Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00186767 Renewal 04/20/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(b)The agency completed self-assessment inspections on 12/09/20 and 03/26/21 and did not use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.1. On 4/22/2020¿s Team Meeting, CEO decided that agency will conduct self-inspection to all houses except Logan Ferry using Self-Inspection in Appendix in RCG. On 4/23/2021, CEO, CCO, Program Specialist, QA/CO, and Health/IDD Manager met to go over each section of the RCG and Self-Inspection. Team learned that they are more items added. However, we gladly have documentations from 2019 pertaining to individual rights. 2. Self-inspection using new tools were completed: a. On 4/30/2021 at Dorothy House and Greenfield House b. On 5/1/2021 at Green Tree House and Highland House c. On 5/2/2021 at Braun House, Delmont House, and Rubco House 3. On 5/3/2021, during team meeting, was the finalization of Self-Assessment Completion. CCO will submit the completed self-inspection on 5/7/2021 4. CCO will submit all the meeting signature sign-in sheets and meeting minutes on 5/7/2021. 05/07/2021 Implemented
SIN-00172622 Renewal 03/12/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(d)The online course in cardio-pulmonary resuscitation completed by Direct Service Worker #1 did not include first aid and an in-person training component. Direct Services Worker #1's first aid certification expired 10/26/2019. The online course in first aid and cardio-pulmonary resuscitation completed by Program Specialist #2 on 10/2/2018 did not include an in-person training component. The online course in first aid and cardio-pulmonary resuscitation completed by Direct Services Worker #3 on 7/15/2019 did not include an in-person training component.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.1. On 3/16/2020 and 3/20/20 Assessment Team conducted conference call meetings, discussing the list of violations emailed by Licensing Officer and the final violations listed in CLS. On 3/30/2020 CCO will send the meeting agenda and minutes of the meeting. 2. On 3/16/2020 team decided to send one of admin staff to be trained as certified as CPR/AED/First Aid trainer. QA/CO volunteered to be trained as certified trainer. 3. CCO contacted EMS Safety Services on 3/19/2020 to register Jennifer for March 28th -29th. However, the class was canceled due to Covid-19. 4. CCO contacted American Red Cross to register Jennifer for April 2nd-3rd¿s training. However, the class was also canceled. There was an offer for April 21st-22nd training. American Red Cross stated that the class might be canceled, but if it is canceled, we will be given the opportunity to reschedule in May or in June. Classes were adjusted to promote social distancing by reducing the number of learners per class and only allows one mannequin per one learner. CCO will send the confirmation of the registered course by April 17th. If it is canceled, CCO will send licensing the email notification from America Red Cross. 5. Due to this uncertainty, it is difficult to estimate when to start the in-person training for Direct Care Worker #1 and Program Specialist #2 all staff that needs in-person training. It would be safe for HR to schedule as early as early June. If Covid-19 is contained beforehand, HR could reschedule the training as soon as it is possible to earlier dates. Note: Direct Care Worker #3 has not been an employee since 3/3/2020 (before inspection). 6. QA/CO could start taking online courses to refresh her CPR/AED/First Aid knowledge before taking the in-person classes. The First Aid courses provided by Relias is recognized by American Red Cross and AHA and will be helpful during in-person training. On 3/30/2020 CCO will send the Relias teaching materials for First Aid Refresher course staff has been taking annually in addition to the CPR/AED/First Aid certificate 06/15/2020 Implemented
SIN-00153957 Renewal 04/23/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(e)Fire drills were held during sleeping hours on 8/22/18 and then again on 3/25/19.A fire drill shall be held during sleeping hours at least every 6 months. On 4/23/2019 during inspection, agency produced a fire drill record proofing that a complied fire drill was held on 12/27/2018. When Individual #1 (Individual #1¿s housemate) participated in fire drill. Individual #1 frequently refuses to participate. Although agency has provided frequent re-training to the Individual #1, notified team, and created and implemented a new ISP Goal on fire drill, during the inspection on 12/27/2018 Individual #1 refused to participate. Supporting documentations were shown and emailed on 4/23/2019 and 4/25/2019, and will be submitted by 5/3/2019.QA/CO will continue announcing monthly fire drill and fire drill during sleeping hours and remind House Supervisor one week before the scheduled fire drill. House Supervisor will email QA/CO the fire drill record and report if it is a fail or a success. If it fails, QA/CO will report to QA/QM Mentor/Safety Commissioner and CCO and investigate the cause, and accordingly arrange another fire drill to be conducted in the same month. If participant(s) refuse(s) to participate, participant will need to sign the refusal section on the fire drill record. House Supervisor will need to record all failed fire drills in the updated Fire Evacuation Record/System Check. Participant(s) will need to be re-trained that participating in fire drill is required and fire drill will be repeated until all participants pass the drill.Agency will continue providing re-training to participant who refuses to participate in fire drill. Agency will continue conducting repeat fire drill until all participants complete and pass all monthly fire drills and fire drills during sleeping hours. Agency will continue communicating participant¿s refusal to the team and/or during team meeting, and if agreed, creating and implementing an ISP goal for fire drill/safety awareness for the participant.On 4/24/19, CCO revised Fire Drill Section of the Residential Fire SafetyQA/CO will allow house supervisors to access outlook reminder notification for monthly fire drill and fire drill during sleeping hours As per Inspector¿s recommendation, CCO added information that fire drill during sleeping hours can be conducted anytime participant is asleep and not necessarily between 11:00 PM to 6:00 AM.On 4/24/2019 CCO revised Fire Evacuation Record/System Check. This will allow House Supervisors and QA/CO to record failed fire drills, House Supervisor will email the scanned copy of failed fire drills and place them in Fire Drill section of Supervisor¿s Binder.On 4/24/2019 CCO revised Fire Drill Record form, this will allow staff to request participant¿s signature when participant refuses to participate. As per Inspector¿s recommendation, agency will involve parents/guardian in resolving frequent refusal to participate in fire drills. CCO on 4/30/2019 emailed SC to discuss the possibility to involve mother (legal guardian) as part of the team.Violation 6400.112 (e) was discussed on 4/25/2019s Assessment Team Meeting. Outlook calendar, meeting agenda, meeting minutes will be sent on 5/3/2019Outlook reminder, email correspondence, updated policy and fire drill record will be submitted by 5/3/2019. [CEO or designee, shall ensure FIRE DRILLS are UNNOUNCED. STAFF PERSONS AND INDIVIDUALS PARTICIPATING IN THE FIRE DRILL CAN NOT BE MADE AWARE OF WHEN THE FIRE DRILLS WILL BE CONDUCTED. A FIRE DRILL DURING SLEEPING HOURS SHALL BE CONDUCTED BY SEPTEMBER 2019. INDIVIDUALS WILL NOT BE MADE TO SIGN REFUSALS OF FIRE DRILL STATEMENTS AS STATED ABOVE. WITH THE INPUT OF THE INDIVIDUALS' PLAN TEAM MEMBERS, INCLUDING THE INDIVIDUAL, A PLAN WILL BE DEVELOPED FOR INDIVIDUALS WHO DO NOT PARTICIPATE IN FIRE DRILLS AS REQUIRED. IN ADDITION, A DESIGNATED STAFF PERSON EDUCATED IN FIRE DRILL SHALL OBSERVE A FIRE DRILL AT THE HOMES WHERE FIRE DRILLS ARE NOT CONDUCTED AS REQUIRED TO ASSIST IN THE DEVELOPMENT OF PLANS, STAFFING RATIONS ETC, TO ENSURE THE HEALTH AND SAFETY OF THE INDIVIDUALS. (DPOC by AES,HSLS on 5/10/19)] 05/03/2019 Implemented
SIN-00134133 Renewal 05/02/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill record for the fire drill held 9/30/17 did not include the amount of time it took for evacuation.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. 1. On 5/4/2018 Staff #1 corrected the violation by putting the duration of evacuation instead of the time of when the evacuation was completed. The firedrill started at 11:20 PM and was completed at 11:22 PM. The Evacuation time has been corrected to 2 minutes. CCO submitted the corrected completed fire drill form on 5/4/2018. 2. On 5/3/2018 CCO revised fire drill form, adding instruction to put minutes and/or seconds for evacuation time, and sent the form to the inspector. On 5/4/2018, per Inspector's suggestion, CCO added sleep drill box in the form. CCO submitted the form on 5/4/2018 and will submit the final revised form on 5/10/218 3. On 5/7/2018 all house supervisors and staff are trained on how to fill out the fire drill form. CCO will submit the completed signature at the houses on 510/2018. If required, CCO will submit the completed signed form from all houses one week form on 5/23/18. 4. Agency put violation on 6400.112 (c ) on the agenda for 6/12/2018 Assessment Team meeting. The meeting agenda, minutes, and timesheet for 6/12/18 meeting will be submitted on 6/14/2018. The outlook reminder and agenda for the meeting on 6/12/2018 05/10/2018 Implemented
6400.186(a)The program specialist completed an ISP review for Individual #1 for the period of 5/1/17-7/31/17 on 8/23/17.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. 1. Former Program Specialist completed ISP review, without the knowledge that individuals' signatures will need to follow 15 day grace period. Current Program Specialist created checklist and posted the deadline of individual's signature in the outlook. The checklist and outlook reminder will be shared with CEO, CCO, and CO/QA. CCO will submit the checklist and outlook calendar reminder on 5/10/2018 2. On 5/7/2018 Program Specialist was assigned to attend ODP training on ISP Checklist. CCO will submit the Program Specialist ISP training certificate on 5/10/2018. 3. CCO revised the ISP Plans and Procedures on 5/7/2018. CEO, Program Specialist, QA/CO, Participant Coordinator signed and acknowledged plans and procedures. CCO will submit the revised and signed ISP Plans and Procedures on 5/10/2018. 4. Agency put violation on 6400.186 (a) on the agenda for 6/12/2018 Assessment Team meeting. The meeting agenda, minutes, and timesheet for 6/12/18 meeting will be submitted on 6/14/2018. The outlook reminder and agenda for the meeting on 6/12/2018 will be submitted by 5/10/2018. 05/10/2018 Implemented
SIN-00114303 Renewal 05/17/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(c)The psychiatric medication review completed for Individual #1 on 2/6/17 did not include the reason for prescribing the Olanzapine and Carbamazepine medications and the need to continue the medications. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Training Supervisor assigned all 6400 staff to a training on 6/7/2017 detailing the agency's protocol for medical appointments that includes the requirement that the psychiatric doctor must include a reason for medication on the appointment form and circle the yes for a continued need for the medication. The training will be completed by 6/14/2017 and a copy will be placed in the 6400 Inspection binder under POC. The completed appointment form will be returned to the Participant Coordinator after the appointment. The Participant Coordinator will review all sections of the form. If there is a section that is unmarked, the PC will contact the doctor, fax over the form, and follow-up with the doctor's office until the form is return. The PC will review the form. If the form is correct, the PC will upload the form into the agency software and place the form in the individual's binder. 06/16/2017 Implemented
6400.213(1)(i)The record of Individual #1 did not include color of eyes.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.Program Specialist corrected the facesheet and showed the inspectors while inspectors were on site. The Participant Coordinator will complete the facesheet for all new individuals in the residential program prior to their first service day. On the first service day, the Program Specialist will review the facesheet to ensure that the name, sex, admission date, birthdate, SS number, language, race, height, weight, hair/eye color, identifying marks, religious affiliation, and next of kin sections are filled in. If a section is blank, the Program Specialist will return it to the Participant Coordinator. The Participant Coordinator will fill in the missing section and print off a new form within 24 hours. [Immediately and at least semi-annually, the program specialist shall review all individual records to ensure all required personal information is included and there are not any required areas left blank and update as needed. (AS 6/13/17)] 06/16/2017 Implemented
SIN-00092321 Renewal 03/31/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(h)Direct Service Worker #1, date of hire 2/5/16, was not trained in first aid techniques before working with the Individuals. Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home, shall be trained before working with individuals in first aid techniques. Human Resources Supervisor updated the Applicant Checklist to include the words First Aid next to CPR card on 4/11/2016. The HR Supervisor will utilize the updated form for all new job applicants starting on 4/11/2015. The HR Supervisor will insure that the applicant is trained in First Aid and make a copy for the applicant¿s file. The HR Supervisor will monitor the checklist for completeness before releasing the employee to Scheduling. The DSW #1 was trained in First Aid on 4/13/2016. A copy of the training certificate and a copy of the updated Applicant Checklist has been filed at the office in a 2016 POC folder. [Prior to Program specialists and direct service workers working with the individual, the CEO will review the applicants checklist to ensure required trainings are completed including first aid techniques. Documentation of reviews shall be kept. (AS 5/26/16)] 04/13/2016 Implemented
6400.64(f)At 4:00 PM, three uncovered trash receptacles containing filled trash bags were outside in the driveway next to the home.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.The Participant Coordinator updated the monthly house checklist to include ¿trash can lids¿. All House Supervisors will utilize the updated monthly checklist as of 4/11/2016. The House Supervisor will complete the checklist every month and submit it to the Participant Coordinator. The Participant Coordinator will monitor the checklist for completeness and timeliness and file them. The Training Coordinator enrolled Greenfield staff in the on-line Relias training ¿Reporting Missing Trash Can Lids,¿ to be completed by 4/30/2016. The House Supervisor bought a new trash can with lid and removed the cans without lids on 4/4/2016. A copy of the picture of the trash can has been filed at the office in a 2016 POC folder.[At least quarterly, the VP of operations shall review the monthly home checklist for community homes to ensure completion and trash outside the homes shall be kept in closed receptacles. Within 1 month of receipt of the plan of correction all staff working in community homes shall be educated that trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. Documentation of trainings and reviews shall be kept. (AS 5/26/16)] 04/17/2016 Implemented
6400.66At 4:00 PM, the outside light on the porch at the entrance on the side of the home next to the driveway was not operable. There is not another source of light in this area.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The Participant Coordinator reviewed the monthly house checklist which does required House Supervisors to check off that all house lights are in working order. The checklist was updated to include other items, so all House Supervisors will utilize the updated monthly checklist as of 4/11/2016. The House Supervisor will continue to utilize the Monthly House Checklist to monitor and insure that the house has working lights. The House Supervisor will complete the checklist every month and submit it to the Participant Coordinator. The Participant Coordinator will monitor the checklist for completeness and timeliness and file them. The Training Coordinator enrolled Greenfield staff in the on-line Relias training ¿Reporting Non-Working Lights,¿ to be completed by 4/30/2016. The House Supervisor replaced the light bulb and sent a picture to office of the working light on 4/2/2016. A copy of the picture of the working light has been filed at the office in a 2016 POC folder.[Within one month of receipt of the plan of correction, the CEO shall develop, implement and train direct service workers working in community homes on a policy and procedure to follow when areas of the home are found to be inoperable or in disrepair. At least quarterly, the CEO shall review the monthly home checklist for community homes to ensure completion and that rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes are lighted to assure safety and to avoid accidents. Within 1 month of receipt of the plan of correction all staff working in community homes shall be educated that rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes are lighted to assure safety and to avoid accidents and the policies and procedures to follow if lights are found to be inoperable. Documentation of trainings and reviews shall be kept. (AS 5/26/16)] 04/30/2016 Implemented
6400.143(a)Individual #1 refused an annual dental appointment on 7/22/15 and an annual vision examination on 1/14/16. Continued attempts to train Individual #1 about the need for health care were not documented in Individual #1's record. If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. If an individual refuses routine medical treatment, the residential staff will contact the House Supervisor and Participant Coordinator and record the refusal on the Refusal Treatment form. The Participant Coordinator will enter the event and date into the appointment calendar and create a reoccurring event at least every three months to retrain the individual in the need for health care. The Participant Coordinator will contact the House Supervisor at least seven days before the retraining event and send a calendar reminder to complete the Retraining of Refusal Treatment form. House Supervisor will retrain individual and complete the Retraining of Refusal Treatment form. Participant Coordinator will monitor that forms are completed in a timely manner. The Training Coordinator enrolled all residential staff in the on-line Relias training ¿Medical Refusal Training,¿ to be completed by 4/30/2016. [Individual #1 had a vision examination on 3/15/16. Within 1 month of receipt of the plan of correction, the program specialist will develop and implement a plan to educate Individual #1 about the need for dental examinations. The program specialist will meet at least monthly with the Individual to provide required training and document the continued attempts. If Individual #1 continues to refuse scheduled medical appointments the program specialist will update Individual #1's assessment and inform plan team members so the team can make a decision on how to proceed with Individual #1's health care. Immediately, the program specialist will review all individual's records to ensure that all individual are attending routine medical and dental examination and treatment and will train the individuals about the need for health care and document as required. Documentation of record reviews shall be kept. (AS 5/26/16)] 04/30/2016 Implemented
6400.163(c)Psychiatric medication reviews completed for Individual #1 on 3/9/15, 5/18/15 and 8/6/15 do not include the need to continue the medications. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The Participant Coordinator will monitor that all psych med appointment summary forms have been completed and a copy returned to the office. The Participant Coordinator will check that the doctor has indicated on the form that the medication needs to continue. If the doctor did not indicate, the Participant Coordinator will contact the doctor¿s office, fax over the incomplete form, monitor for a return fax, contact again if necessary, and receive the completed form. The Participant Coordinator will send the form to the House Supervisor to be placed in the individual¿s book. The Training Coordinator enrolled all residential staff in the on-line Relias training ¿Medical Appointment Checklist,¿ to be completed by 4/30/2016. [Individual #1's psychiatric medication reviews dated 3/9/15, 5/18/15 and 8/6/15 were updated to include the need to continue on 4/14/16. At least quarterly for 1 year, the CEO will review a 25% sample of psychiatric medication reviews to ensure all required information is completed. Documentation of all monitoring and reviews shall be kept. (AS 5/26/15)] 04/30/2016 Implemented
SIN-00060521 Renewal 04/25/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)Powdered laundry detergent and powdered "Borax Detergent Booster" were mixed together in an unlabeled plastic container. The warning label on the Borox reads "if ingested, contact physician immediately."(c) Poisonous materials shall be stored in their original, labeled containers. 1. Program Specialist on 4/24/14 assigned House Supervisor to place the material in their original labeled containers. On 5/1/14 House Supervisor will take pictures of the corrected violation. 2. Compliance Office wrote a policy on procedure on storing poisonous materials. Program Specialist on 4/30/14 assigned staff to read and sign the policy and post laminated instruction. House Supervisor will take pictures of the posted instruction and scanned sign in sheet on 5/1/14. 3. Compliance Officer modified the monthly assessment checklist to include 6400.62(c). Program Specialist and House Supervisor will conduct monthly checking on 5/1/14. Director of Support Services will monitor the implementation of the assessment. 4. Agency put violation on 6400.62(c) on the agenda for 5/7/14 Assessment Team meeting. 05/08/2014 Implemented
SIN-00054828 Renewal 10/07/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment of the home, dated 5/13/13 and 5/14/13, did not assess the following section: Plan Review and Plan Revisions. (a) The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. The agency assigned Compliance Officer to create Assessment Team. Assessment Team will consist of House Inspector, Admission Officer, Director of Human Resources, Program Specialist, Training Managers, and Data Specialist, House Inspector, and House Supervisors. Compliance Officer will assign Assessment Team to conduct general assessment on the first week of March and September to measure and record compliance with Chapter 6400. Team is divided into four (40) sub teams. Team 1 will assess the General Requirements and Individual Rights. Team 2 will assess Staffing, Individual Health, and Staff Health. Team3 will assess Physical Site and Fire Safety. Team 4 will inspect Medication, Nutrition, Assessment, Development of Plan, Plan Content, Participation in Plan Development, Implementation of the Plan, Plan Review and Plan Revision, Copies of the Plan, Provider Services, and Individuals Records. On the first week of April and October, Sub Team will report to the Compliance Officer, submitting finding on non-compliance along with a corrective action plan to address the finding and will include target date. Compliance Officer will report to the CEO. CEO will assign Compliance Officer to monitor the correction progress. CEO, Compliance Officer, and Assessment Team will meet to identify and prevent recurrence of non-compliance. Agency submitted the Implementation Plan for the Assessment Team and completed Self-Assessment. 10/21/2013 Implemented
6400.21(a)Staff #2s criminal history check was completed, 6/10/13 which was not within 5 working days after the person¿s date of hire. Staff #1s date of hire was 5/31/13. Repeat Violation 7/13/12(a) An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. The hire date is the date the employee begins to give his/her paid services. Staff #2¿s first day of work was 6/22/2013. Staff #2¿s date of orientation was 5/31/2013. Agency paid the orientation hours when staff completed scheduled hours during the pay period. To prevent confusion on selecting employee¿s date of hire, agency modified the policy mandating free training prior to working in the field. Agency submitted TLHHC Employee Manual ¿ Policy and Procedures. Page 5: Criminal Background Check, Page 19, Orientation update, and modified checklist. [All Criminal History Checks will be completed with results received and approved before a staff person is hired. The Providers policies and procedures will be amended to include the aforementioned addition by 12/1/13. All current staff members Criminal History Record Checks will be reviewed to ensure that they contain no prohibitive offenses in accordance with the Older Adult Protective Services Act and Act 13 immediately. All administrative staff that plays a role in the hiring process will complete the Department of Aging Abuse and Criminal History Check Training by 12/15/13 which can be found at http://www.portal.state.pa.us/portal/server.pt/community/self_study_course/18031 . Documentation shall be kept. (CHG 11/6/13)] 10/21/2013 Implemented
6400.46(d)The Program Specialist #1 did not complete any hours of training relevant to human services annually. (d) Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. Agency will assign Employee Training Manager to monitor the annual 24 hour training requirement for each employee according to the training year January-December. Training manager will assign a minimum of two courses each month through the care2learn university web application for all current employees, and document the trainings on annual employee¿s training checklist. The document will be placed in employee¿s file. Training Manager will also monitor annual trainings such as fire safety, HIPAA, OSHA, Dysphasia, Reporting Incidents, and ISP Training. Agency submitted modified checklist , Training notification, and Employee Annual Training Chart. Every program specialist and direct service workers training year will be documented in their respective staff record. The training year for existing staff persons is not subject to change. Program Specialist #1 will complete an additional 24 hours of training for the current/upcoming training year. All staff training for the prior training year will be audited and if any are found to have received less than the required 24 hours of training, then the hours will be scheduled to be completed in the current/upcoming training year in addition to the already required 24 hours of training. A schedule of planned courses for the current/upcoming training year will be developed for all staff persons. The schedule of planned courses for the staff persons will identify the need to complete additional hours beyond the 24 hours if applicable. Documentation shall be kept. (CHG 11/6/13)] 10/21/2013 Implemented
6400.106The most recent furnace inspection was completed on 9/26/13. The previous furnace inspection was dated 6/8/12.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. Agency modified the Fire Safety Policy and procedure To ensure that furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company, agency modified the Fire Safety Policy and Procedures, mandating furnace inspection shall be conducted on the first week of June, and the appointment shall be made on the first week of May. Agency submitted the modified fire safety policy and procedures. 10/21/2013 Implemented
6400.112(e)The most recent fire drill during sleeping hours was dated 1/8/13.(e) A fire drill shall be held during sleeping hours at least every 6 months. Agency will assign Compliance Officer and Training Managers to modify the fire drill protocol to ensure that fire drill shall be held during sleeping hours at least every 6 months Protocol will involve Director of Support Services, Program Specialist, House Supervisors, and Training Manager. Agency will put fire drill in meeting agenda with Annual Assessment Team and Compliance Officer to prevent recurrence of non-compliance. Agency submitted the modified fire safety policy and procdures. [One fire drill held during sleeping hours will be conducted every month for the next three months and within every six months thereafter in all community homes. Fire drills not held during sleeping hours will occur monthly during months when a sleeping hours drill is not completed. All individuals will evacuate to an outside designated meeting place during every drill. Fire drills will not be announced. Alternate exit routes will be used during the fire drills every month and clearly documented on the log. The Director will monitor every community homes fire drill record every month to ensure compliance. All staff persons will receive training on the importance of practicing fire drills and the regulatory expectations regarding fire drills by 12/15/13. Documentation shall be kept. (CHG 11/6/13)] 10/21/2013 Implemented
6400.112(f)The fire drills conducted from October 2012 to September 2013 utilized the front door exit. There are two additional exits in the home.(f) Alternate exit routes shall be used during fire drills. Agency modified Fire Drill Form to include front door, back door, and other for exit options. Agency will assign Participant Training Manager to utilize alternative exit during the fire drill. The Training Manager will document the drills on his reports. Agency submitted the modified form. [One fire drill held during sleeping hours will be conducted every month for the next three months and within every six months thereafter in all community homes. Fire drills not held during sleeping hours will occur monthly during months when a sleeping hours drill is not completed. All individuals will evacuate to an outside designated meeting place during every drill. Fire drills will not be announced. Alternate exit routes will be used during the fire drills every month and clearly documented on the log. The Director will monitor every community homes fire drill record every month to ensure compliance. All staff persons will receive training on the importance of practicing fire drills and the regulatory expectations regarding fire drills by 12/15/13. Documentation shall be kept. (CHG 11/6/13)] 10/21/2013 Implemented
SIN-00264236 Renewal 03/19/2025 Compliant - Finalized
SIN-00241794 Renewal 03/27/2024 Compliant - Finalized
SIN-00222912 Renewal 04/11/2023 Compliant - Finalized
SIN-00078150 Renewal 04/09/2015 Compliant - Finalized