Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00258361 Renewal 01/07/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104The current, undated fire department notification letter indicates that there are currently three individuals residing in the home; however, the home's current census is two.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. On January 8th,2025, the compliance coordinator sent an updated fire department notification letter to accurately reflect the current census of two individuals residing in the home. 01/08/2025 Implemented
6400.15(b)The self-assessments completed on 5/23/2024, 11/23/2024, and 12/28/2024 were completed on the 6400 Scoresheet that was last updated in June 2018. This scoresheet does not measure compliance with all the current 6400 regulations.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.The agency will immediately (1/8/2025) transition to using the Department's licensing inspection instrument for community homes to measure and record compliance, The outdated scoresheet used on 5/23/2024, 11/23/2024, and 12/28/2024 will no longer be utilized. 01/08/2025 Implemented
SIN-00256179 Unannounced Monitoring 11/21/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)On 11/21/2024 at 10:28am, the mechanical vent about the kitchen stove was observed with a thick layer of built-up dirt, debris, and grease on the exterior of the device.Clean and sanitary conditions shall be maintained in the home. Maintenance cleaned the mechanical vent thoroughly on 11/22/2024 11/22/2024 Implemented
6400.66On 11/21/2024 at 10:38am, the furnace room in the basement was observed without a light source. On 11/21/2024 at 10:34am, there were no light sources to illuminate the two side egresses from the rear sunporch. [Repeated violation: 4/30/2024 et al and 8/6/2024 et al]Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Maintenance installed a light in the furnace room on 11/21/2024 and installed two lights off the sunporch on 11/22/2024 11/22/2024 Implemented
6400.67(a)On 11/21/2024 at 10:18am, a hole measuring approximately one-inch wide by one-inch high was observed behind the door in Individual #2's bedroom. The hole appeared to be from the turn-lock on the bedroom door knob going through the plaster.Floors, walls, ceilings and other surfaces shall be in good repair. Maintenance fixed the hole on 11/21/2024 and installed a doorknob wall protector and door stopper was also installed behind the bedroom door to prevent damage to the wall again. 11/21/2024 Implemented
6400.71On 11/21/2024 at 10:26am, the cordless phone in the living room was observed without telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center.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. Maintenance immediately placed a new sticker of the emergency numbers on the phone on 11/21/2024 11/21/2024 Implemented
6400.80(b)On 11/21/2024 at 10:33am, a cement block was observed at the right-side egress from the rear sunporch. The cement block was being used as a makeshift step at this egress. The cement block was not stable and rocked when stepped on. The cement block was posing a potential tripping hazard at the egress. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.The step was replaced on 11/22/2024 with a 250-pound capacity step. The new step meets safety and durability standards to accommodate anticipated usage and to prevent hazard. 11/22/2024 Implemented
6400.81(i)On 11/21/2024 at 10:16am, two blinds were hung on the outside of Individual #2's bedroom window to provide privacy. A space was observed between the blinds measuring approximately six-inches wide by three-feet high. No other window coverings were present to provide Individual #2 with privacy. [Repeated violation: 4/30/2024 et al and 8/6/2024 et al]Bedroom windows shall have drapes, curtains, shades, blinds or shutters. Maintenance installed one big blind covering the whole window on 11/22/2024 11/22/2024 Implemented
6400.81(k)(6)On 11/21/2024 at 10:10am, Individual #1's bedroom was observed without a mirror. Individual #1's Support Plan, last updated 10/25/2024, did not indicate that the individual chose not to have a mirror in their bedroom.In bedrooms, each individual shall have the following: A mirror. Non-breakable mirrors were ordered on 11/21/2024 and installed on 11/25/2024 11/25/2024 Implemented
6400.82(e)On 11/21/2024 at 10:12am, the shower in the main level hallway bathroom was observed without a nonslip mat or surface. [Repeated violation: 4/30/2024 et al] Bathtubs and showers shall have a nonslip surface or mat. Maintenance installed nonslip stickers in the tub on 11/21/2024 11/21/2024 Implemented
SIN-00253080 Unannounced Monitoring 09/27/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)On 9/27/2024 at 12:04pm, the water temperature at the kitchen sink measured 123.6°F. On 9/27/2024 at 12:07pm, the water temperature at the bathroom sink measured 123.0°F.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. Maintenance ordered anti-scald devices on Oct 11,2024. They will be delivered Oct 21-22. Maintenance will immediately install the devices on faucets to regulate water temperature by Oct 25, 2024 10/25/2024 Implemented
6400.72(a)On 9/27/2024 at approximately 12:15pm, Individual #1's bedroom windows were observed without screens. The window in individual #1's bedroom has three vertical panes with the outer two panes being operable, sliding windows. [Repeat violation: 4/30/2024 et al]Windows, including windows in doors, shall be securely screened when windows or doors are open. Staff replaced the missing screen in the window on 10/08/2024 10/08/2024 Implemented
SIN-00249205 Renewal 08/06/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The exterior and interior shelves of Individual #1's bedside table was covered in a substantial amount of a powdery white substance.Clean and sanitary conditions shall be maintained in the home. DSP immediately cleaned the individuals' room and bedside table 08/07/2024 08/07/2024 Not Implemented
6400.64(f)At 9:56 AM on 8/07/2024, the trash receptacle on the front curb of the home had trash bags overflowing from the can which prevented the lid to be closed. There were two garbage bags sitting on the front curb that were not in a trash receptacle.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.Tri County picked up the garbage on Wednesday 8/7/2024 after 1:00 PM. Maintenance purchase an extra tote on 8/8/2024. 08/07/2024 Implemented
6400.81(j)On 8/07/2024 at 10:38 AM, Individual #2 did not have a bedroom door for privacy. The door was being stored in the basement of the home. A bedroom shall have doors at all entrances for privacy.Maintenance Installed the bedroom door on 08/08/2024 08/08/2024 Implemented
6400.141(c)(10)Individual #1's physical examination completed on 10/11/2023 did not include specific precautions that must be taken if the individual has a communicable disease.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. The program specialist contacted the physician, and the physical form was updated on 8/30/2024. 08/30/2024 Not Implemented
6400.141(c)(14)Individual #1's physical examination completed on 10/11/2023 did not include medical information pertinent to diagnosis and treatment in case of an emergency was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The program specialists contacted the physician, and got the physical form updated on 8/30/2024. 08/30/2024 Not Implemented
6400.142(a)Individual #1 had a dental examination completed on 10/10/2022 and then again on 11/27/2023.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. The program specialists have documented on 08/23/2024 the oversight and schedule the next examination to occur on or before 11/27/2024 to ensure lines with the annual requirement. 08/23/2024 Implemented
6400.151(a)Program Specialist #1, date of hire 5/28/2024, had their initial physical examination completed on 5/30/2024. 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. HR will correct the issue by documenting the oversight in the program specialist personal file in ensuring that an updated physical examination will be completed every two years thereafter going by 5/28/2024. 08/30/2024 Implemented
6400.32(n)The only telephone in the home is always kept with staff. Individual #2 and Individual #3 have to ask staff to use the phone.An individual has the right to unrestricted and private access to telecommunications.Maintenance installed an additional telephone in a designated closet with a fingerprint pad to ensure the individual 2 and individual 3 can have access to the phone independently without needing to ask staff. The installation happened on 8/8/2024. The director overseed the installation, ensuring that the fingerprint pad was programmed with the fingerprints of the individual 2 and the individual 3 so they can access the phone independently at any time. 08/08/2024 Implemented
6400.32(r)(1)Individual #2 does not have the option to lock their bedroom door because they do not have a bedroom door. There is no regulatory waiver or restrictive procedure for Individual #2 regarding the lack of a bedroom door.Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.Maintenance immediately installed a bedroom door for individual 2 to ensure they have the option to lock their door and maintain privacy. The installation happened 8/8/2024. The director overseed the installation, ensuring that the door and lock was properly installed and functional. 08/08/2024 Implemented
6400.44(c)(2)Program Specialist #1, date of hire 5/28/2024, has a bachelor's degree but only had 22 months of previous experience working directly with individuals with an intellectual disability or autism on the date of hire.A program specialist shall have one of the following groups of qualifications: A bachelor's degree from an accredited college or university and 2 years of work experience working directly with individuals with an intellectual disability or autism.Program specialist has been working with supervision from the director and a policy to correct the issue was made. To ensure proper guidance and support while completing the additional two months of required experience. The supervision began immediately upon hiring and continued until the program specialist reached the full two-year experience of requirements on 8/12/2024. The director was responsible for providing this supervision and documenting the process of the program specialist during that time 08/12/2024 Implemented
6400.46(a)Program Specialist #1 completed a fire safety training on 6/24/2024. This training did not include site specific information such as evacuation procedures and meeting places for the homes they are assigned to work.Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.The program specialist was immediately retrained to include site specific information such as evacuation procedures and meeting places for the homes they are assigned too. The retraining was conducted on 8/09/2024. The training department conducted the retraining session to ensure the program specialists fully understand the site-specific safety protocols. 08/09/2024 Implemented
6400.46(b)Direct Service Worker #2 completed a fire safety training on 8/03/2024. This training did not include site specific information such as evacuation procedures and meeting places for the homes they are assigned to work.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).DSP is no longer with thoughtful needs. The situation will be documented in the employee's record, noting that the fire safety training did not include site specific information. This documentation will be completed immediately. The director will be responsible for updating the employees record to reflect this issue. 08/09/2024 Implemented
6400.51(b)(5)Program Specialist #1 did not receive Individual specific ISP training during orientation.The orientation must encompass the following areas: Job-related knowledge and skills.The program specialist was retrained on ISP's on 08/23/2024 08/23/2024 Implemented
6400.52(c)(2)Program Director/Chief Executive Officer Designee #3 did not receive training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse during the 7/1/2023 - 6/30/2024 annual training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The program specialist completed. the abuse prevention and detection through myODP 08/30/2024 08/30/2024 Implemented
6400.52(c)(4)Program Director/Chief Executive Officer Designee #3 did not receive training on recognizing and reporting incidents during the 7/1/2023 - 6/30/2024 annual training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.The program specialist completed. the abuse prevention and detection through myODP 08/30/2024 08/30/2024 Implemented
6400.52(c)(6)Direct Service Worker #1 did not receive individual specific ISP training during the 7/01/2023 -- 6/30/2024 training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.DSP is no longer with thoughtful needs. The situation will be documented in the employee's record, noting that the DSP didn't receive the specific ISP training. This documentation will be completed immediately. The director will be responsible for updating the employees record to reflect this issue. 08/209/2024 08/09/2024 Implemented
6400.181(b)Individual #1's assessment completed on 5/20/2024 states individual #1 rides safely in cars and uses the telephone independently. Individual #1's Restrictive Procedure Plan dated 8/01/2024 states individual #1 needs to remain in the backseat with child locks engaged while in the car due to Individual #1 trying to elope from the car while in motion. The RPP also states Individual #1 has a history of inappropriate use of electronic communication. Because of this, staff make phone calls for Individual #1.If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have an assessment completed as required under this section.The program specialists updated the assessment on 8/19/2024 08/19/2024 Implemented
6400.182(c)Individual #1's assessment completed on 5/20/2023 was sent to the SC and plan team members on 5/20/2023 for the ISP annual meeting held 1/04/2024. The assessment was completed more than 6 months prior to the ISP annual meeting.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The program specialist corrected the issue on 8/19/2024 by updating the assessments to assured it reflects the most current information. The program revised the assessment schedule to ensure that all future assessments are completed within 6 months of the ISP annual meeting date. 08/19/2024 Implemented
6400.194(d)Record of the human rights team meetings were not kept for Individual #1's Restrictive Procedure Plan.A record of the human rights team meetings shall be kept.The program sessions immediately contacted St Michael's Harbor and obtained the HRT minutes and place them in the individual's file on 08/23/2024 08/23/2024 Implemented
6400.195(b)Individual #1's Restrictive Procedure Plan was not reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews.The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews.The program specialist and the human rights team met on 08/27/2024 to ensure that plans are reviewed and revised within the allotted six-month cycle. 08/27/2024 Implemented
SIN-00244881 Unannounced Monitoring 04/30/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(1)On 5/01/2024, there was no record of financial resources documenting dates and amounts of deposits and withdrawals for Individual #2 and Individual #3. Individual #2 and Individual #3 are assessed to need assistance with managing their funds. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. All individuals who have receive cash on hand have a ledger which we keep record of dates, amounts and where the money was spent. [During the renewal inspection that occurred on 8/6-7/2024 training documents provided by the provider did not address the requirements of 6400.50(a), as the documents did not include the content of the training; therefore compliance could not be measured and implementation could not be verified. DPOC by HDKP, HSLS, on 10/18/2024]. 04/30/2024 Not Implemented
6400.62(a)On 5/01/2024, the following poisonous substances were identified unlocked and accessible in the basement: 3.78 Quart bottle of Optium Concentrated Bleach, 32fl/oz Laundry Stain Remover, Flow Easy Drain Opener, and one can of Scuff Defense Stain Blocking Paint and Primer. Individual #3's individual support plan, last updated 2/28/2024, states they are not aware of poisonous substances. On 5/01/2024 at approximately 1:47 PM, Individual #1 took staff's keys off of the dining room table and unlocked the closet on the first floor, where poisonous substances are located. Individual #1 had an incident on 4/01/2024 where they walked to the hospital and stated that they had sipped Fabuloso.Poisonous materials shall be kept locked or made inaccessible to individuals. All cleaning products are locked up in a tote with two locks one on each side of the tote. [During the renewal inspection that occurred on 8/6-7/2024 this regulation was identified as non-compliance during home inspections. Training documents provided by the provider did not address the requirements of 6400.50(a), as the documents did not include the content of the training; therefore compliance could not be measured and implementation could not be verified. DPOC by HDKP, HSLS, on 10/18/2024]. 05/22/2024 Not Implemented
6400.64(a)On 5/01/2024, the desk in the staff office was covered in dirt and debris. The right corner where the walls meet behind the water heater was covered in debris, dirt, and cobwebs.Clean and sanitary conditions shall be maintained in the home. Staff cleaned the basement and removed all debris, dirt, cobwebs. [During the renewal inspection that occurred on 8/6-7/2024 this regulation was identified as non-compliance during home inspections. Training documents provided by the provider did not address the requirements of 6400.50(a), as the documents did not include the content of the training; therefore compliance could not be measured and implementation could not be verified. DPOC by HDKP, HSLS, on 10/18/2024]. 05/23/2024 Not Implemented
6400.67(b)On 5/01/2024, a screw was sticking out approximately an inch and a half of the left side of the wall while descending the stairs to the basement. In the staff office, there was an open phone jack on the right wall exposing wires, multiple cables, and cords on the floor. Floors, walls, ceilings and other surfaces shall be free of hazards.Screw was removed and the open jack and wires ere fixed. [During the renewal inspection that occurred on 8/6-7/2024 this regulation was identified as non-compliance during home inspections. Training documents provided by the provider did not address the requirements of 6400.50(a), as the documents did not include the content of the training; therefore compliance could not be measured and implementation could not be verified. DPOC by HDKP, HSLS, on 10/18/2024]. 06/04/2024 Not Implemented
6400.72(a)On 5/01/2024, Individual #3's bedroom window did not contain a screen.Windows, including windows in doors, shall be securely screened when windows or doors are open. Screen were installed 06/03/2024 Implemented
6400.76(c)On 5/01/2024, the couch in the living room had a black metal bar exposed underneath the cushions, appearing to be the pull-out bed underneath the couch, and was not in good repair.Furniture shall be comfortable and home-like. New furniture was purchased. [During the renewal inspection that occurred on 8/6-7/2024 training documents provided by the provider did not address the requirements of 6400.50(a), as the documents did not include the content of the training; therefore compliance could not be measured and implementation could not be verified. DPOC by HDKP, HSLS, on 10/18/2024]. 06/03/2024 Not Implemented
6400.81(i)On 5/01/2024, Individual #3's bedroom window did not have drapes, curtains, shades, blinds or shutters.Bedroom windows shall have drapes, curtains, shades, blinds or shutters. Blinds were installed on the outside of the individual bedroom. the individual has access to the back porch to adjust the blind as s/he chooses. [During the renewal inspection that occurred on 8/6-7/2024 this regulation was identified as non-compliance during home inspections. Training documents provided by the provider did not address the requirements of 6400.50(a), as the documents did not include the content of the training; therefore compliance could not be measured and implementation could not be verified. DPOC by HDKP, HSLS, on 10/18/2024]. 06/21/2024 Not Implemented
6400.81(k)(2)On 5/01/2024, Individual #3's bedroom contained a mattress on the floor with no solid foundation.In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. The individual wants their mattress on the floor, but there is a solid foundation stored in the basement of the home in case the individual changes their mind. 06/21/2024 Implemented
6400.81(k)(4)On 5/01/2024, Individual #3's bedroom did not contain a chest of drawers. Individual #3's clothes were being stored in the basement.In bedrooms, each individual shall have the following: A chest of drawers. Program specialist is working with the behavioral specialist on getting a restriction plan to have their dresser in the basement because they will shred their clothing. 06/21/2024 Implemented
6400.82(e)On 5/01/2024, the bathtub in the home did not have a nonslip surface or mat. Bathtubs and showers shall have a nonslip surface or mat. Nonslip mats were purchased and placed in the tub 06/05/2024 Implemented
6400.82(f)On 5/01/2024, the bathroom in the home did not contain soap or individual clean paper or cloth towels.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Hand towels were placed in the bathroom and hand soap. [During the renewal inspection that occurred on 8/6-7/2024 this regulation was identified as non-compliance during home inspections. Training documents provided by the provider did not address the requirements of 6400.50(a), as the documents did not include the content of the training; therefore compliance could not be measured and implementation could not be verified. DPOC by HDKP, HSLS, on 10/18/2024]. 06/05/2024 Not Implemented
6400.112(a)On 5/01/2024 at approximately 1:43 PM, Individual #1 asked staff if they could run the fire drill for April 2024. Direct Service Worker #1 responded "go for it". Individual #1 set off the living room smoke detector and no individuals exited the home. Direct Service Worker #1 then took the April 2024 fire drill form off of the refrigerator and stated to Individual #1 that the fire drill needed to be conducted during the overnight shift. An unannounced fire drill shall be held at least once a month. Staff was retrained on fire safety and the importance of ducting unannounced fire drills and the importance for the clients to exist the homes. [During the renewal inspection that occurred on 8/6-7/2024 training documents provided by the provider did not address the requirements of 6400.50(a), as the documents did not include the content of the training; therefore compliance could not be measured and implementation could not be verified. DPOC by HDKP, HSLS, on 10/18/2024]. 06/03/2024 Not Implemented
6400.32(d)On 5/01/2024 during staff interviews, it was relayed that Individual #3 is not compatible with Individual #1 and Individual #2. When Individual #3 is having a behavior, the other individuals are unable to leave their bedrooms, or they are at risk of escalating Individual #3's behavior.An individual shall be treated with dignity and respect.Develop a safety plan for all individuals in the home if one of the individuals has behaviors to ensure the health and safety of all individuals and staff involved. including strategies for de-escalations and communication with emergency responders if necessary. [During the unannounced monitoring inspection that occurred on 9/27/2024 this regulation was identified as non-compliance during home inspections. Therefore the POC could not be verified as implemented. DPOC by HDKP, HSLS, on 10/18/2024]. 06/05/2024 Not Implemented
6400.32(h)Individual #1 was subject to audio and video recording in their home through 4/26/2024. Individual #2 was subject to audio and video recording in their home through 4/26/2024. Individual #3 was subject to audio and video recording in their home through 4/26/2024. The practice of audio and video recording was being utilized by the agency throughout all of their licensed residential homes.An individual has the right to privacy of person and possessions.The audio was immediately shut down to cease any further audio recording. All residents were informed about the incident and signed a new camera policy/Procedure. 04/26/2024 Implemented
6400.161(a)On 5/01/2024 at approximately 1:45 PM, Individual #1 walked over to dining room table and grabbed their prescribed Albuterol Inhaler from the unlocked medication box. Individual #1 stated to Direct Service Worker #1 that they were going to use the Albuterol inhaler and proceeded to take two puffs from the inhaler. The individual then put the inhaler back in the medication box. Individual #1's individual support plan, last updated 6/09/23, states that they are unable to self-medicate.The home shall provide an individual who has a prescribed medication with assistance, as needed, for the individual's self-administration of the medication.Provide comprehensive training to all staff involved in medication administration and emphasize the importance of following procedures and ensure that staff understands the risks associated with unauthorized medication administration, Emphasize the importance of vigilance and prompt intervention, implement supervision protocols. [During the renewal inspection that occurred on 8/6-7/2024 training documents provided by the provider did not address the requirements of 6400.50(a), as the documents did not include the content of the training; therefore compliance could not be measured and implementation could not be verified. DPOC by HDKP, HSLS, on 10/18/2024]. 06/04/2024 Not Implemented
6400.166(b)On 5/01/2024, Individual #3's following medications were not documented as administered for the 5/01/2024 7:00 AM administration: Divalproex Tablet 500 MG ER with directions to take two tablets by mouth every morning for mood, Fluvoxamine Tablet 100 MG with directions to take once tablet by mouth twice a day for anxiety, Guanfacine Tablet 3 MG ER with directions to take one tablet by mouth daily for ADHD, Levothyroxine Tablet 25 MG with directions to take one tablet by mouth every morning for hypothyroidism, Loratadine 10 MG tablet with directions to take one tablet by mouth daily for allergies, Lorazepam .5 MG with directions to take half tablet by mouth twice a day for anxiety, Omega 3 Fish capsule 1000 MG with directions to take two capsules by mouth daily with meals for supplement, and Omeprazole Capsule 20 MG with directions to take one capsule by mouth every morning for GERD.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.To ensure all medications administered are properly documented by staff initialing the MAR and the blister pack right after administration. [During the unannounced monitoring inspection that occurred on 9/27/2024 this regulation was identified as non-compliance during home inspections. Therefore the POC could not be verified as implemented. DPOC by HDKP, HSLS, on 10/18/2024]. 06/04/2024 Not Implemented
6400.167(a)(1)The following medications were not administered to Individual #1 on 5/01/2024 at 8:00 AM: Fluticasone Spray 50 MCG with directions to use two sprays in each nostril daily for nasal congestion, Lithium Carbonate Tablet 300 MG with directions to take one tablet by mouth twice a day for bipolar disorder, and Vitamin D3 1000 IU with directions to take one capsule by mouth daily for Vitamin D deficiency.Medication errors include the following: Failure to administer a medication.To ensure all medications administered are properly documented by staff initialing the MAR and the bister pack right after administration. [During the renewal inspection that occurred on 8/6-7/2024 this regulation was identified as non-compliance during home inspections. Training documents provided by the provider did not address the requirements of 6400.50(a), as the documents did not include the content of the training; therefore compliance could not be measured and implementation could not be verified. DPOC by HDKP, HSLS, on 10/18/2024]. 06/04/2024 Not Implemented
SIN-00210751 Renewal 09/01/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)On 9/2/22, the water temperature was taken at the bathroom sink at 10:54 AM and measured 124.5 Degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. The maintenance man will do monthly water checks (more if needed) for each house of thoughtful needs. Each month, the maintenance man will record the temperature on a water temperature form for each home. [Monthly water temperature log completed for September 2022 received on 9/30/22 and reviewed on 10/12/22. Documented water temperatures do not exceed 120 degrees Fahrenheit. DPOC by HDKP, HSLS, on 10/12/22]. 09/12/2022 Implemented
6400.72(a)On 9/2/22, the window located in Individual #2's, date of admission 11/30/2020, bedroom at the front side of the house did not contain a screen. The window is operable and can be opened.Windows, including windows in doors, shall be securely screened when windows or doors are open. During the All staff meeting on 9/5/2022, management discussed repairs and hazards with the employees and explained that all repairs and/or hazards need to be reported immediately by completing the Maintenance Request Form and bringing it to the office manager. The screens have been ordered for the windows that do not have a screen. [All staff meeting agenda and attendance sheet, dated 9/6/22, includes the review of repairs and hazards, as well as how to complete the maintenance repair sheet and how to submit repair request received on 9/30/22 and reviewed on 10/12/22. DPOC by HDKP, HSLS, on 10/12/22]. 09/13/2022 Implemented
6400.112(f)The fire drills conducted between October 2021 and August 2022 at did not use alternate exit routes. All fire drills utilized the front door as the exit route. There is more than one exit from the home.Alternate exit routes shall be used during fire drills. Thoughtful Needs had an all staff meeting and discussed fire drills and evacuation routes. The house manager will assign dates for the monthly fire drills and give each home an hypothetical scenario. This will ensure that the homes use alternative routes. [All staff meeting agenda and attendance sheet, dated 9/6/22, includes the review of fire drills documentation requirements, including the requirement to alternate evacuation routes, received on 9/30/22 and reviewed on 10/12/22. DPOC by HDKP, HSLS, on 10/12/22]. 09/12/2022 Implemented
6400.141(c)(10)Individual #1, date of admission 7/18/2022, had a physical examination on 8/31/2022; however, the communicable disease assessment was not addressed. This section of the physical examination was left blank.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. Prior to becoming a resident at Thoughtful Needs, all individuals will be given our physical form that will need completed before his/her first day. Once the individual is establish and going for his/her routine physical, the form will be supplied to the doctor to complete, the staff will bring the form to the program specialist or it will be faxed from the doctor once it is fully completed. Once the Program Specialist receives the physical form, it will be review to ensure its complete. [All staff meeting agenda and attendance sheet, dated 9/6/22, includes the review of doctor appointments, consultation forms, and ensuring that appointment documentation is completed was received on 9/30/22 and reviewed on 10/12/22. DPOC by HDKP, HSLS, on 10/12/22]. 09/12/2022 Implemented
6400.141(c)(11)Individual #1, date of admission 7/18/2022, had a physical examination on 8/31/2022; however, the health maintenance needs assessment was not addressed. This section of the physical examination 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. Prior to becoming a resident at Thoughtful Needs, all individuals will be given our physical form that will need completed before his/her first day. Once the individual is establish and going for his/her routine physical, the form will be supplied to the doctor to complete, the staff will bring the form to the Program Specialist, or it will be faxed from the doctor once it is fully completed. Once the Program Specialist receives the physical form, it will be reviewed to ensure it is complete. [All staff meeting agenda and attendance sheet, dated 9/6/22, includes the review of doctor appointments, consultation forms, and ensuring that appointment documentation is completed was received on 9/30/22 and reviewed on 10/12/22. DPOC by HDKP, HSLS, on 10/12/22]. 09/12/2022 Implemented
6400.141(c)(14)Individual #1, date of admission 7/18/2022, had a physical examination on 8/31/2022; however, the medical information pertinent to diagnosis and treatment in case of an emergency assessment was not addressed. This section of the physical examination was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Prior to becoming a resident at Thoughtful Needs, all individuals will be given our physical form that will need completed before his/her first day. Once the individual is established and going for his/her routine physical, the form will be supplied to the doctor to complete, the staff will bring the form to the Program Specialist, or it will be faxed from the doctor once it is fully completed. Once the Program Specialist receives the physical form, it will be reviewed to ensure it is complete. [All staff meeting agenda and attendance sheet, dated 9/6/22, includes the review of doctor appointments, consultation forms, and ensuring that appointment documentation is completed was received on 9/30/22 and reviewed on 10/12/22. DPOC by HDKP, HSLS, on 10/12/22]. 09/12/2022 Implemented
6400.141(c)(15)Individual #1, date of admission 7/18/2022, had a physical examination on 8/31/2022; however, the special instructions for the individual's diet assessment was not addressed. This section of the physical examination was left blank.The physical examination shall include:Special instructions for the individual's diet. Prior to becoming a resident at Thoughtful Needs, all individuals will be given our physical form that will need completed before his/her first day. Once the individual is established and going for his/her routine physical, the form will be supplied to the doctor to complete, the staff will bring the form to the Program Specialist, or it will be faxed from the doctor once it is fully completed. Once the Program Specialist receives the physical form, it will be reviewed to ensure it is complete. [All staff meeting agenda and attendance sheet, dated 9/6/22, includes the review of doctor appointments, consultation forms, and ensuring that appointment documentation is completed was received on 9/30/22 and reviewed on 10/12/22. DPOC by HDKP, HSLS, on 10/12/22]. 09/12/2022 Implemented
6400.214(a)The following documentation for Individual #1, date of admission 7/18/2022, was not located in the home: Most recent completed assessment 6400.213(6) and lifetime medical history. The following documentation for Individual #2, date of admission 11/30/2022, was not located in home: Most recent completed assessment 6400.213(6), lifetime medical history, and dental hygiene plan 6400.213(5).Record information required in § 6400.213(1-8) (relating to content of records) shall be kept at the home.Thoughtful Needs individual's lifetime medical history will be uploaded into the online Therap system. All staff have access to this system and use it daily to complete attendance, daily tlogs, MAR, ect.. 09/12/2022 Implemented
6400.32(r)On 9/2/22, Individual #1's, date of admission 7/18/2022, bedroom door does not have a lock and a lock declination page was not available. On 9/2/22, Individual #2's, date of admission 11/30/2020, bedroom door does not have a lock and a lock declination page was not available. On 9/2/22, Individual #3's, date of admission 1/24/2022, bedroom door does not have a lock and a lock declination page was not available.An individual has the right to lock the individual's bedroom door.Thoughtful Needs has put two check boxes on the Individual Rights signature page that gives them the option to check if they want a lock or if they choose to not have a lock. If at any time he/she changes his/her mind, we will adjust accordingly. [Individual and Civil Rights form updated to include the option to indicate individual preference for a lock to be reviewed at least annually with every individual receiving services was received on 9/30/22 and reviewed 10/12/22. DPOC by HDKP, HSLS on 10/12/22]. 09/09/2022 Implemented
6400.166(b)Individual #1, date of admission 7/18/2022, is prescribed Nyamc 1,000,000 unit/gm powder. This medication was not logged as administered in the Medication Administration Record on 9/01/2022 at 2:00 PM [Repeat violation 9/28/2021, et. al.]The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.There was an all staff meeting on September 6, 2022, where medications were discussed. The medication trainer explained the importance of giving medications properly and signing off on the medications at the time they are administered. The nurse will check the MAR daily to make sure all meds were administered and signed off on. [All staff meeting agenda and attendance sheet, dated 9/6/22, includes the review of medications administered timely, documenting administration immediately, and reporting of any issues was received on 9/30/22 and reviewed on 10/12/22. DPOC by HDKP, HSLS, on 10/12/22]. 09/12/2022 Implemented
6400.182(c)Individual #2's, date of admission 11/30/2020, Individual Support Plan (ISP) has not been updated to match the information in the most recent assessment. The ISP updated on 8/15/2022 states that poisons are left locked because Individual #2 cannot read labels. The assessment completed on 12/30/2021 states that Individual #2 can safely use and avoid poisons. Individual #2's, date of admission 11/30/2020, ISP has not been updated to match the information in the most recent assessment. The ISP updated on 8/15/2022 states that Individual #2 requires partial assistance to temper their own bath water. The assessment completed on 12/30/2021 states that Individual #2 can temper their own water temperature.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The Program Specialist will do periodic reviews of the ISP(s) to check for any changes. We are contacting all supports coordinators to notified them if changes are made without a critical revision or meeting, we as the provider need to be notified. 09/12/2022 Implemented
SIN-00193805 Renewal 09/28/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The amount of time it took to evacuate the home was not recorded for fire drills held on 12/09/20 and 01/12/21.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. - Thoughtful Needs Program Specialists will collect the Fire Drill Forms every month from each home by the 25th to ensure time to redo if needed.. - After picking up the forms, each form will be thoroughly checked by the Program Specialist. - Upon completion of the check, they will be placed in the specific home binder which will be kept in the office. 10/07/2021 Implemented
SIN-00157228 Renewal 06/13/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.186(b)The program specialist did not sign and date Individual #1's ISP Review for review period from 05/28/18 to 08/28/18.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. The program Specialist reviewed and signed/dated the Quarterly Review for the individual. The Quarterly review form has been updated with a signature/date space for the Program Specialist and the individual. The new Quarterly Review format has been used within the past few months for ISP reviews. There has been no issues reported by the individuals Support Coordinator or Administrative Entities. The Program Specialist will review the individuals file to verify signatures and dates, when preparing for the six (6) month ISP review team meeting that is initiated by the Program Specialist. 06/14/2019 Implemented
SIN-00136724 Renewal 06/15/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(g)Program Specialist #1's most recent fire safety training was 8-10-16.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). Thoughtful Needs will continue to have fire safety in orientation, but will do annual fire safety training twice a year to ensure nobody is missed. [Immediately, Program Specialist #1 was trained areas related to fire safety on 6/18/18. Immediately, the CEO or designee shall develop and implement a tracking system to ensure all Program specialists and direct service workers are trained annually by a fire safety expert in training areas related to fire safety. At least quarterly, the CEO or designee shall review the aforementioned tracking system to ensure program specialists and direct service workers are trained annually by a fire safety expert. (AS 6/29/18)] 07/02/2018 Implemented
6400.112(a)An unannounced fire drill were not held in September 2017 and October 2017. An unannounced fire drill shall be held at least once a month. Program Specialist will have fire drills marked on their calendar and inform group home staff when to conduct drills. The staff will turn in the drill records to the Program Specialist to review and the PS will sign off on it. The PS will also make copies of the fire drill to keep in file at the office and at the home. Program Director will also review Fire Drill records monthly to ensure they are being complete. [Within 15 days of receipt of the plan of correction, the CEO shall educate all staff person's responsible for conducting, documenting and auditing fire drills of the requirements of fire drills as per 6400.112(a)-(I) and their aforementioned responsibilities for conducting, documenting and auditing fire drills to ensure fire drills are conducted and documented as required. Documentation of trainings shall be kept. Documentation of all audits of fire drill records shall be kept. (AS 6/29/18)] 07/02/2018 Implemented
6400.112(d)The fire drill held on 8-18-17 at 9:38 PM had an evacuation time of 3 minutes and 10 seconds. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Program Specialist will review all contents on a fire drill record and ensure the time of evacuation does not exceed the 2.5 minute limit. If the drill is over the time, PS will instruct staff to complete a new fire drill. PS will plan out fire drills and inform staff on when to complete them. PS will sign off on drills and also make copies to have on file at the office and in the home. Program Director will also oversee fire drills to make sure no errors occur. [Within 15 days of receipt of the plan of correction, the CEO shall educate all staff person's responsible for conducting, documenting and auditing fire drills of the requirements of fire drills as per 6400.112(a)-(I) and their aforementioned responsibilities for conducting, documenting and auditing fire drills to ensure fire drills are conducted and documented as required. Documentation of trainings shall be kept. Documentation of all audits of fire drill records shall be kept. (AS 6/29/18)] 07/02/2018 Implemented
6400.186(e)The program specialist did not notify the all the plan team members of the option to decline including Individual #1's mother. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. When creating ISP reviews, a checklist of plan team members will be included to ensure they all have the option of receiving/declining the ISP reviews. If a plan team member declines, it will be noted and filed with the review. [On June 18, 2018, the program specialist notified Individual #1's mother of the option to decline. Immediately and continuing at least quarterly, the Program specialist shall audit all individuals' records including ISP, invitation letter and other documentation along with correspondence documentation to ensure all individuals' residing in the community homes to ensure the program specialist has notified all individuals' plan team members of the option to decline and correspondence documentation is maintained and available for review upon request by the department. Documentation of the audits shall be kept. (AS 6/29/18)] 07/02/2018 Implemented
SIN-00117446 Renewal 07/11/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(15)Program Specialist #1 did not inform Individual #2's plan team members, specifically the home and community habilitation and transitional work providers, of the option to decline the ISP review documentation. The program specialist shall be responsible for the following: Informing plan team members of the option to decline the ISP review documentation as required under § 6400.186(e). Program Director created a declination page to be sent out with reviews. This declination page can be used for assessments as well. The program specialist is responsible for sending the document out to all team members for the individual. Once declination pages are returned, program specialist is responsible for filing with individuals documents. The declination page will be added to the review template and assessment template so that it does not get omitted. Program Specialist will review all necessary sections of reviews in 6400 regulations as a refresher. Declination document sent separately. [On August 8, 2017, Program specialist notified home and community habilitation and transitional work providers via email, the option to decline the ISP reviews. Documentation of the correspondence shall be kept in the individuals' record. (AS 8/9/17)] 08/05/2017 Implemented
6400.163(c)Individual #1's psychiatric medication reviews completed on 2/10/17, 4/7/17, and 5/4/17 did not include the necessary dosage. Individual #2's psychiatric medication review completed on 5/3/17 did not include the necessary dosage. 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.Medication Monitoring forms are taken to all psychiatric appointments. All old med monitoring forms from in the home and filed on the computer were discarded. A new form was created to ensure to include all necessary data (reason for med, need to continue, and dosage). All staff will review forms from appointments to make sure the physician completed each section. Staff will be trained on the importance of medication monitoring in September. All forms will be ready for staff to take to appointments. Staff are responsible for returning paperwork immediately after appointments. New med monitoring form sent separately.[Upon completion, the program specialist shall audit the documentation from the medication review to ensure all required information is included and individuals are administered medications as prescribed. At least quarterly for 1 year, the CEO shall audit a 25% sample of psychiatric medication reviews to ensure all required information is included and individuals are administered medications as prescribed. Documentation of all audits shall be kept. (AS 8/9/17)] 08/05/2017 Implemented
6400.181(a)Individual #3, admission date 10/16/16, had an initial assessment completed on 4/10/17. 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 is responsible for completing the initial assessment within 1 year prior or 60 days after admission. The change that is being made to ensure this is not a violation in the future is that the Program Director created a chart for the Program Specialist to follow for dates of when ISP reviews and assessments are due. The Program Director is also adding to the current policy and procedure that even if an individual is in respite care but reside in the home over 30 days, reviews will need complete as well as initial assessment. This change will be made immediately, ISP review/assessment charts will be made for each individual to ensure this does not happen in the future. The program specialist will make note the dates on desk and computer calendars for completion. Documentation of the chart will be sent separately. [At least quarterly, for 1 year the CEO shall audit the aforementioned tracking system to ensure timely completion of individuals' assessments. Documentation of the audits shall be kept. (AS 8/9/17)] 08/05/2017 Implemented
6400.186(a)The program specialist completed an initial ISP review on 4/11/17 for Individual #3, admission date 10/16/16.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 Program Specialist is responsible for completing ISP reviews every 3 months. The change that is being made to ensure this is not a violation in the future is that the Program Director created a chart for the Program Specialist to follow for dates of when ISP reviews are due. The Program Director is also adding to the current policy and procedure that even if an individual is in respite care but reside in the home over 30 days, reviews will need complete. This change will be made immediately, ISP review charts will be made for each individual to ensure this does not happen in the future. The program specialist will make note the dates on desk and computer calendars for completion due dates. Staff training will be targeted for the program specialist to review how ISP review dates are every 3 months. Documentation of the chart will be sent separately.[At least quarterly, for 1 year the CEO shall audit the aforementioned tracking system to ensure timely completion of individuals' ISP reviews. Documentation of the audits shall be kept. (AS 8/9/17)] 08/05/2017 Implemented
6400.186(b)Individual #1 did not sign and date the ISP review end dated 4/11/17.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. To ensure that signatures are complete on individuals documents, program specialist will mark with either an X, highlight, or sticky note where signatures are required. This change will be implemented immediately for all documentation of individuals records. Program Director will also be responsible for double checking documents to ensure signatures were complete. At the beginning of each month the program specialist will go through the individuals personal log files to make sure nothing was missed for the previous month. This will be ongoing. No training will be necessary. [On 8/1/17, Individual #1 signed and date the ISP review, date 4/11/17. At least quarterly for 1 year, the program manager shall audit all individuals' ISP reviews to ensure the program specialist and individual signed and dated the ISP review signature sheet upon review of the ISP. Documentation of the audit shall be kept. (AS 8/9/2017)] 08/05/2017 Implemented
6400.186(e)Program Specialist #1 did not notify Individual #2's plan team members, including the home and community habilitation provider and transitional work provider, of the option to decline the ISP review documentation. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. Program Director created a declination page to be sent out with reviews. This declination page can be used for assessments as well. The program specialist is responsible for sending the document out to all team members for the individual. Once declination pages are returned, program specialist is responsible for filing with individuals documents. The declination page will be added to the review template and assessment template so that it does not get omitted. Program Specialist will review all necessary sections of reviews in 6400 regulations as a refresher. Declination document sent separately[On August 8, 2017, Program specialist notified home and community habilitation and transitional work providers via email, the option to decline the ISP reviews. Documentation of the correspondence shall be kept in the individuals' record. (AS 8/9/17)] 08/05/2017 Implemented
SIN-00094601 Renewal 05/13/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(b)The agency did not use the Department's licensing inspection instrument to complete the home's self assessment dated 2/3/16.The agency shall use the Department's licensing inspection instrument for the community homes for people with mental retardation regulations to measure and record compliance. During 2015 inspection, provider was shown by the inspector the self-Inspection and declaration tool and was told that it needed to be done every 3 - 6 months and I was following that with that form, During this years inspection provider was shown the inspection instrument score sheet. The department licensing inspection instrument sheet was completed on 05/13/2016. Plan of Correction: The inspection score sheet instrument will be completed by the CEO/director. training was given to the CEO/director on 05/16/2016 and will continue to review the 6400 regulations. 06/03/2016 Implemented
6400.46(e)Direct Service Worker #1, date of hire 2/2/16, did not receive training in the areas of mental retardation, the principles of normalization, rights and program planning and implementation.Program specialists and direct service workers shall have training in the areas of mental retardation, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. Employee #1 was given training on 05/16/2016 on Mental Retardation, Positive approaches and Normalization. Plan of Correction: Mental Retardation and Positive Approaches and Normalization has been added to the orientation criteria syllabus and staff will continue to receive annual training. [Immediately and after completion, CEO will review training orientation documentation to ensure all staff have received the required trainings within the required timeframes and will immediately ensure staff trainings as needed. Documentation of reviews shall be kept. (AS 6/3/16) 06/03/2016 Implemented
6400.151(c)(3)The physical examination for Direct Service Workers #1 and #2 did not 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 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. Employee #1 and #2 The doctor from the Corporate Health Clinic fill out the agency's form that the employee #1 and Employee #2 are free of communicable diseases the form completed on 05/27/2016 Plan of Correction: All Employees will use the agency's physical form that has the question is employee free of communicable diseases. employees will not start work if the agency's is not completed. The CEO/director will review employee records quarterly and was trained on 6400 regulations 05/16/2016. [Immediately and upon completion annually, CEO will review all staff persons' current physical examinations to ensure all required information is present and will immediately obtain missing information. Documentation of reviews of employee record reviews shall be kept. (AS 6/3/16)] 06/03/2016 Implemented
6400.171Grilled chicken breast strips were in and unsealed plastic sandwich bag in the freezer in the kitchen of the home. Food shall be protected from contamination while being stored, prepared, transported and served. The unsealed grilled chicken was put into a freezer zip lock bag. correction made in front of the inspectors. Plan of Correction: Staff was trained on 05/27/2016 when opening food it needs to be stored in a reseal able container or seal able bags and this will be monitored by the Program Specialist during monthly home visits. [Within 30 days of receipt of the plan of correction, CEO will develop and implement and train staff on the policies and procedures to ensure food is protected from contamination while being stored, prepared, transported and served. Documentation of trainings and monthly checks shall be kept. (AS 6/3/16)] 06/03/2016 Implemented
6400.213(1)(i)The records for Individual #1 and Individual #2 did not include color of hair, color of eyes, indentifying marks and religious affiliation.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.Individual #1 and Individual #2 records updated to the hair and eye color, and religion and church preference and identifying marks, and social security number corrections made on 05/13/2016 Plan of correction: The Program Specialist will make updates to individual's recorders quarterly staff will notify the Program Specialist when changes occur. Staff and Program Specialist was given training on 05/27/2016 about the 6400 regulations and when there are changes with the individuals the Program Specialist will make the necessary change immediately. 06/03/2016 Implemented
SIN-00077862 Renewal 05/19/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-inspection within 3 to 6 months of the 6-2-15 expiration date on the license.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. Plan of Correction Self-Inspection and Declaration Tool 6400-15a; what specific change will be made? The Self Assessment Tool will be completed every 3 months. Who will make the changes? Lisa Culp, when will changes be made? Changes were made, on 05/22/2015. What system have you implemented to make sure that the same violation will not occur again? The CEO will be responsible for completing this task every 3 months. What training will be provided to the staff? The CEO will receive the 6400 regulation and will have a training every 6 months on 6400 regulations. 06/08/2015 Implemented
6400.103The written emergency evacuation procedure did not include an emergency shelter location.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. Plan of Correction Emergency Evacuation procedure 6400-103; what specific change will be made? The policy has been updated with the location to where the individuals will go in an emergency. Who will make the changes? Lisa Culp, when will changes be made? Changes were made, on 05/19/2015. How will the changes be made? The policy was updated to clarify the location and the hotel that will be used during an emergency the hotel is Red Roof Inn - Hermitage Pa 16148. What system have you implemented to make sure that the same violation will not occur again? Policy and procedures will be reviewed and updated every 6 months. The CEO will be responsible for all policy and procedures.what training will be provided to staff? The CEO will do continue education on policy and procedures every year 06/08/2015 Implemented
SIN-00064296 Initial review 06/02/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71Emergency telephone numbers are not listed on or near the telephone located in the basement. 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. to make a lable with emergency numbers and add it to the reciever of the phone and post emergency numbers near the phone 06/02/2014 Implemented
SIN-00197447 Unannounced Monitoring 12/06/2021 Compliant - Finalized
SIN-00178807 Renewal 10/27/2020 Compliant - Finalized