| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
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SIN-00229778
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Renewal
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08/22/2023
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(e) | A fire drill was held during sleeping hours on 10/05/22, and then again on 08/10/23. This exceeds the at least every 6-month requirement. | A fire drill shall be held during sleeping hours at least every 6 months. | A fire drill schedule for Sept 2022 to Sept 2023 was created for all of the residential sites. This was shared with the site supervisors. A Microsoft form was created for the staff to complete after the drill. Once they submit the form, the Compliance officer, IDD Director and IDD Residential Manager will get an alert in their email. In addition, reminder alerts have been set in the manager and supervisor¿s outlook calendars. |
08/29/2023
| Implemented |
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SIN-00192946
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Renewal
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09/15/2021
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency did not complete a self-assessment of this home. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| All new site supervisors and residential program manager will be trained on Self-Assessments and completion of Self-Assessment tool as it relates to regulation 6400.15a,b,and c. This training will be completed by October 12, 2021. The training record will be maintained in the employee personnel file.
As per regulation 6400.15a a Self-Assessment tool will be completed for this service location 3-6 months following this licensing review and 3 to 6 months prior to the end of the current licensing agreement date. These are to be completed by December 15, 2021 and the second to be completed by April 15, 2022. and annually there after. |
10/15/2021
| Implemented |
| 6400.77(b) | The first aid kit in the home did not contain tweezers and a thermometer. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Tweezers and Thermometer have been placed in first aid kit at this location as of 10/8/21. |
10/08/2021
| Implemented |
| 6400.111(f) | The fire extinguishers on each floor of the home were most recently inspected by a fire safety expert in 9/2019. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | Residential Program Manager met the fire safety professional at this location on 9/29/21 and all fire extinguishers were inspected and are cleared. |
09/29/2020
| Implemented |
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SIN-00157687
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Renewal
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06/24/2019
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment of the home completed on 2/13/19 did not address regulations 6400.82c, 6400.104, 6400.105, 6400.106, 6400.141(c)(10), 6400.142(g), 6400.168(b) and 6400.213(1)(iv). These sections was left blank. | 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.
| IDD Director and Program Manager will retrain all residential supervisors on completing the Chapter 6400 Community Homes for Individuals with Intellectual Disabilities Self-Assessment Tool. The training will include required deadlines for completing the tool as well as how to complete the form in its entirety. All self-assessments will be handed out to supervisors in December and will be due back to Program Manager by February 28th. The Program Manager will have 7 days to review and submit to IDD Director for final review. [Documentation of the trainings and audits shall be kept. (DPOC by AED,HSLS on 7/11/19)] |
07/11/2019
| Implemented |
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SIN-00137357
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Renewal
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06/26/2018
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency completed a self-assessment of the home on 3/13/18 . The agency's certificate of compliance has an expiration date of 6/9/18. In addition, compliance was not measured for regulations 31(b) through 46(j), 151(a) through 152(c), and 189(a) through 189(c). [Repeat violation 7/20/17 et al.] | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The areas of this self-assessment that were not completed were completed on 7/13/2018 and the document was sent to Nancy Armstrong via email. The self-assessment of programs policy was updated on 7/10/2018 to align with the correct expiration date of the license instead of the licensing visit date. The policy was also updated to include that the program manager will review the documents and work with the site supervisors and administrative assistant to ensure all areas are reviewed. The management team will be trained on the new policy by 8/19/2018.[Documentation of trainings and reviews shall be kept. (AS 7/20/18)] |
08/19/2018
| Implemented |
| 6400.151(c)(2) | Director of ID Services #1 had a Tuberculin skin test completed on 12/23/15 and then again on 1/31/18. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Director of ID Services was unable to get the TB test at the regularly scheduled physical exam on September 21, 2017 and forgot to schedule follow up with the physician before the due date of 12/23/17. The TB test was obtained on 1/31/18. A standard operating procedure has been created to maintain and track physical and TB information for all IDD employees. The information will be maintained by the administrative assistant who will be responsible for alerting all employees and their supervisor via email 60 days before their physical / TB is due. If the documentation is not received 30 days before their physical and TB are due the administrative assistant will notify the employee and their supervisor via interoffice mail. If the documentation is still not received on the due date the administrative assistant will alert the individual, supervisor, program manager, and department director and the staff person will not be allowed to work with individuals until the physical and TB are obtained. When a physical / TB is obtained the administrative assistant will review the form to make sure a general physical examination was completed, there is a written statement regarding the employee being free from communicable disease or what precautions need to be taken to prevent the spread of a communicable disease, any medical concerns that may impact the employees ability to care for the individuals, and the TB must have negative results documented by a registered nurse, licensed practical nurse, certified licensed physician, certified physician¿s assistant, or certified registered nurse practitioner. The administrative assistant was trained on the new SOP on 7/17/18. |
07/17/2018
| Implemented |
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SIN-00118133
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Renewal
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07/20/2017
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency completed a self-assessment (using a Self-Inspection and Declaration tool) between 4/3/17 and 4/18/17. The expiration of the agency's certificate of compliance was 6/9/17. | 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-inspection policy was developed to ensure the correct form is completed within 3-6 months prior to the expiration date of TCV¿s Certificate of Compliance. The policy is below.
It is the policy of TCV Community Services to provide all services in compliance with state, county, and federal regulations. In order to ensure compliance, TCV will conduct a self-assessment of programs 3-6 months before expiration of the current license.
PROCEDURE
The department director or delegate is responsible for ensuring a self-inspection of the program is completed within 3-6 months before the expiration of the current license.
The department director will notify the program manager when the LII is due.
The program manager will work with site supervisors and program specialists to ensure thorough review of all regulatory requirements and accurate documentation of compliance on the licensing inspection instrument scoresheet.
If an area of non-compliance is identified during the self-inspection the program manager and site supervisor are responsible to resolve the issue. If the issue is unable to be resolved, the program manager will notify the department director and a plan of action will be developed to prevent future occurrences of the same violation.
The LII can be found at dhs.state.pa or by searching licensing inspection instrument and selecting the program regulations (either 6400 or 2380)
The program manager will submit the LII to the department director no later than April 1 of each year.
The department director will maintain the LII for the upcoming audit which typically occur in July..[At least 3 months prior to the expiration of the certificate of compliance the Director of IDD Services shall review all self-inspections to ensure timely completion on the Department's licensing inspection instrument. Documentation of the audit of the self inspections shall be kept. (AS 8/11/17)] |
08/04/2017
| Implemented |
| 6400.15(b) | The agency completed a self-assessment of the home using the Department's Self-Inspection and Declaration Tool used for self-inspection of a new home. | The agency shall use the Department's licensing inspection instrument for the community homes for people with intellectual disability regulations to measure and record compliance.
| The correct form was identified on 7/21/2017. Supervisors have been provided the correct LII tool and are working with the program manager and department director to complete self- inspections by 8/31/2017. A self-inspection policy was developed which is included below.
It is the policy of TCV Community Services to provide all services in compliance with state, county, and federal regulations. In order to ensure compliance, TCV will conduct a self-assessment of programs 3-6 months before expiration of the current license.
PROCEDURE
The department director or delegate is responsible for ensuring a self-inspection of the program is completed within 3-6 months before the expiration of the current license.
The department director will notify the program manager when the LII is due.
The program manager will work with site supervisors and program specialists to ensure thorough review of all regulatory requirements and accurate documentation of compliance on the licensing inspection instrument scoresheet.
If an area of non-compliance is identified during the self-inspection the program manager and site supervisor are responsible to resolve the issue. If the issue is unable to be resolved, the program manager will notify the department director and a plan of action will be developed to prevent future occurrences of the same violation.
The LII can be found at dhs.state.pa or by searching licensing inspection instrument and selecting the program regulations (either 6400 or 2380)
The program manager will submit the LII to the department director no later than April 1 of each year.
The department director will maintain the LII for the upcoming audit which typically occur in July.[At least 3 months prior to the expiration of the certificate of compliance the Director of IDD Services shall review all self-inspections to ensure timely completion on the Department's licensing inspection instrument. Documentation of the audit of the self inspections shall be kept. (AS 8/11/17)] |
08/04/2017
| Implemented |
| 6400.71 | The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the telephone in the kitchen. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| The emergency telephone numbers were posted by the telephone in the kitchen on 7/21/17. A policy was developed which is included below. The policy creates a system of accountability and checks to ensure phone numbers are monitored and posted as defined in the regulations.
It is the policy of TCV Community Services to provide all services in compliance with state, county, and federal regulations. In order to ensure quick access to emergency assistance when needed TCV will post emergency phone numbers by all telephones.
If the emergency phone listing is missing or damaged it is the responsibility of the site supervisor to replace it immediately upon notification.
PROCEDURE
Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
Portable telephones will have a sticker label placed on the back of the handset with laminating paper or transparent tape covering the ink to prevent fading.
The site supervisor or delegate is responsible for making sure all phone numbers are accurate.
The site supervisor or delegate is responsible for completing either the residential monthly site inspection or the monthly site inspection ¿ IDD day program each month to confirm the emergency numbers are still posted and accurate.
The monthly site inspection form is to be submitted to the program manager who will verify all issues identified are resolved. |
08/04/2017
| Implemented |
| 6400.163(c) | Individual #1's most recent psychiatric medication review with documentation by a licensed physician was 1/11/17. | 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. | Documentation of psychiatric medication reviews from 4/11/2017 and 7/5/2017 were located and had been misfiled. In internal corrective action is being established. A standardized chart order has been developed along with an individual chart policy which is included below. All staff will be trained on the new policy on August 9, 2017. Charts will be monitored monthly by supervisors for timely filing, and quarterly by the Program Manager for chart order.
It is the policy of TCV Community Services to provide all services in compliance with state, county, and federal regulations. In order to ensure compliance TCV will maintain orderly, consistent charts.
PROCEDURE
Individual charts will be locked except when in use.
Charts will follow the TCV chart order for the program in which the individual is enrolled.
The site supervisor or delegate is responsible for ensuring timely filing of all documentation on at least a monthly basis.
The site supervisor will confirm that all filing has been completed on the submission of monthly documentation form.
The site supervisor will forward the submission of monthly documentation form to the program manager by the fifth of each month.
The program manager will complete quarterly audits to ensure the charts are in proper order. |
08/04/2017
| Implemented |
| 6400.186(d) | The program specialist did not record when Individual #1's ISP review documentation for the review period 7/1/16 to 9/31/16 was provided to the plan team members; therefore, compliance could not be measured. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | The SC was contacted to confirm receipt of the review documentation. We could not get a response from the SC so we resent the documentation on 8/2/2017.
An ISP three month review policy was created and is posted below. The policy creates a new system of accountability for ISP reviews and all staff will be trained on the new policy on 8/9/2017. ¿Individual Documentation Timelines¿ will be completed by Program Specialists by August 31, 2017 for all currently consumers. The program manager will monitor 10% of all 3 month reviews monthly.
It is the policy of TCV Community Services to provide all services as defined by the ISP in compliance with state, county, and federal regulations. Therefore, the program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP.
PROCEDURE
Each program specialist is to document the ISP review date for all assigned individuals. The program specialist will notify the program manager via email of all ISP meetings.
Based on the ISP review date the program specialist will determine monthly and three month review dates and document all due dates on the ¿individual documentation timelines¿ form. (PHI/IDD/IDDPolicy & Procedures / forms)
This form is to be completed and submitted to the program manager by August 31, 2017. The form is to be updated at each annual ISP meeting and submitted to the program manager within 5 days of the meeting.
The three month review is to include the following information:
(1) 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.
(2) A review of each section of the ISP specific to the residential home.
(3) The program specialist shall document a change in the individual¿s needs, if applicable.
(4) The program specialist shall make a recommendation regarding the following, if applicable:
(i) The deletion of an outcome or service to support the achievement of an outcome which is no longer appropriate or has been completed.
(ii) The addition of an outcome or service to support the achievement of an outcome.
(iii) The modification of an outcome or service to support the achievement of an outcome in which no progress has been made.
(5) If making a recommendation to revise a service or outcome in the ISP, the program specialist shall complete a revised assessment as required under § 6400.181(b) (relating to assessments).
(d) The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting.
(e) The program specialist shall notify the plan team members of the option to decline the ISP review documentation.
(f) If a recommendation for a revision to a service or outcome in the ISP is made, the plan lead as applicable, under § § 2380.182(b) and (c), 2390.152(b) and (c), 6400.182(b) and (c), 6500.152(b) and (c) (relating to development, annual update and revision of the ISP), shall send an invitation for an ISP revision meeting to the plan team members within 30 calendar days of receipt of the recommendation.
(g) A revised service or outcome in the ISP shall be implemented by the start date in the ISP as written.
At the end of each month the program specialist will review all documentation to ensure it has been completed, signed, dated, sent to all appropriate team members, and filed appropriately.
The program specialist will complete a monthly checklist and submit it to the program manager by the fifth of each month confirming completion of the all applicable quarterly ISP reviews. |
08/04/2017
| Implemented |
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SIN-00077864
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Renewal
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07/16/2015
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.74 | The outside steps from the kitchen door to the driveway did not have a nonskid surface. | Interior stairs and outside steps shall have a nonskid surface.
| Maintenance was contacted on 7/16/15 and the exterior stairs were resurfaced with non-skid paint on that day. The program manager did a visual inspection of stairways at all 8 houses by 7/21/2015. This requirement was discussed at a leadership team meeting with all residential supervisors and the residential program specialist on August 13, 2015 and the leadership team was directed to monitor the surfaces of all stairs including interior and exterior. This was added to the site inspection that is completed by either the site supervisor or the senior resident advisor (Lead staff person) at the time of the monthly fire drill. Supervisors verbally instructed the SRA's of this requirement in August and September. The leadership team was directed to contact maintenance by the end of their shift if they feel a stairway does not have sufficient non-skid material and also to clearly mark the area so everyone knows there is a potential hazard. In addition, maintenance has added routine checks of all residential sites twice a year. |
11/26/2015
| Implemented |
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SIN-00047641
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Renewal
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03/18/2013
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | On March 19, 2013, the hot water knob in the upstairs bathroom was leaking when turned on which caused a rusted area that ran the length of the shower stall (approximately 4 feet). The bracket that held the shower head was rusted and loose. There was a molded black area that ran along the base of the shower stall.
| (a) Floors, walls, ceilings and other surfaces shall be in good repair.
| Bathroom: A work order for repair, i.e., rust and mold in shower was completed on 3/19/13. New Shower installed on 4/3/13. Staff were trained on the importance of and process for safety checks and reporting hazards to prevent such areas of non-compliance. Completed on 3-27-13. (Supporting documentation to be mailed) |
04/03/2013
| Implemented |
| 6400.72(c) | On March 19, 2013, the kitchen screen door lock was not working properly. Staff and licensing representative were locked outside during the inspection. | (c) Outside doors shall have operable locks.
| A work order was given to our Maintenance Dept on 3/19/2013 for a new lock/handle on screen door. This was corrected on the same day it was found; 3/19/2013. (Supporting documentation will be mailed). |
03/19/2013
| Implemented |
| 6400.80(b) | On March 19, 2013, the cement patio adjacent to the basement had three large 6 foot cracks which presented a tripping hazard. | (b) The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.
| A work order for repair of cracks in back patio was completed on 3/19/2013. A deck was built to cover the patio area. It eliminates the cracked concrete, creating a level, hazzard-free patio. Staff were trained on the importance of and process for safety checks and reporting hazzards to prevent such areas of non-compliance. (Supporting documentation will be mailed), |
04/09/2013
| Implemented |
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