Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
SIN-00209988
|
Renewal
|
08/02/2022
|
Compliant - Finalized
|
|
|
Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.111(a) | There was no fire extinguisher 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. | A fully operational and inspected fire extinguisher purchased on 1/27/2022 was taken from OLALUS storage and placed in the basement in an easily accessible area (see supporting documentation). |
12/06/2022
| Implemented |
6400.112(a) | The fire drills were from January to December 2021, with sleep drills occurring in April, June, July, September, and December; no drills from 2022 were provided. | An unannounced fire drill shall be held at least once a month. | Fire drills were performed on the following dates and times in 2022 1/24/22 @ 2:25pm, 2/15/22 @ 1:02am, 3/16/22 @8:40pm, 4/16/22 @ 10:00am, 5/5/22 @ 7:00pm, 6/12/22 @ 11:00am, 7/19/22 @2:00am. The documentation for these fire drills were complete, available, and uploaded at the time of the inspection (please see supporting documentation). Due to technical difficulties the inspector was unable to access the aforementioned documents despite several attempts to re-upload. |
08/01/2022
| Implemented |
6400.166(b) | The MAR log was not initialed as the medication being administered even though they had been for individual #1. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | It is unclear as to which medication was not initialed as being administered in Individual #1's MAR. However, every medication administered in the month of 8/2022 was documented as such with the administrators initial (please see supporting documentation). |
08/01/2022
| Implemented |
6400.186 | Individual #1's assessment indicate that OLALUS is the rep payee when they are not the representative payee for the individual. The assessment and the ISP are to be in line with the documented information pertaining to the individual. | The home shall implement the individual plan, including revisions. | Individual #1's assessment indicated that Advocacy Alliance was the representative payee for said individual. However, the ISP indicated that OLALUS Group was the representative payee for Individual #1. The Supports Coordinator was contacted via email on 8/2/22 to request an update of information. Individual #1's ISP was updated on 8/4/2022 to reflect Advocacy Alliance as the representative payee (see supporting documentation) |
08/01/2022
| Implemented |
|
|
SIN-00170948
|
Renewal
|
02/13/2020
|
Compliant - Finalized
|
|
|
Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.77(b) | There were no tweezers found 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. | Tweezers has been placed in the first aid kit at the site. OLALUS Sites coordinator has completed an inventory of all first aid kits to ensure that tweezers and all contents of the first aid kit accounted for kept . Monthly, after every fire drill, staff Sites coordinator will do an inventory on all first aid kits to ensure that all its contents are present. (POC Attachment 1) |
03/01/2020
| Implemented |
|
|
SIN-00145130
|
Renewal
|
11/08/2018
|
Compliant - Finalized
|
|
|
Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.64(a) | There was trash and dirt in the bathtub in the second-floor bathroom | Clean and sanitary conditions shall be maintained in the home. | Corrected on site. Bathtub has been cleaned. Sites coordinator has created a shift chore schedule to ensure that clean and sanitary conditions are maintained in the home. Sites coordinator will monitor sites to ensure site cleanliness is maintained at all times. |
11/08/2018
| Implemented |
6400.80(b) | Two slats are missing from the deck in the back of the home. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Deck in the back of the home has been repaired. Missing slats have been replaced. Olalus staff will immediately complete a work order in the event that a repair needs to be completed. Sites coordinator will ensure that maintenance and repairs are expedited. (See Attachments) |
12/03/2018
| Implemented |
6400.81(k)(4) | There was no chest of drawers in Individual #1's room | In bedrooms, each individual shall have the following: A chest of drawers. | Chest has been placed in Individual #1's bedroom. All Individual rooms have a chest of drawers in accordance with 55 PA Code Chapter 6400.81(k)(4). Olalus staff will immediately complete a work order in the event that a repair needs to be completed. Quality assurance will ensure that, upon admission, all individual rooms will come equipped in accordance with 55 PA Code Chapter 6400.81(k)(4). Sites coordinator will ensure that maintenance and repairs are expedited. (See Attachments) |
12/03/2018
| Implemented |
6400.81(k)(6) | There was no mirror in Individual #1's bedroom. | In bedrooms, each individual shall have the following: A mirror. | Mirror has been placed in Individual #1's bedroom. All Individual rooms have a mirror in accordance with 55 PA Code Chapter 6400.81(k)(6). Olalus staff will immediately complete a work order in the event that a repair needs to be completed. Quality assurance will ensure that, upon admission, all individual rooms will come equipped in accordance with 55 PA Code Chapter 6400.81(k)(6). Sites coordinator will ensure that maintenance and repairs are expedited. (See Attachments) |
12/03/2018
| Implemented |
|
|
SIN-00117873
|
Renewal
|
07/19/2017
|
Compliant - Finalized
|
|
|
Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.141(a) | There was no documentation to show that Individual #1 completed an annual physical examination. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1 has completed a physical examination on 8/28/2017. Moving Forward, the program specialist will ensure that all individuals have a physical examination within 12 months prior to admission and annually thereafter. Furthermore, the agency nurse with supervision from the program specialist shall review all individual physicals to ensure that all aspects of the individual physical are completely filled out. |
08/30/2017
| Implemented |
6400.164(a) | Ibuprofen, Amoxicilin, earwax drops and acetaminophen were found in Individual #1's medication box but were not listed/logged in the Individual's medication administration record. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | Ibuprofen, Amoxicilin, earwax drops and acetaminophen have been removed from Individual #1 medication box and the Individual¿s medication log has been updated. The agency nurse also contacted the Individual¿s PCP to verify that the above listed medications were not discontinued. Moving forward, the agency nurse and site manager will check all medications delivered by the pharmacy against the medications listed on the MAR to ensure that all medications delivered are listed and that all listed medications are delivered. All Medication administration staff will be retrained on 9/2/2017. |
08/31/2017
| Implemented |
Article X.1007 | Olalus Community Healthcare Services is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 ¿ 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff # 1 was hired on 4/28/17; the criminal history check was requested on 6/21/17. | 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. | Pre employment documentation checklist has been developed and will be utilized by Quality Assurance and Administrator to ensure that all prospective employees have all required documentation including PA criminal background check completed within 12 months prior to employment and annually thereafter. Moving forward, with the supervision of the Program Director, the administrator and Quality Assurance will ensure that Olalus Community Healthcare meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 ¿ 10225.5102) and its regulations (6 Pa. Code Ch. 15). |
08/30/2017
| Implemented |
|
|
SIN-00090859
|
Initial review
|
03/21/2016
|
Compliant - Finalized
|
|