Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00251338 Renewal 09/10/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(6)Individual #1's physical examination, completed 2/13/2024, did not include specific precautions that shall be taken if the individual has a serious communicable disease. This section was omitted from the agency's physical examination form. Individual #2's physical examination, completed 6/18/2024, did not include specific precautions that shall be taken if the individual has a serious communicable disease. This section was omitted from the agency's physical examination form. Individual #3's physical examination, completed 8/19/2024, did not include specific precautions that shall be taken if the individual has a serious communicable disease. This section was omitted from the agency's physical examination form. Individual #4's physical examination, completed 4/15/2024, did not include specific precautions that shall be taken if the individual has a serious communicable disease. This section was omitted from the agency's physical examination form. Individual #5's physical examination, completed 6/21/2024, did not include specific precautions that shall be taken if the individual has a serious communicable disease. This section was omitted from the agency's physical examination form. Individual #6's physical examination, completed 5/21/2024, did not include specific precautions that shall be taken if the individual has a serious communicable disease. This section was omitted from the agency's physical examination form. Individual #7's physical examination, completed 10/6/2023, did not include specific precautions that shall be taken if the individual has a serious communicable disease. This section was omitted from the agency's physical examination form. Individual #8's physical examination, completed 5/6/2024, did not include specific precautions that shall be taken if the individual has a serious communicable disease. This section was omitted from the agency's physical examination form. Individual #9's physical examination, completed 10/26/2023, did not include specific precautions that shall be taken if the individual has a serious communicable disease. This section was omitted from the agency's physical examination form.The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals.For individual #1, 2, 3, 4, 5, 6, 7, 8, 9 and other individuals: 1. For individual #1, 2, 3, 4, 5, 6, 7, 8, and 9: The CRNP completed an updated annual physical examination to include regulatory required health information including: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals. 2. The Senior Director of Clinical Services issued an in-service on 9/23/24 to the onsite CRNP, the Clinic Nurses and Director of Nursing, citing the need for annual Individual physical examination. 3. The Clinic Nurses will monitor the individual¿s annual physical examinations via tracking form on a monthly basis effective immediately. This tracking form will be additionally overseen by the Director of Nursing. 4. The Director of Nursing will monitor for the individual¿s annual physical examinations being completed per regulatory requirements using the Case Record Review checklist effective 9/24/24, which is monitored and reported on quarterly by the Director of Quality and Compliance. 09/25/2024 Implemented
2380.111(c)(7)Individual #1's physical examination, completed 2/13/2024, did not include an assessment of the individual's health maintenance needs and the need for blood work at recommended intervals. This section was omitted from the agency's physical examination form. Individual #2's physical examination, completed 6/18/2024, did not include an assessment of the individual's health maintenance needs and the need for blood work at recommended intervals. This section was omitted from the agency's physical examination form. Individual #3's physical examination, completed 8/19/2024, did not include an assessment of the individual's health maintenance needs and the need for blood work at recommended intervals. This section was omitted from the agency's physical examination form. Individual #7's physical examination, completed 10/6/2023, did not include an assessment of the individual's health maintenance needs and the need for blood work at recommended intervals. This section was omitted from the agency's physical examination form. Individual #8's physical examination, completed 5/6/2024, did include an assessment of the individual's health maintenance needs and the need for blood work at recommended intervals. This section was omitted from the agency's physical examination form. Individual #9's physical examination, completed 10/26/2023, did not include an assessment of the individual's health maintenance needs and the need for blood work at recommended intervals. This section was omitted from the agency's physical examination form.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.For individual #1, 2, 3, 7, 8, 9 and other individuals: 1. For individual #1, 2, 3, 7, 8, 9: The CRNP completed an updated annual physical examination to include regulatory required health information including: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. 2. The Senior Director of Clinical Services issued an in-service on 9/23/24 to the onsite CRNP, the Clinic Nurses and Director of Nursing, citing the need for annual Individual physical examination. 3. The Clinic Nurses will monitor the individual¿s annual physical examinations via tracking form on a monthly basis effective immediately. This tracking form will be additionally overseen by the Director of Nursing. 4. The Director of Nursing will monitor for the individual¿s annual physical examinations being completed per regulatory requirements using the Case Record Review checklist effective 9/24/24, which is monitored and reported on quarterly by the Director of Quality and Compliance. 09/25/2024 Implemented
2380.111(c)(8)Individual #1's physical examination, completed 2/13/2024, did not include physical limitations of the individual. This section was omitted from the agency's physical examination form. Individual #2's physical examination, completed 6/18/2024, did not include physical limitations of the individual. This section was omitted from the agency's physical examination form. Individual #3's physical examination, completed 8/19/2024, did not include physical limitations of the individual. This section was omitted from the agency's physical examination form. Individual #4's physical examination, completed 4/15/2024, did not include physical limitations of the individual. This section was omitted from the agency's physical examination form. Individual #5's physical examination, completed 6/21/2024, did not include physical limitations of the individual. This section was omitted from the agency's physical examination form. Individual #6's physical examination, completed 5/21/2024, did not include physical limitations of the individual. This section was omitted from the agency's physical examination form. Individual #7's physical examination, completed 10/6/2023, did not include physical limitations of the individual. This section was omitted from the agency's physical examination form. Individual #8's physical examination, completed 5/6/2024, did not include physical limitations of the individual. This section was omitted from the agency's physical examination form. Individual #9's physical examination, completed 10/26/2023, did include physical limitations of the individual. This section was omitted from the agency's physical examination form.The physical examination shall include: Physical limitations of the individual.For individual #1, 2, 3, 4, 5, 6, 7, 8, 9 and other individuals: 1. For individual #1, 2, 3, 4, 5, 6, 7, 8, and 9: The CRNP completed an updated annual physical examination to include regulatory required health information including: Physical limitations of the individual. 2. The Senior Director of Clinical Services issued an in-service on 9/23/24 to the onsite CRNP, the Clinic Nurses and Director of Nursing, citing the need for annual Individual physical examination. 3. The Clinic Nurses will monitor the individual¿s annual physical examinations via tracking form on a monthly basis effective immediately. This tracking form will be additionally overseen by the Director of Nursing. 4. The Director of Nursing will monitor for the individual¿s annual physical examinations being completed per regulatory requirements using the Case Record Review checklist effective 9/24/24, which is monitored and reported on quarterly by the Director of Quality and Compliance. 09/25/2024 Implemented
2380.111(c)(10)Individual #1's physical examination, completed 2/13/2024, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was omitted from the agency's physical examination form. Individual #2's physical examination, completed 6/18/2024, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was omitted from the agency's physical examination form. Individual #3's physical examination, completed 8/19/2024, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was omitted from the agency's physical examination form. Individual #4's physical examination, completed 4/15/2024, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was omitted from the agency's physical examination form. Individual #5's physical examination, completed 6/21/2024, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was omitted from the agency's physical examination form. Individual #6's physical examination, completed 5/21/2024, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was omitted from the agency's physical examination form. Individual #7's physical examination, completed 10/6/2023, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was omitted from the agency's physical examination form. Individual #8's physical examination, completed 5/6/2024, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was omitted from the agency's physical examination form. Individual #9's physical examination, completed 10/26/2023, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was omitted from the agency's physical examination form.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.For individual #1, 2, 3, 4, 5, 6, 7, 8, 9 and other individuals: 1. For individual #1, 2, 3, 4, 5, 6, 7, 8, and 9: The CRNP completed an updated annual physical examination to include regulatory required health information including: Medical information pertinent to diagnosis and treatment in case of an emergency. 2. The Senior Director of Clinical Services issued an in-service on 9/23/24 to the onsite CRNP, the Clinic Nurses and Director of Nursing, citing the need for annual Individual physical examination. 3. The Clinic Nurses will monitor the individual¿s annual physical examinations via tracking form on a monthly basis effective immediately. This tracking form will be additionally overseen by the Director of Nursing. 4. The Director of Nursing will monitor for the individual¿s annual physical examinations being completed per regulatory requirements using the Case Record Review checklist effective 9/24/24, which is monitored and reported on quarterly by the Director of Quality and Compliance. 09/25/2024 Implemented
2380.111(c)(11)Individual #1's physical examination, completed 2/13/2024, did not include special instructions for the individual's diet. This section was omitted from the agency's physical examination form. Individual #2's physical examination, completed 6/18/2024, did not include special instructions for the individual's diet. This section was omitted from the agency's physical examination form. Individual #3's physical examination, completed 8/19/2024, did not include special instructions for the individual's diet. This section was omitted from the agency's physical examination form. Individual #4's physical examination, completed 4/15/2024, did not include special instructions for the individual's diet. This section was omitted from the agency's physical examination form. Individual #5's physical examination, completed 6/21/2024, did not include special instructions for the individual's diet. This section was omitted from the agency's physical examination form. Individual #6's physical examination, completed 5/21/2024, did not include special instructions for the individual's diet. This section was omitted from the agency's physical examination form. Individual #7's physical examination, completed 10/6/2023, did not special instructions for the individual's diet. This section was omitted from the agency's physical examination form. Individual #8's physical examination, completed 5/6/2024, did not include special instructions for the individual's diet. This section was omitted from the agency's physical examination form. Individual #9's physical examination, completed 10/26/2023, did not include special instructions for the individual's diet. This section was omitted from the agency's physical examination form.The physical examination shall include: Special instructions for an individual's diet.For individual #1, 2, 3, 4, 5, 6, 7, 8, 9 and other individuals: 1. For individual #1, 2, 3, 4, 5, 6, 7, 8, and 9: The CRNP completed an updated annual physical examination to include regulatory required health information including: Special instructions for an individual's diet. 2. The Senior Director of Clinical Services issued an in-service on 9/23/24 to the onsite CRNP, the Clinic Nurses and Director of Nursing, citing the need for annual Individual physical examination. 3. The Clinic Nurses will monitor the individual¿s annual physical examinations via tracking form on a monthly basis effective immediately. This tracking form will be additionally overseen by the Director of Nursing. 4. The Director of Nursing will monitor for the individual¿s annual physical examinations being completed per regulatory requirements using the Case Record Review checklist effective 9/24/24, which is monitored and reported on quarterly by the Director of Quality and Compliance. 09/25/2024 Implemented
2380.181(e)(10)Individual #2's most current lifetime medical history addendum was completed on 6/15/2023. Individual #3's most current lifetime medical history addendum was completed on 8/11/2023.The assessment must include the following information: A lifetime medical history.For individual #2 and individual #3: 1. The current lifetime medical history was completed and signed by the CRNP. For all other individuals: 1. The Senior Director of Clinical Services issued an in-service has issued an in-service on 9/23/24 to the Medical Records Technician, Clinic Nurses and the Director of Nursing, citing the need for updating each individual¿s lifetime medical history on an annual basis, with the physician¿s signature. 2. The Medical Records Technician and Clinic Nurses complete the lifetime medical history and has an established process for ensuring this is completed annually and signed off by the physician, effective 9/24/24. 3. The Director of Nursing will monitor for the individual¿s annual lifetime medical history being completed using the Case Record Review checklist effective 9/24/24, which is monitored and reported on quarterly by the Director of Quality and Compliance. 09/25/2024 Implemented
2380.21(u)Individual #1 was informed of their individual rights and the process to report a rights violation on 2/7/2023 and again on 2/29/2024. [Repeat violation: 9/29/2023 et al]The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.For individual #1 and other individuals: 1. The Senior QIDP completed an in-service on 9/24/24 to the QIDPs and Risk and Records Manager. This in-service delineates the annual consent process and tracking of consents, including the individuals¿ rights document, which must occur within the year on an annual basis, to ensure compliance with this regulation. Each QIDP will maintain their caseload¿s consent tracking form to ensure they¿re completed within 365 days from the previous consent. 2. The Senior QIDP will complete monthly monitoring of the Annual Consent Tracking Form beginning on 9/24/24 to ensure this process is being followed and that the individual¿s rights documents are obtained and filed within the appropriate timeframe for all individuals that attend TVFI¿s ATF at the Sewickley Campus. 3. An additional layer of monitoring, via Annual Consent Tracking Form, will be completed by the Records Manager on a monthly basis, beginning on 9/24/24. 09/25/2024 Implemented
2380.36(b)Program Instructor #2 completed fire safety training on 7/11/2023, and then again on 8/26/2024. Direct Service Worker #3 last completed fire safety training on 2/11/23. Their record did not include any subsequent trainings.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).For the Program Instructor #2 and Direct Service Worker #3: 1. The annual fire safety training was issued for immediate re-training for both staff members completed on 9/18/2024. For all direct care staff: 1. The Director of Staff Development increased frequency of fire safety training to be completed every 6 months effective immediately. 2. The Director of Staff Development and ATF Manager issued an in-service on 9/20/24 to direct care staff, to include Program Specialists and Program Instructors, regarding the requirement to complete annual training for fire safety topics included in the in-service. The Director of Staff Development monitors training compliance reports on a bi-weekly basis and reports findings to the Operations Committee, consisting of departmental management/ leadership. 3. The compliance of annual training is also reviewed in the Quarterly Verland Quality management Committee reporting up to the Board, by the Director of Quality and Compliance for monitoring and quality improvement initiatives. 09/25/2024 Implemented
2380.38(b)(5)Direct Service Worker #4, date of hire 4/8/2024, did not participate in training on the implementation of the individual plan for the individuals they work directly with during orientation. Direct Service Worker #5, date of hire 7/22/2024 did not participate in training on the implementation of the individual plan for the individuals they work directly with during orientation. Signature pages indicating that Direct Service Worker #4 and Direct Service Worker #5 completed trainings on the implementation of the individual plan were provided; however, these signature sheets were not dated; therefore, it could not be confirmed that these trainings occurred during the orientation period.The orientation must encompass the following areas: Job-related knowledge and skills.For the Direct Service Worker #4 and Direct Service Worker #5: 1. Completed training on job related knowledge and skills for the individuals they care for, as attested by their signatures/dating on new training and id log beginning on 9/23/24 and going forward. All other direct service workers: 1. The Senior QIDP completed an in-service on 9/24/24 to the House Managers, QIDPs, and Coordinators regarding orientation training including training the Direct Service Workers on the implementation of the individual plan of care for the individuals that they will be working with within 30 days of their start date. 2. Verland updated the individual¿s annual training and ID log template to include a ¿date¿ column to ensure new hire staff members are being trained on their job-related knowledge and skills within the first 30 days of their orientation period. This updated form will be used for all individuals effective 9/23/24. 09/25/2024 Implemented
2380.39(c)(6)Program Specialist #1 did not participate in training on the implementation of the individual plan for the individuals they work directly with during the 1/1/2023 through 12/31/2023 training year. Signature pages indicating that Program Specialist #1 completed trainings on the implementation of the individual plan were provided; however, these signature sheets were not dated; therefore, it could not be confirmed that these trainings occurred during the 1/1/2023 through 12/31/2023 training year. Direct Service Worker #3 did not participate in training on the implementation of the individual plan for the individuals they work directly with during the 1/1/2023 through 12/31/2023 training year.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.For the Direct Service Worker #3 and Program Specialist #1: 1. The ATF Manager issued an in-service on 9/24/24 to Program Specialist #1 to ensure the staff member¿s training on implementation of the individual plan on an annual basis starting on 9/23/24, as attested through use of the new training and id log. 2. The ATF Manager will issue an in-service to Direct Service Worker #3 upon the staff member¿s return to work from his sick leave. The in-service will ensure the staff member¿s training on implementation of the individual plan on an annual basis, as attested through use of the new training and id log. For all other Direct Service Workers, Program Specialists, and Program Instructors: 1. Verland updated the individual¿s annual training and ID log template to include a ¿date¿ column to ensure all direct care staff are being trained on the individual¿s implementation of the individual plan on an annual basis. This updated form will be used for all individuals effective 9/23/24, going forward. 2. All direct care staff and supervisors were issued an in-service on 9/23/24 on the change in the id training log forms and the need to sign and date following training on the implementation of the individuals plan of care. 09/25/2024 Implemented
SIN-00234000 Renewal 09/29/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.21(u)Individual #1 was informed and explained their individual rights and the process to report a rights violation on 2/10/2022 and then again on 6/12/2023. This exceeds the annual requirement.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.For individual #1 and other individuals: 1. The ATF Manager will issue in-service regarding the ¿annual consent procedure (updated 11-15-2023),¿ inclusive of the individual rights, to the Sewickley QIDPs and Risk Records Manager/ Vice Chair of the Human Rights Committee (HRC) to be completed by 11/15/2023. 2. The ATF Manager will conduct two, six-month individual rights record checks for all Sewickley ATF annual assessments completed within that timeframe, in the following months: a. April 2024 b. October 2024 *ATF Manager will check for the presence and completion of this document on the resident charts. 3. The updated process of the HRC includes collecting data on when consents are becoming due under the oversight of the Chair of the HRC, who then notifies the QIDPs as needed, effective 11/15/2023. 11/15/2023 Implemented
2380.39(a)(1)Direct Service Worker #1 completed 17 hours of training related to job skills and knowledge during the 2022 annual training year, dated 1/1/2022 to 12/31/2022.The following shall complete 24 hours of training related to job skills and knowledge each year: Directive service workers.For the Direct Service Worker #1 and other Direct Service Workers: 1. ATF Manager updated the HR/Training policy applicable to all ICF direct care staff, effective 11/16/2023. 2. The Staff Development Manager has issued an in-service to all Sewickley ATF direct care staff on the updated policy, citing the required annual training, including progressive consequence for non-compliance up to re-evaluation of continued employment. Non-compliance will be enforced in collaboration with the HR Department. This staff training is due by 11/30/2023. 3. The compliance of annual trainings are also reviewed in the Quarterly Verland Quality management Committee reporting up to the Board, by the Director of Quality and Compliance for monitoring and quality improvement initiatives. 11/30/2023 Implemented
2380.39(c)(1)Direct Service Worker #1's 2022 annual training hours did not encompass the following areas for the annual training year dated 1/1/2022 to 12/31/2022: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.For the Direct Service Worker #1 and other Direct Service Workers: 1. ATF Manager updated the HR/Training policy applicable to all ICF direct care staff, effective 11/16/2023. 2. The Staff Development Manager has issued an in-service to all Sewickley ATF direct care staff on the updated policy, citing the required annual trainings, including progressive consequence for non-compliance up to re-evaluation of continued employment. Non-compliance will be enforced in collaboration with the HR Department. This staff training is due by 11/30/2023. 3. The compliance of annual trainings are also reviewed in the Quarterly Verland Quality management Committee reporting 11/30/2023 Implemented
2380.39(c)(5)Direct Service Worker #1's 2022 annual training hours did not encompass the following areas for the annual training year dated 1/1/2022 to 12/31/2022: The safe and appropriate use of behavior supports if the person works directly with an individual.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.For the Direct Service Worker #1 and other Direct Service Workers: 1. ATF Manager updated the HR/Training policy applicable to all ICF direct care staff, effective 11/16/2023. 2. The Staff Development Manager has issued an in-service to all Sewickley ATF direct care staff on the updated policy, citing the required annual trainings, including progressive consequence for non-compliance up to re-evaluation of continued employment. Non-compliance will be enforced in collaboration with the HR Department. This staff training is due by 11/30/2023. 3. The compliance of annual trainings are also reviewed in the Quarterly Verland Quality management Committee reporting up to the Board, by the Director of Quality and Compliance for monitoring and quality improvement initiatives. 11/30/2023 Implemented
SIN-00212899 Renewal 10/06/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(b)During the inspection conducted 10/07/2022 the following individuals' physical examinations were not dated and signed by a licensed physician, certified nurse practitioner, or certified physician's assistant: Individual #1's physical examination completed 6/27/2022, Individual #2's physical examination completed 4/01/2022, Individual #3's physical examination completed 7/19/2022, Individual #4's physical examination completed 2/09/2022, Individual #5's physical examination completed 9/13/2022, Individual #6's physical examination completed 4/29/2022, Individual #7's physical examination completed 6/13/2022, and Individual #8's physical examination completed 5/27/2022.The physical examination documentation shall be signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant.Plan of Correction: ¿ The non-compliance areas cited during the inspection conducted on 10/07/2022 indicated that eight individuals¿ physical examinations were not signed and dated by a licensed physician, certified nurse practitioner, or certified physician¿s assistant. ¿ Upon review of the electronic health record, the signed and dated physical examinations for all eight residents were located and sent to the Human Services Licensing Department personnel in the Office of Developmental Programs. ¿ In order to ensure compliance with this regulation and to prevent this citation from reoccurring, the following actions will take place: o All resident annual physical examinations will be signed and dated by a licensed physician, certified nurse practitioner, or certified physician¿s assistant. o Clinic Nurses work directly with the medical professionals to ensure annual physical examinations are completed, signed and dated. o The Medical Records Technician also ensures the annual physical examinations are completed, signed, dated and input into the electronic health record. ¿ The ATF/HSM, Emily Smolak, will check the electronic health record to ensure all annual physical examinations are present, signed and dated for the next four quarters, starting in 2022. (i.e. December 2022, March 2023, June 2023, and September 2023). ¿ The ATF/HSM, Emily Smolak, will issue an in-service to the Clinical Nurses, Director of Nursing and Medical Records Technician to be completed and submitted to the Office of Developmental Programs by October 19, 2022. 10/19/2022 Implemented
SIN-00196425 Renewal 11/19/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Individual #3, date of admission 7/27/2021, did not have a Tuberculin skin testing within two years prior to admission.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.Verland will ensure all individuals admitted to the facility will have a required tuberculin screening within 2 years prior to admitting to the facility. Also, the facility will ensure that the physical examination will include tuberculin skin testing with negative results every 2 years; or; if the tuberculin skin test is positive, an initial chest X-ray with result noted. An in-service to be completed with Social Worker, Clinic Nurses, IDON, and QIDP¿s on pre-admission requirement checklist, and this in-service was started 12/9/21 and completed by 12/19/21. The QA RN will use a monitoring form to ensure all preadmission requirements are being met prior to admission, and all pre-admission requirements will be reviewed by IDON before the admission to ensure compliance and prevent similar future deficiencies. 12/30/2021 Implemented
2380.173(1)(ii)The records for Individual #2, Individual #3 and Individual #4 do not include identifying marks.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.For individuals #3 and 4 a body assessment will be completed and any identifying marks will be recorded in the individuals¿ records. For the individual # 2, a body assessment will be completed the first day that she returns to verland from her parent¿s home and any identifying marks will be recorded in the individuals¿ records. Going forward, the facility will ensure that all individuals admitted will have the required identifying marks screening done within 24 hours of admission to the facility. The Clinic Nurse or admitting RN will ensure that this is done when the individual is admitted to the facility. This process will be reviewed by IDON for each admission to ensure compliance. An in-services to be completed with the Clinic Nurses, IDON, and Charge nurse on the post admission requirements that needs completed on admission. This in-service was started on 12/9/21 and was completed on 12/19/21. The QA RN will use a monitoring form to ensure all requirements post admission are met and are on the chart. All post admission requirements will be reviewed by IDON after each admission in order to prevent future similar deficiencies. 12/30/2021 Implemented
2380.21(u)Individual #1 was informed and explained individual rights on 5/5/2021, Individual #2 was informed and explained individual rights on 9/29/2021, Individual #3 was informed and explained individual rights on 7/27/2021, Individual #4 was informed and explained individual rights on 10/8/2021. The rights documents did not include the following rights: 2380.21c, an individual may not be reprimanded, punished or retaliated against for exercising the individual's rights; 2380.21d, a court's written order that restricts an individual's rights shall be followed; 2380.21e, a court-appointed legal guardian may exercise rights and make decisions on behalf of an individual in accordance with the conditions of guardianship as specified in the court order; 2380.21f, an individual who has a court-appointed legal guardian, or who has a court order restricting the individual's rights, shall be involved in decision-making in accordance with the court order; 2380.21g, an individual has the right to designate persons to assist in decision-making and exercising rights on behalf of the individual; 2380.21j, an individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment; 2380.21k, an individual shall be treated with dignity and respect; 2380.21l, an individual has the right to make choices and accept risks.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.¿ The Individual Rights were updated to include the latest revisions. Individuals #1, #3, & #4 were informed and explained their individual rights on 12/16/2021. Individual #2 has been residing with her family since 10/12/2021; her Individual Rights statement was mailed to their address on file 12/16/2021. In addition, the individual rights for the rest of the individuals will be reviewed and updated to include the missing rights. This process will be checked and verified monthly by Resident Records as part of IPP processing and will be sent out annually to the families/guardians. This process will be reviewed by QIDP/ Program Specialists to ensure the individual rights are covered upon admission to the facility and annually thereafter. This process will also be monitored by ATF manager/ Resident services Director to ensure compliance and prevent any future similar deficiencies. 12/30/2021 Implemented
2380.36(a)Program Specialist #2's most recent fire safety training was completed on 10/15/2020.Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification o the local fire department as soon as possible after a fire is discovered.On 07/22/2021, Program Specialist #2 has received fire safety training, 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, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. The staff development Manager will ensure all required mandatory training for all direct service workers, program specialists, and all other management staff are completed and accounted for by checking and reviewing staff training quarterly. This process will be monitored by the resident services director biannually to ensure compliance and prevent future similar deficiencies.. 12/30/2021 Implemented
2380.38(b)(1)The orientation for Direct Service Worker #1, date of hire 4/12/2021 did not include the application of person-centered practices, community integration, 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.Direct Service Worker #1 has completed required training, the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships by December 19, 2021. The staff development Manager will ensure all required mandatory training for all direct service workers, program specialists, and all other management staff are completed and accounted for by checking and reviewing staff training quarterly. This process will be monitored by the resident services director biannually to ensure compliance and prevent future similar deficiencies. 12/30/2021 Implemented
2380.38(b)(4)The orientation for Direct Service Worker #1, date of hire 4/12/2021 did not include recognizing and reporting incidents.The orientation must encompass the following areas: Recognizing and reporting incident.incident. Direct Service Worker #1 was trained on recognizing and reporting incidents on December 28, 2021. The staff development Manager will be in-serviced on making sure that orientation classes must include recognizing and reporting incidents. Staff development manager must also ensure that all required trainings are completed and accounted for at the end of each orientation class. This process will be monitored by the resident services director at the end of each orientation class to ensure compliance and prevent any future similar deficiencies. 12/30/2021 Implemented
2380.39(c)(1)Program Specialist #2's annual training for the 2020 annual training year did not include the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Program Specialist #2 has completed required training, the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships by December 12, 2021. The staff development Manager will ensure all required mandatory training for all direct service workers, program specialists, and all other management staff are completed and accounted for by checking and reviewing staff training quarterly. Staff development Manager must also encompass these topics in the annual training. This process will be monitored by the resident services director biannually to ensure compliance and prevent future similar deficiencies 12/30/2021 Implemented
2380.39(c)(2)Program Specialist #2's annual training for the 2020 annual training year did not include the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.Program Specialist #2 has completed the missing 2020 annual training topics, the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act, the child protective services law, the Adult Protective Services Act, and applicable protective services regulations on December 12, 2021. The staff development Manager will ensure all required mandatory training for all direct service workers, program specialists, and all other management staff are completed and accounted for by checking and reviewing staff training quarterly. Staff development Manager must also encompass these topics in the annual training. This process will be monitored by the resident services director biannually to ensure compliance and prevent future similar deficiencies 12/30/2021 Implemented
2380.39(c)(4)Program Specialist #2's annual training for the 2020 annual training year did not include the recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Program Specialist #2 has completed the training on recognizing and reporting incidents by December 12, 2021. The staff development Manager will be in-serviced on making sure that orientation classes must include recognizing and reporting incidents. Staff development manager must also ensure that all required trainings are completed and accounted for for each direct service worker, program specialist, and all other administrative staff at the end of each year. This process will be verified by staff development manager quarterly and monitored by Resident services director biannually to ensure compliance and prevent future similar deficiencies. 12/30/2021 Implemented
2380.39(c)(5)Program Specialist #2's annual training for the 2020 annual training year did not include the safe and appropriate use of behavior supports if the person works directly with an individual.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.Program Specialist #2 has completed the training on the safe and appropriate use of behavior supports on December 12, 2021. Staff development manager must ensure that all required trainings are completed and accounted for for each direct service worker, program specialist. This process will be verified by staff development manager quarterly and monitored by Resident services director biannually to ensure compliance and prevent future similar deficiencies. 12/30/2021 Implemented
2380.39(c)(6)Program Specialist #2's annual training for the 2020 annual training year did not include 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.Program Specialist # 2 was trained on IPP implementation process for his 2020 case during IPP year 2020; a copy of all previously completed 2020 IPP trainings will be kept in file along with the 2021 IPP trainings. Once a month, the ATF Manager will verify that all IPP Training for program specialists and direct care workers are completed and accounted for in order to prevent future reoccurrence of similar deficiencies. This process will be monitored by resident services director once a quarter to ensure compliance. 12/30/2021 Implemented
2380.181(f)The program specialist provided Individual #1's assessment, completed 5/5/2021, to Individual #1's plan team members on 5/5/2021 for Individual #1's plan meeting on 5/5/2021. In addition, the entire plan team including the SC was not provided Individual #1's assessment completed 5/5/2021.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.All program Specialists will be in-serviced on making sure that individual assessments are completed and sent to the individual plan team members including the SC at least 30 calendar days prior to the individual plan meeting. Proof of the assessments that were sent 30 calendar days prior to the individual plan meeting must be kept to show compliance. This process will be reviewed by the ATF manager each time there is an individual plan meeting. This also be monitored by the resident services director quarterly to ensure compliance and prevent any future similar deficiencies. 12/30/2021 Implemented
SIN-00158527 Renewal 07/11/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(a)Direct Service Worker #1, date of hire 1/20/03, was most recently trained in fire safety in 2017.Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification o the local fire department as soon as possible after a fire is discovered.On July 15, 2019, Direct Service Worker #1, has completed the training 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, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. Also, the facility conducted a thorough check on every direct service worker to see if anyone else has missed the fire safety training, we discovered that direct service worker #1 was the only one who was missed. In addition, the trainer will be in-serviced to run a query at the end of each Quarter to check compliance of every direct service worker on the training subjects that were completed during that quarter. This procedure was already implemented on the two previous quarters and will be done for the next two quarters. This process will catch any direct service worker who missed any training subjects and provide the opportunity to get them trained and put them back in compliance. Furthermore, the resident services Director will review the training of all direct service workers at the end of each quarter to ensure compliance and prevent reoccurrence of future similar deficiencies. 07/24/2019 Implemented
SIN-00138354 Renewal 07/17/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.91(a)Individual #1 had fire safety training on 3-8-18, and the previous training was on 2-6-17. Individual #2 had fire safety training on 3-8-18, and the previous training was on 2-15-17. Individual #3 had fire safety training on 3-8-18, and the previous training was on 2-9-17. Individual #4 had fire safety training on 3-6-18, and the previous training was on 2-15-17. Individual #5 had fire safety training on 2-28-18, and the previous training was on 2-10-17.An individual 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 facility.All program specialists will be in-serviced on fire safety training. this in-service will cover all of the following: All individuals 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 safety area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility. This in-service will be completed by July 30, 2018. In addition to this in-service, the future fire safety training will be done bi-annually to ensure every individual is trained within the yearly required time frame in order to prevent reoccurrence of the deficiencies we received on individual#1, #2, #3, # 4, and #5. This in-service will be conducted by program specialists and monitored by ATF manager every six month and reviewed by Resident services and Program Director bi-annually to ensure compliance and prevent reoccurrence of similar future incidents. [Immediately, the CEO or designee shall develop and implement a fire safety training tracking system to ensure all individuals complete fire safety training to include all required information, timely. At least quarterly for 1 year, a designated management staff person shall review the aforementioned tracking system to ensure timely completion of fire safety training. (AS 7/23/18)] 07/23/2018 Implemented
SIN-00119434 Renewal 07/28/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(c)Program Specialist #1 had 18 hours of training in the training year from 1/1/2016 to 12/31/2016.Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually.An in-service was given to Program Specialist #1 on 08/18/2017 on the missing 4 hours of training on the topic of Defensive driving/Van safety/vehicle procedures for the year 2016-2017. In addition, the staff development Manager and the ATF manager will be in- serviced on making sure that all Program Specialists and Direct Service Workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. Furthermore, a database training report for every direct service worker and program specialist will be generated by the staff development Manager twice a year to ensure training compliance for all direct service workers and program specialists. This process will be monitored by the ATF Manager to ensure compliance and prevent future similar incidents. 08/28/2017 Implemented
2380.36(f)Direct Service Worker #2's most recent fire safety training was 4/12/16. Direct Service Worker #3's most recent fire safety training was 3/2/16.Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f).An in-service was given to Direct Service Workers #2 and #3, on 08/21/2017, on the missing 2 hours of training on the topic of Fire Safety & Emergencies for the year 2016-2017. In addition, the staff development Manager and the ATF manager will be in- serviced on making sure that all program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. Furthermore, a database training report for every direct service worker and program specialist will be generated by the staff development Manager twice a year to ensure training compliance for all direct service workers and program specialists. This process will be monitored by the ATF Manager to ensure compliance and prevent future similar incidents. 08/28/2017 Implemented
2380.88(c)The kitchen/dining area in the prevocational wing of the facility did not have a fire extinguisher.A fire extinguisher with a minimum 10-B rating shall be located in each kitchen. This extinguisher is required in addition to the extinguishers with a minimum 2-A rating required for each floor in subsections (a) and (b).A fire extinguisher with a minimum 10-B rating was brought and placed in the Kitchen/ dining area in the prevocational wing of the facility. An in-service to the coordinator and the ATF manager will be given to make sure that all fire extinguishers are inspected and accounted for by doing quarterly inspections to ensure prevention of future similar incidents. This in-service will be completed by 08/28/2017. 08/28/2017 Implemented
2380.113(c)(2)Direct Service Worker #3's most recent Tuberculin skin testing was completed 11/22/13. The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant.On 08/21/2017, when Worker #3 returned from vacation was sent for Chest X-Ray, and the result of the Chest X-RAY Exam showed no evidence of parenchymal infiltrate or effusion, and no evidence of acute cardiopulmonary abnormality is seen. An in-service is given to the recruiter and HR manager on making sure that every staff that works with the individuals must have a physical and tuberculin skin testing with negative results before they start working with the individuals and every two years thereafter, or if the tuberculin skin test is positive, an initial chest X-ray with results noted. In addition, a tracking system of physical exam and tuberculin test for every employee will be created and completed by the HR recruiter quarterly, and the HR manager will be monitoring this process to ensure compliance and prevent future similar incidents. 08/28/2017 Implemented