Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00213950 Unannounced Monitoring 10/24/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(f)An uncoverd trash receptacle containing a full white trash bag was in the back yard of the home.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.On 10/24/2022, It was discovered that the lid for one of the sets of trash cans had blown away. The AHH House Manager notified the AHH maintenance crew. A replacement receptacle was purchased and delivered to the residence on 10/24/2022. 11/09/2022 Implemented
SIN-00198069 Renewal 12/16/2021 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(6)Individual #1 had a Tuberculin skin testing on 10/9/2018 and then again on 6/24/2021.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 received a Tuberculin skin test on 10/9/2018 and was due to receive the next Tuberculin skin test by 10/9/2020. Individual #1 was unable to schedule receive a Tuberculin Skin Test that was scheduled on 10/1/20 due to her primary physician¿s office cancelling the appointment that was scheduled with the reason due to the COVID Pandemic. Individual #1 was able to reschedule and received that Tuberculin skin test on 6/24/21. 06/24/2021 Implemented
6400.141(c)(7)Individual #1, date of admission 12/10/2018 did not have a gynecological examination.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. A Gynecological Exam for Individual #1 was completed on 4/24/18, prior to Individual #1s admission date of 12/10/18. This exam was completed within the year of Individual #1s admission. The agency retrieved supporting documentation from the doctors office. No violation. The original documentation was provided during the prelimary. 04/24/2018 Implemented
6400.52(a)(1)Direct Service Worker #1 completed 11 hours of annual training for training year, January 1, 2020 to December 31, 2020.The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.Staff #1s trainings were reviewed for the training year of January 2020-December 2020. Staff #1 completed 28.5 hours for the annual training year January 2020-December 2020., however it was omitted during submission and was not accepted once discovered and told to submit as part of POC. Documentation of Staff #1s training logs will be provided for review as evidence that a minimal of 24 hours were completed throughout the annual training year of January 2020-December 2020. Monthly review audits will be completed by the OM and AD on each staffs annual trainings and training requirements. OM and AD will correct any discrepancies upon discovery during the review audits. 09/17/2020 Not Implemented
6400.52(c)(1)The annual training for training year, January 1, 2020 to December 31, 2020, for Direct Service Worker #1 did not encompass the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Staff #1 received the Person-Centered Practices, Community Integration, Individual Choice, and Supporting Individuals to develop and maintain relationships trainings on 2/24/21. The importance of ODP required trainings was reviewed by the agency's management team. All trainings have been reviewed for clarity and timely execution. To ensure that these specific trainings are completed and in a timely manner, the agency has updated and revised their annual training curriculum tto include the Person-Centered Practices, Community Integration, Individual Choice, and Supporting Individuals to develop and maintain relationships trainings. 02/24/2021 Not Implemented
6400.52(c)(3)The annual training for training year, January 1, 2020 to December 31, 2020, for Direct Service Worker #1 did not encompass individual rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Staff #1 received the Individual Rights training on 2/24/21. The importance of ODP required trainings was reviewed by the agency¿s management team. All trainings have been reviewed for clarity and timely execution. To ensure that these specific trainings are completed and in a timely manner, the agency has updated and revised their annual training curriculum to include the Individual Rights training. 02/24/2021 Not Implemented
6400.52(c)(4)The annual training for training year, January 1, 2020 to December 31, 2020, for Direct Service Worker #1 did not encompass recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Staff #1 received the Recognizing and Reporting Incidents training on 4/15/20. At the time of the training, the agency titled this particular training as Mandated Reporting and Incident Management. 04/15/2020 Not Implemented
6400.52(c)(5)The annual training for training year, January 1, 2020 to December 31, 2020, for Direct Service Worker #1 did not encompass the safe and appropriate use of behavior supports if the person works directly with an individual.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.Staff #1 received the Safe and Appropriate use of Behavior Supports training on 4/4/20. At the time of the training, the agency titled this particular training as ISP/SEE Plan/Fade Plan/ BSP/Restrictive Restraint Policy (RPP) Training and Positive Practices and Approaches w/in Intervention Plans¿. 04/04/2020 Not Implemented
6400.166(a)(11)Individual #1's December 2021 Medication Administration Record did not include the diagnosis or purpose for the following medications: Calcium D3 Tab, Cetirizine and Medroxyprog AC.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Individual #1s MAR was reviewed for the documentation of the Diagnosis and Purposes for L-Carnitine. The review found that the Diagnosis and Purposes for L-Carnitine are included on Individual #1s MAR. 12/17/2021 Not Implemented
SIN-00193862 Unannounced Monitoring 09/21/2021 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(r)(1)Individual #1 does not have access to a key to lock and unlock her bedroom door.Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.The individual received a key to her door on September 22, 2021 and a spare key was placed in the armoire in the dining room. 09/22/2021 Not Implemented
SIN-00189533 Unannounced Monitoring 07/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The wall in the kitchen of the home was soft to the touch and the paint was peeling. There was an open section approximately nine inches by three feet exposing ceiling beams in the ceiling above the stairwell leading from the second floor to the third floor of the home.Floors, walls, ceilings and other surfaces shall be in good repair. Floors, walls, ceilings and other surfaces shall be in good repair. : AHH maintenance stripped the wall in the kitchen to identify the issue. The upstairs bathroom bathtub drain needed repaired. The repairs were made to the bathroom, the walls were also plastered, sanded and painted. The missing piece ceiling was also replaced, plastered, sanded and painted. Maintenance has corrected the violation by mudding and sanding and painting effected area as of 7.7.21. 07/07/2021 Implemented
6400.72(a)There was not a screen in the window on the right closest to the door in Individual #1's bedroom.Windows, including windows in doors, shall be securely screened when windows or doors are open. Maintenance discovered the screen was in the basement. The screen was then installed. 7.1.21 The screen was recovered from the basement and reinstalled back in the individual¿s window. The individual had a window unit air conditioner in which the screen had to be removed for installation purposes. The screen was stored in the basement and upon the change to a more powerful floor the screen was incidentally not replaced back to its original location 07/01/2021 Implemented
6400.165(e)Individual #1's June 2021 Medication Administration Record was not updated to reflect that Omega-3 Cap 1000MG, take 1 capsule by mouth daily was discontinued on 6/28/2021. The staff has been documenting the medication as refused daily since it was discontinued.Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received.Discontinued medications have been disposed of properly by the House supervisor to maintain compliance on 7.1.21 by the house supervisor. to ensure compliance. Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. Discontinued medications have been disposed of properly by the House supervisor to maintain compliance. 07/01/2021 Implemented
6400.166(a)(11)Individual #1's July 2021 Medication Administration Record does not include the diagnosis or purpose for Calcium/D3 TAB 600-5, take 2 tablets by mouth daily, Citalopram TAB 20MG, take 1 tablet by mouth daily, Loratadine 10MG TAB, take 1 tablet by mouth daily.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The house supervisor will the contact the pharmacy to update the medications to include the reason for prescribing the medication (diagnosis) n the Medication Administration Record (MAR). The MARs were then updated. House manager will check daily to ensure that compliance is maintained. A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. 08/05/2021 Implemented
6400.207(4)(I)Individual #1 is prescribed Lorazepam TAB 0.5MG, take 1 tablet by mouth daily at bedtime as needed for anxiety. The symptoms of the specific condition are not defined or listed for the administration of the medication.A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition.Medication was discontinued on 7.30.21. In the future the house supervisor will contact the individual¿s psychiatrist and advise the medication has to have specific behaviors and instructions listed in order to administer the medication. The psychiatrist will be asked to send a detailed prescription to PDC Pharmacy in order to properly administer the medication when needed to the individual. 07/30/2021 Implemented
SIN-00186853 Renewal 04/27/2021 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(r)Individual #1 would like to exercise the right to lock the her bedroom door. The agency has not provided Individual #1 the accommodation for Individual #1 to lock her bedroom door.An individual has the right to lock the individual's bedroom door.Plan of Correction for: 55 PA Code Chapter 6400.32(r) Lock on doors How it was corrected: On May 3, 2021 AHH Maintenance purchased a key and lock doorknob for the individual¿s bedroom door. The Maintenance team will install the new door knob. The individual will be given the key and the spare will be maintained on site for emergency purposes only. When it was corrected: May 3, 2021 Who made the correction: A Helping Home, LLC Maintenance What specific change will be made: The AHH Maintenance will purchase a key and lock doorknob and install it on the individual's bedroom door. Who will make the change: AHH Maintenance 05/03/2021 Not Implemented
SIN-00159758 Renewal 07/23/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self assessment for the home was completed on 7/9/19. The agency's certificate of compliance expires on 8/25/19.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. How was it Corrected: The self-assessments had been completed prior to licensing however were not on file at the office.When it was corrected: On July 24, 2019 Who made the corrections: A Helping Home, LLC CEO Kamar Williams What Specific Change will be made: A file was created to store the site self-assessments at the main office as well as on site.Who will make the change: CEO Kamar Williams When will the change be made: This change took place immediately How will the change be made: CEO Kamar Williams instructed Office Manager Sheena Hancock to create a separate file specifically for site self assessments which will now be completed bi-annually. What system have you implemented to make sure that the same violation will not occur again: CEO Kamar Williams will ensure the site self assessments are properly filed once Associate Director Tamica Wade completes them.hat training will be provided by you to the staff: Staff are not responsible for site self assessments. Supporting Documentation: Training Agenda 07/31/2019 Implemented
6400.21(a)Direct Service Worker #1 date of hire 12/26/18 had a Pennsylvania criminal history check completed 3/8/19.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. How was it Corrected: On August 4, 2019, A Helping Home LLC Operations Manager created a Pre- Hire Documents Checklist Form to keep track and ensure the PA Criminal History is submitted and completed for prospective new hires prior to their start date. (see attached form)When it was corrected: On August 4, 2019 Who made the corrections: Operations Manager Sheena Hancock What Specific Change will be made: The Administrative Assistant have been trained to complete and submit the Pre-Hire Documents Checklist Form to the Operations Manager prior to the prospective new hire being enrolled in AHH company training. The PA Criminal History date of request, date of receipt and eligibility for hire will be recorded on the form. The form must also be signed by both the Administrative Assistant and new hire. Once the form is received by the Operation Manager the hiring process will proceed. Who will make the change: Operations Manager Sheena Hancock When will the change be made: August 5, 2019 How will the change be made: A Helping Home, LLC Operations Manager Sheena Hancock trained the Administrative Assistant Irwin Banks on how to complete and submit the Pre-Hire Documents Checklist Form. Once the completed form is received by the Operations Manager the new hire will be enrolled in company training. The new hire will begin working in the agency homes upon completion of AHH company training What system have you implemented to make sure that the same violation will not occur again: The Administrative Assistant will be trained on new hire steps and how to complete the Pre-Hire Documents Checklist Form. If a completed Pre-Hire Documents Checklist Form is not received by the Operations Manager, the company will not move forward with the hiring process. This prevents the occurrence of employees working at AHH sites without having a Pennsylvania Criminal History Record Check. What training will be provided by you to the staff: The Administrative Assistant will be trained on the hiring process and how to complete and submit the Pre- Hire Documents Checklist Form. This training specifically outlines the checks and balance system put in place during our hiring process. Supporting Documentation: Training Agenda Pre-Hire Documents Checklist Form 08/05/2019 Implemented
6400.66There was not a source of outside lighting at the exit to the porch in the rear of the home.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. How was it Corrected: Outside lighting was put in place to ensure proper lighting for the rear of the site. When it was corrected: On July 31, 2019 Who made the corrections: A Helping Home, LLC maintenance contractors What Specific Change will be made: Outside lighting was added to the back porch to provide proper lighting during the evening and overnight hours. Who will make the change: A Helping Home, LLC maintenance When will the change be made: This change took place immediately How will the change be made: CEO Kamar Williams contacted maintenance to request a light fixture be added to the back porch of the home. What system have you implemented to make sure that the same violation will not occur again: CEO Kamar Williams will ensure proper lighting is available for all sites in the front as well as in the rear of the sites moving forward. What training will be provided by you to the staff: The staff will be advised to report if and when the light goes out and to change to bulb. Supporting Documentation: Training Agenda Picture of the light [On 8/26/19, there was a light at the exit in the rear of the home. (AES,HSLS on 9/24/19)] 07/31/2019 Implemented
6400.141(c)(7)Individual #1, date of admission 12/10/18 did not have a gynecological examination.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. How was it Corrected: A follow-up physical was scheduled for the individual in order to complete all sections of the physical. When it was corrected: On July 30, 2019 Who made the corrections: Associate Director Tamica Wade scheduled the appointment for the individual. What Specific Change will be made: The House Supervisor will attend all future medical appointments to ensure all sections are complete. The Associate Director Tamica Wade will review all medical documentation upon their completion and prior to filing in the individual¿s records. The AD will also review all oncoming paperwork to ensure no appointments are missed.Who will make the change: Associate Director Tamica Wade When will the change be made: This is to be changed immediately How will the change be made: The House Supervisor will attend all physical examinations to ensure a thorough completion. What system have you implemented to make sure that the same violation will not occur again: The House Supervisor will attend all future physical examinations/medical appointments to ensure all sections are complete at the time of the physical examinations. Associate Director Tamica Wade will conduct the preliminary observation of the physical examination paperwork upon its return with the individual and the CEO Kamar Williams will conduct a second review.What training will be provided by you to the staff: The topics will cover the importance of receiving completed documentation for all medical records. Supporting Documentation: Training Agenda Completed Physical (gyn exam completed 8/5/19) [Individual #'1's gynecological examination was completed 8/5/19. (AES,HSLS on 9/24/19)] 07/31/2019 Implemented
6400.141(c)(11)The physical examination for individual #1 completed 10/9/18 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 left 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. How was it Corrected: A follow-up physical was scheduled for the individual in order to complete all sections of the physical. When it was corrected: On July 30, 2019. Who made the corrections: Associate Director Tamica Wade scheduled the appointment for the individual. What Specific Change will be made: The House Supervisor will attend all future physical examinations to ensure all sections are complete at the time of the physical examination. The Associate Director Tamica Wade will review all physical exam documentation upon their completion and prior to filing in the individual¿s records. Who will make the change: Associate Director Tamica Wade When will the change be made: This is to be changed immediately How will the change be made: The House Supervisor will attend all physical examinations to ensure a thorough completion. What system have you implemented to make sure that the same violation will not occur again: The House Supervisor will attend all future physical examinations to ensure all sections are complete at the time of the physical examinations. Associate Director Tamica Wade will conduct the preliminary observation of the physical examination paperwork upon its return with the individual and the CEO Kamar Williams will conduct a second review.What training will be provided by you to the staff: The topics will cover the importance of receiving completed documentation for all medical records.Supporting Documentation: Training Agenda Completed Physical [Documentation of the aforementioned audits of all individuals completed physical examinations shall be kept. (DPOC by AES,HSLS on 9/24/19)] 07/31/2019 Implemented
6400.141(c)(13)The physical examination for Individual #1 completed 10/9/18 did not include allergies or contraindicated medications. This section was left blank.The physical examination shall include: Allergies or contraindicated medications.How was it Corrected: A follow-up physical was scheduled for the individual in order to complete all sections of the physical. When it was corrected: On July 30, 2019 Who made the corrections: Associate Director Tamica Wade scheduled the appointment for the individual. What Specific Change will be made: The House Supervisor will attend all future physical examinations to ensure all sections are complete at the time of the physical examination. The Associate Director Tamica Wade will review all physical exam documentation upon their completion and prior to filing in the individual¿s records. Who will make the change: Associate Director Tamica Wade When will the change be made: This is to be changed immediately How will the change be made: The House Supervisor will attend all physical examinations to ensure a thorough completion. What system have you implemented to make sure that the same violation will not occur again: The House Supervisor will attend all future physical examinations to ensure all sections are complete at the time of the physical examinations. Associate Director Tamica Wade will conduct the preliminary observation of the physical examination paperwork upon its return with the individual and the CEO Kamar Williams will conduct a second review. What training will be provided by you to the staff: The topics will cover the importance of receiving completed documentation for all medical records. Supporting Documentation: Training Agenda Completed Physical [Documentation of the aforementioned audits of all individuals completed physical examinations shall be kept. (DPOC by AES,HSLS on 9/24/19)] 07/31/2019 Implemented
6400.141(c)(14)The physical examination for Individual #1's completed 10/9/18 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. How was it Corrected: A follow-up physical was scheduled for the individual in order to complete all sections of the physical. When it was corrected: On July 30, 2019 Who made the corrections: Associate Director Tamica Wade scheduled the appointment for the individual. What Specific Change will be made: The House Supervisor will attend all future physical examinations to ensure all sections are complete at the time of the physical examination. The Associate Director Tamica Wade will review all physical exam documentation upon their completion and prior to filing in the individual¿s records. Who will make the change: Associate Director Tamica Wade When will the change be made: This is to be changed immediately How will the change be made: The House Supervisor will attend all physical examinations to ensure a thorough completion. What system have you implemented to make sure that the same violation will not occur again: The House Supervisor will attend all future physical examinations to ensure all sections are complete at the time of the physical examinations. Associate Director Tamica Wade will conduct the preliminary observation of the physical examination paperwork upon its return with the individual and the CEO Kamar Williams will conduct a second review.What training will be provided by you to the staff: The topics will cover the importance of receiving completed documentation for all medical records. Supporting Documentation:Training Agenda Completed Physical [Documentation of the aforementioned audits of all individuals completed physical examinations shall be kept. (DPOC by AES,HSLS on 9/24/19)] 07/31/2019 Implemented
6400.141(c)(15)The physical examination for Individual #1 completed 10/9/18 did not include special instructions for the individual's diet. This section was left blank.The physical examination shall include:Special instructions for the individual's diet. How was it Corrected: A follow-up physical was scheduled for the individual in order to complete all sections of the physical. When it was corrected: On July 30, 2019 Who made the corrections: Associate Director Tamica Wade scheduled the appointment for the individual. What Specific Change will be made: The House Supervisor will attend all future physical examinations to ensure all sections are complete at the time of the physical examination. The Associate Director Tamica Wade will review all physical exam documentation upon their completion and prior to filing in the individual¿s records. Who will make the change: Associate Director Tamica Wade When will the change be made: This is to be changed immediatelyHow will the change be made: The House Supervisor will attend all physical examinations to ensure a thorough completion. What system have you implemented to make sure that the same violation will not occur again: The House Supervisor will attend all future physical examinations to ensure all sections are complete at the time of the physical examinations. Associate Director Tamica Wade will conduct the preliminary observation of the physical examination paperwork upon its return with the individual and the CEO Kamar Williams will conduct a second review.What training will be provided by you to the staff: The topics will cover the importance of receiving completed documentation for all medical records. Supporting Documentation:Training Agenda Completed Physical [Documentation of the aforementioned audits of all individuals completed physical examinations shall be kept. (DPOC by AES,HSLS on 9/24/19)] 07/31/2019 Implemented
SIN-00141375 Renewal 07/25/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Direct Service Worker #1, date of hire 6/16/18, had Pennsylvania criminal history record check completed 6/22/18.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. 7/25/18 Anyone employed by A Helping Home, LLC will obtain criminal clearances PRIOR to or within 5 days of date of hire. Beginning 9/1/18, Program Supervisor will track compliance by utilizing employee pre hire compliance checklist to track all pre hire regulatory requirements. Post hire, said checklist will be included in employee file. Program Supervisor will review all employee files quarterly to ensure compliance. All employee files will be reviewed for compliance no later than 10/1/18. [Documentation of audits of employee files by the program supervisor shall be kept. (DPOC by AES, HSLS on 9/25/2018)] 10/01/2018 Implemented
6400.141(c)(11)Individual #1's physical examination completed 2/7/18 did not include an assessment of the individual's health maintenance information. 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. 7/26/18- Physical exam of individual #1 was faxed to Physician and returned with information pertinent to the individual¿s health maintenance needs. Copy of physical with corrections will be provided with this POC. Beginning 9/1/18, Provider will ensure that all annual physicals are fully completed leaving no blank spaces. Program Supervisor and Program Director will review all physicals of potential consumers preadmission to ensure compliance and completion. Team Lead will accompany current individuals supported to annual physical to ensure that physical paperwork is fully completed. Team Lead will submit physical to Program Supervisor within one week for review. [Immediately, the CEO shall educate all staff persons responsible to for reviewing and accompanying individual to medical appointments of the information required in individuals' physical examinations as per 6400.141(c)(1)-(15) and the aforementioned procedures auditing all individuals' physical examinations to ensure all required information is included and there are not any required areas left blank. Documentation of the training shall be kept. (DPOC by AES, HSLS on 9/25/18)] 09/01/2018 Implemented
6400.141(c)(14)Individual #1's physical examination completed 2/7/18 did not include medical information pertinent to diagnosis 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. A Helping Home's supervisor will ensure that specified medical information pertinent to diagnosis and treatment in case of an emergency is completed by physician prior to admission date.[Immediately, the CEO shall educate all staff persons responsible for reviewing and accompanying individuals to medical appointments of the information required in individuals' physical examinations as per 6400.141(c)(1)-(15) and the aforementioned procedures auditing all individuals' physical examinations to ensure all required information is included and there are not any required areas left blank. Documentation of the training shall be kept. (DPOC by AES, HSLS on 9/25/18)] 10/13/2018 Implemented
6400.151(a)Direct Service Worker #2, date of hire 3/4/18, had physical examination completed 3/5/18. 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. A Helping Home's supervisor will ensure that all staff will have a completed physical prior to their date of hire.[Immediately, the CEO or designee shall develop and implement a tracking system to included staff persons physical examination and Tuberculin testing to ensure all staff persons have a physical examination and Tuberculin testing completed, timely. Documentation of the tracking system shall be kept and audited by the CEO or designee at least monthly to ensure all staff are notified in time to have a physical examination and Tuberculin testing completed, timely. Documentation of audits shall be kept. (DPOC by AES, HSLS on 9/25/18)] 10/13/2018 Implemented
6400.151(c)(2)Direct Service Worker #2, date of hire 3/4/18, had Tuberculin skin testing completed on 3/7/18. 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. 7/25/18- All staff members employed by A Helping Home, LLC will have a physical exam and TB test completed and documented on designated agency physical form containing all regulatory requirements as it relates to staff physical exams PRIOR to hire date. Program Supervisor will review all physical forms upon submission to ensure completion. Program Supervisor will review all physicals of staff hired prior to 7/25/18 to ensure all necessary regulatory requirements are met no later than 8/25/18. Any staff member with physical exam not meeting regulatory requirements will be suspended until completion of compliant physical exam on designated agency form is completed and submitted . [Immediately, the CEO or designee shall develop and implement a tracking system to included staff persons physical examination and Tuberculin testing to ensure all staff persons have a physical examination and Tuberculin testing completed, timely. Documentation of the tracking system shall be kept and audited by the CEO or designee at least monthly to ensure all staff are notified in time to have a physical examination and Tuberculin testing completed, timely. Documentation of audits shall be kept. (DPOC by AES, HSLS on 9/25/18)] 08/25/2018 Implemented
6400.161(b)The first aid kit which is kept unlocked in the kitchen, contained aspirin and anti-acid packets. The individuals living in the home are not assessed to safely use or avoid toxic materials.Prescription and potentially toxic nonprescription medications shall be kept in an area or container that is locked, unless it is documented in each individual's assessment that each individual in the home can safely use or avoid toxic materials. 7/25/18- All medication and potentially toxic material was immediately removed from first-aid kit and disposed of in a safe manner. First aid kit currently contains only items set forth by regulation. All medications or potentially toxic materials will be kept locked unless otherwise specified by the ISP of the person supported. Moving forward, Program Supervisor will monitor compliance in this area by utilizing weekly house visit checklist that will serve as a tool to track compliance beginning 9/1/18. [Immediately, the CEO shall educated all staff persons that prescription and potentially toxic nonprescription medications shall be kept in an area or container that is locked, unless it is documented in each individual's assessment that each individual in the home can safely use or avoid toxic materials and the agency's procedures for locking prescription and potentially toxic nonprescription medications and that staff persons shall monitor throughout the course of their daily duties. Documentation of the training shall be kept. (DPOC by AES, HSLS on 9/25/18)] 09/01/2018 Implemented
6400.161(e)Triamcinolone Acetonide 0.1% cream, apply once application externally to affected area twice a day for 14 days prescribed to Individual #1 was dated as filled on 6/18/18; remained in Individual #1's medication box. Individual Ibuprofen 400 mg, take one tablet by mouth every 6 hours as needed for pain for 5 days prescribed to Individual #1's was dated as filled on 6/8/18; remained in Individuals #1's medication box.Discontinued prescription medications shall be disposed of in a safe manner.7/25/18- Discontinued medication was immediately removed from medication box and safely disposed of. Moving forward, Team Lead and Program Supervisor will conduct weekly reviews of each MAR against medications contained in medication box to ensure that only current medications are present beginning 9/1/18. This will occur for every person supported by A Helping home, LLC Discontinued or expired medications will be immediately removed and disposed of by Program Supervisor in a safe manner. [Immediately, the CEO shall educate all staff persons that discontinued prescription medications shall be disposed of in a safe manner and the agency's procedures for disposal of medications in a safe manner. Documentation of the training shall be kept. Documentation of the aforementioned weekly audits shall be kept. (DPOC by AES, HSLS on 9/25/18)] 09/01/2018 Implemented
6400.164(b)Fluticasone 50mg, Levothyroxine50mg, Mag Oxide 400mg, Pantoprazole 40mg, Paroxetine 30 mg, Latuda 80mg, Topiramate 200mg and Trazadone 50 mg prescribed to Individual #1 were not logged as administered on 7/1/18. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. 7/26/18- Staff member responsible for documentation error was identified and provided with additional training regarding Medication Administration on 9/2/18. Moving forward, Provider will ensure weekly checks of MAR for accuracy and completion. Team Lead will review MAR weekly as well as Program Supervisor during house visits. Any areas of noncompliance will be immediately addressed and areas of additional staff training will be identified and addressed by providing additional training at monthly house meetings beginning 9/1/18. [Documentation of aforementioned audits and trainings shall be kept. (DPOC by AES, HSLS on 9/25/18)] 09/01/2018 Implemented
6400.167(b)On 7/25/18, Topiromate 200mg, take one tablet by mouth daily prescribed to Individual #1 was not available in the home for administration. Individual #1 was last administered this medication on 7/5/18. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.7/28/18- Prescribing Physician was notified and contacted the pharmacy in an attempt to rectify previous insurance issue that was preventing approval. Physician submitted necessary documentation to insurance company on 8/08/18. Medication was approved and received by provider 8/15.18. 9/1/18- Provider created Team Lead position in each home. One of the responsibilities of said position is to review MAR weekly to ensure that all medications are logged and administered correctly. Program Supervisor will also review MAR weekly during house visits. Team Lead and Program Supervisor will take point on ensuring that if a medication is not able to be administered as prescribed supporting documentation from prescribing physician is attached to corresponding MAR. [Immediately, and continuing at least weekly for 3 months and then continuing at least monthly and upon any changes in medication orders by a prescribing medical professional, a designated staff person certified to administer medications shall audit all individuals' medication orders, medications and medication administration records to ensure all individuals are administered medications as prescribed. Documentation of all audits shall be kept. (DPOC by AES, HSLS on 9/25/18)] 09/01/2018 Implemented
SIN-00119812 Renewal 08/25/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)At 9:47 AM, the hot water temperature in the bathtub in the bathroom on the second floor of the home measured 123.2 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. Temperature last read was 117. It will be checked daily by staff [On 9/11/17 at 3:30PM, the CFO measured the water temperature at the bathtub which read 117°F. Immediately, the CEO or designee shall develop and implement procedures for measuring, documenting and adjusting the hot water temperature in bathtubs and showers to ensure the hot water does not exceed 120°F. Immediately and upon hire, the CEO or designee shall train all staff of the aforementioned procedures. Documentation of trainings shall be kept. (AS 9/11/17)] 08/29/2017 Implemented
6400.77(b)The first aid kit did not contain 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. We purchased a thermometer [On 9/6/17, the CFO purchase a thermometer and placed in the first aid kit. Immediately and upon hire, the CEO shall train all staff as to the required the items in first aid kits and the storage and replacement procedures to ensure all required items are in first aid kits at all time. At least monthly for 1 year, the CEO or designee shall audit first aid kits to ensure all required items are present. Documentation of audits shall be kept. (AS 9/11/17) 09/07/2017 Implemented
6400.101The door leading into the garage from the basement had a key lock and a deadbolt lock that could only be unlocked from the house side of the door. The garage did not have a man door.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The deadbolt has been changed around so that it doesn't lock from the inside of the house [Immediately and upon hire, the CEO shall train all staff person that all 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. (AS 9/11/17)] 08/24/2017 Implemented
SIN-00235917 Renewal 12/07/2023 Compliant - Finalized
SIN-00235018 Unannounced Monitoring 11/16/2023 Compliant - Finalized
SIN-00232310 Renewal 09/26/2023 Compliant - Finalized
SIN-00228483 Unannounced Monitoring 07/26/2023 Compliant - Finalized
SIN-00223149 Unannounced Monitoring 04/20/2023 Compliant - Finalized
SIN-00221117 Unannounced Monitoring 03/16/2023 Compliant - Finalized
SIN-00215110 Unannounced Monitoring 11/21/2022 Compliant - Finalized
SIN-00203917 Unannounced Monitoring 04/21/2022 Compliant - Finalized
SIN-00196011 Unannounced Monitoring 10/29/2021 Compliant - Finalized
SIN-00173258 Unannounced Monitoring 06/02/2020 Compliant - Finalized
SIN-00172837 Renewal 03/26/2020 Compliant - Finalized
SIN-00134659 Unannounced Monitoring 05/08/2018 Compliant - Finalized