| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Direct Service Worker #1, date of hire 4/20/20, had an application for a Pennsylvania criminal history record check submitted to the State Police on 9/2/20. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| 6400.21(a) an application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals within 5 working days after person's hire date.
Staff person #1 was an employee of HNA prior to being reassigned to the home during the Covid -19 Pandemic during the red phase. As per the ODP Announcement 20-032 dated March 30, 2020, Modification #1: Staff qualified under any service definition in the waiver may render any service, with exceptions. Each waiver service definition includes a list of qualifications staff must meet to render the service. Staff must qualify for each service they are going to render. To allow redeployment of direct support and clinical staff to provide services where they are most needed during the Covid -19 Pandemic, staff persons that meet the qualifications for any one waiver service may render any other service, even if the qualifications are different, except for services that require specific training, educaton, certification or professional licensure.
In addition HNA emailed the PW, 6100 Regulatory Administration for further guidance on Criminal Background checks and received the following reply: Criminal history checks do not need to be repeated if the person already works for you. For example: Staff A was hired to work in a 2380 on 1/1/2020 and had a criminal history check completed as part of onboarding. Staff A was redeployed to assist in a community home on 10/1/2020. A criminal history check is not needed since this person already worked for the company.
HNA does have a policy regarding repeating background checks for current employees who transfer between services; however due to the need to get staff into the residential home quickly and the guidance from ODP, the check was not completed upon her transfer.
HNA will retrain HR personal on the policy to repeat background checks for all employees who transfer to a different waiver service prior to starting under a different waiver. Records will be reviewed by the Program Specialist to ensure compliance.[Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 1/7/2021)] |
11/13/2020
| Implemented |
| 6400.65 | The bathroom along the hallway was not ventilated by an operable window or by mechanical ventilation. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| 6400.65 Living areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
A portable fan has been installed in the bathroom to provide ventilation as well as the crank mechanism on the window will be replaced. The mechanism has been ordered for the window but has not been received as of this date.
Staff will be instructed to report to the Program Specialist when repairs are needed to the home.[Immediately, the CEO or designated management staff will develop policies and procedures for reporting and completing repairs to the home. All staff shall be trained on the policies and procedures. Documentation of all trainings shall be kept. (DPOC by RM, HSLS on 1/7/2021)] |
11/27/2020
| Implemented |
| 6400.113(a) | Individual #1, date of admission 4/20/2020, had initial fire safety training on 7/2/2020. Individual #2, date of admission 1/2/2020, had initial fire safety training on 7/2/2020. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | 6400.113(a) - Individuals will be instructed upon admission and annually on general fire safety.
Home Not Alone will develop a procedure to ensure that Fire Safety Training is completed initially and biannually to ensure that HNA is in compliance with this regulation at all times. Staff will be trained on the new procedure and it will be placed in the Fire Safety Book. The Program Specialist will review the procedure biannually for compliance.[At least quarterly for one year, the CEO or designee will audit all individuals' records to ensure that individuals receive fire safety training upon admission and annually thereafter. Documentation off all trainings and audits shall be kept. (DPOC by RM, HSLS on 1/7/2021)] |
11/13/2020
| Implemented |
| 6400.141(a) | Individual #1, date of admission 4/20/2020, had a physical examination completed on 7/16/2020. Individual #2, date of admission 1/2/2020, had a physical examination completed on 8/17/2020. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | 6400.141(a) the individual shall have a physical examination within 12 months prior to admission and annually thereafter
Individual #1 was admitted as respite on 4/20/2020. The individual had a physical examination on 1/28/2019. Staff attempted to schedule a physical for Individual #1; however, due to Covid-19 her physician was not accepting patients for office visits. When Allegheny County entered the Green Phase, an appointment was made for the first available appointment which was 7/16/2020.
ODP chapter 55 Pa code 6400 at-a-glance reopening guide states " For service locations in green phase counties, provider must resume the following activities that are suspended in red and yellow phase counties within 30 days of county designation as green:
1. Annual individual physical examinations and biennial staff physical examinations should be scheduled for the first available date."
Individual #2 had physicals completed on March 25, 2019 and 6/24/2019 completed at Community Health Clinic, Inc.. Individual #2 presented a copy of the MA 51 upon admission which we were advised during our licensing was not acceptable. Community Health Clinic was contacted and HNA received copies of both physicals as requested.
HNA will not accept the MA 51 for any future admissions.
The Program Specialist will be trained on acceptable documentation for admissions.[Immediately, the CEO or designated management staff will develop individual admission policies and procedures to ensure all requirements for admission of individuals is obtained. All staff responsible for admissions shall be trained on the new policy. Documentation of all trainings shall be kept. (DPOC by RM, HSLS on 1/7/2021)] |
11/13/2020
| Implemented |
| 6400.141(c)(3) | Individual #1's physical examination completed on 7/16/20, had "Tdap-see attached" handwritten on the form. There were no additional documents attached. | 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. | 6400.141(c)(3) The physical examination shall include immunizations for individuals 18 years of age or older as recommended.
Individual #1 physical examination completed on 7/16/2020 does NOT have Tdap handwritten on the physical form. Attached to the physical form is an immunization record printed from Allscripts the electronic medical records of Individual #1 Primary care Physician.
Staff will be retrained to review physical forms prior to leaving the physicians office to ensure that the form is filled out completely with no blank spaces and to clarify any information that the physician writes in the margin. Physicals will be reviewed by the Program Specialist within 7 days of receipt so any discrepancies can be corrected.[At least quarterly for one year, the CEO or designee will audit all individuals' records to ensure physical examinations are complete and accurate. Documentation of all audits and trainings shall be kept. (DPOC by RM, HSLS on 1/7/2021)] |
11/13/2020
| Implemented |
| 6400.141(c)(4) | Individual #2's physical examination completed on 8/17/2020, did not include a hearing screening. This section was left blank. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | 6400.141(c)(4) The physical examination shall include vision and hearing for individuals 18 years of age or older as recommended by the physician.
On 8/17/2020 individual #2 had a physical exam . The review of systems reflects both her vision and hearing are normal.
Staff will be trained on scheduling hearing and vision testing to stay within compliance of PA 55 Code , Chapter 6400.141(c)(4).[At least quarterly for one year, the CEO or designee will audit all individuals' records to ensure physical examinations are complete and accurate. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 1/7/2021)] |
11/13/2020
| Implemented |
| 6400.141(c)(6) | Individual #1, date of admission 4/20/2020, had a Tuberculin skin testing by Mantoux method with negative results read on 7/21/2020. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | 6400.141(c)(6) the physical examination shall include a Tuberculin skin test by Mantoux with negative results every 2 years for individuals 1 year of age or older, or if tuberculin skin test is positive, an initial chest x-ray with results noted.
Individual #1 was admitted as respite on 4/20/2020 under the Red Phase of the Covid 19 Pandemic. . Individual #1 was due for a Tuberculin skin test 6/4/2020 , the green phase began on 6/5/2020 . The earliest available appointment was scheduled on 7/19/2020.
TB testing will be completed every two years. All appointments will be documented on an appointment schedule for Individual #1 and will be reviewed by the Program Specialist quarterly to ensure all medical appointments and testing are in compliance.[At least quarterly for one year, the CEO or designee audit all individuals' records to ensure physical examinations are complete and accurate. Immediately, staff who complete medical appointments shall be trained on the required documentation. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 1/7/2021)] |
11/13/2020
| Implemented |
| 6400.141(c)(7) | Individual #1's physical examination completed on 7/16/2020 did not include a gynecological examination including a breast examination and a Pap test. Individual #2's physical examination completed on 8/17/2020 did not include a gynecological examination including a breast examination and a Pap test. [Repeat violation 5/31/19] | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | 6400.141(c)(7) The physical examination shall include a gynecological examination including a breast examination and a Pap test for women 18 years old or older , unless documented from a licensed physician.
Individual #1 is scheduled for a pelvic exam and a breast exam on November 16, 2020. Her physician stated she will attempt the exam but due to Individual #1 being wheelchair bound with contractures it may not be possible.
Staff contacted Individual #2s physician to schedule her gynecological exam, exam is scheduled for 1st available which is November 17, 2020. Due to Covid 19 the office is just beginning to get caught up.
Gynecological exams and breast examinations will be added to the medical appointments. Staff will be retrained on the frequency of gynecological and breast exams. Program Specialist will review documentation quarterly to ensure compliance with appointments.[Immediately, the CEO or designated management staff will develop a system to track all individual gynecological examinations to ensure they are completed annually or per doctor recommendation. At least quarterly for at least one year, the CEO or designee will audit all individuals' records to ensure gynecological examinations are completed per the required time frames. Immediately, the CEO or designated management staff will train all staff responsible for completing and scheduling medical appointments on the requirements of 6400.141c7. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 1/7/2021)] |
11/13/2020
| Implemented |
| 6400.141(c)(8) | Individual #1, date of birth 6/21/66, had a physical examination completed on 7/16/2020 that did not include a mammogram. Individual #2, date of birth 1/2/68, had a physical examination completed on 8/17/2020 that did not include a mammogram. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | 6400.141(c)(8) The physical examination shall include a mammogram for women at least every year for women 40 through 49 and at least every year for women 50 and older.
Individual #1 is scheduled for the first available mammogram in her health system in 2/2020. On 4/20/2020 she was admitted as respite, on 10/11/2020 she became a permanent resident. Individual #1 did not have any health insurance cards we are in the process of trying to obtain duplicate cards to expedite these screening outside of her health system.
Individual #2 was scheduled for a mammogram on 10/15/2020, which was the first available appointment. This appointment had to be rescheduled due to Covid-19 quarantine as her day program had a positive case. The mammogram was rescheduled for 12/7/2020.
Mammogram appointments will be added to the medical appointment schedules, all future mammograms will be completed on time as scheduled.
Staff will be retrained on medical appointments and Program Specialist will review medical appointments quarterly to ensure all appointments are in compliance.[At least quarterly for one year, the CEO or designee will audit all individuals' records to ensure physical examinations are complete and accurate. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 1/7/2021)] |
11/13/2020
| Implemented |
| 6400.151(a) | Direct Service Worker #1, date of hire 4/20/20, had a physical examination completed on 8/20/20. Program Specialist #2, date of hire 8/10/2020, had a physical examination completed on 9/8/2020. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | 6400.151(a) A staff person who comes into direct contact with the individual or prepares or serves food for more than 5 days in a 6 month period shall have a physical examination within 12 months prior to employment and every 2 years after.
DSW#1 was transferred to the residential home on 4/20/2020, Due to being in the RED phase she was unable to receive a physical examination. on 6/5/2020 when the county went green she was able to secure the first available appointment on 8/20/2020.
Program Specialist #2 date of hire was 8/10/2020,. On 6/5/2020 he was able to schedule the first available appointment on 9/8/2020. PS#2 was not in contact with residents or staff till 9/21/2020.
ODP chapter 55 Pa code 6400 at-a-glance reopening guide states " For service locations in green phase counties, provider must resume the following activities that are suspended in red and yellow phase counties 30 days of county designation as green:
1. Annual individual physical examinations and biennial staff physical examinations should be scheduled for the first available date."
Physical reminders are used in Generations Homecare Software. Staff are mailed and emailed reminders 30 days before expiration of physical so they can schedule their physical and stay in compliance.
Program Specialist will be responsible for ensuring that all physicals are completed and documented in Generations.[At least quarterly for one year, the CEO or designee will audit all staff records to ensure staff receive a physical examination prior to employment and every 2 years after. Documentation of all audits shall be kept. (DPOC by RM, HSLS on 1/7/2021)] |
11/13/2020
| Implemented |
| 6400.151(c)(2) | Program Specialist #2, date of hire 8/10/2020, had a Tuberculin skin testing by Mantoux method with negative results read on 9/10/2020. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | 6400.151(c)(2) The physical examination shall include a Tuberculin skin test by Mantoux with a negative result every 2 years .
Program Specialist #2 was hired on 8/10/2020. The physical examination and implantation of the tuberculin test was done on 9/8/2020 . Results were read as negative on 9/10/2020. The program specialist #2 did not have contact with any of the residential individual or the residential staff till 9/21/2020.
Program Specialists date of TB test will be entered into Generations Software and PS will receive a letter and an email 30 days prior to needing to update the TB test.
Operations Manager will be responsible for compliance with TB test.[At least quarterly for one year, the CEO or designee will audit all staff records to ensure staff receive a tuberculin skin test with negative results prior to employment and every 2 years after. Documentation of all audits shall be kept. (DPOC by RM, HSLS on 1/7/2021)] |
11/13/2020
| Implemented |
| 6400.181(a) | Individual #1, date of admission 4/20/2020, did not have an initial assessment. [Repeat violation 5/31/19] | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | 6400.181(a) Each individual shall have an initial assessment within I year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter.
Individual #1 was admitted on 4/20/2020 as respite and variances were granted monthly to continue respite services. An assessment was completed on 10/1/2020 and Individual #1 became a permanent resident on 10/11/2020.
Program specialist and operations manager will be retrained on requirements needed to transition individual from respite to permanent placement.[Immediately, the CEO or designated management staff will develop policies and procedures to include transition from respite care to admission for individuals who are to exceed 31 calendar days in a year in the residential home. The program specialist shall be trained on the new policies and procedures. Documentation of all trainings shall be kept. (DPOC by RM, HSLS on 1/7/2021)] |
11/13/2020
| Implemented |
| 6400.181(e)(1) | Individual #2's assessment completed on 2/1/2020 does not include the strengths and needs of the individual. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | 6400.181(e)(1) The assessment must include functional strengths, needs and preferences of the individual.
Individual #2: Assessment was revised to reflect functional strengths, needs and preferences.
The Program Specialist will be retrained on completing Annual Skill Assessments.
Operations Manager will review Assessment with PS prior to individual signing document.[At least quarterly for at least one year, the CEO or designee will audit all individuals' records to ensure Assessments are complete and accurate. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 1/7/2021)] |
11/13/2020
| Implemented |
| 6400.181(e)(10) | Individual #2's assessment completed on 2/1/2020 did not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | 6400.181(e)(1) The assessment must include lifetime medical history.
The assessment was corrected and the program specialist will be retrained on the correct completion of the assessment.
Operations Manager will review assessment prior to having individual sign document.[At least quarterly for at least one year, the CEO or designee will audit all individuals' records to ensure Assessments are complete and accurate. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 1/7/2021)] |
11/13/2020
| Implemented |
| 6400.212(b) | Individual #2's assessment was dated 2/1/2020; although, the date had a handwritten entry altering the number "8" to a number "2". This entry that changed the legibility of the date was not dated and signed by the person making the entry. | Entries in an individual's record shall be legible, dated and signed by the person making the entry.
| Entries in the individual's record will be legible, dated and signed by the person making the entry.
Program Specialist was working on annual assessment and was comparing it with the initial assessment. PS inadvertently wrote over the date on the assessment in error.
Program Specialist will be retrained on proper documentation and completing documents legibly.[Documentation of all trainings shall be kept. (DPOC by RM, HSLS on 1/7/2021)] |
11/13/2020
| Implemented |
| 6400.34(a) | Individual #1's, date of admission 4/20/2020, has not been informed and explained individual rights and the process to report a rights violation. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | 6400.34(a) The home shall inform and explain individual rights and the process to report the rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.
Individual #1 was admitted as respite on 4/20/2020. She previously was supported through Home and Community Hab/ Companion Services, W1726 . Lucinda's rights were discussed at her annual ISP meeting prior to her respite admission. On 10/1/2020 , the Program Specialist informed Lucinda of her rights and Lucinda marked the "Participates Individual Rights" February 20202 version document as acknowledgment.
The Program Specialist will be retrained on the "Participants individual Rights" 6400.32 February 2020 version.[At least quarterly for one year, the CEO or designee will audit all individuals' records to ensure individuals have been informed of their rights upon admission and annually thereafter. Documentation of all audits and trainings shall be kept. (DPOC by RM, HSLS on 1/7/2021)] |
11/13/2020
| Implemented |
| 6400.165(g) | Individual #2 is prescribed Tegretol, 200mg take one (1) tablet two times per day and Abilify, 5 mg 1 tablet every bedtime for Impulse Control Disorder. The review of medications prescribed to treat symptoms of a psychiatric illness, completed on 6/4/2020 and 9/3/2020 do not include the reason for prescribing the medications, the need to continue the medications and the necessary dosages. [Repeat violation 5/31/19; previously 6400.163(c)] | 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. | 6400.165(g) 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 include the reason for prescribing medication, the need to continue the medication and the necessary dose.
individual #2 was seen via the telephone for her psychiatric examinations on 6/02020 and 9/3/2020. No in person visits were being done during this time period. The staff documented , the review of medications with the physician as well as not medication change.
The staff will be trained on all necessary information that needs to be documented for psychiatric visits to comply with 55PA Code Chapter 6400.165(g) whether it is an in person visit or a tele-visit.[At least quarterly for one year, the CEO or designee will audit all individuals' records to ensure psychiatric medications reviews are complete and accurate. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 1/7/2021)] |
11/13/2020
| Implemented |
| 6400.181(f) | Individual #2's assessment completed on 2/1/2020 was not provided to the individual plan team members. [Repeat violation 5/31/19] | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | 6400.181(f) The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual planning meeting.
The assessment done on 2/1/2020 was individual #2's initial assessment , done post admission on 1/2/2020. The plan was sent via email to individual #2' SC and declined by the family.
The program specialist will be retrained to provide the proper documentation needed as proof of sending the assessments to the team.[Immediately, the CEO or designated management staff will train the program specialist on the requirement of 6400.181f. At least quarterly for one year, the CEO or designee will audit all correspondence documentation to ensure all individuals plan team members are provided the assessment timely. Documentation of all trainings and audits shall be kept. (DPOC by RM, HSLS on 1/7/2021)] |
11/13/2020
| Implemented |
| 6400.213(7) | Individual #1's record did not include an ISP or a signature page to the annual ISP meeting held on 8/19/2020. Individual #2's record did not include an invitation to the annual ISP meeting held on 5/5/20. | Each individual's record must include the following information: Individual plan documents as required by this chapter. | 6400.213(7) Each individual's record must include individual plan documents as required by this chapter.
Individual #1 has both the ISP and signature page from her annual ISP on 8/19/2020 located in her record.
Program Specialist will review the documentation on a quarterly basis .[Immediately, the CEO or designated management staff will train the program specialist on the requirement of 6400.213(7). At least quarterly for one year, the CEO or designee will audit all ISP documentation to ensure all individuals have received the ISP invitation and signature page or a written request for the documentation has been made. (DPOC by RM, HSLS on 1/7/2021)] |
11/13/2020
| Implemented |