Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00234253 Unannounced Monitoring 10/31/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The bathroom sink in individual #1 bedroom registered at a temperature of 124.7. The hot water temp should not exceed 120. Hot water temperatures in bathtubs and showers may not exceed 120°F. Director recalibrated the water system on the water tank and has had staff check repeatedly over a 6 hour period. Readings steadily declined final reading was at 116°F on kitchen sink 119°F in tub and 119°F in sink in bathroom 11/28/2023 Implemented
SIN-00231440 Unannounced Monitoring 09/20/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(11)The physical examination shall include: The physical examination completed on 9/07/2023 did not include the Individual's health maintenance needs. *line was left blankThe physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Program manager and Director took medical form back to physician to have all blank portions filled out and signed off on to appropriately reflect individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This paperwork is in the medical book in the home. 10/27/2023 Implemented
6400.141(c)(12)The physical examination shall include: The physical examination completed on 9/07/2023 did not include the Individual's physical limitations. *line was left blankThe physical examination shall include: Physical limitations of the individual. Program manager and Director took medical form back to physician to have all blank portions filled out and signed off on to appropriately reflect individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This paperwork is in the medical book in the home. 10/27/2023 Implemented
6400.141(c)(13)The physical examination shall include: The physical examination completed on 9/07/2023 did not include the Individual's allergies. *line was left blankThe physical examination shall include: Allergies or contraindicated medications.Program manager and Director took medical form back to physician to have all blank portions filled out and signed off on to appropriately reflect individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This paperwork is in the medical book in the home. 10/27/2023 Implemented
6400.141(c)(14)The physical examination shall include: The physical examination completed on 9/07/2023 did not include medical information pertinent to diagnosis and treatment in case of emergency. *line was left blankThe physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Program manager and Director took medical form back to physician to have all blank portions filled out and signed off on to appropriately reflect individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This paperwork is in the medical book in the home 10/27/2023 Implemented
6400.141(c)(15)The physical examination shall include: The physical examination completed on 9/07/2023 did not include special instructions for the individual's diet. *line was left blankThe physical examination shall include: Special instructions for the individual's diet.Program manager and Director took medical form back to physician to have all blank portions filled out and signed off on to appropriately reflect individual's health maintenance needs, diet, medication regimen and the need for blood work at recommended intervals. This paperwork is in the medical book in the home 10/27/2023 Implemented
SIN-00228525 Unannounced Monitoring 07/27/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)According to Individual #1's Individual Support Plan (ISP) Individual #1 is not safe handling poisons. Individual #1 is not safe handling poisons as he does not understand the dangers of poisons if used improperly. Poisons need to be locked. At the time of inspection, located in the main bathroom where the washer and dryer are also located, behind the medicine cabinet mirror was what appeared to be a single blue, green, and white liquid laundry detergent pod.Poisonous materials shall be kept locked or made inaccessible to individuals. The laundry pod was removed and put in the garbage at time of inspection by the Program Manager. 07/31/2023 Implemented
6400.62(c)Poisonous materials shall be stored in their original, labeled containers. At the time of inspection, located in the main bathroom where the washer and dryer are also located, behind the medicine cabinet mirror was what appeared to be a single blue, green, and white liquid laundry detergent pod.Poisonous materials shall be stored in their original, labeled containers. The laundry pod was removed and thrown away at time of inspection by Program Manager. 07/31/2023 Implemented
6400.64(a)Clean and sanitary conditions shall be maintained in the home. At the time of inspection, the wall vent located between the living room and the kitchen had a significant layer of dust on it Located in the kitchen cabinet was a packet of Old El Paso Mild Taco Seasoning Mix with the "best if used by 26 May 2023" on it, a container of Duncan Hines Keto Friendly Vanilla Frosting with only ¼ of the contents remaining in it with the with the "best by Feb 07 2023" on it, and a package of Original Premium Saltine Crackers with the "best before 19 APR 23" on it.Clean and sanitary conditions shall be maintained in the home.The vent was wiped down at time of inspection by Program Manager. Expired items were removed. 07/31/2023 Implemented
SIN-00226902 Unannounced Monitoring 06/29/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16During a regulatory monitoring of the home due to the revoked status of the homes license, the Office of Developmental Programs (ODP) Licensing Representative observed Individual #2's being neglected. Individual #2's Individual Service Plan (ISP) that is available in the home that staff are trained on states: "Individual #2 can't be home alone without supervision. Individual #2's staff is funded by Lehigh Valley Children and Youth Services. Individual #2 is a 3:1 ratio. Individual #2 is having numerous aggressive behaviors towards staff and he is an elopement risk. An updated version of Individual #2's ISP that was reviewed following the inspection dated 9/4/22 and updated 5/11/23 that is available in HCSIS states: Individual #2 Can't be alone at home without supervision, Staff is funded by Lehigh Valley Children and Youth Services. Individual #2 is a 2:1 ratio. Individual #2 is having numerous issues of aggressive behaviors toward staff and is an elopement risk. Individual #2 has two security guards at all times funded by children and youth. Individual #2 can have alone time in a designated spot at the house 1perosn either from the Supreme Nursing Care staff or a security guard supervise at the window or door depending on what designated spot he goes to. Individual #2 can't be alone in the community for safety reasons. There is no documentation that staff were trained on the 5/11/23 revised ISP. During the inspection, Individual #2, Staff #1, Staff #2 and the two security guards were preparing to leave the home for an activity in the community. During this time, Individual #2 walked out of the home and was outside unsupervised for approximately 45 seconds. When the ODP Licensing Representative asked where Individual #2 was, the security guard indicated, "he was right there," meaning outside of the front door of the home. Staff #1 and Staff #2 were not outside with Individual #2 at that time, the Security Guards were also inside the home and were standing near the front door that was open. Individual #2 returned inside the home. Staff #3 arrived at the home shortly before this incident and was reviewing documentation upon arrival. Staff #1, Staff #2 and Staff #3 did not appear concerned that Individual #2 had been outside of the home. The ODP Licensing Representative discussed with Staff #3 who had come to the home for the inspection, Individual #1's level of supervision. Staff #3 advised that the individual was 2:1 staffing and was able to be outside of the home if staff have line of sight supervision. The ISP that was available in the home and was the plan utilized to train staff indicated that the individual was 3:1 staffing. Staff #3 indicated that the plan had been changed from 3:1 to 2:1. The inspector clarified that the ISP located in Individual #2's record in the home was the one that was being utilized to train staff. Staff #3 stated that it was. Individual #2, Staff #1, Staff #2 and the two security guards left to go into the community. During the inspection the ODP Licensing Representative reviewed Individual #2's Annual Assessment dated 11/2/22 and the ISP dated 11/21/22 that was available in the home and utilized for training and both documents indicated that Individual #2 requires 3:1 staffing. Approximately an hour after Individual #2 and the staff left, all returned from an activity. The ODP Licensing Representative was inspecting the bathroom of the home and Individual #2's bedroom during the return. The ODP Licensing Representative heard a door slam almost immediately after Individual #2 returned. The ODP Licensing Representative entered the dining room area of the home and observed that Individual #2 was not in the home, however Staff #1, Staff #2 and Staff #3 and the Security Guards were all in the home. The ODP Licensing Representative questioned Individual #2's whereabouts. Staff stated the individual was outside. The front door of the home was closed. The ODP Licensing Representative immediately stated that Individual #2 requires 3:1 staffing and could not be outside alone. Staff #1, Staff #2, and Staff #3 did not respond. The inspector stated to Staff #3," this was the discussion earlier about Individual #2's appropriate levels of supervision." Staff #3 then stated that Staff #1 and Staff #2 need to go outside with Individual #2. Staff #1 was standing near the dining room table completing a task with Individual #2's money and Staff #2 was sitting on the couch on a cell phone. One of the security guards was in the restroom and the other was standing at the window. Staff #3 instructed Staff #1 and Staff #2 to go outside with the Individual again. Staff #1 turned to motion to Staff #2 to go outside and Staff #3 stated both staff need to go. Staff #1 and Staff #2 then went outside along with one of the security guards. Individual #2 was brought back into the home. Within five minutes of returning into the home, Individual #2 again left the home an no staff were with the individual. The ODP Licensing Representative again stated that the individual had left the home and the staff needed to be with him. Staff #1 was again standing at the dining room table to complete a task with Individual #1's money and looked at the ODP Licensing Representative when Staff #3 again stated that Staff #1 and Staff #2 needed to go outside with the individual. When the staff went outside, one of the security guards approached the ODP Licensing Representative and stated, "we were told that we are not supposed to be the one to go with the individual and provider staff are." The ODP Licensing Representative advised the security guard that this was correct. Upon returning into the home, Staff #2 approached the ODP Licensing Representative and Staff #3 and stated, "he is not a prisoner." The inspector advised Staff #2 that this was correct, however Individual #2 resides in a licensed and regulated home and requires a high level of supervision and his ISP states that "the individual requires 3:1 staffing." The ODP Licensing Representative reminded all of the staff in the home that the home is licensed and regulated, and regulations need to be complied with and the purpose for the monthly monitoring is to ensure compliance with the regulations that have not been consistently followed. Individual #2 was neglected. Staff #1, Staff #2 and Staff #3 did not provide appropriate supervision to Individual #2 on 6/29/23 in the presence of a ODP Licensing Representative. Staff #1, Staff #2 and Staff #3 neglected to provide 3:1 supervision to Individual #2 and allowed him to leave the home on three occasions unsupervised and the ODP Licensing Representative needed to advised Staff #1, Staff #2 and Staff #3 that Individual #2 was not able to be left unsupervised.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.An updated version of the ISP was printed and put in the home and reviewed with all staff on site. An EIM report was done to refelct this incident. Staff involved received disciplinary actions of write ups and suspension with no pay. 07/14/2023 Implemented
6400.22(d)(1)The home does not maintain an up to date financial record including disbursements made for Individual #2. The home maintained a financial record that included entries until 6/26/23. The last entry included a balance of $42.26 and the cash available in the home was $27.40 including $10.00 that was in the possession of Individual #2. Staff reported missing funds were utilized for activities between 6/26/23 and 6/29/23, however there were no entries to reflect this information.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. Lead staff reconciled funds to make sure counts are correct. Staff ensured client did not have any money on his person and all. 07/14/2023 Implemented
6400.43(b)(4)The Chief Executive Officer (CEO) is not ensuring the administration and general management of the home including compliance with this chapter. The CEO is not adequately overseeing the daily functioning of the of home and ensuring that all regulations are followed resulting in significant areas of noncompliance including subject area: Abuse, Staff Training and Implementation of the Individual Plan. (REPEAT VIOLATION 10/13/22)The chief executive officer shall be responsible for the administration and general management of the home, including the following: Compliance with this chapter. Inservices will be conducted to cover Abuse and a general staff responsibilities refresher Staff will be trained in full on the updated ISP by 7.30.23 by lead staff program manager and Director. 07/31/2023 Implemented
6400.64(a)Clean and sanitary conditions are not maintained throughout the home. The wall-to-wall carpet in the living room and dining room is dirty and stained throughout the majority both rooms. (REPEAT VIOLATION 10/13/22)Clean and sanitary conditions shall be maintained in the home. Carpets were shampooed . Another treatment is needeed and will be completed byt 7.31.23 07/31/2023 Implemented
6400.181(e)(4)Individual #2's need for supervision is not assessed properly. Individual #2's annual assessment dated 11/2/22 states: "Individual #2 can't be home alone without supervision. Individual #2's staff is funded by Lehigh Valley Children and Youth services Individual #2 is a 3:1 ratio. Staff #3 report that Individual #2 does not require 3:1 supervision and is only 2:1 supervision. A review of the Individual Service Plan that a Staff training document was included with the plan and a statement from Staff #3 that the plan in the Individual's record at the home is what is utilized to train staff indicates that staff are trained utilizing the document that states 3:1 staffing. It is unclear what level of supervision Individual #2 requires. The assessment must include the following information: The individual's need for supervision. Annual assessment was updated by Director 07/06/2023 Implemented
6400.52(c)(6)Staff #1, Staff #2#, Staff #3, Staff #4, Staff #5, Staff#6, Staff #7, and Staff #8 are not trained in the most recent version of Individual #2's Individual Service Plan (ISP). Documentation indicates Staff #1, Staff #2#, Staff #3, Staff #4, Staff #5, Staff#6, Staff #7, and Staff #8 were trained on Individual #2'as ISP that is dated 11/21/22. Individual #2's ISP was revised on 5/11/23 and there is no documentation to support staff received training on this version of the ISP. (REPEAT VIOLATION 10/13/22)The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Staff were trained on the most recent ISP available. It has been updated since and staff will be retrained on the most updated in full by 7.31.23 as some staff are on vacation. 07/31/2023 Implemented
6400.186During a regulatory monitoring of the home due to the revoked status of the homes license, the Office of Developmental Programs (ODP) Licensing Representative observed Individual #2's Individual Service Plan (ISP) to not be implemented. Individual #2's Individual Service Plan (ISP) that is available in the home that staff are trained on states: "Individual #2 can't be home alone without supervision. Individual #2's staff is funded by Lehigh Valley Children and Youth Services. Individual #2 is a 3:1 ratio. Individual #2 is having numerous aggressive behaviors towards staff and he is an elopement risk. An updated version of Individual #2's ISP that was reviewed following the inspection dated 9/4/22 and updated 5/11/23 that is available in HCSIS states: Individual #2 Can't be alone at home without supervision, Staff is funded by Lehigh Valley Children and Youth Services. Individual #2 is a 2:1 ratio. Individual #2 is having numerous issues of aggressive behaviors toward staff and is an elopement risk. Individual #2 has two security guards at all times funded by children and youth. Individual #2 can have alone time in a designated spot at the house 1perosn either from the Supreme Nursing Care staff or a security guard supervise at the window or door depending on what designated spot he goes to. Individual #2 can't be alone in the community for safety reasons. There is no documentation that staff were trained on the 5/11/23 revised ISP. During the inspection, Individual #2, Staff #1, Staff #2 and the two security guards were preparing to leave the home for an activity in the community. During this time, Individual #2 walked out of the home and was outside unsupervised for approximately 45 seconds. When the ODP Licensing Representative asked where Individual #2 was, the security guard indicated, "he was right there," meaning outside of the front door of the home. Staff #1 and Staff #2 were not outside with Individual #2 at that time, the Security Guards were also inside the home and were standing near the front door that was open. Individual #2 returned inside the home. Staff #3 arrived at the home shortly before this incident and was reviewing documentation upon arrival. Staff #1, Staff #2 and Staff #3 did not appear concerned that Individual #2 had been outside of the home. The ODP Licensing Representative discussed with Staff #3 who had come to the home for the inspection, Individual #1's level of supervision. Staff #3 advised that the individual was 2:1 staffing and was able to be outside of the home if staff have line of sight supervision. The ISP that was available in the home and was the plan utilized to train staff indicated that the individual was 3:1 staffing. Staff #3 indicated that the plan had been changed from 3:1 to 2:1. The inspector clarified that the ISP located in Individual #2's record in the home was the one that was being utilized to train staff. Staff #3 stated that it was. Individual #2, Staff #1, Staff #2 and the two security guards left to go into the community. During the inspection the ODP Licensing Representative reviewed Individual #2's Annual Assessment dated 11/2/22 and the ISP dated 11/21/22 that was available in the home and utilized for training and both documents indicated that Individual #2 requires 3:1 staffing. Approximately an hour after Individual #2 and the staff left, all returned from an activity. The ODP Licensing Representative was inspecting the bathroom of the home and Individual #2's bedroom during the return. The ODP Licensing Representative heard a door slam almost immediately after Individual #2 returned. The ODP Licensing Representative entered the dining room area of the home and observed that Individual #2 was not in the home, however Staff #1, Staff #2 and Staff #3 and the Security Guards were all in the home. The ODP Licensing Representative questioned Individual #2's whereabouts. Staff stated the individual was outside. The front door of the home was closed. The ODP Licensing Representative immediately stated that Individual #2 requires 3:1 staffing and could not be outside alone. Staff #1,Staff #2, and Staff #3 did not respond. The inspector stated to Staff #3," this was the discussion earlier about Individual #2's appropriate levels of supervision." Staff #3 then stated that Staff #1 and Staff #2 need to go outside with Individual #2. Staff #1 was standing near the dining room table completing a task with Individual #2's money and Staff #2 was sitting on the couch on a cell phone. One of the security guards was in the restroom and the other was standing at the window. Staff #3 instructed Staff #1 and Staff #2 to go outside with the Individual again. Staff #1 turned to motion to Staff #2 to go outside and Staff #3 stated both staff need to go. Staff #1 and Staff #2 then went outside along with one of the security guards. Individual #2 was brought back into the home. Within five minutes of returning into the home, Individual #2 again left the home an no staff were with the individual. The ODP Licensing Representative again stated that the individual had left the home and the staff needed to be with him. Staff #1 was again standing at the dining room table to complete a task with Individual #1's money and looked at the ODP Licensing Representative when Staff #3 again stated that Staff #1 and Staff #2 needed to go outside with the individual. When the staff went outside, one of the security guards approached the ODP Licensing Representative and stated, "we were told that we are not supposed to be the one to go with the individual and provider staff are." The ODP Licensing Representative advised the security guard that this was correct. Upon returning into the home, Staff #2 approached the ODP Licensing Representative and Staff #3 and stated, "he is not a prisoner." The inspector advised Staff #2 that this was correct, however Individual #2 resides in a licensed and regulated home and requires a high level of supervision and his ISP states that "the individual requires 3:1 staffing." The ODP Licensing Representative reminded all of the staff in the home that the home is licensed and regulated, and regulations need to be complied with and the purpose for the monthly monitoring is to ensure compliance with the regulations that have not been consistently followed. Staff #1, Staff #2 and Staff #3 failed to implement Individual #2's level of supervision identified in the ISP. Staff #1, Staff #2 and Staff #3 allowed Individual #2 to be unsupervised outside of the home on three occasions during the inspection. Individual #2's ISP states "Individual #2 is unable to manage the individual's own finances. Staff failed to implement Individual #2's financial needs of the ISP. Individual #2 is provided with money to keep on the individual's person. At the time of the inspection, Individual #2 was in possession of $10 that the individual is unable to manage.The home shall implement the individual plan, including revisions.The most up to date plan has been placed in the home by Director and will be trained fully by Program Manager by 7.31.23 Staff involved have been disciplined as a result of a repeat infraction. And are on final notice if they are not implementing plan as required. 07/31/2023 Implemented
SIN-00226817 Unannounced Monitoring 05/31/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34The 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. At the time of the inspection, the Licensing Representative (LR) was not able to access the second bedroom in the apartment. The door was locked; Staff #1 stated that the room was always kept locked and that there was no key on the premises to that room.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.The agency has made several more copies of the keys to ensure authorized agents of the Department have full access to the facility and agency and its records during both announced and unannounced inspections. Several copies of sets of keys will are available and will in the home effective 7.10.23 07/10/2023 Implemented
6400.62(a)Poisonous materials shall be kept locked or made inaccessible to individuals. Dawn antibacterial dish detergent was found unlocked and accessible on the kitchen counter next to the sink. Individual #1's annual assessment completed on 11/02/2022 states that the individual is not safe with poisonous materials and that poisons are locked in the home.Poisonous materials shall be kept locked or made inaccessible to individuals. The Dawn antibacterial dish detergent that was found unlocked and accessible on the kitchen counter next to the sink was put in the closest looked away with staff holding the key to ensure health, safety and compliance. 07/10/2023 Implemented
6400.68(b)Hot water temperatures may not exceed 120.0 degrees Fahrenheit. The hot water temperature was measured at 125.0 degrees Fahrenheit in the individual's bathroom. Hot water temperatures in bathtubs and showers may not exceed 120°F. The temperature was adjusted by the Director to be between 115 and 118. The water was measured at 116 in the kitchen 118 in the bathroom after 2 hours. The temperature was taken again on 7.10.23 and measured at 117 in the kitchen and bathroom area. 07/10/2023 Implemented
6400.32(c)An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. Individual #1 requires 2:1 staffing and has a history of elopement, according to the individual's current Individual Support Plan (ISP) updated on 5/26/2023. The Individual also has two security guards assigned to be in the home and are funded by the Office of Children, Youth and Families (OCYF). The security guards are not employees of the residential provider agency, and have not had the required criminal history record checks or the trainings that is required of direct care staff. The security guards are not direct care staff and are not considered to be in the supervision ratio, according to the provider agency. At the time of the unannounced inspection on May 31, 2023, Individual #1 walked out the front door of the home, in full view of the two agency staff that were in ratio, and the security guards. One of the security guards followed the individual outside, while the two direct care staff remained inside the home. The Individual and the security guard got into a parked car and sat inside for a couple of minutes. Neither of the direct care staff went outside until this licensing inspector asked them if they were going to provide supervision to the Individual. At that time, Staff #1 told Staff #2 to go outside. The provider agency staff, by failing to immediately follow the individual outside and allowing the security guard instead to supervise the Individual, subjected Individual #1 to neglect by failing to provide the required supervision to the individual.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.This incident was entered into EIM and an disciplinary action has been taken with staff involved to ensure proper levels of supervision are being kept. Updated ISP has been reviewed by staff and will be signed in completion by 7.14.23 07/17/2023 Not Implemented
6400.165(b)A prescription order shall be kept current. Individual #1is currently prescribed Trazadone Hcl, 300mg. tabs, take one tab by mouth at bedtime. This is the current order and is reflected on the pharmacy label on the blister pack. The medication administration record (MAR), reflects the previous order and administration instructions, and states "Trazadone Hcl, 150mg. tabs, take two tabs by mouth at bedtime."A prescription order shall be kept current.This was updated and corrected by the program manager and reflected in the current medication log. This was completed effective 7.10.23 07/10/2023 Implemented
SIN-00223395 Unannounced Monitoring 04/25/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Floors, walls, ceilings, and other surfaces shall be in good repair. At the time of the inspection, 8 blinds were missing from the blinds that are used for the backdoor exit.Floors, walls, ceilings and other surfaces shall be in good repair. Blinds were purchased and replaced for the backdoor exit. 05/29/2023 Not Implemented
6400.165(c)A prescription medication shall be administered as prescribed. Individual #2 is prescribed Omega-3 Acid ethyl 100mg, take 1 capsule by mouth once daily. This medication was refilled on 3/14/23 and contains a 30-day supply. There were 13 pills that remained in the bottle at the time of the inspection (4/25/23), and another bottle was also in the home with the refill date of 4/17/23. The medication is documented as being administered as prescribed on the Medication Administration Record.A prescription medication shall be administered as prescribed.Team lead took Medication to be update at We care Pharmacy. Pharmacy was informed of the concern and informed lead that once medications get down to five pills it can be called in to ensure there are not a surplus of fish oil supplements on site that could cause an inconsistencies. A separate script was written by the pharmacy to ensure current pills and counts are correct an other bottle in home was taken to the pharmacy for disposal. 06/01/2023 Not Implemented
6400.166(a)(2)Individual #2's April 2023 Medication Administration Record (MAR) did not include the prescriber Katherine Iturralde for their medication Ibuprofen.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.Name of Prescribing doctor was added to MAR by team lead. Director updated MAR to reflect the change on future MARS moving forward. 06/01/2023 Not Implemented
6400.166(a)(9)A medication record shall be kept including the frequency of administration. Individual #2's April 2023 Medication Administration Record (MAR) documented Ibuprofen 600 mg, take one tablet my mouth every 6 hours as needed for pain. However, the pharmacy label on the medication bottle stated to take 1 tablet (600 mg) by mouth every eight hours as needed for mild pain. The frequency of administration was not recorded accurately on the MAR according to the pharmacy label for the medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.Time on PRN medication was updated on MAR by team lead to reflect accuracy of frequency . Director updated MAR to reflect the change on future MARS moving forward. 06/01/2023 Not Implemented
6400.166(d)The directions of the prescriber shall be followed. Individual #2 is prescribed Ibuprofen 600 mg, to take 1 tablet (600 mg) by mouth every eight hours as needed for mild pain. However, Individual #2's April 2023 Medication Administration Record (MAR) documented Ibuprofen 600 mg, take one tablet my mouth every 6 hours as needed for painThe directions of the prescriber shall be followed.Incorrect time on PRN medication was updated on MAR by team lead and Director to reflect accuracy of frequency to every 8 hours for pain . Director updated MAR to reflect the change on future MARS moving forward. 06/01/2023 Not Implemented
SIN-00221637 Unannounced Monitoring 03/16/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(1)Individual #1 is unable to manage money independently, the home did not maintain a separate record of financial resources, including 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. CEO and Lead staff reviewed and reconciled finances. A general plan was also made with consumer DLR to communicate any and all funds he has on his person. Also staff is to review ledgers on shift and at shift change communicate any financial update or changes. 04/10/2023 Not Implemented
6400.68(a)Water temp in the bathtub was too low. The water temp in the bathtub was 95.1 degrees after running the water for 5 minutes. Staff reported that the maintenance was just at the home for this issue and when they tested the water it was 112 degrees. The water temp in the bathroom sink was 113.9 but the temp in the tub never exceeded 95.1. (Repeat violation 2/3/23)A home shall have hot and cold running water under pressure. Staff and Director were able to adjust water temperature using in unit hot water tank. Initially the water in consumers bathroom still ran cooler. However, it has been checked since with a water thermoeter and has measured consistently between 108-114 . 04/10/2023 Not Implemented
6400.77(b)First aid kit did not contain tweezers. (Repeat violation 2/3/23) A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Tweezers were on site however not in the kit at time of review. There now multiple tweezers on site including in the first aid kit. Director ensured tweezer are on site 04/10/2023 Not Implemented
6400.112(f)Alternate exits are not being utilized during fire drills. Fire drills were reviewed from 9/7/22, 10/6/22, 11/22/22, 12/22/22, 1/20/23 and 2/13/23. All drills utilized the front/living room door to exit.Alternate exit routes shall be used during fire drills. Lead staff ensured March fire drill that was conducted at the end of the month used and alternate exit (back door). Staff is to alternate exits monthly to ensure this variance takes place. 04/10/1923 Not Implemented
6400.144Health services, including medical appointments are not being arranged or provided. Individual #1 was referred to an audiologist for follow up as the individual failed a hearing exam on 9/6/22. There has not been an appointment scheduled with an audiologist. (Repeat violation 2/3/23, 12/2/22 and 10/18/22)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. Appointment for audiologist was conducted and onsite. That appointment took place on 10.3.22. Staff onsite overlooked the form. It is yellow and in consumers program book. 04/10/2023 Not Implemented
6400.163(a)Medications are not maintained in original, labeled container. Individual #1 is prescribed Fluticasone Propina 50mcg, two sprays into each nostril daily. There was a bottle of this medication located in the individual's medication box, however it was not in an original labeled container.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.Additional bottle of Fluticasone was removed from medications by Director on site. 04/10/2023 Not Implemented
6400.165(a)Prescription medications are not prescribed in writing by an authorized provider. There were two packets of Sinus relief medication located in the first aid kit of the home. There is no order prescribing this medication to the individual residing in the home.A prescription medication shall be prescribed in writing by an authorized prescriber.The two packets of sinus relief medications were removed by staff immediately. 04/10/2023 Not Implemented
6400.165(g)Documentation of medication reviews on 2/24/23 and 3/14/23 for medications to treat symptoms of psychiatric illness do not include the medication, necessary dosage or the need to continue the medications. (Repeat violation 2/3/23, 12/2/22 and 10/18/22)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.Director created a form to use moving forward that includes all necessary information. This form has been used recently and includes all necessary information. 04/10/2023 Not Implemented
SIN-00219053 Unannounced Monitoring 02/03/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(a)A home shall have hot and cold running water under pressure. At the time of the inspections the water temperature in the bathtub measured 93.7°. The licensing representative allowed the hot water to run for approximately 6 minutes and it never exceeded 93.7°.A home shall have hot and cold running water under pressure. Temperature on the water in home fluctuates. Lead staff is currently working on getting maintenance to leave a detailed service order explaining this. Lead staff and Director are working with apartment complex to get this resolved. Until then Director has a daily tracking sheet to track daily temperatures in the apartment to see the fluctuations and ensure the home has hot and cold water under pressure. 03/10/2023 Implemented
6400.77(b)The first aid kit did not have tweezers at the time of inspection. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Director replaced tweezers in first aid kit in home 03/10/2023 Implemented
6400.141(a)Individual #1 was admitted into Supreme Nursing Care on June 30, 2022, and the current home on September 6.2022. There is no record of Individual #1 having a physical examination. Supreme Nursing Care's Corrective Action Plan indicated that they would schedule a physical examination for Individual #1, and that it would be confirmed by 12/2/22. There was no documentation that this was confirmed or completed. REPEAT violation 1/12/23 and 11/18/22.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual had a physical completed in September of 2022 however the form that was received did not contain all the information that is necessary for regulations. Lead staff attempted to take individual to complete a new physical however it is not allowed by his insurance since he had one within the last year. Lead staff is working with PCP to get the supreme physical form filled out based off the physical from 9/2022 covering the information necessary by 3.10.23. 03/10/2023 Implemented
6400.144Health services are not being arranged or provided for Individual #1 was admitted into Supreme Nursing Care on June 30, 2022, and the current home on September 6.2022. There is no record of Individual #1 having a physical examination. Supreme Nursing Care's Corrective Action Plan indicated that they would schedule a physical examination for Individual #1, and that it would be confirmed by 12/2/22. There was no documentation that this was confirmed or completed. REPEAT violation 1/12/23 and 11/18/22.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. Individual had a physical completed in September of 2022 however the form that was received did not contain all the information that is necessary for regulations. This document is in his program book in the medical section. Lead staff is working with PCP to get the supreme physical form filled out based off the physical from 9/2022 covering the information necessary by 3.10.23. 03/10/2023 Implemented
6400.165(g)At the home during the inspections was a doctor appointment form for medication management for Individual #1 on 12/27/22 with Dr. Solgna the form does not include the medication and necessary dosage, or the reason for prescribing medication. Individual #2 had doctor appointment form dated 1/17/23 for a with Dr. Walters/Dr.Solgna that noted psych eval the form used does not include the medication and necessary dosage, or the reason for prescribing medication. REPEAT violation 1/12/23 and 11/18/22.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.Director is working with Lead staff to get a quarterly schedule established for individual. Also Director has created form listing medications, reason for giving, dosage and prescribing doctors. 03/10/2023 Implemented
6400.166(a)(10)Individual #1 is prescribed a PRN of Ibuprophen 600mg to be taken every 6 hours as needed for pain. The medication administration record reflects the medication should be given every 8 hours as needed. The administration times do not match from the bottle to the MAR.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.This was corrected on the current MAR based of allowed documentation practices by Lead staff who corrected the MAR to reflect the medication label. Director has updated the official MAR to reflect current medication label. 03/10/2023 Implemented
6400.166(b)Individual #1 is prescribed Loratadine 10 mg to be taken daily. The individual is also prescribed Haloperidol 5mg to be taken at 8am. At the time of inspection on 2/3/2023, the medications were removed from the blister packs, but the staff did not sign for the medication in the medication administration record.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.All medications have been reviewed with staff present who did not sign and refreshed on the importance of documentaion for medication. 03/10/2023 Implemented
6400.196(a)Individual #1 has a behavior support plan. Staff working in Individual #1's home implement and manage a behavior component of Individual #1's individual plan. Staff # 1 is not trained in the use of the specific techniques or procedures that are used. REPEAT violation 1/12/23 and 11/18/22.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.Staff has signed of on original form. Staff had BSP reviewed with Director and onsite behavioral staff. 03/10/2023 Implemented
SIN-00216350 Unannounced Monitoring 12/02/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)A bottle of Dawn Antibacterial Hand soap Apple Blossom Scent was located at the kitchen sink. The bottle was filled ¼ of the way with a yellow liquid, and typically the Apple Blossom Scent is green in color. When asked if staff pour another larger container of soap into this bottle they stated "NO." The licensing representative did not find another soap container that had a yellow content. The licensing representative also looked the Dawn Antibacterial Hand soap Apple Blossom Scent up online and the liquid content should be a green color not yellow. Poisonous materials shall be stored in their original, labeled containers.Poisonous materials shall be stored in their original, labeled containers. That bottle of liquid has been removed. Staff in home will be retrained by Director in regard to appropriate storage of poison substances. 01/11/2023 Implemented
6400.64(a)Located under the kitchen cabinet was a 10 lbs bag of Goya Thai Jasmine Rice that was approximately ¼ of the way full of rice, and the bag of rice was not sealed closed. Clean and sanitary conditions shall be maintained in the home. (Repeat violation 10/28/22)Clean and sanitary conditions shall be maintained in the home. Bag of rice was removed. And purchases of smaller bags of rice had been purchased and will be purchased moving forward. Any containers used are labeled and the original item is in its original packaging still with date and signature. Staff will be trained on appropriate food storage in the home by 1.25.23. 01/25/2023 Implemented
6400.141(a)Individual #3 was admitted into Supreme Nursing Care on June 30, 2022, and the current home on September 6.2022. There is no record of Individual #3 having a physical examination. Supreme Nursing Care's Corrective Action Plan indicated that they would schedule a physical examination for Individual #3, and that it would be confirmed by 12/2/22. There was no documentation that this was confirmed or completed.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual's physical is in the home in his Program book. This book will remain on site to ensure compliance with all regulatory items. 01/25/2023 Implemented
6400.144Health services are not being arranged or provided for Individual #3 was admitted into Supreme Nursing Care on June 30, 2022, and the current home on September 6.2022. There is no record of Individual #3 having a physical examination. Supreme Nursing Care's Corrective Action Plan indicated that they would schedule a physical examination for Individual #3, and that it would be confirmed by 12/2/22. There was no documentation that this was confirmed or completed.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. Director has returned program book to the home so those records remain onsite. Individual has had a physical/well check exam however the paper work does not implicitly state it was an annual physical as it coincided with another appointment. Individual had to establish care at a new doctors office given the abrupt nature of his placement. Director is working on getting the correct documentation to reflect an annual physical had indeed taken place between june and sept 2022 to comply with regulations without any ambiguity. That documentation will be kept on site in individuals program book. This will be accomplished by 1.25.23 01/25/2023 Not Implemented
6400.211(b)(4)Emergency information for an individual shall include the following: A copy of the individual's most recent annual physical examination. At the time of inspection, a copy of Individual #2's most recent physical examination was not at the home. Emergency information for each individual shall include the following: A copy of the individual's most recent annual physical examination. Director has returned program book to the home so those records remain onsite. Individual has had a physical/well check exam however the paper work does not implicitly state it was an annual physical as it coincided with another appointment. Individual had to establish care at a new doctors office given the abrupt nature of his placement. Director is working on getting the correct documentation to reflect an annual physical had indeed taken place between june and sept 2022 to comply with regulations without any ambiguity. That documentation will be kept on site in individuals program book. This will be accomplished by 1.25.23 01/25/2023 Not Implemented
6400.32(r)(1)An individual has the right to lock the individual's bedroom door. Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to unlock and lock the door. Individual #2 had a "pin key" lock on their bedroom door at the time of inspection, the staff stated that Individual #2 did not have a key to the door.Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.Director went over having locks with individual and lead staff who helped interpret. Individual does not want a different lock on door and signed off on a release stating that. 01/25/2023 Implemented
6400.32(r)(5)Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. Individual #2 had a "pin key" lock on their bedroom door at the time of inspection, the staff did not have a key to access the door if it was locked.Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.Director has ordered keys estimated to arrive by 1.16.23. At that time Director will give one key to individual. One key will be accessible for staff working with individual and one key will remain at the home office in case of emergency. 01/25/2023: Email between this supervisor and Supreme Nursing. I explained that pin locks are not acceptable. Door locks were changed. KCF 01/25/2023 Implemented
6400.165(c)Individual #2prescribed Omega-3 Acid-Ethyl 100mg cap, take one capsule by mouth in the morning. The bottle had a date filled of 11/29/22 with Qty of 30 and only 4 pills were in the bottle at the time of the monitoring. A prescription medication shall be administered as prescribed. A letter from New liberty pharmacy was provided to the licensing representative dated 12/2/22 stating that they were only able to fill partial fill Individual #2's Omega 3 prescription on 11/29/22 due to a manufacturer backorder. They were able to supply a quantity of 9 capsules on 11/29/22. Only 4 pills remained in the pill bottle at the time of inspection in 12/2/22. The medication is not being administered as prescribed. Individual #2 is prescribed Ibuprofen 400 mg, take one tablet by mouth every 6 hours as needed for mild pain. Date filled 10/7/22 and Qty 20. The pill bottle of the medication was empty at the time of inspection. Individual was administered the medication on 10/22/22, 11/1/22, 11/4/22, and 11/8/22. Licensing representative requested the October Medication Administration Record to review/account for the other 16 pills administration. However, the medication was not available in the home at the time of inspection.A prescription medication shall be administered as prescribed.CEO, Director and lead staff will ensure correct counts of medications upon receipt. Staff will also document on the MAR correctly stating the amount of medications given when PRN. Director will provided a refresher training on PRN medications and documentations to staff All staff available to be trained before 1.25.23. 01/25/2023 Not Implemented
6400.165(g)At the home during the inspections was a doctor appointment form for medication management on 11/8 with Dr. Richard Solgna, but the form appears to be completed by staff the form also does not include a doctor's/physician signature, mediation and necessary dosage, or the reason for prescribing medication. Individual #2 had doctor appointment form dated 11/9/22 for a follow up visit with Dr. Tinery that noted "to be his med management doctor the form appears to be completed by staff in addition the form used does not include a doctor's/physician signature, mediation and necessary dosage, or the reason for prescribing medication. On 11/28/22 a doctor appointment form with Dr. Solgna noting reason for appointment as medication refill. The form appears to be completed by staff the form also does not include a doctor's/physician signature, mediation and necessary dosage, or the reason for prescribing medication.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.Lead staff has been retrained on psychotropic meds and the need for medication management. Those appointments will be scheduled appropriately starting in January 2023. Staff was also advised to only fill out areas of personal information and nothing that would require a physicians overview. At this time an appointment for individuals next medication review has not been confirmed but will be by 1.25.23 01/25/2023 Not Implemented
6400.186The agencies corrective action plan stated that by 11/30/2 all staff working with Individual #3 will review the Individual Service Plan (ISP) and sign off on it's understanding. Staff #5 did not complete the ISP training until 12/4/22, and there is not documentation that staff #7 received the ISP training.The home shall implement the individual plan, including revisions.Staff in this home will all be trained and review individuals most up to date ISP and sign off by 1.25.23 by Director and copies will be kept in the home for review and verification. If a staff is unable or is not on schedule during times of training Director will reach out and conduct a virtual training where applicable. 01/25/2023 Not Implemented
6400.196(a)Individual #3 has a behavior support plan. Staff working in Individual #3's home implement and manage a behavior component of Individual #3's individual plan. Staff # 6 and Staff #7 are not trained in the use of the specific techniques or procedures that are used.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.Staff #6 and #7 in individuals home have been trained and have reviewed the BSP and signed off that they understand it by Director J. Speller. 01/25/2023 Not Implemented
SIN-00213614 Renewal 10/13/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Ten staff members, identified as "security guards", had no dates of hire listed or even information as to when they were assigned to working with Individual #3 in the home. The agency was unable to produce Pennsylvania criminal history record checks which are required to be submitted within 5 working days after the person's date of hire.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. At this time the current home/residence is licensed under 6400 Regulations Per Corporate Protective Services, LLC security team are not part of Supreme Care staff, they are a contracted service provider for LCOCYS. They should not be included in an ISP or considered part of Supreme care staff ratio of 2:1 staffing. Security Staff are not at anytime to be in the role of a caregiver. They are there to provide support and protection if needed. 12/02/2022 Not Implemented
6400.21(e)Individual #3 is the only individual residing in the home. Individual #3 is 17 years of age. None of the staff working in the home completed background checks relating to 23 Pa.C.S. § § 6301---6384 (relating to the Child Protective Services Law).If the home serves primarily individuals who are 17 years of age or younger, 23 Pa.C.S. § § 6301¿6384 (relating to the Child Protective Services Law) applies.All staff are currently getting their background checks updated as needed. 11/30/2022 Not Implemented
6400.62(a)Individual #3's Individual Service Plan indicates that the individual is not safe with poisons and poisons need to be kept locked in the home. Poisons including, Members Mark dish soap, Degree Advanced men's deodorant, Dermasil Cocoa Butter Moisturizing Lotion, Colgate toothpaste, Aim toothpaste, Febreze air freshener, Argon shampoo, Selson Blue shampoo, Head and Shoulders advanced series shampoo, Dial hand soap and Dermasil Aloe Fresh Moisturizing Body Lotion were not locked or made inaccessible to the individual. All items indicated to contact poison control or seek medical care if ingested.Poisonous materials shall be kept locked or made inaccessible to individuals. All of the above mentioned items have been removed and replaced with poison safe items. 11/30/2022 Implemented
6400.64(a)The vent in the living/dining room area was covered in a significant amount of dust.Clean and sanitary conditions shall be maintained in the home. Staff took a broom and rag and cleaned the dust. 11/30/2022 Implemented
6400.77(b)The first aid kit did not contain a thermometer. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. A new first aid kit is on site and has all required items. A new electronic thermometer is also on site. 11/30/2022 Implemented
6400.113(a)Individual #3 moved into a home operated by Supreme Nursing Care on 6/30/2022. The individual then moved into a new home also operated by Supreme Nursing Care on 9/6/2022. Individual #3 was not instructed in the individual's primary language or mode of communication, upon initial admission or upon moving to a new home 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. 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. Director of Residential services along with lead staff who interpreted to Spanish for individual went over individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. Individual had prior fire safety training however the date could not be confirmed at this time. This will be confirmed or individual retrained by 12.2.22. 12/02/2022 Implemented
6400.141(a)Individual #3 was admitted to Supreme Nursing Care on June 30, 2022, and the current home on September 6, 2022. Individual #3 did not have a physical examination within 12 months prior to admission.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Lead staff and CEO scheduled a physical for individual and this will be confirmed by 12.2.22. Also at that time the annual for next year will be scheduled for next year. 12/02/2022 Not Implemented
6400.144Health services, such as pharmaceutical, are not being arranged for or provided. Individual #3 is prescribed Trazadone HCL 150mg tab, Take two tablets by mouth at bedtime. This medication was not administered as prescribed on October 12, 2022. The Medication Administration Record (MAR) indicated that the medication had been discontinued. Documentation on the back of the MAR indicated that the medication had not been discontinued and the pharmacy had not delivered the medication resulting in the medication not being administered. Individual #3 is prescribed Fluticasone Propiona 50mcg, two sprays into each nostril daily. The bottle available in the home is ¾ full and was last filled on 6/8/22. There are 120 metered sprays in the bottle and based on the prescribed dosage, the medication would need to be refilled monthly. The medication is not documented on the Medication Administration Record and there is no record that the medication is being administered as prescribed. Staff reported that the medication may have been discontinued, there is no documentation of a discontinuation order. Individual #3 is prescribed Loratadine10mg tab, take 1 tablet, (10mg total) by mouth daily. This medication was last filled on 6/8/22 with 30 tablets and there were 15 tablets remaining in the bottle. Based on the number of tablets dispensed on 6/8/22, the medication would need to be refilled monthly. The medication is not documented on the Medication Administration Record and there is no record that the medication is being administered as prescribed or refilled since 6/8/22. Staff reported that the medication was as needed and also may have been discontinued, there is no documentation of a discontinuation order.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. Between the dates of 10.27.22 and 11.4.22 CEO and Director of residential updated the MARs and medications to reflect appropriate times. Staff have also had a brief unofficial medication overview. An official refresher training will be done by 12.2.22 12/02/2022 Implemented
6400.181(a)Individual #3 was admitted to the home on 6/30/22 and did not have an initial assessment completed within 1 year prior to or 60 calendar days after admission to the residential home. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. Individual now has a current assessment written by the new Director of Residential Services. 11/30/2022 Not Implemented
6400.212(a)A separate record was not kept in the home for Individual #3. A separate record shall be kept for each individual. Residential director separted the files for individual. 11/18/2022 Not Implemented
6400.18(c)The individual and persons designated by the individual were not notified within 24 hours of discovery of the medication errors including: Individual #3 not receiving Trazadone Trazadone HCL 150mg tab, 2 tablets at bedtime on 10/12/22, Individual #3 receiving Propanol Hydrochl 20mg tab, (take one tablet by mouth twice day). At 4PM instead of 8PM as documented on the Medication Administration Record. Fluticasone Propiona 50mcg, two sprays into each nostril daily and Loratadine10mg tab, take 1 tablet, (10mg total) by mouth daily.The individual and persons designated by the individual shall be notified within 24 hours of discovery of an incident relating to the individual.Between the dates of 10.27.22 and 11.4.22 CEO and Director of residential updated the MARs and medications to reflect appropriate times. Staff have also had a brief unofficial medication overview. An official medication and incident management refresher training will be done by 12.2.22. 12/02/2022 Not Implemented
6400.18(b)(2)Medication errors are not reported through the Department's information management system or on a form specified by the Department with 72 hours of discovery by a staff person. Individual #3 is prescribed Trazadone HCL 150mg tab, Take two tablets by mouth at bedtime. This medication was not administered as prescribed on October 12, 2022. The Medication Administration Record (MAR) indicated that the medication had been discontinued. Documentation on the back of the MAR indicated that the medication had not been discontinued but that the pharmacy had not delivered the medication resulting in the medication not being administered. Individual #3 is prescribed Propanol Hydrochl 20mg tab, take one tablet by mouth twice day. This medication was documented on the Medication Administration Record (MAR) as administered at 8AM and 8PM until 10/11/22. Beginning on 10/12/22, the medication was being administered at 8AM and 4PM. Staff in the home indicated that the individual had an appointment on 10/8/22 and the physician changed the administration times at the time of the appointment. There was no documentation to support a change in the time that the medication is being administered and there is a failure to administer the medication at the prescribed time. Individual #3 is prescribed Oxcarbazepine 600mg, this takes one tablet by mouth twice a day. This medication is documented on the MAR as administered at 8AM, 4PM and 8PM. There is not documentation of a medication change and there is not an additional dose of medication available in the home. The medication and there a failure to administer the medication at the prescribed time. Individual #3 is prescribed Fluticasone Propiona 50mcg, two sprays into each nostril daily. The bottle available in the home is ¾ full and was last filled on 6/8/22. There are 120 metered sprays in the bottle and based on the prescribed dosage, the medication would need to be refilled monthly. The medication is not documented on the Medication Administration Record and there is no record that the medication is being administered as prescribed. Staff reported that the medication may have been discontinued, there is no documentation of a discontinuation order. Individual #3 is prescribed Loratadine10mg tab, take 1 tablet, (10mg total) by mouth daily. This medication was last filled on 6/8/22 with 30 tablets and there were 15 tablets remaining in the bottle. Based on the number of tablets dispensed on 6/8/22, the medication would need to be refilled monthly. The medication is not documented on the Medication Administration Record and there is no record that the medication is being administered as prescribed. Staff reported that the medication was as needed and also may have been discontinued, there is no documentation of a discontinuation order.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.All medications were updated and put onto MAR. 11/30/2022 Not Implemented
6400.34(a)Individual #3 was admitted on June 30, 2022. The home did not inform and explain individual rights and the process to report a rights violation to the individual, and person designated by the individual, upon admission to the home.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.Director of residential services sat with individual and lead staff who served as a translater for spanish to inform and explain individual rights and the process to report a rights violation to individual on 10.27.22 10/27/2022 Implemented
6400.46(a)At least ten staff members, identified as "security guards" working in the home with Individual #3 did not receive training in General fire safety. While it was stated they are not Supreme Care employees, these ten individuals were, at times, counted as staff in the Individual's required supervision ratios.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.Per Corporate Protective Services, LLC security team are not part of Supreme Care staff, they are a contracted service provider for LCOCYS. They should not be included in an ISP or considered part of Supreme care staff ratio of 2:1 staffing. Security Staff are not at anytime to be in the role of a caregiver. They are there to provide support and protection if needed. 11/30/2022 Not Implemented
6400.46(c)At least ten staff members, identified as "security guards," did not receive training in first aid techniques before working with individuals. While it was stated they are not employees, these ten individuals were, at times, counted as staff in the Individual's required supervision ratios.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.Per Corporate Protective Services, LLC security team are not part of Supreme Care staff, they are a contracted service provider for LCOCYS. They should not be included in an ISP or considered part of Supreme care staff ratio of 2:1 staffing. Security Staff are not at anytime to be in the role of a caregiver. They are there to provide support and protection if needed. 11/30/2022 Not Implemented
6400.50(a)Records of orientation and training, including the training source, content, dates, length of training, nor copies of certificates received and staff persons attending, are maintained for least ten staff members identified as "security guards." working with Individual #1. While it was stated they are not Supreme Care employees, these ten individuals were, at times, counted as staff in the Individual's required supervision ratios.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.Per Corporate Protective Services, LLC security team are not part of Supreme Care staff, they are a contracted service provider for LCOCYS. They should not be included in an ISP or considered part of Supreme care staff ratio of 2:1 staffing. Security Staff are not at anytime to be in the role of a caregiver. They are there to provide support and protection if needed. 11/30/2022 Not Implemented
6400.51(b)(1)At least ten staff members with names, dates of hire, and when assigned to Individual #3 unavailable, that are identified as "security guards" working in the home with Individual #1 did not receive training in the application of Person-centered practices, community integration, individual choice and to develop and 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.Per Corporate Protective Services, LLC security team are not part of Supreme Care staff, they are a contracted service provider for LCOCYS. They should not be included in an ISP or considered part of Supreme care staff ratio of 2:1 staffing. Security Staff are not at anytime to be in the role of a caregiver. They are there to provide support and protection if needed. 11/30/2022 Not Implemented
6400.51(b)(2)At least ten staff members, names, dates of hire or when assigned to Individual #3 unavailable, that are identified as "security guards" working in the home with Individual #3 did not receive 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 Service 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.Per Corporate Protective Services, LLC security team are not part of Supreme Care staff, they are a contracted service provider for LCOCYS. They should not be included in an ISP or considered part of Supreme care staff ratio of 2:1 staffing. Security Staff are not at anytime to be in the role of a caregiver. They are there to provide support and protection if needed. 11/30/2022 Not Implemented
6400.51(b)(3)At least ten staff members whose names, dates of hire, or when assigned to Individual #3 unavailable, that are identified as "security guards" working in the home with Individual #3 did not receive training in Individual rights.The orientation must encompass the following areas: Individual rights.Per Corporate Protective Services, LLC security team are not part of Supreme Care staff, they are a contracted service provider for LCOCYS. They should not be included in an ISP or considered part of Supreme care staff ratio of 2:1 staffing. Security Staff are not at anytime to be in the role of a caregiver. They are there to provide support and protection if needed. 11/30/2022 Not Implemented
6400.51(b)(4)At least ten staff members whose names, dates of hire, or when assigned to Individual #3 are unavailable, that are identified as "security guards" working in the home with Individual #3 did not receive training in Recognizing and reporting incidents.The orientation must encompass the following areas: recognizing and reporting incidents.Per Corporate Protective Services, LLC security team are not part of Supreme Care staff, they are a contracted service provider for LCOCYS. They should not be included in an ISP or considered part of Supreme care staff ratio of 2:1 staffing. Security Staff are not at anytime to be in the role of a caregiver. They are there to provide support and protection if needed. 11/30/2022 Not Implemented
6400.51(b)(5)At least ten staff members whose names, dates of hire, or when assigned to Individual #3 are unavailable, that are identified as "security guards" working in the home with Individual #3, did not receive training in job related knowledge and skills specifically implementation of the individual service plan in if the staff works directly with an individual.The orientation must encompass the following areas: Job-related knowledge and skills.Per Corporate Protective Services, LLC security team are not part of Supreme Care staff, they are a contracted service provider for LCOCYS. They should not be included in an ISP or considered part of Supreme care staff ratio of 2:1 staffing. Security Staff are not at anytime to be in the role of a caregiver. They are there to provide support and protection if needed. 11/30/2022 Not Implemented
6400.165(c)Prescription Medications are not being administered as prescribed. Individual #3 is prescribed Trazadone HCL 150mg tab, Take two tablets by mouth at bedtime. This medication was not administered as prescribed on October 12, 2022. The medication. The Medication Administration Record (MAR) indicated that the medication had been discontinued. Documentation on the back of the MAR indicated that the medication had not been discontinued and the pharmacy had not delivered the medication resulting in the medication not being administered as prescribed. Individual #3 is prescribed Fluticasone Propiona 50mcg, two sprays into each nostril daily. The bottle available in the home is ¾ full and was last filled on 6/8/22. There are 120 metered sprays in the bottle and based on the prescribed dosage, the medication would need to be refilled monthly. The medication is not documented on the Medication Administration Record and there is no record that the medication is being administered as prescribed. Staff reported that the medication may have been discontinued, there is no documentation of a discontinuation order. Individual #3 is prescribed Loratadine10mg tab, take 1 tablet, (10mg total) by mouth daily. This medication was last filled on 6/8/22 with 30 tablets and there were 15 tablets remaining in the bottle. Based on the number of tablets dispensed on 6/8/22, the medication would need to be refilled monthly. The medication is not documented on the Medication Administration Record and there is no record that the medication is being administered as prescribed or refilled since 6/8/22. Staff reported that the medication was as needed and also may have been discontinued, there is no documentation of a discontinuation order. Individual #3 is prescribed Propanol Hydrochl 20mg tab, take one tablet by mouth twice day. This medication was documented on the Medication Administration Record (MAR) as administered at 8AM and 8PM until 10/11/22. Beginning on 10/12/22, the medication was being administered at 8AM and 4PM. Staff in the home indicated that the individual had an appointment on 10/8/22 and the physician changed the administration times at the time of the appointment. There was no documentation to support a change in the time that the medication is being administered and there is a failure to administer the medication at the prescribed time. Individual #3 is prescribed Oxcarbazepine 600mg, this takes one tablet by mouth twice a day. This medication is documented on the MAR as administered at 8AM, 4PM and 8PM. There is not documentation of a medication change and there is a failure to administer the medication at the prescribed time.A prescription medication shall be administered as prescribed.Between the dates of 10.27.22 and 11.4.22 CEO and Director of residential updated the MARs and medications to reflect appropriate times. Staff have also had a brief unofficial medication overview. An official refresher training will be done by 12.2.22 Effective immediately (11.18.22) direct care staff, Director of Residential and CEO will ensure Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. 12/02/2022 Not Implemented
6400.165(g)Individual #3 is prescribed medications to treat symptoms of a psychiatric illness. Review of these medications by a licensed physician were not completed at least 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.Director of residential and CEO are currently working with individuals psychiatrist and PCP to schedule the next year of reviews this will be done by 12.2.22. 12/02/2022 Not Implemented
6400.166(b)Individual #3 is prescribed Oxcarbazepine 300mg tab, Take one tablet by mouth at bedtime. This medication is included in the blister packs of medication; however, it is not documented on the Medication Administration Record (MAR). Individual #3 is prescribed Loratadine10mg tab, take 1 tablet, (10mg total) by mouth daily, and Fluticasone Propiona 50mcg, two sprays into each nostril daily. Ibuprofen 400mg, take one tablet by mouth every 6 hours as needed for mild pain, this medication was administered on 10/18/22 in the presence of inspectors. Individual #3 is prescribed Haldol by injection monthly. This medication was not listed on Individual #3's medication administration record. These medications are not documented on the documented on the MAR. Missing information includes the Individual's name, the name of the prescriber, drug allergies, the name of medication, strength of medication, dosage form, dose of medication, route of medication, frequency of administration, administration times, diagnosis or purpose for the medication, including pro re nata, date and time of medication administration, name and initials of the person administering the medication, duration of treatment, if applicable, special instructions if applicable and side effects of the medication, if applicable.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Between the dates of 10.27.22 and 11.4.22 CEO and Director of residential updated the MARs and medications to reflect appropriate times. Staff have also had a brief unofficial medication overview. An official refresher training will be done by 12.2.22 12/02/2022 Implemented
6400.167(a)(1)Individual #3 is prescribed Trazadone HCL 150mg tab, Take two tablets by mouth at bedtime. This medication was not administered as prescribed on October 12, 2022. The medication. The Medication Administration Record (MAR) indicated that the medication had been discontinued. Documentation on the back of the MAR indicated that the medication had not been discontinued and the pharmacy had not delivered the medication resulting in the medication not being administered. Individual #3 is prescribed Fluticasone Propiona 50mcg, two sprays into each nostril daily. The bottle available in the home is ¾ full and was last filled on 6/8/22. There are 120 metered sprays in the bottle and based on the prescribed dosage, the medication would need to be refilled monthly. The medication is not documented on the Medication Administration Record and there is no record that the medication is being administered as prescribed. Staff reported that the medication may have been discontinued, there is no documentation of a discontinuation order. Individual #3 is prescribed Loratadine10mg tab, take 1 tablet, (10mg total) by mouth daily. This medication was last filled on 6/8/22 with 30 tablets and there were 15 tablets remaining in the bottle. Based on the number of tablets dispensed on 6/8/22, the medication would need to be refilled monthly. The medication is not documented on the Medication Administration Record and there is no record that the medication is being administered as prescribed. Staff reported that the medication was as needed and also may have been discontinued, there is no documentation of a discontinuation order.Medication errors include the following: Failure to administer a medication.Between the dates of 10.27.22 and 11.4.22 CEO and Director of residential updated the MARs and medications to reflect appropriate dosage, times and medication. Staff have also had a brief unofficial medication overview. An official refresher training will be done by 12.2.22 12/02/2022 Implemented
6400.167(a)(4)Individual #3 is prescribed Propanol Hydrochl 20mg tab, take one tablet by mouth twice day. This medication was documented on the Medication Administration Record (MAR) as administered at 8AM and 8PM until 10/11/22. Beginning on 10/12/22, the medication was being administered at 8AM and 4PM. Staff in the home indicated that the individual had an appointment on 10/8/22 and the physician changed the administration times at the time of the appointment. There was no documentation to support a change in the time that the medication is being administered and there is a failure to administer the medication at the prescribed time.Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time.Between the dates of 10.27.22 and 11.4.22 CEO and Director of residential updated the MARs and medications to reflect appropriate times. Staff have also had a brief unofficial medication overview. An official refresher training will be done by 12.2.22 12/02/2022 Implemented
6400.167(b)Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, is not kept in the individual's record. Individual #3 is prescribed Trazadone HCL 150mg tab, Take two tablets by mouth at bedtime. This medication was not administered as prescribed on October 12, 2022. The medication. The Medication Administration Record (MAR) indicated that the medication had been discontinued. Documentation on the back of the MAR indicated that the medication had not been discontinued and the pharmacy had not delivered the medication resulting in the medication not being administered. Individual #3 is prescribed Fluticasone Propiona 50mcg, two sprays into each nostril daily. The bottle available in the home is ¾ full and was last filled on 6/8/22. There are 120 metered sprays in the bottle and based on the prescribed dosage, the medication would need to be refilled monthly. The medication is not documented on the Medication Administration Record and there is no record that the medication is being administered as prescribed. Staff reported that the medication may have been discontinued, there is no documentation of a discontinuation order. Individual #3 is prescribed Loratadine10mg tab, take 1 tablet, (10mg total) by mouth daily. This medication was last filled on 6/8/22 with 30 tablets and there were 15 tablets remaining in the bottle. Based on the number of tablets dispensed on 6/8/22, the medication would need to be refilled monthly. The medication is not documented on the Medication Administration Record and there is no record that the medication is being administered as prescribed. Staff reported that the medication was as needed and also may have been discontinued, there is no documentation of a discontinuation order. Individual #3 is prescribed Propanol Hydrochl 20mg tab, take one tablet by mouth twice day. This medication was documented on the Medication Administration Record (MAR) as administered at 8AM and 8PM until 10/11/22. Beginning on 10/12/22, the medication was being administered at 8AM and 4PM. Staff in the home indicated that the individual had an appointment on 10/8/22 and the physician changed the administration times at the time of the appointment. There was no documentation to support a change in the time that the medication is being administered and the medication is not being administered as prescribed.Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record.Between the dates of 10.27.22 and 11.4.22 CEO and Director of residential updated the MARs and medications to reflect appropriate times. Staff have also had a brief unofficial medication overview. An official refresher training will be done by 12.2.22 Effective immediately (11.18.22) direct care staff, Director of Residential and CEO will ensure Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. 12/02/2022 Implemented
6400.167(c)Medication errors including Individual #3 not receiving Trazadone HCL 150mg tab, 2 tablets at bedtime on 10/12/22, and Individual #3 receiving Propanol Hydrochl 20mg tab, (take one tablet by mouth twice day) at 4PM instead of 8PM as documented on the Medication Administration Record, are not being reported as incidents as specified in §6400.18(b) (relating to incident report and investigation).A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation).Between the dates of 10.27.22 and 11.4.22 CEO and Director of residential updated the MARs and medications to reflect appropriate times. Staff have also had a brief unofficial medication overview. An official refresher medication training and ncident management training will be done by 12.2.22 Effective immediately (11.18.22) direct care staff, Director of Residential and CEO will ensure Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. 12/02/2022 Not Implemented
6400.186Individual #3's Individual Service Plan (ISP) is not being implemented. Individual #3's ISP dated 9/4/22 states "he is not safe handling poisons. He is not safe handling poisons as he does not understand the dangers of poisons if used improperly. Poisons need to be locked." All poisons are easily accessible and not locked in Individual #3's home. Individual #3's ISP indicates that the individual requires 3:1 staffing. There were four people working in the home with the individual, only two were identified as staff through Supreme Nursing Care. The other people working in the home were identified as "security guards" and not employed through Supreme Nursing Care and are not counted in staffing ratios.The home shall implement the individual plan, including revisions.All current staff working with individual will review ISP and sign off on its understanding. Per Corporate Protective Services, LLC security team are not part of Supreme Care staff, they are a contracted service provider for LCOCYS. They should not be included in an ISP or considered part of Supreme care staff ratio of 2:1 staffing. Security Staff are not at anytime to be in the role of a caregiver. They are there to provide support and protection if needed. 11/30/2022 Not Implemented
6400.196(a)Individual #3 has a behavior support plan in place. Staff working in Individual #3's home implement and manage a behavior support component of Individual #3's individual plan. Staff working in Individual #3's home are not trained in the use of the specific techniques or procedures that are used.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.Residential Director is working with behavior services to get supreme staff trained in accordance to current behavior by 12.2,22. 12/02/2022 Not Implemented