Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00235337 Renewal 11/08/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(3)Individual #1's October 2023 financial ledger documents purchases on the individual's behalf including $22.18 on 10/16/2023, $18.36 on 10/18/2023, $16.92 on 10/20/2023 and $36.03 on 10/30/2023. There was not documentation by actual receipt or explanation 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. 11/09/2023 Implemented
6400.64(a)At 11:09AM on 11/9/2023, a pill crusher and pill cutter in Individual #1's medication closet contained thick pink and white residue from medications that were previously cut and crushed for the individual.Clean and sanitary conditions shall be maintained in the home. The pill crusher was cleaned. 11/09/2023 Implemented
6400.72(b)At 10:55AM on 11/9/2023, the screen in the bathroom window is bent inward allowing space for insects to enter the home. [Repeat Violation, 8/4/2022] Screens, windows and doors shall be in good repair. The screen was repaired so no insects will enter the home. 11/15/2023 Implemented
6400.113(a)Individual #1, date of admission 4/12/2023, was not instructed in general fire safety. [Repeat Violation, 8/4/2022] An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. Individual 1 was instructed in Fire Safety upon admission. The Fire Safety Training was documented. 11/09/2023 Implemented
6400.141(a)Individual #1 date of admission 4/12/2023 did not have a physical examination.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual #1's most recent physical examination was completed and it is in individual #1 binder. 11/09/2023 Implemented
6400.141(c)(6)Individual #1, date of admission 4/12/2023 did not have Tuberculin skin testing.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's # 1 TB test was attached to his Physical and it was in individual's #1 binder. 11/09/2023 Implemented
6400.142(f)Individual #1, date of admission 4/12/2023, does not have a dental hygiene plan. The Individual Service Plan, last updated 8/30/2023, reads, "he will not participate in any part of maintaining his daily hygiene and requires the support of others to do so." [Repeated violation 8/4/2022]An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. The Dental Hygiene Plan was attached to his Assessment Results, which was located in his binder. 11/09/2023 Implemented
6400.181(a)Individual #1, date of admission 4/12/2023, has not had an initial assessment. [Repeat Violation, 8/4/2022] 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 assessment was located in individual's #1 binder. 11/09/2023 Implemented
6400.34(a)Individual #1, date of admission 4/12/2023, has not been informed and explained individual rights. [Repeat Violation, 8/4/2022]The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Individual's #1 was informed and explained of their individual rights upon admission. A copy of their Individual Rights and signature are in their binder. The original is located in their file. 11/09/2023 Implemented
6400.46(b)Direct Service Worker #1, date of hire 7/24/2021, has not been trained in fire safety.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 #1 was trained in Fire Safety. 11/09/2023 Implemented
6400.46(d)Direct Service Worker #1, date of hire 7/24/2021, has not been trained in first aid, Heimlich techniques and cardio-pulmonary resuscitation.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.Direct Worker #1 was trained in CPR and First Aid. 11/09/2023 Implemented
6400.52(c)(1)Direct Service Worker #1's training 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.Direct Service Worker #1 completed Person Centered Practices. 11/09/2023 Implemented
6400.52(c)(2)Direct Service Worker #1's training for the annual training year, 1/1/2022 through 12/31/2022, did not include the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.Direct Service Worker #1 completed Prevention, Detection and reporting abuse and alleged abuse training: Child Protective Services, Older and Adult Protective Services training. 11/09/2023 Implemented
6400.52(c)(3)Direct Service Worker #1's training 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.Direct Service Worker #1 Individual Rights Certificate is available. 11/09/2023 Implemented
6400.52(c)(4)Direct Service Worker #1's training for the annual training year, 1/1/2022 through 12/31/2022, did not include recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Direct Service Worker #1 completed Recognizing and Reporting Incidents. 11/09/2023 Implemented
6400.52(c)(5)Direct Service Worker #1's training 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.Direct Service Worker #1 was trained in safe and appropriate use of behavior supports. 11/09/2023 Implemented
6400.52(c)(6)Direct Service Worker #1's training 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.Direct Service Worker #1 completed implementation of individual plan. 11/09/2023 Implemented
6400.162(a)Individual #1 is prescribed Diazepam with instructions to, "administer 10MG rectally as needed for seizures lasting more than 5 minutes," and Albuterol Sulfate Inhaler with instructions to, "inhale one puff every four hours as needed for wheezing." Direct Service Worker #1 worked alone with Individual #1 on the morning of 11/9/2023 and has not completed a Department approved medication administration course.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.CEO is the process of completing Medication Administration Training. Upon completing Medication Administration: Train the Trainer course, Direct Service Worker #1 will be trained in Medication administration. Direct Service Worker #1 is trained to administer Diazepam with instructions to, "administer 10MG rectally as needed for seizures lasting more than 5 minutes," and trained to administer Albuterol Sulfate Inhaler with instructions to, "inhale one puff every four hours as needed for wheezing." 12/27/2023 Implemented
6400.165(f)Individual #1 is prescribed medication to treat symptoms of a diagnosed psychiatric illness. There was no documentation provided verifying that a written protocol to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.The Social, Emotional and Environmental Needs Plan is placed in the individual's #1 binder. 12/05/2023 Implemented
6400.165(g)Individual #1, date of admission 4/12/2023, is prescribed medication to treat symptoms of a psychiatric illness. Individual #1 has not had a review of prescribed psychiatric medications by a licensed physician. [Repeat Violation, 8/4/2022]If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Individual #1 has Med Review completed. 11/09/2023 Implemented
SIN-00233360 Unannounced Monitoring 10/19/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(b)(3)Staff interviews revealed that staff has been liquifying Individual #1's medications by boiling water, mixing them together, putting the mixture into juice and then administering the medication with an oral syringe for the past month. Prior to this practice, staff was crushing the medication. The medication label for Individual #1's prescribed, Divalproex, states, "swallow whole. Do not crush or chew." Individual #1 is prescribed Divalproex SOD DR 500 MG tablets with instructions to, "Take 2 tablets in the morning. Take 2 tablets at bedtime." The 8AM dose of this medication has not been administered from 10/1/2023 through 10/19/2023. Individual #1 is prescribed Clonazepam with instructions to, "take one tablet three times a day." Individual #1's prescribed 12PM dose was not administered 10/17-19/2023. Chief Executive Officer #1 has failed to implement and adhere to medication administration policies that support the safety and protection of Individual #1.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. Staff that are medication trained immediately stopped liquifying individual 1's medications by boiling water, mixing them together, putting the mixture into juice and then administering the medication with an oral syringe. Staff that are medication trained also stopped crushing individual 1's medication. 10/19/2023 Not Implemented
6400.62(a)At 11:20AM, a container of Soft Soap Hand Soap with instructions to contact Poison Control if ingested was on the counter in the bathroom on the first floor of the home. At 11:30AM, a container of Disinfectant Wipes with instructions to contact Poison Control if ingested was on a shelf in the unlocked, detached garage in the back of the home. Individual #1 is not assessed safe with poisons. [Repeat Violation, 4/27/2023, 7/25/2023]Poisonous materials shall be kept locked or made inaccessible to individuals. The Soft Hand Soap with instructions to contact Poison Control if ingested was locked in the Chemical closet. The Disinfectant Wipes with instructions to Contact Poison Control if ingested was locked in the Chemical closet. 10/19/2023 Implemented
6400.64(a)At 11:26AM, there was backed up of sewage with a strong, foul odor in the shower in the bathroom in the basement of the home.Clean and sanitary conditions shall be maintained in the home. The Sprinkler System was just installed in the home. The company that installed the Sprinkler System along with the water company were running several water tests throughout the Sewer line and the water line that was connect to the Sprinkler System. Due to the amount of water that was running thru the water pipes at the same time, caused the sewer line to be backed up, which caused and overflow, which caused a strong four odor to come thru the shower in the basement. 10/19/2023 Implemented
6400.67(a)The railing on the porch in the front of the home is not sturdy and wobbles back and forth when in use.Floors, walls, ceilings and other surfaces shall be in good repair. The railing of the porch was tightened. 10/19/2023 Implemented
6400.68(b)At 11:35AM, the hot water temperature measured 123.6°F at the bathtub in the bathroom on the first floor of the home. Hot water temperatures in bathtubs and showers may not exceed 120°F. The water temperature was elevated due to the Sprinkler System being installed and the tests being done on the Sprinkler System. 10/19/2023 Implemented
6400.111(f)The fire extinguisher in the basement of the home does not have a tag or receipt verifying it's inspection or approval by a fire safety expert. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. A Fire safety expert was contacted and installed a new tag on the fire extinguisher. 10/19/2023 Implemented
6400.214(b)Individual #1's incident reports and psychological evaluation were not present at the home. [Repeat Violation, 4/27/2023, 7/25/2023] The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. The incident reports and psychological evaluation were placed in individual's 1 binder. 10/19/2023 Not Implemented
6400.18(a)(5)At 11:25AM on 10/19/2023, Chief Executive Officer #1 was informed of a neglect incident involving the agency's failure to provide medication management. Chief Executive Officer #1 reported the incident in Enterprise Incident Management system, the department's incident management system at 12:37AM on 10/22/2023.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: Neglect. CEO entered the agency's failure to provide medication management in the EIM system that day. However, CEO was informed by the inspector to enter the incident as Neglect instead of a Medication Error. On 10/22/23 the county's Program Specialist contacted the CEO and informed the CEO the incident needs to be entered as Neglect, the CEO entered the incident as Neglect on 10/22/23. 10/19/2023 Implemented
6400.32(c)Staff interviews revealed that staff has been liquifying Individual #1's medications by boiling water, mixing them together, putting the mixture into juice and then administering the medication with an oral syringe for the past month. Prior to this practice, staff was crushing the medication. The medication label for Individual #1's prescribed, Divalproex, states, "swallow whole. Do not crush or chew."An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.Staff that are medication trained immediately stopped liquifying individual 1's medications by boiling water, mixing them together, putting the mixture into juice and then administering the medication with an oral syringe. Staff that are medication trained also stopped crushing individual 1's medication. 10/19/2023 Implemented
6400.162(a)Individual #1 is prescribed Diazepam with instructions to, "administer 10MG rectally as needed for seizures lasting more than 5 minutes," and Albuterol Sulfate Inhaler with instructions to, "inhale one puff every four hours as needed for wheezing." Direct Service Worker #2 worked alone with Individual #1 on the morning of 10/19/2023 and has not completed a Department approved medication administration course.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.Although Direct Service Worker 2 worked alone with individual 1 and has not completed the Medication Administration Course; Direct Service Worker has been trained to administer Diazepam and asthma medication. 10/19/2023 Not Implemented
6400.163(a)Individual #1's Albuterol HFA 90 MCG Inhaler was not in the originally labeled container. The container and label were not present at the home. [Repeat Violation, 4/27/2023, 7/25/2023]Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.Albuterol HFA 90 MCG Inhaler is in the originally labeled container. 10/19/2023 Implemented
6400.165(c)Individual #1 is prescribed Divalproex SOD DR 500 MG tablets with instructions to, "Take 2 tablets in the morning. Take 2 tablets at bedtime." The 8:00AM dose of this medication has not been administered from 10/1/2023 through 10/19/2023. Individual #1 is prescribed Clonazepam with instructions to, "take one tablet three times a day." Individual #1's prescribed 12:00PM dose was not administered from 10/17/2023 though 10/19/2023. [Repeat Violation, 4/27/2023, 7/25/2023]A prescription medication shall be administered as prescribed.Staff that are medication trained immediately stopped liquifying individual 1's medications by boiling water, mixing them together, putting the mixture into juice and then administering the medication with an oral syringe. Staff that are medication trained also stopped crushing individual 1's medication. 10/19/2023 Not Implemented
6400.166(a)(2)Individual #1's October 2023 Medication Administration Record includes a physician who currently does not prescribe medication to Individual #1.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.The Medication Administration Record includes a physician that is currently prescribing the medication. 10/19/2023 Implemented
6400.166(a)(4)Individual #1 is prescribed Divalproex SOD DR 500 MG tablets with instructions to, "Take 2 tablets in the morning. Take 2 tablets at bedtime." The morning dose of this medication has not been administered from 10/1/2023 through 10/19/2023. Individual #1 is prescribed Clonazepam with instructions to, "take one tablet three times a day." Individual #1's prescribed 12PM dose was not administered 10/17-19/2023. [Repeat Violation, 4/27/2023, 7/25/2023]A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.Medication trained staff forgot to sign the Medication Record after administering the medication for dates 10/1/23 to 10/18/23. 10/19/2023 Implemented
6400.166(b)Individual #1 is prescribed Clonazepam .5MG with instructions to, "Take 1 tablet three times a day for seizures." The 12PM administration was initialed on 10/17/2023 and 10/18/2023. Chief Executive Officer #1 filed an incident in Enterprise Incident Management, the department's incident management system, on 8:01PM on 10/19/2023 stating, "Clonazepam was not taken on 10/17/2023 and 10/18/2023 at 12PM." [Repeat Violation, 4/27/2023]The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Medication trained staff is now administering the Clonazepam on time. 12/05/2023 Implemented
6400.167(a)(8)Staff interviews revealed that staff has been liquifying Individual #1's medications by boiling water, mixing them together, putting the mixture into juice and then administering the medication with an oral syringe. Individual #1's prescribed medication, Divalproex, label reads, "Swallow whole. Do not chew or crush."Medication errors include the following: Improper preparation of the medication.Staff that are medication trained immediately stopped liquifying individual 1's medications by boiling water, mixing them together, putting the mixture into juice and then administering the medication with an oral syringe. Staff that are medication trained also stopped crushing individual 1's medication. 10/19/2023 Implemented
SIN-00229396 Unannounced Monitoring 08/08/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)At 1:29PM, an identified clear substance was in an unlabeled plastic spray bottle in a locked closet with additional cleaning products.Poisonous materials shall be stored in their original, labeled containers. The identified clear substance that was in an unlabeled plastic spray bottle was discarded from the home. 08/08/2023 Implemented
6400.64(b)At 1:04PM, there were mouse droppings along base of the wall and on the shelf on the wall in the bathroom in the basement of the home. In addition, there were what appeared to be gnats along the walls in this bathroom.There may not be evidence of infestation of insects or rodents in the home. The mouse droppings along the base of the wall and on the shelf on the wall in the bathroom in the basement were removed. The gnats along the walls in the bathroom in the basement were removed. Also that day, the Exterminator came to the home and placed mouse traps in the basement and traps to attract the gnats. 08/08/2023 Implemented
6400.67(b)At 1:04PM, there was a pipe, protruding the sump pump in the basement of the home, that appears to be leaking and has created a puddle of water on the floor posing slipping hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.The sump pump was repaired. 08/11/2023 Implemented
6400.72(a)The screen, in the kitchen window, was not attached to the bottom of the frame and would not prevent insects from entering the home. [Repeat Violation, 4/27/2023]Windows, including windows in doors, shall be securely screened when windows or doors are open. The entire screen was installed in the kitchen window to prevent insects from entering the home. 08/10/2023 Implemented
6400.73(a)The handrail, on the right leading up the steps on the porch in the front of the home, is completely detached at the bottom. The handrail, on the left side leading up the steps on the porch in the front of the home, is loose and moves when used. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The handrail on the right leading up the stairs on the porch in front of the home was repaired. As well as the handrail on the left was repaired. 08/09/2023 Implemented
6400.76(a)At 1:20PM, the left side hanger on the mirror that goes over the door in Individual #1's bedroom was broken and was no longer attached to the mirror causing the mirror to lean and no longer be secured to the door. At 1:25PM, the bottom two drawers of the dresser in Individual #1's bedroom are not on the tracks causing the drawers to be difficult to open and close. In addition, the bottom panel of the second drawer from the bottom of the dresser in Individual #1's bedroom, is bending from what appears to be the weight of the clothing.Furniture and equipment shall be nonhazardous, clean and sturdy.The broken mirror was removed from the home. A new mirror was installed in the bedroom. 08/08/2023 Implemented
6400.80(b)At 1:35PM, there was a downspout pipe detached from the garage and was on the ground next to the garage. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The downspout pipe was reattached to the garage. 08/11/2023 Implemented
6400.82(f)The full bathroom in the basement of the home did not contain soap, toilet paper, clean individual paper or cloth towels, or a trash can. [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. Soap, toilet paper, clean paper towels and trash can was placed in the bathroom in the basement. 08/14/2023 Implemented
6400.107At 1:25PM, a portable space heater was in the detached garage which is eight feet and two inches from the home. [Repeat Violation, 4/27/2023]Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms. The portable space heater was removed from the detached garage. 08/08/2023 Implemented
6400.171At 12:58PM, an unsealed, partially used package of bacon, five unsealed containers of yogurt and a container of sliced ham lunch meat with a use by date of 7/24/2023 were in 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. The bacon, the five unsealed containers of yogurt were wrapped in aluminim foil. The container of sliced ham that was expired was disposed in the garbage. 08/08/2023 Not Implemented
6400.214(b)The most current copy of individual #1's assessment was not present 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 1's assessment was placed in the binder. 08/14/2023 Not Implemented
6400.216(a)At 1:40PM, a binder containing Individual 1's record, including but not limited to the most recent physical examination, demographic sheet and Individual Service Plan, was unlocked and unattended on a desk in the living room of the home. An individual's records shall be kept locked when unattended. Individual's 1 binder that has his records are locked in the medication closet. 08/08/2023 Implemented
6400.32(r)(3)Individual #1 has not been provided the assistive technology to allow Individual #1 to lock and unlock Individual #1's bedroom door.Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance.Individual 1 Supports Coordinator was contacted to discuss whether or not Individual 1 is in need of a lock or unlocked bedroom door. 08/08/2023 Implemented
6400.163(a)Individual #1's prescribed medication, Diazepam Rectal Gel, was not in the original labeled container and was not labeled with a label issued by the pharmacy. There was a "post-it" note on the medication with the prescribed dose and when to administer. Individual #1's Albuterol Inhaler, was not in the original labeled container and was not labeled with a label issued by the pharmacy. [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.There is a new Diazepam Rectal Gel that is in an original labeled container. 08/08/2023 Implemented
6400.193(b)(2)The home is locking sharp items to include knives in the a cabinet in the kitchen of the home. Individual #1 does not have restrictive procedures requiring the locking of sharp items.For each incident requiring restrictive procedures: A restrictive procedure may not be used unless less restrictive techniques and resources appropriate to the behavior have been tried but have failed.The knives are in the cabinet. 08/08/2023 Implemented
SIN-00224159 Unannounced Monitoring 04/27/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34During a remote inspection beginning that began at 4:03PM on 5/1/2023, Chief Executive Officer #1 muted herself on her cellphone at 4:40PM. From 4:40PM to 5:17PM when the agents of the Deparment ended the call, Chief Executive Officer #1 did not respond or provide access to the agents of the Department's repeated verbal request for her to return to the call.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.During conversations with agents of the Department, periodically make sure the mute button is not on. 05/02/2023 Not Implemented
6400.62(a)At 10:20AM on 4/27/2023, a spray bottle of Spic N' Span cleaner was unlocked and accessible in the cabinet under the sink in the bathroom on the first floor of the home. At 10:30AM, a container of Brillo Basics cleaning wipes was on the counter in the kitchen. Both cleaning products have directions to contact Poison Control if ingested. At 12:30PM on 5/2/2023, spray bottles of Comet, Oxy Cleaner and Spic N' Span were unlocked and accessible in the cabinet under the sink in the bathroom on the first floor of the home.Poisonous materials shall be kept locked or made inaccessible to individuals. Poisonous materials will be locked when not in use. 05/01/2023 Implemented
6400.72(a)There is not a screen in the window in bedroom #2.Windows, including windows in doors, shall be securely screened when windows or doors are open. The screen was out for repair. Once repaired screen will be installed in the window. 04/29/2023 Not Implemented
6400.81(k)(6)There is not a mirror in Individual #1's bedroom.In bedrooms, each individual shall have the following: A mirror. A mirror was purchased and placed in the room. 04/29/2023 Implemented
6400.107At 10:21AM on 4/27/2023, a portable space heater was powered on in the staff office. At 12:32PM on 5/2/2023, a portable space heater was in the staff office.Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms. Portable space heater was removed from the home. 04/27/2023 Implemented
6400.162(b)(2)(vi)Individual #1 is prescribed Diazepam with directions to, "administer 10MG rectally as needed for seizures lasting more than 5 minutes." The staff persons have not been trained to administer this medication.A prescription medication that is not self-administered shall be administered by one of the following: A person who has completed the medication administration course requirements as specified in § 6400.168 (relating to medication administration training) for the administration of the following: Medications, injections, procedures and treatments as permitted by applicable statutes and regulations.Staff will be trained to administer Diazepam. 06/14/2023 Not Implemented
6400.163(a)At 10:30AM on 4/27/2023, Individual #1's medications were removed from their originall labeled containers and stored in a weekly medication organizer. The original labeled containers were not present at the home.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 medication was returned to their original labeled containers. 04/28/2023 Implemented
6400.163(b)At 10:30AM on 4/27/2023, Individual #1's medications were removed from their original container and stored in a weekly medication organizer with the administrations dispensed in advance for the next three days of administrations.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 medication was returned to their original labeled containers. 04/28/2023 Implemented
6400.163(g)At 10:47AM on 4/27/2023, a blister pack of Levocarnitine with one pill exposed was on the shelf in the closet in the kitchen.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.Placed Levocarnitine in a plastic labeled ziploc bag or sealed bag in accordance with the manufacturer¿s instructions. 04/28/2023 Implemented
6400.165(b)Individual #1 is prescribed Divalproex. The medication label on one prescription states, "Divalproex Sod DR 250MG, take 1 tablet by mouth once daily." The medication label on the second prescription states, "Divalproex Sod DR 500MG, take 2 tablets by mouth twice a day." Individual #1's April and May 2023 Medication Administration Record states, "Divalproex Sod DR 500MG, take 2 tablets in the morning, take 1 tablet 250MG at bedtime."A prescription order shall be kept current.CEO contacted doctor to confirm the doctor¿s order of Divalproex Sod DR 250 MG, ¿Take 1 tablet by mouth once daily.¿ An the Divalproex Sod DR 500 MG, ¿Take 2 tablets by mouth twice a day.¿ Dr. confirmed his orders. Divalproex Sod DR 250 MG, ¿Take 1 tablet by mouth once daily, In the morning¿ An the Divalproex Sod DR 500 MG, ¿Take 2 tablets by mouth twice a day. The information was stated on the MAR. 04/27/2023 Implemented
6400.165(c)Individual #1 is prescribed Divalproex. The medication label on one prescription states, "Divalproex Sod DR 250MG, take 1 tablet by mouth once daily." The medication label on the second prescription states, "Divalproex Sod DR 500MG, take 2 tablets by mouth twice a day." Individual #1's April and May 2023 Medication Administration Record states, "Divalproex Sod DR 500MG, take 2 tablets in the morning, take 1 tablet 250MG at bedtime."A prescription medication shall be administered as prescribed.CEO contacted doctor to confirm the doctor¿s order of Divalproex Sod DR 250 MG, ¿Take 1 tablet by mouth once daily.¿ An the Divalproex Sod DR 500 MG, ¿Take 2 tablets by mouth twice a day.¿ Dr. confirmed his orders. Divalproex Sod DR 250 MG, ¿Take 1 tablet by mouth once daily, In the morning¿ An the Divalproex Sod DR 500 MG, ¿Take 2 tablets by mouth twice a day. The information was stated on the MAR. 04/27/2023 Implemented
6400.165(e)On 5/1/2023, Chief Executive Officer #1 discontinued Clonidine HCL and Levocarnitine on Individual #'1 May 2023 Medication Administration Record. Individual #1 was not administered these prescribed medications at 8:00AM on 5/1/2023. These medications were not to be discontined and were not discontinued by physician.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.CEO corrected MAR and placed Clonidine HCL and Levocarnitine back on the MAR. 04/27/2023 Implemented
6400.166(a)(3)Individual #1's April 2023 Medication Administration Record does not include Individual #1's allergies.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Drug allergies.Individual¿s 1 allergies was listed on the MAR. 04/27/2023 Implemented
6400.166(a)(4)Individual #1's April and May 2023 Medication Administration Record does not include the name of Ventolin HFA Inhaler.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.Individual¿s 1 Ventolin HFA Inhaler was listed on the MAR. 04/27/2023 Not Implemented
6400.166(a)(5)Individual #1's April and May 2023 Medication Administration Record does not include the strength of Ventolin HFA Inhaler.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.Individual¿s 1 strength of Ventolin HFA Inhaler was listed on the MAR. 04/27/2023 Implemented
6400.166(a)(6)Individual #1's April and May 2023 Medication Administration Record does not include the dosage of Ventolin HFA Inhaler.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form.Individual¿s 1 dosage of Ventolin HFA Inhaler was listed on the MAR. 04/28/2023 Implemented
6400.166(a)(7)Individual #1's April and May 2023 Medication Administration Record does not include the dose of Ventolin HFA Inhaler.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.Individual¿s 1 dose of Ventolin HFA Inhaler was listed on the MAR. 04/28/2023 Implemented
6400.166(a)(8)Individual #1's April and May 2023 Medication Administration Record does not include the route of administration of Ventolin HFA Inhaler.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.Individual¿s 1 route of Ventolin HFA Inhaler was listed on the MAR. 04/28/2023 Not Implemented
6400.166(a)(9)Individual #1's April and May 2023 Medication Administration Record does not include the frequency of administration of Ventolin HFA Inhaler.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.Individual¿s 1 frequency of Ventolin HFA Inhaler was listed on the MAR. 04/28/2023 Not Implemented
6400.166(a)(10)Individual #1's April and May 2023 Medication Administration Record does not include the administration times of Ventolin HFA Inhaler.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.Individual¿s 1 administration time of Ventolin HFA Inhaler was listed on the MAR. 04/28/2023 Implemented
6400.166(a)(11)Individual #1's April and May 2023 Medication Administration Record does not include the diagnosis or purpose for Ventolin HFA Inhaler.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Individual¿s 1 purpose of Ventolin HFA Inhaler was listed on the MAR. 04/28/2023 Not Implemented
6400.166(a)(13)Individual #1's April 2023 and May 2023 Medication Administration Records do not include the full name of the persons administering the medications.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.Individual¿s 1 had staff¿s full name listed on the MAR. 04/28/2023 Implemented
6400.166(b)Individual #1 was reportedly administered Clonidine HCL and Levocarnitine at 8:00PM on 5/1/2023; however, these medications were 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.Individual¿s 1 had staff¿s initials for the Medications Clonidine HCL and Levocarnitine on the MAR. 04/28/2023 Implemented