Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00215109 Unannounced Monitoring 11/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)The windows inside the staff office are 3 inches wider on each side than the screens.Windows, including windows in doors, shall be securely screened when windows or doors are open. While participating in an unannounced inspection held by licensing reps on 11/21/2022, it was discovered that the window screen of the staff office at the Rose Street location was slightly larger than the window. After it's discovery, the agency's maintenance was instructed to report to the residence to collect the correct measurements and place an order for a replacement to fit the window properly. Due to the window screen being a custom order, it was not available for immediate purchase and will be installed immediately after the order is delivered. The screen was ordered on 11/22/22. 12/31/2021 Implemented
6400.18(a)(4)On 11/5/2022, Operations Manager #1 was contacted by Adult Protective Services pertaining to a physical abuse allegation regarding Individual #1 and a Direct Service Worker. This incident was not entered into the Enterprise Incident Management system until 11/10/2022.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Abuse, including abuse to a individual by another client. On 11/01/2022 at 6:40pm the individual had a minor injury while gathering her pajamas and an internal incident report was created, by AHH staff member D. Williams., who was scheduled from 7:00am-11:00pm. Due to the lack of communication between shift changes, an additional incident report was created by overnight AHH staff member. At 5:00am on 11/02/2022, The staff member sent a text message to the AHH House Manager indicating that there was a mark under the individual¿s left eye. The staff member also indicated that she was unsure of the cause. The House Manager followed up with a phone call, shortly after, and informed M. Smith that the agency would follow up with a wellness check. At 8:00am on 11/02/2022, AHH House Manager went to the individual¿s residence and conducted an exam. During the exam, the AHH House Manager noticed a faint scratch under the individual¿s left eye. During this time, there were no health and safety concerns nor possible indications of abuse. Staff were informed to monitor the area and report any changes. On 11/05/2022 at 10:45am, The Operations Manager received a call from an on-call APS, investigator stating that he was following up on physical abuse allegations regarding the individual. The APS investigator also stated that the reporter alleged severe bruising on the individual¿s face and had reason to believe it was caused by another staff member. As per protocol, the APS investigator and AHH Operations Manager made arrangements for the APS investigator to examine and interview the individual. At around 11:30am, the APS investigator went to the West Mifflin Walmart to meet the individual and her weekend staff member. The investigation ended roughly around noon. At this time, there were no indications or physical signs of abuse. Once the interview concluded, a medication list and current diagnosis was provided to the APS investigator as requested. No additional information was requested at the time. On 11/09/2022, during the individual¿s annual ISP meeting the individual¿s service coordinator informed The Operations Manager that she received an email from ODP of Erie County requesting an EIM entry of the current incident. The Operations Manager then contacted the program specialist of Erie County for clarification on proceeding with the incident. On 11/10/2022, The Operations Manager was instructed to file an EIM and proceed with a certified investigation due to the allegations of abuse. The agency immediately began the process of the investigation by informing the target that she was removed from all shifts, pending the outcome of the investigation. The Operations Manager who was also assigned as CI to the incident went to the individual¿s residence to perform a wellness check, collect evidence, and witness statements. In addition to this, the staff member that was assigned was instructed to take the individual to the emergency room for a physical examination. The individual was then taken to West Penn Hospital where she received a physical examination and head x-ray. A medical follow-up appointment was also made with the individual¿s PCP¿s office on 11/14/2022. Due to the recent events of this incident not being conducted within the 24hr timeframe and to prevent a reoccurrence of this nature, all members of management and staff members of the rose street location will be trained on ODP's Incident Management Bulletin. 11/20/2022 Implemented
6400.18(f)On 11/5/2022, Operations Manager #1 was contacted by Adult Protective Services pertaining to a physical abuse allegation regarding Individual #1 and a Direct Service Worker. The target was not separated from Individual #1 until 11/10/2022.The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident.On 11/05/2022 at 10:45am, The Operations Manager received a call from an on-call APS, investigator stating that he was following up on physical abuse allegations regarding the individual. The APS investigator also stated that the reporter alleged severe bruising on the individual¿s face and had reason to believe it was caused by another staff member. As per protocol, the APS investigator and Operations Manager made arrangements for the APS investigator to examine and interview the individual. At around 11:30am, the APS investigator went to the West Mifflin Walmart to meet the individual and her weekend staff member. The investigation ended roughly around noon. At this time, there were no indications or physical signs of abuse. Once the interview concluded, a medication list and current diagnosis was provided to the APS investigator as requested. No additional information was requested at the time. On 11/09/2022, during the individual¿s annual ISP meeting the individual¿s service coordinator informed the Operations Manager that she received an email from ODP of Erie County requesting an EIM entry of the current incident. The Operations Manager then contacted the program specialist of Erie County for clarification on proceeding with the incident. On 11/10/2022, the Operations Manager was instructed to file an EIM and proceed with a certified investigation due to the allegations of abuse. The agency immediately began the process of the investigation by informing the target that she was removed from all shifts, pending the outcome of the investigation. The Operations Manager who was also assigned as CI to the incident went to the individual¿s residence to perform a wellness check, collect evidence, and witness statements. In addition to this, the staff member that was assigned was instructed to take the individual to the emergency room for a physical examination. The individual was then taken to West Penn Hospital where se received a physical examination and head x-ray. A medical follow-up appointment was also made with the individual¿s PCP¿s office on 11/14/2022. Due to the recent events of this incident not being conducted within the 24hr timeframe and to prevent a reoccurrence of this nature, all members of management and staff members of the rose street location will be trained on ODP's Incident Management Bulletin. 11/20/2022 Implemented
SIN-00203361 Unannounced Monitoring 03/10/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101There is a turn lock on the door in the basement of the home leading to the garage that would prevent egress from the garage when engaged. The garage does not have a man door. [Repeat Violation, 10/29/2021]Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. During the unannounced inspection on 03/10/2022, it was reported that a turn lock on the door in the basement of the home leading to the garage would prevent egress from the garage when engaged. Immediately upon its discovery, the turn lock was reversed to the opposite side of the door as directed. The doors at other homes with garages were also checked and no issues existed. 05/31/2022 Not Implemented
6400.112(c)The written fire drill record for the fire drill conducted on 1/8/2022, did not address problems encountered.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The fire drill record forms that were in use during the unannounced inspection on 03/10/22 were revised by a previous Assistant Director. During the exit interview, it was discovered that the problems encountered section was not included on the revised fire drill record form. Upon its discovery, the Operations Manager removed all of the blank incorrect revised forms from this location and all other sites. After the incorrect forms were removed, the House Manager was trained by the Operations Manager on how to identify missing regulatory requirements for fire drills. After the training was completed, the operations manager provided the correct fire drill forms to the locations to be completed by staff. The updated forms now include 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. 04/30/2022 Not Implemented
SIN-00198070 Renewal 12/16/2021 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)The most recent fire drill held during sleeping hours was conducted on 5/23/2021.A fire drill shall be held during sleeping hours at least every 6 months. Individual #1 conducted a sleep fire drill on 5/23/21. The next sleep fire drill should have been completed in November 2021. On November 13, 2021, an awake fire drill was completed. Immediately upon discovery of this violation on 12/23/21, a sleep fire drill was conducted for Individual #1 on 12/23/21 at 2:21am. The Chapter 6400.112 (e) was reviewed by the agency's management team on 12/22/21. 12/23/2021 Implemented
6400.166(a)(11)Individual #1's December 2021 Medication Administration Record did not include the diagnosis or purpose for the following medications: Gavilax Powder, Sertraline and Moleskin Pads. [Repeat Violation, 7/1/2021]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
6400.166(b)Divalproex 250 mg, take 1 tablet by mouth twice daily for anger/aggression prescribed to Individual #1 was not initialed as administered on the medication administration record on 12/16/21 at 8:00 PM.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Upon discovery of this preliminary violation on 12/17/21, the administering staff documented her initials for the prescription Divalproex 250mg that was administered on 12/16/21 at 8:00pm by 12/17/21. 12/17/2021 Not Implemented
6400.213(7)Individual #1's record did not include a list of person who participate in the Individual Plan team meeting on 7/6/2021.Each individual's record must include the following information: Individual plan documents as required by this chapter.Upon discovery of this preliminary violation during a regulatory visit on December 17, 2021, on December 17, 2021, the OM emailed Individual #1s Supports Coordinator to request the Signature Sheet that documents the participants who attended Individual #1s ISP meeting on 7/6/21. The OM made a 2nd attempt to request this information on 1/6/22. This will be escalated to the SC supervisor 01/31/2022 Not Implemented
SIN-00189534 Unannounced Monitoring 07/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)On 7/1/2021 at 11:18AM, that hot water temperature at the bathtub in the bathroom along the hallway on the first floor of the home measured 129°F. Hot water temperatures in bathtubs and showers may not exceed 120°F. On July 1, 2021 the office manager adjusted the water heater control to lower the temperature of the water. Staff will be trained to conduct water temperature test daily per shift and to make adjustments as needed for temperatures exceeding 120 degrees. The readings will be recorded on a Daily Temperature Check Form. If temperature should ever exceed 120 degrees staff were trained to adjust the water heater temperature to an appropriate temperature not to exceed 120 degrees. 07/01/2021 Implemented
6400.72(a)The window on the right side of the doorway in the sitting room on the second floor of the home did not have a screen.Windows, including windows in doors, shall be securely screened when windows or doors are open. On July 1, 2021 AHH CEO had the AHH Maintenance Team provide the measurements and then ordered window screens for the individual¿s sitting room. Once the screen is received, the AHH Maintenance team will assemble and install in the individual¿s sitting room. Screen was ordered should be in by 8.13.21 and collapsible screen will be used in the meantime so Windows, including windows in doors, shall be securely screened when windows or doors are open. 08/13/2021 Implemented
6400.82(d)There was not a shower curtain or shower curtain rod in the bathtub in the bathroom to provide privacy.Privacy shall be provided for toilets, showers and bathtubs by partitions or doors. Curtains are acceptable dividers if the bathroom is used only by one sex or only by individuals 9 years of age or younger. The individual prefers to take baths and has pulled the shower curtain and rod down on several occasions. Staff decided to leave it down. On July 12, 2021 AHH maintenance reinstalled the shower curtain rod and shower curtain. Staff was trained on regulation 6400.82(d) and its necessity in order to comply with the regulation and meet the need for privacy. 07/01/2021 Implemented
6400.167(a)(3)Individual #1 is prescribed Zoloft 100MG, take 1 and 1/2 tablets by mouth daily. On July 1, 2021, two doses of the Zoloft were removed from two separate blister packs and the packs were dated and initialed as administered. There is no documentation that the extra dosage was disposed of.Medication errors include the following: Administration of the wrong dose of medication.Staff will be trained to check the label of all medications being administered prior to administering the medication as to not pop the same medication from two separate medication blister packs and dispose of any that require disposal as well as complete the Medication Disposal Form. Staff will then initial on Daily Job Responsibilities checklist after completion during each medication administration. 07/02/2021 Implemented
SIN-00172838 Renewal 03/26/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Direct Service Worker #1, date of hire 3/8/20, did not have a Pennsylvania criminal history check completed.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. Plan to Prevent Re-occurrence: Effective immediately, Office Administrator will review clearances received for potential staff to ensure that all required clearances have in fact been received. Once reviewed by Office Administrator, the Associate Director will then review potential employee file to ensure completion prior to hire. Once potential employee file is complete and approved by Associate Director, then they will be hired with the agency. This procedure has been reviewed and trained on by Associate Director and the Office Administrator on 4/1/20. This training will also be completed with executive management upon hire. Training was also done on the needed clearances by reviewing the 6100 and 6400 regulations. This was done on 4/1/20 as well. Once violation was noted, Associate Director reviewed all employee files to ensure compliance. No other violations occurred, which eliminates the possibility of it being a systemic issue. Office Administrator submitted the PA Criminal Record Check for the staff in question, on 3/30/20 and was under review. On 3/31/20, Criminal Record was returned to agency on 3/31/20. Upon review, agency (Associate Director) deemed the employee appropriate for continued employment. [A copy of DSW #1's Pennsylvania criminal history check was provided to the Department on 4/13/20. AES,HSLS on 5/27/20)] 04/01/2020 Implemented
SIN-00163087 Unannounced Monitoring 08/26/2019 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34On 8/26/19, at 10:10AM and at 1:26PM, during an unannounced inspection; agents of the Department, Human Services Licensing Representatives requested the required agency's Certified Investigations for Individual #1 for the following incidents entered in to the Enterprise Incident Management System, ID #8549099, primary category: misuse of funds, 5/3/19; ID#8549100, primary category: neglect, 5/3/19, ID#8550936, primary category: neglect, 5/7/19 and ID#8550938, primary category: neglect, 5/10/19. Additional requests were made for this information to the agency's Chief Executive officer #1 and Associate Director #2 via email on 9/13/19 and 9/24/19. As of 9/25/19 the agency had not provided the requested Certified Investigations. (Repeat violation, 1/18/19)The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients.To reiterate, the facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients. And in order to do so the agency has created and implemented an Unannounced Inspections Policy and Procedure which states that all office personnel will have keys and access to the office and the staff's and individual's locked files. In the off chance that there are no office personnel in the office at the time of an unannounced inspection the Loving Place Front Desk attendant will contact the CEO who will then have an office member in route to the office within 15 minutes. Also included in the policy is access to a spare key at the Centre Avenue location which is less then 2 miles distance from the office. This will ensure full access at all times. All management staff and office personnel have been trained on this policy and this new policy was given a trial run on Friday, October 11, 2019, which was successful. The AD went to the front desk and announced herself as an unannounced auditor and ask to speak to an AHH representative. The front desk called to the AHH office and an office personnel, Office Assistant Irwin Banks, came to the front and escorted the individual back within 2 minutes time. The office personnel was able to access the locked file cabinet and when asked for a personnel file he was able to produce such.[On 10/30/19 at 10:00AM, Agent of the Department entered the public office space and requested a representative from the agency and within a few minutes was greeted by office associate staff. Office associate staff introduced the program specialist/director to the Department within a few minutes. Documentation was requested for training, new policy as per plan of correction and recently hired PS qualifications. Training attendance form and qualifications for PS was provided to the Department, promptly. Policy as per plan of correction was not available at the time of on site inspection. Policy was emailed to the Department at 12:17Pm on 10/30/19 after the department had exited the agency. At 10:53am, certified investigation documentation requested and not available. Immediately, the CEO or designee shall develop and implement policies and procedures to ensure the Department has full access to the agency and its records at the time of inspections. At least quarterly for 1 year, the CEO or designee shall review the agency's policies and procedures and update as needed to ensure access as required. Immediately and upon changes, the CEO or designee shall train all staff persons on the agency's policies and procedures to ensure the Department full access to the agency and its records during inspections. Documentation of audits and trainings shall be kept. (DPOC by AES, HSLS on 10/30/19)] 10/11/2019 Not Implemented
6400.43(b)(4)Chief Executive Officer #1 has failed to maintain compliance with Commonwealth of Pennsylvania, Pennsylvania Code Title 55 Pa. Department of Human Services Code Chapter 6400.18. Reporting of unusual incidents. During unannounced investigations conducted by the Department on 1/18/2019 and 8/26/2019, incidents of misuse of funds and neglect were not entered into the Enterprise Incident management system within the required timeframes. It is indicated in the incident reports that incidents were filed late due to Chief Executive Officer #1 being away or traveling. Also, the explanation of the incidents included "invalid accusation" prior to the required certified investigations. Chief Executive Officer #1 has failed to maintain compliance Commonwealth of Pennsylvania, Pennsylvania Code Title 55 Pa. Department of Human Services Code Chapter 6400.11. Licensure or approval of Facilities and Agencies the requirements specified in Commonwealth of Pennsylvania, Pennsylvania Code Title 55 Chapter 20. During unannounced investigations conducted by the Department on 1/18/2019 and 8/26/2019, the agency has failed to provide the access to requested records including staff trainings and investigation documentation.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Compliance with this chapter. To reiterate, the agency's chief executive officer will be responsible for the administration and general management of the home and agency, including the following of compliance with this chapter. In order to comply and not further violate the order the CEO has created and implemented an Unannounced Inspections Policy and Procedure which states that all office personnel will have keys and access to the office and the staff's and individual's locked files. In creating this policy all inactive files, meaning paperwork and documentation not currently in use ie if it's June then May's paperwork, will be in the office an accessible by any personnel during any unannounced inspections. Management training has taken place in regards to this new policy and procedure. [On 10/30/19, the Department requested new policy and certified investigations which were not able to be obtained while the Department was onsite for an unannounced inspection. Immediately, the CEO shall develop and implement policies and procedures to ensure compliance with PA code 55, Chapter 6400 including incident management and access of the Department to the agency and agency records. At least quarterly, the CEO shall audit all policies and procedures and revise as needed to ensure compliance with chapter 6400. Documentation of audits and revisions shall be kept. (DPOC by AES,HSLS on 10/20/19)] 10/11/2019 Not Implemented
6400.18(a)(5)On 5/3/19, an accusation of neglect, relating to the amount of food in the home was reported to the agency's Chief Executive Officer #1 by Individual #1's Supports Coordinator. Incident #8549100, primary category: neglect for Individual #1 was entered into the Enterprise Incident Management system on 5/7/19. On 5/7/19, the agency became aware of an accusation of neglect. Incident #8550936, primary: category neglect, secondary category: failure to provide protection from hazards for Individual #1 was entered into the Enterprise Incident Management system on 5/11/19.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Neglect. To reiterate, the agency will report any and all incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person.In order to comply with the regulation and not repeat the violation, A HELPING HOME, LLC HAS ADDED AN ADDITIONAL POINT PERSON TO PREVENT ANY FUTURE DELAYED INCIDENT REPORT FILINGS IN THE ABSENCE OF THE CEO, which caused the incident to be FILED OUTSIDE OF THE ODP BULLETIN'S REPORTING REQUIREMENTS. In addition, A HELPING HOME, LLC's ADDITIONAL POINT PERSON, who is the AD has reviewed policies and procedures on myodp.org constituting timely submission of incidents. She has downloaded the contingency form and the western region county fax number to send incident reports to in the case that a point person is unable to access HCSIS within 24 hours. The office personnel have been trained on this procedure as well in order TO PREVENT ANY FUTURE DELAYED INCIDENT REPORT FILINGS IN THE ABSENCE OF THE CEO. [The agency currently has 26 open incidents requiring certified investigations. The department requested the certified investigations but they were not completed as required. Immediately and on going, certified investigations should be completed and incidents closed in EIM as required. Immediately, the CEO or designee shall develop and implement policies and procedures to ensure incident management is completed as required. Upon completion of the policies and procedures, the CEO or designee shall educate all staff persons on incident management and their responsibilities to ensure timely reporting, investigation and closing of incidents as required. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 10/30/19)] 10/11/2019 Not Implemented
6400.18(a)(12)On 5/3/19, an accusation for misuse of Individual #1's funds was reported to the agency's Chief Executive Officer #1 by Individual #1's Supports Coordinator. Incident #8549099, primary category: misuse of funds for Individual #1 was entered into the Enterprise Incident Management system on 5/7/19, over 3 days after notification of the accusation.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Theft or misuse of individual funds.To reiterate, the agency will report any and all incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person. In order to comply with the regulation and not repeat the violation, A HELPING HOME, LLC HAS ADDED AN ADDITIONAL POINT PERSON TO PREVENT ANY FUTURE DELAYED INCIDENT REPORT FILINGS IN THE ABSENCE OF THE CEO, which caused the incident to be FILED OUTSIDE OF THE ODP BULLETIN'S REPORTING REQUIREMENTS. In addition, A HELPING HOME, LLC's ADDITIONAL POINT PERSON, who is the AD has reviewed policies and procedures on MyODP.org constituting timely submission of incidents. She has downloaded the contingency form and the western region county fax number to send incident reports to in the case that a point person is unable to access HCSIS within 24 hours. The office personnel have been trained on this procedure as well in order TO PREVENT ANY FUTURE DELAYED INCIDENT REPORT FILINGS IN THE ABSENCE OF THE CEO.[The agency currently has 26 open incidents requiring certified investigations. The department requested the certified investigations but they were not completed as required. Immediately and on going, certified investigations should be completed and incidents closed in EIM as required. Immediately, the CEO or designee shall develop and implement policies and procedures to ensure incident management is completed as required. Upon completion of the policies and procedures, the CEO or designee shall educate all staff persons on incident management and their responsibilities to ensure timely reporting, investigation and closing of incidents as required. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 10/30/19)] 10/11/2019 Not Implemented
SIN-00159759 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.What 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
SIN-00150296 Unannounced Monitoring 01/18/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34On 1/18/19, during the entrance conference of an unannounced inspection from 11:15AM to 12:00PM, a representative of the Department requested a staffing list to include dates of hires, work schedule at which homes, contact phone numbers, and dates of fire safety and medication trainings and a fire drill record for December 2018 for one home by providing a list of the documents to Chief Executive Officer #1. At 1:50PM, Chief Executive Officer #1 provided a staff roster with dates of hire and contact numbers, all requested staff fire safety trainings, the fire drill for December 2018 and medication trainings for some staff persons.The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients.A HELPING HOME AND CHIEF EXECUTIVE OFICER #1, LLC HAS HIRED A HUMAN RESOURCES MANAGER TO REORGANIZE STAFF FILES, STAFF TRAININGS AND WORK SCHEDULES AND PAYROLL ACCORDINGLY. A HELPING HOME AND CHIEF EXECUTIVE OFICER #1 ALSO REPLACED THE PREVIOUS PROGRAM DIRECTOR RESPONSIBLE FOR INCOMPLETE FILES WITH A NEW PROGRAM DIRECTOR WHO RESPONSIBILITIES INCLUDE SITE FIRE DRILLS AND FILING FOR PROOF OF COMPLETION. [Immediately, the CEO shall develop and implement policies and procedures to ensure the Department has immediate and full access to the agency's records during both announced and unannounced inspections. Within 2 weeks of completion of the aforementioned policy and procedures, the CEO shall educate all staff persons on the aforementioned policies and procedures to ensure the Department has immediate and full access to the agency's records during both announced and unannounced inspections. At least monthly, the CEO or designee randomly ask staff person including the CEO to locate specific items in the agency's records to ensure all staff persons responsible for obtaining records upon request of the Department know where to find the records upon request by the Department. Documentation of the policies and procedures and trainings shall be kept. (DPOC by AES,HSLS on 3/13/19)] 01/31/2019 Implemented
6400.18(d)On 12/11/18, Chief Executive Officer #1 became aware of an incident of neglect for Individual #1 and Individual #2 from 11/24/18. Incident reports, #8500671 and #8500647 of neglect were entered in the Enterprise Incident Management system on 12/17/18.The home shall initiate an investigation of the unusual incident and complete and send copies of an unusual incident report on a form specified by the Department to the county intellectual disability program of the county in which the home is located, the funding agency and the appropriate regional office of intellectual disability, within 72 hours after an unusual incident occurs. A HELPING HOME HIRED AN ASSOCIATE DIRECTOR WHO IS ALSO A PENNSYLVANIA CERTFIED INVESTIGATOR. HER RESPONSIBILITIES HAVE BEEN WRITTEN TO INCLUDED INCIDENT MANAGEMENT QUALITY ASSURANCE WHERE INCIDENTS REQUIRING 24 HOUR DATA ENTRY OR 72 DATA ENTRY WILL OCCUR. SHE WILL ALSO BE RESPONSIBLE FOR FINALIZING INCIDENTS WITHIN THE 30 DAY TIME FRAME OR REQUEST AN EXTENSION, QUARTERLY INCIDENT MANAGEMENT REPORTING, CONDUCTING INVESTIGATIONS AND ANY OTHER HCSIS OR INCIDENT MANAGEMENT ISSUES OR OCCURRENCES. [Within 30 days of receipt of the plan of correction, the CEO and all staff person working in community homes shall be educated on Office of Developmental Program incident management system to ensure timely reporting and investigations. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 3/20/19)] 01/31/2019 Implemented
6400.45(d)Individual #1, requires one staff to two individuals supervision from 11:00PM to 7:00AM. Individual #2, requires one staff to two individuals supervision with auditory supervision at all times. On 11/24/18, for up to one and half hours, between the hours of 11:30PM until 1:00AM, Individual #1 and Individual #2 were unsupervised when Direct Service Worker #2 immediately terminated his position and left the home where he was found sitting in his car when replacement direct service worker reported to the home at 1:00AM.The staff qualifications and staff ratio as specified in the ISP shall be implemented as written, including when the staff ratio is greater than required under subsections (a), (b) and (c). INCIDENT REPORTS FOR NEGLECT - LEAVING INDIVIDUALS UNATTENDED WAS FILED FOR BOTH INDIVIDUAL #1 AND INDIVIDUAL #2, INCIDENT REPORT #8500671 AND #8500647 RESPECTIVELY. THE REMAINING STAFF WERE RETRAINED ON THE IMPORTANCE OF REPORTING AND INCIDENT MANAGEMENT AS WELL AS A REVIEW OF THE INDIVIDUAL'S ISPS WHERE THE FOCUSING WAS LEVELS OF SUPERVISION. [Immediately, the CEO shall develop and implement policies and procedures to ensure individual to staff ratios are maintained. Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff person on the policies and procedures so individual to staff ratios can be maintained even during emergency and call off situations. Documentation of trainings shall be kept. (DPOC by AES,HSLS on 3/20/19)] 01/31/2019 Implemented
6400.161(e)Clonazepam 5mg, take 2 tablets by mouth at bedtime prescribed for Individual #1 was discontinued on 1/11/18 and remained in Individual #1's medication box on 1/10/19 at 9:30AM.Discontinued prescription medications shall be disposed of in a safe manner.On January 18, 2019 the house supervisor and direct care staff on shift disposed of the discontinued Clonazepam 5mg on site. Both signed the medication disposal form documenting the disposal. In light of this occurrence the direct care staff were retrained to check the expiration date of all medications after delivery of monthly medications and dispose of any medications requiring disposal as well as complete the Medication Disposal Form. This process will occur monthly after the cycle medication are delivered to the site. THE TRAINING INCLUDED: Discontinuing a Medication 1. Whenever a medication is discontinued, staff must document this on the front of the MAR. 2. Document on the back of the MAR that the medication was discontinued as per doctor¿s orders. 3. Document in the Medical Progress Record and leave a note in the Daily Log to alert all Staff. 4. Pull the discontinued medication and, with two staff present, properly dispose of the medication. Disposing of Medications There will be times when staff will need to dispose of unused or dropped medications by flushing them down the toilet. These disposed of medications are documented on a Drug Disposal Form. Two staff need to witness the disposal of medications and must sign the Drug Disposal Form. Supervisors must be notified of the disposal of medications. Disposed of medications are also documented on other applicable forms, such as: the Medication Count Record, the Monthly Controlled Medication Count Record, and/or the Controlled Count Record for Shift Changes. [Immediately and continuing at least monthly, a designated staff person certified to administer medications shall audit all individuals' medications, medication administration records, physician's orders to ensure all individuals are administered medications as prescribed and discontinued medications are disposed. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 3/20/19)] 02/15/2019 Implemented
6400.164(b)Olanzapine 10mg tablet, take 1 tablet by mouth at 8:00AM and 8:00PM prescribed for Individual #1 was not initialed as administered on 1/15/19 at 8:00PM. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. A MEDICATION ERROR REPORT WAS ENTERED IN HCSIS FOR THE MEDICATION OMISSION ON 1/15/19. THE STAFF RESPONIBLE FOR THE ERROR WAS RETRAINED ON MEDICATION ADMINISTRATION AND GIVEN A MEDICATION PRACTICUM. THE TRAINING INCLUDED: KEY STEPS FOR ADMINISTERING MEDICATIONS Step #1 ¿ Preparing Administration 1. Clear/clean a space that you will use 2. Wash your hands 3. Unlock the meds 4. Father equipment 5. Identify the person and the medication you will give them Step #2 ¿ Administering 1. First Check ¿ Pull out medications. Match label to MAR. Ensure all five rights are met. 2. Second Check ¿ Match label to MAR again. Ensure all five rights are met. Punch out medications. 3. Third Check ¿ Before administering medications match label to MAR again. Ensure all five rights are met. 4. Administer medications. 5. Observe to ensure individual swallowed the medication. Step # 3 ¿ Completing Administration 1. Document on MAR (initial corresponding block on MAR, sign and initial back of Mar once each month, and initial and date on front of blister pack). 2. Match label to MAR one last time. Ensure all five rights were met. 3. Return and lock medications and binders in storage area. 4. Wash your hands. 5. Observe for effects of medications and binders in storage area. 6. Wash your hands. [Immediately and continuing at least monthly, a designated staff person certified to administer medications shall audit all individuals' medications, medication administration records, physician's orders to ensure all individuals are administered medications as prescribed and documented as required. Documentation of the audits shall be kept. Immediately, the trainer certified to train staff persons on medications administration shall reinstructed staff as needed if medication errors are found during the audits. (DPOC by AES,HSLS on 3/20/19)] 03/01/2019 Implemented
SIN-00141376 Renewal 07/25/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101Individual #1's bedroom door had a locking mechanism requiring a key to enter and exit the bedroom obstructing egress if the door was locked with a key from either side.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. 7/26/18- Lock was removed from the bedroom door of #1 ( Photo Provided). Egress issues will be monitored by Program Supervisor weekly and documented on house visit checklist. Any potential egress violations will be immediately corrected to ensure the health and safety of those supported at all times. Potential egress issues will be further reviewed with all provider staff at monthly house meetings beginning 10/1/18. [Immediately and upon hire, the CEO shall train all 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 to ensure egress are not obstructed and to immediately correct and/or report as needed. Documentation of trainings shall be kept. (DPOC by AES, HSLS on 9/25/18)] 10/01/2018 Implemented
6400.141(c)(6)Individual #1's Tuberculin testing completed on 5/16/18 did not include the results and the person and the qualification of the person who read the results.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. 7/25/18- Physical exam of Individual #1 was faxed to Physician and TB portion was clearly completed with all necessary information. Physical was returned to provider 7/26/18. Beginning 9/1/18- Team Lead will accompany the person supported for annual physical exams. Team Lead will review physical form prior to leaving the Physician¿s office for compliance, completion and signature and credentials of those completing physical and TB. Team Lead will ensure that any blank or noncompliant areas are completed/ corrected immediately. Team Lead will submit physical form to Program Supervisor for review within 7 days of exam. [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)] 09/01/2018 Implemented
6400.141(c)(11)Individual #2's physical examination completed 2/21/18 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 #2 was faxed to Physician and returned 7/27/18 with information pertinent to the individual¿s health maintenance needs. Copy of physical will be provided with this plan as supporting documentation. Beginning 8/1/18- 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. Beginning 9/1/18- 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 of appointment for review. Program Supervisor will review for completion and compliance. Any information identified as noncompliant will be immediately addressed with Physician. [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)] 09/01/2018 Implemented
6400.151(a)Direct Service Worker #1's physical examination completed 1/17/18 did not include general examination. Direct Service Worker #2's physical examination completed 6/18/18 did not include general 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. As of 9/1/18- Direct Service Work #2 is no longer employed with A Helping home, LLC . As of 9/1/18- 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 ( including general examination)as it relates to staff physical exams PRIOR to hire date. No later than 10/1/18- Program Supervisor will review all physical forms upon submission to ensure completion. Program Supervisor will review all physicals of staff hired prior to 7/28/18 to ensure all necessary regulatory requirements are met no later than 8/26/18. Any staff member with physical exam not meeting regulatory requirements will be suspended until completion of compliant physical exam on designated agency form if completed. [Immediately, the CEO shall educate all staff persons responsible for reviewing staff persons physical examinations of the required information of staff persons physical examinations as per 6400.151(c)(1)-(4) and the aforementioned auditing procedures. Documentation of the training shall be kept. (DPOC by AES, HSLS on 9/25/18)] 10/01/2018 Implemented
6400.199(e)Individual #2 is prescribed Alprazolam 0.5mg tab, take one tablet by mouth every 4 hours as needed for panic, severe agitation or aggression.A Pro Re Nata (PRN) order for controlling acute, episodic behavior is prohibited. 8/15/18- Provider has developed a restrictive procedures committee comprised of Program Director, Program Supervisor, Program Specialist and DSP that does not provide support to Individual #2. Committee will meet quarterly beginning 10/1/18 to review any current restrictive procedures. Committee will ensure the following : The restrictive procedure plan shall include: (1) The specific behavior to be addressed and the suspected antecedent or reason for the behavior. (2) The single behavioral outcome desired stated in measurable terms. (3) Methods for modifying or eliminating the behavior, such as changes in the individual¿s physical and social environment, changes in the individual¿s routine, improving communications, teaching skills and reinforcing appropriate behavior. (4) Types of restrictive procedures that may be used and the circumstances under which the procedures may be used. (5) A target date for achieving the outcome. (6) The amount of time the restrictive procedure may be applied, not to exceed the maximum time periods specified in this chapter. (7) Physical problems that require special attention during the use of restrictive procedures. (8) The name of the staff person responsible for monitoring and documenting progress with the plan. The restrictive procedure plan shall be implemented as written. Copies of the restrictive procedure plan shall be kept in the individual¿s record. Committee will log information reviewed during each meeting. During this meeting the current restrictive procedure plan for Individual #2 will be reviewed and compared with pertinent behavioral data contained in monthly and quarterly reports provided by Program Specialist. Program Specialist will make any revisions deemed necessary by committee within 7 days of committee meeting. Any new restrictive procedures will be reviewed and approved by committee prior to implementation.[A PRN protocol was revised and signed by on 10/5/18 by the Psychiatrist which included Individual #1's psychiatric diagnosis and symptoms related to the psychiatric diagnosis and the length of time the specific behaviors continue for the administration of the PRN medications. Additional protocol related to the reporting with in the agency is also included in the protocol. Documentation of the administration, reporting and implementing of the protocol shall be kept and available for review upon request by the Department. 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 10/24/18)] 10/01/2018 Implemented
SIN-00235918 Renewal 12/07/2023 Compliant - Finalized
SIN-00232311 Renewal 09/26/2023 Compliant - Finalized
SIN-00219169 Unannounced Monitoring 02/09/2023 Compliant - Finalized
SIN-00186854 Renewal 04/27/2021 Compliant - Finalized
SIN-00173259 Unannounced Monitoring 06/02/2020 Compliant - Finalized