Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00250924 Renewal 08/26/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(3)Individual #1 had several entries on the financial record exceeding $15, however no receipts was available to support the documentation. The entries with missing receipts were on 5.16.24 in the amount of $30 for pizza/soda; 9.7.23 in the amount of $75.25 for Foreman Mills; 10.13.23 in the amount of $45.56 with no entry for what it was used for; and 6.17.24 in the amount of $50 for day program. 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. At the time of inspection, the requested receipts had been archived. Provider has made copies of the missing receipts and made them available at the site. 10/03/2024 Implemented
6400.66The sliding glass door which leads outside from the basement of the home, did not have a light to assure safety. The lightbulb was not working at the time of the inspectionRooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Provider changed the light bulb immediately. 08/26/2024 Implemented
6400.106Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. The agency provided documentation for furnace inspections on 10.17.22 and 12.18.23. The furnace inspection was late.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. Provider contacted the furnace cleaning company and requested for an appointment to ensure that the inspection is done in a timely manner. 08/30/2024 Implemented
6400.141(c)(13)The individual's physical dated 4.10.24 did not have allergies or contradicted medications. That area of the physical was left blank.The physical examination shall include: Allergies or contraindicated medications.Provider brought the form back to individual #1's doctor to be completed as needed. The allergies and contradicted meds part were completed. 08/30/2024 Implemented
SIN-00225940 Unannounced Monitoring 06/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)Areas of the lower interior surface of the home's oven were coated with a charred, black discoloration. There were two charred, blackened remnants of what appeared to be pasta noodles lying on the lower surface. The presence of these substances in and on the floor of the oven constitutes a fire hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.Provider picked up the pieces of noodles and cleaned the area. 06/07/2023 Implemented
6400.77(b)The home's first aid kit did not contain a thermometer at the 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. Provider placed the thermometer located inside the drawer, back in the first aid kit. 06/07/2023 Implemented
SIN-00223252 Unannounced Monitoring 04/20/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)At time of inspection the small chest freezer in the kitchen contained few food items. Spills of what appeared to be a red substance and covering an area of approximately 6 inches by 8 inches were frozen to the surface of the ledge and bottom of the freezer. At time of inspection on 4/20/23 the only gallon of milk in the refrigerator was open and had an expiration date of 4/18/23. There was one loaf of bread in the home that had an expiration date of 4/15/23.Clean and sanitary conditions shall be maintained in the home. Provider cleaned the red substance that appeared to be fruit juice off the freezer. Milk and bread discarded and replaced. 04/20/2023 Implemented
6400.144The Individual Support Plan (ISP) for Individual #1 last updated on 12/22/22 states "is non-verbal. uses limited sign language. indicates the need to use the toilet and the need to eat through sign language. may communicate pain by crying or screaming." Individual #1 is diagnosed with constipation and is prescribed Colace three times per day, Milk of Magnesia "Take 2 TBS (30ML) by mouth daily as needed for constipation," Polyethylene Glycol "mix 1 capful (17gm) w/8oz of liquid & drink as needed for constipation." The pharmaceutical labels for the Pro Re Nata (PRN) medications Milk of Magnesia and Polyethylene Glycol do not contain adequate information for administration. Medications state to give as needed for constipation. Individual #1 is nonverbal and does not self-report. The medication label does not direct how many days an individual should be absent a bowel movement before the medication should be given, how long the medication should be administered nor does the agency have a protocol in place for the tracking Individual #1's bowel movements. With inadequate information and no tracking of bowel movements or protocol in place the prescribed medications cannot be properly administered.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. Provider called PCP to get clarification on when to administer PRN medication for constipation. 04/26/2023 Implemented
SIN-00221529 Unannounced Monitoring 03/21/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The home does not maintain clean and sanitary conditions. The dryer of the home is vented into the garage. There There was lint located all over the garage floor. (Repeat violation 5/12/22, 6/21/22, 7/25/22, 8/25/22)Clean and sanitary conditions shall be maintained in the home. Maintenance rerouted the vent and attached a lint trap to the end of the vent. 04/12/2023 Implemented
6400.80(b)The outside of the building and the yard or grounds is not well maintained, in good repair and free from unsafe conditions. There is a fire pit located in the back yard of the home to the right of the sliding glass doors in the basement that is approximately 12 to 18 inches from the home. This pit is filled with fire wood. The fire pit presents a hazard as it is too close to the home. There are piles of leaves around the front porch of the home. There is a broken railroad tie that was used as a parking barrier located in the front yard that presents a hazard. There is a rolled up outdoor carpet located on the patio in the back of the home that is a hazard. (Repeat Violation, 6/21/22 and 7/25/22) The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.Provider deconstructed the fire pit. 03/22/2023 Implemented
6400.163(h)Prescription medications that are discontinued or expired are not destroyed in a safe manner according to applicable Federal and State statutes and regulations. Individual #1 is prescribed Acetaminophen 325mg, take 2 tablets (650mg) by mouth 3 times daily as needed for pain/fever. This medication expired on 3/14/23 and remained in the Individual's medication basket. (Repeat Violation 6/21/22)Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Provider contacted practitioner a while before medication expired. Provider followed up a few times until new scripts sent in. New medication delivered. 03/21/2023 Implemented
6400.166(a)(13)Individual #1 was administered Anti diarrheal 2mg cap, take 1 caplet by mouth four times a day as needed for diarrhea. This medication was administered in 3/14/23 according to a date documented on the medication blister pack. The name and initials of the staff person administering the medication was not documented on the Medication Administration Record. (Repeat violation 5/12/22, 6/21/22, 11/14/22, 12/22/22, 2/27/23)A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.Staff that was on shift at the time of medication administration was contacted to verify med administration. A late entry was completed. 03/21/2023 Implemented
SIN-00216599 Unannounced Monitoring 12/22/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(13)Individual #1's Physical dated 1/21/22 does not list allergies or contradicted medications.The physical examination shall include: Allergies or contraindicated medications.Provider returned the form to the doctor for updating. 12/27/2022 Implemented
6400.165(g)Psychiatric medication reviews are not occurring every three months. Individual #1 had a review of psychiatric medications on 8/22/22 and did not have a review in November. The next appointment not until 12/23/22.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.Medical practitioner called to reschedule earlier made appointment. 12/22/2022 Implemented
SIN-00215007 Unannounced Monitoring 11/14/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Poisons were found unlocked and accessible in the home. A closet located in the bedroom hallway contained multiple bottles and containers of cleaning supplies and personal hygiene items; and was not locked at the time of the inspection. The current Individual Support Plan (ISP) for Individual #4 states that the individual is not safe with poisons and that poisons should be locked in the home.Poisonous materials shall be kept locked or made inaccessible to individuals. The poisons closet was immediately locked. Staff involved were retrained on the individuals' ISPs. 11/25/2022 Implemented
6400.82(f)There was no soap available in the bathroom located in the bedroom hallway on the first floor of the home.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. A bottle of soap was immediately placed in the bathroom. Staff involved were trained on the appropriate regulation. 11/25/2022 Implemented
SIN-00213656 Unannounced Monitoring 10/18/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(a)A garden hose was uncoiled and strewn over a portion of the rear patio of the home in a manner that would constitute a tripping hazard for individuals and staff members. Outside walkways shall be free from ice, snow, obstructions and other hazards. The garden hose was coiled and moved into a secure location away from human traffic. 11/19/2022 Implemented
6400.141(c)(4)Individual #1's Physical Examination, dated 01/21/2022, did not include vision or hearing screenings. The corresponding items on the physical form were left blank.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The annual physical form was returned to the PCP for review and completing of the unanswered sections. 11/19/2022 Implemented
6400.141(c)(14)Individual #1's Physical Examination, dated 01/21/2022, does not contain medical information pertinent to diagnosis and treatment in case of an emergency. The corresponding item on the physical form was left completely blank by the physician.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The annual physical form was returned to the PCP for review and completing of the unanswered sections. 11/19/2022 Implemented
6400.144Individual #1 is prescribed "Metaprolol Tartrate 50mg Tab" to be taken twice daily, at 8:00am and 8:00pm. At the time of inspection, only the medication blister pack for the 8:00pm dose could be located within the home. Staff on Site could not provide an explanation for the missing 8:00am medication blister pack of this medication and it could not be located by Staff on Site prior to the conclusion of the on-site inspection. As at least 13 doses of this medication were missing, Staff on Site were unaware that the medication was missing until the medications were reviewed as a part of this inspection, and Staff on Site could not provide an explanation for the missing medication, it is concluded that the provider was not reliably providing pharmaceutical services for the individual as required.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. The medication refill had already been requested and the medication was delivered at 4pm. The individual did not miss any dose. 11/19/2022 Implemented
6400.213(1)(i)Individual #1's Individual Record contains conflicting accounts of their weight. On more than one medical document, including a physical examination dated 01/21/2022, the individual's weight is listed as 173lbs. On a form titled "Resident Sheet," the individual's weight is listed as 240lbs. As this information is not consistent, it cannot constitute a reliable record of the individual's weight.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.The individual's records have been updated to reflect the current weight. 11/19/2022 Implemented
SIN-00208707 Unannounced Monitoring 06/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The provider had failed to empty and clean the refrigerator and freezer of the home when the site became vacant. Consequently, when the power was interrupted to the appliance, it was full of food, At the time of the inspection, there was a foul odor of spoiled food when the inspectors entered the front door of the home; and the interior of the refrigerator and freezer was filled with rotted food. mold and mildew.Clean and sanitary conditions shall be maintained in the home. The refrigerator and the freezer were cleaned and is in good condition. 08/16/2022 Implemented
6400.66The windowless laundry room located in the basement of the home did not have an operable light at the time of the inspection.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Lighting for the laundry room was fixed and there is adequate lighting at this time. 08/16/2022 Implemented
6400.72(a)The windows located in the garage and the hall bathroom were capable of being opened and did not have screens.Windows, including windows in doors, shall be securely screened when windows or doors are open. Screens were installed in the in the windows located in the garage and hallway bathrooms, 08/16/2022 Implemented
6400.72(c)The sliding glass door located at the back of the home did not securely lock and could be opened even when the locking mechanism was engaged. Outside doors shall have operable locks.The lock on the sliding glass door was repaired. 08/16/2022 Implemented
6400.101The 2nd bedroom of the house had a chain type locking device (typically found on the inside of an entry door) installed on the inside of the bedroom door which could be locked by someone on the interior of the room. There would be no way to open the door from the outside if the chain was engaged, other than breaking down the door. In the event of a fire or medical emergency inside the bedroom, staff or emergency responders would not be able to gain access to the room if the party inside was unwilling or unable to remove the chain.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The door chain was removed. 08/16/2022 Implemented
SIN-00202018 Unannounced Monitoring 03/16/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The mini blinds on the window in Individual #8's bathroom had several broken slats. The blind was covering the top half of the window. Plastic Frosting had been placed on the lower half of the window. The carpet in the second/spare bedroom of the home was cut and pulled up from the floor. The doorknob leading to the garage from the left side of the basement steps was falling off. (Repeat Violation 1/25/22)Floors, walls, ceilings and other surfaces shall be in good repair. The mini blinds on the window in individual #8's bathroom was replaced. The carpet in the spare bedroom was repaired The doorknob leading to the garage from the left side of the basement steps was repaired 03/16/2022 Implemented
6400.67(b)The light fixture in the laundry room is hanging by wires connected to the junction box in the ceiling. This presents a hazard as there are exposed wires and the light could fall, potentially causing injury. There is a door in the garage ceiling to access pipes, the door is broken and hanging by two screws, creating a potential hazard. Individual #8 broke the mirror in the individual's bedroom, the broken mirror remained on the individual's dresser. Floors, walls, ceilings and other surfaces shall be free of hazards.The light fixture in the laundry room was fixed. The door in the garage ceiling was fixed. The broken mirror was removed and replaced.. 03/16/2022 Implemented
6400.82(f)The bathroom in the basement level of the home did not contain individual clean paper or cloth towels.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 were placed in the bathroom in the basement. 03/11/2022 Implemented
6400.112(a)Fire drills were not completed in January, or February. (Repeat violation 1/25/22) An unannounced fire drill shall be held at least once a month. Fire drills for January and February completed. Staff responsible for monthly drills, placed them in a drawer in the office. 03/31/2022 Implemented
6400.144Individual #8 is prescribed Vitamin D 50,000 Units. Vitamin D2 1.25mg (50,000) Take 1 capsule by mouth once weekly on Tuesdays at 8AM. This medication was not available in the home and was not administered on March 1 and 8, 2022. Staff indicated that the medication was discontinued in November 2021. There was no documentation of the medication being discontinued. The agency has not provided proper pharmaceutical services for the individual. Individual #8 is prescribed Hydroxyzine PM 50mg cap, take 1 capsule by mouth every 8 hours as needed for anxiety/irritability. The pharmaceutical label does not include specific symptoms displayed by the individual in order for the medication to be administered. The agency has not provided proper pharmaceutical services. (Repeat Violation 9/22/21, 12/14/21, 1/25/22)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. Medication was a one time order. The provider has received the discontinue script from the doctor. 03/30/2022 Implemented
6400.18(c)Individual #8 is prescribed Vitamin D 50,000 Units. Vitamin D2 1.25mg (50,000) Take 1 capsule by mouth once weekly on Tuesdays at 8AM. This medication was not available in the home and was not administered on March 1 or March 8, 2022. This medication error was not reported to the persons designated by the individual within 24 hours. (Repeat Violation 9/22/21, 12/14/21, 1/25/22)The individual and persons designated by the individual shall be notified within 24 hours of discovery of an incident relating to the individual.Medication was previously discontinued. Provider obtained a discontinue order from the medical provider. 03/11/2022 Implemented
6400.18(b)(2)Individual #8 is prescribed Vitamin D 50,000 Units. Vitamin D2 1.25mg (50,000) Take 1 capsule by mouth once weekly on Tuesdays at 8AM. This medication was not available in the home. And was not administered in on March 1 and March 8, 2022. This medication error was not reported in EIM within 72 hours. (Repeat Violation 9/14/21,12/22/21, 1/25/22)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 72 hours of discovery by a staff person: A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner.Medication previously discontinued. Provider received a discontinue order from the medical provider. 03/11/2022 Implemented
6400.165(c)Individual #8 is prescribed Fluticasone PROP 50mg, use 1 spray in each nostril once daily at 8AM. This medication was last refilled on 11/10/21 and contains a 60-day supply. The bottle remains full. The medication is documented as being administered as prescribed on the Medication Administration Record. (Repeat Violation 12/14/21, 1/25/22).A prescription medication shall be administered as prescribed.Individual #8, was admitted multiple times in the last quarter of 2021. In January, the cycle meds were delivered and the newer delivered bottle of Fluticasone PROP 50mg, returned to the pharmacy for credit. 03/11/2022 Implemented
6400.166(a)(13)Individual #8's medication record did not include the initials of the person administering the medication on March 15 and 16, 2022 for any of the individual's medications.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.Staff working with individual #8 administered medications but did not immediately document on the MAR though she was still on shift. Staff initialed the MAR before the end of her shift. 03/11/2022 Implemented
6400.166(c)Individual #8 is prescribed Risperidone 2mg Tablet, take 2 tablets (4mg) by mouth once daily at 8PM and Risperidone 1mg tablet, take 1 tablet by mouth twice daily at 8AM and 8PM. Individual #8 refused the 8AM dose of Risperidone 1mg on March 9 and the 8PM dose of Risperidone 2mg and Risperidone 1mg at 9PM on March 9 and 11, 2022. There is no documentation that the refusal was reported to the prescriber. Individual #8 is prescribed Fluticasone PROP 50mg use 1 spray in each nostril once daily at 8AM. Individual #1 refused this medication on March 3, 4, 5, 9, 10, 11, 12, 13 and 14, 2022. There is no documentation of the medication refusal or that the refusal was reported to the prescriber.Individual #8 is prescribed Loratadine 10mg tablet 1 tablet by mouth daily at 8AM. Individual #1 refused this medication on March 3, 2022. There is no documentation of the refusal or that the refusal was reported to the prescriber. Individual #8 is prescribed Melatonin 3mg tablet. Take 1 tablet by mouth once daily at bedtime. Individual #8 refused this medication on March 3, 2022, March 9, 2022, and March 12, 2022. There is no documentation of the medication refusal or that the refusal was reported to the prescriber.If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual.Leadership met with staff involved and the incident was reviewed. Individual #8's staff were retrained on medication administration documentation. Individual #8's doctor was informed of the refusals. 03/31/2022 Implemented
SIN-00199345 Unannounced Monitoring 01/25/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(f)A garbage can was observed outside of the home, to the left of the front door. The can was uncovered and overflowing with trash.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The garbage can was covered and the lid secured to protect it from being blown away. 01/31/2022 Implemented
6400.67(a)The mini-blind window covering in the first floor hall bathroom had several broken slats.Floors, walls, ceilings and other surfaces shall be in good repair. The damaged mini-blind was removed and the window was frosted half-way up. Individual #1 is still able to have outside view. 01/31/2022 Not Implemented
6400.112(a)There were no records or documentation that an unannounced fire drill was held during the months of June, July and August of 2021. An unannounced fire drill shall be held at least once a month. Unannounced fire drill for June, July, and August was conducted but documentation was not presented during the unannounced inspection. Documentation will be provided upon request. 01/31/2022 Not Implemented
6400.112(c)The written fir e drill record for the drill held on 12/21/2021 did not document the exit that was used during the drill.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The fire drill process was reviewed with all staff involved with focus on documentation 01/31/2022 Implemented
6400.52(c)(1)Staff #1 did not complete annual training during the most recent complete training year in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Staff #1 completed training in Person-Centered practices on 2/4/2022 02/04/2022 Implemented
6400.52(c)(2)Staff #1 did not complete annual training in the most recent complete training year in the area of the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.Staff completed training on Prevention, detection, and reporting of abuse on 2/1/2022 02/01/2022 Implemented
6400.52(c)(3)Staff #1 did not complete annual training in the most recent complete training year in the area of Individual Rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Staff #1 completed training on Individual rights on 2/1/2022 02/01/2022 Implemented
6400.163(h)The medication Sulfamethoxazole was discontinued on 1/23/2022 but, at the time of the inspection, the medication blister pack was still with the current medications.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The discontinued medication (sulfamethoxazole) was removed from the house and disposed of. 01/31/2022 Not Implemented
6400.186Individual #1 has a restrictive behavior support plan that states that the telephone must be locked due to past inappropriate use involving police involvement. The Individual Support Plan also notes that the telephone must be locked, and the Individual must be supervised when using the phone. At the time of this inspection, a cordless telephone handset and the base (plugged into a wall outlet) was found in the living room.The home shall implement the individual plan, including revisions.All the phones in the home have been locked. Individual #1 has access to the phones with staff supervision. 02/01/2022 Implemented
SIN-00184437 Renewal 02/10/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff #3 was hired on 11/16/2020. A Pennsylvania Criminal History record was not completed within 5 days of her hire date. Criminal History record in Staff # file is dated 2/9/2021, approximately 3 months after the hire date.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. Staff #3 background check was completed on 02/09/21, provider will ensure that background checks for new hires will be completed prior to having contact with individuals. 06/28/2021 Implemented
6400.22(c)Receipt provided for Individual #4 dated 10/13/20 show the individual spent $61.85 at PriceRite for groceries. Requests were made for the Individual's Room and Board Contract, Ledgers and additional receipts however, these documents were not received. Based on the documentation provided, the individual does appear to be purchasing food for the home.Individual funds and property shall be used for the individual's benefit. Provider refunded the $61.85 to individual #4 for the purchases made on 10/13/20 04/15/2021 Implemented
6400.112(b)Review of ISPs for both individual that reside in the home indicate a 2:2 staffing ratio. During drills conducted on 4/19/20, 5/20/20, and 6/21/20 three staff were present for each drill. For the drill conducted on 7/15/20, four staff were present for the drill. Drills shall be held during normal staffing conditions. Fire drills shall be held during normal staffing conditions and not when additional staff persons are present. Staff re trained on responsibilities of completing a fire drill. 03/02/2021 Implemented
6400.112(d)For the monthly fire drill completed on 1/9/21, individuals evacuated at 3 minutes and 5 minutes. Both exceeding the required 2.5 minute evacuation time. No repeat drill was conducted. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Individuals re oriented on evacuation procedures. 03/02/2021 Implemented
6400.112(f)For fire drills reviewed from February 2020 through January 2021, the "front door" was the only exit utilized during drills with the exception of the drill conducted in January 2021 which exceeded 2.5 minute evacuation time.Alternate exit routes shall be used during fire drills. Staff re trained on the evacuation protocols. 03/01/2021 Implemented
6400.141(c)(6)At the time of inspection, Individual #4 did not have record of tuberculin skin testing in her file. It is unclear if the individual was cleared of communicable diseases prior to residing in the home due to the lack of documentation.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. Individual #4 completed a tuberculin test on 08/01/2019 03/02/2021 Implemented
6400.143(a)Individual MAR indicates that Individual #4 refused medications on 2/2/2021 at 8pm. Individual #4 also refused dental treatment at her dentist appointment. Request was made for previous months MARs as well as for a behavior/refusal plan/training. Additional documentation was not received.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. Individual#4's refusals documented in the individual's records. 03/02/2021 Implemented
6400.151(c)(2)Staff #3 had physical completed on 7/11/2020 does not include a TB test. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Staff will be required to complete TB tests before working with individuals. Staff #3 requested to complete a TB test before resuming work. 02/22/2021 Implemented
6400.151(c)(3)Staff #3 physical dated 7/11/2020 does not have a signed statement that the staff person is free from communicable diseases 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 #3 requested to provide a signed statement statement stating that the staff is free from communicable diseases. Provider will provide physical exam forms indicating this to all new hires. 03/02/2021 Implemented
6400.151(c)(4)Staff #3 physical dated 7/11/2020 does not include information regarding medical problems the staff may have that would interfere with the health of the individuals.The physical examination shall include: Information of medical problems which might interfere with the health of the individuals.Staff #3 will provide a physical form that includes any information regarding any medical problems the staff may have that would interfere with the health of individuals. 03/02/2021 Implemented
6400.181(d)Individual #4 moved into the home on 2/26/2020. Her assessment was not completed until 6/2/2020, exceeding the requirement for the assessment to be completed within 60 calendar days after admission.The program specialist shall sign and date the assessment. Individual #4 assessment completed 06/02/20, provider ensure completion of initial assessments within 60 days of admissions. 05/03/2021 Implemented
6400.34(a)Individual #4 does not have a signed copy of individual rights located in her file. It is unclear if the agency informed the individual of her rights upon admission due to the lack of documentation.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.Individual #4 was informed of rights upon admission, and a signed copy placed in the individual's file. 02/25/2021 Implemented
6400.51(b)(1)Staff #3 was hired on 11/16/2020. Staff did not complete orientation to include the application of person centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships.The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Individual #3 was re trained on application of person centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships on 03/05/21 03/05/2021 Implemented
6400.51(b)(2)Staff #3 was hired on 11/16/2020. Staff did not complete orientation to include the prevention, detection, and reporting of abuse.The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations.Staff #3 was trained on prevention, detection and reporting of abuse on 03/09/21 03/09/2021 Implemented
6400.51(b)(3)Staff #3 was hired on 11/16/2020. Staff did not complete orientation to include training on Individual rights.The orientation must encompass the following areas: Individual rights.Staff #3 was trained on resident's rights on 03/05/21 03/05/2021 Implemented
6400.51(b)(4)Staff #3 was hired on 11/16/2020. Staff did not complete orientation to include recognizing and reporting incidents.The orientation must encompass the following areas: recognizing and reporting incidents.Staff#3 was trained on recognizing and reporting incidents on 03/09/21 03/09/2021 Implemented
6400.52(c)(6)Staff #3 was hired on 11/16/2020 and did not receive training on the implementation of the individual plan.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Staff#3 was given an overview of the implementation of the individual's plan on 03/12/21 03/12/2021 Implemented
6400.166(a)(10)Individual #4 is prescribed Hydroxyzine Pam 50mg 2 times daily as needed for anxiety. This medication was administered on 2/4/2021. No time of administration was documented on the MAR.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.Provider has retrained staff on administration of PRN meds. 02/24/2021 Implemented
6400.207(4)(I)Individual #4 is prescribed Hydroxyzine Pam 50mg 2 times daily as needed for anxiety. There is no written protocol or plan in place as to when to administer this medication to the individual. It is unclear from the individual's assessment if she would be capable of making this decision to need the medication for the prescribed reason. Request was made for previous months Medication Administration Record to further assess how frequently the medication is being administer, however the documentation was not received. Medication was administered on 2/4/2021.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.Provider submitted a PRN protocol for individual #4's PRN medication. 06/15/2021 Implemented
SIN-00220080 Unannounced Monitoring 02/27/2023 Compliant - Finalized
SIN-00218416 Unannounced Monitoring 01/31/2023 Compliant - Finalized
SIN-00209279 Unannounced Monitoring 07/25/2022 Compliant - Finalized