Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00232214 Renewal 09/26/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(g)Individual #1 is prescribed medication to treat the symptoms of a psychiatric illness. Individual #1 has a psychiatric medication review completed on 7/25/2023; however, the prescribed medications were not indicated on the form [Repeat violation 10/12/22, et. al. and 6/16/23].If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Serenity care staff will ensure that a prescription order shall be kept current, and prescription medication shall be administered as prescribed. Serenity care staff A prescription medication shall be used only by the individual for whom the prescription was prescribed. Serenity care staff will ensure that changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes documentation of the reason for prescribing the medication, the need to continue the medication, and the necessary dosage. 10/13/2023 Implemented
SIN-00231193 Unannounced Monitoring 08/02/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)On 8/2/2023, a puddle of water measuring approximately 3 feet long by 3 feet wide was observed on the floor in the basement, in front of the washing machine posing a slipping hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.Serenity Care maintenance designee will ensure that all floors, walls, ceilings, and other surfaces are free of hazards, and conditions are free of any slipping hazard. Serenity Care CEO has implemented an electronic work order system to ensure that work order requests are documented and submitted to the maintenance designee, Within 24 hours of the issue being discovered. 10/13/2023 Implemented
SIN-00226674 Unannounced Monitoring 06/16/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Garbage was scattered on the basement floor to include used face masks, strips of paper, and food wrappers. The half bathroom located in the basement of the home had feces smeared on the inside of the toilet bowl, hair and a splattered blue substance in the sink basin, dirt and hair on the floor, and a substance splattered on the mirror. The stairs leading to the basement were covered in dirt, dust, and various small pieces of garbage. The blinds and ceiling of the kitchen were covered with splattered food and grease. The kitchen floor was observed with dried food and dirt in front of the refrigerator, in front of the sink, and in front of the trash can. The burners of the gas stove were coated with burnt on and built-up food particles and grease. The outside of the trash can was covered in dirt and built-up food. The inside of the microwave was splattered with dried food. The furnace vent below the window on the left side of the dining room was packed with dirt and dust. In the second-floor full bathroom dirty laundry was scattered throughout the bathroom and trash to include toilet paper, carboard toilet paper rolls, and used floss picks were scattered on the bathroom floor. The sink was full of dirt and hair and the toilet had dried feces smeared in inside the bowl and dried urine on the outside of in various places. The tiles on the bathroom walls were splattered with an unknown substance. The floor of the bathroom was covered with urine around the toilet and was so sticky that the licensing representative's shoes stuck to the floor. Labels from discarded toiletries to include power stick deodorant and soft-soap hand soap were stuck to the left side of the vanity. A container of coconut oil hair conditioner was uncovered on the bathroom sink and was observed with dirt in the oil. Trash to include empty cardboard toilet paper rolls and Tootsie Roll wrappers had been thrown in the cabinet of the vanity. The mattress in Individual #1's bedroom was dirty and was stained brown. An opened kitchen size trash bag, filled with garbage, was found on the floor in the basement of the home.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) 07/25/2023 Implemented
6400.64(b)Multiple small black bugs that appeared to be fruit flies were observed crawling on the ceiling in the kitchen.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
6400.65The half bathroom in the basement of the home does not contain a window and there is no mechanical vent in the bathroom.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. Serenity Care maintenance designee will ensure that the proper ventilation system is installed within the homes of the bathrooms to promote adequate ventilation in the area according to 55 Pa Code Chapter 6400.65. 07/25/2023 Implemented
6400.67(a)multiple holes of various sizes were observed on the walls throughout the home to include the bottom of the stairs in the living room, the dining room, individual's bedroom, and the spare bedroom. The door of the spare bedroom was broken with the bottom 1/3 panel broken out of the door. The door of the staff office was broken with the bottom 1/3 panel still in place, but the panel was not secure and left approximately a 1-inch gap. Inside the linen closet in the 2nd floor hallway, the ceiling was stained from what appeared to be previous water damage and the plaster was flaking.Floors, walls, ceilings and other surfaces shall be in good repair. Serenity Care maintenance designee will ensure that all floors, walls, ceilings, and other surfaces are repaired including the basement, and are in compliance according to 55 PA Code Chapter 6400.67 (a) 07/15/2023 Implemented
6400.67(b)The carpet on the stop step of the stairs leading to the basement was torn in two spots creating a potential tripping hazard. In the living room, near the front door, an approximate 2 inch by 2 inch piece of carpet missing exposing a tack strip which could potentially harm staff or individuals. 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 second floor spare bedroom, the bottom pane is missing from the window at the back of the home. A screen is in the window, but nothing is in place to protect the house from inclement weather. 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)The chairs in the dining room all had various stains. The chair at the dining room table closest to the living room had a seat that had completely come apart from the chair legs and the chair 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(a)The exterior stairs leading out from the basement were covered in moss which was slippery. Outside walkways shall be free from ice, snow, obstructions and other hazards. Serenity Care maintenance designee will ensure that outside walkways shall be free of obstructions and other hazardous conditions including removal of moss Serenity Care maintenance designee will ensure outside of the building and the yard or grounds shall be well maintained, in good repair, and free from unsafe conditions. 07/15/2023 Implemented
6400.81(k)(3)The mattress in Individual #1s bedroom was observed without proper linens. The bed did not have fitted or flat sheets.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 regulations of 55 PA Code Chapter 6400. Serenity Care Program Director will ensure that the home has extra linen in the homes for appropriate for seasons. 07/15/2023 Implemented
6400.114(b)On the front porch, cigarette butts were being disposed of in an empty candle jar. Approximately 50 butts had accumulated in the jar. The ash tray was not being emptied daily by staff per agency policy.Written smoking safety procedures shall be followed.All staff of Serenity Care will be in-serviced and trained on the implemented policies and procedures regarding written smoking safety procedures. 07/15/2023 Implemented
6400.171Expired food was found in the refrigerator to include Heinz Sweet Pickle Relish that expired in 2019, grape jelly that expired in 2021. The refrigerator also contained what appeared to be an onion that had molded beyond identification. Food to include marinating steak, frozen chicken, frozen hot dogs, frozen French fries, and frozen broccoli were found open to contamination in the fridge and freezer.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 ensure all food is protected from contamination while being stored, prepared, transported, and served. 07/15/2023 Implemented
6400.214(b)Individual #1's annual residential assessment was not kept at the residential home. Individual #1's annual vision examination paperwork was not kept at the residential home. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. Serenity Care Program Director will ensure that there is a file for each individual at each home. This file will contain each individual's most recent annual physical, annual assessment, and ISP. This book will keep locked in each home's respective office area. 07/15/2023 Implemented
6400.32(t)Direct support staff #1, Direct Support staff #2, and individual #1 all stated that individual #1 was not allowed to be in the kitchen either supervised or unsupervised due to the individual's history of intentionally setting fires. Individual #1 has a Restrictive Procedure Plan; however, this restriction is not outline in the plan.An individual has the right to access food at any time.Serenity Care staff will ensure that individuals have the right to access food at any time and if there are any restrictions it must be outlined in the individuals Restrictive Procedure Plan. 07/25/2023 Implemented
6400.165(g)Individual #1's psychiatric medication reviews were completed on 2/10/2022, 6/20/2022, 11/4/2022, and 2/10/2023.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Serenity Care CEO, Program Director, agency nurse, and any other leadership designee will ensure that if a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage. 07/15/2023 Implemented
SIN-00213101 Renewal 10/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34On 10/13/22 at 1:58 PM, the home's vacant bedroom and hall closet, located on the upper-level, were secured with key locks. The agency could not provide keys to open the doors of these areas. Therefore, inspection access was not granted.The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients.The Maintenance Technician will keep an extra set of keys to all locks at the residential homes and the main office. 12/01/2022 Implemented
6400.66On 10/13/22 at 1:30 PM, there wasn't any nearby lighting source found outside the exit door of the basement. On 10/13/22 at 1:12 PM, the ceiling light fixture on the back porch off the kitchen exit door was found inoperable. There was no other nearby light source in this area.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. A light will be installed above basement door to assure appropriate lighting. 12/01/2022 Implemented
6400.67(b)The bathtub of the full bathroom located in the basement was observed on 10/13/22 at 1:22 PM without a valve fixture to operate the hot and cold water. Floors, walls, ceilings and other surfaces shall be free of hazards.Maintenance technician will replace the valve fixture to operate the cold and hot water. 12/01/2022 Implemented
6400.101The basement's only exit door to the outside was found on 10/13/22 at 1:25 PM with both a sliding latch door lock and a deadbolt that can only be unlocked with a key from the inside creating 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 and Latch Locks will be removed and replaced with one sided deadbolt locks where a key is only needed for entry not exit. 12/01/2022 Implemented
6400.141(c)(4)Individual #1 had vision screenings completed 6/9/21 and then again 7/12/22.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)(14)Individual #1's physical examination, completed 11/29/21, does not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Serenity Care Program Management will confirm and attach a medication list and diagnosis prior to the participants appointment and ensures the physician reviews signs and dates form at the end of the appointment. 11/01/2022 Implemented
6400.34(a)Individual #1 was informed and explained individual rights and the process to report a rights violation 1/4/21 and then again 5/12/22.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
6400.165(g)Individual #1 is prescribed psychiatric medications to treat mental illnesses. Individual #1 had medication reviews 11/4/21, 2/10/22, 4/29/22, and 6/20/22; there is not documentation of an appointment occurring after 6/20/22. The medication reviews conducted 11/4/21 and 4/29/22 did not include the reason for prescribing the medication. [Repeat Violation 11/30/21 et.al]If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Program Manager will schedule, confirm and document all participant medical appointments annually, monthly and semi annually. The Program Management will confirm and attach a medication list and diagnosis prior to the participants appointment and ensures the physician reviews signs and dates form at the end of the appointment. 11/01/2022 Implemented
6400.181(f)Individual #1's 4/27/22 assessment was provided to the SC and plan team members 5/9/22 for an annual ISP meeting held 5/9/22. [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
6400.182(c)Individual #1's 4/27/22 assessment states Individual #1 has shown an interest in swimming. Individual #1's ISP, last updated 8/24/22, states Individual #1 enjoys swimming and reports that they are a good swimmer. [Repeat violation 11/30/21 et.al]The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.Serenity Care Program Specialist will inform the SC or person authorized to write the individuals ISP of any changes to the Annual Assessment. The individuals assessment will be provided to the SC's by email 30 days prior to ISP meeting. The Program Specialist will review the updated ISP to assure it is consistent with the individuals Annual Assessment. 11/01/2022 Implemented
SIN-00196796 Renewal 11/30/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)On 12/1/21, at 10:34 AM, the water temperature in the bathtub of the bathroom on the second floor to the right of the stairs. measured 129.9 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. The water temperature was immediately adjusted by maintenance not to exceed 120F 12/17/2021 Implemented
6400.165(g)Individual #1 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness. Individual #1's psychiatric medication review, dated 3/8/21, did not include the dosages for the prescribed medications.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Agency has contacted Physician to ensure that the 3 month review documentation includes the reason for prescribing the medication 12/17/2021 Implemented
6400.166(a)(2)Individual #1's December 2021 Medication Administration Record did not include the prescriber of the medications. These medications include, but are not limited to: Vitamin D3 2000iu.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.Agency contacted pharamacist who generates MAR to inform that the MAR must contain the name of the prescriber of medication 12/17/2021 Implemented
6400.166(a)(8)Individual #1's December 2021 Medication Administration Record did not include the route of administration for Vitamin D3 2000iu Take one capsule 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 the diagnosis or purpose of the prescribed medications. These medications include, but are not limited to: Vitamin D3 2000iu.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
6400.182(c)The annual assessment for Individual #1 was completed on 5/24/20, sent to the supports Coordinator and plan team on 6/10/20 for the annual ISP meeting held on 5/13/21. The assessment was more than 11 months old and not current.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The ISP was updated to reflect the current needs of the individual 12/18/2021 Implemented
SIN-00182311 Renewal 01/28/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.105On 1/29/2021 at 10:44AM, a lawnmower was stored less than two inches from the furnace in the basement of the home.Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. On 01/29/2021 at approximately 10:45am the inoperable lawn mower was moved from the immediate area of the furnace in the basement of the home. On 01/29/2021 at approximately 12noon the lawn mower was removed from the home and properly discarded. On 01/29/2021 both the residential lead as well as the maintenance supervisor received training on the importance of safety related fire hazards in the home in accordance to safety regulations. Residential leads will complete weekly inspections of the basement specifically the immediate area of the furnace to ensure that flammable objects are not within the immediate area of the furnace. A check list will require residential leads to certify said information. Maintenance supervisor will verify at minimum monthly. Documentation will be submitted and stored by office manager. 01/29/2021 Implemented
6400.106The 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. 01/29/2021 Implemented
6400.141(a)Individual #1 had a physical examination on 10/11/2019 and then again on 11/13/2020.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. On 09/26/2020 individual was arrested and detained in the Allegheny County Jail for Terroristic Threats and Simple Assault charges. Due to his status future medical appointments were cancelled pending the outcome of his arrest. It was advised that Individual #1 undergo a competency and mental health evaluation prior to attending future medical appointments. Upon release however due to his admission to an institution and possible exposure to Covid-19 individual was recommended to quarantine. Individual was further advised by the Medical practice that his appointment would need to be rescheduled in accordance with CDC guidelines. The next available appointment was 11/13/2020. The information was relayed to his support team for proper documentation and record of delay 01/29/2021 Implemented
6400.141(c)(6)Individual #1 had Tuberculin skin testing completed on 10/5/2018 and then again on 11/16/2020.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. On 09/26/2020 individual was arrested and detained in the Allegheny County Jail for Terroristic Threats and Simple Assault charges. Due to his status future medical appointments were cancelled pending the outcome of his arrest. It was advised that Individual #1 undergo a competency and mental health evaluation prior to attending future medical appointments. Upon release however due to his admission to an institution and possible exposure to Covid-19 individual was recommended to quarantine. Individual was further advised by the Medical practice that his appointment would need to be rescheduled in accordance with CDC guidelines. The next available appointment was 11/16/2020. The information was relayed to his support team for proper documentation and record of delay 01/29/2021 Implemented
6400.15(b)The agency did not use the Department's licensing inspection instrument when completing a self-assessment on 8/24/2020. 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)] 01/29/2021 Implemented
SIN-00164678 Renewal 10/22/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)The interior stairway which had four steps leading to the basement of the home did not have a handrail. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. A handrail has been installed to the steps leading to the basement of the home. located at 1436 Sloan Ave Pittsburgh PA 15221. A review of each ramp, interior stairway and outside steps exceeding two steps shall have a well secured handrail has been added to the maintenance monthly checklist.[Immediately and upon hire, all staff persons shall be educated on their responsibilities of the procedures to report, repair and maintain the physical site of all community homes. At least quarterly for 1 year, the CEO or designee shall audit the aforementioned monthly maintenance check list to ensure competition and the all community homes are maintained as required. Documentation of trainings and audits shall be kept. (DPOC by AES,HSLS on 11/1/19)] 10/25/2019 Implemented
SIN-00145918 Renewal 11/15/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment.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
6400.31(a)Individual #1 was informed of individual right on 5/24/17 and then again on 7/27/18.Each individual, or the individual's parent, guardian or advocate, if appropriate, shall be informed of the individual's rights upon admission and annually thereafter. Individual rights were completed upon admission, and were not reviewed annually. The individual rights have been added to the annual individual packet to be reviewed on the first of the month of the clients anniversary month. The next review will be completed before 5/1/2018. Program Specialist will ensure that the individual's rights are reviewed annually, not once per calendar year. Individual #1 is scheduled for a review of rights prior to 5/1/2018. The Participant Individual Rights 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 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
6400.106The furnace for the home was inspected and cleaned on 5/4/17 and then again on 11/1/18.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. A furnace inspection log has been created and implemented. The furnace check has been added to the annual documentation for the residential site. All residential site furnaces have been inspected for operation. Furnaces will be checked on the 1st of the month of the month prior to the annual deadline. Therefore the next inspection must be completed by 10/1/2019. Maintenance will ensure that the furnaces are operable and inspected within the given time frame. A receipt as well as inspection documentation will be recorded and available for review.The furnace inspection task and dates were added to the participants pre-filled dated calendar for completeness and sign-off by the maintenance staff and Program Manager. [Within 30 days of receipt of the plan of correction, upon hire and at least annually, the CEO or designee shall educate all staff person responsible for ensuring furnace inspection and cleanings are completed of the procedures to ensure timely completion and maintaining documentation as required and available upon request by the Department. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 1/8/19)] 11/16/2018 Implemented
6400.141(c)(13)Individual #1's physical examination, dated 10/3/18, does not include allergies or contraindicated medications. This section of the physical examination form is blank.The physical examination shall include: Allergies or contraindicated medications.A physical examination follow up was scheduled to address allergies or contraindicated medications. The physical form was amended to highlight the missed field. Staff accompanying clients to medical appointments received training regarding the importance of ensuring that every field on the physical form is completed.Program Specialist will ensure that every field is populated following a medical appointment. In the event that a field is not populated, Program specialist will contact medical professional to discover a solution for a remedy.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, dated 10/3/18, updated to include included allergies or contraindicated medications. 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)] 12/07/2018 Implemented
6400.141(c)(14)Individual #1's physical examination, dated 10/3/18, does not include medical information pertinent to diagnosis and treatment in case of an emergency. This section of the physical examination form is blank. [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, 10/3/18 was 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
6400.163(c)Individual #1's psychiatric medication review was conducted on 4/6/18 and then again on 7/27/18. Individual #1's psychiatric medication review, dated 2/28/18, did not include the reasons for prescribing the medication or the need to continue the medication. Individual #1's psychiatric medication review, dated 4/6/18, did not include the reasons for prescribing the medication or the need to continue the medication. [Repeat Violation 11/9/17] 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.The agency contacted the outpatient psychiatric professional to inquire regarding the reason for the prescribe medication which should be held every 3 months. Efforts were made to retrieve written documentation, without avail. Staff attending psychiatric appointments have received adequate training on the importance of receiving this vital information. The psychiatric medial appointment sheet has been updated to highlight the area and instruct both the psychiatric attendant and staff to complete all fields. Program Specialist will review all documentation following psychiatric appointments. In the event that the documentation is not completed in its entirety a follow up appointment for documentation will be scheduled, unless a solution is available to remedy the issue through other means of communication. A calendar and review sign/off document was created for each participant to verify that the scheduled psychiatric examination documents were verified for completeness and accuracy by the staff and program specialist. [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' medication review documentation are completed and reviewed shall be educated in the requirements of individuals' medication review documentation as per 6400.163c and the aforementioned process to have the medication review documentation 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)] 11/16/2018 Implemented
6400.181(e)(6)Individual #1's assessment, dated 5/24/18, 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 company 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(b)Individual #1's ISP review, for review period 8/2017 to 11/2017, was not signed by the individual. Individual #1's ISP review, for review period 11/2017 to 2/2018, was not signed by the individual or the program specialist. Individual #1's ISP review, for review period 2/2018 to 5/2018, was not signed by the individual or the program specialist. Individual #1's ISP review, for review period 5/2018 to 8/2018, was not signed by the individual or the program specialist.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 August 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 the 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 12/11/18. 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 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, A Restrictive procedure calendar was created with the scheduled dates for the meetings to be performed and signed off by the CEO and Program director. The Restrictive procedure meeting dates was also added to the participants pre-filled dated calendar. [Restrictive Procedures Committee Meeting for Individual #1 is scheduled for March 2019. (AES,HSLS on 1/8/19)] 11/16/2018 Implemented
SIN-00124344 Renewal 11/09/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(10)The program specialist did not review, sign and date monthly documentation for Individual #1, date of admission 5/24/17.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 manager has completed, reviewed and signed all monthly reports. [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
6400.64(e)The trash receptacle in kitchen of the home was 23 inches high and did not have a lid.Trash receptacles over 18 inches high shall have lids. The lid was placed on the trash can, found on the back porch. Staff was educated on the importance of placing the lid on the trash can after the trash can is emptied. [On 12/15/17, the trash can was covered. Immediately and upon hire, the CEO shall train all staff person regarding the sanitation requirements as per 6400.64(a)-(f) and to monitor for unsanitary condition throughout the course of their daily duties and to correct or contact the CEO to ensure sanitary conditions are maintained throughout all community homes at all times. Documentation of trainings shall be kept. (AS 2/16/18)] 11/09/2017 Implemented
6400.68(b)At 1:18PM, the hot water temperature at the bathtub in the bathroom on the second floor of the home measured 122.5°F. Hot water temperatures in bathtubs and showers may not exceed 120°F. Hot water temperature was corrected by a Certified Plumber. [On 11/20/17, co-owner adjusted hot water temperature. On 12/15/17, at 2:15PM the hot water temperature at the bathtub measured 89°F. The CEO or co-owner/certified plumber, will immediately and continuing at least weekly until the hot water temperature remains below 120 degrees Fahrenheit for 1 month and then continuing at least monthly, measure the hot water temperatures at all bathtubs and showers in all community home. Documentation of the temperatures shall be kept and audited by the CEO at least quarterly to ensure completion and that the hot water temperature at all bath tubs and showers does not exceed 120°F. Documentation of audits shall be kept. (AS 2/16/18)] 11/20/2017 Implemented
6400.77(b)The first aid kit did not contain scissors. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. First aid kit scissors were located and placed in the first aid kit. Staff was educated on the importance of returning/placing items once used back in the first aid kit promptly. [On 12/15/18, required items were in the first aid kit. . Immediately and upon hire, the CEO shall train all staff person regarding the required items in first aid kits and the replenishment and replacement procedures to ensure all first aid kits are stocked with required items at all time. Documentation of trainings shall be kept. At least monthly, the CEO shall check all first aid kits and replacement supplies to ensure first kits have all required items at all time. Documentation of monthly checks shall be kept. (AS 2/16/18)] 11/10/2017 Implemented
6400.101The door in the basement leading to the storage area below the porch in the front of the home is equipped with lock latch and padlock preventing egress from the storage area when engaged.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The lock latch and padlock was removed from the door in the basement leading to the storage area below the porch in the front of the home and a door handle was installed. [On 11/30/17, Co-owner changed the lock on the door to allow egress from the basement 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, at 2:39PM, 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
6400.112(c)The written fire drill record for the fire drill held on 6/25/17 at 2:10 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
6400.141(c)(3)Individual #1's physical examination completed 3/15/17 did include immunizations.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. Individual #1's received another physical Examination. An immunization record was not present. The PCP informed SerenityCare to contact the Health Department and see if a blood test can be performed to determine if Individual #1 received any immunizations in the past. Health Department will be contacted on 12/5/2017 to schedule an appointment.An additional physical was performed by Individual #1's new PCP (Alma Illery Medical Center) on 11/7/2017. 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. [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)] 12/04/2017 Implemented
6400.141(c)(6)Individual #1's physical examination completed 3/15/17 did include Tuberculin skin testing.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. The tuberculosis/PPD Skin test was performed on 11/9/2017 and read on 11/11/2017. The test will be performed for Individual #1 every 2 years. 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.[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)] 11/11/2017 Implemented
6400.141(c)(10)Individual #1's physical examination completed 3/15/17 did not address communicable disease; therefore, compliance could not be measured.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. The tuberculosis/PPD Skin test was performed on 11/9/2017 and read on 11/11/2017, which indicated Individual #1 was free of communicable disease 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.[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)] 11/13/2017 Implemented
6400.141(c)(12)Individual #1's physical examination completed 3/15/17 did include physical limitations of the individual.The physical examination shall include: Physical limitations of the individual. An additional physical was performed by Individual #1's new PCP (Family Practice Penn Hills) on 12/4/2017. No physical limitations were notated. 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.[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)] 12/04/2017 Implemented
6400.141(c)(14)Individual #1's physical examination completed 3/15/17 did 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. Individual #1's received another physical Examination. The medical information pertinent to diagnosis and treatment in case of an emergency was notated. 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.[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)] 12/04/2017 Implemented
6400.141(c)(15)Individual #1's physical examination completed 3/15/17 did include special instructions for the individual's diet.The physical examination shall include: Special instructions for the individual's diet.Individual #1's received another physical Examination. Special instruction for the individual's diet was notated. 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.[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)] 12/04/2017 Implemented
6400.164(a)Clotrimazole Anti fungal cream 1% was present in Individual #1's medication box. The medication did not have a label and was not on the Individual #1's medication administration record. Olanzapine 5 mg, take one tablet by mouth daily and Olanzapine, 20 mg take one tablet by mouth daily prescribed for Individual #1, were denoted on Individual #1's November 2017 medication administration record with instructions to dissolve in mouth one tablet daily.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. Over the counter drug recommended by the physician without a prescription was discarded. Physician was notified and a prescription was received. 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)] 11/13/2017 Implemented
6400.164(b)Risperdone 3 mg, Divalproex 500 mg, Trazadone 150 mg, Olanzapine 20 mg prescribed for Individual #1 were not initialed as administered on 10/31/17 at 8:00PM. 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 trainings 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)] 11/13/2017 Implemented
6400.181(a)Individual #1, date of admission 5/24/17, 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. Individual 1's initial assessment has been completed, reviewed, and signed. [Individual #1's assessment was completed on 11/10/17. 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 2/16/17)] 12/01/2017 Implemented
6400.186(a)The program specialist did not complete ISP reviews for Individual #1, date of admission 5/24/17.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 has completed an ISP review for individual #1 which was conducted at least once every 3 months. [ISP reviews were completed for Individual #1 for review periods of 5/24/17 to 8/31/17 and 8/31/17 to 11/30/17. 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 2/16/17)] 12/01/2017 Implemented
6400.195(d)Individual #1's restrictive procedure plan, completed 5/20/17, 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. The restrictive procedure has been updated to reflect the review, approval, and signature of the chairperson and program specialist as required. [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