Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00235333 Renewal 11/08/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34On 11/8/2023, Chief Executive Officer #1 arrived at the agency office at 10:30AM for the prescheduled 10:00AM Entrance Conference for the Provisional Renewal inspection. During the Entrance Conference, the Licensing Representatives verbally provided the sample for the individuals, staff, and homes to be reviewed. At the end of the entrance conference, Chief Executive Officer #1 stated that she was leaving the agency office to retrieve the requested documents from her home. At 10:42AM, as follow-up, the Licensing Representatives provided, in writing via email, the sample of individuals and staff and additional documents needed to measure compliance to Chief Executive Officer #1. The requested information included but was not limited to staff and individuals' training records, medical and dental records, individuals' assessments, and individuals' plan documentation. At 11:30AM on 11/8/2023, staff records were provided. At 11:50AM, after reviewing the provided documentation the Licensing Representatives informed Office Manager #2 and Program Specialist #3 of additional training records needed. They reported that Chief Executive Officer #1 had the records. At 12:40PM, the Licensing Representative attempted to call Chief Executive Officer #1 but did not receive a response. At 12:41PM, the Licensing Representative then called Chief Operating Officer #4 who stated that he was on the way to the office with the requested records. When asked by the Licensing Representative when he would be arriving, Chief Operations Officer #4 admitted he had not left his home. The Licensing Representative departed the office to complete the on-site home inspections. From 1:54PM on 11/8/2023 to 5:00PM on 11/9/2023, the Department continued to request staff records and individual records including but not limited to training records, physical and dental examinations, and individual assessments to measure compliance. The Agency did not provide the requested documentation. [Repeat Violation, 4/27/2023]The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients.The individuals files and staff files are now available. 11/15/2023 Implemented
6400.22(e)(3)Individual #1's financial ledger documents a balance of $40.00 was deposited and then withdrawn on 11/3/2023. There was not documentation by actual receipts or explanations of what was purchased. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. Staff misplaced the receipts. However, staff was able to inform management what was purchased. 11/10/2023 Implemented
6400.67(b)At 1:48PM on 11/8/2023, the floor tile in front of the sink in the bathroom on the second floor of the home was loose and warped. In addition, there was a strong smell of what appeared to be mildew in this area. Floors, walls, ceilings and other surfaces shall be free of hazards.The bathroom floor was repaired. 11/16/2023 Implemented
6400.144Individual #1 is prescribed Prazosin HCL with instructions to "please monitor blood pressure." The agency is not documenting that Individual 1's blood pressure is being monitored. [Repeat Violation, 8/4/2022, 7/25/2023]Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Individual's 1 blood pressure is being monitored and the information is stored in his MAR. 11/20/2023 Implemented
6400.151(a)Chief Executive Officer #1, date of hire 5/1/2019, has not had 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. CEO #1 physical form is current and available. 11/09/2023 Implemented
6400.151(c)(2)Chief Executive Officer #1, date of hire 5/1/2019, has not had a Tuberlin skin testing. [Repeat Violation, 8/4/2022] 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. CEO #1 had a TB test completed. The form is available. 11/09/2023 Implemented
6400.18(b)(2)Daily logs revealed that staff reported that Individual #1 did not receive his morning and evening medications on 10/28/2023. As of 11/13/2023, the medication error(s) were not reported into Enterprise Incident Management, the Department's incident management system.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person: A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner.The incident was reported into the EIM system. 12/29/2023 Implemented
6400.46(b)Direct Service Worker #3, date of hire 5/2/2023, has not been trained in fire safety. Chief Operating Officer #2's most recent training in fire safety was completed on 10/22/2022.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Direct Service Worker 3 was trained in Fire Safety. Chief Operating Officer #2 Fire Safety training is current. 11/13/2023 Implemented
6400.46(d)Chief Executive Officer #1, date of hire 5/1/2019, has not been trained in Cardio-pulmonary Resuscitation or basic first aid. Chief Operations Officer #2, date of hire 5/1/2019, has not been trained in Cardio-pulmonary Resuscitation or basic first aid. Direct Service Worker #3, date of hire 5/2/2023, has not been trained in Cardio-pulmonary Resuscitation or basic first aid.Program 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.CEO #1 CPR training is recorded, available and current. 11/20/2023 Implemented
6400.51(b)(4)Direct Service Worker #3, date of hire 5/2/2023, did not complete training on recognizing and reporting incidents.The orientation must encompass the following areas: recognizing and reporting incidents.Direct Service Worker #3 completed Recognizing and Reporting incidents. 11/20/2023 Implemented
6400.51(b)(5)Direct Service Worker #3, date of hire 5/2/2023, did not complete training on job related knowledge and skills.The orientation must encompass the following areas: Job-related knowledge and skills.Direct Service Worker #3 completed job related knowledge and skills. 11/20/2023 Implemented
6400.52(c)(1)Chief Executive Officer #1's trainings for the annual training year 1/1/2022 through 12/31/2022 did not include the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. Chief Operations Officer #2's trainings for the annual training year 1/1/2022 through 12/31/2022 did not include 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.CEO #1 completed Person Centered Practices. 11/16/2023 Implemented
6400.52(c)(3)Chief Executive Officer #1's trainings for the annual training year 1/1/2022 through 12/31/2022 did not include individual rights. Chief Operations Officer #2's trainings for the annual training year 1/1/2022 through 12/31/2022 did not include individual rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.CEO #1 and COO #2 Individual Rights Certificate are available. 11/16/2023 Implemented
6400.52(c)(5)Chief Executive Officer #1's trainings for the annual training year 1/1/2022 through 12/31/2022 did not include the safe and appropriate use of behavior supports. Chief Operating Officer #2's trainings for the annual training year 1/1/2022 through 12/31/2022 did not include the safe and appropriate use of behavior supports.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.CEO #1 and COO #2 have been trained in the safe and appropriate use of behavior supports in 2022 and 2023. 11/15/2023 Implemented
6400.52(c)(6)Chief Executive Officer #1's trainings for the annual training year 1/1/2022 through 12/31/2022 did not include the implementation of the individual plans. Chief Operating Officer #2's trainings for the annual training year 1/1/2022 through 12/31/2022 did not include the implementation of the individual plan.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.CEO #1 and COO #2 have been trained in the implementation of Individual Plans and it is recorded on the their transcript. 11/15/2023 Implemented
6400.169(a)Direct Service Worker #3's Medication Administration Training, dated 5/12/2023, included only two of the four required medication administration observations. Direct Service Worker #1 administered Individual #1 prescribed medications on 11/5/2023 at 8:00AM.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).Direct Service Worker #3 has completed four required medication administration observations. 11/20/2023 Implemented
SIN-00232479 Unannounced Monitoring 09/21/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At 10:49AM, the microwave walls and ceiling had food splatter throughout the inside. The bottom of the oven was covered in grease and burnt food chards.Clean and sanitary conditions shall be maintained in the home. The microwave and oven were cleaned inside and outside. 09/21/2023 Implemented
6400.110(a)At 11:28AM, the smoke detector on the second floor of the home was inoperable. [Repeat Violation, 4/27/2023] A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. A new battery was placed in the smoke detector, to make it operable. 09/21/2023 Implemented
6400.165(c)Divalproex SOD FR 250MG, "take 1 tablet by mouth twice a day together with Divalproex 500MG" prescribed to Individual #1, was not administered from 9/3/2023 at 8:00PM through 9/6/2023 at 8:00AM. Prazosin HCL 1MG with instructions to, "take 1 capsule by mouth three times a day" prescribed to Individual #1, was not administered from 9/5/2023 at 8:00AM through 9/6/23 at 4:00PM.A prescription medication shall be administered as prescribed.Individual 1 is currently taking Divalproex SOD FR 250MG, and Prazosin HCL 1MG. 09/21/2023 Not Implemented
6400.165(e)The Chief Executive Officer #1 reported that Individual #1's prescribed medications were temporarily discontinued from 9/3/2023 to 9/6/2023 and therefore not administered. There were no written orders from the prescriber for the change in medication orders.Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received.Individual 1 is currently taking Divalproex SOD FR 250MG, and Prazosin HCL 1MG. 09/21/2023 Not Implemented
SIN-00229394 Unannounced Monitoring 08/08/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(b)At 11:19AM, mouse droppings were in the drawer in the bathroom on the second floor of the home.There may not be evidence of infestation of insects or rodents in the home. The mouse droppings that were in the drawer were removed from the drawer and disposed in the garbage. The Exterminator came to the home. He stated: "There were no mouse droppings in the drawer. Spiders kill small bugs to take with them later. The spiders wrap the bugs up to eat later. Spiders leave their bugs in areas throughout the home and return later to eat them." 08/09/2023 Implemented
6400.64(e)At 10:54AM, there was not a lid on the trash receptacle in the kitchen of the home. [Repeat Violation, 4/27/2023]Trash receptacles over 18 inches high shall have lids. A lid was placed on the trash receptacle. 08/08/2023 Implemented
6400.67(a)At 11:12AM, there was a section of metal, protruding near the bottom of the awning post of the patio in the back of the home, posing a laceration hazard.Floors, walls, ceilings and other surfaces shall be in good repair. The metal that was protruding near the bottom of the awning post of the patio was removed from the premises. 08/08/2023 Implemented
6400.72(a)Individual #1 has an air conditioner in bedroom window. At 11:26AM, there was a gap between the air conditioner and the window frame on both sides leaving space for insects to enter the home. [Repeat Violation, 4/27/2023]Windows, including windows in doors, shall be securely screened when windows or doors are open. Individual's 1 air conditioner is secured to prevent the insects from entering the bedroom. 08/09/2023 Implemented
6400.72(b)At 11:14AM, the screen, on the storm door on the side exit of the home, was detached on the top and left side. Screens, windows and doors shall be in good repair. The screen on the storm door was installed. 08/09/2023 Implemented
6400.73(a)At 11:37AM, there was not a railing on the three outside steps leading from the basement of the home. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. There was a railing installed outside the basement. 08/09/2023 Not Implemented
6400.74At 10:55AM, the bottom outside step, leading to the front entrance of the home, did not have a nonskid surface. At 11:37AM, the three outside steps, leading from the basement exit of the home, did not have a nonskid surface.Interior stairs and outside steps shall have a nonskid surface. A non-skid surface was installed on the bottom step leading to the front entrance of the home. 08/08/2023 Implemented
6400.76(a)At 11:32AM, there was a high-top table, near the entrance in the home, has a leg that is broken. The table needs to be leaning against the wall or chair to remain upright. Furniture and equipment shall be nonhazardous, clean and sturdy. The high - top table was removed from the home to be repaired. 08/08/2023 Implemented
6400.81(k)(4)The three pillows on Individual #1's bed do not have pillowcases. The pillows have a multitude brownish stains.In bedrooms, each individual shall have the following: A chest of drawers. The pillows are discarded in the garbage. Individual 1 received new pillows. 08/08/2028 Not Implemented
6400.82(f)There are not individual clean paper or cloth towels in the bathroom of the home. [Repeat Violation, 4/27/2023]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. Paper towels were distributed throughout the homes and in the bathroom. 08/08/2023 Implemented
6400.83(c)At 11:09AM, an unwashed glass and eating utensils were in the sink in the kitchen of the home.Utensils used for eating, drinking and preparation of food or drink shall be washed and rinsed after each use.The unwashed glass and eating utensils were washed, dried and stored with the other utensils. 08/08/2023 Implemented
6400.171At 10:54AM, a plate with cooked meat, partially covered by a paper towel, a carton of eggs with a best by date of 8/1/2023 and an unsealed package of cheese slices were in the refrigerator in the kitchen of the home. An open carton of ice cream with the lid sideways inside carton was in the freezer in the kitchen of the home. [Repeat Violation, 4/27/2023]Food shall be protected from contamination while being stored, prepared, transported and served. The plate with the cooked meat was covered with aluminum foil. The eggs were discarded and put in the garbage. The unsealed package of cheese slices were stored in a zip-lock baggie. 08/08/2023 Not Implemented
6400.214(b)The most recent copy of Individual #1's assessment was not at the home. [Repeat Violation, 4/27/2023] The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. Individual's 1 assessment was placed in the binder. 08/14/2023 Not Implemented
6400.207(4)(I)Individual #1 is prescribed Clonazepam with instructions to, "take 1 tablet by mouth twice a day if needed for: Agitation/Anxiety." There are not written instructions by a physician or medical practitioner listing the individual's specific symptoms of the psychiatric diagnosis that would warrant the use of the medication, and the CEO or CEO designee did not authorize the administration of the medication. This medication was administered daily at 8:00AM and 9:00PM from 8/1/2023 through 8/8/2023.A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition.Individual is given the medication as prescribed. Even though the prescription states, "take 1 tablet by mouth twice a day as needed for agitation/anxiety, individual 1 asks for the medication twice a day. 09/06/2023 Implemented
SIN-00229391 Unannounced Monitoring 07/25/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)At 10:49AM, a spray bottle of Clorox All Purpose Cleaner was unlocked and accessible on a book shelf in staff office. Individual #1's Individual Service Plan, completed 10/18/2022, reads, "[Individual #1] must be supervised while using poisonous substances and all poisonous substances should be secured." [Repeat Violation, 4/27/2023]Poisonous materials shall be kept locked or made inaccessible to individuals. Clorox All Purpose Cleaner was placed in locked closet. 07/25/2023 Implemented
6400.64(a)At 11:17AM, soiled clothes were on top of an artificial plant and on a chair in the dining room of the home. There were dark stains on the carpets throughout the home. The floor in the kitchen had a multitude of areas with sticky substances and food crumbs.Clean and sanitary conditions shall be maintained in the home. Soiled clothes were removed from the artificial plant in dining room and washed. Carpet was evaluated by Carpet Specialist to determine if the carpet could be cleaned or did we need to install new carpet. Carpets will be cleaned professionally on 9/29/23. The kitchen floor was mopped. 07/25/2023 Not Implemented
6400.64(e)The trash receptacle in the kitchen did not have a lid.Trash receptacles over 18 inches high shall have lids. A lid was placed on the trash receptacle. 07/25/2023 Implemented
6400.66The light in the back room of the basement leading to the back exit of the home is inoperable.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. A new light bulb was installed in the basement leading to the back exit. 07/25/2023 Implemented
6400.67(b)At 10:47AM, one of the four burners on the electric stove was outside of the base and on top of the middle of the stove. One of the knobs is broken off the control panel of the stove. Floors, walls, ceilings and other surfaces shall be free of hazards.The one burner was replaced, and a new knob was placed on panel of stove. 07/28/2023 Implemented
6400.73(b)The railing on the right side of the porch in the front of the home is loose and moves when in use.Each porch that has over an 18-inch drop shall have a well-secured railing.The railing on the right side of the porch was secured and repaired. 07/25/2023 Not Implemented
6400.77(a)There was not a first aid kit at the home. A home shall have a first aid kit. The First Aid Kit was in the second jour in the filing cabinet located in the staff office. Outside, the second Jour of the filing cabinet is a First symbol to inform and remind staff where the First Aid Kit is located. 04/27/2023 Implemented
6400.80(b)At 10:54AM, there was a broken screen door with jagged metal pieces, leaning against the back of the home posing a tripping and laceration hazard. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The broken screen door with the jagged metal pieces that were leaning against the back of the home was removed from the premises. 07/25/2023 Implemented
6400.101There is a slide lock on the inside of the door in the basement leading to the back exit of the home posing an obstructed egress.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The slide lock in the inside of the door of the basement was removed. 07/25/0223 Implemented
6400.105At 11:02AM, there was a ¾ inch thick accumulation of lint attached to the dryer lint trap. In addition, there was an accumulation of lint in the lint trap holding area of the dryer.Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. Lint was removed from the dryer lint trap. Maintenance personnel completed a thorough cleaning of the dryer ducts in each home. Each home was given dryer brush to remove excess lint. 07/25/2023 Implemented
6400.171At 10:45AM, an uncovered plate with partially eaten hamburgers, a breaded chicken and white sauce was on the top shelf of the refrigerator in the kitchen of the home. An unsealed package of "toaster pastries" with instructions to keep frozen was on the top shelf of the refrigerator in the kitchen of the home. [Repeat Violation, 4/27/2023]Food shall be protected from contamination while being stored, prepared, transported and served. Food that was left uncovered were covered with aluminum foil. The unsealed package of "toaster pastries" were discarded in the garbage. Each home were provided plenty of aluminum foil. saran wrap and baggies, tape and a marker to prevent the food from being contaminated. 07/25/2023 Not Implemented
6400.214(b)The most recent copy of Individual #1's assessment was not in the residential home. [Repeat Violation, 4/27/2023] The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. Individual's 1 assessment was placed in the binder. 08/14/2023 Not Implemented
6400.163(a)At 11:08AM, Individual #1's medications were stored in a plastic storage bag. The original labeled containers were not present at the home. Individual #1's prescribed medication, Clonazepam, is being stored in a previously used prescription bottle with discontinued instructions on the label. [Repeat Violation, 4/27/2023]Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.Individual's 1 medications were placed in their original containers. 07/25/2023 Implemented
6400.163(b)At 11:08AM, Individual #1's medications were removed from the original containers and stored in a plastic storage bag with the next administrations dispensed in advance. [Repeat Violation, 4/27/2023]A prescription medication may not be removed from its original labeled container in advance of the scheduled administration, except for the purpose of packaging the medication for the individual to take with the individual to a community activity for administration the same day the medication is removed from its original container.Individual's 1 medications were placed in their original containers. 07/25/2023 Implemented
6400.163(d)Individual #1 is prescribed Clonazepam, a controlled substance was not stored in a doubled locked area or double locked container.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.Clonazepam was placed in a locked safe and locked in the medication closet. 07/25/2023 Implemented
6400.165(c)Individual #1 is prescribed Clonazepam with instructions to, "take 1 tablet by mouth twice a day as needed for agitation/anxiety was administered daily at 8:00AM from 7/1/2023 through 7/25/2023.A prescription medication shall be administered as prescribed.Individual is given the medication as prescribed. 07/25/2023 Implemented
6400.207(4)(I)Individual #1 is prescribed Clonazepam with instructions to, "take 1 tablet by mouth twice a day as needed for agitation/anxiety. There are not written instructions by a physician or medical practitioner listing the individual's specific symptoms of the psychiatric diagnosis that would warrant the use of the medication, and the CEO or CEO designee did not authorize the administration of the medication. This medication was administered daily at 8:00AM from 7/1/2023 through 7/25/2023.A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition.Individual is given the medication as prescribed. Even though the prescription states, "take 1 tablet by mouth twice a day as needed for agitation/anxiety, individual 1 asks for the medication twice a day. 09/06/2023 Implemented
SIN-00209752 Renewal 08/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(2)Chief Executive Officer #1 had a physical examination completed on 9/28/2021; however, the physical examination did not contain a Tuberculin evaluation. 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. Obtained information from Dr. Gregory George that that he completed the 11/5/20 reading. [Updated physical examination form containing the physician's signature for the Tuberculin evaluation, dated 9/22/22, received on 10/5/22 and reviewed 10/18/22. DPOC by HDKP, HSLS, on 10/18/22]. 09/29/2022 Implemented
6400.151(c)(3)Direct Services Worker #2's physical examination, dated 5/2/22, does not contain a written statement that the staff person if free from a 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. Obtained documentation that Direct Service Worker #2 is free from a communicable disease. {Updated physical examination containing statement that the employee is free from communicable disease, dated 10/3/22, was recieved on 10/5/22 and reviewed 10/18/22. DPOC by HDKP, HSLS, on 10/18/22]. 10/03/2022 Implemented
SIN-00192279 Renewal 08/18/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Program Specialist #1, date of hire 5/01/2019, had a request for a Pennsylvania criminal background check submitted 5/28/2019. Chief Executive Officer #2, date of hire 5/01/2019, had a request for a Pennsylvania criminal background check submitted 5/28/2019.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. CEO and Program Specialist will ensure regulatory compliance by submitting a request for a PA State Police (e-patch) within 5 working days from the staff person¿s date of hire. CEO and Program Specialist will review all employee criminal background checks to ensure that the issue is not systemic throughout the agency. [Within 30 days, the CEO, or designee, shall review all employee criminal background checks for compliance with 6400.21(a)-(d). Documentation of aforementioned annual review of regulations by CEO and Program Specialist shall be maintained. DPOC by HDKP, HSLS, on 10/22/2021]. 09/06/2021 Implemented
6400.112(c)The record for the fire drill completed on 12/15/2020 did not include the amount of time it took for evacuation. This section of the form was blank.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. Following the completion of each fire drill, CEO and Program Specialist will review the entire fire drill form and ensure each section is completed. CEO and Program Specialist will train the staff on the requirements of the fire drill documentation that is stated in 6400.112 (c ). [Within 30 days, the CEO, or designee, shall train all staff responsible for conducting fire drills on the requirements of documentation of fire drills, as required by 6400.112(c). Documentation of training shall be maintained. Documentation of aforementioned quarterly reviews of fire drills by CEO and Program Specialist shall be maintained. DPOC by HDKP, HSLS, on 10/22/2021]. 09/06/2021 Implemented
6400.141(a)Individual #1, admission date 8/09/2021, does not have a physical examination on file.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. CEO and Program Specialist will make sure every individual will have a physical examination prior to them being admitted to our agency and annually thereafter. 09/06/2021 Implemented
6400.166(b)Individual #1, admission date 8/09/2021, is prescribed Olanzapine 10 MG -- Take 1 tablet by mouth at bedtime. This medication was not listed on the Medication Administration Record from 8/01/2021 forward.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The Chief Executive Officer will make sure that each medication is listed on the Medication Administration Record. An the Medication Administration Record will have the date and time of the medication administered. An their will be a record of the name and initials of the person administering the medication. [Within 30 days, the CEO, or designee, shall train all staff responsible for administering medications on the requirement to immediately document administration of any medication to any individual on the Medication Administration Record (MAR). Documentation of the training shall be kept. Documentation of the aforementioned daily and quarterly audits of all individual Medication Administration Records (MARs) shall be maintained. DPOC by HDKP, HSLS, on 10/22/2021]. 09/06/2021 Implemented
6400.213(1)(i)The record for Individual #1, admission date 8/09/2021, did not include 6400.213(1)(i) admission date, 6400.213(1)(ii) height, weight, color of hair, color of eyes and identifying marks, 6400.213(1)(iv) religious affiliation, or 6400.213(1)(v) next of kin.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.On 8/18/21, the missing information was added to the individual¿s file. The CEO and Program Specialist reviewed regulation 6400.213 (1) ¿(8) on 8/18/21. To continue to maintain compliance CEO will review regulation 6400.213 (1) ¿(8) on an annual basis (before 9/6/22) and annually thereafter. [Within 30 days, the CEO, or designee, shall review all individual records to ensure that the individual's record contains all required information in accordance with 6400.213(1)-(8). Documentation of the aforementioned quarterly review of individual records shall be maintained. DPOC by HDKP, HSLS, on 10/22/2021]. 08/18/2021 Implemented
SIN-00226803 Unannounced Monitoring 05/04/2023 Compliant - Finalized
SIN-00175371 Initial review 08/21/2020 Compliant - Finalized