Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00229780 Renewal 08/22/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(7)Individual #1 had a gynecology examination on 9/23/2022 but documentation of a previous exam was not provided. Therefore compliance cannot be measured. Individual #1 is 18 years of age or older.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. This was discussed with Individual #1's legal guardian(mother) during the annual ISP meeting on 8/29/23. She is due for her gynecological exam in 2024. At this time her guardian plans to have her complete the exam. However, due to the trauma of a past exam, she may not wish to continue having these exams completed. This will be discussed with the doctor at next years examination. 09/29/2023 Implemented
SIN-00213826 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
6400.106Furnace inspection and cleaning was completed on 6/4/2021 and then again on 6/29/2022. 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
SIN-00192948 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
6400.104The notification letter to the local fire department, dated 8/15/20021, does not provide the information of the assistance needed for the individuals currently living in the 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. This letter was updated and sent out on 9/28/21. 09/28/2021 Implemented
SIN-00157690 Renewal 06/24/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment completed on 2/14/19 did not address 6400.68(c), 6400.101, 6400.105, 6400.113(b), 6400.200(c)(7) , 6400.213(1)(v) and 6400.213(2). These sections of the form were 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
6400.105Two plastic laundry baskets, three plastic buckets, a mop with a plastic handle and cloth head and an ironing board with a fabric cover were being stored twelve inches from the furnace and hot water tank in the basement of the home.Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. All residential supervisors and senior habilitation specialist will be retrained on state regulations 6400.105 relating to flammable and combustibles being stored within 36 inches of the heating sources. TCV's maintenance department will section off 36 inches on all heating sources by using bright reflective tape. If the heating source is enclosed, a sign will be posted on the door to indicate no storage. [Items were moved away from the furnace at the time of discovery during the inspection. Within 30 days of receipt of the plan of correction, all staff persons shall be notified that flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources and to monitor during the course of their daily duties. Immediately and at least monthly, a designated staff person shall complete a walkthrough of all community living homes to ensure flammable and combustible supplies and equipment are utilized safely and stored away from heat sources. (DPOC by AES,HSLS on 7/11/19)] 07/15/2019 Implemented
6400.112(c)The fire drill records for the fire drills conducted on 10/15/18, 12/13/18, 3/18/19 and 5/20/19 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
6400.141(c)(8)Individual #, date of birth 10/25/59, had a mammogram on 8/23/17 and then again on 9/24/18.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. All staff are encouraged to schedule future follow-up appointments prior to leaving appointments. In the event that an appointment is not scheduled at that time, supervisors are responsible for contacting physician offices up to 6 months prior to the appointment deadline for scheduling of mammograms, prostate exams, and annual physical appointments. Failed attempts to schedule within the required time-frame due to the doctor's availability will be documented. The new time-frame will be updated on the tracking sheet and the information will be given to supervisors during training. [At least quarterly, a designated management staff person shall audit the aforementioned tracking system and a 25% sample of individuals' current physical examinations to ensure timely completion of physical examination with all required information. (DPOC by AES, HSLS on 7/11/19)] 07/11/2019 Implemented
6400.162(a)A bottle of Nystatin 1000,000/gm Powder was in a small, clear plastic bag with the label, Hydrocortisone 2.5% Lotion in Individual #2's medication box.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. All staff responsible for administering medications will be retrained on medication storage and reviewing the 5 rights of medication administration. The Senior Habilitation Specialist will conduct weekly medication checks to make sure the medication is store properly and in it's original container. [Documentation of the trainings and audits shall be kept. (DPOC by AED,HSLS on 7/11/19)] 07/31/2019 Implemented
SIN-00118136 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 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
6400.44(b)(10)The program specialist did not complete monthly documentation of Individual #1's participation and progress during February, March and April 2017.The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of an individual's participation and progress toward outcomes.The monthly documentation for Individual #1 has been completed. A new program specialist monthly documentation policy has been created to develop a system of accountability. All program specialists will be trained on the policy on 8/9/2017. The monthly documentation policy 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 monitor completion of all regulatory documents. PROCEDURE Upon admission and at each annual ISP review meeting the program specialist will complete the Individual documentation timeframes worksheet. When an ISP is scheduled the Program specialist will email the program manager to notify of the meeting. Within 5 days following the meeting the program specialist will update the individual documentation timeframes worksheet and submit a copy to the program manager. Each month the program specialist will complete the monthly documentation checklist for the previous month. The checklist will be submitted to the program manager by the fifth of the month. The program manager will audit 10% of the monthly summaries, 10% of the service plan three month reviews, 100% of incidents, 100% of medication logs, and 10% of financial documentation. The program manager will also follow up on any issues and make sure all documentation is filed appropriately. The program specialist and program manager will meet monthly to review the monthly documentation form. 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
6400.186(a)The program specialist did not complete an ISP review from 12/30/16 to 6/30/17 for Individual #1.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. The three month reviews are completed and will be distributed to the team on 8/7/17. 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 due¿ 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. The program manager will review all monthly checklists and review 10% of 08/04/2017 Implemented
SIN-00089055 Unannounced Monitoring 01/06/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)On 11/8/15, the accounting sheet for Individual #1 indicated a balance of $57.05. On 11/11/15, after 2 transactions the accounting sheet read $75.20, and Individual #1's actual cash on hand was $25.20. There are no records or receipts to account for the missing funds. The house safe where Individual #1's money is kept was unlocked from 10/24/15 to 11/11/15.Individual funds and property shall be used for the individual's benefit. A new procedure for safe storage of individual funds was developed and the safe that was found to be cumbersome at this site is no longer being used. Currently, individual funds of around 30 to meet the individuals anticipated short term needs are stored in a lock box which all staff have access to. The money in this lock box is audited on each shift. Any funds in excess of what is maintained in the general lock box is kept in a lock box within a locked cabinet. Only three individuals have access to the key. Staff are to audit the contents of the safe each time it is accessed. A copy of this procedure has been provided to Ms. Christine DiGregory at BHSL. Missing funds were reimbursed to Individual #1 on 12/23/15. The program manager has begun completing monthly audits of the individual funds and there have been no futher problems since this incident. [Within one month of receipt of the plan of correction all staff at all community homes will be trained on the aforementioned revised policy and procedures and the revised procedures will be implemented at all community homes. Documentation of the monthly audits completed by the program managers shall be maintained and reviewed at least quarterly by the Director of IDD services or designated management or accounting staff person to ensure accuracy in implementing the policy and procedures and to ensure all individual funds and property are used for the each individual's benefit. (AS 4/14/16)] 03/10/2016 Implemented
SIN-00047643 Renewal 03/18/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.164(b)Staff #1 administered Ammonium Lactate 12% Lotion, apply topically to lower legs once a day to Individual #1 on 9/15/12 at 7:30 AM and failed to sign the medication administration record immediately after administration.(b) The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. Staff were trained in regard to signing MARs immediately after administrating medications. Copies of subsequent signed MARs that include all required initials will be mailed under separate cover. 05/20/2013 Implemented
6400.181(f)Individual #1 and plan team members were not informed of the results of the assessment completed on 2/19/2013 at least 30 days prior to the ISP meeting dated 3/15/2013.(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 it was sent, will be kept. (Supporting 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 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)] 05/10/2013 Implemented
SIN-00177758 Renewal 10/14/2020 Compliant - Finalized
SIN-00077867 Renewal 07/15/2015 Compliant - Finalized