Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00229779 Renewal 08/22/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(6)Individual #1's Tuberculin skin testing by Mantoux method administered on 10/03/22, and read on 10/05/22, does not indicate the credentials of the medical professional that completed the reading. Therefore, compliance cannot be measured.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. The annual physical form is being changed. The section for the Tuberculin skin test will be on its own page. This will make the form less crowded and easier to read/review for accuracy. 09/29/2023 Implemented
6400.141(c)(14)Individual #1's physical examination, dated 9/29/2022, did not include: Medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Individual #1 medical information pertinent to diagnosis and treatment in case of an emergency was obtained from primary physician. This information was added to his chart. 09/29/2023 Implemented
SIN-00192947 Renewal 09/15/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC 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
SIN-00157689 Renewal 06/24/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)The fire drill record for the fire drill conducted on 5/17/19 stated "Had to do it twice, Individual refused to leave the house the first time second time he did better and listened to the verbal prompts". The two fire drills were held consecutively. An unannounced fire drill shall be held at least once a month. IDD Director and Residential Manager will write and distribute a memo to supervisors outlining fire drill requirements. Supervisors will also share memo with direct support staff. If all clients do not evacuate in 2.5 minutes during an unannounced fire drill then staff must immediately notify their supervisor. Supervisors are responsible for rescheduling the fire drill for another day that month and notifying staff to conduct the fire drill. [Upon completion of fire drills, the fire drill records shall be audited to ensure completion and documentation of fire drills as required. Documentation of all of the trainings and aforementioned audits shall be kept. (DPOC by AED,HSLS on 7/11/19)] 07/11/2019 Implemented
6400.112(c)The fire drill records for fire drills held on 12/19/18, 1/20/19, 2/21/19, 3/7/19, 4/10/19 and 6/8/19 do not address problems encountered. This section of the form was left blank.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The Fire Drill Report will be updated to include a question on whether there were any issues experienced. If so, a comment box must be filled out explaining the situation. All completed fire drill reports will be sent to residential manager for review. The updated Fire Drill Report will be reviewed with residential supervisors and senior habilitation specialists and will include all requirements of completing the form. The form will be updated by July 11th and training will be provided on July 11th. [Within 30 days of receipt of plan of correction and upon hire, all staff persons responsible for conducting fire drills shall be educated in the procedure for conducting and documenting fire drill including addressing "problems encountered" Documentation of all of the trainings and aforementioned audits shall be kept. (DPOC by AED,HSLS on 7/11/19)] 07/11/2019 Implemented
SIN-00118135 Renewal 07/20/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC 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 6-9 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
6400.112(a)An unannounced fire drill was not held in September 2016. An unannounced fire drill shall be held at least once a month. A new supervisor was in place in September and did not comply with directives and policies. This supervisor is no longer employed by TCV. All current supervisors have been trained on the fire safety policy. All fire drills have occurred monthly with the exception of this one supervisor who did not complete the September drills. The TCV fire safety policy is included below. It is the policy of TCV Community Services to ensure the safety of individuals to the highest extent possible with regard to fire safety. PROCEDURE: On the first day of admission to a TCV day program or residential program every individual will have fire safety training. This training will include general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area, and review of the written smoking safety procedures. If the individual is unable to participate in the fire safety training the facility shall keep documentation specifying why they were unable to participate. Written record of the fire safety training shall be kept. Fire safety training will be held for each individual annually after the initial training. Each site will have an unannounced fire drill at least one time a month. Residential programs will have at least one sleeping drill every 6 months. Staff conducting the drill are to complete the fire drill report and fire drill report attendance sheet immediately. Record of the drills must be maintained and include the following information: ¿ Date of the drill (must be one each month alternating days of the week / time of month) ¿ Time of the drill (must vary throughout program hours, must be during normal attendance and staffing conditions, must include am / pm) ¿ Residential programs must have an overnight / sleeping drill at least every 6 months ¿ Location of the fire (must block alternating exits) ¿ Description of the fire (electrical / paper etc) ¿ Location of the smoke detector / alarm ¿ Time taken to evacuate (EXACT time ¿ minutes and seconds) ¿ Number of people responding to the alarm ¿ What exit was used (a different exit must be completely blocked for each drill) ¿ Where the meeting place is ¿ What staff conducted the drill ¿ What staff reactivated the system (confirmed with monitoring center) ¿ What individuals participated in the drill ¿ Any problems encountered during the drill In the daily operation of TCV sites, staff should ensure that no stairways, halls, doorways, or exits are obstructed. Written emergency evacuation procedures are to be posted at day program sites and maintained at each residential site. The evacuation procedures must include individual and staff responsibilities, means of transportation, an emergency shelter location, and an evacuation diagram specifying exits. Evacuation diagrams are to be posted in each area of the facility. For Day Programs: exit signs are to be posted at all exits. If the exit to the exterior of the building is not immediately visible the exit sign will be marked with arrows indicating the direction of travel to reach the exterior exit. For Residential sites: there must be annual notification to the fire department informing them of the exact bedroom location for each individual who requires assistance to evacuate in case of a fire. Fire extinguishers are to be inspected annually. The date of the inspection is to be kept on the extinguisher. Furnaces are to be inspected and cleaned annually. Documentation is to be maintained. Each site is to have an annual fire safety inspection completed by a fire safety expert. Documentation of the inspection including date, source and results are to be maintained. The inoperative fire alarm policy shall be posted at each site. 08/04/2017 Implemented
6400.112(c)The written fire drill record for the fire drill held on 5/17/17 did not include the time of 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. The alarm company was contacted to confirm the time of the May 17, 2017 drill. The time was added to the drill log along with the confirmation from the alarm company. The fire drill log was updated to include am / pm designation to avoid confusion. Supervisors were instructed to destroy all copies of the old fire drill log on 7/21/2017. [At least quarterly for 1 year, designated staff person(s) shall review monthly fire drill documentation to ensure fire drills are completed and documented as required. Documentation of reviews shall be kept. (AS 8/11/17)] 08/04/2017 Implemented
SIN-00086740 Unannounced Monitoring 10/26/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(a)Individual #1's General Update ISP approved 10/02/2015 reads "S/He requires 24-hour supervision...1:4 staff/client ratios 3 pm-midnight." Individual #2's General Update ISP approved 10/06/2015 reads "S/He is supervised 24 hours/day. Staff/client ratio is 1:4." Individual #3's Annual ISP Update approved 8/4/2015 reads "requires a 1:4 staffing ratio." Individual #4's General Update ISP approved 9/18/2015 reads "S/He can be alone for up to 6 hours. The staff ratio is 1:4." On 10/8/15, direct service workers were not scheduled at the home between 9:00 AM to 3:00 PM. Direct Service Worker #1 did not report to his/her scheduled work shift at 3:00 PM. Individuals #1, #2 and #3 returned to the home from day programs between 3:00 PM and 3:30 PM. Direct Service Worker #2 reported to work at 5:59 PM. Individual #4 was in the home from 9:03 AM to 5:59 PM (8 hours and 56 minutes). On 10/8/15, the following prescription medications were not administered until after Direct Service Worker #2 arrived at 5:59 PM. Lorazepam .05mg tablet, prescribed for Individual #2 at 4:00 PM; Amitiza Gel Cap 24MCG, Metformin ER 500MG tablet and 12 units of Novolog 70/30 Flexpen 3ML prescribed for Individual #2 at 5:00 PM. Lorazepam 2MG tablet prescribed for Individual #3 at 4:00 PM. Artificial Tear Drops, Warfarin SOD 2.5MG tablet, Clonazepam 0.5 mg tablet, Famotidine 20MG tablet, and Potassium CHL ER 20MEQ tablet prescribed for Individual #4 at 4:00 PM. An individual may not be neglected, abused, mistreated or subjected to corporal punishment. On October 8 it was discovered by TCV staff that the person assigned to arrive and provide supervision at the Lynda Lane site from 3 pm ¿ 6 pm did not show up for her scheduled shift. This was reported immediately to the Program Manager and Director of IDD Services. The program manager immediately went to the site and all individuals were monitored to ensure health and safety. The temporary staff person did not respond to telephone calls from TCV or the temporary staffing agency. The temporary staff agency did not have record that the individual had agreed to work this shift. TCV will not use this staff person in the future. On October 9 the program manager distributed a staff check in procedure to all residential sites and the sites will now contact each other by phone at 3 pm and 3 am to ensure proper staffing. This process was emailed to all supervisors and senior resident advisors. The 3 o¿clock calling process is displayed at each site in the staff office area. Each site will now receive and make a call at 3 pm (Monday through Friday) and 3 am (Monday through Sunday). Residential staff will be trained to document the check in call in the communication log and also to report any unanswered check in calls to the on-call supervisor immediately. In addition, if temporary staff are scheduled to be the first staff on site the house supervisor will ensure there is a regular staff there to make sure they understand their responsibilities. Since the check in system has begun (October 10) there have been no reports of unanswered check in calls. 12/10/2015 Implemented
6400.161(e)An opened bottle of Siltussin SA 100mg/5mL with an expiration date of 2/2015 was with Individual #1's current medications in his/her medication drawer. An opened bottle of Skintegrity Wound Cleanser was with Individual #2's current medications in his/her medication drawer. There is no prescription for Skintegrity and it doesn't appear on Individual #2's medication administration record. An unopened bottle of Polyethylene Glycol Powder, filled 5/4/2015 and discontinued 5/5/2015, was with Individual #4's current PRN medications in his/her medication drawer.Discontinued prescription medications shall be disposed of in a safe manner.On October 26 it was discovered that there was an expired medication at the Lynda Lane residential site that was not disposed of. The residential program manager completed an audit of all other residential sites by October 29 and there were no other instances of expired medications not being disposed. The Siltussin SA was disposed of on 10/8/2015. [Email received from IDD Services Director on 12/9/15 with the following correction: Siltussin was actually disposed of on 10/26. (AS 12/10/15)] Documentation of this disposal will be sent to Jared Roser, BHSL. A standard operating procedure was created to serve as a reminder to all staff that every expired medication is to be disposed of appropriately. The supervisor will now be monitoring the expiration dates of medications each week. This information will be documented on the med administration monitoring sheet weekly and will be reviewed by the program manager monthly. The standard operating procedure and med administration monitoring sheet will be emailed to Jared Roser, BHSL and Andrew Miller, TCV Compliance Officer. 12/10/2015 Implemented
6400.164(a)An opened bottle of Polyethylene Glycol Powder prescribed for Individual #4, filled 3/2/2015, was with Individual #4's PRN medications in his/her medication drawer. This medication was not present on medication administration record for 3/2015.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. On October 26 it was discovered that there was a PRN medication at one of the TCV residential sites that did not have a medication administration record. The residential program manager completed an audit of all other residential sites by October 29 and there were no other instances of PRN medications without MAR's at the other sites. A MAR was [[not], as per email received by IDD Services Director on 12/9/15(AS 12/10/15)] created for the polyethylene glycol powder on 10/26/2015. A standard operating procedure was created to serve as a reminder to all staff that every prescribed medication requires a MAR. All staff will be trained on the new operating procedure by December 31. A new medication administration monitoring sheet was developed and is to be completed by the site supervisor on a weekly basis and reviewed by the program manager monthly. This monitoring sheet includes information about whether a MAR is available for all prescribed medications. The standard operating procedure and med administration monitoring sheet will be emailed to Jared Roser, BHSL and Andrew Miller, TCV Compliance Officer. 12/10/2015 Implemented
6400.164(b)Sertaline 100mg 1.5 tablet prescribed to Individual #1 was not logged as administered on 9/15/2015 at 7:30 AM. Metformin ER 500MG 2 tablets at 5:00 PM and Lorazepam 0.5 1 tablet at 4:00 PM prescribed for Individual #2 was not logged as administered on 8/21/2015. Tamsulin 0.4mg 1 cap at bedtime prescribed for Individual #3 was not logged as administered on 8/9/2015. Reguloid Orange Power 1 tablespoon in 12oz of water prescribed for Individual #3 was not logged as administered on 9/2/2015 at 9:00 PM. Clonazepam 0.5mg 1 tablet prescribed to Individual #4 was not logged as administered on 8/16/2015 at 9:00 PM. Artificial tears 1 drop in each eye prescribed to Individual #4 was not logged as administered on 9/2/2015 at 9:00 PM. Potassium CHL ER 20 MEQ 2 tablets, Vitamin D3 1000 I-unit 1 tablet, and Metoprolol Succinate ER 50MG ½ tablet prescribed to Individual #4 were not logged as administered on 9/15/2015 at 7:30 AM. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. On October 26 it was discovered that staff at the Lynda Lane residential site were inconsistent with signing the MAR following medication administration. The residential program manager completed an audit of all other residential sites by October 29 and determined that re-training on this requirement is needed. This training will be completed by 12/31. A standard operating procedure was created to serve as a reminder to all staff that the MAR is to be signed immediately following medication administration. A new medication administration monitoring sheet was developed and is to be completed by the site supervisor on a weekly basis and reviewed by the program manager monthly. This monitoring sheet includes information about whether the MAR is signed accurately as well as ensuring the blister pack is initialed / dated. The standard operating procedure and med administration monitoring sheet will be emailed to Jared Roser, BHSL and Andrew Miller, TCV Compliance Officer. 12/10/2015 Implemented
SIN-00077866 Renewal 07/15/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(c)There was not a first aid manual with the first aid kit. A first aid manual shall be kept with the first aid kit.On 7/16/15 it was discovered that the first aid manual was laying beside the first aid kit inside a drawer and was not placed inside the actual kit. The first aid manual was immediately placed in the kit. The program manager did an inspection of first aid kits 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 contents of the first aid kit during the monthly site inspection. The requirement of having the first aid manual inside the kit was added to the site inspection checklist 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 replace any missing manuals by printing a manual from the internet (for immediate use) then by purchasing a new manual within 48 hours. 11/26/2015 Implemented
SIN-00047642 Renewal 03/18/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(f)Individual #1 and plan team members were not informed of the results of the assessment completed on 5/1/2012 at least 30 days prior to ISP meeting held on 6/18 /12. (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). The assessment will be provided to team members at least 30 calendar days prior to the ISP. Documentation to indicate that is was sent will be kept. (Supporting Documentation to be mailed). [By 8/1/13, the Program Specialist will be reeducated on regulation and documentation requirements. Residential Director will audit individual records monthly to ensure that the individual and plan team members are informed of the results of the assessment at least 30 calendar days prior to the ISP meeting. (CHG 7/5/13)] 05/29/2013 Implemented
SIN-00111238 Unannounced Monitoring 12/27/2016 Compliant - Finalized