Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00213829 Renewal 08/23/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The home did not complete a self-assessment.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 agency will develop a schedule for all agency self-assessments be completed in the month of February which is 4 months prior to the end of the agency's certificate of compliance. All site supervisors will be trained on completion of self assessments to include not leaving any blanks on assessments. 11/16/2022 Implemented
6400.63(a)On 8/24/2022, the water temperature measured 130.6 degrees Fahrenheit at the sink in bathroom in the hallway on the main floor at 10:16am.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. Hot water tank was immediately turned down. Review of September temperature logs indicate 109 degrees on 9/9/22. 08/24/2022 Implemented
6400.68(b)On 8/24/2022, the water temperature measured 129.9 degrees Fahrenheit at the bathtub in bathroom adjacent to the bedroom of individual #1 at 10:14am. Hot water temperatures in bathtubs and showers may not exceed 120°F. Hot water tank was immediately turned down. Review of September temperature logs indicate 109 degrees on 9/9/22. 08/24/2022 Implemented
6400.106The furnace inspection and cleaning was completed on 6/3/2021, and then again on 6/30/2022. This exceeds the annual requirement.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. Agency to schedule with Caruso Heating and Cooling annual furnace inspections prior to 6/29/23 and on an automatic reoccurring annual schedule there after. 08/25/2022 Implemented
6400.141(c)(6)Individual #2's most recent tuberculin evaluation was completed on 12/9/2019. This exceeds the 2-year requirement.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Individual #2 had a TB test on 9/30/22. 09/30/2022 Implemented
6400.166(a)(11)Individual #1's August 2022 Medication Administration Record did not include the diagnosis or purpose for the following medications: Furosemide 20Mg Tablet, Atomoxetine HCL 40Mg, Buspirone HCL 30 MgA medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Verified with pharmacy the diagnosis/purpose for all medications listed on MAR for each individual to be in compliance with this code. 08/25/2022 Implemented
SIN-00192951 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
6400.141(c)(14)Individual #1's physical examination, completed 10/23/2020, does 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's annual physical was on 10/4/21 and his social medical history was attached to his appointment form and reviewed by the physician. 10/04/2021 Implemented
6400.52(c)(2)Chief Executive Officer #1's annual training hours for training year, July 1, 2020 to June 30, 2021, did not include the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The CEO designates the Director of IDD Services as the Executive responsible for the entire IDD program for Turtle Creek Valley MH/MR. The IDD Director meets the qualification of this position by having a BA degree in Criminal Justice and 30 years experience in the IDD field with 28 of those years in a supervisory/administrative positions. Her resume and educational verification along with clearances and training records are maintained at the corporate HR department for review. The IDD Director will complete this training by 10/15/21 and according to the Training calendar there after. All training records will be kept in her personnel file in the departments office for review. 10/15/2021 Implemented
6400.52(c)(3)Chief Executive Officer #1's annual training hours for training year, July 1, 2020 to June 30, 2021, did not include individual rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.The CEO designates the Director of IDD Services as the Executive responsible for the entire IDD program for Turtle Creek Valley MH/MR. The IDD Director meets the qualification of this position by having a BA degree in Criminal Justice and 30 years experience in the IDD field with 28 of those years in a supervisory/administrative positions. Her resume and educational verification along with clearances and training records are maintained at the corporate HR department for review. 10/15/2021 Implemented
6400.52(c)(4)Chief Executive Officer #1's annual training hours for training year, July 1, 2020 to June 30, 2021 did not include recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.The CEO designates the Director of IDD Services as the Executive responsible for the entire IDD program for Turtle Creek Valley MH/MR. The IDD Director meets the qualification of this position by having a BA degree in Criminal Justice and 30 years experience in the IDD field with 28 of those years in a supervisory/administrative positions. Her resume and educational verification along with clearances and training records are maintained at the corporate HR department for review. 10/15/2021 Implemented
6400.52(c)(5)Chief Executive Officer #1's annual training hours for training year, July 1, 2020 to June 30, 2021, did not include the safe and appropriate use of behavior supports if the person works directly with an individual.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.The CEO designates the Director of IDD Services as the Executive responsible for the entire IDD program for Turtle Creek Valley MH/MR. The IDD Director meets the qualification of this position by having a BA degree in Criminal Justice and 30 years experience in the IDD field with 28 of those years in a supervisory/administrative positions. Her resume and educational verification along with clearances and training records are maintained at the corporate HR department for review. 10/15/2021 Implemented
6400.52(c)(6)Chief Executive Officer #1's annual training hours for training year, July 1, 2020 to June 30, 2021, did not include implementation of the individual plan if the person works directly with an individual.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.The CEO designates the Director of IDD Services as the Executive responsible for the entire IDD program for Turtle Creek Valley MH/MR. The IDD Director meets the qualification of this position by having a BA degree in Criminal Justice and 30 years experience in the IDD field with 28 of those years in a supervisory/administrative positions. Her resume and educational verification along with clearances and training records are maintained at the corporate HR department for review. 10/15/2021 Implemented
SIN-00137361 Renewal 06/26/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency completed a self-assessment of the home on 3/28/18. The agency's certificate of compliance has an expiration date of 6/9/18. In addition, compliance was not measured for regulations 181(e)(10) through 181(f). [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
6400.112(d)The fire drill completed 9/9/17, had an evacuation time of 3 minutes and 55 seconds. The home does not have an extended evacuation time in writing by a fire safety expert. 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. The site supervisors and program managers will be re-trained on fire safety requirements by 8/1/2018. Specifically, we will review the following areas: 1. You must have a drill every month 2. The drill must be documented on the updated current form 3. If it takes more than 2 ½ minutes to evacuate you must repeat the drill within 24 hours 4. You must vary the location of the fire 5. You must vary the evacuation route (you can¿t always use the same exit) 6. You must vary the day of week and time of day 7. You must list the time of the drill both minutes and seconds ¿ if it is 2 minutes even put 0 seconds 8. Overnight drills (October & April) must take place between 12:00 midnight and 6 am. 9. If staff do not receive the fire safety training by their annual due date they will be removed from the schedule. All fire drill forms are to be submitted to the department administrative assistant by the 15th of the month. The administrative assistant is responsible for reviewing the drills to make sure they are compliant. If they are not compliant they will be returned to the site supervisor and the drill will be re-done. The department training curriculum is revised annually (in July) so that all employees will receive the fire safety training every 11 months. All supervisors and program managers were re-trained on this policy in July, 2018. [Upon review of fire drill documentation, if an evacuation time exceeds the required evacuation for more than 2 fire drills in a row, a designated management staff will observe a fire drill to determine the problem areas and address as needed with retraining, staffing supervision etc. to ensure all fire drills are conducted as required. Documentation of observations and actions shall be kept. (AS 7/20/18)] 07/27/2018 Implemented
SIN-00098390 Renewal 07/21/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.164(a)Individual #1 is prescribed Alendronate 70 mg 1 tablet once a week; the medication log was initialed as administered on 7/1/16 and 7/2/16 at 7:30 AM. Spironolactone 100 MG tablet prescribed for Individual #1 was not initialed as administered on 7/13/16 at 9:00 PM. 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. The standard operating procedure for medication administration was revised to include information on what to do if there is an error on the MAR. Information was put into the standard operating procedure instructing staff to put one line through an error and initial and date the error then explain the error on the back of the MAR. Supervisors and program specialists were trained on the revised standard operating procedure and all staff are to be trained by 9/30/2016. The site supervisor counseled the staff member who failed to initial the MAR on 7/13/2015 at 9 pm. We were unable to determine if there was an actual medication omission or if it was a documentation error because the blister pack was disposed of by the time the error was discovered. The site supervisor reviewed the importance of signing the MAR at the time of medication administration with all staff at the August house meeting. All other MAR's were reviewed and no other documentation errors were discovered. [At least monthly, the site supervisor and/or program specialist shall review MARs for all individual to ensure aforementioned procedures are being followed and prescribed medications are being administered and documented as required. Additional training shall be provided by the program specialist(s) or site supervisor(s) to staff members who are found during the review process to have a medication documentation or administration error.(AS 9/21/16)] 08/18/2016 Implemented
SIN-00047645 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 done on 1/3/13 at least 30 calendar days prior to ISP meeting held on 1/3/13.(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 ISP to indicate that it was sent; it shall 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
6400.186(a)The document dated 8/17/12 which reviews May, June and July 2012 was not signed and dated by Individual #1.(a) The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. Program Specialist will assure that all three (3) months reviews are signed and dated. (Supportive documentation will 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 the ISP review of the services and expected outcomes in the ISP specific to the residental home is reviewed with the individual every three months or more. (CHG 7/5/13)] 04/05/2013 Implemented
SIN-00229783 Renewal 08/22/2023 Compliant - Finalized
SIN-00077872 Renewal 07/16/2015 Compliant - Finalized
SIN-00061066 Renewal 07/09/2014 Compliant - Finalized