Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00250356 Unannounced Monitoring 08/22/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Poisonous materials were not stored in a secured manner -- Individual 1's ISP indicates that poisons should be locked away when not in use. The cart in the corner of the kitchen contained a spray bottle of bleach and a spray bottle of glass cleaner. On top of the cart there was an aerosol can of disinfectant. Beneath the kitchen sink was a spray bottle of bleach. There were wall-mounted hand sanitizer dispensers in the office and laundry room. The cabinet in the laundry room for safely storing poisons was not locked during inspection. The bathroom sink had aerosol disinfectant spray on the countertop. The cabinet beneath the sink contained a spray bottle of bleach, a container of toilet bowl cleaner, a half-gallon bottle of bleach, a spray bottle of glass cleaner, and a bottle of hydrogen peroxide. Staff began relocating these poisonous materials during the inspection.Poisonous materials shall be kept locked or made inaccessible to individuals. All staff will be retrained during the next house meeting (prior to September 5, 2024) on the individual's ISP plans with an emphasis on poisonous material safety. Locks will be placed on the cabinet doors under the sink in both the bathroom and kitchen so that cleaning supplies can be kept locked in the rooms they will be used, instead of the central location of the mudroom. A ticket was submitted to maintenance on 08/29/2024 requesting the locks be added. Third shift will complete a daily check list to ensure that all poisonous materials are in the designed locked areas. 09/05/2024 Implemented
6400.67(b)There was significant build-up in the clothes dryer's lint trap. Lint build-up increases risk of fire in the home. Floors, walls, ceilings and other surfaces shall be free of hazards.Training on emptying the lint trap will be included in the staff meeting held before September 5, 2024. Also, a third shift check list will be implemented with key items staff will monitor daily. The list will include checking the lint trap daily 09/05/2024 Implemented
6400.82(e)The bathtub in the home did not have a non-slip surface or mat. Bathtubs and showers shall have a nonslip surface or mat. Non-slip mat was purchased by the House Manager on 08/29/2024. This mat was placed in the bathroom at Larkin. Third shift will complete a daily check list that will include a visual inspection of the bathroom to ensure the bathmat is not removed. 09/05/2024 Implemented
6400.163(d)The following prescription medications were found unsecured in the bathroom medicine cabinets -- Chlorhexidine Glucon 0.12% liquid, Triple Antibiotic Plus Ointment (both belonging to Individual 2), and Triamcinolone Acetonide cream 0.1%, (belonging to Individual 1). An additional bottle of Chlorhexidine Glucon 0.12% liquid for Individual 2 was found in the drawers beneath the bathroom sink.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.All medication was removed from the bathroom on the date of inspection and is now stored in the locked medication closet. The third shift check list will include a visual inspection of the bathroom to ensure that no medication is kept outside of the medication closet. 09/05/2024 Implemented
6400.163(h)The PRN medication, Lorazepam 2 mg, for individual 2 expired on 08/18/24 and there was another blister pack of Lorazepam in with the medications that expired in 06/2024.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.A weekly medication audit will be completed by the House Manager/Division Manager to ensure all medications are in compliance. 09/05/2024 Implemented
SIN-00244146 Renewal 05/02/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)The handrail outside going up the front steps was loose and unstable. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. A maintenance ticket was submitted, and the handrail was repaired the day of the inspection. 05/03/2024 Implemented
6400.141(c)(7)For Individual 1 - On the gyn exam dated 12/30/22, it noted that it was difficult to complete the exam and that the next exam will need to be conducted under general amnesia. The records did not indicate what happened next. There is no record of a gyn exam in 2023.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. The individual's next appointment was scheduled for 5/10/24. 06/01/2024 Implemented
6400.181(c)For Individual 1 - The current assessment did not indicate where the information (interviews, progress notes, etc.) derived.The assessment shall be based on assessment instruments, interviews, progress notes and observations. A new sign in sheet was created and the program will be trained on using the document by June 1, 2024. 06/01/2024 Implemented
6400.183(c)For Individual 1 - The is no ISP meeting sign in sheet in the record. At list of the persons who participated in the ISP meeting shall be kept.The list of persons who participated in the individual plan meeting shall be kept.A copy of the ISP sign in sheet was obtained from SC Coordinator. 05/17/2024 Implemented
SIN-00225298 Renewal 05/04/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(h)In May, June and July of 2022 the fire drill records did not list the designated meeting place. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Division Manager will conduct a training on completion of fire drill form 08/11/2023 Implemented
SIN-00204487 Renewal 05/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The dryer contained a ball of lint greater than a golf ball in size.Clean and sanitary conditions shall be maintained in the home. A house meeting will be conducted during June 2022 during which the staff will be retrained on the expectations for the lint to be removed from the dryer. 06/30/2022 Implemented
6400.64(a)There was a coffee can and two jugs filled with used cooking oil in the cabinet next to the ovenClean and sanitary conditions shall be maintained in the home. The unlabeled oil was removed from the home. Staff was told that no unlabeled items can be in the kitchen and that oil should not be reused. 05/04/2022 Implemented
6400.110(a)There was no smoke detector present in the basement. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. The is a smoke detector hard wired into the home in the basement. The detector is under the stairs and was not observed during the virtual audit. 05/04/2022 Implemented
6400.112(c)The majority of the fire drills state "1 min, 1.5 min, 2 min" for evacuation time. The Sept 2021 drills states "1-2 min" for evacuation time. Timing of the drill needs to be exact. Also, there was no evacuation time listed on the Dec 2021 drill.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. Fire drill form is being updated to capture the missing information and will begin to be used on July 1, 2022. 07/01/2022 Implemented
6400.46(a)There were no fire safety expert credentials provided at the time of inspection.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 home, 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.Fire safety credentials will be given to each site so that they are available upon request. 07/01/2022 Implemented
6400.46(d)There is no First Aid/CPR training for Staff #1.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.Staff 1 will complete the first aid CPR training by July 1, 2022. The onboarding and New Employee Orientation Process is being evaluated presently. By July 1, 2022, NEO will include first aid/cpr and staff will complete this requirement prior to working at the site. 07/01/2022 Implemented
SIN-00187580 Renewal 05/06/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Bleach was not kept in a locked cabinet and was accessible to the individual.Poisonous materials shall be kept locked or made inaccessible to individuals. Locks were placed on 2 cabinets that are accessible to the individual to avoid access to hazardous materials. 05/06/2021 Implemented
6400.141(c)(10)Individual #2's annual physical dated 8/31/2020 did not indicate whether or not there was communicable disease present.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. The Annual Physical was returned to the physician to complete the section that confirms or denies evidence of a communicable disease. 06/04/2021 Implemented
6400.141(c)(11)Individual #2's annual physical dated 8/31/2020 did not indicate health maintenance needs. The area on the form was left blank.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. The Annual Physical was returned to the physician to complete the section regarding the individuals' health maintenance needs, medication regimen and the need for blood work at recommended intervals. 06/04/2021 Implemented
6400.165(g)Individual #2 had psychiatric medication appointments on 10/7/2020, 11/4/2020, 12/2/2020 and then on 4/8/2021. The last psychiatric medication review took longer than the allotted 90 days and therefore was out of compliance.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The medication appointment was completed on 6/3/21. The next medication appointment is scheduled for 8/3/21. 06/03/2021 Implemented
SIN-00161678 Renewal 08/27/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(f)Staff #3 did not have annual fire safety over the last training cycleProgram 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 home, 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. Staff #3 is a part time employee and had not completed fire safety training at the time of inspection. There was a fire safety training conducted by the fire Marshall in both December 2018 and March 2019 and the staff failed to attend. Leading up to the inspection, there was not an IDD Coordinator in place which is who would typically track the training compliance. The IDD Manager at the time failed to ensure the training requirements were tracked as well. There is a new IDD Coordinator and a new IDD Manager in place over this location. All trainings are complete. To ensure on-going monitoring, Holcomb has been switched to both live and online training to make it easier for staff to take training and for Holcomb to track the training. Staff training is tracked monthly via the quarter training log and it submitted to the IDD Manager for review. Any areas of concern are reported to the IDD Director so that corrections can be made before the close of the training year 09/01/2019 Implemented
6400.80(a)The outside steps were damaged and had rips in the astro-turf covering. Outside walkways shall be free from ice, snow, obstructions and other hazards. The cement step on the outside of the home were covered in Astra-turf so the broken step was missed prior to inspection. The step was repaired on 8/28/19 by the maintenance department. An end of shift checklist was developed and was implemented in the homes for each shift on 10/15/19. This document will assist staff to identify specific areas to check at the end of each shift to ensure that all physical site items are checked daily. If something is not in good repair, staff are aware to report this to the supervisor who will report this to the maintenance person immediately for repair. Additionally, The House Supervisor does a weekly review of the home specifically looking for all physical plant. The Program Coordinator completes the Environmental of Care (EOC) Checklist quarterly. The EOC checklist is completed and submitted to the IDD Manager and EOC Committee. The IDD Manager and EOC Committee review the checklist for compliance. 08/28/2019 Implemented
6400.46(d)Staff #3 completed 23 hours of training over the past training year.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.Staff #3 is a part time employee and had not completed all of the required 24 hours of training. During this time, there was not an IDD Coordinator in place which is who would typically track the training hours. The IDD Manager at the time failed to ensure the training hours were tracked as well. There is a new IDD Coordinator and a new IDD Manager in place over this location. Going forward, Holcomb has been switched to both live and online training to make it easier for staff to take training and for Holcomb to track the training. Staff training is tracked monthly via the quarter training log and it submitted to the IDD Manager for review. Any areas of concern are reported to the IDD Director so that corrections can be made before the close of the training year. 09/01/2019 Implemented
Article X.1007Holcomb Associates is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff person #2's employee record did not document if they had lived in Pennsylvania for the past 2 consecutive years.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.The staff person originally applied for the criminal History and received it but failed to submit it to HR. When HR conducted an audit and realized that the Criminal History check was not on file, the staff person was contacted and requested to submit it. The staff person reported that the Criminal Finger prints were lost and would apply for new one. New Criminal record finger prints were obtained and submitted to the Human Resource office on 10/22/19. Currently Human Resources uses Ultipro which is an electronic System that manages all personnel components from the time the applicants applies through the hiring process, onboarding and training. This application monitors and will alert the Human Resource members when clearances are not received timely and they will in turn alerts the Director and the staff. All staff not obtaining the proper clearances within the allotted timeframe will be removed from providing support to individual 10/22/2019 Implemented
SIN-00140981 Renewal 06/21/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(d)There were various chemicals stored along with food products in the laundry room closet including sugar, flour, laundry detergent and Lysol.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.It is the responsibility of the program supervisor and coordinator to assure compliance to this regulation. This regulation was out of compliance due to cleaning supplies being stored in the laundry room closet along with flour and sugar. All staff were advised that food and cleaning supplies must be stored separately.Cleaning supplies are now kept in a plastic tote and kept in the basement where they are locked. The supervisor and coordinator will complete weekly checks of the physical site to ensure all cleaning supplies are stored in a separate area from food. The program coordinator and manager will complete quarterly inspections of the site to remain in compliance. This regulation and its' explanation was reviewed with staff as shown on the supporting syllabus. 06/23/2018 Implemented
6400.112(c)On 7/29/17 the fire drill record did not indicate the time of the drill.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. This regulation was out of compliance due to improper documentation. The program supervisor is responsible to assure compliance to this regulation. The residential coordinator will review all fire drill logs and provide feedback to the program manager in any area of non-compliance. It is the responsibility of the program coordinator and program manager to follow up on a quarterly basis to assure proper documentation of time of day and exact time the drill was conducted is completed on the form for each drill. A review of this regulation and its' explanation was conducted with the program staff, supervisor, and coordinator. This was completed on 6/29/18 06/29/2018 Implemented
SIN-00115552 Renewal 06/01/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)THE CURRENT PHYSICAL FOR STAFF #1 WAS DATED 12/12/2016 AND THE PREVIOUS PHYSICAL WAS DATED 09/12/2014 WHICH IS MORE THAN 1 YEAR. 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. A spreadsheet has been developed & posted at all residential sites to assure that physicals & other required trainings are in compliance with 6400 regulations in a timely manner. The Coordinator/Supervisor will , via memo & residential meetings reinforce this. see attached 06/12/2017 Implemented
6400.151(c)(2)THE CURRENT TB TEST FOR STAFF #1 WAS DATED 12/14/2016 AND THE PREVIOUS TB TEST WAS DATED 10/06/2014 WHICH IS MORE THAN 2 YEARS. 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. A spreadsheet has been developed & posted at all residential sites to assure that the TB & other required trainings are in compliance with 6400 regulations in a timely manner. The Coordinator/Supervisor will , via memo & residential meetings reinforce this. see attached 06/12/2017 Implemented
SIN-00090725 Renewal 01/26/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The license expired 12/29/15. The self-assessment was completed between October-November 2015 which was after the required 3-6 month period. 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. According to the license date of 12/29/15 staff should have submitted the self assessment that was done in August 2015 instead of the one completed between October and November 2015. See supporting document of the assessment done in August 2015 02/17/2016 Implemented
6400.76(a)The wooden spindles of a chair in the living room were broken. Furniture and equipment shall be nonhazardous, clean and sturdy. the chair was discarded with the weekly trash. It has always been the responsibility of Holcomb' Environment of Care Representative to assist in ensuring this. EOC Report attached 01/27/2016 Implemented
6400.141(c)(7)Individual # 2 had a GYN exam on 1/21/14 but a pap smear was not completedThe physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. The individual received a pap smear on 3/7/16. The supervisor has always been responsible for ensuring that all annual medical appointments are completed in a timely manner without any lapse in appointments. See supporting documents. [The Program Specialist will review all female Individuals physical examination to ensure that a gynecological examination was included, starting immediately. SW 3.8.17] 03/07/2016 Implemented
6400.163(c)Individual #2 had a psychological review due in April 2015 and it was not completed until May 27, 2015. Individual #2 had a psychological review due in September 2015 and it was not completed until November 6, 2015. 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.There was a lapse in medication review appointments due to the individual's physician's retirement and difficulty finding another provider. It is the site supervisor's responsibility to ensure that all individuals receiving medication to treat maladaptive behavior are seen every 3 months by a licensed physician. Supporting documents submitted to show that the supervisor was trying to find a licensed physician to complete med checks for this individual. Individual # 2 has had a med check I November 2015 & in February 2016 (attached)[The Program Specialist will conduct quarterly reviews of all Individual records to ensure that a medication review is completed if the Individuals are prescribed medications to treat a psychiatric illness, starting immediately. SW 3.8.17] 02/16/2016 Implemented
6400.168(d)Staff 7's previous medication training was completed on 2/14/14 and the annual practicum for 2015 was not completed. Staff 8's previous medication training was completed on 12/2/14 and the most recent was completed on 12/23/15. Staff 9's previous medication training was completed on 12/16/14 and the most recent was completed on 12/23/15. Staff 10's previous medication training was completed on 12/16/14 and the most recent was completed on 1/1/16. "This is a redeated violation from 10/30/14, et al"A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. Per instructions from state inspectors, remediation would need to occur for staff 7 to give meds. On 1/29/ 16 4 MAR Reviews were completed with passing results. On 1/30/16 (2 )practicum observations were completed for this individual with passing results. See supporting documents.[The Program Director will develop an auditing document to track the dates of annual practicums for all staff administering medications within 10 days of receipt of this plan of correction and will audit all staff training to ensure only staff with current practicums are administering medications, starting immediately. SW 3.8.17] 01/30/2016 Implemented
6400.185(a)Individual #2 annual ISP date is 5/8/15. A quarterly dated 6/30/15 indicates it covers April, May and June which reflects that it overlaps two separate ISP plansThe ISP shall be implemented by the ISP's start date. All Program Specialists will use the quarterly chart to ensure they are in compliance with ISP start date for a residential clients. The supervisor and the site coordinator will be responsible for ensuring compliance. A copy of the Quarterly chart will be submitted with supporting documents. [The Program Director will review the quarterly chart to ensure that the ISP is implemented by the start date for all Individuals, starting immediately. SW 3.8.17] 02/16/2016 Implemented
SIN-00077833 Renewal 10/29/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(e)Staff B was hired on 4/23/14, but did not receive training on Individuals with Intellectual Disabilities until 6/6/14. Program specialists and direct service workers shall have training in the areas of mental retardation, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. It is the responsibility of the supervisor to provide on-site orientation & IDD training within 30 days of hire. The coordinator Is responsible to assure that training occurs per 6400 regs. All newly hired staff will receive training on individuals with IDD. See attached 12/05/2014 Implemented
6400.168(a)Staff G administers medication, but has not completed medication administration training. In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. Staff G attended and passed the Medication Course & Practicum on 5/15& 16/14.A policy has been put in effect to require all staff & Medication Administration Trainer to complete required Practicum & MAR Reviews in a timely manner.Documentation to support this on going training is to be submitted quarterly. Staff not in compliance will not be permitted to administer medications. See attached documentation 05/16/2014 Implemented
6400.168(d)Staff H received medication administration training on 8/16/12, but does not have a current medication administration practicum. A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. Staff H attended & passed the Medication Course and Practicum on 12/15& 16/14. A Policy has been put in effect to require all staff & medication Administration Trainer to complete required practicum & MAR reviews in a timely manner. Documentation to support this ongoing training is to be submitted quarterly. Staff not in compliance will not be permitted to administer medications.See Attached documentation 12/16/2014 Implemented
SIN-00053557 Renewal 10/11/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff A was hired 3-25-13 and her criminal history check was completed on 4-3-13.(a) An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. An application for a PA criminal history record check will be submitted to the PA State Police for all prospective employees within 5 days after the person's date of hire. The HR instructions have been revised to reflect this.SEE ATTACHED. In addition the Coordinator will be responsible to check with HR that the check has been completed before the person has direct contact with individuals. SEE ATTACHED MEMO 11/12/2013 Implemented
SIN-00041054 Renewal 09/19/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(8)Annual GYN and mammogram exam was not completed.(8) A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. (7) A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. The individual was admitted on 7/3/12. She had a mammogram on 11/3/11 and had a Genitourinary exam & breast exam on 1/13/12. A pelvic exam was not performed at that time due to patient resistance & anxiety. It was noted that an exam under anesthesia was discussed but was not recommended at the time as individual is not sexually active & has never menstruated. Family physician did not forward this information until 10/4/12. PCP data attached. From the date of this POC, the program coordinator has assumed the ongoing responsibility of reviewing pertinent documentation and ensuring required paperwork is intact as part of the admission process. This task has been added to the coordinators responsibility checklist. See Attached. 10/31/2012 Implemented
6400.181(e)(12)Individual¿s assessment did not include recommendations for specific training, programming or services.(12) Recommendations for specific areas of training, programming and services. The assessment form contains this information however the recommendations for specific training, programming or services had not been filled out. See memo to program specialist to make sure that all assessment information is completed. See attached assessment and memo to program specialist. Program coordinator will review all assessments completed by the program specialist to ensure that all required info is included on an ongoing basis. See attached assessment and memo to program specialist. This has been added to the coordinators responsibility checklist of duties. 10/30/2012 Implemented
6400.181(f)Support Coordinator was not informed of results of individual¿s assessment at least 30 days prior to the ISP annual update meeting.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). The assessment was sent to the SC 30 days prior to the ISP meeting however there was no supporting documentation in the individual's file. A standard form letter has been developed to send with every assessment. See completed signature page for individual assuring that it was sent 30 days prior to ISP meeting. This letter will be sent 30 days prior to all upcoming ISP meetings. 10/09/2012 Implemented
6400.186(a)ISP review for 4/12 and 7/12 was not completed for individual # 2.(a) The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. Review is completed and is included with the POC. Site Coordinators/supervisors will complete and review with team ongoing according to the ISP. see supervisors/coordinators revised schedule. 11/28/2012 Implemented
6400.186(c)(2)ISP review was not specific to the facility.(2) A review of each section of the ISP specific to the residential home licensed under this chapter. The quarterly review was revised to include each section of the ISP specific to the individual and the facility. Ongoing the program coordinator will be responsible to update, monitor, and review with the team. See attached schedule. 11/28/2012 Implemented