almost level with the ground, and the entrance is hardly used. Therefore, Ideal Services underestimated the need for the hand rails.
4. As an immediate fix:
Handrails have been installed. A picture of it is attached ¿ Attachment #9.
5. To prevent this type pf error in the future:
The Residential Director will ensure compliance in all physical aspects of the building. |
08/23/2018
| Implemented |
| 6400.141(c)(14) | Individual #1's physical did not include: Medical information pertinent to diagnosis and treatment in case of an emergency. It was blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter.
(c) The physical examination shall include:
(14) Medical information pertinent to diagnosis and treatment in case of an emergency.
1. This regulation is important because it helps people (including health care treatment teams) have a good knowledge of individual¿s condition to ensure proper treatment, health and safety in the case of an emergency. It will help the individual get the care he needs.
2. This portion of the physical form did not have this section filled out. It was blank.
3. Ideal Services Group (ISG) staff did not fill out this section because we were not aware that we could fill it out, since the Primary Care Physician (PCP) left it blank.
4. As an immediate fix:
The individual¿s physical report has been filled out and it reads:
¿Individual #1 is non-verbal. Individual #1 cannot swallow tablet or capsules. They must be crushed.¿
A copy of the Physical Examination Report (as amended) is attached as Attachment #8, page 2.
5. To avoid this type of error in the future:
Ideal Service Group Administrator and staff will fill out the ¿information pertinent to diagnosis and treatment in case of an emergency¿. All portions of the Documentation of Medical Evaluation (DME) that could be completed by the Residential staff will be completed prior to the in-person evaluation visit with the PCP or Physician¿s Assistant or a Certified Registered Nurse Practitioner. All portions of the form, except the ¿Medical Professional Information¿ section will be thoroughly completed before all future visits. ISG staff will ensure that the DME is filled out in their entirety. |
08/23/2018
| Implemented |
| 6400.163(c) | Individual #1's medication review dated 5/18 did not include the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.
1. This regulation is important because a documented copy of the need for the medication, as well as the recommended dosage, will be available for every care giver of the individual. This will eliminate or reduce the risk of medication errors, especially such potent medications.
2. Individual #1 visit of 5/18/18 did not include the reason for prescribing his medication, the need to continue the medication, and the recommended dosage.
3. Ideal Services Group¿s Physician Visit Sheet did not include all these necessary details.
4. As an immediate fix:
a. A new form (Physician Visit Sheet for Medication¿s Monitoring) has been re-designed. The new form has all the needed information and is attached as Attachment #7.
5. To prevent future occurrence:
a. The Residential Director of Ideal Services Group shall send the detailed Physician Visit Sheet to every medication check of the individual. |
08/23/2018
| Implemented |
| 6400.181(c) | No documentation was present to state that the assessment was based on assessment instruments, interviews, progress notes and observations. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | Each individual shall have an initial assessment ¿ after admission to the residential home and an updated assessment annually thereafter¿.
(c) The assessment shall be based on assessment instruments, interviews, progress notes and observations.
1. This regulation is important because it ensures that the assessment of the individual is based on credible and identifiable sources.
2. The assessment for individual #1 did not identify the sources of information. This is in violation of § 6400.181. Assessment ¿ (c)
3. The Program Specialist did not include the sources from which information for the assessment was gathered.
4. As an immediate fix:
Individual #1¿s assessment has been corrected to include the sources on which the assessment was based. The assessment was based on instruments, interviews, progress notes and observations. This information has been included as a cover page for the Assessment document. A copy of this cover page is included as Attachment #5.
5. To prevent future occurrences:
The Program Specialist has reviewed the regulation and is fully informed of the importance of including all the sources of the assessment information.
The Residential Director will check to ensure the assessments are done according to the specifics of the regulation. |
08/23/2018
| Implemented |
| 6400.181(e)(7) | The assessment did not include the following information: The individual's ability to move away quickly from heat sources which exceed 120° F and are not insulated. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | Each individual shall have an initial assessment ¿. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home.
(e) The assessment must include the following information:
(7) The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.
1. This regulation is important because it protects people from accidental burning which could lead to serious injury or death.
2. The assessment did not include specific information on what the individual would do in the case of being exposed to heat sources which exceed 120 degrees F and are not insulated.
3. The violation occurred because the Program Specialist did not include in the individual¿s assessment information about the individual¿s knowledge of the danger of heat sources and his ability to sense and move away quickly from heat sources which exceed 120 degrees F and are not insulated.
4. As an immediate fix:
a. The Program Specialist has corrected the assessment to read:
¿Individual #1 has the ability to sense and move away quickly from heat sources which exceed 120 degrees F. However, he does not have full knowledge of the danger of heat sources. He does not have proper cooking/appliance use awareness. He would not touch a hot stove, according to his mother. Individual #1 is never exposed to outdoor appliances. He does not have proper safety awareness. Staff will help temper the water for him during baths, and staff will offer supervision to ensure that he does not move close to heat sources.¿
A copy of the corrected Assessment is included as Attachment #6. The correction is on page 4 (#VII).
b. The Program Specialist has reviewed the entire regulation and is fully informed of the importance of including all aspects of individual¿s assessment information.
5. To prevent this kind of occurrence in the future:
a. The Residential Director will review and closely supervise all individuals¿ Assessments (done by the Program Specialist) to ensure that they are done according to the specifics of the regulation.
b. The CEO will re-train the Program Specialist on the details needed in Assessment information so it will be as comprehensive as is required. |
08/23/2018
| Implemented |
| 6400.183(5) | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), did not include the following: A protocol to address the social, emotional and environmental needs of the individual, since medication is prescribed to treat symptoms of a diagnosed psychiatric illness. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:
(5) A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.
1. This regulation is important because it enables all treatment team members to be privy to pertinent information regarding the Social, Emotional, and Environmental Needs Plan (SEEN Plan) of the individual. It will also allow for helpful inputs/feedback from other team members if it is necessary.
2. The SEEN Plan was prepared and it was being used in the home, but it was not sent to the SC to be updated in the ISP.
3. ISG¿s Behavioral Support Specialist did not send a copy of the SEEN Plan to the SC.
4. As an immediate fix:
The SEEN Plan has been forwarded to the SC for necessary update in the ISP. It was e-mailed on 07/26/2018. A copy of the e-mail and the SEEN Plan is attached as Attachment #4.
5. To prevent this error in the future:
ISG Behavior Support Specialist will e-mail the SEEN Plan on time, and any time it is reviewed.
The Residential Director will review and ensure that information is sent to the SC on time. |
08/23/2018
| Implemented |
| 6400.213(11) | Current ISP states Individual #1 has a diagnosis of seasonal allergies. Current physical does not document this. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | Each individual¿s record must include the following information:
(11) Content discrepancy in the ISP, The annual update or revision under § 6400.213.
64OO.213.11. Content Discrepancy in the ISP, the annual update or revision under 6400.213
1. This regulation is important because it ensures that the content of the ISP is accurate and up to date.
2. Individual#1¿s ISP states that he has seasonal allergies. However, his current physical does not document this.
3. The Program Specialist has not sent a request for a revision to the Supports Coordinator and the Plan Team members.
4. As an immediate fix:
The Program Specialist has contacted Individual #1¿s mother to clarify the issue and she (Individual¿s mother) has confirmed that the individual does not have seasonal allergies. The Program Specialist has sent a recommendation to the Supports Coordinator to revise this portion of the ISP for a revision. A copy of the request, as well as e-mail cover, is attached as Attachment #3.
5. To prevent this error in the future:
The Program Specialist shall review all the information on the ISP for correctness, and clarify areas that are incorrect or information that may be obsolete.
The Residential Director will review all information thoroughly to prevent content discrepancy in the future.
The Program Specialist shall forward all requests for correction (as far as Content Discrepancy) to the individuals¿ Supports Coordinators, as needed.
The Residential Director will provide reviews and supervision to ensure that we have current and correct information. |
08/23/2018
| Implemented |
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SIN-00227691
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Renewal
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07/11/2023
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Compliant - Finalized
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SIN-00208900
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Renewal
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08/08/2022
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Compliant - Finalized
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