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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(a) | During the inspection conducted 9/15/2022, Individual #1's bedroom had two windows without screens and there were collapsible screens on the floor near the window. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Windows, including windows in doors, shall be securely screened when windows or doors are open.
All windows at 2059 Hobson have been made screens with ¿Make 2 Fit¿ Screen Frame Kit ~ Build your own custom Sized Screen that fits into the window, with the window in place. When the window is open the screen can be slid up or down on the current tracking. Or for 2059 the screen that was originally built to fit the window was located and placed in the window.
Windows, including windows in doors, shall be securely screened when windows or doors are open.
All but two windows at 304 Little Germany have been made screens with ¿Make 2 Fit¿ Screen Frame Kit ~ Build your own custom Sized Screen that fits into the window, with the window in place. When the window is open the screen can be slid up, down or side to side depending on the window, on the current tracking. |
10/04/2022
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | The written fire drill record for the drill conducted on 5/19/18 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. | The fire drills were fixed on site. On 06/22/2018 all house Supervisors were Trained on Conducting and documenting Fire drills. They will review staff documentation on the fire drill log monthly. Following the regulations. ¿ An unannounced fire drill shall be held at least once a month. ¿ Fire drills shall be held during normal staffing conditions and not when additional staff persons are present. ¿ 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. ¿ Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. ¿ A fire drill shall be held during sleeping hours at least every 6 months. ¿ Alternate exit routes shall be used during fire drills. ¿ Fire drills shall be held on different days of the week and at different times of the day and night. ¿ Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. ¿ A fire alarm or smoke detector shall be set off during each fire drill. ¿ Documenting the fire drill on the fire log must be legible. If you make an error put ONE line through the error that you can see the mistake. Do not scribble through the error. Make sure that you can read all the documentation. ¿ Include the date, time, amount of time it took for evacuation, the exit route, problems encountered and whether the fire alarms or smoke detector was operative. [Within 30 days of receipt of the plan of correction, all staff persons responsible for conducting and documenting fire drills shall be educated the requirements of fire drills as per 6400.112(a)-(I) and the aforementioned trainings. Documentation of trainings shall be kept. (AS 6/27/18)] |
06/22/2018
| Implemented |
| 6400.151(c)(3) | Direct Service Worker #1's physical examination, completed 2/6/18, did not include a signed statement that the staff person is free of communicable disease; this section was left blank. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | The physical on Linda Dillard from 2/6/2018 was fixed on site. Going forward the Human Resources Director and Assistant have a checklist for all physicals that includes that each employee physical has all requirements from the regulations. Staff physical examination.A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. (b) The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician¿s assistant. (c) The physical examination shall include: (1) A general physical examination. (2) Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician¿s assistant or certified nurse practitioner. (3) A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but can work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. (4) Information of medical problems which might interfere with the health of the individuals. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. [Immediately and upon completion a designated staff person trained in the requirements of staff persons physical examinations as per 6400.151(c)(1)-(4) shall review all staff persons physical examinations to ensure all required information is included. (AS 6/27/18)] |
06/22/2018
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment for the home was completed 4-10-16. The Certificate of Compliance has an expiration date of 6-9-16. | 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.
| Armstrong Care, Inc. will in-service all Program Specialists and all Supervisors on making sure a self-assessment of each home serving eight or fewer individuals is completed within 3 to 6 months prior to the expiration date of the Armstrong Care, Inc.`s certificate of compliance. This in-service was completed by July 29, 2016. Also, Armstrong Care, Inc. will remind all Program Specialists and Supervisors to begin completing the self-assessment from February 1st of each year and to be completed and turned in no later than February 28, of each year. This process will be monitored by the Program Specialist Manager and the Program Director in order to prevent similar deficiencies from reoccurring in the future. [Documentation of reviews shall be kept. (AS 9/20/16)]
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08/08/2016
| Implemented |
| 6400.81(i) | The bedroom for Individual #1 did not have drapes, curtains, shades, blinds or shutters. | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. | FOR INDIVIDUAL #1'S BEDROOM WINDOW A WAIVER WAS REQUESTED AND APPROVED FOR NO DRAPES CURTAINS, SHADES, BLINDS, OR SHUTTERS AND WAS APPROVED. IT STIPULATES THAT FROSTED CONTACT PAPER BE APPLIED TO THE WINDOW AND IT HAS BEEN APPLIED AS PER THE WAIVER. A COPY OF THE WAIVER WILL BE SENT TO LICENSING ALONG WITH A PICTURE OF THE WINDOW WITH THE FROSTED CONTACT PAPER ON IT.
BELOW IS A COPY OF THE PRINTED WAIVER:
DEPARTMENT OF HUMAN SERVICES
Mr. Edward Germy, MS, RN, President JUL 2 8 2016
Armstrong Care, Inc.
1400 Fourth Avenue
Ford City, Pennsylvania 16226
Dear Mr. Germy:
RE: Hobson Drive
2059 Hobson Drive
Ford City, Pennsylvania 16226
Thank you for your request for a waiver of 55 Pa. Code Ch. 6400 (relating to community homes for individuals with mental retardation). You have requested a waiver of 55 Pa. Code § 6400.81(i) (relating to individual bedrooms) for Mr. Bradley Kish, an individual living in the above listed home.
A waiver of 55 Pa. Code § 6400.81(i) (relating to individual bedrooms) is hereby granted under the authority of 1 Pa. Code § 35.17-18 (relating to petitions).
This waiver is granted under the following conditions:
1. This waiver applies to Armstrong Care, Inc., and is applicable only for the facility located at 2059 Hobson Drive, Ford City, Pennsylvania 16226.
2. This waiver is applicable only for Mr. Bradley Kish, an individual living in the above listed home.
3. Mr. Kish shall not have drapes, curtains, shades, blinds or shutters on the window(s) in his bedroom, due to agitation.
4. Armstrong Care, Inc. shall use frosted contact paper on the window(s) in Mr. Kish's bedroom.
5. Armstrong Care, Inc. shall note Mr. Kish's behaviors regarding window coverings in his bedroom, as well as this waiver in his assessment and Individual Support Plan (ISP) and update it as needed.
6. All other bedroom requirements pertaining to § 6400.81 shall be met.
7. If at any point in time Mr. Kish's needs change, Armstrong Care, Inc. shall immediately provide drapes, curtains, shades, blinds or shutters on the window(s) in Mr. Kish's bedroom.
Bureau of Human Services Licensing
825 Forster Street, Room 6311 Harrisburg, PA 171201 717.783.3670 IF 717.783.5662 1 www.dha.pa,gov
Mr. Edward Germy 2
This waiver is in effect for as long as the conditions under which the waiver is granted continue to be met. The Department will review this waiver each year. during its annual inspection to determine compliance with the preceding conditions. Failure to comply with the conditions of this waiver or with other requirements of 55 Pa. Code Chapter 6400 may result in termination of this waiver or other licensing action.
Sincerely,
Tara Pride
Director of Regulatory Implementation
cc: Tara Pride Larry Mazza Amy Scharpf MeganTurby Carol Semick
[Within 30 days of receipt of the plan of correction, the program manager will develop and implement procedures to ensure bedroom windows have drapes, curtains, shades, blinds, or shutter to include at least quarterly onsite monitoring and train staff working in community homes on the procedures. immediately and continuing at least quarterly, the safety manager or designated staff person shall complete an onsite inspection of all bedrooms in all community homes to ensure all bedroom window have drapes, curtains, shades, blinds or shutter. Documentation of aforementioned policies and procedures, trainings and onsite monitoring shall be kept. (AS 8/18/16)]
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08/08/2016
| Implemented |
| 6400.141(c)(3) | The physical examination dated 5-31-16 for Individual #1, date of birth 9/26/94 did not include immunizations. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | IMMUNIZATION RECORDS FOR INDIVIDUAL #1
SCANNED FIRST RECORD CAME WITH INDIVIDUAL #1 UPON ADMISSION TO ARMSTRONG CARE, INC. FROM SOUTHWOOD HOSPITAL, THE SECOND CONTAINS A TRANSFER OF THOSE RECORDS OVER TO THE ELECTRONIC RECORDS OF HIS PCP AND HAS HIS ADDITIONAL ONES ADDED TO IT. THESE WERE ATTACHED TO THE PHYSICAL ON THE DAY OF INSPECTION AND WERE THERE UPON ADMISSION TO ARMSTRONG CARE. A COPY WILL BE SENT TO LICENSING FOR INSPECTION. [Immunizations records were obtained by the provider and submitted to the department on 8/17/16. Within 30 days of receipt of the plan of correction and upon receipt and prior to entering into the individuals' records, the program director or designated management staff person shall review all individuals' current physical examinations to ensure all required information is present including immunization and obtain missing information from the physician. Documentation of all reviews shall be kept. (AS 9/20/16) |
08/08/2016
| Implemented |
| 6400.195(e)(2) | The restrictive procedure plan dated 11-3-15 for Individual #1 did not include the single behavioral outcome desired stated in measurable terms. | The restrictive procedure plan shall include: The single behavioral outcome desired stated in measurable terms. | The single behavioral outcome desired stated in measurable terms. Individual #1¿s outcome in measurable terms has been rewritten as: ¿To assist Individual #1 in decreasing his challenging behaviors by educating Individual #1 and his staff in utilizing effective coping strategies interventions so that Individual #1 can manage his challenging behavior with 0 restrictions in 100% of the occasions over the next 6 months." [Within 30 days of receipt of plan of correction, Individual #1's restrictive procedure review committee to include a behavioral specialist will review the restrictive procedure plan and update to include a single behavioral outcome stated in measureable terms; in addition, the restrictive procedures shall be updated to include feedback from the monthly team meetings as provide by the AE Risk Management team meetings. Within 30 days of receipt of the plan of correction, all restrictive procedures shall be reviewed by the President and/or Program director to ensure all required information is present in accordance with 6400.195(a)-(g). (AS 9/20/16)] |
08/08/2016
| Implemented |
| 6400.202(d) | The restrictive procedure plan dated 11-3-15 for Individual #1 did not include a specified time that the individual shall be released from a manual restraint.
| An individual shall be released from the manual restraint within the time specified in the restrictive procedure plan not to exceed 30 minutes within a 2-hour period.
| Restrictive Procedure Plan for Individual #1 dated 11/3/2015 needs time limit for restraint. Previously written in the RPP as: ¿Physical Restraints will be applied for the least amount of time needed to assist Individual #1 in regaining control of his behavior.¿ It has been corrected to: ¿Physical Restraints will be applied for the least amount of time needed to assist Individual #1 in regaining control of his behavior, but not to exceed 30 minutes within a 2-hour period.¿ A copy of Individual #1 Restrictive Procedure Plan is being sent to licensing with the changes noted.[Within 30 days of receipt of plan of correction, Individual #1's restrictive procedure review committee to include a behavioral specialist/DDTT will review the restrictive procedure plan and update to include a specified time ; in addition, the restrictive procedures shall be updated to include feedback from the monthly team meetings as provide by the AE Risk Management team meetings. Within 30 days of receipt of the plan of correction, all restrictive procedures shall be reviewed by the President and/or Program director to ensure all required information is present in accordance with 6400.195(a)-(g). (AS 9/20/16)] |
08/08/2016
| Implemented |
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