Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00246588 Unannounced Monitoring 06/11/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.162(b)(2)(ii)Staff #1 administered Cold + Hot pad, apply I pad topically to affected area as needed to Individual #1 on 5/26/24 at 10pm. There was no documentation that Staff #1 received the additional required trainings to administer the topical medication.A prescription medication that is not self-administered shall be administered by one of the following: A person who has completed the medication administration course requirements as specified in § 6400.168 (relating to medication administration training) for the administration of the following: Topical medications.Medication Administration Trainer was trained by a Registered Nurse for topical medications. Documentation of this training was placed in employee file. Staff #1 was trained by a Medication Administration Trainer to apply topical medications on 7/1/2024. 07/05/2024 Implemented
6400.162(b)(2)(iii)Staff #1 administered Fluticasone SPR 50 MCG, Use 2 sprays in each nostril to Individual #1 at 8am on 6/1/24 and on 6/2/24. There was no documentation that Staff #1 received the additional required trainings to administer the nasal medication.A prescription medication that is not self-administered shall be administered by one of the following: A person who has completed the medication administration course requirements as specified in § 6400.168 (relating to medication administration training) for the administration of the following: Eye, nose and ear drop medications.Medication Administration Trainer was trained by a Registered Nurse to administer eye, nose and eardrop medications. Documentation of this training was placed in employee file. Staff #1 was trained was Medication Administration Trainer for eye, nose and ear-drop medications on 7/1/2024. 07/05/2024 Implemented
6400.165(c)Individual #1 is prescribed Fluticasone SPR 50MCG, use 2 sprays in each nostril once every day. The pharmacy label documents that the medication was last filled on 9/11/23, and the bottle states it's 120 meter spays. The medication is being documented on the Medication Administration Record (MAR) as being administered as being prescribed. At the time of the inspection, the bottle remained approximately ½ the way full of the medication. The medication is not being administered as prescribed as 9/11/23 to 6/11/23 with the 2 sprays in each nostril is approximately 976 sprays. There were 9 unopened boxes of the medication being stored with Individuals #1's extra medications at the time of the inspection. The medication is not being administered as prescribed Also, at the time of the inspection, located with Individual #1's medications was Hydrogencortisone 1% crem, apply to affected area three times daily as needed for rash. The pharmacy label documented a prescribed dated 10/31/23 however the medication was not listed on the June Medication Administration Record (MAR). The agency provided the licensing representative documentation that medication was discontinued on 2/7/24. Individual #1's May 2045 Medication Administration Record (MAR) documented that the medication was administered on 5/7/24 at 8:10 pm. Individual #1's May MAR documented administration of Silver Sulfa CRE 1% to Individual #1 on 5/3/24 at 8pm an 5/5/24 at 8pm, and then the MAR documented "DC on 1/6". These medications were not administered as prescribed.A prescription medication shall be administered as prescribed.: Individual #1s MAR was reviewed and corrected to reflect the correct information for all prescribed medications. The discontinued Hydrogen cortisone cream was removed from the home. 07/05/2024 Implemented
6400.166(a)(4)The insulin pen in the medication box for Individual #1, therefore being the current one being used to administer the insulin medication was labeled with the pharmacy label insulin Glar however the June 2024 Medication Administration Record (MAR) documented Lantus SOLUS. The licensing inspector had to look through multiple insulin boxes in the refrigerator to then match the pharmacy label on an unopened box that was labeled Glargine Solostar generic for Lantus SOLUS to confirm that the modification being administered to Individual #1 was correct. Not only does Individual #1 receive 2 different insulin injection via different brands, but it was not clear that the medication being administered was generic for the medication listed on the MAR. The MAR should clearly distinguish the generic medication as to avoid confusion and discrepancies between the pharmacy labels.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.The MAR at home was corrected to reflect the generic version of the medication. 07/05/2024 Implemented
6400.166(a)(13)A medication record shall be kept, including the Name and initials of the person administering the medication. Individual #1's June 2024 Medication Administration Record (MAR) did not include the initials of the persons administering Individual #1's medication BD Swab Reg Pag single use 6/1 and 6/2 at the 1 pm administration. The MAR also did not include the initials of the person administering Individual #1's medication BD Pen NEED MIS 32GXx4MM on 6/12 at the 1pm administration. Individual #1's May 2024 did not include the initials of the person administering their Fluticasone SPR 50 MCG on 5/4/24 at 8am, Onetouch TES Verio, test blood sugar on 5/4/24 at 8am and 12:00pm, BD Pen Needle MIS 32GX4mm on 5/4/24 at 9:00 am and 1:00 pm, Insulin ASPA INj Flexpen on 5/4/24 at 9:00amA 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 who did not initial the medication administration record was provided individual feedback and an employee procedural/educational form regarding proper documentation was completed. 07/05/2024 Implemented
6400.166(c)Individual #1 is prescribed BD Pen NEED MIS 32GXx4MM use to inject insulin four times daily for diabetes (9am, 12p, 1pm, 6pm), Insulin ASPA Inj Flexpen, Breakfast & dinner SS, and Insulin ASPA Inj Flexpen, test blood sugar at lunch & inject insulin per *SS , and the Medication Administration Record (MAR) documented that Individual #1 refused administrations at breakfast on 6/12/24, 5/3/24, 5/8/24, 5/9/24, 5/12/24, 5/15/24, 5/16/24, 5/21/24,5/23/24, and 5/26/24 lunch administrations on 6/13/24, 5/15/24, and dinner administration on 5/18/24. There is no documentation of the medication refusals being reported to the prescriber.If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual.Damon house staff were provided educational feedback regarding proper documentation. 07/05/2024 Implemented
6400.169(a)A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures, and treatments. The departments medication administration training program annual practicum requirements are two Mediation Administration Record (MAR)Reviews Completed within expected time frame in 1 year period (1 observation every 6 months), and Two Medication Observations Completed within expected time frame in 1 year period (1 observation every 6 months). Staff #2's Original qualification date is 2/15/23, they had 1 Medication review which was completed on 6/12/23, and they had 1 Medication Administration Review on 8/9/23. The rest of the medication administration requalification (Annual) form is not completed. Staff #2 administered medication on 5/4/24 at 8am. Staff #2 has not met the renewal qualifications to administer medications.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).Staff who was out of compliance with medication training was informed she is not permitted to pass medications until she has successfully completed the ODP approved Medication Administration Course. She was reassigned the medication course and will not administer medications until it is completed. 07/05/2024 Implemented
6400.169(b)(1)A staff person may administer insulin injection following successful completion of both the medication administration course specified in subsection 169(a) and A Department-approved diabetes patient education program within the past 12 months. Staff #1 completed diabetes training on 5/9/24, and the medication administration course on 5/21/24. Individual #1's Medication Administration Record (MAR) documented that Staff #1 administered Insulin ASPA inj Flexpen on 5/20/21 at 6:00 pm, BD Pen Needl MIS 32 GX4M on 5/20/24 at 6:00 pm, Insulin ASPA inj Flexpen at dinner on 6/20, alcohol prep pad 70% on 6/20 at 6:00 pm, and Onetouch DEL MIS Plus 33g, at 8pm. Staff #1 had not completed the medication course in its entirety on 5/20/24 when they were administering insulin and testing Individual #1's blood sugar as they had only completed one of the medication observations on 5/20/24, and Staff #1 did not pass the Medication administration course until 5/21/24.A staff person may administer insulin injections following successful completion of both: The medication administration course specified in subsection (a).Staff completed the Medication Administration Course on 5/21/24. 07/05/2024 Implemented
SIN-00235691 Renewal 12/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)Individual #1 had an annual physical examination completed on 7/21/23, however the physical examination did not include all required components including 141c12- physical limitations of the individual, 141c13-allergies or contradicted medications and 141c14-medical information pertinent to diagnosis and treatment in case of an emergency.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The agency medical coordinator forwarded the form to the MD's office so it may be completed in its entirety. 01/12/2024 Implemented
6400.142(a)Individual #1 did not have a dental examination performed by a licensed dentist annually. Individual #1 was last seen for a dental examination in 6/22 with a follow up/recall appointment scheduled in 12/22. There is no documentation that Individual #1 attended the 12/22 appointment. There were no scheduled appointments until 10/27/23 that Individual #1 refused to attend.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 #1 was scheduled for a dental examination on 2/27/24. Staff in the home were trained on individual #1¿s desensitization plan and documentation on 1/12/24. 01/12/2024 Implemented
6400.143(a)Individual #1 refused to attend a dental appointment on 10/27/23. There was no documentation of continued attempts to train the individual about the need for health care documented in the individual's record. Individual #2 refused to eat breakfast and lunch on 11/26, and 11/27 at breakfast and lunch. Individual #1 is prescribed Novolog flex pen at breakfast and lunch. The Novolog is unable to be administered if Individual #1 does not eat. Individual #1 did not receive this mediation on 11/25 and 11/26 at breakfast and lunch. There was no documentation of 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 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. Individual was counseled on the importance of medical care and staff were trained on the individual¿s medical desensitization plan on 1/12/24. 01/12/2024 Implemented
6400.144Health services including follow up medical care are not planned for or arranged for Individual #1. Individual #1 was seen in the Emergency Room (ER) on 10/15/2023 for a mental health concern after utilizing a razor to make cuts in the Individual's arm. Documentation from the ER visit included physicians' instructions that Individual #1 should have a sharp restriction in place. No follow up was completed following these instructions, including discussions with Individual #1's team or psychiatrist. Individual #1 was seen for a neurology appointment on 1/27/23 with instructions to return in 7/2023. There was no documentation that the follow up appointment was completed in 7/23. Individual #1 is followed by a diabetes clinic. Individual #1 was seen at the clinic on 7/20/23 and lab work was ordered. There was no documentation that this lab work was completed. Individual #1 was scheduled to return to the clinic on 10/16/23. There was no documentation that the follow up visit was completed. Individual #1 is followed by a podiatrist. Individual #1 had an appointment on 8/22/23 with a follow up appointment scheduled for 9/26/23. There was no documentation that the follow up appointment was completed. Individual #1 was seen at the Individual's Primary Care Physician on 7/11/23 for tooth pain. Individual #1 was diagnosed with dental caries. Arrangements were not made for Individual #1 to be seen at a dentist to address the dental issues.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 was scheduled for psychiatry appointment on 12/18/23. A diabetes management (MTM) appointment was scheduled for 1/29/24 and lab work for 2/6/24. A follow up with podiatrist was scheduled for 1/12/24. A dental appointment was scheduled for 2/27/24. Medical coordinators and house staff were trained on individual¿s desensitization plan on 1/12/24. 01/12/2024 Implemented
6400.165(c)Medications are not administered as prescribed. Individual #1 is prescribed Eliquis 5mg, take 1 tablet by mouth twice daily at 8am and 8pm and Omeprazole Cap 20, take 1 capsule by mouth twice daily for Gerd at 8am and 8pm. Individual #1's medications are in blister packs and staff document the date of administration on the back of the blister pack where the pills are removed from. The blister pack was dated 12/1, 12/2, 12/3, 12/5, and 12/6 for the 8PM doses. The pills that chronologically would have been for 12/4 remained in the blister pack and there were no other pills removed and marked with that date. The medication administration record is documented with staff initials for administration of both medications on 12/4. Individual #1 is prescribed Flonase use 2 sprays in each nostril daily. The bottle of medication contains 120 metered sprays and is a 30-day supply. The medication was last filled on 11/6/23 and the bottle located in the home was full. The medication administration record was initialed by staff that the medication was administered as prescribed. The medication is not administered as prescribed. Individual #1 is prescribed Skyclarys 50mg caps, take 3 capsules by mouth once daily. The bottle was a 30-day supply containing 90 pills. The bottle was filled on 11/10/23 contained more than a quarter full and 26 pills remained in the bottle. The medication administration record for 12/1, 12/2 and 12/3 had lines through the administration time for these dates with no documented explanation why the medication was not administered. The medication administration record was initialed by staff that the medication was administered as prescribed. This medication is not administered as prescribed. Individual #1 is prescribed Novolog Flex Pen test blood sugar at breakfast, lunch and dinner and inject per sliding scale. This medication was not documented as administered are prescribed on 11/20 at 6PM (dinner). There is no explanation on the Medication Administration Record of a refusal. This medication was not administered as prescribed.A prescription medication shall be administered as prescribed.Medication errors were entered into HCSIS for the missed administrations on 12/7/23. 12/07/2023 Implemented
6400.165(g)Individual #1 is treated with medications for symptoms of psychiatric illness. Individual #1 has not had consistent 3-month reviews of these medications. Individual #1 was due for a medication review in 11/22, 2/23 and 5/23 based on an 8/22 review. Mediation reviews did not occur during this time frame. Individual #1 did not have a medication review from 8/22 until 6/14/23. Individual #1 then had medication reviews on 6/14/23, 7/17/23, 9/12/23 and 10/19/23. Documentation from these medication reviews was incomplete and did not include the reason for prescribing the medication, the need to continue the medication and the necessary dosage.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 #1 was scheduled for and completed a psychiatric medication review on 12/18/23. 12/18/2023 Implemented
6400.166(b)Individual #1 is prescribed Oxcarbazepine tab 150mg, take 1 tablet by mouth twice daily. Initials of the person administering the medication were not documented as administered on 12/4 at 8AM. The pill was missing from the blister pack and the date of 12/4 was documented on the blister pack. Individual #1 is prescribed Eliquis tab 5mg, take 1 tablet my mouth twice daily at 8am and 8pm. The initials of the person administering the medication on 11/13/23 were not documented on the medication administration record. Individual #1 is prescribed Omeprazole Cap 20, take 1 capsule by mouth twice daily for Gerd at 8am and 8pm. The initials of the person administering the medication on 11/13 and 11/28 were not documented on the medication administration record. Individual #1 is prescribed Insulin Glaris 1000ml (substitute for Lantus), Inject 10 units subcutaneously once every day at 12pm. The initials of the person administering the medication on 11/27/23 were not included on the medication administration record. Individual #1 was prescribed Olanzapine tab 10mg, take 1 tablet by mouth at bedtime along with 2.5mg=12.5mg total. This medication was discontinued on 11/15/23. The initials of the person administering the medication on 11/2 and 11/13 were not documented on the medication administration record. Individual #1 is prescribed Trazadone tab 100mg, take 1 tablet every night at bedtime. The initials of the person administering the medication on 11/13 were not documented on the medication administration record.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.It was determined that the problem was a documentation error and not a medication error. The MAR was corrected to reflect the appropriate information. 01/12/2024 Implemented
SIN-00204261 Unannounced Monitoring 04/20/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.163(h)Individual #2 had a medication order for Acetaminophen 500mg tablets as needed. The pharmacy label on the medication bottle reflects this was dispensed on 1/14/2021 and the expiration date on the pharmacy label was 1/14/2022.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The expired medication was removed from the home at the time of the inspection and new medication was requested from the pharmacy. 04/20/2022 Implemented
6400.165(g)Individual #2 is prescribed psychotropic medications by a psychiatrist. Individual #2 did have documentation of medication reviews; however, it did not include the reason for prescribing the medication, the need to continue the medication, or the necessary dosageIf 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.Assigned medical coordinator attempted to request appropriate medication review documentation from the Dual Diagnosis Treatment Team, but was only able to receive email confirmation that the medications were reviewed due to all DDTT appointments with the psychiatrist being virtual. Individual is now under the care of a new psychiatrist, documentation will be received and reviewed by the medical coordinator immediately after the appointment. 05/25/2022 Implemented
6400.213(1)(i)Individual #2 photo was dated 8/31/2019. Individual needs an updated photo.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.Individual #2's photo was updated and a face sheet with updated information was created. 05/26/2022 Implemented
SIN-00199091 Renewal 12/27/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff #1 was hired on 8/31/20. Staff #1's criminal history record check was not completed until 12/12/21.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. HR Generalist has been retrained by Human Resources to ensure she is aware of required regulations and has been requested to create tracking systems and audit all files to ensure full compliance. 02/28/2022 Implemented
6400.61(a)Individual #1 is diagnosed with a physical disability and requires the use of a wheelchair. Individual #1 requires two staff for transfer for the purpose of showering and use of the bathroom facilities. Individual #1's bathroom has limited space that is inadequate for the individual, the individual's wheelchair and two staff assist while in the bathroom. Individual #1 indicated that the individual has fallen while in the bathroom on many occasions.A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. The maintenance department is obtaining bids for reconstruction of the individual's bathroom to update the area to be wheelchair accessible. Bathroom reconstruction to be completed no later than 6.1.22. 06/01/2022 Implemented
6400.67(a)The shower curtain (this is only a shower curtain liner) in individual #1's bathroom is ripped and falling off of the shower curtain bar.Floors, walls, ceilings and other surfaces shall be in good repair. This shower curtain has been replaced 12/30/21 02/28/2022 Implemented
6400.106The furnace has not been inspected annually. The last inspection was on 11/23/20.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. Furnaces throughout Eihab homes have begun to be serviced and will be completed by 2/28/22 02/28/2022 Implemented
6400.144Individual #1 is followed by a psychiatrist for mental health diagnosis and medication management. Individual #1 did not have follow up with the psychiatrist for 6 months from 4/28/21 to 10/5/21. Individual #1 was seen on 5/4/21 at the Gastroenterologist. Individual #1 was to have a six month follow up appointment, this appointment was not scheduled. Repeat Violation 1/22/21, 7/16/21Health 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. Medical coordinator and agency nurse to monitor individual's medical appointments and monitor follow up visits as recommended 02/28/2022 Implemented
6400.32(c)Individual #1's Individual Service Plan indicates that the individual is to have two staff available in the home at all times due to mobility issues and the need for two staff to transfer during bathroom use and showering. On 12/27/2021, during the 7-3 shift, there was only one staff in the home. Individual #1 was neglected and her safety was at risk due to the individual needing to use the bathroom during the shift and only one staff being available to transfer the individual. Repeat Violation 1/22/21An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.Staffing will be provided as per ISP requirements. Program Specialist will be responsible to schedule the Damon House staff and submit to Program Director for approval prior to being posted. In the event staff call off, the agency's emergency back up plan will be implemented. 03/30/2022 Implemented
6400.52(c)(6)Staff #1 is not trained in the implementation of the individual plan.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.Staff #1 was trained on the individuals plan on 9/16/21. 03/30/2022 Implemented
6400.163(a)Individual #1 is prescribed Ozempic 0.25 once a week. The label and the Medication Administration Record(MAR) do not match, the label on the medication states Ozempic 0.25 once a week and the MAR states Ozempic 0.25or 0.50 mg/dose, inject 0.25 once a week. The dose of 0.25mg on the MAR is crossed out and 0.5mg is handwritten and initialed by the Medical Coordinator. The Medical Coordinator indicated that the label is incorrect as the dose had been changed and is not the correct label or package for the medication as the box with the correct label had gone missing and staff placed the medication in the extra labeled bag that was in the home.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.This medication has been properly labeled and is being administered as prescribed. 03/15/2022 Implemented
6400.165(c)Individual #1 is prescribed Ozempic 0.25 once a week. The label and the Medication Administration Record(MAR) do not match, the label on the medication states Ozempic 0.25 once a week and the MAR states Ozempic 0.25or 0.50 mg/dose, inject 0.25 once a week. The dose of 0.25mg on the MAR is crossed out and 0.5mg is handwritten and initialed by the Medical Coordinator. It is unknown what the correct dosage of the medication is. The Medical Coordinator indicated that the label is incorrect as the dose had been changed and is not the correct label or package for the medication as the box with the correct label had gone missing and staff placed the medication in the extra labeled bag that was in the home. The Medical Coordinator advised that staff in the home are administering 0.5mg of the medication based on what was handwritten on the MAR by the Medical Coordinator, not following the dosage that is on the label. Individual #1 is prescribed Fluticasone Prop 50mcg SPR, administer 2 sprays into each nostril daily at 8AM. The medication was filled on 12/1/21 and started on 12/3/21 per the MAR. The medication contains a 30-day supply. The medication is documented as administered as prescribed on the MAR for the month of December, however the bottle was full on December 28, 2021.A prescription medication shall be administered as prescribed.Ozempic medication is being administered as prescribed. Fluticasone, there were two bottles of the medication in question. One was dated December 1 and the second dated December 20 the auditor picked up the bottle that had been most recently delivered. All medication certified staff to be re-trained on the medication administration steps to include checking the pharmacy label on medications. 1/1/22 02/28/2022 Implemented
6400.165(e)Individual #1 is prescribed Lantus Solostar 100 units, inject 30 units under the skin once daily at 12PM. The 30 on the label is crossed out and 35 is handwritten in. There are no initials or information who changed the dose on the label. The Medical Coordinator advised that they had changed the dose when it was changed by the doctor. The MAR reads Inject 35 units under the skin once daily at 12PM.Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received.This medication has been properly labeled and is being administered as prescribed. 1/1/22 02/28/2022 Implemented
6400.165(g)Individual #1 is prescribed psychotropic medications by a psychiatrist. Individual #1 had documentation completed by staff of telehealth visits on 3/30/21, 4/28/21, 10/5/21, 11/2/21 and 12/5/21 documentation did not include the reason for prescribing the medication, the need to continue the medication and the necessary dosage. The documentation does not indicate that the appointments were completed with a licensed physician as the documentation is not signed by a licensed physician. Repeat Violation 1/22/21 and 5/12/21If 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.Documents will be forwarded to provider for signature validating visit. 02/28/2022 Implemented
6400.186Individual #1's Individual Service Plan indicates that the individual requires two staff due to mobility issues. On 12/27/21, there was only one staff available in the home and the individual needed to use the bathroom and the staff transferred the individual without proper assistance. Repeat Violation 1/22/21, 5/12/21 and 7/16/21The home shall implement the individual plan, including revisions.Staffing will be provided as per ISP requirements. Program Specialist will be responsible to schedule the Damon House staff and submit to Program Director for approval prior to being posted. 02/28/2022 Implemented
SIN-00190490 Unannounced Monitoring 07/16/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #1 had a gastroenterology appointment on 1/23/20 with a follow to return in 3 months. There is no documentation that the follow up appointment occurred. (Repeat violation 1/21/21 and 5/12/21)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. May 4th gastro visit did take place, it was a virtual visit the after-visit summary is attached here. 09/01/2021 Implemented
6400.186The agency is not implementing the Individual Service Plan (ISP) for Individual #1 for health and safety risks. Individual #1's ISP indicates that sharp objects are to be locked or kept out of reach to prevent injury. During the inspection on 7/16/21, a butcher block with knives was out on the counter and a sharp knife was in the strainer on in the sink. (Repeat Violation 1/22/21 and 5/12/21)The home shall implement the individual plan, including revisions.Sharps, and Butcher block has been removed from the kitchen. 09/01/2021 Implemented
SIN-00186545 Unannounced Monitoring 03/22/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Eihab is not keeping accurate financial records for Individual #1 and Individual #2. For Individual #1's financial log dated 3/1-3/9/2021, her balance was $18.80 on 3/8/2021. On 3/9/2021, she had a $60 deposit, making her balance $78.80. She made a purchase of $4.78 at Dunkin Donuts and her balance was documented as $42.02, which is incorrect. She made another purchase at Rite Aid for $23.96 and her balance was documented as $50.06. This balance is correct; however, the Dunkin Donuts documentation was a mathematical error. For Individual #1's financial log dated 3/11-3/20/2021, it appears as if all deposits were not being recorded. The ending balance was $105.88. When all purchases were calculated, the ending balance came to negative $76.08. For Individual #1's financial log dated 3/23-3/29/2021, deposits were not recorded, and calculations didn't add up correctly. On 3/28/2021, her balance was negative $5.97. This balance wasn't recorded. Her next balance on this date was $62.00, but there was no deposit documented. There are also discrepancies on Individual #2's financial logs. On her financial log dated 2/21-3/23/2021, there is no starting balance. This Licensing Representative was able to determine the starting balance was $15.15. On 3/22/2021, her balance was $15.81. On 3/23/2021, she made a purchase of $9.38, leaving her with a balance of $6.43. Her balance was documented as $129.06 on this date & no other deposits were documented. On Individual #2's log dated 3/8-3/24/2021, her balance was negative $1.47 on 3/11/2021. On 3/15/2021, no purchases were documented, and her balance was negative $20.46. She made 2 Amazon purchases on 3/24/2021 ($13.98 and $19.06). No balance was logged after these purchases. On her financial log dated 3/24-3/29/2021, there is no starting balance. This Licensing Representative was able to determine the starting balance was $15.81. On 3/24/2021, her balance was $13.19. She made a $14.00 purchase, leaving her with a balance of negative $0.81. Her balance was documented as $0.19. On 3/25/2021, she had a $10.00 deposit and made a $3.98 purchase. Her balance was documented as $22.95; however, it should have been $5.21. A $20.00 deposit was logged on 3/27/2021, bringing her balance to $25.91. On 3/28/2021, she made purchases of $12.38 and $11.38 and on 3/29/2021, made a purchase of $6.32. Mathematically, this made her balance negative $$10.52; however, her balance was documented as $0.00.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. The March 2021 and April 2021 ledgers will be reallocated and documented to determine the correct balance for individual number one and individual #2. Necessary funds will be issued to ensure the financial records are accurate and up to date. The Residential Program Manager and/or designated staff member will be trained how to maintain and keep accurate financial records for Individual #1 and Individual #2 to ensure that personal possession and funds received by or deposit with the home is properly documented and up to date. 06/15/2021 Implemented
6400.22(e)(3)Eihab is not keeping receipts for purchases greater than $15.00 for Individual #1 and Individual #2. The following receipts could not be provided by Eihab for Individual #1: 2/27/2021: Shein ($23.46); 2/15/2021 Grub hub/Taco Bell ($25.00); 2/16/2021: Rainbow Shops ($23.46); 2/17/2021: Shein ($57.99); 2/19/2021: Dominos ($16.29); 2/22/2021: Grub hub/Wendy's (21.14); 3/7/2021: Grub hub/McDonalds ($24.96); and 3/24/2021: Walmart ($24.84). The following receipts could not be provided by Eihab for Individual #2: 3/6/2021: Ebay ($31.79); 3/6/2021: Pay Pal/Best Stuff ($33.90); 3/24/2021: Walmart ($50.00); 4/3/2021: Ebay ($31.25); and undated entry on log: Walmart ($20.00). (Repeat Violation: 1/22/2021). If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. The March 2021 and April 2021 ledgers will be reallocated and documented to determine the correct balance for individual number one and individual #2. Necessary funds will be issued to ensure the financial records are accurate and up to date. 06/15/2021 Implemented
SIN-00183782 Unannounced Monitoring 01/25/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(d)Individual #1 was not treated with dignity and respect by Staff #1 on 12/25/2020. Individual #1 asked Staff #1 to pierce her nose. Even though Staff #1 has done different piercings on others, she did not complete a formal body piercing apprenticeshipAn individual shall be treated with dignity and respect.This incident was filed in the EIM on 12/26/2020; the incident was filed as Physical Abuse and a Certified Investigation was completed. An Administrative Review was conducted on 1/27/21, and the allegation was deemed confirmed. The following recommendations were made to address the incident and mitigate the risk of recurrence. The Vice President provided guidance and coaching to Ms. Nolan on directives for staff, administrative roles and when to follow up on staff directives in addition to ensuring individuals safety. The Program Specialist completed appropriate disciplinary action to Masha Boyarski due to her actions of piercing Ariel Elmore Carrillo¿s nostrils. The Training Coordinator conducted training for the Damon Staff on Boundaries; the roles of DSP and service provision as opposed to a license professional service. The Behavior Specialist provided counseling to Ariel and evaluate her understanding of rendering professional services as opposed to DSP services. 02/26/2021 Implemented
SIN-00181628 Renewal 01/19/2021 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(3)Receipts were not kept for the following purchases for Individual #3: 6/20/2020: $27.88 (Walmart); 6/21/2020: $22.91 (Walmart); and 7/29/2020: $19.00 (Plato's Closet) and $19.41 (Rue 21). If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. Individual #3's receipts were located for the purchases: 6/20/2020 for $27.88 (Walmart), 6/21/2020 for $22.91 (Walmart) and 7/29/2020 for $19.00 (Plato's Closet) and $19.41 (Rue 21). Management and Administration will receive additional training regarding how to allocate, retain receipts 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 to ensure documentation, by actual receipt or expense record, of each single purchase exceeding $15 are made on behalf of the individual carried out by or in conjunction with a staff person. 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 Not Implemented
6400.73(a)There are approximately 6 steps going up through the Bilco doors in the basement. There is no handrail at this exit. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Since the time of the audit the 6 steps going up through the Bilco doors in the basement has been evaluated to install handrail at the exit. 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 each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Program Management will review this physical plant on a weekly basis, 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
6400.142(a)Individual #3 did not have a dental examination in 2020.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. Since the time of survey, individual #3 dental exam has been scheduled, which is scheduled on 4/15/21. 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 #3 had a PAP completed on 6/2/2020. She was instructed to go back for a follow-up on 8/4/2020. A follow-up appointment was not completed.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. Since the time of survey, individual #3 GYN follow up appointment for her PAP has been scheduled, which is scheduled 4/1/21 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 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. 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
6400.32(c)Individual #3's supervision needs were neglected. According to the Individual Support Plan dated 7/1/2020 to 6/30/2021, Individual #3 requires 2:1 supervision from 7AM to 3PM for mobility needs. On 2/3/2021, the home was single staffed through the morning hours.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.The program management are ensuring that the residence is scheduling staff according to Individual #3¿s needs indicated in her current ISP. The program administration meets on a weekly basis to review the staffing schedule and ensure individual are not abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. A monthly team meeting (with AE) occurs and reviews how her needs are being met in a CLA setting. 02/10/2021 Not Implemented
6400.51(b)(1)Staff #2 was hired on 11/16/2020. Her orientation did not include person-centered practices, individual choice, and supporting individuals to develop and maintain relationships.The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Since the time of survey Staff #2 is no longer employed with the agency. The new hire orientation training process has been revised to include new staff will not work on shift in ratio until all required training has occurred. The Training Director will provide an approval to the Program Specialist and the HR Department to indicate employees has passed all required training and can work in ratio on shift. that staff will only shadow and no in ratio. Agency and ODP required training will be conducted under the Training Coordinator or designee facilitation. The Quality Assurance Director has developed an internal self-assessment tool to assist management and administration to conduct routine training record reviews. The training record reviews will consist of ensuring orientation includes all required areas including the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. The Training Coordinator 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
6400.51(b)(4)Staff #2 was hired on 11/16/2020. Her orientation did not include recognizing and reporting incidents.The orientation must encompass the following areas: recognizing and reporting incidents.Since the time of survey Staff #2 is no longer employed with the agency. The new hire orientation training process has been revised to include new staff will not work on shift in ratio until all required training has occurred. The Training Director will provide an approval to the Program Specialist and the HR Department to indicate employees has passed all required training and can work in ratio on shift. that staff will only shadow and no in ratio. Agency and ODP required training will be conducted under the Training Coordinator or designee facilitation. The Quality Assurance Director has developed an internal self-assessment tool to assist management and administration to conduct routine training record reviews. The training record reviews will consist of ensuring orientation includes all required areas including recognizing and reporting incidents. The Training Coordinator 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
6400.165(g)Individual #3 did not have psychiatric medications reviews every 3 months. The last psychiatric medication reviews Individual #3 were on 2/14/2020 and 3/12/2020. No other psychiatric medication reviews were performed. The psychiatric medication review form completed on 3/12/2020, does not include the need to continue to medication and the necessary dosage.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.Since the time of survey, individual #3 medical record has been reviewed and required 3-month psychiatric medication review has been scheduled, which was 2/10/21. 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)(13)The following medication was not initialed as administered for Individual #3: Mupirocin 2% ointment on 12/31/2020 at 8pm.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.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 is completed to include the name and initials of the person administering the medication; 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 Not Implemented
6400.186The Individual Support Plan(ISP) for Individual #3 was not properly implemented. According to the ISP dated 7/1/2020 to 6/30/2021, Individual #3 requires 2:1 supervision from 7AM to 3PM. On 2/3/2021, the home was single staffed through the morning hours.The home shall implement the individual plan, including revisions.In addition to individual #3's 45 day-discharge request, program management are ensuring that the residence is scheduling staff according to Individual #3's needs indicated in her current ISP. The program administration meets on a weekly basis to review the staffing schedule and ensure the individual's plan includes necessary revisions. A monthly team meeting (with AE) occurs and reviews how her needs are being met in a CLA setting. In the event of an emergency and/or the scheduled staff cannot or fail to arrive on shift, management staff will expedite to arrange coverage for the shift. Staff will be mandated to ensure individual #3¿s needs are met according to her ISP. If staff cannot be identified, management staff will complete the shift. Additionally, administrative staff have been scheduled to work from the facility at a minimum of five days to ensure there is additional staffing according to Individual #3¿s ISP supervision needs. We are currently working on a designated per diem list and a staffing agency to assist with on-call emergency staffing needs in the facilities. 03/15/2021 Implemented
6400.213(1)(i)Individual #3's religion was not listed in her record and this section was blank on her face sheet.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. iv: ReligionSince the time of survey, the face sheet was updated to include Individual #3¿s religion. The Quality Assurance Director has developed an internal self-assessment tool to assist management and administration to conduct routine record reviews. The review will consist of daily to monthly monitoring to ensure individual records include personal information, including religion. 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
SIN-00162274 Renewal 09/25/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)There was a missing fire drill in January 2019. One was run on 12-26-18, then not again until 02-25-19. An unannounced fire drill shall be held at least once a month. In January 2019 there was no documentation of a fire drill. An unannounced fire drill must be held at least once a month. An annual training calendar will be created to schedule fire drills prior. Fire drill documentation will be emailed to the Program Specialist by the 25th of every month. Staff will be retrained on appropriate fire drill procedures in upcoming and ongoing trainings. Documentation will be available for review by the Quality Assurance department monthly to ensure individuals shall be able to evacuate the entire building or to a fire safe area designated. 11/01/2019 Implemented
6400.143(a)Individual #3 had multiple refusals of meds and no training was documented anywhere.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. Individual #3 refused medications multiple times and no documentation of training was provided. Behavior Specialist will develop a desensitization plan for this individual. All staff will be trained on the plan. The Behavior Specialist will continue to work with this individual to positively reinforce medication compliance. 11/01/2019 Implemented
SIN-00139349 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
6400.68(b)The water temperature in the bathroom read 126.1 degrees, which exceeds the requirement by 6.1 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. Water temperature was adjusted during licensing period. To prevent this from happening in the future, staff will be retrained on how to correctly take a water temperature. 09/12/2018 Implemented
6400.113(a)Individual #4 was admitted on 6/29/2018. As of the date of this inspection, she did not receive initial fire safety training. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. Fire safety training was completed with individual during licensing period and provided. Program specialist, who has since been terminated, failed to provide fire safety training. To prevent this from happening in the future, new program specialist will ensure any individual admitted with have fire safety training on admission. 08/15/2018 Implemented
6400.141(c)(11)The Health Maintenance Needs section was blank on Individual #4's physical exam dated 6/12/2018.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. The health maintenance portion of the exam was listed on an MA51. The 6400 form was given to the supports coordinator for completion prior to admission. The program specialist, since terminated, did not get clarity on admission. To prevent this from happening in the future, the physical examination will be entirely reviewed for completeness prior to admission. 09/12/2018 Implemented
6400.213(1)(i)Identifying marks were not listed in the records for both Individual #3 and Individual #4. Religious affiliation was not listed in the records for both Individual #3 and Individual #4.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. Correction completed at time of licensing. To prevent this from happening in the future, program specialist will review all emergency face sheets prior to placing in record for completeness. 08/17/2018 Implemented