Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00230317 Renewal 09/06/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Individual #3's plan requires poisons be locked. Cleaning poisons were found unlocked in a basement cabinet, whose door was broken so it cannot be adequately locked without repair or replacement. Detergent pods were also found unlocked under the kitchen sink.Poisonous materials shall be kept locked or made inaccessible to individuals. All poisonous materials were removed from a kitchen cabinet and stored in a locked basement room. Staff was retrained on their responsibilities in regards to keep poisonous materials in a basement and keep door locked at all times (see attachment#7) 09/07/2023 Implemented
6400.64(a)The second floor of the property has a strong ammonia smell, especially in and approaching Individual #3's bedroom.Clean and sanitary conditions shall be maintained in the home. Individual roommate was educated on keeping his room clean and not urinating in a bottle in his room. Area was cleaned and disinfected by staff. 09/15/2023 Implemented
6400.69(c)Individual #3's bedroom temperature was dangerously warm. At the time of the inspection, outside temperatures were in the 90s with a heat advisory in effect from the National Weather Service. The individual was found in their room with no air conditioner running, no fan, and the door and window closed. When the indoor temperature exceeds 85°F, mechanical ventilation, such as fans shall be used.An Individual was educated on a need to ensure proper ventilation in his room and to turn on an installed window AC to cool a temperature in a room on hot days. 09/15/2023 Implemented
SIN-00211875 Renewal 09/08/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)In the kitchen there were two cabinets which had a yellowish brown sticky substance coating the interior.Clean and sanitary conditions shall be maintained in the home. Kitchen cabinets were cleaned by staff on 09/08/2022 to remedy the violation. 09/08/2022 Implemented
6400.76(a)The wooden bedframe belonging to individual #2 was broken near the foot of the bed. Furniture and equipment shall be nonhazardous, clean and sturdy. Footboard from individual's bed was removed by Assistant Residential Director on 10/19/2022 (see attachment 5) 10/19/2022 Implemented
6400.143(a)Follow up apt for hearing per his most recent physical. Agency indicate individual #1 declined the follow up visit, however, no verification that individual #1 refused his appointment on with his ear nose and throat provider.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. On 10/19/2022 emalied to licesing individual #1 daily note from 12-1-21 documenting individual refusal to attend a scheduled ENT appoitment (see attachment #9). 10/19/2022 Implemented
6400.144Follow up apt to see a nutritionist per individual #1's most recent physical. The agency states Individual #1 attended a tele-visit, however there was no verification provided to assert he attended the tele-visit.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Obtained and sent email on 09/26/2022 to licensing from a medical provider with Telehalth Nutiritionist appoitment summary (see attachment #8). 09/26/2022 Implemented
SIN-00192317 Renewal 09/02/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(b)(1)The agency's COVID policy, dated 8/12/21, contains information that does not fully capture the details of several mandates and requirements issued by the Commonwealth of Pennsylvania and the City of Philadelphia. Page 11 of their policy indicates anyone who is vaccinated is not required to wear a mask, and that masks should only be worn by unvaccinated individuals who receive services during community activities. However, per communication released on 7/7/2020 by the Department of Health, masks must be worn by all staff who provide services. Per ODP Announcement 20-088, dated 7/28/20, masks should be worn by individuals who receive services during activities in the community, and does not distinguish between vaccinated and unvaccinated individuals. Per the City's 8/10/21 mandate, masks must be worn if an institution or business does not require vaccination and is not tied to individual staff members' vaccine status; at the time of inspection, Bright Ways Services does not require staff COVID vaccination. The agency's COVID policy must be updated to better reflect these guidelines and mandates: to require masking for staff during service provision, and recommending mask usage for individuals receiving services during community activities, while also allowing for applicable exceptions. During the inspection, the agency submitted an updated policy that requires staff to wear a mask.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. BWS COVID-19 Plan (see attachment #1) was updated in accordance with ODP Announcement 20-088, CDC and City guidelines. 10/08/2021 Implemented
6400.66At time of inspection the light in the back of the home 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 inoperable lighting fixture located outside in the back of the home has been replaced with a new fixture (see attachment #2) by the Assistant Residential Director to remedy the violation. 09/22/2021 Implemented
6400.141(c)(6)It cannot be determined if Individual 1 had a Tuberculin (TB) test since individual 1 admission on 11/18/19, at the time of inspection.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. Program Specialist personally visited PCP office to obtain an updated Individual Physical Exam Form with a negative chest X-ray results (see attachment #3). Program Specialist reviewed Physical Exam Forms for all individuals in a program. 09/27/2021 Implemented
6400.141(c)(10)Individual 1 had a physical examination on November 18, 2021; the physician indicated the individual was positive of a 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. Program Specialist personally visited PCP office to obtain an updated Individual Physical Exam Form with a negative chest X-ray results (see attachment #3). Program Specialist reviewed Physical Exam Forms for all individuals in a program. 09/27/2021 Implemented
6400.151(c)(3)Staff Member 2's 2/28/20 physical does not include a signed statement from their physician clearing them from communicable disease. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. BWS Employee Physical Exam Form has been updated in accordance to Chapter 6400.141. Staff Member 2 has provided an updated physical form (see attachment #4). HR Director reviewed all employees Physical Exam Forms to ensure code compliance. 09/20/2021 Implemented
6400.50(a)Records of the program specialist/Staff Member 1's CPR inspection were not kept by the agency at time of inspection. After the inspection, the agency submitted CPR training documentation for the staff member that had an expiration date of 7/12/21.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.Program Specialist CPR documentation was added to the employee records. HR Director reviewed all employees CPR to ensure code compliance. 09/20/2021 Implemented
SIN-00176223 Renewal 09/02/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(12)Physical limitations were not discussed in the physical dated 6/17/20 for individual 1.The physical examination shall include: Physical limitations of the individual. Individual Physical Exam Form was updated in accordance to Chapter 6400.141. Program Specialist will ensure that form is fully completed after each exam and any verbal instructions are documented. 09/23/2020 Implemented
6400.181(c)The assessment dated 12/27/19 for individual 1 does not notate what it is based on.The assessment shall be based on assessment instruments, interviews, progress notes and observations. Individual Assessment Form has being updated on 9/15/2020. Executive Director to ensure form compliance with a Chapter 6400 going forward. 09/15/2020 Implemented
6400.181(e)(4)Supervision levels weren't adequately discussed in the assessment for individual 1. The assessment dated 12/27/19 discussed street and traffic supervision but not supervision levels for other daily routines. The assessment must include the following information: The individual's need for supervision. Individual Assessment Form has being updated on 9/15/2020. Executive Director to ensure form compliance with a Chapter 6400 going forward. 09/15/2020 Implemented
6400.181(e)(5)The assessment dated 12/27/2020 for individual 1 did not discuss the ability to self administer medications.The assessment must include the following information:  The individual's ability to self-administer medications.Individual Assessment Form has being updated on 9/15/2020. Executive Director to ensure form compliance with a Chapter 6400 going forward. 09/15/2020 Implemented
6400.181(e)(6)The ability to avoid poisons were not discussed in the assessment dated 12/27/19 for individual 1. The assessment notated the individual is aware of "nonfood items" but it was unclear whether or not potentially poisonous substances needed to be locked or if the individual can use or recognize them with or without supervision.The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. Individual Assessment Form has being updated on 9/15/2020. Executive Director to ensure form compliance with a Chapter 6400 going forward. 09/15/2020 Implemented
6400.46(d)Staff person #2 did not have CPR certification in the record at time of inspectionProgram 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.Program specialist is scheduled to compete CPR training on 9/29/2020. Executive Director will ensure records and training complaince for staff going forward. 09/29/2020 Implemented
Article X.1007Bright way Services is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff person 1,2, and 3 did not have a declaration that they lived in Pennsylvania for the past 2 consecutive years.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.BWS JOB Application Form has being updated on 9/3/2020 to include length of residence in PA. Executive Director to ensure Code compliance with a hiring new staff going forward. 09/03/2020 Implemented
SIN-00174252 Unannounced Monitoring 07/23/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The oven had residue consistent with grease and dirt on the inside of the door and on the bottom of the ovenClean and sanitary conditions shall be maintained in the home. Oven was cleaned by a staff on 7/23/2020 (see item7.jpg). The plan to prevent it in future - added verifying that cooking appliances are in clean and sanitary conditions to the list of items to inspect during House Manager Bi-Weekly House inspection procedure. To follow up on this the Executive Director will review House Manager Bi-Weekly Inspection Form for compliance every month and visit sites for physical inspection. 07/23/2020 Implemented
6400.67(a)The left handle was missing on the wardrobe closet in the vacant bedroom on the second floor.Floors, walls, ceilings and other surfaces shall be in good repair. Handle was installed on a wardrobe closet by maintenance sub-contractor on 7/25/2020 (see item6.jpg). The plan to prevent it in future - added furniture to list of items to inspect during House Manager Bi-Weekly House inspection procedure. To follow up on this the Executive Director will review House Manager Bi-Weekly Inspection Form for compliance every month. 07/25/2020 Implemented
6400.68(b)The water temperature measured at 124.8 degrees Fahrenheit in the bathtub of the second floor bathroom at the time of inspection. Hot water temperatures in bathtubs and showers may not exceed 120°F. Water temperature setting was adjusted on boiler by House Manager on 7/23/2020 (see item5.jpg). The plan to prevent it in future - added temperature check to the list of items to inspect during House Manager Bi-Weekly House inspection procedure in addition to a monthly fire drills temperature check. To follow up on this the Executive Director will review House Manager Bi-Weekly Inspection Form for compliance every month and visit sites for physical inspection. 07/23/2020 Implemented
6400.71There were no emergency telephone numbers located near the telephone in the kitchen.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 was removed by House Manager on 7/23/2020 (see item4.jpg) from the kitchen as company deemed it unnecessary to have two phone within reach to each other (adjustment living room has phone). The plan to prevent it in future - added verifying emergency contact info next to the phone to the list of items to inspect during House Manager Bi-Weekly House inspection procedure. To follow up on this the Executive Director will review House Manager Bi-Weekly Inspection Form for compliance every month. 07/23/2020 Implemented
6400.72(b)The door pump on the screen storm basement door was damaged at the time of inspection Screens, windows and doors shall be in good repair. Storm Door was removed from a basement by maintenance sub-contractor on 7/25/2020 (see item3.jpg) as company deemed it unnecessary to have storm door there. Basement area where storm door was located is not a livable space. The plan to prevent it in future - added doors to the list of items to inspect during House Manager Bi-Weekly House inspection procedure.To follow up on this the Executive Director will review House Manager Bi-Weekly Inspection Form for compliance every month and visit sites for physical inspection. 07/25/2020 Implemented
6400.110(c)There was no smoke detector in the hallway common area on the second floor. All smoke alarms and detectors on the second floor were in the individual bedrooms.The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. New Smoke Detector was installed by maintenance sub-contractor on 7/25/2020 (see item2.jpg). The plan to prevent future occurrences of this problem is to have the House manager inspect operation of smoke detectors as part of Bi-Weekly House Inspection procedure. To follow up on this the Executive Director will review House Manager Bi-Weekly Inspection Form for compliance every month and visit sites for physical inspection. 07/25/2020 Implemented
6400.163(g)Medication brand Pepto-bismol was stored in the cabinet above the stove without a label designating to whom it belonged. The medication was stored in a place that may generate excess heat and it was not with any of the other medications in the household. The medication was used but unknown who last used the medication.Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions.Medication Pepto-Bismol was disposed on 07/23/2020 by a House Manager. The plan to prevent future occurrences - memo was sent to the staff on 08/11/2020 to remind them about the company policy in regards to bringing personal medication to the sites and storing individuals non-prescribed medications. House Manager will conduct bi-weekly checks to ensure proper storage of over the counter medications. 08/11/2020 Implemented
SIN-00172760 Unannounced Monitoring 03/11/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)Back bedroom window was open and it did not contain a screen. Screens in kitchen and front door are torn and need to be replaced.Windows, including windows in doors, shall be securely screened when windows or doors are open. The plan to fix the problem of the window screen in the back bedroom was remedied . There is a screen located on that window, however it was not pulled down., moving forward the screen will be pulled down when ever the window is open. Screens in the kitchen and front door that were torn have been repaired by CFO on 3/20/2020 A plan to to prevent future occurrences of these problems. The house manager has trained staffed to lower the screen on the back bedroom window when the window is opened. The house manager shall inspect all Windows , including windows in doors and screens on windows and doors for tears and report for repair or replacement immediate, and document the inspection on a on a weekly check off list. The Executive Director will double check and verify this while doing her monthly inspections of the sites and document on a monthly check off list as well. 03/20/2020 Implemented
6400.76(a)Bathroom vanity mirror is broken at base and when vanity is opened mirror becomes loose. Furniture and equipment shall be nonhazardous, clean and sturdy. The plan to fix the problem of the broken vanity mirror has been remedied. It has been repaired by the CFO on 3/20/2020. the mirror no longer comes loose from the frame (see Ex 11) The plan to prevent future occurrences of this problem, the house manager shall inspect all furniture and equipment weekly to ensure all is nonhazardous clean and sturdy and document on a weekly check off list. The Executive Director double check and verify this while doing her monthly inspections of the sites and document on a monthly check off list. 03/20/2020 Implemented
6400.77(b)First aid kit did not contain scissors, tape, tweezers or thermometer. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. To correct the immediate problem of the first aid kit not containing scissors, tape, tweezers or thermometer , the CFO has purchased a new kit that includes a firs aid manual and placed in the house. This was completed 3/16/2020 . The plan to prevent future occurrences of this problem the house manager is to inspect the first aid kit weekly to ensure that all required components are present in the kit. , The Executive Director will follow up on this while doing her monthly inspections of the sites and document of a monthly check off list that this has been done. Staff have been -retrained to ensure that if any items is removed from the kit. that it should be placed back in the kit. 03/16/2020 Implemented
6400.77(c)First aid kit did not contain a first aid manual. A first aid manual shall be kept with the first aid kit.To correct the immediate problem of the first aid kit not having a manual , the CFO has purchased a new kit that includes a fits aid manual and placed in the house. This was completed 3/16/2020 . The plan to prevent future occurrences of this problem the house manager is to inspect the first aid kit weekly to ensure that all required components are present in the kit. , The Executive Director will follow up on this while doing her monthly inspections of the sites and document on a monthly check off list that this has been done. Staff have been -retrained to ensure that if any items is removed from the kit, that it should be returned to the kit immediately. 03/16/2020 Implemented
6400.82(f)There were no paper or cloth towels in the bathroom.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. To fix the immediate problem of no towels in the bathroom was remedied by placing a roll of paper towels in the bathroom by the house manager.(see Ex10) This was corrected on 3/12/2002 The plan to prevent future occurrences of this problem is to have the house manager inspect the bathroom on a daily bases and on days off, the lead will inspect the bathroom and sign off on a check off list that this has been done. To follow up on this the Executive Director will look over the daily check off list for compliance while doing her monthly inspection of the sites. 03/12/2020 Implemented
6400.144-Individual #1 was prescribed medications that were not present in home during inspection. These medications are clindamycin Phosp, ibuprofen, Flonase, levofloxacin, methylprednisolone, vitamin D3 and Zyrtec. -Ceterizine hcl tab was present in Individual #1 medication box but not on the medication log. It could not be determined if this prescribed medication is being administered as prescribed.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. To remedy the immediate problem in regard to meds indicated on the MAR that were not in the house was reviewed by the Executive Administrator on March 12 and matched with the most recent scripts. It was found that discontinued meds were not indicated as discontinued or eliminated if discontinued in a previous months from the MAR ( ibuprofen, levofloxacin, methylprednisolone, Vitamin D) ....clindamycin phosp was in the med box , however the label on the box was faded due to water (see Ex 9) Zyrtec is/was in the med box and is indicated on the MAR and labeled as CETIRIZINE HCL TAB (ZYRTEC), Yes Ceterizine hcl tabs was present as indicated on your report and is the same med as ZYRTEC (see EX 8) The Plan of correction moving forward is when scripts are discontinued based on the Dr. written documentation the Exec. Administrator shall review Dr. documentation and make any changes of meds in Caresoft, The name of the med that appears on the label will be verified to match exactly whats on the MAR. The process will be doubled checked by the Executive Director immediately after making updates that all meds are accurate and a check off off list will be used to ensure this has been done. Aside from this verification, the daily med check by the House manager and the Monthly review by the Executive Director with double check and verify the process a checked off list will further ensure compliance. The house manager and all staff have also been re-trained to review the MAR for accuracy. 03/12/2020 Implemented
6400.163(a)Individual #1 medication box contained medication Flovent hfa, which was not labeled or in the original container from the pharmacy. It could not be determined if this medication is being administered as prescribed.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.The medication Flovent hfa has been placed back in the box with the label of administration instructions by the house manager. The box with the label from the pharmacy was in the med box, because there is no lid to that box the med slipped out of it. The plan of correction is to rearrange the med box so the medication Flovent hfa will not fall on its side and out of the original packaging. Staff has also been trained to ensure that all meds be kept in the original box with the label of instruction and secured in the box when not administering. This process will be followed up by the daily med verification check by the House manager and the Monthly review by the Executive Director with verification checked off on a check off list will further ensure compliance. 03/12/2020 Implemented
6400.165(c)Individual #1 prescribed medication Albuterol states on label to inhale 1 puff every 4 hours as needed, however on the medication log it states 2 puffs every 4 hours as needed for wheezing. [REPEATED VIOLATION 10/29/19]A prescription medication shall be administered as prescribed.To remedy the problem. the Executive Admin has updated the MAR to reflect the correct dosage of the Albuterol to match the label on the med box. The script was changed from 2 puffs to 1 puff as needed and it was an oversight that the MAR was not updated, the MAR has been updated (see Ex. 7) The Plan of correction moving forward to prevent future occurrences is when scripts are received and inputted in the Caresoft program by the Executive Admin, ensuring that the name, strength, dosage, instructions and frequency of the med matches exactly what appears on the scripts and later matched with the actual med label. Any discontinued med if will be indicated if needed. The process will be doubled checked by the Executive Director immediately after inputting the med into Caresoft that all meds are accurate using a check off list.. Aside from this verification the daily med check by the House manager and the Monthly review by the Executive Director with verification check off list will further ensure compliance. The house manager and all staff have also been re-trained to review the med label against the MAR to ensure that labels on the meds in the med box appears exactly as it appears on the MAR. 03/12/2020 Implemented
6400.166(a)(9)-Individual #1 medication log is signed out that prescription medications were administered, however the medications were not present in the home to have been administered. These medications are clindamycin phosp, Flonase, ibuprofen, levofloxacin, methylprednisolone, vitamin D3 and Zyrtec. -Pepto Bismol was in Individual #1 med box, but not listed on the med log and staff could not explain if or how often this medication was being administered to this individual.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.The plan to fix the problem in regards to meds indicated on the MAR that were not in the house was reviewed by the Executive Administrator on March 12 and matched with the most recent scripts. It was found that discontinued meds were not indicated as discontinued or eliminated if discontinued in a previous months from the MAR ( ibuprofen, levofloxacin, methylprednisolone, Vitamin D) ....clindamycin phosp was in the med box , however the label on the box was faded due to water (see Ex 9) . The meds where the dosage was changed by the Dr. (Flonase) both entries remained on the MAR, the old dosage and the new. This glitch in the Caresoft system has been pointed out to Caresoft and corrected. In regards to Zyrtec, This med was in the med box labeled as Cetirizine HCL Tab (Zyrtec) and was in a container not a bubble pack. (see Ex 8) and was administered as directed. The over the counter Pepto Bismol has been removed from the med box.. The MAR has been updated. (see Ex 7) The Plan of correction moving forward to prevent future occurrences, is when scripts are received and inputted in the Caresoft program by the Executive Admin, the name, strength, dosage, instructions and frequency of the med shall matches exactly what¿s appears on the script and indicate any discontinued med if needed.When meds are recieved from the pharmacy the label will be double checked against the MAR by the house manager and double checked by the Ex. Admin. Meds with labels that are not legible, the pharmacy will be notified to provide a new label, no over the counter med will be administered unless a script is written and a label can be placed on the med bottle. The process will be checked again by the Executive Director immediately after inputting the med into Caresoft that all meds are accurate and a check off list will be used to ensure that this has been done. Aside from this verification the daily med check by the House manager and the Monthly review by the Executive Director with verification using a checked off list to ensure compliance. The house manager and all staff have also been re-trained to review the med label against the MAR 03/12/2020 Implemented
SIN-00165153 Unannounced Monitoring 10/29/2019 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Individual #1's current Individual Support Plan (ISP) stated poisons need to be locked, and cleaning products in the dining room were left unlocked.Poisonous materials shall be kept locked or made inaccessible to individuals. BWS House Manager/Supervisor has ensured that poisons and cleaning products have been locked away and made inaccessible to all individuals. The plan to prevent future occurrence is to train staff to lock items up immediately after usage. The House Manager/Lead, shall inspect on a daily bases that all items are locked and sign off on a daily check off list that this has been done. The Executive Director is responsible to do a weekly walk through, inspect the check off list, date and initial the check off list, as well as verify the that items are locked away. In addition a monthly inspection of the house will be done and documented on a Monthly Inspection list by the Executive Director. 11/15/2019 Implemented
6400.64(f)The outside trash can did not have a lid.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.A new trash can was purchased that has a non removeable lid and placed outside the house site.. The can was purchased by the CFO at a local store.(see photo) To prevent future occurrence of the violation the House Manager is responsible to monitor on a weekly bases that the trash cans are kept closed and sign off on a check list located at the site. . In addition the Executive Director is responsible to review the list for completion and also check the cans and document on a monthly check off list that that this has been completed 11/15/2019 Implemented
6400.183(5)Individual #1 is diagnosed with impulse disorder and takes psychotropic medications, and does not have a plan in place for their social, emotional and environmental needs.The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. To remedy the issue., Individual #1 SC has been notified by BWS Executive Director that the ISP does not include a plan for social, emotional and environmental needs due to diagnoses of impulse disorder and the he takes psychotropic medications. BWS plan to prevent future occurrence moving forward is to address the omission of a plan and require the ISP be updated with a critical revision before accepting the individual into the program. The ISP will be reviewed initially by the Office manger for identification of the protocol for individuals diagnosed with impulse disorders and taking Psychotropic medication, This item will be included on the check off list at Intake. The Executive Director will review both the check off list and the ISP and document by signing off the Intake list after review. 11/15/2019 Implemented
6400.214(b)The home did not have current records of individual #1's program or medical. They were in the office. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. To remedy the violation, a copy of the most current records information including medical has been put in a binder and taken to the home site by the House Manager. To prevent future occurrence the plan is to ensure that a program binder is created with all record information and medical information, binder will be placed at the site when an individual arrives. The Office Manager will ensure that all records are included in the Binder from a check off list. . The House manager will verify the contents of the Binder from a check off list . On a weekly basis the House manager will ensure that the binder is updated with current medical and records information. The Executive Director will Monitor on a monthly bases and sign off on a check off list that that this has been done (See attached) on a monthly bases. 11/15/2019 Implemented
6400.162(a)Staff person #1 and staff person #2 did not have documentation of medication administration in their training files, and were administering medications for individual #1.A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication.To remedy the violation that Staff #1and 2 did not have documentation of Med Admin Cert in their training files and were administration meds are as follows: BWS Office manager has documented on the employee check off list that Med Cert Documents have been received by BWS. , and ensured that current Med Admin Cert is included in staff training files. The Executive Director will review and monitor the Office Managers.documentation and all employees files at Hire and on a monthly bases. The Executive Director shall sign off that the review has been done on a Monthly Inspection check off list. Moving forward the plan to prevent future occurrences: All staff at hire that will be required to administer meds. must provide documentation of Med certification and have a practicum completed by BWS trainer or complete a Med Admin Cert training . Office Manager will ensure that the documentation is in the training file before staff is put on schedule and document of an employee check off list that documentation is present. . The Executive Director will then review all new hires training file to ensure that the Office manager has followed procedure and sign off the new hire to be scheduled. The Executive Director is also responsible to review all employees files on a monthly basis and document on a Monthly inspection check off list. 11/15/2019 Not Implemented
6400.165(c)Individual #1's morning medications of Diazepam 10mg I tablet, Hydroxyzine Pamoate 100mg 1 tablet, Oxcarbazepine 600mg 1 tablet, Oxcarbazepine 150mg 1 tablet, and Quetiapine Fumarate 300mg 1 tablet on 10/22/19 were not signed for and were still in the medication pack.A prescription medication shall be administered as prescribed.Individual #1's morning medications of Diazepam 10mg I tablet, Hydroxyzine Pamoate 100mg 1 tablet, Oxcarbazepine 600mg 1 tablet, Oxcarbazepine 150mg 1 tablet, and Quetiapine Fumarate 300mg 1 tablet on 10/22/19 were administered as prescribed and signed off on the electronic MAR system Caresoft . Staff administering the meds did not punch the meds from the correct chronological day of the month as indicated on the bubble pack. The plan to prevent this from occurring moving forward is to retrain staff on how to administer meds using the procedure of following the chronological day of the month to match the actual calendar day of the month. The House Manager/Lead will be responsible to monitor the Meds on a daily bases ensuring this procedure is implemented and followed. and to document on a daily check list that they have done so.. The Executive Director will inspect the list and the meds on a weekly bases and Monthly inspect again and document on an Monthly inspection check off list 11/15/2019 Not Implemented
6400.166(b)Individual #1's am medications of Diazepam 10mg I tablet, Hydroxyzine Pamoate 100mg 1 tablet, Oxcarbazepine 600mg 1 tablet, Oxcarbazepine 150mg 1 tablet, and Quetiapine Fumarate 300mg 1 tablet were not logged as given on 10/12/19, 10/19/19, 10/22/19, and 10/26/19. Individual #1's pm medications of Diazepam 10mg I tablet, Doxepin Hydrochloride 100mg, Hydroxyzine Pamoate 100mg 1 tablet, Oxcarbazepine 150mg 2 tablet, and Quetiapine Fumarate 300mg 1 tablet were not logged as given on 10/13/19, 10/18/19, 10/19/19, 10/20/19, 10/21/19, 10/25/19, and 10/26/19.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.A record of the time of administration of meds was documented in an electronic system Caresoft, not in a paper form that was reviewed at the site. Oxcarbazepine 150 mg script was transferred and first re-filled August 6, 2019 by with a 30 day bubble pack. Day 1 was popped August 6, 2019 which left 5 pills left over (Day 1-5) at the end of August, (see attached) Staff popped those pills instead of starting " Day 1" of the Septembers bubble pack , all the refills were dated on the first of every month moving forward. This left an ongoing 5 days each month left over. , To fix the issue. this med has been married with the others and the bubble pack "day 1" was popped starting December 1. To fix the violation of the MAR documentation , All reporting has been fully converted to Caresoft program on November 1, 2019, Prior MAR's were done in a paper form as well as electronically during the conversion, Recent staff have been trained by the office manager at Orientation on the Caresoft program and all other staff were also trained by the Office Manager. To prevent future occurrences , all paper MARs are removed from the sites and all staff have been directed to use only the Caresoft program for reporting. When meds are prescribed anytime during the month and filled , staff has been trained to start the actual day of the month that corresponded on the bubble pack. , the following month at time of refill left over meds shall be returned to the pharmacy and a full 30/31 day bubble pack will be delivered starting all meds at Day 1. The House Manager and Lead are responsible to monitor the records in Caresoft on a daily bases along with monitoring that meds are administered as prescribed and directed and document on a daily check off list. . The Executive Director is responsible to monitor the House Manager/Leads documentation weekly and on a monthly bases inspect MAR accuracy and sign off on a Monthly inspection list that it has been done 11/15/2019 Not Implemented
6400.167(b)Individual #1's medication on 10/22/19 were not administered, and no incident report was made for the medication error.Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record.Individual #1's were administered as prescribed and signed off on the electronic MAR system Caresoft . Staff administering the meds did not punch the meds from the correct chronological day of the month as indicated on the bubble pack. The plan to prevent this from occurring moving forward is to retrain staff on how to administer meds using the procedure of following the chronological day of the month to match the actual calendar day of the month. The House Manager/Lead will be responsible to monitor the Meds on a daily bases ensuring this procedure is implemented and followed. and to document on a daily check list that they have done so. (see attached) . The Executive Director will inspect the list and the meds on a weekly bases and Monthly inspect again and document on an Monthly inspection check off list 11/15/2019 Not Implemented
6400.169(d)Staff person #1 and staff person #2 did not have a record of the medication training they said they had completed.A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.To remedy the violation that Staff #1 and 2 did not have documentation of Med Admin Cert that they said they had. BWS Office manager documented on the employee check off list, and ensured that current Med Admin Cert is included in staff training files and a copy is in the binders at the house sites. The Executive Director will review and monitor the Office Managers.documentation and all employees files at Hire and on a monthly bases. The Executive Director shall sign off that the review has been done on a check off list. Moving forward the plan to prevent future occurrences: All staff at hire that will be required to administer meds. must provide documentation of Med certification and have a practicum completed by BWS trainer or complete a Med Admin Cert training . Office Manager will ensure that the documentation is in the training file before staff is put on schedule. The Executive Director will then review all new hires training file to ensure that the Office manager has followed procedure and sign off the new hire to be scheduled. The Executive Director is also responsible to review all employees files on a monthly basis and document it has been done. 11/11/2019 Not Implemented
SIN-00155196 Initial review 05/09/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)The basement stairs 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 has been installed for the basement stairs by the President, Vlad Brodsky. on 5/13/2019. Photos of the install have been forwarded to the inspector. To prevent this from happening moving forward, Regular weekly maintenance inspections and monitoring of the site will assure that all steps exceeding two steps have secure and safe hand rails 05/13/2019 Implemented
6400.111(a)The basement and second floor did not have a fire extinguisher.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. A fire extinguisher with a minimum 2-A rating has been installed on both the second floor and the basement by the President Vlad Brodsky, installation was complete on 5/13/2019, photos have been forward to the inspector. To prevent this from happening in the future, ongoing monitoring by daily walk thoughs of the site to inspect and assure that all extinguishers are in place will be conducted moving forward. 05/13/2019 Implemented
SIN-00173046 Unannounced Monitoring 04/23/2020 Compliant - Finalized