Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00256033 Renewal 11/19/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.45(a)Life Sharing Provider #1's training in first aid and Heimlich techniques expired 9/14/23. Life Sharing Provider #1 was not retrained in first aid and Heimlich techniques until 11/01/23.The primary caregiver shall be trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid and Heimlich techniques prior to an individual living in the home and annually thereafter.The Training Coordinator will develop and review an excel spreadsheet with expiration dates for Staffs¿ first aid training and Heimlich techniques on a monthly basis to ensure that First Aid and Heimlich training are scheduled to meet regulatory requirements. Another training class was just completed on December 4, 2024. 12/31/2024 Implemented
6500.133(b)On 11/20/24, Individual #1's medications in capsule and/or tablet form were placed in a 7-day pill dispenser for the next three weeks of medications.A prescription medication may not be removed from its original labeled container in advance of the scheduled administration, except for the purpose of packaging the medication for the individual to take with the individual to a community activity for administration the same day the medication is removed from its original container.Individual #1 has consented to switching to a pharmacy that packages pills in blister/bubble packs and supplies MARS. The Nursing Coordinator has talked with the Family Living Provider to review medication administration procedures and the requirement that no pill dispensers are permitted to be used by regulation except for medication administration during a community activity. The Family Living Program Specialist and Nursing Coordinator will provide monthly monitoring of medication administration in Individua#1¿s home. Laurel House has a nursing on-call system that can also provide technical assistance. This Family Living Provider is scheduled to take the Modified Medication Administration course in January 2025. 12/31/2024 Implemented
6500.133(h)The following medications were discontinued for Individual #1 but were still present in the home on 11/20/2024: Doxycycline HYC 100 MG Caps with directions to take 1 capsule (100 MG) by mouth twice daily; and Nystop Top Pwder 100,000 60 GM with directions to apply topically twice daily for 2 days.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The Nursing Coordinator will explain the process of disposing of discontinued medication and completion of required forms according to the regulatory requirements. The Nursing Coordinator will coordinate Individual #1¿s medical appointments and ask the Family Living Provider to call back with any doctor¿s recommendations to discontinue medication. The Nursing Coordinator and Family Living Specialist will make a minimum of monthly home visits to review the regulations and processes and procedures for medication administration if changes in medication occur. The Nursing Coordinator will meet with this Family Living Provider and walk through and complete the Family Living Provider¿s responsibilities in disposing of the discontinued medication. 12/06/2024 Implemented
6500.136(a)(5)Individual #1 is prescribed Levothyroxine 0.125 MG with directions to take 1 tablet (125 MCG) by mouth every morning for Hypothyroidism. Their November 2024 Medication Administration Record states the strength of the medication is 0.175 MG.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.Individual #1 has consented to switching to a pharmacy that packages pills in blister/bubble packs and supplies MARS. When the MARS arrives, the Nursing Coordinator will instruct the Family Living Provider to review the 5 Rights (the strength of the medication) on the MARS and check it against the medications that are packaged in the blister/bubble packs. The Family Living Provider will report any discrepancies in information or medication packaging to the Nursing Coordinator or Nursing on-call so they can assist in working with the pharmacy to make the needed correction. 12/31/2024 Implemented
6500.136(a)(6)The following medication for Individual #1 does not include the dosage form on their November 2024 Medication Administration Record and read as follows: Vitamin D3 - 1000 IU.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form.Individual #1 has consented to switching to a pharmacy that packages pills in blister/bubble packs and supplies MARS. When the MARS arrives, the Nursing Coordinator will instruct the Family Living Provider to review the 5 Rights (including the dosage of the Medication of Vitamin D3-1000 IU) on the MARS and check it against the medications that are packaged in the blister/bubble packs. The Family Living Provider will report any discrepancies in information or medication packaging to the Nursing Coordinator or Nursing on-call so they can assist in working with the pharmacy to make the needed correction. The new MARS will be sent from the pharmacy. 12/31/2024 Implemented
6500.136(a)(7)Individual #1 is prescribed Gabapentin 300 MG Capsule with directions to take 3 capsules by mouth three times daily. Their November 2024 Medication Administration Record states to take 4 capsules 3 times per day.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.Individual #1 has consented to switching to a pharmacy that packages pills in blister/bubble packs and supplies MARS. When the MARS arrives, the Nursing Coordinator will instruct the Family Living Provider to review the 5 Rights (including the dosage of the Medication Gabapentin 300 MG Capsule-take 3 capsules, 3 times a day) on the MARS and check it against the medications that are packaged in the blister/bubble packs. The Family Living Provider will report any discrepancies in information or medication packaging to the Nursing Coordinator or Nursing on-call so they can assist in working with the pharmacy to make the needed correction. The new MARS will be sent from the pharmacy. 12/06/2024 Implemented
6500.136(a)(8)Individual #1 is prescribed the following medications that did not include the route of administration on their November 2024 Medication Administration Record: BISOPROL/HCTZ - 2.5 MG/6.25 MG TABLET; BROVANA - 15 MCG/2 ML VIAL; BUDESONIDE -- 0.5 MG/2ML VIAL; CALCIUM + D3 600 MG TABLET; FOLIC ACID 1 MG TABLET; and GABAPENTIN 300 MG CAPSULE, LEVETIRACETAM 750 MG TABLET, VITAMIN B COMPLEX -- TABLET, and VITAMIN D3 -- 1000 IUA medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration.Individual #1 has consented to switching to a pharmacy that packages pills in blister/bubble packs and supplies MARS. When the MARS arrives, the Nursing Coordinator will instruct the Family Living Provider to review the 5 Rights (including the route of administration of the Medication-Gabapentin 300 MG Capsule, Bisoprol/HCTZ-2.5 MG/6.25 MG Tablet, Brovana-15 MCG/2 ML vial, Budesonide-0.5 MG/2ML vial, Calcium +D3 600 MG Tablet, Folic acid 1 MG Tablet, Levetiracetam 750 MG tablet, Vitamin B complex-tablet, Vitamin D3-1000IU)) on the MARS and check it against the medications that are packaged in the blister/bubble packs. The Family Living Provider will report any discrepancies in information or medication packaging to the Nursing Coordinator or Nursing on-call so they can assist in working with the pharmacy to make the needed correction. The new MARS will be sent from the pharmacy to include the route of medication administration. 12/31/2024 Implemented
SIN-00146724 Renewal 12/06/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.23(d)Family Member #1 most recently had a Pennsylvania criminal history record checks completed 11/15/16. Individual #1 began residing in the home on 11/13/18.Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to an individual living or receiving respite care in the homeFamily member #1 had a Pennsylvania criminal history record check completed on 12/6/18. Results were "has no criminal record in Pennsylvania. "The family living specialist will continue to monitor when family criminal history checks are due when new individual moves into the home by way of creating a form for documentation of these dates. The current dates will be entered onto the form. If a new individual is placed in an existing home, the family living specialist will immediately refer to the dates on this form. If a new check needs to be completed for a provider and current family members, the family living specialist will complete this immediately via the PATCH website and document and initial this date on the new form. The program director will then review the form and dates and initial as well. This document will be received anytime a new individual or family member moves into the home. Supporting documentation attached. The program director will follow up on this and check to ensure that PA criminal history checks are completed in a timely fashion. All family living providers and family living specialists were trained on this regulation 12/20/18. Supporting documentation is attached. 12/06/2018 Implemented
6500.125(a)Family Member #1 did not have physical examination. Individual #1 began residing in the home on 11/13/18.Family members and persons living in the home shall have a physical examination within 12 months prior to the individual living in the home.Family member #1 completed a physical on 12-8-18. The family living specialist will continue to monitor when family physicals are due when new individual moves into the home. The program director will follow up on this and check to ensure that physicals are completed in a timely fashion. All family living providers and family living specialists were trained on this regulation 12/19/18. Supporting documentation is attached. By creating a form for documentation of these dates, as soon as it is determined that a new individual will move into an existing family living home, the family living specialist will refer to this form to check dates of physicals and Tuberculin tests to determine whether new exams are necessary for the family living provider and all family members. The family living specialist will then notify the family if these tests need done. These tests will be completed immediately, and the family living specialist will document the new dates and initial. The program director will then review the new date and document as well. If new physicals and TB tests are needed, they will need to be completed immediately upon notification of the placement. Supporting documentation attached. 12/08/2018 Implemented
6500.125(c)(2)Family Member #1 did not have a Tuberculin skin testing by Mantoux. Individual #1 began residing in the home on 11/13/18.The physical examination shall include: (2) Tuberculin skin testing by Mantoux method with negative results every 2 years for family members 1 year of age or older; or, if a 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 licensed practical nurse instead of a licensed physician.Family member #1 completed a Tuberculin skin test by Mantoux method. The test was administered on 12/8/18 and read on 12/10/18. Results were negative. The family living specialist will continue to monitor when Tuberculin skin tests are due are due when new individual moves into the home by creating a form for documentation of these dates, as soon as it is determined that a new individual moves into an existing family living home, the family living specialist will refer to this form to check dates of physicals and Tuberculin tests to determine whether new exams are necessary for the family living provider and all family members. The family living specialist will then notify the family if these tests need done. These tests will be completed immediately, and the family living specialist will document the new dates and initial. The program director will then review the new date and document as well. If new physicals and TB tests are needed, they will need to be completed immediately upon notification of the placement. Supporting documentation attached. The program director will follow up on this and check to ensure that Tuberculin tests are completed in a timely fashion. All family living providers and family living specialists were trained on this regulation 12/19/18. Supporting documentation is attached. 12/08/2018 Implemented
SIN-00074131 Renewal 01/07/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.17(a)The self-assessment of the home was completed on 7/3/14; however, the certificate of compliance expired on 10/1/14.If an agency is the legal entity for the family living home, the agency shall complete a self-assessment of each home the agency is licensed to operate 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.Self-assessment to be done 3 to 6 months before expiration of license. Self-inspections to be dated after April 1, 2015, and before July 1, 2015. Self-assessment form attached. 02/14/2015 Implemented
6500.73The 6 outside basement steps did not have a handrail.An interior stairway exceeding two steps that is accessible to individuals, ramp and outside steps exceeding two steps, shall have a well-secured handrail.Ramp installed, photo attached. Safety checklist created attached. Family living provider to review on a monthly basis and information given to the family living specialist at which time all necessary repairs will be completed. Training given to family living provider and family living specialist. 02/14/2015 Implemented
6500.121(c)(9)The most recent prostate examinations for Individual #1 were completed on 7/11/13 and 11/13/14. The physical examination shall include: A prostate examination for men 40 years of age or older.Prostate examination scheduled. Form created to make sure that all medical appointments are completed within the annual time frame. Form attached. Family living specialist responsible for seeing that appointments are done within the time frame, and the program director will oversee this as well. Training given to family living provider and family living specialist. 02/14/2015 Implemented
6500.133(c)Medication reviews for Individual #1 were completed on 11/12/13, 2/20/14, and 8/7/14. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Form created to keep track of due dates for psychotropic medication reviews. Next review already scheduled (form attached). Family living specialist responsible for seeing that appointments are scheduled and completed. Program director to review this information as well. Training given to family living provider and family living specialist. 02/14/2015 Implemented
6500.151(e)(1)Individual #1's assessment, dated 10/4/14, did not include the functional strengths, needs and preferences of the individual.The assessment must include the following information: Functional strengths, needs and preferences of the individual.Functional strengths, needs, and preferences of the individual completed on the assessment. Family living specialist to review that the assessment was completed annually after signing off on the assessment. It will also be reviewed by the program director. Training given to family living provider and family living specialist. 02/14/2015 Implemented
6500.151(e)(2)Individual #1's assessment, dated 10/4/14, did not include the likes, dislikes and interests of the individual.The assessment must include the following information: The likes, dislikes and interest of the individual.The likes, dislikes, and interests of individuals #1 and #2 were completed on the assessment. Family living specialist approved the changes. Family living specialist will review the assessment annually to see that all information is completed and current. The program director will then also review the assessment. Training given to family living provider and family living specialist. 02/14/2015 Implemented
6500.182(c)(1)(vi)Individual #1's photograph was dated May, 2001.Each individual's record must include the following information: Personal information, including: A current, dated photograph.Current photo taken and dated. All photographs to be retaken within a 5-year period. The family living specialist will supervise that the time frame has been met and the program director will also see that the family living specialist has checked to see that photos are current. Training given to family living provider and family living specialist. 02/14/2015 Implemented
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