| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency did not complete a self-assessment of their home. | 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.
| Regulation 6400.15(a) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO to ensure compliance and timeliness with future self-assessments (Attachment #1). Program Specialist Stephanie Smith completed the self-assessment 7/2-7/6/18. The ¿Chapter 6400 Self-Assessment Tool ¿document was not physically available during the time of inspection because Stephanie Smith had completed the tool in an excel file. The excel file lists each regulation, a brief description, a label of ¿C,¿ ¿V,¿ or ¿NA,¿ the name of the person responsible for managing the regulation, and any administrative notes to reference for the regulation. The official Chapter 6400 Self-Assessment document has been printed and filled out by Program Specialist Stephanie Smith and dated 7/6/18 to correspond with the completed excel document (Attachment #36). |
07/12/2018
| Implemented |
| 6400.22(d)(2) | Individual #1's record did not include the receipt for a $40.59 purchase at Giant in July 2018 or a $20 withdrawl from PNC bank. | (2) Disbursements made to or for the individual.
| Regulation 6400.22(d)(2) was reviewed with the Program Specialist on 7/12/18 by the CEO (Attachment #1). Program Specialist Stephanie Smith located receipt for $40.59 Giant purchase and $20 PNC withdrawal in Round Hill¿s old disbursement filing folder (Attachment #34). Receipts were relocated to current disbursement filing system labeled ¿Jan-Dec 2018 Receipts.¿ The current filing system is an expanding file folder, with a tab for each month, where individual independently files her receipts after each outing. Filing system is independently managed by individual. Program Specialist developed Weekly Receipt Reconciliation POC protocol on 8/1/18 to oversee filing system (Attachment #35). Program Specialist Stephanie Smith is responsible for providing weekly bank statements which will be reconciled by individual and staff on shift every Saturday evening at 8:10 p.m. Individual and all staff will receive training by PS Stephanie Smith during their next scheduled shift and sign-off on POC, beginning 8/4/18. |
07/29/2018
| Implemented |
| 6400.31(b) | Individual #1 has been residing with the provider since their initial license received on 7/10/17 and Individual #1 did not receive, sign and date acknowledging receipt of the information on rights until 9/10/17. | 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. | Regulation 6400.31(b) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). There was confusion on the start date of the licensed facility, because Round Hill Services wasn¿t registered as a provider until 9/10/17, and the individual was already living in the home prior to licensure as an ¿unlicensed adult residential facility,¿ so Round Hill reviewed rights with the individual on 9/10/17 (Attachment #33). No further action can be taken to correct the noncompliance. |
07/12/2018
| Implemented |
| 6400.44(b)(2) | The three program specialists, Staff #2, #4 and #5, did not receive training on their program specialist job duties. Their hire date was 7/10/17 and licensing was conducted on 7/10/18. | The program specialist shall be responsible for the following: Providing the assessment as required under § 6400.181(f) (relating to assessment). | Regulation 6400.44(b)(2) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). Program Specialist Melinda Desmarais will receive training on Program Specialist job duties during upcoming ISP meeting on 8/8/18 (Attachment #4) by CEO Patricia Smith. Program Specialist Jennifer Diffenderfer will receive training on Program Specialist job duties during her scheduled shift on 8/8/18 by Program Specialist Stephanie Smith. |
08/08/2018
| Implemented |
| 6400.46(a) | Staff #1 and #2 were not oriented to their responsibilities, the daily operation of the home and policy and procedures of the home at the time of licensing on 7/10/18. The home has been open since 7/10/17 and that is also Staff #1 and #2's date of hire. | The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. | Regulation 6400.46(a) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). The staff training syllabus has been revised by the Behavioral Specialist on 8/3/18 to include the training source, content, dates, and length of training (Attachment #29). All future group trainings require a staff sign-in (Attachment #30) which are retained along with any applicable certificates of completion. |
08/03/2018
| Implemented |
| 6400.46(c) | The chief executive officer, Staff #3, only received 20 hours of training from 7/10/17-7/10/18. | The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually. | Regulation 6400.46(c) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). There was confusion on the start date of the licensed facility, because Round Hill Services wasn¿t registered as a provider until 9/10/17, and the individual was already living in the home prior to licensure as an ¿unlicensed adult residential facility.¿ So, Round Hill Services had established their annual training year to begin 9/10/17 and end 9/10/18. Round Hill has changed their training year to 7/10/17-7/10/18, in accordance with licensing requirements. Program Specialist Stephanie Smith will provide training resources for the CEO to meet her annual 24-hour training requirements for 7/10/18-7/10/19. |
07/12/2018
| Implemented |
| 6400.46(e) | Staff #1 and #2 did not receive training in the areas of intellectual disability, the principles of normalization, and rights at the time of licensing on 7/10/18. Staff #1 and #2's date of hire was 7/10/17. Staff #1 did not receive training in program planning and implementation. | Program specialists and direct service workers shall have training in the areas of intellectual disability, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. | Regulation 6400.31(b) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). 4/8 Program Specialists and direct support staff received documented training in the areas of intellectual disability, the principles of normalization and rights prior to the time of licensing on 7/10/18 (Attachment #31). 5/8 staff still need training in areas of ID, the principles of normalization, and rights. 3/8 Program Specialists and direct service workers received training in program planning and implementation (Attachment #31.5). 5/8 Program Specialists and direct service workers need training in program planning and implementation. Program Specialist Stephanie Smith is responsible for ensuring all employees meet training requirements and providing employees with the resources and materials to meet these requirements. The deadline for completion of training areas of ID, principles of normalization, rights, and program planning and implementation is 9/30/18. |
09/30/2018
| Implemented |
| 6400.46(f) | Staff #2's date of hire was 7/10/17 and she did not receive training in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building, smoking safety procedures, 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 until 7/26/17. | 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. | Regulation 6400.46(f) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). There was confusion on the start date of the licensed facility, because Round Hill Services wasn¿t registered as a provider until 9/10/17, and the individual was already living in the home prior to licensure as an ¿unlicensed adult residential facility.¿ So, Round Hill Services provided training to all employees in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building, smoking safety procedures, 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 prior to the anticipated ¿hire date¿ of 9/10/17 (Attachment #32). No further action can be taken to correct the noncompliance. |
07/12/2018
| Implemented |
| 6400.46(j) | There was not documentation to indicate that any staff working with Individual #1 was trained on Individual #1's restrictive procedure plan. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | All current staff have been trained on the individual¿s restrictive procedure plan as part of their orientation training on and as reviewed at quarterly staff meetings. All future staff will be trained on the individual¿s restrictive procedure plan as part of their orientation training and will document on a signed & dated acknowledgement form.
Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, are retained in the employee¿s file (Attachment #29). |
08/03/2018
| Implemented |
| 6400.64(a) | The threshold on the back egress sliding doors contained a lot of dirt and debris from outside. The front of the garage and garage lights were covered with cobwebs. | Clean and sanitary conditions shall be maintained in the home. | Regulation 6400.64(a) was reviewed with the Program Specialist on 7/12/18 by the CEO (Attachment #1). The threshold on the back egress sliding doors has been cleaned, and garage lights were swept (Attachment #28). A weekly site checklist is being developed by Program Specialist Stephanie Smith, and will include regulation 6400.64(a) as part of the weekly home inspection to be conducted by either staff or Program Specialist to ensure clean and sanitary conditions shall be maintained in the home. The checklist must be completed by 8/31/18 and employee trainings will begin 9/1/18. |
08/31/2018
| Implemented |
| 6400.67(a) | There were approximately 5-6, 3 inch, brown circular stains on the living room carpet. | Floors, walls, ceilings and other surfaces shall be in good repair. | Regulation 6400.67(a) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). Program Specialist Stephanie Smith was responsible for getting quotes and scheduling carpet cleaned in timely manner. An employee from Certified Carpet came on 8/3/18 and gave a quote on the carpets (Attachment #26). Certified Carpet is scheduled to treat carpet of entire home on 8/13/18. A weekly site checklist is being developed by Program Specialist Stephanie Smith, and will include regulation 6400.67(a) as part of the weekly home inspection to be conducted by either staff or Program Specialist to floors, walls, ceilings and other surfaces are in good repair. The checklist will be completed by 8/31/18 and Stephanie Smith will begin employee trainings on 9/1/18. |
08/13/2018
| Implemented |
| 6400.67(b) | The was a down spout covering approximately 8 inches of the front walkway. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Regulation 6400.67(b) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). Spout extension was removed (Attachment #27) and sidewalk is clear. CEO is responsible for arranging the relocation of downspout extension under the sidewalk. CEO will have downspout excavated by end of the year. A weekly site checklist is being developed by Program Specialist Stephanie Smith, and will include regulation 6400.67(b) as part of the weekly home inspection to be conducted by either staff or Program Specialist to ensure floors, walls, ceilings and other surfaces are free of hazards. The checklist will be completed by 8/31/18 and Stephanie Smith will begin employee trainings on 9/1/18. |
08/31/2018
| Implemented |
| 6400.76(a) | The dryer contained approximately a baseball sized ball of lint. The home was not currently washing or drying laundry. | Furniture and equipment shall be nonhazardous, clean and sturdy. | This citation was resolved immediately, the lint filter was cleaned while licensors were on site. Since the licensing visit, a sign has been placed on the front of the dryer to remind the individual and residential staff to clean the lint filter after each use (Attachment #25). Regulation 6400.76(a) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). A weekly site checklist is being developed by Program Specialist Stephanie Smith, and will include regulation 6400.76(a) as part of the weekly home inspection to be conducted by either staff or Program Specialist to ensure furniture and equipment is nonhazardous, clean and sturdy. The checklist will be completed by 8/31/18 and Stephanie Smith will begin employee trainings on 9/1/18. |
07/11/2018
| Implemented |
| 6400.80(b) | There is a large tree off of the back deck that is so overgrown that the branches are hitting the house, roof, deck, and sliding glass egress. The back deck steps and egress path are infiltrated with overgrown bushes. There is a large tree and weeds overgrown onto the garage exit path and door. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Regulation 6400.80(b) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). Lawn care team came on 7/12/18 and removed tree and overgrowth around the home (Attachment #24). A weekly site checklist is being developed by Program Specialist Stephanie Smith, and will include regulation 6400.80(b) as part of the weekly home inspection to be conducted by either staff or Program Specialist to ensure the outside of the building and the yard or grounds is well maintained, in good repair and free from unsafe conditions. The checklist will be completed by 8/31/18 and Stephanie Smith will begin employee trainings on 9/1/18. |
07/12/2018
| Implemented |
| 6400.101 | The sliding glass was very hard to open. The back sliding screen door was stuck and wouldn't open for multiple attempts. The handle of the screen door was sticking, thus making it extremely difficult to open to door. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Regulation 6400.101 was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). Letter to handyman sent by CEO Patricia Smith on 7/11/18 via email to fix or replace sliding back door (Attachment #23). Handyman fixed door 7/12/18 and was checked at end of day on 7/12/18 by CEO Patricia Smith. A weekly site checklist is being developed by Program Specialist Stephanie Smith, and will include regulation 6400.101 as part of the weekly home inspection to be conducted by either staff or Program Specialist to ensure stairways, halls, doorways, passageways and exits from rooms and from the building are unobstructed. The checklist will be completed by 8/31/18 and Stephanie Smith will begin employee trainings on 9/1/18. |
07/12/2018
| Implemented |
| 6400.103 | The written emergency evacuation procedure did not indicate the means of transportation to be used during an emergency evacuation situation. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| Regulation 6400.103 was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). Stephanie Smith revised RHS Emergency Medical/Response Plan to indicate means of transportation to be used during an emergency evacuation situation (Attachment #10). Copies of the plan will be distributed to employees at Round Hill and a group text has been sent to sign and date the acknowledgement form during their next scheduled shift. |
07/12/2018
| Implemented |
| 6400.104 | The home did not notify the local fire department in writing of the location of Individual #1's bedroom and his/her level of assistance to evacuate in the event of an actual fire. | 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.
| Regulation 6400.104 was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). Local fire department was notified in writing on 3/25/17 of the address of the home and the exact location of Carly¿s bedroom (Attachment #21). Patricia Smith notified the local fire department on 8/2/18 with the same letter, but added ¿may require verbal directives to exit the home in the event of an emergency¿ to further describe level of assistance needed to evacuate in the event of a fire (Attachment #22). |
08/02/2018
| Implemented |
| 6400.111(f) | The fire extinguishers in the kitchen and the basement did not contain the date of the inspection by a fire safety expert. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | Regulation 6400.111(f) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). Fire safety expert Bill Fair inspected and dated the fire extinguishers in the kitchen and the basement on 7/17/18 (Attachment #19, Attachment #20). Checks that the fire extinguishers contain the date of the inspection has been added to the monthly Smoke and CO2 Detector Check forms (Attachment #16). |
07/17/2018
| Implemented |
| 6400.112(a) | The home was licensed on 7/10/17 and a fire drill was not held until 10/26/17. The fire drills on 4/28/18 and 2/27/18 were held with staff prior notice of the drill. | An unannounced fire drill shall be held at least once a month. | There was confusion on the start date of the licensed facility, because Round Hill Services wasn¿t registered as a provider until 9/10/17, and the individual was already living in the home prior to licensure as an ¿unlicensed adult residential facility.¿ So, the first fire drill wasn¿t until 10/26/17. Regulation 6400.112(a) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). Fire drills will no longer be announced effective 7/12/18. Stephanie Smith and CEO Patricia Smith will share responsibility of conducting unannounced fire drills with individual and staff at Round Hill. |
07/12/2018
| Implemented |
| 6400.112(c) | All smoke detectors in the home were not checked for operability during the fire drills held in October and November of 2017 and January, March, May and June of 2018. According to the log, the smoke detectors were tested days prior to conducting a fire drill. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Regulation 6400.112(c) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). Smoke detectors were checked monthly since October 2017, but some were not within the 48-hour window after a fire drill occurred (Attachment #15). Stephanie Smith updated Smoke and CO2 Detector Check forms to indicate completion immediately after fire drills (Attachment #16), and staff will be instructed by Stephanie Smith to fill out Smoke and CO2 Detector Checks following each fire drill. |
07/12/2018
| Implemented |
| 6400.112(e) | A fire drill was not held during sleeping hours from the time the agency received the license on 7/10/17 until the time of licensing on 7/10/18. | A fire drill shall be held during sleeping hours at least every 6 months. | Regulation 6400.112(e) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). One fire drill was held during the individuals sleeping hours from the time the agency received the license on 7/10/17 (Attachment #17), but it was misunderstood that the individual needed to be completely asleep. A 12-month fire drill schedule is being developed by Program Specialist Stephanie Smith for office use as a date and time scheduling tool for fire drills. This fire drill schedule is for the CEO and Program Specialist only, to ensure a fire drill is held during sleeping hours at least every 6 months. The schedule will be completed by 8/31/18. |
08/31/2018
| Implemented |
| 6400.112(h) | The fire drill forms don't indicate if Individual #1 evacuated to the designated meeting place during each drill. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Regulation 6400.112(h) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). Fire drill forms have been updated by Program Specialist Stephanie Smith on 7/23/18 to indicate if Individual #1 evacuated to the designated meeting place during each fire drill (Attachment #18). |
07/23/2018
| Implemented |
| 6400.113(a) | Individual #1 has been residing with the agency in their residential facility since the time of their initial license certificate on 7/10/17. Individual #1 did not receive training in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building and smoking safety procedures until 7/30/17. | 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. | 6400.113(a) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). There was confusion on the start date of the licensed facility, because Round Hill Services wasn¿t registered as a provider until 9/10/17, and the individual was already living in the home prior to licensure as an ¿unlicensed adult residential facility.¿ So, Round Hill Services provided training to Individual #1 in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building, and smoking safety procedures prior to the anticipated ¿admission date¿ of 9/10/17 (Attachment #14). Individual #1 is currently the only client. No further action can be taken to correct the noncompliance. |
07/12/2018
| Implemented |
| 6400.141(c)(3) | Individual #1's 5/7/17 and 12/28/17 physical examination forms did not include his/her immunizations for individuals 18 years or older as recommended by the United State Public Health Service, Centers for Disease Control. There wasn't a spot on the physical form to include this, nor was a copy of immunizations attached to the physical. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | 6400.141(c)(3) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). CEO Patricia Smith scheduled physical for Individual #1 with general practitioner on 8/2/18. Physical examination form included immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333 (Attachment #13). Individual #1 is Round Hill Service¿s only client. Job description was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO, to achieve and maintain ongoing compliance with regulations within PA Chapters 6400 (Attachment #3). |
08/02/2018
| Implemented |
| 6400.141(c)(4) | Individual #1's 5/7/17 and 12/28/17 physical examination forms did not include a vision and hearing screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | 6400.141(c)(4) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). CEO Patricia Smith scheduled physical for Individual #1 with general practitioner on 8/2/18. Physical examination form included vision and hearing screening for individuals 18 years of age or older, as recommended by the physician (Attachment #13). Individual #1 is Round Hill Service¿s only client. Job description was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO, to achieve and maintain ongoing compliance with regulations within PA Chapters 6400 (Attachment #3). |
08/02/2018
| Implemented |
| 6400.141(c)(6) | Individual's 5/7/17 and 12/28/17 physical examination forms did not include a Tuberculin skin test. The agency did not have record of Individual #1 receiving a Tuberculin skin test or the results since their initial license date of 7/10/17. | 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. | 6400.141(c)(6) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). CEO Patricia Smith scheduled physical for Individual #1 with general practitioner on 8/2/18. Physical examination form included 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 (Attachment #13). TB test is still awaiting results from doctor. Individual #1 is Round Hill Service¿s only client. Job description was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO, to achieve and maintain ongoing compliance with regulations within PA Chapters 6400 (Attachment #3). |
08/02/2018
| Implemented |
| 6400.141(c)(7) | Individual #1's 5/7/17 and 12/28/17 physical examination forms did not include a gynecological examination including a breast examination and a Pap test for women 18 years of age or older. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | 6400.141(c)(7) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). CEO Patricia Smith scheduled physical for Individual #1 with general practitioner on 8/2/18. Physical examination form included a gynecological examination including a breast examination and a Pap test (Attachment #13). Pap test is still awaiting results from doctor. Individual #1 is Round Hill Service¿s only client. Job description was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO, to achieve and maintain ongoing compliance with regulations within PA Chapters 6400 (Attachment #3). |
08/02/2018
| Implemented |
| 6400.141(c)(10) | Individual #1's 5/7/17 and 12/28/17 physical examination forms did not include if he/she was free from communicable diseases or specific precautions that must be taken in the individual has a communicable disease to prevent spread of the disease to other individuals. There wasn't a spot for this on the physical examination form and the doctor did not indicate in writing if Individual #1 was 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. | 6400.141(c)(10) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). CEO Patricia Smith scheduled physical for Individual #1 with general practitioner on 8/2/18. Physical examination form included if individual was free from communicable diseases and specific precautions that must be taken if the individual has a communicable disease to prevent spread of the disease to other individuals. (Attachment #13). Individual #1 is Round Hill Service¿s only client. Job description was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO, to achieve and maintain ongoing compliance with regulations within PA Chapters 6400 (Attachment #3). |
08/02/2018
| Implemented |
| 6400.141(c)(12) | Individual #1's 5/7/17 and 12/28/17 physical examination forms did not include physical limitation of the individuals. | The physical examination shall include: Physical limitations of the individual. | 6400.141(c)(12) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). CEO Patricia Smith scheduled physical for Individual #1 with general practitioner on 8/2/18. Physical examination form included physical limitations of the individual (Attachment #13). Individual #1 is Round Hill Service¿s only client. Job description was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO, to achieve and maintain ongoing compliance with regulations within PA Chapters 6400 (Attachment #3). |
08/02/2018
| Implemented |
| 6400.141(c)(14) | Individual #1's 5/7/17 and 12/28/17 physical examination forms did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | 6400.141(c)(14) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). CEO Patricia Smith scheduled physical for Individual #1 with general practitioner on 8/2/18 (Attachment #13). Physical form filled out on 8/2/18 will be modified by Stephanie Smith to include ¿medical information pertinent to diagnosis and treatment in case of an emergency,¿ and brought to the individual¿s appointment with her psychiatrist on 9/19/18 to be completed. |
09/19/2018
| Implemented |
| 6400.141(c)(15) | Individual #1's 5/7/17 and 12/28/17 physical examination forms did not include specific instructions for the individual's diet. | The physical examination shall include:Special instructions for the individual's diet. | 6400.141(c)(15) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). CEO Patricia Smith scheduled physical for Individual #1 with general practitioner on 8/2/18. Physical examination form included special instructions for the individual¿s diet (Attachment #13). Individual #1 is the Round Hill Services only client. Job description was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO, to achieve and maintain ongoing compliance with regulations within PA Chapters 6400 (Attachment #3). |
08/02/2018
| Implemented |
| 6400.144 | On 12/28/17 Individual #1's physician indicated on a medical appointment form that Individual #1 was to see a nutritionist. Individual #1 did not have an appointment with a nutritionist until 6/29/18 and there was no documentation to indicate why there was a 6 month time frame between the doctors recommendation and the actual appointment. Staff #3 indicated to licensing that an attempt to get a referral was not made until May or June 2018. | 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.
| All staff have been provided with information and training regarding the new dietary guidelines provided by the individual¿s nutritionist via email on 8/3/18 (Attachment #11, Attachment #12). Additionally, the individual¿s current diet is under review by Behavioral Specialist Melinda Desmarais and changes enacted in order to better meet the recommendations set forth by the nutritionist. |
08/03/2018
| Implemented |
| 6400.145(2) | The written emergency medical plan did not include the method of transportation to be used. | The home shall have a written emergency medical plan listing the following: The method of transportation to be used. | Regulation 6400.145(2) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). Stephanie Smith revised RHS Emergency Medical/Response Plan to indicate means of transportation to be used during a medical emergency (Attachment #10). Copies of the plan will be distributed to employees at Round Hill and a group text has been sent to sign and date the acknowledgement form during their next scheduled shift. |
07/12/2018
| Implemented |
| 6400.163(c) | At Individual #1's 4/11/18 psychiatric medication review, his/her CRNP indicated two different times of administration for Tenex; 2pm and 2:30pm. The medication was to be administered at 2:30pm. | 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. | Regulation 6400.163(c) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). Individual #1 has appointments scheduled with her psychiatrist, the prescribing physician for psychiatric medications, every 3 months. An upcoming appointment is scheduled for 9/19/18 at 4pm. All medications and dosages are reviewed at each appointment. A medical appointment form is filled out by the physician at each visit (Attachment #9). The Program Specialist Stephanie Smith will review all documentation from these appointments for any discrepancies and will communicate any changes immediately to staff. Individual #1 is the only client. |
09/19/2018
| Implemented |
| 6400.181(a) | Individual #1 has been residing at the agency residential facility since their license start date of 7/10/17 and at the time of licensing on 7/10/18, an assessment has not been completed for Individual #1. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. 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. | An individual assessment has been completed for the individual by Program Specialist/Behavioral Specialist Melinda Desmarais (Attachment #7). The assessment was submitted to the SC & ISP team on 8/3/18 (Attachment #8). Any future participants will be assessed within 6 months prior to their admission to a licensed residential home. CEO has reviewed regulation 6400.181(a) with Program Specialist Stephanie Smith (Attachment #1) and Behavioral Specialist/Program Specialist Melinda Desmarais. All individuals will receive an updated assessment annually thereafter. Individual #1 is currently the only client. |
08/03/2018
| Implemented |
| 6400.183(4) | Individual #1's Individual Support Plan (ISP) did not include a plan to reduce his/her 2:1 and 1:1 intensive staffing level. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. | Regulation 6400.183(4) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). Next ISP meeting is scheduled on 8/8/18 (Attachment #4) to include a plan to reduce 2:1 and 1:1 intensive staffing level. Individual's ISP will be revised at upcoming ISP review meeting on 8/8/18 to state that intensive staffing levels will be systematically faded over time, at the discretion of the BCBA, as warranted by the individual's progress towards behavioral outcomes identified in the restrictive procedures plan, as follows: 0 instances or attempts of High-Intensity Behavior over a period of 36 consecutive months and 0 instances or attempts of Low-Intensity Behavior over a period of 12 consecutive months. The individual's progress towards behavioral outcomes will be evaluated on a quarterly basis by the BCBA. A follow-up ISP review meeting is scheduled for 8/8/18 containing this request for revision. |
08/08/2018
| Implemented |
| 6400.185(b) | Individual #1's Individual Support Plan (ISP) does not indicate that he/she can handle any amount of money independently. Currently Individual #1 is being given up to $20 or more at a time to handle independently on his/her person. | The ISP shall be implemented as written. | Behavioral Specialist/Program Specialist Melinda Desmarais conducted formal assessment of individual¿s ability to handle money on 8/1/18: Individual is largely unable to manage her own finances. Individual is able to safely carry and manage her personal debit card and a cash amount up to $40. Individual is able to count coins and bills in amounts up to $40 and is able to calculate change owed, however she requires assistance to accept and check change received in a transaction. A follow-up ISP review meeting is scheduled for 8/8/18 containing this request for revision (Attachment #4). |
08/08/2018
| Implemented |
| 6400.186(a) | Individual Support Plan (ISP) reviews were completed for Individual #1 on 12/1/17 and not again until 4/1/18. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | Regulation 6400.186(a) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). Job description was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO, to achieve and maintain ongoing compliance with regulations within PA Chapters 6400 (Attachment #3). Last ISP review was conducted 6/27/18, and next ISP review is scheduled for 8/8/18 (Attachment #4). No further correction can be made. |
07/12/2018
| Implemented |
| 6400.186(b) | Individual #1 did not sign and date any of his/her Individual Support Plan (ISP) reviews. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Regulation 6400.186(b) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). Stephanie Smith scheduled ISP meeting on 8/8/18 to make corrections and comply with licensing violations (Attachment #4). Individual will sign and date ISP reviews at 8/8/18 meeting, with the option to contribute to any revisions as necessary. Job description was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO, to achieve and maintain ongoing compliance with regulations within PA Chapters 6400 (Attachment #3). |
08/08/2018
| Implemented |
| 6400.186(c)(2) | Individual #1's Individual Support Plan (ISP) reviews do not include a review of his/her behavior support plan, restrictive plan, intensive supervision level and community participation. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | Regulation 6400.186(c)(2) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). Review of the individual¿s current ISP is scheduled on 8/8/18 with SC Heather Johnson (Attachment #4). A quarterly review of the individual¿s ISP will be conducted by the Program Specialist Stephanie Smith in conjunction with the Behavior Specialist and submitted to the SC within 15 days of the end of each quarter. Any revision(s) to the ISP will be reviewed by all staff and ISP team members within 15 days of the change(s) being made, and records will be retained to indicate compliance.
The provider¿s Quarterly Progress Note & ISP Review form was revised on 7/24/18 to include dedicated sections pertaining to the individual¿s Behavior Support Plan, restrictive procedures, intensive supervision level and community participation. The individual¿s most recent quarterly review has been revised by Behavior Specialist in accordance with the new Quarterly Progress Note & ISP Review form (Attachment #6). |
08/08/2018
| Implemented |
| 6400.186(d) | There was no documentation to indicate that any of Individual #1's Individual Support Plan (ISP) reviews were sent to any team member. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | Regulation 6400.186(d) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). Updated ISP documentation is typically uploaded to the Employee Google Drive folder. The next ISP meeting is scheduled on 8/8/18 (Attachment #4). The Program Specialist Stephanie Smith or Melinda Desmarais shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting on 8/8/18, and at all future ISP meetings. Plan team members will be required to sign and date acknowledgement of receipt. |
08/08/2018
| Implemented |
| 6400.186(e) | The program specialist did not notify Individual #1's plan team members of the option to decline Individual #1's Individual Support Plan (ISP) review documentation. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | Regulation 6400.186(e) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). Option to decline the ISP review documentation will be included in the sign and date acknowledgement of all future ISP reviews. |
07/12/2018
| Implemented |
| 6400.195(d) | Individual #1's 12/1/17 restrictive procedure plan review meeting was not signed and dated by the chairperson and program specialist. | The restrictive procedure plan shall be reviewed, approved, signed and dated by the chairperson of the restrictive procedure review committee and the program specialist, prior to the use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least every 6 months.
| Regulation 6400.195(d) was reviewed with the Program Specialist on 7/12/18 by the CEO (Attachment #1). The restrictive procedure plan was reviewed, approved, signed and dated by the chairperson of the restrictive procedure review committee and the Program Specialist on 12/2/17 (Attachment #5). |
07/12/2018
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include his/her (i) date of admission to the agency, (ii) race, hair color, eye color, identifying marks, (iii) language or means of communication spoken or understood, (iv) religious affiliation, and (vi) current dated photograph. | 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.
| Regulation 6400.213(1)(i-iv) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). Individual #1¿s record sheet was updated on 8/1/18 by Stephanie Smith to include regulation 6400.213(1)(i) her date of admission to the agency, 6400.213(1)(ii) race, hair color, eye color and identifying marks, 6400.213(1)(iii) language or means of communication spoken or understood 6400.213(1)(iv) religious affiliation, and 6400.213(1)(vi) current dated photograph (Attachment #2). Individual #1 is the only client under RHS and is the only resident record to be reviewed and corrected. Job description was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO, to achieve and maintain ongoing compliance with regulations within PA Chapters 6400 (Attachment #3). |
08/01/2018
| Implemented |
| 6400.213(11) | Individual #1's Individual Support Plan (ISP) indicated that Individual #1 could not self administer his/her medications and that he/she requires staff assistance with medication administration. Individual #1's psychiatrist indicated on a physician form that Individual #1 is not able to self medicate. Currently, the agency is allowing Individual #1 is self medicate all of his/her medications. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | Regulation 6400.213(11) was reviewed with the Program Specialist Stephanie Smith on 7/12/18 by the CEO (Attachment #1). Program Specialist Stephanie Smith scheduled ISP review meeting on 8/8/18 and will address 6400.213(11) violation (Attachment #4). Individual #1 has a scheduled appointment with her psychiatrist on 9/19/18 to review ability to self-medicate. Stephanie Smith will include content discrepancy in the individuals record within 7 days from the 8/8/18 meeting. |
08/15/2018
| Implemented |