| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
|
SIN-00276888
|
Renewal
|
12/01/2025
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | The 07/07/25 fire drill does not specify if the drill was conducted at 345 am or 345 pm, both times are indicated as the time of the drill on the form. | 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 program manager reviewed the July 7, 2025, fire drill form and corrected the documentation error by clarifying the accurate drill time. The corrected drill record has been updated and filed in the home's fire drill log.
All fire drill records for the past 12 months were reviewed to ensure no additional forms contained duplicate or unclear time entries. No other discrepancies were found.
The program manager will ensure that staff enter only once during drill completion and verify accuracy before submitting the drill form. The program director will review and approve all fire drill logs monthly to confirm accuracy and completeness.
See attached #1. |
12/12/2025
| Implemented |
| 6400.141(c)(15) | Individual #1's most recent physical completed on 04/07/25 does not document if the individual has special diet instructions. It is documented as N/A. This is an applicable regulation to this individual. Per Individual #1's Dietary Plan they are not to consume eggs daily due to their cholesterol medication. | The physical examination shall include:Special instructions for the individual's diet. | The program manager contacted the individual's primary care provider and requested an updated physical form that accurately reflects the individual's special dietary instructions. The corrected physical, including the dietary restriction related to egg consumption and cholesterol management, has been received and filed in the individual's medical record.
The dietary plan has been updated, and all staff have been trained on the revised requirements.
All physical examination forms for every individual in the program were reviewed to ensure that all required dietary information is documented. No additional missing dietary instructions were identified.
see attached#2 |
12/12/2025
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's most recent assessment completed on 03/25/25 does not depict a clear picture of Individual #1's financial independence | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| The program manager updated Individual #1's assessment to clearly document the individual's current level of financial independence, including their ability to manage money, handle purchases, understand budgeting, and the level of support required. The revised assessment now accurately reflects the individual's financial skills and progress over the past 365 days.
A new financial plan has been created, and all staff have been trained on the updated requirements.
All assessments for every individual in the program were reviewed to identify whether financial independence sections were complete and accurately described. Any assessments requiring clarification or updates were corrected.
The corrected assessment for Individual #1 was finalized and filed on, also was sent to his team along with his LMH.
see attached #3 |
12/12/2025
| Implemented |
| 6400.18(b)(2) | The medication errors identified in 167a1 and 167a2 were not reported in Enterprise Incident Management (EIM). | 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. | The program director reviewed the medication documentation errors cited in 167a1 and 167a2 and immediately entered both incidents into the Enterprise Incident Management (EIM) system. Each incident now includes a full description, classification, and corrective actions taken.
A full review of all medication administration records and incident logs for the past 90 days was completed to ensure no other medication errors were unreported. No additional unreported incidents were identified.
Staff involved in the incidents were counseled and retrained on reporting requirements.
All corrective entries were completed on 12/9/2025
See attached #4. |
12/12/2025
| Implemented |
| 6400.165(c) | Individual #1 is to have Head/Shoulders 1% applied topically to the scalp every other day. This was applied to Individual #1's scalp every day from 4/7/25 to 4/17/25. 5/7-5/9, 5/12-5/16, 5/19-5/24, 5/26-5/30, 6/1-6/5, 6/9-6/12. 6/16-6/30, 7/1-7/4, 7/7-7/18, 7/28-7/31, 8/4-8/7, 8/11-8/15, 8/18-8/21, 8/25-8/29. | A prescription medication shall be administered as prescribed. | The program manager reviewed the MAR and identified that Head & Shoulders 1% was administered daily rather than every other day, as prescribed. Staff involved were counseled and retrained on following the exact prescription instructions.
The individual's medication administration record was corrected moving forward, and the correct administration schedule has been re-taught to all staff assigned to the home. The individual's current medication list and MAR were updated to ensure the instructions are clearly visible and highlighted.
All individuals' topical medication orders and MARs were reviewed to ensure there were no additional administration errors involving frequency or application instructions. All corrections were completed.
Attached #5. |
12/12/2025
| Implemented |
| 6400.166(a)(2) | Individual #1 has Hydrocortisone Cream handwritten on their April 2025 Medication Administration Record (MAR). No prescriber is documented. Individual #1 was prescribed Doxycycline and Cephalexin in July 2025, 1 tablet twice a day for 7 days. No prescriber was documented. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | The Program Manager reviewed the April 2025 MAR and updated the entry for Hydrocortisone Cream to include the prescribing provider's name as documented on the medication order. The July 2025 prescriptions for Doxycycline and Cephalexin were also updated to reflect the correct prescriber information.
All MARs for every individual in the program were reviewed to ensure prescriber names were documented for each prescription medication. Missing or unclear entries were corrected immediately.
Staff responsible for handwritten MAR entries were counseled and retrained on documenting complete medication information.
See attached #6. |
12/12/2025
| Implemented |
| 6400.166(a)(11) | Individual #1 has Hydrocortisone Cream handwritten on the April 2025 MAR. No diagnosis or purpose is documented. Individual #1 was prescribed Doxycycline and Cephalexin in July 2025, 1 tablet twice a day for 7 days. No diagnosis/purpose was documented. | 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. | The program manager reviewed Individual #1's April 2025 MAR and updated the Hydrocortisone Cream entry to include the correct diagnosis/purpose as written on the medical order. The July 2025 prescriptions for Doxycycline and Cephalexin were also corrected to reflect the diagnoses/purposes documented by the prescriber.
All MARs for every individual in the program were reviewed to ensure diagnosis or purpose was documented for each prescription medication. All missing or unclear entries were corrected.
Staff responsible for completing or updating MARs were counseled and retrained on documenting full medication details, including diagnosis/purpose. |
12/12/2025
| Implemented |
| 6400.167(a)(1) | Individual #1 is to have 1 drop of Visine/Refresh instilled in both eyes four times a day. Individual #1 did not receive their 12pm dose from 04/02/25 to 4/30/25. Individual #1 did not receive their Famotidine on 4/27/25. Individual #1 did not receive their Atorvastatin on 7/10, 7/12, or 7/13. Individual #1 did not receive their 8pm dose of Propranolol on 7/3/25. Individual #1 was prescribed Doxycycline on 7/3/25, 1 tablet twice a day for 7 days. Individual #1 was not given this medication in the pm of 7/5 or 7/7/25. The medication was not administered at all on 7/6/25, 7/8/25, or 7/9/25. Vitamin D3 not given on 8/13/25. Clobetasol not administered 10/31/ at 8am. Visine not given 11/28 at 8am. | Medication errors include the following: Failure to administer a medication. | The Program Director reviewed the MAR and confirmed multiple medication administration issues for Individual #1, including missed doses, doses incorrectly marked as "administered at home," and entries with missing staff initials. Each verified missed dose was documented as a medication error. Entries marked "administered at home" without verification were corrected, and missing initials were addressed through staff follow-up to determine whether the dose was given or missed. Corrections were made to the MAR where allowable, and medication error reports were completed when administration could not be confirmed.
EIM reports were entered for all verified medication errors in accordance with regulatory requirements. Staff responsible for incomplete or inaccurate documentation were counseled and retrained on accurate MAR completion.
See attached #7. |
12/12/2025
| Implemented |
| 6400.167(a)(2) | Trihexyphenidyl was discontinued at the quarterly psychiatric medication review on 09/19/25. This medication was still administered ongoing and was not discontinued at the home. | Medication errors include the following: Administration of the wrong medication. | The Program Manager reviewed the psychiatric medication review dated 09/19/25 and confirmed that Trihexyphenidyl was dose-adjusted from 2 mg twice daily to 1 mg at 8am and 2 mg at 8pm. The medication continued to be administered incorrectly at the old dose.
The MAR was immediately corrected to reflect the new dosing schedule, and staff were instructed to follow the updated order. The medication packaging was reviewed and relabeled by the pharmacy to ensure clarity.
All individuals' psychiatric medication reviews and MARs for the past 90 days were reviewed to confirm that all medication changes were properly updated in the home. No additional discrepancies were found.
Staff involved were counseled and retrained on verifying updated medication orders following provider appointments.
See attached #7. |
12/12/2025
| Implemented |
|
|
|
SIN-00260887
|
Renewal
|
03/10/2025
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | During the walk-through of the home on 3/12/25 there was paint chipping on the top wooden ledge of the handrail on the second floor. The toilet seat in the full bathroom on second floor had paint peeling off lid of the seat. | Floors, walls, ceilings and other surfaces shall be in good repair. | Following the inspection a maintenance request was put in with the property management for wooden ledge of the handrail on the second floor. The toilet seat in the full bathroom was been repaired on the 3/20/25. Pictures were taken and provided in separate email. |
03/20/2025
| Implemented |
| 6400.111(f) | The fire extinguishers were inspected on 1/4/24 and not again until 1/9/25, which is outside of the annual timeframe. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | The next annual inspection has been scheduled to ensure continued adherence to fire safety regulations. The Program Director has scheduled the annual inspection for December 2025.
Please see attached appointment confirmation in separate email. |
03/18/2025
| Implemented |
| 6400.181(d) | Individual #1's assessment did not contain the program specialist signature & date. | The program specialist shall sign and date the assessment. | New assessment has been created and corrected for accuracy and to include all regulatory information. All Program Managers have been retrained on annual assessments and the new form created for GHHS. Completed on 3/18/2025.
See attached |
03/18/2025
| Implemented |
| 6400.214(a) | During the walk-through on 3/12/25 Individual #2 did not have a current assessment at the home. The assessment in the home was dated 9/8/23. All staff working in the home did not have a way to access the information on the computer. | Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home. | The current assessment for Individual #2 was immediately printed and placed in the home, Staff now have access to the most recent assessment.
Completed 3/12/2025. |
03/18/2025
| Implemented |
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|
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SIN-00221897
|
Renewal
|
04/03/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | (Repeated Violation - 4/5/22) The self-assessment dated 9/5/22 was not complete. Most regulations were not assessed. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | Self-assessment that was completed on 8/30/22 did not include the corrective taken for identified violations. Another self-assessment was completed on 1/20/23, however, this was outside 3 to 6 months prior to 12.28.22, when the previous certificate of compliance expired, and therefore not compliant. The assigned staff person who completed the 8/30/22 self-assessment is no longer with GHHS. An assessment based on the recent licensing inspection has been completed (for the house that was full review) and used as part of the training process, to include corrective action.
Attached file: Self-assessment signed training policy on scheduling self-assessments. |
05/17/2023
| Implemented |
| 6400.15(c) | The self-assessment completed on 9/5/22 did not include a plan of correction for 6400.72b, 6400.141c1 -- 15, and 6400.145(1). | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| Self-assessment that was completed on 8/30/22 did not include a summary the corrections for identified violations. Another self-assessment was completed on 1/20/23, however, this was outside 3 to 6 months prior to 12.28.22, when the previous certificate of compliance expired, and therefore not compliant. The assigned staff person who completed the 8/30/22 self-assessment is no longer with GHHS. An assessment based on the recent licensing inspection has been completed (for the house that was full review) and used as part of the training process, to include corrective action.
Attached file: Self-assessment signed training policy on scheduling self-assessments. |
05/08/2023
| Implemented |
| 6400.104 | (Repeated Violation - 4/5/22) The letter to the local fire department does not include the total number of people in the home. There were multiple letters sent, but none of the provided letters indicated the correct number of people in the home. | 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.
| On 4/6/23 a letter with the number of people in the home was sent to the fire department. This was shared with the licensing inspector.
Attached file 1: Fire Occupancy Letter and Attached File 2: General Fire Safety - Furnace Signed Training Schedule and Policy |
05/17/2023
| Implemented |
| 6400.106 | (Repeated Violation - 4/5/22) The home's furnace was inspected 01/22/20 and not again until 01/27/23, outside of the annual timeframe. | 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.
| Most recent inspection was 1/27/23, however, this was outside the 12 months since the previous furnace inspection. Staff that were responsible to schedule and ensure completion of furnace inspection during that time period are no longer with the company. New agency management team was trained on this regulatory item to ensure annual inspection. The Program Manager has scheduled annual furnace inspection for the company owned houses, and request has been made to property manager of the rented homes, and it also saved as an appointment on the shared Outlook calendar. Inspection for 2023 has been scheduled with the furnace company and will take place on 9/5/23 and 9/6/23. Evidence is attached file: General Fire Safety - Furnace Signed Training Schedule and Policy. |
05/17/2023
| Implemented |
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|
|
SIN-00202900
|
Renewal
|
04/05/2022
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | There was no self-assessment completed for this home. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | The self-assessments for 2021 were incomplete because all administrative personnel were working providing direct support in the homes. Greater Hearts will be doing self-assessments for all homes by 5/1/22. The self-assessments will include vacant homes as well. |
04/27/2022
| Implemented |
| 6400.64(a) | At the time of the inspection on 4/6/22, there was a yellow substance dried on the bathroom wall and bathroom door. | Clean and sanitary conditions shall be maintained in the home. | During the day of inspection staff cleaned the yellow substance. A picture of all the cleaned surface were provided to the licensing staff before the end of the day when they returned to the office from the houses. |
04/19/2022
| Implemented |
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|
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SIN-00181667
|
Renewal
|
01/20/2021
|
Compliant - Finalized
|
|
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.82(f) | At the time of the inspection, there was no hand soap present in the downstairs half bathroom or the individuals' upstairs bathroom. | 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. | During the inspection, all homes run by Greater Hearts were inspected. Each of the homes had handwashing soap in all bathrooms except for the home referenced in this violation. The individuals at this location are generally safe with chemicals. However, following a team meeting for one of them in January 2021, the individuals assessment was updated to reflect that chemicals /poisons should be locked when he is exhibiting certain symptoms. It is for this reason that staff had lock the hand soaps that were in the bathrooms during the inspection. This notwithstanding, we acknowledge that non-poisonous soaps should have been made available after the assessment was updated. This violation was corrected on 1/22/21. Non-poisonous hand soaps were added to both bathrooms (See attachments # 14a & 14b). To prevent similar situations in future, all residential supervisors were informed on 1/27/21 and again on 2/4/21 to only purchase non-poisonous hand washing soaps for the various homes under their supervision. Program Specialist and COO during their visits to the homes will ensure that this directive is being followed. |
01/22/2021
| Implemented |
| 6400.141(c)(4) | Individual #1's 1/19/21 physical did not include a vision/hearing screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual #1 uses glasses and sees an ophthalmologist / optometrist for his vision care. His last vision appointment was 11/17/20 (see attachment #15) and he is supposed to have an annual follow up in November 2021. Regarding hearing exams, during the individuals 2020 physical examination, it was recorded that he did not hear when the test was done at the PCPs office as such the individual followed up with an audiologist who currently provides the needed hearing exams. The individual had a hearing appointment on 9/21/20 (see attachment #16) and an annual follow up is due in September 2021. Copies of the individuals vision and hearing tests were available to the PCP during his 1/19/21 physical appointment. Program specialist and the residential supervisor for individual #1 will ensure that all follow up appointments are completed. |
01/19/2021
| Implemented |
| 6400.141(c)(10) | Individual #1's 1/19/21 physical did not include whether or not Individual #1 has a communicable disease. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Individual #1 had his annual physical appointment on 1/19/21 as evidenced by attachment # 17c. When going for the appointment the staff member mistakenly took the regular medical appointment forms (attachment # 17a) instead of the required physical examination form (attachment #17b). To correct this mistake, the staff returned to the PCPs office on 1/19/21 and delivered the correct forms for it to be completed. A follow up phone call by the program specialist and residential supervisor confirms that the PCP office has received the correct form, but the doctor is yet to complete it. Once completed, the form will indicate whether Individual #1 has a communicable disease or not. To ensure that correct appointment forms are used for each appointment in future, Microsoft Outlook Groups have been created for each house ran by Greater hearts. Residential supervisors are uploading all required appointment forms on the group page for each house. This will ensure that each form is available to staff both in print and electronically. On the day before a scheduled annual physical examination for each individual, the residential supervisor for that individual will ensure that the correct form is prepared and is available to the staff who will be accompanying the individual to the appointment. After each appointment, residential supervisors and/or program specialist will review the appointment form used to ensure among other things that the form was completed accurately. Residential Supervisors were trained with regards to this responsibility on 2/4/21. |
01/19/2021
| Implemented |
| 6400.141(c)(12) | Individual #1's 1/19/21 physical did not include any physical limitations. | The physical examination shall include: Physical limitations of the individual. | Individual #1 had his annual physical appointment on 1/19/21 as evidenced by attachment # 17c. When going for the appointment the staff member mistakenly took the regular medical appointment forms (attachment # 17a) instead of the required physical examination form (attachment #17b). To correct this mistake, the staff returned to the PCP¿s office on 1/19/21 and delivered the correct forms for it to be completed. A follow up phone call by the program specialist and residential supervisor confirms that the PCPs office has received the correct form, but the doctor is yet to complete it. Once completed, the form will indicate any physical limitations and will be filed placed in records upon receipt.
To ensure that correct appointment forms are used for each appointment in future, Microsoft Outlook Groups have been created for each house ran by Greater hearts. Residential supervisors are uploading all required appointment forms on the group page for each house. This will ensure that each form is available to staff both in print and electronically. On the day before a scheduled annual physical examination for each individual, the residential supervisor for that individual will ensure that the correct form is prepared and is available to the staff who will be accompanying the individual to the appointment. After each appointment, residential supervisors and/or program specialist will review the appointment form used to ensure among other things that the form was completed accurately. Residential Supervisors were trained with regards to this responsibility on 2/4/21. |
01/19/2021
| Implemented |
| 6400.141(c)(14) | Individual #1's 1/19/21 physical did not include medical information pertinent to diagnosis or treatment in the event of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | This violation occurred because of the circumstances described when addressing violation 55 PA Code Chapter 6400.141(c)(12). The individuals PCP currently has the correct form which upon completing will include any medical information pertinent to diagnosis or treatment in the event of an emergency. The correct physical form upon receipt will be filed as part of the individuals records.
To ensure that correct appointment forms are used for each appointment in future, Microsoft Outlook Groups have been created for each house ran by Greater hearts. Residential supervisors are uploading all required appointment forms on the group page for each house. This will ensure that each form is available to staff both in print and electronically. On the day before a scheduled annual physical examination for each individual, the residential supervisor for that individual will ensure that the correct form is prepared and is available to the staff who will be accompanying the individual to the appointment. After each appointment, residential supervisors and/or program specialist will review the appointment form used to ensure among other things that the form was completed accurately. Residential Supervisors were trained with regards to this responsibility on 2/4/21. |
02/04/2021
| Implemented |
| 6400.142(b) | On Individual #1's dental examination dated 10/19/20, the question regarding medications causing dental issues is not answered. | An individual who is using medication known to cause dental problems shall have a dental examination by a licensed dentist at intervals recommended in writing by the dentist. | DSPs usually accompany individuals supported to dental appointments. To ensure that dentists have the necessary medication information to accurately answer all the required sections of the dental form, DSPs will be retrained on the need to attach a copy of an individual current medication list to appointment forms. Also, as part of the retraining, DSPs will be educated on how to check appointment forms prior to leaving the dentists office for completeness and accuracy. This retraining will be done between 2/15/21 and 3/31/21 as part of the monthly house meetings. Additionally, residential supervisors and / or program specialists will also review all dental and medical appointment forms to ensure accuracy once the forms brought to the house before filing them as part of the individual¿s record. A meeting has been scheduled for Greater Hearts program team to meet on 2/15/21. At this meeting, the dental appointment form for Greater Hearts will be updated to include sections for DSPs and residential supervisors / program specialist to document their review of dental appointment forms after each appointment. |
03/31/2021
| Implemented |
| 6400.165(g) | There is no indication that a licensed physician has completed a 3 month medication review for Individual #1 since 8/25/20. There are 2 other appointment forms provided, but both of them were completed by Greater Hearts, not the physician. | 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. | A licensed psychiatrist completed a 3-month medication review for individual #1 on 10/20/20 @ 3:00pm and 12/01/20 @ 11:30am. However, due to the Covid-19 pandemic, these appointments were done virtually and there was a delay in receiving the necessary documentations from Penn State Hershey Outpatient Psychiatry Department. The unsigned Greater Hearts appointment forms which were placeholders for the documentation from the psychiatrists office has since been replaced with the appointment summaries received from Penn State Hershey (see attachments # 18 and # 19). Since the beginning of the COVID-19 pandemic, it has been our experience that some doctors offices take a longer time to complete the forms that we fax to them for virtual/telephone visits. Where applicable, individuals and/or their guardians have been encouraged to sign up onto their providers electronic health records platform so that appointment summaries can be downloaded for the individuals records at Greater Hearts. In cases when this is not an option, we have had to wait on the doctors offices to get the documentations to us. While we might not be able to control how long it takes doctors to complete forms for virtual visits, the program team will make continuous follow ups until the appropriate documentations are received. Copies of fax or email messages will be kept as placeholders as well as documentations of attempts to get the appropriate documentations. |
01/22/2021
| Implemented |
| 6400.166(a)(11) | There is not a diagnosis or purpose listed for the following medications on Individual #1's Medication Administration Records: Aripiprazole, Benztropine, Divalproex 500mg, Divalproex 250mg, Melatonin, Trazodone, Venlafaxine, Imodium. | 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. | Cognizant of this violation, the program specialist and residential supervisors are reviewing the current MARs for everyone supported. It appears that this is also a problem for other individuals besides individual#1.The pharmacy that serves the individuals supported by Greater Hearts has been contacted regarding the need to include the diagnosis or purpose for each medication on the MARs they provide. However, it appears that the actual prescriptions from the prescribers are the cause of this error. Some did not indicate the reason or diagnosis for the medications. According to the pharmacy, they cannot include diagnoses on the medication labels or MARs unless such diagnoses or reasons are stated as part of the prescriptions. To help rectify this, the program team at Greater Hearts is sending letters (see attachment # 11 for sample) to the various prescribers for scripts to be rewritten to include the purpose for each medication. Once the pharmacy receives the new scripts from the prescribers, they would be able to update the MARs accordingly. Going forward, program specialist and residential supervisors in reviewing new scripts will take the necessary steps to ensure compliance with 55 PA Code Chapter 6400.166(a)(11). |
02/04/2021
| Implemented |
| 6400.167(a)(1) | Individual #1's Medication Administration Record does not indicate that the following medications were administered on 11/1/20: Benzotropine (8:00pm dose), Divalproex (8:00pm dose), and Trazodone (10:00pm dose). | Medication errors include the following: Failure to administer a medication. | The medications mentioned above were administered as evidence from the medication count on the MAR for October 31st, 2020 and November 2nd, 2020 as well as the shift change notes (also referred to as Cross Over form at Greater Hearts) for November 1st, 2020. However, the staff forgot to document on the MAR. At the time the documentation error was discovered the staff concerned had resigned from Greater Hearts and as such could not recertify it. Staff members have been reminded to report documentation errors when they discover them timely so that appropriate steps could be taken to address them. To prevent medication related errors including documentation errors, Greater Hearts will be mandating all DSPs to take annual refresher course in medication administration (beginning in 2021 calendar year) as part of the annual recertification reprocess. Also, all supervisors, program specialists and/or COO will be required to be pass the practicum observer training so that they can provide the necessary monitoring and coaching to DSPs. All current program specialists and residential supervisors are expected to complete the training by April 15th, 2021. Additionally, to ensure earlier detection of medication related errors, practicum observers and medication administration trainers will review the MAR for everyone supported on a bi-weekly basis. |
04/15/2021
| Implemented |
| 6400.167(b) | There is no documentation that there was a failure to administer Individual 1's medications on 11/1/20. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | The medications mentioned above were administered on 11/1/20 as evidence from the medication count on the MAR for October 31st, 2020 and November 2nd, 2020 as well as the shift change notes (also referred to as Cross Over form at Greater Hearts) for November 1st, 2020. However, the staff forgot to document on the MAR. At the time the documentation error was discovered the staff concerned had resigned from Greater Hearts and as such could not recertify it. Staff members have been reminded to report documentation errors when they discover them timely so that appropriate steps could be taken to address them. To prevent medication related errors including documentation errors, Greater Hearts will be mandating all DSPs to take annual refresher course in medication administration (beginning in 2021 calendar year) as part of the annual recertification reprocess. Also, all supervisors, program specialists and/or COO will be required to be pass the practicum observer training so that they can provide the necessary monitoring and coaching to DSPs. All current program specialists and residential supervisors are expected to complete the training by April 15th, 2021. Additionally, to ensure earlier detection of medication related errors, practicum observers and medication administration trainers will review the MAR for everyone supported on a bi-weekly basis. |
04/15/2021
| Implemented |
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SIN-00148703
|
Renewal
|
01/17/2019
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The Self assement was completed on 10/6/18 and needed to be completed between 7/3/18 and 10/3/18. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| It should have been completed on 7/3/18 and 10/3/2018. The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Conducting a self-assessment allows us as a provider to identify areas of deficiency and enact plans to correct and comply with appropriate regulations. Regulations are set up to ensure health and safety and quality of provision of services to those we support. When deficiencies are identified and corrected, the provider is able to support people in a healthier more person-centered way. Agency self-assessment was couple of months late need to be completed on 7/3 and 10/3/18 respectively. It is not possible to correct this issue until the next self-assessment cycle which begins on 7/3/19. This violation occurs because person responsible for doing the assessment had just given birth via C-section and was out for those three months and was unable to do self-assessment. In the future, Program Director/CEO and Program Specialist will ensure a full review of records and in conjunction with supervisors and staff will also complete a full physical site inspection by that date. Current License expires 1/3/19 GHHS will ensure Self-Assessment is completed and submitted by 6/3/19. Program Director will ensure self-assessment tools are distributed to all departments before 6/3/19. |
01/19/2019
| Implemented |
| 6400.64(a) | There were fecal matter on the light switch and in the shower in the individual #1's bathroom. | Clean and sanitary conditions shall be maintained in the home. | It is important the home be clean and sanitary to assure the health and safety of those living in the home. The home was found to have fecal matter on the light switch and shower ¿ individual ISP states he engages in anal stimulation and has the tendency to smear feces which might be the reason for the feces on the switch and bathroom. His team (parents, SC, BSS GHHS staff and psychiatrist) are aware of this and according to his psychiatrist this is a behavioral issue. What was witnessed during the visit to the house was just an episode. His team is working with him to help him learn how to clean or partner with staff to clean using the cleaning kit specifically provider for this purpose. His team had a meeting on 12/21/18 during which the fecal smear behavior and how best to support the individual was a major topic. He also gets upset (physical) when staff goes in his room to clean most times he would have to be out of the home (at work or with parents) to properly clean his room. Staff member cleaned his room on the day of licensing 01/17/2019, however, an depth cleaning was done when he left for work. GHHS has reached out to Shannon Rico (ODP Clinical Specialist) to further help assist in providing the best support for individual #1 on this issue. See attachment #8 e-mail to Shannon. |
01/17/2018
| Implemented |
| 6400.81(k)(6) | There were no mirrors in individual #1 or individual #2's bedroom. | In bedrooms, each individual shall have the following: A mirror. | Individual #1 e-mail sent to SC from Program Specialist on requesting update to ISP indicating that individual does not want to have a mirror in his room. See attachment #4. According to his mother after talking to ¿he would prefer not to have a mirror in the bed room since he has one in his bathroom that he uses in his words ¿ works just fine.¿ See attachment #5 mom¿s e-mail. Individual #2 had mirror installed in his room the day of the inspection. See attachment #6. Program specialist and supervisors will be trained on this regulation and their responsibilities of meeting this regulation to ensure all required items are located in the individual rooms. If items are not in the room due to an individual request or behavioral purpose, supervisors are to notify the Program Specialists and the Program Specialist will notify the Supports Coordinator to update the ISP. See attachment #7 PS e-mail. Supervisors and Program Specialist are responsible for oversight to ensure all regulated items are obtained and placed in an individual¿s room, unless otherwise noted in the individual ISP. Program Specialist, CEO/Director are responsible for providing quarterly monitoring of the residential homes to ensure compliance with this regulation. |
01/17/2019
| Implemented |
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SIN-00164777
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Renewal
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01/22/2020
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Compliant - Finalized
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