Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00142872 Renewal 11/13/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The annual furnace inspection was late. An inspection was completed 07-06-17 then not again until 08-14-18.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. Linda Reilly has put a tracking system in place to assure that the furnace inspection will be completed annually. The Service Coordinator will notify the Director 1 month prior to the inspection date to assure compliance. 12/06/2018 Implemented
SIN-00106309 Renewal 01/04/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(8)Individual #1 was 40 when admitted to the program on 12/31/15 and no mammogram was completed until a year later on 12/07/16 when the individual was already 41 years of age.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. The Program Specialist and the Health and Wellness Coordinator were confused as to the scheduling of Individual #1's mammogram. Because this individual was having a very difficult time adjusting to the death of her father and moving out of the home she lived in for 40 years and the fact that she never had any kind of medical testing, they held off on the mammogram until she became accustomed to living in the CLA and seeing physicians on a regular basis. They believed it was in this individual's best interest to wait until her yearly physical was due to have the mammogram administered. The CLA Director explained regulation 6400.141(c)(8) to them and tne fact that a mammogram should have occurred prior to her turning 41 years of age. The CLA Director will monitor medical appointments monthly. This citation was not part of our exit interview so we just became aware of this when we received the POC. The CLA Director completed the discussion with the Program Specialist and the Health and Wellness Coordinator when we received the POC. 02/15/2017 Implemented
6400.199(e)Individual #1 has a script for Lorazepam 0.5mg tablets, one tablet to be given before procedures/appointments or "other stressful activities". However, what those other "stressful activities" might be is not defined or specified on the script, thus leaving it to be determined by staff. It was reported through conversations with staff to have been used for additional expected behavioral issues within the community setting.A Pro Re Nata (PRN) order for controlling acute, episodic behavior is prohibited. The PRN order for Individual #1 was changed on January 9, 2017 to read: Lorazepam 0.5mg tablets, one table to be given before Lab Work. The Program Specialists, the Health and Wellness Coordinator and the Jomar Drive CLA staff responsible for medication orders, were trained that on a PRN order must be written for a specific time limited stressful event. Which in this case, Lab Work is the time limited stressful event. Ongoing, each month, the Program Specialists will monitor that medication orders are written in compliance with this regulation. 01/09/2017 Implemented
SIN-00096804 Unannounced Monitoring 06/29/2016 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(a) Individual #1 moved into the home on 4/1/16 after being discharged from the Longterm Acute Care facility at the Regional Scranton Hospital where the individual had been receiving treatment after a hospitalization that occurred on 2/1/16 for pneumonia and vomiting a coffee grounds like substance. On 4/3/16, Individual #1 was hospitalized at the Geisinger Community Medical Center for vomiting blood. Individual #1 was discharged back to the home on 4/8/16. On 4/23/16, Individual #1 was taken to the ER for treatment of a blocked G-tube. The g-tube was changed and Individual #1 was discharged returning to the home at approximately 6:00pm. Shift Exchange Information Reports for the 11pm-7am shift that evening stated that Individual #1 vomited 3 times, 1 small amount and 2 large amounts green in color, and was administered a PRN Zofran for nausea at 2:00am. Staff interviews and Shift Exchange Information Reports stated that Individual #1 was "spitting up" and making "dry-heave sounding burps" from 7AM until 12PM on 4/24/16. Individual #1 vomited large amounts of a yellowish substance on 4/24/16 at 12pm, and was administered Zofran. Staff interviews report that Individual #1 continued to make "dry-heave sounding burps" after her dose of Zofran at 12PM. Individual #1 vomited large amounts of a yellowish liquid at 4PM, 6PM, and 8PM. Individual #1 received another dose of Zofran at 6PM. Individual #1 was dry-heaving from 8PM to 11PM. At approximately 11:15PM, Individual #1 vomited a medium sized amount of a greenish/yellowish substance. Zofran was administered at 12AM. At approximately 1:30AM, Individual #1 was found to be unresponsive and 911 was called. Individual #1 passed away on 4/25/16 from cardiopulmunary arrest. St. Joseph's Center's Emergency Medical Plan for Individual #1 states that 911 should be called immediately for persistent nausea or vomiting. St. Joseph's Center was neglectful as medical treatment was not sought for Individual #1 who was persistently vomiting from 2AM on 4/24/16 until she was found unresponsive at 1:30AM on 4/25/16.An individual may not be neglected, abused, mistreated or subjected to corporal punishment. 1. Medical Emergency Response Plan was revised on 7/8/16 to include: "All other medical concerns not requiring a call to 911 have to be addressed with the Individual's Primary Care Physician." All staff will be trained on the revised policy as of 7/26/16. 2. All new employees will be trained on the Medical Emergency Response Plan during their orientation as of 7/15/16. 3. A supervisor's response plan for follow up after hospitalizations and ER discharges was developed on 7/8/16 and all supervisory staff will be trained as of 7/15/16. (Validation Status: Partially Implemented Inadequate Progress 10/5/2016 -CH) (-staff should be given a knowledge test after Medical Emergency Response Plan training. Supervisors should be given a knowledge test after ER/ Hospitalization Response Plan training. documentation of the trainings and knowledge test shall be kept. On-going training of the Medical Emergency Response Plan shall be conducted at least two times annually. - CH 10/13/2016) 07/26/2016 Not Implemented
6400.145(1)St. Joseph's Center's Emergency Medical Plan states that 911 should be contacted for persistent nausea or vomiting. On 4/24/16, Individual #1 vomited 3 times starting at approximately 2AM and vomited again at 12PM, 4PM, 6PM, 8PM, and 11:15PM. The required items were listed in the Emergency Medical Policy; however, the policy was not followed as 911 was not contacted for Individual #1 until 1:30AM on 4/25/16 when she became unresponsive.The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. 1. Medical Emergency Response Plan was revised on 7/8/16 to include: "All other medical concerns not requiring a call to 911 have to be addressed with the Individual's Primary Care Physician." All staff will be trained on the revised policy as of 7/26/16. 2. All new employees will be trained on the Medical Emergency Response Plan during their orientation as of 7/15/16. 3. A supervisor's response plan for follow up after hospitalizations and ER discharges was developed on 7/8/16 and all supervisory staff will be trained as of 7/15/16. (Validation Status: Partially Implemented Inadequate Progress 10/5/2016 CH) (-staff should be given a knowledge test after Medical Emergency Response Plan training. Supervisors should be given a knowledge test after ER/ Hospitalization Response Plan training. documentation of the trainings and knowledge test shall be kept. On-going training of the Medical Emergency Response Plan shall be conducted at least two times annually. - CH 10/13/2016) 07/26/2016 Not Implemented
SIN-00068097 Renewal 09/09/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(a)The concrete patio on the side of the house has a great deal of moss and some cracked areas which may be hazardous to people walking in that area. There is an exit door which leads directly to this outside patio. Outside walkways shall be free from ice, snow, obstructions and other hazards. The patio on side of the house has been professionally power washed and all of the moss has been removed. Maintenance will visually monitor the area and schedule cleanings as needed. 09/17/2014 Implemented
SIN-00082685 Renewal 10/14/2015 Compliant - Finalized