Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00184996 Renewal 03/18/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(3)Individual #1 most recently received the Tdap immunization on 07/20/09. Tdap booster shots are recommended by the Unites States Public Health Service, Center for Disease Control every 10 years.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. The most recent physical examination form for Individual #1 did not include updated vaccination information. A request was immediately made to individual #1¿s primary care physician and confirmation of an appointment to receive any necessary vaccines was received (attachment #1). The individual #1 attended this appointment and received the TDAP vaccines (attachment #2). The Program Manager will ensure that clients receive necessary vaccines by adding a new section to the physical forms related to vaccines (attachment #3) and ensuring that Program Specialists review the physical form after every appointment to ensure information is complete. During the physical form review process and on an ongoing basis when physical forms are received by the Program Manager or Program Specialist, the physical form will be reviewed against PA Code 6400.141(c) regulations pertaining to required information to be included in the physical form documentation. This includes information pertinent to vaccinations. When areas of information are discovered to be missing on an individual¿s physical form, the Program Manager will fax a letter of request to the physicians' office requesting the missing information. The missing information received following the request shall be signed by the physician or designee (as specified in the PA Code 6400.141(b) and will be added as an addendum stapled to the physical form. The Program Manager will maintain a folder of all faxed requests. When the information is complete, the Program Manager will denote on the request, the date and time the information was received and ensure the information is filed in the individual¿s record. In instances where 1 week has elapsed and the information has not yet been received, the Program Manager will send a second request via fax to the physician's office. Once all physical information is complete, the Program Manager will inform the Director via email that all actionable items have been addressed pertaining to the individual¿s physical form. The Program Manager and all Program Specialists were trained on this process 3/29/2021 (attachment #4). 03/30/2021 Implemented
6400.142(a)Individual #1's most recent dental examination was completed on 02/15/18.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. The most recent dental examination for Individual #1 was completed in 2018. A request was immediately made to individual #1¿s dental care provider and confirmation of an appointment for routine gum and denture care was scheduled for April 21, 2021 (attachment #5). Beginning April 1, 2021, the Program Manager or designee will review individual¿s scheduled appointments to ensure that all individuals are scheduled for and attend dental appointments in accordance with PA Code 6400.142. If an individual refuses to attend an appointment, the Program Manager or designee will document this in accordance with PA Code 6400.143. 04/21/2021 Implemented
SIN-00105954 Renewal 12/22/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.164(a)Levetiracetam, 250 mg tablet, one tablet, twice daily prescribed for Individual #1 was discontinued on 9-26-16. The medication was listed on the Individual #1's December 2016 medication log. A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. All medications received for the individual #1 will be checked with the labels prior to distribution to individual #1. This will be done initially when the medications are received from the pharmacy and then staff will check labels and medication with the Medication Administration Report (MAR) prior to administering medications to individual #1. Staff will complete the MAR each time medications are administered and program specialist will review the MAR on a regular basis. [Immediately and at least monthly, the program specialist shall review all individuals' medications, medication administration records and physician's orders to ensure all individuals are administered medication as prescribed and the medication administration records list the medications prescribed as required. Immediately, all staff persons qualified to administer medication shall be trained in the aforementioned procedures to ensure all individuals are administered the correct medications and the medication administration record for all individual list the prescribed medications as required. Documentation of training shall be kept. (AS 2/3/17)] 01/20/2017 Implemented
6400.186(b)Individual #1 did not sign the 3 month ISP review ending on 1-14-16.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. The program specialist will ensure that all required signatures are obtained and reviewed prior to the end of meetings. The program specialist will create a meeting agenda to include an area for obtaining the individual #1's signature at the close of all meetings. The program specialist will be able to demonstrate this at individual #1's quarterly meeting on 01/19/2017. [Immediately, the program specialist(s) shall review all individuals most recent 3 month ISP review to ensure the program specialist and individual sign and date the ISP review upon review. At least quarterly, for 1 year the executive director shall review a 25% sample of 3 month reviews to ensure the program specialist and individual sign and date the ISP review upon review. (AS 2/3/17)] 01/20/2017 Implemented
SIN-00087560 Renewal 12/11/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)At 9:27 AM, the hot water measured 129.7 degrees Fahrenheit in the bathtub in the home. Hot water temperatures in bathtubs and showers may not exceed 120°F. The water heater was turned down in the home. The thermometer that was being used to test the water temperature was malfunctioning and reading temperatures that were 20 degrees off actual temperatures. A new extech thermometer was purchased to use for water temperature checks. The water temperature has been placed on the monthly site visit check form to check for compliance. In addition, any time that staff feels that the water temperature may exceed 120 degrees the staff have been trained by the Program Specialist to inform the Program Specialist so that water can be checked more frequently if necessary[Activity Coordinator will complete site visit checklist and submit to Program Coordinator for review. Program Coordinator will assign needed work to the Program Specialists to be completed or coordinate with maintenance department within one week and then report back to Program Coordinator. (AS 12/31/15)] 12/23/2015 Implemented
6400.77(b)The first aid kit did not contain a thermometer. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. A thermometer was purchased and placed in the first aid kit. The contents of the first aid kit has been placed on the monthly site visit list to be checked on a monthly basis for compliance. A copy of the site visit form will be sent to BHSL for review.[Activity Coordinator will complete site visit checklist and submit to Program Coordinator for review. Program Coordinator will assign needed work to the Program Specialists to be completed or coordinate with maintenance department within one week and then report back to Program Coordinator. (AS 12/31/15)] 12/23/2015 Implemented
SIN-00146341 Renewal 12/04/2018 Compliant - Finalized