Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00226756 Renewal 06/29/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)On 6/28/2023, the bedroom to the right of the staff office had a ceiling light which had insects and debris on the inside of the glass light fixture. The closet to the right of the basement bathroom had spiders hanging from the ceiling and dead insects and debris on the floor.Clean and sanitary conditions shall be maintained in the home. During the inspection on 6/28/23 insects were present in the light fixture on the ceiling of the bedroom with furniture. Staff cleared the fixture of all dust and debris on 6/29/23. 06/29/2023 Implemented
6400.66On 6/28/2023, there was no lighting outside the back of the home (Repeated Violation-10/03/2022).Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. On 6/28/23 the light fixture on the patio did not have a bulb in it. Staff replaced the light bulb on 6/28/23. The CEO has developed a policy for employees to inform staff of the procedure to be followed to ensure light fixtures have bulbs and are functional at all times. 07/05/2023 Implemented
6400.67(a)On 6/28/2023, in the basement behind the furnace, there were two rectangular holes in the concrete where bricks had once been, exposing the inside of the wall, debris, and insulation (Repeated Violation-10/03/2022).Floors, walls, ceilings and other surfaces shall be in good repair. On 6/28/23 in the basement next to the furnace there were three rectangular holes in the concrete where bricks were. On 7/5/23 the concrete was replaced with bricks filling in the holes. 07/05/2023 Implemented
6400.73(a)On 6/28/2023, the railing leading from the staff office to the attic, was not well-secured and could be bent when pressure was applied to it. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. On 6/28/23 the hand rail leading to the attic from the staff office needed to be tightened to ensure the safety of who access it. The staff has completed the necessary repair to the hand rail and tested the sturdiness to ensure it is safe when in use. The CEO developed a policy that outlines the process to check the hand rail to the attic and ensure it is good repair. If repairs needs to be done staff will notify supervisory staff supervisory staff will ensure repairs are completed within 72 hours of discovery. 07/05/2023 Implemented
6400.74On 6/28/2023, the stairs descending to the basement and the stairs ascending to the attic did not have a nonskid surface.Interior stairs and outside steps shall have a nonskid surface. On 6/28/23 there was no skid surface on the basement stairs or the stairs leading to the attic. There was non-skid surface on the previous set of stairs that leads to the basement are new with the updates of the home. Non-skid surface has been applied to the basement stairs to ensure the safety of individuals and staff when using the stairs. The CEO has developed a policy regarding interior and exterior steps of the home. 07/05/2023 Implemented
6400.82(e)On 6/28/2023, the full bathroom in the basement did not have a nonslip surface or mat in the shower. Bathtubs and showers shall have a nonslip surface or mat. The basement bathroom was installed in the home during recent renovations that took place and will be used as a staff bathroom. The main bathroom is equipped with the necessary items that ensures individuals have basic hygiene items for safety and comfort. Cloth towels and a waste basket has been placed in the basement bathroom as well as a non-skid mat into the shower. The CEO has developed a policy that ensures that individuals are able to maintain their hygiene needs. 07/05/2023 Implemented
6400.82(f)On 6/28/2023, the full bathroom in the basement did not have paper or cloth towels and a trash receptacle (Repeated Violation-4/17/2023).Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. The basement bathroom was installed in the home during recent renovations that took place and will be used as a staff bathroom. The main bathroom is equipped with the necessary items that ensures individuals have basic hygiene items for safety and comfort. Cloth towels and a waste basket has been placed in the basement bathroom as well as a non-skid mat into the shower. The CEO has developed a policy that ensures that individuals are able to maintain their hygiene needs. 07/05/2023 Implemented
6400.101On 6/28/2023, the sliding glass door leading from the dining room to the back of the home contained a 2x4 piece of wood in the track of the door on the left side, preventing someone from being able to get outside.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. On 6/28/23 the 2x4 piece of wood that was on the track of the patio doors was removed. Staff discarded the wood to ensure it would not obstruct any doorway or exits. The CEO developed a policy to discard any objects that could pose a threat to someone not being able to get outside. 07/05/2023 Implemented
6400.103The emergency evacuation procedure, last updated 9/27/2022, did not include means of transportation and an emergency shelter location.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. Brite Light's CEO has revised the emergency evacuation procedure to include means of transportation and a designated shelter location in the event of an emergency. 07/05/2023 Implemented
6400.145(1)The emergency medical plan does not include the hospital or source of health care that will be used in an emergency..The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. Brite Light's CEO has revised the emergency medical plan to include the specific hospital to transport individuals to in case of an emergency instead of a general direction of nearest hospital. 07/05/2023 Implemented
6400.151(a)Program Specialist #1 had a physical examination completed 1/22/2021 and not again since. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. The program specialist had a physical that was conducted on 7/7/23. The physical examination has been filed in the employees personnel file. 07/07/2023 Implemented
6400.46(a)Program Specialist #1 was trained in fire safety 9/15/2021 and then again 6/27/2023.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.The program specialist was trained on 6/27/23 in fire safety through a video that was conducted by a fire safety expert. The training certificate was placed in his personnel file and training record was updated. 06/27/2023 Implemented
6400.52(c)(3)Program Specialist #1 was not trained in individual rights, during the training year from 7/01/2021 thru 6/30/2022.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.The program specialist was trained on individual rights on 7/9/23. The training certificate was placed in his personnel file and training record was updated. 07/09/2023 Implemented
SIN-00223552 Unannounced Monitoring 04/17/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)On 4/17/2023, the water temperature measured 137.4°F at 10:25am at the kitchen sink, and it measured 129.9°F at 10:15am at the bathtub on the first-floor of the home. Hot water temperatures in bathtubs and showers may not exceed 120°F. On Saturday April 15, a new hot water heater was installed in the home. On Monday April 17th, the water temperature was turned down immediately. The water temperature was tested four times to ensure it did not exceed 120 degree Fahrenheit. The other water sources were checked to ensure that they did not exceed 120 degree Fahrenheit and they did not. 04/17/2023 Implemented
6400.76(d)On 4/17/2023, the living room did not have any furniture to seat the individuals. In homes serving eight or fewer individuals, there shall be a sufficient amount of living and family room furniture to seat all individuals at the same time. The furniture in the living area was thrown out and will be replaced with new furniture after the agency relocates and prior to the admission of any individuals. 08/01/2023 Implemented
6400.82(f)On 4/17/2023, the first-floor bathroom did not have soap, toilet paper, and paper or cloth towels.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. On April 17, hand soap, toilet paper, and paper towels were restocked into the bathroom. Staff will ensure that the bathroom is stocked with these essentials to promote clean and safe practices by staff and the individuals served. 04/17/2023 Implemented
6400.110(a)On 4/17/2023, all smoke detectors tested inoperable at 10:29am, it was unable to be determined if the smoke detectors were interconnected due to them being inoperable. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. On 4/17/23 an interconnected smoke alarm system was replaced in the basement, and the battery of the smoke alarm was changed in the hallway of the first floor. All three alarms were tested and are now interconnected. The smoke alarms were tested two times to ensure they were working properly and in sync with one another. 04/17/2023 Implemented
SIN-00212341 Unannounced Monitoring 10/03/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66During the inspection conducted 10/03/2022 there was no operable lighting on the basement interior stairway and the light at the bottom of the basement steps was inoperable.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The light that is provided for the basement has been replaced. There was an issue with the circular light bulb that was purchased. The agency contacted an electrician, and they came out on 10/8/20222 to inspect the light fixture and discovered that the issue was that the bulb that was purchased was incorrect. 10/08/2022 the Director replaced the circular light, and it is now operable and provides lighting for the basement staircase. 10/08/2022 Implemented
6400.67(a)During the inspection conducted 10/03/2022, in the basement behind the furnace, there were two rectangular holes in the concrete where bricks had once been, exposing the inside of the wall, debris, and insulation. There were two ceiling panels on the basement ceiling that were lifted and not in place, exposing wood and the interior of the ceiling.Floors, walls, ceilings and other surfaces shall be in good repair. The ceiling panels were immediately readjusted on 10/3/2022 to their original position and to avoid exposing the interior of the ceiling. The two spots next to the furnace were also cleaned of debris and insulation immediately on 10/3/2022 to prepare for a masonry to replace the bricks in that space. The Director was able to schedule an appointment to have the space filled in with bricks and the appointment is scheduled to take place on November 29th, 2022. 11/29/2022 Implemented
6400.67(b)During the inspection conducted 10/03/2022 the basement window facing the back of the home had a drill bit laying on the window sill. Floors, walls, ceilings and other surfaces shall be free of hazards.On 10/3/2022 the drill bit was removed from the window seal and disposed of. The RA and Director did a walk-through of the facility to ensure there was no other hazardous material exposed throughout the facility. 10/03/2022 Implemented
6400.72(b)During the inspection conducted 10/03/2022 the window in the basement on the left side of the home had a large horizontal crack the length of the window. There was a cardboard rectangle in front of the broken window from the basement. The window in the basement, facing the back of the home, contained multiple cracks in the glass. Screens, windows and doors shall be in good repair. On 10/3/2022 the Director removed the cardboard from the window to the left side of the facility and replaced it with a piece of plywood. Plywood was also placed in the window located to the back of the facility. On 10/3/2022 a window specialist was contacted to come out and repair or replace the windows. An appointment is scheduled for the first week of December. 10/03/2022 Implemented
6400.163(h)During the inspection conducted 10/03/2022 the first aid kit was located unlocked in the hall closet and contained Non-Aspirin Acetaminophen 325mg tablet which expired in July 2022.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.On 10/4/2022 the RA and Director disposed of the expired medication and removed all remaining medication packets from the first aid kit to avoid a similar issues from occurring in the future. 10/03/2022 Implemented
SIN-00203254 Unannounced Monitoring 04/08/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)During the inspection on 4/08/2022 the water temperature measured 124.7°F at the kitchen sink at 12:19pm.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. On 4/8/22 the hot water heater was turned down. The water temperature in the sink was tested by the residential administrator three times and the temp was below 120 degrees fahrenheit each reading. All other faucets were tested and did not exceed 120 degrees fahrenheit. 04/08/2022 Not Implemented
6400.141(a)Individual #1, date of admission 3/11/2022, had an initial physical examination completed 3/29/2022.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The CEO reviewed the individual's physical form with the Residential Administrator on 4/10/2022, and discussed that all factors included must be addressed and/or completed prior to admission. The agency's Residential Administrator will conduct a thorough review of all individual's physical exams prior to admission of any individuals 04/10/2022 Not Implemented
6400.141(c)(1)Individual #1's physical examination completed 3/29/2022 did not include: A review of previous medical history.The physical examination shall include: A review of previous medical history. The CEO reviewed the individual's physical form with the Residential Administrator on 4/10/2022, and discussed that all factors included must be addressed and/or completed prior to admission. The agency's Residential Administrator will conduct a thorough review of all individual's physical exams prior to admission of any individuals to ensure that all medical information has been addressed and completed. 04/10/2022 Not Implemented
6400.141(c)(3)Individual #1's physical examination completed 3/29/2022 did not include: Immunizations. [Repeat violation 2/4/21 et al]The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. On 4/10/2022 the CEO reviewed the individual's physical exam form and discussed that all factors included on the form must be addressed and/or completed prior to admission. The agency's RA will conduct a thorough review of all individual's physical exams prior to admission of any individuals. Immunizations records for individual #1 has been retrieved and stored with her medical records. 04/10/2022 Not Implemented
6400.141(c)(6)Individual #1, date of admission 3/11/2022, had a tuberculin skin test by Mantoux method read 3/31/2022. [Repeat violation 2/4/21 et al]The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. On 4/20/2022 the Residential Administrator created a pre-admission checklist to ensure that a tuberculin skin test is administered and read prior to admission. The RA will audit and track documentation for all individuals moving into the home. Documentation of all trainings and audits will be kept. 04/20/2022 Not Implemented
6400.141(c)(11)Individual #1's physical examination completed 3/29/2022 did not include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The CEO reviewed the individual's physical form with the Residential Administrator on 4/10/2022,and discussed that all factors included must be addressed and/or completed prior to admission. The agency's Residential Administrator will conduct a thorough review of all individual's physical exams prior to admission of any individuals to ensure that all medical information has been addressed and completed. 04/10/2022 Not Implemented
6400.141(c)(14)Individual #1's physical examination completed 3/29/2022 did not include: Medical information pertinent to diagnosis and treatment in case of an emergency. It was left blank. [Repeat violation 2/4/21 et al]The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The CEO reviewed the individual's physical form with the Residential Administrator on 4/10/2022,and discussed that all factors included must be addressed and/or completed prior to admission. The agency's Residential Administrator will conduct a thorough review of all individual's physical exams prior to admission of any individuals to ensure that all medical information has been addressed and completed. 04/10/2022 Not Implemented
6400.166(b)Individual #1 was prescribed Ziprasidone 20mg capsule, which was discontinued on 3/05/2022. During the inspection on 4/08/2022, Individual #1's April 2022 medication administration record documented 8am administrations on 4/05/2022, 4/06/2022, and 4/07/2022;Individual #1's April 2022 medication administration record documented 8pm administrations on 4/06/2022 and 4/07/2022. There was no Ziprasidone in the home at the time of the inspection. Individual #1 is prescribed Chlorhexidine Gluconate Oral Rinse 0.12%, use ½ capful 2 times daily to prevent mouth infections. The 8pm administration on 4/01/2022 was not initialed as administered.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.On 4/19/2022 staff were retrained by the RA on the process to discontinue medications, and documenting when medications are administered or refused. Staff will be trained annually thereafter. Staff training records has been updated and will be monitored quarterly by the agency's Director of Operations to ensure trainings are completed and up to date. 04/19/2022 Not Implemented
SIN-00201690 Renewal 03/08/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.52(c)(1)Direct Service Professional #1, date of hire 10/31/2019, has no record of having been trained in the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. Program Specialist #2, date of hire 10/31/2019, has no record of having been trained in the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. Section 3aiii from the settlement agreement entered into on 9/29/2021 indicates that all current staff under the agencies employ shall receive annual training on the topics listed in paragraph 3aii. Sections 3aii indicates that the agency will create a training plan including but not limited to the requirements listed in 55 Pa code 6400.51 and 6400.52.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Direct service workers #1 and #2 completed the needed training the application of Person-Centered Practices, community integration, individual choice, and supporting individuals to develop and maintain relationships on Wednesday March 9th, 2022. The Residential Administrator updated staff training records to reflect the training, and training have been added to the electronic calendar system to ensure trainings will be updated in a timely matter and remain current. Residential administrator will monitor staff records quarterly will ensure records are completed and up to date. 03/09/2022 Not Implemented
SIN-00196720 Unannounced Monitoring 11/15/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)During the inspection on 11/15/2021, piles of dirt, cardboard, plastic, bricks, and other miscellaneous items were identified on the floor in the garage.Clean and sanitary conditions shall be maintained in the home. On 11/15/2021 the Director of the facility cleared the garage floor of all materials and debris that occupied the space. The Director and Residential Administrator has implemented a plan/policy that requires all work spaces be cleaned daily to ensure they are free from materials and debris. The Director has trained all current staff on the plan/policy on 12/1/2021 and all future staff will be trained on the plan as well. Training of the policy will be conducted annually thereafter. 12/01/2021 Implemented
6400.67(b)During the inspection on 11/15/2021, there were nails sticking out at the top of the wall, to the left of the garage entrance. The thin plywood wall to the right of the basement staircase, descending down the stairs, was not secure and was protruding out onto the stairs causing a tripping hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.On 11/15/2021 the Director removed the nails that were sticking out at the top of the wall to the left of the garage entrance. The director also removed the thin panel and repaired the remaining panel that is located to the right of the basement staircase. The Director and Residential Administrator has implemented a plan/policy to help staff to identify and report hazardous conditions of the site. The Director has trained all current staff and all future staff will be trained. Trainings will be conducted annually thereafter. 12/01/2021 Implemented
6400.107During the inspection on 11/15/2021, a Frocom Magnum portable heater was identified in the basement, under the staircase.Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms. On 11/15/2021 the facility director removed the frocom portable heater from the site 18 forest hills rd. One 11/1/2021 the Director trained current staff on section 107 of the regulatory compliance guide pertaining to the health and safety of individuals and staff with portable heating devices and why they are not allowed in the facility for any reason. All future staff will be trained on the regulation as well. The training will be conducted annually for current staff and all future staff. 12/01/2021 Implemented
SIN-00187308 Unannounced Monitoring 05/05/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)On 5/5/2021 at 11:50AM the temperature of the water in the Kitchen sink measured 125°F.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. Immediately the hot water heater was turned down. The water in the kitchen was tested two times to ensure it did not exceed 120 degrees F. The water in the bathtub was tested again and did not exceed 120 degrees F. A new thermometer was purchased 5/5/21 to obtain a more accurate read of water temperatures. Direct service workers received a demonstration from the director that included how to use the new thermometer and record temps. Staff will continue to test the kitchen sink water and the bathtub water weekly to make sure water temps are safe and does not exceed 120 degrees F. 05/05/2021 Implemented
6400.151(c)(2)The Tuberculin skin test completed 3/18/2021 for Chief Executive Officer #1 was read by a Certified Clinical Medical Assistant. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. On 5/5/21 The residential administrator updated the agency¿s physical examination form to include that Tuberculin skin test can read and signed by MD, PA,PA-C, NP, or a Nurse. The CEO or designee will inform new hires/staff that the tuberculin skin test are only be read by the medical professionals listed within this plan for correction. 05/05/2021 Implemented
6400.50(a)The record of training for Chief Executive Officer #1, Direct Service Worker #2, Direct Service Worker #3, and Direct Service Worker #4 did not include the training source and copies of certificates received.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.The source of the trainings was sent to Ms. Melanie Clark the inspector that was conducting the unscheduled inspection on 5/5/21. Training certificates along with policies and procedures that staff were trained on and the name of videos used as trainings were included in the information emailed on 5/5/21. On 5/5/21 the agency¿s residential administrator updated employee training records to include the source of the training that is completed. The agency¿s residential administrator will also be included on the training sign in sheet for employees. The staff records and training sign in sheets will continue to be audited quarterly by the CEO or designee to ensure all information regarding the training is present and complete. 05/05/2021 Implemented
SIN-00182667 Renewal 02/04/2021 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34The Department requested documentation of the Certified Investigation for three abuse incidents, (ID#: 8779812, ID#: 8779852, and ID#: 8785489) on 2/4/2021 and 2/5/2021. The requested documentation was not provided to the Department.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.Certified investigations for three incidents for abuse were scanned in and emailed to the department for review at the department's request. All agency records, staff, individuals, and facility are available during announced and unannounced inspections. The agency will resend the department the certified investigation reports for incident numbers 8779812, 8779852, and 8785489 and will request a receipt that it was received to ensure that they are delivered. The agency will also request receipts of receiving information for future request to ensure the documentation is received in a timely fashion All agency staff will have access to requested information as needed by the department for announced and unannounced visits to the site. The Residential Administrator will ensure all staff are aware and knowledgeable on where requested documents are located. [Immediately, the CEO shall develop policies and procedures for record retention and guidelines for providing requested documents to the department. The CEO shall train all staff responsible for record retention and those responsible for providing requested records to the department on the new policies and procedures. Documentation of all trainings shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 02/28/2021 Not Implemented
6400.16On 8/18/2020, Individual #1 requested ice water and was given a bottle of water by Direct Service Worker #4. After Individual #1 drank the water, Individual #1 went back to Direct Service Worker #4 and asked for an additional glass of water. Direct Service Worker #4, while on his cell phone, stated racial insults at Individual #1 and expletives within ear shot of Individual #1. Direct Service Worker #4 instructed Individual #1 to go to his room and go to bed. Individual #1 went to his room where the interaction evolved into a physical altercation. Individual #1 was transported and admitted to Western Psychiatric Hospital. On 12/10/2020, Individual #1 stated that Direct Service Worker #5 banged him to the wall of his bedroom and pressed his nose against the wall. On 12/10/2020, Individual #1 stated that Direct Service Worker #5 pushed him into his bed. On 12/17/2020, Direct Service Worker #1 held down Individual #1's arms and pulled him to the wall. Direct Service Worker #1 was not trained in Crisis Intervention, Safe-Physical Intervention, and De-Escalation Techniques as required by October 2020 behavior support plan for Individual #1. On 1/1/2021, an incident involving physical abuse occurred between Direct Service Worker #3 which resulted in Individual #1 having scratch marks on his chest. In addition, Direct Service Worker #3, twisted Individual #1's arm/hand and said, "it hurts, right, you better behave yourself so I don't have to keep doing this to you." Direct Service Worker #3 was not trained in Crisis Intervention, Safe-Physical Intervention, and De-Escalation Techniques as required by October 2020 behavior support plan for Individual #1. On 1/16/2021, Direct Service Worker #4 twisted Individual #1's arm and threw him on the bed. Individual #1 stated that Direct Service Worker #4 punched him in the arm 13 times, told him to "stop crying like a F-ing girl", and attempted to pull his arm back into place. Emergency assistance was not called. Direct Service Worker/Site Supervisor #6 took Individual #1 to the UPMC East emergency room where he was admitted on 1/16/2021 at 1:18 AM. Individual #1 was diagnosed with a broken arm. Direct Service Worker #4 is not trained in Crisis Intervention and Safe-Physical Intervention as required by October 2020 behavior support plan for Individual #1.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.During the time that supports were rendered to individual #1 there were false allegations reported against staff members by individual #1 and their family on several occasions. Individual #1 transitioned to a new provider on 2/24/21. DSW #4 and #6 are currently on a wait list for a train the trainer course for crisis intervention and safe physical intervention at WPIC and will be able to train all employees in the courses listed. DSW #1 completed de-escalation training on 12/30/20 and training records has been updated to reflect that the training was completed. DSW #2 was trained in de-escalation on 11/1/20. Training records has been updated to reflect the training was completed. Agency staff will contact police/ambulance to transport individuals if a suspected injury occurs to the nearest hospital UPMC East. Brite Light prohibits any acts of abuse. 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. The CEO/RA will be responsible for monitoring employee training records quarterly to ensure the records are completed and current. When a training is coming due the RA will notify the staff member and of the training needed and ensure it is recorded upon completion. [Immediately, the CEO or designee shall develop a plan to have all staff trained by an outside source on Crisis Intervention, Safe-Physical Intervention, and De-Escalation Techniques until the agency is able to secure an internal trainer. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 3/16/2021)] 03/02/2021 Not Implemented
6400.21(a)Direct Service Worker #2, date of hire 9/14/2020, had a criminal background check requested on 9/20/20. [Repeat Violation -- 10/21/2019]An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees 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.Direct service #2 actual date of hire was 9/27/20. His interview date was confused with date of hire. Brite Light Director will continue to request Pennsylvania criminal history records for potential employees who will have direct contact with individuals including part-time, and temporary staff within 5 working days after the persons date of hire.[Immediately, the CEO or designee shall develop a system for requesting and tracking criminal background checks to ensure that all staff have a criminal background check per the regulations of the chapter. Immediately and at least quarterly for one year, the CEO or designee shall audit all individuals records to ensure criminal background checks have been completed and are on file. (DPOC by RM, HSLS on 3/18/2021)] 02/28/2021 Not Implemented
6400.43(b)(3)The Chief Executive Officer #3 failed to ensure staff had trainings required by Individuals #1's behavior support plan. Individual #1 sustained a broken arm during an unauthorized use of restraint.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. The CEO #3 has developed a policy as of 2/27/21 to monitor and record the required staff trainings to ensure staff are properly trained when working with individuals to maintain the safety and protection of individuals at all times. The policy is effective and implemented as of 2/27/21. The CEO will monitor training records monthly to ensure employees trainings are recorded and up to date. When trainings are due to expire the CEO will notify the Director/Residential Administrator to ensure that the employee gets the needed training completed in a timely manner to continue the safety and protection of all individuals.[Immediately, the CEO or designee shall audit all staff records to ensure trainings are up to date per the regulations of the chapter. Documentation of all audits and trainings shall be kept (DPOC by RM, HSLS on 3/18/2021)] 02/27/2021 Not Implemented
6400.43(b)(4)The Chief Executive Officer #3 failed to ensure compliance with 55 Pa.Code Chapter 6400 by not ensuring that Direct Service Workers had timely physical examinations, Tuberculin tests, and the required trainings. The Chief Executive Officer #3 failed to ensure that Individual #1 had an assessment, had all the requirements of a physical examination, and that incidents were reported and filed within the required timeframes.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Compliance with this chapter. Individual #1 has transitioned to a new provider as of 2/24/21. The CEO is responsible for the administration and general management of the home including ensuring the compliance of Direct service workers having timely physical exams, tuberculin test, and required trainings. The CEO along with the Director will be responsible for reviewing medical records prior to admission for future admissions. If needed information is not present the CEO or Director will gather the needed information prior to an individual admission. The CEO/PS will be responsible for ensuring all individuals receives assessments within the required time frame of 60 days after admission if one has not been done within the prior 12 months. The CEO/PS will be responsible for completing an assessment for individuals annually thereafter.[Immediately, the CEO or designated management staff shall develop a system to track direct service workers physical examinations, Tuberculin tests, and required training. Immediately, the CEO or designated management staff shall develop a system to track Individuals assessments and physical examinations with all requirements. At least quarterly for one year, the CEO or designee shall audit all individual and staff records to ensure all requirements by the chapter are up to date and present in the records. (DPOC by RM, HSLS on 3/18/2021)] 03/01/2021 Not Implemented
6400.68(b)During the remote inspection of the home on 2/5/2020 there was no thermometer available to measure hot water temperature, therefore compliance could not be measured. Hot water temperatures in bathtubs and showers may not exceed 120°F. A thermometer was purchased on 2/5/21 and the bathtub temperature was measured and did not exceed 120 degrees Fahrenheit. The thermometer will be kept in the kitchen and staff are aware of where to find it when the temperature is checked weekly. The staff will let the site supervisor know if there is an issue with the thermometer and if it needs to be replaced. It will be replaced within 24 hours of discovery of an issue. If the temperature exceeds 120 degrees it will be adjusted accordingly to ensure the temperature is safe for individuals to use.[Immediately, The CEO or designee shall train all staff the requirement for checking water temperatures and for reporting hot water temperatures. At least quarterly for one year, the CEO or designee shall audit all weekly water temperatures. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 02/05/2021 Not Implemented
6400.77(c)On 2/5/2020 there was not a first aid manual with the first aid kit. A first aid manual shall be kept with the first aid kit.The first aid manual was not replaced after being used. It was replaced on 2/5/21. It has been noted to staff that when the manual is used to replace with the first aid kit for reference of the contents inside. If the manual becomes damaged or misplaced staff will report it to the site supervisor immediately so that the manual can be replaced within 24 hours of discovery.[The CEO or designee shall develop a system for staff to inventory the contents of the first aid kit to ensure all required materials are present. At least quarterly, the CEO or designee shall audit the inventories. Documentation of all audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 02/05/2021 Not Implemented
6400.82(e)On 2/5/2020 the bathtub in the bathroom, located on the ground floor to the right of the L shaped hallway, did not have a nonslip surface or mat. Bathtubs and showers shall have a nonslip surface or mat. On 2/5/21 a non-slip mat was placed in the bathroom located on the ground floor. If for any reason the non-slip mat is damaged or wore out it will be replaced within 24 hours of discovery. Staff will notify site supervisor when the non-slip mat is damaged or wore out so that it can be replaced in a timely manner.[Immediately, the CEO or designee shall develop policies and procedures and train staff on inspecting the home and reporting any areas of disrepair. At least quarterly for one year, the CEO or designee shall inspect the home for areas of disrepair. Documentation of all audits and trainings shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 02/05/2021 Not Implemented
6400.112(c)The written fire drill records for the fire drills completed between August 2020 and January 2021 did not include the time of day and whether the fire alarm or smoke detector was operative.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. A new fire drill record was formatted on 2/5/21 by the Director to comply with the standards of the department and to record the date, time, amount of time it takes to evacuate, the exit route used, problems encountered (if any), and whether the smoke detector is operable. The fire drill record will be used in future monthly fire drills to ensure the safety and effectiveness of fire safety.[The new fire drill form was viewed by the department on 3/5/2021. Immediately, all staff shall be trained on the new fire drill form and the requirements per the chapter. At least monthly for one year then continuing quarterly, the CEO or designee shall audit all fire drill records to ensure they are complete and complaint. (DPOC by RM, HSLS on 3/18/2021)] 02/05/2021 Not Implemented
6400.141(c)(3)Individual #1's physical examination, completed 6/28/20, does not address immunizations.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. When an individual is placed within our agency the Director will be responsible to review that the required components are included with any previous examinations that occurred. If/when the required components are not present the Director will ensure that the individual gets a physical exam that is thorough and includes all needed information to maintain compliance.[The CEO or designated management staff shall develop a process to audit and track all admission documentation for all individual moving into the home to ensure they meet the requirements of the chapter. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 02/27/2021 Not Implemented
6400.141(c)(6)Individual #1, date of admission 8/17/2020, has not had a Tuberculin skin test.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Individual #1 had a tuberculin skin test on 08/10/20 as requested by the agency Brite Light Residential on 08/06/20. However records were not kept to reflect the test that was completed. The Director will review individuals medical records upon admission to ensure the required test are complete and in compliance with the department. The individual medical records will be kept in the individuals file and reviewed annually/as needed by the Director to keep track of compliance needs. If test is coming due the Director will make the appropriate appointments to have the tuberculin skin test done and ensure compliance.[The CEO or designated management staff shall develop a process to audit and track all admission documentation for all individual moving into the home to ensure they meet the requirements of the chapter. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 02/27/2021 Not Implemented
6400.141(c)(10)Individual #1's physical examination, completed 6/28/20, does not address communicable disease.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. Brite Light's Director will review all individual's medical records to ensure that the required information regarding communicable diseases are present and correct. In the event an individual has any communicable diseases the individual will be separated from other individuals during the course of infection to prevent the spread. Staff members will disinfected common areas as the infected individual uses them and the entire site will be disinfected daily to help prevent the spread to other individuals and staff members until the individual is free of any communicable disease. Staff members will be responsible for transporting individuals to a PCP to be tested and a new record stating they are free from any communicable diseases will be kept.[The CEO or designated management staff shall develop a process to audit and track all admission documentation for all individual moving into the home to ensure they meet the requirements of the chapter. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 02/28/2021 Not Implemented
6400.141(c)(12)Individual #1's physical examination, completed 6/28/20, does not address physical limitations.The physical examination shall include: Physical limitations of the individual. Individual #1 did not have any physical limitations. Brite Light's Director will review all medical records prior to admission into the agency to ensure that physical limitations if any are clear and present within the physical exam. If they are not present the Director will see that an appointment is scheduled with the PCP to address limitations if any and make sure they are properly documented. If any limitations arise then the Director will ensure they are documented accordingly. The Director will monitor individual physical exams annually to ensure physical limitations are updated and current.[The CEO or designated management staff shall develop a process to audit and track all admission documentation for all individual moving into the home to ensure they meet the requirements of the chapter. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 02/27/2021 Not Implemented
6400.141(c)(13)Individual #1's physical examination, completed 6/28/20, does not address allergies.The physical examination shall include: Allergies or contraindicated medications.Individual's physical exam was conducted prior to the admission into Brite Light. Brite Light's Director will be responsible to ensure a thorough and complete physical exam documentation including the knowledge of allergies or any medications that are contraindicated for the individual are acquired prior to the admission of an individual. Also it will be the responsibility of the Director to ensure that the physical exam is updated as needed and all required information is present. The Director will monitor individuals records annually to ensure all information is updated as needed.[The CEO or designated management staff shall develop a process to audit and track all admission documentation for all individual moving into the home to ensure they meet the requirements of the chapter. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 02/28/2021 Not Implemented
6400.141(c)(14)Individual #1's physical examination, completed 6/28/20, does not address information pertinent to diagnosis in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Individual's physical exam was conducted prior to the admission into Brite Light. Individual #1 transitioned to a new provider on 2/24/21. Brite Light's Director will be responsible to ensure a thorough and complete physical exam document for the individual are acquired prior to the admission of an individual. The physical exam will include medical information that is needed for the diagnosis and treatment in case of an emergency. It will be the responsibility of the Director to ensure that the physical exam is updated as needed and all required information is present. The Director will monitor the physical exam document annually to ensure the information is updated as needed to ensure compliance is maintained.[The CEO or designated management staff shall develop a process to audit and track all admission documentation for all individual moving into the home to ensure they meet the requirements of the chapter. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 02/28/2021 Not Implemented
6400.151(a)Direct Service Worker #1, date of hire 8/14/2020, had an initial physical examination on 8/30/2020. Direct Service Worker #2, date of hire 9/14/2020, had an initial physical examination on 9/24/2020. Program Specialist #3, date of hire 8/1/2018, has not had a physical examination. Direct Service Worker #4, date of hire 8/1/2018, has not had a physical examination. [Repeat Violation - 10/21/2019] A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Brite light will ensure all employees will receive the proper health documents prior to having direct contact with individuals whom they will serve. To prevent further violations the director will be in charge of keeping current tuberculin skin test, and all physicals of employees will be monitored checked every six months to ensure compliance is maintained.[Immediately, the CEO shall coordinate obtaining a current physical examination for staff. Immediately and at least quarterly for one year, the CEO or designee will audit all staff records to ensure staff have current physical examinations. Immediately, the CEO or Designated management staff will develop a tracking system to ensure staff physical examinations are completed once every 2 years. Documentation of all audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 03/02/2021 Not Implemented
6400.151(c)(2)Direct Service Worker #1, date of hire 8/14/2020, had an initial Tuberculin skin test completed 9/2/2020. Direct Service Worker #2, date of hire 9/14/2020, had an initial Tuberculin skin test completed 9/24/2020. Program Specialist #3, date of hire 8/1/2018, has not had a Tuberculin skin test. The Tuberculin skin test completed 11/1/2019 for Direct Service Worker #4 was read by a Certified Clinical Medical Assistant. [Repeat Violation - 10/21/2019) The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Program Specialist #3 will have a Tuberculin skin test by 03/26/2020. BL will ensure employees physical and Tuberculin records are recorded and current. The records will be monitored every 6 months by Director to ensure records are complete and current and to ensure compliance is being maintained.[Immediately, the CEO shall audit all staff records to ensure staff have a current Tuberculin skin test read by a qualified medical professional as outline by 6400.151c2. Immediately and at least quarterly for one year, the CEO or designee will audit all staff records to ensure staff have current Tuberculin skin test. Immediately, the CEO or Designated management staff will develop a tracking system to ensure staff Tuberculin skin tests are completed once every 2 years. Documentation of all audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 03/02/2021 Not Implemented
6400.181(a)Individual #1, date of admission 8/17/2020, does not have an assessment. 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 #1 has transitioned to a new provider as of 2/24/21. The RA will be responsible to verify if an assessment has been completed no later than 12 months prior to admission. If an assessment has not been done within 12 months the Program Specialist will ensure each individual has an initial assessment within 60 days after admission to the residential facility. The assessment will be updated annually thereafter. The assessment will include an assessment of adaptive behavior and level of skills completed.[Immediately, the CEO or designated management staff will develop a tracking system to ensure individual assessments are completed within 60 days of admission and annually thereafter. Documentation of all audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 03/01/2021 Not Implemented
6400.18(a)(4)The home reported the alleged abuse incident (ID#: 8785489) that occurred on 12/17/2020 into the Department's information management system on 12/23/2020. The home reported the alleged abuse incident (ID#: 8789459) that occurred on 1/1/2021 into the Department's information management system on 1/4/2021. The home reported the alleged verbal abuse incident (ID#: 8801506) that occurred on 1/16/2021 into the Department's information management system on 1/28/2021. The home reported the alleged physical abuse incident (ID#: 8801346) that occurred on 1/16/2021 into the Department's information management system on 1/28/2021.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Abuse, including abuse to a individual by another client. The incident 8730715 that occurred on 8/19/20 was entered into the EIM system on 8/21/20 because the point person did not have access to the EIM system, but an incident contingency form was faxed to the county's appropriate contacts where individual #1 is from. Incident 8785489 that occurred on 12/17/20 was reported by individual #1's father to his SCO. After speaking with the staff that was on shift and individual #1 it was discovered that there was no physical contact between the staff and Individual #1 regarding these allegations which is why it was not reported to the supervisory staff. The incident was entered after speaking with the SCO and her bringing awareness to the allegations. The agency then did an internal investigation along with a certified investigation. Incident 8789459 that occurred on 1/1/21 but was entered on 1/4/21 was not reported by the staff as they reported they were not aware of the scratch. Another staff started their shift they noticed the scratch as individual #1 was preparing for bed and the incident was reported at the time of discovery. The incident 8801506 that occurred on 1/16/21 but reported on 1/28/21 was not mentioned upon internal investigation. Individual #1 father made a report to APS and reported verbal abuse allegations. Upon receiving that information the report of verbal abuse was entered into he EIM system 1/28/21. Incident 8801356 that occurred on 1/16/21 was initially entered with the incorrect classification and required it be reclassified. After the agency received knowledge of the need for reclassification it was changed accordingly. The agency will report incidents and alleged incidents through the departments EIM system or on a form specified by the department within 24 hours of discovery by a staff person for incidents that included abuse including abuse to an individual by another individual. The staff will be aware to report incidents or suspected incidents to the site supervisor so they can be entered in a timely manner. Incidents will be entered within the approved time frame by the Residential Administrator and followed up accordingly and as needed.[Immediately, the CEO or designated management staff will train all staff on reporting requirements of the chapter. At least monthly for 6 months and then continuing at least quarterly, the CEO or designated management staff shall audit and analyze incidents to ensure all are reported, investigated, reviewed and analyzed as required as per 6400.18-6400.20. Upon completion of quarterly reviews training for any areas of noncompliance shall be completed as needed. Documentation of trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 03/01/2021 Not Implemented
6400.18(a)(13)The home reported the alleged rights violation incident (ID#: 8797753) that occurred on 1/16/2021 into the Department's information management system on 1/21/2021.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: A violation of individual rights.The incident 8797753 involving the allegations that occurred on 1/16/21 was entered on 1/21/21 was not reported to any Brite Light staff members. It was not reported to the agency resulting in it not being entered into the EIM system in a timely manner. The alleged rights violation was reported by individual #1's father and at that time an internal investigation was launched along with a certified investigation. The home will report alleged incidents and suspected incidents of violation of individuals rights through the Departments EIM system or on a form specified by the department within 24 hours of discovery by the agency's point person to ensure compliance is being maintained.[Immediately, the CEO or designated management staff will train all staff on reporting requirements of the chapter. At least monthly for 6 months and then continuing at least quarterly, the CEO or designated management staff shall audit and analyze incidents to ensure all are reported, investigated, reviewed and analyzed as required as per 6400.18-6400.20. Upon completion of quarterly reviews training for any areas of noncompliance shall be completed as needed. Documentation of trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 03/01/2021 Not Implemented
6400.18(c)The persons designated by Individual #1 were notified on 1/14/2021 of the alleged abuse incident, which occurred 1/1/2021.The individual and persons designated by the individual shall be notified within 24 hours of discovery of an incident relating to the individual.There was an error when completing the submission for an incident involving individual #1. The persons designated by the individual was notified upon discovery of the incident in question which was 1/4/21. Supervisory staff will continue to notify individuals and the persons designated by the individual within 24 hours of discovery of an incident relating to the individual.[Immediately, the CEO or designated management staff will train all staff on reporting requirements of the chapter. At least monthly for 6 months and then continuing at least quarterly, the CEO or designated management staff shall audit and analyze incidents to ensure all are reported, investigated, reviewed and analyzed as required as per 6400.18-6400.20. Upon completion of quarterly reviews training for any areas of noncompliance shall be completed as needed. Documentation of trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 03/01/2021 Not Implemented
6400.18(g)The home initiated an investigation of the abuse incident (ID#: 8730715), which occurred 8/19/2020, with the assignment of a certified investigator on 9/2/2020. The home initiated an investigation of the abuse incident (ID#: 8785489), which occurred 12/17/2020, with the assignment of a certified investigator on 12/23/2020. The home initiated an investigation of the abuse incident (ID#: 8789459), which occurred 1/1/2021, with the assignment of a certified investigator on 1/4/2021.The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person.The investigations including incident ID # 8730715 that occurred on 8/19/20 was assigned a certified investigator on 9/2/20 because the agency had to sub contract for the certified investigation service. The agency that was able to assist with the certified investigation was not contracted until the 9/2/20 resulting in the certified investigator being assigned after the 24 hour time frame. The incident ID # 8785489 that occurred on 12/17/20 had a certified investigator assigned within the 24 hour time frame that it was discovered by the agency. The incident ID # 8789459 that occurred on 1/1/21 had a certified investigator assigned on 1/4/21 because of the time of discovery. The incident was not discovered until 1/3/21 and after an internal investigation it was founded that a report will be submitted and a certified investigation would be launched. The home will continue to initiate investigations of incidents, alleged incidents, or suspected incidents within 24 hours of discovery by a staff person. The agency's point person will be retrained on incident management by 3/15/21 and will be responsible for entering incidents within the approved time frame. The Director will verify that the training is completed within the given time frame and monitor ongoing training requirements annually. The Director will inform the point person of the need to update the training to avoid being out of compliance with the department.[At least monthly for 6 months and then continuing at least quarterly, the CEO or designated management staff shall audit and analyze incidents to ensure all are reported, investigated, reviewed and analyzed as required as per 6400.18-6400.20. Upon completion of quarterly reviews training for any areas of noncompliance shall be completed as needed. Documentation of trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 03/15/2021 Not Implemented
6400.20(a)(2)The corrective action plan as entered by the agency for abuse incident on 8/18/2020 (ID#: 8730715), stated that Direct Service Worker #4 would be retrained on restrictive interventions and elimination of restraint policies by 8/28/2020. Direct Service Worker #4 was not trained in these areas. The corrective action plan, related to the abuse incident on 12/17/2020 (ID#: 8785489), stated that Direct Service Worker #1 would be retrained on risk mitigation, conflict resolution, and de-escalation by 12/28/2020. Direct Service Worker #1 was not trained in these areas.The home shall complete the following for each confirmed incident: Corrective action, if indicated.Direct service worker #4 was retrained on restrictive intervention on 8/22/20, retrained on elimination of restraints on 8/27/20, and trained on recognizing and mitigating risk on 9/10/20. Direct service worker #1 Completed the conflict resolution on 12/29/20. The Residential Administrator has developed a training record sheet as of 2/27/21 to keep more accurate records of employee trainings as they are completed. The Residential Administrator will check employee records monthly to ensure trainings are properly recorded and up to date.[At least monthly for 6 months and then continuing at least quarterly, the CEO or designated management staff shall audit and analyze incidents to ensure all are reported, investigated, reviewed and analyzed as required as per 6400.18-6400.20. Upon completion of quarterly reviews training for any areas of noncompliance shall be completed as needed. Documentation of trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 02/27/2021 Not Implemented
6400.46(d)Program Specialist #3 was not trained in first aid, Heimlich techniques and Cardio-Pulmonary ResuscitationProgram specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.The program will be trained in first aid, Heimlich techniques, and CPR no later than 4/1/21. All other direct service workers first aid, heimlich techniques, and CPR trainings are complete and current. The CEO/Director will ensure all new hires are trained upon hire and will monitor their training records quarterly to ensure compliance is being maintained.[Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 03/02/2021 Not Implemented
6400.50(a)The record of training for Direct Service Worker #4 did not include the length of the training. The record of training for Program Specialist #3 did not include the length of the training. [Repeat Violation -- 10/21/2019]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.Training records for Ps #3 and DSW #4 has been updated to include the length of training. All training record documents has been revised to include the date, course name, and length of training for all employees. The CEO/Director will monitor the training records quarterly to ensure compliance is being maintained.[Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 03/02/2021 Not Implemented
6400.52(c)(1)Program Specialist #3's training for training year from July 1st, 2019 to June 30th, 2020 did not encompass the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. Direct Service Worker #4's training for training year from July 1st, 2019 to June 30th, 2020 did not encompass the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.PS #3 and DSW #4 are scheduled to take a training including person centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships on 3/10/21. The agency's CEO/RA will be responsible for monitoring employee records to ensure trainings are complete and current. When trainings are coming due the CEO/RA will ensure that the staff member completes the required training and update the training record as needed.[Immediately and at least quarterly for one year, the CEO or designee shall audit all staff records to ensure they have all trainings required by the chapter and per individuals plans. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 03/10/2021 Not Implemented
6400.52(c)(2)Direct Service Worker #4's training for training year from July 1st, 2019 to June 30th, 2020 did not encompass the prevention, detection, and reporting of abuse.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.DSW #4 was trained on prevention, detection, and reporting of abuse on 3/1/21. DSW #4 training record has been updated to reflect the training that was completed. The CEO/RA will monitor training records quarterly to ensure trainings are current and recorded to ensure compliance is being maintained.[Immediately and at least quarterly for one year, the CEO or designee shall audit all staff records to ensure they have all trainings required by the chapter and per individuals plans. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 03/01/2021 Not Implemented
6400.52(c)(3)Program Specialist #3's training for training year from July 1st, 2019 to June 30th, 2020 did not encompass Individual Rights. Direct Service Worker #4's training for training year from July 1st, 2019 to June 30th, 2020 did not encompass Individual Rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.PS #3 and DSW #4 were trained on individual rights on 3/1/21. PS #3 and DSW #4 training records has been updated to reflect the training was completed. The CEO/RA will monitor employee training records quarterly to ensure trainings are current and recorded to ensure compliance is being maintained.[Immediately and at least quarterly for one year, the CEO or designee shall audit all staff records to ensure they have all trainings required by the chapter and per individuals plans. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 03/01/2021 Not Implemented
6400.52(c)(4)Program Specialist #3's training for training year from July 1st, 2019 to June 30th, 2020 did not encompass recognizing and reporting incidents. Direct Service Worker #4's training for training year from July 1st, 2019 to June 30th, 2020 did not encompass recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.PS #3 and DSW #4 was trained on incident management and recognizing and reporting incidents on 3/1/21. PS # 3 and DSW #4 training records were updated to reflect the training was completed. The CEO/RA will monitor employee training records quarterly to ensure trainings are current and recorded to ensure compliance is being maintained.[Immediately and at least quarterly for one year, the CEO or designee shall audit all staff records to ensure they have all trainings required by the chapter and per individuals plans. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 03/01/2021 Not Implemented
6400.196(a)Direct Service Worker #4 was not trained in Crisis Intervention and Safe-Physical Intervention as required by the October 2020 behavior support plan for Individual #1; Direct Service Worker #3 was not trained in Crisis Intervention, Safe-Physical Intervention, and De-Escalation Techniques as required by the October 2020 behavior support plan for Individual #1; Direct Service Worker #1 was not trained in Crisis Intervention, Safe-Physical Intervention, and De-Escalation Techniques as required by the October 2020 behavior support plan for Individual #1.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.Individual #1 has relocated to a new provider as of 2/24/21. Direct service worker #4 along with the Residential Administrator are currently on a waiting list to receive crisis intervention and safe-physical intervention training course at WPIC. The train the trainer course will allow direct service worker #4 and RA to train all staff members who work directly with individuals. Direct service worker #1 completed de-escalation training on 12/30/20 and training record has been updated to reflect training was completed. The CEO/RA will be responsible for monitoring employee training records on a monthly basis to verify that required trainings are being completed and properly recorded to ensure compliance is being maintained.Immediately, the CEO or designee shall develop a plan to have all staff trained by an outside source on Crisis Intervention, Safe-Physical Intervention, and De-Escalation Techniques until the agency is able to secure an internal trainer. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 03/01/2021 Not Implemented
6400.213(1)(i)Individual #1's record did not include hair color, eye color, or identifying marks.Each individual's record must include the following information: Personal information, including: (ii) the race, height, weight, color of hair, color of eyes and identifying marks.Individual #1 has moved to a new provider out of the city and closer to his family. Moving forward Brite Light's agency RA will ensure that individual's personal records will include their race, height, weight, eye color, hair color, and any identifying marks if that information is not listed. The personal information will also be updated as needed for example if the individual dyes their hair, lose/gain weight etc. The RA will be responsible for ensuring all individual personal information is correct and updated as required to ensure compliance.[Immediately, the CEO or designated management staff shall develop policies and procedures for information under 6400.213 to be completed upon admission of an individual. All staff responsible for completion of the information shall be trained on the policies and procedures. At least quarterly for one year, the CEO or designee shall audit all individual records to ensure the information in the individual record is complete and accurate. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 02/27/2021 Not Implemented
6400.213(1)(i)Individual #1's record did not include religious affiliation.Each individual's record must include the following information: Personal information, including: (iv) The religious affiliation.Individual records will Individual #1 has moved to a new provider out of the city and closer to his family. Moving forward Brite Light's agency RA will ensure that individual's personal record includes their religious affiliation if that information is not listed. The RA will be responsible for ensuring all individual personal information is correct and updated as required to ensure compliance.[Immediately, the CEO or designated management staff shall develop policies and procedures for information under 6400.213 to be completed upon admission of an individual. All staff responsible for completion of the information shall be trained on the policies and procedures. At least quarterly for one year, the CEO or designee shall audit all individual records to ensure the information in the individual record is complete and accurate. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 02/27/2021 Not Implemented
6400.213(1)(i)Individual #1's record did not include a current, dated photo.Each individual's record must include the following information: Personal information, including: (vi) A current, dated photograph.Individual #1 record did include a current photo to date. The photo is placed at the beginning of his daily communications log. However the photo was not sent to the department. A photo will be kept with individuals records and updated annually to ensure it is current and up to date.[Immediately, the CEO or designated management staff shall develop policies and procedures for information under 6400.213 to be completed upon admission of an individual. All staff responsible for completion of the information shall be trained on the policies and procedures. At least quarterly for one year, the CEO or designee shall audit all individual records to ensure the information in the individual record is complete and accurate. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 3/18/2021)] 02/05/2021 Not Implemented
SIN-00165352 Renewal 10/21/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment of the home.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The site supervisor completed the self assessment tool immediately (10/21/19) upon knowledge that self assessment was not done in appropriate time frame . A schedule has been established by the CEO to prevent missing the 3-6 month window to have self assessment completed. The task of completing the self assessment tool will be added to monthly checklist May-October to ensure the task is being completed in the time allowed. The CEO has trained the site supervisor on how to properly complete the self assessment tool and the site supervisor will be responsible for completing the self assessment tool. The inspection compliance date is good through 11/1/20, with that date at hand starting 5/1/20 will begin the start date of getting the self assessment tool completed. The CEO will review the license of compliance to review and make sure all information is current and accurate. 10/21/2019 Implemented
6400.21(a)Chief Executive Officer/Program Specialist #1, date of hire 8/1/18, did not have a Pennsylvania criminal history record check. Direct service worker #2, date of hire 3/1/18, did not have a Pennsylvania criminal history record check. Direct service worker #3, date of hire 3/1/18, Pennsylvania criminal history record check.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. Background check request were submitted for CEO/PS, and direct service workers #2 and #3 on October 30, 2019. Results were placed in employee personnel files for all staff listed. The CEO has composed a new hire check list to ensure background checks are completed prior to potential hires. [Prior to hire the CEO shall audit the aforementioned check list and all staff persons back ground checks to ensure all staff persons have all required background checks completed timely. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 12/6/19)] 10/30/2019 Implemented
6400.151(a)Direct Service Worker #2, date of hire 3/1/18, does not have a physical examination. Direct Service Worker #3, date of hire 3/1/18, does not have a physical examination. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Physical examination records were placed in employee files for direct service workers #2 & #3 on 11/1/19. The site supervisor will perform a monthly review and communicate findings to appropriate staff of upcoming physical exam renewals at least 60 days prior to the document expiration date. Te notification will also be sent to the affected staff reminding them of upcoming renewals needed. The CEO will be responsible for making sure the physicals are done in a timely fashion and to review forms to ensure all required information is included and valid. The monthly check will be initiated on 11/1/19 and will be done on a monthly basis thereafter. [Documentation of the month checks shall be kept. [Immediately, the CEO/Program Specialist shall familiarize themselves with the 6400 regulations to ensure compliance is able to measured and documentation is available upon request by the Department. (DPOC by AES,HSLS on 12/6/19)] 11/01/2019 Implemented
6400.151(c)(2)Direct Service Worker #2, date of hire 3/1/18, does not have a Tuberculin screening. Direct Service Worker #3, date of hire 3/1/18, does not have a Tuberculin screening. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Direct service worker #2 had an appointment scheduled for November 1, 2019 and has acquired the required tuberculin skin test. On October 22, 2019 direct service worker #3 scheduled an appointment to acquire another tuberculin skin test. The test was administered on 11/1/2019. The site supervisor will perform a monthly review of staff files and make notifications at least 60 days prior to the document expiration date.This notification will be sent to all staff affected to remind them of upcoming renewals. The supervisor has been trained by the CEO of new responsibilities. The CEO will review forms to ensure all required information is included and valid. The monthly check will be initiated on 12/1/19 and will be done on a monthly basis thereafter. [Documentation of the month checks shall be kept. [Immediately, the CEO/Program Specialist shall familiarize themselves with the 6400 regulations to ensure compliance is able to measured and documentation is available upon request by the Department. (DPOC by AES,HSLS on 12/6/19)] 11/01/2019 Implemented
6400.44(c)(1)Chief Executive Officer/Program Specialist #1, date of hire 8/1/18, did not have documentation of education and work experience qualifications; therefore, compliance could not be measured.A program specialist shall have one of the following groups of qualifications: A master's degree or above from an accredited college or university and 1 year of work experience working directly with individuals with an intellectual disability or autism.PS qualification documents were placed in the PS personnel file immediately (10/21/19) upon becoming aware of missing information. PS credentials and experience includes a Bachelors degree from a university and 5 years of work history working directly with persons with ID/Autism. [Immediately, the CEO/Program Specialist shall familiarize themselves with the 6400 regulations to ensure compliance is able to measured and documentation is available upon request by the Department. (DPOC by AES,HSLS on 12/6/19)] 10/21/2019 Implemented
6400.50(a)Chief Executive Officer/Program Specialist#1, date of hire 8/1/18, did not have records of orientation and training, including the training source, content, dates, and length of training. Direct service worker #2, date of hire 3/1/18, did not have records of orientation and training, including the training source, content, dates, and length of training. Direct service worker #3, date of hire 3/1/18, did not have records of orientation and training, including the training source, content, dates, and length of training.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.The CEO received training's on agency policies and procedures on 1/9/19, 1/15/19, 1/25/19, and 2/11/19. Training's were also conducted from fire safety videos. Training records will be checked monthly to ensure up to date records are being maintained and to avoid certificates from expiring. Site supervisor will perform a monthly review and make notifications to the CEO of upcoming training's at least 60 days prior to the document expiration date so the CEO can schedule needed training in appropriate time frame.The supervisor has been trained on new responsibilities by the CEO. The monthly check will be initiated on 11/1/19 and will be done on a monthly basis thereafter. [Documentation of the month checks shall be kept. Immediately, the CEO/Program Specialist shall familiarize themselves with the 6400 regulations to ensure compliance is able to measured and documentation is available upon request by the Department. (DPOC by AES,HSLS on 12/6/19)] 10/22/2019 Implemented
6400.50(b)The home did not keep a training record for Chief Executive Officer/ Program Specialist#1, date of hire 8/1/18. The home did not keep a training record for Direct Service Worker #2, date of hire 3/1/18. The home did not keep a training record for Direct Service Worker #3, date of hire 3/1/18.The home shall keep a training record for each person trained.PS and direct service workers #2 and #3 received training's on agency policies and procedures on 1/9/19, 1/15/19, 1/25/19, 2/11/19, 4/8/19, 4/24/19, 5/1/19, 8/10/19, and 9/20/19. Training's were also conducted from safety videos, first aid /cpr class. Training records will be checked monthly to ensure up to date records are being maintained and to avid certificates from expiring. The site supervisor will perform a monthly review and make notifications to the appropriate staff of upcoming renewal training. The monthly check will be initiated on 11/1/19 and will be done on a monthly basis thereafter. Training's will be scheduled by the CEO [Documentation of the month checks shall be kept. [Immediately, the CEO/Program Specialist shall familiarize themselves with the 6400 regulations to ensure compliance is able to measured and documentation is available upon request by the Department. (DPOC by AES,HSLS on 12/6/19)] 10/22/2019 Implemented
SIN-00144518 Initial review 11/01/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(f)The trash receptacle outside of the side door had a lid that was larger than the opening of the trash receptacle and did not fit tightly; therefore, not preventing the penetration of insects and rodents.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.A trash can with a fitting lid was placed outside the home. In the event the trash can or the lid becomes inoperable we will replace the trash can or the lid as soon as possible. [Immediately, the CEO shall develop and implement policies and procedures to include training, reporting, cleaning and monitoring schedule and documentation to ensure the physical site of the home is maintained to ensure the health and safety of the individuals in a homelike environment. Upon hire, the CEO or designee shall educate all staff persons of the policies and procedures to ensure the physical site of the home is maintained at all times including that trash outside the home is kept in closed receptacles. Documentation of the trainings shall be kept. At least monthly, the CEO or designee shall complete an onsite check of the home to ensure the home is maintained and the aforementioned policies and procedures are implemented. Documentation of the onsite checks shall be kept. (DPOC by AES,HSLS on 11/20/18)] 11/06/2018 Implemented
6400.66The overhead light in garage of the home was not operable; there is not another source of light in this area. The outside light at the front door of the home was not operable; there is not another source of light in this area.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Light bulb was replaced in the garage. Staff will be aware of where replacement bulbs can be found to replace blown bulbs [Immediately, the CEO shall develop and implement policies and procedures to include training, reporting, cleaning and monitoring schedule and documentation to ensure the physical site of the home is maintained to ensure the health and safety of the individuals in a homelike environment. Upon hire, the CEO or designee shall educate all staff persons of the policies and procedures to ensure the physical site of the home is maintained at all times including that rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes are lighted to assure safety and to avoid accidents. Documentation of the trainings shall be kept. At least monthly, the CEO or designee shall complete an onsite check of the home to ensure the home is maintained and the aforementioned policies and procedures are implemented. Documentation of the onsite checks shall be kept. (DPOC by AES,HSLS on 11/20/18)] 11/01/2018 Implemented
6400.67(a)There was a stream of water approximately 1 foot wide on the floor of the basement leading from the lower section of the wall in the middle of the home to the floor drain approximately 8 feet away.Floors, walls, ceilings and other surfaces shall be in good repair. Stream of water was concealed with water resistant mortor. Mortor will prevent water from entering building[Immediately, the CEO shall develop and implement policies and procedures to include training, reporting, cleaning and monitoring schedule and documentation to ensure the physical site of the home is maintained to ensure the health and safety of the individuals in a homelike environment. Upon hire, the CEO or designee shall educate all staff persons of the policies and procedures to ensure the physical site of the home is maintained at all times including floors, walls, ceilings and other surfaces are in good repair. Upon hire, the CEO or designee shall educate all staff persons of the policies and procedures to ensure the physical site of the home is maintained at all times including that floors, walls, ceilings and other surfaces are in good repair. Documentation of the trainings shall be kept. At least monthly, the CEO or designee shall complete an onsite check of the home to ensure the home is maintained and the aforementioned policies and procedures are implemented. Documentation of the onsite checks shall be kept. (DPOC by AES,HSLS on 11/20/18)] 11/06/2018 Implemented
6400.71The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the 2 telephones in the kitchen of the home.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Telephone numbers to the nearest hospital, police department, fire department, ambulance and poison control are listed by both telephones in the home. One telephone is located in the kitchen and the other is located in the office and emergency contact list are posted in both areas. We will ensure that emergency contact numbers are posted at all times by telephones. [Immediately, the CEO shall develop and implement policies and procedures to include training, reporting, cleaning and monitoring schedule and documentation to ensure the physical site of the home is maintained to ensure the health and safety of the individuals in a homelike environment. Upon hire, the CEO or designee shall educate all staff persons of the policies and procedures to ensure the physical site of the home is maintained at all times including telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center are on or by each telephone in the home with an outside line. Upon hire, the CEO or designee shall educate all staff persons of the policies and procedures to ensure the physical site of the home is maintained at all times including that floors, walls, ceilings and other surfaces are in good repair. Documentation of the trainings shall be kept. At least monthly, the CEO or designee shall complete an onsite check of the home to ensure the home is maintained and the aforementioned policies and procedures are implemented. Documentation of the onsite checks shall be kept. (DPOC by AES,HSLS on 11/20/18)] 11/06/2018 Implemented
6400.72(a)The window in the dining area at the back of the home was able to be opened and did not have a screen.Windows, including windows in doors, shall be securely screened when windows or doors are open. New windows were installed 11/08/2018 with screen attached. Staff will do a monthly check of windows and screens to ensure that all screens are free of wear and tear and if needed they will be repaired or replaced.[Immediately, the CEO shall develop and implement policies and procedures to include training, reporting, cleaning and monitoring schedule and documentation to ensure the physical site of the home is maintained to ensure the health and safety of the individuals in a homelike environment. Upon hire, the CEO or designee shall educate all staff persons of the policies and procedures to ensure the physical site of the home is maintained at all times including windows, including windows in doors, shall be securely screened. Upon hire, the CEO or designee shall educate all staff persons of the policies and procedures to ensure the physical site of the home is maintained at all times including that windows, including windows in doors, shall be securely screened. Documentation of the trainings shall be kept. At least monthly, the CEO or designee shall complete an onsite check of the home to ensure the home is maintained and the aforementioned policies and procedures are implemented. Documentation of the onsite checks shall be kept. (DPOC by AES,HSLS on 11/20/18)] 11/08/2018 Implemented
6400.73(a)The interior stairway from the office to attic of the home did not have a handrail. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. A well secured handrail was added to the stair way of the attic. In the event the handrail needs repaired staff will notify the appropriate person responsible and ensure that the issue is taken care of in a timely fashion.[Immediately, the CEO shall develop and implement policies and procedures to include training, reporting, cleaning and monitoring schedule and documentation to ensure the physical site of the home is maintained to ensure the health and safety of the individuals in a homelike environment. Upon hire, the CEO or designee shall educate all staff persons of the policies and procedures to ensure the physical site of the home is maintained at all times including that each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Documentation of the trainings shall be kept. At least monthly, the CEO or designee shall complete an onsite check of the home to ensure the home is maintained and the aforementioned policies and procedures are implemented. Documentation of the onsite checks shall be kept. (DPOC by AES,HSLS on 11/20/18)] 11/08/2018 Implemented
6400.74The interior stairs from the kitchen to the basement of the home did not have a nonskid surface.Interior stairs and outside steps shall have a nonskid surface. Nonskid surface was added to the basement stairs. Moving forward Brite Light will ensure that the nonskid surface placed on the basement stairs is in place at all times. In the event the surface needs to be replaced we will ensure that it is done so in an appropriate time frame to ensure the safety of our participants and staff. [Immediately, the CEO shall develop and implement policies and procedures to include training, reporting, cleaning and monitoring schedule and documentation to ensure the physical site of the home is maintained to ensure the health and safety of the individuals in a homelike environment. Upon hire, the CEO or designee shall educate all staff persons of the policies and procedures to ensure the physical site of the home is maintained at all times including windows, including windows in doors, shall be securely screened. Upon hire, the CEO or designee shall educate all staff persons of the policies and procedures to ensure the physical site of the home is maintained at all times including that Interior stairs and outside steps shall have a nonskid surface. Documentation of the trainings shall be kept. At least monthly, the CEO or designee shall complete an onsite check of the home to ensure the home is maintained and the aforementioned policies and procedures are implemented. Documentation of the onsite checks shall be kept. (DPOC by AES,HSLS on 11/20/18)] 11/06/2018 Implemented
6400.77(b)The first aid kit did not contain a thermometer, tweezers, tape and scissors. 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. The contents that were missing thermometer, tweezers, tape, and scissors were added to the First Aid kit. In the event an item is used entirely or needs to be replaced, staff will know to add the items to the homes shopping list to replenish items. [Upon hire, the CEO or designee shall educate all staff persons of the required items in first aid kits and the replacement and replenishment procedures to ensure first aid kits have all required items at all time. Documentation of the trainings shall be kept. At least monthly, the CEO or designee shall complete an onsite check of the home including first aid kits and first aid supplies to ensure first aid kits have all required items at all times. Documentation of the onsite checks shall be kept. (DPOC by AES,HSLS on 11/20/18)] 11/06/2018 Implemented
6400.81(i)The windows in bedroom #2 and bedroom #3 did not have drapes, curtains, shades, blinds or shutters.Bedroom windows shall have drapes, curtains, shades, blinds or shutters. Drapes were added to both bedrooms 2 & 3 to ensure privacy to participants. Brite Light will ensure that windows are covered at all times. [Prior to admission of an individual, the CEO or designee shall ensure all required bedrooms items are available and in place as per 6400.81K(1)-(6). At least quarterly, the CEO or designee shall complete an onsite check of the home to ensure the home is maintained and all required items are in place an in good repair. Documentation of the onsite checks shall be kept. (DPOC by AES,HSLS on 11/20/18)] 11/08/2018 Implemented
6400.81(k)(4)Bedroom #2 and bedroom #3 did not have a chest of drawers.In bedrooms, each individual shall have the following: A chest of drawers. A chest was purchased for bedroom 2. At this time Brite Light will only service one participant. Brite Light will purchase more furniture ie Chest, bed, ect. as needed.[Prior to admission of an individual, the CEO or designee shall ensure all required bedrooms items are available and in place as per 6400.81K(1)-(6). At least quarterly, the CEO or designee shall complete an onsite check of the home to ensure the home is maintained and all required items are in place an in good repair. Documentation of the onsite checks shall be kept. (DPOC by AES,HSLS on 11/20/18)] 11/08/2018 Implemented
6400.81(k)(6)Bedroom #2 did not have a mirror.In bedrooms, each individual shall have the following: A mirror. A mirror was placed in bedroom #2[Prior to admission of an individual, the CEO or designee shall ensure all required bedrooms items are available and in place as per 6400.81K(1)-(6). At least quarterly, the CEO or designee shall complete an onsite check of the home to ensure the home is maintained and all required items are in place an in good repair. Documentation of the onsite checks shall be kept. (DPOC by AES,HSLS on 11/20/18)] 11/08/2018 Implemented
6400.101There was a chain lock on the door between the kitchen and basement of the home preventing egress from the basement when engaged. There was a chain lock on the storm door leading to the outside of the home preventing egress from the home when engaged. At the bottom of the stairway between the office and the attic were several coils of cable cord and extension cord obstructing egress from the attic. At the side door of the kitchen leading to the outside of the home was a coiled up garden hose obstructing egress from the home.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The chain lock located between the kitchen and the basement was removed to ensure there is no prevention of egress from the basement when needed. There will not be a lock of any kind on the door to ensure that no entry way or exit is obstructed. [On 11/19/18, the chain locks were off the basement and storm door and the wiring was not at the bottom of the attic way and the hose was not outside the kitchen door. Immediately, the CEO shall develop and implement policies and procedures to include training, reporting, cleaning and monitoring schedule and documentation to ensure the physical site of the home is maintained to ensure the health and safety of the individuals in a homelike environment. Upon hire, the CEO or designee shall educate all staff persons of the policies and procedures to ensure the physical site of the home is maintained at all times including that stairways, halls, doorways, passageways and exits from rooms and form the building shall be unobstructed. Documentation of the trainings shall be kept. At least monthly, the CEO or designee shall complete an onsite check of the home to ensure the home is maintained and the aforementioned policies and procedures are implemented. Documentation of the onsite checks shall be kept. (DPOC by AES,HSLS on 11/20/18)] 11/06/2018 Implemented
6400.105A wooden table was located approximately 6 inches from the furnace in the basement of the home.Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. Wooden table was moved away from furnace to ensure that there isn't a fire hazard within the home. Staff will take fire safety training to ensure they are knowledgeable of fire safety. [Immediately, the CEO shall develop and implement policies and procedures to include training, reporting, cleaning and monitoring schedule and documentation to ensure the physical site of the home is maintained to ensure the health and safety of the individuals in a homelike environment. Upon hire, the CEO or designee shall educate all staff persons of the policies and procedures to ensure the physical site of the home is maintained at all times including that flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. Documentation of the trainings shall be kept. At least monthly, the CEO or designee shall complete an onsite check of the home to ensure the home is maintained and the aforementioned policies and procedures are implemented. Documentation of the onsite checks shall be kept. (DPOC by AES,HSLS on 11/20/18)] 11/06/2018 Implemented
6400.110(a)The attic of the home did not have a smoke detector. The smoke detector in basement of the home did not sound when tested at 10:55AM. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Interconnected smoke alarm was installed on November 6, 2018 and tested at 6:45pm . Smoke alarm will be tested once a month by staff to ensure that all smoke alarms are in sync and operable. If upon test alarm isn't operable or in sync staff will be knowledgeable on how to re-program alarm and replace batteries on wireless device.[Immediately, the CEO shall develop and implement policies and procedures to include training, reporting, cleaning and monitoring schedule and documentation to ensure the physical site of the home is maintained to ensure the health and safety of the individuals in a homelike environment. Upon hire, the CEO or designee shall educate all staff persons of the policies and procedures to ensure the physical site of the home is maintained at all times including that the home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Documentation of the trainings shall be kept. At least monthly, the CEO or designee shall complete an onsite check of the home to ensure the home is maintained and the aforementioned policies and procedures are implemented. Documentation of the onsite checks shall be kept. (DPOC by AES,HSLS on 11/20/18)] 11/06/2018 Implemented
6400.110(e)The home has 3 stories including the basement and attic and does have an interconnected fire alarm system.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. Interconnected smoke alarm was installed in the attic on November 6, 2018 and tested at 6:45 pm. Smoke alarm will be tested once a month by staff to ensure that all smoke alarms are in sync and operable. If upon test alarm isn't operable or in sync staff will be knowledgeable on how to re-program alarm and replace batteries on wireless device..[Immediately, the CEO shall develop and implement policies and procedures to include training, reporting, cleaning and monitoring schedule and documentation to ensure the physical site of the home is maintained to ensure the health and safety of the individuals in a homelike environment. Upon hire, the CEO or designee shall educate all staff persons of the policies and procedures to ensure the physical site of the home is maintained at all times including that the home shall have a at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. Documentation of the trainings shall be kept. At least monthly, the CEO or designee shall complete an onsite check of the home to ensure the home is maintained and the aforementioned policies and procedures are implemented. Documentation of the onsite checks shall be kept. (DPOC by AES,HSLS on 11/20/18)] 11/06/2018 Implemented
SIN-00214988 Unannounced Monitoring 11/09/2022 Compliant - Finalized