| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(b) | Staff member #1 who resided in New York State till 4/19 did not have an FBI criminal history check prior to employment in Pennsylvania. | If a prospective employee who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire. | Per policy all employees: hired after July 1, 1998 are required to have a Pennsylvania State Police Criminal Background Check (¿PSP check¿). Shared Values is required to maintain criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 § 10225.5102) and its regulations (6 Pa. Code Ch. 15). Criminal background checks are required to be completed within 12 months prior to the date of hire for all potential employees. PSP checks must be completed on the Pennsylvania State Police Request for Criminal Background Check form (SPF-164) or done through the Pennsylvania State Police¿s ¿E-Patch¿ online system. New Hires will not be allowed to begin orientation without a completed criminal history check. If the applicant has lived outside of Pennsylvania in the last two years, an FBI Clearance will be required in addition to the criminal background check. Upon review, Staff member #1 who resides in New York did not have a criminal history check in the file prior to employment. Staff member #1 has since put in resignation due to other employment opportunities in New York. Staff member #1 will remain eligible for rehire, however, the employee must submit FBI criminal history check information to HR prior to be re-instated. Moving forward, HR has been advised to ensure all employees are appropriately screen. The administrative assistant will keep all on-boarding documents on the internal provider monitoring tool created by the executive director. The HR coordinator and executive director will monitor the tool and completion of FBI checks on-going. 10/16/2020 |
10/16/2020
| Submitted |
| 6400.66 | There was insufficient lighting in the mudd room area where the laundry is kept. All light fixtures did not function when attempting to turn lighting. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| |
| Requested |
| 6400.68(b) | The water temperature in the shower of the main bathroom measured at 136.2 degrees Fahrenheit at the time of physical site review. Kitchen sink and water throughout home measured approximately 136 degrees. | 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 program directors have completed site visits to review for compliance and corrective actions. The homes were checked on 10/15/2020 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 check water temperature with close oversight from the community manager. 10/15/2020 |
10/15/2020
| Accepted |
| 6400.71 | Emergency Telephone numbers were not located nearby telephones at the time of review.. | 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 will ensure emergency phone numbers are present and posted by the phones per 6400.71. The emergency contact has been updated with the nearest hospital, police department, fire department, ambulance, and position control center. Shared Values will ensure this information is continuously review and updated. A new community manager has been secured for residential oversight. The community manager has revised the emergency phone numbers for all residential homes. The emergency contact numbers have been posted on-site. The information has been revised and approved by the program director. The community manager will be responsible for ongoing compliance with emergency phone numbers listed on-site. To ensure this is review the community manager will complete a provider self-assessment every six months. This will be submitted and reviewed by the program director. Completion Date 10/14/2020 |
10/14/2020
| Accepted |
| 6400.81(k)(6) | There was no mirror in individual #1's Bedroom. | In bedrooms, each individual shall have the following: A mirror. | Shared Values will ensure all homes have mirrors in the participants bedrooms. The program director has purchased a mirror for the participant¿s home on 10/15/2020. The mirror is a full body mirror that will be mounted on the closet door by maintenance upon approval of the team. Individual #1 has documented SIB. The team will meet on 10/22/2020 to discuss adding whether a mirror should be incorporated in the room. If the team agrees a mirror is not needed it will be included in the ISP and updated on site. If the team deems the mirror appropriate the mirror will be mounted same day by maintenance. In the event the mirror is broken. It will be discarded and replaced immediately. Community managers will be responsible for overseeing compliance in conjunction with maintenance. 10/22/2020 |
10/22/2020
| Accepted |
| 6400.112(b) | No staff are listed on fire drills for May2020 - June 2020 and therefore unable to determine if normal staffing conditions were present. | 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
| Accepted |
| 6400.112(d) | No evacuation times are listed on May 2020 and July 2020 fire drills. | 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. | 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 with evacuation times and meeting place included. 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(h) | Meeting place is not listed for May 2020 and June 2020 fire drills. | 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 with evacuation times and meeting place included. 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(a) | Individual #2's 12/6/19 annual physical exam on file is not complete, it does not include immunizations, TB test, physical limitations, allergies, or special diet. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #2 received a physical exam. Documentation kept on file. In review, the examination was missing immunization, TB test, physical limitation, allergies, and special diet. The behavioral specialist has scheduled medical appointments for all participants. Shared Values will create a physical exam form for the PCP to complete upon examination. The physical exam form will capture the requirements outlines in 6400.141 ensuring to obtain all information for the individual. The behavioral specialist will work in collaboration with the program specialist to ensure direct support professionals are utilizing the form when accompanying staff to appointments. The program director will be responsible for monitoring appointment compliance. |
11/02/2020
| Submitted |
| 6400.144 | Medication labeled on the medication administration record, Lorazepam .5mg take one tablet by mouth twice a day as needed was not located on site for individual #2.
Also for individual #2 , Blood Sugar was not being checked as noted on the medication administration record on the medication record at 8am, 12pm and 4pm on 9/1/20. | 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
The Behavioral Specialist has reviewed all medication onsite for individual #2. A review of medication was completed. Individual #2 lorazepam is a PRN and was found located in the home. The behavioral specialist has contacted the to request a script clarifying the medication as a PRN. Participant #2 is scheduled to see the PCP on 10/15/2020 at 1:40pm. Medication Administration: 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 nurse will retrain all employees on insulin and review blood sugar logs. Participant #2 blood sugar logs have been revised to ensure staff have instructions on when to call the Dr. if glucose levels are below 70 and above 350. 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 |
| 6400.151(b) | Staff member #2 did not have on file a current physical. Staff member #3 did not have a current physical exam on file. Staff member #4 who started May 13th did not have a physical on file. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Physical Exam/PPD 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, 2020 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. If the employee does not update their medical information or submit the physical documentation the employee will be removed from the 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. 10/30/2020 |
10/30/2020
| Submitted |
| 6400.181(d) | The Program specialist signature was not present on the annual assessment dated 7/22/20. | The program specialist shall sign and date the assessment. | An assessment was reviewed by the inspector. The program specialist submitted the annual assessment without signature. Moving forward shared values will ensure all employees sign every annual assessment at the date it is completed. In the event the assessment is not signed it will be rejected pending signature. The program director will be responsible for reviewing assessment signature. The assessments will be reviewed when completing January Jobs (internal annual compliance form) and when completing the 6400 self-assessment. The program director will also review and sign that the assessment has been review to date. 10/15/2020 |
10/15/2020
| Submitted |
| 6400.181(e)(4) | The need for the individual #2 supervision is inconsistent in the assessment dated 7/22/20. Under 'needs' on the first page of the assessment it is stated 'individual #2 should always be supervised in the community' and under 'Functional skills' on page 2 it states 'He can go to the Acme store by himself as he does not have to cross a street go get to it.' | The assessment must include the following information: The individual's need for supervision.
| Shared Values will ensure all annual assessments are completed as outline in 6400.181. Individual #1 supervision levels were not consistent in the assessment. Shared Values behavioral specialist has reviewed the document and has updated supervision levels to ensure consistency is parallel through the assessment. The behavioral and program specialist will collaborate to ensure all ongoing assessments are consistent as outlined in the ISP. The program director will be responsible for final review of all assessments. 10/14/2020 |
10/14/2020
| Submitted |
| 6400.165(c) | Medication was not administered as prescribed for individual #2 according to the medication administration record.
The following medications were not administered:
Losartan Pot 50mg tablet to be taken once daily at 8am, Citalopram 20mg to be taken once daily at 8am, folic acid 1mg tablet to be taken once daily at 8am, Levemir Flextouch 40 units, and Glipitide 5mg tablet 8am dose, all were not logged as administered on 9/1/20 and 9/6/20.
The medication administration for the listed dates were left blank. | 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 |
| 6400.207(4)(I) | Psychotropic medication Lorazepam .5mg to be taken twice a day as needed was listed on the Medication administration record without an physician order and a specific Plan for the individual #2. Without a specific plan by a physician it was unable to be determined if it was used as a chemical restraint. Last documented administration was noted in June 2020. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition. | 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 and 6400.207. 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. The target deadline for completion is November 2, 2020. The physician¿s order was retrieved and added on file. |
11/02/2020
| Submitted |