Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00253767 Renewal 11/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At the time of the inspection, there was a significant amount of dust on the living room ceiling fan and vent.Clean and sanitary conditions shall be maintained in the home. Ceiling fan and vent has been dusted and wiped down. 11/08/2024 Implemented
6400.82(f)At the time of the inspection, there were no paper towels or individual hand towels available in individual #2's bathroom. Staff did replenish the paper towels immediately.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Paper towels have been replenished in the bathroom and HCA is purchasing hand towels to keep in all bathrooms as backup. 11/08/2024 Implemented
6400.151(a)Staff #2 had an annual physical completed 03/11/22 and not again until 3/12/24. Staff #4 had an annual physical completed 02/22/19 and not again until 2022. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Provider will ensure physicals are completed during the 11th month by all staff moving forward. 11/15/2023 Implemented
6400.151(b)Staff #4 had an annual physical completed in 2022 that was signed, but not dated by the attending physician. The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. Provider will review all annual physicals upon receipt to ensure regulatory guidelines have been met. 11/15/2023 Implemented
6400.171At the time of the inspection there were four food products that had previously expired: Mustard (expired on 7/11/24), Honey Mustard Dressing (expired on 5/27/24), Tartar Sauce (Expired on 4/18/24), and Mayonnaise (Expired on 8/31/22).Food shall be protected from contamination while being stored, prepared, transported and served. All expired products have been removed and discarded. 11/08/2024 Implemented
6400.181(a)The initial assessment was due within 60 days of individual #1's date of admission on 7/7/24 and should have been completed by 9/4/24, however the Individual Skills Assessment was completed on 9/7/24. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. HCA will utilize a schedule tracker to ensure they are following the 60 day mark exactly, and not simply going off of 2 months out. 11/12/2024 Implemented
6400.181(e)(1)The Individual Skills Assessment did not identify individual #1's Preferences as it was marked as N/A. The assessment must include the following information: Functional strengths, needs and preferences of the individual. An addendum to the initial assessment has been completed to include the individual's preferences. 11/12/2024 Implemented
SIN-00233481 Renewal 11/07/2023 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(c)During the inspection of the home on 11/18/23 when reviewing the items in the homes first aid kit, there was no first aid manual with the first aid kit provided for inspection. A first aid manual shall be kept with the first aid kit.All first aid kits will contain a list of required items to be kept in the box. The missing items were added to the first aid kit. 11/15/2023 Accepted
SIN-00217081 Unannounced Monitoring 01/03/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Individual #1 has three types of financial records. Individual #1 has a cash log and two debit card logs. The debit card log for Individual #1's ABLE account was not current and up to date. In October 2022, the ending balance was computed as $1987.23. According to the transactions documented, the ending balance should have been $1987.21. This was never rectified.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. Separate tracking sheets will be utilized for each account and cash-on-hand. The DSP's will keep the receipts from all daily transactions and hand them in daily to the house manager. The manager will be doing daily "balance checks" and recording what the balance is. If there is a different in the balance, the manager will then note why there is a difference (withdrawal, interest payment, etc) and document a receipt for the difference. Any time a receipt is handwritten for a missing receipt, the individual will sign off on the receipt, confirming it is correct. 01/16/2023 Implemented
6400.22(e)(1)Both of Individual #1's debit card logs were missing documentation of deposits and withdrawals from the accounts. The debit card that Individual #1 uses for daily purchases had 36 transactions that were not documented on the log. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. Separate tracking sheets will be utilized for each account and cash-on-hand. The DSP's will keep the receipts from all daily transactions and hand them in daily to the house manager. The manager will be doing daily "balance checks" and recording what the balance is. If there is a different in the balance, the manager will then note why there is a difference (withdrawal, interest payment, etc) and document a receipt for the difference. Any time a receipt is handwritten for a missing receipt, the individual will sign off on the receipt, confirming it is correct. 01/16/2023 Implemented
6400.77(b)There were no scissors in the first aid kit at the time of the 1/4/23 inspection. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. All homes have been issued a first aid "tackle box" that will be the main first aid kit for each home. Staff made sure that each tackle box had all needed items for the first aid kit, including scissors. The list of items required has been taped to the inside of the box. 01/11/2023 Implemented
6400.142(a)Individual #1 had a dental exam on 4/6/21 and not again until 9/13/22, outside of the annual timeframe.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Appointment forms have been updated to include regulatory compliance requirements (dental exam required annually). Apt forms now indicate whether the dentist completed a prophylaxis. 01/09/2023 Implemented
6400.144(Repeated Violation -- 3/8/22) Individual #1 was prescribed Acetaminophen on 10/11/22. Individual #1 did not begin taking Acetaminophen daily until 10/21/22, ten days later.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Manager's will be required to inform CEO and program specialist (as well as all of their staff) when there is a new medication and the date it is to begin per the doctor. 01/16/2023 Implemented
6400.163(h)At the time of the 1/5/23 inspection, Individual #1 had the following medications in the home that had expired: Naproxen, Ondansetron, and Motrin.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.All expired medications have been removed from the home and replaced with medications that are not expired. 01/04/2023 Implemented
6400.165(c)(Repeated Violation - 3/8/22) Individual #1 is prescribed Debrox to be taken three times a week. Currently, Individual #1 is receiving ear drops every other day, which equates into four times a week at times.A prescription medication shall be administered as prescribed.MAR has been updated to reflect the medication be taken every Monday, Wednesday, and Friday 01/04/2023 Implemented
6400.165(g)(Repeated Violation -- 3/8/22) Individual #1 had a quarterly medication review on 9/13/22 and not again since, outside of the quarterly time frame.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Apt forms have been updated to indicate medication reviews need to occur every 3 months. If unable to do so, staff will get written documentation from the doctor as to why the apt is not happening within the allotted timeframe. 01/16/2023 Implemented
6400.166(a)(2)(Repeated Violation -- 3/8/22) Individual #1 is prescribed Florastor to be taken daily. The prescriber for the Florastor is not listed on the MAR.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.Prescriber has been added to the MAR. 01/12/2023 Implemented
SIN-00202757 Renewal 03/08/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The exterior light, outside the sliding glass door, was not operable during the time of the 3/10/22 inspection.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Light bulb on exterior light was replaced and is now in working order. 05/04/2022 Implemented
6400.67(a)There were scuffed, black, marks and streaks over most of the white walls and white baseboards throughout the home.Floors, walls, ceilings and other surfaces shall be in good repair. Staff have buffed/cleaned scuff marks off of the walls 05/05/2022 Implemented
6400.111(f)At the time of the 3/8/22 inspection, there are no records maintained that the home had the fire extinguishers inspected by a fire company on an annual basis. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. All fire extinguishers have been inspected by a fire safety expert and are up to date. 05/10/2022 Not Implemented
6400.18(a)(4)Individual #1 reported to the Department and agency Staff persons #1 and #2 during the 3/10/2022 onsite inspection of the home, that Staff person #3 has told Individual #1 on a few occasions "don't be lazy" and reported it upset the individual. Staff person #2 confirmed that they and the individual talked about the incident(s) and had a meeting with Staff person #3 about the incident(s). The suspected verbal abuse incident was never reported to the Department. Individual #1 also stated that an unidentified staff doesn't like the individual's personal vacuum and wants Individual #1 to buy another one for the house. Individual #1 reported they purchased the vacuum with their own money, this is the vacuum the home uses, and this is the only vacuum available in the home. The individual's funds and property are to only be used for the individual's benefit.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Abuse, including abuse to a individual by another client. The House Manager of Individual 1's home did not report the incident to the appropriate people, and they are no longer with the company as of March 2022. Individual #1 and Staff person #3 spoke about the incident and Individual #1 has stated that Staff person #3 apologized and has not spoken those words, or similar words, to them since the incident occurred. The House Manager and Staff person #3 met to discuss the incident and how their actions affected Individual #1. Individual #1 has stated that they feel safe and comfortable with Staff person #3 and wants them to continue working with them in their home. 05/27/2022 Not Implemented
6400.18(g)There are no records maintained that the home initiated investigations into the incidents described in 6400.18(a)(4) of this report.The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person.The company Incident Management policy will be sent to all House Managers to remind them of the procedures. 05/27/2022 Implemented
SIN-00181110 Renewal 01/04/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103The 04/09/20 Emergency Evacuation Plan does not include the Individuals' responsibility in an emergency.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. The following has been added into our Emergency Relocation/Emergency Evacuation Plan "In the event of an emergency, the individual will evacuate to the best of their ability, with staff verbal and physical assistance, and follow all directions to the best of their ability." 01/25/2021 Implemented
6400.181(e)(7)The 10/24/20 Assessment does not address Individual #1's ability to "move away quickly from heat sources".The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. We have added this into the assessment and made it a two part assessment. Part 1: Individual has knowledge of the danger of heat sources. Part 2: Individual is able to sense and move away quickly from heat sources which exceed 120 degrees F and are not insulated. The program specialist will evaluate the individual's abilities in both areas annually. 01/25/2021 Implemented
6400.34(a)The Department issued updated regulatory rights, effective 2/3/2020, stating that individuals have additional rights they need to be informed of. At the time of the 1/04/2021 annual inspection, Individual #1 was never informed of the additional individuals rights as described in 6400.32.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Document addressing individual rights has been updated to reflect the updated regulatory rights, effective 2/3/2020, to include all listed rights as well as process to report a rights violation. Clients will sign off upon intake and annually thereafter. 01/25/2021 Implemented
SIN-00160891 Renewal 09/17/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)In the past year, the sliding doors leading to the patio exit was not used during a fire drill, only the garage and front door was used. The agencies residential fire safety policy and procedures document dated 5/1/19 list the 3 exits to be used during fire drills.Alternate exit routes shall be used during fire drills. A. What was the Issue/Violation- House 2005 Crestwyck Circle did not utilize an alternate exit (kitchen patio door) during monthly fire drills. B. Who is Responsible for Making these Corrections: House Manager, Program Specialist C. What action should have been taken/addressed- Alternate exit routes shall be used during fire drills. D. When/How will the violation/issue be addressed- September 2019 fire drill will utilize the kitchen patio exit as their exit route during drill. E. Proof of Materials/Information to be Reviewed- September 2019 Fire Drill for 2005 Crestwyck Circle. A. What was the Issue/Violation- House 501 Crestwyck Circle did not utilize an alternate exit (kitchen patio door) during monthly fire drills. B. Who is Responsible for Making these Corrections: House Manager, Program Specialist C. What action should have been taken/addressed- Alternate exit routes shall be used during fire drills. D. When/How will the violation/issue be addressed- September 2019 fire drill will utilize the kitchen patio exit as their exit route during drill. E. Proof of Materials/Information to be Reviewed- September 2019 Fire Drill for 501 Crestwyck Circle. 09/23/2019 Implemented
SIN-00141592 Renewal 10/17/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.103The written emergency evacuation plan did not include individual responsibilities.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. A. Who- CEO, Program Specialist, House Managers, DSPs B. What- The written emergency evacuation plan will include the individual responsibilities. C. When and How- As of 10/18/2018 all Emergency Evacuation Plans were updated by HCA CEO to include the responsibilities of the individual during an emergency evacuation. All updated Evacuation plans were reviewed with current staff and individuals to ensure all parties were aware of the responsibilities of the individual during an emergency evacuation. The plan will continue to include responsibilities of the individual and be reviewed annually or as needed for any changes throughout the year. 10/24/2018 Implemented
6400.145(2)The written emergency medical plan did not list the following: The method of transportation to be used.The home shall have a written emergency medical plan listing the following: The method of transportation to be used. A. Who- CEO, Program Specialist, House Managers, DSPs B. What- The written medical emergency plan will list the method of transportation being used. C. When and How- As of 10/18/2018 all Medical Emergency Plans were updated by HCA CEO to include the method of transportation used in the case of an emergency. All updated plans were reviewed with current staff and individuals to make all parties aware of the method of transportation used in a medical emergency. The plan will continue to include method of transportation used and be reviewed annually with staff and individuals or as changes are needed throughout the year. 10/24/2018 Implemented
SIN-00121479 Renewal 10/11/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Repeat 9/27/16: Individual #1's financial records were not accurately recorded. Individual #1's financial debit ledger report an end balance on 7/30/17 of $42.83 however the financial debit ledger on 8/1/17 states a begining balance of $63.44. The July debit ledger has a begining balance of $25.05 however the last entry and end balance on the June 2017 statement on 6/24/17 stated a balance of $18.56. The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. A. Who- House Managers, Direct Support Staff, Program Specialist B. What- The home will keep an up to date financials and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. C. When and How- Financial tracking has been reviewed with the management team and staff members as of 11/2. The financial assessments and plans will continue to assess the individual on their financial supports needs including how much cash the individual is responsible in carrying. Staff will work to ensure that all receipts are documented accurately and will follow the financial protocol reviewed in training to ensure accuracy of all financial records. To be sent by 11/2/2017 for corrective proof: - Updated financial protocol reviewed with staff detailing how to properly document all individual financials. - Updated financial assessment and plan based on individual needs. 11/02/2017 Implemented
6400.141(c)(14)Individual #1's physical dated 3/7/17 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This area on the physical was left blank. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. A- Who: House Managers, Program Specialist, Direct Support Professionals B- What: The physical exam will include comment from the doctor on medical information pertinent to diagnosis and treatment in case of an emergency. C- When and How: Staff have been retrained on the physical as of 10/17/17 and 10/18/17 in regards to proper completion of the annual physical form. Staff and management will ensure that the doctor is completing the physical in its entirety before leaving the scheduled appointment. To be sent by 11/2/2017 for proof of corrective action: - Retraining on completion of the annual physical. 10/18/2017 Implemented
6400.141(c)(15)Individual #1's physical dated 3/7/17 did not contain special diet instructions for the individual's diet. This area of the physical was left blank.The physical examination shall include:Special instructions for the individual's diet. A- Who: House Managers, Program Specialist, Direct Support Professionals B- What: The physical exam will include comment from the doctor on any special instructions for the individual's diet. C- When and How: Staff have been retrained on the physical as of 10/17/17 and 10/18/17 in regards to proper completion of the annual physical form. Staff and management will ensure that the doctor is completing the physical in its entirety before leaving the scheduled appointment. To be sent by 11/2/2017 for proof of corrective action: - Retraining on completion of the annual physical. 10/18/2017 Implemented
6400.144Repeat 9/27/16: A letter written from Individual #1's doctor on 10/6/16 stated that if Individual #1's blood sugar levels are below 70 he/she should be given a quick sugar food/drink and retest blood sugar levels in 15 minutes. On 6/3/17 staff recorded Individual #1's AM sugar reading as 55. On 5/6/17 staff recorded Individual #1's AM blood sugar reading as 68. On both occasions Individual #1 was given a cup of milk however, there is no documentation that his/her blood sugar levels were rechecked 15 minutes after being given the milk. Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. A. Who- House Manager, Program Specialist, Direct Support Staff B. What- Staff will provide the health services needed as prescribed by the provider. C. How and When- Blood sugar has been updated as of 10/25/2017 to reflect a column now designated to the retaking of blood sugar after a low reading as per the Diabetes protocol in place for the individual written by the individual's PCP. To be sent by 11/2/2017- - Updated and completed blood sugar tracking. 10/25/2017 Implemented
6400.181(d)Individual #1's assessment dated 12/15/16 was not signed by the program specialist.The program specialist shall sign and date the assessment. A. Who- Program Specialist B- What- All assessments are to be signed and dated by the Program Specialist after completion. C- How and When- The Program Specialist has signed the assessment as of 10/20/2017. The Program Specialist will ensure that all assessments are signed and scan and/or send the signed assessments to the CEO for approval. To be sent by 11/2/2017: - Signed assessment by Program Specialist 10/20/2017 Implemented
6400.186(c)(2)Repeat 9/27/17: Individual #1's ISP reviews dated 10/25/16, 1/26/17, 4/26/17 and 7/26/17 did not review information reagarding his/her diagnosis of diabetes. Individual #1 has a diabetes protocol in place and has his/her blood sugars tested twice daily. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. A. Who- Program Specialist B. What- All monthly and quarterly reviews will include information regarding the individual's diagnoses (i.e. Diabetes) and the comment on the protocols in place for such diagnoses. C. How and When- The monthly and quarterly reviews have been updated as of Friday, 10/20/2017 to include comments on the following areas: Behavioral Observations including comments on the SEEN plan and Comments on Health and Safety Protocols, including any comments on diagnoses such as diabetes, seizures, etc. To be sent by 11/2/2017 for corrective proof: - Updated quarterly assessment including comments on behavioral and health and safety observations. - Updated monthly assessment including comments on behavioral and health and safety observations. 10/20/2017 Implemented
6400.213(11)Repeat 9/27/16: Individual #1's assessment dated 12/15/16 states that Individual #1 requires line of sight supervision in his/her home unless in his/her room taking a nap. Individual #1's ISP updated 9/28/17 did not state that he/she requires line of sight supervision at home. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. A. Who- Program Specialist and House Managers B. What- Each individual's record shall include content discrepancy in the ISP, the annual update or revision date under 6400.186. C. When and How- Upon the receipt of all updated ISPs (both annual revisions and updates throughout the year), House Managers and the Program Specialist will read thoroughly through the ISP ensuring all information is accurate. Any discrepancies found in the ISP will be send to the SC by the Program Specialist within a week of receiving the updated ISP. To be sent by 11/2/2017 for corrective proof: - E mail sent to the Supports Coordinator with ISP discrepancy. 10/30/2017 Implemented
Article X.1007Repeat 9/27/16: Hoffman Care Associates is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 ¿ 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff #1 was hired on 3/7/17; the criminal history check was requested on 3/13/17. Staff #2 was hired on 3/13/17; the criminal history check was requested on 3/16/17. Staff #3 was hired on 3/29/17; the criminal history check was requested on 3/30/17. Staff #4 was hired on 4/18/17; the criminal history check was requested on 4/27/17. Staff #5 was hired on 2/23/17; the criminal history check was requested on 2/24/17. Staff #6 was hired on 2/23/17; the criminal history check was requested on 2/24/17.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.A. Who- Executive Team B. What- All criminal history checks for new hires will be completed or requested prior to the individual's official start date. C- When and How- Hoffman Care Associates will help ensure compliance by having administrative two staff members follow the new-hire process. The Chief Operating Officer and the Executive Administrator will both be responsible for tracking all new-hire requirements, including criminal background checks. Criminal background checks will be conducted prior to the new hire¿s official start date. D. To be sent for corrective proof- - Updated New Hire Process 10/30/2017 Implemented
SIN-00101399 Renewal 09/27/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency's certification of compliance expired on 8/20/16. The agency did not complete a self-assessment of the home until 9/19/16.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. A. Who- Program Specialist, CEO, House Managers B. What- The agency will complete a self-assessment of each home the agency operates serving eight or fewer individuals, 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. C. When and How- the CEO has created reminders on the agency¿s google calendar to ensure proper completion of the self-assessment packet. The CEO has scheduled a training for the completion of the assessment prior to the assessment packet due date in March of 2017. To be sent by 11/18/2016 for corrective proof: - Due dates listed on google calendar - Training proof provided to managers on completion of assessment packet. 11/18/2016 Implemented
6400.15(c)The self-assessment completed on 9/19/16 did not include a written summary of the violations or corrections made. A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. A. Who- Program Specialist, CEO, House Managers B. What- A copy of the agency¿s self-assessment results and written summary of corrections made shall be kept by the agency for at least one year. C. When and How- House managers and program specialist will be retrained on the completion of self-assessment packets to ensure proper completion. Training will be provided a month prior to the March 2017 completion of agency self-assessment packets. Managers will keep self-assessment packets in the home and comment on completion of corrections made. To be sent by 11/18/2016 for corrective proof: - Training materials on completion of agency self-assessment packet. 11/18/2016 Implemented
SIN-00069368 Renewal 05/14/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)21(a) REPEAT The Criminal History check for staff person #3 who was hired on 12/3/13 was not conducted until 5/13/14.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. Background checks are completed prior to any employee working with individuals, as part of the New Hire process (Form 1). Criminal History check for staff #3, (Form 10). Implemented
6400.46(a)46a Staff #1, #2 & #3 did not have orientation to the relevance of their responsibilities, the daily operation of the home before working with Individuals or their appointed positions.The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. Hoffman Care Associates, Inc. (HCA) has implemented a ¿New Hire Process¿. (See Forms 1-6), to ensure all new staff receive trainings which are standardized and in the proper order (completed prior to working with individuals) according to the 6400 regulations. The Compliance Officer will oversee the process. Implemented
6400.112(a)There were no fire drills held April 2014, February 2014 & November 2013. An unannounced fire drill shall be held at least once a month. Fire drill training was reviewed with staff (Form 7). Fire drill forms were updated to include all necessary information is recorded. Fire drills are held once per month. See ¿Fire drill Summary Log¿ for 2005 Crestwyck (Form 8) and ¿Fire drill Checklist¿ (Form 9-pg 1 & 2). House Manager reviews and signs all fire drill documentation completed for each drill done. Implemented
6400.112(e)There were no fire drills held during sleeping hours for the year.A fire drill shall be held during sleeping hours at least every 6 months. Fire drills are held during sleeping hours at least every 6 months. (Form 8, 9). Compliance Officer will monitor for compliance. Implemented
6400.112(g)Fire drills 9/28/13, 8/18/13, 7/24/13 & 5/27/13 did not contain a time that the drills where held. Fire drills shall be held on different days of the week and at different times of the day and night. Fire drill forms now include ¿Day of the week¿, and ¿Time of day/ night¿. (See Form 8, 9). Compliance Officer will monitor for completion. Implemented
SIN-00177763 Renewal 04/05/2021 Compliant - Finalized
SIN-00038897 Initial review 08/08/2012 Compliant - Finalized