| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1, diagnosed with Moderate ID, anxiety disorder, ADHD, and unspecified bipolar disorder, lacks understanding of money and is at risk of exploitation due to limited stranger awareness. Their parents are their representative payee. In April 2024, Individual #1 was exploited online by someone posing as a country star, leading to the sharing of personal information, explicit photos, and the installation of a phone tracker.
After entering respite care on 7/19/24 and transitioning to full-time residential care on 7/29/24, a Positive Behavior Support Plan (BSP) was implemented to address exploitation risks. Despite this, between 8/29/24 and 3/10/25, there have been 8 reported incidents of exploitation, including sending gift cards, sharing bank details, and providing their state ID. At least 3 lines of credit and a PayPal account were opened in the individual's name without their consent.
Sisters and Brothers Keepers, the care provider, reported only one incident to law enforcement (12/23/24), and a recommendation for a restrictive component to address internet use was made on 10/21/24. However, as of 3/24/25, no effective safety procedures have been implemented. A voluntary lockbox for phone safekeeping was not used by Individual #1, and on 3/10/25, it was discovered that the individual had filed taxes, sent another gift card, and changed their SSA direct deposit to a potentially compromised Chime account. The lack of proper safeguards has left Individual #1's safety at serious risk. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | Effective 3/26/2025 Sisters and Brothers Keepers (SBK) has reported all the incidences of abuse to the Hummelstown police station. SBK is committed to protecting the health and safety of the individual. Some background information: Even with the ongoing challenges, SBK was directed by the SCO and the Representative Payee to give money whenever Individual #1 requested it. Rep payee bought several gift cards for the individual in some of the EIMs listed in the citations. To address these challenges SBK requested HCQU trainings on internet safety and stranger awareness. The individual and staff participated in these trainings.
On 4/1/2025, SBK staff took the individual to the local police to report an incident, that the Individual and the rep payee bought a $20 apple gift on the night of 3/31/25 and the individual proceeded to send to the online scammer. Report was done per ODP regulation. On the same day, the individual signed an agreement with the police officer. This will be attached. Sisters and Brothers Keepers (SBK) has updated the BSP to include addressing the individual's use of the internet and the phone. A discussion was held with the family about prior incidents when the Representative Payee (mother) gave the individual cash and gift cards based on their demand and disclosure that they intend to send them to online scammers. Provider was left out of these arrangements.
Effective 4/9/2025, Representative payee has decided to take the individual shopping for all their personal needs and provide a small amount of cash with specific instructions to Individual #1 that the money will be in the lockbox and only for their personal use. Sisters and Brothers Keepers is responsible for safeguarding the money, in agreement with the rep payee. Responsible party: Residential Manager, Program Specialist, Behavior Support Specialist, and DSPs will work as a team to ensure the individual is safe from exploitation. |
04/04/2025
| Implemented |
| 6400.22(d)(2) | There is currently a cash ledger that is kept in the home for Individual #1. In August, September, and October 2024, the ledger amounts recorded do not correlate with the actual amount of money that should have been present, with a $.14 difference at the end of August, which was never fully rectified. Additionally, in October, Individual #1 had a purchase for $11.93 at the Dollar Tree, but only $8.08 was subtracted. In December 2024, the ledger records that Individual #1 had $2.38, however, the January 2025 ledger notes a starting balance of $2.37. It is unclear where the discrepancy occurs. | (2) Disbursements made to or for the individual.
| Sisters and Brothers Keepers (SBK) has a policy for managing individuals finances.
This is to ensure SBK staff are trained on the agency's policy/protocol, ODP/ policy and regulations to help individuals manage and budget their money. On 4/4/2025 staff were retrained to ensure all necessary protocols and procedures are followed. At intake, Sisters and Brothers Keepers ensure the individual has a locked box for their money and receipts. The individual will get guidance as needed on their expenses and receipts. Staff will count money on the locked box and document at the change of all shifts. The policy was updated on 4/4/2025, and staff training documented, to be attached to this plan of correction. |
04/04/2025
| Implemented |
| 6400.43(b)(1) | Individual #1 has a PRN prescription for hydroxyzine due to their diagnosis of anxiety. Sisters and Brothers Keepers failed to create a PRN protocol for the proper administration of this medication. This medication was administered to Individual #1 on 2/18/25 and 2/19/25. The provider agency did not create a protocol for this medication until 3/24/25, after the start of the inspection.
Additionally, during the inspection, Sisters and Brothers Keepers provided Medication Administration Record documents that were created after the start of the inspection, providing false information on the administration of Individual #1's PRN medication. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | Sisters and Brothers Keepers (SBK) has PRN protocol for administering medications.
Effective 3/24/25 SBK updated the original protocol to specify the administration of Hydroxyzine, as it was prescribed for Anxiety: symptoms (a sensation of heat in her face, tightness in chest, heavy breathing). On 3/24/2024, Hydroxyzine protocol with written instructions from a medical professional detailing the specific symptoms required for administration was established and staff trained on it.
Staff will obtain authorization from the CEO or CEO designee for all future PRN medication administrations.
0n 4/4/202 Staff were trained on the proper use of PRN medications, including the importance of adhering to established protocols and obtaining necessary authorizations. The PRN policy was revised.
Protocol is attached. |
03/24/2025
| Implemented |
| 6400.144 | At Individual #1's 1/10/25 psychiatric medication review, it was recommended that Individual #1 would benefit from outpatient individual therapy. As of 3/24/25, this recommendation has not been followed by the provider agency. | 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.
| Reviewed notes from 01/10/2025 to see what was discussed and if there was a breakdown of communication between the psychiatric provider and Sisters and Brothers Keepers. There was no recommendation for Therapy; "staff present with individual #1 encouraged them to consider individual outpatient therapy." On 4/1/2025, Individual had a session with their Behavior Support to discuss the pros and cons of therapy. Though Individual #1 is still 100% committed to therapy, they agreed to call the preferred provider, Wellspan Philhaven since they do not have an opening was placed on a waiting list. |
04/01/2025
| Implemented |
| 6400.181(e)(10) | Individual #1's 9/27/24 assessment does not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Lifetime Medical history was completed for the individual but not attached to the assessment.
0n 4/1/2025, the lifetime medical history was added on the 9/27/24 assessment and updated the assessment accordingly. |
04/02/2025
| Implemented |
| 6400.18(a)(6) | On 1/3/25, it was discovered that Individual #1 was being charged too much rent by the provider agency. Additionally, the provider agency was not paying for items required under the room and board agreement. This exploitation incident was not entered in the department's incident management system until 1/10/25. | 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:
Exploitation
. | From approved correction on EIM # 9549372
Policy, Procedure, Protocol Revised
Sisters and Brothers Keepers reimbursed all the funds that were paid for room and board and revised the Room & Board contract for 2025. SBK also talked to the Rep Payees for all the individuals that receive residential services to ensure that they are being charged the correct amount for Room and Board. They confirmed that all contracts for 2023 -2024 were correct but individuals received new SSI award letters in January with increase with SSI and SBK has not increased the Room & Board. A ledger was also created to keep track of all room and board checks. |
01/10/2025
| Implemented |
| 6400.18(f) | Individual #1 has a history of sending money and personal information to unknown people that they meet online. This is a form of exploitation, and a crime has been committed in these instances, including bank accounts and lines of credits opened in the Individual's name by these people Individual #1 has engaged with online. This occurred on the following dates and law enforcement was not contacted by the provider agency:
· 8/27/24 -- EIM #9474329
· 10/21/24 -- EIM #9504676
· 10/30/24 -- EIM #9511280
· 12/10/24 -- EIM #9532327
· 1/9/25 -- EIM #9549217
· 2/10/25 -- EIM #9566914
· 3/10/25 -- EIM #9583286 | The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident. | Effective 3/26/2025 Sisters and Brothers Keepers (SBK)reported all incidences of exploitation to the Hummelstown police department. |
03/26/2025
| Implemented |
| 6400.18(g) | On 1/3/25, it was discovered that Individual #1 was being charged too much rent by the provider agency. Additionally, the provider agency was not paying for items required under the room and board agreement. A Certified Investigation was not initiated within 24 hours of discovery of the incident. | The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person. | From approved correction on EIM # 9549372
Policy, Procedure, Protocol Revised
Sisters and Brothers Keepers reimbursed all the funds that were paid for room and board and revised the Room & Board contract for 2025. SBK also talked to the Rep Payees for all the individuals that receive residential services to ensure that they are being charged the correct amount for Room and Board. They confirmed that all contracts for 2023 -2024 were correct but individuals received new SSI award letters in January with increase with SSI and SBK has not increased the Room & Board. A ledger was also created to keep track of all room and board checks. |
01/10/2025
| Implemented |
| 6400.165(g) | Individual #1 had a quarterly psychiatric medication review on 8/8/24 and not again until 1/10/25. | 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. | There was a scheduled virtual appointment on 11/11/2024 but Individual #1 and staff had connectivity issues and called provider to let them know.
Starting on 4/1/2025, quarterly psychiatric medication reviews will be scheduled right after the appointment to ensure they are within 3 months and will use psychiatric checklist during appointments. |
04/01/2025
| Implemented |
| 6400.166(a)(10) | There is no administration time documented for 3 administrations of PRN Hydroxyzine to Individual #1 in February 2025. There were 2 doses administered on 2/18/25 and 1 dose was administered on 2/19/25. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | On 3/26/2025, Sisters and Brothers Keepers staff were trained on medication administration policy to emphasize the importance of documenting administration times for all medications, including PRNs.
Develop a checklist or tracking system to ensure accurate documentation of medication administration.
Include training on the health and safety implications of accurate medication records. |
03/26/2025
| Implemented |
| 6400.207(4)(I) | Individual #1 was prescribed hydroxyzine as PRN medication for anxiety on 1/10/25. This medication was administered to Individual #1 twice on 2/18/25 and once on 2/19/25. The provider agency did not have a protocol in place with written instructions from a medical professional of the specific symptoms that must be present in order to consider administering this medication. In addition, there was not authorization sought from the CEO or CEO designee for the administrations. This is considered a chemical restraint and is not permitted. The PRN protocol provided by the agency was not created until 3/24/25, after the start of the inspection. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition. | On 3/24/2025, Hydroxyzine protocol with written instructions from a medical professional detailing the specific symptoms required for administration was established and staff trained. Staff will obtain authorization from the CEO or CEO designee for all future PRN medication administrations. |
04/04/2025
| Implemented |