Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00257179 Renewal 12/03/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.50(a)Documentation of the number of hours completed was not maintained for Staff #1.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.Documentation for training for designated CEO for EIHAB Human Services Pennsylvania, was obtained for the 2024 training calendar year. 12/15/2024 Implemented
6400.52(b)(1)The training records provided for Staff #1 did not record the length of the trainings. A total of the hours of training for Staff #1 was requested and not received. The number of hours of training received by Staff #1 could not be determined.The following shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons.Documentation for training for designated CEO for EIHAB Human Services Pennsylvania, was obtained for the 2024 training calendar year, including the hours of training. . 12/30/2024 Implemented
SIN-00219543 Renewal 12/15/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Two toothbrushes belonging to Individual #1 were found lying directly on the bathroom counter without a cover to protect them for sanitary use. Additionally, the toothbrushes were not in an acceptable condition for use. Both toothbrushes had bristles that were extremely worn and splayed out in different directions.Clean and sanitary conditions shall be maintained in the home. Individual's toothbrushes were discarded and replaced the day of inspection. 01/13/2023 Implemented
6400.112(c)The fire drill record for the drill conducted on 3/04/2022 did not document the exit used. The fire drill record for the drill conducted on 10/20/2022 did not document that the fire alarm or smoke detector was operable.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. Agency Fire Safety Policies were updated to include: updates to the fire safety policy, update to the fire drill form, creation of a fire drill tracking log and updating fire safety binders for each residence. 01/04/2023 Implemented
6400.112(h)The fire drill records for drills conducted on 2/25/2022, 3/04/2022 and 6/16/2022 did not document whether the individuals evacuated to the designated meeting place. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Agency Fire Safety Policies were updated to include: updates to the fire safety policy, update to the fire drill form, creation of a fire drill tracking log, and updating fire safety binders for each residence. 01/04/2023 Implemented
6400.46(b)Staff #2 had annual fire safety training on 8/12/2021, then not again until 10/21/2022.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Agency's annual training calendar was updated to ensure all staff are adequately trained and within the annual requirement. 01/02/2023 Implemented
SIN-00204264 Unannounced Monitoring 04/20/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)First aid kit did not contain antiseptic. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Antiseptic had been used the evening prior to the inspection. Alcohol prep pad were purchased to replace the missing antiseptic on 4.21.22 04/20/2022 Implemented
6400.214(a)There was no Assessment in the home for Individual #3.Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home.Due to previous issues with late assessments or missing items from individuals' assessments, all agency individuals will have new skill assessments completed no later than 7.15.22. Individual's binders for record keeping are also being updated to ensure documents are easily located. 07/15/2022 Implemented
6400.165(g)There was no documentation in the home completed by a licensed physician indicating that the medications were reviewed by a licensed physician.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.Agency medical coordinator continues to work with receptionist and nurse at the psychiatrist office to obtain signed copies of medication reviews. Individual has transitioned to in person appointments so that documentation may be obtained at the time of the appointment. 05/25/2022 Implemented
6400.167(a)(1)Individual #3 was not administered medications, Gabapentin 100mg, Erythromycin RYR, Poly Alcohol 1.4% or Fluoroethylene 0.1% on April 1 and April 3, 2022, at 12 Noon as there was no staff available at the home who was medication administration certified.Medication errors include the following: Failure to administer a medication.In the event that the staff working in the home are not medication certified, the medical coordinator or program specialist will create a medication administration schedule to ensure medications are administered as prescribed. 06/30/2022 Implemented
SIN-00199090 Renewal 12/27/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff #5 date of hire is 8/10/21 and their Pennsylvania criminal history record check was requested on 12/15/21. This exceeds the requirement.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. Staff #5 initial criminal history check was requested on 7/19/21 as indicated by attachment. 07/19/2021 Implemented
6400.77(b)The first aid kit did not contain scissors. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Scissors have been purchased an added to the first aid kit 12/29/21 02/28/2022 Implemented
6400.141(c)(11)Individual #4's physical exam dated 8/17/21 health maintenance section was not assessed as it was left blank on the form.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Agency nurse will receive all medical documentation and will review to ensure completion prior to filing in the individual's medical record. 02/28/2022 Implemented
6400.142(f)There is no record of a Dental Hygiene plan for Individual #4.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. Agency to update Dental visit form by 3.13.22 to include a section for Dental Hygiene plan to be approved by the individual's dentist at each visit. ( Individual's dentist will be contacted for dental hygiene plan -CH 3/18/22) 03/30/2022 Implemented
6400.144Individual #4's is medication Lorazepam 0.5 mg for anxiety to be given pro re nata (PRN). The pharmaceutical label does not include specific symptoms displayed by the individual in order for the medication to be administered. The agency has not provided proper pharmaceutical services.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. This medication has been discontinued 1/30/22 01/30/2022 Implemented
6400.181(e)(10)Lifetime Med History: Lifetime Medical History was not included in Individual #4's assessment dated 1/1/2021. (Repeat violation 1/22/21)The assessment must include the following information: A lifetime medical history. Agency nurse will complete the Lifetime Medical History in conjunction with the Program Specialist during the individual's annual assessment. 02/28/2022 Implemented
6400.34(a)Individual #4 was informed of his rights on 2/19/2021. The rights haven't been updated to reflect the current Chapter 6400 regulations. The missing rights include: make choices/accept risks, refusal of activities, control schedule, voice concerns, telecommunications, choice of roommate, furnish/decorate bedroom and common areas, lock bedroom door, entry mechanism to lock/unlock the front door, access to food, make health care decisions, and rights may only be modified in accordance with § 6400.185 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. (Repeat violation 1/22/21)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 rights will be updated to reflect current 6400 regulations. 02/28/2022 Implemented
6400.165(g)Individual #4 had 3-month reviews on 10/26/21, 9/28/21, and 8/17/21 that were conducted via tele visit and there was no documentation that they were completed by a licensed physician as they were not signed. (Repeat Violation 1/22/2021)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.Agency nurse will receive all medical documentation and will review to ensure completion prior to filing in the individual's medical record. 02/28/2022 Implemented
SIN-00193649 Unannounced Monitoring 09/24/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(11)The physical for Individual #1 completed on 8/17/21 did not assess health maintenance needs, and the need for blood work at recommended intervals.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Eihab¿s annual physical examination form has been returned to the PCP of individual #1 to be properly completed. 10/20/2021 Implemented
6400.141(c)(15)The physical for Individual #1 completed on 8/17/21 did not assess Individual #1's special instructions for the individual's diet.The physical examination shall include:Special instructions for the individual's diet. Eihab¿s annual physical examination form has been returned to the PCP of individual #1 to be properly completed. 10/20/2021 Implemented
SIN-00191679 Unannounced Monitoring 08/06/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(d)The annual assessment completed 1/01/2021 was not signed and dated by the program specialist who wrote the assessment.The program specialist shall sign and date the assessment. An assessment was completed in January for individual # 2. This document was completed but not signed. This document was updated by our current Program Specialist as of 7/3/21. 08/09/2021 Implemented
6400.166(a)(11)The Medication Administration Record (MAR) does not contain a diagnosis or purpose for prescribing for the following medications: Artificial Tears eye drops, Genteal Tears Severe eye gel, Polymyxin eye drops and Ketotifen Fumarate eye drops. ((Repeat Violation: 1/19/2021, 5/12/2021, 7/16/2021))A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Program Managers are monitoring Medication Administration Records daily with Medical Coordinators auditing weekly. Staff have undergone retraining to follow ODP Medication Administration protocols. Medical coordinators and Program Specialists have met with Pharmacy Administrators to review with them our regulatory needs related to the MAR. 08/26/2021 Implemented
SIN-00190669 Unannounced Monitoring 07/16/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144The medication Tylenol is listed on the current medication administration record (MAR) for Individual #1 to be administered on a pro re nata (PRN) basis for mild pain or fever, but the medication was not available in the home at the time of the 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. This medication was obtained on 7/19/21 and is onsite. 07/19/2021 Implemented
6400.166(a)(11)The medication administration record (MAR) for Individual #1 did not include a diagnosis or reason for prescribing the medications gabapentine and benztropine. (Repeat Violation: 1/19/2021, 5/12/2021)A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.The diagnosis information for these medications was added to the MAR, as of 7/19/21. Gabapentin is to be taken for mood disorder, and Benztropine is prescribed for mild Intellectual disability. 07/19/2021 Implemented
6400.207(4)(I)The medication Lorazepam 0.5mg is listed on the medication administration record (MAR) for Individual #1 to be given "1 tablet every 8 hours as needed for anxiety." The prescribing orders did not list symptoms or behaviors, or criteria for when the medication should be administered. Without specific guidelines or protocol for administration, the medication is considered a chemical restraint which is prohibited.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.The medication was added to the MAR as of 7/19/21, it is to be taken if for anxiety. 07/19/2021 Implemented
SIN-00186554 Unannounced Monitoring 03/22/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(a)The smoke detector in the attic was not operable at the time of this monitoring. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. The smoke detector in the attic was repaired on the day of the monitoring visit. 05/30/2021 Implemented
SIN-00181627 Renewal 01/19/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)Individual #11 received a $125.00 spending check from The Advocacy Alliance dated 11/3/2020, and there is no documentation on his November 2020 financial record of the check being cashed or deposited. There is no documentation on individual #11's December 2020 financial record of his monthly Advocacy Alliance check being cashed or deposited.Individual funds and property shall be used for the individual's benefit. Individual #11¿s financial records were reviewed and cross referenced with bank statements. The $125.00 check has been tracked to be issued to Individual #11¿s sister on (date) Management and Administration will receive additional training regarding how to allocate and accurately document monthly financial records. The Quality Assurance Director has developed an internal self-assessment tool to assist management and administration to conduct routine financial record reviews. The review will consist of daily to monthly monitoring ot ensure individual funds and property is used for the individuals benefit. Program Specialist will review for compliance on a monthly basis and the QA Department will review on a quarterly basis. The training and implementation for this procedure will be conducted by March 15,2021. 03/15/2021 Implemented
6400.22(e)(1)For individual #11 there was no documentation of an August 2020 financial record which would including the dates and amounts of deposits and withdrawals during the month. Individual #11 purchased an electric shaver from Walmart on 9/1/2020 for $21.17. This purchase was recorded on the financial record as a withdrawal of $20.00. The financial record is not accurate. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. Since the time of the survey, a financial record for Individual #11 has been completed for August 2020. Based on the purchases made for/by Individual #11, the deposits and withdrawals during the month was indicated. The electric shaver purchased on 9/1/2020 has also been corrected to indicate the exact purchase of $21.17 ledger completed. A skills assessment will be completed for Individual #11 to determine the amount of funds he is able to self-manage upon his return to the residence. The Quality Assurance Director has developed an internal self-assessment tool to assist management and administration to conduct routine financial record reviews. The review will consist of daily to monthly monitoring to ensure a separate record of financial resources, with dates and amounts of deposits ans withdrawals are complete and accurate. Program Specialist will review for compliance on a monthly basis and the QA Department will review on a quarterly basis. The training and implementation for this procedure will be conducted by March 15,2021. 03/15/2021 Implemented
6400.80(b)Facing the back of the home, the underneath of the overhang above the concrete walkway had approximately 4 shingles missing, and one was falling down. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.An exterior physical plant review was conducted. The area facing the back of the home, the underneath of the overhang above the concrete walkway has been repaired and the shingles have replaced and secured. The Quality Assurance Director has developed an internal self-assessment tool to assist management and administration to conduct routine physical plant reviews throughout the residence. The physical plant review will consist of all compliant areas involving safety, interior repairs and exterior repairs. Program Management will review this physical plant on a weekly basis, Maintenance Department and Program Specialist on a monthly basis and the QA Department on a quarterly basis. The training and implementation for this procedure will be conducted by March 15,2021. 03/15/2021 Implemented
6400.112(c)The 3/25/20 and the 11/17/20 fire drill did not record the time of day that the drill occurred.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. The Vice President has developed a Fire Drill Report Review Procedure which includes a Shared Fire Drill Annual Calendar amongst management and administration. On the shared calendar, drills will be scheduled to ensure various conditions with indicate alternate exits to be used. This shared calendar will be reviewed on a daily basis by the Program Specialist to ensure and verify that all scheduled drills have been completed. In addition, staff will upload the documented fire drill report for the Management and Program Specialist to review the drill report within 24-72 hours. Management and the Program Specialist will review the drill report to ensure that the scheduled drill was successful and documentation was complete and accurate; to include the completed and accurate 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. Training will be done with all Management and Administrative Staff on this procedure and implementation will be in effect by March 15, 2021. This procedure will be monitored on a daily basis by the Program Specialist for oversight and ensure that all drill reports completed as indicated. The Quality Assurance Department will be conducting quarterly reviews of all fire drills to ensure this procedure is followed and fire drills procedures are in compliance. 03/15/2021 Implemented
6400.141(c)(9)individual #11 did not have a prostate exam completed.The physical examination shall include: A prostate examination for men 40 years of age or older. Individual #11 has not been discharged and return to the CLA. The need for scheduled appointment has been relayed to his Supports Coordinator. Upon his return to the residence, a medical review will be conducted and all necessary follow up appointment will be made upon his return to the residence. The Vice President has developed an agency Medical Appointment Review Procedure which includes a shared Medical Appointment Monthly Calendar amongst management and administration. On the shared calendar, medical appointments will be entered upon scheduling. This shared calendar will be reviewed on a daily basis by the Management and the Program Specialist to ensure and verify that all scheduled appointments have occurred and any recommended follow up appointments are entered. In addition, the Medical Visit Report will be uploaded for the Management and Program Specialist to review within 24-72 hours to ensure all recommendations are followed. The Quality Assurance Director has developed an internal self-assessment tool to assist management and administration to conduct routine medical record reviews. The medical record reviews will consist of all medical and health requirements, including a prostate examination for men 40 years of age or older. Program Management will review this on a monthly basis and the QA Department on a quarterly basis. The training and implementation for this procedure will be conducted by March 15, 2021. 03/15/2021 Implemented
6400.142(a)Individual #11 had a dental exam on 10/17/19 and has not had one completed since. This exceeds the annual regulatory requirement.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. Individual #11 has not been discharged and return to the CLA. The need for scheduled appointment has been relayed to his Supports Coordinator. Upon his return to the residence, a medical review will be conducted and all necessary follow up appointment will be made upon his return to the residence. The Vice President has developed an agency Medical Appointment Review Procedure which includes a shared Medical Appointment Monthly Calendar amongst management and administration. On the shared calendar, medical appointments will be entered upon scheduling. This shared calendar will be reviewed on a daily basis by the Management and the Program Specialist to ensure and verify that all scheduled appointments have occurred and any recommended follow up appointments are entered. In addition, the Medical Visit Report will be uploaded for the Management and Program Specialist to review within 24-72 hours to ensure all recommendations are followed. The Quality Assurance Director has developed an internal self-assessment tool to assist management and administration to conduct routine medical record reviews. The medical record reviews will consist of all medical and health requirements, including dental examination performed by a licensed dentist annually Program Management will review this on a monthly basis and the QA Department on a quarterly basis. The training and implementation for this procedure will be conducted by March 15,2021 03/15/2021 Implemented
6400.144Individual #11's 9/27/19 and 3/16/2020 audiology appointments recommend ear cleaning with Primary Care Physician. There were no follow-up cleaning appointments completed. At Individual's #11's 11/19/20 audiology exam they were unable to complete the hearing test due to wax build up. During inspection Individual #11's Allevlyn Hydrocream and Gavilyte-G solution were not at the homeHealth 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. Individual #11 has not been discharged and return to the CLA. The need for scheduled appointment has been relayed to his Supports Coordinator. Upon his return to the residence, a medical review will be conducted and all necessary follow up appointment will be made upon his return to the residence. The Vice President has developed an agency Medical Appointment Review Procedure which includes a shared Medical Appointment Monthly Calendar amongst management and administration. On the shared calendar, medical appointments will be entered upon scheduling. This shared calendar will be reviewed on a daily basis by the Management and the Program Specialist to ensure and verify that all scheduled appointments have occurred and any recommended follow up appointments are entered. In addition, the Medical Visit Report will be uploaded for the Management and Program Specialist to review within 24-72 hours to ensure all recommendations are followed. The Quality Assurance Director has developed an internal self-assessment tool to assist management and administration to conduct routine medical record reviews. The medical record reviews will consist of all medical and health requirements and ensure that health services; such as audiology, medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided dental examination performed by a licensed dentist annually. This review will include ensuring that all prescribed medication is available and administered as order or accurately documented as discontinued. Program Management will review this on a monthly basis and the QA Department on a quarterly basis. The training and implementation for this procedure will be conducted by March 15,2021. 03/15/2021 Implemented
6400.181(e)(10)Lifetime Medical History was not included in Individual #11's assessment dated 5/1/2020.The assessment must include the following information: A lifetime medical history. Individual #11 assessment has been updated to include Lifetime Medical History. The Vice President has developed a procedure to monitor the timeliness of the required skills assessment. Assessments will be completed within 30 days of admissions and quarterly reviews thereafter. Program Specialist will be trained to review skills assessment on a quarterly basis and to complete the assessment during the quarter prior the annual review date. The Program Specialist will review that the assessments on file are completed to included but no limited to the Lifetime Medical History. There will be shared calendar to provide oversight to indicate when each individual¿s skills quarterly review and annual assessment will be completed. Training will be done with all Management and Administrative Staff on this procedure and implementation will be in effect by March 15, 2021. 03/15/2021 Implemented
6400.181(e)(13)(v)Progress & growth in this area was not evaluated as this section was left blank on Individual #11's assessment dated 5/1/2020.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. Individual #11 assessment has been updated to include Progress and Growth to note the progress of Individual #11's Socialization The Vice President has developed a procedure to monitor the timeliness of the required skills assessment. Assessments will be completed within 30 days of admissions and quarterly reviews thereafter. Program Specialist will be trained to review skills assessment on a quarterly basis and to complete the assessment during the quarter prior the annual review date. The Program Specialist will review that the assessments on file are completed to included but no limited to the individual's progress over the last 365 calendar days and current level in socialization. There will be shared calendar to provide oversight to indicate when each individual¿s skills quarterly review and annual assessment will be completed. Training will be done with all Management and Administrative Staff on this procedure and implementation will be in effect by March 15, 2021. 03/15/2021 Implemented
6400.181(e)(13)(ix)Progress & growth in this area was not evaluated as this section was left blank on Individual #11's assessment dated 5/1/2020.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.Individual #11 assessment has been updated to include Progress and Growth to note the progress of Individual #11's Community-Integration. The Vice President has developed a procedure to monitor the timeliness of the required skills assessment. Assessments will be completed within 30 days of admissions and quarterly reviews thereafter. Program Specialist will be trained to review skills assessment on a quarterly basis and to complete the assessment during the quarter prior the annual review date. The Program Specialist will review that the assessments on file are completed to included but no limited to the individual's progress over the last 365 calendar days and current level in socialization. There will be shared calendar to provide oversight to indicate when each individual¿s skills quarterly review and annual assessment will be completed. Training will be done with all Management and Administrative Staff on this procedure and implementation will be in effect by March 15, 2021. 03/15/2021 Implemented
6400.34(a)Individual #11 was informed of his rights on 1/8/2020. The rights haven't been updated to reflect the current Chapter 6400 regulations. The missing rights include: make choices/accept risks, refusal of activities, control schedule, voice concerns, telecommunications, choice of roommate, furnish/decorate bedroom and common areas, lock bedroom door, entry mechanism to lock/unlock the front door, access to food, make health care decisions, and rights may only be modified in accordance with § 6400.185 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others.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.The Rights policy and procedures were updated to reflect the current Chapter 6400 regulations; however Individual #11 was in the hospital when reviewing the revised chapter. The revised Rights Chapter will be reviewed with individual #11 upon his return to the residence. The Quality Assurance Director has developed an internal self-assessment tool to assist management and administration to conduct routine record reviews. The record review will include but not limited to ensuring that the home informed and explained individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission and annually. The training and implementation for this procedure will be conducted by March 15,2021. 03/15/2021 Implemented
6400.165(g)Individual #11 had a 3-month psychiatric medication review completed on 8/28/2019, and the next one was completed on 9/2/2020. No other psychiatric medication reviews were completed.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.Individual #11 has not been discharged and return to the CLA. The need for scheduled appointment has been relayed to his Supports Coordinator. Upon his return to the residence, a medical review will be conducted and all necessary follow up appointment will be made upon his return to the residence. The Vice President has developed an agency Medical Appointment Review Procedure which includes a shared Medical Appointment Monthly Calendar amongst management and administration. On the shared calendar, medical appointments will be entered upon scheduling. This shared calendar will be reviewed on a daily basis by the Management and the Program Specialist to ensure and verify that all scheduled appointments have occurred and any recommended follow up appointments are entered. In addition, the Medical Visit Report will be uploaded for the Management and Program Specialist to review within 24-72 hours to ensure all recommendations are followed. The Quality Assurance Director has developed an internal self-assessment tool to assist management and administration to conduct routine medical record reviews. The medical record reviews will consist of all medical and health requirements and ensuring a licensed physician review occurs at least every 3 months and the reason for prescribing the medication is documented with the need to continue the medication and the necessary dosage. A Psychiatric Medical Visit Report will be revised by February 28, 2021 to ensure all required indications by the license physician. Program Management will review this on a monthly basis and the QA Department on a quarterly basis. The training and implementation for this procedure will be conducted by March 15,2021. 03/15/2021 Implemented
6400.166(a)(11)Individual #11's Medication Administration Record (MAR) did not have the diagnosis or purpose for the medication Eliquis.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Since the time of the survey, Individual #11¿s Medication Administration Record has been reviewed and updated to include the purpose of al medications including Eliquis. As a result of pharmacy not meeting the agencies needs and causing potential medication errors, in January 2021, administration has changed pharmacies. Prior to licensing, the new pharmacy has been notified of MAR requirements to meet the agency¿s medication administration practices and ODP regulations. Staff will be retrained on the Accountability Log Procedure to include each shift reviewing the MAR in preparation to administer medication. Residence management will be conducting weekly reviews to ensure that all medications are transcribed correctly to include the diagnosis or purpose of the medication and pro re nata. The Medication Trainer will conduct monthly reviews in addition to the Quality Assurance Department conducting quarterly reviews. Staff will be retrained to review the five rights when administering medication. Staff, Management and Administration will be trained on the oversight and monitoring procedure by March 15, 2021 03/15/2021 Implemented
6400.167(a)(1)On 11/20/2020 Individual #12 was not administer his 8am dose of Divalproex, Omeprazole Dr, Probiotic, and Tasigna. On 12/3/2020 Individual #4 was not administered his 7am dose of Dilantin and 8am doses of Fluoxetine, Fluticasone, Calcium.Medication errors include the following: Failure to administer a medication.Since the time of survey, a medication error has been completed and during the preliminary review it was discovered that the medication was administered however not documented. All Medication Trained staff will be trained by February 22, 2021 on accurate Medication Administration Record documentation. Staff will be retrained on the Accountability Log Procedure to include each shift reviewing the MAR in preparation to administer medication and reporting documentation concerns. Residence management will be conducting weekly reviews to ensure that all medications documentation are complete; the Medication Trainer will conduct monthly reviews in addition to the Quality Assurance Department conducting quarterly reviews. Staff, Management and Administration will be trained on the oversight and monitoring procedure by March 15, 2021 03/15/2021 Implemented
6400.182(c)Individual #11's 5/1/2020 assessment states he requires line of sight and 1:1 staffing, but the Individuals ISP states he requires 24 hours supervision daily while in his home and in the community. He may be in another room of the house with supports checking on him every 15 minutes. Staff should always be in the line of sight when he is using the bathroom. Individual #11's assessment also states he is independent and capable of being alone in the tub or shower, and they have expressed wanting to bath himself with staff supervision. He demonstrated the ability to bathe himself with provided him a sense of autonomy, however the ISP states he needs physical assistance to bathe himself thoroughly.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.An updated skills assessment will be completed upon his return to the residence to ensure that Individual #11¿s current assessment coincides with the current plan. The Vice President has developed a procedure to monitor the accuracy of current assessment and that is coincides with plans on file and that assessments are revised annually and revised when an individual's needs change based upon the current plan. There will be shared calendar to provide oversight to indicate when each individual¿s skills quarterly review and annual assessment will be completed. Training will be done with all Management and Administrative Staff on this procedure and implementation will be in effect by March 15, 2021. 03/15/2021 Implemented
SIN-00184642 Unannounced Monitoring 01/11/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)Individual #1's Advocacy Alliance bank activity register documented that a check was made from his funds on 11/28/2020 to Hartzell's pharmacy for $43.24 for gloves. The gloves would be used by staff to assist with care and is the responsibility of the agency to provide. Individual #1 has 11 long sleeve shirts in his possession and his sister claims that he should have 15 long sleeve shirts in his personal possession. Individual #1 is also missing a walker.Individual funds and property shall be used for the individual's benefit. The agency has reimbursed Individual #1 for the $43.24 check from his bank account for gloves. At this time there are no individuals residing in the Lynwood CLA, however the agency will implement the following plan of action once the CLA admits individuals. By April 15, 2021, program management and designee¿s will receive training in the agency¿s Individual Funds Procedure as per the ODP Regulations. The Program Specialist will conduct monthly reviews of the individuals¿ personal funds to be sure that all procedures and guidelines are followed. In addition, the agency has developed a Personal/Clothing Inventory sheet that will be updated as needed and no more than every six months to be sure that the home has accurate inventory of personal belongings. Training and implementation will be completed by April 15, 2021. 04/15/2021 Implemented
6400.144On 6/9/2020, Individual #1 had an appointment with their Primary Care Physician for stage 2 pressure injury on the buttocks where it documents frequent offloading/repositioning every 2 hours. Individual #1's 6/19/2020 Wound management and Hyperbaric Center Care appointment document physician's order that he was to use a foam wedge when in his bed and wheelchair, and to reposition Individual #1 every 2 hours. The 6/19/2020 Wound management and Hyperbaric Center Care appointment discharge instructions for wound on left buttocks keep weight and pressure off would at all times. Turn every 2 hours. Avoid positioning direct pressure to wound site. Limit side lying to 30-degree tilt. Limit the head of the bead elevation to 30 degrees. Individual #1's hospital discharge from his hospitalization from 12/25-12/29/2020 instructions dated 12/29/2020 from St. Luke's University Bethlehem campus for sacral decubitus ulcer wound care was to turn/reposition every 2 hours for pressure redistribution of the skin. Staff did not receive training on wound care or repostitioning until 12/31/2020. individual #1 was not provided with proper medical care by repositioned according to physician instructions between 6/9/20 and 12/31/20.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. Individual #1 has not returned to the home. At this time there are no individuals residing in the Lynwood CLA, however the agency will implement the following plan of action once the CLA admits individuals. Since the time of the survey the Vice President has developed an agency Medical Appointment Review Procedure which includes a shared Medical Appointment Monthly Calendar amongst management and administration. On the shared calendar, medical appointments will be entered upon scheduling. This shared calendar will be reviewed daily by the Management and the Program Specialist to ensure and verify that all health services, such as medical, nursing, pharmaceutical, dental, dietary, and psychological services that are planned or prescribed for all individuals are arranged and provided. In addition, the Medical Visit Report will be immediately uploaded for the Management and/or designees to review and ensure all recommendations are followed. The Quality Assurance Director has developed an internal self-assessment tool to assist management and administration to conduct routine medical record reviews. The medical record reviews will consist of all medical and health requirements. Program Management and designee will review this on a monthly basis and the QA Department on a quarterly basis. The training and implementation for this procedure was completed by March 15,2021. 03/15/2021 Implemented
6400.181(e)(13)(i)Individual #1's assessment dated 5/1/2020 did not address the history and progress related to an ongoing ulcer on his buttocks. Individual #1 required surgical debridement of this ulcer on 1/3/21.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. Individual #1 has not returned to the home. At this time there are no individuals residing in the Lynwood CLA, however the agency will implement the following plan of action once the CLA admits individuals. Since the time of the survey, the Vice President has developed a procedure to monitor the completion and that it includes updated health information. Assessments will be completed within 30 days of admissions and quarterly reviews thereafter. Program Specialist will be trained to review skills assessment on a quarterly basis and to complete the assessment during the quarter prior the annual review date. The Program Specialist will review that the assessments on file are completed to include individual¿s progress over the 365 calendar days and the current level in health. There will be shared calendar to provide oversight to indicate when each individual¿s skills quarterly review and annual assessment will be completed. The training and implementation for this procedure was completed by March 15,2021. 03/15/2021 Implemented
6400.32(c)Individual #1 had a stage 2 ulcer on his sacrum which became unstageable with purulent drainage requiring him to undergo surgical debridement on 1/3/2021. Individual #1 had an appointment on 6/9/2020, Individual #1 had an appointment with their Primary Care Physician for stage 2 pressure injury on the buttocks where it documents frequent offloading/repositioning every 2 hours. On 6/19/2020, Wound management and Hyperbaric Center Care appointment discharge instructions for wound on left buttocks keep weight and pressure off would at all times. Turn every 2 hours. Following Individual #1's hospital discharge from his hospitalization from 12/25-12/29/2020 instructions dated 12/29/2020 from St. Luke's University Bethlehem campus for sacral decubitus ulcer wound care was to turn/reposition every 2 hours for pressure redistribution of the skin. Staff were unaware of any repositioning orders from physicians for individual #1 and received no training on reposition orders until 12/31/20. Individual #1 was neglected as staff did not reposition him in accordance with physician orders between 6/19/20 and 12/31/20.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.Individual #1 has not returned to the home. The agency has filed an allegation of neglect on behalf of Individual #1 in regards to Individual #1¿s wound in December 2020. A certified investigation has also been completed by the Quality Assurance Department and reviewed by the Incident/Administrative Review Committee. The recommendations as per the I/ARC meeting has been completed. Since the time of the survey the Vice President has developed an agency Medical Appointment Review Procedure which includes a shared Medical Appointment Monthly Calendar amongst management and administration. On the shared calendar, medical appointments will be entered upon scheduling. This shared calendar will be reviewed daily by the Management and the Program Specialist to ensure and verify that all health services that are planned or prescribed for all individuals are arranged and provided. In addition, the Medical Visit Report will be uploaded immediately for the Management and/or designees to review and to ensure all recommendations are followed. The Program Specialist will be trained on this procedure upon recruitment. The Quality Assurance Director has developed an internal self-assessment tool to assist management and administration to conduct routine medical record reviews. The medical record reviews will consist of all medical and health requirements. Program Management will receive refresher training on the classifications of abuse. 04/15/2021 Implemented
6400.52(c)(6)Staff working in the home with individual #1 did not receive training on the individual's needs. On 6/9/2020, Individual #1had an appointment with their Primary Care Physician for stage 2 pressure injury on the buttocks where it documents frequent offloading/repositioning every 2 hours. Individual #1's 6/19/2020 Wound management and Hyperbaric Center Care appointment document physician's order that he was to use a foam wedge when in his bed and wheelchair, and to reposition Individual #1 every 2 hours. Staff were unaware of any repositioning orders from physicians for individual #1. Staff were trained on 12/31/20 after Individual #1 was hospitalized due to stage 2 ulcer on the individual's sacrum that required surgical debridement.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Individual #1 has not returned to the home. At this time there are no individuals residing in the Lynwood CLA. As a result, there are no staff scheduled to work at this residence and scheduled trainings for individuals¿ plans are pending. The agency will implement the following plan of action once the CLA admits individuals. The Program Management or designee will ensure that all orders are implemented as prescribed and necessary staff training are conducted immediately and conduct shift trainings prior to working on shift to ensure all staff are providing health services planned or ordered by the doctor. The Medical Visit Report will be uploaded for the Management and/or designees to review within 24 hours to ensure all recommendations are followed. The Quality Assurance Director has developed an internal self-assessment tool to assist management and administration to conduct routine medical record reviews. The medical record reviews will consist of all medical and health requirements. Program Management and designee will review this monthly and the QA Department on a quarterly basis. The training and implementation for this procedure was completed by March 15,2021. 03/15/2021 Implemented
6400.165(c)Individual #1 is prescribed Remedy Phytoplex Hydragua to apply to sacrum and bilateral buttock twice daily as needed. Individual #1 had a had a stage 2 ulcer on his sacrum which became unstageable with purulent drainage requiring him to undergo surgical debridement on 1/3/2021. This medication was never documented as being administered on Individual #1's Medication Administration Record (MAR)from 11/6/2020-12/5/2020. The medication not administered to Individual #as prescribed.A prescription medication shall be administered as prescribed.Individual #1 has not returned to the home. At this time there are no individuals residing in the Lynwood CLA, however the agency will implement the following plan of action once the CLA admits individuals. Program Management and/or designee will conduct daily reviews of the Medication Administration Record to ensure that all medications are being administered correctly, the Medication Trainer will conduct this review monthly. The Medical Visit Report will be uploaded for the Program Management or designees to review within 24 hours to ensure all recommendations are followed. The Program Management will ensure that all orders are administered as prescribed. Program Management was trained on this review procedure by March 15, 2021. 03/15/2021 Implemented
SIN-00162273 Renewal 09/25/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(6)Individual #1 has no current TB test. His last TB test was on 07-14-17.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Individual #1 received his most current TB test on 10.26.19. Prior to this test, the individual¿s last TB test was 7.14.17. Ensuring all individuals complete a physical examination which includes: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year or older, the Program Specialist will conduct annual chart reviews to identify and ensure all individuals receive physical examinations including but not limited to TB testing. 10/26/2019 Implemented
6400.44(c)(2)Staff #1 does not meet the required qualifications for the Program Specialist position he holds. While he has a bachelor's degree, he does not have two years of experience working directly with the ID population.A program specialist shall have one of the following groups of qualifications: A bachelor's degree from an accredited college or university and 2 years of work experience working directly with individuals with an intellectual disability or autism.Staff #1 resume has been updated on 10.3.19 to reflect the relevant experience for the role as Program Specialist. Prior experience obtained at Montgomery County Youth Center and Easton Manor- Mathom House reflects 2+ years of experience working directly with individuals with an intellectual disability or autism. 10/03/2019 Implemented
6400.46(a)Staff #1 was hired on 08-05-19 and his initial fire safety training was 09-04-19. Staff #2 was hired on 05-13-19 and her initial fire safety training was 06-10-19.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.Staff #1 was hired on 8.5.19 and the initial fire safety training was 9.4.19. Staff #2 was hired on 5.13.19 and the initial fire safety training was 6.10.19. Program Specialist and Direct Service Workers will follow previously established agency training calendar. Staffs whom do not complete the annual fire safety training will be removed from the schedule pending completing of the assigned training. The Training Coordinator will track all trainings needed and schedule required trainings 30 days before expiration to ensure compliance and recertification occurs in the respective positions. Quality Assurance department will review all trainings semiannually to ensure compliance. 10/28/2019 Implemented
6400.46(b)Staff #3 last had annual fire safety training on 08-22-18 and none since.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Staff #3 received the annual fire safety training on 8.22.18 and none thereafter. To ascertain training occurs annually, Program Specialist and Direct Service Workers will follow previously established agency training calendar. Staffs whom do not complete the annual fire safety training will be removed from the schedule pending completing of the assigned training. The Training Coordinator will track all trainings needed and schedule required trainings 30 days before expiration to ensure compliance and recertification occurs in the respective positions. Quality Assurance department will review all trainings semiannually to ensure compliance. ((Staff #3 was trained in fire safety 10/28/19 -CH 11/14/2019)) 10/28/2019 Implemented
SIN-00139348 Renewal 08/14/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)Self-assessments are not being done for each home. 1 self-assessment is being used for all 7 homes on this license.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. To prevent this from happening in the future, a single self assessment will be used for each home 3 to 6 months prior to the expiration date of the COC, 9/2/2019. ((Staff responsible for completing self-assessments will be trained in the regulation and EIhab's procedures -CH 9/20/18)) 09/10/2018 Implemented
6400.111(f)The fire extinguishers in the basement and kitchen have not been inspected since 6/2017, which exceeds the annual requirement. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The contracted fire safety expert did not replace the fire extinguishers timely due to personnel issues; staff reading the tag did not understand how to read the tags to report expiration. Two fire extinguishers replaced on 8/16/18. To prevent this from happening in the future, Lynnwood staff will be retrained on how to read a fire extinguisher tag. 09/12/2018 Implemented
6400.112(c)The fire drill record dated 12/5/2017 did not list which exit route was utilized during the fire drill.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. To prevent this from happening in the future, Lynnwood staff will be retrained on how to correctly document a fire drill. 09/12/2018 Implemented
6400.168(d)Staff #2 had hid initial med training on 3/10/2017. He didn't complete his med practicum until 6/28/2018, which exceeds the annual requirement. Staff reported that he continued to pass medications during this time.A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. Practicum was completed by certified med trainer. Med trainer failed to place this staff's practicums in the staff's training binder at time of licensing. Documentation sent. To prevent this from happening in the future, a medication practicum data collection spreadsheet was created to easily create an alert to med trainer to complete practicums in a timely manner. 09/10/2018 Implemented
SIN-00185106 Unannounced Monitoring 03/23/2021 Compliant - Finalized
SIN-00124570 Renewal 11/14/2017 Compliant - Finalized