Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00240261 Renewal 03/05/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.70At 10:21AM on 3/6/2024, the telephone in the living room of the home did not have a dial tone or number pad rendering inoperable.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. Immediately on March 6, 2024, the telephone was replaced with a corded phone with dial pad. All phones in other homes were checked for functionality and were in good repair. All staff supporting our individuals were trained to inform the program manager immediately for a dysfunctional telephone, the importance of having a telephone that will work in the event of a power outage and is easily accessible to individuals and staff. 04/17/2024 Not Implemented
6400.112(e)The fire drills held during sleeping hours were completed on 5/17/2023 and 1/20/2024.A fire drill shall be held during sleeping hours at least every 6 months. FSU has addressed the importance of the regulation with the program manager and program specialist [while it may seem unkind to conduct fire drills during inclement weather or in the middle of the night, practicing under such conations is the best test of a home's ability to safely evacuate individuals and offers the peace of mind that comes with knowing that the home has taken every possible step to protect lives.] FSU has developed a fire drill schedule and policy to ensure the drills are held on different days of the week, at different times of the day and night, not routinely held when additional staff persons are present and not routinely held at times when individual attendance is low. The schedule is only accessible to the person responsible for setting of the alarm/detector and recording the results. This policy was reviewed with the members of management. 03/06/2024 Implemented
6400.171At 10:12AM on 3/6/2024, two sandwich size and one quart size food storage containers that were unlabled and undated containing what appeared to be used cooking oil and food particles were on a shelf in the pantry in the kitchen of the home.Food shall be protected from contamination while being stored, prepared, transported and served. Immediately, the unlabeled food item was discarded and staff supporting this individual were trained on labeling and storing food according to this regulation. A formal staff training was completed on dating and labeling of food items for all staff on March 27 and March 28, 2024. 03/28/2024 Implemented
6400.214(b)At 10:27AM on 3/6/2024, the most current assessment for individual #1 that was present at the home was completed on 3/1/2023. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. Immediately, on March 6, 2024, an updated copy of the physical examination was placed in the home. All other charts in the homes were reassessed for physical examinations. The charts with missing physical examination were sited. [PLAN OF CORRECTION DOES NOT ADDRESS THE VIOLATION> (AES,HSLS on 4/23/2024)] 03/06/2024 Not Implemented
6400.32(h)At 10:28AM on 3/6/2024, cameras were in the dining room and living room of the home. The agency did not have a current videography recording and retention policy. Individual #1 had not signed videography consents.An individual has the right to privacy of person and possessions.In order to correct this violation a Videography Policy and Consent form has been developed to ensure compliance with privacy regulations and to obtain explicit consent from individuals regarding videography in their living spaces. Individual #1 has now signed the Videography Policy and Consent form, and a copy has been placed in both the home and the client file for reference. 04/15/2024 Implemented
6400.165(g)Individual #1 had a psychiatric medication review completed on 1/19/2023 and then again on 4/26/2023.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.Individual #1 had a psychotropic medication review on 1/9/2023 and 4/26/2023. According to this regulation the April review was 7 days late. The appointment should have occurred on 4/19/2023 or before. There are no grace periods granted for any regulations in the medication administration section. Immediately, the residential director reviewed all upcoming psychotropic review dates and instructed the medical coordinator to reschedule appointments exceeding 90 days if needed. After review, there were not any appointments that were out of compliance with this regulation. 03/07/2024 Not Implemented
SIN-00186596 Renewal 04/21/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106Written documentation for the 2019 furnace inspection and cleaning was not kept.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. Family Services United (FSU) recognized the importance of PA Code 6400.106 - 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. [Combustible and flammable materials can be ignited by heat sources, leading to explosions and fires.] Annual furnace inspections promote safety and well-being for individuals residing in the home. Although FSU was able to provide images of the furnace tags for 2019 and 2020 via SharePoint for each home, the documentation for 2019 could not be produced. 04/22/2021 Implemented
6400.112(e)A fire drill was held during sleeping hours on 1/16/2020 and then again on 10/18/2020.A fire drill shall be held during sleeping hours at least every 6 months. An overnight (between 11pm ¿ 7am) fire drill was conducted on 1/16/2020 and 10/18/2020. This is a nine-month gap. According to regulation 6400.112(e) - A fire drill shall be held during sleeping hours at least every 6 months. Family Services United (FSU) has addressed the importance of this regulation with the program manager and program specialist [While it may seem unkind to conduct fire drills during inclement weather or in the middle of the night, practicing under such conditions is the best test of a home¿s ability to safely evacuate individuals ¿ and offers the peace of mind that comes with knowing that the home has taken every possible step to protect lives.] FSU did not have a policy to schedule and monitor overnight fire drills. To correct this deficiency, an overnight fire drill was conducted on 4/23/2021 to comply with the six-month requirement per regulation. On 4/23/2021, the job description for the program manager and program specialist were updated to include designated months for overnight fire drills. 04/23/2021 Implemented
6400.113(a)Individual #1, date of admission 10/7/2020 was instructed in general fire safety on 10/14/2020.[Repeated violation 3/4/2020] 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. Individual #1 was admitted on 10/7/2021. This individual was trained in fire safety on 10/14/2021. According to regulation, 6400.113(a), [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]. This violation occurred due to an ineffective admission process. To correct this deficiency, Family Services United (FSU) has revised the admission process by creating a checklist to designate specific management personnel to each item on the checklist and revising the program manager and program specialist job descriptions. 04/27/2021 Implemented
6400.141(a)Individual #1, date of admission 10/7/2020 had an initial physical examination 11/23/2020.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual #1 was admitted on 10/7/2020. This agency received correspondence from the supports coordinator that her last physical was completed on 12/19/2021. This agency accepted individual #1 without obtaining all required documentation. The individual was taken for a physical examination on 11/23/2020 after receiving notice that documentation from the last physical could not be produced. This violation occurred due to an ineffective admission process. To correct this deficiency, Family Services United (FSU) has revised the admission process by creating a checklist to designate specific management personnel to each item on the checklist and revising the program manager and program specialist job descriptions. 04/27/2021 Implemented
6400.141(c)(3)Individual #1's physical examination did not include immunizations.[Repeat violation 3/4/2020]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. Family Services United (FSU) attaches a consultation form to the physical examination form for each medical appointment. The consultation form has the diagnoses, updated medication list, height, weight, recent vital signs, and other information pertinent information to the visit. Individual # 1 had a physical examination on 11/23/2020. The physician recorded the immunizations on the consultant form instead of the actual physical examination form. Individual #1 received a flu and shingles vaccine that visit (11/23/2020), Tdap 12/2017 and a TB on 12/5/2019 in which the new PCP was able to view in the UPMC Database. The physician signed and dated both the consultation form and the physical examination form. The state representative received this information via SharePoint. According to regulation 6400.141(c)(3) [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] immunizations for Individual #1 are up to date. To prevent reoccurrence and future confusion, FSU will no longer utilize consultation forms for any medical appointments. The physical examination form has changed. The new form includes a signature line for the program manager and residential director or designee to acknowledge required information is written on the physical examination form and not on an attachment. 04/27/2021 Implemented
6400.141(c)(6)Individual #1's physical examination did not 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. Individual #1 was admitted to Family Services United (FSU) 10/7/2020. Individual #1 had a TB test on 12/5/2019. According to regulation 6400.141(c)(6) [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] individual #1 is up to date. Next TB is due on or before 12/5/2021. The physical examination form did not have immunizations recorded on it. The immunizations were recorded on an attachment as the TB was done at a previous visit. The physician signed and dated both the consultation form and the physical examination form. FSU attaches a consultation form to the physical examination form for each medical appointment. The consultation form has the diagnoses, updated medication list, height, weight, recent vital signs, and other information pertinent to the visit. 04/27/2021 Implemented
6400.34(a)Individual #1 was informed and explained individual rights on 10/7/2020. The rights document did not include the following rights: 6400.32b, an individual has the right to civil and legal rights afforded by law, including the right to vote, speak freely, practice the religion of his choice and practice no religion; 6400.32e, the right to make choices and accept risks; 6400.32g, to control his own schedule and activities; 6400.32j, the right to voice concerns about the services the individual receives; 6400.32k, the right to participate in the development and implementation of the individual plan; 6400.32L, the right to receive scheduled and unscheduled visitors, and to communicate and meet privately with whom the individual chooses, at any time; 6400.32p, the right to 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, keypad code or other entry mechanism to lock and unlock entrance door of the home; 6400.32t, to access food at any time; 6400.32u, to make health care decisions; 6400.32v, right may only be modified accordance with 6400.185.[Repeat violation 3/4/2020]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.Family Services United (FSU) recognizes the importance of regulation 6400.34(a) [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]. As an agency we will ensure that individuals are educated on their rights per regulation. Individual #1 was informed and received explanation of individual rights on admission (10/7/2020), however, the Family Services United admission packet did not include the following rights: 6400.32(e), 6400.32(g), 6400.32(j), 6400.32(k), 6400.32(L), 6400.32(q) 6400.32(p), 6400.32(r), 6400.32(s), 6400.32(t), 6400.32(u), and 6400.32(v). The FSU admission packet was updated on 2/20/2021 to include all the rights listed above. Individual #1 and all other individuals residing at FSU signed the updated rights on 2/24/2021 in which the state representative received copies of the signature page for sample individuals via SharePoint. FSU will 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 as stated in the regulation. FSU has updated the individual rights notification to individuals and the policy and procedure to ensure that the information from the new regulation is included. 02/24/2021 Implemented
SIN-00172121 Renewal 03/04/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency completed a self-assessment on 1/20/20. The agency's certificate of compliance had an expiration date of 3/14/20.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.In order to correct this violation, on 3/13/2020 FSU has implemented a copy of the 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 FSU to ensure compliance will be completed within 30 days of acknowledgment. Moving Forward the self-assessment due dates were added to the residential director's calendar for completeness and a sign-off by CEO. 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 by the CEO shall be kept. (DPOC by AES,HSLS on 4/2/20)] 03/13/2020 Implemented
6400.21(a)Direct Service Worker #2, date of hire 3/4/19, had a Pennsylvania criminal history record check submitted and completed on 3/14/19.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. In order to correct this violation, FSU has created a on-boarding checklist to track new hire documentation. Moving forward FSU will not start any new hires without obtaining a Pennsylvania criminal history record check within five working days of hire date. Residential director will check for accuracy all new hires on- boarding documentation before working in direct contact with individuals. [Upon receipt of the required criminal history checks, the CEO shall audit the documentation to make employment decision to ensure compliance with the commonwealth court's guidance regarding exercising hiring discretion on a case-by-case base (consulting with attorney as needed) considering factors outlined in 6400 RCG under Criminal History Record Check 6400.21a-21e. Documentation of audits and reviews by Residential director and CEO shall be kept. (DPOC by AES, HSLS on 4/2/20)] 03/12/2020 Implemented
6400.66At 1:42PM, the outside light on brick wall above the porch outside the kitchen of the home was not operable when switched on. There is not another source of lighting 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. In order to correct this violation, FSU had the light bulb replaced on 3/4/2020 on the porch outside of the kitchen area. Moving forward the house manager will check outside lighting monthly to replace bulbs when needed and report any repairs to maintenance within 24 hours. [Site Audit check list completed March 13, 2020, to include "check all outdoor lighting." Immediately, the CEO or designee shall educate all staff persons on the physical site requirements of community homes and the agency's repair and replacement procedures to ensure all areas of home are lighted to assure safety to avoid accidents and to monitor throughout the course of their daily duties. (DPOC by AES,HSLS on 4/2/20)] 03/04/2020 Implemented
6400.113(a)Individual #2, date of admission 7/22/19, has not been instructed in general fire safety. 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. In order to correct this violation, individual #2 was trained on 3/9/2020 general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the residence and smoking safety procedures. Moving forward program specialist will ensure upon admission and annually thereafter that every individual has been instructed in general fire safety . Documentation will be well be kept and organized. [Immediately, the program specialist shall develop and implement a tracking system to ensure all individuals are educated in all areas of fire safety, timely. At least quarterly for 1 year, the CEO shall audit the aforementioned tracking system and the fire safety trainings to ensure competition, timely. (DPOC by AES,HSLS (4/2/20)] 03/09/2020 Implemented
6400.141(c)(10)Individual #2's physical examination, completed 5/13/19, did not address communicable disease.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. To correct this violation, any individual being admitted to FSU will have their medical documentation screened for accuracy. The medical documentation will include a statement indicating whether or not the individual is free from communicable disease to ensure the safety of self and other individuals. The RN will examine the documents for missing information. On 3/14/2020 staff was trained on how to examine and check physical forms for accuracy before leaving appointments. [Documentation of aforementioned audits of completed physical examinations shall be kept. (DPOC by AES,HSLS on 4/2/20)] 03/14/2020 Implemented
6400.141(c)(14)Individual #2's physical examination, completed 5/13/19, did 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. To correct this violation, any individual being admitted to FSU will have their medical documentation screened for accuracy. The RN will examine the documents for missing information. On 3/14/2020 staff was trained on how to examine and check physical forms for accuracy before leaving appointments. [Documentation of aforementioned audits of completed physical examinations shall be kept. (DPOC by AES,HSLS on 4/2/20)] 03/13/2020 Implemented
6400.151(a)Direct Service Worker #1, date of hire 9/04/19, had an initial physical examination completed on 11/6/19. Direct Service Worker #2, date of hire 3/4/19, had an initial physical examination on 2/2/20. 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. In order to correct this violation FSU has created on-boarding checklist to track new hire documentation. Moving forward FSU will not start any new hire without a physical exam and tuberculin skin test. Residential director will check for accuracy all new hires on- boarding documentation before working in direct contact with our individuals. [On 3/10/20, CEO educated management staff persons for two hours on responsibilities and completing aforementioned checklists and audit forms. Documentation of training provided to the Department on 3/25/20. Within 30 days of receipt of the plan of correction, the CEO or designee shall develop and implement a notification and tracking system to ensure staff are notified and have physical examinations completed, timely. Within 45 days of receipt of the plan of correction, the CEO or designee shall educate the staff person responsible for implementation of the aforementioned tracking and notification system of their responsibilities to ensure staff persons have physical examinations completed, timely. Documentation of the trainings shall be kept. (DPOC by AES, HSLS on 4/2/20)] 03/10/2020 Implemented
6400.151(c)(2)Direct Service Worker #1, date of hire 9/4/19, had an initial tuberculin skin testing completed on 11/09/19. Direct Service Worker #2, date of hire 3/4/19, had an initial tuberculin skin testing completed on 12/21/19. 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. In order to correct this violation, on 3/10/2020 FSU has created a new on boarding checklist to track new hire documentation. Moving forward FSU will not start any new hire without a physical exam and tuberculin skin test. Residential director will check for accuracy all new hires on-boarding documentation before working in direct contact with individuals. [On 3/10/20, CEO educated management staff persons for two hours on responsibilities and completing aforementioned checklists and audit forms. Documentation of training provided to the Department on 3/25/20. (DPOC by AES,HSLS on 4/2/20)] 03/10/2020 Implemented
6400.34(a)Individual #2, date of admission 7/22/19, has not been informed and explained individual rights and the process to report a rights violation.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.In order to correct this violation, individual #2 was informed of resident rights and explained the process to report a rights violation on 3/9/2020. Moving forward the program specialist will assure upon admission and annually that individuals have been informed of their rights and the process to report during admission and annually. CEO will audit all admission and annual paperwork. Documentation of the audits will be kept. [Individual #2 was informed of right (updated version to include regulations 6400.31a through 34b) on 4/3/20. Immediately, the CEO shall review regulations 6400.31a through 34b to develop procedures and train staff persons on informing, educating, assisting and providing the accommodations necessary for individuals to make choices and understand and exercise the individuals' rights. Documentation of trainings shall be kept. Immediately, the CEO shall review regulations 6400.31a through 34b and update documentation of rights and inform and explain individual rights and the process to reports rights violations to the individuals and persons designated by the individuals. Documentation of the copy of the signed rights statements shall be kept. (DPOC by AES,HSLS on 4/6/20)] 03/09/2020 Implemented
6400.46(d)Direct Service Worker #2, date of hire 3/4/19, was trained in first aid, Heimlich techniques and cardio-pulmonary resuscitation on 10/18/19.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.In order to correct this violation, on 3/9/20 a form and electronic calendar was created and will alert the Residential Director of new hires' CPR deadline and of current staff's annually training due dates. Moving forward staff will receive first aid, Heimlich techniques and cardio-pulmonary resuscitation within 6 months of hire. [Immediately and at least monthly for 1 year, the CEO or designee shall audit the aforementioned tracking document and the current CPR/FA training documentation to ensure all staff persons are trained as required, timely. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 4/2/20)] 03/09/2020 Implemented
6400.165(g)Individual #2 had a review of medications used to treat symptoms of a psychiatric illness completed on 6/22/19 and then again 10/22/19.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.In order to correct this violation, on 3/13/2020, individual #2 was explained why it is important for psych medication reviews to be completed every three months. Moving forward FSU has created a form for individual refusal of treatment . The nurse will educate individuals on the importance of the treatment that is being refused. Registered nurse will make sure all psych med reviews forms are completed and documentation of the review is kept. [On 3/10/20, CEO educated management staff persons for two hours on responsibilities and completing aforementioned checklists and audit forms. Documentation of training provided to the Department on 3/25/20. Within 30 days of receipt of the plan of correction, the CEO or designee shall develop and implement scheduling and tracking system to ensure medication review by the physician are scheduled to ensure completion, timely. Within 45 days of receipt of the plan of correction, the CEO or designee shall educate the staff person responsible for implementation of the aforementioned scheduling and tracking system of their responsibilities to ensure completion of medication reviews by the physician are completed, timely. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 4/2/20)] 03/13/2020 Implemented
6400.166(b)Trazadone Tab 100MG, take 1 tablet by mouth daily, prescribed to Individual #2 was not initialed as administered at 8:00PM on 3/3/20.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.In order to correct this violation, the direct support staff was retrained on 3/10/20 on how to use electronic medication administration documentation properly and its importance (Therap). Moving forward program specialist will check daily for medication documentation accuracy. [At least monthly, a designated staff person shall audit all individuals medication administration record, medications and physicians orders to ensure all individuals are administered medications as prescribed and documented as required. Documentation of the audits shall be kept. Additional training shall be completed as needed based on audits. (DPOC by AES,HSLS on 4/2/20)] 03/10/2020 Implemented
SIN-00144984 Unannounced Monitoring 11/06/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(2)Direct Service Worker #1's physical examination on 8/14/18 did not include a Tuberculin skin test. 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. In order to correct this violation, the compliance officer informed Direct Service Worker #1 that physical form needed updated. TB was given just needed the physician to put the dates TB was completed, a updated form was completed on 11/13/2018 physical form was updated with the dates the tb was given. Going forward the CEO will ensure employee physicals are filled out completely and includes the TB skin testing results and dates. [Immediately and upon completion the CEO or designee shall audit all staff person's current physical examinations to ensure all required information is included. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 11/20/18)] 11/13/2018 Implemented
6400.167(b)Individual #1 is prescribed RA Col-Rite 100 mg capsules with the instructions "take one capsule by mouth at bedtime for constipation." The medication was prescribed on 10/3/18; however has not been administered. The medication is listed as a PRN in the Medication Administration Record (MAR). Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.On 11/12/2018 Doctor fax over a new label which list the medication a prn. From now on the nurse will review all new medication orders and assure MAR documentation is correct. The CEO has implemented a monthly process for ensuring the individual MARS has the current medications listed. To remain in compliance staff has been informed to notify the nurse when new prescriptions have been prescribed to update the MARS. [Immediately, upon receipt of new medications order and at least monthly, the nurse or designee certified to administer medications shall audit all individuals medications, medication administration records and physician orders to ensure all individual are administered medications as prescribed and documented as required. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 11/20/18)] 11/12/2018 Implemented
6400.181(e)(14)Individual #1's assessment, dated 6/30/18 does not include the individual's knowledge of water safety and ability to swim.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. The water safety and the ability to swim section of the assessment was accidentally moved during a revision but located in another area of the assessment and has been highlighted on the assessment. Immediately, the CEO will educate the program specialist as to what must be included in individual assessments. At least quarterly, the Program specialist shall review individual assessments to ensure all required information is present and individual's are accurately assessed. [At least quarterly for 1 year, the CEO shall audit all completed individual assessment to ensure all required information is included. Documentation of all audits shall be kept. (DPOC by AES,HSLS on 11/20/18)] 11/12/2018 Implemented
6400.186(b)The program specialist and Individual #1 did not sign and date the ISP review completed 8/23/18 for Individual #1.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. On 11/08/2018 Individual #1's ISP review were reviewed and signed and dated by the individual and the program specialist. From now on the house manager and compliance officer will ensure ISP reviews are signed and dated by the program specialist and the individual when completed quarterly. Check list were put in place to make sure ISP reviews are being signed. [At least quarterly for 1 year, the CEO shall audit the check lists and a 10% sample of ISP reviews to ensure the program specialist and individual are signing and dating the ISP reviews. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 11/20/18)] 11/08/2018 Implemented
6400.186(d)The program specialist did not provide Individual #1s ISP review, completed 8/23/18 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 program specialist will ensure the team members will receive the ISP reviews within 30 calendar days after the ISP review meeting. The CEO will provide ongoing training and timelines for the ISP reviews to be completed and submitted to the team members. The CEO has implemented a Tracker as a guideline and timeline to ensure compliance is met with this regulation. 11/12/2018 Implemented
SIN-00137253 Renewal 06/28/2018 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment of the home.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter.In order to correct this violation,FSU completed the self-assessment for residential site and used the self-assessment summary instructions for the timeline to complete, which it stated 3-6 months prior to inspection, opposed to license renewal. FSU has since corrected the due date on our calendar and will issue notification at our team meetings. Going forward FSU will hire a Compliance Manager which will be responsible for placing the due date on the calendar 6 months prior to the license renewal and share the date with House manager and the CEO. The House manager is responsible for making sure the self assessment is completed no less than 4 months prior to license renewal. [As of 8/10/18, the self assessment of the home was not completed. Prior to 3 months before the expiration date of the certificate of compliance, the CEO and house manager shall review completed self-assessments to ensure timely completion of the self- assessments to measure and record compliance with this chapter. Documentation of the reviews shall be kept. (DPOC by AES,HSLS on 9/7//18)] 07/01/2018 Not Implemented
6400.21(a)Chief Executive Officer #1, date if hire 7/1/17 had a Pennsylvania criminal history record check completed 7/27/17. Program Specialist #2, date of hire 7/1/17 had Pennsylvania criminal history record check completed 7/27/17. Direct Service Worker #3, date of hire 3/1/17, did not have a Pennsylvania criminal history record check.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. In order to correct this violation, Immediately, the CEO will develop and implement policies and procedures to include a new hire checklist including background checks to ensure that all required criminal background checks are completed as required and maintained and available for review. CEO will review all criminal background checks to ensure submission and completion as required within 5 working days after the person's date of hire. Documentation of policies and procedures and reviews shall be kept. [Direct Service Worker #3 had a PA state police criminal record check completed on 6/29/2018. Documentation of the CEO's audit of criminal record checks shall be completed. Immediately and prior to hire and continuing at least quarterly, the CEO shall audit the "pre-employment checklist" to ensure completion with all required information including required criminal history checks. Documentation of the audit shall be kept. (DPOC by AES,HSLS on 9/7//18)] 07/05/2018 Implemented
6400.21(c)Direct Service Worker #4, date of hire 7/1/17, had a Pennsylvania criminal history check dated 6/7/16; the criminal history check indicates a criminal record; however, the record was not attached.The Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person¿s date of hire. In order to correct this violation, Direct care worker #4 has summitted a new criminal clearance with all the attachments placed in direct worker#4 employee file. 6/29/2018 Going forward, the CEO has revised the new hire checklist to include the information and the steps required to hire an individual that has a prior criminal record. Hiring manager are required to take the online training to become knowledgeable. These steps are closely monitored by the CEO during the entire hiring process. All paperwork is required to be collected by the house manager and forwarded to the CEO for final review. Once all the pertinent documents are collected and reviewed by the CEO, only then can an employment offer be made.6/29/2018 [Direct Service Worker #4 had a PA state police criminal record check completed on 6/29/2018. Documentation of the CEO's audit of criminal record checks shall be completed. Immediately and prior to hire and continuing at least quarterly, the CEO shall audit the "pre-employment checklist" to ensure completion with all required information including required criminal history checks. Documentation of the audit shall be kept. (DPOC by AES,HSLS on 9/7//18)] 06/29/2018 Implemented
6400.31(a)Individual #1, date of admission 3/17/18, was not informed of the individual's rights upon admission.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. In order to correct this violation, Individual #1 signed a revised rights form which included the missing rights 6/29/2018. Going forward, the program specialist will be responsible for having the individuals sign the "rights" both upon admission and annually. Program specialist will document on the new admission checklist. Annual documentation including "rights" is tracked on calendar by the Program specialist. CEO will review new admission checklists and tracking and compare to individual records to ensure timely completions of receipt of rights. [Individual #1 signed an individual rights document on 7/1/18. Documentation of audits of rights documentation, tracking system and individual records by the CEO shall be kept. (DPOC by AES,HSLS on 9/7//18)] 06/29/2018 Implemented
6400.43(b)(4)Chief Executive Officer #1 did not demonstrate compliance with Chapter 6400 regulations, related to Community Homes for people with Intellectual Disabilities. In addition, Chief Executive Officer #1 was not present during the scheduled annual inspection.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Compliance with this chapter. In order to correct this violation, The CEO will be retained on the job responsibility per 6400.43(A)-(C) and policies and procedures of FSU organization. Chief Executive Officer #1 was not present during the scheduled annual inspection but will be present so forth on scheduled inspections. Going forward, FSU will hire a compliance officer to assist the CEO and administrative staff on tracking systems and compliance. Family services united board of director shall educate the CEO of the responsibilities of the position as per 6400.43(b)(1)-(4). Documentation of quarterly reviews shall be kept.7/9/2018 [As of 8/10/18 the CEO has not been trained in the CEO responsibilities and did not participate in the unannounced inspection by the Department on 8/10/18. The agency has not hired a Compliance Officer. Immediately, the CEO shall be educated in the responsibilities of the CEO position as per 6400.43(b)(1)-(4) to include a review of the 6400 chapter, the agency policies and procedures, the admission and discharge procedure. Documentation of the training shall be kept. as stated in POC. Quarterly review documentation not available for review. (DPOC by AES,HSLS on 9/7//18)] 07/09/2018 Not Implemented
6400.44(b)(10)Individual #1, date of admission 3/17/18, did not have monthly documentation of the individual's participation and progress towards outcomes.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.In order to correct this violation, ISP Goal Data documentation has been implemented on 7/2/18. With this in place, a monthly review will be generated stating 7/2/18. This ISP review will be provided to all members of individual #1's team. Going forward CEO 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 10 days of receipt of the plan of correction, the CEO shall educate 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 will 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 shall be kept. 7/3/2018 [As of 8/10/18, the program specialist has not completed monthly reviews for individual #1 and the program specialist has not been educated of the responsibilities of the position. (DPOC by AES, HSLS on 9/7/18)] 07/03/2018 Not Implemented
6400.44(b)(18)Program Specialist #2, did not ensure that direct service workers in the home were properly trained in the Health and Safety needs of Individual #1, admitted 3/17/18. This includes, but it not limited to, qualified and trained staff to administer medications.The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. In order to correct this violation, the program specialist received a disciplinary action for not ensuring that direct service workers in the home were properly trained in the Health and Safety needs of Individual #1. This includes, but it not limited to, qualified and trained staff to administer medications., Moving forward the CEO shall educate the program specialists of the responsibilities of the program specialist position as per 6400.44b (1)-(19). Documentation of the training shall be kept. Documentation of quarterly reviews shall be kept.7/5/18 [As of 8/10/18, the program specialist has not been educated of the responsibilities of the position and staff have not been trained in medication administration. A registered nurse is currently administering all medications. Immediately, the CEO shall ensure staff persons are trained on the health and safety needs relevant to each individual. Documentation of the training shall be kept. At least weekly for 3 months and at least weekly for 3 months after hire, the CEO and Program Specialist shall observe each staff person to ensure that all direct service workers are implementing the training in the health and safety needs relevant to each individual including administered medications as applicable. Documentation of the trainings and observations shall be kept.(DPOC by AES, HSLS on 9/7/18)] 07/05/2018 Not Implemented
6400.46(a)Direct service worker #4, hired 7/1/17, did not have an 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.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. In order to correct this violation, Direct service worker #4 had update orientation relevant to their responsibilities, the daily operation of the home and policies and procedures of FSU. Documentation of training was added to Direct service worker #4 employee file .7/2/2018 Going forward, CEO and program specialist will review all employees training records and documents on orientation. Program specialist and house manager was trained on a tracking system and reviewed all of 6400 training regulations. This will be the responsibility of the Program Specialist. The Program Director will review all staff files to ensure all staff have received orientation to each individual¿s needs, the homes policies/procedures and their specific job responsibilities, All training will be accurately documented in employee files and reviewed by CEO. Quarterly, the CEO shall review all training documents and staff training tracking document to ensure all required staff training is completed and documented as required .7/2/2018 [Direct Service worker #4 had training from 6/29/18 to 7/3/18. Documentation of aforementioned quarterly audits of staff training by the CEO shall be kept. Immediately, the CEO and Program specialist shall review staff training requirements as per 6400.46 and develop a training plan and documentation system to ensure training for all staff persons is completed as required, timely. Documentation of all staff trainings shall be kept as required. (DPOC by AES, HSLS on 9/7/18)] 07/02/2018 Implemented
6400.46(f)Direct service worker #4, date of hire 7/1/17, did not have an initial fire safety training.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. In order to correct this violation, Direct care worker#4 and program specialist has been trained in general fire safety, evacuation procedures, and responsibilities during fire drills. 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. as of 07/02/18. Documentation of trainings was added to Direct care worker#4 and program specialist employees¿ files. Going forward CEO and program specialist will review all employees training records and documents on fire safety. Program specialist and house manager was trained on a tracking system and reviewed all of 6400 training regulations. This will be the responsibility of the Program Specialist. Quarterly, the CEO shall review all training documents and staff training tracking document to ensure all required staff training is completed and documented as required7/2/18 [Direct service worker #4 had fire safety training on 7/18/18. Program specialist had fire safety training on 7/2/18. Documentation of aforementioned quarterly audits of staff training by the CEO shall be kept. Immediately, the CEO and Program specialist shall review staff training requirements as per 6400.46 and develop a training plan and documentation system to ensure training for all staff persons is completed as required, timely. Documentation of all staff trainings shall be kept as required. (DPOC by AES, HSLS on 9/7/18)] 07/02/2018 Implemented
6400.46(i)Program Specialist #2, date of hire 7/1/17, was not trained in first aid, Heimlich techniques, and cardio-pulmonary resuscitation.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. In order to correct this violation,Program specialist was trained in CPR/First Aid didn¿t have a copy of certificate on site in personal file, Program Specialist employee file was updated. Moving forward, FSU will ensure that all prospective employees receive training in First Aid/CPR before working with the Individuals/participants. FSU has contacted with a Certified CPR/FA instructor to coordinate schedule sessions prior to expiration date of staff certification to ensure no lapse in certification. This will allow for an unforeseen absence and the ability to reschedule if needed and still maintain current certification. The CEO will develop a new hire checklist ensuring that all required trainings are completed as outlined in the regulations within the prescribed timeframes within 10 days receipt of this plan of correction. [Program Specialist #2 was trained in first aid, Heimlich techniques, and cardio-pulmonary resuscitation on 7/24/18. Immediately, the CEO and Program specialist shall review staff training requirements as per 6400.46 and develop a training plan and documentation system to ensure training for all staff persons is completed as required, timely. Documentation of all staff trainings shall be kept as required. (DPOC by AES, HSLS on 9/7/18)] 07/05/2018 Implemented
6400.67(b)There was a red brick protruding approximately 4 inched above the top of a floor drain in the basement of the home posing a tripping hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.in order to correct this violation, The floor drain was properly covered with a new drain and bricks were removed.7/5/2018 Going forward, the house manager will be responsible to do monthly inspections for house repairs. The house manager will complete monthly inspection forms. [A monthly checklist by staff as an internal inspection of safety was competed 6/29/18 by the program specialist, reads drain cover was replaced on 7/1/8. Document read pleas complete and return to CEO and House Manager for review. Documentation of reviews of completed form by the CEO and House manager shall be kept. Within 30 days of receipt of the plan of correction, the CEO shall educated all staff persons responsible for completing on site checks of the homes on checking the home and completing the checklist and the submission to CEO and House manager process. Documentation of the trainings shall be kept. (DPOC by AES, HSLS on 9/7/18)] 07/05/2018 Implemented
6400.71The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the cordless telephone left of the fireplace in the living room of the home. The telephone numbers of the nearest hospital, police department, fire department, and ambulance were not on or by the cordless telephone to the right of the fireplace in the living room of the home.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. In order to correct this violation, the House manager reprinted the list of emergency numbers on and by any land line phone at the residential site. The list contains emergency numbers for the police, fire department, poison control center, closest hospital and fire department. To ensure on going compliance the CEO informed all staff to notify House manager if there are not emergency numbers located by a telephone at a residential site. During new hire orientation staff will trained on the location of emergency numbers and equipment. Completed 6/29/2018 (emergency numbers) Monthly, CEO will complete an on-site visit of residential site to ensure all required telephone numbers are on or by each telephone with an outside line. Documentation of on-site visits shall be kept. 6/29/2018 [A monthly checklist by staff as an internal inspection of safety was competed 6/29/18 by the program specialist, reads "all telephone numbers replaced, 6/29/18." Document read "please complete and return to CEO and House Manager for review." Documentation of reviews of completed form by the CEO and House manager shall be kept. Within 30 days of receipt of the plan of correction, the CEO shall educated all staff persons responsible for completing on site checks of the homes on checking the home and completing the checklist and the submission to CEO and House manager process. Documentation of the trainings shall be kept. (DPOC by AES, HSLS on 9/7/18)] 06/29/2018 Implemented
6400.77(c)There was not a first aid manual with the first aid kit in the kitchen of the home. A first aid manual shall be kept with the first aid kit.In order to correct this violation, First Aid manual has been placed in the first Aid kit. Going forward a procedure is in place that required the House manager and RN to do a walk through monthly to assure that all necessary regulatory items are in place. The first aid kit check will be added to the monthly checklist and the house manager will check to ensure all required item are in the first aid kit at least monthly. The Program specialist will review the monthly checklist at least quarterly to ensure completion and accuracy. Documentation of the checks shall be kept. 7/5/2018 [A monthly checklist by staff as an internal inspection of safety was competed 6/29/18 by the program specialist, reads "first aid manual purchased, 6/29/18." Document read "please complete and return to CEO and House Manager for review." Documentation of reviews of completed form by the CEO and House manager shall be kept. Within 30 days of receipt of the plan of correction, the CEO shall educated all staff persons responsible for completing on site checks of the homes on checking the home and completing the checklist and the submission to CEO and House manager process. Documentation of the trainings shall be kept. (DPOC by AES, HSLS on 9/7/18)] 07/05/2018 Implemented
6400.106The furnace in the home was not inspected and cleaned by a professional furnace cleaning company within the past year.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. in order to correct this violation, Furnace inspection was done by a certified HVAC inspector and approved on 7/3/2018. Documentation is on file. Going forward, the house manager will check annual tracking system at least quarterly to ensure timely completion of annual furnace inspection are scheduled and complete. CEO will assure furnace is inspected and approved annually by a HVAC expert. Documentation of the policies and procedures and checks shall be kept. [Furnace Inspection completed 7/3/18. A monthly checklist by staff as an internal inspection of safety was competed 6/29/18 by the program specialist, reads "Annual inspection completed 7/3/18." Document reads "please complete and return to CEO and House Manager for review." Documentation of reviews of completed form by the CEO and House manager shall be kept. Within 30 days of receipt of the plan of correction, the CEO shall educated all staff persons responsible for completing on site checks of the homes on checking the home and completing the checklist and the submission to CEO and House manager process. Documentation of the trainings shall be kept. (DPOC by AES, HSLS on 9/7/18)] 07/03/2018 Implemented
6400.111(f)The fire extinguishers in the kitchen, in the laundry area of the basement and at the top of the stairs outside of the bathroom were not inspected and approved by a fire safety expert and there were not dates of inspection on the fire extinguishers. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. In order to correct this violation, the CEO has scheduled a fire extinguishers inspection. All fire extinguishers will be inspected and tagged by a fire safety expert on 7/12/2018 at 1:00p.m. Going forward the CEO will ensure the fire extinguishers are tagged and inspected annually. (service receipts photo of inspection tags will be kept) [Immediately, the CEO shall develop and implement policies and procedures to include a tracking system and notification system and monthly checks of fire extinguishers. CEO will assure fire extinguishers are inspected and approved annually by a fire safety expert. Documentation of the policies and procedures and checks shall be kept. 7/12/18 [Fire extinguishers serviced and tagged on 7/12/18. A monthly checklist by staff as an internal inspection of safety was competed 6/29/18 by the program specialist, reads "Annual inspection completed 7/12/18." Document reads "please complete and return to CEO and House Manager for review." Documentation of reviews of completed form by the CEO and House manager shall be kept. Within 30 days of receipt of the plan of correction, the CEO shall educated all staff persons responsible for completing on site checks of the homes on checking the home and completing the checklist and the submission to CEO and House manager process. Documentation of the trainings shall be kept. (DPOC by AES, HSLS on 9/7/18)] 07/05/2018 Implemented
6400.112(c)The written fire drill records for the fire drill held from July 2017 to June 2018 did not include the exit route used for evacuation.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. In order to correct this violation, FSU has retrained staff on alternating exits and proper documentation for fire drills. Going forward FSU will keep a written fire drill record of the date, time, the amount of time it took for evacuation, the exit route used, alternating of exits, problems encountered and whether the fire alarm or smoke detector was operative. This will be the responsibility of the House manager. The compliance officer and house manager will review the fire drill documentation monthly to ensure compliance and maintain documentation for review by 7/4/2018 [Fire drills held on 6/29/18 and 7/18/18 include exits route used. Documentation of staff training on completing and documenting fire drills shall be kept. (DPOC by AES, HSLS on 9/7/18)] 07/04/2018 Implemented
6400.112(d)The fire drill held on 4-14-18 had an evacuation time of 5 minutes. The fire drill held on 5-15-18 had an evacuation time of 3 minutes. There was no written documentation of an extended evacuation time by a fire safety expert.Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home.In order to correct this violation, The Program Specialist and house manager retrained the staff and individual #1 on 7/4/2018. A fire drill test for evacuation time was done 7/4/2018 and individual #1 evacuation time was 2minutes. Going forward to speed up the evacuation time FSU will do frequent evacuation drills and train individual #1 on the important to take evacuation seriously for safety. if evacuation time is still not in compliance FSU will schedule for a fire safety expect for extended evacuation time. The Program Specialist will review the fire drill records during monthly team meetings and Trainings and Compliance Manager is responsible for reviewing the fire drill record for accuracy during the weekly compliance visit. Within 30 days of receipt of the plan of correction, the CEO or House manager shall observe a fire drill to ensure fire drills are conducted and documented as required.7/3/2018 [Fire drills held on 6/29/18 and 7/18/18 had evacuation times with in 2 1/2 minutes. Documentation of staff training on completing and documenting fire drills shall be kept. (DPOC by AES, HSLS on 9/7/18)] 07/04/2018 Implemented
6400.113(a)Individual #1, date of admission 3/17/18, was not instructed in fire safety upon initial admission. 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. in order to correct this violation, Individual #1 has been trained on 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 documentation has been added to individual #1 file, Going forward, FSU will make sure that each individual, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building, . The Program Specialist will confirm that individuals received the required Fire and Safety Training. The Program Director will review all the Individuals records bi-annually to ensure fire safety training has been completed. CEO will review new admission checklists and annual tracking system at least quarterly to ensure timely completion of initial and annual trainings are up to date.7/4/2018 [Individual was trained in fire safety on 6/29/18. Immediately, the CEO shall completed the aforementioned new admission checklist and annual tracking system. Documentation of all of aforementioned reviews by the program specialist, the program director and the CEO shall be kept. (DPOC by AES, HSLS on 9/7/18)] 07/04/2018 Implemented
6400.141(c)(3)The physical examinations for Individual #1, dated 10/10/17 and 3/5/18, do not include a record of immunizations. This section was left blank.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. In order to correct this violation, Individual #1 received The Tetanus shot and her file was updated on 06/29/2018. Going forward CEO will ensure all individuals at FSU will have completed immunizations before moving into a residential site. The current intake form used at FSU list immunizations are a requirement. All administrative staff will be train on this regulation to be compliant. An bi annual appointment checklist was created, and also a tracking system was put in place to assure that all medical needs are met and in compliance. Immediately, the CEO shall train Program Specialist and the House manager of the requirements of individuals physical examinations as per 6400.141(c)(1)-(15) and that no required areas of physical examinations shall be left blank. Documentation of training shall be kept. Immediately and upon completion, the reviews of physical examinations shall be completed, and missing information shall be immediately obtained. Documentation of trainings and reviews shall be kept. [As of 8/10/18 Individual #1's physical examination does not include immunizations and there is not a record of the immunization purchased (Boostrix injection 0.5mL (DTAP) being administered. Immediately, implement aforementioned plan of correction. (DPOC by AES, HSLS on 9/7/18)] 07/02/2018 Not Implemented
6400.151(a)Program Specialist #2, date of hire 7/1/17, did not have a physical examination. Direct service worker #4, date of hire 7/1/17, did not have a physical examination. 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. Program Specialist#2 and Direct care worker #4 has provided copies of pre-employment physicals 07/3/2018 all employee records gas been updated. Going forward, the CEO revised the new hire check list to include deadlines for required documents. The CEO has implemented a new policy where all new hires must have their physical on file prior to the first day of work. The Program Specialist and CEO will review the new hire files to assure that the physical form and criminal background is on file. Documentation of the reviews shall be kept ensuring staff physicals are completed timely. Tracking system is in place to remind program specialist when staff files needs updated 7/3/2018 [Program Specialist #2 had a physical examination completed 10/20/17 and Direct Service Worker #4 had a physical examination completed 6/29/18. Immediately, upon completion and at least quarterly, for 1 year, the Program specialist and the CEO shall audit all staff person's physical examination and the aforementioned tracking system and the aforementioned checklist to ensure all staff person's have a current physical examination with all required information completed timely and available for review upon request by the Department.(DPOC by AES, HSLS on 9/7/18)] 07/03/2018 Implemented
6400.151(c)(2)Program Specialist #2, date of hire 7/1/17, did not have Tuberculin skin testing. Direct service worker #4, date of hire 7/1/17, did not have Tuberculin skin testing. 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. In order to correct this violation, Immediately, Program Specialist #2 and Direct care staff #4 has provided copies of pre-employment physicals 07/3/2018 which included TB testing. The CEO revised the new hire check list to include deadlines for required documents. The CEO has implemented a new policy where all new hires must have their physical with TB testing completed on file prior to the first day of work. The Program Specialist and CEO will review the new hire file to assure that the physical form and criminal background is on file. Documentation of the reviews shall be kept ensuring staff physicals are completed timely. Tracking system is in place to remind program specialist when staff files needs updated 7/3/2018 [Program Specialist #2 had a Tuberculin skin testing completed 10/19/17 and Direct Service Worker #4 had a physical examination completed 7/2/18. Immediately, upon completion and at least quarterly, for 1 year, the Program specialist and the CEO shall audit all staff person's physical examination including Tuberculin skin testing and the aforementioned tracking system and the aforementioned checklist to ensure all staff person's have a current physical examination with all required information completed timely and available for review upon request by the Department.(DPOC by AES, HSLS on 9/7/18)]] 07/03/2018 Implemented
6400.151(c)(3)Direct service worker #3's physical examination, completed 3/8/18 did not include a statement that the employee is free from a communicable disease or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. In order to correct this violation (7/3/2018 House manager had new physical form documentation from physician stating she was free from communicable disease. Going forward, The CEO will ensure all employee physicals are accurate during the new hire process. CEO will ensure all physicals have a section that state the employee is free of communicable diseases that a health professional must address during the physical Immediately and prior to entering into staff files, the CEO shall review all staff physical examinations to ensure all required information is present and there are not any required areas left blank including communicable disease. Documentation of reviews shall be kept. 7/3/2018 [Program Specialist #2 had a physical examination including a signed statement that the staff person is free of communicable diseases completed 10/20/17 and Direct Service Worker #4 had a physical examination including a signed statement that the staff person is free of communicable diseases completed 6/29/18. Immediately, upon completion and at least quarterly, for 1 year, the Program specialist and the CEO shall audit all staff person's physical examination and the aforementioned tracking system and the aforementioned checklist to ensure all staff person's have a current physical examination with all required information including a signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals completed timely and available for review upon request by the Department.(DPOC by AES, HSLS on 9/7/18)] 07/03/2018 Implemented
6400.163(c)Individual #1, date of admission 3/17/18, is prescribed medications to treat symptoms of diagnosed Anxiety, Depression, and Intermittent Explosive Disorder; however, the individual has not had a review with a licensed physician regarding the reasons the medication is prescribed, the need to continue the medication, or the necessary dosages of prescribed medications. 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.In order correct this violation the Program Specialist created a quarterly psychiatric medication review form to be completed quarterly for psychiatric medications. For individual # 1 the most recent psychiatric medication review was 7/3/2018. Going forward the form must be completed quarterly. (psychiatric medication quarterly review form) Immediately, the CEO will develop and implement policies and procedures to include a tracking, notification, review and training to ensure medication reviews are completed timely with all required information. Documentation of aforementioned policies and procedures shall be kept. 7/3/18 [Individual #1 had a psychiatric medication review completed 7/3/18 to include all required information. Upon completion of the psychiatric medication review by the licensed physician, a designated staff person certified to administer medications and trained in the requirements of psychiatric medication reviews as per 6400.163(c) shall audit all psychiatric medication reviews to ensure all required information is included and individuals are administered medications as prescribed. Documentation of audits shall be kept. Immediately, the aforementioned submitted plan of correction shall be implemented. (DPOC by AES, HSLS on 9/7/18)] 07/03/2018 Implemented
6400.167(a)Direct service worker #3, who is not certified to administer medications, administered medications to Individual #1 from 3/17/18 to 6/28/18. Direct Service worker #5, who is not certified to administer medications, administered medications to Individual #1 from 3/17/18 to 6/28/18. Individual #1 has not been assessed to self-administer medications. Prescription medications and injections of a substance not self-administered by individuals shall be administered by one of the following: (1) A licensed physician, licensed dentist, licensed physician's assistant, registered nurse or licensed practical nurse. (2) A graduate of an approved nursing program functioning under the direct supervision of a professional nurse who is present in the home.(3) A student nurse of an approved nursing program functioning under the direct supervision of a member of the nursing school faculty who is present in the home. (4) A staff person who meets the criteria specified in § 6400.168 (relating to medications administration training) for the administration of oral, topical and eye and ear drop prescriptions and insulin injections. In order to correct this violation, After the follow up licensing visit, a medication administration plan of correction was developed and implemented immediately. Registered nurse will pass all meds until all staff are med trained. All staff who were not properly certified to administer medications ceased administering medications that same day. FSU continued to implement the steps of the plan of correction until all staff are certified to administer medications. Going forward, the RN will become a medication administration trainer next available class. RN will review all training materials and documentation to ensure staff are properly trained and certified prior to administering medications. The RN is responsible for maintaining documentation and records on an ongoing basis. quarterly for 1 year, the CEO shall audit all staff persons documentation of certification to administer medications to ensure only staff persons who are certified to administer medications are administering medication. Documentation of all review shall be kept 6/28/2018 [A registered nurse is currently administering all medications. Documentation of Medication Administration training for direct service workers not available for review. Immediately, implement aforementioned submitted plan of correction. (DPOC by AES, HSLS on 9/7/18)] 06/28/2018 Implemented
6400.181(a)Program Specialist #2 did not complete an assessment for Individual #1, date of admission 3/17/18. 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. The Program Specialist completed individual # 1 assessment on 7/5/2018 as per 6400.181 (a)-(f).Going forward to ensure on going compliance with this violation the Program Specialist and CEO will determine the assessment due date during the intake process. This will ensure the Program Specialist is aware of when the assessment must be completed to be compliant. All administrative staff will be trained on this regulation during new hire orientation and annually. Individual #1's assessment was completed on 7/5/18. Within one week of receipt of the plan of correction and at least quarterly for one year and annually thereafter, the CEO/program specialist shall review the responsibilities of the position as per 6400.44(b)(1)-(19) and sign and date upon review. Within 30 days of receipt of the plan of correction the CEO shall develop and implement a new admission and annual checklist to include a tracking system to ensure timely completion of initial and annual requirements including assessments. At least monthly the CEO shall review the tracking to ensure timely completion of assessments. Documentation of reviews shall be kept. [Individual's assessment was completed 6/30/18.Immediately, the aforementioned submitted plan of correction shall be implemented. (DPOC by AES, HSLS on 9/7/18)] 07/05/2018 Implemented
6400.186(a)Program Specialist #2 did not complete an ISP review for Individual #1, date of admission 3/17/18.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. In order to correct this violation, Program Specialist#2 has completed the 3-month ISP review for Individual #1 on 07/5/2018. Going forward the CEO has created a tracking system to document when the three-month reviews are completed coinciding with the ISP dates. The Program specialist will review the regulations 6400. 186, (a) through (g) pertaining to the ISP Review and Revision. The program specialist will contact the Supports Coordinator to develop a timeline for the ISP and 3-month reviews and will send them to all team members. At the Annual ISP, the program specialist will complete the declination form with the team members. Program Specialist will conduct a quarterly review of all records to ensure that the necessary signatures are obtained. In addition, the House manager and compliance office will conduct spot checks of files to ensure compliance. Immediately, the program specialist and Individual #1 shall review the ISP review and sign and date as required. Within 15 days of receipt of the plan of correction, the CEO shall educate the program specialists of the responsibilities of the program specialist position as per 6400.44b (1)-(19). Documentation of the training shall be kept. Documentation of quarterly reviews shall be kept. 7/26/18 [The program specialist completed an ISP review for Individual #1 on 6/29/18. Immediately, the aforementioned submitted plan of correction shall be implemented. (DPOC by AES, HSLS on 9/7/18)] 07/05/2018 Implemented
6400.186(e)Program Specialist #2 did not notify Individual #1's plan team members of the option of the option to decline ISP reveiws. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. In order to correct this violation, a signature form has been created for SC to sign and indicate a copy, agree and/or if declined to review. The form will be filed with the reviews and reviewed by CEO and program specialist. Program Specialist will email all team members the option to decline ISP reviews. Going forward to stay in compliance the program specialist will ensure the option to decline letter is sent to team members once the individual has completed the intake process. CEO will review the intake documentation to ensure the individuals team members will be sent the option to decline letter. The program specialist notified the plan team members for Individual #1 of the option to decline the ISP review documentation on 7/3/2018 via email. Within one week of receipt of the plan of correction and quarterly for 1 year, the CEO will review with the program specialist the responsibilities of the position as per regulation 6400.44(b)(1)-(19) and sign and date upon review. Documentation of the CEO's review of options to decline shall be kept.7/10/2018 [The program specialist notified the plan team members of the option to decline ISP review documentation on 6/28/18.Immediately, the aforementioned submitted plan of correction shall be implemented. (DPOC by AES, HSLS on 9/7/18)] 07/03/2018 Implemented
6400.213(9)Individual #1's record did not include a copy of the current ISP for Individual #1. Each individual's record must include the following information: A copy of the current ISP. To correct this violation, program specialist #2 contacted SC for Individual #1's record was updated to include current ISP Immediately, Going forward Program specialist shall review individual records to ensure all required information as per 6400.213(1)-(14) is present including copy of ISP. Documentation of all reviews shall be kept. 6/29/2018 The program specialist will ensure during the intake process of admittance, A updated ISP will be in individuals files. Once the intake information is gathered the CEO will review the individual's file to check for accuracy as per 6400.213(1)-(14). This change was made effective as of 6/29/2018, by the CEO. Regarding individual files administrative staff will be retrained how to keep individuals files up to date how to identify missing information. as per 6400.213(1)-(14) [As of 8/10/18, Individual #1's current ISP was in Individual's Record. Immediately and continuing at least quarterly, a designated staff person trained in the information required to be in the individuals' records shall audit all individuals' record to ensure all required information is included. Documentation of the audits shall be kept. (DPOC by AES, HSLS on 9/7/18)] 06/29/2018 Implemented
SIN-00117835 Renewal 07/19/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.74The outside steps from the kitchen of the home did not have a nonskid surface.Interior stairs and outside steps shall have a nonskid surface. On 7/24/17 maintenance applied a non-skid surface to the steps located in the back of the home leading to the deck. [At least monthly, the CEO shall complete a check of the home to ensure interior and outside steps have nonskid surfaces in good repair. Documentation of monthly home checks shall be kept. (AS 8/8/17)] 07/30/2017 Implemented
6400.77(b)The first aid kit did not contain tweezers, tape and a thermometer. 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. On 7/20/17 a first aid kit was purchased with assurance that it contained 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. [CEO shall develop and implement procedures to ensure first aid kits remained stocked with required items at all times to include replacement and replenishment procedures and at least monthly checks. Upon hire, the CEO shall train all staff as to the required items in first aid kits and the aforementioned procedures to ensure first aid kits contain all required items at all times. Documentation of trainings and monthly checks shall be kept. (AS 8/8/17)] 07/30/2017 Implemented
6400.80(b)The outside of the home has areas of disrepair posing tripping and injury hazards to include multiple and varying chips and cracks in the sidewalks in the front and side of the home, a stone structure with loose bricks and cement debris, overgrowth of vegetation, exposed tree roots and a pile of tree logs in the back of the home and a large chip along the edge of porch in the front of the home. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.On 7/24/17 demolition began to replace sidewalks having cracks as well as crack on the front of the porch posing any tripping hazards. All over grown vegetation was cut and removed on 7/24/2017 and will be maintained weekly to keep area welcoming and safe. All tree logs have been removed and disposed of on 7/24/17. [CEO shall develop and implement procedures to ensure the outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions and at least monthly checks. Upon hire, the CEO shall train all staff on the aforementioned procedures to ensure the outside of the building and the yard or grounds are well maintained, in good repair and free from unsafe conditions. Documentation of trainings and monthly checks shall be kept. (AS 8/8/17)] 07/30/2017 Implemented
6400.82(f)The bathroom did not have a trash receptacle.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle.On 7/24/17 maintenance dept. placed a trash receptacle in the bathroom. [CEO shall develop and implement procedures to ensure each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle to include replacement and replenishment procedures. Upon hire, the CEO shall train all staff as to the required items in bathroom areas and the aforementioned procedures to ensure bathrooms have all required items at all times. Documentation of trainings shall be kept. (AS 8/8/17)] 07/30/2017 Implemented
6400.101The bedroom door to the left of the stairway on the second story of the home and the bathroom door were equipped with skeleton key locks that could prevent egress if locked.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. On 7/24/17 all locking mechanisms located on the second story of the home were removed and replaced with non-locking mechanisms there- by removing all obstructions. [Upon hire, the CEO shall educated staff persons that stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed and to monitor throughout the course of their daily duties. Documentation of trainings shall be kept. (AS 8/8/17)] 07/30/2017 Implemented
6400.105An opened cardboard box containing a wine cabinet and styrofoam packaging material was eighteen inches from the furnace and two stereo speakers were thirty-five inches from the furnace in the basement/ground level of the home. Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. On7/24/17 maintenance dept. removed all supplies and materials, placing them at a safe distance away from all fire and combustible hazards.[Upon hire, the CEO shall educated staff persons that Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources and to monitor throughout the course of their daily duties. Documentation of trainings shall be kept. (AS 8/8/17)] 07/30/2017 Implemented
SIN-00221742 Renewal 03/28/2023 Compliant - Finalized
SIN-00203735 Renewal 04/12/2022 Compliant - Finalized
SIN-00149250 Renewal 01/23/2019 Compliant - Finalized