Inspection ID

Reason for Inspection

Inspection Date

Inspection Status

SIN-00228926

Unannounced Monitoring

08/02/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.68(b)	At the time of inspection, the hot water measured 127.1°F in the bathtub/shower.	Hot water temperatures in bathtubs and showers may not exceed 120°F.	The scald guard was adjusted to 116 degrees	08/02/2023	Implemented
6400.112(c)	The fire drill conducted on 7/5/23 did not include the time that the drill was completed. The time section of the fire drill had "living room" in the section.	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 for 7/5/2023 was updated.	08/03/2023	Implemented

SIN-00227433

Unannounced Monitoring

07/11/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.68(b)	The hot water temperature in the bathtub of the home exceeded 120 degrees. The hot water temperature measured at 124.8 degrees. (Repeat Violation 10/18/22, 11/16/22, 2/27/23, 4/20/23 and 6/7/23)	Hot water temperatures in bathtubs and showers may not exceed 120°F.	The installed scald guard was adjusted to a lower temperature	07/11/2023	Implemented

SIN-00225938

Unannounced Monitoring

06/07/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.68(b)	The hot water in the bathroom sink registered at 140 degrees, and the temperature in the bathroom tub registered at 130 degrees. The hot water temperature should not exceed 120 degrees.	Hot water temperatures in bathtubs and showers may not exceed 120°F.	Provider replaced an anti scald guard that was previously installed in the individual's shower.	06/07/2023	Implemented

SIN-00223254

Unannounced Monitoring

04/20/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.68(b)	The hot water in the home exceeded the regulatory 120 degrees and was measured at 133.1 degrees. (Repeat Violation 4/8/22, 5/12/22, 10/18/22, 11/14/22, 12/22/22, 2/27/23)	Hot water temperatures in bathtubs and showers may not exceed 120°F.	Provider replaced the anti scald valve.	04/20/2023	Implemented
6400.144	Individual #1 is prescribed Clonazepam 0.5mg tablet. Take 1 tablet by mouth 2 times daily as needed. This medication was administered to Individual #1 on April 1, 2023, and April 2, 2023, at 8AM and 8PM, April 4, 2023, April 6, 2023, and April 10 at 8PM; April 9, 2023, at 7PM and April 12 and April 19 at unknown times. The pharmaceutical label does not include specific symptoms displayed by the individual in order for the medication to be administered. The agency has not provided proper pharmaceutical services.	Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.	Provider located the PRN protocol missing from the MAR. Staff are regularly trained on the PRN protocol.	04/20/2023	Implemented
6400.165(c)	Medications are not administered as prescribed. Individual #1 is prescribed Risperidone 4mg tablet. Take 1 tablet by mouth nightly at 8PM. Individual #1 did not receive the April 19, 2023, does of medication. The medication was located in the blister pack and was not documented as administered. Individual #1 is prescribed Naproxen 500mg Tablet, 1 tablet by mouth 2x day as needed with meals 2 days prior to menstrual cycle. This medication was administered on April 1, 2023, at an unknown time. This medication is not administered as prescribed as individual #1 is prescribed birth control and April 1, 2023, would not have been two days prior to the individuals menstrual cycle based on the cycle of the Individual's birth control pills. April 20, 2023, the date of the inspection would have been 2 days prior to the individual's menstrual cycle based on the birth control pill cycle. (Repeat Violation 4/8/22, 5/12/22, 6/21/22, 7/25/22, 11/14/22)	A prescription medication shall be administered as prescribed.	Provider contacted the psych doctor and entered an EIM report.	04/24/2023	Implemented
6400.166(a)(12)	Individual #1 is prescribed Clonazepam 0.5mg tablet. Take 1 tablet by mouth 2 times daily as needed. This medication was administered to Individual #1 on April 12 and April 19, 2023. The Medication Administration Record does not include the time of administration of this medication on April 12 or April 19, 2023. (Repeat Violation 12/22/22)	A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration.	Provider addressed and retrained staff on how to administer PRN medication.	04/24/2023	Implemented
6400.166(a)(13)	Individual #1 is prescribed Naproxen 500mg Tablet, 1 tablet by mouth 2x day as needed with meals 2 days prior to menstrual cycle. This medication was administered on April 7, 2023, at 5PM. The initials of the person administering the medication were not documented at the time of administration. (Repeat Violation 5/12/22, 6/21/22, 10/18/22,11/14/22, 12/22/22, 3/21/22, 2/27/23)	A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.	Provider retrained staff involved in medication administration.	04/20/2023	Implemented

SIN-00221523

Unannounced Monitoring

03/21/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.32(r)	At the time of the inspection the staff did not have a key to be able to unlock the door to the bedroom of the individual.	An individual has the right to lock the individual's bedroom door.	Provider changed the locks to individual's bedroom and provided staff with a key.	03/21/2023	Implemented

SIN-00220084

Unannounced Monitoring

02/27/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.68(b)	Water temperature in the bathtub of the home measured at 126.5 degrees, exceeding the allotted 120 degrees.	Hot water temperatures in bathtubs and showers may not exceed 120°F.	Provider requested maintenance to readjust anti scald valve.	02/27/2023	Implemented
6400.163(a)	Prescription medications are not maintained in their original labeled container. Individual #1 is prescribed Junel Fe 1mg-20 mcg tablet (Norteth-estrad-fe 1-0.02) take 1 tablet by mouth daily at 8am (birth control). This medication was in its original packaging, however, did not contain a pharmacy label.	Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.	Medication appeared to have slipped from the small bag that has the label. Provider placed the medication back in the small labeled bag.	02/27/2023	Implemented

SIN-00218415

Unannounced Monitoring

01/31/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.67(b)	At the time of inspection, there was a tennis-ball-sized collection of lint in the dryer lint trap. The collection of lint in the dryer lint trap creates an increased risk of fire within the home.	Floors, walls, ceilings and other surfaces shall be free of hazards.	Provider removed lint from the dryer.	01/31/2023	Implemented

SIN-00216601

Unannounced Monitoring

12/22/2022

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.67(a)	The bathroom cabinet had 3 sections of mirrors which opens toward you. The mirror on the far-right side of the cabinet would not open and was jamming next to the middle mirror.	Floors, walls, ceilings and other surfaces shall be in good repair.	Provider requested maintenance to re-align vanity mirror door.	12/23/2022	Implemented
6400.166(a)(12)	The individual was prescribed Risperidone 1mg to be given 2 x day at 8am and 12 noon. At the time of inspection, which was approximately 10am, the staff had initialed for both the 8am and 12 noon medication. It was apparent that the 8am medication was provided as the blister back was popped. The 12-noon medication was still in the blister pack and the staff initialed the noon MAR in error.	A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration.	Provider brought it to the attention of staff on said error. Staff requested to cross off signed med, and record the error in the back of the MAR.	12/22/2022	Implemented
6400.166(a)(13)	Individual #1 is prescribed Gabapentin 100mg 3 x a day. The 8am medication was administered according to the blister pack, however the staff forgot to initial the medication administration record.	A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.	Staff on duty erroneously signed below the line of the said medication. Error addressed while licensor on site.	12/22/2022	Implemented

SIN-00215003

Unannounced Monitoring

11/14/2022

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.68(b)	The hot water in the home exceeded 120 degrees. The hot water temperature measured 123.8 degrees	Hot water temperatures in bathtubs and showers may not exceed 120°F.	The maintenance staff adjusted the scald guard after which the water temperature in the shower was 118 degrees.	11/14/2022	Implemented
6400.141(c)(4)	Individual #1 had an annual physical completed on 9/23/22. There was no hearing exam completed at the time of the physical examination and there was no documentation that Individual #1 has had a hearing exam since 9/20/2021.	The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician.	Individual #1 missed her original ear appointment due to hospitalization. She was rescheduled for 12/15/2022.	11/15/2022	Implemented
6400.181(e)(5)	Individual #1's ability to self-medicate is not accurately assessed. Individual #1's annual assessment dated 4/12/22 indicates that the individual is able to self-medicate. After discission with the Program Specialist, it was indicated that Individual #1 does not self-medicated in the home and was only assessed as able to self-medicate due to attending a day program where the staff did not administer medications and the individual's need to take medications during the day. The Program Specialist indicated that the Individual has the desire to self-medicate in the home, however staff do not feel that the individual is ready to self-medicate in the home.	The assessment must include the following information: The individual's ability to self-administer medications.	The provider is working with individual #1 to ensure she is able to fully self-medicate at home. The annual assessment was updated to reflect the current ability.	12/31/2022	Implemented
6400.165(c)	Prescription medications are not administered as prescribed. Individual #1 was prescribed Oxycodone HCL 5mg tablet, 1 tablet by mouth every 4 hours as needed for mod pain for up to 10 days. This medication was first administered on 10/25/22. This medication was documented as administered on 11/6/22 at 8AM. The medication was not discontinued after 10 days as prescribed.	A prescription medication shall be administered as prescribed.	The provider reviewed with staff the protocols for administering and documenting time-limited medications.	11/18/2022	Implemented
6400.166(a)(13)	Individual #1 is prescribed Acetaminophen 500mg, 1 tablet by mouth every 6 hours as needed for headache or fever. This medication was administered to Individual #1 at 8AM on 11/14/22. The Medication Administration Record did not include the name and initials of the person administering the medication.	A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.	The staff involved was retrained on PRN documentation and the documentation completed.	11/18/2022	Implemented
6400.213(7)	Individual #1's record that is maintained in the home did not contain a current Individual Plan.	Each individual's record must include the following information: Individual plan documents as required by this chapter.	A current ISP was printed and placed in the resident binder.	11/15/2022	Implemented

SIN-00213664

Unannounced Monitoring

10/18/2022

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.68(b)	At the time of the inspection, the hot water temperature in the bathroom sink was registering at 125 degrees. The temperature in the bathroom tub was registering at 123 degrees. The staff report that there was a temperature suppressor on the bathtub; however, the water temperature still exceeded 120.	Hot water temperatures in bathtubs and showers may not exceed 120°F.	Provider put a work order to request maintenance for the scald guard adjustment.	10/18/2022	Implemented
6400.165(g)	At the time of the inspection, there was only documentation of a psychotropic medication review for Individual #1 on 04/28/2022 and on 07/21/2022. Documentation of the medication review for October 2022 was missing. Staff on site report that the individual did attend; however, the documentation was not available at the time of inspection. Psychotropic medication reviews are due every 3 months.	If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.	Provider walked into psychiatrist's office and requested for the completed form. Provider requested to come back at the end of the day for the form. Provider obtained said form.	10/19/2022	Implemented

SIN-00210739

Unannounced Monitoring

08/25/2022

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.22(e)(1)	At time of inspection gift cards for Burger King and Dunkin Donuts were located in the money pouch for Individual #2. Staff #1 indicated that the cards were used to purchase items for Individual #2. The money pouch for Individual #2 also contained numerous receipts for both Dunkin Donuts and Burger King. A beginning, ending or current balance could not be determined as there was no record of financial resources, including the dates and amounts of deposits and withdrawals for the Dunkin Donuts and Burger King gift cards. Gift cards are to be treated as financial resources and require a separate record that includes the dates and amounts of deposits and withdrawals.	If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals.	Individual #2 periodically receives gift cards from the grandmother. The gift cards were separated and logged separately from individual's funds.	08/29/2022	Implemented
6400.64(a)	The beige leather sofa in the living room of Individual #2 had two large, brown smeared areas on the middle cushion. All cushions on the sofa appeared to be soiled with a buildup of a slightly darker substance. Staff # 1 indicated that the sofa was cleaned daily and stained. Staff #1 wiped the surface of the cushions with a Clorox wipe which began to remove the buildup and was visible on the Clorox wipe. The surface of the cushion wiped was a visibly cleaner. Clean and sanitary conditions shall be maintained in the home.	Clean and sanitary conditions shall be maintained in the home.	Staff wiped down the sofa at the time of inspection.	08/18/2022	Implemented

SIN-00209277

Unannounced Monitoring

07/25/2022

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.64(a)	The home does not maintain clean and sanitary conditions. The vent in the bathroom in Individual #6's bathroom was covered in approximately 1 inch of dust. The shower in Individual #6's bathroom had mold and mildew throughout the shower, there were three wet wash cloths that appeared to not have been recently used on the floor of the shower. Staff indicated that the individual does not use the shower in this bathroom. The blinds in the kitchen were very dirty. (Repeat Violation 6/21/22, 5/12/22, 3/11/22)	Clean and sanitary conditions shall be maintained in the home.	The bathroom was cleaned. The team was met with and addressed on the responsibilities to provide safe and sanitary living environment. The blinds in the kitchen was replaced and is in good repair.	08/16/2022	Implemented
6400.67(b)	The home is not free of hazards. The sliding glass doors on the shower in Individual #6's bathroom is off the track and present a hazard. (Repeat Violation 3/11/22)	Floors, walls, ceilings and other surfaces shall be free of hazards.	The sliding door was addressed by maintenance.	08/16/2022	Implemented

SIN-00205222

Unannounced Monitoring

05/12/2022

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.68(a)	Water temperature was too low, 98.6 degrees. (Repeat 3/11/22)	A home shall have hot and cold running water under pressure.	The water temperature was adjusted to meet regulations. On the day of submitting this response, the water temperature was 116 degrees.	08/16/2022	Implemented
6400.32(r)(1)	Individual #4 has a lock on the individual's bedroom door, however the individual does not have a key to the lock. (Repeat 3/11/22)	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.	A key was made available for individual #4. Individual expressed concerns about possibility of losing the key if it were in her person. The team has worked with her on her concerns and skills to keep the key safe.	08/16/2022	Implemented
6400.165(g)	Individual #4 is prescribed psychotropic medications for psychiatric illness. Individual #4 had virtual visits with the psychiatrist on February 23, 2022, March 14, 2022, March 31, 2022, and April 28, 2022. There is no documentation completed by a licensed physician of the medication reviews that took place on February 23, 2022, March 14, 2022, and March 31, 2022, medication reviews. (Repeat Violation 4/8/22)	If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.	Individual #4 has received medication review since this visit.	08/16/2022	Implemented

SIN-00204064

Unannounced Monitoring

04/08/2022

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.165(c)	Individual #4 is prescribed Linzess 290 mcg capsule- 1 capsule by mouth everyday 8am. The bottle in the home at time of monitoring was properly labeled and dated as filled on 2/26/22. The bottle of Linzess was labeled to contain 30 capsules. The bottle of Linzess was empty at time of monitoring on April 8, 2022, at 10:00am. The March 2022 and April 2022 Medication Administration Record (MAR) for Individual #4 was initialed for each day to indicate the medication had been administered. When questioned Staff #1 stated that they must have run out that morning after administering the 8am dose. Depending upon start date of the bottle filled on 2/26/22 a refill would have been required as the prescription would have run out between 3/28/22 and 4/2/2022. No documentation was provided to account for the missed administrations nor could staff offer an explanation of why there would have been remaining doses left in the prescription between 4/2/22 and 4/8/22.	A prescription medication shall be administered as prescribed.	Individual #4 was hospitalized from 3/16/22 to 3/20/22, leading to left over medication.	04/08/2022	Implemented
6400.165(g)	There was no documentation to support that medication reviews have been conducted for Individual #4. Previous citation corrective action stated that "Provider requested to be placed on psychiatrist's appointments cancellation list. will ensure the psychiatric appointment scheduled for 02/23/22, is attended." Licensing representative requested documentation of the stated 2/23/22 appointment. Staff #1 stated that "The only document we do not have is the 90-day med review. It has been with "their" current psych for two months now. I believe the form will be due in May." Documentation of the 2/23/22 or other reviews conducted were not provided. Review by a licensed physician at least every 3 months that includes documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage is required to meet regulation. Repeat violation 9/22/21, 12/14/21	If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.	Individual #4 started seeing a new psychiatrist on 2/23/22. Medication will be reviewed at individual #4's next visit.	04/08/2022	Implemented
6400.166(b)	Individual #4 is prescribed Linzess 290 mcg capsule- 1 capsule by mouth everyday 8am. The bottle in the home at time of monitoring was properly labeled and dated as filled on 2/26/22. The bottle of Linzess was labeled to contain 30 capsules. The bottle of Linzess was empty at time of monitoring on April 8, 2022, at 10:00am. The March 2022 and April 2022 Medication Administration Record (MAR) for Individual #4 was initialed for each day to indicate the medication had been administered. When questioned Staff #1 stated that they must have run out of medication that morning after administering the 8am dose. Depending upon start date of the bottle filled on 2/26/22 a refill would have been required between 3/28/22 and 4/2/2022. No information either from staff or documentation could be provided to explain why doses of medication would have been left over from the prescription to administer after 4/2/22.	The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.	Individual #4 was hospitalized from 3/16/22 to 3/20/22, leading to left over medication.	04/11/2022	Implemented

SIN-00201986

Unannounced Monitoring

03/11/2022

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.144	Individual #1 is prescribed Fluticasone Prop 50 mcg, instill 1 spray into each nostril daily as needed. The medication was not available in the home. Individual #1 is prescribed Colace 100 mg capsule, take 1 capsule by mouth 2x daily @ 8a-8p. The medication was not available in the home. Pharmaceuticals that are prescribed for the individual shall be provided. (Repeat violation 9/22/21, 12/14/21, 1/25/22)	Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.	At the time of inspection, Fluticasone 50mcg and Colace 100mg, had been discontinued, but the DC'd scripts were unavailable at the home. Provider scheduled an appointment and obtained the discontinued order for the individual #1's folder.	03/30/2022	Implemented
6400.18(b)(2)	Individual #1 is prescribed Norethind-eth Esrad 1-0, take 1 tablet by mouth once daily at 8am. The Medication Administration Record (MAR) was initialed and documented as the medication being administered on 3/8/22, but the medication remained in the blister pack for 3/8/22, indicating that the medication was not properly administered resulting in a medication error. This medication error was not reported in EIM within 72 hours are required. Individual #1 is prescribed Colace 100mg capsule, take 1 capsule by mouth 2x daily at 8a-8p. At the time of the inspection, the medication was not available at the home. There were no initials on the Medication Administration Record (MAR) for the current month (3/1/22-3/11/22) to indicate that the medication was administered twice per day as ordered resulting in mediation errors. This medication errors were not reported in EIM within 72 hours are required. Licensing Representative instructed agency staff#1 to enter the medication errors into EIM. (Repeat violation 9/22/21, 12/14/21, 1/25/22)	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 72 hours of discovery by a staff person: A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner.	Leadership met with staff involved, in the 3/8/22 Norethind-eth Esrad 1-0 med error, and reviewed the incident per medication administration guidelines. Provider made an appointment to obtain a DC script for the solace 100mg from the doctor.	03/31/2022	Implemented
6400.163(h)	Individual #1 is prescribed Milk of Magnesia Suspensi, take 1 TBSP (15ml) by mouth daily at 8pm x5 DYS *Beg 2/11. This medication remains in the home and has not been disposed of properly upon completion of the 5 days of administration. (Repeat Violation 1/25/22)	Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.	Provider removed medication Milk of magnesium suspension from the home.	03/11/2022	Implemented
6400.165(c)	Individual #1 is prescribed Colace 100mg capsule, take 1 capsule by mouth 2x daily at 8a-8p. There were no initials on the Medication Administration Record (MAR) for the current month (3/1/22-3/11/22) to indicate that the medication was administered twice per day as ordered. Individual #1 is prescribed Norethind-eth Esrad 1-0, take 1 tablet by mouth once daily at 8am. The Medication Administration Record (MAR) was initialed and documented as the medication being administered on 3/8/22, but the medication remained in the blister pack for 3/8/22, indicating that the medication was not administered as prescribed.(Repeat Violation 12/14/21, 1/25/22)	A prescription medication shall be administered as prescribed.	Colace 100mg, was previously discontinued. Discontinue script was unavailable in the home at the time of inspection. Leadership met with Staff involved in the medication error of the Norethind-sth Estrad 1-0, and reviewed the error.	03/18/2022	Implemented
6400.166(a)(13)	Individual #1 is prescribed Risperdal 1 mg tablet, take 1 tablet by mouth 2x daily at 8a & 2p. The medication appears to have been administered as they were removed from the blister pack but are not initialed on the Mediation Administration Record (MAR) as being administered from 3/1/22-3/10/22 at 2pm.	A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.	Provider met with the individual involved in the documentation error, and reviewed medication administration guidelines and documentation procedures.	03/30/2022	Implemented
6400.167(b)	Individual #1 is prescribed Norethind-eth Esrad 1-0, take 1 tablet by mouth once daily at 8am. The Medication Administration Record (MAR) was initialed and documented as the medication being administered on 3/8/22, but the medication remained in the blister pack for 3/8/22, indicating that the medication was not properly administered resulting in a medication error. Individual #1 is prescribed Colace 100mg capsule, take 1 capsule by mouth 2x daily at 8a-8p. At the time of the inspection, the medication was not available at the home. There were no initials on the Medication Administration Record (MAR) for the current month (3/1/22-3/11/22) to indicate that the medication was administered twice per day as ordered. There is no documentation of this medication errors, any follow up actions taken or the providers response (Repeat Violation 9/22/21, 12/14/21)	Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record.	Medication errors have been entered into the EIM.	04/12/2022	Implemented

SIN-00199344

Unannounced Monitoring

01/25/2022

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.67(a)	The closet doors in Individual #1's room were hanging off the track. The door knob on Individual #1's bedroom door was broken and falling off.	Floors, walls, ceilings and other surfaces shall be in good repair.	The closet doors have been put back on the tracks	01/31/2022	Implemented
6400.51(b)(1)	Staff #1 did not receive orientation training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain friendships.	The orientation 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 completed training in the application of person-centered practices on 2/4/2022	02/04/2022	Implemented
6400.51(b)(2)	Staff #1 did not receive orientation training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations.	The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations.	Staff #1 received training in the prevention, detection, and reporting of abuse on 2/1/2022	02/01/2022	Implemented
6400.51(b)(3)	Staff #1 did not receive orientation training in individual rights.	The orientation must encompass the following areas: Individual rights.	Staff #1 completed training in Individual Rights on 2/1/2022	02/01/2022	Implemented
6400.51(b)(4)	Staff #1 did not receive orientation training in recognizing and reporting incidents.	The orientation must encompass the following areas: recognizing and reporting incidents.	Staff #1 completed training in Recognizing and Reporting incidents on 2/1/2022	02/01/2022	Implemented
6400.52(c)(1)	Staff #1 did not complete annual training in the most recent complete training year in the areas of the application of person-centered practices, community integration and individual choice.	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 completed training in the application of person-centered practices on 2/4/2022	02/04/2022	Implemented
6400.52(c)(2)	Staff #2 did not complete annual training in the most recent complete training year in the area of the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.	The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.	Staff #2 completed trainings in the prevention, detection, and reporting of abuse on 2/1/2022.	02/01/2022	Implemented
6400.52(c)(3)	Staff #1 did not complete annual training in the most recent complete training year in the area of Individual Rights.	The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.	Staff #1 completed training in Individual Rights on 2/1/2022.	02/01/2022	Implemented
6400.166(a)(4)	Individual #1 is prescribed Vita Drop gummies, chew 1 gummy by mouth once daily at 8am. The name of the medication listed on the prescription label and the name of the medication on the Medication Administration Record (MAR) do not match.	A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.	A new label with the updated information was received from the pharmacy. The instructions on the new pharmacy label matches the instructions in the MAR.	02/01/2022	Implemented
6400.166(b)	Individual #1 is prescribed Ibuprofen 600mg. tablet, take 1 tablet by mouth every 6 hours as needed for pain for up to five days. This medication was administered to Individual #1 on 1/10/2022. The medication is not listed on the Medication Administration Record (MAR), and was not documented as administered on 1/10/2022. Individual #1 is prescribed Acetaminophen 500mg. caplet, take 1 caplet by mouth every 6 hours as needed for pain for up to five days. This medication was administered to Individual #1 on 1/06/2022. The medication is not listed on the Medication Administration Record (MAR), and was not documented as administered on 1/06/2022.	The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.	Ibuprofen 600mg was originally prescribed as a PRN for mild pain. It was discontinued and replaced with Tylenol 500mg.	01/31/2022	Implemented

SIN-00194676

Unannounced Monitoring

09/22/2021

Non Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.16	Individual #1 has not had appropriate psychiatric care for an unknown amount of time resulting in the neglect of the individual's psychiatric and behavioral health needs. Individual #1 was discharged from the mental health provider (last appointment was 3/20/2021) after missing several therapy appointments, leaving the individual without a Psychiatrist to monitor, review and refill medications. Individual #1 ran out of medication refills for Melatonin 5mg tablet, Take 1 tablet by mouth daily at bedtime at 8PM on 8/26/21; Risperdal 1mg tablet (Risperidone 1mg tablet) take 1 tab by mouth daily at 8AM on 8/27/21; Risperdal 2mg tablet (Risperidone 2mg tablet), take 1 tablet by mouth daily at 8PM on 8/28/21; Buspar 10mg tablet, Buspirone HCL 10mg tablet, take 1 tablet by mouth daily at 8AM, 12PM, 4PM and 8PM on 8/29/21; Desyrel 100mg tablet Trazadone 100mg tablet, Take 1 tablet by mouth at bedtime 8PM and Lexapro 20mg tablet (Escitalopram 20mg tablet), take 1 tablet by mouth daily at 8AM on 8/31/21 and was unable to consistently take medications to alleviate symptoms of psychiatric diagnosis resulting in behavioral issues. Individual #1's medications that are prescribed for treatment of psychiatric diagnosis were not filled as the Emergency Department indicated that they would not fill them as that is not the purpose of the Emergency Department. Individual #1's needs are neglected as Individual #1 does not have a psychiatrist and medications are not being re-filled. Individual #1's medical needs were neglected as the individual was not administered prescribed medications for a period of three days resulting in the individual having a seizure. Individual #1 destroyed the medication blister packs in the home on 9/14/21. The medications could not be refilled/reissued under the individual's medical insurance and alternative methods to obtain the medications were not explored until 9/15/21 and the new medications were not obtained until 9/17/21. Individual #1 missed several does of medications including, Linzess 290mg Capsule, take one capsule by mouth every day at 8AM. This medication was not available to Individual #1 on 9/15 and 9/16. Adult Multi-Vit-Gum, chew 1 gummy by mouth once daily at 8AM. This medication was not available to Individual #1 on 9/14 and 9/15; Magnesium Oxide 400mg TA (Magnesium Oxide 400mg TA) take 1 tablet every day at 8AM; Microgestin 21 1-20 Tablet (Norethind-ETH Estrad 1-0), Take 1 tablet by mouth daily at 8AM; Mirilax Powder (Polyethylene Glycol 3350), mix 1 capful (17gm) in 8oz liquid and drink at 8AM; Protonix DR 40mg tablet (Pantoprazole Sod DR 40mg), take 1 tablet by mouth daily at 7AM; Singular 10mg Tablet (Montelukast sod 10mg tab), take 1 tablet by mouth nightly at 8P; Vitamin D3 1,000 Unit Tab, take 1 tablet by mouth daily at 8PM; Keppra 500mg tablet (levetiracetam 500mg tabl), take 1 tablet by mouth 2 times a day at 8A and 8P; Neurontin 100 mg capsule (Gabapentin 100mg capsule) take 2 caps (200mg) by mouth twice daily at 8A and 5P and Carafate 1gm/10ml susp (Sucralfate 1gm/10ml sus) take 2tsp (10ml) by mouth 4x daily at 8AM, 12PM, 5PM and 8PM; These medications were not available to Individual #1 from 9/14-9/17/21.	Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.	Individual #1's therapist resigned and the provider was not notified thus leading to missed appointments. When the provider called to schedule routine visit, the provider was informed that individual #1 had been discharged for missing therapy appointments. Provider immediately began searching for a new Psychiatrist. Individual #1 had initial intake appointment on 09/28/2021.	09/28/2021	Not Implemented
6400.68(b)	Water temp at the time of the inspection was 136.6 degrees.	Hot water temperatures in bathtubs and showers may not exceed 120°F.	The provider checked water temperature on every shift for two weeks. The provider installed scald guard in the shower.	11/14/2021	Not Implemented
6400.144	Individual #1 s diagnosed with Autism, Attention Deficit Hyperactivity Disorder (ADHD) Intermittent Explosive Disorder, Bipolar Disorder, Anxiety Disorder and Unspecified Depressive Disorder. Psychiatric care is not being provided for Individual #1. Pharmaceutical services for Individual #1 are not being arranged or provided. Individual #1 has been without a psychiatrist for an unknown amount of time. Individual #1 ran out of medications to treat their psychiatric illness and was without the medications for 20 days. Individual #1 is prescribed Klonopin .5mg as needed for anxiety. The medication is listed on the Medication Administration Record as a current medication but is not available in the home. (Repeat Violation 2/2021).	Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.	Individual #1 had intake appointment on 09/28.2021. Individual #1 had been discharged by her psychiatrist and the provider had not been informed. The PCP was not willing to prescribe psychiatrist medication in the interim. A new provider could not be located to schedule a sooner appointment to review and prescribe medications on time before the missed doses.	09/28/2021	Not Implemented
6400.181(c)	Individual #1's assessment does not address the current skill level in all areas. The assessment does not accurately reflect the individual's skill level and what the individual is capable of doing. The assessment reflects that the individual is not capable of completing tasks based on the individual's refusal to complete the task, not the ability to complete it.	The assessment shall be based on assessment instruments, interviews, progress notes and observations.	Individual #1's assessment was completed in a timely manner. During the submission of the required documentations for the inspection, an incomplete assessment was submitted. The point person for annual inspection will review each document diligently before submission.	11/08/2021	Not Implemented
6400.181(e)(13)(i)	Individual #1's assessment does not include progress over the past 365 calendar days and current level in health.	The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.	Individual #1's assessment was completed in a timely manner. Assessment includes health. An incomplete assessment was submitted in error.	11/08/2021	Not Implemented
6400.181(e)(13)(ii)	Individual #1's assessment does not include progress over the past 365 calendar days and current level in motor and communication skills.	The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills.	The provider completed the assessment in its entirety. Assessment includes motor and communication skills. Assessment sent for review was incomplete.	11/08/2021	Not Implemented
6400.181(e)(13)(iii)	Individual #1's assessment does not address progress over the last 365 calendar days and current level in the following areas: Activities of residential living.	The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living.	Provider completed the annual assessment on time but submitted an incomplete document. Assessment includes activities of residential living.	11/08/2021	Not Implemented
6400.181(e)(13)(iv)	Individual #1's assessment does not include progress over the past 365 calendar days and current level in personal adjustment.	The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment.	Provider completed the annual assessment on time but submitted an incomplete report. Assessment includes personal adjustment.	11/08/2021	Not Implemented
6400.181(e)(13)(v)	Individual #1's assessment does not include progress over the past 365 calendar days and current level in socialization.	The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization.	The provider completed the annual assessment on time but submitted an incomplete copy. The assessment includes socialization.	11/08/2021	Not Implemented
6400.181(e)(13)(vi)	Individual #1's assessment does not include progress over the past 365 calendar days and current level in recreation.	The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation.	Provider completed the annual assessment. The assessment includes recreation. Assessment submitted was in error.	11/08/2021	Not Implemented
6400.181(e)(13)(vii)	Individual #1's assessment does not include progress over the past 365 calendar days and current level in financial independence.	The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.	The provider completed the annual assessment on time that includes financial independence, but submitted an incomplete copy of the document.	11/08/2021	Not Implemented
6400.181(e)(13)(viii)	Individual #1's assessment does not include progress over the past 365 calendar days and current level in managing personal property.	The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property.	The assessment was completed in a timely manner in its entirety. Assessment includes managing personal property. Assessment submitted was in error.	11/08/2021	Not Implemented
6400.181(e)(13)(ix)	individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.	The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.	Provider completed the assessment in a timely manner in its entirety. The assessment included community integration.	11/08/2021	Not Implemented
6400.18(a)(3)	Individual #1 was admitted to the hospital on October 1, 2021 for an obstruction and remained hospitalized until October 9, 2021. An incident was no reported in the Enterprise Incident Management system.	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: Inpatient admission to a hospital.	EIM report was reported on EIM contigency form on 10/10/2021 for hospital admission.	11/15/2021	Implemented
6400.18(c)	There is no documentation that Individual #1's designated emergency contact was not notified of the individual missing medications on 8/19, 8/20, 8/27-8/31 and 9/1-9/17/21 or of Individual #1's hospitalization on 10/1/21..	The individual and persons designated by the individual shall be notified within 24 hours of discovery of an incident relating to the individual.	Individual #1's family (mother) was informed of all the above listed incidents by both staff and individual #1.	11/15/2021	Not Implemented
6400.18(b)(2)	Individual #1 missed dosses of Melatonin 5mg tablet, Take 1 tablet by mouth daily at bedtime at 8PM on 8/26/21; Risperdal 1mg tablet (Risperidone 1mg tablet) take 1 tab by mouth daily at 8AM on 8/27/21; Risperdal 2mg tablet (Risperidone 2mg tablet), take 1 tablet by mouth daily at 8PM on 8/28/21; Buspar 10mg tablet, Buspirone HCL 10mg tablet, take 1 tablet by mouth daily at 8AM, 12PM, 4PM and 8PM on 8/29/21; Desyrel 100mg tablet Trazadone 100mg tablet, Take 1 tablet by mouth at bedtime 8PM and Lexapro 20mg tablet (Escitalopram 20mg tablet), take 1 tablet by mouth daily at 8AM on 8/31/21. These medication errors were not reported in the Enterprise Incident Management system. Individual #1 missed several does of medications including, Linzess 290mg Capsule, take one capsule by mouth every day at 8AM. This medication was missed on 9/15 and 9/16. Adult Multi-Vit-Gum, chew 1 gummy by mouth once daily at 8AM. This medication was missed on 9/14 and 9/15; Magnesium Oxide 400mg TA (Magnesium Oxide 400mg TA) take 1 tablet every day at 8AM; Microgestin 21 1-20 Tablet (Norethind-ETH Estrad 1-0), Take 1 tablet by mouth daily at 8AM; Mirilax Powder (Polyethylene Glycol 3350), mix 1 capful (17gm) in 8oz liquid and drink at 8AM; Protonix DR 40mg tablet (Pantoprazole Sod DR 40mg), take 1 tablet by mouth daily at 7AM; Singular 10mg Tablet (Montelukast sod 10mg tab), take 1 tablet by mouth nightly at 8P; Vitamin D3 1,000 Unit Tab, take 1 tablet by mouth daily at 8PM; Keppra 500mg tablet (levetiracetam 500mg tabl), take 1 tablet by mouth 2 times a day at 8A and 8P; Neurontin 100 mg capsule (Gabapentin 100mg capsule) take 2 caps (200mg) by mouth twice daily at 8A and 5P. These medications were missed from 9/14-9/17/21. Carafate 1gm/10ml susp (Sucralfate 1gm/10ml sus) take 2tsp (10ml) by mouth 4x daily at 8AM, 12PM, 5PM and 8PM; This medication was missed on 8/19 and 8/20 at 8AM, 12PM, 5PM and 8PM, on 8/21/21 at 8AM and 12PM and from 9/14-9/17/21.	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 72 hours of discovery by a staff person: A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner.	The above mentioned medications were administered but not documented.	11/15/2021	Not Implemented
6400.51(b)(5)	Individual #1's Individual Support Plan (ISP) was updated and implemented on 7/8/21. Staff #1, #2, #3, #4 and #-5 were last trained on the ISP on April 6, 2021. (Repeat violation 2/21/21).	The orientation must encompass the following areas: Job-related knowledge and skills.	The provider reviewed the ISP manual and identified the appropriate dates trainings should occur. Provider will enter HCSIS to review plan approval status.	11/14/2021	Not Implemented
6400.165(b)	Individual #1 is prescribed Klonopin .5mg. The prescription for Klonopin expired on 8/24/21. The medication has not been discontinued by an authorized prescriber and is not available in the home to the individual.	A prescription order shall be kept current.	Individual #1's Klonopin was not refilled due to individual not having a psychiatrist. The primary physician and the emergency room were not willing to issue new scripts for the medication.	11/08/2021	Not Implemented
6400.165(g)	Individual #1 was receiving psychiatric services through Omni Health, Individual #1 cancelled several therapy appointments and was discharged from the provider at an unknown date. Upon discharge, Individual #1 did not have access to medication management. It is unknown how long the individual has been without medication management as the last date of an appointment was 3/20/21, however this was not signed by a doctor as it was a telehealth visit. There is no documentation of any psychiatric visits since 3/20/21. Individual #1 has not had psychiatric medications reviewed every 3 months. (Repeat violation 2/11/2021).	If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.	Individual #1 was seen via Telehealth on 05/05/21. Psychiatry provider then discharged individual #1 with three refills of psych meds without informing provider. Upon discovery of this, provider started searching for a new psychiatrist and was put on a waiting list at current psychiatrist. Individual #1had an intake appointment on 09/28/2021 with new psychiatry provider.	11/15/2021	Not Implemented
6400.167(b)	Individual #1 did not receive prescribed medications on 8/19, 8/20, 8/27-8/31 and 9/1-9/17/21.There is no documentation of the medication errors maintained, follow-up action or the prescriber's response.	Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record.	Medications were administered on the above listed dates but staff did not document administration. Staff involved were retrained 10/21/2021 on documentation.	10/21/2021	Not Implemented
6400.167(c)	Individual #1 did not receive prescribed medications. Individual #1 missed dosses of Melatonin 5mg tablet, Take 1 tablet by mouth daily at bedtime at 8PM on 8/26/21; Risperdal 1mg tablet (Risperidone 1mg tablet) take 1 tab by mouth daily at 8AM on 8/27/21; Risperdal 2mg tablet (Risperidone 2mg tablet), take 1 tablet by mouth daily at 8PM on 8/28/21; Buspar 10mg tablet, Buspirone HCL 10mg tablet, take 1 tablet by mouth daily at 8AM, 12PM, 4PM and 8PM on 8/29/21; Desyrel 100mg tablet Trazadone 100mg tablet, Take 1 tablet by mouth at bedtime 8PM and Lexapro 20mg tablet (Escitalopram 20mg tablet), take 1 tablet by mouth daily at 8AM on 8/31/21. These medication errors were not reported in the Enterprise Incident Management (EIM) system. Individual #1 missed several does of medications including, Linzess 290mg Capsule, take one capsule by mouth every day at 8AM. This medication was missed on 9/15 and 9/16. Adult Multi-Vit-Gum, chew 1 gummy by mouth once daily at 8AM. This medication was missed on 9/14 and 9/15; Magnesium Oxide 400mg TA (Magnesium Oxide 400mg TA) take 1 tablet every day at 8AM; Microgestin 21 1-20 Tablet (Norethind-ETH Estrad 1-0), Take 1 tablet by mouth daily at 8AM; Mirilax Powder (Polyethylene Glycol 3350), mix 1 capful (17gm) in 8oz liquid and drink at 8AM; Protonix DR 40mg tablet (Pantoprazole Sod DR 40mg), take 1 tablet by mouth daily at 7AM; Singular 10mg Tablet (Montelukast sod 10mg tab), take 1 tablet by mouth nightly at 8P; Vitamin D3 1,000 Unit Tab, take 1 tablet by mouth daily at 8PM; Keppra 500mg tablet (levetiracetam 500mg tabl), take 1 tablet by mouth 2 times a day at 8A and 8P; Neurontin 100 mg capsule (Gabapentin 100mg capsule) take 2 caps (200mg) by mouth twice daily at 8A and 5P. These medications were missed from 9/14-9/17/21. Carafate 1gm/10ml susp (Sucralfate 1gm/10ml sus) take 2tsp (10ml) by mouth 4x daily at 8AM, 12PM, 5PM and 8PM; This medication was missed on 8/19 and 8/20 at 8AM, 12PM, 5PM and 8PM, on 8/21/21 at 8AM and 12PM and from 9/14-9/17/21. These medication errors were not reported in the Enterprise Incident Management System.	A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation).	Individual #1 had no refills for Melatonin 5mg, Risperdal 1mg, Risperdal 2mg, Buspar 10mg tablet, Desyrel 100mg, Trazadone 100mg, Lexapro 20mg. PCP not willing to prescribe meds. Provider located new provider. Missed meds of Linzess 290mg, Adult multivitamin gum, Magnesium oxide 400mg, microgestin 21 1-20 tablet, Miralax powder 3350, protonix 40mg, Singulair 10mg, Vitamin D3 1,000units, Keppra 500mg, Neurontin 100mg, Medication were discarded by Individual #1 during a behavior. Provider purchased medication out of pocket, as the insurance could not refill medications at that time.	11/15/2021	Not Implemented
6400.194(d)	Individual #1 has a Behavior Support Plan/Restrictive Plan (BSP/RPP) which restricts telephone access. There is no documentation of human rights team meetings that indicates that the Human rights team has reviewed the BSP/RPP.	A record of the human rights team meetings shall be kept.	Provider received the HRT from the BSC. Provider will ensure that HRT notes are readily available upon request.	11/15/2021	Not Implemented
6400.196(a)	Individual #1's Restrictive Procedure Plan which restricts telephone access was implemented on 11/20/20, Staff # 1,, #2, #3, #4 and #5 were not trained on the plan until 12/2/20.	A staff person who implements or manages a behavior support component of an individual plan shall be trained in the use of the specific techniques or procedures that are used.	BSC was out on sick leave and unable to train immediately. Provider ensured staff read plan in its entirety until BSC was able to train.	11/01/2021	Not Implemented

SIN-00184436

Renewal

02/10/2021

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.141(a)	Individual #2 did not have a physical exam until 9/18/2020. Individual #2 had an admission date was 4/4/2019. The exam was not completed within the time frame allotted.	An individual shall have a physical examination within 12 months prior to admission and annually thereafter.	Individual #2 moved in with a physical dated 09/07/2018. The next physical per insurance guidelines was completed on 09/17/2019.	06/28/2021	Implemented
6400.141(c)(1)	Individual #2 did not have medical history on her physical exam.	The physical examination shall include: A review of previous medical history.	We will request the physician to complete the previous medical history section on the physical.	05/06/2021	Implemented
6400.141(c)(3)	Individual #2 did not have immunizations listed on their physical exam.	The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.	Provider printed immunization records and placed them in individual #2's binder.	03/01/2021	Implemented
6400.142(d)	Individual #2 Dental exam did not report if a cleaning was completed on the dental form. It is not known if a cleaning was completed.	The dental examination shall include teeth cleaning or checking gums and dentures.	Provider contacted Individual #2's dental provider and received copies of dental cleaning record.	06/15/2021	Implemented
6400.142(g)	Individual #2 did not have a dental hygiene plan.	A dental hygiene plan shall be rewritten at least annually.	Provider completed an annual dental hygiene plan for individual #2.	03/01/2021	Implemented
6400.144	Individual #2 was prescribed two PRNs; Robitussin Chest Congestion & Zofran which were both on the MARS, but the medication was not present in the home and it was reported the medication ran out.	Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.	Provider previously called in PRN medications to the pharmacy. Medication delivered as ordered.	03/01/2021	Implemented
6400.151(a)	Staff #1 did not have a physical exam until 6/21/2020, date of hire was 4/4/2019. Staff shall have an exam with in 12 months prior to employment and every 2 years after. A prior exam was requested but not provided and it is unclear if staff had an exam prior to their hire date.	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.	Staff will provide a physical exam upon hire.	03/01/2021	Implemented
6400.151(c)(1)	Staff #1 did not have a general physical exam at the time of inspection.	The physical examination shall include: A general physical examination.	Staff #1 had a physical completed on 06/23/21	06/23/2021	Implemented
6400.151(c)(3)	Staff #1 did not have record if they were free of communicable diseases.	The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals.	Staff #1 had a physical completed on 6/23/21 that includes a statement that states, staff is free from communicable disease.	06/23/2021	Implemented
6400.151(c)(4)	Staff #1 did not have record if they had any health conditions that could interfere with their job duties.	The physical examination shall include: Information of medical problems which might interfere with the health of the individuals.	Staff had a physical completed on 6/23/21 that states staff has no health problems that may interfere with health of individuals.	06/23/2021	Implemented
6400.152(b)	Staff #1 exam was not dated and signed by a licensed physician or Nurse Practitioner or Licensed Physician's Assistant.	Written authorization from a licensed physician shall include a statement that the person will not pose a serious threat to the health, safety or well-being of the individuals and specific instructions and precautions to be taken for the protection of the individuals at the home.	Staff #1provided a physical signed and dated by a health care provider.	06/23/2021	Implemented
6400.181(d)	The assessment was not signed by Program Specialist.	The program specialist shall sign and date the assessment.	Provider requested program specialist to sign assessment upon completion.	03/01/2021	Implemented
6400.32(r)(5)	The individual bedroom had a pin lock on the door. At the time of inspection there was no pin or key accessible to be able to open the door if it was to be locked.	Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.	Provider changed the door lock to Individual #1's bedroom to have a key.	06/15/2021	Implemented
6400.34(b)	Individual #2 rights are not updated to reflect the current regulations.	The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights.	Individual #2 rights updated to reflect current rights.	03/01/2021	Implemented
6400.46(c)	Staff #1 was not trained in first aid techniques until 7/8/19. Date of hire was 4/4/2019 and it is required that this staff should be trained prior to working with individuals.	Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques.	Provider will train staff in first aid techniques before first day of employment.	03/01/2021	Implemented
6400.51(b)(1)	Staff #2 did not have 12 hours of annual training. It was reported that the training schedule followed the fiscal year from June 2019 to June 2020 and staff #2 only had 2 trainings during that time frame. In November 2020 staff #2 completed positive approaches and crisis interventions. Certifications were uploaded for these trainings however there was no time documented for the hours it took to complete the trainings. All other trainings provided were not within the training year.	The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.	Provider will utilize the annual training calendar to complete trainings.	03/01/2021	Implemented
6400.51(b)(1)	Staff #1 was not trained in person centered practices, community integration, individual choice and supporting individuals to maintain relationships.	The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.	Staff will be trained on person centered practices, community integration, individual choice and supporting individuals to maintain relationships.	03/01/2021	Implemented
6400.51(b)(2)	Staff #1 did not have orientation that encompasses the prevention and detection and reporting of abuse, suspected abuse and alleged abuse.	The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations.	Provider will schedule and review abuse training with staff .	02/26/2021	Implemented
6400.165(g)	Individual #3 did not have medication reviews of her psychotropic medications.	If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.	Individual #2 had a psychiatry med review appointment on 03/02/2021	03/02/2021	Implemented

SIN-00166742

Renewal

11/12/2019

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.68(b)	The water temperature in the bathroom was 126.7 degrees.	Hot water temperatures in bathtubs and showers may not exceed 120°F.	Maintenance department requested to turn water temperature down. Water temperature checks will be completed monthly. The group home manager will ensure that a working thermometer is present at all times.	11/12/2019	Implemented
6400.112(a)	There is no record of fire drills being held in September and October of 2019.	An unannounced fire drill shall be held at least once a month.	Staff retrained on fire safety and documentation procedures. Group home manager, will ensure that drills are completed on a monthly basis as required.	11/06/2019	Implemented
6400.113(a)	Individual #3 was admitted on 4/4/2019. She didn't receive fire safety training until 4/18/2019.	An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home.	A new admission checklist will be present at all times in the individual's admission packet. Admitting contact will ensure that fire safety training is completed on the date of the admission.	12/24/2019	Implemented
6400.181(e)(9)	This area was not evaluated on Individual #3's assessment dated 5/10/2019.	The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations.	Individual 3's assessment will be completed in it entirety, including individual 3's disability function and medical limitations.	12/24/2019	Implemented
6400.181(e)(13)(i)	This area was not evaluated on Individual #3's assessment dated 5/10/2019.	The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.	Individual 3 assessment will be completed and all collected data including health, will be entered appropriately. The program specialist, will ensure all required spaces are completed entirely.	12/24/2019	Implemented
6400.181(e)(13)(viii)	This area was not evaluated on Individual #3's assessment dated 5/10/2019.	The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property.	Individual 3 progress will be completed and managing personal property added to it. Program specialist will collect appropriate data and ensure all data entered correctly on the assessment.	12/24/2019	Implemented
6400.34(a)	Individual #3 was admitted on 4/4/2019. She was not informed of her Individual Rights until 4/5/2019.	The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.	Individual's rights will be presented to new admissions at the time of admission. A checklist will be kept to keep track of the rights. Staff were retrained on the regulatory requirements.	12/24/2019	Implemented
6400.165(g)	Individual #3's psychiatric medication reviews did not include the reason for prescribing the medication, the need to continue the medication and the necessary dosage.	If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.	Psychiatrist requested to add the reason for the medication and need to continue the medication as well as the necessary dosage of the med on the med review form. Med review forms will be brought at the appointment for Psychiatrist to complete.	12/24/2019	Implemented