Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00235566 Renewal 12/04/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)The door leading from the kitchen to the basement had a slide lock on the kitchen side of the door, causing possible entrapment in the basement. Floors, walls, ceilings and other surfaces shall be free of hazards.In order to become compliant stability home care has taken off the slide lock from the door leading from the kitchen to the basement 12/14/2023 Implemented
6400.151(c)(3)Direct Service Worker #1's physical examination completed 12/9/22, did not include a signed statement that the staff person is free of communicable diseases. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Service person#1 was provided an agency specific physical form that includes all regulatory compliance requirements to complete a new physical. 01/12/2024 Implemented
SIN-00229953 Unannounced Monitoring 08/25/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)on 8/25/2023 the cover for the living room ceiling light had numerous dead bugs. There was what appeared to be mold which was black in color around the rubber sealing of the freezer in the kitchen. Within 3 feet of the front door, in the living room was a pile, approximately 5 feet high, of the previous Individual's belongings; this individual was discharged 7/14/23. In the living room, next to the front door, was a second pile, approximately 3 feet high, of the previous Individual's belongings. The living room carpet was torn, and snagged in multiple areas and has numerous large stains in several areas.Clean and sanitary conditions shall be maintained in the home. Stability home care has taken the following steps to rectify the non compliance : The individual's belongings were transferred to the individual's new provider, the appliance's were inspected and ensured to be in operating and sanitary condition and the home is being renovated to meet all regulatory guidelines. 10/16/2023 Implemented
6400.64(d)On 8/25/2023 located in the kitchen, on the table, was a plastic shopping bag filled with garbage.Trash in the bathroom, dining and kitchen areas shall be kept in cleanable receptacles that prevent the penetration of insects and rodents. The home is vacant. Stability home care has taken the opportunity to do a deep clean and renovations. The garbage receptacles have been replaced. 10/16/2023 Implemented
6400.66The stairwell leading from the diningroom to the ground floor of the home did not have an operable light.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Stability home care replaced the light bulb in the stairway upon discovery of the violation. 10/16/2023 Implemented
6400.76(a)On 8/25/2023 the chairs in the dining area were covered with numerous stains and dirt. Furniture and equipment shall be nonhazardous, clean and sturdy. Stability home care will remove the stained chairs and will be replaced with new chairs. 10/16/2023 Implemented
6400.80(b)On 8/25/2023, the driveway of the home was significantly overgrown with weeds, brush and low hanging tree branches. The driveway was also very long and treacherous requiring the licensing representative to use 4-wheel drive to get to the home. There was also vegetation growing out of the gutter along the back of the home. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.Stability home care will have the gutters of the home cleaned and made the driveway to be safe, free of debris, overgrown bushes and resurface the driveway. 10/16/2023 Implemented
6400.171Located In the freezer, in the kitchen, was 2 packages containing what appeared to be freezer burnt meat. It was not able to be determined what type of meat due to the ice crystals built up in the package.Food shall be protected from contamination while being stored, prepared, transported and served. Stability home care removed all food items from the refrigerator and freezer and thoroughly cleaned and sanitized the unit as a whole. 10/16/2023 Implemented
6400.163(d)Located in the staff office, unlocked, on the floor, in a yellow plastic "Dollar General" bag, were 6 boxes of Sumatriptan Succinate Injectable, 6 mg, 2 boxes of Epinephrine Injection, USP Auto-Injectors .3mg., a blister pack with 1 pill of Vitamin D3 not popped, all prescribed to Individual #1 who was discharged 7/14/2023. Located in the staff office, in an unlocked plastic toolbox was a bottle of prescribed Cerave Foaming Facial Cleanser; a bottle of Ketofin .25% eye drops, a Ventolin HFA inhaler all prescribed to Individual #2 and a blister pack with 7 Gabapentin 800 mg tablets prescribed for Individual #1 who discharged 7/14/21.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.The medications were secured in locked container and placed in the locked office and all expired medications were properly disposed of by returning them to the pharmacy. 10/16/2023 Implemented
6400.163(h)Located in the staff office, were 2 boxes of Epinephrine Injection, USP Auto-Injectors .3mg with an expiration date of 9/24/21; prescribed Cerave Foaming Facial Cleanser with an expiration date of 9/16/20; a Ventolin HFA inhaler with an expiration date of 9/3/20 and 6 boxes of Sumatriptan Succinate Injectable, 6 mg with an expiration date of April 2023.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The medications were secured in locked container and placed in the locked office and all expired medications were properly disposed of by returning them to the pharmacy. 10/16/2023 Implemented
SIN-00227620 Renewal 06/26/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.74The two wooden steps located outside the kitchen door did not have a nonskid surface.Interior stairs and outside steps shall have a nonskid surface. The violation was remedied/corrected by adding nonskid surface tape to stairs on the day of the discovered violation. 08/11/2023 Implemented
6400.101The exit located in the basement, near the washer and dryer, was overgrown with weeds and vegetation blocking the exit.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The violation was remedied at the time of its finding by inspection staff. 08/11/2023 Implemented
6400.106The furnace of the home was inspected and cleaned 1/19/22 and then again 2/21/23. [Repeat violation 6/22/22 et. al]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. Moving forward, the CEO is now charged with scheduling the yearly furnace inspections. The CEO will secure any and all needed documentations for record keeping and compliance. 08/11/2023 Implemented
6400.141(a)Individual #1 had a physical examination completed 9/24/21 and then again 11/1/22.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. All individual annual physical examinations will be scheduled for at least 14 days prior to the annual due date. Any and all acceptable reasons/excuses for cancellations and rescheduling will require approval from Primary Care Physician. Staff will obtain signed documentation from Primary Care Physician stating approval for the cancellation and rescheduling. 08/11/2023 Implemented
6400.141(c)(14)Individual #1's 11/1/22 physical examination does not include medical information pertinent to diagnosis and treatment in case of an emergency. The form did not have a space for this information.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The new updated individual physical examination form that includes medical information pertinent to diagnosis and treatment in case of an emergency will be obtained and utilized for all annual individual physical examinations. 08/11/2023 Implemented
6400.181(a)Individual #1, date of admission 7/11/19, had an assessment completed 4/28/23. Documentation for previous assessments was not provided. Therefore, compliance could not be measured. 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. A 2022 assessment for individual #1 exists but was misplaced during file purge and can be provided. 08/11/2023 Implemented
6400.165(g)Individual #1 is prescribed medications to treat psychiatric illness. Individual #1 had medication reviews 4/22/22 and then again 8/12/22. [Repeat violation 6/22/22 et. al]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.Any 90 day medication review appointments that are outside the allotted time frame of 3 months must be done so at the consent of the Psychiatric Physician and a written order expressing said consent will be obtained/required. 08/11/2023 Implemented
6400.182(c)Individual #1's ISP last updated 1/31/23 states "WHILE IN THE COMMUNITY, Individual #1 IS ABLE TO GO BY HERSELF FOR UP TO 30 MINUTES AT A TIME". Individual #1's 4/28/23 assessment states "requires total supervision within community". [Repeat Violation 6/22/22 et.al]The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The correction to the individuals annual assessment addressing Individual #1 supervision while in the community will be done. 08/11/2023 Implemented
SIN-00212530 Renewal 06/22/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment of the home, dated 3/12/22, was not completed. The following areas of the self-assessment were not addressed, as they were left blank: 6400.15b-6400.15c, relating to self-assessment of the home; 6400.18f, 6400.18i, 6400.18j, relating to incident reporting; 6400.19b through and including 6400.20d, relating to risk mitigation and quarterly quality management reviews; 6400.43b2 through and including 6400.43b4, relating to Chief Executive Officer responsibilities; 6400.166a15 and 6400.166a16, relating to Medication Administration Record content requirements; and 6400.195a through and including 6400.195d, relating to Behavior Support.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. To rectify the non-compliance, staff#2 will review and make the necessary corrections to the annual assessment dating 03/12/2022. [A completed self-assessment, dated 11/10/2022, was provided on 1/10/2023 and reviewed on 1/11/23. DPOC by HDKP, HSLS, on 1/11/23]. 11/10/2022 Implemented
6400.63(a)On 7/18/22, at approximately 12:17 PM, the hot water at the kitchen sink measured 123.9 degrees Fahrenheit.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. To rectify the non-compliance, 2 separate thermometers will be utilized to record water temperature and ensure accurate readings. [Documentation of weekly water temperature checks, dated from 11/2/2022 through 1/9/2023, were received on 1/25/2023 and reviewed 1/25/2023. DPOC by HDKP, HSLS, on 1/25/2023]. 11/02/2022 Implemented
6400.68(b)On 7/18/22, at approximately 12:15 PM, the hot water at the bathtub in the bathroom adjacent to the dining area measured 126.1 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. To rectify the non-compliance, 2 separate thermometers will be utilized to record water temperature and ensure accurate readings. [Documentation of weekly water temperature checks, dated from 11/2/2022 through 1/9/2023, were received on 1/25/2023 and reviewed 1/25/2023. DPOC by HDKP, HSLS, on 1/25/2023]. 11/02/2022 Implemented
6400.106The home's furnace was inspected and cleaned by a professional furnace cleaning company on 4/6/20, and then again on 1/19/22, exceeding the annual requirement.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. To rectify non-compliance, staff#2 will be charged with tracking furnace inspection due dates, make appointments for inspection and collect all documentations relating to furnace inspection results. [A blank "Furnace inspection Tracking Sheet" was provided on 1/25/2023 and reviewed 1/25/2023. DPOC by HDKP, HSLS, on 1/25/2023]. 11/11/2022 Implemented
6400.113(a)Individual #1 completed fire safety training on 10/15/2020, and then again 11/7/21, exceeding the annual requirement. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. To rectify the non-compliance, staff#2 will be charged with ensuring that all of individual#1 required trainings are completed on a timely basis. [A blank copy of the "Individual Fire Safety Tracking form for Individual #1 was provided on 1/10/2023 and reviewed 1/11/2023. DPOC by HDKP, HSLS, on 1/11/2023]. 11/11/2022 Implemented
6400.142(a)Individual #1 had a dental appointment 10/27/2020, and then again on 2/28/22, exceeding the annual requirement. [Repeat violation 7/28/21].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. To rectify non-compliance, staff#2 will be charged with creating a form to track all annual medical appointments for individual#1 to ensure that all appointments are made within required time frames. [A blank "Annual Medical Appointment Tracking Sheet" was provided on 1/10/2023 and reviewed 1/11/2023. This tracking system includes areas to document the last dental appointment and when the next appointment is due. DPOC by HDKP, HSLS, on 1/11/23]. 11/11/2022 Implemented
6400.142(c)Individual #1 had a dental examination on 2/28/22; however, the agency could not provide a written record of the dental examination, procedures completed, and follow-up treatment recommended. The agency provided a "Statement of Account" as documentation of the dental appointment.A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. To rectify the non compliance, a dental form will be created with all the required information and will be taken to every dental appointment. [A blank copy of the updated dental appointment form was provided on 1/10/2023 and reviewed on 1/11/2023. The revised dental appointment form includes an area that addresses the dental examination, procedures completed, and follow-up treatment that is recommended. DPOC by HDKP, HSLS, on 1/11/2023]. 11/01/2022 Implemented
6400.142(f)Individual #1 did not have a written dental hygiene plan. There is no documentation from the interdisciplinary team indicating that Individual #1 has achieved dental hygiene independence.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. To rectify non-compliance, staff#2 will confer with support team members and devise a dental hygiene plan for individual#1. [Documentation of Individual #1's written dental hygiene plan was received on 1/25/2023 and reviewed 1/25/2023. DPOC by HDKP, HSLS, on 1/25/2023]. 11/11/2022 Implemented
6400.52(c)(2)Chief Executive Officer #1 did not complete the following training topic in the annual training year 7/1/20 through 6/30/21: The prevention, detection, and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adult Protective Services Act (OAPSA), the Adult Protective Services Act, the Child Protective Services Law and applicable adult protective services regulations.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.To rectify the non-compliance, staff#1 will review the list of required annual trainings and then complete training relating to: The prevention, detection, and reporting of abuse and alleged abuse in accordance with (OAPSA), the Adult Protective Services Act, the Child Protective services Law and applicable adult protective services regulations. [Documentation of completed training for CEO#1, dated 2/7/22, related to the prevention, detection and reporting of abuse, suspected abuse and alleged abuse was received on 1/25/2023 and reviewed 1/25/2023. DPOC by HDKP, HSLS, on 1/25/2023]. 11/11/2022 Implemented
6400.165(g)Individual #1 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness. Individual #1 had a psychiatric medication review completed on 10/12/21, and then again 1/31/22, exceeding the 3-month requirement.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.To rectify non-compliance, staff#2 will be charged with creating a form to track all quarterly psych medication review appointments for individual#1 to ensure that all appointments are made within required time frames. [Documentation of a completed psychiatric medication review, dated 8/12/2022, was received on 1/25/2023 and reviewed 1/25/2023. DPOC by HDKP, HSLS, on 1/25/2023]. 11/11/2022 Implemented
6400.182(c)Program Specialist #2 sent Individual #1's assessment, dated 9/8/21 to the plan team members on 9/8/21 for the Individual Support Plan meeting held on 6/23/22. There was no review of the assessment prior to the ISP meeting to ensure the information remained current.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.To rectify the non-compliance, program specialist#2 will complete and submit individual#1 assessment to team members and maintain a record of submission. [A blank "ISP Meeting Requirement Tracking Sheet" that includes tracking mechanism for sending the individual assessment 30 days prior to ISP meeting was received on 1/25/2023 and reviewed 1/25/2023. DPOC by HDKP, HSLS, on 1/25/2023]. 11/02/2022 Implemented
6400.183(c)Individual #1's record did not contain a record or list of persons who participated in the individual plan meeting conducted on 6/23/22.The list of persons who participated in the individual plan meeting shall be kept.To rectify the non-compliance, staff#2 is charged with maintaining and collecting all records pertaining to individual#1 annual ISP meeting. Records to include sign in sheet. [A copy of the Individual Support Plan Signature Form, dated 6/23/22, was provided on 1/10/2023 and reviewed on 1/11/2023. DPOC by HSKP, HSLS, on 1/11/2023]. 11/02/2022 Implemented
SIN-00196902 Renewal 07/28/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill completed 4/02/2021 does not include the amount of time it took for evacuation.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. Provider met with the staff that completed the fire drill and made the necessary correction on the form. Verbally counseled the staff about the importance of the entire completion and proper documentation of each fire drill. 08/11/2021 Implemented
6400.141(c)(4)Individual #1's most recent hearing screening was completed 6/04/2020.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. A hearing screening was scheduled and completed for individual #1 on 08/03/2021. 08/17/2021 Implemented
6400.141(c)(6)Individual #1, date of admission 7/10/2019, had an initial Tuberculin skin test completed 10/09/2019.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. A physical with Tuberculin skin test was scheduled for the first available appointment on 09/24/2021 with individual #1 pcp. 09/24/2021 Implemented
6400.142(a)Individual #1 had a dental examination completed 7/15/2019 and then again 10/27/2020.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. A dental appointment for individual #1 was made for 02/28/2022, which was the earliest appointment available. 02/28/2022 Implemented
6400.51(a)(1)Chief Executive Officer, date of hire 9/13/2019, has no documentation of completing an orientation.Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons.Staff #1 orientation packet was completed, and all required trainings were documented. 08/18/2021 Implemented
6400.163(h)Nayzilam 5mg nasal spray, with instructions to administer 1 spray intranasally as needed for seizure and call 911, was identified during the inspection on 7/28/2021 and had an expiration date of 2/23/2021.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The medication that was expired was removed from individual #1 medication box and was disposed of properly. The medication was refilled and placed with the current medications in the locked box. 08/11/2021 Implemented
6400.181(f)The assessment for Individual #1 completed 9/7/2020 was not provided to the plan team members for the individual service plan meeting held 6/22/2021.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.A copy of individual #1 assessment was provided to the plan team member during the ISP meeting. 08/26/2021 Implemented
SIN-00175407 Renewal 08/21/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(13)Individual #1's physical examination, dated 7/9/2020 did not include allergies and contraindicated medications. This section was blank.The physical examination shall include: Allergies or contraindicated medications.Individual #1 physical examination, dated 7/9/2020 will be returned to the PCP to be corrected and amended. Management will address with staff expectations during doctors appointments and the importance that the physical form is completed in its entirety. [On 9/20/2020, Individual #1's physical examination was updated to include a list of allergies. Copy of the physical examination provided to the Department on 10/19/2020. Immediately, the CEO or designee shall educate all staff person responsible for ensuring all individual's physical examination are completed and health services are arranged and provided of the requirements of individual's physical examinations as per 6400.141c1-15. Documentation of the trainings shall be kept. Upon completion, a designated staff person educated in the requirements of individual's physicals examinations shall audit all current individual physical examination to ensure completion with all required information and there are not any required areas left blank and all individuals' hearth services are arranged and provided. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 10/19/2020)] 09/21/2020 Implemented
6400.51(b)(3)The orientation, completed 6/3/2020 for Direct Service Worker #2, date of hire 6/3/2020, did not encompass individual rights.The orientation must encompass the following areas: Individual rights.Service worker #2 will complete the training on individual rights. [DIRECT SERVICE WORKER #2 COMPLETED INDVIIDUAL RIGHTS TRAINING ON 9/21/20. STAFF ORIENTATION CHECK LIST WAS UPDATED TO INCLUDE INDIVIUDAL RIGHTS, COPIES PROVIDED TO THE DEPARTMENT ON 9/29/20. UPON HIRE AND PRIOR TO WORKING WITH INDIVIDUALS, THE CEO OR DESIGNEE SHALL AUDIT ALL STAFF PERSON'S ORIENTATION DOCUMENTATION AND CERTIFICATES TO ENSURE ALL REQUIRED ORIENTATION TOPICS INCLUDING INDIVIDUAL RIGHTS IS COMPLETED. DOCUMENATION OF AUDITS SHALL BE KEPT. (DPOC BY AES,HSLS ON 10/1/20)] 09/21/2020 Implemented
6400.51(b)(4)The orientation, completed 6/3/2020 for Direct Service Worker #2, date of hire 6/3/2020, did not encompass recognizing and reporting incidents.The orientation must encompass the following areas: recognizing and reporting incidents.Service worker #2 will complete the required training on recognizing and reporting incidents. [DIRECT SERVICE WORKER #2 COMPLETED RECOGNIZING AND REPORTING INCIDENTS TRAINING ON 9/29/20. STAFF ORIENTATION CHECK LIST WAS UPDATED TO INCLUDE RECOGNIZING AND REPORTING INCIDENTS, COPIES PROVIDED TO THE DEPARTMENT ON 9/29/20. UPON HIRE AND PRIOR TO WORKING WITH INDIVIDUALS, THE CEO OR DESIGNEE SHALL AUDIT ALL STAFF PERSON'S ORIENTATION DOCUMENTATION AND CERTIFICATES TO ENSURE ALL REQUIRED ORIENTATION TOPICS INCLUDING RECOGNIZING AND REPORTING INCIDENTS IS COMPLETED. DOCUMENATION OF AUDITS SHALL BE KEPT. (DPOC BY AES,HSLS ON 10/1/20)] 09/21/2020 Implemented
6400.168(a)The Department's approved Medication Administration course requires four medication administration observations. Direct Service Worker #1's initial Medication Training documentation, dated 7/7/2020, included only two observations. Direct Service Worker #1 administered medications to Individual #1 on 8/1/2020 through and including 8/5/2020 at 9:00AM.If an individual has a suspected adverse reaction to a medication, the home shall immediately consult a health care practitioner or seek emergency medical treatment.Service worker #1 was immediately suspended from medication administration. Service worker #1 will be observed 2 additional times before passing medication. Management will ensure that no staff member will pass medications prior to being observed the required 4 times. [Immediately, the Program manager suspended Direct Service Worker #1 from passing medications. Program manager and direct service worker/office Manager who are qualified to administer medication took over passing medications. Direct Service Worker #1 departed employment on September 24, 2020 and returned to employment on Monday October 5, 2020. Direct Service Worker #1 is scheduled on 11/4/20 to complete medication training. As per the program manager on 10/19/20. Program manager added Medication administration training to orientation documentation and will review all medication documentation to ensure the Medication trainer completed the training as required whether is initial or annual training. Documentation of audits shall be kept. Agency hired a registered nurse on 8/23/2020 to assist with medication and medical needs of the individuals. (DPOC by AES,HSLS on 10/19/20)] 09/21/2020 Implemented
SIN-00173029 Unannounced Monitoring 04/10/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Direct Services Worker #1, date of hire 7/27/2019, had a Pennsylvania criminal history record check completed on 9/17/19. [Repeat violation 10/1/2019]An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. Service worker#1 is on leave and was instructed to bring updated criminal background checks in order to be added to the schedule. To ensure that said violation is not repeated the program manager has revised the monthly staff checks. The staff file check will be done monthly by the office manager and will be reviewed by the program manager to ensure it accuracy/compliance. [Documentation of audits by the office and program manager of staff file check list shall be kept. (DPOC by AES,HSLS 6/26/20)] 06/12/2020 Implemented
6400.141(b)Individual #1, date of admission 7/10/2019, had a physical examination that was not dated by the physician.The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. to correct this violation provider has made is schedule to meet with individual#1 PCP on 06/05/2020 to make corrections to the physical. To Ensure that said violation does not reoccur the office manager have been charged with reviewing every medical form upon returning from any medical appointment. [Individual #1 had a physical examination completed 7/9/20. Upon completion of all Individual physical examinations, the CEO or designee educated in the requirements of physical examinations, shall audit all physical examinations to ensure all required information is included and there are not any required areas of the physical examination left blank and individuals' health services are arranged and provided. If there are any areas left blank, information shall be immediately obtained. Documentation of audits of physical examinations shall be kept. (DPOC by AES, HSLS on 7/9/2020) 06/12/2020 Implemented
6400.141(c)(4)Individual #1, date of admission 7/10/2019, had an undated physical examination that did not include hearing screening. [Repeat violation 2/26/2020]The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. To correct this violation an audiologist appointment is schedule for individual#1 on 06/04/2020 at 3 pm. to ensure that said violation does not reoccur the program manager has been charged with reviewing all medical forms/ documents upon returning from any medical appointments. [Individual #1 had a hearing screening complete 6/4/2020. Upon completion of all individuals' physical examinations, the CEO or designee educated in the requirements of physical examinations, shall audit all physical examinations to ensure all required information is included and there are not any required areas of the physical examination left blank and individuals' health services are arranged and provided. If there are any areas left blank, information shall be immediately obtained. Documentation of audits of physical examinations shall be kept. (DPOC by AES, HSLS on 7/9/2020) 06/04/2020 Implemented
6400.141(c)(11)Individual #1, date of admission 7/10/2019, had an undated physical examination that did not include an assessment of individual's health maintenance needs and medication regime. These sections were left blank. The physical examination completed 3/16/2020 for Individual #2, date of admission 12/20/2019 did not include the individual's medication regime.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. to correct this violation provider has made is schedule to meet with individual#1 PCP on 06/05/2020 to make corrections to the physical. To Ensure that said violation does not reoccur the office manager have been charged with reviewing every medical form upon returning from any medical appointment. [Individual #1 had a physical examination completed 7/9/20 to included health maintenance needs and medication regime. Upon completion of all Individual physical examinations, the CEO or designee educated in the requirements of physical examinations, shall audit all physical examinations to ensure all required information is included and there are not any required areas of the physical examination left blank and individuals' health services are arranged and provided. If there are any areas left blank, information shall be immediately obtained. Documentation of audits of physical examinations shall be kept. (DPOC by AES, HSLS on 7/9/2020) 06/12/2020 Implemented
6400.141(c)(14)Individual #1, date of admission 7/10/2019, had an undated physical examination that 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. to correct this violation provider has made is schedule to meet with individual#1 PCP on 06/05/2020 to make corrections to the physical. To Ensure that said violation does not reoccur the office manager have been charged with reviewing every medical form upon returning from any medical appointment. [Individual #1 had a physical examination completed 7/9/20 to included health maintenance needs and medication regime. Upon completion of all Individual physical examinations, the CEO or designee educated in the requirements of physical examinations, shall audit all physical examinations to ensure all required information is included and there are not any required areas of the physical examination left blank and individuals' health services are arranged and provided. If there are any areas left blank, information shall be immediately obtained. Documentation of audits of physical examinations shall be kept. (DPOC by AES, HSLS on 7/9/2020) 06/12/2020 Implemented
6400.151(a)Direct Services Worker #1, date of hire 7/27/2019, had an initial physical examination, dated 9/24/19. [Repeat violation 10/1/2019] 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. service worker#1 is on leave and was instructed to bring a complete physical including tuberculin test with a negative result upon returning from leave in order to be put on the schedule.To ensure that said violation is not repeated the program manager has revised the monthly staff checks. The staff file check will be done monthly by the office manager and will be reviewed by the program manager to ensure it accuracy/compliance. [Prior to hire and at least annually, the CEO or designee shall audit all staff person's physical examinations to ensure timely completion with all required information. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 7/1/20)] 06/12/2020 Implemented
6400.151(c)(2)The Tuberculin testing completed, 11/16/18 for Direct Services Worker #1, date of hire 7/27/2019, did not include the credentials of the person completing the testing; therefore, compliance could not be measured. The Tuberculin testing completed, 9/11/19 for Direct Service Worker #2, date of hire 9/13/19, was completed "2 hours early," as stated on the testing results. [Repeat violation 10/1/2019] 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. service worker#1 is on leave and was instructed to bring a complete physical including tuberculin test with a negative result upon returning from leave in order to be put on the schedule. Service Worker#2 has been taking off the schedule pending the result of a new tuberculin test. To ensure that said violation is not repeated the program manager has revised the monthly staff checks. The staff file check will be done monthly by the office manager and will be reviewed by the program manager to ensure it accuracy/compliance. [Immediately, upon completion and at least quarterly, the CEO or designee shall audit all staff person's physical examinations to ensure all required information is included including completed Tuberculin skin testing. Documentation of audits shall be kept. (DPOC by AES,HSLS on 7/2/2020)] 06/12/2020 Implemented
6400.181(a)The assessment completed for Individual #2, date of admission 12/20/2019 was not dated; therefore, compliance could not be measured. 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. To correct this violation the program specialist will sign and date individual#2 assessment and make all needed corrections. Ensure that said violation does not reoccur CEO will review all assessment to ensure its compliance with 55 PA Code Chapter 6400 [A signed signature sheet (dated 3/11/20) was provided to the Department on 5/27/20. Documentation of the aforementioned audits by the CEO shall be kept. (DPOC by AES,HSLS on 6/26/20)] 06/12/2020 Implemented
6400.181(d)Program Specialist #3 did not sign and date Individual #2's assessment.The program specialist shall sign and date the assessment. To correct this violation the program specialist will sign and date individual#2 assessment and make all needed corrections. Ensure that said violation does not reoccur CEO will review all assessment to ensure its compliance with 55 PA Code Chapter 6400 [A signed signature sheet (dated 3/11/20) was provided to the Department on 5/27/20. Documentation of the aforementioned audits by the CEO shall be kept. (DPOC by AES,HSLS on 6/26/20)] 06/12/2020 Implemented
6400.181(e)(1)Individual #1's assessment, dated 9/1/19, does not include the individual's functional strengths, needs, and preferences. Individual #2's assessment does not include the individual's functional strengths, needs, and preferences. The assessment must include the following information: Functional strengths, needs and preferences of the individual. To correct the violation the program manager will make the needed corrections to both individual #1 and #2 assessment to include their strengths, preferences and needs. to ensure that said violation does not reoccur all future assessment will be reviewed by CEO to ensure compliance with 55 PA Code chapter 6400 [Updated assessments for Individual #1 (assessment date 9/1/19) and #2 (assessment date 3/11/20) to include strengths/needs/preferences was provided to the department on 5/27/20. Documentation of the aforementioned audits by the CEO shall be kept. (DPOC by AES,HSLS on 6/26/20)] 06/12/2020 Implemented
6400.181(e)(2)Individual #1's assessment, dated 9/1/19, does not include the individual's likes, dislikes, and interests. Individual #2's assessment does not include the individual's likes, dislikes, and interests.The assessment must include the following information: The likes, dislikes and interest of the individual. To correct the violation the program manager will make the needed corrections to the individual#1 and individual#2 assessment to include likes, dislikes and interests . to ensure that said violation does not reoccur all future assessment will be reviewed by CEO to ensure compliance with 55 PA Code chapter 6400 [Updated assessments for Individual #1 (assessment date 9/1/19) and #2 (assessment date 3/11/20) to include likes, dislikes, and interests was provided to the department on 5/27/20. Documentation of the aforementioned audits by the CEO shall be kept. (DPOC by AES,HSLS on 6/26/20)] 06/12/2020 Implemented
6400.181(e)(9)Individual #1's assessment, dated 9/1/19, does not include documentation of the individual's disability, including functional and medical limitations. Individual #2's assessment does not include documentation of the individual's disability, including functional and medical limitations.The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. To correct the violation the program manager will make the needed corrections to the individual#1 and individual#2 assessment to include areas of training, staffing and support needs, disability and medical limitations. to ensure that said violation does not reoccur all future assessment will be reviewed by CEO to ensure compliance with 55 PA Code chapter 6400 [Updated assessments for Individual #1 (assessment date 9/1/19) and #2 (assessment date 3/11/20) to include functional and medical limitations was provided to the department on 7/9/20. Documentation of the aforementioned audits by the CEO shall be kept. (DPOC by AES,HSLS on 7/9/20)] 06/12/2020 Implemented
6400.181(e)(10)Individual #1's assessment, dated 9/1/19, does not include a lifetime medical history. Individual #2's assessment does not include a lifetime medical history.The assessment must include the following information: A lifetime medical history. To correct the violation the program manager will make the needed corrections to the individual#1 assessment to include lifetime medical history for both individual#1 and Individual#2. to ensure that said violation does not reoccur all future assessment will be reviewed by CEO to ensure compliance with 55 PA Code chapter 6400[Updated assessments for Individual #1 (assessment date 9/1/19) and #2 (assessment date 3/11/20) to include medical history was provided to the department on 7/9/20. Documentation of the aforementioned audits by the CEO shall be kept. (DPOC by AES,HSLS on 7/9/20)] 06/12/2020 Implemented
6400.181(e)(12)Individual #1's assessment, dated 9/1/19, does not include recommendations for specific areas of training, programming, and services. Individual #2's assessment, not dated, does not include recommendations for specific areas of training, programming, and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. To correct the violation the program manager will make the needed corrections to the individual#1 assessment to include areas of training, staffing and support needs. to ensure that said violation does not reoccur all future assessment will be reviewed by CEO to ensure compliance with 55 PA Code chapter 6400 [Updated assessments for Individual #1 (assessment date 9/1/19) and #2 (assessment date 3/11/20) to include recommendations for specific areas of training, programming, and services was provided to the department on 7/9/20. Documentation of the aforementioned audits by the CEO shall be kept. (DPOC by AES,HSLS on 7/9/20)] 06/12/2020 Implemented
6400.34(b)Individual #1, date of admission 7/10/2019, did not have a copy of the signed statement acknowledging receipt of information on individual rights.The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights.To correct the violation provider presented individual #1 with her individual rights document, the individuals rights document was read and explained to individual#1. Individual#1 signed her individuals rights document. to ensure that program manager is charged with doing a quarterly review of all individuals files/record to ensure compliance. [Individual #1 signed rights information on 2/20/20, documentation provided to the Department 7/8/2020. Documentation of the quarterly audits shall be kept. (DPOC by AES,HSLS on 7/9/20)] 06/09/2020 Implemented
6400.166(b)Azelastine 137 mcg prescribed to Individual #1 was not initialed as administered on 4/7/2020 at 9:00PM.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Staff will be retrained in medication administration to correct the violation, to ensure that said violation does not reoccur the program manager will be charged with doing a MAR review/inspection weekly to ensure compliance. [Documentation of MAR audits shall be kept. If medication or documentation errors are found or reported, staff shall be immediately retrained in medications administration. Documentation of all trainings shall be kept. (DPOC by AES,HSLS on 7/2/2020)] 06/09/2020 Implemented
6400.166(d)Certirize 10 mg prescribed to Individual #1 was not administered on 3/2/20, 3/7/20, 3/8/20, and 3/9/20 at 9:00 AM.The directions of the prescriber shall be followed.Staff will be retrained in medication administration to correct the violation, to ensure that said violation does not reoccur the program manager will be charged with doing a MAR review/inspection weekly to ensure compliance. [Documentation of MAR audits shall be kept. If medication or documentation errors are found or reported, staff shall be immediately retrained in medications administration. Documentation of all trainings shall be kept. (DPOC by AES,HSLS on 7/2/2020)] 06/09/2020 Implemented
6400.186The Individual Support Plan (ISP), updated 3/6/2020 for Individual #1, date of admission 7/10/2019, reads that Individual #1 requires intensive supervision by 2 staff at all times in the home, lives in a 1-person Residential Habilitation home, is "unable to live safely with peers or have any animals in the home." Individual #1's assessment, dated 9/1/2019, does not indicate any intensive staffing needs. As of 12/20/2019, Individual #1 resides with a house mate. In addition, a pet cat is living in the home.The home shall implement the individual plan, including revisions.To correct the violation the provider is in the process of securing an apartment for individual#1 to be without a roommate, individual will be trained, counselled on how to properly take care of her pet cat and goals will be implemented to monitor/measure that individual # 1 continue to care for her pet cat properly.[Immediately, the CEO and Program specialist shall audit all individuals' ISP to ensure the agency is implementing all individuals ISP as written including revisions. Immediately, the CEO or program specialist shall schedule a meeting with Individual #1's team members to ensure Individual #1 is supported as ISP states and updates to the ISP will be made as needed. Documentation of team meeting for Individual #1 will be kept. (DPOC by AES, 7/9/20)] 06/19/2020 Implemented
SIN-00171763 Unannounced Monitoring 02/26/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(i)Individual #1's bedroom windows do not have drapes, curtain, shades, blinds or shutters.Bedroom windows shall have drapes, curtains, shades, blinds or shutters. Individual #1 agreed to have blinds instead of curtains in the bedroom. Stability Home Care Services install new blinds in individual #1 bedroom on 03/02/2020. To prevent a reoccurrence of this violation Stability Home Care Services will provide an option between curtains, blinds or both to any new individuals during the transition process. [Immediately, the CEO or designee shall develop and implement policies and procedures to ensure all individuals' are educated, assisted and provided accommodations necessary for the individual to make choices and understand the individuals' rights as per 6400.31a through 6400.32v including the right to furnish an decorate the individual's bedroom as per 6400.32q. Within 30 days of receipt of the plan of correction, upon hire and at least annually, the CEO or designee shall educate all staff persons working in community homes on the requirements of individuals' bedrooms as per 6400.81(a) through 6400.81(l) and the aforementioned policies and procedures and individual rights. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 3/30/2020)]Partially Implemented Inadequate Progress 03/02/2020 Implemented
6400.111(f)The fire extinguisher on the wall in the kitchen was most recently inspected October 2018. The fire extinguisher at the bottom of the basement stairs was most recently inspected October 2018. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. Stability Home Care Contacted ABC Extinguisher and had both the kitchen and downstairs fire extinguisher inspected. To prevent any reoccurrence of this violation Stability Home Care Services has charge the program manager to contact ABC Fire Extinguisher to come in on February 26th of every year to come and inspect both the kitchen and downstairs fire extinguishers. [Immediately, the CEO or designee shall develop and implement a tracking and notification system to ensure all fire extinguishers are be inspected and approved annually by a fire safety expert and the date of the inspection is on the extinguisher. At least monthly, the CEO or designee shall audit all fire extinguisher to ensure the date of the inspection is on the fire extinguisher. Documentation of the audits shall be kept. Within 30 days of receipt of the plan of correction, upon hire and at least annually, the CEO or designee shall educate staff persons on the location and policies and procedures to ensure fire extinguishers are inspected and approved annually and the date of the inspection shall be on the fire extinguisher. Documentation of the trainings shall be kept. (DPOC by AES, HSLS on 3/30/2020)]Partially implemented Inadequate progress 03/02/2020 Implemented
6400.141(c)(4)The physical examination, completed 2/11/2020 for Individual #1, date of admission 1/30/2020, did not include a hearing screening.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Individual #1 returned to the doctor on 03/16/2020 and complete the physical that included a TB screening, the results was read on 03/18/2020 showing negative. To prevent any reoccurrence of this violation Stability Home Care Services has Charged the program manager to inspect and verify that all necessary medical documents/records which includes all current immunization records, TB screening, vision and hearing testing results. [Immediately and upon hire, the program manager (as stated above) shall be educated or review the requirements of individuals' physical examination as per 6400.141c(1)-(15). Upon completion, the program manager shall audit individuals completed current physical examination to ensure all required information is included and/or attached and health services are arranged and provided. Documentation of all audits shall be kept. (DPOC by AES,HSLS on 3/30/2020)] Partially Implemented Inadequate progress 03/16/2020 Implemented
6400.141(c)(6)The physical examination, completed 2/11/2020 for Individual #1, date of admission 1/30/2020, did not include a tuberculin testing.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Individual #1 returned to the doctor on 03/16/2020 and complete the physical that included a TB screening, the results was read on 03/18/2020 showing negative result. To prevent any reoccurrence of this violation Stability Home Care Services has Charged the program manager to inspect and verify that all necessary medical documents/records to includes all current immunization records, TB screening, vision and hearing testing results upon transitioning to Stability Home Care Services.[Immediately and upon hire, the program manager (as stated above) shall be educated or review the requirements of individuals' physical examination as per 6400.141c(1)-(15). Upon completion, the program manager shall audit individuals completed current physical examination to ensure all required information is included and/or attached and health services are arranged and provided. Documentation of all audits shall be kept. (DPOC by AES,HSLS on 3/30/2020)]Partially Implemented Inadequate progress 03/16/2020 Implemented
SIN-00164455 Renewal 10/01/2019 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment of the home.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The CEO and the program specialist completed the correct self assessment on 11/23/2019. The program manager and the CEO will complete the self assessments BY the 30th of July every year. [On 12/10/19, the completed self assessment of the home was not dated as to when it was completed. On 12/10/19, the program specialist dated the self assessment, 10/2/19, in the presence of the Licensing Representative. Upon receipt of the certificate of compliance (COC), the CEO or designee shall audit the expiration date on the COC and determine the time frame for competition of the self assessment and develop a tracking system to ensure timely completion of the self assessment. Prior to 3 months of the expiration of the COC, the CEO shall audit the self assessment to ensure timely, full and accurate completion. Documentation of the audit shall be kept. (DPOC by AES,HSLS on 12/12/19)] 11/23/2019 Not Implemented
6400.21(a)Program Specialist #2, date of hire 7/8/19, had a Pennsylvania criminal history record check completed 8/5/19.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. The office manager and the program specialist were trained on 10/02/2019 on the 6400 regs and the office manage has been instructed to check all staff files for compliance by the 15th of every month and check it off on the excel sheet. The CEO will check the same binders quarterly for compliance. [The "Monthly staff files check" lists a staff names and files checked (yes or no) columns, the specifics of what is being audited is not listed. The November 2019 staff file check document was signed by office manager and CEO on 11/6/19 with "y" for each staff name. Immediately, the CEO or designee shall develop and implement an auditing document to include the specifics of what is being audited and train the staff persons responsible for completion of what is to be audited and how often for completion and the updating process for the auditing document. (DPOC by AES,HSLS on 12/12/19)] 10/02/2019 Not Implemented
6400.77(b)The first aid kit did not contain a thermometer. 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. A thermometer was purchased on 10/01/2019 and placed in the first Aid box. A list of required materials for the first aid box was placed in the binder for fire drills and checking of the first aid kit added to the list of things to be checked in the monthly fire drills. [On 12/10/19, the first aid kit contained all required items. As of 12/10/19, the "first aid kit box" placed on fire drill record has not been completed. Immediately, the CEO or designee shall educate all staff person responsible for checking first aid kits of the required items in first aid kits and the replacement and replenishment process and their responsibilities to complete the aforementioned checks and document. Documentation of the trainings shall be kept. At least monthly for one year, the CEO or designee shall audit the aforementioned documentation to ensure audits of first aid kits are completed as stated above. Documentation of the audits of the documentation shall be kept. (DPOC by AES,HSLS on 12/12/19)] 10/02/2019 Not Implemented
6400.113(a)Individual #1, date of respite admission 7/10/19, was not trained in fire safety. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. Individual #1 was retrained on fire training on 10/02/2019 and the Program manager was trained on the documents required by 6400 regs for admissions of individuals. The office manager will check the individuals binder by the 15th of every month for compliance. The CEO will check the same file quarterly for compliance. [Documentation of aforementioned monthly and quarterly audits shall be kept. (DPOC by AES,HSLS on 12/12/19)] 10/02/2019 Implemented
6400.151(a)Program Specialist #2, date of hire 7/8/19, had a physical examination completed 7/18/19. Direct Service Worker #3, date of hire 7/18/19, had a physical examination completed 7/19/19. Direct Service Worker #4, date of hire 7/15/19, had a physical examination completed 8/22/19. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. The Office manager and the Program manager were trained on 10/02/2019 on all the requirements by 6400 regs for staff compliance and the Office manager will by the 15th of every month check the staff binder for compliance and sign off on the excel sheet. The CEO will check the same binder quarterly for completion. [As of 12/10/19, the aforementioned monthly checks have not been completed. A blank document titled "monthly staff file check" was provided to the Department. Immediately, the CEO or designee shall educate the staff persons responsible for ensuring timely completion of staff persons initial and annual physical examinations on the policies and procedures to ensure timely completion and competition of the aforementioned monthly checks. Training shall include actual completing the documentation. Upon completion of the aforementioned monthly documentation, the CEO shall audit the check list document and the required documents including physical examination to ensure accurate and timely completion. Documentation of audits shall be kept. (DPOC by AES,HSLS on 12/12/19)] 10/02/2019 Not Implemented
6400.151(c)(2)Direct Service Worker #3, date of hire 7/18/19, had a physical examination on 7/19/19 that indicates that the employee had an X-ray due to a history of positive tuberculin evaluations; however, the results of the X-ray were not in the employee's record. Direct Service Worker #4, date of hire 7/15/19, had a Tuberculin evaluation on 8/22/19. 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. Direct Service worker #3 got a letter from the DR stating that they will print the results of the TB test and forward to him when they resolve their computer problems.On the training for the 6400 regs. by the Program Specialist and the office manager They were instructed that any x-rays must be accompanied with the exact reading of the x-ray by a competed medical personal.The Office manager will check the staff files by the 15th of every month for compliance and record such on the excel sheet. The office manager will be checking monthly for the compliance of all staff with, Yearly Physical, LEIE, FBI check, Child Abuse, Yearly required trainings and all relevant documents. [As of 12/10/19, the aforementioned monthly checks have not been completed. A blank document titled "monthly staff file check" was provided to the Department. Immediately, the CEO or designee shall educate the staff persons responsible for ensuring timely completion of staff persons physical examinations including Tuberculin testing on the policies and procedures to ensure timely completion and competition of the aforementioned monthly checks. Training shall include actual completing of the documentation. Upon completion of the aforementioned monthly documentation, the CEO shall audit the check list document and the required documents including Tuberculin testing to ensure accurate and timely completion. Documentation of audits shall be kept. (DPOC by AES,HSLS on 12/12/19)] 10/02/2019 Not Implemented
6400.151(c)(3)The physical examination completed 7/18/19 for Program Specialist #2, date of hire 7/8/19 did not address communicable disease. 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. Program specialist #2 took back his physical to the doctors to specifically address the communicable disease. The Program specialist and the Office manager were trained on all the documentations for compliance of staff. Included in this training is that there should be no blank pages on the physical form. [Program Specialist #2 physical examination was updated on 11/7/19 to state free of communicable disease. Immediately, the CEO, program specialist and office manager shall review regulations related to the requirements of staff person's physical examinations. Documentation of the training shall be kept. Immediately and upon competition, the CEO or designated trained staff person shall audit all staff person's current physical examination to ensure all required information is included. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 12/12/19)] 10/02/2019 Implemented
6400.251(b)Individual #1, respite admission date 7/10/19, does not have a physical examination. If an emergency placement occurs, § 6400.141 (relating to individual physical examination) shall be met within 31 calendar days after placement. Individual #1 Physical was completed on 10/07/19. This was the earliest day that we could get from the doctor. The Program manager and the office manager were trained on requirements for respite admission on 10/02/2019 and going forward, the program manager will thick on the excel sheet that all requirements as per reg are completed upon admission. [Individual #1's physical examination completed on 10/7/19 was completed by a Registered Nurse. Individual #1's physical examination completed on 10/7/19 did not include a review of medical history, immunizations, a vision screening a hearing screening, a gynecological examination, an assessment of health maintenance needs, a medication regime and the need for bloodwork, physical limitations, allergies or contraindicated medications, and medical information pertinent to diagnose and treatment incase of an emergency or special diet instructions. Immediately, Individual #1 shall be supported in having a physical examination by a licensed physician, certified nurse practitioner or licensed physician's assistant to include all required information as per 6400.141(c)(1)-(15). Immediately, the CEO shall educate all staff persons responsible for supporting Individual #1 in the home of the requirements of individuals' initial and annual physical examinations and the agency's policies and procedures to ensure all individuals physical examinations are completed, timely, with all required information and individuals' health services are arranged for and provided. Documentation of the trainings shall be kept. Upon completion, all individuals' physical examination documentation shall be audited by a designated trained staff person to ensure timely completion with all required information. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 12/12/19)] 10/02/2019 Not Implemented
6400.46(a)Chief Executive Officer #1, date of hire 7/8/19, did not have fire safety training. Program Specialist #2, date of hire 7/8/19, did not have fire safety training. Direct Service Worker #3, date of hire 7/18/19, did not have fire safety training. Direct Service Worker #4, date of hire 7/15/19, did not have fire safety training.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 CEO #1 was trained on fire training by the Program specialist. The fire training was repeated on 10/02/2019 every staff watched the you tube video "get out alive" All staff after the video where shown all the exits in the house and the meeting place by the end of the property leading to the stairs unto the road. The office manager will place the sign each sheets on a training binder. The Office manager will make sure that all staff undergo this training upon hire and sign off that the training was completed. The CEO will go through the same binder and confirm that the sign in sheet by the staff is in place and that the office manager Checked it off on the excel sheet. Further more, the office manager by the 15th of every month, check off on the excel sheet that all staff have their sign in sheets on the training binder. [As of 12/10/19, the aforementioned monthly checks have not been completed. A blank document titled "monthly staff file check" was provided to the Department. Immediately, the CEO or designee shall educate the staff persons responsible for ensuring timely completion of staff persons fire safety training on the policies and procedures to ensure timely completion and competition of the aforementioned monthly checks. Training shall include actual completing of the documentation. Upon completion of the aforementioned monthly documentation, the CEO shall audit the document and the required documents including fire safety to ensure accurate and timely completion. Documentation of audits shall be kept. (DPOC by AES,HSLS on 12/12/19)] 10/02/2019 Not Implemented
SIN-00142808 Initial review 10/10/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The outside doorway leading from the kitchen to a landing with five outside steps to the yard on the side of the home does not have a source of lighting.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. October 10, 2018 ¿ Cited for not having an exterior light on the side entrance / exit near the kitchen. October 17, 2018 - A licensed contractor had installed an exterior ¿Dusk to Dawn¿ LED light on the house 3 feet above the entrance / exit of the house When new exterior light was installed ¿ Light was checked for functionality On the First Day of Every Month - All lights interior will be checked for functionality daily and monthly The Exterior light, will be monitored by the Agency¿s House supervisor. [Upon hire, the CEO or designee shall educate all staff persons that rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents and the agency's procedures for repairs and replacement of lighting as needed. (Directed Plan of Correction (DPOC) by AES, HSLS on 10/23/18)] 10/18/2018 Implemented
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