Inspection ID

Reason for Inspection

Inspection Date

Inspection Status

SIN-00259647

Renewal

01/31/2025

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.43(b)(1)	Chief Executive Officer #1 failed to ensure that Direct Service Worker #3 had a current physical examination. The documentation of the current physical examination and Tuberculin testing for Direct Service Worker #3 had obvious signs of alterations and inaccurate dates. The year of date of administration of the PDD test and the date of the examination were written over in a thick darker writing to read "23"; however, the reading date of the PPD was 10/14/17. The Department Licensing Representative inquired to Chief Executive Officer #1 about the obvious inconsistency of dates on Direct Service Worker #3's physical examination; he left the room to make a call regarding the physical examination. Chief Executive Officer #1 returned and allegedly made a call to the physician's office. The woman with whom Chief Executive Officer #1 was speaking asked for the date of birth of Direct Service Worker #3 and then stated numerous dates until eventually confirming 10/11/23 as the date of Direct Service Worker #3's physical examination. At 1:52PM, Chief Executive Officer #1 provided the Department Licensing Representative a new version of Direct Service Worker #3's physical examination with the explanation that the physician's office completed a new physical examination document for Direct Service Worker #3. At 1:56PM, the Department Licensing Representative reviewed the document and then contacted the physician's office, who requested identity verification of the Licensing Representative and a copy of Direct Service Worker #3's physical examination documentation. The requested information was provided. At 2:29PM, confirmation was received that the physician's office did not complete the documentation for Direct Service Worker #3's physical examination and Direct Service Worker #3 was not seen at the physician's office in 2023.	The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures.	Staff is not longer with the agency. CEO will review on a quarterly base the files of the staff to ensure Implementation of policies and procedures.	02/03/2025	Implemented
6400.64(a)	At 1:04PM, the inside of the air fryer had an excessive amount of food particles and crumbs in the bottom of the fryer basket. At 1:05PM, the inoperable chest freezer in the kitchen of home contained what appeared to be rust, mildew and mold. In addition, there was a stagnant brownish liquid at the bottom and a foul smell emanating from the appliance. At 1:44PM, the "mini" refrigerator, in the staff office on the third floor of the home, contained what appeared to be mold and/or mildew.	Clean and sanitary conditions shall be maintained in the home.	Fryer basket was cleaned the same day. Chest freezer and mini refrigerator was removed from the home immediately.	02/01/2025	Implemented
6400.67(a)	The carpeting throughout the home has various sizes and colors of stains to include in the dining room, the vacant bedrooms on the second floor of the home. The ceiling tiles throughout the home have dark stains from what appears to be water leaks to include in the vacant bedroom on the second floor and above the closet in Individual #1's bedroom. The walls and ceilings throughout the home have multiple varying length cracks to include all four corners in Individual #1's bedroom, between the windows in the hallway on the second floor and between the window and a corner and on the ceiling in the staff office on the second floor, and under the windows and on the ceiling in the stairwell leading to the third floor.	Floors, walls, ceilings and other surfaces shall be in good repair.	Carpets were shampooed throughout the house on 2/7/25. We brought in a general contractor to assess the cracks. Due to the settling size of the home, the home is settling. March 4th he will begin to repair cracks throughout the property. On 2/24/25 Castillo Restoration LLC will come to assess the roof of any leaks. After which all tiles will be changed	02/07/2025	Implemented
6400.68(a)	At 1:16PM, the water temperature at the sink in the bathroom on the second-floor of the home measured only 93.7 degrees Fahrenheit.	A home shall have hot and cold running water under pressure.	The individual had not been home in two weeks therefore the water had not run in the home since then. The water was adjusted the day of inspection. For the next few weeks staff will check the temperature consistently to ensure it maintains the required 110-120.	02/01/2025	Implemented
6400.70	At 1:15PM, the cordless telephone, in the living room of the home, did not have an operable outside line; the display read "insert battery." The additional telephones in the home with operable outside lines were locked in the offices on the second and third floors of the home.	A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.	The phone was currently operable. This is the same phone in which inspector had CEO contact the staff and the doctors office. The phone rang several times while inspectors were in home as well. Staff will change the batteries of the cordless device to ensure phone is operable and easily accessible to individual.	02/01/2025	Implemented
6400.72(a)	At 1:13PM, the operable window. in the hallway on the second floor of the home, did not contain a screen.	Windows, including windows in doors, shall be securely screened when windows or doors are open.	The second floor screen was replaced on 2/7/25.	02/07/2025	Implemented
6400.72(b)	At 1:03PM, there were three tears, each approximately one to two inches by two inches, in the screen in the kitchen door at the rear of the home.	Screens, windows and doors shall be in good repair.	Organization will purchase new screening and replace the current screen to be in good repair. The new screen was purchased on 2/7/25.	02/07/2025	Implemented
6400.77(b)	At 1:15PM, the first aid kit did not contain scissors.	A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served.	After reviewing the first aid kit there were scissors at the bottom of the kit. CEO will make more visible for easier access.	02/05/2025	Implemented
6400.112(c)	The written fire drill record for the fire drill held on 8/17/24 did not include the amount of time it took for evacuation. [Repeated Violation 1/30/24, et al]	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.	CEO reviewed fire drill policy with Program Specialist policy. Program Specialist reviewed the previous fire drills.	02/07/2025	Implemented
6400.141(c)(1)	Individual #1's physical examination, completed 12/8/24 did not contain a review of previous medical history.	The physical examination shall include: A review of previous medical history.	CEO and Program Specialist has reviewed the physical examination form. Staff assisting individual to appointment will ensure documents are thoroughly completed.	02/07/2025	Implemented
6400.141(c)(10)	Individual #1's physical examination, completed 12/8/24 did not address communicable disease. This section 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.	CEO and Program Specialist has reviewed the physical examination form. Staff assisting individual to appointment will ensure documents are thoroughly completed.	02/07/2025	Implemented
6400.141(c)(14)	Individual #1's physical examination, completed 12/8/24 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. [Repeated Violation 1/30/24, et al]	The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.	CEO and Program Specialist has reviewed the physical examination form. Staff assisting individual to appointment will ensure documents are thoroughly completed.	02/07/2025	Implemented
6400.151(a)	Direct Service Worker #3's most recent physical examination was completed on 10/30/2021. The agency provided a physical examination, dated 10/16/23 for Direct Service Worker #3, with obvious alterations and inconsistencies including a darker, written over year in the date of examination and administration of PDD and a PDD read date of 10/14/17. Confirmation was received from the physician's office that Direct Service Worker #3 was never seen in the office in 2023.	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.	Staff is no longer with agency. All staff documents will be reviewed by program specialist. CEO will review on a quarterly base the files of the staff to ensure Implementation of policies and procedures.	02/07/2025	Implemented
6400.151(c)(2)	Direct Service Worker #3's most recent Tuberculin testing was completed on 10/30/2021. The agency provided a physical examination, dated 10/16/23 for Direct Service Worker #3, with obvious alterations and inconsistencies including a darker, written over year in the date of examination and administration of PDD and a PDD read date of 10/14/17. Confirmation was received from the physician's office that Direct Service Worker #3 was never seen in the office in 2023.	The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner.	Staff is no longer with agency. All staff documents will be reviewed by program specialist. CEO will review on a quarterly base the files of the staff to ensure Implementation of policies and procedures.	02/07/2025	Implemented
6400.171	At 1:07PM, the following expired foods were found in the upper pantry cabinet to the left of the refrigerator in the kitchen of the home: a 6.4 oz box of Hamburger Helper Stroganoff with a best if used by date of 11/8/2024, a 28 oz jar of Giant Eagle creamy peanut butter with a best before date of 1/5/2024, and a 26.5 oz jar of Nutella spread with a best by date of January 2021.	Food shall be protected from contamination while being stored, prepared, transported and served.	All food within cabinets were thoroughly assessed on 02/01/2025. All foods that were out of date were removed. CEO reviewed policy with staff on 02/02/2025. Program Specialist reviewed on 2/3/25.	02/05/2025	Implemented
6400.46(b)	The annual fire safety training completed 4/10/2024 for Chief Executive Officer #1, Program Specialist #2, and Direct Service Worker #3 did not include home specific information relating to evacuation procedures and designated meeting place.	Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).	CEO has made contact with Fire Chief CJ of East Pittsburgh to provide the necessary training for the organization. His soonest availability is Monday, March 17th which he will come to the home to assess the current procedures and designated meeting places. He then will train both CEO and Program Specialist annually.	02/05/2025	Implemented
6400.52(c)(4)	The annual training hours for the training year from 1/1/2024 to 12/31/2024 for Chief Executive Officer #1 did not include recognizing and reporting incidents.	The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.	CEO will completed recognizing and reporting incidents via ODP training site rather than outside trainer. This will be completed 3/15/25.	02/07/2025	Implemented
6400.163(d)	At 1:22PM, a 100g tube of Diclofenac Sodium Topical Gel, 1% was unlocked atop the dresser in Individual #1's bedroom.	Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.	Staff will be more attentive of items individuals obtain when not in care. Individual stated that they receive this ointment from his mother during the visit. CEO had a conversation with both individual and his mother about the ointment. Individual thought the product was lotion therefore did not think to inform staff. Staff will ensure that only medications that are prescribed by his doctor are provided.	02/05/2025	Implemented
6400.165(a)	At 1:22PM, A 100g tube of Diclofenac Sodium Topical Gel, 1% was atop the dresser in Individual #1's bedroom. Chief Executive Officer #1 confirmed that Individual #1 does not have a prescription for this medication.	A prescription medication shall be prescribed in writing by an authorized prescriber.	Staff will be more attentive of items individuals obtain when not in care. Individual stated that they receive this ointment from his mother during the visit. CEO had a conversation with both individual and his mother about the ointment. Individual thought the product was lotion therefore did not think to inform staff. Staff will ensure that only medications that are prescribed by his doctor are provided.	02/05/2025	Implemented
6400.166(a)(9)	"Individual #1 is prescribed Clonazepam 5mg with instructions on the medication label to "take one tablet by mouth two times a day and one additional tablet as needed before stressful outings. Hold for sedation." Individual #1's January 2023 Medication Administration Record reads "take 1 tablet by mouth daily." [Repeated Violation 1/30/24, et al]	A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.	Program Specialist will contact individual prescriber to request an updated and clarified instruction. The organization will have a separate line as an PRN to identity if individual is taking as an PRN until the update has changed.	02/05/2025	Implemented
6400.169(d)	Medication Administration Trainer #4 completed the annual medication administration training practicums for Chief Executive Officer #1 on 5/2/2024, Program Specialist #2 on 5/11/2024, and Direct Service Worker #3 on 11/1/2024. Medication Administration Trainer #4 is not employed by the agency. The agency does not have a contract with the Medication Administration Trainer #4's employer stating that Medication Administration Trainer #4 is permitted to complete medication administration training for staff at this agency.	A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.	The ongoing policy will be for TGC Staff to take Medication Administration in person at an ODP scheduled training rather than continue to have be trained by an outside entity.	02/05/2025	Implemented
6400.182(c)	Individual #1's assessment, completed 10/5/24 indicates that Individual #1 can be left unsupervised for approximately 1 hour in the community. In the supervision care needs section of Individual #1's individual plan, last updated 12/30/24 reads, "[Individual #1] is able to have up to 8 hours of unsupervised time daily in the community. Unsupervised time is used when he is working in the community without his job coach and catching the bus to and from his family's homes."	The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.	CEO contacted the SC to regarding the specific in the plan. Program specialist will review the plan and send an email to the SC with the specific request to be implemented.SC made some inital changes upon individuals discharge from hospital Staff then will review the updated ISP and trained on the new practices to implement the plan for the individual.	02/05/2025	Implemented
6400.186	On 1/19/25 at 10:15AM, Individual #1 returned home from work and encountered Program Specialist #2, who inquired about Individual #1's purchases and consumption of soda and snack cakes. Individual #1 became anxious and eventually stated that he wanted to go for a walk. The incident report, primary category Missing Person entered in the Department Incident Management System by Chief Executive Officer #1, reads "walks around the community are norms for [Individual #1]. In the supervision care needs section of Individual #1's Individual Plan, last updated 12/30/24 reads, "[Individual #1] is able to have up to 8 hours of unsupervised time daily in the community. Unsupervised time is used when he is working in the community without his job coach and catching the bus to and from his family's homes." Individual #1 was found at a Homeless Shelter two days later.	The home shall implement the individual plan, including revisions.	CEO contacted the SC to regarding the specific in the plan. Program specialist will review the plan and send an email to the SC with the specific request to be implemented.SC made some inital changes upon individuals discharge from hospital Staff then will review the updated ISP and trained on the new practices to implement the plan for the individual.	02/05/2025	Implemented

SIN-00238808

Renewal

01/30/2024

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.15(a)	The agency completed a self-assessment for this site on 7/10/23 without using the Department's most current version from 2/20/20. Instead, the agency had used the Department's obsolete version from 2018. [Repeated Violation-1/31/23, et al]	The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.	Agency will use the updated assessment located https://home.myodp.org/resources/licensing-and-regulations/ known as 6400 ¿ Provider Self-Assessment Form 2-20-20. Human Services Licensing Representative guided us to the updated assessment during his time on-site. Director shared with Program Specialist on 2/7/24 how to locate the assessment to use on-going.	02/07/2024	Implemented
6400.22(e)(3)	On 1/31/24, Individual #1's financial record contained a handwritten receipt dated for 1/18/24 in the amount of $60, stated for "Money on Hand and Haircut". There was no actual, itemized receipt provided verifying that a purchase had been made for a haircut. In an interview, CEO #1 explained that the handwritten receipt dated for 1/18/24 in the amount of $60 had been money given directly to Individual #1. Individual #1's most recent assessment completed on 9/1/23, states they need assistance to ensure the correct change is returned after purchase, and their Individual Plan last updated on 6/28/22 indicates they could be easily victimized with money while out in the community.	If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person.	As per Human Services Licensing Representative agency will be particular when documenting on Individual's financial record to state "Money to Individual" instead of "Money on Hand." While Individual provides his receipts when he spends his money "on hand" it unclear when writing a specific action such as Haircut and money on hand together. Staff will ensure that transactions are separate and specified on the financial record.	02/07/2024	Implemented
6400.66	At 11:53 AM on 1/31/24, there was no light outside the basement's only exit. No other sufficient nearby lighting source existed.	Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.	Denny of Roycroft Electric was contacted on 2/1/24 pertaining to adding additional outside lighting near the basement exit. The automatic light system was installed on 2/9/24.	02/09/2024	Implemented
6400.67(b)	On 1/31/24, the area outside of the basement's only exit to the outside consisted of four concrete steps leading up to a grade-level concrete slab. At 11:53 AM, three of the four steps were found covered in thick moss and foliage that could cause a potential slipping hazard, especially when wet. Additionally, atop the four concrete steps, a two inch-by-four-inch piece of wood measuring approximately two feet in length was found secured on its two-inch side to the grade-level concrete slab and extended across the entire exit path, causing a potential tripping hazard.	Floors, walls, ceilings and other surfaces shall be free of hazards.	On 2/1/24 director and staff cleared the concrete steps of the moss and foliage that Human Services Licensing Representative mention during his visit. The wood was also removed by the director at the same time.	02/07/2024	Implemented
6400.112(c)	The agency's written fire drill record submitted from 1/20/23 to 1/12/24 contained drills conducted on 6/21/23, 7/15/23, and 1/12/24 that did not address problems encountered. [Repeated Violation-1/31/23, et al]	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.	Agency gained better understanding and clarity from Human Services Licensing Representative regarding "addressing problems encountered." Agency will only documents negative or coachable instance during the fire drill instead of the positive praise was often written during the drill. Director explained and review the information and code in the hand book with the program specialist.	02/07/2024	Implemented
6400.141(c)(3)	Individual #1's birthdate is 11/26/88. They had received their most recent tetanus-diphtheria vaccine on 1/25/13.	The 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.	Individual was already scheduled for updated tetanus-diphtheria vaccine on 2/14/24. Individual received up to date immunization and agency obtained updated immunization record.	02/14/2024	Implemented
6400.141(c)(11)	Individual #1's most recent physical examination completed on 8/15/23, did not include an assessment of their medication regimen and the need for blood work at recommended intervals. Both fields were left blank. [Repeated Violation-1/31/23, et al]	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.	Agency will ensure the physical form itself is completed in its entirety. The current physical information to assessment of their medication regimen and the need for blood work at recommended intervals was attached to the physical rather than written on the physical.	02/07/2024	Implemented
6400.141(c)(14)	Individual #1's most recent physical examination completed on 8/15/23, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.	The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.	Agency will ensure the physical form itself is completed in its entirety. The current physical information to assessment of their medication regimen and the need for blood work at recommended intervals was attached to the physical rather than written on the physical.	02/07/2024	Implemented
6400.181(e)(10)	Individual #1's most recent assessment completed on 9/1/23 did not include a lifetime medical history or any documented attempts of gathering any relevant historical information. [Repeated Violation-1/31/23, et al]	The assessment must include the following information: A lifetime medical history.	Agency will review the previous lifetime medical history assessment to add to the current assessment. Human Services Licensing Representative shared information that is vital and how that information can be captured. Director reviewed the code and information shared with Program Specialist on 2/7/24. Program Specialist is given to the next quarterly review to have an updated lifetime medical history assessment from their fact and historic review.	02/07/2024	Implemented
6400.181(e)(13)(viii)	Individual #1's most recent assessment completed on 9/1/23 did not address their progress over the last 365 calendar days and current level in the following area: Managing personal property.	The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property.	Director reviewed with Program Specialist the assessment and provided the insight given by the Human Services Licensing Representative. The code was also read and reviewed for clarity. Program Specialist will updated the assessment for review by the quarterly review.	02/07/2024	Implemented
6400.181(e)(13)(ix)	Individual #1's most recent assessment completed on 9/1/23 did not address their progress over the last 365 calendar days and current level in the following area: Community Integration.	The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.	Director reviewed with Program Specialist the assessment and provided the insight given by the Human Services Licensing Representative. The code was also read and reviewed for clarity. Program Specialist will updated the assessment for review by the quarterly review.	02/07/2024	Implemented
6400.166(a)(4)	On 1/31/24, the following pro re nata medication prescribed for Individual #1, Diclofenac Sodium Topical Gel 1% 100 GM and 12-Hour Nasal Decongestion 0.05% Spray, were recorded on their January 2024 Medication Administration Record as "Valtonen Gel" and "Nasal Spray," respectively.	A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.	Program Specialist contact the prescribing physician of the medication to have the medication name changed. On one document which agency adhere to was different from the medication that was provided by pharmacy.	02/08/2023	Implemented
6400.166(a)(5)	On 1/31/24, the following pro re nata medication prescribed for Individual #1: Diclofenac Sodium Topical Gel 1% 100 GM and 12-Hour Nasal Decongestion 0.05% Spray---were recorded on their January 2024 Medication Administration Record as "Valtonen Gel" and "Nasal Spray," respectively, and were missing corresponding strengths.	A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.	Program Specialist contact the prescribing physician of the medication to have the medication name changed. On one document which agency adhere to was different from the medication that was provided by pharmacy.	02/08/2024	Implemented
6400.166(a)(9)	On 1/31/24, Individual #1's prescribed pro re nata medications, Diclofenac Sodium Topical Gel 1% 100 GM---Apply a small application to the affected area twice daily as needed for pain, and 12-Hour Nasal Decongestion 0.05% Spray---instill 2 sprays 2 times a day as needed, were recorded respectively on their January 2024 Medication Administration Record as follows: "Valtonen Gel---Applied to pulled muscle 3x a day as needed," and "Nasal Spray---2 sprays 2 times a day as needed," thus exhibiting differences in their corresponding frequencies of administration.	A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.	Program Specialist contact the prescribing physician of the medication to have the medication name changed. On one document which agency adhere to was different from the medication that was provided by pharmacy.	02/08/2024	Implemented
6400.166(a)(11)	On 1/31/24, Individual #1's prescribed pro re nata medications, Diclofenac Sodium Topical Gel 1% 100 GM---Apply a small application to the affected area twice daily as needed for pain, and 12-Hour Nasal Decongestion 0.05% Spray---instill 2 sprays 2 times a day as needed, did not include purposes or diagnoses on their January 2024 Medication Administration Record. [Repeated Violation-1/31/23, et al]	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.	Program Specialist contact the prescribing physician of the medication to have the medication name changed. On one document which agency adhere to was different from the medication that was provided by pharmacy.	02/08/2024	Implemented

SIN-00218629

Renewal

01/31/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.15(a)	The-self assessment instrument completed 7/17/2022 was last updated in 2018 and did not include all of the regulations.	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.	This Generation Cares will utilize the updated self-assessment which includes all the regulations that were missed from the outdated self-assessment. This has been download and placed into circulation with the previous self assessment being removed. Program Specialist was informed and introduced to the new self assessment form.	03/30/2023	Implemented
6400.67(a)	The bedroom to the right of Individual #1's bedroom had a broken wood door with approximately 1/2 of the wood panels missing.	Floors, walls, ceilings and other surfaces shall be in good repair.	The bedroom that has the broken wood panels is an empty available room for a individual not the present individual housed in the facility. The director has replace the door on the bedroom on 2/4/23.	02/07/2023	Implemented
6400.80(a)	The back exit out of the kitchen had a deck with wooden steps descending to the back yard, which were entirely covered with snow. The back exit from the basement has a cement staircase ascending to the outside, which was covered in snow and leaves.	Outside walkways shall be free from ice, snow, obstructions and other hazards.	During the day of inspection the stairs were cleared by staff however during the time of inspection it began to snow again which cause snow to be present. Staff cleared the snow once they returned from the individual appointment on 2/1/23. Staff will continue to maintain the safety of the outside of the facilities during their shifts.	02/06/2023	Implemented
6400.81(i)	Individual #1's bedroom contains a window across from his bed, facing the street, with a sheer, transparent curtain, violating the individual's privacy.	Bedroom windows shall have drapes, curtains, shades, blinds or shutters.	Program Specialist replaced blinds back over the window. Director and Program Specialist had a conversation with individual about placing the blinds back because he did not want them. Individual felt were were violating his right of chose however we explained our regulation to maintain his privacy. Staff reviewed the regulation with both individual on 2/5/23 and staff on 2/6/23.	02/07/2023	Implemented
6400.104	A fire department notification was sent to the local fire department 12/11/2022 documenting that two individuals lived in the home and Individual #1 is the only individual residing in the home. Individual #1 needs verbal prompting with evacuation and the notification letter did not state the exact location of Individual #1's bedroom.	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.	Director resend a new fire department notification on 2/7/23. Director reviewed with Program Specialist of the in accurate information.	02/07/2023	Implemented
6400.112(c)	The fire drill conducted 5/23/2022 did not include the amount of time it took for evacuation. It was blank.	A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative.	Director reviewed the fire drill along with the regulation that was incomplete with Program Specialist on 2/5/23. Program Specialist reviewed with staff on 2/6/23 during the review meeting.	02/06/2023	Implemented
6400.141(c)(11)	Individual #1's physical examination completed 2/04/2022 did not include an assessment of the individual's health maintenance needs and the need for blood work at recommended intervals.	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.	Director updated physical examination form to include health maintenance needs and the need for blood work at recommended intervals. Director shared the updated form with Program Specialist on 2/5/23. Program Specialist removed the previous forms and reviewed with staff during the 2/6/23 meeting to have complete when taking individuals to their appointments.	02/06/2023	Implemented
6400.151(c)(2)	Direct Service Worker #3, date of hire 12/21/2021, had an initial Tuberculin skin test read 1/14/2022.	The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner.	Director will ensure all staff Tuberculin will be prior to the start date of all staff. Director reviewed with Program Specialist of policy, procedure and regulation.	02/06/2023	Implemented
6400.181(e)(10)	Individual #1's assessment completed 9/19/2022 did not include a lifetime medical history.	The assessment must include the following information: A lifetime medical history.	Program Specialist has been informed of the lifetime medical history portion of the assessment. Director reviewed the policy and regulation with Program Specialist on 2/6/23.	02/06/2023	Implemented
6400.32(r)	Individual #1's bedroom door does not contain a door lock.	An individual has the right to lock the individual's bedroom door.	Director contacted Support Coordinator to add to the plan of the individual because has declined having a lock on his door. Director is willing and ready to add a lock on the individual's door for privacy.Director reviewed policies and procedures of the individuals rights during the staff review on 2/6/23.	02/06/2023	Implemented
6400.50(a)	Chief Executive Officer #1 was trained 1/17/2022 on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships, and documentation did not include the training source, content, and copies of certificates received. Chief Executive Officer #1 was trained 1/24/2022 and 7/13/2022 on recognizing and reporting incidents, and documentation did not include the training source, content, and copies of certificates received.	Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.	CEO will obtain and maintain training source, content, and copies of certificates received.	02/07/2023	Implemented
6400.52(c)(2)	Chief Executive Office #1's 2022 annual training hours did not encompass the prevention, detection and reporting of abuse, suspected abuse and alleged abuse. Direct Service Worker #2's annual training from 10/16/2021 to 10/15/2022 did not encompass the prevention, detection and reporting of abuse, suspected abuse and alleged abuse.	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.	Chief Executive Office 2023 will annual training hours will encompass the prevention, detection and reporting of abuse, suspected abuse and alleged abuse. Direct Service Worker #2's annual training will encompass the prevention, detection and reporting of abuse, suspected abuse and alleged abuse.	02/09/2023	Implemented
6400.166(a)(11)	On 2/01/2023, Individual #1's February 2023 medication administration record did not include diagnosis or purpose for the following medication: Trihexyphenidyl 2mg tablet, Clonazepam 0.5mg tablet, Omeprazole 40mg tablet, and Olanzapine 15mg 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.	Director reviewed with Program Specialist the form of MAR. Program Specialist will include the diagnosis or purpose.	02/07/2023	Implemented
6400.182(c)	Individual #1's assessment completed 9/19/2022 states the individual has up to 1 hour unsupervised in the community setting and Individual #1's individual support plan, last updated 6/28/2022 states the individual requires 24-hour supervision in the community.	The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.	Program Specialist contacted Support Coordinator to have the plan updated to include his unsupervised hours in the community setting. The email was sent on 1/31/23.	02/18/2023	Implemented
6400.192	The restrictive procedures policy describes circumstances in which the following prohibited procedures can be used: seclusion, chemical restraints, and mechanical restraints.	The home shall develop and implement a written policy that defines the prohibition or use of specific types of restrictive procedures, describes the circumstances in which restrictive procedures may be used, the staff persons who may authorize the use of restrictive procedures and a mechanism to monitor and control the use of restrictive procedures.	Director have updated the restrictive procedures policies to remove the seclusion, chemical restraints, and mechanical restraints as of 2/4/23.	02/06/2023	Implemented

SIN-00199902

Renewal

02/11/2022

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.112(d)	The fire drill conducted on 12/19/21 indicates an evacuation time of 2 minutes and 48 seconds. There is no extended evacuation time specified in writing within the past year by a fire safety expert.	Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee 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.	This Generation Cares will ensure all individuals and staff will evacuate home under 2 1/2 minutes. Director reviewed with Program Specialist the policy and procedures on 2/ 13/22. Program Specialist reviewed with both individual and staff on 2/15/22 during staff training. [Documentation of Director's review of policy and procedures with Program Specialist, dated 2/13/22, verified on-site on 6/7/22. Training for direct care staff conducted by the Program Specialist, dated 2/15/22, verified on-site on 6/7/22. Documentation of fire drills conducted in March, April, and May of 2022 verified on-site on 6/7/22. DPOC by HDKP, HSLS, on 6/7/22.]	02/15/2022	Implemented
6400.112(e)	Documentation review of fire drills conducted from 01/29/21 to 01/12/22 indicated that a fire drill was held during sleeping hours on 11/24/21 and 12/19/21. No other fire drills during this time occurred during sleeping hours.	A fire drill shall be held during sleeping hours at least every 6 months.	This Generation Cares Program Specialist and Manager will sign off on all fire drills to ensures they are in compliance with regulations. [Documentation of Director's review of policy and procedures with Program Specialist, dated 2/13/22, verified on-site on 6/7/22. Training for direct care staff conducted by the Program Specialist, dated 2/15/22, verified on-site on 6/7/22. Documentation of fire drill conducted during sleeping hours, dated 4/17/22, reviewed on=site on 6/7/22. DPOC by HDKP, HSLS, on 6/7/22.]	02/15/2022	Implemented
6400.181(f)	The program specialist provided the assessment for Individual #1, completed 10/08/21, to the individual plan team members on 10/09/21 for an individual plan meeting that occurred on 10/26/21 [Repeat Violation 03/04/21].	The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.	Director reviewed with Program Specialist the policy and procedures of the assessment on 2/ 13/22. Program Specialist was required to create a chart with dates target dates to send out assessment. Director received on 2/17/22. Electronic and paper tracking systems for individual assessments were reviewed on-site on 6/7/22. Tracking system includes a reminder that individual assessments must be sent 30-days prior to the annual ISP meeting. DPOC by HDKP, HSLS, on 6/7/22.]	02/17/2022	Implemented

SIN-00184284

Renewal

03/04/2021

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.106	The furnace was inspected on 11/4/2019 and then again on 12/27/2020.	Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.	Due to covid-19 restrictions multiple HVAC companies were not making appointments unless they were emergency. CEO will begin contacting HVAC companies two months prior to the due date of inspection. Program Specialist will confirm with CEO that the furnace inspection have been completed prior to its inspection date.	03/08/2021	Implemented
6400.141(a)	Individual #1 had a physical examination on 2/5/2020 and then again 2/22/2020. Individual #2 had a physical examination on 10/10/2019 and then again on 11/3/2020.	An individual shall have a physical examination within 12 months prior to admission and annually thereafter.	Due to covid the doctor's offices was unable to see the individual within its 15-day grace period which was documented by the physician. Residential Management will schedule appointments within the 15 days grace period. Resident Manager will use a tracker to highlight the individual¿s date. CEO will review the tracker quarterly to ensure compliance. If individual is unable to get the physical examination completed, then documentation by their physical will be requested for our records.	03/08/2021	Implemented
6400.142(a)	Individual #2 had a dental examination on 5/2/2019 and then again on 11/5/2020.	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.	Residential Management will schedule dental appointments every 6 months within the 15 -days grace period. Resident Manager will use a tracker to highlight the individual¿s date. CEO will review the tracker quarterly to ensure compliance. If individual is unable to get the dental examination completed, then documentation by their physician will be requested for our records. [At least quarterly, the CEO shall audit the aforementioned tracking document to ensure dental appointments are scheduled and completed, timely. Documentation of all aforementioned audits by the CEO shall be kept. (DPOC by AES,HSLS on 3/15/21)]	03/08/2021	Implemented
6400.165(g)	Individual #1's reviews of medications prescribed to treat symptoms of a psychiatric illness completed on 10/27/2020 and 1/26/2021 do not include the reason for prescribing the medication, the need to continue the medication and the necessary dosage.	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.	Staff will ensure the individual's treatment form is completed in its entirety prior to leaving their appointment. CEO review the participate treatment form with Resident Manager on 3/9/2021. Resident Manager will review the treatment forms after each scheduled appointment to ensure documentation is thoroughly completed. [Immediately, the CEO or resident manager shall educate the staff person responsible for supporting individuals with medications reviews on their responsibilities and the requirements of medication reviews. Documentation of the trainings shall be kept. Documentation of the aforementioned audits shall be kept. (DPOC by AES,HSLS 3/15/21)]	03/09/2021	Implemented
6400.181(f)	The program specialist provided Individual #1's assessment, completed 10/13/2020 to the individual plan team members on 10/13/2020 for the individual plan meeting on 10/6/2020. The program specialist provided Individual #2's assessment, completed 5/12/2020 to the individual plan team members on 5/12/2020 for the individual plan meeting on 6/5/2020.	The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.	Individuals Support Coordination was going on leave therefore requested an abrupt ISP meeting. Residential Management will ensure assessment are sent out 30 days prior to ISP meeting. Residential Management will decline any meeting prior to remain in compliance. CEO will review ISP invitation and assessment quarterly. [At least quarterly, the CEO shall audit the correspondence documentation to ensure the program specialist provided assessments to all plan team members, timely. Documentation of all aforementioned audits by the CEO shall be kept. (DPOC by AES,HSLS on 3/15/21)]	03/09/2021	Implemented

SIN-00166524

Renewal

11/22/2019

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.142(a)	Individual #1 had a dental examination on 8-30-19, and the previous dental examination was on 1-2-18.	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.	Program Specialist contacted individual's dental office and schedule appointment. They did not have any opening until 2/26/20. Program Specialist and Staff was made aware at the meeting 11/30/19 of the code 6400.142. CEO and Program Specialist has created a spread sheet which will be updated quarterly. All new staff will be trained and current staff will have refreshers training on the codes. [Immediately, the CEO shall develop and implement a policy and procedures to ensure timely completion of dental appointments and educate all staff persons on the aforementioned policy and procedures. Documentation of policy, procedures and trainings shall be kept. (DPOC by AES,HSLS on 3/31/20)]	12/09/2019	Implemented
6400.151(c)(2)	Program Specialist #1's most recent Tuberculin testing was completed on 9-1-17. [Repeat violation: 11-26-18]	The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner.	CEO was unclear to the date the regulations when by because the TB date was different from the physical itself. Clarity was gained at the exit interview of the inspection. CEO and Program Specialist reviewed the code 6400.151 individually and collectively for a discussion. CEO then explained the code to Program Specialist and staff at the 11/30/19 meeting and training. CEO has created a spreadsheet that will be reviewed by Program Specialist quarterly for all staff to be aware needed exams to stay in compliance. [Program specialist #1 had a Tuberculin testing completed on 1/23/2020 with negative results, documentation provided to the Department on 3/31/2020). At least quarterly for 1 year, the CEO shall audit the aforementioned spread sheet and completed Tuberculin skin testing to ensure completion, timely. Documentation of all audits by the program specialist and the CEO shall be kept. (DPOC by AES,HSLS on 3/31/20)]	12/09/2019	Implemented
6400.165(g)	Individual #1 had a reviews of medications prescribed to treat symptoms of a psychiatric illness on 9-4-18, then again on 1-15-19, then again on 4-30-19 and then again on 8-20-19. [Repeat violations: 11-26-18]	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.	On 11/30/19 a staff meeting and training was held with staff and program specialist to ensure individuals are being scheduled with their psychiatric within the 3 months windows. It was explained for staff to ensure the facility knows the individuals are in residential facility and must be seen within those day for compliance purpose. 12/2/19 Program Specialist and CEO contacted Mon-Yough to speak with Karen of the scheduling department to refresh her about the individuals TGC supports and how they reside in a residential facility therefore its needed for their psychiatric appointment to be within the 3 month timeframe. Mon-Yough assured they would note and schedule their the individuals within the 3 months and document it on the Participant Treatment Form. In addition a spreadsheet of individual psychiatric appointment has been created by the Program Specialist on 12/6/19 with the three month intervals that will checked by the CEO by quarterly. This will be updated and maintained per appointment by PS. New staff will be trained on this information upon hire and current staff will be reminded of this information during training opportunities. [Documentation of audits of aforementioned chart by the CEO shall be kept. (DPOC by AES,HSLS on 3/31/20)]	12/09/2019	Implemented

SIN-00146347

Renewal

11/26/2018

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.141(a)	Individual #1 had a physical examination completed on 1/27/17 and then again on 3/1/18.	An individual shall have a physical examination within 12 months prior to admission and annually thereafter.	Director has created a chart which outlines all of individual's due dates for physical examination which program specialist will have has a reference. Program Specialist and Staff will obtain forms of documentation when the doctor's office reschedule appointments and cause for physical to go beyond it's intended time. The spread sheet was created on 12/3/18. The staff meeting to inform of the standard moving forward was 11/29/18. [Immediately and at least quarterly, the CEO or designee shall audit all individuals' physical examinations and the aforementioned tracking system to ensure all individuals' have a physical examination completed, timely. (DPOC by AES,HSLS on 2/13/19)]	11/29/2018	Implemented
6400.141(c)(14)	Individual #2's physical examination, completed 11/15/18, did not include medical information to pertinent to diagnosis and treatment in case of emergency; this section was left blank. [Repeat violation 12/12/17]	The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.	Director has created a chart which outlines all of individual's due dates for physical examination which program specialist will have has a reference. Program Specialist and Staff will obtain forms of documentation when the doctor's office reschedule appointments and cause for physical to go beyond it's intended time. The spread sheet was created on 12/3/18. The staff meeting to inform of the standard moving forward was 11/29/18. [NOT ACCEPTABLE, the plan of correction does not address the violation. Individual #2 was discharge from the home on 12/29/18. Immediately and upon completion, the CEO or designee shall audit all individuals' current physical examination to ensure all required information is included and health services are arranged and provided for, as per 6400.141(c)(1)-(15). Prior to assisting individuals in obtaining a physical examination, the CEO or designee shall educate the staff person in the requirements of individuals' physical examinations as per 6400.141(c)(1)-(15) and to ensure no required information is left blank on the physical examination. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 2/13/19)]	11/29/2018	Implemented
6400.151(a)	Program Specialist #1 had a physical examination completed on 5/2/16 and then again on 6/28/18. Direct Service Worker #2 had a physical examination completed on 4/28/16 and then again on 6/4/18.	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.	Director has created a chart which outlines all of individual's due dates for physical examination which program specialist will have has a reference. Program Specialist and Staff will obtain forms of documentation when the doctor's office reschedule appointments and cause for physical to go beyond it's intended time. The spread sheet was created on 12/3/18. The staff meeting to inform of the standard moving forward was 11/29/18. [Immediately and upon completion and at least quarterly, the CEO or designee shall audit all staff persons' physical examinations and the aforementioned tracking system to ensure all staff persons' have a physical examination completed, timely. (DPOC by AES,HSLS on 2/13/19)]	11/29/2018	Implemented
6400.151(c)(2)	Direct Service Worker #2 had a Tuberculin skin test by the Mantoux method on 5/4/16 and then again on 6/8/18.	The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner.	Director has created a chart which outlines all of individual's due dates for physical examination which program specialist will have has a reference. Program Specialist and Staff will obtain forms of documentation when the doctor's office reschedule appointments and cause for physical to go beyond it's intended time. The spread sheet was created on 12/3/18. The staff meeting to inform of the standard moving forward was 11/29/18. [Immediately and upon completion and at least quarterly, the CEO or designee shall audit all staff persons' physical examinations and the aforementioned tracking system to ensure all staff persons' have a physical examination including Tuberculin skin testing completed, timely. (DPOC by AES,HSLS on 2/13/19)]	11/29/2018	Implemented
6400.163(c)	Individual #1 had a review of medications to treat symptoms of a diagnosed psychiatric illness completed on 5/15/18 and then again on 9/4/18. [Repeat violation 12/12/17]	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.	Director has created a chart which outlines all of individual's psychiatric check's are due quarterly which program specialist will have has a reference. In addition Program Specialist is assigned to confirm appointment with director by email to ensure that they are scheduled within the alott window. Program Specialist and staff are required to obtained documentation from psychiatric if appointment are cancelled. Meeting was held on 11/29/18 with staff and program specialist to review this information. [Immediately and at least quarterly, the CEO or designee shall audit all individuals' psychiatric medications reviews and the aforementioned tracking system to ensure all individuals' have psychiatric medications reviews completed, timely and with all required information. (DPOC by AES,HSLS on 2/13/19)]	11/29/2018	Implemented
6400.171	At 2:15PM, the refrigerator in the home contained a nine by twelve inch aluminum pan approximately half full of macaroni and cheese which was loosely covered with aluminum foil on the corners of the pan leaving the food exposed and not protected from contamination.	Food shall be protected from contamination while being stored, prepared, transported and served.	Staff received a refresher on the specific code. The staff meeting was held on 11/29/18 Management agreed to utilize either zip lock bags or sealed container instead of aluminum foil moving forward. [Immediately, upon hire and at least quarterly for 1 year, the CEO or designee shall educated all staff person working in community home on the agency's policies and procedures to ensure food is protected from contamination while being stored, prepared, transported and served and to monitor throughout the course of their daily duties and at least at the end of each shift. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 2/13/19)]	11/29/2018	Implemented
6400.181(d)	Individual #1's annual assessment, completed 10/15/18, was not signed by the program specialist. Individual #2's annual assessment, completed 4/28/18, was not signed by the program specialist.	The program specialist shall sign and date the assessment.	Director will not sign any annual assessment moving forward. Program Specialist has been informed of their required signature. Director will review signature annually using as a guide the spread sheet created to track dates of each individual.[Immediately, upon hire and at least annually, the CEO or designee shall educate the program specialist on the responsibilities of the program specialist position as per 6400.44(b)(1)-(19) and the aforementioned tracking system. Documentation of the trainings shall be kept. At least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking system and all completed assessments to ensure the program specialist signed and dated the assessments. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 2/13/19)]	12/03/2018	Implemented
6400.186(a)	The program specialist reviewed Individual #1's ISP review, end dated 1/15/18 with Individual #1 on 1/31/18.	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.	Director has created a chart which outlines all of individual's due dates for monthly, quarterly and annual assessments which program specialist will have has a reference. In addition they are assigned to be completed two days prior than the required date. This will prohibit going pass the required date. [Immediately, upon hire and at least annually, the CEO or designee shall educate the program specialist on the responsibilities of the program specialist position as per 6400.44(b)(1)-(19) and the aforementioned tracking system. Documentation of the trainings shall be kept. At least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking system and all completed ISP reviews to ensure completion, timely. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 2/13/19)]	12/03/2018	Implemented

SIN-00126579

Renewal

12/12/2017

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.141(c)(14)	Individual #1's physical examination completed 11/29/17 did not include information pertinent to diagnosis in case of emergency. (Repeated Violation 12/12/16, et al)	The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.	The physical examination form was updated in 2016 however the older form was still in circulation. All old forms have been collected and discard. All staff will used the updated physical form. The physical form will be completed at the appointment. Staff will then give that completed physical form to the Program Specialist for review to ensure that information pertinent to diagnosis as well and the form itself is completed thoroughly. [Immediately, the program specialist will contact the physician to completed missing information from Individual #1's physical examination. Immediately and upon completion, a designee trained by the CEO on information required in individuals' physical examination as per 6400.141(c)(1)-(15) shall audits individuals' current physical examination to ensure all required information is included and there are not any required areas left blank. At least quarterly for 1 year, the CEO shall audit physical examination completed during that quarter to ensure all required information is included and there are not any required areas left blank. Missing information shall be immediately obtained from the completing physician. Documentation of all audits and trainings shall be kept. (AS 2/22/18)]	12/19/2017	Implemented
6400.163(c)	Individual #2's psychiatric medication reviews completed 5/16/17, 8/7/17, 9/5/17, 10/3/17 and 11/28/17 did not include the reasons that the medications were prescribed or the need to continue the medications (Repeated Violation 12/12/16, et al).	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.	The individuals Participant Treatment Form has been updated with the specific language Reason for Medication. The updated document will be used on-going to ensure the reason is clear. All older Participant Treatment Forms have been removed for staff use. All staff have been trained on the updated form on 12/18/17. All new hires will be trained on this document as part as their initial training. [Immediately and upon completion, a designee trained by the CEO on information required in individuals' psychiatric medication reviews as per 6400.163c shall audits individuals' psychiatric medication reviews to ensure all required information is included. At least quarterly for 1 year, the CEO shall audit psychiatric medication reviews completed during that quarter to ensure all required information is included. Missing information shall be immediately obtained from the reviewing physician. Documentation of all audits and trainings shall be kept. (AS 2/22/18)]	12/18/2017	Implemented
6400.181(a)	Individual #2, date of admission 10/16/16 had an initial assessment completed 12/28/16.	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.	All initial assessment will be completed by Program Specialist or the assigned personal within 50 days of admission. It will be given to the CEO with all required mailing articles that will be sent to the SC. The CEO will review for accurate information, proper signatures and dates. After reviews and is sufficient CEO will mail out to the appropriate team members and place the original in the individual's record. This protocol has been updated in police and procedures and shared with the Program Specialist. All newly hired Program Specialist will be trained on this protocol and procedure. This will also be added to the annual review for Program Specialist during the year as a refresher. [Documentation of aforementioned training and audits and correspondence of assessments being provided to all plan team members as required shall be kept. (AS 2/22/18)]	12/18/2017	Implemented
6400.186(b)	Individual #2's ISP reviews completed 10/15/16, 1/15/17, 4/15/17, and 7/15/17 were not dated by the program specialist.	The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.	All reviews were signed and promptly date on 12/13/17. New protocol has been implemented that Program Specialist will submit all reviews to CEO after completed to check for proper signatures and dates. This protocol has been shared with the Program Specialist. The updated protocol will be added to the initial training for newly hired Program Specialist. The protocol will be review yearly for Program Specialist during their annual training as a refresher. [Documentation of aforementioned trainings and CEO audits shall be kept. (AS 2/22/18)]	12/15/2017	Implemented

SIN-00104789

Renewal

12/12/2016

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.15(a)	A self-assessment of the home was not completed. The agency's certificate of compliance has an expiration date is 12/1/16.	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.	CEO has completed self-assessment of the home. CEO has adapted a protocol that the Residential Manager will complete a self-assessment on each home every 3 months. CEO will conduct self-assessment every 6 months to ensure that the assessment are completed when required.	12/23/2016	Implemented
6400.112(c)	The fire drill conducted on 9/7/16 did not indicated the time that the drill was completed.	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.	CEO has updated the Fire Drill to specify the exact physical time of the drill. The form will be used by staff and will be checked by the residential manager monthly to ensure compliance. CEO will review the forms by monthly to ensure compliance.[Within 30 days of receipt of the plan of correction, the CEO shall train all staff persons responsible for conducting fire drills and completing documentation of the requirements as per 6400.112(a)-(I) and the aforementioned fire drill record. Documentation of the training shall be kept. (AS 1/19/17)]	12/23/2016	Implemented
6400.141(c)(1)	The physical examination dated 6/15/16 for Individual #1 did not include a review of previous medical history. The physical examination dated 5/2/16 for Individual #2 did not include a review of previous medical history.	The physical examination shall include: A review of previous medical history.	CEO has updated the Participant Physical Examination Form. A space for medical history has been added which includes sections for recent concerns and/ or problems, recent lab results and recent appointment/visits/ admission. This updated document has been given to each of the individuals PCP to be completed for the individual's file. Residential Manager and CEO will ensure moving forward that this updated document is used and checked for completion when an appointment is scheduled.[Individual #1's had a physical examination completed on 12/30/16 to include a review of previous medical history. Within 5 days of completion of individuals' physical examinations the CEO or designated staff person shall review the physical examination to ensure completion and there are not any required areas left blank. Immediately, missing required information will be obtained from the completing physician. At least quarterly for 1 year the CEO will review a 25% sample of completed physical examination to ensure all required information is included and there are not any required areas left blank. (AS 1/19/17)]	12/23/2016	Implemented
6400.141(c)(11)	The physical examination dated 6/15/16 for Individual #1 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The physical examination dated 5/2/16 for Individual #2 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. These sections were 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.	CEO has updated the Participant Physical Examination Form. A space for health maintenance needs, medication regimen and the need for blood work at recommended intervals. This updated document has been given to each of the individuals PCP to be completed for the individual's file. Residential Manager and CEO will ensure moving forward that this updated document is used and checked for completion when an appointment is scheduled.[Individual #1's had a physical examination completed on 12/30/16 to include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. CEO requested updated physical examination for Individual #2 from Family Health Center via fax on 1/12/17 and will follow up as needed to obtain updated physical examination with required information. Within 5 days of completion of individuals' physical examinations the CEO or designated staff person shall review the physical examination to ensure completion and there are not any required areas left blank. Immediately, missing required information will be obtained from the completing physician. At least quarterly for 1 year the CEO will review a 25% sample of completed physical examination to ensure all required information is included and there are not any required areas left blank. (AS 1/19/17)]	12/23/2016	Implemented
6400.141(c)(13)	The physical examination dated 6/15/16 for Individual #1 indicated there are no allergies. The emergency information for Individual #1 indicates the individual has an allergy to Sulfa Drugs.	The physical examination shall include: Allergies or contraindicated medications.	CEO has updated the Participant Physical Examination Form. A space for allergies/adverse reactions. This updated document has been given to each of the individuals PCP to be completed for the individual's file. Residential Manager and CEO will ensure moving forward that this updated document is used and checked for completion when an appointment is scheduled. CEO received the completed form on 1/12/17 that identifies the individual's allergy to sulfa drugs.[Individual #1's had a physical examination completed on 12/30/16 to include allergies or contraindicated medications. Within 5 days of completion of individuals' physical examinations the CEO or designated staff person shall review the physical examination to ensure completion and there are not any required areas left blank. Immediately, missing required information will be obtained from the completing physician. At least quarterly for 1 year the CEO will review a 25% sample of completed physical examination to ensure all required information is included and there are not any required areas left blank. (AS 1/19/17)]	12/23/2016	Implemented
6400.141(c)(14)	The physical examination dated 6/15/16 for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of an emergency. The physical examination dated 5/2/16 for Individual #2 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.	CEO has updated the Participant Physical Examination Form. A space for Emergency Information: Pertinent To Diagnosis And Treatment In The Event Of An Emergency. This updated document has been given to each of the individuals PCP to be completed for the individual's file. Residential Manager and CEO will ensure moving forward that this updated document is used and checked for completion when an appointment is scheduled. CEO received the completed form on 1/12/17 that identifies the necessary information. Staff will continue to use this form and CEO and Residential Manager will review the documents monthly to ensure compliance.[Individual #1's had a physical examination completed on 12/30/16 to include medical information pertinent to diagnosis and treatment in case of an emergency. CEO requested updated physical examination for Individual #2 from Family Health Center via fax on 1/12/17 and will follow up as needed to obtain updated physical examination with required information. Within 5 days of completion of individuals' physical examinations the CEO or designated staff person shall review the physical examination to ensure completion and there are not any required areas left blank. Immediately, missing required information will be obtained from the completing physician. At least quarterly for 1 year the CEO will review a 25% sample of completed physical examination to ensure all required information is included and there are not any required areas left blank. (AS 1/19/17)]	12/23/2016	Implemented
6400.151(a)	Program Specialist #1, hire date 4/10/16, had a physical examination completed on 5/2/16. Direct Service Worker #2, hire date 4/17/16, had a physical examination completed on 4/18/16. Direct Service Worker #3, hire date 4/17/16, had a physical examination completed on 5/4/16.	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.	It is hiring protocol for all staff to have a physical and TB prior to hire and working specifically with any individual. CEO and Residential Manager will ensure that each staff as the physical complete prior to working with individuals. [Prior to hire, the CEO shall review staff persons physical examinations to ensure timely completion. (AS 1/19/17)]	12/23/2016	Implemented
6400.163(c)	Psychiatric medication reviews dated 12/8/16, 11/1/16, 10/6/16, 9/8/16, 8/11/16, 7/14/16, and 5/26/16 for Individual #1 did not include the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Psychiatric medication reviews dated 12/8/16 and 11/1/16 for Individual #2 did not include the reason for prescribing the medication, the need to continue the medication and 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.	The Participant Treatment Form has been revised to include a table to identify the prescribed medication, reason for medication, the dosage and the need to continue the medication. This document will be provided to staff supporting the individual to their psychiatric appointment at least every 3 months. Management will review form monthly to ensure the form is completed in its entirety with the psychiatrist signature. [Individual #1 had a review of psychiatric medication by a physician on 1/10/17 to include the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Within 5 days of completion of individuals' psychiatric medication reviews, the CEO or designated staff person shall review to ensure completion with the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Immediately, missing required information will be obtained from the completing physician. At least quarterly for 1 year the CEO will review a 25% sample of completed medication reviews to ensure all required information is included. (AS 1/19/17)]	12/23/2016	Implemented

SIN-00083678

Initial review

12/01/2015

Compliant - Finalized