Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00213131 Renewal 09/07/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(11)Individual #1's September 2022 Medication Administration Record did not include the diagnosis or purpose for the following medication: Latuda 20 mg tablet.A 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.EIG recognizes the importance of this regulation and will ensure that a 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. EIG acknowledges that there was a medication that did not include the purpose of the medication in one of our homes. [Individual #1's December 2022 MAR, that includes diagnosis/purpose for each medication, was received on 1/10/23 and reviewed 1/24/23. DPOC by HDKP, HSLS, on 1/24/2023]. 09/12/2022 Implemented
SIN-00178835 Renewal 11/04/2020 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not listed on or by the base of the telephone in the home. The cordless telephone was missing from the base and not able to located; therefore, compliance could not be measured.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. EIG recognizes the importance of this regulation so that as an agency we will ensure that the telephone numbers of the nearest hospital, police department, fire department, ambulance, and poison control center are listed on all site phones. 1. The cordless phone for this site was located and placed on the base. The phone has the nearest hospital, police department, fire department, ambulance, and poison control center on the phone. [Immediately and at least quarterly for 1 year, the CEO or designee will audit all homes to ensure emergency number are posted on or by all telephones in the home. Immediately, the CEO or designated management staff will develop and implement policies on procedures for monitoring and report missing telephone numbers and train staff on the policies and procedures. Documentation of all audits and trainings shall be kept. (DPOC by RM, HSLS on 12/20/20)] 11/30/2020 Implemented
6400.72(b)The latch in the lower pane of the window in the bathroom was not secure to the outer track leaving the window loose and able to be easily pulled out. Screens, windows and doors shall be in good repair. EIG recognizes the importance of this regulation so that as an agency we will ensure that all screens, windows, and doors are in good repair. 1. EIG hired a general contractor to repair the latch in the lower pane of the window in the bathroom to ensure that it is secure. [On 12/2/2020 the latch on the window was still loose and a projected date of repair has not been given. Immediately, the CEO or designated management staff will ensure the window is repaired or replaced. Immediately, the CEO or Designated management staff will develop and implement policies and procedures for reporting and completing repairs to the home and train staff on the policies and procedures. Documentation of all audits and trainings shall be kept. (DPOC by RM, HSLS on 12/10/20)] 11/30/2020 Not Implemented
6400.74The five wooden outside steps leading from the door to the yard at the back of the home did not have a nonskid surface. [Repeat violaton-6/26/19; et al.]Interior stairs and outside steps shall have a nonskid surface. EIG recognizes the importance of this regulation so that as an agency we will ensure that the steps leading from the door to the yard have a nonskid surface. 1. The general contractors at EIG Services utilizes paint that has non-skid materials/ingredients in it to prevent any slippage and/or accidents from occurring. 2. This paint will be applied to the interior stairs leading to the outside steps. [Immediately and at least quarterly for 1 year, the CEO or designee will audit all homes to ensure all interior and outside steps have nonskid surfaces. Immediately, the CEO or Designated management staff will develop and implement policies and procedures for reporting and completing repairs to the home and train staff on the policies and procedures. Documentation of all audits and trainings shall be kept (DPOC by RM, HSLS on 12/10/20)] 11/30/2020 Implemented
6400.110(e)The smoke detector on the first floor of the home was not interconnected. The home has four floors including the basement, first floor, second floor and third floor which includes the individuals' bedrooms.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. EIG recognizes the importance of this regulation so that as an agency we will ensure that the steps leading from the door to the yard have a nonskid surface. 1. The general contractors at EIG Services utilizes paint that has non-skid materials/ingredients in it to prevent any slippage and/or accidents from occurring. 2. This paint will be applied to the interior stairs leading to the outside steps. [NOT ACCEPTABLE PLAN OF CORRECTION DOES NOT MATCH VIOLATION. On 12/2/2020 the department observed the smoke detectors in the home to be interconnected. Immediately and at least quarterly for 1 year, the CEO or designee will audit all homes to ensure all smoke detectors for homes serving four or more individuals or that have 3 or more floors have interconnected and operable smoke detectors. Documentation of all audits shall be kept. (DPOC by RM, HSLS on 12/10/20)] 11/05/2020 Not Implemented
6400.112(e)The most recent fire drill held during sleeping hours was 04/17/20. [repeat violation-6/26/19; et al.]A fire drill shall be held during sleeping hours at least every 6 months. The reason why this regulation is important is to teach the individuals how to safely evacuate during a sleeping fire drill when the smoke detector is activated. This regulation also ensures staff is aware of how to quickly wake up the individuals if they do not wake up to the sound of the smoke detector when activated during an emergency. It is the responsibility of staff to quickly and safely get the individuals out of the residence when the smoke detector is activated. The reason why this violation occurred is that the sleeping fire drill was done twice a year but not once every six months which is required by 6400 regulations. See Plan of Correction: 1. An EIG designee will complete the night (Sleeping hours) fire drill at least once every six months and submit the documentation to the Program Specialist unless the Program Specialist completes the night (sleeping hours) fire drill. Oversight will be the CEO reviewing completed fire drill documentation. If the fire drill has not been completed by the 20th of the month the EIG designee will have 10 days to complete the sleeping fire drill and submit the documentation to the CEO for confirmation. 2. To ensure compliance with this regulation a fire drill will be conducted at this site for the month of November 2020. The next scheduled unannounced sleeping fire drill will be in six months to remain compliant with this regulation. Going forward EIG licensed residential sites will conduct the sleeping fire drills during the same months every year based on the last sleeping fire drill to ensure compliance with this regulation. [The fire drill conducted on 11/23/20 was not held during sleeping hours. Immediately, the CEO or designee will complete a fire drill held during sleeping hours. Immediately, the CEO or designated management staff will develop a tracking system to track fire drills to ensure sleep drills are occurring for all homes at least once every 6 months. Immediately, the CEO or Designated management staff will train all staff on the regulations required for fire drills and fire drill documentation. Documentation of all audits and trainings shall be kept. (DPOC by RM, HSLS on 12/10/20)] 11/30/2020 Not Implemented
6400.113(c)There was not a written record of the fire safety training for Individual #1, date of admission 5/23/19. A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept.EIG recognizes the importance of this regulation so that as an agency we will ensure that fire safety training is completed for individuals on the date of admission. EIG acknowledges that the fire safety training was not completed for the individual that was admitted on 5/23/19. See Plan of Correction: 1. Moving forward, EIG will ensure that fire safety training is completed for all new admission. 2. EIG will be implementing a new admission checklist for individuals coming into Residential Services [The department received documentation of fire safety training completed on 5/20/20 for the individual. Immediately, the CEO or designee will audit all individuals' records to ensure fire safety training has been conducted and documentation of the training is present in the record. Immediately, The CEO or designated management staff will develop a system to track fire safety training to ensure all individuals receive fire safety training annually and documentation of the training is in the individuals' record. Documentation of all audits shall be kept. (DPOC by RM, HSLS on 12/10/20)] 11/30/2020 Not Implemented
6400.141(a)Individual #1's, date of admission 5/23/19, has not had an physical examination.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. EIG recognizes the importance of this regulation so that as an agency we will ensure that individuals¿ health and safety needs are met according to regulation. Individual 1# did have a physical on the date of admission 5/23/19, however, it presumed that agency records for the individual have either been destroyed and/or taken by previous management. While there is no actual proof of what happened to the individual records, the agency takes full responsibility for maintaining individuals¿ records, so that EIG Services can demonstrate that an initial physical exam was completed initially and annually thereafter. See Plan of Correction: 1. Due to the sensitivity and confidential information that is in individuals 1# records, EIG filed a rights violation on 11/2/20. 2. EIG will secure all individual records at the main office located at 4328 Old William Penn Highway, Suite 2k. Monroeville, PA 15146. [Immediately, the CEO shall coordinate obtaining a current physical examination for the individual. Immediately and at least quarterly for one year, the CEO or designee will audit all individuals' records to ensure a current physical examination is complete and present in the record. Immediately, the CEO or Designated management staff will develop a tracking system to ensure all Individual physical examinations are completed annually. Documentation of all audits shall be kept. (DPOC by RM, HSLS on 12/10/20 )] 11/30/2020 Not Implemented
6400.181(a)Individual #1, date of admission 5/23/19, has not had an initial assessment. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. EIG recognizes the importance of this regulation so that as an agency we will ensure that individuals¿ have an initial assessment within 1 year or 60 days after admission and the assessment will be updated annually. Individual 1# did have an initial assessment 60 days after the admission date of 5/23/20, however, it presumed that agency records for the individual have either been destroyed and/or taken by previous management. While there is no actual proof of what happened to the individual records, the agency takes full responsibility for maintaining individuals¿ records, so that Moving forward, EIG Services will ensure that an initial assessment is completed per regulations and annually thereafter. 1. Due to the sensitivity and confidential information that is in individuals 1# records, EIG filed a rights violation on 11/2/20. 2. EIG will secure all individual records at the main office located at 4328 Old William Penn Highway, Suite 2k. Monroeville, PA 15146. 3. EIG has hired a new administrative team, which is composed of the Executive Director, Program Manager, and three supervisors who will now be responsible for ensuring that individuals¿ assessments are completed per the regulations. [An assessment for the individual was completed 11/16/20. Immediately and at least quarterly for one year, the CEO or designee will audit all individuals' records to ensure a current assessment is complete and in the individuals' records. Immediately, the CEO or designated management staff will develop a tracking system to ensure individual assessments are completed within 60 days of admission and annually thereafter. Documentation of all audits shall be kept. (DPOC by RM, HSLS on 12/10/20)] 11/30/2020 Not Implemented
6400.34(b)Individual #1's, date of admission 5/23/19, record did not include copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights.The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights.EIG recognizes the importance of this regulation, so that as an agency we will ensure that the individual¿s record include a statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights. The individual did sign information on individual rights, however, it presumed that agency records for the individual have either been destroyed and/or taken by previous management. While there is no actual proof of what happened to the individual records, the agency takes full responsibility for maintaining individuals¿ records, so that moving forward, EIG Services will ensure that a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights. See Plan of Correction: 1. Due to the sensitivity and confidential information that is in individuals 1# records, EIG filed a rights violation on 11/2/20. 2. EIG will secure all individual records at the main office located at 4328 Old William Penn Highway, Suite 2k. Monroeville, PA 15146. [Individual was informed of his rights on 11/18/20. Immediately, The CEO or Designee will audit all Individuals' records to ensure Individuals have been informed of their rights and a signed statement of receipt of individual rights is in the record. Immediately, the CEO or Designated management staff will develop a tracking system to ensure individuals are informed of their rights annual and a signed statement of receipt of individual rights is obtained. Documentation of all audits shall be kept (DPOC by RM, HSLS on 12/10/20)] 11/30/2020 Not Implemented
6400.165(g)Individual #1 is prescribed Adderall XR, 10mg, 1 capsule by mouth per day and Clonidine, .2mg, 1 tablet by mouth per day to treat ADHD and Major Depression. The most recent review of medications prescribed to treat symptoms of a psychiatric illness was completed on 7/30/19.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.EIG recognizes the importance of this regulation so that as an agency we will ensure that individuals¿ health, safety, and medical needs are met. The individual did have a medication review after 7/30/2019, however, it presumed that agency records for the individual have either been destroyed and/or taken by previous management. While there is no actual proof of what happened to the individual records, the agency takes full responsibility for maintaining individuals¿ records, so that Moving forward, EIG Services will ensure that medications that are prescribed to treat symptoms of a psychiatric illness, will be reviewed by a licensed physician at least every 3 months that includes documenting the reason for prescribing the medication, the need to continue the medication and the necessary dosage. 1. Due to the sensitivity and confidential information that is in individuals 1# records, EIG filed a rights violation on 11/2/20. 2. EIG will secure all individual records at the main office located at 4328 Old William Penn Highway, Suite 2k. Monroeville, PA 15146. 3. EIG has hired a new administrative team, which is composed of the Executive Director, Program Manager, and three supervisors who will now be responsible for ensuring that quarterly psychiatric medication reviews are completed by a licensed physician and/or psychiatrist. [Immediately, the CEO shall coordinate obtaining a current psychiatric medication review for the individual. Immediately and at least quarterly for one year, the CEO or designee will review all individual records to ensure psychiatric medication reviews are completed every 3 months and present in the individuals' records. Immediately, the CEO shall train all staff who will be reviewing psychiatric mediation reviews on the requirements by the chapter. Documentation of all audits and trainings shall be kept. (DPOC by RM, HSLS on 12/10/20)] 11/30/2020 Not Implemented
SIN-00157976 Renewal 06/26/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(c)Staff Person #1 does not meet educational qualifications required for the program specialist position. A program specialist shall have one of the following groups of qualifications: (1) A master's degree or above from an accredited college or university and 1 year work experience working directly with persons with intellectual disability. (2) A bachelor's degree from an accredited college or university and 2 years work experience working directly with persons with intellectual disability. (3) An associate's degree or 60 credit hours from an accredited college or university and 4 years work experience working directly with persons with intellectual disability.This regulation is important to ensure all employees who are hired for the Program Specialist position of EIG meets the qualification required as stated in 6400 regulations. The reason this violation occurred is due to the CEO following the Program Specialist guidelines on the ODP Provider Qualification tool. CEO will ensure the Program specialist will meet the 6400 regulations qualifications for this position during the interviewing process. To ensure compliance with this regulation the CEO will follow the requirements of 6400 regulations in regards to qualifications of a Program Specialist in a licensed residential home. [The CEO replaced Staff Person #1 as the Program Specialist. Prior to hire, the CEO shall audit staff person's qualification to ensure candidate meets the qualifications for the position. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 7/30/19)] 07/10/2019 Implemented
6400.73(a)The five wooden steps at exit in the back of the home did not have a handrail. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. This regulation is important to ensure the residential site is well maintained at all times and free from unsafe conditions that could potentially cause harm to the individuals, staff and any other person at the residential site. The reason why this violation occurred is when the exterior steps were completed last year a railing wasn¿t installed since there were more than two steps. The CEO hired a contractor to install a railing outside on the exterior steps located in the backyard at 761 Montclair. The contracted completed this on Wednesday, July 3rd, 2019. CEO will ensure that the residential site meets the requirements for physical site compliance. [At least quarterly, the CEO or designee shall complete a walk through of all community homes to ensure compliance with all physical site requirements. Documentation shall be kept. (DPOC by AES,HSLS on 7/30/19)] 07/03/2019 Implemented
6400.74The five wooden steps at the exit in the back of the home did not have a nonskid surfaces.Interior stairs and outside steps shall have a nonskid surface. This regulation is important to ensure the residential site is well maintained at all times and free from unsafe conditions that could potentially cause harm to the individuals, staff and any other person at the residential site. The reason why this violation occurred is when the exterior steps were completed last year the contractor did not apply a nonslip surface paint on the wooden stairs to prevent a potentially hazardous issue. The CEO hired a contractor who applied a non-skid paint on the stairs located in the backyard at 761 Montclair. The contracted completed this on Wednesday, July 3rd, 2019. CEO will ensure that the residential site meets the requirements for physical site compliance.[At least quarterly, the CEO or designee shall complete a walk through of all community homes to ensure compliance with all physical site requirements. Documentation shall be kept. (DPOC by AES,HSLS on 7/30/19)] 07/03/2019 Implemented
6400.112(e)There was not a fire drill held during sleeping hours between 7/31/2018 and 4/23/19.A fire drill shall be held during sleeping hours at least every 6 months. The reason why this regulation is important is to teach the individuals how to safely evacuate during a sleeping fire drill when the smoke detector is activated. This regulation also ensures staff is aware of how to quickly wake up the individuals if they do not wake up to the sound of the smoke detector when activated during an emergency. It is the responsibility of staff to quickly and safely get the individuals out of the residence when the smoke detector is activated. The reason why this violation occurred is because the sleeping fire drill was done twice a year but not once every six months which is required by 6400 regulations.An EIG designee will complete the night (Sleeping hours) fire drill at least once every six months and submit the documentation to the Program Specialist unless the Program Specialist completes the night (sleeping hours) fire drill. Oversight will be the CEO reviewing completed fire drill documentation by the 20th of the month of July and December. If the fire drill has not been completed by the 20th of the month of July or December the EIG designee will have 10 days to complete the sleeping fire drill and submit the documentation to the CEO for confirmation. To ensure compliance with this regulation a fire drill was conducted at this site for the month of July 2019. The next scheduled unannounced sleeping fire drill will be held in December 2019 which is six months to remain compliant with this regulation. Going forward all EIG licensed residential sites will conduct the sleeping fire drills during the same months every year July and December to ensure compliance with this regulation. [A fire drill was held at 3:30AM on 7/3/19. Prior to conducting future fire drills, the CEO shall educate the staff person responsible for conducting fire drills on the requirement of conducting and documenting fire drills. Documentation of the trainings shall be kept. Documentation of aforementioned audits of fire drill records shall be kept. (DPOC by AES,HSLS on 7/30/19)] 07/12/2019 Implemented
SIN-00138110 Renewal 07/10/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill records did not indicate the accurate amount of time it took for evacuation for the fire drills held on 4/9/18, 3/2/18, 3/1/18, 2/13/18, 1/3/18, 12/17/17, 11/21/17, 9/21/17, 8/28/17, 7/8/17. The evacuation times were documented as 2 minutes, 30 seconds. The fire drill record held on 7/8/17 does not indicate the time that the fire drill was held.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. In order to address the non compliance the CEO will ensure all fire drill forms are completed correctly. To prevent this from occurring EIG staff will not put the time allowed for the evacuation (2 minutes and 30 seconds) but instead the actual evacuation time it took the individual(s) to evacuate the residence which must be under the 2 minutes and 30 seconds. 112c [Immediately, upon hire and at least quarterly for 1 year and then continuing at least annually, the CEO shall educate all staff person responsible for conducting fire drill of the requirements of fire drills as per 6400. 112(a)-(I). Documentation of the trainings shall be kept. Within 5 days of completion, the CEO shall audit all fire drill records to ensure fire drills are conducted and documented as required. Documentation of audits by the CEO shall be kept. (DPOC by AES,HSLS on 8/28/18)] 07/11/2018 Implemented
6400.151(c)(1)Direct Service Worker #1, hired 4/6/18, did not have a general physical examination. A document, dated 5/2/17, signed by a physician read the employee was "employable." The physical examination shall include: A general physical examination. In order to address the non compliance the CEO will ensure the EIG physical form is filled out completely and states a general physical has been completed by a physician or health care professional. [Direct Services Worker #1's physical examination has been updated to include a general physical examination. Immediately, upon completion and continuing at least annually, the CEO shall audit all staff persons' physical examinations to ensure all required information is included. Documentation of audits shall be kept.(DPOC by AES,HSLS on 8/28/18)] 07/11/2018 Implemented
6400.151(c)(3)Direct Service Worker #1, hired 4/6/18, did not have a physical examination that included a signed statement that the staff person was free from communicable diseases. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. In order to address the non compliance the CEO will ensure the EIG physical form is filled out completely and states a general physical has been completed by a physician or health care professional and is free of communicable diseases. [Direct Services Worker #1's physical examination was updated to address communicable disease. Immediately, upon completion and continuing at least annually, the CEO shall audit all staff persons' physical examinations to ensure all required information is included. Documentation of audits shall be kept.(DPOC by AES,HSLS on 8/28/18)] 07/11/2018 Implemented
6400.163(c)The psychiatric medication review, dated 8/7/17 for Individual #1 did not include the need to continue the medications and was missing the prescribed medication of Risperidone 4 MG. In addition, psychiatric medication review, dated 8/7/17 for Individual #1, who is prescribed medications to treat symptoms of a diagnosed psychiatric illness by a physician, was reviewed by certified registered nurse practitioner. 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.In order to address this non compliance the CEO faxed over the Psychotropic Medication Review to Individual #1 psychiatrist for completion for the appointment on 8/7/2017. Once received this documentation will be forwarded to licensing for verification. Going the the program specialist will ensure the psychotropic medication review is completed by the physician and filed in the individual record. [Individual #1's psychiatric medication review dated 8/7/17 was updated to include the required information. Immediately and upon completion the CEO or a designated staff person trained to administer medications and the requirements of psychiatric medication reviews shall audit all individuals' psychiatric medication reviews to ensure all required information is included and medications, current medication administration records and physician's orders to ensure all individuals are administer medications as prescribed and documented as required. (DPOC by AES,HSLS on 8/28/18)] 07/27/2018 Implemented
6400.164(a)The June 2018 Medication Administration Record (MAR) for Individual #2 indicated that the individual is prescribed Aripiprazole 15 MG with the instructions "take one half tablet (7.5 MG) twice a day." However, the doctor's order, dated 6/11/18 stated Apripiprazole 20 MG with the instructions "take one half tablet (10 MG) twice a day."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. In order to address this non compliance the CEO correct the MAR during the inspection to be in compliance. Going forward the program specialist will verify the MAR and on site medications when medications are delivered as well as enure the electronic MAR is updated at needed to remain in compliance with regulations. [At least weekly and when medications changes are made, a designated staff person trained to administer medications shall audit all individuals' medications, current medication administration records and physician's orders to ensure all individuals are administer medications as prescribed and documented as required. At least monthly, the CEO or designee shall audit all individuals' medications, current medication administration records and physician's orders to ensure all individuals are administer medications as prescribed and documented as required.(DPOC by AES,HSLS on 8/28/18)] 07/11/2018 Implemented
6400.181(a)Individual #2, admitted 3/1/18, had an assessment completed 5/1/18. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The program specialist will ensure the assessment is completed 60 calendar days after admission and annually thereafter. The program specialist will complete the assessment with the individual and once completed submitted to the CEO for verification going forward. The assessment date will be established during intake based on the individual(s) admission date. [Immediately and upon admission, the CEO shall develop and implement a tracking system for all individuals to ensure the program specialist completes individuals' assessments, timely. Upon completion and at least quarterly for 1 year, the CEO shall audit the aforementioned tracking system and all individuals' assessment to ensure completion, timely.(DPOC by AES,HSLS on 8/28/18)] 07/11/2018 Implemented
6400.186(b)Individual #1's ISP review for period 3/1/18 to 5/31/18 was not signed by the Program Specialist. Individual #1's ISP review for period 9/1/17 to 11/30/17 was not dated when the individual signed the document. Individual #2's ISP review for period 3/1/18 to 5/31/18 was not signed by the individual.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. In order to address the non compliance the program specialist will ensure ISP reviews are signed and dated by the program specialist and the individual when completed quarterly. The ISP review will be submitted to the CEO for verification going forward. [Individual #1's ISP reviews were reviewed and signed and dated by the individual and the program specialist. Immediately, upon hire and at least annually, the CEO shall educate the program specialist of the responsibilities of the program specialist position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. At least quarterly for 1 year, the CEO shall review all individuals ISP reviews to ensure the program specialist and individual sign and date the ISP review signature sheet upon review of the ISP, timely. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 8/28/18)] 07/11/2018 Implemented
SIN-00117240 Renewal 07/12/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment of the home was completed on 6/1/17. The home's Certificate of Compliance expired on 6/19/17.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. The CEO will ensure the self assessment is completed 3 to 6 months prior to the certificate of compliance expiration date. [Immediately, the CEO shall complete a self-assessment of all community homes on the Department's licensing inspection instrument. Upon receipt of the certificate of compliance from the Department, the CEO shall implement a tracking system to ensure the self-assessments of all community homes are completed within 3 to 6 months prior to the expiration date of the agency's certificate of compliance. Prior to 3 months of the expiration date of the certificate of compliance, the CEO shall review the self-assessment to ensure timely completion on the Department's licensing inspection instrument for all community homes. Documentation of the review shall be kept. (AS 10/6/17)] 07/31/2017 Implemented
6400.15(b)The agency used the Self Inspection and Declaration Tool to complete the home's self-assessment. 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 CEO will ensure the correct licensing inspection instrument is used to measure and record compliance. [Immediately, the CEO shall complete a self-assessment of all community homes on the Department's licensing inspection instrument. Upon receipt of the certificate of compliance from the Department, the CEO shall implement a tracking system to ensure the self-assessments of all community homes are completed within 3 to 6 months prior to the expiration date of the agency's certificate of compliance. Prior to 3 months of the expiration date of the certificate of compliance, the CEO shall review the self-assessment to ensure timely completion on the Department's licensing inspection instrument for all community homes. Documentation of the review shall be kept. (AS 10/6/17)] 07/31/2017 Implemented
6400.21(a)Direct Service Worker #1, date of hire 8/1/16, had a Pennsylvania criminal history record check completed on 1/30/17. (Repeated Violation-7/6/16, et al)An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. The CEO will ensure Criminal Clearances are completed within 5 days of hired date. [Upon hire, the CEO shall review the candidates information and request a Pennsylvania criminal history record check and other record checks as required, timely. (AS 10/6/17)] 07/31/2017 Implemented
6400.62(a)Four bottles of "Clorox clean up with bleach" and a 14 ounce can of "Comet with bleach" with warning labels which read "call poison control or doctor for treatment if swallowed" were unlocked and accessible to individuals on shelves near the clothes washer and dryer in the basement of the home.(Repeated Violation-7/6/16, et al)Poisonous materials shall be kept locked or made inaccessible to individuals.The CEO removed the poisonous materials that were accessible to the individuals and they are in a locked cabinet. [Immediately and at least weekly for 1 month and continuing at least monthly, the CEO or designated staff person shall complete a walk through of all community homes to ensure all poisonous material is kept lock or made inaccessible to individuals. Within 30 days of receipt of the plan of correction, the CEO shall train all staff as to the procedures to ensure all poisonous materials are kept lock or made inaccessible to individuals and to monitor throughout the course of their daily duties. Documentation of training shall be kept.(AS 10/6/17)] 07/31/2017 Implemented
6400.66The top of the interior stairway leading from the first floor to the basement did not have adequate lighting to assure safety and to avoid accidents.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The CEO will have purchase a light fixture for the top of the basement stairs for adequate lighting to assure safety and to avoid accidents. [A light was installed at the top of the interior basement stairway to provide adequate lighting. Immediately and at least monthly, the CEO or designee shall complete a walk through of the community homes to ensure rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes are lighted to assure safety and to avoid accidents. Within 30 days of receipt of the plan of correction all staff persons shall be trained to monitor for adequate lighting throughout the course of their daily duties and the procedures for repair or replacement of lighting to ensure adequate lighting. (AS 10/6/17)] 07/31/2017 Implemented
6400.72(b)The screens in the windows of Individual #1's bedroom were torn approximately eighteen inches and were not attached at the bottom of the window screen frame. Screens, windows and doors shall be in good repair. The CEO will have the screen replaced so it is in good repair.[New Screens were installed on 9/26/17. At least monthly, the CEO or designee shall complete a walk thorough of all community homes to ensure screens, windows and doors are in good repair. Documentation of onsite monitoring shall be kept. (AS 10/5/17)] 07/31/2017 Implemented
6400.80(b)The outside of the home has areas in extreme disrepair posing significant tripping and injury hazards including a large cracks, divots, uneven and separating cement, loose bricks, broken sections and varying sizes of broken pieces of cement and cinder blocks and over grown vegetation along walkways and steps in the back and side of the home. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The CEO will have a contractor remove the hazardous cement in the backyard to ensure the grounds are free from unsafe conditions. Going forward the CEO will ensure the outside of the building is well maintained. [Within 30 days of receipt of the plan of correction, the CEO shall develop and implement policies and procedure to ensure the outside of the home and the yard is well maintained, in good repair and free from unsafe conditions. Within 45 days of receipt of the plan of correction, all staff person responsible for maintaining the homes and grounds maintenance shall be trained in their responsibilities by the CEO. At least weekly for 1 month and continuing at least monthly, the CEO shall complete a walk through of the home to ensure the home and grounds are well maintained, in good repair and free from unsafe conditions. (AS 10/6/17)] 07/31/2017 Implemented
6400.101The doors in the living room, bathroom, bedrooms and Individual #1's bedroom closet have skeleton key locks that could prevent egress if locked. Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The CEO will fill the skeleton key holes with a filler that would prevent egress if locked. There are not keys for these doors. [Within 30 days of receipt of the plan of correction, the CEO shall educate all staff persons that Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed and to monitor throughout the course of their daily duties. (AS 10/6/17) 07/31/2017 Implemented
6400.105Two cardboard boxes were nine inches from the hot water tank and a mattress was twenty-seven inches from the furnace in the basement of the home. Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources. The CEO will ensure flammable and combustible items are stored away from heat sources. All staff will be trained on this regulation in order to stay in compliance.[Cardboard boxed and mattress were moved away from heat sources. Within 30 days of receipt of the plan of correction, CEO shall educated all staff persons that flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources and to monitor throughout the course of their daily duties. Documentation of trainings shall be kept. (AS 10/6/17)] 07/30/2017 Implemented
6400.141(c)(11)The physical examination for Individual #1, completed 2/8/17, did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section was left blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The Program specialist implemented an addendum to the County physical form that addresses health maintenance needs, medication regimen and the need for blood work at recommended intervals. The Program specialist will review the physical examination form to ensure it is completed in its entirety by the physician.[Individual #1 was discharged from the home. Immediately and upon completion, the CEO or designee shall audit all individuals' current physical examination to ensure all required information is included and there are not any required areas left blank. Immediately, the CEO shall obtain missing information. Documentation of audits shall be kept. (AS 10/6/17)] 07/31/2017 Implemented
6400.141(c)(13)The physical examination for Individual #1, completed 2/8/17, did not include contraindicated medications. The physical examination shall include: Allergies or contraindicated medications.The Program specialist implemented an addendum to the County physical form that addresses contraindicated medications. The Program specialist will review the physical examination form to ensure it is completed in its entirety by the physician.[Individual #1 was discharged from the home. Immediately and upon completion, the CEO or designee shall audit all individuals' current physical examination to ensure all required information is included and there are not any required areas left blank. Immediately, the CEO shall obtain missing information. Documentation of audits shall be kept. (AS 10/6/17)] 07/31/2017 Implemented
6400.141(c)(14)The physical examination for Individual #1, completed 2/8/17, 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. The Program specialist implemented an addendum to the County physical form that addresses Emergency Medical Information. The Program specialist will review the physical examination form to ensure it is completed in its entirety by the physician.[Individual #1 was discharged from the home. Immediately and upon completion, the CEO or designee shall audit all individuals' current physical examination to ensure all required information is included and there are not any required areas left blank. Immediately, the CEO shall obtain missing information. Documentation of audits shall be kept. (AS 10/6/17)] 07/31/2017 Implemented
6400.151(a)Direct Service Worker #2, date of hire 11/18/16, had a physical examination on 11/18/16. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. The CEO will ensure any candidate that will be hired has a physical completed before the date of hire. [Immediately, the CEO shall develop and implement a tracking system to ensure staff person who come indirect contact with individuals or who prepare or serve food for more than 5 days in a 6-month period have a physical examination completed, timely. (AS 10/6/16)] 07/31/2017 Implemented
6400.163(c)The most recent review of psychiatric medication with documentation by a licensed physician for Individual #2 was 4/3/17. 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.Individual #2 most recent psychiatric medication review was completed on June 19th, 2017. Documentation will be submitted. [Individual #2 had a psychiatric medication review signed by CRNP (the prescriber) on 8/7/17. Immediately and upon completion, the CEO shall audit the current psychiatric medication review to ensure completion with documentation by a licensed physician or CRNP who prescribes the medication, timely. Documentation of audits shall be kept. (AS 10/6/17)] 07/31/2017 Implemented
6400.181(e)(11)The assessment for Individual #1, completed 5/19/17, did not include a psychological evaluation.The assessment must include the following information: Psychological evaluations, if applicable. The CEO requested the Psychological Evaluation from the Psychiatrist of Individual #1. The Psychological Evaluation was received on July 12, 2017 and is on file. Going forward the CEO will ensure the Psychological evaluation is included with the assessment and sent to the team members. [Psychiatric evaluation for Individual #1 was in the record on 8/7/17. Individual #1 was discharged from the home. Immediately, the CEO shall educate the Program Specialist as to what is required in individuals assessments as per 6400.181(e)(1)-14) including psychiatric evaluations. Documentation of the training shall be kept. At least quarterly for 1 year, the CEO shall review all individuals' assessments to ensure all required information is included and accurate. Documentation of reviews shall be kept.(AS 10/6/17] 07/31/2017 Implemented
6400.181(e)(12)The assessment for Individual #1, completed 5/19/17, did not include recommendations for specific areas of training, programming and services. This section was left blank.The assessment must include the following information: Recommendations for specific areas of training, programming and services. The program specialist will ensure each section of the assessment is entirely completed. The recommendation section will state how EIG staff will continue to provide supports and address progress or lack of progress based on the outcomes addressed in the ISP. [Individual #1 was discharged from the home. Immediately, the CEO shall educate the Program Specialist as to what is required in individuals assessments as per 6400.181(e)(1)-14) including recommendations for specific areas of training, programming and services. Documentation of the training shall be kept. At least quarterly for 1 year, the CEO shall review all individuals' assessments to ensure all required information is included and accurate. Documentation of reviews shall be kept.(AS 10/6/17] 07/31/2017 Implemented
6400.186(d)The program specialist provided the ISP review documentation for Individual #1 with a completion dates of 10/1/16 and 1/13/17 to the plan team members on 2/14/17. The program specialist provided the ISP review documentation for Individual #1 with a completion date of 4/1/17 to the plan team members on 7/3/17. The program specialist provided the ISP review documentation for Individual #2 with completion dates of 5/28/16, 8/28/16, 12/1/16 and 3/1/17 to the plan team members on 7/9/17. (Repeated Violation-7/6/16, et al)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 program specialist will ensure the team members will receive the ISP reviews within 30 calendar days after the ISP review meeting. The CEO will provide on going training and timelines for the ISP reviews to be completed and submitted to the team members. The CEO has implemented a Report Tracker for each participant as a guideline and timeline to ensure compliance is met with this regulation..[At least quarterly, the CEO shall audit the aforementioned tracking system/schedule and a 25% sample of correspondence documentation showing the program specialist provide individuals' ISP review documentation to plan team members, as required, timely. Documentation of audits shall be kept. (AS 10/6/17)] 07/31/2017 Implemented
SIN-00097480 Renewal 07/06/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Direct Service Worker #1, date of hire 2/26/16, had Pennsylvania criminal history record check requested 3/7/16. Direct Service Worker #2, date of hire 10/2/15, had Pennsylvania criminal history record check requested 5/13/14. Direct Service Worker #4, date of hire 2/26/16, had Pennsylvania criminal history record check requested 3/7/16.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. In order to correct this violation staff # 4 submitted a criminal clearance which was completed within a year of being hired at EIG. The CEO of EIG completed a current clearance for staff # 2 and staff #1 was unable to locate her previous clearance. Going forward to be compliance with this regulation the CEO will ensure of applicants have their criminal clearances within 5 days of being hired by EIG Services. [Immediately, the CEO will develop and implement policies and procedures to include a new hire checklist including background checks to ensure that all required criminal background checks are completed as required and maintained and available for review. CEO will review all criminal background checks to ensure submission and completion as required. Documentation of policies and procedures and reviews shall be kept. (AS 9/20/16)] 08/20/2016 Implemented
6400.71Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were not on or by the telephone in the sun room.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. In order to correct this violation the CEO reprinted and laminated the list of emergency numbers by any land line phone at the residential site. The list contains emergency numbers for the police, fire department, poison control center, closest hospital and fire department. To ensure on going compliance the CEO informed all staff to notify a supervisor if there are not emergency numbers located by a telephone at a residential site. During new hire orientation staff are trained on the location of emergency numbers and equipment. Completed 7/8/16 (emergency numbers)[At least monthly, CEO will complete an on-site visit of all community homes to ensure homes all required telephone numbers are on or by each telephone with an outside line. Documentation of on-site visits shall be kept. (AS 9/20/16)] 07/08/2016 Implemented
6400.80(b)The concrete wall outside the back door to the basement that measured 18" high x 42" long x 6" wide was cracked and crumbing in several areas and leaning several inches in the direction of the route of egress from the back door. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.In order to correct this violation the CEO hired an independent contractor the remove the concrete retaining wall outside of the back door to the basement. In order to prevent an unsafe condition for the participants or staff the retaining wall was removed on July 29, 2016. The CEO will ensure the building and grounds are monitored regularly to ensure safe conditions and upkeep. Completed 7/29/16 (pictures of wall))[At least monthly, CEO will complete an on-site visit of all community homes to ensure the outside of the building and the yard or grounds are well maintained, in good repair and free from unsafe conditions. Documentation of on-site visits shall be kept. (AS 9/20/16)] 07/29/2016 Implemented
6400.111(f)The fire extinguisher in the kitchen, basement, and top of stairs on second floor were not inspected and approved annually by a fire safety expert. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. In order to correct this violation the CEO had all fire extinguishers inspected and tagged by a fire safety expert on 8/1/2016. Going forward to stay in compliance the CEO will ensure the fire extinguishers are tagged and inspected annually. (service receipts photo of inspection tag)[Immediately, the CEO shall develop and implement policies and procedures to include a tracking system and notification system and monthly checks of fire extinguishers to ensure fire extinguishers are inspected and approved annually by a fire safety expert. Documentation of the policies and procedures and checks shall be kept. (AS 9/20/16)] 08/01/2016 Implemented
6400.112(f)The front door exit was used for all fire drills completed from 6/3/15 through 6/28/16.Alternate exit routes shall be used during fire drills. In order to address this violation the CEO and or administrative staff will ensure fire drill are completed using the alternative route which is the basement door instead of only using the front door. All staff have been notified of the change as of July 12, 2016. Going forward to stay in compliance the Fire drill policy will address using alternative exits for fire drills. (updated fire drill policy stating the use of alternative exits during fire drills)[Fire drills conducted in 7/16 through 9/16 have used alternative exits. At least quarterly, the CEO shall observe a fire drill and at least monthly the CEO shall review fire drill records to ensure fire drills are completed as required. Documentation of observations and reviews of fire drill documentation shall be kept. (AS 9/20/16)] 07/12/2016 Implemented
6400.141(c)(3)Individual #1's Td/Tdap immunization was completed 1/20/2006 and 4/28/2016The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. In order to correct this violation the CEO will ensure all individuals at EIG Services will have completed immunizations before moving into a residential site. The current intake form used at EIG Services list immunizations as a requirement. All administrative staff will be train on this regulation to be compliant. (training record & intake form)[Immediately and prior to entering into individuals' records, the CEO shall review all individuals' physical examinations to ensure all required information is present and there are not any required areas left blank including immunizations. Documentation of reviews shall be kept. (9/20/16)] 07/25/2016 Implemented
6400.141(c)(10)Individual #1's physical examinations, dated 12/30/15 and 4/28/16, did not address communicable disease; therefore, compliance could not be measured.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. 1. In order to correct this violation Individual #1 PCP addressed that individual #1 is free of communicable diseases. EIG uses the OID individual physical exam form to be completed for physicals. In order to stay in compliance the CEO and or the Program Specialist will ensure physicals for completed for accuracy and state if the individual is free of communicable diseases. Administrative staff will be trained on this regulation. (administrative training record & XXXXX's physical))[Individual #1's physical examination dated 4/28/16 was updated by the physician on to state individual #1 was free of communicable disease. Immediately and prior to entering into individuals' records, the CEO shall review all individuals' physical examinations to ensure all required information is present and there are not any required areas left blank including communicable disease. CEO will immediately obtain any missing information from the physician completing the physical examination. Documentation of reviews shall be kept. (9/20/16)] 08/01/2016 Implemented
6400.151(c)(3)Program Specialist #3's physical examination, dated 10/23/14, did not address communicable diseases. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. The CEO will ensure all employee physicals are accurate during the new hire process. CEO will ensure all physicals have a section that state the employee is free of communicable diseases that a health professional must address during the physical. In regards to the Program Specialist's physical dated 10/23/14 a new physical will be completed by 10/23/16 for compliance.)[Program Specialist #3 had a physical examination to include a signed statement that staff person is free of communicable diseases on 9/16/16. Immediately and prior to entering into staff files, the CEO shall review all staff physical examinations to ensure all required information is present and there are not any required areas left blank including communicable disease. Documentation of reviews shall be kept. (9/20/16)] 07/14/2016 Implemented
6400.163(c)The most recent psychiatric medication review for Individual #1, date of admission 2/28/16, was completed 3/11/2016. 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.In order correct this violation the Program Specialist created a quarterly psychiatric medication review form to be completed quarterly for psychiatric medications. For individual # 1 the most recent psychiatric review was 7/12/2016. In order to stay in compliance with this regulation the Program Specialist has informed the doctor's office to complete the previous reviews to be added to the individual's medical file at EIG and made aware going forward the form must be completed quarterly. (psychiatric medication quarterly review form)[Individual #1 had a medication review completed on 10/17/16. Immediately, the CEO will develop and implement policies and procedures to include a tracking, notification, review and training to ensure medication reviews are completed timely with all required information. Documentation of aforementioned policies and procedures shall be kept. (AS 9/20/16)] 07/12/2016 Implemented
6400.168(e)The medication administration training records for Direct Service Worker #4 and Direct Service Worker #5 did not include the date of completion, signature of Medication Administration Trainer #6, or the date of Medication Administration Trainer #6's most recent trainer certificate. Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept.The CEO and or administrative staff will ensure medication administration training records will be completed as scheduled to ensure compliance. The CEO will keep all medication administration records and review. The CEO will censure the DPW Medication Administration trainer has a current certificate on site with the employee medication administration records. (included completed med records and trainer certificate)[Direct Service Worker #4 and #5 are no longer employed with the agency. Medication Administration Trainer #6 most recent trainer certificate expires on 10/20/18. Immediately, the CEO shall review all staff medication trainings to ensure completion and accuracy. Within one month of receipt of the plan of correction, the CEO will develop and implement a system to keep required documentation of medication trainings and review the system at least quarterly to ensure training is completed and kept as required. Documentation of reviews shall be kept. (AS 9/20/16)] 07/11/2016 Implemented
6400.181(a)The initial assessment for Individual #1, date of admission 2/28/16, was completed on 5/28/16. Individual #2, date of admission 3/19/16, had no assessment completed. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The Program Specialist completed individual # 2 assessment on July 10th, 2016. To ensure on going compliance with this violation the Program Specialist and or the CEO will determine the assessment due date during the intake process. This will ensure the Program Specialist is aware of when the assessment must be completed to be compliant. All administrative staff will be trained on this regulation during new hire orientation and annually. [Individual #1's assessment was completed on 7/10/16. Within one week of receipt of the plan of correction and at least quarterly for one year and annually thereafter, the CEO/program specialist shall review the responsibilities of the position as per 6400.44(b)(1)-(19) and sign and date upon review. Within 30 days of receipt of the plan of correction the CEO shall develop and implement a new admission and annual checklist to include a tracking system to ensure timely completion of initial and annual requirements including assessments. At least monthly the CEO shall review the tracking to ensure timely completion of assessments. Documentation of reviews shall be kept. (AS 9/20/16)] 07/10/2016 Implemented
6400.213(1)(i)Individual #2's record did not include identifying marks.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.In order to correct this violation the CEO of EIG Services will ensure during the intake process of admittance to any EIG licensed residential site the information sheet will obtain any known identifying marks. Once the intake information is gathered the CEO will review the individual's information sheet to check for accuracy. This change was made effective as of July 11, 2016 by the CEO. In regards to training administrative staff will be trained to check for incomplete information and how to complete the form. In regards to DSP staff during new hire orientation new employees will be trained how to document information on this form. (included XXXX¿s updated info sheet.)[Individual #1's record was updated to include identify marks. Immediately and at least quarterly, the CEO shall review all individual records to ensure all required information as per 6400.213(1)-(14) is present including identifying marks. Documentation of all reviews shall be kept. (AS 9/20/16)] 07/11/2016 Implemented
SIN-00077772 Renewal 07/07/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)Individual #1, admission date 1/31/15 was instructed in fire safety on 2/2/15. Individual #2, admission date 5/1/15 was instructed in fire safety on 5/4/15. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. EIG Services LLC will ensure all participants will complete fire safety training upon initial admission at any facility at EIG Services LLC. [As per conversation with the CEO 10/22/15, CEO created an admission checklist for Individuals who are moving into their program which includes fire safety training on the first day of admission to the home. CEO will instruct individuals in fire safety and document on the checklist. (AS 10/22/15)] 07/30/2015 Implemented
6400.151(a)Program Specialist #1, hire date 4/2/15 did not have a pre-employment physical examination. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Program Specialist will submit pre employment physical by 07/30/2015. [As per conversation with the CEO on 10/22/15, the CEO has developed a checklist new hires which includes the physical examination. The CEO will review information for potential candidates for employment and ensure that their physical examination is completed within regulatory time frames and contains all required elements and in the personnel record prior to working in the home. (AS 10/22/15)] 07/30/2015 Implemented
6400.186(a)The Program Specialist did not complete a 3 month ISP review for Individual #1, admission date 1/31/15. 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. [added to the POC 8/26/14 - The Program Specialist will develop a tracking system to ensure that the three month reviews are completed on time and that they will coincide with the ISP dates by 9/30/15. The Program Specialist will review the regulations 6400. 186, (a) through (g) pertaining to the ISP Review and Revision. The Program Specialist will contact the Supports Coordinator to develop a timeline for the ISP AURD date and the 3 month reviews and will send them to all team members. At the Annual ISP, the Program Specialist will complete the declination form with the team members.]The Program Specialist will complete the 3 month ISP review for Individual #1 by 07/30/2015. [As per conversation with the CEO on 10/22/15, the CEO has created a tracking system to document when the three month reviews are completed coinciding with the ISP dates. The CEO will review the regulations 6400. 186, (a) through (g) pertaining to the ISP Review and Revision. The CEO will contact the Supports Coordinator to develop a timeline for the ISP AURD date and the 3 month reviews and will send them to all team members. At the Annual ISP, the CEO will complete the declination form with the team members. (AS 10/22/15)] 07/30/2015 Implemented
SIN-00249686 Renewal 07/30/2024 Compliant - Finalized
SIN-00193398 Renewal 09/21/2021 Compliant - Finalized
SIN-00185912 Renewal 04/06/2021 Compliant - Finalized
SIN-00182452 Unannounced Monitoring 02/02/2021 Compliant - Finalized
SIN-00110481 Unannounced Monitoring 01/18/2017 Compliant - Finalized
SIN-00064344 Initial review 06/19/2014 Compliant - Finalized