Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00283834 Renewal 02/24/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)Financial records for Individual #1 contained two Dollar Tree receipts dated 1/16/26 and 10/24/25 that showed purchases of body wash, deodorant, and shower gel that were standard toiletries and should have been paid for by the provider in accordance with the room and board contract.Individual funds and property shall be used for the individual's benefit. The agency will ensure that staff immediately notify the manager when an individual's toiletries are running low so that replenishment can be arranged, rather than utilizing the individual's personal funds. This incident was the result of a genuine miscommunication involving a staff member. The staff member had been instructed to retrieve the company credit card from the designated company card pouch to purchase toiletries for Individual #1. However, the staff member mistakenly accessed Individual #1's personal funds pouch and used those funds for the purchase. All funds used for purchases on 10/24/25 and 01/16/26 were fully reimbursed to Individual #1 on 02/27/26. Following this incident, staff received re-education on proper procedures, including clear guidelines on the appropriate use of individual funds and the distinction between personal and agency resources. 02/24/2026 Implemented
6400.62(a)Poisons in the home were kept under the kitchen sink. The cabinet doors were closed with a padlock and hasp. When checked the padlock was in the hasp but the locking arm was not engaged leaving the lock unlocked and the poisons accessible to Individual #1 who "is not safe around poisonous materials and has no access to poisonous materials" according to their Individual Support Plan (ISP) last updated on 2/3/26. The ISP further states that "poisonous materials are locked at all times due to [their] tendencies of ingesting non-food items (pica diagnosis)" according to the ISP. Poisons shall be kept locked or made inaccessible to individuals.Poisonous materials shall be kept locked or made inaccessible to individuals. The agency educated the staff member on the importance of double-checking padlocks on cabinet doors to ensure that the locking arms are properly engaged after each use. 02/27/2026 Implemented
6400.68(a)The hot water in the home did not reach above 72° in the only bathroom in the home. The hot water in the home was not warm enough for comfortable bathing as required.A home shall have hot and cold running water under pressure. The agency contacted facility maintenance immediately upon discovering the issue. The water temperature was promptly adjusted on the heating and cooling system, thereby resolving the problem. 02/24/2026 Implemented
6400.72(b)The upstairs front bedroom of the home was missing the screen in the left window. Screens, windows and doors shall be in good repair. At the time of the inspection, only Bedroom One and Bedroom Two were occupied by individuals, which was communicated to the inspector. However, the screen has since been replaced. 02/24/2026 Implemented
6400.82(f)At the time of inspection there was no soap accessible in the bathroom of the home. Corrected at time of inspection.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. The house manager shall ensure that hand soaps are out and accessible at all times. 02/24/2026 Implemented
6400.141(c)(1)The physical dated 1/15/26 for Individual #1 did not include a review of previous medical history as required.The physical examination shall include: A review of previous medical history. The Agency Nurse will conduct a thorough review of the individual's annual physical forms after each appointment to ensure all sections are completed. The forms were resent to Individual #1's physician for correction. 02/27/2026 Implemented
6400.141(c)(11)The physical dated 1/15/26 for Individual #1 did not include an assessment of the individual's health maintenance needs, medication regimen as required. REPEAT VIOLATION 5/22/25The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The Agency Nurse will conduct a thorough review of the individual's annual physical forms after each appointment to ensure all sections are completed. The forms were resent to Individual #1's physician for correction. 02/27/2026 Implemented
6400.141(c)(13)The physical dated 1/15/26 for Individual #1 did not include information on allergies or contraindicated medications as required.The physical examination shall include: Allergies or contraindicated medications.The Agency Nurse will conduct a thorough review of the individual's annual physical forms after each appointment to ensure all sections are completed. The forms were resent to Individual #1's physician for correction. 02/27/2026 Implemented
6400.141(c)(14)The physical dated 1/15/26 for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of an emergency. REPEAT VIOLATION 5/22/25The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The Agency Nurse will conduct a thorough review of the individual's annual physical forms after each appointment to ensure all sections are completed. The forms were resent to Individual #1's physician for correction. 02/27/2026 Implemented
6400.144Individual #2 has a prescribed diabetic diet due to being an insulin dependent diabetic. Individual #2 is nonverbal and relies upon provider staff to assist in following the prescribed diet. Personal spending receipts reviewed indicate that Individual #2 purchases food from McDonalds, Popeyes and other fast-food vendors several times per month. Individual #2 receives Admelog insulin on a sliding scale with dosages dependent upon grams of carbohydrates per meal and blood sugar numbers taken at mealtime factored together to determine the number of units of insulin to be administered. Receipts indicate that on 2/24/26 at 11:27 am two $5 McChicken Meals were purchased for Individual #1's lunch. The two meals contained 2 McChickens, two 4 piece nuggets, two small fries and two small sprites. Staff reported that the two meals were purchased as one was not enough to satisfy Individual #1. The grams of carbohydrates entered to determine the dose of insulin given was documented at lunch time on 2/24/26 as 45grams. 45 grams of carbohydrates would require 9 units of insulin. The calculation of carbohydrates for the meal staff stated Individual #2 consumed would be 268grams. If administered according to the sliding scale for carbohydrates the number of units to be administered would have been 53. The diabetic diet for Individual #2 is not followed as prescribed and accurate recording of grams per meal in question. Health services, such as medical, nursing, pharmaceutical, and dietary that are planned or prescribed for the individual shall be arranged for or provided.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. The agency ensured that staff adhered to Individual #2's diet plan, including proper carbohydrate counting and appropriate insulin administration in relation to food intake. Staff were retrained on the individual and the individual diet protocol. 02/28/2026 Implemented
6400.151(a)Staff #3 had a biannual physical on 7/28/23. The next physical completed was dated 1/12/26 extending beyond the required two-year time frame for completion. 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 agency located Staff #3's annual physicals for the period that was missing from his file at the time of the inspection. 02/28/2026 Implemented
6400.181(c)The assessment for Individual #2 dated 9/7/25 did not include documentation that it was based upon assessment instruments, interviews, progress notes and observations as required.The assessment shall be based on assessment instruments, interviews, progress notes and observations. The Program Specialist and Program Director will ensure that all assessments are thoroughly reviewed for completeness before being sent to the Support Coordinator and properly filed. The assessment for individual #2 was reviewed and corrected. 02/28/2026 Implemented
6400.181(d)The assessment for Individual #1 documented as sent to the team members on 12/14/25 was not signed nor dated by the program specialist as required.The program specialist shall sign and date the assessment. The Program Specialist and Program Director will ensure that all assessments are thoroughly reviewed for completeness before being sent to the Support Coordinator and properly filed. The assessment for individual #2 was reviewed and corrected. 02/28/2026 Implemented
6400.181(e)(1)The assessment for Individual #2 dated 9/7/25 did not include an assessment of the Individual's Functional strengths and needs and of the individual as required. The assessment must include the following information: Functional strengths, needs and preferences of the individual. The Program Specialist and Program Director will ensure that all assessments are thoroughly reviewed for completeness before being sent to the Support Coordinator and properly filed. The assessment for individual #2 was reviewed and corrected. 02/28/2026 Implemented
6400.181(e)(2)The assessment for Individual #2 dated 9/7/25 did not include documentation of the Individual's dislikes as required.The assessment must include the following information: The likes, dislikes and interest of the individual. The Program Specialist and Program Director will ensure that all assessments are thoroughly reviewed for completeness before being sent to the Support Coordinator and properly filed. The assessment for individual #2 was reviewed and corrected. 02/28/2026 Implemented
6400.181(e)(4)The assessment for Individual #2 dated 9/7/25 did not include the individual's need for supervision as required. The assessment must include the following information: The individual's need for supervision. The Program Specialist and Program Director will ensure that all assessments are thoroughly reviewed for completeness before being sent to the Support Coordinator and properly filed. The assessment for individual #2 was reviewed and corrected. 02/28/2026 Implemented
6400.181(e)(5)The assessment for Individual #2 dated 9/7/25 did not include the individual's ability to self-administer medications as required.The assessment must include the following information:  The individual's ability to self-administer medications.The Program Specialist and Program Director will ensure that all assessments are thoroughly reviewed for completeness before being sent to the Support Coordinator and properly filed. The assessment for individual #2 was reviewed and corrected. 02/28/2026 Implemented
6400.181(e)(6)The assessment for Individual #2 dated 9/7/25 did not include the individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. The Program Specialist and Program Director will ensure that all assessments are thoroughly reviewed for completeness before being sent to the Support Coordinator and properly filed. The assessment for individual #2 was reviewed and corrected. 02/28/2026 Implemented
6400.181(e)(7)The assessment for Individual #2 dated 9/7/25 did not include the individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated as required.The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. The Program Specialist and Program Director will ensure that all assessments are thoroughly reviewed for completeness before being sent to the Support Coordinator and properly filed. The assessment for individual #2 was reviewed and corrected. 02/28/2026 Implemented
6400.181(e)(8)The assessment for Individual #2 dated 9/7/25 did not include the individual's ability to evacuate in the event of a fire as required.The assessment must include the following information: The individual's ability to evacuate in the event of a fire. The Program Specialist and Program Director will ensure that all assessments are thoroughly reviewed for completeness before being sent to the Support Coordinator and properly filed. The assessment for individual #2 was reviewed and corrected. 02/28/2026 Implemented
6400.181(e)(9)The assessment for Individual #2 dated 9/7/25 did not include documentation of the individual's disability, including functional and medical limitations as required.The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. The Program Specialist and Program Director will ensure that all assessments are thoroughly reviewed for completeness before being sent to the Support Coordinator and properly filed. The assessment for individual #2 was reviewed and corrected. 02/28/2026 Implemented
6400.163(a)Individual #2 is prescribed Basaglar and Admelog insulin. At the time of inspection, the insulins were in a plastic container in the refrigerator. There were new pens in the original labeled containers and two in-use pens, one of each medication, that were in a blue Velcro pouch together. The medication shall be maintained in their original labeled containers.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.The Agency Nurse contacted the pharmacy to request the original container for the insulin. Staff were trained on the proper storage of insulin medication. 02/24/2026 Implemented
6400.163(f)Individual #2 is prescribed Basaglar and Admelog insulin. At the time of inspection, the insulins were in an unlocked plastic container in the refrigerator. Prescription medications stored in a refrigerator shall be kept in an area or container that is locked.Prescription medications stored in a refrigerator shall be kept in an area or container that is locked.The agency purchased a medication lock box with combination code to store individual # 2 insulin medication and retrained staff on proper storage. 02/24/2026 Implemented
6400.163(g)Individual #2 is prescribed Basaglar and Admelog insulin. Both in-use and not in-use pens of the medications were stored in the refrigerator. According to manufacturer's instructions for the Admelog, the in-use pen should be stored at room temperature. Package instructions state "Store in-use pen at room temperature up to 86°F (30°C). Do not put your pen back in the refrigerator." The manufacturer's instructions for the Basaglar indicate that "store in use pen at room temperature up to 86°F." The insulins were not stored in accordance with the manufacturer instructions as required.Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions.The agency purchased a medication lock box with combination code to store individual # 2 insulin medication and retrained staff on proper storage. 02/24/2026 Implemented
6400.165(c)Individual #1 is prescribed Peg Powder to be administered as "Take 17g by mouth once daily for constipation. The bottle in use at the time of inspection was full and filled by the pharmacy on 11/18/25. The bottle contained 14 Once-Daily doses. The length of time from date filled on 11/18/25 to the date of inspection on 2/26/26 indicates that the full bottle of medication had not been administered as prescribed. Individual #2 is prescribed PEG Powder to be administered "Use 1 to 2 capfuls dissolved in water or juice daily for constipation." At the time of inspection there were two open bottles of the medication that were more than ¾ full. Each bottle contained 30 once daily doses. Both bottles had a pharmacy label placed over another pharmacy label. The top pharmacy label on both bottles had a script date of 10/8/25. The labels under the top labels had fill dates of 8/12/25 and 10/8/25. Using either the original fill dates or the updated fill date of 10/8/25 more than 60 days have transpired between indicating that the medication was not administered as prescribed. Individual #2 is prescribed Clonidine HCL 0.3mg to be administered as "Take 1 tablet by mouth everyday at bedtime." The pharmacy label on the bottle indicates that the medication was filled on 6/12/25 and contained 34 pills. The length of time from 6/12/25 and inspection on 2/25/26 indicate that the medication was not administered as prescribed. Individual #2 is prescribed Admelog insulin with sliding scale dosages administered based upon a carbohydrate count with additional doses based upon blood sugar taken. The doses or units of insulin are calculated then administered at the same time at 8am, Noon and 5pm. Using the Medication Administration Record (MAR) and the blood sugar tracking sheet completed at each administration time it was determined that the wrong dose of medication was administered during 57 of the 72 administrations during the month of February 2026.A prescription medication shall be administered as prescribed.Staff were retrained on Individual #1 and Individual #2's medication administration protocols, including the importance of administering medications as prescribed. 02/24/2026 Implemented
6400.166(a)(7)The February Medication Administration Record (MAR) for Individual #2 contained an entry for PEG Powder to be administered "Use 1 to 2 capfuls dissolved in water or juice daily for constipation." Each administration was initialed as given. The MAR entry lacked the dose of the administration. The MAR did not indicate if one or two capfuls had been administered. The dose of the medication shall be kept.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.Staff were retrained on Individual #1 and Individual #2's medication administration protocols, including the importance of administering medications as prescribed. 02/24/2026 Implemented
6400.166(a)(11)The Admelog and Dicyclomine entry for Individual #2 did not record the purpose of the medication on the MARS The Align entry for Individual #1did not record the purpose of the medication on the Mar. The diagnosis or purpose for the medication, including pro re nata. REPEAT VIOLATION 5/22/25A 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.The agency contacted the pharmacy to ensure that medication administration records (MARs) include the correct diagnosis or purpose for each medication, in accordance with PA Code 6400 regulations. 02/28/2026 Implemented
6400.169(b)(2)Review of training records for Staff #2 and Staff #3 documented training on diabetes provided by the Health Care Quality Unit through the Advocacy Alliance. The training provided was not a department approved diabetes patient education program as required to fulfill the regulatory standard. The Provider stated that additional training was provided by the Provider nursing staff. There was no documentation to illustrate that the Provider nurses maintained the required certifications to teach the required course.A staff person may administer insulin injections following successful completion of both: A Department-approved diabetes patient education program within the past 12 months.The agency contracted with professional with the department approved credential to retrain staff. 02/28/0206 Implemented
SIN-00266697 Renewal 05/21/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.51(a)(3)Staff #1 was hired on 12/03/2024 and started working with individuals on 12/09/2024 but did not complete the following required orientation trainings prior to working alone with individuals and within 30 days after hire. The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships (not completed until 3/07/2025) · Recognizing and reporting incidents (not completed until 12/16/2024) REPEAT VIOLATION FROM PREVIOUS INSPECTION CONDUCTED ON 5/01/2024Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons.The Agency's Program Specialist and Trainer will verify that all new hire orientation trainings are completed within 30 days or sooner after hire. The agency will take extra steps to ensure new hire training tracker are monitored on a monthly basis to ensure no trainings are missed. 05/24/2025 Implemented
6400.166(a)(11)A medication record shall be kept, including the following for each individual for whom a prescription medication is prescribed: The diagnosis or purpose for administering a medication The diagnosis or purpose for administering a medication was not recorded on the Medication Administration Record (MAR) 3for the following medications that are prescribed for Individual #1: Aripiprazole 20 mg. tablets, magnesium oxide 400 mg. tablets and melatonin 5 mg. tablets.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.The Agency site manager shall ensure all new prescriptions (especially PRN) are recorded on the MAR accordingly depicting the purpose of the medication. The staff manager shall take additional steps by contacting the Pharmacy to have the PRN medication information included on the MAR including the purpose of the medication. 05/22/2025 Implemented
6400.166(a)(13)A medication record shall be kept, including the following for each individual for whom a prescription medication is prescribed: Initials of the person administering the medication to Individual #1 were not present on: · Amantadine 100 mg. tablets, 1 tablet administered at 4 PM on 5/02/2025 · Aripiprazole 10 mg. tablets, 1 tablet administered at 8 AM on 5/16/2025 · Clonidine Hcl 0.1 mg. tablets, 1 tablet administered at 12 PM on 5/02/2025 · Clonidine Hcl 0.1 mg. tablets, 1 tablet administered at 8 PM on 5/02/2025A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.The Agency site manager shall ensure that all staff members certified to administer medication are initially after administering medication and are following the proper medication administration protocol and documentation. Staff will be retrained on documetation. 05/22/2025 Implemented
Article X.1007Kind Heart Services is required to maintain criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15). The Older Adults Protective Services Act (OAPSA), as amended by Act 169 of 1996 and Act 13 of 1997, mandates that specific facilities, including those operated under a Chapter 6400 license, require applicants for employment to submit criminal history record information. In accordance with OAPSA, applicants need to obtain a criminal history record check from the Pennsylvania State Police PRIOR to the date of employment. Staff #1 was hired on 12/03/2024 and the application for a Pennsylvania State Police criminal history record check was not submitted until 3/28/2025.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.Kind Heart Services Human Resource / Hiring manager shall ensure all new hires complete criminal background clearances including PA police clearance prior to making contact with the individuals. If new hire already has a PA clearance, the agency HR manager/ Hiring manger shall verify it is within one year. 05/29/2025 Implemented
SIN-00242064 Renewal 05/01/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC 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
6400.104Notification 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
6400.144Individual #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
6400.186Individual #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
SIN-00224719 Initial review 05/15/2023 Compliant - Finalized