| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
|
SIN-00250890
|
Renewal
|
09/05/2024
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.21(b) | The facility expanded the size of its "Life Skills" programming area located on the building's second floor without obtaining the Department's approval for increased capacity to license the specific area. During the Entrance Conference on 9/5/24, Director #1, Chief Executive Officer #2, and Assistant Director #3 revealed that the unlicensed area of the enlarged programming room was currently being occupied and used by the individuals. | The legal entity responsible for a facility or agency subject to licensure under Article X of the Public Welfare Code (62 P. S. § § 1001¿1080) shall submit an application for a certificate of compliance prior to commencing operation of the facility or agency and may not commence operation until notified that a certificate of compliance will be issued. | Program Specialist has filled out the required documentation-Increase Capacity Form, submitted it to the regional licensing manager as well as emailed our AE for approval. See attached for visual evidence-(sent email to AE, sent email to regional licensing manager and Increase Capacity Form) We are currently awaiting a response from licensing regional manager on how to proceed next. |
09/30/2024
| Implemented |
| 2380.55(a) | At 3:12 PM on 9/5/24, both microwaves in the kitchen located in the cafeteria programming area on the building's basement level were observed with several dried-up food splatters scattered throughout the interior of the appliances. [Repeated Violation- 9/6/23] | Clean and sanitary conditions shall be maintained in the facility. | Program specialist has done a thorough job of cleaning and sanitizing the interior microwaves. Program Specialist has inspected both microwaves and thoroughly cleaned all food splatter inside the interior microwaves. Program Specialist used a mixture of dawn dish soap, water, lemon juice and white vinegar- applied the mixture to a sponge to scrape and sanitize the interior. Visual evidence of a clean microwave see attachments (microwave 1 and microwave 2). |
09/06/2024
| Implemented |
| 2380.56 | On 9/5/24, the mechanical ventilation grates located in the women's and men's bathrooms located on building's second floor licensed for programming and in the men's bathroom located on the basement level licensed for programming were found covered with a thick film of dust and debris reducing functionality at the following times, respectively, 3:00 PM, 3:05 PM, and 3:10 PM. | Program areas, dining areas, kitchens, bathrooms and first aid rooms shall be ventilated by operable windows or mechanical ventilation such as fans or air conditioning. | Program Specialist immediately cleaned the mechanical ventilation gates located in the women and men¿s bathrooms on the building second and basement floor. Program Specialist used a handheld vacuum to the vents to remove the dust and dirt. Program Specialist used a damp microfiber cloth to wipe the outside of the vent. Visual evidence of clean vents- see attachments (2 floor men, 2 floor women and basement men). |
09/06/2024
| Implemented |
| 2380.84 | The facility had annual onsite fire safety inspections completed in November 2022, and then again on 1/17/24. | The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept. | CFO oversight. 2023 fire Safety inspection for Center for Hearing and Deaf Services was scheduled for November 17, 2023, however, no one showed up. The next available appointment was January 17, 2024. Center for Hearing and Deaf Services completed Fire Safety inspection on 1/17/2024 and that report was submitted to licensing prior to inspection. |
01/17/2024
| Implemented |
| 2380.111(c)(1) | Individual #4's most recent physical examination completed on 5/6/24, did not include a review of their previous medical history, as the document lacked this required field entirely. | The physical examination shall include: A review of previous medical history. | Individual #4¿s physical has been revised to include their previous medical history and has been stored in their file. See Attached (individual 4 med history). |
09/06/2024
| Implemented |
| 2380.174(b) | The individual plan found on site at the facility for Individual #3 was last updated for the 7/1/23 to 6/30/24 fiscal year. However, the most current individual plan for Individual #3 found in the Home and Community Services Information System was last updated for the 7/1/24 to 6/30/25 fiscal year. | The most current copies of record information required in § 2380.173(2)¿(11) shall be kept at the facility. | Individual #3¿s plan for 7/1/24 to 6/30/25 has been printed from HCIS and stored in their file. See attached (Individual 3 ISP) |
09/06/2024
| Implemented |
| 2380.181(e)(1) | Individual #1's current assessment completed on 10/10/23, did not address their preferences, as the document lacked this required field entirely. Individual #2's current assessment completed on 6/3/24, did not address their preferences, as the document lacked this required field entirely. Individual #3's current assessment completed on 1/30/24, did not address their preferences, as the document lacked this required field entirely. Individual #4's current assessment completed on 5/20/24, did not address their preferences, as the document lacked this required field entirely. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | Individual #1¿s assessment has been updated and revised to include their preferences.
Individual #2¿s assessment has been updated and revised to include their preferences.
Individual #3¿s assessment has been updated and revised to include their preferences
Individual #4¿s assessment has been updated and revised to include their preferences.
For visual evidence see attachments (Assessment 1, Assessment 2, Assessment 3 and Assessment 4) |
09/06/2024
| Implemented |
| 2380.181(e)(2) | Individual #1's current assessment completed on 10/10/23, did not address their interests, as the document lacked this required field entirely. Individual #2's current assessment completed on 6/3/24, did not address their interests, as the document lacked this required field entirely. Individual #3's current assessment completed on 1/30/24, did not address their interests, as the document lacked this required field entirely. Individual #4's current assessment completed on 5/20/24, did not address their interests, as the document lacked this required field entirely. | The assessment must include the following information: The likes, dislikes and interests of the individual, including vocational and employment interests. | Individual #1¿s assessment has been updated and revised to include their interests.
Individual #2¿s assessment has been updated and revised to include their interests.
Individual #3¿s assessment has been updated and revised to include their interests
Individual #4¿s assessment has been updated and revised to include their interests.
See attachments (ASSESSMENT 1, ASSESSMENT 2, ASSESSMENT 3 and ASSESSMENT 4) |
09/06/2024
| Implemented |
| 2380.181(e)(4) | Individual #1's current assessment completed on 10/10/23, did not address their supervision needs at the facility, as the document lacked this required field entirely. Individual #2's current assessment completed on 6/3/24, did not address their supervision needs at the facility, as the document lacked this required field entirely. Individual #3's current assessment completed on 1/30/24, did not address their supervision needs at the facility, as the document lacked this required field entirely. Individual #4's current assessment completed on 5/20/24, did not address their supervision needs at the facility, as the document lacked this required field entirely. | The assessment must include the following information: The individual¿s need for supervision. | Individual #1¿s assessment has been updated and revised to include their supervision needs at the facility.
Individual #2¿s assessment has been updated and revised to include their supervision needs at the facility.
Individual #3¿s assessment has been updated and revised to include their supervision needs at the facility.
Individual #4¿s assessment has been updated and revised to include their supervision needs at the facility.
See attachments (ASSESSMENT 1, ASSESSMENT 2, ASSESSMENT 3 and ASSESSMENT 4) |
09/06/2024
| Implemented |
| 2380.181(e)(10) | Individual #2's current assessment completed on 6/3/24, and their entire content of records did not include a lifetime medical history. Individual #3's current assessment completed on 1/30/24, and their entire content of records did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Individual #2¿s assessment has been revised and updated to include their lifetime medical history. See attached for visual evidence (Individual 2 lifetime med). Individual #3¿s assessment has been updated to include their lifetime medical history. See attached for visual evidence (Individual 2 lifetime med and Individual 3 lifetime med) |
09/06/2024
| Implemented |
| 2380.181(e)(11) | Individual #1's current assessment completed on 10/10/23, and their entire content of records did not include a psychological evaluation. Additionally, the facility did not provide documentation of having ever attempted to obtain one. | The assessment must include the following information: Psychological evaluations, if applicable. | Program Specialist contacted individual #1¿s psych doctor (9/6/24), residential provider (9/9/24) and support Coordinator (9/9/24) in attempt to obtain psych records. Psych doctor did not have, residential prover responded and faxed evaluation to program specialist on (9/12/24). Program Specialist reviewed individual #1¿s Psych Evaluation and added to his file. See attached updated evaluation (Individual 1 Psych) |
09/12/2024
| Implemented |
| 2380.181(e)(12) | Individual #1's current assessment completed on 10/10/23, did not address recommendations for specific areas of training, vocational programming, and competitive community-integrated employment. This field was left blank. | The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment. | Individual #1¿s assessment has been updated and now addresses the areas of specific training, vocational programing and competitive community-integrated employment. See attached for visual evidence of completion (Assessment 1) |
09/09/2024
| Implemented |
| 2380.181(f) | Individual #3's current assessment completed on 1/30/24, was sent by Program Specialist #3 on 2/8/24, to individual plan team members for an annual review meeting that was held on 3/5/24. | 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 Specialist #3 has been retrained on 55 PA Code Chapter¿2380.181(f) and now understands the requirements of emailing individual plan team members assessment 30 days prior to their annual review meeting. |
09/11/2024
| Implemented |
| 2380.182(c) | Individual #2's current assessment completed on 6/3/24, indicated they require partial physical assistance to safely identify, avoid, and use poisonous materials. However, Individual #2's most recent individual plan last updated on 6/19/24, states they can safely identify, avoid, and use poisonous materials with independence. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Individual #2¿s assessment has been updated to reflect that of what is written in their ISP. Individual #2 can safely identify, avoid and use poisonous materials with independence. See attached (Assessment 2) |
09/12/2024
| Implemented |
|
|
|
SIN-00230218
|
Renewal
|
09/06/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.55(a) | At 2:34PM, two microwaves, in the kitchen on the first floor, had a multitude of food splatter and food crumbs throughout the top and botton and sides inside walls and ceiling. At 2:36PM, a plastic basin completely filled with a foul smelling greenish black moldy water in a cabinet under the sink in the kitchen on the first floor of the facility. | Clean and sanitary conditions shall be maintained in the facility. | A clean and sanitary kitchen is very important to us. Every afternoon the Kitchen is cleaned, however, there are other departments and people in the building that do not always do this. The areas in question have been cleaned. Pictures will be attached. Cleaning will be maintained every day in the future. |
09/15/2023
| Implemented |
| 2380.59(a) | At 2:48PM, the hot water was not operable at the men's bathroom sink on the second floor. When the faucet was turned to hot, there was just a trickle of water which measured only 91.4 degrees Fahrenheit. | The facility shall have hot and cold running water under pressure in bathrooms and kitchen areas. | The hot water not working in the 2nd floor men's bathroom was brought to the attention of our CFO who in turn reached out to a plumber who unfortunately had to reschedule. The male staff and clientele have been using the 3rd and 1st floor men's bathrooms until the problem is fixed. The Plumber arrived 9/15/2023. he has fixed the hot water in the 2nd floor bathroom and has regulated the water temperature to 110 degrees at all bathroom water sources. |
09/15/2023
| Implemented |
| 2380.59(b) | At 2:34PM, the hot water temperature measured 122.1 degrees Fahrenheit at the sink in the kitchen on the first floor of the facility. | Hot water temperatures in areas accessible to individuals may not exceed 120°F. | The hot water temperature in our kitchen has been brought to the attention of our CFO who in turn reached out to a plumber. The Plumber arrived 9/15/2023. he said the sink in the Kitchen has to have a mixing valve installed to regulate the water temp. He said he has to order the part and will be back next week to install it. When the Mixer is installed will take a picture of the finished work and send it. |
09/20/2023
| Implemented |
| 2380.72(b) | There is a multitude of overgrown shrubbery extending over the outside walkway and outside stairway leading from the exit at the back of the facility, blocking this egress from the facility. | The outside of the building and the facility grounds shall be well maintained, in good repair and free from unsafe conditions. | throughout the summer our CFO has been trying to get a landscaping co. to come out and trim our bushes and green areas around the facility. apparently, no one wants to do the job until last week There is a landscaper coming out 9/15/23 to trim back the weeds that are blocking the walkway on the side of the building.. Pictures of the cut back area in question will be attached. |
09/15/2023
| Implemented |
| 2380.111(c)(3) | Individual #2's most recent Tetanus immunization was completed 5/3/2010. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Physical exams and TB tests are often times a struggle for us to get from residential. I am finding that many times things are missing from the physical or only part of the physical is sent. I was able to obtain Individual #2 physical but they did not send immunizations. I have since e-mailed #2 home staff. They have sent me an up to date immunization record for her. On it you will see that her tetanus is up to date. a copy will be attached. |
09/19/2023
| Implemented |
| 2380.111(c)(8) | Individual #1's physical examination, completed 9/7/2022, does not include the physical limitations of the individual. | The physical examination shall include: Physical limitations of the individual. | The Program specialist has contacted individual #1 home. and requested that they take his Physical exam back to the DR and have this section filled out. I am anticipating getting this back by 9/18/23. Maybe sooner. A copy of the filled out form will be attached. |
09/18/2023
| Implemented |
| 2380.111(c)(10) | Individual #1's physical examination, completed 9/7/2022, does not include medical information pertinent to diagnosis and treatment in case of an emergency. Individual #2's physical examination, completed 1/18/2023, does not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Program specialist has contacted individual #1 and Individual #2 home. and requested that they take his Physical exam back to the DR and have this section filled out. I am anticipating getting this back by 9/18/23. Maybe sooner. |
09/18/2023
| Implemented |
| 2380.111(c)(11) | Individual #1's physical examination, completed 9/7/2022, does not include special instructions for an individual's diet. | The physical examination shall include: Special instructions for an individual's diet. | The Program specialist has contacted individual #1 home. and requested that they take his Physical exam back to the DR and have this section filled out. I am anticipating getting this back by 9/18/23. Maybe sooner. |
09/18/2023
| Implemented |
| 2380.113(b) | Direct Service Worker #1's physical examination, dated 10/6/2021, is not signed and dated a licensed physician, certified nurse practitioner or certified physician's assistant. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant. | I don't know how this got by the staff person or myself. This is such an obvious thing to check. The Program Specialist will slow down and take the time needed to read thoroughly each and every Physical exam he receives. Direct service worker has taken the exam back to her dr. to get it signed. The Dr. that filled out the Physical 2 years ago, 2021, is no longer with the practice. The Dr. who saw Staff #1 this week for her current Physical said she could not sign the old one because it's 2 years old and she is not the person who performed the Physical. |
09/15/2023
| Implemented |
| 2380.113(c)(2) | Direct Service Worker #1's most recent Tuberculin Skin Testing by Mantoux method, dated 10/8/2021, is not certified by a medical professional. | 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 is from the same physical exam as the one above. such an obvious thing to check. I don't know how we missed it. Staff #1 Direct service worker has taken the exam back to her dr. to get it signed. The Dr. that filled out the Physical 2 years ago, 2021, is no longer with the practice. The Dr. who saw her this week for her current Physical said she could not sign the old one because it's 2 years old and she is not the person who performed the Physical. |
09/15/2023
| Implemented |
|
|
|
SIN-00211663
|
Renewal
|
09/21/2022
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(c)(4) | Individual #2, date of admission 5/23/1989, had a physical completed on 10/17/2021. The physical did not include a vision or hearing screening. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | The residential facility only sent the first page of the physical. this got past the program specialist. Once this was brought to our attention we immediately contacted residential and they sent the second page of the physical. |
10/03/2022
| Implemented |
| 2380.39(c)(1) | Chief Executive Officer #1, date of hire 11/01/2016, did not complete the following training during the 2021 calendar training year: 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. | I was able to find one of the missing trainings "Individual Rights" The CEO will complete the missed trainings immediately. A copy of the certificates will be attached. Certificates of Achievement, dated 9/29/22, that include Building Relationships, Person Centered Practices, and Community integration were received on 10/4/22 and reviewed on 10/4/22. Policy on Staff Training that includes the required annual training topics, as required by 6400.52c1-6, and signed by CEO on 9/29/22 was received on 10/4/22 and reviewed 10/4/22. DPOC by HDKP, HSLS, on 10/4/22]. |
09/29/2022
| Implemented |
| 2380.181(f) | The assessment dated 4/28/2022 for Individual #1, date of admission 4/29/2011, was provided to the individual plan team members on 5/05/2022 for the individual plan meeting held on 6/02/2022.
The assessment dated 7/29/2022 for Individual #2, date of admission 5/23/1989, was provided to the individual plan team members on 8/02/2022 for the individual plan meeting held on 8/30/2022.
The assessment dated 7/08/2022 for Individual #3, date of admission 8/20/2009, was provided to the individual plan team members on 7/12/2022 for the individual plan meeting held on 8/10/2022. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | The Program Specialist will be a wear of the time constraints with assessments. |
10/10/2022
| Implemented |
|
|
|
SIN-00195287
|
Renewal
|
10/22/2021
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(a) | Individual #4 had a physical examination completed 3/28/19 and then again 9/14/21. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | This was due to Program Specialist overlooking this . Individual #4 left our program in march of 2020 . returned in April 2021. I was assured that i would be getting a copy of her Physical but it never happened. The Program Specialist, with the help of our IT dept. will set up a colander in Outlook with the dates of the current Physical and TB test for all Clients and staff. There will also be a 120 day reminder , from each date, to alert the Program Specialist and staff of that up coming physical or TB test.. |
11/12/2021
| Implemented |
| 2380.111(c)(4) | Individual #2's physical examination completed 9/14/21 did not include a vision and hearing screening. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | This is due to The Program Specialist not looking at the Physical exam close enough. This will not happen again. The program Specialist will check thoroughly the exams of every client and staff. If vision and hearing screening is not included The program Specialist will contact the Physician to see if one was given. The program Specialist is currently contacting the Residential facility to get the date and a copy of each individuals latest vision and hearing screening. |
11/12/2021
| Implemented |
| 2380.111(c)(6) | Individual #1's physical examination completed 7/15/21 did not indicate if the individual was free from communicable disease. It was left blank. Individual #3's physical examination completed 7/15/21 did not indicate if the individual was free from communicable disease. It was left blank. | The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals. | This is due to The Program Specialist not looking at the Physical exam close enough. This will not happen again. The program Specialist will check thoroughly the exams of every client and staff. If If Free of all communicable Diseases is not checked. The program Specialist will contact the Physician to find the reason. If it was just overlooked the Program Specialist will take the Physical to the Physician to have him check the box. The client will not be able to attend program until this matter has been cleared up. |
11/05/2021
| Implemented |
| 2380.111(c)(10) | Individual #1's physical examination completed 7/15/21 did not include medical information pertinent to diagnosis and treatment in case of an emergency. It was left blank. Individual #3's physical examination completed 7/15/21 did not include medical information pertinent to diagnosis and treatment in case of an emergency. It was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | This is due to The Program Specialist not looking at the Physical exam close enough. This will not happen again. The program Specialist will check thoroughly the exams of every client and staff. If Medical information pertinent to diagnosis and treatment in case of emergency is not included The program Specialist will contact the Physician to see if one was given. The program Specialist will contact the Physician to find the reason. If it was just overlooked the Program Specialist will take the Physical to the Physician to have him check the box. |
11/05/2021
| Implemented |
| 2380.113(a) | Direct Service Worker #4 had a physical examination completed 2/05/19 and then again 10/07/21. | 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. | This was due to Program Specialist overlooking this . Staff #4 said she had a cancelation but does not have any communication showing that. The Program Specialist, with the help of our IT dept. will set up a colander in Outlook with the dates of the current Physical and TB test for all staff. There will also be a 120 day reminder , from each date, to alert the Program Specialist and staff of that up coming physical or TB test.. |
11/12/2021
| Implemented |
| 2380.181(a) | The most recent assessment for Individual #4 was completed 9/21/20. | 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. | This was due to Program Specialist not being sure when and if there was going to be an ISP invitation being sent out. During 2020 many ISC's gave team members very short notice on when the ISP meeting was going to be scheduled. I had an idea of the time of year when #4 should behaving their meeting As it turned out i was about 60 days too soon. #4's meeting was Dec 10. 2020. I received her invitation via e-mail Nov.30. 2020. so you see how short notice that is. The program Specialist will add tot he Outlook colander The dates of the last ISP date for each client with a 60 day reminder. |
11/12/2021
| Implemented |
| 2380.36(b) | Program Specialist #2, Direct Service Worker #3, and Direct Service Worker #4 had training in general fire safety on 8/05/19 and then again 4/21/21. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | This was due to our CEO's inability to set a class up with the city of Pittsburgh fire training during the 2020 year. Moving forward and with some idea's from our inspector we will no longer just depend on the city of Pittsburgh's fire training has we have in the past. We will investigate other avenues of training such as videos and/or other certified classes on the subject. . |
11/12/2021
| Implemented |
| 2380.39(c)(2) | Chief Executive Officer #1, date of hire 11/01/06, has no record of having annual training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse. Program Specialist #2, date of hire 1/24/04, has no record of having annual training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse. Direct Service Worker, date of hire 10/01/05, has no record of having annual training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | This was due to Program Specialist over looking this dead line. The above trainings have been completed and copies will be attached. The program specialist did eventually remember about these trainings and they have been completed before inspection but not before Dec 2020. I know that didn't help much. Moving forward a policy has been written and will be signed by all staff quarterly to remind us of these trainings. Our director will sign off on this. A copy of the policy with signatures will be attached. |
11/12/2021
| Implemented |
| 2380.39(c)(3) | Chief Executive Officer #1, date of hire 11/01/06, has no record of having annual training in individual rights. Program Specialist #2, date of hire 1/24/04, has no record of having annual training in individual rights. Direct Service Worker, date of hire 10/01/05, has no record of having annual training in individual rights. Direct Service Worker #4, date of hire 7/01/17, has no record of having annual training in individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | This was due to Program Specialist over looking this dead line. The above trainings have been completed and copies will be attached. Moving forward a policy has been written and will be signed by all staff quarterly to remind us of these trainings. Our director will sign off on this. A copy of the policy with signatures will be attached. |
11/12/2021
| Implemented |
| 2380.39(c)(4) | Chief Executive Officer #1, date of hire 11/01/06, has no record of having annual training in recognizing and reporting incidents. Program Specialist #2, date of hire 1/24/04, has no record of having annual training in recognizing and reporting incidents. Direct Service Worker, date of hire 10/01/05, has no record of having 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. | This was due to Program Specialist over looking this dead line. The above trainings have been completed and copies will be attached. Moving forward a policy has been written and will be signed by all staff quarterly to remind us of these trainings. Our director will sign off on this. A copy of the policy with signatures will be attached. |
11/12/2021
| Implemented |
| 2380.39(c)(5) | Direct Service Worker #3, date of hire 10/01/05, has no record of having annual training in the safe and appropriate use of behavior supports if the person works directly with an individual. Direct Service Worker #4, date of hire 7/01/17, has no record of having 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. | This was due to Program Specialist over looking this dead line. The above trainings have been completed and copies will be attached. Moving forward a policy has been written and will be signed by all staff quarterly to remind us of these trainings. Our director will sign off on this. A copy of the policy with signatures will be attached. |
11/12/2021
| Implemented |
|
|
|
SIN-00179506
|
Renewal
|
11/10/2020
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.21(v) | The facility did not keep a copy of the statement acknowledging receipt of the information on individual rights signed by Individual #1. The facility did not keep a copy of the statement acknowledging receipt of the information on individual rights signed by Individual #2. | 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. | This was due to administration error. We were set to do the rights training in March of 2020 but never got to it due to closure from the pandemic. A copy of our new Clients rights policy is attached. This training will be done annually and will be the responsibility of the program specialist to see that it is done during the month of January every year. A check off list with date of training for each Client training will be kept in their file . I am unable to send the up dated training for the two individuals at this time due to our emergency closure last week, our new clients rights policy had not yet been completed. All clients will have their rights training immediately upon return to our program. |
11/24/2020
| Implemented |
|
|
|
SIN-00158637
|
Renewal
|
07/11/2019
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.113(a) | Direct Service Worker #1, date of hire 02/09/17, had physical examination on 10/20/16 and then again on 12/18/18. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Direct staff #1 did not have her Physical exam in on time. This was due to administration oversight. The staff member was informed but she was not informed in enough time to make an appointment with her PCP before her previous physical expired. Our Plan of correction is to set up a program in our computers with a list of all staff members and when their Physical exams are due. This program will alert the director , Program Specialist and the staff member 60 days before their current Physical expires . This should give the person enough time to make an appointment before the due date. [At least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking and notification system and a 25% sample of staff person's physical examination to ensure all staff persons have physical examinations completed, timely. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 7/30/19)] |
08/30/2019
| Implemented |
| 2380.36(b) | Direct Service Worker #1 had annual fire safety training on 07/24/17 and then again on 08/21/18. Program Specialist #2 had annual fire safety training on 07/21/17 and then again on 08/21/18. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Our Fire safety training violation was due two reasons. 1, the meeting was set up for the 7/18/2018 but the fire official who does the training got sick and asked us to reschedule.. When we called to set another date the earliest we could get was 8/21/2018. This is going to be corrected in the same way the other violation is corrected. We are going to install a program into our calendar system that will remind our administrator to make this appointment 120 days before the annual due date. this notification will continue to alert her everyday until she puts in the date of the next fire safety training. We believe 90 days is enough time to to set up an appointment without going over last years date. [According to the Program Specialist, the next fire safety training is scheduled for August 5, 2019. At least quarterly for 1 year, the CEO or designee shall audit a 25% sample of staff persons' fire safety trainings to ensure timely completion and the aforementioned process is working. (DPOC by AES,HSLS on 8/1/2019)] |
08/23/2019
| Implemented |
|
|
|
SIN-00138377
|
Renewal
|
07/18/2018
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.33(b)(10) | The March 2018 monthly ISP review for Individual #1 was not signed by the Program Specialist.
The May 2018 monthly ISP review for Individual #1 was not signed by the Program Specialist until 6/30/18. | The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of an individual's participation and progress toward outcomes. | This was due to oversight.After typing up a progress note, (monthly's) , the program specialist prints it out and signs it. This one, the program specialist missed. The program specialist will review all clients monthly's to see if anymore signatures have been missed. this will be completed 8/31/2018. If there are missing signatures they will be signed. The mistake with the date on #1 was a typing error . It should read 5/30/18. program specialist hit 6 by mistake. The program specialist will review all clients monthly's to see if dates are correct. this will be completed 9/30/2018.
It is the program specialists responsibility to make sure that monthly's are completed as per 2380.33 , therefore for the next year the director of the ATF will review 2380.33(b)(10) with the program specialist quarterly. The program specialist will sign off when each review is completed. [Documentation of the audits by the Director of the ATF shall be kept. (DPOC by AES,HSLS on 8/14/18)] |
07/27/2018
| Implemented |
| 2380.87(d) | The inoperable fire alarm policy did not include a written procedure for fire safety monitoring in the even the fire alarm is inoperative. | There shall be a written procedure for firesafety monitoring in the event the fire alarm is inoperative. | The ATF does have an inoperable fire alarm policy. It was missing part (d) of the code. This was due to program specialist error. The program specialist has added this to the policy saying; The program specialist and the director of the ATF will walk around the area of the inoperable fire alarm every half hour to make sure there are no smoke or fire issues. Staff will be trained on this and will sign off on it. A copy of the policy will be attached.. |
07/24/2018
| Implemented |
| 2380.91(c) | Individual #2, admitted 11-11-16, had fire safety on 9/11/17. There was not a written record of the prior fire safety training; therefore, compliance could not be measured. Individual #3, admitted 10-11-16, had fire safety on 8/15/17. There was not a written record of the prior fire safety training; therefore, compliance could not be measured. Individual #4, admitted 11-17-16, had fire safety on 8/14/17. There was not a written record of prior fire safety training; therefore, compliance could not be measured. | A written record of firesafety training, including the content of the training and individuals attending, shall be kept. | The program specialist has fire safety training for the clients at a minimum 4 times a year. Nowhere on the signature pages were the signatures of the individuals 2,3,4 . The program specialist along with staff have recently given individual 2,3,4 updated fire safety training. A copy of their training is attached. The program specialist will go through all clients files to see if anyone else has missed a training.. if they have they will be retrained. The ATF has different clients attend on various days. The program specialist will take one week quarterly to have fire safety training everyday that week to ensure all clients have the training.
It is the program specialists responsibility to make sure all clients are trained on fire safety, therefore for the next year the director of the ATF will review all of 2380.91 with the program specialist quarterly. The program specialist will sign off when each review is completed.[Documentation of the audits by the Director of the ATF shall be kept. (DPOC by AES,HSLS on 8/14/18)] |
07/27/2018
| Implemented |
| 2380.111(a) | Individual #1 had a physical examination on 2-10-17 and than again on 6-28-18. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The program specialist did not realize the separation between 2017's physical exam and 2018's. The program specialist will review all clients physicals to see if there are variances with the dates from year to year. The Program Specialist, in conjunction with the CEO has developed a tracking sheet for each clients Physical exams Dates of when these Are due will be checked monthly. 30 days before a Physical is due The program specialist will inform the team. If a clients Physical does not arrive at the time it is due the Client will not be able to attend the program. until one is received. A copy of the tracking sheet will be attached.
It is the program specialists responsibility to make sure Physical exams are up to date, therefore for the next year the director of the ATF will review all of 2380.111 with the program specialist quarterly. The program specialist will sign off when each review is completed.[Documentation of the audits by the Director of the ATF shall be kept. (DPOC by AES,HSLS on 8/14/18)] |
07/27/2018
| Implemented |
| 2380.111(c)(5) | Individual #1, admitted 5-23-16, had physical examinations on 2-10-17 and 6-28-18; however, both physicals did not contain a Tuberculin skin 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. | This was due to oversight. The program specialist assumed that an individuals residence and/or family would see to it that this is done. The program specialist called individual #1 sister. She said she would set up an appointment as soon as possible. Individual # 1 has been suspended until a`TB test is obtained The Program Specialist, in conjunction with the CEO has developed a tracking sheet for each clients TB tests Dates of when these Are due will be checked. 30 days before a TB test is due The program specialist will inform the team through e-mail and phone calls. If a clients test does not arrive at the time it is due the Client will not be able to attend the program. until one is received. A copy of the tracking sheet will be attached. This tracking sheet will not just be something we do for a year. this will be something the program specialist updates yearly and continues with.
It is the program specialists responsibility to make sure that all clients TB tests are up to date., therefore for the next year the director of the ATF will review all of 2380.111 with the program specialist quarterly. The program specialist will sign off when each review is completed.[Documentation of the audits by the Director of the ATF shall be kept. (DPOC by AES,HSLS on 8/14/18)] |
07/27/2018
| Implemented |
| 2380.181(a) | Individual #1's most recent assessment was completed on 1/16/17. Individual #2's most recent assessment was completed on 1/11/17. | 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. | this was due to Oversight. The program specialist did not send assessments to individual #1 and #2 team for 2018. when they were due. The program specialist did complete them and sent them on 7/24/2018. A copy of the sent e-mail to the team will be attached. The Program specialist will review all client assessment for the last 2 years to see if there are any more assessment that were not sent. if there are they will be sent. To ensure this does not happen again The Program Specialist, in conjunction with the CEO has developed a tracking sheet for each clients Assessments. Dates of when these Are due will be checked and signed off by the CEO when they are sent.
It is the program specialists responsibility to make sure Assessments are written, reviewed and sent out, therefore for the next year the director of the ATF will review all of 2380.181 with the program specialist quarterly. The program specialist will sign off when each review is completed.[Documentation of the audits by the Director of the ATF shall be kept. (DPOC by AES,HSLS on 8/14/18)] |
07/27/2018
| Implemented |
| 2380.181(e)(10) | Individual #3's assessment, dated 2-21-18, did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | This was due to Oversight. The program specialist was not aware that a life time medical history had to be attached to all assessments. After reviewing 2380.181(e)(10) the program specialist obtained individual #3 med. history on 7/ 19/2018. The program specialist will go through all the clients files to see if there are med. history's. This will be completed by 8/31/2018. If there are any history's missing the program specialist will contact the team through e-mail and phone calls to obtain a life time medical history for that individual. A copy of the sent e-mails will be kept in the clients file to show the program specialists attempts to receive this information.
It is the program specialists responsibility to make sure goal plans are written, reviewed and sent out, therefore for the next year the director of the ATF will review all of 2380.181with the program specialist quarterly. The program specialist will sign off when each review is completed.[Documentation of the audits by the Director of the ATF shall be kept. (DPOC by AES,HSLS on 8/14/18)] |
08/10/2018
| Implemented |
| 2380.181(e)(11) | Individual #4's assessment, dated 6-15-18, did not include a copy of a psychological evaluation. Individual #4 requires psychological services. | The assessment must include the following information: Psychological evaluations, if applicable. | This was due to Oversight. The program specialist was not aware that a evaluation was to be attached to assessments. After reviewing 2380.181(e)(10) the program specialist obtained individual #4 Psych evaluation. on 7/ 20/2018. The program specialist will go through all the clients files to see if they have or are in need of a psych evaluation. This will be completed by 8/31/2018. If there are any Psych. evaluations missing the program specialist will contact the team through e-mail and phone calls to obtain them for that individual. A copy of the sent e-mails will be kept in the clients file to show the program specialist's attempts to receive this information.
It is the program specialists responsibility to make sure goal plans are written, reviewed and sent out, therefore for the next year the director of the ATF will review all of 2380.181with the program specialist quarterly. The program specialist will sign off when each review is completed.[Documentation of the audits by the Director of the ATF shall be kept. (DPOC by AES,HSLS on 8/14/18)] |
08/10/2018
| Implemented |
| 2380.181(f) | The program specialist did not provide Individual #3's assessment, dated 2-21-18, to the SC or plan team members prior to the ISP meeting on 3-26-18. The program specialist provided Individual #4's assessment, dated 6-15-18, to the SC and plan team members on 7-3-18 for the ISP meeting on 7-13-18. | The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). | This was due to oversight. #3 Assessment has been updated and sent to the team. The program specialist uses the individuals ISP date to calculate when the individuals annual assessment is due. this in retrospect is not the best idea. The program specialist will now use the date of the last assessment as the Individuals annual assessment date not the 30 days before their ISP. Assessment will still be sent 30 days before an ISP. It will just be an additional one. The Program Specialist, in conjunction with the CEO has developed a tracking sheet for each clients Assessments. Dates of when these Are due will be checked and signed off by the CEO when they are sent. A copy of this tracking sheet will be attached.
It is the program specialists responsibility to make sure assessment are sent out on time, therefore for the next year the director of the ATF will review all of 2380.181 with the program specialist quarterly. The program specialist will sign off when each review is completed.[Documentation of the audits by the Director of the ATF shall be kept. (DPOC by AES,HSLS on 8/14/18)] |
07/27/2018
| Implemented |
| 2380.186(b) | Individual #1's ISP reviews, end dated 7-31-17, 10-31-17, 1-31-18, and 4-31-18, are not dated when signed by the Program Specialist or the Individual. Individual #2's ISP reviews, end dated 7-30-17, 10-30-17, 1-30-18, and 4-30-18, are not dated when signed by the Program Specialist or the Individual. Individual #3's ISP reviews, end dated 7-30-17, 10-30-17, 1-30-18, and 4-30-18, are not dated when signed by the Program Specialist or the Individual.
Individual #4's ISP reviews, end dated 10-30-17, 1-30-18, and 4-30-18, and 6-15-18 are not dated when signed by the Program Specialist or the Individual. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | This was due to Program Specialist oversight. After reviewing 2380.186(b) . The goal plans for the individuals in question have been dated. The program specialist will review all client goal plan for the last 2 years to see if there are anymore noncompliance. if there are they will be corrected. This should be completed by 8/31/2018. The program specialist has made changes to the monthly goal plans for each client. Now beside the line for the clients signature there will also be a space labeled date. Previously there was just a space for signature. An example of this will be attached for your viewing. The program specialist in conjunction with the director of the ATF have developed a tracking sheet with the date when all goal plans are due. The Director will sign off on these date when the Program specialist send these goal plans.
It is the program specialists responsibility to make sure goal plans are written, reviewed and sent out, therefore for the next year the director of the ATF will review all of 2380.186 with the program specialist quarterly. The program specialist will sign off when each review is completed.[Documentation of the audits by the Director of the ATF shall be kept. (DPOC by AES,HSLS on 8/14/18)] |
07/25/2018
| Implemented |
| 2380.186(d) | The program specialist did not provide Individual #3's ISP review, end dated 7-30-17, to the SC or the plan team members. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | This was due to Program Specialist oversight. The program specialist Collects all of the monthly goal plans for that quarter at one time. The program specialist sends, via e-mail ,these goal plans to their designated team. The program specialist missed this one. It has been resent. The program specialist will review the past year goal plans for all clients to make sure they have been sent. If any were not they will be resent.. After reviewing 2380.186d the Program Specialist, has hin conjunction with the Director has developed a tracking sheet for each clients goal plans. Dates of when these goal plans are due will be checked and signed off by the director when they are sent.
It is the program specialists responsibility to make sure goal plans are written, reviewed and sent out, therefore for the next year the director of the ATF will review all of 2380.186 with the program specialist quarterly. The program specialist will sign off when each review is completed.[Documentation of the audits by the Director of the ATF shall be kept. (DPOC by AES,HSLS on 8/14/18)] |
07/27/2018
| Implemented |
|
|
|
SIN-00118302
|
Renewal
|
07/27/2017
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.36(g) | Only one staff person employed by the facility is trained in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | There shall be at least one staff person for every 18 individuals, with a minimum of two staff persons present at the facility at all times who have been trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation within the past year. If a staff person has formal certification from a hospital or other recognized health care organization that is valid for more than 1 year, the training is acceptable for the length of time on the certification. | Only one staff person was trained in CPR/First-aid. This was due to our CEO inability to schedule training before our previous training had expired. Our CEO, aware of 2380.36(g), searched to find someone to train staff. The earliest they could schedule the training was Aug. 8, 2017. Our inspection by the state was July 27, 2017. As of today all staff are certified in CPR/First-aid. Documentation of this will be sent to [the Department][On 8/7/17, six staff persons and on 8/8/17 seven staff persons were trained in first aid, Heimlich techniques and cardio-pulmonary resuscitation. The CEO shall develop and implement a tracking system to ensure there is at least one staff person for every 18 individuals with a minimum of two staff person present at the facility at all times who are trained in FA/CPR, as required. (AS 8/18/18)] |
08/17/2017
| Implemented |
| 2380.91(a) | Individual #1, admitted 10-11-16 was instructed in general fire safety on 12-6-16. | 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 #1 did not have fire safety training upon initial admission to the program. This was due to Program specialist oversite. After reviewing 2380.91(a), a policy has been developed to ensure cliental will be trained in our fire safety procedures. All staff will be trained on this policy immediately and then annually thereafter.. Documentation will be kept on file. A check list will be developed for each client and marked off as they complete each part the training. The individual will sign and date the training along with staff that did the training. A copy of this policy will be sent to [the Department][At least quarterly for 1 year, the CEO shall review the aforementioned checklist to ensure timely completion of individuals' fire safety training. (AS 8/18/17)] |
08/17/2017
| Implemented |
| 2380.111(a) | Individual #2's most recent physical examination was completed 10-12-15. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | There was no current physical examination for Individual #2,. This was due to Program Specialists inability to get a response from the individual¿s support coordinator. Our program specialists contacted the individual¿s ISC¿ to obtain copies of Physical exam many times with no response. The day after our inspection individual #2 physical exam was obtained. A policy will be written for obtaining physical exams this policy will include everything required in 2380.111 and will be signed and dated by our program specialist immediately and reviewed annually signed and dated. A copy of this policy is attached and sent to [The Department] AS 8/18/17)] |
08/17/2017
| Implemented |
| 2380.111(c)(3) | Individual #3's most recent immunization was completed 4-3-07. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Individual #3 did not have updated immunizations. This was due to Program Specialists inability to get a response from the individual¿s support coordinator and family. . Our program specialists contacted the individual¿s ISC and family to obtain copies of immunizations many times with no response. The program specialist contacted the ISC supervisor and was able to obtain what they had, which was immunizations completed on 4/3/07. Individual #3 has recently moved out of her home and is living in a residential facility. The program Specialist has contacted the facility and is in the process of obtaining current immunizations for individual #3.. This will be completed by Aug. 31. A policy has be written for obtaining physical exams this policy will include everything required in 2380.111 and will be signed and dated by our program specialist immediately and reviewed annually signed and dated. A copy of this policy is attached and sent to [The Department] AS 8/18/17)] |
08/17/2017
| Implemented |
| 2380.113(c)(2) | Direct Service Worker #1's physical examination, completed 1-4-17, does not include a completed Tuberculin skin test. Direct Service Worker #2's physical examination, completed 1-24-17, does not include a completed Tuberculin skin test. | 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. | Staff workers 1 and 2. Physical exams do not include a Tuberculin skin test. This is due to Program Specialist oversight. The 2 staff in question got there physical exams at Med Express who¿s forms lack information that is required under 2380.113. Upon the program specialist reviewing 2380.113 C (2) it has been decided that upon an individual¿s acceptance of a position with our Adult training facility, the program Specialist will give them our physical examination form, which has all the necessary information required under 2380.133c. The staff members in question are currently getting their Tuberculin skin test. This will be completed by Aug 31.[Immediately and upon completion, the program specialist shall audit all staff persons' physical examinations to ensure all required information is included. Documentation of audits shall be kept. (AS 8/18/17)] |
08/17/2017
| Implemented |
| 2380.113(c)(3) | Direct Service Worker #2's physical examination, dated 1-24-17, did not include whether the person is free of communicable diseases. | The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in § 27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals. | Staff worker 2. Physical exam does not include whether the person is free of communicable disease . This is due to Program Specialist oversight. The staff in question got her physical exams at Med Express who¿s forms lack information that is required under 2380.113c(3). Upon the program specialist reviewing 2380.113 C (3) it has been decided that upon an individual¿s acceptance of a position with our Adult training facility, the program Specialist will give them our physical examination form, which has all the necessary information required under 2380.133c. The staff member in question is no longer working with our agency[Immediately and upon completion, the program specialist shall audit all staff persons' physical examinations to ensure all required information is included. Documentation of audits shall be kept. (AS 8/18/17)] |
08/17/2017
| Implemented |
| 2380.173(1)(ii) | The records for Individuals #1, #2 and #3 did not include 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. | There was No documentation of identifying marks for clients 1.2 and 3 on their information sheet. This was due to the program specialist assuming that glasses, color of hair, eye color and weight were enough of a description. After reviewing 2380.173(1)(ii) The program specialist will revise this information to include any physical identifying marks. The program specialist will be the responsible party who will see to it that identifying marks are added to each client¿s information sheet. This will be completed immediately. |
08/17/2017
| Implemented |
|
|
|
SIN-00098824
|
Renewal
|
08/03/2016
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.20(a) | Direct Service Worker #1, date of hire 6/14/16, had a criminal history check completed on 7/22/16. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the facility who will have direct contact with individuals, and for part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. | PA State Police background check for staff #1 was not submitted within 5 working days of hire. This was due to oversight. MaryAnn previously worked for our department in 2013. We had her clearances for that time. Upon re-hire our program Specialist believed the old Clearance would still be valid. We have since discovered through our first state inspection that this is not the case. Our Program Specialists, after reviewing 2380.20A, are now aware that PA applications for criminal history background checks for full time, part time and temporary staff persons must be submitted within 5 working days after a person¿s hire date and no later than 1 year before hire. It is our plan that during the hiring process to have the individual complete and submit an application for this clearance within their first 5 days of hire. Policy attached. [Immediately and upon hire, the CEO shall review criminal background checks for staff person having direct contact with individuals to ensure timely request and completion of criminal background checks. (AS 10/6/16)] |
08/23/2016
| Implemented |
| 2380.36(a) | The facility did not provide orientation for Direct Service Worker #1, date of hire 6/14/16. | The facility shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals or in their appointed positions. | The facility did not provide orientation for Direct Service Worker #1, date of hire 6/14/16.There is no documentation showing staff orientation for staff # 1.. After our first state inspection we were informed we had no documentation showing staff orientation. This was due to over sight. We do have staff orientation that follows the guild lines of 2380.36a,d,e however 2380.36h was overlooked for staff orientation. Our program specialists will develop a check list for staff orientation that will follow the requirements of 2380.36a,d,e,and h . When staff orientation is completed the staff and program specialist will date and sign. A record of this orientation will be kept in staff file. A copy of this checklist is attached. [Direct Service Worker #1 completed orientation training on 11/9/16. At least quarterly for 1 year, the CEO shall review the orientation checklist and supporting documents to ensure all staff persons are trained as required prior to working with individuals or in their appointed positions. (AS 11/21/16)] |
08/27/2016
| Implemented |
| 2380.36(h) | The most recent fire safety training record for program specialists and direct service workers was dated 7/22/16. There were no prior record of training; therefore, compliance could not be measured. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | Annual Fire safety training had no documentation of who attended. Although we did have our annual fire safety training and have the documentation of the training there was no documentation attached showing who or how many staff attended the training. This was an oversight. It is our plan moving forward to have a sign in sheet for all staff to record that they were present for the training. This form will be attached to the documentation of the fire safety training. [Added to staff orientation check list. [Staff persons signed as receiving fire safety training on 7/22/16. The CEO shall schedule fire safety training and ensure all staff receive the training and document as required. The CEO shall review the training documentation to ensure all required information is present including the staff persons trained. Documentation of review shall be kept. (AS 11/21/16)] |
08/27/2016
| Implemented |
| 2380.70(e) | The first aid kit did not contain a first aid manual. | A first aid manual shall be kept with each first aid kit. | The first aid kit did not contain a first aid manual.. This was due to over sight. A first aid manual has been obtained and put into the sick room. A picture of the manual is attached. [At least monthly, a designated staff shall audit the first aid kit to ensure all required items are present. (AS 11/2/16)] |
08/27/2016
| Implemented |
| 2380.89(c) | The fire drill records do not include problems encountered and whether the fire alarm was operable. | 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 records do not include problems encountered and whether the fire alarm was operable. Our Fire drill records do not show a space for problems encountered or whether fire alarm was operable. Our program does have monthly fire drills with all the required criteria listed except; problems encountered and whether the alarm was operable. After our state inspection and reviewing 2380.89c we understand that these two criteria are required. Our program specialist has added to our fire drill log Problems encountered and fire alarm operable. A copy of this form is attached. [Fire drills conducted on 8/31/16, 9/29/16 and 10/28/16 address problem encountered and whether the fire alarm was operative. At least quarterly for 1 year, the CEO shall review the fire drill records to ensure all required information is addressed as required. (AS 11/21/16)] |
08/27/2016
| Implemented |
| 2380.111(a) | The most recent physical examination for Individual #1 was dated 5/20/2015. Individual #3 did not have a physical examination. Individual #4, date of admission 11/17/15 had a physical examination completed on 1/2/16. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The most recent physical examination for Individual #1 was dated 5/20/2015. Individual #3 did not have a physical examination. Individual #4, date of admission 11/17/15 had a physical examination completed on 1/2/16. This was due to Program Specialists over sight. Our program specialists contact individual¿s ISC¿s to obtain copies of Physical exams. Sometimes they are sent to us sometimes they are not. Our program specialists plan to ensure that we receive these physical exams in a timely manner. After reviewing 2380.111(a) a policy will be written for obtaining physical exams and will be signed and dated by our program specialists immediately and reviewed annually signed and dated. [Individual #1 had a physical examination completed on 8/15/16. Individual #3 had a physical examination completed on 4/18/16. Immediately, the CEO shall develop a tracking system to ensure all individuals have a physical examination completed, timely. (AS 11/21/16)] |
08/27/2016
| Implemented |
| 2380.111(c)(1) | The physical examination for Individual #1, dated 5/20/15 did not include a review of previous medical history. | The physical examination shall include: A review of previous medical history. | The physical examination for Individual #1, dated 5/20/15 did not include a review of previous medical history. This was due to Program Specialists over sight. Our program specialists contact individual¿s ISC¿s to obtain copies of Physical exams. These physical exams come to us not always complete. Our program specialists have obtained a more in-depth physical form that has in it what is required in 2380.111 ( c ) (1 ) a policy will be written for obtaining physical exams and will be signed and dated by our program specialists immediately and reviewed annually signed and dated.[Individual #1 had a physical examination completed on 8/15/16 to include all required information including previous medical history. Upon completion of all physical examinations the program specialist shall review to ensure all required information is present and there are no required areas left blank. Documentation of reviews shall be kept. (AS 11/22/16)] |
08/27/2016
| Implemented |
| 2380.111(c)(3) | The physical examination for Individual #1, dated 5/20/15 did not include the immunizations. This section was left blank. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The physical examination for Individual The physical examination for Individual #1, dated 5/20/15 did not include the immunizations. This section was left blank. This was due to Program Specialists over sight. Our program specialists contact individual¿s ISC¿s to obtain copies of Physical exams. These physical exams come to us not always complete. Our program specialists have obtained a more in-depth physical form that has in it what is required in 2380.111 ( c ) (3 ). We will offer this form to team members who take this individual for their physical exam. A policy will be written for obtaining physical exams and will be signed and dated by our program specialists immediately and reviewed annually signed and dated. A copy of this policy is attached along with the physical form.[Individual #1 had a physical examination completed on 8/15/16 to include all required information including immunizations. Upon completion of all physical examinations the program specialist shall review to ensure all required information is present and there are no required areas left blank. Documentation of reviews shall be kept. (AS 11/22/16)] |
08/27/2016
| Implemented |
| 2380.113(a) | Direct Service Worker #1, date of hire 6/14/16, Direct Service Worker #2, date of hire 12/5/11, and Program specialist #3, date of hire 4/1/2002 did not have physical examinations. | 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 1, 2 and 3 do not have physical exams as required. This is due to CEO oversight. Prior to being licensed Physical exams had not been required for our program staff. After our first state inspection we were informed that it is necessary for all staff to have a physical exam every two years. Upon our CEO¿s reviewing 2380.113 A,B,C A plan will be implemented to include all the criteria in 2380.113 A,B.C.. A policy has been written to include this process. I twill be signed and dated by all staff immediately and reviewed annually and signed and dated. a copy of the policy is attached.[Immediately, Direct Service Worker #1, Direct Service Worker #2 and Program specialist #3 will not work until physical examinations are completed. Immediately, the CEO will review all staff persons records to ensure physical examinations are completed and staff will not work until physical examinations are completed. Prior to staff persons working with individual or preparing or serving food, the CEO will ensure that physical examinations are completed as required. Documentation of reviews shall be kept. (AS 11/22/16)] |
08/27/2016
| Implemented |
| 2380.173(1)(i) | The records for Individuals #1, #2, #3 and #4 did not include the admission dates. | Each individual's record must include the following information: Personal information including: The name, sex, admission date, birthdate and social security number. | Some required emergency information about each client was missing from their information page. This is due to over sight. All of our client files have a description summary in the front. After our first state inspection it was determined that for individuals 1, 2, 3 and 4. Personal information including: The name, sex, admission date, birth date and social security number, were not included. After reviewing all the information under 2380.173 (1) (i) the program specialist has added this information to their description summary. It is the program specialist responsibility to include this information for each individual client. A copy of our updated description summary is attached. [The records for Individuals #1, #2, #3 and #4 were updated include the admission dates. Immediately and at least quarterly, all individual records will be reviewed and updated by the program specialist to include all required personal information. (AS 11/22/16)] |
09/02/2016
| Implemented |
| 2380.173(1)(ii) | The records for Individuals #1, #2, #3 and #4 did not include color of hair, color of eyes and 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. | Some required emergency information about each client was missing from their information page. This is due to over sight. All of our client files have a description summary in the front. After our first state inspection it was determined that for individuals 1, 2, 3 and 4. Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. were not included. After reviewing all the information under 2380.173 (1) (ii) the program specialist has added this information to their description summary. It is the program specialist responsibility to include this information for each individual client. A copy of our updated description summary is attached.[The records for Individuals #1, #2, #3 and #4 were updated include the personal information including color of hair, color of eyes and identifying marks. Immediately and at least quarterly, all individual records will be reviewed and updated by the program specialist to include all required personal information. (AS 11/22/16)] |
09/02/2016
| Implemented |
| 2380.173(1)(iv) | The records for Individuals #1, #2, #3 and #4 did not include religious affiliation. | Each individual¿s record must include the following information: Personal information including: Religious affiliation. | Some required emergency information about each client was missing from their information page. This is due to over sight. All of our client files have a description summary in the front. After our first state inspection it was determined that for individuals 1, 2, 3 and 4. Personal information including: Religious affiliation was not included. After reviewing all the information under 2380.173. (1) (iv) the program specialist has added this information to their description summary. It is the program specialist responsibility to include this information for each individual client. A copy of our updated description summary is attached.[The records for Individuals #1, #2, #3 and #4 were updated include the personal information including religious affiliation. Immediately and at least quarterly, all individual records will be reviewed and updated by the program specialist to include all required personal information. (AS 11/22/16)] |
09/02/2016
| Implemented |
| 2380.173(1)(v) | The records for Individuals #1, #2, #3 and #4 did not include a current dated photograph. | Each individual¿s record must include the following information: Personal information including: A current, dated photograph. | Some required emergency information about each client was missing from their information page. This is due to over sight. All of our client files have a description summary in the front. After our first state inspection it was determined that for individuals 1, 2, 3 and 4. Personal information including: A current dated photograph was not included. After reviewing all the information under 2380.173.1v the program specialist has added this information to their description summary. It is the program specialist responsibility to include this information for each individual client. A copy of our updated description summary is attached..[The records for Individuals #1, #2, #3 and #4 were updated include the personal information including a current dated photograph. Immediately and at least quarterly, all individual records will be reviewed and updated by the program specialist to include all required personal information. (AS 11/22/16)] |
09/02/2016
| Implemented |
| 2380.181(a) | Individual #1, admission date 11/17/15 had the initial assessment completed on 4/1/16. Individual #2, admission date 5/16/16 did not have an initial assessment. | 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. | No documentation of Functional assessments being completed 60 days after admittance for individual 1 and 2. Prior to our state inspection our program specialists does an assessments and sends them out to team members. Our program specialist did not write assessments 60 days after admittance. This was due to over sight. After reviewing 2380.181a the program specialist will revise the Assessment schedule to include assessments to be done 60 days after admittance and 60 days before date of ISP. These assessments will be scanned and E-mailed to team members. A copy of the sent E-mail will also be attached to the assessment as proof of correspondence. The program specialist will be responsible for writing a policy explaining this process. It will be signed and dated immediately and reviewed annually signed and dated This policy is attached [Individual #2's assessment was completed on 10/20/16. Immediately, the program specialist shall review all individuals' records to ensure the assessments are completed as required. Immediately, the CEO shall develop and implement a tracking system to ensure timely completion of assessments for all individuals. Immediately, the CEO shall review the program specialists responsibilities with the program specialist as per 2380.33(b)(1)-(19) and the tracking system. Documentation of the training shall be kept. (AS 11/22/16)] |
08/27/2016
| Implemented |
| 2380.181(f) | The program specialist did not provide the assessment for Individual #1, dated 5/1/16 to the entire plan team members including the supports coordinator. The program specialist did not provide the assessment for Individual #2, dated 4/1/16 to the entire plan team members including the supports coordinator. The program specialist did not provide the assessment for Individual #4, dated 7/6/16 to the entire plan team members including the supports coordinator and residential provider. | The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). | The program specialist did not provide the assessment for Individual #1, 2, and 4, 30 calander days before ISP meeting. Prior to our state inspection our program specialists does an assessments and sends them out to team members. Our program specialist did not write assessments 30 days before ISP. for these individuals. This was due to over sight. After reviewing 2380.181 and 2380.182 the program specialist will revise the Assessment schedule to include assessments to be done 30 days before date of ISP. These assessments will be scanned and E-mailed to team members. A copy of the sent E-mail will also be attached to the assessment as proof of correspondence. The program specialist will be responsible for writing a policy explaining this process. It will be signed and dated immediately and then reviewed annually by the program specialists who will sign and date to show they have reviewed the policy. This policy is attached [The program specialist sent Individual #1's assessment to the plan team on xxxxxxx. The program specialist sent Individual #2's assessment to the plan team on 11/11/16. The program specialist sent Individual #4's assessment to the plan team on 11/11/16 Immediately, the program specialist shall review all individuals' records to ensure the assessments have been sent to all the plan team members as required. Immediately, the CEO shall develop and implement a tracking system to ensure assessments are provided to all plan team members for all individual, timely. Immediately, the CEO shall review the program specialists responsibilities with the program specialist as per 2380.33(b)(1)-(19) and the tracking system. Documentation of the training shall be kept. (AS 11/22/16)] |
08/27/2016
| Implemented |
| 2380.186(b) | The three month reviews dated 1/30/16, 4/30/16, and 7/30/16 for Individual #1, Individual #3, and Individual #4 were not signed and dated by the Individual and the Program Specialist. The three month review for Individual #2, dated 5/15/16 was not signed and dated by the Individual and the Program Specialist. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | There was No documentation of Quarterly goal plans being sign by clients 1, 3 and 4 Prior to our state inspection our program specialists type up goal plans and send them out to team members via E-mail however the program specialist did not have the individuals sign the plan.after reviewing 2380.186b The program specialist will revise the goal plans to show that the plan was reviewed by the individual and the individual and the program specialist will sign and date the form. The program specialists will create a policy explaining this process. It will be signed by the program specialist. immediately and reviewed and signed by the program specialists annually. [Individual #1, #3 and #4 signed the reviews dated 1/30/16, 4/30/16, and 7/30/16 on 10/31/16. Immediately, the CEO will review all Individuals'' current ISP review to ensure the program specialist and individual signed and dated the reviews upon review. At least quarterly for 1 year, the CEO shall review the ISP review to ensure the program specialist and individual sign and date the ISP reviews signature sheet upon review of the ISP. Documentation of the reviews shall be kept. (AS 11/23/16)] |
08/27/2016
| Implemented |
| 2380.186(d) | The program specialist did not provide the ISP review documentation dated 1/30/16, 4/30/16, and 7/30/16 for Individual #1, Individual #3, and Individual # 4 to the supports coordinator and plan team members. The program specialist did not provide the ISP review documentation for Individual #2, dated 5/15/16 to the supports coordinator. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | There was No documentation of Quarterly goal plans and assessments for clients 1.3 and 4 being sent to team members. Prior to our state inspection our program specialists type up goal plans and send them out to team members via E-mail and assessments were sent by U.S Mail however the program specialist did not keep documentation of these interactions. After reviewing 2380.186d The program specialist will revise this process to show that team members are receiving the plans and recommendations. A copy of the sent E-mails will also be attached to the goal plan and the assessment. The program specialist will be the responsible party who will write up a policy explaining this process. The program specialists will sign and date it immediately. It will also be reviewed annually and signed and dated. A copy of this policy is attached. [The program specialist provided the ISP review documentation dated 10/30/16 for Individual #1, Individual #3, and Individual # 4 to the supports coordinator and plan team members on 10/31/16. Immediately and at least quarterly thereafter for 1 year, the CEO will review the correspondence documentation to ensure the program specialist has provided the ISP review documentation for individuals' plan team members as required. Documentation of reviews shall be kept. (AS 11/23/16)] |
08/27/2016
| Implemented |
| 2380.186(e) | The program specialist did not notify the plan team members of the option to decline the ISP review documentation for Individuals #1, #2, #3 and #4. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | Our program does not have a letter offering team members the option of opting out of receiving ISP review documentation from our program for individuals 1,2,3 and 4.. This was brought to our attention during our first state inspection. After reviewing 2380.186e a form will be written up and given to each team member, except ISC¿s, giving them the choice of continuing to receive review documentation of their clients or declining this information. The program specialist will be responsible for passing this form to all team members at the ISP meeting. A copy of this letter is attached. [The program specialist notified the plan team members of the option to decline the ISP review documentation for Individuals #1, #2, #3 and #4. Immediately, the CEO shall review the program specialists responsibilities with the program specialist as per 2380.33(b)(1)-(19) and the tracking system. Documentation of the training shall be kept. Immediately and at least quarterly thereafter, the program specialist shall review the all individual records to ensure all plan team member have been notified of the option to decline and documentation is kept. (AS 11/23/16)] |
08/27/2016
| Implemented |
|
|
|
SIN-00081929
|
Initial review
|
07/30/2015
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | The following poisons were under the kitchen sink and unlocked: charcoal lighter fluid, Comet cleanser, and generic automatic dish washer detergent. All stated "if swallowed seek immediate medical attention or call poison control." | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | The specific instance of non-compliance was due to not having a lock for the cabinet under our sink. This was over looked by staff. This has been corrected as of 8/5/2015. A lock has been put on the cabinet doors. The key is only accessable to the direct staff and program specialists. It is the responsiblity of the direct staff and program specialist to ensure this cabinet stays locked and is only opened by staff. |
08/24/2015
| Implemented |
| 2380.62 | The emergency numbers for the nearest hospital, police department, fire department, and ambulance were not posted by each telephone in the facility. | 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 specific instance of non-compliance was due to Not having the proper format for our emergency call list. This has been corrected has of 8/5/2015. A new list of emergency numbers has been made that shows the coorect format.
Mercy Hospital 412-232-8111
Police 911
Fire 911
Ambulance 911
Poison Control 1-800-222-1222
These numbers have been placed on of beside each phone. It will be the responsiblity of the program specialist to maintain the accuracy of these numbers annually. |
08/24/2015
| Implemented |
| 2380.70(b) | The first aid area did not contain a bed or cot, a blanket, and a pillow. | The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit. | The specific instance of non-compliance was due to not having a cot, blanket and pillow in our first aide room. This was due to our being unaware that these things were needed. This has been corrected as of 8/5/2015.To prevent rreccurrence The cot, blanket and pillow will remain set up in the health office. It will be the responsiblility of the program specialist to ensure this room is maintained. This has begun 8/5/2015 |
08/24/2015
| Implemented |
| 2380.70(d) | The first aid kit did not contain a thermometer. | First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors. | The specific instance of non-compliance was due to not maintaining the first aid cabinet. This was due to staff/ administrators neglecting to check the medicine cabnet. This has been corrected as of.8/5/2015. Missing items , a thermometer, Has been purchased and put into the first aid cabinet. It will be the responsiblity of the program specialist to ensure the first aid cabinet is maintained. This will be done on a monthly basis. Starting 8/5/2015 |
08/24/2015
| Implemented |
|
|