| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
|
SIN-00231187
|
Unannounced Monitoring
|
08/02/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.71 | On 8/2/2023, two cordless telephone handsets were observed on the windowsill to the left of the fireplace. Neither handset had the telephone numbers of the nearest hospital, police department, fire department, ambulance, and poison control center on or near the device. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| Serenity Care staff will ensure that Telephone numbers of the nearest hospital, police department, fire department, ambulance, and poison control center shall be on or by each telephone in the home with an outside line. |
10/13/2023
| Implemented |
| 6400.166(a)(11) | On 8/2/2023, the following medications prescribed to Individual #1 did not indicate the diagnosis or purpose for prescribing the medication on the August 2023 medication administration record: Omeprazole DR 20mg capsule, Ferrous Sulfate 325mg tablet. | 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. | Serenity Care will ensure that A medication record shall be kept for each individual for whom a prescription medication is administered. Serenity Care will ensure that if an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. |
10/13/2023
| Implemented |
|
|
|
SIN-00226857
|
Unannounced Monitoring
|
06/16/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Maintenance Staff #3 did not have a Pennsylvania criminal history record check submitted within 5 working days of hire. The only criminal history record check on file was submitted on 6/29/2023. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| Serenity Care staff will ensure that PA Criminal History Clearance checks for New hires are done timely, and would be within the 5 working days as stipulated in PA Code Chapter 6400.21(a). |
07/15/2023
| Implemented |
| 6400.62(a) | In the basement of the home, numerous poisonous substances to include 1 gallon of Behr Wet-Lock Sealer, 1 quart of Minwax Protective Finish, 14oz of Titebond II Wood Glue, and 1 quart of Rapid Set Concrete Leveler Primer were not in a locked area. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The Program Director will ensure that all poisonous materials shall be kept locked are made inaccessible to individuals. Serenity Care staff will ensure that all poisonous materials are kept out of the access of individuals while being used and immediately locked after each use and made inaccessible to individuals. |
07/15/2023
| Implemented |
| 6400.64(a) | The stove was observed with burnt on food remnants and debris built up around the burners. The microwave in the kitchen was black on the top inside which appeared to be caused by a fire inside the appliance. The microwave also contained splattered on food remnants throughout the inside and rust on the inside of the door of the appliance. In the living room of the home, the furnace vent was covered in a thick layer of dust, dirt, and cobwebs. In individual #1's bedroom, a fan was located on the individual's bed, the fan blades and front guard was covered in a thick layer of dirt and dust. In the full bathroom on the second floor of the home, the inside of the medicine cabinet was coated in a brownish colored substance. In the full bathroom on the second floor of the home, the bathtub walls and surrounding tiles were covered with dirt and what appeared to be mold and/or mildew. | Clean and sanitary conditions shall be maintained in the home. | Serenity care staff will ensure that homes remain clean and in sanitary conditions. Serenity care staff will complete daily cleaning logs documenting the completion of daily mandatory cleaning shift responsibilities. Serenity care staff will deep clean homes weekly to ensure they are in regulatory compliance with Chapter 6400.64(a) . |
07/15/2023
| Implemented |
| 6400.64(b) | In individual #1's bedroom, the windowsill in the closet had a significant amount of what appeared to be small black bugs as well as a dead bee. | There may not be evidence of infestation of insects or rodents in the home. | Serenity Care staff will ensure that homes are in clean and sanitary conditions shall be maintained in the home at all times. Serenity care staff will complete daily cleaning logs for all chores that are completed daily. Serenity care staff will deep clean homes weekly to ensure that the homes meet sanitary conditions. Serenity Care staff will ensure that the kitchens are cleaned and disinfected daily to ensure that there is no evidence of infestation of insects or rodents in the home. |
07/15/2023
| Implemented |
| 6400.67(b) | In the basement of the home, a puddle of water approximately five feet by 3 feet was located on the floor creating a potential slipping hazard. In individual #1's bedroom, the closet door was obstructed by clothing that was piled approximately 3 feet high on the floor creating a potential tripping hazard. In individual #1's bedroom, an area rug is located on the floor, that was not flat against the floor and presented a possible tripping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The maintenance designee will ensure that all work orders are addressed within the priority of the issues, and all efforts towards fixing the maintenance order will be adequately and appropriately documented within the work order system. ( Including the use of outside vendors)
Serenity care staff and maintenance designee will ensure that there are no potential hazards within the home and all safety measures are taken to ensure the area is secured until the work order is completed. Serenity care staff will monitor the activity in the area to ensure that any potential hazard does not harm the individual. |
07/15/2023
| Implemented |
| 6400.72(b) | In the window of the living room of the home, the screen had multiple rips in various lengths and does not protect from possible infestation. | Screens, windows and doors shall be in good repair. | Serenity Care program director will conduct monthly checks to ensure that screens are still installed and submit work orders for the maintenance designee to fix any screens that need to be completely sealed. All staff of Serenity Care was trained and in-service on regulation 6400.72(a) and reported any screens not properly sealed immediately to the program director. |
07/15/2023
| Implemented |
| 6400.76(a) | One of the chairs located at the dining room table had a broken leg and was not sturdy. All of the chairs located at the dining room table had dirt and dust covering the backs and edges and the seat cushions were covered in various stains. In individual #2's bedroom, a dining room chair was located in the corner of the room and the chair had a broken seat was not sturdy. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Serenity care staff will replace any broken or hazardous furniture with non-hazardous furniture. The Program Manager will ensure this site is well maintained according to 55 PA Code Chapter 6400.76(a) and that all furniture remains clean and sturdy. |
07/15/2023
| Implemented |
| 6400.80(b) | Next to the exterior walkway at rear of the home, a piece of wood, that appeared to have once been a portion of a railing was sticking out of the ground approximately 2 inches creating a potential tripping hazard. In the rear of the home, is a broken fence and on the opposite side of the fence is a steep hillside. The broken portion of the fence may potentially pose a risk if a staff or individual were to fall, allowing them to roll over the hillside. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Serenity Care Maintenance designee will ensure that any broken or hazardous furniture or materials are removed from the outside of the building and the yard or grounds and that the grounds are well maintained and free from unsafe conditions.
All staff of Serenity Care will be serviced and trained on the implemented policies regarding reporting maintenance issues within 24 hours of discovering the problem in the home to ensure that issues are addressed to ensure homes meet the standards outlined in the 6400 Regulations to prevent any future violations from re-occurring. |
07/15/2023
| Implemented |
| 6400.81(k)(2) | In individual #2's bedroom, the mattress was covered with various stains and appeared to be turning brown in color over the entirety of the mattress. | In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. | Serenity care staff will replace all soiled mattresses with new ones and ensure all mattress covers are washed weekly to ensure that the bed is protected and maintained in compliance with 55 PA Code Chapter- 6400.81(k)(2). |
07/15/2023
| Implemented |
| 6400.81(k)(3) | In individual #2's bedroom, the mattress did not have linens or a pillow. | In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season. | Serenity Care staff will ensure that each individual bedroom has adequate bedding, including pillows, linens, and blankets appropriate for the season.
Serenity Care staff will ensure that all linen is washed weekly and/or as needed to ensure that they are clean and in compliance with the 55 PA Code Chapter 6400 regulations.
Serenity Care Program Director will ensure that the home has extra linen in the homes for appropriate seasons. |
07/15/2023
| Implemented |
| 6400.81(k)(5) | In individual #1's bedroom the clothing racks were not accessible to be used due to the inside of the closet which is obstructed by clothing that is piled approximately four feet high on the floor. | In bedrooms, each individual shall have the following: Closet or wardrobe space with clothing racks and shelves accessible to the individual. | Serenity Care Maintenance designee will ensure that bar and or clothes racks and shelves are accessible to the individual.
The Program Director will ensure the bars/ and or clothing racks remain in the bedrooms and is accessible to the individual and clothes are properly hung and stored to remain in compliance with regulation 6400.81(k)(5). |
07/15/2023
| Implemented |
| 6400.83(c) | In the kitchen of the home, a George Foreman brand counter-top grill had caked on food and grease and it appeared that the grill is not being cleaned after each use. | Utensils used for eating, drinking and preparation of food or drink shall be washed and rinsed after each use. | Serenity care staff will ensure that all dishes are properly washed and disinfected, and stored in the proper storage areas in the designated area in the kitchen.
Serenity care staff will ensure that appliances are properly cleaned after each use. |
07/15/2023
| Implemented |
| 6400.105 | An open kitchen size trash bag filled with dryer lint was leaning against the hot water tank in the basement of the home. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| Serenity care staff will check dryers after each use to ensure no excess lint buildup. The Program Director or other leadership designee will complete weekly on-site inspections to ensure dryers are free of fire hazards. |
07/15/2023
| Implemented |
| 6400.107 | A Konwin Compact Fan Heater space heater for a small size room was found in the basement of the home. | Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms.
| Serenity Care Program Director will immediately remove Konwin Compact Fan Heater space heater from the home. |
07/15/2023
| Implemented |
| 6400.151(a) | Direct support staff #2, date of hire 11/19/2022, had their initial physical examination completed on 9/22/2021. Maintenance staff #3 does not have a current physical examination on file, date of hire was not provided. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Serenity Care Ceo will complete an audit of employee files to ensure all staff are in compliance with the required physical examination |
07/15/2023
| Implemented |
| 6400.151(c)(2) | Direct support staff #2, date of hire 11/19/2022, had their initial tuberculin skin test completed on 9/24/2021. Maintenance staff #3 does not have a current tuberculin skin test or chest x-ray on file, date of hire was not provided. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Serenity Care Ceo will complete an audit of employee files to ensure all staff are in compliance with the required tuberculin skin test by Mantoux method with negative results every 2 years; and if the tuberculin skin test is positive, an initial chest x-ray with results noted. |
07/15/2023
| Implemented |
| 6400.171 | In the refrigerator, a half-eaten bowl of what appeared to be oatmeal and milk was left uncovered and open to contamination in the back of the fridge. Other unsealed foods to include a half-use package of kielbasa sausage, two half-used package of bacon, a half-eaten package of hot dogs, and an open package of shredded cheese were found in the fridge. In the fridge, a dried-up, rotting, mushy plum was found along with packaged deli meat with a use-by date of 4/24/2023. A Banquet meatloaf dinner was also being stored in the fridge while the packaging states to keep the food frozen. In the pantry, the following expired food were found: Old ElPaso Street Taco Kit with best use date of 12/8/2022, Casa Mamita 12 crunchy taco shells with expiration date of 9/30/2021, box of Earthly Grains New Orleans style Jambalaya with a best use date of 1/5/2022, box of Kraft Macaroni and cheese with best use date of 5/21/2023, Teriyaki Noodles with best use date of 4/15/2022, Box of Casa Mamita 12 crunchy taco shells with best by date of 10/15/2020, box of Earthly Grains New Orleans style Jambalaya with a best by date of 8/18/2021, box of New Orleans Style dirty rice mix with a best by date of 8/15/2021, and box of Earthly Grains rice pilaf with a best use date of 11/4/2021 and a container of Muscle Milke Powder with a best by date of 10/2020. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Serenity Care staff will ensure that all expired food is discarded and weekly checks are conducted to ensure no expired foods are in the refrigeration and/or pantry or storage areas.
Serenity Care staff will protect all food from contamination while being stored, prepared, transported, and served. |
07/15/2023
| Implemented |
| 6400.46(a) | Direct support staff #2, date of hire 11/19/2022, completed their initial fire safety training on 3/27/2023. | 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. | Serenity Care CEO will ensure that all general fire safety training is completed, documented, and in on-site training binders before working with Individuals. The Program Manager will review all new hire orientation documentation for compliance with PA 6400.46(a) before getting approval from the CEO to place the new staff on the schedule or allowing access to working around individuals. |
07/15/2023
| Implemented |
| 6400.46(c) | Direct support staff #2, date of hire 11/19/2022, completed their initial first aid training on 3/27/2023. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques. | Serenity Care CEO will ensure that all initial and ongoing first aid training is completed, documented, and in on-site training binders before working with Individuals. The Program Director will review all new hire orientation documentation for compliance with PA 6400.46(c) before getting approval from the CEO to place the new staff on the schedule or allowing access to working around individuals. |
07/15/2023
| Implemented |
| 6400.51(a)(3) | Direct support staff #2, date of hire 11/19/2022, had orientation training completed 2/14/2023. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons. | Serenity Care CEO will ensure that all staff prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons. is completed, documented, and in on-site training binders before working with Individuals.
The Program Director will review all new hire orientation documentation for compliance with PA 6400.51(a)(3) before getting approval from the CEO to place the new staff on the schedule. |
07/15/2023
| Implemented |
| 6400.51(b)(1) | Direct support staff #2, date of hire 11/19/2022, did not complete training to encompass the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships during orientation. There was record of this training was completed on 11/1/2021 prior to hire but outside of the 12-month window for the training. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Serenity Care CEO will ensure that all staff prior to working alone with individuals, complete the required training to encompass the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships.
The Program Director will review all new hire orientation documentation for compliance with PA 6400.51(b)(1) before getting approval from the CEO to place the new staff on the schedule. |
07/15/2023
| Implemented |
| 6400.52(b)(2) | Maintenance staff #3 did not complete 12 hours of training during the 1/1/2022 -- 12/31/2022 staff training year. | The following shall complete 12 hours of training each year: Dietary, housekeeping, maintenance and ancillary staff persons. This provision does not include a person who provides dietary, housekeeping, maintenance or ancillary services, if the person is employed or contracted by the building owner and the licensed facility does not own the building. | Serenity Care CEO will ensure that all staff completes the required annual 12 hour training.
The Program Director will review all required training documentation for compliance with PA 6400.46(a) before getting approval from the CEO to place the new staff on the schedule or allowing access to working around individuals. |
07/15/2023
| Implemented |
| 6400.52(c)(1) | Maintenance staff #3 did not complete training on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships during the 1/1/2022 -- 12/31/2022 staff training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Serenity Care CEO will ensure that all staff prior to working alone with individuals, complete the required training to encompass the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships.
The Program Director will review all new hire orientation documentation for compliance with PA 6400.52(c)(1) before getting approval from the CEO to place the new staff on the schedule. |
07/15/2023
| Implemented |
| 6400.52(c)(2) | Maintenance staff #3 did not complete training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse during the 1/1/2022 -- 12/31/2022 staff training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | Serenity Care CEO will ensure that all staff prior to working alone with individuals complete training on the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse.
The Program Director will review all new hire orientation documentation for compliance with PA 6400.52(c)(2) before getting approval from the CEO to place the new staff on the schedule. |
07/15/2023
| Implemented |
| 6400.52(c)(3) | Maintenance staff #3 did not complete training on individual rights during the 1/1/2022 -- 12/31/2022 staff training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Serenity Care CEO will ensure that all staff prior to working alone with individuals complete training on individual rights.
The Program Director will review all new hire orientation documentation for compliance with PA 6400.52(c)(3) before getting approval from the CEO to place the new staff on the schedule. |
07/15/2023
| Implemented |
| 6400.52(c)(4) | Maintenance staff #3 did not complete training on recognizing and reporting incidents during the 1/1/2022 -- 12/31/2022 staff training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Serenity Care CEO will ensure that all staff prior to working alone with individuals complete training on on recognizing and reporting incidents.
The Program Director will review all new hire orientation documentation for compliance with PA 6400.52(c)(4) before getting approval from the CEO to place the new staff on the schedule. |
07/15/2023
| Implemented |
| 6400.165(c) | Individual #2's medication is not being administered as prescribed. Individual #2 is prescribed Docuasate Sodium with instruction to take 1 capsule twice a day. On April 11 2023 the medication was filled with 60 pills; currently 51 capsules are present. This medication was also filled on 5/12/23 with 60 pills; currently 51 of these capsules are present. Individual #2 is also prescribed Advair inhaler with instructions to inhale 1 puff by mouth twice a day. This medication was filled on 11/9/22 with 60 puffs and there are currently 11 puffs left. Then this medication was refilled again on 4/7/23 with 60 puffs and there are currently 45 puffs left. | A prescription medication shall be administered as prescribed. | Serenity Care will ensure that all prescription medications are administered at the designated time and documented adequately on the individual's MAR. Serenity Care will ensure that if an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record.
Serenity Care certified assigned nurse will complete weekly audits to ensure there are no data gaps on individuals' mars and daily administering is properly documented. |
07/15/2023
| Implemented |
| 6400.169(a) | Direct support staff #1 was trained on medication administration through the Department's Modified Medication Administration Training Course on 1/21/2023. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Serenity Care CEO and or other leadership designee will ensure that there is documentation to support staff successfully completing a department-approved medication administration course, including the course renewal requirements. |
07/15/2023
| Implemented |
|
|
|
SIN-00213100
|
Renewal
|
10/12/2022
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(1) | On 10/13/22 at 12:20 PM, the home did not have a financial ledger to account for Individual #1's cash on hand allowance that had been distributed onto a pre-paid Visa gift card. Individual #1, who was at day programming, had possession of this Visa gift card; therefore, a card balance could not be obtained. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | Serenity Care will create a separate Financial Ledger for each client that will be kept at the clients home, updated and monitored on a daily basis. The Financial Ledger will include the amount distributed to clients, and the addition or subtraction of monetary transactions. |
11/01/2022
| Implemented |
| 6400.66 | The only light bulb inside the refrigerator was observed burnt out at 11:58 AM on 10/13/22, causing insufficient lighting. On 10/13/22 at 12:00 PM, the half bathroom located in the basement was observed with having 3 non-functioning battery-operated push lights mounted on both sides of the mirror causing insufficient lighting in the vanity area. On 10/13/22 at 12:25 PM, there wasn't any nearby lighting source found outside the exit door of the enclosed porch. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The light bulb was replaced immediately after inspection. |
11/01/2022
| Implemented |
| 6400.101 | The basement door located near the inactive fireplace leading into the garage was observed at 12:05 PM on 10/13/22 with a deadbolt that can only be unlocked with a key from the garage side. The garage's man door to the outside also has a deadbolt that only can be unlocked with a key from inside the garage. Therefore, the garage is a potential entrapment area and its man door is a blocked egress. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| All deadbolt locks with the keys that can only lock from the inside will be removed and replaced with one sided deadbolt locks where a key is only needed for entry not exit. |
12/01/2022
| Implemented |
| 6400.113(a) | Individual #1 received training in general fire safety 9/1/22 and then again 9/21/22. | 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. | All annual individual Fire Safety Trainings will be signed and dated by the client, based off the client's admission date (month/ day) to Serenity Care and the current year. |
11/01/2022
| Implemented |
| 6400.141(a) | Individual #1 had physical examinations completed 11/5/20 and then again 12/9/21. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Serenity Care will assure that all Physical Examination appointments are scheduled 12 months apart and monitored by the Program Manager. |
11/01/2022
| Implemented |
| 6400.141(c)(4) | Individual #1 had vision screenings completed 7/2/21 and then again 8/16/22. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The Program Management will schedule confirm and document all participant medical appointments completed according to 6400 regulations. |
11/01/2022
| Implemented |
| 6400.141(c)(7) | Individual #1, date of birth 10/29/87, had a gynecological examination, including a breast examination and a Pap test completed 6/30/21 and then 8/12/22. | 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. | The Program Management will schedule confirm and document all participant medical appointments completed according to 6400 regulations. |
11/01/2022
| Implemented |
| 6400.141(c)(13) | Indivdiual #1's physical examination completed 12/9/21 did not include contraindicated medications. This section was left blank. | The physical examination shall include: Allergies or contraindicated medications. | Serenity Care Program Management will confirm and attach a medication list, contraindicated medications and diagnosis prior to the participants appointment and assures the physician reviews signs and dates form at the end of the appointment. |
11/01/2022
| Implemented |
| 6400.34(a) | Individual #1 was informed of and explained individual rights and the process to report a rights violation 9/1/21 and then again 9/21/22. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | All annual Individual Rights will be signed and dated by the client, based off the client's admission date (month/ day) to Serenity Care and the current year. |
11/01/2022
| Implemented |
| 6400.181(f) | Individual #1's 10/11/21 assessment was provided to the SC and plan team members 10/21/21 for an annual ISP meeting held 11/4/21. [Repeat violation 11/30/21 et. al] | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Serenity Care Program Specialist will provide clients individual team plan members with an Annual Assessment 30 days prior to the ISP meeting. |
11/01/2022
| Implemented |
|
|
|
SIN-00196795
|
Renewal
|
11/30/2021
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.166(a)(8) | Individual #1's December 2021 Medication Administration Record did not include the route of administration for the following medications: Chlorpromazine 200mg Take one tablet two times a day and Cholecalciferol 2000 unit Take one capsule daily. Individual #2's December 2021 Medication Administration Record did not include the route of administration for the following medications: Quetiapine Fumarate 100mg Take one tablet daily at bedtime, Quetiapine Fumarate 50mg Take one tablet daily in morning at 8AM and at bedtime, Sertraline 50 mg Take one tablet daily in the morning at 8AM | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | Pharmacist was contacted who creates MAR and notified of the requirement to add "route" of medication. Program Specialist will review and ensure that each MAR includes the route of administration |
12/17/2021
| Implemented |
| 6400.166(a)(11) | Individual #1's December 2021 Medication Administration Record did not include a purpose or diagnosis for prescribed medications. These medications include, but are not limited to: Individual #2's December 2021 Medication Administration Record did not include a purpose or diagnosis for prescribed medications. These medications include, but are not limited to:
Chlorpromazine 200mg Take one tablet two times a day
Cholecalciferol 2000 unit Take one capsule daily | 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. | Pharmacist was contacted who creates MAR and notified of the requirement to add "route" of medication. Program Specialist will review and ensure that each MAR includes the purpose of administration |
12/17/2021
| Implemented |
| 6400.166(a)(13) | Individual #1's December 2021 Medication Administration Record was initialed for medication administration on 12/1/21 at 8 AM; however, the name of the staff person whose initials were on the form was not indicated on the form, as required. Individual #2's December 2021 Medication Administration Record was initialed for medication administration on 12/1/21 at 8 AM; however, the name of the staff person whose initials were on the form was not indicated on the form, as required | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | The name and initial for each individual who is certified to administer medication shall be recorded on a medication record available in the MAR |
12/17/2021
| Implemented |
| 6400.181(f) | Individual #2's assessment, completed on 10/11/21, was sent to the Supports Coordinator and plan team members on 10/21/21 for the Annual ISP meeting, held on 11/4/21. | 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 has adjusted the SEND BY date for the assessment to be received at least 30 days prior to the ISP |
12/17/2021
| Implemented |
|
|
|
SIN-00182310
|
Renewal
|
01/28/2021
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.106 | The furnace was inspected and cleaned on 4/12/2019 and then again on 11/9/2020. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The furnace was last inspected and cleaned on 09/12/2019 (correction to 04/12/2019) noted in the violation; then again on 11/9/2020.
The agency has a contract with the undisclosed professional furnace cleaning company to complete a cleaning annually which is scheduled in collaboration with the agency's maintenance supervisor as well as the furnace company scheduler.
The appointment is then provided to the office manager who maintains a calendar schedule of all maintenance appointments.
Due to the impact of COVID-19 at the time of scheduling for the September 2020 cleaning, the agency was advised that the company was unable to schedule any maintenance service calls that were not emergent.
Documentation of the appointments have been uploaded to reflect POC |
02/12/2021
| Implemented |
| 6400.15(b) | The agency did not use the Department's licensing inspection instrument when completing a self-assessment on 8/23/2020. The document did not include all of the elements of the 55 Pa. Code Chapter 6400 regulations including but not limited to the following sections: general requirements, individual rights, staffing, fire safety, individual health, individual records and restrictive procedures. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | On 1/29/2021; the office manager obtained the most up to date and current licensing inspection instrument available at: https://www.dhs.pa.gov/Services/Disabilities-Aging/Documents/Developmental%20Programs%20Licensing/Chapter%206400%20Score%20Sheet%20(s_002510).pdf.
It.
The CEO, Maintenance Supervisor, Office Manager, and Residential House Leads were trained in accordance to the form. information from the agency created inspection tools were transferred to the Department's licensing inspection instrument
The Department licensing form will be distributed 30 days prior to its deadline to residential leads to be completed within 7 days returned to office manager. Office Manager will transfer documentation to Maintenance supervisor to be returned within 7 days to Office Manager. The form will be reviewed and approved by CEO and returned to Office Manager for submission at least 3 business days prior to deadline. The form will be maintained by Office Manager pending Department on-site inspection [Documentation of the aforementioned review and approval by the CEO shall be kept. (DPOC by AES,HSLS on 3/9/21)] |
01/29/2021
| Implemented |
| 6400.34(a) | Individual #1 was informed and explained individual rights on 5/12/2020. The rights document did not include the following rights: 6400.32g, the right to control his own schedule and activities; 6400.32l, to receive scheduled and unscheduled visitors and to communicate and meet privately with whom the Individual chooses, at any time; 6400.32m, the right to unrestricted access to send and receive mail and other forms of communications , unopened and unread by others, including the right to share contact information with whom the individual chooses; 6400.32m, the right to unrestricted and private access to telecommunications; 6400.32o, the right to manage and access the individual's finances; 6400.32p, choose persons with whom to share a bedroom; 6400.32q, to furnish and decorate the Individual's bedroom and the common areas of the home; 6400.32r, to lock the Individual's bedroom door; 6400.32s, to have a key, access card, key code or other entry mechanism to lock and unlock an entrance door of the home; 6400.32t, to access food at any time. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | On 02/3/2021 the individual was provided an updated and current copy of the Individual Rights of the individual to include all rights listed under 6400.32a-v. The document was obtained and created by the office manager from: https://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/055/chapter6400/s6400.32.html&d=reduce
and distributed to residential lead to be reviewed and completed with individual. A copy was provided to the individual with a signed copy maintained by the office manager. The individual annual packet was updated to include the current Rights of the Individual Form.
Office Manager will be responsible for ensuring that current individual rights form is current and up to date.
[On 3/11/21, a copy of the signed (2/3/21) updated right documents was provided to the Department. AES,HSLS on 3/11/21)] |
02/03/2021
| Implemented |
|
|
|
SIN-00145917
|
Renewal
|
11/15/2018
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency did not completed a self-assessment for the 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.
| The agency has completed a self assessment for the residential site. The agency has implemented a hard copy self assessment into the annual inspection packet with a deadline of completion 4 month prior to the annual inspection.Areas that require the attention of the agency to ensure compliance will be completed within 30 days of acknowledgment.The Home Self Assessment task and dates were added to the participants pre-filled dated calendar for completeness and sign-off by CEO and Program Manager. [Self-Assessment of home completed on 12/10/18. Prior to 3 months of the expiration of the current certificate of compliance, the CEO shall audit all self-assessments of the homes to ensure timely and full completion as required. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 1/8/19)] |
12/07/2018
| Implemented |
| 6400.21(a) | Direct Service Worker #1, date of hire 7/13/18; however, the Pennsylvania criminal history record check was requested 7/19/18. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| The initial Pennsylvania criminal history record check was completed 3/13/2017, however direct service worker #1 deferred start date. Direct Service worker #1 start date was amended to 7/13/18, a follow up criminal check was completed on 7/19/18. Human resources will ensure that a criminal background check will be completed within 5 working days after the person's date of hire. A new employee validation checklist was created with tasks and required dates to be completed for each new or re-hired staff. [Within 5 days of hire, the CEO or designee shall audit all staff persons Pennsylvania criminal history record checks and aforementioned employee validation checklist to ensure timely completion of Pennsylvania criminal history record check. Documentation of audits shall be kept. (DPOC by AES,HSLS on 1/8/19)] |
11/16/2018
| Implemented |
| 6400.21(c) | Direct Services Worker #2, date of hire 8/12/18, had a Pennsylvania criminal history record check completed on 1/28/17. | The Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person¿s date of hire.
| Direct Service Worker #2 is a rehire, . An update criminal check was completed on 11/15/2018. Human resources will ensure that the criminal background checks are completed no more than 1year prior to direct worker's date of hire. A review of all direct care workers criminal checks have been completed to ensure that all are in compliance in accordance to the above regulation.Human resources will ensure that a criminal background check will be completed within 5 working days after the person's date of hire. A new employee validation checklist was created with tasks and required dates to be completed for each new or re-hired staff. [Within 5 days of hire, the CEO or designee shall audit all staff persons Pennsylvania criminal history record checks and aforementioned employee validation checklist to ensure timely completion of Pennsylvania criminal history record check. Documentation of audits shall be kept. (DPOC by AES,HSLS on 1/8/19)] |
11/16/2018
| Implemented |
| 6400.110(h) | There was not a written procedure for fire safety monitoring in the even the smoke detector or fire alarm is inoperative. | There shall be a written procedure for fire safety monitoring in the event the smoke detector or fire alarm is inoperative. | A written procedure has ben created and implemented for safety monitoring in the event the smoke detector or alarm is inoperative. Staff have been trained on the implementation of the procedure. The procedure has been filed at each residential site.Upon hiring, each staff person will be trained on the information,.The CEO will validate the Company's current policies with Chapter 6400 required Policies, anything non compliant, Serenitycare will create and train staff. [Policy updated to include a fire safety monitoring procedure. Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff persons of the written procedure for fire safety monitoring in the event the smoke detector or fire alarm is inoperative. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 1/8/19)] |
11/16/2018
| Implemented |
| 6400.112(c) | The written fire drill for the fire drill held on 3/1/18 does not indicate the amount of time it took for evacuation. [Repeat Violation 11/9/17] | 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. | The fire drill on 3/11/18 has been updated to indicate the amount of time it took for evacuation. All fire drills were reviewed to ensure that the amount of time it took for evacuation is documented. Program Specialist and Program Manager will review and sign off on all fire drills. [Within 30 days of receipt of the plan of correction, upon hire, at least annually and prior to conducting a fire drill, the CEO or designee shall educate all staff person responsible for conducting and reviewing fire drill documentation of the requirements of conducting and documenting fire drills as per 6400.112(a)-(I). Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 1/8/19)] |
11/16/2018
| Implemented |
| 6400.141(c)(6) | Individual #1 had a Tuberculin skin test by Mantoux method with a negative result on 4/20/16 and then again on 10/19/18. [Repeat Violation 11/9/17] | 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. | A immunization log has been created to reflect the time frame and deadline in accordance with the regulatory guidelines for immunizations. The next administration is due two years from the most recent date of the injection.
Upon admission of clients, a review of client immunization will be reviewed to populate the calendar for upcoming immunization.The Required vaccines and dates were added to the participants pre-filled dated calendar for completeness and sign-off by Program Specialist and Program Manager. Additionally, the staff received training not to accept the participant without proper vaccines prior to transition to Serenitycare. [Immediately, and at least quarterly for 1 year, the CEO or designee shall audit all Individualized calendars and aforementioned review documentation to ensure completion and regulatory requirements are met. (DPOC by AES,HSLS on 1/8/19)] |
12/14/2018
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination, dated 3/28/18, does not include medical information pertinent to diagnosis and treatment in case of an emergency. [Repeat Violation 11/9/17] | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Information pertinent to diagnosis and treatment in case of an emergency has been populated by a medical professional. The physical medical form has been amended to highlight the missed field. Training has been provided to staff to ensure that all fields are completed at the conclusion of each medical appointment.
Program Specialist will review each form for completion following medical appointment. A follow up appointment will be scheduled in the event that the field is not populated accurately.A calendar and review sign/off document was created for each participant to verify that the scheduled physical examination documents were verified for completeness and accuracy by the staff and program specialist. [Individual's physical examination form, updated to included information pertinent to diagnosis in case of an emergency. Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff person responsible for ensuring all required areas of individuals' physical examinations are completed and reviewed shall be educated in the requirements of individuals' physical examinations as per 6400.141(c)(1)-(15) and the aforementioned process to have physical examinations completed and documented on the aforementioned calendar. Documentation of trainings shall be kept. Immediately, and at least quarterly for 1 year, the CEO or designee shall audit all Individualized calendars and aforementioned review documentation to ensure completion and regulatory requirements are met. (DPOC by AES,HSLS on 1/8/19)] |
12/14/2018
| Implemented |
| 6400.181(e)(6) | Individual #1's assessment, dated 4/5/18, does not include the individual's ability to safely use or avoid poisonous materials. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | The assessment was amended to reflect the individual's ability to safely use or avoid poisonous materials. An amended assessment has been signed and dated by both the individual and program specialist. The assessment has been recorded in the clients profile. The SC as well as team members have been notified of the updated information reflected in the assessment. Program Specialist and Program Manager will ensure that all fields are created and verified per compliance standards on all company created documents, prior to document distribution and staff usage. [Individual #1's assessment was updated on 11/15/18 to include the individual's ability to safely use or avoid poisonous materials. Within 30 days of receipt of the plan of correction, the CEO or designee shall educate the program specialist as to the requirements of individuals' assessments as per 6400.181(e)(1)-(14). Documentation of trainings shall be kept. Upon completion for 1 year, the CEO or designee shall audit all individuals' assessments and Individualized calendars to ensure completion and regulatory requirements are met. (DPOC by AES,HSLS on 1/8/19)] |
11/16/2018
| Implemented |
| 6400.186(a) | The program specialist completed an ISP review for Individual #1 for a review period of 10/1/17 to 1/31/18; a review period which exceeds 3 months. [Repeat Violation 11/9/17] | 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. | The ISP was updated immediately to reflect the month/day/ year format. The above date was not recorded on the review, the format stated month/year which did not clearly indicate the review period. An updated forma has been completed to reflect accuracy regarding the review period.Program Manager will ensure that the periods of review clearly reflect the 3 month period from date to date through proper dating format.The ISP Quarterly review task and dates were added to the participants pre-filled dated calendar for completeness and sign-off by Program Specialist and Program Manager. [Immediately and upon hire and continuing at least annually, the CEO or designee shall educate the program specialist(s) of the responsibilities of the position as per 6400.44(b)(1)-(19) and the aforementioned process to ensure all responsibilities are met including completing 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. Documentation of the trainings shall be kept. Immediately, and at least quarterly for 1 year, the CEO or designee shall audit all Individualized calendars and aforementioned review documentation to ensure completion and regulatory requirements are met. (DPOC by AES,HSLS on 1/8/19)] |
11/16/2018
| Implemented |
| 6400.186(b) | Individual #1's ISP review, for review period 10/1/17 to 1/31/18, was not signed by the program specialist or Individual #1. Individual #1's ISP review, for review period 1/31/18 to 4/30/18, was not signed by the program specialist or Individual #1. Individual #1's ISP review, for review period 5/1/18 to 8/31/18, was not signed by the program specialist or Individual #1. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | The ISP review sheet was amended immediately to reflect a signature line for both the individual and client. The ISP was signed immediately by both the program specialist and client reflecting the current date. All ISP's for all clients have been reviewed to ensure that appropriate signatures have been recorded. Program Specialist will ensure signatures have been recorded on all ISPs.The ISP review signature task and dates were added to the participants pre-filled dated calendar for completeness and sign-off by Program Specialist and Program Manager.
[Individual 1's ISP reviews were signed by the individual on 11/15/18. Upon completion for 1 year, the CEO or designee shall audit all individuals' ISP reviews and Individualized calendars to ensure completion and regulatory requirements are met. (DPOC by AES,HSLS on 1/8/19)] |
11/16/2018
| Implemented |
| 6400.186(d) | The program specialist did not provide Individual #1's ISP review documentation completed from October 2017 to August 2018 to the plan team members. | 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. | The ISP's reviews have been forwarded to the appropriate and designated SC's. A record f submission and notification has been recorded and filed in the appropriate client profile. Future ISP documentation will be sent within 15 calendar day if an onsite monitoring is not scheduled within 30 calendar days. A log to record the documentation of submission has been implemented. Program Specialist will ensure that the documentation is submitted within the designated and allotted time.The ISP review task and dates were added to the participants pre-filled dated calendar for completeness and sign-off by Program Specialist and Program Manager. The email sent to the team or team sign-off form is a required document to be attached to the ISP review when filed.
[Individual #1's ISP reviews were provided to plan team members on 12/11/18. Immediately and upon hire and continuing at least annually, the CEO or designee shall educate the program specialist(s) of the responsibilities of the position as per 6400.44(b)(1)-(19) and the aforementioned process to ensure all responsibilities are met including providing 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. Documentation of the trainings shall be kept. Immediately, and at least quarterly for 1 year, the CEO or designee shall audit all Individualized calendars and aforementioned review documentation to ensure completion and regulatory requirements are met. (DPOC by AES,HSLS on 1/8/19)] |
12/07/2018
| Implemented |
| 6400.186(e) | The program specialist did not notify Individual #1's plan team members of the option to decline ISP review documentation. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | An option to decline was sent to the members of the individual's team. A print out of the record of receipt is maintained in the client's profile. Upon admission of a new client, an option to decline will be distributed to every member of the team upon introductory to the team. Program Specialist will ensure that all members receive option to decline.The ISP review Option Out task was added to the Participant calendar. The email sent to the team or team sign-off form is a required document to be attached to the Participant Anniversary ISP meeting documentation. The calendar task will be reviewed by the Program Manager for completeness. [The program specialist notified Individual #1's plan team members of the option to decline ISP review documentation on 12/7/18. Immediately and upon hire and continuing at least annually, the CEO or designee shall educate the program specialist(s) of the responsibilities of the position as per 6400.44(b)(1)-(19) and the aforementioned process to ensure all responsibilities are met including notifying the plan team members of the option to decline the ISP review documentation. Documentation of the trainings shall be kept. Immediately, and at least quarterly for 1 year, the CEO or designee shall audit all Individualized calendars and aforementioned review documentation to ensure completion and regulatory requirements are met. (DPOC by AES,HSLS on 1/8/19)] |
12/14/2018
| Implemented |
| 6400.194(c) | The restrictive procedure review committee for Individual #1 met 2/12/18 and then again on 9/25/18. [Repeat Violation 11/9/17] | The restrictive procedure review committee shall establish a time frame for review and revision of the restrictive procedure plan, not to exceed 6 months between reviews.
| The restrictive committee members were informed immediately of the error. A plan was implemented to schedule restrictive procedure meetings every 5 months, with a back up plan B date scheduled 2 weeks prior to the deadline in the event the initial date is not upheld. This plan of action is in regards to all clients at Serenity Care with a restrictive procedure plan. Upon admission of new clients, this plan will be in effect. The first meeting following admission, will begin the clients review period. The Program Manager will ensure that all clients are reviewed within the designated time period. The chairperson of the restrictive procedure committee will ensure that follow up meetings are held in a timely manner. An invitation for the upcoming meeting will be dispersed prior to the conclusion of he meeting, as well as a reminder sent 30 days prior to the next meeting, [Restrictive Procedures Committee Meeting for Individual #1 is scheduled for March 2019. (AES,HSLS on 1/8/19)] |
11/16/2018
| Implemented |
|
|
|
SIN-00124343
|
Renewal
|
11/09/2017
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.44(b)(10) | The program specialist did not review, sign and date monthly documentation for Individual #1, date of admission 4/5/17. | The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of an individual's participation and progress toward outcomes. | The program specialist reviewed, signed and dated the necessary monthly documentation. The CEO will review all documents produced by the program specialist for accuracy and completeness for a year. [Agency promoted qualified staff person into the program specialist position. Immediately, upon hire and continuing at least annually, the CEO shall train the program specialist(s) of the responsibilities of the position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. At least quarterly, the CEO shall audit monthly documentation of all individuals' participation and progress toward outcomes to ensure the program specialist is reviewing, signing and dating as required. Documentation of the audits shall be kept. (AS 2/16/18) |
12/01/2017
| Implemented |
| 6400.82(f) | The bathroom to the right of the stairs on the second floor of the home did not have soap. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Hand soap was placed in bathroom. Staff was educated on the importance of having hand soap in the bathroom at all times and to check the status before the change of every shift. [On 12/15/18, required items were in the bathroom. Immediately and upon hire, the CEO shall train all staff person regarding the required items in bathrooms and the replenishment and replacement procedures to ensure all bathrooms are stocked with required items at all time. Documentation of trainings shall be kept. At least monthly, the CEO shall check all bathrooms and replacement supplies to ensure bathrooms have all required items at all time. Documentation of monthly checks shall be kept. (AS 2/16/18)] |
11/09/2017
| Implemented |
| 6400.101 | The door in the basement leading to the garage is equipped with lock requiring a key from either side. There is not a man door in the garage. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| A Hall and Closet door fixture was installed on the door in the basement leading to the garage .[On 11/30/17, Co-owner changed the lock on the door to allow egress from the garage into the home. Immediately, upon hire and continuing at least annually, the CEO shall educated all staff persons that stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed and to immediately correct or report to the CEO. (AS 2/16/18)] |
11/30/2017
| Implemented |
| 6400.110(e) | The home, which had three stories including the basement, the first floor and the second floor, did not have an interconnected smoke detector on each floor or an automatic fire alarm system that is audible throughout the home. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | Interconnected smoke detectors were installed on the main level, second level and basement. [On 12/15/17, interconnected smoke detectors were tested and working. At least monthly, CEO or designated staff person shall test all smoke detectors. Documentation of the testing shall be kept. (AS 2/16/18)] |
11/27/2017
| Implemented |
| 6400.111(a) | The fire extinguishers on each of the three floors of the home had 1-A 10 BC rating. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | New fire extinguishers were installed in the all houses with the 2-A rating. Locations included: main level, 2nd level and basement. [On 12/15/17, fire extinguishers with 2-A rating were on each floor of the home. At least monthly the CEO or designee who is trained by the CEO in the requirements of fire extinguishers as per 6400.111(a)-(f) will check all fire extinguisher in all community homes to ensure all requirements regarding fire extinguisher is followed. Documentation of trainings and onsite visits to the homes shall be kept. (AS 2/16/18)] |
11/20/2017
| Implemented |
| 6400.112(c) | The written fire drill record for the fire drill held on 9/15/17 at 10:04 PM did not include the amount of time it took for evacuation. The written fire drill record for the fire drills held 6/26/17 at 1:42 and 7/16/17 at 1:34 did denote AM or PM. | 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. | A new fire drill form was created to capture the am/pm date, in addition to the during sleeping hours documentation. The staff was properly trained on how to document the new fire drill document and the importance of entering the data correctly. The program specialist or program manager will review and sign off all fire drill forms. [Immediately, the CEO shall review the new fire drill documentation form to ensure all required information including 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 is on the form. Immediately and upon hire, the CEO shall train all staff persons responsible for conducting fire drill on the requirements of fire drills and documentation of fire drills as per 6400. 112(a)-(I). Prior to staff persons conducting a fire drills on their own, the staff person shall be observed by the CEO or owner in conducting and documenting the fire drill. Upon completion of a fire drill, the CEO shall audit the fire drill documentation to ensure fire drills are completed and documented as required. Documentation of the audits shall be kept. (AS 2/16/18)] |
11/10/2017
| Implemented |
| 6400.112(e) | Fire drills were not held during sleeping hours from 4/5/17 to 11/9/17. | A fire drill shall be held during sleeping hours at least every 6 months. | A new fire drill form was created to capture the am/pm date, in addition to the during sleeping hours documentation. The staff was properly trained on how to document the new fire drill document and the importance of entering the data correctly.[Immediately, the CEO shall review the new fire drill documentation form to ensure all required information including 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 is on the form. Immediately and upon hire, the CEO shall train all staff persons responsible for conducting fire drill on the requirements of fire drills and documentation of fire drills as per 6400. 112(a)-(I). Prior to staff persons conducting a fire drills on their own, the staff person shall be observed by the CEO or owner in conducting and documenting the fire drill. Upon completion of a fire drill, the CEO shall audit the fire drill documentation to ensure fire drills are completed and documented as required. Documentation of the audits shall be kept. (AS 2/16/18)] |
11/10/2017
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination completed 3/29/17 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The individual received a follow up physical at which time the medical information pertinent to diagnosis and treatment was populated to reflect: none. In the future SerenityCare will not accept any individuals from any institution unless all the physical examination forms are reviewed for completeness and accuracy, prior to SerenityCare accepting the individual. [Individual #1 had physical examination on 4/17/17 that included medical information pertinent to diagnosis and treatment in case of an emergency. Immediately and upon competition, the CEO shall audit all individuals' current physical examinations to ensure required information is included. Documentation of the audits shall be kept. (AS 2/16/18)] |
12/01/2017
| Implemented |
| 6400.161(a) | A weekly medication organizer containing eight pills in the section marked Thursday AM was in Individual #1's medication box. Individual #1 is not assessed to self-administer medications. | Prescription and nonprescription medications shall be kept in their original containers, except for medications of individuals who self-administer medications and keep the medications in personal daily or who self-administer medications and keep the medications in personal daily or weekly dispensing containers. | The weekly medication organizer containing eight pills was discarded. Staff certified to administer medication were provided coaching regarding medication being stored in its original containers. The Medication Trainer or assigned designee will monitor the Medical Appointment Record entries Monthly. [Aforementioned training was completed by certified medication trainer for 2 direct service workers and the program manager. At least monthly, a certified medication trainer shall audit all individual medications, doctors' orders and medication administration records to ensure all individual are administered medications as prescribed and documented as required and that medications are stored in their original containers. Documentation of the audits shall be kept. (AS 2/16/18)] |
11/10/2017
| Implemented |
| 6400.163(c) | Individual #1's psychiatric medication reviews were completed 6/11/17 then again 9/27/17. Individual #1's psychiatric medication reviews completed 6/11/17 did not include the need to continue the medications Risperdone 3 mg and Chlorpromazine 50 mg. | 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. | Staff certified to administer medication were provided coaching regarding Medication Appointment Record Documentation for accuracy and completeness. The Medication Trainer or assigned designee will monitor the Medical Appointment Record entries Monthly. [Immediately, the CEO shall educate all staff persons who assist individual in having medication reviews of the requirements that medication reviews need to include the reason for prescribing the medication, the need to continue the medication and the necessary dosage and to audit the documentation at the time of the review/appointment. Documentation of the trainings shall be kept. Immediately and upon completion, the CEO and staff person certified to administer medications shall audit all documentation from the physician reviewing individuals' medications prescribed to treat diagnosed psychiatric illness to ensure all required information is included and individuals are being administered medications as prescribed. Documentation of audits shall be kept. (AS 2/16/18)] |
11/10/2017
| Implemented |
| 6400.164(a) | Clotrimazole Betameth cream 45 mg was present in Individual #1's medication box was not listed on Individual #1's current 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. | The Clotrimazole Betameth cream 45 mg was discarded for Individual #1 per prescription's directive for the 7 day use. Staff certified to administer medication were provided coaching regarding Medication Administration Documentation. The Medication Trainer or assigned designee will monitor the MARS book weekly. [Aforementioned training was completed by certified medication trainer for 2 direct service workers and the program manager. At least monthly, a certified medication trainer shall audit all individual medications, doctors' orders and medication administration records to ensure all individual are administered medications as prescribed and documented as required. Documentation of the audits shall be kept. (AS 2/16/18)] |
11/10/2017
| Implemented |
| 6400.164(b) | Levothyroxine 75 mcg, Loratidine 10 mg, Vitamin D, Sertraline HCL 50 mg, Klenor 1/35, Chlorpromazine 50 mg, Risperdone 3 mg prescribed for Individual #1 were not initialed as administered on 11/9/17 at 8:00AM. | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | The information specified was logged to notate that the medication was administered at the correct time. Staff certified to administer medication were provided coaching regarding Medication Administration Documentation. The Medication Trainer or assigned designee will monitor the MARS book weekly. [Aforementioned training was completed by certified medication trainer for 2 direct service workers and the program manager. At least monthly, a certified medication trainer shall audit all individual medications, doctors' orders and medication administration records to ensure all individual are administered medications as prescribed and documented as required. Documentation of the audits shall be kept. (AS 2/16/18)] |
11/09/2017
| Implemented |
| 6400.181(a) | Individual #1, date of admission 4/5/17, did not have an initial assessment. | 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 assessment was created and completed assessing the client's adaptive behavior. The CEO or designee assigned by the CEO will review the required initial assessment and any required documents created by the program specialist for any new clients for accuracy and completeness in the proper timeframe. [Individual #1's assessment was completed on 11/13/17. Immediately, upon hire and continuing at least annually, the CEO shall train the program specialist(s) of the responsibilities of the position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. Immediately, the CEO shall develop and implement a tracking system for all required documentation to ensure timely completion. At least quarterly, the CEO shall audit the tracking system to ensure timely completion of required documentation for all individuals including assessments. Documentation of audits shall be kept.(AS 2/16/18)] |
12/01/2017
| Implemented |
| 6400.186(a) | The program specialist did not complete ISP reviews for Individual #1, date of admission 4/5/17. | 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. | The program specialist completed an ISP review to properly document and reflect service changes needed [ISP reviews were completed for Individual #1 for review periods of 5/5/17 to 7/5/17 and 7/6/17 to 11/6/17 on 12/1/17. Immediately, upon hire and continuing at least annually, the CEO shall train the program specialist(s) of the responsibilities of the position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. Immediately, the CEO shall develop and implement a tracking system for all required documentation to ensure timely completion. At least quarterly, the CEO shall audit the tracking system to ensure timely completion of required documentation for all individuals including ISP reviews. Documentation of audits shall be kept.(AS 2/16/18)] |
12/01/2017
| Implemented |
| 6400.194(c) | The restrictive procedure review committee for Individual #1's most recently reviewed Individual #1's restrictive procedures on 3/27/17. | The restrictive procedure review committee shall establish a time frame for review and revision of the restrictive procedure plan, not to exceed 6 months between reviews.
| The restrictive procedure has been updated to reflect the reviews conducted by the review committee not to exceed 6 months. [Immediately, prior to implementation and at least quarterly, the CEO shall audit all restrictive procedures to ensure all requirements of restrictive procedures are followed as per 6400.191-206. Documentation of the audits shall be kept. (AS 2/16/18)] |
12/01/2017
| Implemented |
| 6400.195(d) | Individual #1's restrictive procedure plan, completed 3/27/17, was not signed and dated by the 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.
| Restrictive procedure has been reviewed, approved, signed, and dated by the chairperson of the restrictive procedure review committee and the program specialist [Immediately, prior to implementation and at least quarterly, the CEO shall audit all restrictive procedures to ensure all requirements of restrictive procedures are followed as per 6400.191-206. Documentation of the audits shall be kept. (AS 2/16/18)] |
12/01/2017
| Implemented |
| 6400.195(e)(1) | Individual #1's restrictive procedure plan, completed 3/27/17, did not include the specific behavior to be addressed and the suspected antecedent or reason for the behavior. | The restrictive procedure plan shall include: The specific behavior to be addressed and the suspected antecedent or reason for the behavior.
| The restrictive procedure includes, and describes the specific behavior to be addressed as well as the suspected antecedent or perceived reason for the behavior [Individual #1's restrictive procedure was updated by the CEO on 12/1/17 to include the specific behavior to be addressed and the suspected antecedent or reason for the behavior. Immediately, prior to implementation and at least quarterly, the CEO shall audit all restrictive procedures to ensure all requirements of restrictive procedures are followed as per 6400.191-206. Documentation of the audits shall be kept. (AS 2/16/18)] |
12/01/2017
| Implemented |
| 6400.195(e)(2) | Individual #1's restrictive procedure plan, completed 3/27/17, did not include the single behavioral outcome desired stated in measurable terms. | The restrictive procedure plan shall include: The single behavioral outcome desired stated in measurable terms. | The restrictive procedure includes the desired behavioral outcome stated in measurable terms. [Individual #1's restrictive procedure was updated by the CEO on 12/1/17 to include the single behavioral outcome desired stated in measurable terms. Immediately, prior to implementation and at least quarterly, the CEO shall audit all restrictive procedures to ensure all requirements of restrictive procedures are followed as per 6400.191-206. Documentation of the audits shall be kept. (AS 2/16/18)] |
12/01/2017
| Implemented |
| 6400.195(e)(3) | Individual #1's restrictive procedure plan, completed 3/27/17, did not include methods for modifying or eliminating the behavior, such as changes in the individual's physical and social environment, changes in the individual's routine, improving communications, teaching skills and reinforcing appropriate behavior. | The restrictive procedure plan shall include: Methods for modifying or eliminating the behavior, such as changes in the individual's physical and social environment, changes in the individual's routine, improving communications, teaching skills and reinforcing appropriate behavior.
| The restrictive procedure includes and lists methods for decreasing and eliminating the behavior such as changed in the individuals environment, routine, communication, and reinforcement of desirable behavior [Individual #1's restrictive procedure was updated by the CEO on 12/1/17 to include the Individual #1's restrictive procedure was updated by the CEO on 12/1/17 to include methods for modifying or eliminating the behavior. Immediately, prior to implementation and at least quarterly, the CEO shall audit all restrictive procedures to ensure all requirements of restrictive procedures are followed as per 6400.191-206. Documentation of the audits shall be kept. (AS 2/16/18)] |
12/01/2017
| Implemented |
| 6400.195(e)(5) | Individual #1's restrictive procedure plan, completed 3/27/17, did not include a target date for achieving the outcome. | The restrictive procedure plan shall include: A target date for achieving the outcome.
| The restrictive procedure states a target date for achieving the desired outcome. The CEO will review the restrictive procedures monthly. [Individual #1's restrictive procedure was updated by the CEO on 12/1/17 to include a target date. Immediately, prior to implementation and at least quarterly, the CEO shall audit all restrictive procedures to ensure all requirements of restrictive procedures are followed as per 6400.191-206. Documentation of the audits shall be kept. (AS 2/16/18)] |
12/01/2017
| Implemented |
| 6400.195(e)(6) | Individual #1's restrictive procedure plan, completed 3/27/17, did not include: The amount of time the restrictive procedure may be applied. | The restrictive procedure plan shall include: The amount of time the restrictive procedure may be applied, not to exceed the maximum time periods specified in this chapter.
| The restrictive procedure was updated to reflect the amount of time in which the restrictive procedure may be applied. A checklist was created to ensure that all fields are populated. [Individual #1's restrictive procedure was updated by the CEO on 12/1/17 to include the amount of time the restrictive procedure may be applied, not to exceed the maximum time periods specified in this chapter. Immediately, prior to implementation and at least quarterly, the CEO shall audit all restrictive procedures to ensure all requirements of restrictive procedures are followed as per 6400.191-206. Documentation of the audits shall be kept. (AS 2/16/18)] |
12/01/2017
| Implemented |
| 6400.195(e)(7) | Individual #1's restrictive procedure plan, completed 3/27/17, did not include: Physical problems that require special attention during the use of restrictive procedures. | The restrictive procedure plan shall include: Physical problems that require special attention during the use of restrictive procedures.
| The restrictive procedure plan has been populated to reflect physical problems that require attention during the use of restrictive procedures. A checklist has been created to ensure that all fields are populated. [Individual #1's restrictive procedure was updated by the CEO on 12/1/17 to include physical problems that require special attention during the use of restrictive procedures. Immediately, prior to implementation and at least quarterly, the CEO shall audit all restrictive procedures to ensure all requirements of restrictive procedures are followed as per 6400.191-206. Documentation of the audits shall be kept. (AS 2/16/18)] |
12/01/2017
| Implemented |
| 6400.195(e)(8) | Individual #1's restrictive procedure plan, completed 3/27/17, did not include: The name of the staff person responsible for monitoring and documenting progress with the plan. | The restrictive procedure plan shall include: The name of the staff person responsible for monitoring and documenting progress with the plan.
| The restrictive procedure plan has been populated to include the name of the staff person responsible for monitoring and documenting progress with the plan. A checklist has been created to ensure that all required fields are populated. [Individual #1's restrictive procedure was updated by the CEO on 12/1/17 to include the name of the staff person responsible for monitoring and documenting progress with the plan. Immediately, prior to implementation and at least quarterly, the CEO shall audit all restrictive procedures to ensure all requirements of restrictive procedures are followed as per 6400.191-206. Documentation of the audits shall be kept. (AS 2/16/18)] |
12/01/2017
| Implemented |
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SIN-00232213
|
Renewal
|
09/26/2023
|
Compliant - Finalized
|
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SIN-00164677
|
Renewal
|
10/22/2019
|
Compliant - Finalized
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SIN-00104348
|
Renewal
|
11/28/2016
|
Compliant - Finalized
|
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