Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00251408 Renewal 09/13/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(7)Individual 1 had an annual gyn appointment on 5/18/23. The next annual gyn appointment was on 8/7/24. 1 year, 2 months, 30 days elapsed between the two appointments, which exceeds the annual requirement.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. Nurse will ensure that medical appointments including gyn appointments are monitored and scheduled as per their due dates. Managers including the nurse were retrained on 9/13/24, Attachment #3 09/13/2024 Implemented
6400.34(a)For individual 1 - there is a 2/1/24 signature page in the book with Civil rights information details. However, there is no 2024 Individual rights information page that indicates that the full individual rights were reviewed with the individual.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Individual Right was completed on 9/16/24, Attachment #1. Program Specialist was retrained on 9/18/24, Attachment #2 and managers were trained on 9/13/24, Attachment #3. 09/16/2024 Implemented
SIN-00230704 Renewal 09/12/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)This location was missing the August, October, November, and December 2022 fire drills documentation. An unannounced fire drill shall be held at least once a month. Director of Residential Services will ensure that monthly unannounced fire drills are conducted. Fire drills for September 2023, October 2023, November 2023, December 2023 and January 2024 are attached. (Attachment #1 through Attachment #5). Attachments #16 and #17 for in-service date of 12/7/23 on training. 12/07/2023 Implemented
6400.141(a)Individual #1's last year physical was 2/15/22, and this year's wasn't until 3/17/23, which is more than 1 year.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Nurse will ensure that medical appointments and annual physicals are monitored and scheduled as per their due dates Next annual physical is scheduled on 3/18/24. See attachment. #18. 12/07/2023 Implemented
6400.141(c)(4)Individual #1's physical recommended a hearing follow up from 3.17.23, but none has been completed. A Hearing Exam is scheduled for 10.12.23.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The nurse contacted the doctor on 9/14/23 as there was a discrepancy on the physical with respect to charting. Annual physical form indicates that hearing is intact. Further clarification and verbal order from doctor indicated that not further hearing evaluation is needed. See attachment #19. 09/14/2023 Implemented
SIN-00211059 Renewal 09/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Poisons were unlocked in the room of Individual 1 including several perfumes, lotions and personal care products.{Repeated Non-Compliance 9/15/2021}Poisonous materials shall be kept locked or made inaccessible to individuals. Poisonous substances, including several perfumes, lotions and personal care products were found in the bedroom of Individual 1 unlocked, accessible at the time of inspection. The community manager has been retrained in identification and secured storage of poisonous materials to ensure oversight of staff practices with hazardous chemicals in the residential homes 9/19/2022. A full site visit will be completed by the program director and the community manager on 10/15/2022 to ensure compliance has continued. Since the inspection, all hazardous supplies have been placed in a hygiene bin designated to Individual 1 and relocated to the supplies closet in the bathroom, equipped with a working lock. The supplies closet door will remain locked at all times when items are not being retrieved, with 24-hour supervision of the substances inside. The compliance director will ensure and maintain compliance moving forward. The compliance director will uphold compliance by completing site visits and completing the self-assessments of the homes with site inspection reports monthly 10/12/2022. The community manager will uphold compliance by completing site visits and completing the compliance checklists of the homes weekly 9/23/2022. 09/19/2022 Implemented
6400.67(a)There is a broken corner shelf in the kitchen right across from the bathroom where one section was snapped off and resting on the area below it. {Repeated Non-Compliance 9/15/2021}Floors, walls, ceilings and other surfaces shall be in good repair. Shared Values will ensure all homes are in good repair. Upon inspection there was a broken corner shelf in the kitchen right across from the bathroom where one section was snapped off and resting on the area below it. On October 27, 2022, Shared Values will be conducting a mandatory full staff meeting for all direct support staff. During this time, all employees will revisit the process on submitting work orders for residential repairs. The facilitators will keep a sign-in sheet of all attendees. Employees who miss the meeting will be required to attend a follow-up meeting with their direct supervisor. Maintenance has been tasked to complete a residential corrective action as a result of licensing inspection. All items needing repair must be completed by 10/16/2022. On 10/17/2022 the program director and community mangers will complete scheduled residential site visits to follow-up on the status of all aging repairs. The compliance director will uphold compliance by completing site visits and completing the self-assessments of the homes and site inspection reports monthly. 10/16/2020. 10/16/2022 Implemented
6400.68(b)The water temperature in the bathroom was 122.7. {Repeated Non-Compliance 9/15/2021} Hot water temperatures in bathtubs and showers may not exceed 120°F. Shared Values has put in a work order with maintenance to have the running water decrease to the appropriate temperature not to exceed 120 degree Fahrenheit. The community managers and compliance director(s) have completed site visits to review for compliance and corrective actions 9/13/2022. Maintenance lowered the water temperature to ensure it does not exceed 120 degrees Fahrenheit 9/12/2022. The homes were checked on 9/15/2022 to ensure there are adequate functioning thermometers to check the water temperature of the bathrooms and kitchens. Maintenance will be responsible to come and adjust the temperature at any time the water exceeds regulations. The community manager will also perform routine checks monthly upon residential house reviews. Direct support staff will continue to routinely monitor water temperature with close oversight from the community manager. 10/15/2022 09/12/2022 Implemented
6400.106There was no furnace inspection for this home over the past year.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. Shared Values was non-compliant in regulatory code 6400.106, there was no furnace inspection on file for the home over the past year. Shared Values residential properties are rented, not owned. The furnace inspections have been maintained by the property owners/landlords of the residential sites and newly transitioned administrative staff were unable to locate copies of completed inspections. All property managers for all residential homes were contacted 10/10/2022 in request of completed furnace inspections. Property Managers were given 10 days to produce documentation of completed furnace inspections. If a completed furnace inspection is not produced for any home by 10/20/2022, Shared Values will schedule and have completed all necessary inspections in all applicable residential programs. 10/20/2022 10/20/2022 Implemented
6400.113(a)Individual 1's fire safety was completed on 2/10/22. There was no previous training submitted to licensing. 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. Shared Values was not compliant with 6400.113 a. In efforts to ensure compliance, all staff will be trained on completion of annual fire safety with all individuals The mandatory training will take place on Thursday, October 27, 2022. The training will be virtual, facilitated by the Program Specialist and Director of Residential Services recently on-boarded. During this time, Admin will ensure staff are educated on the importance of completing fire safety annually, in entirety, on-time as scheduled. Admin will stress the importance of ensuring fire safety is thoroughly reviewed with individuals. Admin will also discuss requirements for completion of the fire safety training. All fire safety must be completed annually. The Community Managers will complete fire safety training with Individuals 1 and 2 on 10/15/2022. The Community Managers will review all client records to ensure compliance with Fire Safety and/or complete any trainings absent from the client's record 10/14/2022. All new hires will be trained during the on-site residential training on how to complete fire safety with individuals. All fire safety trainings will be collected by the community manager and submitted to the Program Director for review. Fire safety training documentation will be given to the administrative assistant for filling and documentation purposes. 10/15/2022 Implemented
6400.114(a)Individual 1 had an annual physical on 2/15/22 but no prior physical was provided to licensing.If an individual or staff person smokes at the home, there shall be written smoking safety procedures. Individual 1 received a physical exam 2/15/2022 and documentation was kept on file accordingly. In review, the prior year's physical was missing and documentation of it's completion could not be verified. The Program Specialist will review all scheduled medical appointments for all participants, and will schedule any overdue appointments or upcoming follow-up appointments as necessary 10/28/2022. Shared Values will retrain all staff on the physical exam form for the PCP to complete upon examination, as well as physical exam form filing requirements outlined in 6400.141 ensuring to keep the current and prior year's Annual Physical documentation on file 10/27/2022. The Director of Residential services will work in collaboration with the Program Specialist to ensure direct support professionals are transporting individuals to all medical appointments as scheduled, utilizing the Annual Physical or Medical Appointment Summary form when accompanying individuals to appointments, and turning completed medical appointment summaries in to the Community Manager to be filed appropriately. The program director will be responsible for monitoring appointment compliance. 10/27/2022 Implemented
6400.144The following medications prescribed to Individual 1 were not present on site: Acetaminophen 325mg: Take one tablet by mouth every 4 hours as needed (Crush tablets and put in applesauce). Individual 1 takes her medications crushed in applesauce. The following two medications were being crushed however did not have those directions documented on the medication administration record: Risperidone 4mg: Take one tablet by mouth ad bedtime at 8pm; Trazadone 100mg: Take 2 tablets by mouth at bedtime at 9pm. The following medication prescribed to Individual 2 was present in the medication box but not listed on her medication administration log: Neutrogena Lotion: Apply as advised. The following medications prescribed to Individual 2 were not present on site: Fluticasone Spray 50mcg: Use 2 sprays in each nostril daily as needed for allergies; Naproxen Sod 550mg Tab: Take 1 tablet by mouth evert 12 hours as needed for pain. {Repeated Non-Compliance 9/15/2021}Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. All employees of Shared Values that work in the 6400-residential program as a Direct Support Professional (DSP) are required to take and pass the Department of Human Services (DHS) Medication Administration Training program. Only staff that have been certified can administer prescription and non-prescription medications to the clients we support. Shared Values policy requires that employees who administer prescription and non-prescription medications to the clients we support review the Medication. The Community Manager has reviewed all medication onsite for individuals 1 and 2. A review of medication was completed 9/16/2022. Individual 1 PRN Acetaminophen 325mg was ordered and delivered by the affiliate pharmacy 9/14/2022. The Program Specialist has contacted the prescribing physician to request a script clarifying Individuals 1's Risperidone 4mg and Trazadone 100mg medication to be crushed in applesauce 10/5/2022. The Program Specialist will continue follow-up on this until new scripts are transcribed and sent to the pharmacy accordingly for update of the MAR, by a deadline on 10/15/2022. Individual 2's Medical Administration Record has been updated to include all prescribed medications 9/13/2022. The affiliate pharmacy will update the MAR for upcoming months 10/1/2022. Individual 2 PRN Fluticasone Spray 50mcg: Use 2 sprays in each nostril daily as needed for allergies; and Naproxen Sod 550mg Tab was ordered and delivered by the affiliate pharmacy 9/14/2022 Medication Administration: Direct Support Staff will review the Medication Administration Record (MAR) daily to make sure there are no errors. Medication labels should also be compared to the MAR during this period of review. All staff will be retrained on MAR Reviews during staff meeting scheduled 10/17/2022. Shared Values will ensure all participants receive medication as prescribed by a physician. In response to the licensing inspection, Shared Values has implemented an internal corrective action to the Community Manager whom provides managerial oversight to the residential program. Shared Values will contract with nurses to review MARs and medication administrations, and reconcile medication and/or MAR related discrepancies with the prescribing physician or pharmacy as needed 11/7/2022. All employees who administer medication must be certified with valid up to date training documentation in their file reviewed by the Office Manager. All PRN medication will be reviewed monthly against the medication list received upon the delivery of medication. All expired and unused medication must be removed from the site by the community manager each month with new medication deliveries. An additional community manager has been hired and onboarded for operational oversight 9/26/2022. The community managers will be required to review medication and MARS during each site visit. The community mangers are required to have a minimum of three site visits a week. The program specialist will be required to review medication at all homes at least once a week. The Director of Residential Services will be required to conduct random reviews of MARs at all homes. The Compliance Director has reviewed job descriptions and completed internal training with the community managers with medication oversight of all the residential homes 9/26/2022. The nurse will be responsible for reviewing the MARs, blood sugar logs and additional medical documentation. The nurse will retrain all employees on insulin and review blood sugar logs. Community Managers have instructions on when to call the pharmacy for refills if PRN medication supplies fall to 10 doses left. The program specialist visits the homes at least twice a week. The Director of Residential services has begun reviewing the MARs to ensure medication is being reviewed 9/28/2022. 10/17/2022 Implemented
6400.151(c)(3)Staff Member 1's 4/4/22 physical does not contain a statement clearing them of communicable disease; that section of the form is blank. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. During the time of inspection, Staff Member 1's 4/4/22 physical did not contain a statement clearing them of communicable disease. Shared Values requires that each applicant completes a physical examination within 12 months prior to the date of hire and every 2 years thereafter. PPD test must be completed before employment can start. These guidelines have been established by the Pennsylvania Department of Human Services (DHS) 6400 regulations and 6500 Regulations (55 PA Code). The physical examination must include a PPD test (tuberculosis skin test) and a statement indicating that the employee is free from communicable diseases prior to working at Shared Values and must be documented on the agency approved form. If a potential employee yields a positive tuberculin skin test, then an initial chest x-ray is needed with results being noted. No additional chest x-rays are needed following the initial report, unless requested by Shared Values. The Human Resources department has been tasked to ensure and review compliance for all employees. An internal corrective action date of October 30, 2022 has been given to the department. All employees out of compliance will have until this date to provide documentation of their physical and tb shot, including a statement clearing them of communicable disease. If the employee does not update their medical information or submit the physical documentation the employee will be removed from schedule. Moving forward the human resources department is not permitted to approve onboarding of any employee unless a medical clearance form has been completed stating the physical was completed with a tb shot. The form must also state the employee is free of communicable diseases. 10/30/2022 Staff Member 1 attained an addendum statement from her physician, clearing Staff 1 of communicable diseases. 9/19/2022. 09/19/2022 Implemented
6400.217Individuals 1 and 2's records did not contain consents for information to be shared. {Repeated Non-Compliance 9/15/2021}Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. It is the obligation of Shared Values to protect the private information of the individuals we support. Each individual, the individual's parent, guardian or advocate if appropriate, must consent to private health information being shared within the parameters of safe practice upon admission, and annually thereafter. There must be a signed and dated statement consenting to sharing private information kept in the client's record. Each individual must be encouraged to exercise his or her rights. Upon completion of inspection, Individual 1 and Individual 2 did not have an updated consent statement. Individuals 1 and 2 will be provided with an updated consent to share information statement 10/17/2022. The Community Managers will review all client records to ensure all are compliant with signed consents 10/17/2022. The program specialist will maintain and update tracking spreadsheets to ensure all forms have been reviewed and signed annually. The compliance director will maintain ongoing monitoring of all Individuals' annually signed consents and notices of rights on a monthly basis. 10/17/2022 Implemented
6400.18(i)Individual 1 has two incidents that have remained open with incomplete corrective plans long beyond their extended due dates: Incidents 8922057 and 8872340, both of which were due on 1/16/22.The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension.Upon inspection, Shared Values was non-compliant in areas of Incident Management, wherein incidents remained open in EIM beyond their extended due dates. Individual 1 has incidents entered by an administrator who has since separated from Shared Values, as has the direct support staff who would be able to recall any details or follow-up completed on the incidents. Shared Values will work with Jackie Grimes, Incident Manager of Montco Department of HHS to close all open and overdue incidents by 11/1/2022. 11/01/2022 Implemented
6400.31(b)Individual 1 and 2's records did not contain a copy of signed rights.The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights.It is the obligation of Shared Values to protect the rights of the individuals we support. Each individual, the individual's parent, guardian or advocate if appropriate, must be informed of the Individual's Rights upon admission, and annually thereafter. There must be a signed and dated statement acknowledging receipt of information on rights kept in the client's record. Each individual must be encouraged to exercise his or her rights. Upon completion of inspection, Individual 1 and Individual 2 did not have an updated rights statement. Individuals 1 and 2 will be provided with an updated individual right statement 10/15/2022. The Community Managers will review all client records to ensure compliance with maintaining an updated annual Individual Rights document that is signed accordingly 10/17/2022. The program specialist will maintain and update tracking spreadsheets to ensure all forms have been reviewed and signed annually. The compliance director will maintain ongoing monitoring of all Individuals' annually signed consents and notices of rights on a monthly basis. 10/17/2022 Implemented
6400.46(d)Staff Member 2 does not have current first aid/CPR training.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.During the time of inspection, Staff Member 2 did not have current first aid/CPR training Shared Values requires that each applicant in the position of program specialist, direct service worker, and drivers of and aides in vehicles shall be trained within 30 days after the day of initial employment and bi-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. These guidelines have been established by the Pennsylvania Department of Human Services (DHS) 6400 regulations and 6500 Regulations (55 PA Code). Staff member 2 completed first aid/CPR training 9/16/2022. The Human Resources department has been tasked to ensure and review compliance for all employees. An internal corrective action date of October 30, 2022 has been given to the department. All employees out of compliance will have until this date to provide documentation of their completed CPR/First Aid Training.. If the employee does not update CPR/First Aid Certification before expiration the employee will be removed from schedule until the training is effectively completed 10/30/2022 09/16/2022 Implemented
6400.163(h)The following medications prescribed to Individual 1 were present in the medication box but not listed on her medication administration log: Polyethylene Glycol 3350: Directions illegible; Diazepam 5mg: Take one tablet by mouth one and a half hours prior to procedure; Risperidone Oral Solution 1mg/mL: Take 4 mL by mouth at bedtime at 8pm. {Repeated Non-Compliance 9/15/2021}Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.All employees of Shared Values that work in the 6400-residential program as a Direct Support Professional (DSP) are required to take and pass the Department of Human Services (DHS) Medication Administration Training program. Only staff that have been certified can administer prescription and non-prescription medications to the clients we support. Shared Values policy requires that employees who administer prescription and non-prescription medications to the clients we support review the Medication. The Community Manager has reviewed all medication onsite for individuals 1 and 2. A review of medication was completed 9/16/2022. Individual 1's Medical Administration Record has been updated to include all prescribed medications 9/16/2022. The affiliate pharmacy will update the MAR for upcoming months 10/1/2022. The Compliance Director has reviewed job descriptions and completed internal training with the community managers with medication oversight of all the residential homes 9/26/2022. The Director of Residential services has begun reviewing the MARs to ensure medication is being reviewed 9/28/2022. 09/16/2022 Implemented
SIN-00197978 Unannounced Monitoring 12/10/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Laundry detergent and Fabuloso cleaner is unlocked in the bathroom/laundry area cabinet. Poisons were unlocked in the kitchen cabinet which contained (Clorox, Ajax. surface cleaners) and other poisonous material.Poisonous materials shall be kept locked or made inaccessible to individuals. Chemical storage checks are included in the community manager¿s weekly site walk through to ensure that all poisonous chemicals are secured to ensure resident health and safety. 01/19/2022 Implemented
6400.64(a)There is grease splatter on most of the kitchen cabinets, leaving a sticky residue. There was food left, presumably overnight, in the oven which needs to be cleaned.Clean and sanitary conditions shall be maintained in the home. All areas with grease stains were cleaned. In addition the community manager¿s site inspection checklist includes ensuring there¿s no grease splatter or residue on the stove, range and cabinets. 01/20/2022 Implemented
6400.67(a)A knob is missing on the kitchen cabinet, located under the sink.Floors, walls, ceilings and other surfaces shall be in good repair. See attachment #3. This citation could not be corrected to add a knob to the cabinet door under the sink due to the proximity of the cabinet door to the oven door. Oven door would not be able to open if a knob is installed. Shared Values maintenance however added a steel plate in place of the knob. 01/20/2022 Implemented
6400.70The only telephone in the home was inoperable at the time of inspection.A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons. Corrected on 12/23/21. See Attachment #4. (video). Shared Values replaced the defective phone with a properly working one. 12/23/2021 Implemented
6400.82(e)There is no non-slip mat in the bathroom tub. Bathtubs and showers shall have a nonslip surface or mat. Community manager will continue conducting weekly site walkthroughs and inform the associate director of any site related needs. 01/19/2022 Implemented
6400.84(b)In the bedroom of Individual #1 her clothing was on the floor throughout the room. It could not be determined what was clean or soiled.Clean laundry shall be stored in an area separate from soiled laundry.All Shared Values staff will continue to take the person-centered planning refresher courses each year so they are well trained on how to partner with the residents to provide meaningful care. 12/22/2021 Implemented
6400.144Cetirizine 10 mg PRN is listed on Individual #1 MAR but was not present at the time of inspection.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The community manager and or nurse will conduct an initial medication and MAR review to ensure all meds are accurate on the MAR and on-site. The community manager will conduct weekly medication checks to ensure medication accuracy. 12/22/2021 Implemented
6400.190(c)The agency failed to provide documentation of recreational and social activities, as individual #1 stated she doesn't get out much.Documentation of recreational and social activities shall be kept in the individual¿s record. Shared values will make the agency vehicles available to residents for outings. The community manager and program specialist will coordinate monthly outings for all residents and document outings on the activity chart. 12/22/2021 Implemented
6400.32(d)Individual #1 stated she is not treated like an adult but as a child, she spends all her time in her bedroom.An individual shall be treated with dignity and respect.Individual #1 chose to spend the majority of her time in her bedroom and came to the common area when she felt like it. 01/20/2022 Implemented
6400.46(a)Staff #2 Agency did not provide proof that Staff #2 was trained annually in Fire Safety. No Annual Fire Safety training was provided for Staff #5.Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.Corrected 1/20/22. See attachment #10 01/20/2022 Implemented
6400.46(b)Staff #3 did not sign the Fire Safety Training Form dated 11/03/2020.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).All agency staff training records are kept at Shared Values¿ corporate office. Completed 1/20/22. See attachment #11. 01/20/2022 Implemented
6400.163(a)Medication GAVILAX was located in the bathroom medicine cabinet, the label issued by the pharmacy was partially ripped off and this medication was not on the individual #2 MAR. The partial label identified the medication belonged to individual #2.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.Corrected 12/23/21. Medication was properly disposed of. 12/23/2021 Implemented
6400.163(d)There was no lock on med boxes that were located on living room floor for Individual #1. and Individual #2 medication box was unlocked and siting out in the dining area.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.Corrected on 1/19/22. See Attachment #14. Shared Values provided locks for both med boxes. 01/19/2022 Implemented
6400.163(h)Clonazepam 0.5 MG for Ind. #1is not listed on the MAR but is in the med boxPrescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Corrected on 1/18/22. See attachment #17. 01/18/2022 Implemented
6400.166(b)For Individual #1, there was no initials for 12/9/21 8 PM meds (Levetiraceta 500 MG & Risperidone 0.5 MG). There are no initials for 12/10 8 AM meds (Levothyroxin 88 MCG, Divalproex 500 MG, Metformin 500 MG) All medication given to Ind. #2 on 12/05/2021, 12/09/2021 and 12/10/2021 was not signed as administered on the MAR.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Corrected on 1/18/22. See attachment #17. 01/18/2022 Implemented
6400.169(a)Staff #1 was not trained in Medication Administration before administering medication to individuals. No varication was provided during review. Agency did not provide full Medication Administration course Training for Staff #3. (missing observation).A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).See attachment #18. The agency med certifier did not show for the 12/18 scheduled zoom meeting at 7am to conduct the medication practicum. Staff #1 decided to administer meds although she wasn't fully certified to do so. 01/24/2022 Implemented
SIN-00193962 Renewal 09/15/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66The light in the back of the home is inoperable.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Corrected on 10/31 See Attachment #: 1. Shared Values will ensure all external pathways are properly lighted to provide a safe walkway for the residents. 10/31/2021 Implemented
6400.77(a)There is no first aid kit in the home. A home shall have a first aid kit. Corrected on 9/17/21. See Attachment #: 2. Shared Values will ensure that all sites have first aid kits with all needed items. The community manager purchased a first aid kit for Garfield on 9/17/21. 09/17/2021 Implemented
6400.82(f)There was no trash can, paper towels or hand towels in the 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. Corrected on 9/22/21. See Attachment #: 3. At the time of inspections, the resident that lives that 759 Garfield was hospitalized and the house was vacant however Shared Values will ensure that each bathroom has the necessary items for the residents¿ comfort. 09/22/2021 Implemented
6400.110(a)There is no operable smoke detector in the home. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Shared Values will ensure that each site is properly equipped with a fire monitoring system that will alert resident and staff of a fire so they can safely exit the site. The smoke detectors were activated and tested on 9/17/21 and were in good working order. See Attachment #: 4. 09/17/2021 Implemented
6400.112(a)Monthly fire drills were not conducted in April or May 2021. An unannounced fire drill shall be held at least once a month. Corrected on 9/28 and 9/30/21. See Attachment #: 5. Fire drills were conducted in late September as a substitute to the missed fire drills from April and May. 09/28/2021 Implemented
6400.112(d)Several fire drills exceeded the allowable evacuation time of 2 1/2 minutes: 2/1/21- 4 minutes; 6/7/21- 5 minutes; 7/5/21-5 minutes; 7/30/21 - 4 minutes; 7/30/21 - 4 minutes; 8/2/21- -5 minutes and 8/18/21 - 5 minutes Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. Corrected on 10/7/21. See Attachment #: 6. In reviewing Shared Values fire drill practices with staff during a meeting held on 10/7/21, staff informed management that they were waiting to get to the meeting place before ending the drill. Management informed staff that the drill was over once the resident cleared the threshold and see sky. 10/07/2021 Implemented
6400.112(e)Thee was only one overnight drill provided for the past 12 months. This sleep drill was completed on 2/1/21.A fire drill shall be held during sleeping hours at least every 6 months. See Attachment #: 7. Shared values didn¿t have a community manager or program specialist during the period of January to April of 2021. The program director during the period didn¿t instruct staff to conduct overnight fire drills. 09/30/2021 Implemented
SIN-00176158 Renewal 09/14/2020 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)Individual #1 financial disbursement records for funds given to her for her own use were missing documentation 5/17/19 till 8/9/19 and further documentation was missing until 1/24/2020. Her weekly spending money was increased from $5 to $10 weekly but the only documentation of disbursement was on 3/16/20 and then on 8/17/20. It could not be determined that funds were used for the individual's benefit.Individual funds and property shall be used for the individual's benefit. Per Individual #1 ISP: [The participant is to receive $5 every two weeks to spend on things that she would like to purchase. Staff is to monitor her money and what she buys to ensure the purchased items are safe and healthy for the participant.] In the event Individual #1 did not receive the $5, Individual #1 would receive an additional $10 to off-set the funds not received. After review of the files, Individual #1 has inconsistencies in documentation with the client acknowledgment of funds forms kept on file. Individual #1 is currently out of our care. Upon return, Shared Values will ensure to insert notification in the participants financial binder explaining the financial gap in disbursement. Shared Values will also ensure to disburse $5 every other week as stated in the ISP to Individual #1. Distribution of funds will be monitored monthly by the Program Specialist and Program Director. Shared Values will ensure to keep an up-to-date financial and property record for every individual that includes disbursements made to and for the individual moving forward. Shared Values did not keep documentation on specifics purchased by the participant. The participant was at leisure to spend the funds as desired. A receipt was not requested from the Individual #1. Per regulations. 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. Moving forward, Shared Values will ensure to identify withdrawals when the individual is given money directly. The Client Acknowledgement of Funds Form has been revised to note funds have been disbursed directly to the individual for the participants benefit. 11/02/2020 Submitted
6400.22(d)(2)Documentation that funds disbursed to Individual #1 were not documented that these funds were used for the individuals benefit. Staff assistance in helping individual #1 make choices was not documented.(2) Disbursements made to or for the individual. Shared Values staff will ensure to provide all participants with the necessary assistance in helping to make personal choice when funds are distributed directly to the participant. The Client Acknowledgement of Funds Form has been revised to note funds have been disbursed directly to the individual for the participants benefit. The form has also been revised ensuring staff sign off on acknowledgment of financial assistance. Shared Values has added an additional review process of disbursement of funds. The program specialist and program director¿s signature are now required for review. The form must be submitted for review within 2 business days to management. Please see: Client Acknowledgement of Funds Form 11/02/2020 Submitted
6400.22(f)Shared Values LLC had a joint business checking account with individual #1 for the individual's funds.There may be no commingling of the individual's personal funds with the home or staff person's funds. Shared Values executive team reviewed financial governance in the beginning of 2020. In review, the client¿s funds were being deposited in a separated account specifically for the participant with the individuals name on it. Shared Values implemented an internal corrective action. The participant was taken to the bank (PNC) to open a personal account separated from Shared Values funds. This was completed on 02/19/2020. Shared Values is not permitted to gain access to the account while the participant is out of our care. Upon return, the account will be set up to add Shared Values as a rep payee on the account. Shared Values has completed a full review of the account containing the individual¿s funds. The remaining funds will be removed from the shared account and deposited in the new account for the participant. Moving forward, clients must open separate accounts with Shared Values added as the rep payee. 11/02/2020 Submitted
6400.64(a)The home presented with unsanitary conditions during the inspection on 9/14/2020. There was an odor present throughout the entire home. The surfaces of the counter tops, tables and dishwasher all had sticky residue present. The exhaust fan in the bathroom was covered in dust/dirt.Clean and sanitary conditions shall be maintained in the home. Shared Values will ensure all homes are clean and sanitary. During the time of inspection, the home contained an odor and needed internal cleaning. Staff on-site have been instructed to clean the home and maintain sanitary conditions. Additional cleaning supplies were purchased and left on-site. Trash was removed from the home and emptied by the direct support professional on-site. Shared Values has hired two community managers since the inspection. Both community managers will collaborate to ensure all homes are cleaned daily. A full staff meeting will be held on September 28, 2020 to review DSP expectations while on-site regarding cleaning and site cleanliness. The team meeting will be held by the program director and new community managers. The team meeting is expected to take place on Wednesday, October 28, 2020. During this time management will set the expectations of cleaning and checklist requirements. 10/28/2020 Submitted
6400.67(a)The toilet seat was cracked/broken causing potential for injury.Floors, walls, ceilings and other surfaces shall be in good repair. Shared Values shall ensure to keep residential property in good repair to avoid potential injury to any participants. Upon inspection, the toilet seat was cracked. Maintenance was called immediately to rectify the repair. The toilet seat was removed and discarded. A new toilet seat was purchased and installed by Maintenance. Staff have been reminded to report all needed repairs to their manager. Shared Value Shares has recently on-boarded two community managers. The community managers will be responsible for ensuring site cleanliness and compliance by utilizing the self-assessment. Completed on 9/16/2020 09/16/2020 Implemented
6400.71The list of emergency phone numbers was not present by telephone at time of inspection.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Shared Values shall ensure to keep residential property in good repair to avoid potential injury to any participants. Upon inspection, the toilet seat was cracked. Maintenance was called immediately to rectify the repair. The toilet seat was removed and discarded. A new toilet seat was purchased and installed by Maintenance. Staff have been reminded to report all needed repairs to their manager. Shared Value Shares has recently on-boarded two community managers. The community managers will be responsible for ensuring site cleanliness and compliance by utilizing the self-assessment. Completed on 10/14/2020 10/14/2020 Not Accepted
6400.76(a)The washing machine was missing the front lower panel and the detergent compartment was broken and exposed. Furniture and equipment shall be nonhazardous, clean and sturdy. Our washing machine was missing a front panel. In addition, the detergent compartment was broken and exposed. Since the inspection, the items have been repaired and are now nonhazardous clean and sturdy. The repairs were made by Shared Values maintenance. Shared Values has also on-boarded two community managers. The community managers will be responsible for ensuring ongoing cleanliness and residential site repairs are reported and repaired in a timely manner to avoid any injuries and maintain compliance. Our community managers will be training utilization of the provider self-assessment to check for regulatory issues. Staff will continue with protocol to contact a supervisor immediately in the event there is a residential repair needed. 10/05/2020 Submitted
6400.77(a)A first aid kit was not present in the home during inspection. A home shall have a first aid kit. Shared Values has re-purchased a first aid kit for all homes. The first aid kits contain the following antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, and scissors. New first aid kits were purchased for all homes on 3/24/2020. Upon inspection, the first aid kit was not in the home. A replacement first aid kit was purchased same day as inspection on 9/14/2020. The inspection kits were delivered on 9/15/2020 and taken to the home the same day. 09/15/2020 Submitted
6400.80(b)The backyard had debris which included a bucket filled with water that was attracting insects. There were landscaping pavers on side of home that presented as a tripping hazard. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.Shared Values will ensure all outside walkways are free from all hazards. Upon inspection, the backyard at the residence needed maintenance. All debris has been removed and discarded. The bucket containing water has been emptied and discarded. The landscaping paver on the side of the home will be removed. A new community manager has been onboarded and assigned to the home. We have also on-boarded a new Program Director. The community manager will be responsible for ongoing maintenance of the property with collaboration of maintenance. The community manager will be required to complete a full onsite walk through with the program director every other month in conjunction with their weekly visits. Moving forward Shared Values will ensure to keep the outside of all residential homes including yards well maintained and in good repair. The community manager and program director are conducting full site visits on 10/15/2020 to re-inspect the home. 10/15/2020 Implemented
6400.111(f)There were 2 fire extinguishers present in the home that did not have evidence of inspection and approval by a fire safety expert. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. Two fire extinguishers present in the home did not have evidence of inspection and approval by a fire safety expert. Our HR Coordinator has contacted the Emergency Response Team on October 8, 2020 to come out and re-inspect all fire extinguisher in our residential homes. The safety expert is scheduled to inspect and retag the fire extinguishers on Monday, October 26, 2020. There was no earlier appointment. Moving forward all fire extinguishers will be checked monthly by the community manager. The supervisor on-site will ensure meets all requirements as outlined in Chapter 6400.111 Fire Extinguishers. In efforts to ensure future and ongoing compliance the Fire Drill Report has been revised to review oversight of fire extinguishers on-site. If the inspection date is not located on the fire extinguisher employees are required to notify a supervisor and record the date of notification. The community managers are expected to review and train all employee on the correct protocol on conducting fire drills and ensuring compliance. This staff meeting is expected to take place on October 28, 2020. The Human Resources Coordinator will be responsible for scheduling annual renewal. 10/28/2020 Submitted
6400.112(b)There were No staff listed on fire drills from March 2020--April 2020 fire drills and therefore unable to determine if normal staffing conditions were present during the drill. Fire drills shall be held during normal staffing conditions and not when additional staff persons are present. In review of the plan of correction received, Shared Values was not compliance with 6400.112 b, d, and h. In efforts to ensure compliance, all staff will be trained on completion of fire drills. The mandatory training will take place on Wednesday, October 28, 2020. The training will be virtual, facilitated by the Program Director and two Community Mangers recently on-boarded. During this time management will ensure staff are educated on the importance of completing fire drills in entirety, on-time as scheduled. Management will stress the importance of ensuring staff are signing off on all fire drills completed. Management will also discuss requirements for completion of the fired drills. All fire drills must be completed under normal staffing conditions and must not exceed 2 ½ minutes. The community manager will also put emphasis on designated meeting places during the fire drill. All new hires will be trained during the on-site residential training on how to complete fire drills. All fire drills will be collected by the community manager and submitted to the Program Director for review. Fire drills will be given to the administrative assistance for filling and documentation purposes. 10/28/2020 Submitted
6400.112(d)Fire evacuation time exceeded 2.5 min from August 2019 - February 2020. The documented times include but are not limited to: August 2019 -- 9 minutes September 2019 -- 11 minutes October 2019 -- 8 minutes November -- 9 minutes No time evacuation times listed for March - July 2020 fire drills and therefore unable to determine the evacuation time.Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home.In review of the plan of correction received, Shared Values was not compliance with 6400.112 b, d, and h. In efforts to ensure compliance, all staff will be trained on completion of fire drills. The mandatory training will take place on Wednesday, October 28, 2020. The training will be virtual, facilitated by the Program Director and two Community Mangers recently on-boarded. During this time management will ensure staff are educated on the importance of completing fire drills in entirety, on-time as scheduled. Management will stress the importance of ensuring staff are signing off on all fire drills completed. Management will also discuss requirements for completion of the fired drills. All fire drills must be completed under normal staffing conditions and must not exceed 2 ½ minutes. The community manager will also put emphasis on designated meeting places during the fire drill. All new hires will be trained during the on-site residential training on how to complete fire drills. All fire drills will be collected by the community manager and submitted to the Program Director for review. Fire drills will be given to the administrative assistance for filling and documentation purposes. 10/28/2020 Not Accepted
6400.112(h)The designated meeting place not listed for July 2020 fire drill. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.In review of the plan of correction received, Shared Values was not compliance with 6400.112 b, d, and h. In efforts to ensure compliance, all staff will be trained on completion of fire drills. The mandatory training will take place on Wednesday, October 28, 2020. The training will be virtual, facilitated by the Program Director and two Community Mangers recently on-boarded. During this time management will ensure staff are educated on the importance of completing fire drills in entirety, on-time as scheduled. Management will stress the importance of ensuring staff are signing off on all fire drills completed. Management will also discuss requirements for completion of the fired drills. All fire drills must be completed under normal staffing conditions and must not exceed 2 ½ minutes. The community manager will also put emphasis on designated meeting places during the fire drill. All new hires will be trained during the on-site residential training on how to complete fire drills. All fire drills will be collected by the community manager and submitted to the Program Director for review. Fire drills will be given to the administrative assistance for filling and documentation purposes. 10/28/2020 Submitted
6400.141(c)(4)Individual #1 physical exam completed on 2/26/20 did not have a hearing screening, and recommended further evaluation, which was not completed.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Individual #1 received a physical exam on 2/26/2020. The individual did not have a hearing screening. The exam recommends further evaluation. Individual #1 is currently out of our care. Upon return, individual # 1 will have a hearing screening evaluation scheduling. Individual #1 will also receive further evaluation as outlined by the PCP during the physical exam. Shared Values contracted behavioral specialist has been working with the team to assist with case management until the Program Specialist is on-board. The acting program specialist will ensure medical appointments are scheduled and follow-up information has been completed. Upon return, the acting program specialist will schedule the following appointments (follow-up medical appointments, including hearing screening, recommended follow-up information, and a gynecological appointment and mammogram (completed annually). To ensure compliance, the executive director has created an appointment tracking for all clients. This tool has been implemented, to ensure each individual team has access to medical appointment dates and annual appointments are closely monitor. This tracking tool will be monitored by the program specialist, program director and executive director on-going. Expected completion date for scheduled appointments: 10/23/2020 10/23/2020 Submitted
6400.141(c)(7)Individual #1 last gynecological exam was completed on 2/6/19 and said to return in a year.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. Individual #1 received a physical exam on 2/26/2020. The individual did not have a hearing screening. The exam recommends further evaluation. Individual #1 is currently out of our care. Upon return, individual # 1 will have a hearing screening evaluation scheduling. Individual #1 will also receive further evaluation as outlined by the PCP during the physical exam. Shared Values contracted behavioral specialist has been working with the team to assist with case management until the Program Specialist is on-board. The acting program specialist will ensure medical appointments are scheduled and follow-up information has been completed. Upon return, the acting program specialist will schedule the following appointments (follow-up medical appointments, including hearing screening, recommended follow-up information, and a gynecological appointment and mammogram (completed annually). To ensure compliance, the executive director has created an appointment tracking for all clients. This tool has been implemented, to ensure each individual team has access to medical appointment dates and annual appointments are closely monitor. This tracking tool will be monitored by the program specialist, program director and executive director on-going. Expected completion date for scheduled appointments: 10/23/2020 10/23/2020 Not Accepted
6400.141(c)(8)Individual #1 last mammogram was 3/26/19 and did not have a repeated annually.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. Individual #1 received a physical exam on 2/26/2020. The individual did not have a hearing screening. The exam recommends further evaluation. Individual #1 is currently out of our care. Upon return, individual # 1 will have a hearing screening evaluation scheduling. Individual #1 will also receive further evaluation as outlined by the PCP during the physical exam. Shared Values contracted behavioral specialist has been working with the team to assist with case management until the Program Specialist is on-board. The acting program specialist will ensure medical appointments are scheduled and follow-up information has been completed. Upon return, the acting program specialist will schedule the following appointments (follow-up medical appointments, including hearing screening, recommended follow-up information, and a gynecological appointment and mammogram (completed annually). To ensure compliance, the executive director has created an appointment tracking for all clients. This tool has been implemented, to ensure each individual team has access to medical appointment dates and annual appointments are closely monitor. This tracking tool will be monitored by the program specialist, program director and executive director on-going. Expected completion date for scheduled appointments: 10/23/2020 10/23/2020 Not Accepted
6400.144Individual #1 is not receiving medication, Alendronate, as prescribed.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. All employees of Shared Values that work in the 6400-residential program as a Direct Support Professional (DSP) are required to take and pass the Department of Human Services (DHS) Medication Administration Training program. Only staff that have been certified can administer prescription and non-prescription medications to the client¿s we support. Shared Values policy requires that employees who administer prescription and non-prescription medications to the client¿s we support review the Medication Administration Record (MAR) daily to make sure there are no errors. Medication labels should also be compared to the MAR during this period of review. Shared Values will ensure all participants receive medication as prescribed by a physician. In response to the licensing inspection, Shared Values has implemented an internal corrective action. Due to the medication discrepancies and errors, all employees have been removed from administering medication until further notice. Shared Values has contracted with nurses to administer medication until all staff are retrained on medication administration and insulin training. All employee who administer medication must be certified with valid up to date training documentation in their file reviewed by human resources. Temp-agency employees are not permitted to administer medication. All PRN medication will be reviewed monthly against the medication list received upon the delivery of medication. All expired an unused medication must be removed from the site by the community manager each month with new medication deliveries. Staff are not permitted to initial the MAR¿s unless medication has been given. Two community managers have been secure for operational oversight. The community managers will be required to review medication and MARS during each site visit. The community mangers are required to have a minimum of three site visits a week. The program specialist will be required to review medication at all homes at least once a week. The program director will be required to conduct random reviews of MAR¿s at all homes. The program director has reviewed job descriptions and completed internal training with the community managers with medication oversight of all the residential homes. Shared Values has also secured a nurse that is not contracted. The nurse will be responsible for reviewing the MAR¿s, blood sugar logs and additional medical documentation. The behavioral specialist visits the homes at least twice a week. The behavioral specialist has begun reviewing the MAR¿s to ensure medication is being review. Upon notification of any medication errors will be inserted in EIM. All Shared Values DSP are expected to be trained by Friday, October 30, 2020. 10/30/2020 Submitted
6400.32(d)The Office of Developmental Programs requires that staff who provide direct services wear a mask that covers the nose and mouth during the entirety of service provision. The direct support professional at the home was not wearing a mask during the inspection on September 14, 2020. Failure to wear masks is undignified and disrespectful in that it creates a risk of transmitting the COVID-19 virus from staff to individuals.An individual shall be treated with dignity and respect.Shared Values has utilized resources from The Department of Human Services¿ (DHS) Office of Developmental Programs (ODP) and the Pennsylvania Department of Health (DOH) to ensure preparations for a response to a possible Coronavirus (COVID-19) outbreak in the State. It is the obligation of Shared Values to protect the rights of the client¿s we support. All employees are required to wear Personal Protective Equipment (PPE) until further notice. Mask are mandatory and must always be worn in the participants home to ensure the safety of our participants and employees. Employees who do not comply with these mandates will be subject to disciplinary actions up to including separation from employment with Shared Values. Our company has sent reminders to all employees twice since the licensing inspection. The employee reminders were sent on 9/30/2020 and 10/14/2020 by the Executive Director. The Humans resources department has been task to send out a acknowledgement form to all employees advising of the severity and requirements of wearing mask. The expected completion is 10/20/2020. 10/20/2020 Not Accepted
6400.34(a)Individual #1 last signed rights statement was on 1/11/19.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.It is the obligation of Shared Values to protect the rights of the client¿s we support. Each client, the client's parent, guardian or advocate if appropriate, must be informed of the ¿Individual's Rights¿ upon admission and annually thereafter. There must be a signed and dated statement acknowledging receipt of information on rights kept in the client's record. Each client must be encouraged to exercise his or her rights. Shared Values has revised its individual rights statement form. Upon completion of inspection, Individual #1 did not have an updated rights statement. Individual #1 is currently out of our care. Upon return, Individual #1 will be provided with an update individual right statement. Shared Values has implemented January Jobs. January Jobs is a consumer checklist completed in January ensuring all forms have been reviewed and signed annually. This form will be completed annually by the Program Specialist and reviewed by the Program Director. Please see attachment: JANUARY JOBS Consumer File Review 10/20/2020 Submitted
6400.162(b)(2)(iv)Staff members #1 and contracted employee are not certified in insulin injections.A prescription medication that is not self-administered shall be administered by one of the following: A person who has completed the medication administration course requirements as specified in § 6400.168 (relating to medication administration training) for the administration of the following: Insulin injections.All employees of Shared Values that work in the 6400-residential program as a Direct Support Professional (DSP) are required to take and pass the Department of Human Services (DHS) Medication Administration Training program. Only staff that have been certified can administer prescription and non-prescription medications to the client¿s we support. Shared Values policy requires that employees who administer prescription and non-prescription medications to the client¿s we support review the Medication Administration Record (MAR) daily to make sure there are no errors. Medication labels should also be compared to the MAR during this period of review. Shared Values will ensure all participants receive medication as prescribed by a physician. In response to the licensing inspection, Shared Values has implemented an internal corrective action. Due to the medication discrepancies and errors, all employees have been removed from administering medication until further notice. Shared Values has contracted with nurses to administer medication until all staff are retrained on medication administration and insulin training. All employee who administer medication must be certified with valid up to date training documentation in their file reviewed by human resources. Temp-agency employees are not permitted to administer medication. All PRN medication will be reviewed monthly against the medication list received upon the delivery of medication. All expired an unused medication must be removed from the site by the community manager each month with new medication deliveries. Staff are not permitted to initial the MAR¿s unless medication has been given. Two community managers have been secure for operational oversight. The community managers will be required to review medication and MARS during each site visit. The community mangers are required to have a minimum of three site visits a week. The program specialist will be required to review medication at all homes at least once a week. The program director will be required to conduct random reviews of MAR¿s at all homes. The program director has reviewed job descriptions and completed internal training with the community managers with medication oversight of all the residential homes. Shared Values has also secured a nurse that is not contracted. The nurse will be responsible for reviewing the MAR¿s, blood sugar logs and additional medical documentation. The behavioral specialist visits the homes at least twice a week. The behavioral specialist has begun reviewing the MAR¿s to ensure medication is being review. Upon notification of any medication errors will be inserted in EIM. All Shared Values DSP are expected to be trained by Friday, October 30, 2020. 10/30/2020 Submitted
6400.163(h)PRN medication, Pharbetol (acetaminophen) was expired and present at time of inspection for both individuals at residence.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.All employees of Shared Values that work in the 6400-residential program as a Direct Support Professional (DSP) are required to take and pass the Department of Human Services (DHS) Medication Administration Training program. Only staff that have been certified can administer prescription and non-prescription medications to the client¿s we support. Shared Values policy requires that employees who administer prescription and non-prescription medications to the client¿s we support review the Medication Administration Record (MAR) daily to make sure there are no errors. Medication labels should also be compared to the MAR during this period of review. Shared Values will ensure all participants receive medication as prescribed by a physician. In response to the licensing inspection, Shared Values has implemented an internal corrective action. Due to the medication discrepancies and errors, all employees have been removed from administering medication until further notice. Shared Values has contracted with nurses to administer medication until all staff are retrained on medication administration and insulin training. All employee who administer medication must be certified with valid up to date training documentation in their file reviewed by human resources. Temp-agency employees are not permitted to administer medication. All PRN medication will be reviewed monthly against the medication list received upon the delivery of medication. All expired an unused medication must be removed from the site by the community manager each month with new medication deliveries. Staff are not permitted to initial the MAR¿s unless medication has been given. Two community managers have been secure for operational oversight. The community managers will be required to review medication and MARS during each site visit. The community mangers are required to have a minimum of three site visits a week. The program specialist will be required to review medication at all homes at least once a week. The program director will be required to conduct random reviews of MAR¿s at all homes. The program director has reviewed job descriptions and completed internal training with the community managers with medication oversight of all the residential homes. Shared Values has also secured a nurse that is not contracted. The nurse will be responsible for reviewing the MAR¿s, blood sugar logs and additional medical documentation. The behavioral specialist visits the homes at least twice a week. The behavioral specialist has begun reviewing the MAR¿s to ensure medication is being review. Upon notification of any medication errors will be inserted in EIM. All Shared Values DSP are expected to be trained by Friday, October 30, 2020. 10/30/2020 Submitted
6400.165(c)Individual #1 did not receive her Alendronate as prescribed. August and September medications were still on site at time of inspection.A prescription medication shall be administered as prescribed.All employees of Shared Values that work in the 6400-residential program as a Direct Support Professional (DSP) are required to take and pass the Department of Human Services (DHS) Medication Administration Training program. Only staff that have been certified can administer prescription and non-prescription medications to the client¿s we support. Shared Values policy requires that employees who administer prescription and non-prescription medications to the client¿s we support review the Medication Administration Record (MAR) daily to make sure there are no errors. Medication labels should also be compared to the MAR during this period of review. Shared Values will ensure all participants receive medication as prescribed by a physician. In response to the licensing inspection, Shared Values has implemented an internal corrective action. Due to the medication discrepancies and errors, all employees have been removed from administering medication until further notice. Shared Values has contracted with nurses to administer medication until all staff are retrained on medication administration and insulin training. All employee who administer medication must be certified with valid up to date training documentation in their file reviewed by human resources. Temp-agency employees are not permitted to administer medication. All PRN medication will be reviewed monthly against the medication list received upon the delivery of medication. All expired an unused medication must be removed from the site by the community manager each month with new medication deliveries. Staff are not permitted to initial the MAR¿s unless medication has been given. Two community managers have been secure for operational oversight. The community managers will be required to review medication and MARS during each site visit. The community mangers are required to have a minimum of three site visits a week. The program specialist will be required to review medication at all homes at least once a week. The program director will be required to conduct random reviews of MAR¿s at all homes. The program director has reviewed job descriptions and completed internal training with the community managers with medication oversight of all the residential homes. Shared Values has also secured a nurse that is not contracted. The nurse will be responsible for reviewing the MAR¿s, blood sugar logs and additional medical documentation. The behavioral specialist visits the homes at least twice a week. The behavioral specialist has begun reviewing the MAR¿s to ensure medication is being review. Upon notification of any medication errors will be inserted in EIM. All Shared Values DSP are expected to be trained by Friday, October 30, 2020. 10/30/2020 Submitted
6400.165(f)Individual #1 is prescribed psychotropic medication Sertraline 10 mg 1 tablet at am, did not have a written protocol for social, emotional, and environmental needs.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.Shared Values Behavioral Specialist has transitioned to assist with the reviewal of Psychotropic medication. The program specialist will work in collaboration with the behavioral specialist and program director to ensure psychotropic medication is compliant with 6400.165. The reviewal of written protocol for social, emotional, and environmental needs will be included for review in January Jobs for consumer review and to ensure compliance. The behavioral specialist has been assigned to create written protocol for all clients receiving psychotropic meds. Once the documents are completed, the behavioral specialist will review it with the team. The behavioral specialist will also be responsible for reviewing the document with direct support staff. The target deadline for completion is November 2, 2020. 11/02/2020 Submitted
6400.165(g)Individual #1 Medication Sertraline 10mg 1 tablet at 8am, last medication review was completed on 1/8/2020, and should be reviewed every 3 months.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.Shared Values will ensure all participants receive their 90 days review as outlined in 6400.165. 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. Individual #1 is currently out of our care. Upon return, individual #1 one will be scheduled for a 90-day review. Our behavioral specialist has come onboard assisting with consumer related items. The behavioral specialist will be responsible for scheduling the appointment. The executive director has created a medical monitoring tool to track all medical appointments. This toll will be utilized by the community mangers, program specialist, behavioral specialist, and program director to monitor and review medical appointments and regulatory compliance. 11/6/2020 11/06/2020 Submitted
6400.166(b)Individual #1's MARs are not being completed correctly. There are initials on file indicating medications were given however medications are still on site and there are medications missing however no initials on MAR indicating they were given. This is evident for several medications.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.All employees of Shared Values that work in the 6400-residential program as a Direct Support Professional (DSP) are required to take and pass the Department of Human Services (DHS) Medication Administration Training program. Only staff that have been certified can administer prescription and non-prescription medications to the client¿s we support. Shared Values policy requires that employees who administer prescription and non-prescription medications to the client¿s we support review the Medication Administration Record (MAR) daily to make sure there are no errors. Medication labels should also be compared to the MAR during this period of review. Shared Values will ensure all participants receive medication as prescribed by a physician. In response to the licensing inspection, Shared Values has implemented an internal corrective action. Due to the medication discrepancies and errors, all employees have been removed from administering medication until further notice. Shared Values has contracted with nurses to administer medication until all staff are retrained on medication administration and insulin training. All employee who administer medication must be certified with valid up to date training documentation in their file reviewed by human resources. Temp-agency employees are not permitted to administer medication. All PRN medication will be reviewed monthly against the medication list received upon the delivery of medication. All expired an unused medication must be removed from the site by the community manager each month with new medication deliveries. Staff are not permitted to initial the MAR¿s unless medication has been given. Two community managers have been secure for operational oversight. The community managers will be required to review medication and MARS during each site visit. The community mangers are required to have a minimum of three site visits a week. The program specialist will be required to review medication at all homes at least once a week. The program director will be required to conduct random reviews of MAR¿s at all homes. The program director has reviewed job descriptions and completed internal training with the community managers with medication oversight of all the residential homes. Shared Values has also secured a nurse that is not contracted. The nurse will be responsible for reviewing the MAR¿s, blood sugar logs and additional medical documentation. The behavioral specialist visits the homes at least twice a week. The behavioral specialist has begun reviewing the MAR¿s to ensure medication is being review. Upon notification of any medication errors will be inserted in EIM. All Shared Values DSP are expected to be trained by Friday, October 30, 2020. 10/30/2020 Submitted