Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00240550 Renewal 03/12/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Individual #1 did not have a personal property inventory list in the record.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. All individuals records were deleted from the company's server. Crossroads will now keep a digital and paper copy of all inventory records. 04/08/2024 Implemented
6400.22(e)(1)The financial ledger dated 12/12/23, states "change from McDonald's" but then there was nothing written in the deposit section, but the balance was recorded correctly. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. All financial ledgers will have a withdrawal and deposit per transaction. All ledgers will be verified by Residential Director 04/08/2024 Implemented
6400.106The furnace inspection for this home was completed on 12/4/22 and/or 12/7/22 and not again until 12/23/2023, which exceeds the one year and 15-day grace time period allowed for this regulation.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The company will schedule the annual furnace inspection 30 days prior to the previous inspection. Furnace inspections are completed by Rhoades Plumbing and Heating. 04/08/2024 Implemented
6400.112(c)Repeat Violation 03.14.23 -The fire drill conducted on 2/08/2024 did not indicate the amount of time it took to exit the home during the fire drill.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. Fire drills will be verified for accuracy by Program Specialist Carrie Schenk and Residential Director Julie Bare. 04/08/2024 Implemented
6400.145(2)The emergency medical plan does not indicate the method of transportation to be used in the event of emergency and non-emergency situations.The home shall have a written emergency medical plan listing the following: The method of transportation to be used. The emergency medical plan will be updated to provide a method of transportation. 04/08/2024 Implemented
6400.181(f)Individual # 1's most recent assessment dated 2/22/2023 was not sent 30 days prior to the ISP team meeting that was held on 3/16/2023.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.All individuals will have their annual assessments sent 30 days prior to their annual ISP meeting. 04/08/2024 Implemented
SIN-00202168 Unannounced Monitoring 03/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Individual #1 tall dresser by his closet, the second drawer on the top left was missing a knob.Floors, walls, ceilings and other surfaces shall be in good repair. The missing hardware (knobs) for the cited furniture was replaced to achieve regulatory compliance. Pictures have been submitted via email to verify this correction occurred. 03/23/2022 Implemented
SIN-00184831 Renewal 03/15/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill record for this home had multiple discrepancies. On 4/11/20, the fire drill log indicates the drill took place on a Monday. However, 4/11/20 was a Saturday. On 5/15/20, the fire drill log indicates the drill took place on a Monday, but 5/15/20 was a Friday. A fire drill was also logged as having been conducted on 5/14/20; so, it is unclear if another fire drill was held the very next day. On 10/9/20, the fire drill log says the drill occurred on a Tuesday. However, 10/9/20 was a Friday. The discrepancies make it unclear as to when fire drills occurred.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. The Residential Supervisor failed to complete a fire drill record with complete accuracy. The Residential COO completed a zoom training with the house supervisors for all residential locations on 3/23/2021, which included the requirements for fire drills and accurate documentation of the drill on the fire drill record. The training sheet will be attached to the licensing email as Attachment #1 upon submission of the POC to the Department. 03/23/2021 Implemented
SIN-00167433 Renewal 02/11/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106Current furnace inspection was completed on 2/03/2020 and last year's inspection was completed on 1/05/2019; regulation 106 states that furnace cleanings must be completed yearly; this providers records document that the inspection was completed almost a month late.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The Maintenance Supervisor will be responsible to ensure that all of the applicable residential homes furnaces are inspected and cleaned at least annually by a professional furnace cleaning company. The Maintenance Supervisor has a reminder added to the company calendar that includes Crossroads CEO and Residential COO to ensure that the inspection is scheduled a minimum of 30 days prior to the annual deadline. The Maintenance Supervisor will ensure that there is written documentation of the inspection and cleaning and that the documentation clearly specifies the cleaning and inspection in the invoice provided to Crossroads. 03/05/2020 Implemented
6400.112(e)sleep drills must be completed every 6 months; This home completed a sleep drill on 3/16/19 @ 12am and not again until 10/13/19 at 11:15pm, which is one month late.A fire drill shall be held during sleeping hours at least every 6 months. The Residential Supervisor failed to complete a fire drill during sleeping hours at least every 6 months. An asleep drill was conducted on 2/18/2020 for remediation purposed and the fire drill log has been attached for supporting documentation. Residential Supervisors are responsible for completing fire drills in the residential locations. The Program Specialists are responsible and completed retraining for all Residential Supervisors on to ensure that fire drills are completed at least every 6 months. This training was conducted on 3/3/2020 for remediation purposed and the training sheet for overnight fire drills has been attached for supporting documentation. The Program Specialists will review all fire drills upon completion to verify the accuracy of the drill, full completion of the drill, identify and address any concerns during the drill, and ensure that drills are conducted during sleeping hours at least every 6 months. 03/03/2020 Implemented
SIN-00148960 Renewal 01/23/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)There was bleach stains in size from 1 inch to ½ inch near the front door and closet door. They were in a 3 foot wide area and consisted of 20 spots.Floors, walls, ceilings and other surfaces shall be in good repair. The carpet in the living room was removed and replaced with a new surface in good repair on 2/5/2019. Please see Attachments (Flooring pictures) to view the photographs of the replaced flooring. CSI staff will continue to monitor the residential homes utilizing the residential daily checklist and identify all physical site violations by immediately completing and submitting a work order to the CSI maintenance team for timely completion of these physical site violations. Please refer to Attachment (Residential Daily Checklist) and Attachment (Maintenance Work Order). 02/05/2019 Implemented
6400.141(c)(3)Individual #1's 4/20/18 physical did not include diphtheria.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. The CSI medical coordinator Sarah Nelen has remodified all areas of the current physical form for residential (Attachment CSI Physical Form) and highlighted all required areas to meet this regulation. The CSI medical coordinator Sarah Nelen will be responsible to review each physical to ensure that all areas of the physical have been completed. If any of these areas are incorrect or left blank on the physical after the medical appointment, the CSI nurse will be responsible to ensure that the physical form is returned to the physician to have all regulatory areas completed before entry into the individual¿s record. Once fully completed and reviewed, the CSI medical coordinator Sarah Nelen will initial the physical form identifying that it has been reviewed and found compliant to the 6400 regulations. Once the CSI medical coordinator has completed the review and initialed, the Residential COO will complete a final review on all regulatory areas of the physical before being placed into the individual¿s record. 02/07/2019 Implemented
6400.141(c)(9)Individual #1's 4/20/18 physical did not include a prostate examination. DOB 2/29/68The physical examination shall include: A prostate examination for men 40 years of age or older. The CSI medical coordinator Sarah Nelen has remodified all areas of the current physical form for residential (Attachment CSI Physical Form) and highlighted all required areas to meet this regulation. The CSI medical coordinator Sarah Nelen will be responsible to review each physical to ensure that all areas of the physical have been completed. If any of these areas are incorrect or left blank on the physical after the medical appointment, the CSI nurse will be responsible to ensure that the physical form is returned to the physician to have all regulatory areas completed before entry into the individual¿s record. Once fully completed and reviewed, the CSI medical coordinator Sarah Nelen will initial the physical form identifying that it has been reviewed and found compliant to the 6400 regulations. Once the CSI medical coordinator has completed the review and initialed, the Residential COO will complete a final review on all regulatory areas of the physical before being placed into the individual¿s record. 02/07/2019 Implemented
6400.163(c)Individual #1's record stated he is on Seroquil and sertraline for depression. He was not seen by a physician to have these medications reviewed. DOA 10/18/18. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The CSI medical coordinator Sarah Nelen will be responsible to review all current medications and upon receiving a new medication to verify any medications that treat the symptoms of a diagnosed psychiatric illness from any psychiatrist or prescribing physician. This will be reviewed using Attachment (Monthly Medication Review Form). Once a medication is identified to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. A psychiatric review has been added to the existing CSI medical consult form (Attachment CSI Medical Consult Form) as an additional measure to address any psychiatric medications at least every 3 months. 02/07/2019 Implemented
6400.168(a)Staff #2 was passing medication and did not have medication admin documents in their record. In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. The Medication Administration Trainers at CSI are responsible to ensure that all employees passing medication have completed and passed the Department¿s Medications Administration Course and are permitted to administer oral, topical and eye and ear drop prescription medications. Staff #2¿s documentation was unable to be located during the licensing inspection. The Medication Administration trainer responsible for staff #2¿s documentation is no longer employed and proper tracking and record keeping and transference of this documentation did not occur with the new Medication Administration trainer exposing an organizational flaw. Currently CSI has 2 additional staff that have already passed the trainers course and will begin teaching medication classes by March 2019. Each medication trainer will be responsible to ensure that all medication classes, practicum, and observation documentation is kept in a one (not separate) filing area determined by the Residential COO to prevent any loss or ease of access associated with management staff turnover. In addition, any Medication Administration trainer will be responsible to ensure they document all trainings they conduct as designed from when they completed their trainer training. The Medication Administration trainer will be responsible for conducting and completing all documentation on staff including all observations, reviews and practicums. This documentation must be upheld and remain current in order to continue passing medications and remaining in compliance. In this specific case, Staff #2 is no longer passing medications for CSI until proper verification or retraining occurs. As an order of prevention in the future the medication administration trainers will meet or collaborate monthly to review documentation and assign all annual practicums, medication observations, medication reviews, etc. in order to assure compliance with regulations. 02/07/2019 Implemented
Article X.1007Staff #1's DOH was 11/20/18 and he did not have state police clearences until 11/21/18.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.CSI Human Resources Manager, Jaime Zaliznock was previously adhering to Chapter 55 6400.21(a) An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individual¿s, within 5 working days after the person¿s date of hire. CSI Human Resources Manager, Jaime Zaliznock was unaware of Article X.1007 or that it superseded Chapter 55 6400.21(a) in regards time allotments for submitting Pennsylvania State Police Criminal History check prior to a new employee starting their position at CSI. CSI Human Resources Manager, Jaime Zaliznock will be responsible to ensure that a Pennsylvania State Police Criminal History check is submitted prior to a new employee starting their position at CSI. This check will be run no more than 5 days prior to the beginning of employment and up to the day of employment. 02/07/2019 Implemented
SIN-00129814 Technical Assistance 02/16/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(e)The home is video recording the entrances and exits of the home's outside corridors. However the area outside of the home that has video recording was not equipped with signs indicating that images are being record. There was signs outside the home indicating video surveillance was taking place, but not video recording.An individual has the right to privacy in bedrooms, bathrooms and during personal care. Plan of correction: immediately must put signs up on outside of home in the locations being recorded that indicates images are being recorded in said areas. Have home supervisor conduct daily checklists to make sure signs are still posted in areas that are video recorded. At any point the home supervisor notices a sign indicating images are being recorded is missing, replace immediately. If other individuals move into the home where video recording is taking place, inform individual upon admission to the home of the recording and keep documentation in their record. Have home supervisor submit daily checklists to their supervisor at least weekly for review. Have program specialist review home at least monthly to ensure signs are posted and individuals are informed of the recording. 03/05/2018 Implemented
SIN-00129811 Unannounced Monitoring 02/16/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The reclining chair in the Individual's bedroom to the left of the back entrance of the home, contained approximately a soccer ball sized brown stain.Clean and sanitary conditions shall be maintained in the home. Plan of Correction: clean the recliner or replace as soon as possible. Have home supervisor complete daily checklists of the home to ensure that surfaces are in good repair and clean and sanitary. Immediately clean the surface/item upon noticing it, or submit a maintenance request the same day clean and sanitary conditions are noticed. The home supervisor should turn the daily checklists into their supervisor for review at least weekly. The home supervisor should document when the cleaning is completed. Program specialist shall review maintenance requests of the home monthly and follow up within the same month to ensure all surfaces are clean. 03/05/2018 Implemented
SIN-00128383 Unannounced Monitoring 01/29/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Individual # 1's dresser was missing a handle on the bottom drawerFloors, walls, ceilings and other surfaces shall be in good repair. Agency will repair missing dresser handles on bottom drawer. Agency will train all staff on physical site inspections and review chapter regulations. Agency will conduct a monthly physical site walk through of every home and document violation findings and indicate date of correction. Supervisor of home supervisors will review monthly physical site walk through documentation on a quarterly basis. 01/30/2018 Implemented
SIN-00126644 Unannounced Monitoring 12/08/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)6400.67(a)-Physical site-surfaces in good repair- The right knob was missing from the dresser drawer from the Individual bedroom off the bathroom. The brown carpet in the living room area had many (10 plus) bleach spots all over it. The carpet appeared to be ruined and needed replaced. Staff had attempted to clean the carpet with a bleach solution, but did not have it mixed properly, causing the carpet to be bleached in areas.Floors, walls, ceilings and other surfaces shall be in good repair. Plan of correction: have maintenance come and replace the knob as soon as possible. Have the carpet in the living room replaced. The home supervisor shall complete daily checklists of the home to ensure that surfaces are in good repair. Have home supervisor complete and submit a maintenance request the same day a surface is found not in good repair. The home supervisor should turn the daily checklists into their supervisor for review at least weekly. The home supervisor should document when the repair is completed. Program specialist shall review maintenance requests of the home monthly and follow up within the same month to ensure all surfaces are fixed. 01/31/2018 Implemented
SIN-00122997 Unannounced Monitoring 10/10/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(e)The home is video recording the entrances and exits of the home's outside corridors. However the home did not have documentation that the individuals were informed that these areas were subject to video recording and the area outside of the home that has video recording was not equipped with signs indicating that images are being record. An individual has the right to privacy in bedrooms, bathrooms and during personal care. agency must immediately must inform individuals of video recording at entrance/exits of home. Agency must document in Individual's record that they are aware recording is taking place, and ok with it. Agency must immediately put signs up on outside of home in the locations being recorded, that indicates images are being recorded in said areas. Have home supervisor conduct daily checklists to make sure signs are still posted in areas that are video recorded. Retrain staff on May 2015 clarification for 33(e) and 33(g). At any point the home supervisor notices a sign indicating images are being .recorded is missing, replace immediately. If other individuals move into the home where video recording is taking place, inform individual upon admission to the home of the recording and keep documentation in their record. Have home supervisor submit daily checklists to their supervisor at least weekly for review. Have program specialist review home at least monthly to ensure signs are posted and individuals are informed of the recording. The daily checklist has been update to include checking that the video monitoring signs are in place, If they are not in place the supervisor will replace them immediately. The individuals residing in the home have been made aware that there is video monitoring on the outside of their homes and they have agreed to allow it. Attachment#9. We have requested from the security company that signs be placed on the property. When the signs are in place the department will be notified via email with pictures. staff are being trained on the clarification 6400 33(e) and (g). all staff will be trained by 10/31/17. 11/02/2017 Implemented
6400.64(a)An extra adult brief and two toothbrushes were found in the mirror vanity in the hallway bathroom. The adult brief and toothbrushes were not protected from contamination and the inside of the mirror vanity was rusted and covered in dirt and old hair. Clean and sanitary conditions shall be maintained in the home. remove items immediately from the vanity so they can not be used. Have the home supervisor conduct and record daily checks of the home to ensure that clean and sanitary conditions are kept at the home. If surfaces are found not clean and sanitary, immediately clean surfaces upon finding the issue. The home supervisor should turn the daily checklists into their supervisor for review at least weekly. Program specialist shall review checklists of the home monthly and follow up within the same month to ensure clean and sanitary conditions are met. The items were removed on 10/10/17. attachment #8. the home supervisor will check the vanity daily to ensure nothing is in the vanity. 11/02/2017 Implemented
6400.67(a)The right door knob was broken on the bathroom sink vanity in the hallway bathroom. The knob was a flat piece of metal and it appeared that the outer, flat piece of the knob was broken off, leaving just the metal post sticking out of the door. Floors, walls, ceilings and other surfaces shall be in good repair. have maintenance come and repair the knob by the date of agreement to this POC. Have home supervisor complete daily checklists of the home to ensure that surfaces are in good repair. Have home supervisor complete and submit a maintenance request the same day a surface is found not in good repair. The home supervisor should turn the daily checklists into their supervisor for review at least weekly. The home supervisor should document when the repair is completed. Program specialist shall review maintenance requests of the home monthly and follow up within the same month to ensure all surfaces are fixed. The knob was replaced on 10/11/17. Attachment #7.upon finding any surfaces needing repair, the home supervisor will indicate item on the daily checklist and submit the work order to maintenance. 11/02/2017 Implemented
6400.72(b)The screen in the backdoor screen door contained approximately 10 rips and holes ranging from 1/4th an inch to an inch wide. Screens, windows and doors shall be in good repair. have maintenance come and repair the screen as soon as possible. Have home supervisor complete daily checklists of the home to ensure that surfaces are in good repair. Have home supervisor complete and submit a maintenance request the same day a surface is found not in good repair. The home supervisor should turn the daily checklists into their supervisor for review at least weekly. The home supervisor should document when the repair is completed. Program specialist shall review maintenance requests of the home monthly and follow up within the same month to ensure all surfaces are fixed. The screen was repaired on 10/11/17.. Attachment #5. the supervisor will complete a daily checklist and immediately report to maintenance through a work order of the repair (s) needed. attachment #6 . 11/02/2017 Implemented
SIN-00124226 Unannounced Monitoring 10/05/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16Staff staff #2 neglected individual #1 by failing to provide the needed care, EIM incident #8333057. Staff #2 should have immediately called 911 after individual #1 fell on 7/16/2017. Per witness statements 8/24/2017 staff #2 stated that she attempted to call medical coordinator, staff #3, after she helped individual #1 off the floor and into her wheelchair¿; and 8/24/2017 witness statement from staff #4 stated that staff #2 did not attempt to call the medical coordinator, staff #3, until staff #4 prompted her to. (Also, staff #2 should have not moved individual #1 after the fall due to her diagnosis of Osteopenia). Staff #2 left her shift without following the agency¿s Incident Management policy and procedures and failed to implement the training she received on 12/5/2016 on Calling 911 in a Medical Emergency, a Health Alert provided by the Office of Developmental Programs. Staff #2 never reported the incident; staff Staff #4 reported the incident to medical coordinator, staff #3. Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.Retrain all staff on Incident Management Policies and Procedures. Retrain all staff on the Health Alert provided by the Office of Developmental Programs on Calling 911 in a Medical Emergency. Retrain staff on all individual medical emergency plans. Implement a policy and procedure that all staff are trained in all individual¿s ISP¿s and any critical revisions. Retrain all staff on individual¿s ISPs. Implement a policy and procedure that all staff are trained on the specific diagnoses and any applicable plan or protocol of each individual and how staff can support them (ODP recommends utilizing the HCQU as a resource). Retrain all staff on the on-call policy and procedures. Implement a secure back-up plan of available staff when assistance is requested. Implement a policy and procedure on expected communication standards and the importance of detailed documentation; ensure this is also a part of new hire orientation and annual thereafter. Implement a policy and procedure that as a part of new hire orientation, all staff are trained on individual¿s body language (if applicable) prior to working with them independently. 11/08/2017 Implemented
6400.43(b)(1)Staff #5 failed to implement the agency¿s incident management policies and procedures. Staff #5 did not receive the details of EIM incident #8333057 from witness, staff #2. Staff #5 did not instruct Staff #2 to escort individual #1 to the emergency room so she can provide the details of the incident to the physician. Staff #5 did not file an incident of neglect; staff #2 left a medical emergency without caring for the individual. Also, the initial incident description to EIM incident #8333057 is incorrect and only partially been addressed formally. The initial incident states, ¿Staff #4 (DCP) then soon arrived and Staff #2 called Staff #3 (medical coordinator) to inform her of what occurred. Staff #3 informed Staff #2 that individual #1 needed to go to the ER to be checked out. Staff #4 immediately escorted indiviual #1 to the ER.¿ Per ODP witness statement 8/24/2017, Staff #2 stated that she was assisting individual #1 off the toilet; individual #1 was waving her arms as if she did not want to get off the toilet and fell forward ¿dead weight¿ and hit her head off of Staff #2 left knee. Individual #1 nose was bleeding a little. Staff #2 stated she tried to call the Staff #3 but there was no answer. Staff #2 left her shift when Staff #4 came on to relieve her. The 8/24/2017 witness statement from staff Staff #4 stated that Staff #2 did not attempt to callStaff #3 until Staff #4 prompted her to. Staff #2 did leave her shift and left Staff #4 with the responsibility to care for individual #1. Staff #4 did eventually get in contact with Staff #3, and she contacted CEO Staff #5 to inform her of the incident. It was at that time Staff #5 gave the orders to take individual #1 to the ER. The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. Implement a policy and procedure that the incident management point person and CEO receive the details of an incident from the witness. Implement a policy and procedure that the witness to an incident escort the individual to the emergency room and speak to those caring for the individual. Implement a policy and procedure to correct false statements documented in EIM. Retrain all staff on Incident Management Policies and Procedures. Retrain all staff on the Health Alert provided by the Office of Developmental Programs on Calling 911 in a Medical Emergency. Retrain staff on all individual medical emergency plans. Implement a policy and procedure that the CEO of the agency will meet with the witness and/or initial reporter to a reportable incident that must be investigated within 24hrs to confirm the details of the incident. This is highly recommended for all individual incidents that require emergency room care. Implement policy and procedures to ensure oversight of the status and quality reported incidents and of all certified investigations. 11/08/2017 Implemented
6400.43(b)(3)On 7/17/2017 EIM incident #8333165 was reported. individual #1 was to be seen at the ER for bruising on her left hand and bruising on her right hip area. Crossroads did conduct an investigation and was unable to conclude how individual #1 bruised her left hand. Crossroads interviewed staff who worked with individual #1 two days prior to her fall on 7/16/2017 and no staff noticed any bruising on her left hand. This injury to her left hand may have been an additional injury to her fall the previous day, EIM incident #8333057. On 7/16/2017 CEO Staff #5 did not instruct witness, staff Staff #2, to escort indivdual #1 to the emergency room so she can provide the details of EIM incident #8333057 to the physician. If the physician at the emergency room had all the details of the fall on 7/16/2017 he may have conducted a full exam of the body. Also, individual #1 bruising of her right hip was never addressed at the emergency room 7/17/2017. Staff #5 confirmed via email on 11/3/2017, ¿I was told only about the bruising on her hand. I did read the incident/investigation. When I questioned about the hip no one seemed to remember any hip bruising and felt that Staff #6 added it in error. I know 100 percent certainty that I was only told about her hand¿. Per phone conversation with Staff #4 11/3/2017, she stated, ¿the emergency room physician never examined individual #1 right hip¿. The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. Implement a policy and procedure that the incident management point person and CEO receive the details of an incident from the witness. Implement a policy and procedure that the witness to an incident escort the individual to the emergency room and speak to those caring for the individual. Implement a policy and procedure to correct false statements documented in EIM. Retrain all staff on Incident Management Policies and Procedures. Implement a policy and procedure that the CEO of the agency will meet with the witness and/or initial reporter to a reportable incident that must be investigated within 24hrs to confirm the details of the incident. This is highly recommended for all individual incidents that require emergency room care. Implement policy and procedures to ensure oversight of the status and quality reported incidents and of all certified investigations. Implement a policy and procedure on expected communication standards and the importance of detailed documentation; ensure this is also a part of new hire orientation and annual thereafter. 11/08/2017 Implemented
SIN-00115926 Unannounced Monitoring 06/12/2017 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Individual #1's financial ledger states on 4/6/17 there was a withdraw of $60.00 for The ARC and baseball membership fees. There was a receipt present dated 4/21/17 for $35.00 for baseball fees. No receipt or documentation was present as to where the additional $25.00 was.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. A new role of Team Leader has been created and is in the process of being filled for each residential home in order to complete daily checks of the spending ledgers. This will add more oversight and ensure that direct care staff are documenting the transactions properly. The Team Leader will check the spending ledgers for each home that they are assigned and address any discrepancies immediately. The Team Leaders will then turn the individual spending ledgers in to the Residential Supervisor on a weekly basis. The Residential Supervisor will then do a double check on the accuracy and completeness of the ledgers. After the Residential Supervisor reviews the spending ledgers, she will then turn them in to the Human Resources Manager every month for a third check of the accuracy and completeness of the ledgers. Completion Date of 8/18/2017 08/18/2017 Not Implemented
6400.22(d)(2)Individual #1's financial ledger stated there was a purchase on 6/7/17 for $8.00 for "delgrosso special olympics" however there was no receipt in the financial record for this purchase.(2) Disbursements made to or for the individual. A new role of Team Leader has been created and is in the process of being filled for each residential home in order to complete daily checks of the spending ledgers. This will add more oversight and ensure that direct care staff are documenting the transactions properly. The Team Leader will check the spending ledgers for each home that they are assigned and address any discrepancies immediately. The Team Leaders will then turn the individual spending ledgers in to the Residential Supervisor on a weekly basis. The Residential Supervisor will then do a double check on the accuracy and completeness of the ledgers. After the Residential Supervisor reviews the spending ledgers, she will then turn them in to the Human Resources Manager every month for a third check of the accuracy and completeness of the ledgers. Completion Date of 8/18/2017 08/18/2017 Not Implemented
6400.62(a)Palmolive antibacterial soap was unlocked under the kitchen sink. Individuals residing in the home are not safe with poisons.Poisonous materials shall be kept locked or made inaccessible to individuals.An email has been sent to Individual #1s support coordinator requesting his ISP be updated to include which poisons he is safe around. (attachment#6) . All other individuals in the home have ISPs that reflect that they are safe around all poisons. Residential supervisor will be responsible to ensure that all poisons which are not listed in the ISP are locked. Residential supervisor/team leader will do daily walk throughs and ensure no poisons are left unlocked. 6/22/17 06/22/2017 Not Implemented
6400.161(e)Nystatin 100,000 topical powder was present with Individual #1's PRN medications. The medication stated "Apply topically to affected area 3 x daily PRN" It states that this medication was discontinued on 2/9/17 however it was not disposed of. Individual #1 had Tylenol Cold-flu severe medication with PRN meds "take 30 ml every 4 hours PRN" however this medication was discontinued on 3/6/17 and was not disposed of. Individual#1's PRN box included Tamiful 75 mg caps which he/she was instructed to "take by mouth twice daily for 5 days then discontinue on 2/12/17. The medication was still present in the home and was not disposed of. Discontinued prescription medications shall be disposed of in a safe manner.Health Coordinator will be retrained by Medication Administration Trainer on proper disposal of medications. This training will include how to discontinue a medication and how to dispose of the medication. Health Coordinator will then be responsible to notify staff (verbally and in writing) of any discontinued medication. Health Coordinator will also be responsible to discontinue the medication on the MAR. Health Coordinator will the properly dispose of the medication. The compliance specialist will be required to check each individuals medications and MARS to ensure that all medications are discontinued properly and disposed of. Completion Date : 8/18/17 08/18/2017 Not Implemented
6400.162(a)There was a loose pill present in Individual #1's PRN medication box. The pill size, shape and color matched his/her Loperamide 2 mg capsule. The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. Health Care coordinator will be retrained on Medication Administration. This training will be the PA DPW training. This training includes that all medications must remain in the original container. Following successful completion of this training, Health coordinator will be responsible to ensure that all medications are in the original container. Health Care Coordinator will also be responsible to ensure that Physicians include all pertinent information when prescribing a medication and that the pharmacy prints the label including all information. During quarterly record reviews, Compliance specialist will check all medications and ensure the labels are comprehensive, unaltered and accurate. Completion Date: 8/18/17 08/18/2017 Not Implemented
6400.164(a)Individual #1 is prescribed to take Nystatin 10000 u/gm three times daily as needed. On 4/27/17 and 4/28/17 staff initialed as administering the medication but did not indicated the time the medication was administered.A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. All current employees will be retrained on the PA DPW Medication Administration. Any newly hired staff will be trained on the PA DPW medication Administration. Beth Zeth or Amanda Barnhart will be responsible to schedule the trainings and ensure they are completed properly. Amanda Barnhart, Heath Coordinator, will be responsible to review the MARS weekly. Compliance Specialist will conduct quarterly record reviews, during these reviews he will identify any errors and notify health coordinator. Completion date 8/18/18 08/18/2017 Not Implemented
SIN-00113026 Unannounced Monitoring 04/10/2017 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(2)Staff #2 became a Program Specialist on 8/15/16 there was no documentation in the record of being trained in the Program Specialist responsibilities.The program specialist shall be responsible for the following: Providing the assessment as required under § 6400.181(f) (relating to assessment). All current Program Specialists will be retrained on their job duties and sign the training. Kasey Bradley will be responsible for ensuring that all Program specialists are retrained. All new staff will be given their job description and trained on it. Jamie Zaliznock, HR director will be responsible to provide the training during orientation. 06/30/2017 Implemented
6400.46(a)Staff person #1 began working with Individuals on 2/10/17. There was no orientation documentation that Staff #1 was trained in their responsibilies of daily operation of the home before working with Individuals. The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. a new daily operations of residential homes has been developed (attachment #11). All new employees will be trained on the daily operations of the home. the training will be completed by Beth Zeth, Residential supervisor. During quarterly record reviews, Compliance specialist will ensure all new hires have completed the daily operations training. completion date 6/30/17 06/30/2017 Implemented
6400.46(e)Staff person #1 was hired 1/18/17 and was not trained in the arera of normalization until 2/24/17. There is no documentation that staff person #1 has yet to be trained in program planning and implementation. Program specialists and direct service workers shall have training in the areas of Intellectual Disability, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. Human resource manager will be retrained in the need for normalization and program planning and implementation to be completed within 30 days of hire. Human resource manager will be responsible;pe to ensure that all new staff complete the training on normalization a implementation and program planing within 30 days of hire. Compliance specialist will conduct quarterly record reviews. during these reviews, he will ensure that these training have been completed with in the 30 day of hire. Completion Date 6/30/17 06/30/2017 Implemented
6400.62(a)The following items where found in the home unlockes or accessible to Individuals whom are not deimed safe around poisionous materials: mouth wash, toothpaste and hand sanitizer. Poisonous materials shall be kept locked or made inaccessible to individuals.ALl residential employees will be retrained on poisonous materials. The training will be done by Beth Zeth, Residential supervisor. The training will include what constitutes poisonous substances and how to properly store the items. Also updates to individuals plans will be made to indicate what substances the individuals are safe around (tooth paste etc) the program specialist will make changes and send to the supports coordinator. Beth Zeth will do weekly walk through of each home to ensure that no poisonous materials are left unlocked. completion date 6/30/17 06/30/2017 Not Implemented
6400.64(a)The plastic coating on the toliet seat in the handicapped bathroom is worn off exposing the wooden material. Clean and sanitary conditions shall be maintained in the home. Maintenance worker, Nate Monahan inspected the toilet and found an additional crack in the toilet itself. Nate Monahan then replaced the entire toilet which included a new toilet seat as well. This was completed on May 15, 2017. Compliance Specialist, Andy Hamilton will complete quarterly reviews to ensure that all areas have been corrected. (attachment#10) 05/15/2017 Not Implemented
6400.67(a)The bath tub does not drain well, the pipe from the faucet to the tub is missing a cover and the vanity mirror is broken. Floors, walls, ceilings and other surfaces shall be in good repair. Maintenance worker, Nate Monahan has used a snake on the drain but has been unsuccessful in getting the tub to drain any faster. Nate Monahan will be contacting Rhodes Plumbing and Heating in order to address the issue. Nate Monahan has already replaced the missing cover as of May 15, 2017. Compliance Specialist, Andy Hamilton will complete quarterly reviews to ensure that all areas have been corrected. Attachment #10 05/15/2017 Not Implemented
6400.68(b)The water temperature in the bathroom was 122.9F. Exceeding the 120F. Hot water temperatures in bathtubs and showers may not exceed 120°F. It has been determined that staff have been turning the water temperature up on the water heater which has resulted in the high temperature readings. Maintenance worker, Nate Monahan has contacted Rhodes Plumbing and Heating and they are looking in to options of locking the temperature control knob on the water heater itself. Maintenance worker, Nate Monahan will be in charge of making sure this issue is resolved by June 19, 2017. Compliance Specialist will complete quarterly reviews to ensure that all areas have been corrected. 06/19/2017 Not Implemented
6400.104The fire notification letter sent on 10/26/16 indicated that 2 males-non-ambulatory resided in the home, but then stated 3 bedrooms are being used. The floor plan that was attached to the fire letter talked about 1 Individual-but this Individual no longer resided at this home.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. letter has been sent to the fire department. The letter now includes the date it was sent. The letter also includes a current residential setting. It describes the individuals living in the home and the location of their bedrooms. Kasey Bradley will be responsible to send the letter yearly or if a change in the home occurs. Compliance specialist will ensure that the letters are accurate and dated during his quarterly record reviews. completion date 6/30/17 (Attachment 9) 06/30/2017 Implemented
6400.111(f)The fire extinguisher that was located in the attic has not been inspected since 2015. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. Compliance Specialist, Andy Hamilton will be in charge of conducting quarterly monitoring¿s of each home in order to ensure compliance in all areas including inspection of fire extinguishers. This will be completed as of June 30, 2017. 06/30/2017 Implemented
6400.145(3)The home did not have a written plan that contained an emergency shelter. The home shall have a written emergency medical plan listing the following: An emergency staffing plan.All residential homes will have a new written emergency plan which includes emergency shelter. Program Specialist will be responsible to update the plans yearly. The compliance specialist will ensure these plans are current and accurate during quarterly record reviews. completion date 6/30/17 06/30/2017 Not Implemented
6400.151(c)(3)Staff person #2 date of hire was 5/23/16, the 10/27/15 physical did not indicate free from disease staus. The check box on the physical form was left blank. 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. Kasey Bradley, director, will retrain Human Resource Manager on how a physical needs completed. This training will include the need for all areas of the physical to be completed. Including the free from communicable disease box being checked. Andrew Hamilton, Compliance specialist will perform record reviews quarterly and ensure that all areas of staff physicals are complete. If any area is found blank, HR manager will be notified. Completion Date 6/30/17 06/30/2017 Not Implemented
6400.151(c)(4)Staff person #2 physical dated 10/27/15 did not indicate if there was any medical problems. This section was left blank on the physical form. The physical examination shall include: Information of medical problems which might interfere with the health of the individuals.Kasey Bradley, director, will retrain Human Resource Manager on how a physical needs completed. This training will include the need for all areas of the physical to be completed. Including information of medical problems which might interfere with the health of the individuals. Andrew Hamilton, Compliance specialist will perform record reviews quarterly and ensure that all areas of staff physicals are complete. If any area is found blank, HR manager will be notified. Completion Date 6/30/17 05/21/2017 Not Implemented
SIN-00105017 Renewal 01/04/2017 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)Crossroad Services' certificate of compliance expired on 4/29/16. The self-assessment was completed on 11/15/16.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. A self assessment will be completed 3-6 months prior to the expiration of CSIs license. The self assessment will be completed by compliance specialist Andrew Hamilton. Andrew Hamilton has been trained on the checklist for the self assessment (Attachment #11). 04/30/2017 Implemented
6400.15(c)The 11/15/16 self-assessment did not include a summary of violations.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. A self assessment will be completed 3-6 months prior to the expiration of CSIs license. The self assessment will be completed by compliance specialist Andrew Hamilton. Andrew Hamilton has been trained on the checklist for the self assessment (Attachment #11). Andrew hamiliton will be responsible to ensure the summary of violations is completed on each self assessment 04/28/2017 Implemented
6400.22(c)Approximately $5,579.00 was stolen from Individual #1. Individual funds and property shall be used for the individual's benefit. There is a current court case pending on an former employee who has been charge with stealing over 30,000 dollars of individuals funds. The case is represented by the Blair county District attorney. Until any future restitution is made by the former employee, CSI has given each individual who was affected by the theft the money which was stolen. A new employee, Jaime Zaliznock, now acts as rep payee for our individuals. She must submit a financial ledger monthly to the director for oversight. (Attachment#24) 04/30/2017 Implemented
6400.22(e)(1)There were no financial ledgers prior to June 2016 for Individual #1. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. There is a current court case pending on an former employee who has been charge with stealing over 30,000 dollars of individuals funds. The case is represented by the Blair county District attorney. Any financial ledgers prior to the thefts discovery were destroyed by the former employee. A new employee, Jaime Zaliznock, now acts as rep payee for our individuals. She must submit a financial ledger monthly to the director for oversight. Jaime must also scan the ledger in to CSIs computer system in order to have a copy to ensure they do not go missing at any future date. (attachment#25) 04/30/2017 Implemented
6400.31(b)Individual #1 was notified of his/her rights on 8/3/15 and not again until 9/8/16.Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. A record review was completed 2/28/17-3/2/17. All individuals have had their individual rights updated if they were late (Attachment #8). The program specialist was trained on Individual Rights and the expectation that all individuals receive the individual rights at least annually, (attachment # 9) Compliance Specialist. Program Specialist will do a record review quarterly and sign and date that the Individual rights is current and correct. (attachment #10) 03/06/2017 Implemented
6400.67(a)There were 4 broken handles on Individual #2's bedroom dresser.Floors, walls, ceilings and other surfaces shall be in good repair. Nate Monahan, Maitenence worker, will be responsible to ensure the residential homes are in good repair. Nate completed residential walk throughs and identified any repairs needed and is responsible to ensure they are completed. (attachment #17) The handles on the dresser have been replaced and are secure. (attachment #17) Nate will do quarterly walk throughs of each property and identify and fix any items needing repair. 03/07/2017 Not Implemented
6400.80(b)The gutter above the front bay windows was not secured to the home. The gutter was falling towards the front porch. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.Nate Monahan, Maitenence worker, will be responsible to ensure the residential homes are in good repair. Nate completed residential walk throughs and identified any repairs needed and is responsible to ensure they are completed. The gutter was reattached and is now in good repair. (attachment #17) Nate will do quarterly walk throughs of each property and identify and fix any items needing repair. 03/07/2017 Implemented
6400.112(d)The 6/16/15 and 7/16/15 fire drill logs indicated evacuation times of 2 minutes and 43 seconds and 2 minutes and 41 seconds, respectively. An extended evacuation letter was not received until 10/26/16. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. A record review of the Fire drill logs was completed by Beth Zeth, residential supervisor. No more errors were found (attachment #13). A letter from the fire company is now on file in the home. (attachment #14) All employees attended fire safety training on 3/7/17. (attachment#15) 03/07/2017 Implemented
6400.144Individual #1's physician ordered blood sugar testing once daily. Individual #1's glucometer did not have blood sugar readings on 9/25/16, 10/1/16, 10/2/16, 10/16/16, 10/31/16, 11/9/16, 12/1/16, 12/8/16, and 112/19/16. On 10/22/16, Individual #1's glucometer had a blood sugar reading of 221 however, the medication log had a reading of 219. On 10/29/2016, the glucometer had a reading of 264. The medication log had a reading of 220. On 11/1/16, the glucometer had a reading of 195. The medication log had a reading of 176. On 12/6/16, the glucometer had readings of 192 and 241. The medication log had a reading of 172. On 12/7/16, the glucometer had a reading of 188. The medication log had a reading of 230. Crossroad Services' staff members had no explanation for the discrepency in readings. A blood sugar protocol was not in place for Individual #1. 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. All current employees and newly hired employees will be trained on diabetic care. (Attachment #12) The training includes the proper use of a glucometer. The training also stresses the importance of proper documentation on the glucometer readings. Health coordinator will check all residential glucometers and compare the readings to the MAR weekly. The health coordinator will sign and date that she completed the review. A review of the current and past 3 month MARS and glucometer were reviewed on 3-6-17. Any errors found were identified and the employees who made the errors will attend additional trainings on the glucometer (Attachment # 12) . The employees needing additional training will not be able to perform blood sugar readings until they have been retrained. 04/30/2017 Not Implemented
6400.145(1)The emergency medical plan did not include the source of health care to be used in an emergency.The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. All residential medical emergency plans have been updated. Attachment #6 They now include the source of Health Care to be used in an emergency. Compliance Specialist, Andrew Hamilton, will ensure each emergency medical plan has the source of health care to be used in an emergency listed. Andrew Hamilton will do a record review quarterly and sign/date that the emergency medical plan is correct and all information is included. If there is information missing he will notify program specialist of missing information. Program specialist will be required to add missing information into the Emergency Medical Plan and Andrew Hamilton will follow up with Program Specialist to ensure it was completed. Attachment #7 04/30/2017 Implemented
6400.145(2)The emergency medical plan did not include the method of transportation to be used in an emergency.The home shall have a written emergency medical plan listing the following: The method of transportation to be used. All residential medical emergency plans have been updated. Attachment #6 They now include the Method of Transportation to be used in an emergency. Compliance Specialist, Andrew Hamilton, will ensure each emergency medical plan has the method of transportation to be used in an emergency listed. Andrew Hamilton will do a record review quarterly and sign/date that the emergency medical plan is correct and all information is included. If there is information missing he will notify program specialist of missing information. Program specialist will be required to add missing information into the Emergency Medical Plan and Andrew Hamilton will follow up with Program Specialist to ensure it was completed. Attachment #7 03/30/2017 Implemented
6400.145(3)The emergency medical plan did not include an emergency staffing plan.The home shall have a written emergency medical plan listing the following: An emergency staffing plan.All residential medical emergency plans have been updated. Attachment #6 They now include an emergency staffing plan to be used in an emergency. Compliance Specialist, Andrew Hamilton, will ensure each emergency medical plan has the emergency staffing plan to be used in an emergency. Andrew Hamilton will do a record review quarterly and sign/date that the emergency medical plan is correct and all information is included. If there is information missing he will notify program specialist of missing information. Program specialist will be required to add missing information into the Emergency Medical Plan and Andrew Hamilton will follow up with Program Specialist to ensure it was completed. Attachment #7 03/30/2017 Not Implemented
6400.163(a)On 11/22/16, Individual #1 was administered Trileptal. This medication was not prescribed to Individual #1. Prescription medications shall only be used by the individual for whom the medication was prescribed. All current employees will be retrained on the PA DPW Medication Administration. Any newly hired staff will be trained on the PA DPW medication Administration. Beth Zeth or Amanda Barnhart will be responsible to schedule the trainings and ensure they are completed properly. Amanda Barnhart, Medication trainers, Beth Zeth and Amanda Barnhart, will be required to do random observations of Medication Passes. During observation, the Trainer will ensure that all steps to proper medication administration are completed. If the staff passing the medication does not complete the pass correctly, he/she will need to attend a retraining on medication Administration. The staff will not be allowed to pass medications until the training is complete. The trainer will complete an observation form (ATTACHMENT #5) during the observation. 04/30/2017 Implemented
6400.164(b)On 12/11/2016, Thick It, Metformin, Glimepiride, and Furosemide were administered. The staff member administering the medications did not sign off on the medication administration log. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. All current employees will be retrained on the PA DPW Medication Administration. Any newly hired staff will be trained on the PA DPW medication Administration. Beth Zeth or Amanda Barnhart will be responsible to schedule the trainings and ensure they are completed properly. Amanda Barnhart, Heath Coordinator, will be responsible to review the MARS weekly. After reviewing the MAR, she will fill out a form identifying any errors and sign/date that the review was completed. Attachment # 4 04/30/2017 Not Implemented
6400.181(e)(3)(i)Individual #1's 3/2/16 assessment did not include current performance level and progress in functional skills.The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. A record review was completed 2/28/17-03/2/17. Assessments were reviewed and updated. (attachment #27) Program Specialist will be trained on what is included in an assessment . The program Specialist will be required to report on all areas of the assessment Compliance specialist will do a record review quarterly. Any information missing from the assessment will be identifies and passed on to the program specialist for corrections. . The Compliance specialist will then follow up with the program specialist to ensure that the assessment has been update. The program specialist will then send out updated assessments to the individuals team members. 04/30/2017 Not Implemented
6400.181(e)(12)Individual #1's 3/2/16 assessment does not include recommendations for specific areas of training, programming, and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. A record review was completed 2/28/17-03/2/17. Assessments were reviewed and updated. (attachment # 27) Program Specialist will be trained on what is included in an assessment. The program Specialist will be required to report on all areas of the assessment Compliance specialist will do a record review quarterly. Any information missing from the assessment will be identifies and passed on to the program specialist for corrections. The Compliance specialist will then follow up with the program specialist to ensure that the assessment has been update. The program specialist will then send out updated assessments to the individuals team members. 04/30/2017 Implemented
6400.181(e)(13)(vii)Individual #1's 3/2/16 assessment does not include progress over the past year in financial independence.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. A record review was completed 2/28/17-03/2/17. Assessments were reviewed and updated. (attachment # 27) Program Specialist will be trained on what is included in an assessment The program Specialist will be required to report on all areas of the assessment Compliance specialist will do a record review quarterly. Any information missing from the assessment will be identifies and passed on to the program specialist for corrections. The Compliance specialist will then follow up with the program specialist to ensure that the assessment has been update. The program specialist will then send out updated assessments to the individuals team members. 04/30/2017 Not Implemented
6400.186(c)(1)Individual #1's 6/16/16 and 9/19/16 Individual Support Plan Reviews did not include progress on his/her church outcome.The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. A record review was completed on 2/28/17-3/2/17. Any areas that did not comment on progress and growth were corrected. (attachment #30) Program Specialist will be trained on outcome statements and the importance of progress and growth related to the outcome. Program specialist will be responsible to ensure that the ISP reviews include progress and growth. Compliance specialist will be responsible to complete quarterly record reviews. If progress and growth is not included, compliance specialist will notify program specialist. Program specialist will then make corrections and send the updated ISP review to the team members. Compliance specialist will follow up with the program specialist to ensure the ISP review has been updated. 04/30/2017 Not Implemented
6400.213(11)Individual #1's 3/14/16 physical exam indicated Individual #1 was to follow a diabetic diet. The Individual Support Plan indicated honey thickened liquids was required. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. On 3/1/17, A training on content discrepancies between the Individuals records and documents was conducted by Kasey Bradley, Director. Residential Program specialist's and Health coordinators attended the training. Attachment #1. A record review for all residents of CSI was completed 2/28/17-3/2/17. The changes to the assessment, physical, and ISPs are attached Attachment #2. In order to ensure that discrepancies are not found in the future, a new compliance specialist position has been created. Andy Hamilton has been promoted to this position. Andy will do a record review every 6 months on each of the individuals CSI supports. upon completing the record review, Andy will instruct Program specialist or health coordinator on what discrepancies were found. Andy will sign that he completed the record review and date. He will also sign when he informed Program specialist. He will then follow up to make sure that the discrepancies were addressed and were no longer in the individuals records. attachment #3 03/02/2017 Not Implemented
SIN-00078318 Renewal 04/20/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104An updated notification letter was not sent to the fire department. One individual moved out of the home in October of 2014 and another individual moved in. Two individuals in the home use wheelchairs and need assistance to evacuate. The letter doesn't indicate where the bedrooms are of those who need assistance. The previous notification letter was sent on 1/10/2014.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Program director notified local fire department in writing of the address of the home and exact location of individuals in the home which require assistance evacuating in the event of an actual fire. The HR manager will continue to send updated letters with any new admissions or discharges to the residential facilities. Attachment #11 06/01/2015 Implemented
6400.112(h)The fire drill logs from 3/19/14 to 4/3/15 do not indicate if all individuals met at the meeting place. The logs just state the location of the meeting place. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.A new fire drill log has been made. There is now an area that asks if all individuals made it to the meeting place. the residential supervisor is responsible to ensure that the fire log is filled out properly and this area is compliant. Attachment #7 06/01/2015 Implemented
6400.145(1)The emergency medical plan did not indicate the hospital or source of health care to be used in an emergency.The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. A new Emergency medical plan for all individuals has been added to their permanent file. The new emergency medical plan now lists the hospital and source of healthcare in the event of an emergency Attachment#4 06/01/2015 Implemented
6400.145(2)The emergency medical plan did not include the method of transportation to be used in an emergency.The home shall have a written emergency medical plan listing the following: The method of transportation to be used. A new Emergency medical plan for all individuals has been added to their permanent file. The new emergency medical plan now lists the method of transportation to be used in an emergency Attachment#4 06/01/2015 Implemented
6400.145(3)The emergency medical plan did not include an emergency staffing plan in the event of an emergency. The home shall have a written emergency medical plan listing the following: An emergency staffing plan.A new Emergency medical plan for all individuals has been added to their permanent file. The new emergency medical plan now lists specific emergency staffing plans Attachment #4 06/01/2015 Implemented
SIN-00059015 Renewal 02/11/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)Because of Staffing issues, there was no documentation of fire drills being held for the last licensing year.(a) An unannounced fire drill shall be held at least once a month. Partially Implemented- Adequate Progress A new fire drill book is being completed for the agency that will include our regular company fire drill monthly sheets. This book will replace the book that went missing when our house Program Specialist suddenly left the job. Drills will be scheduled monthly at the home and will be completed by the house Program Specialist and will be reviewed by the Grounds Manager. The book will be kept locked in the Crossroads Services Office, at this point. A copy of the fire drill will be forwarded to the licensing director. 03/18/2014 Implemented
SIN-00047031 Renewal 02/25/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(d)Staff #1 did not have a Medication Administration practicum annually, but continued pass medications.(d) A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. Cassie Burick and Kasey Bartley are medication trainers. They will be responsible for checking the training records quarterly. Ifstaff has not met the yearly requirements they will be suspended from administering medications. The staff will then have to retake the medication administration training. The staff will then be able to administer medications after successful completion of the training. 05/27/2013 Implemented
SIN-00201239 Renewal 03/15/2022 Compliant - Finalized
SIN-00145602 Unannounced Monitoring 11/15/2018 Compliant - Finalized
SIN-00141770 Technical Assistance 09/19/2018 Compliant - Finalized