Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00276435 Renewal 09/26/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)There was a potentially poisonous cleaning liquid found in an unlabeled container.Poisonous materials shall be stored in their original, labeled containers. The unmarked chemical container was removed. Staff have been directed to ensure that all soap products, cleaning detergents and other chemical substances are contained in their original, labeled containers for safety purposes. In addition, Embolden has placed reminders on the interior of cabinet doors, to reinforce this directive to staff. 09/26/2025 Implemented
SIN-00263799 Unannounced Monitoring 04/03/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)The soap in the bathroom of individual #1 was not in its original labeled container and could not be validated as safe and not a poison.Poisonous materials shall be stored in their original, labeled containers. The unmarked soap container was removed. Staff have been directed to ensure that all soap products, cleaning detergents and other chemical substances are contained in their original, labeled containers for safety purposes. 04/03/2025 Implemented
6400.64(a)The stove top and inside the oven in the kitchen had an abundance of grease and grime.Clean and sanitary conditions shall be maintained in the home. The stove top and inside the oven was cleaned of grease and grime. Images of the stove top and oven were sent to the inspector via email on 4/16/2025. 04/03/2025 Implemented
6400.64(b)There were rodent droppings in the cabinet below the kitchen sink. An exterminator needs to be sent out.There may not be evidence of infestation of insects or rodents in the home. The ¿droppings¿ were cleaned up. Viking Pest Control came to the home on 4/8/25 and inspected the home and crawl space underneath the home and found no rodents. 04/08/2025 Implemented
6400.101The exit to the outside of the sun porch of the home was obstructed by a wicker loveseat. The seat was moved from in front of the door during the inspection.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The chair was removed from the exit outside of the sun porch. Staff were directed to ensure that all exits always remain unobstructed. 04/03/2025 Implemented
6400.112(a)There was no fire drill completed in the month of March 2025 after individual #1 moved into the home. An unannounced fire drill shall be held at least once a month. A copy of the completed March 2025 fire drill form was emailed to the inspector on 4/16/2025 and is filed in the Fire & Disaster Plan. 04/16/2025 Implemented
6400.141(a)There was no documentation of a completed physical examination for individual #1.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual #1 physical examination was completed on 3/21/25 and a copy was included individual #1¿s medication record binder. Individual #1 came to Embolden as an emergency respite placement on 2/12/25 due to unsafe conditions in his previous placement. Prior to entry into Embolden¿s residential program, individual #1 resided at home and no physical examination had been completed in at least two years so Embolden was unable to obtain a copy of a recent physical prior to the move. Embolden obtained a new PCP for individual #1 and arranged to have it completed on 3/21/25 as noted above. A copy of the physical examination was sent to the inspector via email on 4/16/2025. 03/21/2025 Implemented
6400.163(h)The medication box for individual #1 contained a discontinued medication - Risperidone 1MG which needs to be removed.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Resperidone 1MG was removed from the medication box and disposed of. 04/03/2025 Implemented
6400.165(g)There were no medication reviews on file for individual #1 however the individual takes medications to treat psychiatric illness.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.Individual #1 came to Embolden as an emergency respite placement on 2/12/25 due to unsafe conditions at home. Individual #1 had not been receiving any medical care (psych included) for at least two years prior to placement at Embolden. Embolden shall ensure that all quarterly psychiatric medication review(s) are included in individual #1¿s medication record. Embolden ensured that individual #1 began receiving psychiatric services at Lenape Valley Foundation on 2/25/25. Individual #1 is not due for a quarterly psych medication review(s) until May 2025. To clarify, on 2/25/25, Individual 1 was not taking any psychotropic medications and this visit was merely the initial meeting between the individual and the Foundation, and Embolden does not have any documents from that visit. 04/03/2025 Implemented
6400.166(a)(7)Individual #1 is prescribed 'Hydroxyzine PAM 50MG -- Take 1-2 capsules by moth at bedtime for insomnia'. This RX order is unclear on exactly how many the staff should administer. Additionally, when this medication is administered, there is no indication as to whether 1 or 2 of the capsules were administered at each administration time.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.As part of our Medication Administration Policy, specific to administering PRN Medications, Embolden has introduced the following protocols: o Direct Care Staff who observe symptoms associated with the need of a PRN Medication (and prior to administering any PRN Medication) shall contact the Embolden Nurse to obtain guidance on administering the PRN medication. 09/11/2025 Implemented
6400.166(b)There were no initials for any of the medications administered to individual #1 for the month or April 2025 up to the time of inspection on 4/3/25. Staff in the home reported that the mediations were being administered but not documented.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Based on the medication count documented on Embolden¿s Medication Tracking Form(s), it has been determined that the medication was administered just not documented on the Medication Administration Record (MAR). Staff have been directed to make sure that they document the administration of each medication that is given on the MAR as soon as possible to ensure that there is no missing information on the MAR. 03/03/2025 Implemented
6400.207(4)(I)Individual #1 is prescribed Hydroxyzine PAM 25MG -- Take 1-2 Capsules by mouth 3 times a day as needed for anxiety. This is considered a chemical restraint because there is no additional direction which provides guidance for staff beyond the order itself. Additionally, the medication was being administered regularly through the month of March, and the MAR did not indicate if 1 or 2 tablets were being administered.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.As part of our Medication Administration Policy, specific to administering PRN Medications, Embolden has introduced the following protocols: o Direct Care Staff who observe symptoms associated with the need of a PRN Medication (and prior to administering any PRN Medication) shall contact the Embolden Nurse to obtain guidance on administering the PRN medication. 09/11/2025 Implemented
SIN-00234441 Unannounced Monitoring 11/14/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Chemicals and poisonous material up to and including cleaning items were not kept locked throughout the home.Poisonous materials shall be kept locked or made inaccessible to individuals. All chemical substances have been placed in the supply closet and locked. 12/01/2023 Implemented
6400.70The home did not have an operable telephone with an outside line.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. An operable landline will be installed. 12/16/2023 Implemented
6400.77(c)The first aid kit did not contain a first aid manual. A first aid manual shall be kept with the first aid kit.A first aid manual has been placed with the first aid kit. 12/01/2023 Implemented
6400.81(k)(6)This home has three (3) bedrooms, none of the bedrooms had a mirror.In bedrooms, each individual shall have the following: A mirror. Mirrors have been placed in each bedroom. 12/01/2023 Implemented
SIN-00226221 Unannounced Monitoring 06/13/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)A thick layer of grease build-up was observed on all surfaces around the stove -- i.e., the stovetop, counters nearby, the microwave above, etc. The dishwasher had a thick build-up of chalky white material consistent with grime, soap scum, or other detritus on various interior surfaces. The vent in the bathroom is caked with dust.Clean and sanitary conditions shall be maintained in the home. ¿ Residential Manager (Karen Finley) assigns shift duties in writing for all staff persons who are scheduled to work in designated shifts. Shift duties specify cleaning tasks. Ms. Finley made all residential staff aware again on 09/06/2023, that to the extent they note cleanliness issues that require additional cleaning products, additional assistance, or outside services, they should notify her by phone or e-mail immediately. Ms. Finley¿s email and phone number (along with all staff contacts) are contained in the Best Practices Binder. 09/06/2023 Implemented
6400.64(b)Due to bags of rotten potatoes and onions in the kitchen pantry, the entire property has an infestation of fruit flies. Flies were found on all surfaces in the kitchen, and on many surfaces throughout the house.There may not be evidence of infestation of insects or rodents in the home. Bags of rotten potatoes and onions stored in the kitchen pantry were immediately thrown out on 6/13/2023. Viking pest control was contracted to exterminate the fruit flies on 06/16/2023. A copy of the contract was provided t licensing on 06/16/2023 as requested. 06/13/2023 Implemented
6400.66The property's rear door does not have a light.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. A solar powered light was installed on 06/17/2023 per work order. 06/17/2023 Implemented
6400.72(b)There is a large hole in the screen for the crawlspace window located near the trapdoor that leads down into that space. Screens, windows and doors shall be in good repair. The large hole in the screen for the crawl space window located near the trapdoor that leads down into that space was patched on 6/17/2023 06/17/2023 Implemented
6400.77(b)There were no tweezers in the first aid kit. 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. Tweezers were placed in the first aid kit on 06/14/2023 06/14/2023 Implemented
6400.171Bags of rotten potatoes and onions were found in the kitchen pantry closet. Open bags of flour, sugar, and sesame seeds were found stored in kitchen cabinets, providing a risk of food contamination and pest infestation.Food shall be protected from contamination while being stored, prepared, transported and served. Bags of rotten potatoes and onions stored in the kitchen pantry were immediately thrown out on 6/13/2023. Viking pest control was contracted to exterminate the fruit flies on 06/16/2023. A copy of the contract was provided t licensing on 06/16/2023 as requested 06/13/2023 Implemented
6400.163(a)Individual #1 medication kit contained an old bottle of their prescription Lubricant eye drops, stored without pharmacy or intact manufacturer labeling. This bottle was not disposed of when the currently used bottle replaced it in the kit.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.All individuals¿ medication orders and the Medication Administration Record were reviewed by the Program Specialist for accuracy and completeness on 9/11/2023. 09/11/2023 Implemented
6400.207(4)(IV)207(4)iv Individual #1 is prescribed PRN olanzapine for hallucinations. Psychotropic medication cannot be used on a PRN basis. Its orders must more clearly define its administration instructions.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: A specific, time-limited stressful event or situation to assist the individual to control the individual's own behavior.According to 00-02-09 bulletin, ¿medications prescribed on a PRN basis for the treatment of episodically occurring and well-defined symptoms of an underlying disorder (such as an anxiety disorder, auditory hallucinations, etc.) and not simply for behavior control, are not considered chemical restraints and therefore are not prohibited.¿ Individual #1 was prescribed Olanzapine ODT 5MG, the pharmacy label reads ¿take 1 tablet by mouth once a day as needed for hallucinations.¿ Hallucinations are a symptom of individual #1 documented underlying disorder of schizophrenia. To ensure compliance with §6400.207(4) and to exhibit that the purpose of the PRN is to treat an episode of a known psychiatric diagnosis, the following guidelines must be followed: ¿ Confirmed documentation by a physician or a medical practitioner of the individual¿s psychiatric diagnosis must be present in the individual¿s record. ¿ Written instructions by a physician or medical practitioner listing the individual¿s specific symptoms of the psychiatric diagnosis that would warrant the use of a PRN psychotropic medication must be included in the physician¿s prescription of the medication. ¿ Prescribed directions on the pharmacy label must include frequency (dose and allowable rate of recurrence of dosage) for administration of the PRN. ¿ Authorization by the CEO or CEO¿s designee for each instance of administration of a PRN psychotropic medication must be documented in the applicable medication administration record. ¿ Monitoring as indicated by a physician or medical professional and as directed on the pharmacy label of the actual response to medication each time a PRN is administered must be documented in the individual¿s record. With regards to individual #1 we believe that we have met the guidelines specified above: ¿ There is documentation from his psychiatrist specifying his underlying condition of schizophrenia in his records. ¿ Pharmacy label describes the symptoms of the psychiatric diagnosis that would warrant the use of a PRN (which are reflected in the prescription) as well as the frequency (dose and allowable rate of recurrence of dosage) for administration of the PRN. ¿ As it pertains to guideline #4-Embolden¿s CEO has identified an appropriate designee for administration of PRN psychotropic medications-and required documentation is maintained within the MAR for each instance of administration of the medication. While the Chapter 6500 RCG does not prescribe the credentials of the designee, Embolden ensures that the CEO designee is limited to only staff meeting all required medication administration trainings. ¿ Individual #1¿s response to medication each time a PRN is administered is documented in the individual¿s medication administration record. Individual #1 was prescribed Olanzapine ODT 5MG, the pharmacy label reads ¿take 1 tablet by mouth once a day as needed for hallucinations.¿ Hallucinations are a symptom of individual #1 documented underlying disorder of schizophrenia. To ensure compliance with §6400.207(4) and to exhibit that the purpose of the PRN is to treat an episode of a known psychiatric diagnosis, the following guidelines must be followed: ¿ Confirmed documentation by a physician or a medical practitioner of the individual¿s psychiatric diagnosis must be present in the individual¿s record. ¿ Written instructions by a physician or medical practitioner listing the individual¿s specific symptoms of the psychiatric diagnosis that would warrant the use of a PRN psychotropic medication must be included in the physician¿s prescription of the medication. ¿ Prescribed directions on the pharmacy label must include frequency (dose and allowable rate of recurrence of dosage) for administration of the PRN. ¿ Authorization by the CEO or CEO¿s designee for each instance of administration of a PRN psychotropic medication must be documented in the applicable medication administration record. ¿ Monitoring as indicated by a physician or medical professional and as directed on the pharmacy label of the actual response to medication each time a PRN is administered must be documented in the individual¿s record. With regards to individual #1 we believe that we have met the guidelines specified above: ¿ There is documentation from his psychiatrist specifying his underlying condition of schizophrenia in his records. ¿ Pharmacy label describes the symptoms of the psychiatric diagnosis that would warrant the use of a PRN (which are reflected in the prescription) as well as the frequency (dose and allowable rate of recurrence of dosage) for administration of the PRN. ¿ The CEO¿s designee (staff persons) for each instance of administration of a PRN psychotropic medication is documented in individual #1¿s medication administration record. ¿ Individual #1¿s response to medication each time a PRN is administered is documented in the individual¿s medication administration record. 09/15/2023 Implemented
SIN-00219598 Unannounced Monitoring 02/15/2023 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff 13 - the entire personnel record for this person could not be found at the time of inspection therefore there is no documentation available regarding whether a criminal history check was performed.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. As requested, records concerning staff person 13 was sent via email Thursday February 23 2023 and the receipt of records was confirmed on Tuesday March 7 2023. Ensure that all active personnel records are kept separately from inactive personnel records. 03/31/2023 Not Accepted
6400.72(b)The screen (right side window) located in the living room was damaged and in need of repair of replacement. Screens, windows and doors shall be in good repair. The small scratch on the screen was patched, image sent via email on March 7 2023. Supervisory personnel shall conducted biweekly site inspections to ensure that there's no damage to any screens, windows, etc. using the ECA Self Inspection Tool. 03/31/2023 Not Accepted
6400.151(a)Staff 5 - no physical examination form was found in the staff record. 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. Staff person has completed the ECA attestation form verifying that they are free of communicable diseases. The ECA Physical form has been revised to include this health attestation verification. 03/31/2023 Not Accepted
6400.151(c)(3)Staff 1 - There was no statement stating the staff is free from communicable disease noted on the physical exam. Staff 5 - There was no statement stating staff is free from communicable disease on the physical exam. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Staff person has completed the ECA attestation form verifying that they are free of communicable diseases. The ECA Physical form has been revised to include this health attestation verification. 03/31/2023 Not Accepted
6400.46(a)Staff 1 - the last fire safety training was completed on 2/12/2022. The next training was due by 2/2023 and there was no documentation that this training took place in the staff record. Staff 5 - the fire safety training was completed on 1/15/2022. Th next training was due by 1/2023, however there was no indication that the training was completed based on the records review.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.Staff person has completed fire safety training as recommended by licensing. HR personnel (or other designated personnel in their absence) shall ensure that all staff persons working with any individuals shall complete the fire safety training in the first training quarter of their employment. 03/31/2023 Not Accepted
6400.52(a)(1)Staff 13 - the entire personnel record for this person could not be found at the time of inspection therefore there was no record of any training having been completed.The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.As requested, records concerning staff person 13 was sent via email Thursday February 23 2023 and the receipt of records was confirmed on Tuesday March 7 2023. Ensure that all active personnel records are kept separately from inactive personnel records. 03/31/2023 Not Accepted
6400.52(a)(3)Staff 1had 19.25 hours of training for the 2022 training. year instead of the required 24 hours of training.The following shall complete 24 hours of training related to job skills and knowledge each year: Program specialists.Staff person has completed all 24 hour training for 2022, records sent via email on March 7 2023. 03/31/2023 Not Accepted
6400.52(c)(1)Staff 13 - the entire personnel record for this person could not be found at the time of inspection therefore there is no way to determine if this staff member received any of the required training.c(1) 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. (2) 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. (3) Individual rights. (4) Recognizing and reporting incidents. (5) The safe and appropriate use of behavior supports if the person works directly with an individual. (6) Implementation of the individual plan if the person works directly with an individualAs requested, records concerning staff person 13 was sent via email Thursday February 23 2023 and the receipt of records was confirmed on Tuesday March 7 2023. Ensure that all active personnel records are kept separately from inactive personnel records. 03/31/2023 Not Accepted
6400.169(d)Staff 1 has an incomplete medication administration packet. - There was no indication that they received the 12/10/22 portion of the MAR review because the checklists were not completed. The Annual Practicum form was not dated. Staff 4 did not complete their 4th MAR review which was due 12/2022 and the form is not dated or signed. No hand washing and glove skills checklists for 2022 were in the records at the time of the review. Staff 5 did not complete the 12/2022 MAR review based on the record review. The form was not dated by the medication administration trainer. Staff 7 - the med admin trainer - the annual practicum form was completed with no supporting documentation such as handwashing. Staff 8 - The staff did not have a reviewer or observer indicated on the Annual Practicum form, and it was not dated. No hand washing and glove skills checklist was included in the packet in the training record for 2022. The packet was incomplete; it was missing the MAR review checklist.A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.Staff person completed MAR review records were send via email on March 7 2023. 03/31/2023 Not Accepted
SIN-00215221 Unannounced Monitoring 11/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)There were cleaning chemicals unlocked in the kitchen area above the refrigerator. There was a bottle of children's liquid Tylenol unlocked.Poisonous materials shall be kept locked or made inaccessible to individuals. All chemical substances have been locked away. 11/30/2022 Implemented
6400.72(a)The bathroom that is attached to the kitchen had the window open with no screen installedWindows, including windows in doors, shall be securely screened when windows or doors are open. Window screen has been installed. 11/30/2022 Implemented
6400.83(a)The oven was not functional and taped shut. A home shall have a kitchen area with a refrigerator, sink, cooking equipment and cabinets for storage. The oven is fully functional--oven door was recently fixed-- staff forgot to remove the tape 12/08/2022 Implemented
6400.141(a)The Annual Physical dated 5/2/22 for individual #1 was incomplete.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The May 2022 annual physical examination form was faxed to PCP for revision purposes, but we have yet to receive it and are currently following up. 01/30/2023 Implemented
6400.181(e)(8)The Annual Assessment dated 4/12/22 for individual #1 does not state ability to evacuate in event of a fire.The assessment must include the following information: The individual's ability to evacuate in the event of a fire. Annual assessment has been revised to include the requested information. 12/30/2022 Implemented
6400.181(e)(14)The Annual Assessment dated 4/12/22 for individual #1 does not state ability to swim.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. Annual assessment has been revised to include the requested information. 11/30/2022 Implemented
6400.24Individual #1 is prescribed Clonazepam 1mg which is a controlled substance, however there was no controlled substance count being conducted in the home as outlined in the Controlled Substance Act of 1970.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.Embolden tracks all medications (controlled or uncontrolled) on one tracking form (med tracking form), going forward, Embolden will ensure that controlled substances are also tracked on the ECA Controlled Substances Form 01/30/2023 Implemented
6400.163(a)Individual #1's medication box contained Melatonin 10mg being distributed from a ziplock bag with no pharmacy labelPrescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.Medication contained in the zip lock bag has been returned to the pharmacy for disposal. 11/30/2022 Implemented
6400.207(4)(I)The following medications prescribed to individual #1 are prescribed in order to treat episodic behavior: Olanzapine 5mg -- take one tablet by mouth once a day as needed for agitation Aripiprazole 10mg tablet -- take one tablet by mouth every day as needed for agitationA 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.From Executive Director to Licensing Representative Via Email: I've revised the policy based on the bulletin. I contacted SB's psychiatrist and they have yet to send the revised label to the pharmacy, 01/30/2023 Implemented
SIN-00204604 Renewal 04/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)The cleaning supplies were left unlocked in the hall closet and under the bathroom sink..[REPEATED NON-COMPLINCE 4/13/21]Poisonous materials shall be kept locked or made inaccessible to individuals. All cleaning supplies have been locked in the hallway supply closet and house managers shall ensure that all chemical/poisonous substances are locked away 05/24/2022 Implemented
6400.81(k)(6)There are no mirrors in the bedrooms belonging to individual 1 or individual 2..[REPEATED NON-COMPLINCE 4/13/21]In bedrooms, each individual shall have the following: A mirror. Mirrors have been placed in each individual's rooms 05/24/2022 Implemented
6400.141(c)(9)Individual 1did not have an annual prostate exam performed.The physical examination shall include: A prostate examination for men 40 years of age or older. A prostate exam has been scheduled 05/24/2022 Implemented
6400.141(c)(10)Individual #1's 2/14/22 physical does not indicate if they are free of communicable diseases.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. Individual #1 is free of communicable diseases. This is in reference to another individual who resides at a separate location 05/24/2022 Implemented
6400.141(c)(14)Individual 1's 2/14/22 physical did not include information pertinent to diagnosis in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Individual #1 annual physical form does contain pertinent information relating to his diagnosis and such information can be used in emergency situations 05/24/2022 Implemented
6400.142(a)Individual 1 did not have an annual dental exam completed.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. A dental exam was completed on 2/1/22 for individual #1 but the Dental Case note form was not returned by the dental office 05/24/2022 Implemented
6400.142(g)Individual 1 did not have a dental hygiene plan completed annually.A dental hygiene plan shall be rewritten at least annually. N/A due to the fact that the annual date has not occurred yet (last dental appointment was 2/1/22) 05/24/2022 Implemented
6400.181(e)(10)individual 1's initial 8/5/21 assessment does not include a lifetime medical historyThe assessment must include the following information: A lifetime medical history. Ensure that the lifetime medical history is included in all assessment forms 05/24/2022 Implemented
6400.166(b)The Mar's form for individual 1 , was initialed for giving Seroquel on the next day (4/13/2022), instead the current date should have been initialed on (4/12/2022).The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Ensure that MARs are reviewed daily to ensure the accuracy of the information 05/24/2022 Implemented
6400.213(1)(i)Individual 2 record did not include date of admission.Individual 2 record did not include the individuals' height, weight, eye color or identifying marksEach individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.The Face Sheet has been revised to include the individual's height, weight, eye color (no identifying marks- marked N/A) 05/24/2022 Implemented
SIN-00194365 Renewal 04/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Financials were missing for Individual #1 for March 2021 at time of inspection.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. The March 2021 expense report for individual #1 was found as it was mistakenly placed in the wrong binder but it was completed. The expense report itemizes all the expenses for March as well as deposits. The issue was we did not have a systematic approach to organizing consumer records so we developed a standardized way of organizing consumer records across our homes to prevent records from being misplaced. 04/30/2021 Implemented
6400.22(e)(3)No receipts provided for transactions over $15 for all individuals reviewed (Individual #1) If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. We make copies of all receipts of monthly consumer expenditures and attach them to their corresponding monthly expense reports. Before we used to save receipts in a secured area in the home and compile them when creating expense reports at the end of the month-- we noticed that this approach does not eliminate the chance that the receipt could be easily misplaced. Making copies of receipts and immediately attaching them to their corresponding expense report has eliminated this problem. 04/30/2021 Implemented
6400.62(a)Poisonous materials were not kept locked or made inaccessible to individual #1 there was Drain Maintenance cleaner in an unlocked bathroom drawer under the sink.Poisonous materials shall be kept locked or made inaccessible to individuals. Each home was searched and all poisonous materials were kept in locked areas. 04/30/2021 Implemented
6400.77(b)The first aid kit did not contain a scissors at time of 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. A new first aid kit was purchased which contains scissors, bandages, etc. First aid kits are checked routinely to ensure that all the necessary items are included. 04/30/2021 Implemented
6400.101The exit route outside the backdoor gate was obstructed, the gate could not be utilized at time of inspection.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The gate is secured as individual #1 is an elopement risk when experiencing symptoms of his psychosis which are unpredictable- behaviors have been noted on the ISP and BSP. The staff have been given the combination for the lock in the event of any emergency situations. 04/30/2021 Implemented
6400.112(c)Fire Drills were not compliant. From October 2020 thru March 2021,evacuation start and end time not clearly identified.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 or smoke detector was operative. The fire drill forms were revised as requested to document start and end time as they were not clearly stated in the previous form. 04/30/2021 Implemented
6400.113(a)No proof of fire safety training was provide during this inspection for Individual #1An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, 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 home.The signed Fire Drill policy statement and Annual Fire Safety Training Record for individual #1 was submitted along with other requested documentation. 04/30/2021 Implemented
6400.141(c)(1)No medical history provided on Individual #1 Physical Examination Form dated 2/07/2021, this portion was omitted. (or left blank)The physical examination shall include: A review of previous medical history. Ensure that the clinician documents each individuals' medical history on subsequent Physical Examination forms; however, this examination form pre-dates the individual's care from Embolden- individual began receiving care from Embolden on April 1 2020 04/30/2021 Implemented
6400.141(c)(6)The physical examination form dated 1/07/2020 for Individual #1 did not include a Tuberculin test by any method with negative results. This portion of the exam was left blank.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. This examination form pre-dates the individual's care from Embolden. The individual began receiving services from Embolden April 1, 2020. 04/30/2021 Implemented
6400.31(a)At time of inspection there was no signed copy of rights for Individual #1An individual may not be deprived of rights as provided under § 6400.32 (relating to rights of the individual.)The signed copy of rights for individual #1 was provided. 04/30/2021 Implemented
6400.46(a)It could not be determined if direct service worker Staff #2 was trained before working with individuals in general fire safety, no verification of completed training provided at time of inspection.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.The General Fire Safety training certificate was provided for direct service worker #2. Each home has a custom Fire & Disaster Plan which also specifies 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, smoking safety procedure, etc. 04/30/2021 Implemented
6400.46(b)It could not be determined if Program specialists Staff #1 was trained annually by a fire safety expert. No verification of completed training was provided at time of inspection.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).We have found local businesses that specialize in fire prevention to conduct additional fire safety training for staff. 04/30/2021 Implemented
6400.163(h)Prescription medications Quetiapine Fumarate 300mg was discontinued on 4/7/2021, the medication was located in the individual's #1 active medication box.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The Quetiapine Fumarate (AKA Seroquel) was increased from 200MG to 300MG on April 6 2021- only the 300MG medication was in the medication box (the discontinued 200MG had been disposed) as specified on the email sent April 18 2021. Thus the 300mg dose of the Seroquel (or Quetiapine Fumarate) was not discontinued and there was no compliance issue. 04/30/2021 Implemented
6400.165(e)Medication review for Individual #1 shows it cannot be determined if medication is being administered as prescribed. Medication OMEPRAZOLE DR is listed on the individuals MAR as 200MG, the prescription label on the medication bottle shows 20MG.Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received.The MAR was revised to Omeprazole to document 20MG instead of 200MG. The instructions however were correct and after calculating the date the medication was filled, frequency and the quantity that was dispensed we found there was no errors in terms of administration. Nonetheless, we constantly make sure there no such errors on MARs. 04/30/2021 Implemented
6400.169(a)Qualification to administer medication for Program Specialist Staff #1 was not completed annually, last 12/09/2019.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).The Program Specialist has completed the medications administration course - the Annual Practicum certification form was not submitted with the Initial training certification form by mistake. 04/30/2021 Implemented
SIN-00252330 Renewal 09/12/2024 Compliant - Finalized