Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00209285 Renewal 07/28/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace was inspected 2/03/2021, 7/20/2021, 1/13/2022, and 6/16/2022 but there is no documentation it was cleaned by a professional cleaning company.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. Maintenance staff will be re-certified to inspect and clean the furnace. The Certification will be kept on file. A form will be developed to document the date the Maintenance staff will clean furnaces and inspect the furnace. The furnace will be re-inspected and re-cleaned by October 1, 2022. 10/01/2022 Implemented
6400.113(c)Individual #1's fire safety training did not include content of the training. A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept.Descriptive content detailing what individuals are instructed on during monthly fire drills was developed and will be distributed to all homes as a resource for staff completing the drill and instructing consumers 09/05/2022 Implemented
6400.141(a)Individual #1 had a physical examination completed 3/10/2021 and then again 3/28/2022.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Annual physical exams will be scheduled no more than 15 days later than the previous year's annual physical 09/08/2022 Implemented
6400.144Individual #1's physical examination completed 3/28/2022 documented the individual's hearing to be abnormal and no further follow up has occurred since.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. Consumer wasseen on 8/18/22 by audiologist 09/08/2022 Implemented
6400.166(a)(11)Individual #1's July 2022 medication administration record did not include diagnosis or purpose for the following medications: Aspirin Low 81mg EC Tablet, Buspirone 10mg tablet, Doxycycl HYC 100mg tablet, Linzess 145mcg capsule, and Metformin 1000mg tablet.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 Specialists and Directors will review all Medication Administration Records to ensure that all medications prescribed have a diagnosis and reason for medication. Any found missing this information will be remediated by contacting the prescribing physician 10/01/2022 Implemented
6400.166(a)(13)Individual #1's July 2022 medication administration did not include name and initials of the person who administered Buspirone 10mg tablet on 7/02/2022 at 8:00pm.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.Staff will be retrained on documentation of omission of medication and reporting medication errors 09/12/2022 Implemented
6400.182(c)Individual #1's individual service plan, last updated 6/22/2022 states he is not considered a choking risk and may need reminders to slow down while eating, and then states he is considered a choking risk as he tends to eat very quickly. The individual service plan also states Individual #1 is hard of hearing and refuses to wear a hearing aid, thus, Daniel requires assistance from staff to evacuate the home in the event of a fire as he is unable to hear the fire alarm. It states he has strobe lights in his bedroom which go off when the fire alarm sound. Individual #1's assessment completed 3/09/22 states he is independent with evacuating. Staff testimony confirms the individual is independent when evacuating and can hear the smoke alarm, when sleeping, and without his hearing aids.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.Correction of ISP has been requested to alleviate contradictory statements 09/08/2022 Implemented
SIN-00153766 Renewal 04/16/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(1)Individual #1's assessment, dated 10/4/18, was completed by a house manager and a direct service worker. In addition, the program specialist did not sign Individual #1's assessment dated 10/4/18.The program specialist shall be responsible for the following: Coordinating and completing assessments. VP of ID Services will provide to Program Director's written requirement for the proper completion and review process for the assessment. Program Director's will retrain Program Specialists on ISP review date requirements. [Within 30 days of receipt of the plan of correction and upon hire, the Program director shall educate the program specialist(s) of the responsibilities of the position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. At least quarterly for 1 year, the CEO or designee shall audit a 10% sample of individuals' assessments to ensure completion as required by the program specialist. (DPOC by AES,HSLS on 5/3/19)] 05/17/2019 Implemented
6400.186(a)The program specialist did not completed an ISP review for Individual #1 that included the date of 11/29/18.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. This was corrected by providing via email to the Licensing lead on the day of notification during the exit interview. VP of ID Services will provide to Program Director's written requirement for the proper completion and review process for Monthly and Quarterly Review of the ISP. Program Director's will retrain Program Specialists on ISP review date requirements [Within 30 days of receipt of the plan of correction and upon hire, the Program director shall educate the program specialist(s) of the responsibilities of the position as per 6400.44(b)(1)-(19). Documentation of the training shall be kept. At least quarterly for 1 year, the CEO or designee shall audit a 10% sample of individuals' ISP reviews to ensure completion as required by the program specialist. (DPOC by AES,HSLS on 5/3/19)] 05/17/2019 Implemented
SIN-00091389 Renewal 03/02/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(1)The assessments for Individual #1, dated 7/7/15 and 1/21/16 were not completed by the program specialist. The program specialist shall be responsible for the following: Coordinating and completing assessments. A new annual assessment tool will be developed by 7/1/2016. As of 3/5/2016 only staff who meet the Program Specialist employment qualifications have been completing assessments. Program Managers will ensure assessments are completed in full and signed by staff who meet the Program Specialist employment qualifications. Individual #1 at 3614 Priscilla will have a new assessment completed by 7/15/2016. [At least quarterly for 1 year, CEO or designated or designated management staff person will review a 25% sample of assessments to ensure program specialists are completing individuals' assessments as required. (AS 5/23/16)] 05/02/2016 Implemented
6400.71The telephone number of the ambulance service was not posted on or near any of the telephones in the home.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. Program Managers and House Supervisors in Erie were retrained by Program Director on regulation 6400.71 on 04/04/2016 that telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center need to be on or by each telephone in the home with an outside line. On 03/04/2016 printed lists of each of the above mentioned emergency telephone numbers were posted by each telephone within the home of Individual #1 at 3614 Priscilla. Program Managers will check all waiver facilities with outside lines to ensure there are postings with a list of updated emergency numbers by each phone by 05/13/2016. [Immediately and at least quarterly, program managers or program specialist will check all telephones with an outside line in all community homes to ensure all required telephone numbers are on or by the telephones, missing required telephone numbers will immediately placed on or by telephones with an outside line. Documentation of all checks shall be kept. (AS 5/23/16)] 05/02/2016 Implemented
6400.112(c)The fire drill record for the fire drill held on 12/11/15 did not indicate if the fire alarm or smoke detector was operative.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. Program Managers and House Supervisors in Erie were retrained by Program Director on 04/04/2016 on completing fire drill forms and reviewing fire drill forms for completeness. The Compliance Officer will reveiw March and April 2016 fire drill records from Individual's #1 home at on Priscilla to verify proper procedures were followed and the forms were fully completed. A process to check fire drill records to ensure all necessary sections are complete will be developed by Program Directors by 6/1/2016.[Within 90 days of receipt of the plan of correction, all staff responsible for conducting and documenting fire drills will be trained by the program director or designated supervisory staff person to ensure fire drills are conducted and documented as required. At least quarterly for 1 year the compliance officer or designated supervisory staff person will review all fire drill records to ensure fire drill are conducted and documented as required. Documentation of reviews shall be kept. (AS 5/25/26)] 05/02/2016 Implemented
6400.186(a)An ISP reviews for Individual #1 were completed on 4/1/15 and then again on 8/3/15.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. Program Managers and House Supervisors in Erie were retrained on 04/04/2016 on ensuring ISPs are reviewed every 3 months. A written process to ensure ISPs are reviewed every 3 months will be developed by Program Directors by 06/30/2016. This process will be given to all staff for review. The Program Manager will ensure the House Supervisors 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. The Compliance Officer will reveiw Individual's #1 3 month ISP review to ensure they have been to be completed on time though June 2016. Program Managers will perform these checks every 3 months on an ongoing basis. [CEO and/or designated management will develop, implement and train program specialists on a tracking system to ensure all individuals' 3 month reviews are completed within the required timeframes. At least quarterly for 1 year, the compliance officer will review the tracking system and a 10% sample of individuals' 3 month reviews to ensure timely completion. Documentation of all reviews shall be kept. (AS 5/25/16)] 05/02/2016 Implemented
SIN-00060202 Renewal 03/05/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(6)Individual (#1) did not have a mirror in his room.(6) A mirror. Mirror will be installed. 03/24/2014 Implemented
6400.143(a)Individual (#2) had a dental appointment on 12-6-12 and the recommendation was made by the dentist to return in 6 months. The individual refused to attend the appointment scheduled in June 2013. The home did not attempt to train and educate the individual about the need for dental treatment.(a) 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. A desensitization plan has been developed and implemented. 03/24/2014 Implemented
SIN-00093070 Unannounced Monitoring 03/04/2016 Compliant - Finalized