| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff #2 was hired on 4/02/2022 and staff's criminal background check was not completed until 4/30/2022. According to OAPSA (Older Adult Protective Services Act) criminal background checks must be completed on or before the first day. | 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.
| Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400. 21(a)
Dignity and Respect yearly inspection was conducted on august 22nd. Dignity and Respect's inspectors recognized that the agencies were in violation of 6400.21 where staff #2 criminal background check was not completed till 4/30/2022.
Staff # 2 was hired on 4/2/2022. Immediately after hired, she started her training and did not provide service or come in contact with any of our individual till 5/11/2022 after her trainings.
Dignity and Respects director is responsible, to make sure that all new hired staffs undergo a Pennsylvania criminal history record check with the State Police before training or before providing any services with the agencies
Dignity & Respect understands that making a bad hire can prove costly for our agency in wasted resources, damage to our reputation, and lower morale among our team. By conducting a criminal background check for employment as part of our agencies screening process. Dignity & Respect will reduce the chances of bringing in an employee with a troubling criminal past. |
08/22/2022
| Implemented |
| 6400.62(a) | A bottle of cleaning spray with containing bleach was under the bathroom sink unlocked. Poisonous materials must be kept locked due to Individual # 1's safety needs. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400. 62(a)
Dignity and Respect annual yearly inspection was conducted on august 22nd to 26th.
Dignity and Respect's inspector recognized that the agencies were in violation of 6400.62 when he observed a bottle of bleach under the bathroom sink.
Exposure to chemicals commonly used in workplaces can have short- and long-term health effects on both our staffs and the individuals we sever.
Dignity and Respect understands the seriousness of the citation and also made corrected in the present of the inspector in order to maintain compliance.
Dignity & Respect's House manager is responsible to make sure that all poisonous materials are locked and put away at all times
D & R will keep all household chemicals and cleaning products - including detergent tablets for the dishwasher or washing machine - out of sight and in cupboards with a key lock.
D & R will keep potentially harmful products out of reach of individuals at risk of poisonous materials, never under the sink or on the floor by the toilet
D & R will dispose of empty containers safely and out of individuals reach and
locked after every cleanings at the home. |
08/22/2022
| Not Implemented |
| 6400.62(c) | There was a spray bottle with fluid under the bathroom sink not in it's original labeled container. | Poisonous materials shall be stored in their original, labeled containers. | Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400. 62(c)
Dignity and Respect annual yearly inspection was conducted on august 22nd to 26th.
Dignity and Respect's inspector recognized that the agencies were in violation of 6400.62 (c) when he observed a spray bottle under the bathroom sink was not in it's original labeled container.
Exposure to chemicals commonly used in workplaces can have short- and long-term health effects on both our staffs and the individuals we sever.
Dignity and Respect understands the seriousness of the citation. Dignity and Respect made corrected immediately by removing and disposing the spray bottle the present of the inspector in order to maintain compliance.
Dignity & Respect's House manager is responsible to make sure that all poisonous materials are in its original labeled container. The house manager is also responsible to make sure that all poisonous materials are put away and locked after every use. |
08/22/2022
| Implemented |
| 6400.67(a) | The sliding closet doors in the extra bedroom and individual # 2's bedroom do not have bottom guides to keep the closet doors secure from falling off the top roller track. | Floors, walls, ceilings and other surfaces shall be in good repair. | Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400. 67(a) After our yearly inspection on August 22rd - 26th.
Dignity and Respects inspector recognized that Bedroom #2 did not have a bottom guides to keep the closet secured which is required by 6400 regulations
Dignity and Respect made correction immediately by purchasing a closet door guides at home depot and made the repair.
The house manger is responsible to make sure that all floors, walls, ceilings and other surfaces including the closet doors are in good repair.
The House manger will check each rooms closet door on a weekly basic to ensure the doors are working properly and in order to maintain compliance |
08/23/2022
| Not Implemented |
| 6400.82(f) | The bathroom did not have individual clean paper towels or a cloth towel. | 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. | Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400. 82(a) Dignity and Respects yearly inspection was held on august 22nd to 26th.
While at the inspection at the home Dignity and Respect's inspector recognized that the agencies were in violation of 6400.82(a) where one of the bathrooms did not have a hand towel.
Dignity and Respect understands that hand towels are a necessity in the restroom. The house manager at Dignity & Respect will make sure that each bathroom and toilet area that is used by the individual must have a hand towel where individual and staffs can use to clean their hands after using the bathroom.
Paper toilet was immediately installed in the present of the inspector in order to prevent future occurrence |
08/22/2022
| Implemented |
| 6400.103 | The emergency evacuation procedure does not indicate the means of transportation to the emergency shelter location. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400.103
During our yearly inspection held on August 22nd -26th
Dignity and Respect Home has an emergency evacuation plan in place at the time of the inspection, which was submitted to the inspector during the time of inspection. Our emergency evacuation plan clearly states that each house has a vehicle present at the house at all time for daily activity. Our inspector advised that the agencies emergency evacuation plan must indicate the vehicle to be use as a means of transportation to the emergency shelter location.
Dignity and Respect director quickly made the correction, by updating and revising its emergency evacuation procedure. The correction that was made by the director states that the agency vehicle will be used to transport individuals to the emergency shelter location.
Dignity and Respect home¿s director also sent the corrected and revised emergency evacuation procedure to the inspector via email on the same day to become compliant. |
08/22/2022
| Implemented |
| 6400.104 | The Fire Department Notification letter does not provide the exact location of the bedrooms of the individuals who reside in the home and their needs for assistance in evacuating in the event of an emergency. The Fire Department notification letter was not dated. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400. 104 After our yearly inspection held on August 22nd -26th. Dignity and Respects fire department notification letter was not dated and did not provide the exact location of individuals bedrooms.
Dignity and Respect's inspector noticed the violation while reviewing the agencies fire department notification letter. After reviewing, the inspector advised our agency to make correct of the violation.
Dignity and Respect director immediate updated and revised its fire department notification letter as soon as the inspector brought the violation to our attention.
The new revised fire department notification letter is dated and also has a diagram of the residences.
The diagram also shows, the structure of the home which helps to explain to the fire department the exact location of each individuals bedroom. The diagram will help the fire department to locate each individual room in an event of a fire.
The new fire department notification letter was revised by dignity and Respect director and was also sent to the inspector via email for revision. |
08/22/2022
| Implemented |
| 6400.112(e) | An asleep fire drill was held on 10/01/21 and not again until 08/03/22 exceeding the 6 month asleep drill requirement. | A fire drill shall be held during sleeping hours at least every 6 months. | On August 22nd 2022 annual inspection, Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400.112
Dignity and Respects asleep fire drill was last conducted on August 2022 instead of twice a year by regulation.
Dignity and Respect takes fire drill and fire safety very seriously. Our agency is in violation because of a misunderstanding of the regulations.
Dignity and Respect was under the impression that the asleep fire drill has to be conducted twice in a calendar year instead of once every six months.
Dignity and Respect's director is responsible to correct the violation and ensure it does not reoccur in the future.
Dignity and Respect's director will update its policy on fire safety to include asleep fire drill to be conducted once every 6 months instead of twice a year to stay in compliance with 55 PA Code Chapter 6400.112 |
08/26/2022
| Implemented |
| 6400.113(a) | Individual #2's fire safety training did not include individual responsibilities during a fire drill or the providers smoking policy, if any of the individual's smoke.
Also, per regulation the training must be completed upon admission and yearly thereafter. Individual #2 did not have fire safety training upon admission on 3/25/2021. Individual #2's fire safety training was conducted on 6/14/2021 and yearly training should have been completed on or before 6/14/2022, however at the time of the inspection, there was no documentation demonstrating that individual #2 completed the annual training. | An 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. | Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400. 113(a)
Dignity and Respect House understand the violation but currently do not have any individuals that smokes in our agency.
Dignity and Respect's director has updated its fire safety policy to include smoking safety procedures for any individuals or staff that smoke. The new procedures also explains staff and individuals responsibilities during an event of a fire drill.
Dignity and Respect's director immediately revised and corrected its fire safety policy . Dignity and Respect director also sent the smoking safety procedure to the inspector via email. |
08/23/2022
| Implemented |
| 6400.141(a) | Regulation requires Individuals to have a physical within 12 months prior to admission. Individual #2 was admitted on 3/25/2021 and the first physical for individual #2 is dated for 9/16/2021; 6 months after admission. The agency does not have a physical examination from 12 months prior to admission for individual # 1. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | August 22nd to 26th 2022, Dignity and Respect held its 2022 annual inspection.
Dignity and Respect Homes located at the home was in violation for 55 PA Code Chapter 6400.141(a) Individual #1 was an emergency admission; he did not have his heath physical examination prior to admission.
Dignity and Respect understands the seriousness of Physical examination for our individuals prior to admission.
Physical before admission, helps the agency to understand any health issues before admission and also help to protect the other individuals from communicable disease.
Dignity and Respect support specialist will make sure that the agency is in compliance by verifying that every new admission has his or her physical examination before admission. |
08/26/2022
| Implemented |
| 6400.141(b) | Individual # 1's physical examination dated 12/15/21 was not filled in or completed as required by this regulation. Many spaces were left blank and "see attached" was written on the physical. An appointment summary was attached but did not include a TB test, Vision or hearing screenings. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | August 22nd to 26th 2022, Dignity and Respect held its annual inspection. Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400.141(b) Individual #1s physical examination form was not properly filled out by his physician. Individual # 1s physician left some space blank and attached his summary visit on the back of his physical examination form.
Dignity and Respect understands that individuals physical examination is the pillar of diagnostic evaluation. Dignity and Respect's house manger will review and double check individuals doctors visit summary form, to make sure that the physician did not leave any space blank.
The director of the agency will also double check after the house manger to verify that all doctors visit form are properly filled out by the physician. This will go into affect immediately for dignity and Respect to stay in compliance. |
08/26/2022
| Not Implemented |
| 6400.141(c)(4) | Individual # 1's 12/15/21 physical examination does not include vision or hearing screenings. The check boxes on the form were left blank. Individual #2's most recent physical dated 9/16/2021 did not include a hearing screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Dignity and Respect Homes inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.141(c)(4) Individual #1 physical examination did not include his vision and hearing screening.
Individual # 1 has a vision and hearing appointment scheduled for September 27 at Penn state health. This appointment was scheduled earlier this year before the inspection. Attachment will contain his doctors information for verification.
Dignity and Respect's Home manger and director will make sure that each physical examination includes individuals vision and hearing screening. This action will be implemented immediately for the agency to stay in compliance
Dignity and Respect will implement and follow all 55 PA Code Chapter 6400.141 (c)(4) to stay in compliance by. |
08/25/2022
| Not Implemented |
| 6400.141(c)(6) | Individual # 1's 12/15/21 physical examination does not include a TB test.I ndividual #2's most recent physical dated 9/16/21 did not include a TB test. The physical states "NA". The individual still has not had a TB test at the time of this inspection. | 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. | Dignity and Respect Homes inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.142(c)(6)
Dignity and Respect will implement and follow 55 PA Code Chapter 6400.141 (c)(6) to stay in compliance Our agency understands that many people who have TB don't have any symptoms. In order to protect our individuals and staffs.
Dignity and respect's support specialist is responsible to make sure that all staffs and individuals have their T.B test results before admission or hire.
Dignity and Respect takes the health safety of our individuals very seriously.
TB (tuberculosis) testing and screening are essential for health safety of our individuals here at Dignity and Respect.
TB can be deadly and spreads from person to person easily; our agency understands it's important to get tested during physical. |
08/25/2022
| Not Implemented |
| 6400.141(c)(9) | Individual #1 had a prostate exam/colon cancer screening via laboratory services (due to the individual refusing the actual prostate exam) on 6/25/2021 but has not been completed yet for 2022. This is a yearly requirement. At the time of inspection, 8/2022, this screening has not yet been completed. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Dignity and Respect Homes inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.142(c)(9)
Individual #1 refused prostate exam but agreed for colon screening via laboratory services. Individual #1 has his annual physical examination coming up on september12th where his prostate exam will be checked.
Prostate cancer is the second most common form of cancer among American men, Dignity and Respect Homes understands the seriousness of prostate exam for our individuals. In an event where any of our individual refuse for the exam,
The agency house manger is responsible to educated the individual about the seriousness of prostate exam.
The education will include that as men get older, their health needs change, and they need additional screenings and exams. One of the health considerations they should remember is a prostate exam. Prostate exams are essential for detecting prostate cancer early when it is most treatable |
08/26/2022
| Not Implemented |
| 6400.142(d) | Individual # 1's 04/28/22 dental examination does not indicate that a cleaning was completed. | The dental examination shall include teeth cleaning or checking gums and dentures. | Dignity and Respect Home¿s inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.142(d)
Individual #1 did make his dental visit and his teeth were also cleaned by his dentist. After the visit, the dentist did not properly document on individuals discharge summary that his teethes were cleaned, which was why our agency was in violation.
Dignity and Respect will implement and follow 55 PA Code Chapter 6400.142(d) to stay in compliance by making sure the dentist cleans teethes and properly documents the cleaning while at the dentist office.
Dignity and Respects house manger is responsible to verify the discharge summary before exiting the dentist office
Annual dental exams for our individuals here in dignity and Respect are very important to the population we serve.
Annual dental exams help to find tooth decay, gum disease, and other oral health problems early, when they're easier to treat.
Dignity and Respect understands the essential importance of annual dental care for our individuals. Annual dental also includes cleaning which helps build good habits that can give our individuals a life of good dental health. |
08/26/2022
| Not Implemented |
| 6400.143(a) | There was no documentation demonstrating that Individual #2 was educated/trained on the importance and need for health care after individual #2 refused a prostate exam. | 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. | Dignity and Respect Homes inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.143(a)
Individual #2 refused prostate exam but agreed for colon screening via laboratory services. Individual #2 has his annual physical examination coming up on september12th where his prostate exam will be checked.
Prostate cancer is the second most common form of cancer among American men, Dignity and Respect Homes understands the seriousness of prostate exam for our individuals. In an event where any of our individual refuse for the exam,
The agency house manger is responsible to educated the individual about the seriousness of prostate exam.
The education will include that as men get older, their health needs change, and they need additional screenings and exams. One of the health considerations they should remember is a prostate exam. Prostate exams are essential for detecting prostate cancer early when it is most treatable. |
08/24/2022
| Implemented |
| 6400.144 | Individual # 1's most recent physical dated 12/15/21 reads that he should receive a regular diet. The provider has been pureeing the diet as per a previous physical dated 10/21 and guardian direction. A current physician order for a mechanical soft diet is not contained within the record. | 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.
| Dignity and Respect Home¿s inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.144 Individual #1 recent physical dated 12/15/21 reads that the individual should receive a regular diet
Individual # 1 has always been on a pureed diet long before admission. Individuals ISP also reflect a pureed diet, this evidences was showed to the inspector. His physician made an error while filling out his 12/15/21 health physical summary by stating regular diet instead of pureed diet.
The inspector advised the agency to contact the individuals physician, to update and make corrections on his physical summary
Dignity and Respect understands that If our individual cannot be able to chew or parts of their digestive tract don't work well, eating solid food can be a challenge. It could even be dangerous if the individual were to choke on a piece of food he or she weren't able to chew well. |
08/24/2022
| Implemented |
| 6400.151(a) | No physical examination was completed for staff # 3. Staff # 3 completed a physical during the inspection on 08/24/22 when brought to the attention of the CEO. | 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. | August 22nd to 26th 2022, Dignity and Respect held its annual inspection. Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400.151(a) Staff #3 health physical was completed on 8/24/22.
Staff #3 physical examination was up to date but her doctor used the wrong form while filling her summary. Dignity and Respect's support specialist decided for her to get a new physical examination on 8/24 to be in compliance with 55 PA code chapter 6400. 151(a)
Dignity and Respect is committed to preventing, identifying and controlling infections, and minimizing risks of communicable diseases to all Individuals receiving services under our agency.
Dignity and Respect¿s support specialist is responsible to make sure that all new staff obtain their health physical before rendering services to our individuals.
Dignity and Respect will comply with OSHA guidelines by providing annual physical examination to every new employee before working with any of our individuals. |
08/26/2022
| Implemented |
| 6400.151(c)(2) | Staff #2's hire date was 4/02/2022 but staff's TB test was not completed until 4/06/2022. According to regulation, the TB must be completed on or before hire date. | 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. | Dignity and Respect Home¿s inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.151 (c)(2) Staff #2 was hired on 4/2/22 but her TB test showed 4/6/22
Dignity and Respect understands that physical examination and TB test is the pillar of diagnostic evaluation.
The staff in question was indeed hired on 4/2/22 but started her trainings immediately. Staff # 2 was not allowed to provide services to any of our individuals still after she completed all her trainings.
Dignity and Respect's support specialist is responsible to make that every hire at the agency has their physical examination with TB test before training and services.
The agency director will also double check after the support specialist to verify that all physical examinations are properly done before employment. This will go into effect immediately for dignity and Respect to stay in compliance. |
08/26/2022
| Implemented |
| 6400.181(a) | - Individual # 1's assessment was completed on 03/08/22. This assessment does not indicate if Individual # 1 needs his food pureed or has a regular diet. There is a physical exam dated 12/21/21 which says regular diet and another physical exam in 10/21 which indicates pureed diet. Individual # 1's dietary needs are not addressed nor were the dietary needs clarified by the Program Specialist in the 03/08/22 assessment | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | August 22nd to 26th 2022, Dignity and Respect held its annual inspection. Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400.181(a) Individual #1s assessment did not indicate that his food has to be pureed or a regular diet.
Dignity and Respect's support specialist is responsible to immediately implement a plan of correction.
dignity & respect support specialist will correct and develop a new individual assessment in order to stay in compliance with 6400 rules and regulations. Dignity and Respect new individual assessment will include information missing from the initial inspection. Information such as individuals needs for a pureed diet. |
08/26/2022
| Not Implemented |
| 6400.181(e)(3)(i) | Repeat 09/14/21- Individual #2's most recent assessment dated 4/08/2022 did not include current level and progress in the area of functional skills. It was left blank. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. | Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400. 181(e)(3)(i) After our yearly inspection on August 22rd to 26th.
Dignity and Respects inspector recognized that the agencies individual assessment form was missing some information including current level and progress in the area of personal functional skills, which is a required by 6400 regulations
Dignity and Respect's support specialist is responsible to immediately implement a plan of correction.
The agency support specialist will correct and develop a new individual assessment in order to stay in compliance with 6400 rules and regulations.
Dignity and Respect new individual assessment will include missing information from the initial inspection. Information such as individual personal functional skills. |
08/25/2022
| Implemented |
| 6400.181(e)(3)(ii) | Repeat 09/14/21-Individual #2's most recent assessment dated 4/08/2022 did not include current level and progress in the area of communication. It was left blank. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. | Dignity and Respect Homes inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.181(e)(3)(ii) Individual #2 most recent assessment did not include a current level and progress in the area of communication.
Dignity and Respect's support specialist is responsible to immediately implement a plan of correction.
dignity & respect support specialist will correct and develop a new individual assessment in order to stay in compliance with 6400 rules and regulations. Dignity and Respect new individual assessment will include information missing from the initial inspection. Information such as individual individuals current level of performance and progress in communication.
Communication is everything when providing services to our clients; Lack of communication can creates unwanted situations. Dignity and Respect understands the important of communication and Listening between staff and individuals |
08/26/2022
| Implemented |
| 6400.181(e)(3)(iii) | Repeat 09/14/21- Individual #2's most recent assessment dated 4/08/2022 did not include current level and progress in the area of personal adjustment/socialization. It was left blank. | The individual's current level of performance and progress in the following areas: Personal adjustment. | Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400. 181(e)(3)(ii) After our yearly inspection on August 22rd to 26th.
Dignity and Respects inspector recognized that the agencies individual assessment form was missing some information including current level and progress in the area of personal adjustment, which is a required by 6400 regulations
Dignity and Respect's support specialist is responsible to immediately implement a plan of correction.
The agency support specialist will correct and develop a new individual assessment in order to stay in compliance with 6400 rules and regulations. Dignity and Respect new individual assessment will include information missing from the initial inspection. Information such as individual personal adjustment
Dignity and Respect understands the general factors related to personal growth and adjustment in an individual¿s assessment plan. Some of the characteristic of an individual¿s personal adjustment can be maturity in thinking, emotional balance, warm and understanding towards others, free from tension due to routine events and Independent in decision making. |
08/26/2022
| Implemented |
| 6400.181(e)(3)(iv) | Repeat 09/14/21- Individual #2's most recent assessment dated 4/08/2022 did not include current level and progress in the area of personal needs/activities in the home and the community and areas of residential living. It was left blank. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others. | Dignity and Respect Home's inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.141(e)(3)(iv)
Dignity and Respects inspector recognized that the agencies individual assessment form was missing some key information including Personal needs/actives in the home and the community.
Dignity and Respect support specialist is responsible to developed a new individual assessment plan for all its clients to be in compliance with 6400.
The support specialist will complete all sections of the assessment without living any blank space in the individuals assessment.
Our agencies new individual assessment includes individuals personal needs with or without assistance from other and all 6400 rulers and regulation that is required to be in an individual assessment. |
08/26/2022
| Implemented |
| 6400.181(e)(4) | Individual #2's most recent ISP dated 9/01/2021 states that individual #2 should have line of sight supervision in the community. Individual #2's most recent assessment dated 4/08/2022 under item #61 does not indicate this level of supervision. The assessment also indicates that individual #2 can function independently and safely for a short time period; however, under the prompt to "define length of time" this was left blank. Therefore "short time" was not quantified. | The assessment must include the following information: The individual's need for supervision.
| Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400. 181(e)(3)After our yearly inspection on August 22rd to 26th.
Dignity and Respect's inspector recognized that the agencies individual assessment form dated 9/01/2021 was left blank and missing some information.
Information such as individual #2 needing supervision while out in the community, which is a required by 6400 regulations
Dignity and Respect's support specialist is responsible to immediately implement a plan of correction.
The agency support specialist will correct and develop a new individual assessment in order to stay in compliance with 6400 rules and regulations.
Dignity and Respect new individual assessment will include all missing information from the initial inspection. Information such as individual having line of sight supervision while in the community. |
08/25/2022
| Implemented |
| 6400.181(e)(10) | A lifetime medical history was not included in the 03/08/22 assessment for individual #1. | The assessment must include the following information: A lifetime medical history. | Dignity and Respect Home¿s inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.181(e)(10)
Dignity and Respect understands there seriousness of individuals assessment plan, Our agency's plan of correction is to develop a new Individual assessment Plan which will include individuals lifetime medical history.
Dignity and Respect's support specialist is responsible to develop a new individual assessment in order to stay in compliance with 6400 rules and regulations.
Dignity and Respect's support specialist new individual assessment will include all information missing from the initial inspection. Information such as individuals lifetime medical
Dignity and Respect understands that a medical record is a systematic documentation of a patients medical history and care. while filling an assessment all information must be included. |
08/26/2022
| Implemented |
| 6400.181(e)(12) | (Repeat 09/14/21) There are no recommendations provided in the 03/08/22 assessment for individual # 1. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Dignity and Respect Home¿s inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.181(e)(12)
Individual #1 assessment was missing recommendation by our agency on 3/8/22
Diginity and respect understands that our recommendation or suggestion helps to provide better service to our individuals.
Dignity and Respect's support specialist is responsible to develop a new individual assessment in order to stay in compliance with 6400 rules and regulations. Dignity and Respects support specialist new individual assessment will include information missing from the initial inspection. Information such as recommendations and suggestions |
08/24/2022
| Implemented |
| 6400.181(e)(13)(i) | Progress in Health was not reported on individual # 1's the 03/08/22 assessment. The space was left blank. Individual #2 's most recent assessment dated 4/08/2022 did not include the individual's progress over the last 365 days in the area of Health and safety | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| Dignity and Respect Home¿s inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.181(e)(13)(i)
Dignity and Respect's assessment for individual #1 most recenet assessment did not include progress in health.
Dignity and Respect understands that individuals progress in health help to identify the root cause of health systems. Progress in health also helps in diagnosing and providing the best service to our individuals.
Dignity and Respect's support specialist is responsible to develop a new individual assessment in order to stay in compliance with 6400 rules and regulations. Dignity and Respect new individual assessment will include information missing from the initial inspection. Information such as individuals progress in health. |
08/25/2022
| Implemented |
| 6400.181(e)(13)(ii) | Progress in Motor/communication was not reported on individual # 1's 03/08/22 assessment. The space was left blank. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | Dignity and Respect Home¿s inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.181(e)(13)(ii)
Individual # 1's assessment did not include progress in motor/communication.
Communication is everything when providing services to our clients; Lack of communication can creates unwanted situations. Dignity and Respect understands the important of communication in individuals assessment plan.
Dignity and Respect's support specialist is responsible to develop a new individual assessment in order to stay in compliance with 6400 rules and regulations. Dignity and Respect new individual assessment will include information missing from the initial inspection. Individual's new assessment will include missing Information such as individual progress in motor/communication.
Our agency support specialist will make sure that no column or space in an individuals assessment plan is left blank |
08/25/2022
| Implemented |
| 6400.181(e)(13)(iii) | Progress in Daily living was not reported on individual # 1's 03/08/22 assessment. The space was left blank. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | Dignity and Respect Home's inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.181(e)(13)(iiI)
Dignity and Respect's support specialist left some key information blank while filling individuals assessment plan. information such as progress in daily living.
Daily living activities are tasks related to individuals care, basic daily living skills includes showering and bathing, eating, using the toilet and transferring between a bed and chair.
Dignity and Respect's support specialist is responsible to develop a new individual assessment in order to stay in compliance with 6400 rules and regulations.
Dignity and Respect new individual assessment will include information missing from the initial inspection. Information such as individual's progress in daily living and activities of residential living. |
08/26/2022
| Implemented |
| 6400.181(e)(13)(iv) | Progress in Personal Adjustment was not reported on individiual # 1's 03/08/22 assessment. The space was left blank. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | Dignity and Respect Home's inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.181(e)(13)(iv)
Dignity and Respect's support specialist left some key information blank while filling out individual #1's assessment. Information like progress in personal adjustment
Dignity and Respect understands the general factors related to personal growth and adjustment in an individuals' assessment plan. Some of the characteristic of an individuals' personal adjustment can be maturity in thinking, emotional balance, warm and understanding towards others, free from tension due to routine events and Independent in decision making.
Dignity and Respect's support specialist is responsible to develop a new individual assessment in order to stay in compliance with 6400 rules and regulations. Dignity and Respect new individual assessment will include information missing from the initial inspection. Information such as individual personal adjustment . |
08/26/2022
| Implemented |
| 6400.181(e)(13)(v) | Progress in Socialization was not reported on individual # 1's 03/08/22 assessment. The space was left blank. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | Dignity and Respect Home's inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.181(e)(13)(v)
Dignity and Respect's self assessment for individual #1 was missing information sure as progress in socialization.
Dignity and Respect understands the importance for our individuals to socialize and mix with other in the community. The key role of socialization is to acquaint individuals with the norm of a given social group or society. Progress in socialization is one of the key information that can not be left blank in an individuals assessment plan
Dignity and Respect's support specialist is responsible to develop a new individual assessment in order to stay in compliance with 6400 rules and regulations. Dignity and Respect new individual assessment will include information missing from the initial inspection. Information such as individual progress in socialization in the community. |
08/25/2022
| Implemented |
| 6400.181(e)(13)(vi) | Progress in financial independence was not reported on Individual # 1's 03/08/22 assessment. The space was left blank. Individual #2's most recent assessment dated 4/08/2022 did not include the individual's progress over the last 365 days in the area of need for supervision at home and in the community. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | Dignity and Respect Home's inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.181(e)(13)(vi)
Dignity and Respects' inspector recognized that the agencies individual assessment form was missing Progress in financial independence for individual # 1.
Dignity and Respect understands the importance of our individuals finances.
An individual financial progress help the agency and ODP to keep a track record on how an individuals money is been spent. An individuals funds must be used only for the individual's needs and wants and a proper documentation must be provided by the dignity & Respect on the behalf of the individual.
Dignity and Respect's support specialist is responsible to develop a new individual assessment in order to stay in compliance with 6400 rules and regulations. Dignity and Respect new individual assessment will include information missing from the initial inspection. Information such as individual #'1 progress on his finances. |
08/26/2022
| Implemented |
| 6400.181(e)(13)(viii) | Progress in Managing personal property was not reported on Individual # 1's 03/08/22 assessment. The space was left blank. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | Dignity and Respect Home's inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.181(e)(13)(vii)
Dignity and Respects' inspector recognized that the agencies individual assessment form was missing Progress in managing personal property for individual # 1.
Dignity and Respect's support specialist is responsible to develop a new individual assessment in order to stay in compliance with 6400 rules and regulations.
Dignity and Respect's new individual assessment will be properly filled by the support specialist.
Individual's ones assessment must include information missing from the initial inspection. Information such as individual # 1 Progress in managing personal property
Dignity and Respect Homes understands the importance of our individuals property and possessions. Dignity and Respect will record and document each individual property and are valuable upon admission.
Our individual property documentation must be updated and reviewed each time our individuals purchase a new property. This document should also be updated when family members brings or purchase a new any items for the individuals. |
08/25/2022
| Implemented |
| 6400.181(e)(13)(ix) | Progress in community integration was not reported on individual # 1's 03/08/22 assessment. The space was left blank. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | Dignity and Respect Home's inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.181(e)(13)(ix)
Dignity and Respects' inspector recognized that the agencies individual assessment form was missing Progress in community integration for individual # 1.
Dignity and Respect's support specialist is responsible to develop a new individual assessment in order to stay in compliance with 6400 rules and regulations.
Dignity and Respect new individual assessment will include information missing from the initial inspection. Information such as individual # 1's Progress in community integration
Dignity and Respect will immediately completes individual # 1's assessment form its completion, no column will be left blank or incomplete. |
08/26/2022
| Implemented |
| 6400.181(e)(14) | The 03/08/22 assessment for individual # 1 does not indicate his 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. | Dignity and Respect Home's inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.181(e)(14)
Dignity and Respects' inspector recognized that the agencies individual assessment form was missing key information such as individual # 1's ability to swim.
Dignity and Respect's support specialist is responsible to develop a new individual assessment in order to stay in compliance with 6400 rules and regulations.
Dignity and Respect new individual assessment will include all missing information from the initial inspection, information such as individual #1 ability to swim. |
08/26/2022
| Not Implemented |
| 6400.211(b)(3) | The person who is able to provide emergency medical consent was not identified in the record for Individual # 1. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| Dignity and Respect Home's inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.211 (b)(3)
Dignity and Respects' inspector recognized that the agencies records was missing individual # 1 emergency medical consent person.
Individual # 1's mother Ms. Yvonne is his emergency medical consent person, dignity & Respect also provided this information to our inspector via the one drive folder, the inspector provided during inspection.
Dignity and Respect's support specialist is responsible to make sure that each individual's emergency information is included on his or her record. Information such as medical consent person, name of the consent person, address and telephone of the consent person.
Dignity & Respect will provide this information on individual #1's fill immediately in order to stay in compliance with 6400 rules and regulations. |
08/26/2022
| Implemented |
| 6400.251(b) | Individual # 3 was an emergency placement on 05/20/22. As of 08/25/22, there is no physical exam contained within the individual record. | If an emergency placement occurs, § 6400.141 (relating to individual physical examination) shall be met within 31 calendar days after placement.
| August 22nd to 26th 2022, Dignity and Respect held its annual inspection. Dignity and Respect Homes was in violation for 55 PA Code Chapter 6400.251(b)
Individual #3s physical examination was not completed prior to admission.
Individual # 3 was an emergency placement on 05/20/22. Our agency scheduled his physical examination the following day but he ended up admitted in the hospital for a month for psych evaluation. After Individual's #3 discharge from the hospital, Dignity & respect rescheduled another physical examination with his PCP.
Dignity and Respect understands that individuals physical examination is the pillar of diagnostic evaluation.
Dignity and Respect's director will make that all new admission into the agency has his or her physical examination before admission in order to protect our other individuals from transmissible diseases.
The director will put this into affect immediately for dignity and Respect to stay in compliance. |
08/24/2022
| Implemented |
| 6400.34(a) | Individual #2 signed individual Rights documentation on 3/25/2021 upon admission. Individual #2 has not been informed or educated on rights since admission. | 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. | Dignity and Respect Home's inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.34(a) Individual # 2 did nor sign his individual rights in 2022, only on admission 3/25/21
Dignity and Respect is in violation because of misunderstanding of the regulations,our agency was under the impression that each individual only signs Rights during admission.
Dignity and Respect support specialist is responsible to make sure that each indiviual rights are explained and sgined on admission and annually thereafter. |
08/25/2022
| Implemented |
| 6400.46(d) | Staff #2 was hired on 4/02/2022 and the provider does not have documentation showing that the staff was trained in first aid, Heimlich techniques, and CPR within 6 months of hire. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Dignity and Respect Home's inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.46(d)
Dignity and Respect made sure that Staff #2 received her first aid, Heimlich techniques and CPR training 6 months after hire.
Staff#2 was hired on 4/2/22 and received her training on 6/4/22 which was also submitted into the One Drive folder provided by our inspector.
Dignity and Respect's support specialist is responsible to make sure that each new hire at the agency received his or her first aid, Heimlich techniques and CPR training 6 months after hire |
08/25/2022
| Implemented |
| 6400.166(a)(11) | Repeat 09/24/21-The Medication administration record that was originally uploaded for review for individual #2 did not indicate the diagnosis or purpose for any of the medications listed on the MAR for the previous 6 months. It was handwritten in and resent to inspectors after inquiry. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Dignity and Respect Home's inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.166(a)(11)
Dignity and Respect submitted six months of its MAR to our inspectors as requested, it appears that our pharmacy forgot to write the diagnosis on some of the medication which resulted in the violation. Dignity and Respect also made the correcation and sent to our inspector immediately after the violation was pointed out by the inspector.
Dignity and Respect understands that MAR or medical record is an important tool that serves as a basis for planning care, communicating between medical providers and other workers, and providing documentation as to the course of illness, treatment, and response to treatment.
Dignity and Respect understands that MAR record is the collection of all pertinent facts concerning a person¿s illnesses, treatment, and past medical history.
Dignity and Respect support specialist is responsible to hand write each diagnosis for each medication, in each individuals MAR in order to stay in compliance with 6400 rules and regulations.
Dignity and Respect support specialist is responsible. |
08/26/2022
| Implemented |
| 6400.213(1)(i) | The Demographic page did not include Individual # 1's Date of Admission and the photograph was not dated.Individual #2's photo was not dated, and the date of admission was not indicated on the demographic sheet (it was later handwritten on the individual's assessment).
Individual #2's social security number and place of birth was not listed on the information/demographic sheet. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Dignity and Respect Home's inspection was held on August 22nd to 26th 2022. After the annual inspection, dignity and respect homes was in violation for 55 PA Code Chapter 6400.213(1)(i)
Individual #2 and individual #1 demographic page did not include date of admission.
Dignity and Respect understands that a dated photograph pictures of our individuals are very important in providing services to our individuals here at Dignity and Respect.
Dignity and Respect's support specialist is responsible to make sure that every new admission have date demographic page of the individual in order to stay in compliance with 6400 rules and regulations.
Face recognition is one of the most studied aspects in our society today. Dated photographs will help in recognizing the people we serve.
In an event of a missing person, law enforcement will need to see the current photograph of the individual who is missing in order to art quickly.
Dated photograph will help any person or persons reviewing our individuals files, to know the current appearance |
08/25/2022
| Not Implemented |