| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(b) | Staff #1 was hired on 9/4/23. Staff #1 did not reside in Pennsylvania for two years prior to the date of hire. Staff #1 did not complete an application for a Federal Bureau of Investigation (FBI) criminal history record check within 5 days of hire. The application for Federal Bureau of Investigation criminal history record check was submitted on 10/18/23. | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| Kind Heart Services Human Resources Manager shall ensure that all new hires who resides in Pennsylvania for less than two years completes FBI criminal background check with in five (5) days of hire.
The agency's HR manager shall verify upon receipt of all prospective employee's background check results to ensure that:
(a) the prospective employee completed the appropriate criminal background check
(b) the criminal background checks were completed with 5 days of hire. |
05/02/2024
| Implemented |
| 6400.22(d)(1) | Individual #1's Individual Service Plan does not contain any information about the individual's ability to manage money. Staff report Individual #1 is the individual's own rep payee and manages money independently. There is no documentation to support the individual's ability to so. The home does not maintain a financial record for Individual #1.
Individual #2's Individual Service Plan states " Individual #2's money will be monitored by the individual's mother. As per the annual assessment, Individual #2 can recognize money and can discriminate different coins and dollar denominations. Individual #1 needs staff support for handling money and managing a check book."
Staff indicated that Individual #1 is the individual's own rep-payee and manages money independently. The home does not maintain a financial record for the individual. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | Kind Heart Services shall ensure that individuals ISPs are updated by their support coordinators when changes occur to reflect their current status including their health, safety and funds management.
Kind Heart Services contacted support Coordinator to update individuals Rep payee status to SELF. ISP is now updated. |
05/17/2024
| Implemented |
| 6400.104 | Notification to the fire department was not kept current. Individual #3 moved into the home on 9/11/23, increasing the census in the home to 3. Notification to the fire department was not updated at that time. | 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.
| Kind Services shall ensure that all letters to the local fire department are current and reflect the capacity of the home. The agency shall give a precise location of the individuals bedrooms. The agency shall also ensure that letters are reviewed for accuracy prior to filing in its fire record binder.
Note: The Agency printed and mailed the correct letter to fire department when the new individual #3 was admitted, however, staff member accidently printed out the unedited version of the letter and flied without reviewing. Agency representative at the time of the inspection informed inspector of the situation and asked if the actual letter can be retrieved from our system and printed but the request was declined.
Agency corrected the letter to the fire department 05/01/2024 and filed accordingly. |
05/02/2024
| Implemented |
| 6400.141(a) | Individual #1 was admitted to the home on 8/11/23. Individual #2 was admitted to the home on 10/20/23. Individual #1 and Individual #2 did not a physical examination within 12 months prior to admission. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Kind Heart Services shall ensure all individuals physicals are completed prior to admission. The agency's Program specialist shall request all relevant health inform needed during the intake meeting.
Physicals shall be up to date by keeping records of medical appointments in tracker to ensure no appointments are missed to stay compliant. |
05/02/2024
| Implemented |
| 6400.143(a) | Individual #1 had a dental examination on 9/23/23. Documentation from the appointment included a recommendation for follow up with an oral surgeon. There was no documentation of a scheduled appointment with an oral surgeon. Staff reported that individual #1refused to see an oral surgeon and an appointment was not scheduled. There were no documented attempts to train Individual #1 about the need for health care.
Individual #2 is prescribed Divalproex, Guanfacine and Olanzapine. Individual #1 refused to take these medications on 4/6/24. Ther was no documentation of attempts to train Individual #2 about the need for health care including medication management. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Program Site supervisor and program Specialist shall train all staff on ensuring on reviewing the after-visit summaries after each visit. The escorting staff MUST take note of any follow up instructions or recommendations by the doctor. (PCP, Dental, Psych etc..)
Site supervisor shall ensure all follow up appointments are scheduled immediately after each visit, or recorded on house Calander if an appointed was scheduled at the providers office after the visit.
KHS shall implement a plan that will ensure individuals are trained on the importance of attending appointments and taking their medications as prescribed. The Agency's nurse shall facilitate trainings of the individuals.
KHS created an appointment refusal form to document all refusals and take appropriate action. |
05/02/2024
| Implemented |
| 6400.144 | Individual #1 has a dental examination on 9/26/23. Documentation from the examination included a recommendation for an oral surgeon. There was no documentation of an appointment scheduled with an oral surgeon. Individual #1 was ordered to complete lab work on 8/23/23. Documentation from 11/30/23 indicated that the lab work was not complete. There was no documentation of further follow to complete the lab work.
Individual #1's is medication Hydroxyzine 25mg to be used for anxiety to be given pro re nata (PRN). The pharmaceutical label does not include specific symptoms displayed by the individual in order for the medication to be administered and there is not a written protocol outlining when and how the medication is to be administered. The agency has not provided proper pharmaceutical services.
Individual #2 had a dental examination completed on 12/1/23 with the recommendation to see an oral surgeon. There was no documentation that an appointment was scheduled or took place. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| KHS have implemented a protocol on how PRN medication are to be administered. The agency's nurse and CEO shall be contacted for authorization prior to administering PRN that are planned or prescribed. |
05/09/2024
| Implemented |
| 6400.181(e)(4) | Individual #2's initial assessment does not include the individual's need for supervision. | The assessment must include the following information: The individual's need for supervision.
| Kind Heart Services will ensure that the individuals support coordinator update the individuals plans to reflect their current situation. Program Specialist will communicate any change in the individuals plans to support coordinator promptly. |
05/02/2024
| Implemented |
| 6400.181(e)(9) | Individual #2's initial assessment did not include documentation of the Individual's disability. This section of the assessment was blank. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | The program specialist shall review assessment for accuracy and completeness. Assessment was reviewed and updated. |
05/02/2024
| Implemented |
| 6400.51(b)(1) | Staff #3 was hired on 3/29/24. Staff #3 did not receive orientation training in the application of community integration, individual choice and supporting individuals to develop and maintain relationships. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Program Specialist and trainer shall ensure that all required trainings for new hires are within the new hire orientation training packet. The program specialist shall maintain a staff training program tracker to measure staff training progress. Staff shall be informed about training deadlines via email, bulletin, and verbally by direct supervisor. Staff # 3 have completed the required trainings. |
05/06/2024
| Implemented |
| 6400.51(b)(5) | Staff #1 was hired on 9/4/23 and Staff #3 was hired on 3/29/24. Staff #1 and Staff #3 did not receive job-related knowledge, specifically the safe and appropriate use of behavior supports if the person works directly with an individual. | The orientation must encompass the following areas: Job-related knowledge and skills. | Program Specialist and trainer shall ensure that all required trainings for new hires are within the new hire orientation. training packet. The program specialist shall maintain a staff training program tracker to measure staff training progress. Staff shall be informed about training deadlines via email, bulletin, and verbally by direct supervisor. Staff #1 and Staff # 3 have completed the required trainings in the job-related skills including the safe and appropriate use of behavior support. |
05/13/2024
| Implemented |
| 6400.52(c)(1) | Staff #2 was hired on 12/21/22. Staff #2 indicated that the staff has worked directly with Individuals in the home. Staff #2 did not complete annual training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Program Specialist and trainer shall maintain a staff training program tracker to measure staff training progress. Staff shall be informed about training deadlines via email, bulletin, and verbally by direct supervisor. Staff #2 have completed the required trainings person Centered Practices. |
05/15/2024
| Implemented |
| 6400.52(c)(2) | Staff #2 was hired on 12/21/22. Staff #2 indicated that the staff has worked directly with Individuals in the home. Staff #2 did not complete annual training in The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | The 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. | Program Specialist and trainer shall maintain a staff training program tracker to measure staff training progress. Staff shall be informed about training deadlines via email, bulletin, and verbally by direct supervisor. Staff #2 have completed the required trainings in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse. |
05/01/2024
| Implemented |
| 6400.52(c)(3) | Staff #2 was hired on 12/21/22. Staff #2 indicated that the staff has worked directly with Individuals in the home. Staff #2 did not complete annual training in Individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Program Specialist and trainer shall maintain a staff training program tracker to measure staff training progress. Staff shall be informed about training deadlines via email, bulletin, and verbally by direct supervisor. Staff #2 have completed the required training in Individual rights |
05/15/2024
| Implemented |
| 6400.52(c)(4) | Staff #2 was hired on 12/21/22. Staff #2 indicated that the staff has worked directly with Individuals in the home. Staff #2 did not complete annual training in Recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Program Specialist and trainer shall maintain a staff training program tracker to measure staff training progress. Staff shall be informed about training deadlines via email, bulletin, and verbally by direct supervisor. Staff #2 have completed the required training in recognizing and reporting incident. |
05/16/2024
| Implemented |
| 6400.52(c)(5) | Staff #2 was hired on 12/21/22. Staff #2 indicated that the staff has worked directly with Individuals in the home. Staff #2 did not complete annual training in the safe and appropriate use of behavior supports if the person works directly with an individual. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Program Specialist and trainer shall maintain a staff training program tracker to measure staff training progress. Staff shall be informed about training deadlines via email, bulletin, and verbally by direct supervisor. Staff #2 have completed the required training in the safe and appropriate use of behavior
support. |
05/16/2024
| Implemented |
| 6400.166(b) | Individual #1 is prescribed Acetaminophen tablet 500mg PRN for pain. This medication is not documented on the Medication Administration Record. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The Program manager will ensure all PRN medications are documented on the individuals MAR. The house Nurse and program manager will inform the pharmacy to add all PRN on the individuals MAR. Staff shall be trained on documenting the reason for the PRN administration on the back of the MAR. |
05/03/2024
| Implemented |
| 6400.185(1) | Individual #1's Individual Service Plan (ISP) does not include revisions. Individual #1 requires 1:1 staffing from 9AM - 9PM. this began on an unknown date in March 2024. There is no documentation in the ISP of this increase in staffing. | The individual plan, including revisions, must include the following: The individual's strengths, functional abilities and service needs. | Program Specialist and Director communicated with support Coordinator to update the individual's plan.
to reflect current status. Plan is now updated. |
05/01/2024
| Implemented |
| 6400.186 | Individual #2's Individual Service Plan (ISP) is not implemented. Individual #1's ISP contains conflicting information regarding supervision in the community. Individual #2's ISP states " David should have direct supervision while in the community. It further states: Individual #2 has 15 minutes of alone time in order to walk to the mailbox and only requires 20 hours of community supervision." Staff report Individual #2 was allowed 15 minutes to walk to the mailbox, however staff now walk with Individual #2 as the individual was going to other locations than the mailbox. It is unclear what the actual level of supervision is based on the information in the ISP. | The home shall implement the individual plan, including revisions. | Program Specialist and Director communicated with support Coordinator to update the individual's plan.
to reflect current status. Plan is now updated. |
05/01/2024
| Implemented |
| 6400.194(a) | The home does not use a human rights team. Individual #1 requires 1:1 supervision from 9AM-9PM. Individual #1 does not have a restrictive procedure plan that is reviewed by a human rights team. | If a restrictive procedure is used, the home shall use a human rights team. The home may use a county mental health and intellectual disability program human rights team that meets the requirements of this section. | KHS have contracted with Redco to provide behavioral support services and to assist with the creation of the human rights team. |
05/25/2024
| Implemented |
| 6400.195(a) | Individual #1 is provided 1:1 staffing from 9AM to 9PM. Individual #1's Individual Service Plan does not include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | Kind Heart services contracted with Redco to provide behavior support services on 3/18/2024 . Redco will assist KHS in creating a Human rights team. |
05/01/2024
| Implemented |