Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00249508 Renewal 08/19/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(c)The fire drill logs do not document if problems were encountered during the drills or what prompting was needed, if any.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 was operative.The fire drill logs will document, moving forward, problems encountered during the fire drills including any prompting needed. 08/30/2024 Implemented
2380.111(c)(3)There is no documentation that Individual #1 has had their diphtheria test. Additionally, their last tetanus shot was completed more than 10 years ago. It is not documented if Individual #2 has had their Diphtheria. Individual #4 is out of compliance for Tetanus since they have not had a booster within 10 years. It is not documented if Individual #4 has had their Diphtheria. There is no documentation that Individual #6 has had their Diphtheria.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Director of Programs has contacted those for whom there is no documentation available. Attachment 2380.111c3_#1 documents TDAP administered 6/19/2023. Attachment 2380.111c3_#2 documents TDAP administered 5/4/2018. Individual #4 is scheduled for their annual physical October 14 and will receive boosters at that time. Attachment 2380.111c3_#6 documents TDAP administered 7/12/2021. 09/16/2024 Implemented
2380.111(c)(4)Individual #1 has not had a vision or hearing screening. Individual #3 had a vision screening on 2/28/22 and not again since, outside of the annual timeframe. There was no documentation that Individual #3 had a Hearing Screening in 2022. Individual #5 last had their vision checked in 2022. They have not had a hearing screening.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Program Specialist for Individual #1, Individual #3, and Individual #5 will inform their team members that a vision and hearing screening need to be completed by 9/30/24. If the individual resides in a group home, the most recent vision and hearing screening will be requested. 09/30/2024 Implemented
2380.111(c)(8)Individual #4's annual physical does not indicate if they have any physical limitations. This section was left blank.The physical examination shall include: Physical limitations of the individual.Program Specialist will pre-populate the front page of Individual #4's physical exam form, including Physical Limitations, for the physical due 10/31/24. 09/10/2024 Implemented
2380.111(c)(9)Individual #5's most recent physical completed on 9/5/23 does not have their allergies/contraindicated medications correct. The only allergy listed is cats. Individual #5 is also allergic to dust mites and has seasonal allergies.The physical examination shall include: Allergies or contraindicated medication.Program Specialist will pre-populate the front page of Individual #5's physical exam form, including all allergies, for the physical due 9/20/24. 09/10/2024 Implemented
2380.111(c)(10)Individual #5's most recent physical completed on 9/5/23 does not document what their information pertinent to treat/diagnose in the event of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Program Specialist will pre-populate the front page of Individual #5's physical exam form, including medical information pertinent to diagnosis and treatment in case of an emergency, for the physical due 9/20/24. 09/10/2024 Implemented
2380.173(1)(v)Individual #2, #3, #4, and #5 last had their photo updated in February 2023, outside of the annual timeframe.Each individual's record must include the following information: Personal information including: A current, dated photograph.Director of Programs shall ensure that a current, dated photograph will be added for Individual #2, Individual #3, Individual #4, and Individual #5. Attachment 2380.173(1)(v) _#2, 2380.173(1)(v) _#3, 2380.173(1)(v) _#4, and 2380.173(1)(v) _#5, are updated photos. 09/30/2024 Implemented
2380.177At the time of the inspection, Individual #1 did not have a valid signed release of information in the record.Written consent of the individual, or the individual's parent or guardian if the individual is incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.Program Specialist shall obtain a Release of Information form, completed and signed by Individual #1. Attachment 2380.177 is a Release of Information form for Individual #1. 09/06/2024 Implemented
2380.181(e)(1)Individual #1's most current assessment completed on 7/26/24 did not identify their strengths or preferences. Individual #2's most current assessment completed on 3/28/24 did not identify their preferences. Individual #3's most recent assessment completed on 4/29/24 did not identify their strengths or preferences. Individual #4's most current assessment completed on 5/18/24 did not identify their needs and preferences. Individual #5's most recent assessment completed on 4/22/24 did not identify their strengths, needs, or preferences. Individual #6's most recent assessment did not document their strengths, needs, or preferences.The assessment must include the following information: Functional strengths, needs and preferences of the individual.Assessments for Individuals #1, #2, #3, #4, #5, and #6 will be updated to document their functional strengths, needs, and preferences related to the programs at Lighthouse. Attachments 2380.181e1, numbers 1 - 6 are updated assessments for these individuals. 09/10/2024 Implemented
2380.21(u)Individual #1 did not have their annual rights reviewed with them upon admission.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.Program Specialist shall ensure that a complete and current annual rights review is conducted with Individual #1. 09/10/2024 Implemented
SIN-00230531 Renewal 09/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(b)(REPEAT from 9/26/22 annual inspection): During an inspection of the building on 9/21/23, an unlabeled bottle of a white liquid substance was unlocked and accessible in one of the single-stall bathrooms by the sliding glass doors. Individuals in the facility are assessed to be unsafe with poisonous materials and require them to be locked and made inaccessible. Agency staff did not know what the substance was.Poisonous materials shall be stored in their original, labeled containers.Program Specialists have been retrained on the requirement to store all poisonous materials in their original, labeled containers. Attachment PST 2380. 11/07/2023 Implemented
2380.87(b)(REPEAT from 9/26/22 annual inspection): Individual #6 attends the facility and is unable to hear the fire alarm system. The first aid and sensory rooms were not equipped with strobe lights to alert the individual that there is an emergency. The individual did not have any other personal body devices worn to alert them in the event of an emergency when the fire alarm system was activated.If one or more individuals or staff persons are not able to hear the fire alarm system, the fire alarm system shall be equipped so that each person who is not able to hear the alarm shall be alerted in the event of a fire.Strobe lights shall be installed in the first aid room, the sensory room, and the rear of the kitchen used for programming. Attachments 2380.87(b)-1, 2380.87(b)-2, 2380.87(b)-3 and 2380.87(b)Inv 11/06/2023 Implemented
2380.89(g)The fire drill records for the previous year, September 2022 to current, August 30th, 2023, did not indicate if all participants made it to the meeting place during every monthly fire drill.Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Fire drill documentation form has been updated to indicate that all participants made it safely to the meeting place. 10/30/2023 Implemented
2380.91(a)Individual #2's date of admission was 7/21/23. They did not receive fire safety training until 7/27/23, after admission, and it didn't include the specific content that was reviewed during the training. Individual #4's date of admission to the facility was 4/21/22. Individual #4 did not receive fire safety training on their date of admission. For all individuals attending the facility, there isn't documentation by the fire safety trainer (agency staff) conducting the fire safety training to individuals, which individuals are attending fire safety trainings, when the training occurred, and the content discussed.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, 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 facility.Individual #4 did receive fire safety training on their date of admission. It is noted on the Orientation Form in the Intake Documents folder in their file. Attachment 2380.91a. 11/07/2023 Implemented
2380.111(a)REPEAT from 9/26/22 annual inspection: Individual #4 started attending the facility on 4/21/22 and did not receive a physical examination until either 7/6/22 or 8/5/22; as the information produced is unclear which date the individual may have received a physical examination or what information was reviewed on either date. The physical examination records from 7/6/22 and 8/5/22 do not include a review of all requirements of 2380.111(a)-(d), many of the fields were left blank. The facility didn't receive a physical examination record for Individual #4 that included all regulatory physical examination record requirements until 7/11/2023.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.A physical examination from 7/21/21 is included in Individual #4's intake paperwork. In the future, intake paperwork will be presented during the licensing process even for individuals who are not new admissions. Attachment 2380.111a 11/07/2023 Implemented
2380.111(c)(4)REPEAT from 9/26/22 annual inspection: Individual #1's current, 10/13/22 physical examination record didn't include a hearing or vision screening, or documentation of a recommended deferment and the medical reasoning for the deferment. Their physical examination record stated the vision and hearing screenings were unable to be performed and to see the note. However, a note or attachment was not included with the examination record. Individual #3's 5/4/23 and 9/8/23 physical examination records didn't include an examination of their hearing or recommendations for further follow up. The record said they had hearing loss, and their ears were not examined.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Program Specialists will be trained to review physical forms upon their return, and to send them back if incomplete. 11/07/2023 Implemented
2380.111(c)(5)REPEAT from 9/26/22 annual inspection: Individual #4's records and physical examination records do not include current documentation for the date their Tuberculin skin test was read or the name and credentials of the person who read the individual's results. The agency produced a record where the date was illegible for when the results were read, and only included the name of the person completing the form, not the name and credentials of the person reading the individual's Tuberculin skin test results. At the time of the 9/19/2023 inspection, the last documented Tuberculin skin test with negative results read by the individual's physician was completed on 7/23/21. Individual #1 has been attending the facility for approximately 10 years. The facility was unable to produce the individual's previous results of their Tuberculin skin test by Mantoux method and the results to show compliance with receiving this negative test every 2 years. At the time of the 9/19/23 inspection, the only record of a negative Tuberculin skin test result was completed on 9/15/22.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.Program Specialists will be trained to review returned physical forms to ensure completeness, including TB results which are legible, dated, and signed by an individual with the proper credentials. Individual #1 received 2390 services for most of the years mentioned. LVS protocol is now that all participants, whether in 2380 or 2390, receive a TB test every two years. 11/07/2023 Implemented
2380.111(c)(7)Individual #2's current, 6/8/23 physical examination record did not include health maintenance needs. The field to include this was left blank. Their physical examination record did not include their medication regimen or the recommended need for bloodwork. The field to include their medications indicated to "see attached" but the record did not include any attachments that listed the individual's medications that were reviewed with their physician during the physical examination. The physical examination did not include a field to indicate the recommended need to complete blood work.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.Program Specialists will be trained to fill in demographic information on the LVS Medical Evaluation form, and to review attachments when any part of the physical examination says "see attached." Attachment 2380.111c7 is the physical examination form sent to Individual #2's parents to be completed by the physician. Attachment 2380.111c7email is the email sent to the parents requesting an updated, complete physical examination. Attachment 2380.111c7protocol is the Seizure Protocol form which was sent to the parents requesting that it be completed by the physician. 11/07/2023 Implemented
2380.111(c)(8)Individual #2's current, 6/8/23 physical examination record did not include their physical limitations. The field to include this was left blank.The physical examination shall include: Physical limitations of the individual.Program Specialists will be trained to fill out demographic information on the LVS Medical Evaluation form. 11/07/2023 Implemented
2380.111(c)(10)REPEAT from 9/26/22 annual inspection: Individual #2's current, 6/8/23 physical examination record and Individual #3's 5/4/23 and 9/8/23 physical examination records did not include medical information pertinent to the diagnosis and treatment in case of an emergency. The field to include this was left blank on Individual #2's record and missing from Individual #3's records.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Program Specialists will be trained to fill out demographic information on the LVS Medical Evaluation form. . Attachment PST2380 11/07/2023 Implemented
2380.113(c)(2)Staff person #3's Tuberculin skin test by Mantoux method was read negative on 3/17/23, but the credentials of the staff person who read the results were not included on the medical documentation and the results were not included on the physical examination record. The credentials of the personnel that read Staff person #2's Tuberculin skin by Mantoux method test as negative on 6/30/23 was not included on the record; only initials were recorded next to the result.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the 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, certified nurse practitioner or certified physician's assistant.This issue has been addressed with the company which completes this provider's staff physicals. 10/31/2023 Implemented
2380.171(b)(3)REPEAT from 9/26/22 annual inspection: Individual #3's record doesn't include the name, address, and telephone number of the person able to give emergency medical consent.Emergency information for each individual shall include: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.Individual #3's record has been updated to include the name, address, and telephone of the person able to give emergency medical consent. Attachment 2380.171(b)(3). 10/25/2023 Implemented
2380.173(1)(ii)Individual #3's record doesn't include their race, hair color, or identifying marks.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.Individual #3's record has been updated to include their race, hair color and identifying marks. Attachment 2380.173(1)(ii) and Attachment 2380.173(1)(ii)Race. 11/02/2023 Implemented
2380.174(b)Individual #3 started attending the facility on 5/30/23. The individual's individual support plan (ISP) in their record, and available for staff to view, was last updated on 3/17/23, prior to starting services at the facility. The ISP has been updated 5 times since their admission to the facility.The most current copies of record information required in §  2380.173(2)(11) shall be kept at the facility.Program Specialists shall check each participant's ISP at least quarterly to ensure the current ISP is available for staff to review. 11/07/2023 Implemented
2380.181(e)(3)(iv)Individual #2's current, 9/19/23 assessment and Individual #4's current, 6/15/23 assessment do not include their current level of performance and progress in personal needs with or without assistance in completing restroom and hygiene skills. Individual #4's assessment is unclear what their current abilities and performance is in eating and ambulation. The assessment marks a checkbox indicating the individual is independent in both areas, but also includes written information that these areas don't apply to the individual. No further explanation is provided on the individual's current needs and abilities for those two categories. Individual #4's current, 6/15/23 assessment doesn't include their current level of performance to complete hygiene and bathroom tasks. According to their assessment, the only information documented for this category was information about ambulation and eating abilities, which the individual's abilities were unclear as stated above. According to Individual #4's current, 9/11/23 individual support plan (isp), they have had incontinence while attending the facility, are not thorough with cleanliness after using the restroom, several occasions staff smelled odor on the individual and realized the individual had been at day program for several hours with adult briefs being soiled and not telling anyone. The individual's performance and assistance needed was not included in their assessment. Individual #1's current, 9/16/22 assessment doesn't include their performance and progress with personal hygiene skills when using the restroom.The assessment must include the following information: The individual s current level of performance and progress in the following areas: Personal needs with or without assistance from others.Individual #4's assessment has been updated to include the required information. Attachment 2380.181(3)(iv) #4. Individual #1's assessment has been updated to include the required information. Attachment 2380.181(3)(iv) #1. Individual #2's assessment has been updated to include the required information. Attachment 2380.181(3)(iv) #2. 11/08/2023 Implemented
2380.181(e)(5)Individual #2's current, 9/19/23 assessment does not include their ability to self-administer medications. The assessment included the following: · Yes, they take medication at the facility. · No, they can't take the correct dosage without assistance. · No, they can't identify the correct time without assistance. · With assistance they can identify the type of medication they are taking. · They can consume medication independently. · They have medication at the facility if they need it. · Their individual plan states the individual doesn't feel comfortable administering their own medication and would like staff to do it for them. · A medication trained staff would help them. Clarification on the assistance needed and if they can self-administer medications wasn't included or clarified within the individual's assessment.The assessment must include the following information: The individual's ability to self-administer medications.Assessment form will be updated to include a clearer question. "Can the individual self-administer medications? Y/N." Attachment 2380.181(3)(iv) Update. Staff trained to administer medications shall assess the individual's ability to self-administer medications and the assessment shall be updated accordingly. 11/09/2023 Implemented
2380.181(e)(9)Individual #4's current, 6/15/23 assessment doesn't include all their function and medical limitations.The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations.Individual #4's assessment has been updated to include the required information. Attachment 2380.181(3)(iv) #4. 11/09/2023 Implemented
2380.181(e)(13)(i)Individual #1's current, 9/16/22 assessment doesn't include their current level and progress in health.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health.Individual #1's assessment will be updated to include current level and progress in health. Attachment 2380.181(3)(iv) #1. 11/08/2023 Implemented
2380.181(e)(13)(ii)Individual #4's current, 6/15/23 assessment doesn't include their current level of performance and progress over the previous year in motor and communication skills. The assessment includes contradictory statements that make it unclear what their needs were assessed as during the time of the completion of the assessment. Individual #1 does not speak words daily and requires communication devices and other means to communicate, including familiar staff. The individual's needs for familiar staff and inability to speak words wasn't included in the assessment. The assessment states they can independently communication their needs and wants but needs prompting to do so. The individual requires additional support to relay their wants and needs. Individual #1's individual support plan (isp) states the individual will not interact much with their peers, will spend time around them but not interact much. This is a different description of the individual's communication and socialization abilities and needs, than what is captured in their assessment. Their isp states their family is usually able to distinguish what they may say if the individual attempts to speak. Their isp says they can say some words or phrases but only does so occasionally. According to the agency, Lighthouse Rehabilitation Center, they have only ever heard one phrase with a distinguishable word be spoken by Individual #1 once over the previous year.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas:  Motor and communication skills.Individual #4's assessment has been updated to include the required information. Attachment 2380.181(3)(iv)4. 11/08/2023 Implemented
2380.181(e)(13)(iv)Individual #4's current, 6/15/23 assessment doesn't include their current level of performance and progress over the previous year in socialization skills. The assessment documents the progress and growth section is "n/a" or not applicable, to be assessed. However, the regulatory requirement to assess individuals' current level of performance and progress over the previous year is applicable and must be included in all individuals' assessments. Individual #1's current, 9/16/22 assessment unclear how they socialize based on their communication style and needs. Their assessment states the individual initiates conversations, responds when spoken to, and no changes have been made over the previous year. However, Individual #1 does not speak words or phrases and uses various ways to socialize (using their iPhone, pictures, noises and may take to you items they want or needs). The assessment does not report that the individual does not speak words at the facility and the assessment is unclear of their current performance in communication skills and if they have made any progression or regression with their socialization over the previous year. Individual #1's individual support plan (isp) states they will not interact much with their peers, will spend time around them but not interact much. This is a different description of the individual's communication and socialization abilities than what is captured in their assessment.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization.Both assessments for these individuals have been updated to include the required information. Attachment 2380.181(3)(iv) _#4 and Attachment 2380.181(3)(iv) _#1. 11/09/2023 Implemented
2380.181(e)(13)(v)Individual #4's current, 6/15/23 assessment doesn't include their current level of performance and progress over the previous year in recreation skills. The assessment only listed 6 activities the individual enjoyed over the past year. An assessment and description of the individual's skills and abilities in this category and what progress or regression they have made from the previous year, was not included. Individual #1's current, 9/16/22 assessment doesn't include current level of performance and progress over the previous year in recreation skills. Their assessment lists items they enjoy (listening to music and dancing), that they both observe and participate, and maintained current level. However, a description of their assessed skills to observe and participate, and if that is a maintained skill wasn't included.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.Both assessments for these individuals have been updated to include the required information. Attachment 2380.181(3)(iv) #4 and Attachment 2380.181(3)(iv) #1. 11/08/2023 Implemented
2380.21(u)At the time of the inspection, Individual #1 through Individual #4's rights were not reviewed with their legal guardians. In addition, Individual #3 did not have their individual rights reviewed with them at the time of admission.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.Senior Program Specialists shall ensure rights are reviewed with their legal guardians. Senior Program Specialists shall ensure rights are reviewed at the time of admission. 11/07/2023 Implemented
2380.125(b)The facility does not have the current order for Individual #5's medication, Methylphenidate 20mg. According to the pharmacy issued medication label on the medication bottle, the medication is to be administered 3 times a day and within half an hour to one hour before meals. The facility is administering the medication daily, at 10am and 2pm. The facility does not know if or when the individual receives this medication at home and does not have specific written physician's orders to administer the medication at 10am and 2pm.A prescription order shall be kept current.Provider has requested a current order for the individual's medication but has not yet received it. 11/08/2023 Implemented
2380.125(c)The facility does not have the current order for Individual #5's medication, Methylphenidate 20mg. According to the pharmacy issued medication label on the medication bottle, the medication is to be administered 3 times a day and within half an hour to one hour before meals. The facility is administering the medication daily, at 10am and 2pm. The facility does not know if or when the individual receives this medication at home and does not have specific written physician's orders to administer the medication at 10am and 2pm. The individual eats lunch around noon daily and does not return home until after 3pm most days; therefore, the administrations at 10am and 2pm would fall outside the instructions to administer the medication within half an hour to one hour prior to meals.A prescription medication shall be administered as prescribed.Provider has requested a current order for the individual's medication but has not yet received it. 11/08/2023 Implemented
2380.126(a)(11)Individual #5's medication administration records from September 2022 to current, September 19, 2023, do not include the diagnosis or purpose for administering and prescribing their Methylphenidate two times per day while in attendance.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.Individual #5's MAR for the month of October 2023 is attachment 2380.126a11 and includes the diagnosis for this medication. 11/09/2023 Implemented
2380.126(a)(13)Individual #5's August 2023 medication administration record (mar) does not include the name and initials of the staff person who administered Methylphenidate to the individual at 10am and 2pm on 8/18/23. Staff person #4 included their initials but not their name. The name of the staff person who administered Methylphenidate to Individual #5 at 10am on 7/21/23 and 10am and 2pm on 7/25/23 was not legible on the individual's mars.A 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.Individual #5's MAR for the month of October 2023 is attachment 2380.126a11 and includes the name and initials of those who administered medications. 11/09/2023 Implemented
2380.127(a)(1)Individual #5 did not receive their 2pm dose of Methylphenidate hcl 20mg on 9/7/23 due to it not being available at the facility. The individual didn't receive their 2pm dose of Methylphenidate on 1/25/23.Medication errors include the following: Failure to administer a medication.Provider has implemented a new system whereby medications for this individual are received in blister packs, thus ensuring regular supply of medication. 11/09/2023 Implemented
2380.127(a)(2)On 1/30/23, agency staff recognized that the pill bottle Individual #5's family sends the individual's two doses (2 total pills) of Methylphenidate in for the day contained two different pills, by reporting "one is a different size and color than normal." Agency staff only requested for written confirmation from Individual #5's family that the two different pills "were correct pills so they could administer it this afternoon." The home received an email from the individual's family stating, "There are different looking pills in {the individual's} pill bottle. Must've happened at the pharmacy. Probably taken from different sources. They are methylphenidate." The agency did not attempt to or receive written confirmation from the medication prescriber or pharmacist of the medication that was in the individual's Methylphenidate medication bottle. The agency administered both doses of medication to the individual at 10am and 2pm on 1/30/23 after only receiving the above statement from the individual's family. The agency does not know what the medication that they administered to Individual #5 was at 10am and 2pm on 1/30/23.Medication errors include the following: Administration of the wrong medication.Provider has implemented a new system whereby medications for this individual are received in blister packs, thus ensuring regular supply of medication. 11/09/2023 Implemented
2380.127(b)Documentation of the medication error, follow up action taken, and the prescriber's response from failing to administer Individual #5 their Methylphenidate 20mg at 2pm on 1/25/23 was not in the individual's record.Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record.Staff have been retrained to document all required aspects of a medication error per regulatory requirements. 11/09/2023 Implemented
2380.127(c)The agency did not report their failure to administer Individual #5 their Methylphenidate 20mg at 2pm on 1/25/23 as an incident as specified in 2380.17(b).A medication error shall be reported as an incident as specified in § 2380.17(b) (relating to incident report and investigation).Staff have been retrained to report medication errors per regulatory requirements. 11/09/2023 Implemented
2380.129(a)At the time of the 9/19/23 inspection, Staff person #5 is administering medications to individuals at the facility. The facility produced records that the staff had their annual medication administration training completed on 5/28/21 and not again until 5/26/23, outside the annual time frame requirement. Additionally, its unclear if the required medication administration record reviews or medication observations (2 of each) were completed in 2023 as records of their completion were not produced during the inspection. At the time of the 9/19/23 inspection, Staff person #6 is administering medications to individuals at the facility. The facility produced records that the staff had their annual medication administration training completed on 6/3/21 and not again until 5/26/23, outside the annual time frame requirement. Additionally, its unclear if the required medication administration record reviews or medication observations (2 of each) were completed in 2023 as records of their completion were not produced during the inspection. At the time of the 9/19/23 inspection, Staff person #4 administered medication to Individual #5 in the facility on 7/25/23. The agency, Lighthouse Rehabilitation Center, did not complete any medication training (initial or annual) to Staff person #4 prior to them administering medications. Staff person #4 purportedly received annual medication administration training from another provider.A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures and treatments as specified in § 2380.122 (relating to medication administration).Staff persons 4 and 5 annual training was missed during staff transition. Attachment 2380.129a is documentation that staff person 6 did receive annual medication training from another provider. However, staff person 6 is not permitted to administer medications until their annual training is completed. 11/06/2023 Implemented
2380.181(f)REPEAT from 9/26/22 annual inspection: The facility did not send or provide Individual #2's or their father (who is a part of the plan team) with a copy of the individual's current, 9/19/23 assessment. The assessment did not indicate that it was provided to the individual or their father, but it was provided to their other team members. The facility did not send or provide individual #4 or their legal guardian with a copy of their current, 6/15/23 assessment. Individual #1's 9/16/22 assessment wasn't provided or sent to them.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.Provider's Plan of Correction: Individual #2's assessment was updated and sent to the team on 10/5/23. Individual #2's parents share an email account, and the assessment was sent to the joint email account per their wishes. The 10/5/23 assessment was offered to the individual, but they declined to receive a copy. Attachment 2380.181fMU. Individual #4's assessment was updated a sent to the team, including the guardian. Attachment 2380.181(e)(3)(iv)4. 11/08/2023 Implemented
2380.186Individual #2's record includes a fall prevention plan, seizure protocol, and SEEN (Social, Emotional, Environmental Needs) plan that require staff to monitor and aid with falls or near falls, seizures, and symptoms of anxiety and depression. The facility was unable to produce records that they are monitoring and documenting all individual plan and protocol requirements.The facility shall implement the individual plan, including revisions.Individual #2's record has been updated to include areas for DSPs to document all protocols. Attachment 2380.186-1 11/08/2023 Implemented
2380.183(c)A list of the persons who participated in individual #4's individual plan meeting(s) was not kept by the facility.The list of persons who participated in the individual plan meeting shall be kept.Program Specialists shall ensure they keep and maintain a list of persons who participated in individual plan meetings. 11/07/2023 Implemented
SIN-00211609 Renewal 09/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(b)At the time of the inspection, there were multiple bottles of a liquid labeled "Lysol" that were not kept in the original, labeled bottle.Poisonous materials shall be stored in their original, labeled containers.1. The bottles in question will be replaced with bottles that contain the original label. 11/04/2022 Implemented
2380.87(b)The two individual bathrooms near the offices ("new" bathrooms added during the most recent remodel) do not have audial or visual fire alarms. There are individuals in the facility who are hard of hearing.If one or more individuals or staff persons are not able to hear the fire alarm system, the fire alarm system shall be equipped so that each person who is not able to hear the alarm shall be alerted in the event of a fire.Strobe lights were installed in the two bathrooms referenced in this citation. Attachment 1 is the invoice for installation. 10/17/2022 Implemented
2380.111(a)(Repeat from Inspection completed 11/15/21) Individual #1 had a physical completed on 9/26/20 and not again since, outside of the annual time frame. Individual #3 had an annual physical completed on 7/7/21 and not again until 9/22/22, outside of the annual timeframe.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.1. Program Specialists were trained (Attachments 2 and 3) by Senior Program Specialist to: a. Track due dates for physicals using the Task List feature in Setworks. b. Notify participant's caregivers at least 45 days prior to the annual due date for the physical to be completed. c. Provide the appropriate form. 11/04/2022 Implemented
2380.111(c)(1)Individual #2's most recent physical completed 8/3/22 did not include the individual's medical history.The physical examination shall include: A review of previous medical history.1. Individual #2's most recent physical has been updated to include the individual's medical history. The history was not added directly to the form because the form was already signed by the physician. The form was added to their Medical file in Setworks. See Attachment 6. 10/25/2022 Implemented
2380.111(c)(3)(Repeat from Inspection completed 11/15/21) Individual #2's most recent physical completed on 8/3/22 did not include immunizations. Individual #4's most recent physical completed 9/26/22 did not include immunizations.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.1. A list of Individual #2's immunizations record is included as Attachment 7. It has been filed with the annual physical. 2. A list of Individual #4's immunizations record is included as Attachment 8. It has been filed with the annual physical. 10/25/2022 Implemented
2380.111(c)(4)(Repeat from Inspection completed 11/15/21) No documentation was provided for Individual #1 or Individual #3 indicating that they have had a vision or hearing screening. Individual #2's most recent physical completed on 8/3/22 did not include a vision and hearing screening. Individual #4's most recent physical completed 9/26/22 did not include a vision or hearing screening.The physical examination shall include: Vision and hearing screening, as recommended by the physician.1. The physical examination form used by Lighthouse has been revised to include all required elements. Attachment 9 2. Program Specialists have been trained to review physical examinations when they are returned to ensure it is filled out. (Attachments 2 and 3) 10/25/2022 Implemented
2380.111(c)(5)No documentation was provided for Individual #1 or Individual #3 indicating that they have had a TB test completed. Individual #2's most recent physical completed on 8/3/22 did not include a TB test. Individual #4's most recent physical completed 9/26/22 did not include a TB test.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.1. The Senior Program Specialist has identified all participants who do not have a current TB test. 10/25/2022 Implemented
2380.111(c)(10)Individual #4's most recent physical completed 9/26/22 did not include information pertinent to treat/diagnose in the event of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.1. The physical examination form used by Lighthouse has been revised to include all required elements. Attachment 9 2. Individual #4's Emergency Information Form was updated to include information pertinent to treat/diagnose in the event of an emergency. This information was not added to the physical completed 9/26/22 because the physician had signed it. Attachment 11 10/25/2022 Implemented
2380.171(b)(2)Individual #4's demographic information did not include the address of the physician.Emergency information for each individual shall include: The name, address and telephone number of the individual¿s physician or source of health care.1. Individual #4's demographic information has been updated to include the address of the physician. Attachment 11 10/25/2022 11/18/2022 Implemented
2380.171(b)(3)(Repeat from Inspection completed 11/15/21) Individual #2's demographic info does not identify who to contact for medical consent.Emergency information for each individual shall include: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.1. Individual #2's demographic info has been updated to include who to contact for medical consent. Attachment 12 10/24/2022 11/18/2022 Implemented
2380.181(a)(Repeat from Inspection completed 11/15/21) Individual #2's annual assessment was completed on 5/10/21 and not again until 5/26/22, outside of the annual timeframe. Individual #4's admission was 2/14/22. The initial assessment was completed on 4/28/22, outside of the 60-day window.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.1. Program Specialists were trained (Attachments 2 and 3) by Senior Program Specialist to: a. Track due dates in the Tasks section of Setworks so that assessments are sent to the ISP team within the required timeframe. b. Develop an effective task reminder system 10/19/2022 Implemented
2380.181(e)(1)Individual #1's most recent assessment completed on 2/25/22 does not identify any of the individual's needs. Individual #3's most recent assessment completed 3/21/22 does not identify the individual's needs and preferences.The assessment must include the following information: Functional strengths, needs and preferences of the individual.1. Individual #1's most recent assessment has been updated to identify some of their needs. Attachment 13 2. Individual #3's most recent assessment has been updated to identify some of their needs and preferences. Attachment 14 3. Program Specialists were trained (Attachments 2 and 3) to ensure that assessments include strengths, needs, and preferences. 11/18/2022 Implemented
2380.181(f)(Repeat from inspection completed 11/15/21) Individual #2's most recent assessment was provided to the team on 5/26/22. The Individual Support Plan team meeting was on 6/9/22.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.1. Attachment 15 is an assessment completed since licensing which documents it was sent to the team on 10/14/22. 2. Attachment 16 is the demographic information from the same participant's ISP which shows the next ISP due date is 2/19/2023. 10/25/2022 Implemented
SIN-00196382 Renewal 11/15/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.32(b)(4)The agency does not request the residency status of any new employee upon or before hire. Staff person #1 was employed on 5/10/21 and Staff person #2 was employed on 7/12/21. The agency did not obtain FBI background checks for either staff, nor inquire with either staff if they have lived in the state of Pennsylvania over the previous two years.The chief executive officer shall be responsible for the administration and general management of the facility, including the following: Compliance with this chapter.The agency requires prospective employees to complete a form authorizing Lighthouse to conduct background checks. The form asks for information about where the applicant lived prior to applying to work at LVS. The forms authorizing Lighthouse to conduct background checks for Staff Person #1 and Staff Person #2 are attached. 12/14/2021 Implemented
2380.53(a)There are individuals attending the program that are assessed to be unsafe around poisonous materials. During the 11/18/21 inspection of the building, there were multiple poisonous materials that contained a label to contact poison control center if ingested found accessible throughout the facility. Examples included bathroom scent spray in a few of the bathrooms, antibacterial hand gel in a few of the bathrooms, throughout the program area, and in the first aid area, and eye wash, triple antibiotic ointment, sting relief pads and antibacterial wipes in the first aid room.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.All Aspirin was removed from the first aid kit immediately during licensing. All bottles of alcohol based hand sanitizer were removed. 11/19/2021 Implemented
2380.53(b)The first aid room contained a generic, clear spray bottle with a name-tag-like label placed on it stating it was hand sanitizer.Poisonous materials shall be stored in their original, labeled containers.The generic, clear spray bottle was removed from the first aid at the time of inspection. 11/18/2021 Implemented
2380.55(d)Individuals attending the program were utilizing the program area to also eat their lunch during the COVID-19 pandemic. There were at least 6 trash receptacles located within the program area that were not equipped with a lid or other device to provide closure to the device and prevent the penetration of insects and rodents.Trash in bathroom, dining, kitchen and first aid areas shall be kept in covered, cleanable receptacles that prevent the penetration of insects and rodents.Trash cans have been designated for Food Trash and all have a lid. DSPs shall monitor to ensure food trash is disposed of in the proper receptacle. 12/03/2021 Implemented
2380.62The telephone number to the nearest hospital was not stored on or near the telephone in the program specialists' offices. The number was half cut off the bottom of the attached sticker.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line.The incomplete sticker was replaced with stickers that were complete and legible. 12/14/2021 Implemented
2380.83(a)The written emergency evacuation plan did not include an emergency shelter location or the means of transportation to the emergency shelter location in the event of a fire or emergency not allowing for re-entry of the building.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation, an emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency.The emergency evacuation plan was updated and provided to the reviewer during the inspection. Evacuation diagrams were posted throughout the building at the time of inspection. 12/14/2021 Implemented
2380.89(c)The fire drills completed while the facility was open from March 2021 to current, November 2021 did not include the exit route used and the egress door used by participants during the fire drill.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 was operative.Responsibility to conduct monthly fire drills and document them accurately has been assigned to the Transportation and Safety Coordinator. The fire drill form was revised to include required elements. A fire drill was conducted December 16, 2021. Both the form and 12/16 drill are attached. 12/16/2021 Implemented
2380.91(a)Individual #2 started attending the 2380 facility around June 2021 and prior to, attended the 2390 program within the same facility building. At the time of the 11/15/21 inspection, the only record of fire safety training being provided to Individual #2 was completed on 10/20/21, not annually or upon admission in June 2021. Individual #3 received fire safety training on 7/29/19 and not again until 10/21/21. They were out of program from 3/17/2020-3/15/2021 but did not receive fire safety training upon re-entry to the facility in March 2021, or on their annual fire safety training due date of 7/29/21.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, 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 facility.The Director of Programs shall ensure fire safety training is completed in accordance with this regulation. 01/17/2022 Implemented
2380.111(a)Individual #3 is attending the facility. At the time of the 11/15/2021 inspection, they had a physical examination on 10/26/2020 and not again since then.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Lighthouse Program staff shall make every effort to obtain required physical examinations within the required time-frame. Documentation of such efforts shall be kept. Individual #3's physical examination dated November 17, 2021 is attached. 12/10/2021 Implemented
2380.111(c)(3)Individual #2's 10/27/21 physical examination record didn't include a record of their immunizations.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Individual #3's physical examination dated November 17, 2021 is attached and includes a record of immunizations. 12/10/2021 Implemented
2380.111(c)(4)Individual #2's 10/27/21 physical examination record didn't include a vision and hearing screening or record of deferment.The physical examination shall include: Vision and hearing screening, as recommended by the physician.Individual #3's physical examination dated November 17, 2021 is attached and includes a vision and hearing screening. 12/10/2021 Implemented
2380.111(c)(7)Individual #2's 10/27/21 physical examination record didn't include health maintenance needs or recommendations for blood work.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.Individual #3's physical examination dated November 17, 2021 is attached and includes health maintenance needs and recommendations for blood work. 12/10/2021 Implemented
2380.113(a)Staff person #3 has been working in the facility for over a year. At the time of the 11/15/2021 inspection, Staff person #3 has not had a physical examination completed.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 persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.Staff person #3's physical exam was located after licensing was completed. It is attached. 01/28/2022 Implemented
2380.115(1)The written emergency medical plan does not include the specific hospital or source of health care that the individual's will be transported to in the event of an emergency. The current plan states, "transported to the nearest hospital."The facility shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency.The emergency medical plan has been updated to specify Ephrata Community Hospital as the place where participants will be transported to in case of emergency. The plan is attached 12/14/2021 Implemented
2380.171(b)(1)Individual #2's record does not include the name or relationship of the person who is the designated emergency contact.Emergency information for each individual shall include: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.Individual #2's electronic record is attached. Please note the dates on the right all of which indicate the required information was present at the time of licensing. The paper copy of emergency information was updated and is also attached. 01/13/2022 Implemented
2380.171(b)(3)Individuals #1, #3's records did not include the name, address and telephone number of the person able to give consent for emergency medical treatment.Emergency information for each individual shall include: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.Records for Individuals 1 and 3 have been updated to include information about the person able to give consent for emergency medical treatment. Records attached. 01/13/2022 Implemented
2380.173(1)(ii)Individuals #1-#3's records did not include their identifying marks. There was a field for this located on their identification sheet, however it was found blank. This information was not recorded throughout their record.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.Individual #1's and Individual #3's records have been updated to include identifying marks. Records are attached. 01/13/2022 Implemented
2380.173(1)(iv)REPEAT from 11/30/2020 annual inspection: Individuals #2 and #3's records didn't include their religious affiliation.Each individual¿s record must include the following information: Personal information including: Religious affiliation.Records for Individuals 2 and 3 have been updated to include their religious affiliation. Records are attached. 01/06/2022 Implemented
2380.173(1)(v)Individuals #1's and #3's records did not include a dated photograph. The photograph in their records were not dated. Individual #2's record didn't contain a current, dated photograph. The photograph in their record was last dated in 2018.Each individual¿s record must include the following information: Personal information including: A current, dated photograph.A current dated photograph of Individual #1 was taken and placed in her file. The photo is attached. Individual #3's attendance has been sporadic. A photograph of her will be taken when she attends program. 02/04/2022 Implemented
2380.173(3)Individual #1's current, 12/21/2020 physical examination record was not kept in their record at the facility. The examination record was brought to the facility after the Department's request during the 11/15/2021 inspection.Each individual¿s record must include the following information: Physical examinations.The provider is not certain what transpired in this instance. The Senior Program Specialist recalls providing the PE electronically, then providing it again in paper format. The PE was in the facility. 11/19/2021 Implemented
2380.181(a)Individual #1 had an assessment completed on 8/26/2020 and not again until 11/2/2021. Individual #3 had an assessment completed in January 2020. They were out of program from 3/17/2020 to 3/15/2021. At the time of the 11/15/2021 inspection, Individual #3 did not have an assessment completed to address their needs, assistance, and skills since they have been back at program for the previous 8 months.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.Program Specialists shall be trained to ensure assessments are completed within prescribed time frames. 01/28/2022 Implemented
2380.181(e)(3)(i)Individual #1's 11/2/2021 assessment and Individual #2's 8/18/2021 assessment don't include and define the assistance needed for functional skills.The assessment must include the following information: The individual¿s current level of performance and progress in the following areas:  Acquisition of functional skills.Program Specialists shall be trained to ensure all facets of the assessment are completed and each section must be updated annually 01/28/2022 Implemented
2380.181(e)(3)(ii)Individual #1's 11/2/2021 assessment and Individual #2's 8/18/2021 assessment don't include and define the assistance needed in communication skills.The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication.Program Specialists shall be trained to ensure all facets of the assessment are completed and each section must be updated annually 01/28/2022 Implemented
2380.181(e)(3)(iii)Individual #1's 11/2/2021 assessment and Individual #2's 8/18/2021 assessment don't include and define the assistance needed for personal adjustment skills.The assessment must include the following information: The individual¿s current level of performance and progress in the following areas:  Personal adjustment.Program Specialists shall be trained to ensure all facets of the assessment are completed and each section must be updated annually 01/28/2022 Implemented
2380.181(e)(5)Individual #1's 11/2/21 assessment and Individual #2's 8/18/2021 assessment don't include their ability to administer medications. The assessments are unclear of their assessed ability due to the verbiage used to describe their needs. Currently, the assessment state that the individuals need assistance to take the correct dosage but consume medication independently.The assessment must include the following information: The individual¿s ability to self-administer medications.The assessment for both Individual #1 and Individual #2 shall be revised to clarify their ability to self-administer medications. 01/28/2022 Implemented
2380.181(e)(9)Individual #1's 11/2/21 assessment doesn't include their allergy to oral contraceptive pills that was identified on their physical examination records. Additionally, the individual's assessment states they do not have a seizure or fall protocol. However, they do have a seizure and fall protocol that needs implemented while at program.The assessment must include the following information: Documentation of the individual¿s disability, including functional and medical limitations.Individual #1's 11/2/21 assessment shall be revised to include her allergy to oral contraceptive pills. Individual #1's 11/2/21 assessment shall be revised to indicate she does have a seizure and fall protocol that needs to be implemented while at program. 01/07/2022 Implemented
2380.181(e)(10)Individual #1's 11/2/21 assessment doesn't include a lifetime medical history. Their assessment has a section for this information, however, only includes their diagnoses and functional limitations that are required for 2380.181(e)(9).The assessment must include the following information: A lifetime medical history.Individual #1's 11/2/21 assessment shall be revised to include a lifetime medical history. Program Specialists shall be trained to include a lifetime medical history in each assessment. 01/28/2022 Implemented
2380.181(e)(13)(i)Individual #1's 11/2/21 assessment and Individual #1's 8/18/21 assessment don't include their current level and progress over the previous 365 days in health.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Health.The assessment for both Individual #1 and Individual #2 shall be revised to include their current level and progress over the previous 365 days in health. Program Specialists shall be trained to include each individual's current level and progress over the previous 365 days in health. 01/28/2022 Implemented
2380.181(e)(13)(ii)Individual #1's 11/2/21 assessment and Individual #1's 8/18/21 assessment don't include their current level and progress over the previous 365 days in motor and communication skills.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas:  Motor and communication skills.The assessment for both Individual #1 and Individual #2 shall be revised to include their current level and progress over the previous 365 days in motor and communication skills. Program Specialists shall be trained to include all required sections in the assessment. 01/28/2022 Implemented
2380.181(e)(13)(iii)Individual #1's 11/2/21 assessment and Individual #1's 8/18/21 assessment don't include their current level and progress over the previous 365 days in personal adjustment.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment.The assessment for both Individual #1 and Individual #2 shall be revised to include their current level and progress over the previous 365 days in personal adjustment. Program Specialists shall be trained to include all required sections in the assessment 01/28/2022 Implemented
2380.181(e)(13)(iv)Individual #1's 11/2/21 assessment and Individual #1's 8/18/21 assessment don't include their current level and progress over the previous 365 days in socialization.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.The assessment for both Individual #1 and Individual #2 shall be revised to include their current level and progress over the previous 365 days in personal socialization. Program Specialists shall be trained to include all required sections in the assessment 01/28/2022 Implemented
2380.181(e)(13)(v)Individual #1's 11/2/21 assessment and Individual #1's 8/18/21 assessment don't include their current level and progress over the previous 365 days in recreation.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Recreation.The assessment for both Individual #1 and Individual #2 shall be revised to include their current level and progress over the previous 365 days in recreation.. Program Specialists shall be trained to include all required sections in the assessment 01/28/2022 Implemented
2380.181(e)(13)(vi)Individual #1's 11/2/21 assessment and Individual #1's 8/18/21 assessment don't include their current level and progress over the previous 365 days in community-integration.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration.The assessment for both Individual #1 and Individual #2 shall be revised to include their current level and progress over the previous 365 days in personal socialization. Program Specialists shall be trained to include all required sections in the assessment 01/28/2022 Implemented
2380.21(u)REPEAT from 11/30/2020 annual inspection: Individual #1 was not informed of their rights defined in Pa. Code 55 Chapter 2380.21(a)-(t) upon their admission to the facility on 3/3/2020. Additionally, individual rights 2380.21(a)-(f) and 2380.21(r)-(t) weren't reviewed with the individual when a review of individual's rights was documented to occur on 2/26/21 and 9/3/21. Individual #2 started attending the 2380 program around June 2021 and prior to, attended the vocational setting. Individual rights defined in 2380.21(a)-(u) weren't reviewed with Individual #2 until 9/1/21. Additionally, the rights reviewed with them did not include a review of individual rights 2380.21(a)-(f) and 2380.21(r)-(t). There are no records of individual rights being reviewed with Individual #2 in 2020. Individual #3 was not informed of their individual rights defined in 2380.21(a)-(f) and 2380.21(r)-(t) during the review on 9/7/2021. There are no records of a review of individual rights with Individual #3 in 2020 or when they returned to program in 3/15/2021, after being absent from the facility from 3/17/2020-3/15/2021.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.Individual #1 has been informed of her rights. Documentation is attached. 12/13/2021 Implemented
2380.36(b)At the time of the 11/18/21 inspection, Staff person #3 received general fire safety training on 9/18/2020 and not again since then.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Documentation of fire safety training for staff person #3 has been located. It is attached. Content of the training is also included as attachment 2380.36(b) Training Content. 12/10/2021 Implemented
2380.37(a)Staff person #3's training records do not include the source, content, and trainer of the trainings. For example, their training record states they received "Mentoring" training and "ODP required trainings" on 3/19/21, OSHA on 4/16/21, and multiple trainings on 5/21/21 but did not include any further details about the content of the training or the training source. Additional details and contents of the trainings could not be produced. The Incident Management, Coaching, Time Clock, Dealing with change, ARC update, and documentation training that was all documented as occurring on 5/21/21 for Staff persons #1, #3 and #4 indicated it was for a total of 16 hours. According to the agency, the length of all the trainings was only 8 hours, not 16. The content of all topics the staff received training on could not be produced. The content of individual-specific plan training provided to any staff member was not kept or produced.Records or orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept.Content, source and trainer information for all training can be located in the folder titled "Training Content 2380.37(a). 01/14/2022 Implemented
2380.38(b)(2)Orienting training provided to Staff persons #1 and #2 did not include a review of all individuals rights described in 55 Pa. Code chapter 2390.21.The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The list of rights from Chapter 6100 was mistakenly used during orientation. The correct list of rights from Chapter 2380 was reviewed with both staff persons. Documentation attached. 01/06/2022 Implemented
2380.38(b)(5)Individuals #1 and #3 both experience seizures and have a seizure plan staff are to implement while at program. There are no records that staff providing support to both individuals received training in the individual-specific seizure plans or the individual-specific seizure signs and symptoms they are to monitor while at program. Orientation training provided to staff on individual-specific plans (isp, assessments, etc) is not conducted by a trainer, either remotely or in-person, to review the plans and orient staff to the specific job skills and knowledge needed prior to working with individuals.The orientation must encompass the following areas: Job-related knowledge and skills.Staff who work with these participants received training on both related to plans and protocol. Documentation of training is attached. 01/18/2022 Implemented
2380.39(a)(3)Staff person #4 only received 16 hours of training for the training year. The agency provided training documentation stating Staff person #4 received 16 hours of training on 5/21/21 and 8 hours of training on 9/17/21.ed in September. However, the agency reported that the 16 hours earned on 5/21/21, was only 8 hours and was documented incorrectly. Therefore, Staff person #4 only received 16 hours of training in the agency's training year.The following shall complete 24 hours of training related to job skills and knowledge each year: Positions required by this chapter.Additional training documentation was located for staff person #1 totaling 38 hours of training for the agency's training year, October 1 - September 30. Errors on the 5/21/21 documentation form have been corrected. 12/14/2021 Implemented
2380.39(c)(1)There are no records that Staff person #3 received annual training in the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain friendships.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.Attachment 39(c)(1) includes documentation of this training for Staff #3. Content can be found in the folder labeled "Training Content". 12/03/2021 Implemented
2380.39(c)(2)There are no records that Staff person #3 received annual training in the prevention and detection of reporting 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.Attachment 39(c)(1) includes documentation of this training for Staff #3. Content can be found in the folder labeled "Training Content". 12/03/2021 Implemented
2380.39(c)(3)There are no records that Staff person #3 received annual training in individuals rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Attachment 39(c)(1) includes documentation of this training for Staff #3. Content can be found in the folder labeled "Training Content". 12/03/2021 Implemented
2380.39(c)(4)There are no records that Staff person #3 received 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.Attachment 39(c)(1) includes documentation of this training for Staff #3. Content can be found in the folder labeled "Training Content". 12/03/2021 Implemented
2380.39(c)(5)There are no records that Staff person #3 received annual training in the safe and appropriate use of behavior supports.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.Attachment 39(c)(1) includes documentation of this training for Staff #3. Content can be found in the folder labeled "Training Content". 12/03/2021 Implemented
2380.39(c)(6)There are no records that Staff person #3 received annual training in implementation of the individual plan.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Attachment 39(c)(1) includes documentation of this training for Staff #3. Content can be found in the folder labeled "Training Content". 12/03/2021 Implemented
2380.123(d)Multiple, individually packaged containers of Aspirin were unlocked and accessible in the first aid kit in the first aid area. There are individual's attending the facility that are assessed to be unable to self-administer medications and unsafe around poisonous materials.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.All Aspirin was removed from the first aid kit in the first aid area the day of inspection. 11/18/2021 Implemented
2380.125(f)Individual #1's individual support plan (isp) did not include a social, emotional, and environmental needs plan to address their symptoms of their psychiatric diagnoses, Mood Disorder, Obsessive Compulsive Disorder, and Depression. Individual #2's social, emotional and environmental needs (seen) plan included in their isp didn't include a review of all symptoms related to their psychiatric diagnoses and plans to support the individual through those symptoms. According to their isp they are prescribed psychotropics for anxiety, depression, and delusional disorder NOS. Their seen only includes some symptoms for their depression and delusional disorder NOS.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.Individual #1's SEEN plan was sent to the Supports Coordinator so that it can be added to the ISP 01/18/2022 Implemented
2380.173(1)(i)Individuals #1's and #2's records did not include their date of admission to the facility.The name, sex, admission date, birthdate and Social Security number.Records which include the date of admission for Individuals #1 and #2 are included in the attachments. 01/17/2022 Implemented
2380.181(f)Individual #1's individual support plan meeting was held on 5/27/21 and there are no records that their assessments were sent to any team member prior to the planning meeting. Individual #2's record didn't include records that their 8/18/21 assessment was sent to any team member.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.Program Specialists have been trained to ensure the annual assessment is provided to support team members at least 30 days prior to the ISP. The prompt that an assessment is due has been adjusted to 30 days prior to 60 days prior. 01/06/2022 Implemented
2380.185(1)Individuals #1's and #2's supervision needs and assistance while at the program and when out in the community with program staff is not included in their individual support plan.The individual plan, including revisions, must include the following: The individual's strengths, functional abilities and service needs.An excerpt from Individual #1's ISP, which is attached, indicates the level of supervision required. 01/18/2022 Implemented
2380.185(5)Individual #1's individual support plan (isp) didn't include their fall protocol that needs to be implemented at program to prevent potential injury. Individual #3's isp doesn't include their choking protocol that program staff are to implement at the facility. Their isp states at the facility they can make healthy food choices and eat independently. This is different then the choking protocol provided by the facility; keep within visual light of sight supervision and provide prompts to slow down, swallow, take a drink or smaller bites. There are no records that the facility sent the individual's choking protocol to the supports coordinator or isp team.The individual plan, including revisions, must include the following: Risks to the individual's health, safety or well-being, behaviors likely to result in immediate physical harm to the individual or others and risk mitigation strategies, if applicable.Program specialist shall notify the Supports Coordinator that the fall protocol needs to be added to the plan. 01/18/2022 Implemented
2380.183(c)Individual #2's record didn't include a list of all participants who attended their individual support plan planning meeting.The list of persons who participated in the individual plan meeting shall be kept.Program Specialists have been trained to include a list of all participants who attend annual ISP meetings. 01/06/2022 Implemented
SIN-00180166 Unannounced Monitoring 11/30/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(1)Medical history was not included with Individual #2 physical examination.The physical examination shall include: A review of previous medical history.The Director of Programs developed a form to be completed as part of the annual physical examination process. Program Specialists were directed via email on December 11, 2020 and again in a Teams meeting December 15, 2020, to include the review of previous medical history when annual physical examinations are completed. Furthermore, Program Specialists shall request a copy of the current Lifetime Medical History for participants who live in a group home. 12/16/2020 Implemented
2380.111(c)(10)The 10/02/20 physical does not address if Individual #1 has medical information pertinent to Diagnosis and Treatment in case of an Emergency. The form lists a few diagnoses in another area, but important information like a diagnosis for Scoliosis, broken rods in the lower back, or Osteoporosis.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The Director of Programs instructed Program Specialists, via email on December 11, 2020 and again in a Teams meeting December 15, 2020, to prepopulate the physical examination form prior to it going to the physician. Specifically, Program Specialists shall review the participants ISP, focusing on Medical information, to ensure required information is prepopulated on the physical examination. 12/16/2020 Implemented
2380.173(1)(iii)Individual #2 record did not include the means of communication/primary language.Each individual's record must include the following information: Personal information including: The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English.The Director of Programs shall instruct each Program Specialist to update each participants record to include the language or means of communication used by the participant and the primary language used in the participants natural home. 12/31/2020 Implemented
2380.173(1)(iv)Individual #1 and #2 records did not include religious affiliation.Each individual's record must include the following information: Personal information including: Religious affiliation.The Director of Programs shall instruct each Program Specialist to update each participants record to include each participants religious affiliation. A checkbox has been added to the Custom Fields box in Setworks to document the Religious Preference for each participant. As Program Specialists speak with families and participants, They shal ask what their religious preference is, then document it in the checkbox. They shall document their conversation in the Communications section of Setworks. This information was communicated in a team Huddle on December 15. 01/15/2021 Implemented
2380.21(u)The Department issued updated Individual Rights effective 02/03/20. There is not proof that these rights were reviewed with Individual #1 or Individual #2.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.The Senior Program Specialist ensured rights were reviewed with both Individual #1 and Individual #2, on December 3, 2020. The Director of Programs shall ensure the required information is completed during the admission process and annually thereafter. 01/15/2021 Implemented
2380.21(v)There is no record of the annual requirement for the Individual Rights for Individual #1 or Individual #2 being maintained.The facility 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.A form has been developed to review and obtain signatures that participants have been informed of their rights upon admission and annually thereafter. The form has been added to the packet of forms to be reviewed at the annual ISP meeting. The form shall also be included in the admissions process. This process was communicated to Program Specialists by the Director of Programs on December 16, 2020. It was also discussed at a meeting with the Program Specialists on December 15. Documentation shall be maintained in the participants file. 12/16/2020 Implemented
SIN-00151864 Renewal 03/15/2019 Compliant - Finalized
SIN-00151400 Renewal 02/26/2019 Compliant - Finalized
SIN-00108707 Initial review 02/07/2017 Compliant - Finalized