Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00248983 Renewal 07/31/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The agency completed a self-assessment from 3/1/2024 through 3/25/2024, and documented the following violations, 6400.18g, 6400.18j, 6400.141c, 6400.181a and 6400.181f. A written summary of corrections was not kept by the agency.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. The Program Director, Program Manager, and Program Supervisors will be retrained by the Assistant Executive Director on the self-assessment process including the assessment window and documentation process of corrections by September 30th, 2024. Training forms will be provided as documentation (Attachment Training A). 09/30/2024 Implemented
SIN-00213825 Renewal 08/23/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The home did not complete a self-assessment.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The agency will develop a schedule for all agency self-assessments be completed in the month of February which is 4 months prior to the end of the agency's certificate of compliance. All site supervisors will be trained on completion of self assessments to include not leaving any blanks on assessments. 11/16/2022 Implemented
6400.151(c)(3)Direct Care Worker #1 had a physical examination completed on 5/19/2022; however, the examination does not include a signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Staff #1 was sent back for physical examination to indicate she was free from communicable disease. Human Resources will review all physicals as they are received to ensure compliance with this code. 09/20/2022 Implemented
6400.51(b)(1)Direct Services Worker #2 's orientation training, dated 2/9/2022, did not address the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationshipsThe orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Program Manager informed Temp Agencies that we require their staff to receive the ODP approved training on application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. 08/25/2022 Implemented
6400.51(b)(3)Direct Service Worker #2's orientation training, dated 2/9/2022, does not address the topic of Individual rights.The orientation must encompass the following areas: Individual rights.Program Manager informed Temp Agencies that we require their staff to receive the ODP approved training on client rights 08/25/2022 Implemented
SIN-00157688 Renewal 06/24/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment completed on 2/14/19, did not address regulation 6400.110d. This section was left blank.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter.IDD Director and Program Manager will retrain all residential supervisors on completing the Chapter 6400 Community Homes for Individuals with Intellectual Disabilities Self-Assessment Tool. The training will include required deadlines for completing the tool as well as how to complete the form in its entirety. All self-assessments will be handed out to supervisors in December and will be due back to Program Manager by February 28th. The Program Manager will have 7 days to review and submit to IDD Director for final review.[Documentation of the trainings and audits shall be kept. (DPOC by AED,HSLS on 7/11/19)] 07/11/2019 Implemented
6400.112(c)The fire drill records dated 10/20/18, 11/19/18, 4/1/19 and 5/4/19 do not address problems encountered. This section of the form was left blank.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The Fire Drill Report will be updated to include a question on whether there were any issues experienced. If so, a comment box must be filled out explaining the situation. All completed fire drill reports will be sent to residential manager for review. The updated Fire Drill Report will be reviewed with residential supervisors and senior habilitation specialists and will include all requirements of completing the form. The form will be updated by July 11th and training will be provided on July 11th. [Within 30 days of receipt of plan of correction and upon hire, all staff persons responsible for conducting fire drills shall be educated in the procedure for conducting and documenting fire drill including addressing "problems encountered" Documentation of all of the trainings and aforementioned audits shall be kept. (DPOC by AED,HSLS on 7/11/19)] 07/11/2019 Implemented
6400.151(a)Direct Service Worker #2 had physical examinations complete on 2/12/16 and then again 4/6/18. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Program Manager and Program Director will train Administrative Assistant on job responsibility of tracking staff physical forms. A tracking system will be utilized for Administrative Assistant to review when physical forms are due for each staff. Staff will submit physical forms to Administrative Assistant for review. Administrative Assistant will notify supervisors whether the physical form is compliant. If compliant, Administrative Assistant will mark on the tracking sheet and notify supervisor. If not compliant, the staff will be pulled from the staff schedule until the physical form is completed correctly in its entirety.[Documentation of trainings and audits shall be kept. (DPOC by AED,HSLS on 7/11/19)] 07/11/2019 Implemented
6400.151(c)(2)Direct Service Worker #1's Tuberculin skin testing by Mantoux method read on 10/18/17, was not signed by the person who read the results. Direct Service Worker #2 had Tuberculin skin testing by Mantoux method with negative results completed on 2/4/16 and then again on 4/8/18. Program Specialist #3, date of hire 11/27/18, had a pre-employment Tuberculin skin testing by Mantoux method with negative results completed on 8/14/17. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if 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, licensed physician's assistant or certified nurse practitioner. Program Manager and Program Director will train Administrative Assistant on job responsibility of tracking staff physical forms. A tracking system will be utilized for Administrative Assistant to review when physical forms are due for each staff. Staff will submit physical forms to Administrative Assistant for review. Administrative Assistant will notify supervisors whether the physical form is compliant. If compliant, Administrative Assistant will mark on the tracking sheet and notify supervisor. If not compliant, the staff will be pulled from the staff schedule until the physical form is completed correctly in its entirety. [Immediately and upon completion, a designated staff person educated in the requirements of staff persons' physical examinations shall audit all staff persons' current physical examinations to ensure all required information is included and the staff persons are cleared to work with individuals. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 7/11/19] 07/11/2019 Implemented
6400.151(c)(4)Direct Service Worker #2's physical examination completed 4/6/18, indicates that Direct Service Worker #2 has medical problems which might interfere with the heath of the individual on the reverse of the form; however, the form was blank on the reverse side.The physical examination shall include: Information of medical problems which might interfere with the health of the individuals.Program Manager and Program Director will train Administrative Assistant on job responsibility of tracking staff physical forms. A tracking system will be utilized for Administrative Assistant to review when physical forms are due for each staff. Staff will submit physical forms to Administrative Assistant for review. Administrative Assistant will notify supervisors whether the physical form is compliant. If compliant, Administrative Assistant will mark on the tracking sheet and notify supervisor. If not compliant, the staff will be pulled from the staff schedule until the physical form is completed correctly in its entirety. [Compliance Officer provided copy of DSW #2 physical examination completed 4/7/18 which includes that DSW #1 does not have medical problems which might interfere with the health of the individuals and address as needed. Immediately and upon completion, a designated staff person educated in the requirements of staff persons physical examination shall audit all staff persons' current physical examination to ensure all required information is included and the staff persons are cleared to work with individuals. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 7/11/19] 07/11/2019 Implemented
SIN-00118134 Renewal 07/20/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency completed a self-assessment (using a Self-Inspection and Declaration tool) between 4/3/17 and 4/18/17. The expiration of the agency's certificate of compliance was 6/9/17.. The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. A self-inspection policy was developed to ensure the correct form is completed within 6-9 months prior to the expiration date of TCV¿s Certificate of Compliance. The policy is below. It is the policy of TCV Community Services to provide all services in compliance with state, county, and federal regulations. In order to ensure compliance, TCV will conduct a self-assessment of programs 3-6 months before expiration of the current license. PROCEDURE The department director or delegate is responsible for ensuring a self-inspection of the program is completed within 3-6 months before the expiration of the current license. The department director will notify the program manager when the LII is due. The program manager will work with site supervisors and program specialists to ensure thorough review of all regulatory requirements and accurate documentation of compliance on the licensing inspection instrument scoresheet. If an area of non-compliance is identified during the self-inspection the program manager and site supervisor are responsible to resolve the issue. If the issue is unable to be resolved, the program manager will notify the department director and a plan of action will be developed to prevent future occurrences of the same violation. The LII can be found at dhs.state.pa or by searching licensing inspection instrument and selecting the program regulations (either 6400 or 2380) The program manager will submit the LII to the department director no later than April 1 of each year. The department director will maintain the LII for the upcoming audit which typically occur in July..[At least 3 months prior to the expiration of the certificate of compliance the Director of IDD Services shall review all self-inspections to ensure timely completion on the Department's licensing inspection instrument. Documentation of the audit of the self inspections shall be kept. (AS 8/11/17)] 08/04/2017 Implemented
6400.15(b)The agency completed a self-assessment of the home using the Department's Self-Inspection and Declaration Tool used for self-inspection of a new home.The agency shall use the Department's licensing inspection instrument for the community homes for people with intellectual disability regulations to measure and record compliance. The correct form was identified on 7/21/2017. Supervisors have been provided the correct LII tool and are working with the program manager and department director to complete self- inspections by 8/31/2017. A self-inspection policy was developed which is included below. It is the policy of TCV Community Services to provide all services in compliance with state, county, and federal regulations. In order to ensure compliance, TCV will conduct a self-assessment of programs 3-6 months before expiration of the current license. PROCEDURE The department director or delegate is responsible for ensuring a self-inspection of the program is completed within 3-6 months before the expiration of the current license. The department director will notify the program manager when the LII is due. The program manager will work with site supervisors and program specialists to ensure thorough review of all regulatory requirements and accurate documentation of compliance on the licensing inspection instrument scoresheet. If an area of non-compliance is identified during the self-inspection the program manager and site supervisor are responsible to resolve the issue. If the issue is unable to be resolved, the program manager will notify the department director and a plan of action will be developed to prevent future occurrences of the same violation. The LII can be found at dhs.state.pa or by searching licensing inspection instrument and selecting the program regulations (either 6400 or 2380) The program manager will submit the LII to the department director no later than April 1 of each year. The department director will maintain the LII for the upcoming audit which typically occur in July. 08/04/2017 Implemented
6400.181(a)Individual #1's most recent assessment was completed 2/29/16. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. An assessment was completed on 7/26/2017 and distributed to Individual #1's team. A new policy for completing three month reviews has been created and as a part of this policy the program specialist is required to complete a documentation timeframes worksheet. This worksheet includes the assessment due date and will be monitored by the program specialist, program manager, and department director to ensure compliance. The assessment policy is: It is the policy of Turtle Creek Valley MH/MR, Inc. to complete functional assessments in accordance with ODP regulations annually and when a change in need or ability is observed. PROCEDURE: Upon admission to a TCV day program or residential program every individual will be assigned a program specialist. The program specialist will complete an initial assessment within 60 days after admission. The assessment will then be updated annually or whenever a change in need or functioning occurs or when a recommendation to change or revise a service or outcome in the ISP is made. The program specialist will complete a documentation timeframe worksheet at each annual ISP review meeting and submit the form to the program manager within 5 days of the meeting. This will assist the department with tracking assessment due dates. The program specialist will base the assessment results on assessment instruments, interviews, progress notes, and direct observations. The assessment is to include the following areas: ¿ functional strengths, needs and preferences ¿ likes, dislikes, and interests (including vocational / employment) ¿ current level of performance and progress related to acquisition of functional skills, communication, personal adjustment, and personal needs with or without assistance from others ¿ need for supervision ¿ ability to self-administer medications ¿ ability to safely use or avoid poisonous materials ¿ knowledge of danger of heat sources and ability to move away quickly ¿ ability to evacuate during a fire ¿ documentation of disability including functional and medical limitations ¿ lifetime medical history ¿ most recent psychological evaluation ¿ recommendations for specific areas of training (vocational / community employment) ¿ progress over the past year and current level in the following areas: health, motor and communication skills, personal adjustment, socialization, recreation, community integration, ¿ ability to manage his or her own personal property ¿ knowledge of water safety and ability to swim. The program specialist will sign and date the functional assessment in the Qualifacts system. The assessment is to be distributed to all members of the individual¿s team 120 days before the annual review. 08/04/2017 Implemented
6400.186(d)The program specialist did not record when the Individual #1' ISP review documentation for review period 1/4/17 to 4/3/17 was provided to the plan team members; therefore, compliance could not be measured. The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. Service plans for the period 1/4/2017 - 4/3/2017 and 4/4/2017 - 7/3/2017 are completed and have been distributed to the team members. An ISP three month review policy was created and is posted below. The policy creates a new system of accountability for ISP reviews and all staff will be trained on the new policy on 8/9/2017. ¿Individual Documentation Timelines¿ will be completed by Program Specialists by August 31, 2017 for all currently consumers. The program manager will monitor 10% of all 3 month reviews monthly. It is the policy of TCV Community Services to provide all services as defined by the ISP in compliance with state, county, and federal regulations. Therefore, the program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP. PROCEDURE Each program specialist is to document the ISP review date for all assigned individuals. The program specialist will notify the program manager via email of all ISP meetings. Based on the ISP review date the program specialist will determine monthly and three month review dates and document all due dates on the ¿individual documentation due¿ form. (PHI/IDD/IDDPolicy & Procedures / forms) This form is to be completed and submitted to the program manager by August 31, 2017. The form is to be updated at each annual ISP meeting and submitted to the program manager within 5 days of the meeting. The three month review is to include the following information: (1) A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. (2) A review of each section of the ISP specific to the residential home. (3) The program specialist shall document a change in the individual¿s needs, if applicable. (4) The program specialist shall make a recommendation regarding the following, if applicable: (i) The deletion of an outcome or service to support the achievement of an outcome which is no longer appropriate or has been completed. (ii) The addition of an outcome or service to support the achievement of an outcome. (iii) The modification of an outcome or service to support the achievement of an outcome in which no progress has been made. (5) If making a recommendation to revise a service or outcome in the ISP, the program specialist shall complete a revised assessment as required under § 6400.181(b) (relating to assessments). (d) The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. (e) The program specialist shall notify the plan team members of the option to decline the ISP review documentation. (f) If a recommendation for a revision to a service or outcome in the ISP is made, the plan lead as applicable, under § § 2380.182(b) and (c), 2390.152(b) and (c), 6400.182(b) and (c), 6500.152(b) and (c) (relating to development, annual update and revision of the ISP), shall send an invitation for an ISP revision meeting to the plan team members within 30 calendar days of receipt of the recommendation. (g) A revised service or outcome in the ISP shall be implemented by the start date in the ISP as written. At the end of each month the program specialist will review all documentation to ensure it has been completed, signed, dated, sent to all appropriate team members, and filed appropriately. The program specialist will complete a monthly checklist and submit it to the program manager by the fifth of each month confirming completion of the all applicable quarterly ISP reviews. The program manag 08/04/2017 Implemented
SIN-00098386 Renewal 07/21/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(1)Individual #1's physical examination, completed 4/11/16, did not include a review of previous medical history; this section was left blank.The physical examination shall include: A review of previous medical history. A policy was developed to ensure thorough review of annual physicals as they are obtained. Site supervisors and program specialists were trained on the new policy on 8/12/2016. The policy includes a list of all regulatory requirements for the annual physical and identifies the program specialist as the person who is responsible to ensure all information is included on the document. If there is missing information or if the information is not consistent with the ISP the program specialist is to contact the team members including the physician to ensure accurate information is on the physical and in the ISP and TCV Service plan. [Individual #1's physical examination was updated on 8/22/16 to include a review of medical history. Within 30 days of receipt of the plan of correction, all individuals' current physical examinations shall be reviewed using the aforementioned policies and procedures. (AS 9/21/16)] 08/18/2016 Implemented
SIN-00077865 Renewal 07/16/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone number of the nearest hospital was not on or by the telephone in the kitchen of the home.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The telephone list was revised to include the number of the nearest hospital on 7/16/15. The program manager completed a visual inspection of all emergency phone lists at all 8 houses by 7/21/2015. This requirement was discussed at a leadership team meeting with all residential supervisors and the residential program specialist on August 13, 2015 and the leadership team was directed to make sure the phone lists remain current by reviewing them at the time of the monthly site inspection. A clarification of the emergency phone list requirement was made on the site inspection form that is completed by either the site supervisor or the senior resident advisor (Lead staff person) at the time of the monthly fire drill. Supervisors verbally instructed the SRA's of this requirement in August and September. The leadership team was directed to correct any errors on the emergency contact phone list and repost accurate information before the end of their shift. 11/26/2015 Implemented
SIN-00061062 Renewal 07/08/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(e)Staff person #1 was trained in medication administration by Staff Person #2. Staff Person #2 does not have documentation of dates and locations of his/her medication administration training.  Staff #2 had current certification for medication administration. The certificate for staff #2 was obtained and faxed to BHSL on 7-10-14. To prevent training records from not being available in the future, supervisors responsible for maintaining training records will review TCV's IDD Department Training policy.All training records will be kept in the staff auxillary personell file maintained by the supervisor. 07/26/2014 Implemented
SIN-00177757 Renewal 10/14/2020 Compliant - Finalized