Inspection ID

Reason for Inspection

Inspection Date

Inspection Status

SIN-00252694

Renewal

09/17/2024

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.22(e)(3)	The agency is Individual #1's representative payee. Individual #1's 6/12/24 assessment stated they require assistance in budgeting and spending. Their individual support plan last updated on 6/17/24, did not address financial skills. However, Individual #1's financial ledgers from July and August 2024 displayed purchases of greater than $15, 2for which the agency did not provide receipts.	If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person.	The program manager and or staff designee will ensure there is documentation, by actual receipt or expense record, of every single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person.	10/14/2024	Implemented
6400.66	On 9/30/24 at 10:33 AM, two ceiling light receptacles were found inoperable: one located in the center of the basement, and one found near the basement's only exit to the outside. Consequently, lighting was insufficient in both areas.	Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.	Serenitycare maintenance designee will ensure that rooms, hallways, stairways, steps, doorways, porches, ramps, and fire escapes must be lit to ensure safety and prevent accidents.	10/14/2024	Implemented
6400.105	At 10:27 AM on 9/18/24, the outside dryer vent cover was found missing, exposing a build-up of lint coating the inside of the appliance's exhaust pipe.	Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.	Serenity care staff will check dryers after each use to ensure no excess lint buildup. The Program Director or other leadership designee will complete weekly on-site inspections to ensure dryers are free of fire hazards.	10/14/2024	Implemented
6400.18(a)(4)	Enterprise Incident Management # 9422767, involving physical abuse with Individual #1, was discovered on 5/23/24 and reported on 5/28/24. Enterprise Incident Management # 9410974, regarding psychological abuse with Individual #1, was discovered on 5/5/24 and reported on 6/3/24.	The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Abuse, including abuse to a individual by another client.	Serenitycare will ensure to report abuse to an individual by another individual within 24 hours of discovery within the department's information management system or on a form specified by the Department within 24 hours of discovery.	10/14/2024	Implemented
6400.18(a)(6)	Enterprise Incident Management # 9434339, involving exploitation with Individual #1, was discovered on 6/14/24 and reported on 6/17/24.	The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Exploitation .	Serenitycare will ensure to report exploitation to an individual by another individual within 24 hours of discovery within the department's information management system or on a form specified by the Department within 24 hours of discovery.	10/14/2024	Implemented
6400.32(r)(5)	At 10:48 AM on 9/18/24, a sliding chain-link lock was observed on the inside of Individual #1's bedroom door, preventing staff from entering in the event of an emergency.	Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.	Serenitycare Maintenance designee will ensure that new doorknobs on all the individual's bedrooms to ensure each individual has the right to lock their door but staff have access and a key for entry to ensure compliance and safety.	10/14/2024	Implemented
6400.166(b)	On 9/18/24, Individual #1's September 2024 Medication Administration Record revealed that their prescribed Hydroxyzine Pamoate 50 mg/ Cap.---Take 1 capsule by mouth three times daily for bipolar---was not documented as being administered on 9/9/24 at 12:00 PM.	The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.	Serenity Care staff will ensure that each individual's MAR complies with regulations and company policies and procedures, including the medication record at the time the medication is administered. Serenity Care designee will be responsible for completing weekly MAR and medication audits to ensure that each individual's MAR complies with regulations and company policies and procedures, including the medication record at the time the medication is administered	10/14/2024	Implemented

SIN-00245575

Unannounced Monitoring

04/24/2024

Compliant - Finalized

SIN-00232215

Renewal

09/26/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.73(a)	Leading up to the front porch of the house from the front walkway there are two free standing steps plus an additional third rise to step up onto the porch and there is no handrail for stability. Leading up to the back porch of the house from the back yard there are two free standing steps plus an additional third rise to step up onto the porch and there is no handrail for stability [Repeat violation 10/12/22, et. al.].	Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail.	Serenity Care Maintenence Designee will ensure that each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Each porch that has over an 18-inch drop shall have a well-secured railing.	10/13/2023	Implemented
6400.141(a)	Individual #1 had a physical examination on 2/1/2022 and then on 5/4/2023. This exceeds the annual requirement [Repeat violation 10/12/22, et. al.]	An individual shall have a physical examination within 12 months prior to admission and annually thereafter.	Serenity Care staff will ensure that all individuals are in compliance with the required physical examination within 12 months prior to admission and annually thereafter.	10/13/2023	Implemented
6400.141(c)(14)	Individual #1's physical examination, dated 5/4/2023, did not include medical information pertinent to diagnosis and treatment in case of an emergency [Repeat violation 10/12/22, et. al.].	The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.	Serenity Care staff will ensure that all individuals are in compliance with the required medical information pertinent to diagnosis and treatment in case of an emergency	10/13/2023	Implemented
6400.142(g)	Individual #1 had a written dental hygiene plan dated 3/4/2022, and then again on 8/11/2023. This exceeds the annual requirement.	A dental hygiene plan shall be rewritten at least annually.	Serenity care staff will ensure that individuals have a dental hygiene plan shall is rewritten at least annually.	10/13/2023	Implemented
6400.34(b)	The agency did not keep a copy of the statement signed by the individual acknowledging receipt of the information on individual rights for 2022 for Individual #1.	The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights.	Serenity care staff will ensure that individual rights and the process to report a rights violation are provided to individuals, and persons designated by the individual, upon admission to the home and annually thereafter. Serenity Care Program Director will ensure that the home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights.	10/13/2023	Implemented
6400.51(b)(4)	Chief Executive Officer #1, date of hire 5/5/2022, did not participate in orientation training prior to working with individuals and within 30-days after hire that encompassed the following training topic: Recognizing and Reporting Incidents.	The orientation must encompass the following areas: recognizing and reporting incidents.	Serenity Care training designee will ensure that all staff complete training prior to working with individuals and within 30 days after hire that encompassed the following training topic:	10/13/2023	Implemented
6400.52(a)(1)	Direct Support Staff #2, date of hire 2/22/2018, did not participate in 24 hours of training related to job skills and knowledge during the 1/1/2022-12/31/2022 annual staff training year. The agency was not able to produce documentation of annual training hours for Direct Support Staff #2 for the annual training year.	The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.	Serenity Care training designee will ensure that all staff complete training prior to working with individuals of the required 24 hours of training related to job skills.	10/13/2023	Implemented
6400.52(c)(1)	Direct Support Staff #2, date of hire 2/22/2018, did not participate in annual training to encompass the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships during the 1/1/2022-12/31/2022 annual staff training year.	The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.	Serenity Care training designee will ensure that all staff complete training prior to working with individuals of the required annual training hours	10/13/2023	Implemented
6400.52(c)(2)	Direct Support Staff #2, date of hire 2/22/2018, did not participate in training to encompass the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse during the 1/1/2022-12/31/2022 annual staff training year [Repeat violation 6/16/23].	The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.	Serenity Care training designee will ensure that all staff complete training prior to working with individuals The prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.	10/13/2023	Implemented
6400.52(c)(3)	Direct Support Staff #2, date of hire 2/22/2018, did not participate in annual training to encompass individual rights during the 1/1/2022-12/31/2022 annual staff training year [Repeat violation 6/16/23].	The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.	Serenity Care training designee will ensure that all staff complete training prior to working with individuals and the required annual training hours specified in subsection	11/13/2023	Implemented
6400.52(c)(4)	Direct Support Staff #2, date of hire 2/22/2018, did not participate in annual training to encompass recognizing and reporting incidents during the 1/1/2022-12/31/2022 annual staff training year [Repeat violation 6/16/23].	The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.	Serenity Care training designee will ensure that all staff complete training prior to working with individuals and the required annual training hours.	10/13/2023	Implemented
6400.52(c)(5)	Direct Support Staff #2, date of hire 2/22/2018, did not participate in annual training to encompass the safe and appropriate use of behavior supports during the 1/1/2022-12/31/2022 annual staff training year.	The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.	Serenity Care training designee will ensure that all staff complete training prior to working with individuals and the required annual training hours.	10/13/2023	Implemented
6400.52(c)(6)	Direct Support Staff #2, date of hire 2/22/2018, did not participate in annual training to encompass the implementation of the individual plan during the 1/1/2022-12/31/2022 annual staff training year.	The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.	Serenity Care training designee will ensure that all staff complete training prior to working with individuals and the required annual training hours.	10/13/2023	Implemented
6400.165(g)	Individual #1 is prescribed medication to treat the symptoms of a psychiatric illness. Individual #1 had a psychiatric medication review appointment on 12/6/2022. There was a note of "med increase" but the medications and necessary dosages were not indicated [Repeat violation 10/12/22, et. al. and 6/16/23].	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.	Serenity care staff will ensure that a prescription order shall be kept current, and prescription medication shall be administered as prescribed. Serenity care staff A prescription medication shall be used only by the individual for whom the prescription was prescribed. Serenity care staff will ensure that changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional, and environmental needs of the individual related to the symptoms of the psychiatric illness. If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes documentation of the reason for prescribing the medication, the need to continue the medication, and the necessary dosage.	10/13/2023	Implemented

SIN-00226661

Unannounced Monitoring

06/16/2023

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.64(a)	The cold cellar in the basement was covered in thick dust and cobwebs. The walls in the kitchen above the doorway leading to the foyer area had dried food stains that appeared to be ketchup. The microwave in the kitchen was had splattered on dried food inside of the appliance. The stairs leading to the second floor of the home were covered with thick dust and debris. Individual #1's bedroom was observed with trash scattered on the floor to include candy wrappers, used floss picks, broken make-up palettes, and business cards.	Clean and sanitary conditions shall be maintained in the home.	Serenity Care staff will ensure that homes are in clean and sanitary conditions shall be maintained in the home at all times. Serenity care staff will complete daily cleaning logs for all chores that are completed daily. Serenity care staff will deep clean homes weekly to ensure that the homes meet sanitary conditions. Serenity Care staff will ensure the homes are swept and dusted, removing all spiderwebs including in the basement.	07/25/2023	Implemented
6400.64(b)	The basement of the home was covered with thick cobwebs and multiple spiders were located throughout the cellar.	There may not be evidence of infestation of insects or rodents in the home.	Serenity Care staff will ensure that homes are in clean and sanitary conditions shall be maintained in the home at all times. Serenity care staff will complete daily cleaning logs for all chores that are completed daily. Serenity care staff will deep clean homes weekly to ensure that the homes meet sanitary conditions. Serenity Care staff will ensure the homes are swept and dusted, removing all spiderwebs in the basement.	07/25/2023	Implemented
6400.64(c)	While speaking with Owner #1, it was disclosed that the trash should have been put to the curb for pick-up the morning licensing inspected the home; however, the staff did not take the trash to the curb for weekly removal.	Trash shall be removed from the premises at least once per week.	Serenity Care staff will ensure that all trash is removed from the premises at least once per week and placed out in a timely matter to ensure the city sanitation picks it up. Serenity Care staff will ensure that all trash in the bathrooms, dining area, and kitchen areas are kept in clean receptacles and disinfected weekly to the penetration of insects and rodents. Serenity care staff will ensure that all trash receptacles over 18 inches high have lids, and trash receptacles outside the home are kept in closed receptacles to prevent the penetration of insects and rodents.	07/15/2023	Implemented
6400.67(b)	Bags of clothes and miscellaneous personal items were piled approximately four feet high in two areas along the walls in the individual #1's bedroom creating potential tripping hazards. The basement floor had a puddle of water, measuring approximately 2' X 6' leading from the corner of the cold cellar at the back of the home into the main portion of the basement. The puddle was creating a potential slipping hazard for staff and individuals.	Floors, walls, ceilings and other surfaces shall be free of hazards.	Serenity Care will ensure that all s floors, walls, ceilings, and other surfaces shall be free of hazards. Serenity care staff will ensure that walls individuals' items are stored in the proper storage areas, such as the closet and dressers. Serenity Care maintenance designee will inspect the homes for any hazardous conditions and or water leaks and ensure that they are fixed and the homes comply with Chapter 6400.67(b) regulations.	07/25/2023	Implemented
6400.72(a)	The windows on the front porch/living room of the home contained screens, but the frames of the screens were bent and did not provide a secure seal to prevent from the penetration of insects. The dining room windows at the back of the home did not contain screens.	Windows, including windows in doors, shall be securely screened when windows or doors are open.	Serenity Care maintenance designee will inspect and replace any screens to ensure windows, including windows in doors, are securely screened when windows or doors are open. All staff of Serenitycare will be serviced and trained on the implemented policies regarding reporting maintenance issues within 24 hours of discovering the problem in the home to ensure that concerns are addressed to ensure homes meet the standards outlined in the 6400 Regulations to prevent any future violations from re-occurring.	07/25/2023	Implemented
6400.165(c)	On 6/13/2023, the following medications were not administered to individual #1 at 8:00PM. Guanfacine 2mg tablet, Hydroxyzine Pamoate 50mg tablet, Lithium Carbonate 600mg tablet, Quetiapine 300mg tablet. the medications were still present in the pillow pack for that date and time.	A prescription medication shall be administered as prescribed.	Serenity Care will ensure that all prescription medications are administered at the designated time and documented adequately on the individual's MAR. Serenity Care will ensure that if an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. Serenity Care certified assigned nurse will complete weekly audits to ensure there are no data gaps on individuals' mars and daily administering is properly documented.	07/15/2023	Implemented
6400.166(a)(4)	The June 2023 medication administration record does not list acetaminophen 325mg tab, prescribed to individual #1; however, the medication, filled by the pharmacy on 4/29/2023, was present in the home.	A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.	Serenity Care CEO and other leadership designees will ensure that all staff responsible for medication administration will be trained on checking medications and ensuring labels and MARs match. A certified Serenity Care nurse will ensure that the MAR and the label match the physician's orders for each medication.	07/15/2023	Implemented
6400.166(a)(5)	The June 2023 medication administration record lists the dosage for Errin birth control, prescribed to individual #1, as 0.3mg while the medication dosage prescribed by the physician and filled by the pharmacy is 0.35mg. The June 2023 medication administration record does not list acetaminophen 325mg tab, prescribed to individual #1; however, the medication, filled by the pharmacy on 4/29/2023, was present in the home.	A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.	Serenity Care will ensure that A medication record shall be kept, including the following for each individual for whom a prescription medication is administered and the correct strength for the individual. Serenity Care will ensure that if an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record.	07/15/2023	Implemented
6400.166(a)(6)	The June 2023 medication administration record does not list acetaminophen 325mg tab, prescribed to individual #1; however, the medication, filled by the pharmacy on 4/29/2023, was present in the home.	A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form.	Serenity Care staff will ensure that each individual's MAR reflects all medications filled by the pharmacy and present in the home. Serenity Care certified nurse will be responsible for completing weekly MAR and medication audits to ensure that each individual's MAR reflects all medications filled by the pharmacy and present in the home. The designated site nurse will immediately report concerns to the CEO and other leadership designees.	07/15/2023	Implemented
6400.166(a)(7)	The June 2023 medication administration record does not list acetaminophen 325mg tab, prescribed to individual #1; however, the medication, filled by the pharmacy on 4/29/2023, was present in the home.	A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.	Serenity Care staff will ensure that each individual's MAR complies with regulations and company policies and procedures, including the individual for whom a prescription medication is administered and the correct dose. Serenity Care certified nurse will be responsible for completing weekly MAR and medication audits to ensure that each individual's MAR complies with regulations and company policies and procedures, including the individual for whom a prescription medication is administered and the correct dose. The designated site nurse will immediately report concerns to the CEO and other leadership designees.	07/15/2023	Implemented
6400.166(a)(8)	The June 2023 medication administration record does not list acetaminophen 325mg tab, prescribed to individual #1; however, the medication, filled by the pharmacy on 4/29/2023, was present in the home.	A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.	Serenity Care staff will ensure that each individual's MAR complies with regulations and company policies and procedures, including the individual for whom a prescription medication is administered and the correct route of administration. Serenity Care certified nurse will be responsible for completing weekly MAR and medication audits to ensure that each individual's MAR complies with regulations and company policies and procedures, including the individual for whom a prescription medication is administered and the correct route of administration. The designated site nurse will immediately report concerns to the CEO and other leadership designees.	07/15/2023	Implemented
6400.166(a)(9)	The June 2023 medication administration record lists the frequency of administration for Quetiapine 300 mg tab, prescribed to individual #1, as take 1 tablet by mouth daily at 8:00PM while the medication labels states to take 1 tablet my mouth twice a day. The June 2023 medication administration record does not list acetaminophen 325mg tab, prescribed to individual #1; however, the medication, filled by the pharmacy on 4/29/2023, was present in the home.	A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.	Serenity Care staff will ensure that each individual's MAR complies with regulations and company policies and procedures, including the individual for whom a prescription medication is administered and the correct route of administration. Serenity Care certified nurse will be responsible for completing weekly MAR and medication audits to ensure that each individual's MAR complies with regulations and company policies and procedures, including the individual for whom a prescription medication is administered and the frequency of administration. The designated site nurse will immediately report concerns to the CEO and other leadership designees.	07/15/2023	Implemented
6400.166(a)(10)	The June 2023 medication administration record does not list acetaminophen 325mg tab, prescribed to individual #1; however, the medication, filled by the pharmacy on 4/29/2023, was present in the home.	A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.	Serenity Care staff will ensure that each individual's MAR complies with regulations and company policies and procedures, including the individual for whom a prescription medication is administered and the correct administration times. Serenity Care certified nurse will be responsible for completing weekly MAR and medication audits to ensure that each individual's MAR complies with regulations and company policies and procedures, including the individual for whom a prescription medication is administered and the administration times. The designated site nurse will immediately report concerns to the CEO and other leadership designees.	07/15/2023	Implemented
6400.166(a)(11)	The June 2023 medication administration record does not list acetaminophen 325mg tab, prescribed to individual #1; however, the medication, filled by the pharmacy on 4/29/2023, was present in the home.	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.	Serenity Care staff will ensure that each individual's MAR complies with regulations and company policies and procedures, including the individual for whom a prescription medication is administered and the diagnosis or purpose for the medication, including pro re nata Serenity Care certified nurse will be responsible for completing weekly MAR and medication audits to ensure that each individual's MAR complies with regulations and company policies and procedures, including the individual for whom a prescription medication is administered and the diagnosis or purpose for the medication, including pro re nata The designated site nurse will immediately report concerns to the CEO and other leadership designees.	07/15/2023	Implemented
6400.166(a)(13)	The June 2023 Medication Administration Record did not contain the initials of the staff that administered the following medications to individual #1: Guanfacine 2mg tab on 6/1/2023 at 8:00PM, 6/5/2023 at 8:00PM, 6/9/2023 at 8:00AM, 6/12/2023 at 8:00PM, 6/15/2023 at 8:00PM; Hydroxyzine Pamoate 50mg tab on 6/1/2023 at 8:00PM, 6/5/2023 at 8:00PM, 6/9/2023 at 8:00AM, 6/12/2023 at 8:00PM, 6/15/2023 at 8:00PM; Lithium Carbonate 600 mg tab on 6/1/2023 at 8:00PM, 6/5/2023 at 8:00PM, 6/9/2023 at 8:00AM, 6/12/2023 at 8:00PM, 6/15/2023 at 8:00PM; Omega 3 1000mg soft-gel on 6/9/2023 at 8:00AM; Quetiapine 300 mg tab on 6/1/2023 at 8:00PM, 6/5/2023 at 8:00PM, 6/15/2023 at 8:00PM; Vitamin D 1000 IU soft-gel on 6/9/2023 at 8:00AM; and Errin 0.35mg tab on 6/9/2023 at 8:00AM.	A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.	Serenity Care staff will ensure that each individual's MAR complies with regulations and company policies and procedures, including the individual for whom a prescription medication is administered and the name and initials of the person administering the medication. Serenity Care certified nurse will be responsible for completing weekly MAR and medication audits to ensure that each individual's MAR complies with regulations and company policies and procedures, including the individual for whom a prescription medication is administered and the name and initials of the person administering the medication. The designated site nurse will immediately report concerns to the CEO and other leadership designees.	07/15/2023	Implemented

SIN-00213102

Renewal

10/12/2022

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.21(b)	Chief Executive Officer #1's criminal history check, completed on 5/5/22, was submitted through the Criminal Justice Information Services Division in Clarksburg, VA, not through the Pennsylvania Department of Aging. Chief Executive Officer #1 resides in Florida.	If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.	Serenity Care HR department will assure any prospective employee with direct contact with individuals will undergo a complete criminal background check in their current city of residence and the Pennsylvania Criminal Justice Department according to the 6400 regulations.	11/01/2022	Implemented
6400.66	On 10/13/22 at 3:10 PM, outside the exit door of the basement, did not have a lighting source.	Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.	A light will be installed above basement door to assure appropriate lighting.	12/01/2022	Implemented
6400.73(a)	The sidewalk off the back porch has 3 steps leading down to another sidewalk on the side of the house. This set of 3 steps was observed on 10/13/22 at 2:58 PM without a railing or handrail.	Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail.	Maintenance Technician will install a handrail along back steps leading to the sidewalk.	12/01/2022	Implemented
6400.101	The only exit door, leading from the basement to the outside, was found at 3:10 PM on 10/13/22 with 4 sliding latch door locks creating a blocked egress.	Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.	All deadbolt locks with the keys that can only lock from the inside and Latch Locks will be removed and replaced with one sided deadbolt locks where a key is only needed for entry not exit.	12/01/2022	Implemented
6400.151(b)	Direct Service Worker #2 and Direct Service Worker #4 had Tuberculin skin testing by Mantoux method with negative results completed 10/7/21 and 4/24/22; respectively. The credentials of the medical professionals who read the results were not included.	The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant.	Serenity Care HR Department will update Employee Physical Exam Form to include the entities signature whom is certified to read the TB results.	11/01/2022	Implemented
6400.18(a)(1)	Incident #9045999, psychological abuse involving Individual #1, was discovered 9/8/22 at 12:00 AM and reported 9/22/22 at 3:52 AM. Incident #9092444, physical abuse involving Individual #1, was discovered 9/8/22 at 12:00 AM and reported 9/20/22 at 11:55 AM.	The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Death	Serenity Care will be in compliance with 55 PA Code Chapter 6400.18 (a) (1) and the Program Manager will monitor and track all reported incident daily and every 10 days for review and 30 days for final.	11/01/2022	Implemented
6400.46(b)	Direct Service Worker #2 completed fire safety training on 2/3/21 and then again on 6/20/22.	Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).	Serenity Care HR Department will be in compliance with 55 PA Code Chapter 6400.46 (b). HR will monitor and track all Fire Safety Trainings.	11/01/2022	Implemented
6400.46(d)	Direct Service Worker #4, date of hire 4/14/22, was provided training in general fire safety 6/22/22.	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.	Serenity Care HR Department will be in compliance with 55 PA Code Chapter 6400.46 (d). HR will monitor and track all Fire Safety Trainings.	11/01/2022	Implemented
6400.51(a)(1)	Chief Executive Officer #1, date of hire 5/5/22, was provided orientation 7/22/22.	Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons.	Serenity Care HR Department will be in compliance with 55 PA Code Chapter 6400.51 (a) (1). HR will monitor and track all orientations.	11/01/2022	Implemented
6400.51(a)(3)	Direct Service Worker #4's date of hire 4/14/22, orientation completion date was not provided, therefore compliance was unable to be measured.	Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons.	Serenity Care HR Department will be in compliance with 55 PA Code Chapter 6400.51 (a) (3). HR will monitor and track all orientations.	11/01/2022	Implemented
6400.51(b)(2)	Chief Executive Officer #1's orientation did not include completion of the prevention, detection, and reporting of abuse required training.	The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations.	Serenity Care HR Department will be in compliance with 55 PA Code Chapter 6400.51 (b) (2). HR will monitor and track all orientation documentation.	11/01/2022	Implemented

SIN-00182312

Renewal

01/28/2021

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.106	The furnace was inspected and cleaned on 4/12/2019 and then again on 11/9/2020.	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.	The furnace was last inspected and cleaned on 09/12/2019 (correction to 04/12/2019) noted in the violation; then again on 11/9/2020. The agency has a contract with the undisclosed professional furnace cleaning company to complete a cleaning annually which is scheduled in collaboration with the agency's maintenance supervisor as well as the furnace company scheduler. The appointment is then provided to the office manager who maintains a calendar schedule of all maintenance appointments. Due to the impact of COVID-19 at the time of scheduling for the September 2020 cleaning, the agency was advised that the company was unable to schedule any maintenance service calls that were not emergent.	01/29/2021	Implemented
6400.112(e)	A fire drill was held during sleeping hours most recently on 6/2/2020.	A fire drill shall be held during sleeping hours at least every 6 months.	On 02/01/2021 an overnight sleeping fire dill was completed; therefore the agency is now in compliance. The next overnight drill will be completed after 07/01/2021 but not before 7/31/2021 between the hours of 11pm and 5am. A fire drill log has been created by the office manager to include a minimum of 1 fire drill held during sleeping hours at least every 6 months. The log was reviewed by program specialist to ensure compliance Training was completed with the office manager to establish a schedule as well as define sleeping hours. Sleeping hours have been defined as between the hours of 11pm-5am. The log will not be distributed to houses to avoid the ability for participants and staff preparation. Office manager will contact each house with instructions to engage the fire alarm within 2 minutes of notification. Proper documentation will be submitted within 24 hours to office manager to be approved by program specialist. [Documentation of aforementioned approval of fire drill documentation by the program specialist shall be kept. (DPOC by AES,HSLS on 3/9/21)]	02/01/2021	Implemented
6400.15(b)	The agency did not use the Department's licensing inspection instrument when completing a self-assessment on 8/23/2020. The document did not include all of the elements of the 55 Pa. Code Chapter 6400 regulations including but not limited to the following sections: general requirements, individual rights, staffing, fire safety, individual health, individual records and restrictive procedures.	(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.	On 1/29/2021; the office manager obtained the most up to date and current licensing inspection instrument available at: https://www.dhs.pa.gov/Services/Disabilities-Aging/Documents/Developmental%20Programs%20Licensing/Chapter%206400%20Score%20Sheet%20(s_002510).pdf. It. The CEO, Maintenance Supervisor, Office Manager, and Residential House Leads were trained in accordance to the form. information from the agency created inspection tools were transferred to the Department's licensing inspection instrument The Department licensing form will be distributed 30 days prior to its deadline to residential leads to be completed within 7 days returned to office manager. Office Manager will transfer documentation to Maintenance supervisor to be returned within 7 days to Office Manager. The form will be reviewed and approved by CEO and returned to Office Manager for submission at least 3 business days prior to deadline. The form will be maintained by Office Manager pending Department on-site inspection [Documentation of the aforementioned review and approval by the CEO shall be kept. (DPOC by AES,HSLS on 3/9/21)]	01/29/2021	Implemented

SIN-00145919

Renewal

11/15/2018

Compliant - Finalized

Regulation	LIS Non-Compliance Area	Correction Required	Plans of Correction	Correction Date	POC Status
6400.44(b)(4)	Program Specialist/Chief Executive Officer #1 did not attend the annual ISP meeting for Individual #1 held on 10/2/18.	The program specialist shall be responsible for the following: Attending the ISP meetings.	Future ISP meetings will be attended by the Program Specialist. In the event of an emergency, program specialist will contact SC to reschedule meeting to ensure compliance. Program Specialist may attend via phone in the event of an unavoidable emergency if rescheduling will cause a conflict with the annual review of ISP. Serenitycare will add a part/time Program Specialist to the staff within 6 months to support the business need. [Immediately and upon hire and continuing at least annually, the CEO or designee shall educate the program specialist(s) of the responsibilities of the position as per 6400.44(b)(1)-(19) and the aforementioned process to ensure all responsibilities are met including attending ISP meetings. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 1/8/19)]	11/16/2018	Implemented
6400.141(c)(3)	Individual #1's physical examination, dated 11/7/17, did not include immunization information. [Repeat Violation 11/9/17]	The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.	Available immunization records have been attached to the physical sheet. In the event that an immunization is not made available through transfer of medical records, client will be subjected to an immunization review blood draw conducted by a medical professional to detect the immunization records of client. All members applicable to the client's medical record will be contacted as an effort to obtain medical records. Physical forms stating "see attached" must have the attached documents on record and can not be directed to a file that is not readily available. A calendar and review sign/off document was created for each participant to verify that the scheduled physical examination documents were verified for completeness and accuracy by the staff and program specialist [Individual #1's immunization information was obtained to included: TDAP 12/13/18, TB 12/14/18. Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff person responsible for ensuring all required areas of individuals' physical examinations are completed and reviewed shall be educated in the requirements of individuals' physical examinations as per 6400.141(c)(1)-(15) and the aforementioned process to have physical examinations completed and documented on the aforementioned calendar. Documentation of trainings shall be kept. Immediately, and at least quarterly for 1 year, the CEO or designee shall audit all Individualized calendars and aforementioned review documentation to ensure completion and regulatory requirements are met. (DPOC by AES,HSLS on 1/8/19)]	12/07/2018	Implemented
6400.141(c)(14)	Individual #1's physical examination, dated 11/7/17, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section of the form was blank. [Repeat Violation 11/9/17]	The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.	Information pertinent to diagnosis and treatment in case of an emergency has been populated by a medical professional. The physical medical form has been amended to highlight the missed field. Training has been provided to staff to ensure that all fields are completed at the conclusion of each medical appointment. Program Specialist will review each form for completion following medical appointment. A follow up appointment will be scheduled in the event that the field is not populated accurately. A calendar and review sign/off document was created for each participant to verify that the scheduled physical examination documents were verified for completeness and accuracy by the staff and program specialist [Individual's physical examination form, dated 11/28/18, included information pertinent to diagnosis in case of an emergency. Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff person responsible for ensuring all required areas of individuals' physical examinations are completed and reviewed shall be educated in the requirements of individuals' physical examinations as per 6400.141(c)(1)-(15) and the aforementioned process to have physical examinations completed and documented on the aforementioned calendar. Documentation of trainings shall be kept. Immediately, and at least quarterly for 1 year, the CEO or designee shall audit all Individualized calendars and aforementioned review documentation to ensure completion and regulatory requirements are met. (DPOC by AES,HSLS on 1/8/19)]	12/14/2018	Implemented
6400.163(c)	Individual #1's had a psychiatric medication review on 6/28/18 and then again on 10/16/18. Individual #1's psychiatric medication review, dated 10/16/18, did not include the reason for prescribing the medication or the need to continue the medication. Individual #1's psychiatric medication review, dated 5/3/18, did not include the reason for prescribing the medication or the need to continue the medication. Individual #1's psychiatric medication review, dated 2/6/18, did not include the reason for prescribing the medication or the need to continue the medication. Individual #1's psychiatric medication review, dated 1/11/18, did not include the reason for prescribing the medication or the need to continue the medication. [Repeat Violation 11/9/17]	If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.	The agency contacted the outpatient psychiatric professional to inquire regarding the reason for the prescribe medication which should be held every 3 months. Efforts were made to retrieve written documentation, without avail. Staff attending psychiatric appointments have received adequate training on the importance of receiving this vital information. The psychiatric medial appointment sheet has been updated to highlight the area and instruct both the psychiatric attendant and staff to complete all fields. Program Specialist will review all documentation following psychiatric appointments. In the event that the documentation is not completed in its entirety a follow up appointment for documentation will be scheduled, unless a solution is available to remedy the issue through other means of communication.A calendar and review sign/off document was created for each participant to verify that the scheduled psychiatric examination documents were verified for completeness and accuracy by the staff and program specialist. [Within 30 days of receipt of the plan of correction, the CEO or designee shall educate all staff person responsible for ensuring all required areas of individuals' medication review documentation are completed and reviewed shall be educated in the requirements of individuals' medication review documentation as per 6400.163c and the aforementioned process to have the medication review documentation completed and documented on the aforementioned calendar. Documentation of trainings shall be kept. Immediately, and at least quarterly for 1 year, the CEO or designee shall audit all Individualized calendars and aforementioned review documentation to ensure completion and regulatory requirements are met. (DPOC by AES,HSLS on 1/8/19)]	11/16/2018	Implemented
6400.181(e)(6)	Individual #1's assessment, dated 10/11/18, does not include the individual's ability to safely use or avoid poisonous materials.	The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.	The assessment was amended to reflect the individual's ability to safely use or avoid poisonous materials. An amended assessment has been signed and dated by both the individual and program specialist. The assessment has been recorded in the clients profile. The SC as well as team members have been notified of the updated information reflected in the assessment. Program Specialist and Program Manager will ensure that all fields are created and verified per compliance standards on all company created documents, prior to document distribution and company usage. [Individual #1's assessment was updated on 11/15/18 to include the individual's ability to safely use or avoid poisonous materials and provided to the plan team members on 12/7/18. Within 30 days of receipt of the plan of correction, the CEO or designee shall educate the program specialist as to the requirements of individuals' assessments as per 6400.181(e)(1)-(14). Documentation of trainings shall be kept. Upon completion for 1 year, the CEO or designee shall audit all individuals' assessments and Individualized calendars to ensure completion and regulatory requirements are met. (DPOC by AES,HSLS on 1/8/19)]	11/16/2018	Implemented
6400.186(b)	Individual #1's ISP review, for review period 10/11/17 to 12/31/17, was not signed by the individual. Individual #1's ISP review, for review period 1/1/18 to 3/31/18, was not signed by the individual. Individual #1's ISP review, for review period 4/1/18 to 6/30/18, was not signed by the individual. Individual #1's ISP review, for review period 7/1/18 to 9/30/18, was not signed by the individual.	The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.	The ISP review sheet was amended immediately to reflect a signature line for both the individual and client. The ISP was signed immediately by both the program specialist and client reflecting the current date. All ISP's for all clients have been reviewed to ensure that appropriate signatures have been recorded. Program Specialist will ensure signatures have been recorded on all ISPs. Additionally, The ISP review signature task and dates were added to the participants pre-filled dated calendar for completeness and sign-off by Program Specialist and Program Manager.The ISP review signature task and dates were added to the participants pre-filled dated calendar for completeness and sign-off by Program Specialist and Program Manager. [Individual 1's ISP reviews were signed by the individual on 11/15/18. Upon completion for 1 year, the CEO or designee shall audit all individuals' ISP reviews and Individualized calendars to ensure completion and regulatory requirements are met. (DPOC by AES,HSLS on 1/8/19)]	11/16/2018	Implemented
6400.186(d)	The program specialist did not provide Individual #1's ISPs review documentation completed from October 2017 to September 2018.	The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting.	The ISP's reviews have been forwarded to the appropriate and designated SC's. A record f submission and notification has been recorded and filed in the appropriate client profile. Future ISP documentation will be sent within 15 calendar day if an onsite monitoring is not scheduled within 30 calendar days. A log to record the documentation of submission has been implemented. Program Specialist will ensure that the documentation is submitted within the designated and allotted time. The ISP review task and dates were added to the participants pre-filled dated calendar for completeness and sign-off by Program Specialist and Program Manager. The email sent to the team or team sign-off form is a required document to be attached to the ISP review when filed. [Individual #1's ISP reviews were provided to plan team members on 12/7/18. Immediately and upon hire and continuing at least annually, the CEO or designee shall educate the program specialist(s) of the responsibilities of the position as per 6400.44(b)(1)-(19) and the aforementioned process to ensure all responsibilities are met including providing the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. Documentation of the trainings shall be kept. Immediately, and at least quarterly for 1 year, the CEO or designee shall audit all Individualized calendars and aforementioned review documentation to ensure completion and regulatory requirements are met. (DPOC by AES,HSLS on 1/8/19)]	12/07/2018	Implemented
6400.186(e)	The program specialist did not notify Individual #1's plan team members of the option to decline ISP review documentation.	The program specialist shall notify the plan team members of the option to decline the ISP review documentation.	An option to decline was sent to the members of the individual's team. A print out of the record of receipt is maintained in the client's profile. Upon admission of a new client, an option to decline will be distributed to every member of the team upon introductory to the team. Program Specialist will ensure that all members receive option to decline.The ISP review Option Out task was added to the Participant calendar. The email sent to the team or team sign-off form is a required document to be attached to the Participant Anniversary ISP meeting documentation. The calendar task will be reviewed by the Program Manager for completeness. [The program specialist notified Individual #1's plan team members of the option to decline ISP review documentation on 12/7/18. Immediately and upon hire and continuing at least annually, the CEO or designee shall educate the program specialist(s) of the responsibilities of the position as per 6400.44(b)(1)-(19) and the aforementioned process to ensure all responsibilities are met including notifying the plan team members of the option to decline the ISP review documentation. Documentation of the trainings shall be kept. Immediately, and at least quarterly for 1 year, the CEO or designee shall audit all Individualized calendars and aforementioned review documentation to ensure completion and regulatory requirements are met. (DPOC by AES,HSLS on 1/8/19)]	12/14/2018	Implemented
6400.194(c)	The restrictive procedure review committee for Individual #1 met 2/12/18 and then again on 9/25/18. [Repeat Violation 11/9/17]	The restrictive procedure review committee shall establish a time frame for review and revision of the restrictive procedure plan, not to exceed 6 months between reviews.	The restrictive committee members were informed immediately of the error. A plan was implemented to schedule restrictive procedure meetings every 5 months, with a back up plan B date scheduled 2 weeks prior to the deadline in the event the initial date is not upheld. This plan of action is in regards to all clients at Serenity Care with a restrictive procedure plan. Additionally, a Restrictive procedure calendar was created with the scheduled dates for the meetings to be performed and signed off by the CEO and Program director. The Restrictive procedure meeting dates was also added to the participants pre-filled dated calendar.Upon admission of new clients, this plan will be in effect. The first meeting following admission, will begin the clients review period. The Program Manager will ensure that all clients are reviewed within the designated time period. The chairperson of the restrictive procedure committee will ensure that follow up meetings are held in a timely manner. An invitation for the upcoming meeting will be dispersed prior to the conclusion of he meeting, as well as a reminder sent 30 days prior to the next meeting, A Restrictive procedure calendar was created with the scheduled dates for the meetings to be performed and signed off by the CEO and Program director. The Restrictive procedure meeting dates was also added to the participants pre-filled dated calendar. [Restrictive Procedures Committee Meeting for Individual #1 is scheduled for March 2019. (AES,HSLS on 1/8/19)]	11/16/2018	Implemented

SIN-00196797

Renewal

11/30/2021

Compliant - Finalized

SIN-00164679

Renewal

10/22/2019

Compliant - Finalized