Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00248798 Renewal 08/05/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)At the time of the inspection on 8/7/24, the water temperature in all the sinks in the home was above the allowed 120 degrees. The water temperature in the kitchen sink was 125.2 degrees, the temperature in the downstairs bathroom sink was 125.7 degrees, and the upstairs bathroom sink was 127.2 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. A maintenance request was submitted on 8/7/24 to turn the water temperature down. Water temperature was turned down and now set to 110 degrees. Water temperature was checked for three consecutive days to ensure compliance 08/14/2024 Implemented
6400.112(h)The fire drill completed on 3/30/24 did not indicate if all individuals evacuated to the designated meeting place during the drill. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Updated letter to Residential Program Assistant and Incident Risk Quality Manager with the expectations for reviewing the fire drill forms each month. 08/12/2024 Implemented
6400.144There is conflicting information in individual #1's record regarding whether or not the individual can safely swallow whole pills. Individual #1 is prescribed a mechanical pureed diet with thin liquids per the choking prevention care plan dated 5/3/24. The individual is considered a choking risk and also has a diagnosis of dysphagia. The ISP states medications are crushed unless otherwise indicated. The individual's annual assessment states that Lamictal, docusate sodium, and Keppra cannot be crushed. The individual is given these medications whole. There is a letter in the individual's chart from Wellspan Family Medicine dated 11/30/21 that states "Because of individual #1's history of choking, pills should be crushed and given in applesauce" signed by a physician. This letter does not specify that the individual can safely swallow any pills.The provider did not pursue other forms of medication, such as a crushable alternative or liquid form, for individual #1.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. Reached out to doctors regarding his dysphagia diagnosis and requested clarification regarding medications being crushed vs being given whole. Medications were switched to liquid/ dissolvable tablets, or the ok to crush pills was given. Letter to LPNs regarding expectations for medications that are prescribed to individuals on pureed diets. 08/15/2024 Implemented
6400.214(b)Individual # 1's current assessment was not available in the home at the time of the inspection on 8/7/24.The most current copies of record information required in § 6400.213 (2)(14) shall be kept at the residential home.Program Specialists will add to the email sending the assessment to the team a note to the RPS of the house reminding them to print the assessment and file it in the individual's daily book at the home. 08/12/2024 Implemented
SIN-00237346 Unannounced Monitoring 11/27/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16Individual #1 had a diagnosis of dysphagia, Alzheimer's, dementia, acid reflux, apraxia of speech, and down syndrome. Individual #1 required a pureed diet, unless a food was naturally soft (for example: a cupcake, pudding, jello). Individual #1 also had a Choking Prevention Care Plan in place that was updated by their physician on 10/11/23 indicating that Individual #1 had signs and symptoms of choking/aspiration that were unique to Individual #1, including coughing, teary-eyed, and frequent throat clearing. There were a total of 19 staff who worked in Individual #1's home between 9/1/23 and 11/11/23. Only 4 of these staff (staff persons #2, 6, 12, and 15) were trained in how to properly prepare Individual #1's pureed diet. Only 6 staff (staff persons #1, 3, 12, 13, 15, and 17) were trained on the 10/11/23 Choking Prevention Care Plan. Only 5 staff (staff persons #1, 2, 4, 15, and 17) were trained in Individual #1's Individual Support Plan. All 19 staff were trained in Dr. Cherpes' Health Alert. On 11/11/23 at 4:00pm, staff person #1 served Individual #1 pork chops that were "in tiny bite size pieces, covered in BBQ sauce, small enough that it looked shredded" instead of pureed per their diet protocol. At 4:50pm, staff person #1 noted that Individual #1 finished their pork chops and began coughing, including coughing up spit. Staff person #1 patted Individual #1's back but did not provide any further medical attention. At 5:15pm, staff person #1 gave Individual #1 a drink, and the individual started to choke again, "like [they] couldn't get the water down." At 5:30pm, Individual #1 began breathing more heavily, tried to take a drink, started breathing more loudly, and their nose started to run. Staff person #1 contacted an agency point person when Individual #1's lips began to turn blue. 911 was not contacted until 5:40pm. Individual #1 was transported to Memorial Hospital, where they were sedated and put on a ventilator. Individual #1 passed away in the hospital on 11/22/23. Despite being trained on Dr. Cherpes' Health Alert, staff person #1 delayed calling 911 for approximately 50 minutes, even when Individual #1 was showing the signs and symptoms of choking. Failure to properly train staff on Individual #1's health and diet preparation needs and a delay in seeking emergency medical care created conditions conducive to serious harm for Individual #1.Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.Train all staff on how to properly prepare individuals food and verify that staff know and are able to replicate what they are shown. Update Incident Management Policy and train all staff on policy (Director, Training Coordinator, Incident Manager) Update Orientation and Annual Training Policy and train all staff on policy (Director, Training Coordinator) Update Health and Behavioral Emergencies and Crisis Policy and train all staff on policy (Director, Incident Manager, Training Coordinator) Ensure that all staff are retrained on the 911 health alert and what to do in emergency situations (Incident manager, Training Coordinator) Ensure that all staff are trained on an individual's plan, assessment, procedures, and protocols PRIOR to working directly with an individual. (LPN, PC, Training Coordinator, Assistant Training Coordinator, Residential Program Supervisors who have been trained by PS) Update training documentation to better reflect the information that staff have been trained on. All Supervisors were trained last week on all individual plans during the course of a two-day training Train all staff on all individual plans, protocols, and procedures in three small group sessions (4 houses per session) in order to get all staff initially trained. This began 2/20/24 and 2/23/24 which will cover the first round of 4 house sessions. We will rotate these staff through the other two 4 house sessions which will end with all staff trained on all individuals. These trainings are scheduled for March 5th, 8th, 14th and 15th. 02/23/2024 Implemented
6400.52(c)(6)There were a total of 19 staff who worked in Individual #1's home between 9/1/23 and 11/11/23. Only 4 of these staff (staff persons #2, 6, 12, and 15) were trained in how to properly prepare Individual #1's pureed diet. Only 6 staff (staff persons #1, 3, 12, 13, 15, and 17) were trained on the 10/11/23 Choking Prevention Care Plan. Only 5 staff (staff persons #1, 2, 4, 15, and 17) were trained in Individual #1's Individual Support Plan. Additional staff signed a sheet indicating that they "read and understood" Individual #1's Individual Support Plan, however, in person training with the Individual physically present is required for this regulation.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.Ensure that staff are trained in person with the individual present for a portion of the training (Program Specialist, Training Coordinator, LPN) Ensure that staff are fully trained on each individual's plan, protocols, and procedures prior to working alone with the individuals (Training Coordinator, Assistant Training Coordinator) Verify documentation of training prior to staff working alone with an individual (Training Coordinator, Assistant Training Coordinator, Program Specialist) 02/23/2024 Implemented
SIN-00144171 Renewal 10/24/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.183(4)Individual # 1's current ISP does not include his supervision needs in the community. Assessment states he is able to be alone in the community for periods of up to 1 hour.The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. Who: Program Coordinators (Specialist by regulations) What: Ensure that a protocol and schedule outlines specifics periods of time for the individual to be without direct supervision is listed in the ISP if the individual¿s current assessment states the individual may be without director supervision and if the individual¿s ISP includes an expected outcome which requires the achievement of a higher level of independence. (ISP did not include supervision needs for the community) When: 1. Annually at time of assessment 2. Annual review meeting for ISP 3. On a PRN basis How: 1. Program Coordinators were retrained in this regulation. 2. All records (ISPs and Assessments) were checked to ensure that supervision needs were documented correctly. 3. An email was sent t the Supports Coordinator requesting that changes be made to individual¿s ISP. Attachments: 3.) 2 emails - 1st email is actually 3 emails in a row (dated 10/24/2018 at 5:05 PM through 10/25/2018 at 8:55 AM). 2nd email (dated 10/25/2018 at 9:12 AM) 4.) Letter verifying Program Coordinators (Specialist by regulations) were trained in this POC and are aware of the expectations of their position to ensure compliance with regulations 12/12/2018 Implemented
SIN-00078881 Renewal 03/25/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.164(b)Individual #1's restasis drops 10pm dose no initials/ signature of person who administered. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. WHO: All staff who have successfully completed the department¿s medication administration training and can administer medication. WHAT: Ensure that staff are signing the MAR immediately after administering medication, as per regulations. WHEN: Each and every time a staff administers medication. HOW: ¿ All staff attended a training in which two medication administration trainers reviewed the proper way to administer medication (verify 5 rights, complete 1st, 2nd and 3rd check, administer medication, complete 4th check, sign MAR¿s). ¿ Change in procedures if staff fail to immediately sign an MAR indicating that they administered medication. Attachments: ¿ Power Point presentation. All staff in the residential program was trained on POC. Trainings were held on 4/27/15 and 4/28/15. Signature sheets are included. (attachment # 2). ¿ Letter explaining change in procedures (attachment #13). 04/28/2015 Implemented
6400.181(e)(13)(ii)Individual #1's assessment did not include progress and growth over the last 365 calendar days and current level in motor and communication.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. WHO: Program Coordinators (Specialist) WHAT: Ensure that individual¿s progress over the last 365 calendar days is clearly documented in each area covered under regulation 6400.181.13 ¿ section I through ix. WHEN: At the time each individual¿s annual assessment is completed and when needed for a critical revision of the individual¿s ISP. HOW: ¿ Program Coordinators (Specialist) were re-trained in expectations of how to meet t his regulation when documenting information in an assessment. ¿ All staff attended a training in which the topic of ¿progress¿ was discussed in detail. ¿ New form was created for staff to document progress when noted. The form will be submitted with the individual¿s quarterly reviews. These forms will then be summarized when the Program Coordinator is completing the annual assessment. ¿ Assessments were reviewed for compliance. Assessments were updated as required to be in compliance with chapter 6400.181 (13) i ¿ ix. Attachments: ¿ Letter signed by Program Coordinators verifying retraining. (attachment #1) ¿ Power Point presentation. All staff in the residential program was trained on POC. Trainings were held on 4/27/15 and 4/28/15. Signature sheets are included. (attachment #2). ¿ New form ¿ Information form previous years assessment is documented. Staff are to update as progress is noted (Attachment # 9). ¿ Individual¿s # 1¿s assessment. ¿ Individual¿s assessment was updated (attachment # 10). 05/24/2015 Implemented
6400.181(e)(13)(iii)Individual #1's assessment did not include progress and growth over the last 365 calendar days and current level in activities of residential living. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. WHO: Program Coordinators (Specialist) WHAT: Ensure that individual¿s progress over the last 365 calendar days is clearly documented in each area covered under regulation 6400.181.13 ¿ section I through ix. WHEN: At the time each individual¿s annual assessment is completed and when needed for a critical revision of the individual¿s ISP. HOW: ¿ Program Coordinators (Specialist) were re-trained in expectations of how to meet t his regulation when documenting information in an assessment. ¿ All staff attended a training in which the topic of ¿progress¿ was discussed in detail. ¿ New form was created for staff to document progress when noted. The form will be submitted with the individual¿s quarterly reviews. These forms will then be summarized when the Program Coordinator is completing the annual assessment. ¿ Assessments were reviewed for compliance. Assessments were updated as required to be in compliance with chapter 6400.181 (13) i ¿ ix. Attachments: ¿ Letter signed by Program Coordinators verifying retraining. (attachment #1) ¿ Power Point presentation. All staff in the residential program was trained on POC. Trainings were held on 4/27/15 and 4/28/15. Signature sheets are included. (attachment #2). ¿ New form ¿ Information form previous years assessment is documented. Staff are to update as progress is noted (Attachment # 9). ¿ Individual¿s # 1¿s assessment. ¿ Individual¿s assessment was updated (attachment # 10). 05/24/2015 Implemented
6400.181(e)(13)(v)Individual #1's assessment did not include progress and growth over the last 365 calendar days and current level in socialization. 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. WHO: Program Coordinators (Specialist) WHAT: Ensure that individual¿s progress over the last 365 calendar days is clearly documented in each area covered under regulation 6400.181.13 ¿ section I through ix. WHEN: At the time each individual¿s annual assessment is completed and when needed for a critical revision of the individual¿s ISP. HOW: ¿ Program Coordinators (Specialist) were re-trained in expectations of how to meet t his regulation when documenting information in an assessment. ¿ All staff attended a training in which the topic of ¿progress¿ was discussed in detail. ¿ New form was created for staff to document progress when noted. The form will be submitted with the individual¿s quarterly reviews. These forms will then be summarized when the Program Coordinator is completing the annual assessment. ¿ Assessments were reviewed for compliance. Assessments were updated as required to be in compliance with chapter 6400.181 (13) i ¿ ix. Attachments: ¿ Letter signed by Program Coordinators verifying retraining. (attachment #1) ¿ Power Point presentation. All staff in the residential program was trained on POC. Trainings were held on 4/27/15 and 4/28/15. Signature sheets are included. (attachment #2). ¿ New form ¿ Information form previous years assessment is documented. Staff are to update as progress is noted (Attachment # 9). ¿ Individual¿s # 1¿s assessment. ¿ Individual¿s assessment was updated (attachment # 10). 05/24/2015 Implemented
6400.181(e)(13)(vii)Individual #1's assessment did not include progress and growth over the last 365 calendar days and current level in financial independence.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. WHO: Program Coordinators (Specialist) WHAT: Ensure that individual¿s progress over the last 365 calendar days is clearly documented in each area covered under regulation 6400.181.13 ¿ section I through ix. WHEN: At the time each individual¿s annual assessment is completed and when needed for a critical revision of the individual¿s ISP. HOW: ¿ Program Coordinators (Specialist) were re-trained in expectations of how to meet t his regulation when documenting information in an assessment. ¿ All staff attended a training in which the topic of ¿progress¿ was discussed in detail. ¿ New form was created for staff to document progress when noted. The form will be submitted with the individual¿s quarterly reviews. These forms will then be summarized when the Program Coordinator is completing the annual assessment. ¿ Assessments were reviewed for compliance. Assessments were updated as required to be in compliance with chapter 6400.181 (13) i ¿ ix. Attachments: ¿ Letter signed by Program Coordinators verifying retraining. (attachment #1) ¿ Power Point presentation. All staff in the residential program was trained on POC. Trainings were held on 4/27/15 and 4/28/15. Signature sheets are included. (attachment #2). ¿ New form ¿ Information form previous years assessment is documented. Staff are to update as progress is noted (Attachment # 9). ¿ Individual¿s # 1¿s assessment. ¿ Individual¿s assessment was updated (attachment # 10). 05/24/2015 Implemented
6400.181(e)(13)(viii)Individual #1's assessment did not include progress and growth over the last 365 calendar days and current level in managing personal property.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. WHO: Program Coordinators (Specialist) WHAT: Ensure that individual¿s progress over the last 365 calendar days is clearly documented in each area covered under regulation 6400.181.13 ¿ section I through ix. WHEN: At the time each individual¿s annual assessment is completed and when needed for a critical revision of the individual¿s ISP. HOW: ¿ Program Coordinators (Specialist) were re-trained in expectations of how to meet t his regulation when documenting information in an assessment. ¿ All staff attended a training in which the topic of ¿progress¿ was discussed in detail. ¿ New form was created for staff to document progress when noted. The form will be submitted with the individual¿s quarterly reviews. These forms will then be summarized when the Program Coordinator is completing the annual assessment. ¿ Assessments were reviewed for compliance. Assessments were updated as required to be in compliance with chapter 6400.181 (13) i ¿ ix. Attachments: ¿ Letter signed by Program Coordinators verifying retraining. (attachment #1) ¿ Power Point presentation. All staff in the residential program was trained on POC. Trainings were held on 4/27/15 and 4/28/15. Signature sheets are included. (attachment #2). ¿ New form ¿ Information form previous years assessment is documented. Staff are to update as progress is noted (Attachment # 9). ¿ Individual¿s # 1¿s assessment. ¿ Individual¿s assessment was updated (attachment # 10). 05/24/2015 Implemented
SIN-00195500 Renewal 11/08/2021 Compliant - Finalized
SIN-00117361 Renewal 08/21/2017 Compliant - Finalized
SIN-00045343 Renewal 02/21/2013 Compliant - Finalized