Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00186276 Renewal 04/15/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(f)The program specialist provided Individual #1's assessment, completed 8/14/2020, to the plan team members on 8/14/2020, for the ISP meeting on 9/08/2020.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Going forward the Program Manager will send the assessment packet and any changes needed to the ISP, to the SC 60 days prior to the scheduled ISP meeting. The Program Manager will utilize a newly created excel spreadsheet to track important ISP related dates. This includes the SC invitation letter, scheduled ISP date, and the due date the assessment will be sent to team members. All Program Managers were training on this new process on 4/30/21. On May 3, 2021 AMA Program Director completed an audit on 5 additional individual charts to determine if violations discovered during licensing exist in other AMA records. All assessment notifications audited were sent to team members 30 calendar days prior to the individuals ISP. 04/30/2021 Implemented
6400.182(c)Individual #1's assessment, completed 8/14/2020 states, "she is independent when it comes to both using cleaning and other poisonous materials in a safe manner and avoids poisonous/hazardous materials." Individual #1's ISP last updated 11/02/2020 states, "she has no knowledge of poisonous liquids and should be out of reach of her."The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.On 4/27/21 the Program Manager for individual #1 sent an email to the individuals SC requesting an update to the individuals ISP so that the document accurately reflects the individual's current skill level pertaining to poisonous/hazardous materials. Program Manager will continue to have contact with the SC via email regarding the requested change. On May 3, 2021 AMA Program Director completed an audit on 5 additional individual charts to determine if violations discovered during licensing exist in other AMA records. No discrepancies between the current AMA assessment and the individuals current ISP regarding poisons/hazardous materials were found during this audit. 05/03/2021 Implemented
SIN-00151800 Renewal 03/13/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Program Specialist #1, date of hire 10/1/18, had a Pennsylvania criminal history record check completed on 2/19/19. Direst Service Worker #5, date of hire 8/1/17, had a Pennsylvania criminal history record check completed on 3/19/18.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. PLAN TO PREVENT REOCCURENCE: As of February 1, 2019, the agency is using the ADP Workforce Now system to log and track all personnel and employment-related requirements. Upon offer of employment but prior to hire, the HR Manager will submit a Pennsylvania Criminal History record check and review the results upon receipt. Prospective employees who have records of criminal activities that would exclude them from employment under laws and regulations will not be hired. Prospective employees who cannot demonstrate adequate length of time as a PA resident will undergo further background checking before hire. Prospective employees with an acceptable criminal background will proceed with pre-hire processes. The HR Manager will file the criminal history record check in the employees personnel file and will log the date that the criminal history record check results were received in the ADP system. Prior to the targeted date of hire the Chief Operations Officer will review the personnel file and give approval. If the Criminal History Record check is not present, not compliant or not logged in the ADP system the employee will not be hired. [Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff persons responsible for ensuring all staff person have required background checks completed timely of their responsibilities and the aforementioned procedures to ensure all staff persons have required criminal background checks completed timely. Documentation of training shall be kept. (DPOC by AES,HSLS on 4/24/19)] 03/29/2019 Implemented
6400.46(d)Direct Service Worker #2, date of hire 11/15/17, had 16 hours of training for the training year from 1/1/18 to12/31/18. Direct Service Worker #3, date of hire 9/1/17, had 6 hours of training for the training year from 1/1/18 to 12/31/18. Direct Service Worker #4, date of hire 8/24/17, had 6 hours of training for the training year from 1/1/18 to 12/31/18. Direct Service Worker #6, date of hire 10/31/17, had 5 verifiable hours of training for training year 1/1/18-12/31/18.Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. PLAN TO PREVENT REOCCURENCE: As of March 1st, 2019: 24 hours of annual training will be tracked with new training document that contains the employee¿s name, signature, position, hire date as well as the name, source, date, and length of time for each training, and total hours of training for that year. A subsequent page will be used as a syllabus (training content guide) specifying the name of the training and the content. Training manager will enter the hours, name, and the date of the training into the personnel database. The training manager will pull reports from the database on a monthly basis in order to audit the progress and implement more training as necessary. [Immediately, the CEO or designee shall educate all staff persons responsible for ensuring all staff persons have required amount of training of their responsibilities. Documentation of training shall be kept. Documentation of monthly audits shall be kept. DPOC by AES,HSLS on 5/2/19)] 03/01/2019 Implemented
6400.46(g)Direct Service Worker #2, date of hire 11/15/17 did not have annual fire safety training. Direct Service Worker #3, date of hire 9/1/17, did not have annual fire safety training. Direct Service Worker #4, date of hire 8/24/17, did not have annual fire safety training. Direct Service Worker #6, date of hire 10/31/17, did not have annual fire safety training.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). PLAN TO PREVENT FUTURE OCCURENCE: As of March 1st, 2019: Fire safety training will be conducted through the College of Direct Support. Training hours, name, and date will be entered into the personnel database. The training manager will pull reports from the database on a monthly basis in order to audit the progress and make the expiration dates of fire safety training known. The training manager will then have program specialists and DSPs complete the fire safety training on the College of Direct Support prior to the expiration of their previous fire safety training.[DSW#'s 2, 3, 4, and 6 completed fire safety training on 3-26-19, 3-18-19, 2-12-19 and 3-3-19, respectively. The training manager conducted a full file audit of all employees on April 4 to ensure that all fire safety training is current, and all training dates have been entered into the personnel database. Employees whose training dates are expiring within the next month have all been assigned fire safety training in the College of Direct Support system, and the next monthly audit is scheduled to occur in May, as per the ongoing corrective action plan describes. Immediately, the CEO or designee shall educate all staff persons responsible for ensuring all staff persons have required amount of training of their responsibilities. Documentation of training shall be kept. Documentation of audits shall be kept. DPOC by AES,HSLS on 5/2/19)] 03/01/2019 Implemented
6400.112(c)The written fire drill record for the fire drill held on 5/9/18 did not include the amount of time it took for evacuation. The written fire drill records for the fire drills held on 12/14/18 and 1/25/19 did not include the time of the fire drills.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. ACTION TO CORRECT VIOLATION: Reviewed how to properly document fire drills with the staff person who conducted these drills. Clarified how to document the amount of time it took for evacuation. Verified on documentation for the March fire drill that this employee understood the review and completed the form correctly. PLAN TO PREVENT REOCCURENCE: Beginning March 20, 2019 and then monthly thereafter, the House Manager will hold an unannounced fire drill, will complete the fire drill form and will submit the form to his or her respective Program Manager. The Program Manager will review the fire drill, and if not compliant with respect to all aspect of Fire Safety regulations, will instruct the House Manager to repeat the drill. If compliant, the Program Manger will submit the completed Fire Drill to the Chief Operations Officer (COO). The COO will log the completed fire drill on the excel spreadsheet located in the company¿s shared drive and will file the fire drill form in the master fire binder. [Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff person responsible for conducting fire drills and reviewing fire drill records of the requirements of fire drills as per 6400.112(a)-(I). Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 4/24/19)] 03/20/2019 Implemented
6400.112(e)The most recent fire drill held during sleeping hours was completed on 7/12/18.A fire drill shall be held during sleeping hours at least every 6 months. ACTIONS TO CORRECT VIOLATION: Overnight (sleep) drill conducted on 3-19-19. PLAN TO PREVENT REOCCURENCE: Beginning March 20, 2019 and then ever 6 months thereafter, the House Manager will hold an unannounced fire drill during sleeping hours, will complete the fire drill form and will submit the form to his or her respective Program Manager. The Program Manager will review the fire drill, and if not compliant with respect to all aspect of Fire Safety regulations, will instruct the House Manager to repeat the drill. If compliant, the Program Manger will submit the completed Fire Drill to the Chief Operations Officer (COO). The COO will log the completed fire drill on the excel spreadsheet located in the company¿s shared drive and will file the fire drill form in the master fire binder.[Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff person responsible for conducting fire drills and reviewing fire drill records of the requirements of fire drills as per 6400.112(a)-(I). Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 4/24/19)] 03/20/2019 Implemented
6400.151(a)Direct Service Worker #3, dated of hire 9/1/17, had an initial physical examination completed on 11/3/17. 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. PLAN TO PREVENT REOCCURENCE: As of February 1, 2019, the agency is using the ADP Workforce Now system to log and track all personnel and employment-related requirements. Upon offer of employment but prior to hire, the HR Manager will refer the prospective employee to the agency¿s employment medical service vendor for his or her physical. The vendor will provide the physical to the employee using the agency¿s physical exam form and will return the completed form to the HR Manager. The HR Manager will review the form and ensure compliance to agency and regulatory requirements. Only prospective employees who meet or exceed these requirements will proceed with pre-hire processes. The HR Manager will then file the completed physical form in the employee¿s personnel file and will log both the completion date of the physical and the due date of the next physical in the ADP system. Prior to the targeted date of hire the Chief Operations Officer will review the personnel file and give approval. If the physical is not present, not compliant or not logged in the ADP system the employee will not be hired. On a monthly basis thereafter the HR Manager will run a personnel profile report from ADP, check physical exam due dates and refer employees for physicals prior to the expiration of the previous assessment. As employees complete updated physical through the agency¿s vendor the HR Manager will enter the both the new complete and due dates in the ADP system and will file the documentation in the employee¿s personnel file. The ADP system will flag employees who have expired physicals on record, and in response, the HR Manager will remove them from the schedule. [Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff persons responsible for ensuring all staff person have physical examinations completed timely with all required information of their responsibilities and the aforementioned procedures to ensure all staff persons physical examinations are completed timely and with all required information. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 4/24/19)] 03/29/2019 Implemented
6400.151(c)(2)Direct Service Worker #4, dated of hire 8/24/17, had an initial Tuberculin skin testing by Mantoux method with negative results completed on 2/12/19. 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. PLAN TO PREVENT REOCCURENCE: As of February 1, 2019, the agency is using the ADP Workforce Now system to log and track all personnel and employment-related requirements. Upon offer of employment but prior to hire, the HR Manager will refer the prospective employee to the agency¿s employment medical service vendor for TB Mantoux testing. The vendor will administer and read the TB test using the agency¿s physical exam form and will return the results to the HR Manager. The HR Manager will review the form and ensure compliance to agency and regulatory requirements. Only prospective employees who meet or exceed these requirements will proceed with pre-hire processes. The HR Manager will then file the completed TB testing results in the employee¿s personnel file and will log both the completion date and the due date for the next Mantoux tuberculin skin test in the ADP system. Prior to the targeted date of hire the Chief Operations Officer will review the personnel file and give approval. If the TB results are not present, not compliant or not logged in the ADP system the employee will not be hired. On a monthly basis thereafter the HR Manager will run a personnel profile report from ADP, check Mantoux TB testing due dates and refer employees for repeat TB Mantoux testing prior to expiration. As results of updated TB Testing through the agency¿s vendor are received, the HR Manager will enter the current and due dates in the ADP system and will file the documentation received in the employee¿s personnel file. The ADP system will flag employees who have expired TB tests on record, and in response, the HR Manager will remove them from the schedule. [Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff persons responsible for ensuring all staff person have physical examinations completed timely with all required information of their responsibilities and the aforementioned procedures to ensure all staff persons physical examinations are completed timely and with all required information including Tuberculin skin testing. Documentation of the trainings shall be kept (DPOC by AES,HSLS on 4/24/19)] 03/29/2019 Implemented
SIN-00131428 Renewal 03/19/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(b)Individual #1, date of admission 1/2/18, did not sign and date acknowledging receipt of the information on rights upon admission.Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. The plan to address this issue of non-compliance is to have individual #1 sign and date the information for Individual's Rights. This was completed on 4.6.2018.The plan to alleviate this violation moving forward is that AMA has implemented an Admission Process that utilizes a Transition plan to review all individuals referred for services at AMA In the Transition Plan, On Move in Day , the Program Specialist will Review the Statement of Individual Rights with the individual and or the individual's parent, guardian or advocate and have them sign this form. This review will occur annually thereafter. [Individual #1 signed statement acknowledging receipt of information on rights on 4/18/2018. Immediately, the CEO or designee shall develop and implement a tracking system to ensure all individuals are informed of individual right, timely and signed statements are kept. Immediately, upon admission and quarterly for 1 year, the CEO or designated management staff person shall audit all individuals statements acknowledge receipt of information of rights and the aforementioned tracking system to ensure all individuals are informed of individual rights timely and statement acknowledging receipt is kept. Documentation of audits shall be kept. (AS 5/1/18)] 04/06/2018 Implemented
6400.44(b)(10)The program specialist did not review, sign, and date the monthly documentation for Individual #1, date of admission 1/2/18. The program specialist did not review, sign, and date the monthly documentation for Individual #2, date of admission 8/3/17.The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of an individual'ss participation and progress toward outcomes.The plan to address this issue of non-compliance is that ISP Goal Data documentation has been implemented on 2.26.2018. With this in place, a monthly review will be generated on 4.9.2018. This ISP review will be provided to all member's of individual #1's team. The plan to alleviate this violation in the future is that AMA Support Serrvices has implemented a Monthly Review Process The Program Specialist is responsible for the monitoring and completion of this process. This process is, the Program Specialist will generate monthly documentation of an individual's participation and progress toward outcomes.[Within 15 days of receipt of the plan of correction, the CEO or designee shall educated the program specialist of the responsibilities of program specialist position as per 6400.44(b)(1)-(19). Documentation of the trainings shall be kept. At least quarterly for 1 year, the CEO or designee shall review all individuals' monthly documentation to ensure the program specialist reviews, signs and dates all individuals' monthly documentation of an individual's participation and progress toward outcomes as required. Documentation of audits shall be kept. (AS 5/1/18)] 04/09/2018 Implemented
6400.46(a)The home did not provide orientation for Direct Service Worker #1, date of hire 1/1/18.The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. The plan to address this issue of non-compliance is that the Direct-Service Worker # 1 completed this orientation training on 4.5.2018.The plan to alleviate this violation moving forward is implementation of the New Hire Orientation Training/On-boarding program at AMA Support Services. This is a week-long orientation/training program for all newly hired staff. The New Hire Orientation program is scheduled for the 1st and 3rd week of each month. [Direct Service Worker #1 had orientation on 4/5/18. Immediately and upon hire, the CEO or designee shall audit all staff persons' orientations to ensure all staff persons have orientation relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. Documentation of audits shall be kept. (AS 5/1/18)] 04/05/2018 Implemented
6400.46(e)Direct Service Worker #1, date of hire 1/1/18, did not have training in the areas of intellectual disability, the principles of normalization, rights, and program planning and implementation.Program specialists and direct service workers shall have training in the areas of intellectual disability, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. The plan to address this issue of non-compliance is that the Direct-Service Worker # 1 completed this orientation training on 4.5.2018.The plan to alleviate this violation moving forward is implementation of the New Hire Orientation Training/On-boarding program at AMA Support Services. This is a week-long orientation/training program for all newly hired staff. The New Hire Orientation program is scheduled for the 1st and 3rd week of each month. [Direct Service Worker #1 had training in the areas of intellectual disability, the principles of normalization, rights, and program planning and implementation on 4/5/18. Program Specialist #2 had training in the areas of intellectual disability, the principles of normalization, rights, and program planning and implementation on 3/5/18. Immediately and upon hire and continuing at least quarterly for 1 year, the CEO or designee shall audit all staff persons' trainings to ensure all staff persons have training in the areas of intellectual disability, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. Documentation of audits shall be kept. (AS 5/1/18)] 04/05/2018 Implemented
6400.46(f)Direct Service Worker #1, date of hire 1/1/18, did not have fire safety training before working with individuals.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. The plan to address this issue of non-compliance is that the Direct-Service Worker # 1 completed this orientation training on 4.5.2018.The plan to alleviate this violation moving forward is implementation of the New Hire Orientation Training/On-boarding program at AMA Support Services. This is a week-long orientation/training program for all newly hired staff. The New Hire Orientation program is scheduled for the 1st and 3rd week of each month. [Direct Service Worker #1 had fire safety training on 4/5/18. . Immediately and upon hire and continuing at least quarterly for 1 year, the CEO or designee shall audit all staff persons' trainings to ensure all staff persons are trained 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. . Documentation of audits shall be kept. (AS 5/1/18)] 04/05/2018 Implemented
6400.46(h)Direct Service Worker #1, date of hire 1/1/18, did not have training in first aid techniques before working with individuals.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. The plan to address this issue of non-compliance is that the Direct-Service Worker # 1 completed this training in first aid techniques on 4.5.2018. The plan to alleviate this violation moving forward is implementation of the New Hire Orientation Training/On-boarding program at AMA Support Services. This is a week-long orientation/training program for all newly hired staff. The New Hire Orientation program is scheduled for the 1st and 3rd week of each month. [Direct Service Worker #1 was trained in CPR/FA on 4/5/18.Immediately and upon hire and continuing at least quarterly for 1 year, the CEO or designee shall audit all staff persons' trainings to ensure all staff persons are trained before working with individuals in first aid techniques. Documentation of audits shall be kept. (AS 5/1/18)] 04/05/2018 Implemented
6400.68(b)On 3/20/18, at 11:13 AM, the hot water temperature in the bathtub to the left of the hallway on the main floor measured 151.3°F. Hot water temperatures in bathtubs and showers may not exceed 120°F. The plan to address this issue of non-compliance is that the thermometer on the water tank in this home was lowered. The water was re-tested within 6400 regulation guidelines on 3.20.2018. The plan to alleviate this violation is that mixing valves will be placed on all water heaters by a certified plumber to maintain water temperatures within the 6400 regulation guidelines. [On 4/18/18, the hot water temperature did not exceed 120°F. Mixing valves were installed on 4/16/18. Immediately, and continuing at least weekly for 2 months and then continuing at least monthly, the CEO or designee educated in measuring and adjusting hot water temperatures shall measure all the hot water temperature in all bathtubs and showers at all community homes to ensure the hot water temperatures in bathtubs and showers does not exceed 120°F. Documentation of temperatures shall be kept and reviewed by a designated management staff person at least monthly. (AS 5/1/18)] 04/30/2018 Implemented
6400.113(a)Individual #1, date of admission 1/2/18, did not have fire safety training. 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. The plan of correction to address this issue of non-compliance is that individual # 1 will complete fire safety training on 4.5.2018.The plan to alleviate this violation moving forward is the implementation of the Admission process here at AMA. As outlined in the Admission Process, on the day of admission at AMA all individuals will complete emergency training. From this admission date, Individual Emergency Training will be completed annually. The Program Specialist will be responsible for the completion of this initial and annual Individual Emergency Training.[Immediately and continuing quarterly for 1 year, the CEO or designee shall audit all individuals' fire safety training to ensure all individual are 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, timely. (AS 5/1/18)] 04/05/2018 Implemented
6400.141(c)(4)Individual #2's physical examination completed 12/12/17 did not include a hearing screening. This section was left blank.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The plan to alleviate this violation moving forward is the implementation of an Admission Process here at AMA Support Services. AMA has implemented an Admission Process for the review of all individual referred for services. As part of this Admission Process, a Transition Plan has been developed. In Section 4 of this Transition Plan: One Week Prior to Admission Day, securing a Physical Examination completed by a Licensed Physician will include a vision and hearing screening test. This Admission Process is the responsibility of the Program Specialist. [Individual #2 has a physical examination scheduled on 5/14/18. Within 15 days of receipt of the plan of correction, the CEO or designee shall educated the program specialist on the required information to be included in individuals' physical examinations as per 141(c)(1)-(15) and that required areas must not be left blank. Documentation of the training shall be kept. Immediately, upon admission and upon completion and at least quarterly for 1 year, the CEO or designee shall audit all individuals' current physical examinations to ensure all required information is included and there are not any required areas left blank. Documentation of the audits shall be kept. (AS 5/1/18)] 03/21/2018 Implemented
6400.141(c)(6)Individual #2's physical examination completed 12/12/17 did not include Tuberculin 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 plan to alleviate this violation moving forward is that AMA Support Sertvices has implemented an Admission Process for the review of all individual referred for services. As part of this Admission Process, a Transition Plan has been developed. In Section 4 of this Transition Plan: One Week Prior to Admission Day, securing a Physical Examination completed by a Licensed Physician will include a negative Mantoux test. This Admission Process is the responsibility of the Program Specialist. The TB testing will then be completed every 2 years as long as the individual remains in AMA Support Services care. [Individual #2 has a physical examination scheduled on 5/14/18. Within 15 days of receipt of the plan of correction, the CEO or designee shall educated the program specialist on the required information to be included in individuals' physical examinations as per 141(c)(1)-(15) and that required areas must not be left blank. Documentation of the training shall be kept. Immediately, upon admission and upon completion and at least quarterly for 1 year, the CEO or designee shall audit all individuals' current physical examinations to ensure all required information is included and there are not any required areas left blank. Documentation of the audits shall be kept. (AS 5/1/18)] 03/21/2018 Implemented
6400.141(c)(11)Individual #2's physical examination completed 12/12/17 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section was blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The plan to alleviate this violation moving forward is that AMA Support Services has implemented an Admission Process for the review of all individual referred for services. As part of this Admission Process, a Transition Plan has been developed. In Section 4 of this Transition Plan: One Week Prior to Admission Day, securing a Physical Examination completed by a Licensed Physician providing an assessment of the individual's health maintenance needs, medication regimen and need for blood work at recommended levels. This Admission Process is the responsibility of the Program Specialist. [Individual #2 has a physical examination scheduled on 5/14/18. Within 15 days of receipt of the plan of correction, the CEO or designee shall educated the program specialist on the required information to be included in individuals' physical examinations as per 141(c)(1)-(15) and that required areas must not be left blank. Documentation of the training shall be kept. Immediately, upon admission and upon completion and at least quarterly for 1 year, the CEO or designee shall audit all individuals' current physical examinations to ensure all required information is included and there are not any required areas left blank. Documentation of the audits shall be kept. (AS 5/1/18)] 03/21/2018 Implemented
6400.141(c)(12)Individual #2's physical examination completed 12/12/17 did not include: physical limitations of the individual. This section was blank.The physical examination shall include: Physical limitations of the individual. The plan to alleviate this violation moving forward is that AMA Support Services has implemented an Admission Process for the review of all individual referred for services. As part of this Admission Process, a Transition Plan has been developed. In Section 4 of this Transition Plan: One Week Prior to Admission Day, securing a Physical Examination completed by a Licensed Physician will include information regarding the any physical limitations of the individual. This Admission Process is the responsibility of the Program Specialist. [Individual #2 has a physical examination scheduled on 5/14/18. Within 15 days of receipt of the plan of correction, the CEO or designee shall educated the program specialist on the required information to be included in individuals' physical examinations as per 141(c)(1)-(15) and that required areas must not be left blank. Documentation of the training shall be kept. Immediately, upon admission and upon completion and at least quarterly for 1 year, the CEO or designee shall audit all individuals' current physical examinations to ensure all required information is included and there are not any required areas left blank. Documentation of the audits shall be kept. (AS 5/1/18)] 03/21/2018 Implemented
6400.141(c)(14)Individual #2's physical examination completed 12/12/17 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 plan to alleviate this violation moving forward is that AMA Support Services has implemented an Admission Process for the review of all individual referred for services. As part of this Admission Process, a Transition Plan has been developed. In Section 4 of this Transition Plan: One Week Prior to Admission Day, securing a Physical Examination completed by a Licensed Physician will include pertinent medical information to diagnosis and treatment in case of emergency. This Admission Process is the responsibility of the Program Specialist. [Individual #2 has a physical examination scheduled on 5/14/18. Within 15 days of receipt of the plan of correction, the CEO or designee shall educated the program specialist on the required information to be included in individuals' physical examinations as per 141(c)(1)-(15) and that required areas must not be left blank. Documentation of the training shall be kept. Immediately, upon admission and upon completion and at least quarterly for 1 year, the CEO or designee shall audit all individuals' current physical examinations to ensure all required information is included and there are not any required areas left blank. Documentation of the audits shall be kept. (AS 5/1/18)] 03/21/2018 Implemented
6400.151(a)Direct Service Worker #1, date of hire 1/1/18, had physical examination completed 2/19/18. 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. The plan to alleviate this violation in the future is the implementation of the New Hire/On boarding process implemented here at AMA. This process is managed by the HR manager who completes an initial screening of all potential applicants, completes a telephone pre-screening, schedules an interview and if the applicant is selected as an AMA employee, an offer letter with instructions on completing a Physical/TB and the required Physical form is provided to the potential AMA employee. Prior to being scheduled for New Hire orientation, the potential staff must provide a copy of the Physical with a TB test that has been read to the HR Manager. Once this is secured, the potential employee is scheduled for New Hire Orientation Training Class.[Immediately and upon hire and continuing at least quarterly for 1 year, the CEO or designee shall audit all staff persons' records to ensure all 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. Documentation of audits shall be kept. (AS 5/1/18)] 04/03/2018 Implemented
6400.151(c)(2)Direct Service Worker #1, date of hire 1/1/18, had tuberculin skin testing completed 2/22/18. 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. The plan to alleviate this violation in the future is the implementation of the New Hire/On boarding process implemented here at AMA. This process is managed by the HR manager who completes an initial screening of all potential applicants, completes a telephone pre-screening, schedules an interview and if the applicant is selected as an AMA employee, an offer letter with instructions on completing a Physical/TB and the required Physical form is provided to the potential AMA employee. Prior to being scheduled for New Hire orientation, the potential staff must provide a copy of the Physical with a TB test that has been read by a registered nurse or a licensed practical nurse, licensed physician, licensed physician's assistant or a certified nurse practioner to the HR Manager. Once this is secured, the potential employee is scheduled for New Hire Orientation Training Class.[Immediately and upon hire and continuing at least quarterly for 1 year, the CEO or designee shall audit all staff persons' records to ensure all 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 including Tuberculin testing within 12 months prior to employment and every 2 years thereafter. Documentation of audits shall be kept. (AS 5/1/18)] 04/03/2018 Implemented
6400.163(c)Individual #1's psychiatric medication review completed 3/8/18 did not include the need to continue the medication and the necessary dosage. Individual #2's psychiatric medication reviews completed 12/1/7, 1/3/18, 2/1/18/ 3/1/18, 3/17/18 did not include the need to continue the medication and the necessary dosage. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The plan to alleviate this violation moving forward is the implementation of the Medical Appointment Process. This process will be the responsibility of the Program Specialist. This process will be : all medical appointments will be entered in Therap-the web-based electronic record and documentation system utilized by AMA Support Services. All medical appointments will be entered for each individual in the Health section in Therap. Once entered, the appointments populate on the Therap Appointment Calendar. Reminders for all up and coming appointments are provided through the Therap system. In addition to tracking all medical appointments, a medical consultation form is generated with space provided for the licensed physician to document : the reason for prescribing the medication, the need to continue the medication and the necessary dosage.[Immediately and upon completion, the CEO or designee who is certified to administer medication and educated in the requirements of psychiatric medication reviews as per 6400.163(c) shall audit all individuals' psychiatric medication reviews to ensure timely completion and that all required information is included and individuals are administered medications as prescribed. Documentation of audits shall be kept. (AS 5/1/18)] 05/01/2018 Implemented
6400.181(e)(1)The assessment dated 9/30/17 for Individual #2 did not include functional strengths, needs and preferences of the individual. This section was blank. The assessment must include the following information: Functional strengths, needs and preferences of the individual. The plan to address this issue of non-compliance is that the Program Specialist has updated individual # 1's assessment to include functional strengths, needs and preferences of the individual. This was completed on 3.22.2018.The plan to alleviate this violation moving forward is the implementation of an Assessment Process at AMA. This process is : the Program Specialist will complete the Initial Functional Assessment within 60 days of admission and annually thereafter. [Within 15 days of receipt of the plan of correction the CEO or designee shall educate the program specialist of the information that must be included in individual assessments as per 6400.181(e)(1)-(14). Documentation of the training shall be kept. Immediately and within 5 days of completion for 1 year, the CEO or designee shall audit all individuals' assessments to ensure the program specialist completed all individuals' assessments with all required information. Documentation of the audits shall be kept. (AS 5/1/18)] 03/22/2018 Implemented
6400.181(e)(2)The assessment dated 9/30/17 for Individual #2 did not include likes, dislikes and interest of the individual. This section was blank.The assessment must include the following information: The likes, dislikes and interest of the individual. The plan to address this issue of non-compliance is that the Program Specialist has updated individual # 1's assessment to include the likes, dislikes and interests of the individual. This was completed on 3.22.2018. The plan to alleviate this violation moving forward is the implementation of an Assessment Process at AMA. This process is : the Program Specialist will complete the Initial Functional Assessment within 60 days of admission and annually thereafter.[Within 15 days of receipt of the plan of correction the CEO or designee shall educate the program specialist of the information that must be included in individual assessments as per 6400.181(e)(1)-(14). Documentation of the training shall be kept. Immediately and within 5 days of completion for 1 year, the CEO or designee shall audit all individuals' assessments to ensure the program specialist completed all individuals' assessments with all required information. Documentation of the audits shall be kept. (AS 5/1/18)] 03/22/2018 Implemented
6400.186(a)The program specialist did not complete an ISP review for Individual #2, date of admission 8/3/17.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 plan to address this issue of non-compliance is that ISP Goal Data documentation has been implemented on 2.26.2018. With this in place, a 3-month review will be generated on 5.26.2018. This ISP review will be provided to all member's of individual #2's team. This Quarterly Report will be generated on 5.26.2018. The plan to alleviate this violation in the future is that AMA has implemented a Quarterly Review Process The Program Specialist is responsible for the monitoring and completion of this process. This process is, the Program Specialist will generate a 3-month, ISP review report from the ISP data that has been entered in Therap, the web-based recording and documentation system in use by AMA. The Program Specialist will provide the ISP review report will be provided to all members on the individuals team.[Within 15 days of receipt of the plan of correction, the CEO or designee shall educated the program specialist of the responsibilities of program specialist position as per 6400.44(b)(1)-(19). Documentation of the trainings shall be kept. At least quarterly for 1 year, the CEO or designee shall audit all individuals' ISP reviews to ensure the program specialist has completed ISP reviews 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 audits shall be kept. (AS 5/1/18)] 02/26/2018 Implemented
6400.213(1)(i)Individual #1's record did not include identifying marks and there was not a date on the photograph.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. The plan to address this issue of non-compliance is that the identifying marks missing from Individual # 1's record has been revised to include all identifying mark information. A date on Individual # 1's photo has been placed on the back of this photo.The plan on how this violation will be alleviated moving forward is-AMA has implemented the use of an electronic record system, Therap. Therap is a web-based service that provides an integrated system for documentation, reporting and communication. AMA has implemented an Admission Process for the review of all individual referred for services. As part of this Admission Process, a Transition Plan has been developed. In Section 4 of this Transition Plan: One Week Prior to Admission Day, entering the individual's personal information in the Individual Data form in Therap is an identified step to be completed in this Transition Plan. In Section 4 of the Transition Plan: On Move in Day-taking a picture and uploading this photo into Therap on the Individual data form is an identified step in this Transition Plan. The Admission Process and completion of the Transition Plan is the responsibility of the Program Specialist. The Admission Process is supported in AMA's Policy and Procedure Manual; Section F: Program Record Keeping-F1: Individual Records-Procedure-Each record will include-Personal information including : name, sex, admission date, birthdate, social security #, race, height, weight, color of hair, color of eyes and identifying marks. Language and the means of communication spoken or understood by the individual and the primary language used in the individual's home, if other than English. Religious affiliation, next of kin and a current dated photograph.[Immediately and continuing at least quarterly for 1 year, the CEO or designee educated in the required information in individuals' records as per 6400.213(1)-(14) shall audit all individuals' records to ensure all required information as per 6400.213(1)-(14) is included. Documentation of audits shall be kept. (AS 5/1/18)] 03/22/2018 Implemented
SIN-00221381 Renewal 03/21/2023 Compliant - Finalized