Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00264592 Unannounced Monitoring 04/14/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(2)The name of the prescriber listed on each of Individual #1's medications is not listed on the MAR.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.Agency nurse, updated each of the medications on 4/17/2025 to ensure the prescriber was included. 04/17/2025 Implemented
6400.166(a)(11)The MAR does not list the diagnosis for each medication listed for Individual #1.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Agency nurse, updated each of the medications on 4/17/2025 to ensure the diagnosis was included. 04/17/2025 Implemented
SIN-00257712 Unannounced Monitoring 11/13/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(b)(1)Staff # 9 reported during an interview on 12/17/24, that the Division Manager is required to complete weekly audit forms as per the Division Manager Job Description. The Division Manager Job Description reads "Conduct scheduled and unscheduled site visits on a weekly basis to review environment, documentation, staff, and person served activities/interactions to ensure compliance with Agency and regulatory standards. Visits should rotate to different shifts over the month, complete weekly audit forms to document visits. Numerous Medication Administration documentation errors occurred in July 2024, September 24, and November 24. The medication administration documentation errors were verified by staff # 2, via email, during this investigation. Staff # 9 did not ensure the implementation of policies and procedures of the agency as the Division Manager did not complete weekly audit forms as per the Division Manager Job Description. Email Confirmation that the Division Manager did not complete weekly audit forms was provided by Staff # 1 on 12/17/24.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. The Division Manager in Lancaster was terminated effective 12/06/2025 for various reasons, including failure to perform job duties as assigned. An interim Division Manager was put into place until permanent staffing can be hired. A House Manager was hired and started work on 01/21/2025. The job description of the Division Manager was changed to allow for any level of management to complete a weekly audit form of the site. The weekly audit form was revised and implemented on 01/03/2025 (see attachment 14). The completed site forms will be submitted and reviewed by the IDD Director on a bi-weekly basis. All identified deficiencies will be addressed by the program management. IDD Director will report to COO during weekly supervision re: compliance with Weekly Audit completion. 01/21/2025 Not Implemented
6400.43(b)(3)As indicated in the violations of Chapter 6400:20b, 20c3, 20e, 32c, 32g, 169a and 186, the safety and protection of Individual # 1 was not ensured by the staff #9.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. Staff participated in a mandatory townhall meeting on 01/14/2025 (see attachment 2). The COO was in attendance along with the Compliance Manager, IDD Director and other program leadership. The topics discussed were Incident Management including incident reporting timelines, Recognizing and Reporting Incidents and Abuse/Neglect/Exploitation. Emergency Procedures were discussed including the use of a phone tree (see attachment 1) to notify management of unusual outcomes including potential or actual medication errors. During the meeting COO reviewed the incidents which occurred re: 20c3, 20e and informed all staff of the requirement to report issues to supervisor or above. Also reviewed Ethics Point (see attachment 3) as a secondary option to report concerns. COO also visited the homes on 1/14/25 and spoke to staff individually to reiterate the expectation of staff reporting as well as outreaching IDD Director and COO for any concerns. 01/14/2025 Not Implemented
6400.62(a)(Repeat 06/26/23) Cleaning supplies under the kitchen sink which are poisonous were left unlocked during an unannounced physical site walk through on 11/15/24. The padlock was left open.Poisonous materials shall be kept locked or made inaccessible to individuals. The House Manager was terminated on 12/5/24 due to failure to perform job duties. The padlock was replaced on 1/6/25 with an automatic lock (see attachment 13). The door now automatically locks when closed. See Attachment 13 for evidence of New Automatic Lock. Additionally, effective 1/8/25, the interim Division Manager retrained all staff on the ISPs. The ISP training including the requirement of locking cleaning supplies and all poisonous objects as per ISP (see attachment 8). See Attachment 8 for evidence of ISP Training. 01/08/2025 Implemented
6400.67(a)The closet bifold door (left door) outside of the bathroom was off its track and unable to be opened during the physical site walk through on 11/15/24.Floors, walls, ceilings and other surfaces shall be in good repair. The sliding door was repaired by Holcomb maintenance team on 12/23/2024 (see attachment 9). See Attachment 9 re: Evidence of Repair. As of 1/7/25, the interim Division Manager retrained all staff on agency ticket system used to report maintenance needs in the home (see attachment 10). See Attachment 10 for evidence of staff training on Ticket System. 01/07/2025 Implemented
6400.181(a)An annual assessment was not completed for Individual # 1 in 2024 as of 12/01/24. The previous assessment was completed on 05/21/23. This has been confirmed by Staff # 1 via email on 12/04/24, who wrote "she (program specialist), has yet to produce a signed copy to us.". 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. The Division Manager and House Manager of Lancaster County were terminated for not following Chimes/Holcomb's policies/procedures. Although multiple polices/procedures were violated, the Program Specialist procedure violation was a contributing factor to both terminations. A new program specialist was designated on 12/05/2024 and was fully trained on the duties/responsibilities and procedures the Program Specialist is required to follow. A new assessment was completed for the individual on 12/23/2024 (see attachment 6). The updated assessment was sent to the Supports Coordinator. 12/23/2024 Implemented
6400.213(6)An annual assessment was not completed for Individual # 1 as of 12/01/24. The previous assessment was completed on 05/21/23. This has been confirmed by Staff # 1 via email on 12/04/24, who wrote "she (program specialist), has yet to produce a signed copy to us.".Each individual's record must include the following information: Assessments as required under § 6400.181 (relating to assessment). The Division Manager and House Manager of Lancaster County were terminated for not following Chimes/Holcomb's policies/procedures. Although multiple polices/procedures were violated, the Program Specialist procedure violation was a contributing factor to both terminations. A new program specialist was designated on 12/05/2024 and was fully trained on the duties/responsibilities and procedures the Program Specialist is required to follow. A new assessment was completed for the individual on 12/23/2024. The updated assessment was sent to the Supports Coordinator. See Attachment 6 - Assessments to show all assessments are complete. 12/23/2024 Implemented
6400.20(c)(3)Incident Report # 9343736 describes a medication omission for Individual # 1 on 01/05/24. The description reads "Staff working at time of medication administration was temporary staff and not certified to administer medication. Division manager was unable to administer medications due to covid positive status but directed another staff member from a different residence to go to residence to administer medications, but staff misunderstood instructions and Division manager did not follow up to ensure instructions were followed. This reporter was unaware of the medication error until 1/10/24 which is why this report is late. Staff responsible for initial reporting will be retrained to address lateness of reporting". Incident Report # 9349227 describes a medication omission for Individual # 1 on 01/20/24. The description reads "Staff on duty at the time of the medication administration was temporary staff and not certified to administer medication. House supervisor did have a plan in place to send staff to administer medications. Staff designated to travel and administer medications did attempt to travel to the home, but the weather conditions were unsafe to travel. Staff did attempt to reach the home but turned back when the medication administration window had exceeded one hour." Agency completes incident reviews each month as per staff # 2. Staff #5 reported during an investigatory interview on 11/27/24 that "(first home) staff don't work at (second home) but (second home) staff have been mandated to help at (first home) to give meds." Incident # 9516320 which occurred on 11/08/24 describes a medication omission for Individual # 1. The description reads "Staff on shift was not certified to administer medications, by the time alternated staff arrived who was certified, the hour window for medication administration had passed." The agency did not identify and implement preventive measures to reduce the number of incidents.The home shall identify and implement preventive measures to reduce: The likelihood of an incident recurring.An empirical analysis was completed for all medication related issues identified during the ODP visit, including the medication omissions from January 2024 and November 2024. The results, discussed in the Quality Management meeting on 12/19/2024, indicated a lack of MAT trained staff in Lancaster. In response, on 12/02/2024 Chimes Holcomb contracted with a nurse who is a certified medication trainer (see attachment 4). The nurse trained all staff in Medication Administration so that the agency has a deeper pool of Med Trained staff to be used in order to prevent incidents such as medication omissions. The agency also made a change and is now certifying agency staff (Temps) in Medication Administration. The first medication class was held on 12/27/2024. A subsequent training class was conducted on 01/10/2025. Further, effective 1/21/25, when releasing the schedule, the Manager will identify back up staff for medication administration on each shift in order to prevent future incident. Staff participated in a mandatory townhall meeting on 01/14/2025 (see attachment 2). The COO was in attendance along with the Compliance Manager, IDD Director and other program leadership. The topics discussed were Incident Management including incident reporting timelines, Recognizing and Reporting Incidents and Abuse/Neglect/Exploitation and clients rights. Emergency Procedures were discussed including the use of a phone tree (see attachment 1) to notify management of unusual outcomes including potential or actual medication errors. The phone tree was posted in both Lancaster sites on 1/4/2025. 01/14/2025 Not Implemented
6400.20(e)Incidents # 9343736, # 9349227 and # 9516320 all describe staff on shift not certified to administer medications. Actions were not taken by the agency to mitigate or manage risks. Recurrent pattern of the impact of staff not certified to administer medications on Individual # 1 is demonstrated by; Individual # 1 was required to travel to another home on 08/12/24, 09/29/24, 09/30/24 and 10/22/24 (rights violations) due to not having enough medication trained staff to pass medications. Staff # 1 confirmed via email that the reason Individual # 1 had to go to another home was due to staffing shortages and for staff to pass medications. In addition, the agency did not complete the three-month incident analysis as described in violation # 20b.The home shall monitor incident data and take actions to mitigate and manage risks.An empirical analysis was completed for all medication related issues identified during the ODP visit, including the medication omissions from January 2024 and November 2024. The results, discussed in the Quality Management meeting on 12/19/2024, indicated a lack of MAT trained staff in Lancaster. In response, Chimes Holcomb contracted with a nurse who is a certified medication trainer (see attachment 4). The nurse trained all staff in Medication Administration so that the agency has a deeper pool of Med Trained staff to be used in order to prevent incidents such as medication omissions. The agency also made a change and is now certifying agency staff (Temps) in Medication Administration. The first medication class was held on 12/27/2024. A subsequent training class was conducted on 01/10/2025. In order to mitigate future risk, effective 1/21/25, the manager will now identify a back up staff who will conduct medication administration should something occur whereby original staff is unable to administer medication. Further, staff participated in a mandatory townhall meeting on 01/14/2025 (see attachment 2). The COO was in attendance along with the Compliance Manager, IDD Director and other program leadership. The topics discussed were Incident Management including incident reporting timelines, Recognizing and Reporting Incidents and Abuse/Neglect/Exploitation. Use of Phone tree (see attachment 1) was identified to all staff by IDD Director, and staff were re-trained that they must adhere to phone tree/Emergency protocol to notify management immediately if med admin will/may not occur timely. Client's Rights was also retrained at the townhall by COO, Compliance Manager and IDD Director. 01/21/2025 Implemented
6400.32(c)On 09/17/24, Individual # 1 was required to attend a medical appointment for another individual due to short staffing. Staff # 2 emailed to this investigator that the reason for Individual # 1 being required to attend the medical appointment for another individual was "Staffing was quite low, and they were focused on accommodating the appointment". Individual # 1's daily case note reads "Individual # 1 fell asleep beginning of shift until 9:39. Individual # 1 went with staff to take Individual # 2 to appointment. VERY ANXIOUS THERE." Staff # 6 who brought Individual # 1 to the appointment reported during an interview that Individual # 1 was not offered the option of not attending the appointment. Additionally, Staff # 6 reported that Individual # 1 was required to go into the treatment room for Individual # 2's eye exam. On 09/10/24, Individual # 1 was required to attend a medical appointment for Individual # 2. Staff # 6 who brought Individual # 1 to the dental appointment for Individual # 2 reported that Individual # 1 was not offered the option to not attend the appointment. Staff # 2 explained via email that the reason why Individual # 1 was required to attend the medical appointment was "Due to overall staffing being very minimal, and they wanted to accommodate the appointment". On 07/10/24, Individual # 1 was required to attend a medical appointment for Individual # 3. Staff # 6 who brought Individual # 1 to the dental appointment for Individual # 2 reported that Individual # 1 was not offered the option to not attend the appointment. Staff # 2 explained via email that the reason why Individual # 1 was required to attend the medical appointment was "Staffing was poor, and they were focused on accommodating the appointment."An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.An interim Division Manager has been identified and started working in the Lancaster homes. A permanent Division Manager is being identified and will solei be responsible for management of the Lancaster homes. A House Manager for Lancaster was hired and began work on 01/21/2025. In order to address the staffing shortage for Lancaster, the recruitment department assigned a recruiter specifically to the Lancaster sites. A staffing agency has been identified to locate immediately temporary staffing to fill the gaps in the schedule until permanent staff can be hired. Two outside recruitment agencies have been identified and are assisting in the location and hiring of permanent staff. Two hiring events have been scheduled for 01/22/2025 and 01/30/2025. The pay scale has also been increased in Lancaster to be more competitive with other IDD providers in the area. As of 1/14/25, all staff were trained in Abuse Prevention. See Attachment 2. A mandatory training was conducted on 01/14/2025 (see attachment 2) by compliance manager, IDD Director and COO - during which compliance retrained all Lancaster staff on incident reporting timelines as well as abuse, neglect and exploitation and individual rights (see attachment 5). During this townhall, emergency procedures were discussed including the use of a phone tree (see attachment 1) to notify management of issues including potential or actual medication errors. The training department has developed a tracking system for all IDD training. COO reiterated that under no circumstances should an individual attend another's appointment. COO informed staff they must use emergency protocol/phone tree and report if staff are being asked to do so or if they witness an attempt to do so. 01/30/2025 Implemented
6400.32(g)On 11/15/24 from 8:45-11:20 pm, Individual # 1 was observed being required to sit in the staff office instead of receiving support in his home. Staff # 3 stated "on the days that she has office hours, Indivdiual # 1 sits in the office with her." She reported that she has office hours one time per week and that they were planning to stay in the office until lunch time outing. When I inquired how long Individual # 1l has been in the office, she reported since 8:45 am. Individual # 1 sat in office with staff until they left for lunch at 11:30 am. Additionally, Individual # 1 was required to go to another home for staff to pass medications (he did not request to visit) on 08/12/24, 09/29/24, 09/30/24 and 10/22/24. Staff #1 confirmed via email, during the investigation, that Individual # 1 needed to go to other home due to staffing shortage and for staff to pass medications.An individual has the right to control the individual's own schedule and activities.In order to address the staffing shortage for Lancaster, the recruitment department assigned a recruiter specifically to the Lancaster sites. A staffing agency has been identified to locate immediately temporary staffing to fill the gaps in the schedule until permanent staff can be hired. Two outside recruitment agencies have been identified and are assisting in the location and hiring of permanent staff. Two hiring events have been scheduled for 01/22/2025 and 01/30/2025. The pay scale has also been increased in Lancaster to be more competitive with other IDD providers in the area. The Lancaster management (House and Division Managers) were terminated due to a failure to follow Chimes Holcomb's policies and procedures including individual rights and incident management. The House Manger was terminated on 12/05/2024. The Division Manager was terminated on 12/6/2024. A copy of the Individual's Rights (attachment 11) was posted in all sites on 01/03/2025 as well as information on the Ethics Point (see attachment 3) hotline. Ethics Point allows staff to report issues anonymously. Staff participated in a mandatory training on 01/14/2025 (see attachment 2). The COO was in attendance along with the Compliance Manager, IDD Director and other program leadership. The topics discussed included Individual Rights; Incident Management including Recognizing and Reporting Incidents, Abuse/Neglect/Exploitation and incident reporting timelines. Emergency Procedures were discussed including the use of a phone tree (see attachment 1) to notify management of unusual outcomes such as when an individual is not controlling his schedule, if staff are being asked to transport individuals to other locations for medications, or to accompany another resident to their appointment. Specific information was provided to staff regarding the transportation of individuals to other locations for the ease of programming and how this is a violation of rights. All staff were trained that if a request is made for them to transport their individual to another home for any reason other than a social event that both the individual going and individuals at the destination agree to, they are to report immediately to the next level manager above the requester. Additionally, the training stated that all decisions that may be in violation of a Chimes/Holcomb policy and procedure must be approved by management prior to action being taken. Effective 1/14/25, all staff have been trained in Individual Rights (see attachment 5). 01/30/2025 Not Implemented
6400.44(b)(1)Staff # 4 is the Program Specialist. It was reported by Staff #3, during an interview, that the program specialist does not write the assessment and merely signs the assessment that Staff # 3 writes. Staff # 4 reported during an interview that Individual # 1's last assessment was in 2023 and Staff # 3 did it. Staff # 3 is not a program specialist. Staff # 1 verified during the investigation that the Program Specialist did not complete the 2023 assessment and just signed off on it.The program specialist shall be responsible for the following: Coordinating the completion of assessments.The Division Manager and House Manager of Lancaster County were terminated for not following Chimes/Holcomb's policies/procedures. Although multiple polices/procedures were violated, the Program Specialist procedure violation and failure to follow chain of command were contributing factors to both terminations. A new program specialist was designated on 12/05/2024 and was fully trained on the duties/responsibilities and procedures the Program Specialist is required to follow. A new assessment was completed for the individual on 12/23/2024 (see attachment 6). The updated assessment was sent to the Supports Coordinator. See Attachment 6 - Assessments to show all assessments are complete. 12/23/2024 Implemented
6400.51(b)(5)Staff # 3 has a date of hire of 05/06/24. There is no documentation that staff # 3 was trained in job related knowledge and skills.The orientation must encompass the following areas: Job-related knowledge and skills.The Division Manager was terminated on 12/6/2024. A review was done of all training files for Lancaster staff. All staff were reoriented to the sites and retrained on job related skills on 01/10/2025 (see attachment 12). 01/10/2025 Implemented
6400.52(b)(3)Staff # 8 is a staff who was hired through a temporary agency on 11/11/23. There is no documentation that Staff # 8 received Orientation training in Individual Rights. Additionally, Staff # 3 has a date of hire of 05/06/24. There is no documentation that Staff # 3 was trained in Individual Rights during orientation.The following shall complete 12 hours of training each year: Consultants and contractors who are paid or contracted by the home and who work alone with individuals, except for consultants and contractors who provide a service for fewer than 30 days within a 12-month period and who are licensed, certified or registered by the department of state in a health care or social service field.The agency staff is no longer being utilized by Chimes/Holcomb. The House Manager was terminated from employment on 12/5/2024. The Division Manager was terminated on 12/6/2024. A review was done of all training files for Lancaster staff. Staff participated in a mandatory training on 01/14/2025 (see attachment 2). The COO was in attendance along with the Compliance Manager, IDD Director and other program leadership. The topics discussed included Individual Rights. Additionally, all Holcomb employees completed the ODP Individual Rights (see attachment 5) course. 01/14/2025 Implemented
6400.52(c)(3)(Repeat 05/14/24)- Staff #8 is a staff who was hired through a temporary agency. There is no documentation that staff # 4 received annual training in individual rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.A review was done of all training files for Lancaster staff. As of 1/14/25, all staff including temps have been trained in Individual Rights. See Attachment 5. Staff including temps participated in a mandatory training on 01/14/2025 (see attachment 2). The COO was in attendance along with the Compliance Manager, IDD Director and other program leadership. Compliance Manager included Individual Rights in his presentation training. 01/14/2025 Not Implemented
6400.52(c)(6)There is no documentation that Staff # 7 or Staff # 8 were trained in Individual # 1's Behavior Support Plan dated 08/08/24 to ensure Plan Implementation.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.The Clinical and IDD Directors met with the Behavior Specialist on 12/23/2024 to review the requirements for staff training on the behavior support plan (initial, at the time of updates and annually). All staff were retrained on the individual's plan on 01/08/2025 (see attachment 7). 01/08/2025 Implemented
6400.169(a)Staff # 5 and Staff # 6 received Initial Medication Training on 06/20/23. Staff # 5 and # 6 had a practicum observation completed on 12/15/23 but did not complete the required second practicum observation prior to their 06/20/24 expiration date. Additionally, Staff # 5 & # 6 did not receive required remediation within 90 days of the original practicum due date. Staff # 5 and # 6 were not recertified to pass medications from July 2024-December 2024 of which they did regularly.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).A contract nurse was hired with the qualifications to teach medication administration and observe practicums (see attachment 4). Medication administration classes were held on 12/27/2024 and on 01/10/2025. All staff in Lancaster were certified in Medication Administration. The agency also made a change to policy to allow for agency staff (temps) to be trainline by Holcomb for Medication Administration. Temps are in process of securing MAT; this will be finalized one the ODP site is back up. 01/31/2025 Implemented
6400.181(f)An annual assessment was not completed for Individual # 1 as of 12/01/24. The previous assessment was completed on 05/21/23. On 12/02/24, staff # 1 confirmed via email that "the program specialist, has yet to produce a signed copy to us." A copy of the plan is to be sent to the SC/Plan team at least 30 days prior to the Annual ISP.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.The Division Manager and House Manager of Lancaster County were terminated for not following Chimes/Holcomb's policies/procedures. Although multiple polices/procedures were violated, the Program Specialist procedure violation was a contributing factor to both terminations. A new program specialist was designated on 12/05/2024 and was fully trained on the duties/responsibilities and procedures the Program Specialist is required to follow. A new assessment was completed for the individual on 12/23/2024 (see attachment 6). The updated assessment was sent to the Supports Coordinator. 12/23/2024 Implemented
6400.182(a)An annual assessment was not completed for Individual # 1 as of 12/01/24. The county service coordinator sent a letter to the agency which requested a copy of the assessment of which they did not receive. The county service coordinator emailed that "A letter that was dated 10/16/24, was sent to the residential provider as I/BHDS had never received AA's annual assessment." On 12/02/24, staff # 1 confirmed via email that "the program specialist, has yet to produce a signed copy to us.The program specialist shall coordinate the development of the individual plan, including revisions with the individual and the individual plan team.The Division Manager and House Manager of Lancaster County were terminated for not following Chimes/Holcomb's policies/procedures. Although multiple polices/procedures were violated, the Program Specialist procedure violation and lack of responsiveness was a contributing factor to both terminations. A new program specialist was designated on 12/05/2024 and was fully trained on the duties/responsibilities and procedures the Program Specialist is required to follow. A new assessment was completed for the individual on 12/23/2024 (see attachment 6). The updated assessment was sent to the Supports Coordinator. 12/23/2024 Implemented
6400.186(Repeat 06/26/23)- Individual # 1's ISP last updated 10/02/24 reads "Individual # 1 has a history of elopement. He will often elope from his bedroom window. Safety checks occur every 10 minutes. Staff will provide Individual # 1 with the needed supervision." Additionally, Individual # 1's Behavior Support Plan dated 08/08/24 reads, "His Alone Time sheet is to be completed daily by all staff. He is to be checked on during alone time every 10 minutes during the day and night." Staff # 1 reported via email on 12/06/24 that "There are no safety checks for Individual # 1". An email with the county service coordinator received on 12/13/24 indicated that the safety checks were still in place and current as written in the 10/02/24 ISP. Individual # 1's Behavior Support Plan last updated 08/08/24 identified Goal # 5 as related to his health and safety in removing his eyebrows. The plan reads "When Individual # 1 is out of eyesight, check on him frequently (every 10-15 minutes) to ensure that he is not picking his eyebrows." On 10/03/24, a daily note written by Staff # 3 reads "It was noted that Individual # 1 pulled all of his eyelashes and eyebrows out the day before." There is no documentation that 10--15-minute checks were completed to ensure Individual safety. Staff # 1 reported via email on 12/06/24 that "There are no safety checks for Individual # 1". An email with the county service coordinator received on 12/13/24 indicated that the safety checks were still in place and current in the ISP. Individual # 1's Behavior Support Plan dated 08/08/24 reads, "Mark a tally for adaptive urinating and/or defecating on your data sheet. Also note what happened before and after in the comments section below clearly and legibly." Bowel Tracking was not completed on the following dates 09/08, 15, 22, 28, 29/24; 10/06, 12, 13, 20, 26, 27/24; 11/10, 11, 17, 21, 23, 24, 28, 29, 30/24 and 12/01/24. Additionally, comments of what happened before and after were not completed for each bowel movement. Urinating was not tracked on the daily data sheet as required. Individual # 1's ISP last updated 10/02/24 reads "Individual #1 requires constant staff supervision (within eyesight) at all times when in the home, while awake." The ISP also reads "Individual # 1 requires constant supervision and structure. This is important to Individual # 1 because he can be unpredictable and Impulsive." During an on-site health and safety check on 11/15/23, at 11:06 am, Staff # 3 left the office area and went into the office storage area while Individual # 1 was in the office. Constant line of sight supervision was not maintained. Additionally, at 11:23 am, Staff # 3 left Individual # 1 in the parking lot area by the van to go back into the office. Constant line of sight supervision was not maintained. Staff # 3 returned at approximately 11:24 am. Finally, at approximately 12:00 pm, Staff # 3 was washing dishes while Individual # 1 was pacing between the living room and dining room. Constant line of sight supervision was not maintained.The home shall implement the individual plan, including revisions.The Division Manager was terminated from employment effective 12/06/2024 for multiple reasons including not following company policy and procedure. The Clinical Director, Director of IDD, and the Behavior Specialist met on 12/19/24 to over all Behavior Specialist role and requirements, BSP planning, notification to SC, and to discuss the individual's plan. Updates were made to the plan eliminating behavior tracking. The Director reached out to the Supports Coordinator with the needed updates to the ISP on 12/23/2024. The ISP was updated in HCSIS on 01/07/2025. Lancaster staff were trained on the updated ISP and BSP on 01/08/2025 (see attachment 7 and attachment 8). 01/08/2025 Implemented
SIN-00244607 Renewal 05/14/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.142(a)Individual # 1 received a Dental Examination on 07/15/22 but did not receive a dental examination in 2023. An appointment refusal was made on 04/11/23. No Follow Up appointment was scheduled in 2023.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. Individual # 1 is scheduled for a dental exam on 9/23/24. 06/01/2024 Implemented
6400.142(e)Individual # 1's Dental examination on 07/15/22 diagnosed Periodontal Disease, Needs SRP all quadrants and 4 appointments needed due to local anasthesia. No Follow up treatment was provided.Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed.All periodontal disease will be addressed at next scheduled appointment. Staff will request dentist to review full chart to inform the team of any needed procedures or treatment. 06/01/2024 Implemented
6400.144Individual # 1 was recommended a Low fat Diet at the Annual Physical on 02/14/24 due to Fatty Liver Disease Diagnosis. There is no documentation of tracking of Individual # 1's Low Fat Diet.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The individual's dietary guidelines were updated in Therap. Documentation sent directly to inspector. 06/01/2024 Implemented
6400.151(a)Staff # 1 received a Physical Exam on 02/05/21 and not again until 10/17/23. 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. HR will review all staff files and ensure all incoming staff are scheduled for physical examinations 06/01/2024 Implemented
6400.151(c)(2)Staff # 1 received a TB Test on 09/07/21 and not again until 10/19/23. 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. HR will review all staff files to ensure TB test are conducted according to the state guidelines. 06/01/2024 Implemented
6400.151(c)(3)Staff # 2's physical on 08/16/23 does not include a communicable disease statement. 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. On 7/31/23, Staff #2 completed a physical that included the information related to communicable disease. Form will be attached. 05/14/2024 Implemented
6400.50(a)There are no lengths of trainings on some training certificates i.e. Communicable Disease Training, Bloodborne Pathogens, Fire Safety for Community and Residential Living. Lengths of training are required for training records.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.The training department will update certificates to include the length of time for trainings and create an inspection checklist for annual inspections. 06/01/2024 Implemented
6400.52(c)(3)Staff # 3 did not receive Individual Rights training in 2023.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Staff # 3 completed the Individual Rights training on 5/26/24. Please see attached certificate. 06/01/2024 Implemented
SIN-00225397 Renewal 06/26/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)The first aid kit was unlocked in a closet aside the kitchen. The kit contained BZK Antiseptic Towelettes that state contact poison control center. Individual #1 is not safe around poisons.Poisonous materials shall be kept locked or made inaccessible to individuals. First aid kit was locked during the inspection period on June 27th, 2023. All staff will be informed to keep first aid kit locked at this home unless being utilized for medical reasons by 7/30/2023. 07/30/2023 Implemented
6400.67(a)The outside upper front door light is dirty. The light was filled with debris and bugs.Floors, walls, ceilings and other surfaces shall be in good repair. Provider staff cleared the debris from light on June 28th, 2023 and sent pictures. 06/28/2023 Implemented
6400.112(e)Asleep fire drill was greater than 6 months from previous asleep fire drill. Drills were recorded on 2/27/23 and 6/14/22.A fire drill shall be held during sleeping hours at least every 6 months. Provider will conduct an unannounced fire drill during sleeping hours on 7/26/2023 and then conducted each quarter thereafter. 07/26/2023 Implemented
6400.216(a)Individual #1 personal communication/data sheet/daytime check-in/sleep chart/body exam/dental hygiene/ ISP book was left out, unlocked on the kitchen counter by fridge during the licensing walkthrough. An individual's records shall be kept locked when unattended. All individual records were locked immediately after discovery on June 27th, 2023. Staff will be re-trained by Division Manager to keep all individual records locked when unattended by 7/30/2023. 07/30/2023 Implemented
6400.15(b)The self-assessment completed for the East Petersburg home on 5/31/23, located on Main Street East Petersburg, contained multiple violations that did not include a plan of correction. The self-citations included: 62a Poisons locked; 62b Poisons unlocked; 64b infestation; 66 lighting; 72a windows doors screens; 82F Bathroom items; 113a Individual trained; 141a physical form; 142 Dental Exam; 151a Staff health; 81e10 Lifetime medical history; 181e13i-181e14 progress assessment; 213 (3) Physical exams; 213(5) Dental Hygiene plans(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.Division manager will be re-trained on the use of self-assement tool by IDD Residential Director. 07/30/2023 Implemented
6400.15(b)The self-assessment completed for the Hempfield home on 5/11/23, located on Cochran Drive Lancaster, contained multiple violations that did not include a plan of correction. The self-citations included: 62c original containers; 64e lids on trash cans; 72a Windows/doors screens; 80b outside conditions;82e nonslip surface; 101 Unobstructed egress; 141c15 diet instructions on physical; 141c14 emergency details not completed on physical form; 181c10 lifetime medical history(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.Division manager will be re-trained on the use of self-assement tool by IDD Residential Director. 07/30/2023 Implemented
SIN-00190751 Unannounced Monitoring 07/20/2021 Needs Verification
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(8)According to regulation, an annual mammogram must be conducted yearly for woman 50 years and older. Individual #2 had an annual exam on 7/12/2019 and not again until 10/21/20. This exceeds the one year and 15 day grace period guidelines set forth by ODP regulation. Individual #2 turned 50 in 2019.The physical examination shall include: 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. All appointments moving forward will be noted in the Medical Module Appointments for Therap. Therap is the electronic record that Chimes is using in all subsidiaries. 09/10/2021 Accepted
6400.181(a)The annual assessment for individual #2 was completed on 5/20/2020 of last year and not again until 7/19/21 which exceeds the one year and 15 day grace period permitted by ODP 6400 regulation. 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. All assessments will be moved to the electronic record (Therap). Once in Therap, all management will be able to check the assessments for timeliness and accuracy. 09/10/2021 Accepted
6400.181(e)(10)There are documentation inconsistencies for Individual #1's medications. The medications on the June and July MAR do not match the medications listed in the most current ISP.The assessment must include the following information: A lifetime medical history, especially for ensuring that medical records are consistent with provider's documentation of individuals' needs.The Division Manager emailed the Supports Coordinator with the updated medications. 09/10/2021 Accepted
6400.166(a)(11)The Medication Administration Record (MAR) for individual #2 lists the following medication: "Medroxyprogesterone 150 mg/m. Generic or medroxyprogesterone 150. Inject every 12 weeks as directed". However, it does not indicate the diagnosis or purpose for the medication on the MAR.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.At the time of the inspection, Chimes was in the process of changing pharmacies from Ganse Apothecary to PDC Pharmacy. The pharmacy officially changed to PDC on 08/18/2021. One reason for the change was the difficulty getting the diagnosis listed under medications with lengthy information included on the MAR. Ganse was providing two copies of the MAR upon delivery. Staff used the version without the diagnosis during the July inspection instead of using the copy of the MAR with the diagnosis. We were able to locate the correct MAR from Ganse for the month of July. Moving forward, the MAR will be electronic in Therap with PDC. 09/10/2021 Accepted
6400.181(f)The assessment for individual #2 was not completed and sent to the individual plan team 30 days prior to the individual plan meeting. The individual plan meeting was held on 5/14/2021 and a letter was sent from the SC to the provider on 6/29/2021 stating that the annual assessment still had not been received. The annual assessment was not completed until 7/19/2021 and wasn't sent to the individual plan team until 7/22/2021. This is a repeat of last year as well. The annual assessment was not sent to the SC until 5/27/2020 but the ISP meeting was held prior to the date it was sent.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.All assessments will be moved to the electronic record, Therap. 09/10/2021 Accepted
6400.181(f)Holcomb staff were unable to verify when or if the assessment for AA was sent to SC.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.All assessments will be moved to the electronic record, Therap. 09/10/2021 Accepted
SIN-00177929 Unannounced Monitoring 10/08/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone located on the office desk does not have emergency phone numbers on or by the telephoneTelephone 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. Holcomb will fix the immediate issue. Then they will conduct a walkthrough of each home to assure compliance for the agency. Holcomb will comply with the settlement agreement. During the monitoring, Assistant Manager, attached the emergency numbers to the new phone in the office at the location. 10/08/2020 Implemented
SIN-00176800 Unannounced Monitoring 09/25/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The outside front porch light was full of dead bugs and debris.Clean and sanitary conditions shall be maintained in the home. Provider will continue to follow the settlement agreement and implement technical assistance provided by the department. Maintenance was dispatched to the home to clean the front porch light. They cleaned the fixture and removed the dead bugs and debris. 09/28/2020 Implemented
6400.74The steps to the attic do not have a nonskid surface,Interior stairs and outside steps shall have a nonskid surface. Provider will continue to follow the settlement agreement and implement technical assistance provided by the department. The attic access is a pull down ladder. A non-skid surface was added to the rungs of the ladder. 09/28/2020 Implemented
6400.76(a)Individual #1's nightstand is broken. The top panel above the top drawer is broken off and was laying on top of the nightstand. Individual #1's long dresser with mirror, the right side, third drawer down is broken. The left side of the drawer has broken wood. Furniture and equipment shall be nonhazardous, clean and sturdy. Provider will continue to follow the settlement agreement and implement technical assistance provided by the department. Individual #1's nightstand was repaired. 09/28/2020 Implemented
SIN-00173225 Unannounced Monitoring 06/03/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The first aid kit did not contain scissors. 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. Holcomb will correct the immediate issue and then correct the issue agency wide. They will continue to follow the settlement agreement. 06/03/2020 Implemented
6400.77(c)The first aid kit did not contain a first aid manual. A first aid manual shall be kept with the first aid kit.Holcomb will correct the immediate issue and then correct the issue agency wide. They will continue to follow the settlement agreement. 06/03/2020 Implemented
SIN-00172664 Unannounced Monitoring 03/20/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The shower/bathtub spout was broken, thus only allowing the individuals to engage the shower head mechanism to shower. The option to use the bathtub was not operable during the 3/20/2020 inspection.Floors, walls, ceilings and other surfaces shall be in good repair. Provider, Holcomb, will fix the shower/bathtub faucet by the time the POC due date, 4/6/2020. Direct support staff will document daily that all surfaces are in good repair throughout the entire home. If any surface is found not in good repair, staff will document the issue, and report any and all issues the same day to management staff. Any surface not in good repair that is found and reported, will be fixed immediately. 03/23/2020 Implemented
6400.32(r)(1)Individuals #1's and #2's bedroom doors did have a key locking mechanism on the door. However, per quality management Staff #1 conducting the monitoring with licensing on 3/20/2020, Individuals #1 and #2 have not been informed of their right to lock their individual bedroom doors nor were they provided a key to their bedroom doors. At the time of the inspection, there is only one key to each individual's bedroom door, in the possession of direct support staff when they are home.Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.Provider will inform individuals of all new rights described under 6400.32 immediately and document the review in each individuals' record. Provider will assess individual's safety and understanding with having a key locking mechanism on each individual's bedroom door and document their assessment. Individuals will be offered a key to their bedroom door. Provider will document the individual's choice if they want to have a key to access their bedrooms or if they are ok with only staff having a key. Staff working at the home must carry the keys to both individuals' bedroom door, on their person at all times while working to use in the event of an emergency situation. 04/06/2020 Implemented
SIN-00169473 Unannounced Monitoring 01/14/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The bedroom on the Left contained a window with broken window blinds in need of repair.Floors, walls, ceilings and other surfaces shall be in good repair. Curtains were ordered for replacement; once arrived, curtains were installed in the noted bedroom. Staff will complete an end-of-shift checklist daily, to ensure that all surfaces are in good repair. 01/30/2020 Implemented
6400.80(a)The outside walkways had dead leaves accumulated up directly in front of the door and also at the step leading from the porch to the sidewalk. Outside walkways shall be free from ice, snow, obstructions and other hazards. Outside walkways were cleared of debris (leaves) on the same day as the inspection--01.14.2020. The landscaper was contacted for prompt removal of leaves after each servicing. Staff will complete an end-of-shift checklist daily, to ensure that pathways are free of obstructions and other hazards. 01/14/2020 Implemented
SIN-00164698 Unannounced Monitoring 10/22/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Individual #1's small nightstand on the right side of her bed is missing a knob; the knob missing is the top drawer, right hand side.Floors, walls, ceilings and other surfaces shall be in good repair. During inspection it was found that Shannon¿s knob on her night stand was missing a knob. The home was actively being painted and remodeled during the time of inspection. The furniture in every room had been moved within the last 2 weeks. During this move, one of the knobs came off of the handle of her night stand. The knob was located last night in the room and was screwed back on the night stand. No further correction needed. 10/22/2019 Implemented
SIN-00165344 Unannounced Monitoring 09/19/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16The events from January 6, 2019 described under 6400.163(d) constitute neglectAbuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.A new incident (EIM # 8618454) was created on 11/6/19 and is being investigated as neglect. As an immediate remedy, on 10/22/19 all staff were trained on client rights by the new Director of IDD Services who was hired in June 2019. Staff were additionally trained in incident management and recognizing and reporting abuse. This training occurred via live format of 10/22/19 and via on line training. A new leadership were hired on 9/30/19 as well as a house supervisor in October team was put in place in Lancaster that consists of an IDD Manager, IDD Coordinator that 2019. Staff #1 was suspended 7/19/19 pending the outcome of several findings from the July 2019 inspection and no longer works for the agency. Holcomb administration including but not limited to Director of Operations, Clinical Director, Compliance Officer, Chief Operating Officer and Chief Program Officer provide unannounced site visits at least one time per week or more frequently as needed. Administration will provide an additional layer of check and balance for staff support and program compliance. 11/06/2019 Implemented
6400.43(b)(1)Holcomb Associates reported to the Department that Individual #1 ingested several generic antacid tums on January 6, 2019 resulting in an emergency room visit. Discharge instructions from the emergency room visit read, "Patient may have diarrhea or loose stools from taking the Linzess." The reason for the visit reads, "overdose, accidental." Upon realization that Individual #1 did not consume tums, but rather Linzess, Holcomb Associates failed to update the report and the Department with the correct information. To date, incident report #8506975 contains inaccurate information related to the accidental overdose. Providing false information to the Department does not demonstrate the ability to operate a community home.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. During 9/19/19 it was discovered by the inspectors that information that was entered into EIM on Jan 6, 2019 was not consistent with the documentation found in the home. None of the employees that were involved in EIM incident #8506975 are still employed with the agency. Since this incident was in a closed status, no new information could be entered into this report. A new incident (EIM # 8618454) was created on 11/6/19 to reflect the discrepancy in the information provided and to begin an investigation of the actual incident occurrences. This incident is currently being investigated. As an immediate remedy, on 10/22/19 all staff were trained on client rights by the new Director of IDD Services who was hired in June 2019. Staff were additionally trained in incident management and recognizing and reporting abuse. This training occurred via live format of 10/22/19 and via on line training. A new leadership (IDD Manager, Program Specialist, and House Supervisor) were hired on 9/30/19. Staff #1 was suspended 7/19/19 pending the outcome of several findings from the July 2019 inspection and no longer works for the agency. Holcomb does recognize and take full responsibility for the failures outlined and is aggressively working to rectify all violations and more importantly to ensure a plan for sustaining quality. The following actions have been taken to strengthen the agency¿s ability to carry out commitments and obligations: Senior leadership worked aggressively with Human Resources to fill all open positions. At this time all Administrative and Management positions within the structure that existed, have been filled. The following actionable and measurable practices have been put in place since the July 2019 unannounced visits by ODP Licensing Representative: ¿ A member of senior leadership (i.e., COO, Clinical Director, Director of Operations, and IDD Director) has been present in the home a minimum of 1 time/week each week since July 2019. ¿ The IDD Director and/or IDD Manager are on-site at least 3 times per week to ensure adequate supervision and monitor quality of services/day to day programming, physical site and implementation of new practices. ¿ Staff Training records are being migrated to a Learning Management System that will track completion and provide advance notice when training is in need of update. Holcomb had taken steps needed to develop new or update policies and procedures to clearly reflect requirements and needs, staff re-training now and ongoing, and a tiered communication and oversight plan that we believe will resolve the contributing factors and will ensure the Health and Welfare of the individuals. Holcomb is aware of the new requirements in the 6100 regulations effective 10/5/19 and is incorporating all new expectations into Holcomb policies and procedures. Holcomb is participating in all ODP trainings regarding the roll out. We will continue to watch for upcoming or future communications and trainings released by ODP and participate in those as they occur. We are committed to this process of improvement. Further, we are familiar with the QA expectations on Incident Management Bulletins specifying the operating procedures and directions for the incident management process. We are working with an outside consultant to strengthen our existing system and to create automated QM tools to support new uniform practices for incident management. ¿ All newly hired staff were provided orientation and trained prior to working with the consumers. ¿ Annual Staff training identified as deficient have been or are planned for update. Staff with training that does not meet regulatory expectation will not be scheduled for work until this is completed. ¿ All staff have been re-trained in Identifying and reporting health issues, Identifying and reporting incidents, fire safety. ¿ All training curricula will be reviewed to ensure that the scope provides for the acquisition of knowledge by 11/06/2019 Implemented
6400.64(a)REPEAT from July 2019 inspection: Individual #1's bedroom had a strong smell of urine.Clean and sanitary conditions shall be maintained in the home. A strong smell of urine was found to be emanating from the carpeting in Individual #1¿s bedroom. Individual #1¿s bedroom flooring was changed from carpet to wood laminate 10/16/19. Additionally, an outside company was hired 10/19/19 to complete a deep clean of the home. An End-of-Shift Checklist was created to ensure both functioning and cleaning of items in the home, including, sanitizing surfaces. The End-of-Shift Checklist is completed by at least one DSP at the end of a shift and reviewed by the House Supervisor daily to monitor for completion of tasks. Effective 10/16/19, trainings regarding Environment of Care (EOC) and the IDD End of Shift Check list will occur during the onboarding process for new hires by the House Supervisor and/or IDD Coordinator. Such trainings include a review of physical site needs and overall environment cleanliness. Supervisor will have daily oversight of the physical site to ensure that everything is clean and in in working order. Additionally, Holcomb administration including, but not limited to, Director of Operations, Clinical Director, Compliance Officer, Chief Operating Officer and Chief Program Officer provide unannounced site visits one time per month or more frequently as needed. Administration will provide an additional layer of check and balance of physical site and cleanliness. 10/19/2019 Implemented
6400.76(a)REPEAT from July 2019 inspection: The dryer contained approximately a golf-ball sized piece of lint. Furniture and equipment shall be nonhazardous, clean and sturdy. During the time of inspection, laundry was in the process of being done during the day shift. The dryer stopped and lint was found in the dryer. The lint was removed during time of inspection. An End-of-Shift Checklist was created to ensure both functioning and cleaning of items in the home, including, emptying lint traps. The End-of-Shift Checklist is completed by at least one DSP at the end of a shift and reviewed by the House Supervisor daily to monitor for completion of tasks. Effective 10/16/19, trainings regarding Environment of Care (EOC) and the IDD End-of-Shift Checklist occurs during the onboarding process for new hires by the House Supervisor and/or Program Specialist 09/19/2019 Implemented
6400.113(a)REPEAT from July 2019 inspection: Individual #1 & #2 received fire safety training on 3/24/18 and not again since then. However, the training they received on 3/24/18 was conducted at a different residential home location. The individuals have not received training in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place, and smoking safety procedures as they relate to their residential location in over two years. An individual, including an individual 17 years of age or younger, 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 home. At the time of inspection, Individual #1 and Individual #2¿s last fire training was completed on 3/24/18, but it did not occur in their home. This occurred because the previous IDD Manager had Individuals trained by the fire marshal remotely as staff were misinformed that the training could be completed at a remote location. Additionally, staff members were aware that this training could be completed with Individuals by a trained Program Specialist instead of the fire marshal. This regulation was reviewed the Program Specialist and IDD Manager at the time of their hire on 9/30/19. Both Individuals¿ fire training was completed by the Director of IDD Services on 7/24/19 while also pulling a fire drill to address general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place, and smoking safety procedures; however, this training documentation was not filed by the time of the 9/19/19 inspection ¿ It was put on the chart on 10/1/19. Ongoing fire training with the trained Program Specialist is scheduled on an annual basis in compliance with Regulations. The IDD Manager completes quarterly audits to ensure all forms are complete and in order in the charts. Additional annual reviews are completed by QA personnel, and internal auditing committee¿Clinical Performance Improvement Committee (CPIC). All findings are reported back to IDD Director by CPIC and findings are communicated to Quality Management committee for review of completion, trending, and corrections necessary. 10/01/2019 Implemented
6400.141(c)(10)(repeat) Individual #1's 6/3/19 physical examination did not indicate if the individual was free of communicable diseases or specific precautions that must be taken if the individual has a communicable disease. The physical form was not completed to answer the question on the form, "Is the individual free of communicable disease?"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 physician did not thoroughly complete the Physical Examination form and provided incomplete form to Holcomb. The form was resubmitted to the treating physician on 10/10/19 for re-review and updated information was added. For ongoing sustainability, the Policy and Procedure regarding the requirement for all sections of the physical exam to be completed was reviewed with all staff effective 8/12/19. To ensure that all medical forms are completed in their entirety, effective 10/22/19, training for staff occurs for new hires includes procedure for obtaining, maintaining, documenting, and communicating health services appointments with review of documentation (i.e. Treatment Summary for Outside Consultations/Primary Physician, TSOC, form), expectations of advocacy for Individuals during health services appointments (i.e. comprehensive completion of all medical forms), and on-call protocol. Continued review and training regarding this information will occur quarterly and/or as needed, specifically, when new items/concerns have been identified. House Supervisor will have direct, daily oversight of DSPs to ensure adherence to individuals¿ plans for meeting their needs. Upon receipt of the Physical Examination form, the Supervisor or IDD Coordinator will review for completeness. If form is not complete, form will be returned to physician to more thoroughly complete with no missing sections. The IDD Coordinator is responsible for returning and obtaining complete physical examination form. The IDD Coordinator will complete monthly reviews of Individuals¿ charts, monitoring for documentation to ensure completeness. The IDD Manager completes quarterly audits to ensure all forms are complete and in order in the charts. Additional annual reviews are completed by QA personnel, and internal auditing committee¿Clinical Performance Improvement Committee (CPIC). All findings are reported back to IDD Director by CPIC and findings are communicated to Quality Management committee for review of completion, trending, and corrections necessary. 10/10/2019 Implemented
6400.141(c)(14)- (repeat) Individual #1's 6/3/19 physical examination form did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank on the form.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The physician did not thoroughly complete the Physical Examination form and provided incomplete form to Holcomb. This form was re-submitted to the treating physician for re-review; this missing information was added on 11/8/19. For ongoing sustainability, the Policy and Procedure regarding the requirement for all sections of the physical exam to be completed was reviewed with all staff effective 8/12/19. To ensure that all medical forms are completed in their entirety, effective 10/22/19, training for staff occurs for new hires includes procedure for obtaining, maintaining, documenting, and communicating health services appointments with review of documentation (i.e. Treatment Summary for Outside Consultations/Primary Physician, TSOC, form), expectations of advocacy for Individuals during health services appointments (i.e. comprehensive completion of all medical forms), and on-call protocol. Continued review and training regarding this information will occur quarterly and/or as needed, specifically, when new items/concerns have been identified. House Supervisor will have direct, daily oversight of DSPs to ensure adherence to individuals¿ plans for meeting their needs. Upon receipt of the Physical Examination form, the Supervisor or IDD Coordinator will review for completeness. If form is not complete, form will be returned to physician to more thoroughly complete with no missing sections. The IDD Coordinator is responsible for returning and obtaining complete physical examination form. The IDD Coordinator will complete monthly reviews of Individuals¿ charts, monitoring for documentation to ensure completeness. The IDD Manager completes quarterly audits to ensure all forms are complete and in order in the charts. Additional annual reviews are completed by QA personnel, and internal auditing committee¿Clinical Performance Improvement Committee (CPIC). All findings are reported back to IDD Director by CPIC and findings are communicated to Quality Management committee for review of completion, trending, and corrections necessary. 11/08/2019 Implemented
6400.144REPEAT from July 2019 inspection: On 6/3/19, Individual #1'sprimary physician reported that they wanted to see the individual again, "recheck in 3 months" and "screening labs ordered." The individual did not return for a follow up appointment. The individual's record does not include documentation of any laboratory records completed per the physician's request on 6/3/19. On 4/30/18, the individual was seen by their physician and "surveillance EGD (Esophagogastroduodenoscopy) recommended May 2019." The individual did not return for a EGD. Individual#1 received annual vision exams on 5/22/17 and 6/14/18 but none since. The individual is prescribed glasses. The individual's 6/3/19 physical examination form recorded that a vision and hearing exam was "not done because form not available during appointment."Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. In July 2019, the unannounced inspection revealed that various medical appointments had not been scheduled or followed up on due to multiple staff vacancies and lack of oversight. The site was without a House Supervisor and Program Specialist; the IDD Manager at the time failed to oversee the medical appointments and follow up. Individual #1 was supposed to return to see the Primary Care Provider in 3 months from the 6/3/19 appointment for Follow up. Additionally, he was ordered to complete lab work. This lab work was completed on 10/10/19 and his follow up appointment with his PCP occurred on 11/14/19. Follow up GI appointment for Individual #1 occurred on 10/29/19; it is recommended that he return in 1 year. Individual #1 was seen at Vision works on 10/10/19 and he received eye glasses on the same day. The Hearing screening for Individual #1 occurred on 11/14/19. At this appointment, he also received his Flu shot and TDap vaccination. Since the July 2019 inspection, the previous IDD Manager and previous IDD Director are no longer with the organization and a new House Supervisor, Program Specialist, and IDD Manager were hired to oversee the operations and overall programmatic and medical compliance. Additionally, a new Director of IDD Services was hired. It is the House Supervisor and Program Specialist¿s role to ensure that medical appointments are followed up as ordered. In the absence of the Program Specialist, this responsibility defaults to the IDD Manager. All medical appointments and orders are monitored by the Program Specialist monthly and quarterly by the Manager. In addition to this level of oversight, the Individuals¿ records are audited by the agency¿s internal auditing body¿Clinical Performance Improvement Committee (CPIC)¿annually and/or as needed. Any areas of non-compliance found is corrected upon time of audit. To ensure that all medical forms are available during appointments and that they are completed in their entirety, effective 10/22/19, training for staff occurs for new hires includes procedure for obtaining, maintaining, documenting, and communicating health services appointments with review of documentation (i.e. Treatment Summary for Outside Consultations/Primary Physician, TSOC, form), expectations of advocacy for Individuals during health services appointments (i.e. comprehensive completion of all medical forms), and on-call protocol. Continued review and training regarding this information will occur quarterly and/or as needed, specifically, when new items/concerns have been identified. House Supervisor will have direct, daily oversight of DSPs to ensure adherence to individuals¿ plans for meeting their needs. 11/14/2019 Implemented
6400.181(a)REPEAT from July 2019 inspection: Individual #1 had an assessment completed on 6/11/18, by a direct support staff that did not have the qualifications of a program specialist, and none since then. Individual #2 had an assessment completed on 1/31/18 and none since. 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. Individual Assessments for Individual #1 and Individual #2 were not completed at time of inspection due to multiple staff vacancies and a lack of oversight by the previous IDD Manager and IDD Director; neither of which are still employed with the organization. A new IDD Coordinator and an IDD Manager were hired (9/30/19) to oversee the operations and overall compliance of the program. A new House supervisor was hired in October. Additionally, a new Director of IDD Services was hired. Since the assessments were not completed in a timely manner as it relates to the previous year, the new leadership set the goal to have all outstanding items completed, though they would be out of the timeframe for compliance. At the time of the 9/19/19 inspection, the updated assessments were in various stages of completion and were not yet in the charts for review. Although Individual #1¿s assessment was completed on 9/18/19, it was not yet filed. Individual #2¿s assessment was completed on 9/20/19. Both Assessments were completed by someone with the qualifications of a Program Specialist and are signed and dated by both the individual and the writer. Additionally, both assessments were filed into the appropriate charts by 9/20/19. It is the Program Specialist¿s role to ensure that the all individuals¿ initial and annual assessments are completed in compliance with regulatory guidelines as it relates to content and timelines. All newly hired Program Specialists are trained on their responsibilities per the regulations. In the absence of the Program Specialist, this responsibility defaults to the IDD Manager. All Individuals¿ charts are monitored by the Program Specialist monthly and quarterly by the IDD Manager. In addition to this level of oversight, the Individuals¿ records are audited by the agency¿s internal auditing body¿Clinical Performance Improvement Committee (CPIC)¿annually and/or as needed. Any areas of non-compliance found is corrected upon time of audit. Effective 10/22/19 Program Specialist maintains a tracking mechanism to alert when due date of assessment is approaching. IDD Manager oversees the tracker to ensure timeliness of assessment completion, effective 10/22/19. In development, Chimes Holcomb is obtaining an Electronic Health Record, TherApp, to be used in 2020. Holcomb parent company, Chimes International, signed a contract to secure TherApp effective 9/10/19. Chimes IT Department is in process of securing TherApp and will be building system. When TherApp is available for use, Assessment time frames will be calculated automatically and will alert Program Specialist of an assessment due. TherApp will also alert Program Specialist¿s supervisor, the IDD Manager. TherApp is currently scheduled to roll out 1/2/20. 10/01/2019 Implemented
6400.31(a)On January 6, 2019, Individual #1 was taken to an unfamiliar setting so that staff #1 could perform work duties at another home. There is no evidence to suggest Individual #1consented to visiting the home. Individual #1 was not able to participate in individual-specific program planning with his/her 1:1 staff member while staff#1 was performing job duties at a second location.An individual may not be deprived of rights as provided under § 6400.32 (relating to rights of the individual.)During 9/19/19 inspection incident #8506975 was brought to the attention of the new Leadership of IDD Services. Based on the information provided in the EIM report from Jan 6, 2019, Individual #1 was taken to 3112 Cochran Drive for Staff #1 to administer medications at that site. Since this incident was over 9 months old and in a closed status, no new information could be entered into this report. A new incident (EIM # 8618454) was created on 11/6/19 to reflect the newly discovered information. This incident is currently being investigated by a certified investigator. None of the employees that were involved in EIM incident #8506975 are currently employed with the agency. On 10/22/19, all staff were trained on client rights by the new Director of IDD Services who was hired in June 2019. Staff were additionally trained in incident management and recognizing and reporting abuse. This training occurred via live format of 10/22/19 and via on line training. A new leadership team was put in place in Lancaster that consists of an IDD Manager and an IDD Coordinator that were hired on 9/30/19 as well as a house supervisor in October 2019. Staff #1 was suspended 7/19/19 pending the outcome of several findings from the July 2019 inspection and no longer works for the agency. Holcomb administration including but not limited to Director of Operations, Clinical Director, Compliance Officer, Chief Operating Officer and Chief Program Officer provide unannounced site visits one time per month or more frequently as needed. Administration will provide an additional layer of check and balance for staff support and program compliance. 11/06/2019 Implemented
6400.31(b)Individual #2's Individual rights where not dated. Someone had Individual #2 sign the form, and other forms in the record, but there are no dates when it was signed.The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights.During time of inspection, there was documentation that individual #2¿s right were reviewed with them as indicated by their signature, but the document was not dated by the reviewer. As a correction, the Individual Rights form was updated to ensure that all of the necessary rights were covered and to add a ¿reviewer¿ line with a date. Individual #2¿s rights were reviewed again with her by the House Supervisor on 10/22/19 and both Individual #2 and the reviewer signed and dated the form. Going forward, this will be the form used. It is the Supervisor and Program Specialist¿s role to ensure that Individuals¿ rights are reviewed with them annually and documented. In the absence of the Program Specialist, this responsibility defaults to the IDD Manager. All Individuals¿ charts are monitored by the Program Specialist monthly and quarterly by the IDD Manager. In addition to this level of oversight, the Individuals¿ records are audited by the agency¿s internal auditing body: Clinical Performance Improvement Committee (CPIC) annually and/or as needed. Any areas of non-compliance found is corrected upon time of audit 10/22/2019 Implemented
6400.163(d)On January 6, 2019, Individual #1 visited another home operated by Holcomb Associates, accompanied by staff #1, his 1:1 staff person. According to Individual #1's Individual Support Plan (ISP) .), he/she requires "constant 1:1 staff supervision (within eye sight) at all times when in the home, when awake" and " constant 1:1 supervision and should be within arm's length at all times (except when engaged in a sport activity) due to lack of awareness and current safety concerns, when in the community." According to the ISP , 1:1 staffing is required due to a history of aggressive behaviors and "unpredictable and impulsive" behaviors. According to staff #1, Individual #1 ran to the unlocked staff office, shut the door and locked himself in. While unsupervised in the staff office, Individual #1 located and consumed an unknown amount of medication (Linzess), not prescribed to him. Subsequently, staff #1 called Individual #1's primary care physician and reported the above. The doctor was advised to take him/her to the emergency room. The emergency room discharge instructions report the reason for the visit as "overdose, accidental" with notes that read, "please ensure that patient doesn't take medications not prescribed to him/her. Patient may have diarrhea or loose stools from taking the Linzess." Individual #1 was not assessed to be safe around poisonous materials and required medications to be inaccessible or locked. Upon arrival to the home, staff #1 failed to ensure hazardous areas were secured such that an individual #1 not safe with poisonous materials was able to access and consume an unknown amount of medication, not prescribed to him/her.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.The incident that occurred on January 6, 2019 was entered into EIM by the leadership at that time and investigated see incident # 8506975. According to this incident as it was reported in EIM, Staff #1 was administering medication at 3112 Cochran Drive and had Individual #1 present with her who is to receive 1:1 supervision. Staff #1 was at this site administering medication due to a lack of staff that were certified to administer medications on shift that day. Staff #1 did not secure the medications in the staff office properly and was not provided the correct supervision to individual #1 at the time of the incident. This failure to secure the medications resulted in Individual # 1 taking medications that were not prescribed to him. This incident was entered and investigated, and was subsequently concluded and closed both by Holcomb, the County and Region based on the information presented in the report in EIM. Staff #1¿s failure to secure the medications violated the Regulations, Medication Administration protocol and Holcomb¿s policy. The employees involved in EIM incident #8506975 are no longer employed with the agency. In June 2019, a new Director of IDD Services was hired who is well versed in Regulatory compliance and Incident Management. Additionally, a new Program Specialist and IDD Manager were hired on 9/30/19, as well as a house supervisor in October 2019. Staff #1 was suspended 7/19/19 pending the outcome of several findings from the July 2019 inspection and no longer works for the agency. Since this time, a medication administration class was conducted in Lancaster on 10/9/19 & 10/10/19 for the Lancaster staff to all be retrained and recertified in medication administration to ensure that all staff are trained appropriately and have demonstrated the skills and competency to administer medications safely. Additionally, this will ensure that there is adequate staff that are currently certified to administer medication so that staff will not be going between locations to administer medications. As an ongoing remedy, 2 management staff in Lancaster have been identified to go through the train the trainer course for medication administration so that classes and med practicums can continue to occur on a regular basis. This also provides an additional resource for monitoring medication passes to ensure proper protocols are being implemented. All staff in the home were trained that all residents must be assessed to be unsafe around poisonous materials. Effective 10/22/19. Trainings regarding individuals¿ plans for health and safety¿particularly noted in their ISPs¿ occur during the orientation process for new hires by the House Supervisor and/or Program Specialist within their first week of hire prior to their work with individuals. Such trainings include a review of each individuals¿ charts, focusing on their medical, physical, mental health, behavioral health needs, as well as their abilities and level of supervision required. Continued review and training regarding this information will occur quarterly and/or as needed, specifically, when new items/concerns have been identified. House Supervisor will have direct, daily oversight of DSPs to ensure adherence to individuals¿ plans for meeting their needs, reporting to the IDD Coordinator/Program Specialist. 10/10/2019 Implemented
6400.165(g)Individual #2 had an appointment on 3/19/19 where the doctor instructed to return in 2 months. There was no return appt in May 2019. The 8/22/19 medical consult with the doctor did not contain the list of medication that Individual #2 is to continue to take. The 8/22/19 appt is also late.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.Individual #2 had a follow up appointment with the doctor on 4/24/19 and then again on 8/22/19. While the appointment did occur, the documentation of that appointment was not in the chart and available during the time of inspection. During the July 2019 inspection, it was identified that there was missing supporting documentation on the individual¿s charts. This was due to a vacant House Supervisor and Program Specialist position and a lack of oversight by the previous IDD Manager and IDD Director. The current leadership was in the process of securing all of the missing documentation for the chart at time of this 9/19/19 inspection. Both of these Medical Summary forms are now on the chart. While the current medications were not written on the medical consult on 8/22/19, it is customary for the staff to take a copy of the current MAR and attach it to the medical consult form. Moving forward, the current medications will be filled in prior to the appointment. If this is not possible then the MAR will be brought to the appointment for review and it will be indicated as such by writing (See Attached MAR) on the line for the ¿list of current medications¿ section. A new Program Specialist, and IDD Manager were hired on 9/30/19 to oversee the operations and overall programmatic and medical compliance. A new House supervisor was hired in October. Additionally, a new Director of IDD Services was hired. It is the House Supervisor and Program Specialist¿s role to ensure that medical appointments are followed up as ordered. In the absence of the Program Specialist, this responsibility defaults to the IDD Manager. All medical appointments and orders are monitored by the Program Specialist monthly and quarterly by the IDD Manager to ensure appropriate and timely scheduling of all appointments 10/01/2019 Implemented
SIN-00159755 Unannounced Monitoring 07/16/2019 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16Individual #1's most recent assessment, completed on 01/22/18, reads, "At the individual's next PCP and medication management appointments, Holcomb staff will work together with the individual's medical team to formulate a choking protocol, and see if the pudding and yogurt is necessary to continue." PCP is defined as Primary Care Physician. On 7/18/19, Staff #1 stated that Individual #1 does not have a choking protocol nor was medical attention sought from 1/22/18 to 7/18/19 to identify the individual's dietary and swallowing needs and address the individual's choking concerns. Additionally, Individual #1's assessment reads "At the medical appointments, the individual's team will decide how often the blood pressure should be taken and who it should be taken by." Staff #1 stated that that individual's blood pressure was not taken or tracked. Staff #1 confirmed that from 1/2/18 to 7/18/19, the agency did not seek follow up treatment from a medical professional around the blood pressure recommendation. Holcomb's failure to seek medical attention such that dietary needs and swallowing/choking concerns could be identified and rectified, does not demonstrate the ability to protect the health and safety needs of residents and constitutes neglect. According to incident report #8446771, "Staff member [Staff #2] was in the kitchen at East Petersburg at 4:10PM on 7/3/18. [Staff #2] walked into the hallway between the bedrooms and the living room. [Staff #2] then observed [Staff #1] get up out of the living room chair and grabbed Individual #1's hair and pulled it down towards the living room table. Individual #1 then said, "Don't pull my hair ever again, that hurts." Individual #1 continued to repeat, "Don't touch my hair. Don't ever pull my hair again." The report also stated "[Staff #2] called House Supervisor, [Staff #3], at 4:20 PM and alerted him of the situation. [Staff #3] called Program Coordinator [Staff #4], at 4:31 PM. And notified him of the allegation. [Staff #4] drove to the East Petersburg House and arrived at 5:00PM. [Staff #4] then pulled [Staff #1] aside with [Staff #3] present and told her that an allegation of abuse has been made against her, and she would be off the schedule pending an investigation." The incident is still an open incident in EIM and the report indicates that there are findings that are waiting to be entered into EIM "pending investigation." Staff #1 continued to work at the home until 7/18/19. Staff #1 reported to licensing staff that she mainly works at the East Petersburg home where Individual #1 resides. Individual #1 was forced to live with her alleged attacker, Staff #1, from the date of the initial report on 7/3/18 until 7/18/19. Individual #1's alleged attacker was promoted to the home supervisor position around February 2019, putting the staff in a more authoritative position.Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.Prior to the July inspections, there was not a Coordinator at this home to over the medical scheduling of appointments. Since this time, there has been increased and consistent administrative oversight of all programming and medical aspects of this residence. A new IDD Coordinator has been identified and a new home supervisor has been hired. Additionally there has been increase clinical oversight and routine visits by the Director of IDD Services and the Director of Operations. Since the July inspection, Individual #1 has had her Annual Physical (8/10/19) with her PCP and all history and current health areas were reviewed. Her PCP did not recommend a plan for choking or a plan for consistent blood pressure checks at that time. She has additionally seen the dentist on 8/21, the podiatrist on 9/3, her med review on 8/22 and she is scheduled for her mammogram on 9/24. We will continue to evaluate all health and daily living needs and ensure that all areas of concern are followed through on. All fields on the EIM have been completed, including entering findings resulting from investigations by Holcomb¿s Certified Investigators. The EIM has been validated and submitted. Holcomb has identified and is currently utilizing outside Certified Investigators to support for timely investigations as investigation process was not completed within mandated times frames due to lack of availability by internal Certified Investigators. Staff #1 has remained off rotation during the investigation process and pending further Administrative Review. 09/17/2019 Not Accepted
6400.33(d)Very little snack and food items were found at the home. Very little Individual- preferred food items were at the home. Snack items found at the home included 7 granola bars and 7 clementines. Staff #1 stated that Individual #2 loved bananas and both individuals prefer fruits and vegetables, fruit cups and a few other items. The grocery receipts obtained from the provider show that the only time Individual #2's preferred food item were purchased was on 5/28/19. Both Individuals' preferred food item, fruit bowls, were last purchased on 5/10/19. The home had gluten-free food options available. Staff #1 reported that the individuals do not like any of the gluten-free food nor was it their preference or recommended diet. On 7/18/19, Staff #1 confirmed that the individuals are not given the option to participate in menu planning or food selection. On 7/18/19 Staff #1 reported that Individual #2's bedroom window had a device installed on the windows to prevent the individual from opening the windows more than 2 inches. Staff #1 stated other staff in the home believed Indivdiual #2 was throwing t-shirts out his window and into the bushes. Holcomb staff failed to investigate how the t-shirts were getting outside and the reason the t-shirts were outside and instead installed a device on the windows to prevent Individual #2 from completely opening the window. Individual #2's Individual Support Plan did not include the window device as an acceptable strategy to prevent the throwing of t-shirts. A team meeting to discuss the behavior and preventative strategies did not occur, per Staff #1. As referenced under 6400.173 in this report, the home was lacking in food items that were of preference to the individuals. A large quantity of food found in the home was expired, some items containing expiration dates of 2001. Staff #1, who is responsible for completing grocery shopping for the home, confirmed on 7/18/19 that Individual #2's favorite food to eat was bananas. According to grocery receipts for the home, Staff #1 withheld from ordering the Individual's favorite food item since 5/28/19. Staff #1 also stated on 7/18/19 that she waits until Friday every week to see if the home or individuals needs any item to be purchased. Neither Individual #1 or #2 have their driver's license or understand money management, rendering them reliant on staff to obtain items of need for them. If either individual would need an item (toiletries, hygiene items, medications, clothing, etc) Monday through Thursday, they would not have the opportunity to obtain these items until at least Friday but possibly later. This omission of an act to obtain items for Individuals #1 and #2 in a timely manner, deprives the individuals of their rights and human dignity which may cause or causes actual physical or emotional harm to the individuals.An individual has the right to participate in program planning that affects the individual.Residents have been actively participating in menu planning. Following inspection on 07/18/2019, Director of IDD, Shanda O¿Dennis and Director of Operations, Henry Hor, met with staff and residents to develop a list of preferred food items and menus options. Purchasing of groceries was completed based on this list that evening. Following inspection staff continually support residents in identifying their preferences for grocery shopping and meal planning. Staff have been notified that shopping occurs as needed with a minimum of one time weekly; this includes the provision that staff obtain groceries and household goods when such items need to be replenished, not solely based on weekly ordering patterns. Staff were informed that residents must be provided with opportunities to purchase their own toiletries as needed as well as personal items in a timely manner, outside of the weekly grocery purchasing. Following the 07/18/2019 inspection and at present, staff members escort residents to and from local businesses to obtain needed and preferred items, from food and drinks to personal care products and so forth, supporting them in the purchasing transaction (money handling and management). Staff will be trained ongoing in purchasing house goods and money management support for clients. Staff #1¿s statement that devices had been installed on Individual #2¿s bedroom window as a result of him throwing T-shirts into the bushes was inaccurate. Sash Limiters are a feature of the windows that come standard and are installed at the time of manufacture, not as a result of Individual #2¿s actions. Once administrators¿Director of IDD and Director of Operations were made aware that these sash limiters were activate, both met with Individual #2 to deactivate the limiters and review window functions (activating and deactivating sash limiters, locking and unlocking windows, and opening and closing windows) with Individual #2; Individual #2 noted understanding. During this process, IDD Director and Director of Operations discussed with Individual #2 safety concerns regarding use of windows (i.e. exiting through windows and throwing objects outside of his windows); Individual #2 acknowledged understanding and insisted that he does not engage in these behaviors. Staff were addressed regarding their inability to limit any resident¿s access to window functions (i.e. fully opening windows). 08/01/2019 Not Accepted
6400.46(e)Staff #5 has been employed with the agency since 6/11/18. At the time of the inspection on 7/16/19, there was no documentation that he received training in the areas of intellectual disability, the principles of integration, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. Staff #6 has been employed by Holcomb since 10/3/17 and has worked over 40 hours every month in the last year. She has worked anywhere from 69 hours a month to 153 hours in a month. She has never received training in the areas of intellectual disability, the principles of integration, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. According to the agency on 7/16/19-7/18/19 and from documentation provided on 7/24/19 by the agency, Staff #6 is a contracted staff and never received training required under 6400.46.Program specialists and direct service workers shall have training in the areas of intellectual disability, 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. An audit of all personnel files was conducted on 07/31/2019 to review certification and training needs. Staff with missing trainings, were identified to be scheduled for upcoming training. Specifically, training records have been requested for Staff #6 from search firm Delta-T Group. Direct oversight of these training needs will be maintained by the IDD Supervisor, Coordinator, and Director. Moving forward, staff not in compliance will be removed from scheduling. Staff will be trained in required trainings by 8/31/19 08/31/2019 Not Accepted
6400.46(g)Staff #5 received 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 home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department on 6/11/18 and not again until 6/26/19. This is outside the regulatory annual time frame requirement. However, the training that was provided on 6/26/19 occurred at another residential home site location. Therefore, the training provided on 6/26/19 did not review the specific general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the home, smoking safety procedures, the use of fire extinguisher, smoke detectors and fire alarms and notification of the local fire department specific to the residential home location of this home, Main Street in East Petersburg PA where Staff #5 primary works. Staff #6 has been employed by Holcomb since 10/3/17 and has worked over 40 hours every month in the last year. She has worked anywhere from 69 hours a month to 153 hours in a month. She has never received training in the areas of 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 initially before working with individuals or on an annual basis by a fire safety expert. According to the agency on 7/16/19-7/18/19 and from documentation provided on 7/24/19 by the agency, Staff #6 is a contracted staff and never received training required under 6400.46.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). For Staff #6, search agency, Delta-T Group, provided up-to-date Fire Safety training certificates, noting completion dates of 09/28/2018. Staff #5 will receive site-focused Fire Training by 08/12/2019 by IDD Director or designee. Fire Safety training will be held on site moving forward. 08/12/2019 Not Accepted
6400.46(i)Staff #6 received a 2-year certificate for training in first aid, Heimlich techniques and Cardiopulmonary resuscitation on 1/19/17 and not again until 1/26/19. This is outside the annual time frame requirement or every 2 years if the certificate allows.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 trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. An audit of all personnel files was conducted on 07/31/2019 to review certification and training needs. Staff with missing and/or out of date certifications for First Aid, Heimlich techniques, and CPR, were identified to be scheduled for upcoming certification classes. Direct oversight of these training needs will be maintained by the IDD Supervisor, Coordinator, and Director. Moving forward, staff not in compliance will be removed from scheduling. Staff in need of CPR/First Aid training will be trained by 8/31/19. 08/31/2019 Not Accepted
6400.62(a)According to Individual #2's Individual Support Plan (ISP), he is assessed to be unsafe with poisonous materials. Quad-active technology laundry detergent pods, that contained a label to contact poison control center if ingested, was found unlocked and accessible in the hallway closet.Poisonous materials shall be kept locked or made inaccessible to individuals. On 07/18/2019, IDD Director addressed staff regarding proper storage of poisonous materials, ensuring that they are kept locked or made inaccessible to individuals based on ISP indications. A checklist has been developed noting maintenance and needs of the home. Staff will sign the checklist at the end of each shift to ensure completion of tasks. 07/18/2019 Not Accepted
6400.64(a)The bathroom tub jets were covered with black and brown residue which was able to be removed with a paper towel during the 7/18/19 onsite inspection. The back, screen door egress was covered in dirt, sticks, bugs, grass and outside debris. There was so much debris that it got stuck a few times on the debris while pulling it closed.Clean and sanitary conditions shall be maintained in the home. Maintenance staff, Earle Williams and Walt Taylor, had been assigned to clean the jets of the bathtub and clear the screen door egress. Maintenance cleared pathways surrounding the home and pressure washed the siding and footpaths. Staff have been retrained on maintaining a sanitary home environment. Staff assist residents in maintaining common living skills, including cleaning. Staff will follow up after residents to ensure a clean, sanitized home. A monthly checklist has been developed to support in monitoring completion of tasks. A cleaning service had been contacted for a deep clean of the home, with a consultation scheduled for 08/06/2019. 08/19/2019 Not Accepted
6400.64(f)Two boxes of plastic recycling items were outside the side entrance of the home, not stored in closed receptacles that prevent the penetration of insects. A large, blue, 94-gallon trash can on wheels was located towards the back of the home, outside the activity room. This lid had a large slit in it. There were approximately 20+ ants on the bag inside the trash can along with numerous flies and bees flying in and out of the slit in the trash can lid. The trash was not stored in a closed receptacle that prevented the penetration of insects.Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents.New lids will be purchased by IDD Director, Shanda O¿Dennis, to ensure that receptacles are not penetrated by insects and rodents by 08/09/2019. 08/09/2019 Not Accepted
6400.67(a)The cover plate on the light switch in the attic was broken. · There were black marks and scuff marks located in multiple locations of three different walls in the living room. · The baseboard heater in Individual #1's bedroom, located by the door that leads to other rooms of the home, was dented. It had the appearance of being kicked in or an large item pushed against it.Floors, walls, ceilings and other surfaces shall be in good repair. Maintenance staff, Earle Williams and Walt Taylor, replaced the cover on the attic light switch on 07/18/2019. Black marks and scuffs on the walls of the living room were cleaned on 07/18/2019. Maintenance was notified to repair/replace baseboard heater cover. 07/18/2019 Not Accepted
6400.71The telephone numbers to the nearest fire, police, ambulance and hospital were not located on or near the telephone in the activity room.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. Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center were placed by each phone with an outside line on 07/18/2019. 07/18/2019 Not Accepted
6400.72(b)The screen located in the back, screen door, contained approximately 10 long rips. The rips mirrored what is done when a cat or dog scratches a screen door with their paw/nails. ·The back, screen door egress would not close completely or latch. Screens, windows and doors shall be in good repair. Maintenance staff, Earle Williams and Walt Taylor, completed repairs to the back screen door by 08/02/2019. However, the screen will be replaced by 08/16/2019. 08/16/2019 Not Accepted
6400.73(a)The metal and wood handrail located by the 3 side entrance steps was not well secured. When grabbed, the handrail moved back and forth approximately 6 inches. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Maintenance staff, Earle Williams and Walt Taylor, secured the hand with cement by 08/02/2019. Site checklist will be completed monthly to ensure the proper maintenance of the property. Monthly, the IDD Director will inspect the grounds and report any conditions to facilities to repair immediately. Additionally, staff will be trained to monitor the physical conditions and to report any concerns immediately to the supervisor and coordinator via email. If the situation requires immediate repair they are to inform the IDD Director. If the repair does not occur within 3 days they are to follow-up with the IDD Director. 08/02/2019 Not Accepted
6400.76(a)Individual #2's trampoline to be utilized daily as a de-escalation technique per their behavior support plan was broken. A screw was coming out of the bent frame causing the trampoline to partially fold in half. The legs on the trampoline were angled inward. Twenty-two of the elastic straps, approximately 80% of the total straps holding the trampoline to the frame, on the trampoline were so stretched out that when you stepped on the trampoline, it went to the floor. Furniture and equipment shall be nonhazardous, clean and sturdy. A new trampoline was purchased by the COO, Nicole Brown, on 07/25/2019, and was delivered to the home on 07/27/2019. 07/27/2019 Not Accepted
6400.76(c)The living room furniture was not home-like. There was a table with benches as a place to sit. This table and benches resembled a picnic table that is usually utilized outside. · The only two "larger" pieces of living room furniture were 2 small, love seats. The backs of both love seats were only approximately 3 tall. If someone wanted to sit down and recline their head, they could not rest their head on the love seat as the back is not high enough. This does not fit the description of furniture being comfortable and home-like. · Individual #1's personal items that she uses daily in the activity room per her behavior support plan, are stored in 3 large garbage bags on the ground. Some of the items in the bags were spilling out onto the ground and scattered under a loveseat. The home does not have any home like furniture in the activity to store her belongs.Furniture shall be comfortable and home-like. Storage bins were purchased on 07/24/2019 to contain residents¿ personal items. Furniture has been secured and will be delivered to the home by 08/16/2019 by maintenance staff, Earle Williams and Walt Taylor. 08/16/2019 Not Accepted
6400.80(a)The walkway that leads from the side of the home to the front entrance of the home was half covered with bushes that have overgrown and overtaken the walkway. Outside walkways shall be free from ice, snow, obstructions and other hazards. Maintenance staff, Earle Williams and Walt Taylor, completed clearing pathways surrounding the home of debris and over-grown bushes/shrubs by 07/26/2019. Monthly, the IDD Director will inspect the grounds and report any conditions to facilities to repair immediately. Additionally, staff will be trained to monitor the physical conditions and to report any concerns immediately to the supervisor and coordinator via email. If the situation requires immediate repair they are to inform the IDD Director. If the repair does not occur within 3 days they are to follow-up with the IDD Director. 08/05/2019 Not Accepted
6400.80(b)The outside of the home and the yard/grounds were not well maintained. The grass in gardening area located towards the back of the home, is overgrown and approximately 12 inches in length in some spots. The gate leading to the garden area is not secure. The bolts are missing from the lower hinges on the gate. Grass is growing out of gutter on the roof in the back of house. There were sticks and other debris located in the gutters around the entire house. There were 3 articles of clothing (appeared to be t-shirts) located on the roof of the activity room, which is the last room towards the back of the home. The t-shirts had moss and dirt covering them and they appeared to be on the roof for a long time. There were also a few t-shirts hanging off the inside of the bush on the side of the house. This bush was located to the right of Individual #2's bedroom window next to the driveway. The siding, exterior walls, gutters, bricks and wooden porch located outside the activity room towards the back of the house, was covered in moss and brown and black dirt. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.By 08/02/2019, the outside of the home was cleaned. The siding, exterior walls, gutter and brick were cleaned of moss and dirt, t-shirts were removed from the roof and the bush, and the gutters were cleaned. The IDD Supervisor, Coordinator, or a designee will complete site reviews of the outside of the building, yard and grounds to monitor that they are in good repair and free from unsafe conditions weekly. Monthly, the IDD Director will inspect the grounds and report any conditions to facilities to repair immediately. Additionally, staff will be trained to monitor the physical conditions and to report any concerns immediately to the supervisor and coordinator via email. If the situation requires immediate repair they are to inform the IDD Director. If the repair does not occur within 3 days they are to follow-up with the IDD Director. 08/05/2019 Not Accepted
6400.81(g)Individual #1's bedroom is used by staff and another housemate as a regular passageway to the storage room, activity room and outdoor egress to the garden and back deck that's currently in use. Staff #1 stated during the 7/18/19 onsite inspection that the additional rooms and outdoors are used frequently. Staff #1 also confirmed that the additional side door entrance to the activity room is always kept locked and not used by staff and individuals to access the activity room. A bedroom may not be used by other individuals or staff persons as a regular or frequent passageway to another part of the home or to the outdoors. IDD Director will coordinate a meeting with SC by 08/09/2019 to discuss options for room composition. 08/09/2019 Not Accepted
6400.110(a)There is an accessible attic with pull down steps located in the activity room. Pool items such as, pool liner, steps, vacuum, cover, etc. were stored in the attic. The attic was not equipped with a smoke detector. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. All items were removed from the attic on 07/18/2019 and the door has been screwed shut making it inaccessible. 07/18/2019 Not Accepted
6400.111(a)There is an accessible attic with pull down steps located in the activity room. Pool items such as, pool liner, steps, vacuum, cover, etc. were stored in the attic. The attic was not equipped with a fire extinguisher.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. All items were removed from the attic on 07/18/2019 and the door has been screwed shut making it inaccessible. 07/18/2019 Not Accepted
6400.112(a)There was no record of fire drills being conducted in February, March or May 2019. An unannounced fire drill shall be held at least once a month. The supervisor was required to conduct monthly fire drills according to 6400 regulations. This did not occur. Staff #1 was responsible for EOC review and for conducting monthly fire drills. Staff #1 is currently on suspension and personnel action is to follow. A third shift unannounced fire drill was conducted on 7/24/2019 by the IDD Director; residents successfully evacuated. Unannounced fire drills will be conducted monthly by IDD Supervisor or designee and paperwork related to fire drills will be reviewed by IDD Director to be certain that fire drills occur as required and documentation is complete. 08/05/2019 Not Accepted
6400.171A few food items were stored in the kitchen cabinets in open containers and not protected from contamination while being stored. Some of the items were a large box of instant mashed potatoes, box of pancakes, a back of gluten free oats, and small bag of flour.Food shall be protected from contamination while being stored, prepared, transported and served. Staff have been trained on proper food storage and the need to discard any expired food as of 07/19/2019. Protocol is established that when groceries are purchased weekly and placed in cupboard that staff check food in the cabinet and refrigerator to be certain that all expired food is discarded. Additionally, as part of the site checklist, Supervisor, Coordinator, and/or designee will review all cabinets and refrigerator weekly for expired food items. Large plastic bags were purchased so that items that are in open containers can be stored and protected from contamination. 08/05/2019 Not Accepted
6400.173Four boxes of expired food was found in the storage area of the home by the back-door egress. Some of the items found in the boxes were expired to 2001. During the onsite inspection on 7/18/19, Staff #1 reported she recently removed all the expired food from the kitchen cabinets in May 2019 but the food has been in the cabinets for as long as she has been at the home since 2017. She also confirmed that the individuals do not like any of the food that was in the boxes nor was it their preference to have at the home. There were very little snacks and food items at the home, or snack and food items that were of preference of the individuals living in the home. The only snack items found at the home were 7 granola bars and 7 clementines. Staff #1 stated that Individual #2 loves bananas and that both individuals prefer fruits and vegetables, fruit cups and a few other items. According to the grocery receipts obtained from the provider, the only time Individual #2's preferred food item, bananas, were purchased was on 5/28/19. Individuals' preferred food item, fruit bowls, was last purchased on 5/10/19 and not again since then. The frozen food stored at the home did not contain a date that the food was frozen. It was unable to be determined if the food in the freezer was frozen prior to the use/freeze by date on the packaging. There were two gallons of milk in the refrigerator with expiration dates of 4/14/19 and 6/9/19. The milk jug with expiration date of 6/9/19 was almost completely empty. Per Staff #1, she freezes the milk containers and just got those two out recently for use. However, there wasn't a date on either container to indicate that it was used and/or frozen by the date recommended. The 4/14/19 jug did have a slushy substance in it, potentially a chunk of ice. There were food items found located in the kitchen cabinets with expiration dates that have expired. Those items were: instant mashed potatoes expired 3/17/19, pancakes expired 12/19/17, herb season stuffing expired 5/17/19, 3 pork stuffing mixes expired 5/17/19, 2-2 pound gluten free pancake mix bags expired 2/19/19, 10 ounce real mayo container expired 2/27/19, 3- 7 ounce chickpea crumbs expired 1/17/01, 16.3 ounce jar of Skippy peanut butter expired 11/29/18, and 28 ounce jar of Skippy peanut butter expired 12/2/18. There was a 10 ounce jar of sweet peppers in the refrigerator that expired 4/2018. Four 28-ounce bags of gluten free rolled oats were found in the kitchen cabinets. As stated above, gluten free items are not of the individual's preference nor a doctor's ordered dietary recommendation for either individual.The quantity of food served for each individual shall meet minimum daily requirements as recommended by the United States Department of Agriculture, unless otherwise recommended in writing by a licensed physician. All expired food was discarded on 7/18/2019. On 7/18/2019, a grocery list was created based on individual 1 and individual 2 requests. Each week since then, the grocery list has been created based on the requests of both individuals. Menus have been created in collaboration with residents, noting residents¿ preferred food items and shopping lists are developed based on the menu. Site checklist review includes review of food storage and discarding of any items that are expired. Milk is purchased and not frozen. There is a review of the food completed at each shift to monitor the food supplies. Food is ordered weekly and/or as needed. Staff member #1 has been suspended. 08/05/2019 Not Accepted
6400.181(a)Individual #1's current assessment was completed 01/22/18. A 2019 assessment was not found in the record or completed. This is outside the annual regulatory time frame requirement. ·Individual #2's assessment was last completed on 6/11/18 and not again since then. 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. Assessments will be revised for individual 1 and individual 2 by 08/12/2019. Both individual 1 and individual 2 require annual updates of the assessment. The updated assessment will be distributed to the team. The IDD Director reviewed why assessments were not completed; it appears that assessments were not completed timely because there was no coordinator for the home. If no program Coordinator is available, the IDD Manager or designee will complete the assessments for individuals. 08/12/2019 Not Accepted
6400.181(e)(6)Individual #2's 6/11/18 assessment does not include his ability to safely use or avoid poisonous materials.The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. This assessment will be completed by an individual who meets the qualifications for a Program Specialist and sent out to team members and the SC no later 08/12/2019, overviewing individual¿s ability to safely use or avoid poisonous materials. IDD Coordinator and Manager, with oversight from IDD Director, will review individual records to ensure files present with most up to date information. 08/12/2019 Not Accepted
6400.18(e)According to incident report #8446771 entered into the Departments incident reporting database, Enterprise Incident Management (EIM), "Staff member (Staff #2) was in the kitchen at East Petersburg at 4:10PM on 7/3/18. (Staff #2) walked into the hallway between the bedrooms and the living room. (Staff #2) then observed (Staff #1) get up out of the living room chair and grabbed Individual #1's hair and pulled it down towards the living room table. The individual then said, "Don't pull my hair ever again, that hurts." The individual continued to repeat, "Don't touch my hair. Don't ever pull my hair again." The report also indicated "(Staff #2) called House Supervisor (Staff #3) at 4:20 PM and alerted him of the situation. (Staff #3) called Program Coordinator (Staff #4) at 4:31 PM. And notified him of the allegation. (Staff #4) drove to the East Petersburg House and arrived at 5:00PM. (Staff #4) then pulled (Staff #1) aside with (Staff #3) present, and told her that an allegation of abuse has been made against her, and she would be off the schedule pending an investigation." The incident is still an open incident in EIM and the report indicates that there are findings that are waiting to be entered into EIM "pending investigation."The incident report, or a summary of the incident, the findings and the actions taken, redacted to exclude information about another individual and the reporter, unless the reporter is the individual who receives the report, shall be available to the individual, and persons designated by the individual, upon request.All fields on the EIM have been completed, including entering findings resulting from investigations by Holcomb¿s Certified Investigators. The EIM has been validated and submitted. Holcomb has identified and is currently utilizing outside Certified Investigators to support for timely investigations as investigation process was not completed within mandated times frames due to lack of availability by internal Certified Investigators. Staff #1 has remained off rotation during the investigation process and pending further Administrative Review. 09/17/2019 Not Accepted
6400.44(b)(1)A program specialist did not complete the last assessment in the record for Individual #1. Staff #3 completed the individual's assessment. Per Holcomb staff, Staff #3 was not a program specialist, nor did he have qualifications to be a program specialist.The program specialist shall be responsible for the following: Coordinating the completion of assessments.This assessment will be completed by an individual who meets the qualifications for a Program Specialist and sent out to team members and the SC no later 08/12/2019. IDD Coordinator and Manager, with oversight from IDD Director, will review individual records to ensure files present with most up to date information. 08/12/2019 Not Accepted
6400.51(a)(6)Staff #5 has been a full-time employee since 6/11/18. As of 7/16/19, there was no evidence that he received orientation training relevant to job responsibilities, daily operations of the home and policies and procedures of the home. Staff #6 has been employed since 10/3/17 and has worked anywhere between 69 to 153 hours in a month. She did not receive orientation training that included her job responsibilities, orientation to daily operations of the facility, agency policy and procedures, or other job-related knowledge and skills training.Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Consultants and contractors who are paid or contracted by the home and who will work alone with individuals, except for consultants and contractors who provide a service for fewer than 30 days within a 12-month period and who are licensed, certified or registered by the department of state in a health care or social service field.Staff #5 and Staff #6 completed the required orientation trainings. The previous Coordinator completed the trainings with staff; however, staff or Human Resources were unable to locate this documentation. Staff completed attestations noting that these trainings, including job responsibilities, orientation to daily operation of the facility agency policy and procedures, and job-related knowledge and skills to care for individuals at the home, were completed during the time of on-boarding. To ensure that this will be completed for all staff during the first 5 days of employment prior to working with individuals, IDD Coordinator and Manager, with oversight from IDD Director, will review orientation with each staff member. Forms will be scanned and emailed to IDD Director for review and electronic filing. 08/07/2019 Not Accepted
6400.52(b)(3)Staff #6 has been employed by Holcomb since 10/3/17 and has worked over 40 hours every month in the last year. She has worked anywhere from 69 hours a month to 153 hours in a month. As described under 6400.52(b)(3), she is a contractor who is contracted by the home through a temporary agency. At the time of the inspection 7/16/19, there is no documentation that she received any training since her date of hire. According to the agency statements on 7/16/19-7/18/19 and documentation provided on 7/24/19 by the agency, Staff #6 is a contracted staff through a temporary agency and never received training required under 6400 regulations. Annual training requirements used to be captured under 6400.46(d) for any staff working with individuals and they are now captured under 6400.52(b)(3) for contracted staff.The following shall complete 12 hours of training each year: Consultants and contractors who are paid or contracted by the home and who work alone with individuals, except for consultants and contractors who provide a service for fewer than 30 days within a 12-month period and who are licensed, certified or registered by the department of state in a health care or social service field.Training records have been requested for Staff #6 from search firm Delta-T Group. Direct oversight of these trainings needs will be maintained by the IDD Supervisor, Coordinator, and Director. Quarterly, the Program Coordinator and IDD Director will review that all staff have required trainings. If a staff member or consultant or contractor do not have required trainings they will be completed immediately. 08/05/2019 Not Accepted
6400.52(c)(6)REPEAT from 1/31/19 annual inspection: Staff #1 did not receive training in the implementation of Individual #2's individual plan. The individual was assessed in his plans to be unsafe around poisonous materials and required them to be locked in the home. During the 7/18/19 onsite inspection, Staff #1 stated she did not know if the individuals were safe with poisonous materials, did not know what their assessments indicated or what was recorded in their Individual Support Plans (ISPs). This regulatory requirement was previously found under 6400.44(b)(18), training of the direct support professionals based on the individual's health and safety needs. This requirement can now be found under 6400.52(c)(6), training of the direct support professionals based on the individual's health and safety needs addressed in their plans.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.Staff #1 was present at the ISP meeting and was a part of the development of the plan for Client #2¿s, indicating that she was aware of the information entered into the ISP. The statement made by staff #1 related to not being aware if Client #2 was safe around poisons was not correct. All staff in the home were trained that all residents must be assessed to be unsafe around poisonous materials. Staff members on each shift check that all poisonous materials are locked. Additionally, as routine checklists review of home, administrative staff review that poisonous material are locked. Staff member #1 is currently suspended. 08/05/2019 Not Accepted
6400.186Individual #2's Individual Support Plan (ISP) states that when he becomes verbally aggressive, staff will encourage him to engage in physical exercise jumping on the trampoline located in the home. Per Staff #1 on 7/18/19, the individual's behavior support plan also includes the use of a trampoline as a de-escalation technique. During the onsite inspection on 7/18/19 the individual's trampoline was witnessed to be broken. A screw was coming out of the bent frame causing the trampoline to partially fold in half. The legs on the trampoline were angled inward. Twenty-two of the elastic straps on the trampoline, approximately 80% of the total straps holding the trampoline to the frame, were so stretched out that when you stepped on the trampoline, it went to the floor. Staff #1 stated that the behavior support person told her last week that the trampoline was broken, and the individual needed a new one. Staff #1 stated she did not notify anyone that the individual needs a new trampoline. Individual #2 is unable to use his trampoline for de-escalation techniques as both his ISP and behavior support plan indicate he should do in the event he has increased behaviors and verbal aggression. The regulatory requirement to implement the individual's plan as written has not changed. However the number associated with it has. This requirement used to be found under 6400.185(b) but is now captured under 6400.186.The home shall implement the individual plan, including revisions.New ISP for both individuals in the home have been printed and reviewed with all staff. All staff reviewed and signed acknowledgement that plans were reviewed (documents are attached). Holcomb COO purchased a new trampoline on 7/25/2019, and was delivered to the home on 7/27/19. Individual #1 is able to use trampoline as indicated on ISP. IDD Director also met with all staff including BSP to inform them that if item from ISP require repair or purchase, this needs to be communicated to Supervisor and Coordinator immediately. If item is not repair or purchase within 3 days they need to inform IDD Director. As part of Administrative oversight, IDD Director, Program Manager and Director of Operations will complete walkthrough of home and review that items related to ISP are in working order. As part of this finding, it was reported that BSP did inform Supervisor Staff #1 that the trampoline was broken. Staff member #1 is currently suspended and removed from schedule. 08/05/2019 Not Accepted
6400.188(a)Individual #2 is diagnosed with Post Traumatic Stress Disorder (PTSD), Pervasive Developmental Disorder not otherwise specified (PDD NOS), Schizo-effective Disorder, Mild Intellectual and Developmental Disabilities, Anxiety, Impulsivity, and psycho-social stressors. He has an Individual Support Plan (ISP)and behavior support plan that staff are to utilize to assist the individual through episodes of aggression and personal adjustment concerns. The plans state that when the individual becomes verbally aggressive, staff will encourage him to engage in physical exercise jumping on the trampoline located in the home. During the onsite inspection on 7/18/19, the individual's trampoline was witnessed to be broken. A screw was coming out of the bent frame causing the trampoline to partially fold in half. The legs on the trampoline were angled inward. Twenty-two of the elastic straps on the trampoline, approximately 80% of the total straps holding the trampoline to the frame, were so stretched out that when you stepped on the trampoline, it went to the floor. Staff #1 stated that the behavior support person told her last week that the trampoline was broken, and the individual needed a new one. Staff #1 stated she did not notify anyone that the individual needs a new trampoline. Individual #2 is unable to use his trampoline for de-escalation techniques as both his ISP and behavior support plan indicate he should do in the event he has increased behaviors and verbal aggression. The residential home has been unable to provide services including assistance, training and support for the acquisition, maintenance or improvement of the mental health needs of the individual due to the inability to implement the individual's behavior de-escalation techniques.The home shall provide services, including assistance, training and support for the acquisition, maintenance or improvement of functional skills, personal needs, communication and personal adjustment.Holcomb COO, Nicole Brown, purchased a new trampoline on 7/25/2019 and was delivered to the home on 7/27/2019. Individual #1 is able to use trampoline. IDD Director also met with all staff including BSP to inform them that if item(s) from ISP require repair or purchase, it should be communicated to Supervisor and Coordinator immediately. If the item(s) is not repaired or purchased within 3 days, the IDD Director should be informed. As part of Administrative oversight, IDD Director, Program Manager and Director of Operations will complete walkthrough of home and review that items related to ISP are in working order. As part of this finding, it was reported that BSP did inform Supervisor Staff #1 that the trampoline was broken. Staff member #1 is currently suspended. (STAFF TRAINING OF ISP). PICTURE and receipt OF TRAMPOLINE INCLUDED 08/05/2019 Not Accepted
SIN-00149911 Renewal 01/31/2019 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)The most current financial record in the home is dated November 2018, and is not up to date. The record documents a starting balance of $20. Home cash on hand was counted to be 23.16 on 2/1/2019. No financial log was observed to be kept with funds in the home (2 receipts were present in the home - one for 10.60 and one for 4.24).The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. The financial log was updated on 3/8/2019 to reflect the current balance of cash on hand for individual #1. It is the responsibility of the program specialist to ensure that financial records for all individuals are current. The process will be that the program specialist or designee will track and enter all money received on behalf of each individual at the program and enter the amount of money on hand and each receipt for purchases on the financial ledger on a weekly basis or the day of the purchase effective immediately. The receipts will be kept on file in the individuals¿ financial record. The program coordinator should review the financial records for 25 percent of individuals on a monthly basis and sign the monthly ledger to ensure compliance. If at any point the ledger is not balanced with the amount of cash on hand, the coordinator should follow up with the program manager for further guidance and training. This regulation was reviewed with the program specialist on 2/21/2019 and additional training for all staff will be completed by 4/30/2019 during the annual IDD training. 04/30/2019 Not Implemented
6400.31(b)Rights were signed by the individual on 10/15/17 and not again since.Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. The program specialist/ coordinator received training on 2/5/2019 describing their responsibility that includes to have all individuals sign all rights forms and consents are signed annually. The program coordinator or designee will review the required annual forms on a quarterly basis to ensure individuals are informed of their rights. This regulations has been added to the Coordinator and Supervisors Responsibilities Schedule. The coordinator or manager will follow up on any area of non-compliance and give feedback and training as needed during internal audits to be completed every 6 months of all program documentation 04/30/2019 Not Implemented
6400.68(b)The water temperature in the bathroom sink and tub was observed to be 123 degrees F. Hot water temperatures in bathtubs and showers may not exceed 120°F. The mixing valve on the hot water heater was adjusted on 2/12/2019 and set at 115 degrees F. The water temperature has not exceeded 120 degrees since the adjustment was made. The program specialist and direct support staff will test the temperature of the water on a daily basis and document on the posted water temperature log. Logs will be kept on file at each program location and any reoccurring issues with the water temperature will be sent to the Environment of Care Committee for safety review. The program specialist, coordinator or designee will notify the facilities manager via email immediately if the water exceeds 120 degrees F. All staff will be retrained in this regulation during the annual IDD training(s) to be completed by 4/30/2019 04/30/2019 Implemented
6400.103There was no emergency evacuation procedure present in the record for the home.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. A Disaster/Evacuation plan was developed to include the staff and client responsibilities, means of transportation and emergency shelter location for all locations. This was completed on 2/5/2019. It is the responsibility of the program specialist and coordinator to ensure this plan is current and posted for all staff to follow in case of an emergency evacuation. This regulation was out of compliance due to the inaccurate documentation during quarterly Environment of Care audits completed on a quarterly basis. The program coordinator and program specialist or designee will a complete these audits together on the existing quarterly schedule and the program manager will review upon completion for accuracy. The program manager will provide feedback and guidance in any area of noncompliance of the internal audit. This regulation was reviewed with the program coordinator on 1/31/2019 and a review for all staff will be conducted during the annual IDD Training(s) to be completed by 4/30/2019. 04/30/2019 Implemented
6400.106Furnace inspection was completed on 6/30/17 and not again until 8/1/18.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The Facilities Manager and program specialist/coordinator will keep a spreadsheet with documentation of the annual due dates for all furnaces to be cleaned and inspected. The facilities manager will contact the vendors to complete a review of HVAC systems at each location on a routine basis. The program specialist and coordinator will work with the Facilities manager to arrange that the proper cleaning and maintenance required is scheduled and completed by the vendors. The coordinator and program manager will review the spreadsheet with the director on a quarterly basis to ensure cleanings and inspections were completed in a timely manner. This regulation will be reviewed with all staff during the annual IDD training(s) to be completed by 4/30/2019 04/30/2019 Implemented
6400.141(a)Individual #1 had a physical exam on 3/6/17 and not again until 5/30/18.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The annual physical exam for Individual #1 was out of compliance due to a missed appointment. The annual exam for this individual is scheduled for 5/24/19.It is the responsibility of the program specialist to ensure all appointments are within the required time frame. The program specialist now uses a large appointment book/calendar to indicate the date and time of all appointments with health practitioners. All staff attending appointments with the individual will schedule any follow up treatment and required appointment prior to the end of the visit with said medical provider. The program specialists will review the calendar each week in advance in preparation for upcoming appointments and notify staff by indicating the appointment on the staff schedule. The program coordinator or designee should conduct reviews of 50 percent of medical file on a quarterly basis and notify the program specialist via email of any follow up medical appointment/treatment needed. A review of this regulation with all staff will be completed during the annual IDD training on 4/30/2019. 04/30/2019 Not Implemented
6400.141(c)(14)Individual #1's physical did not include medical information pertinent to diagnosis and treatment in case of an emergency. It was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The annual physical form for individuals living in the program has been revised using red lettering to bring attention to the section that pertains to the information pertinent to diagnosis and treatment in case of emergency for medical providers to complete. It is the responsibility of the program specialist and direct support staff to ensure all sections of all medical forms are filled out completely at the close of each medical appointment they attend. This section of the annual physical form for individual #1 was completed on 3/13/2019. Moving forward, the coordinator will conduct an internal audit and review and initial all medial forms on a monthly basis and immediately follow up on any areas of non-compliance. The coordinator will notify the program specialist via email and contact the provider. This regulation has been reviewed with the program specialist and all staff will be trained on this regulation during the annual IDD training(s) to be completed on 4/30/2019. 04/30/2019 Not Implemented
6400.144Individual #1 had a dental cleaning and exam on 8/8/17 and was to return in six months (Feb 18). Individual did not return for cleaning and exam until 6/15/18. Individual was to return in 3 months (Sept 18), and has not yet returned. Individual #1 had a 3 month psychiatric medication review on 9/11/18 and not again until 1/29/19 (late).Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The dental cleaning and exam for individual #1 has been scheduled for 3/29/2019. The Coordinator and program specialist/supervisor are responsible for planning and scheduling appointments for all individuals to assure that nursing, medical, pharmaceutical, dental, dietary & psychological services are arranged/provided. The program specialist now uses a large appointment book/calendar to indicate the date and time of all appointments with health practitioners. Program specialists will review the calendar each week in advance in preparation for upcoming appointments and notify staff by indicating the appointment on the staff schedule. The program coordinator or designee will conduct reviews of each medical file on a quarterly basis and notify the program specialist via email of any follow up medical appointment/treatment needed. A review of this regulation with all staff will be completed during the annual IDD training on 4/30/2019 04/30/2019 Not Implemented
6400.163(c)The 9/11/18 review did not include the reason for prescribing the medication (diagnosis for each medication was missing). 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.The Treatment Summary for Outside Consultant Form has been modified to explain the reason for prescribing psychotropic medication, the need to continue the medication and the necessary dosage to assure that whenever an individual has a quarterly medication review that this information is noted. The program specialist is responsible to check that all pertinent information is clearly written on the treatment summary form at the close of each appointment. The Coordinator should review 25 percent of records on a monthly basis during an internal audit using a checklist as indicated in 213(3) to assure that pertinent data is available and filed on a timely basis. The Manager or designee should review 50 percent of records quarterly to assure that required data is present and filed as required. The program specialist and direct support staff have been trained on the use of the checklist via a 2/8/2019 Memo from the Manager/Director to include this information. This regulation will be reviewed during the annual IDD training(s) to be completed by 4/30/2019. 04/30/2019 Implemented
6400.186(a)There is no current ISP review (quarterly) in the record for the dates of 10/17/18 to 1/17/19 (with 15-day grace period due 2/1/19).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. The ISP quarterly review was completed for individual #1 on 3/10/2019. The program specialists will generate reviews of the ISP goals and outcomes for the individual every three months or more frequently if the individuals needs change as noted on the supervisor schedule. There was a recent change in leadership at the program level and the process of hiring more staff. Additional staff will help to alleviate the program specialists¿ work load and focus on completing the required paperwork in a timely manner. It is the responsibility of the program coordinator to monitor this process on a quarterly basis by signing the completed reviews of all individuals in the program to assure compliance. The ISP reviews are to be sent to the ISP team members via email/fax, with an acknowledgement receipt of delivery form signed by the team member in the required time frame. The program manager or designee are to also conduct internal audits of each program every 6 months to support compliance and supply feedback and guidance as needed to ensure standards are met. Documentation of these audits will be kept on file for 1 year at the program location. This regulation will be reviewed with all staff during the annual IDD training that will be completed on 4/30/2019 04/30/2019 Implemented
6400.186(d)There was no documentation in the record that the ISP reviews dated 10/16/18, 7/16/18, 4/16/18 were sent to team members.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. 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. The ISP reviews were completed on 3/8/2019. The 186d protocol has been updated and the process to ensure compliance is that the program specialist will generate an ISP review based on the date of the ISP and it will be send out to all team members and the SC. This will be sent via email to all members and a copy of the email will be filed in the individuals¿ chart with the ISP review. The program specialist is responsible to assure compliance and the coordinator will conduct an internal audit of all monthly reviews on a quarterly basis. The coordinator will supply feedback to the program specialist as needed. This regulation was reviewed with the coordinator on 2/12 and all staff will receive training on this regulation during the annual IDD training to be completed by 4/30/2019 04/30/2019 Not Implemented
6400.213(11)Individual's current ISP lists allergies to Geodone and Clonidine. Current physical exam and assessment document no known allergies. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. The ISP for individual #1 was revised to clarify the discrepancy between the annual physical, the annual assessment and the current ISP. A review of the medical history including allergies was completed by the individuals¿ physicians, and the ISP revision will be completed on 3/13/2019. The program specialist will review all treatment summary forms as needed and document any changes and notify the individuals¿ team so critical changes are made to the ISP via email. The residential coordinator will review all ISP¿s, and all other documentation pertaining to the individual for any inconsistencies and provide feedback via email to the program specialists in any area of non-compliance on a quarterly basis. The program specialist is responsible to assure compliance to this regulation. It is the responsibility of the program coordinator and program manager to conduct an internal audit of 25 percent of records on a quarterly basis starting 3/20/2019 to assure there are no discrepancies and that any revisions needed were documented via email and sent to the team members. A record of this audit should be kept on file for 1 year at the program location. This regulation will be reviewed with all staff during the annual IDD training that will be completed on 4/30/2019. 04/30/2019 Not Implemented
SIN-00119683 Renewal 01/22/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)Self Assessments dated 03/06/17 and 03/10/17 had no summary of results or corrections made.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. Self-assessments have been completed for both Hempfield and East Petersburg locations in accordance with the 6400 regulations. ¿Please see attached completed self-assessments. The coordinator/ Supervisors were retrained on 2/21/18 see attached syllabus- by the manager/Director on the importance of completing self- assessments including a written summary of corrections. Coordinator will assure that all self-assessments are completed within 3-6 months of the licensure date. 02/21/2018 Implemented
6400.44(b)(6)Individual # 1's current ISp last updated 01/09/18 does not included his/her current status as being supported by Holcomb. The Program Specialist did not review Individual # 1's ISP.The program specialist shall be responsible for the following: Reviewing the ISP, annual updates and revisions under § 6400.186 for content accuracy. The ISP was not updated by the Supports Coordinator, to indicate that Holcomb was the residential Provider, and the Program Coordinator/Supervisor failed to notice this. A critical revision meeting was held and changes were made to Individual number 1¿s ISP on 1/31/2018. These changes included Holcomb is listed as the Residential provider. The coordinator/ Supervisors were retrained on 2/21/18 see attached syllabus- by the manager/Director on the importance of making sure the ISP has been updated to reflect all current information, and the team has been notified of all changes. 01/31/2018 Implemented
6400.44(b)(11)The Program Specialist did not report changes related to Individual # 1's needs to the SC and plan team members. Such changes include taking all medications with water, needing to be anesthesized for dental appointments, no longer having manic episodes of behavior, current supports needed with ambulating, eating a healthy diet and a loss of 30 lbs.The program specialist shall be responsible for the following: Reporting a change related to the individual's needs to the SC, as applicable, and plan team members. A critical revision meeting took place on 1/31/18, and all changes were made in the ISP. Team members signed a form stating that they read the new ISP¿s and the changes that occurred. The coordinator/ Supervisors were retrained on 2/21/18 see attached syllabus- by the manager/Director on the importance of having all pertinent changes made in the individuals ISP. 03/05/2018 Implemented
6400.71Emergency telephone numbers were not located near the telephone in the recreation room.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. A copy of the emergency numbers was posted by the phone at East Petersburg on 1/23/2018 The Supervisor was retrained on 2/21/18 see attached syllabus- by the Manager/Director on the importance of having all emergency numbers listed by all phones in the house. 02/27/2018 Implemented
6400.82(e)The bathtub/shower did not contain a nonslip surface or bath mat. Bathtubs and showers shall have a nonslip surface or mat. A non-slip mat was purchased for the East Petersburg bathroom tub and placed there on January 30th as the picture indicates in the supported documentation marked 82E. The Supervisor was retrained on 2/21/18 see attached syllabus- by the Manager/Director on the importance of having a non-slip mat in all bathroom tubs. 01/30/2018 Implemented
6400.104The fire notification letter dated 09/09/17 for 5740 Main St does not include the address of the residence.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. The Fire letter was rewritten by the program Coordinator stating the full address of the East Petersburg House. A copy of the letter was rewritten on January 22nd 2018. The updated letter then was replaced in both individuals main file. A copy of this letter is included in the supporting documentation marked 104. The coordinator/ Supervisors were retrained on 2/21/18 see attached syllabus- by the manager/Director on the importance of completing a proper fire letter. Coordinator will assure that all fire letters are updated annually as needed. 01/23/2018 Implemented
6400.141(c)(6)Individual # 1's date of admission was 09/08/17. A TB test was read 10/19/17. Physical exam to include TB test is to be completed within 12 months prior to date of admission.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Individual number 1 had her admission physical on 8/8/17, and at that time her updated TB test was not due. Her prior TB test was 11/14/15. The TB test was repeated on 10/17/17 and read on 10/19/17 according to TB protocol of every 2 years. See attachments marked 141(c6). 10/17/2017 Implemented
6400.141(c)(7)Individual # 1's Date of admission was 09/08/17. No comprehensive gynecological examination is contained in the record.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. Individual number 1¿s physical dated 8/8/17 indicates permanent deferral for both PAP and breast exam, however, we wanted a follow-up appointment with her PCP which was scheduled for 3/26/18. Her PCP, Dr. Messick cancelled this appointment and referred individual number 1 to a GYN specialist on 4/2/18. The PCP felt the individual should be sedated prior to the exam because a 2/1/18 visit for a vaginal discharge upset her when a swab was performed. A prescription for a Mammogram will be requested at that time. 08/08/2017 Implemented
6400.168(a)Staff # 1 was trained in medication on 08/19/16. Annual practicum documentation was not contained in the record nor available upon request. 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 number 1 was retrained in medication course on 3/2/18 and four practicums were completed on 3/15/18. Med course and Practicum documentation is attached marked 168(a). Coordinator/supervisor were retrained on 2/21/18, see attached syllabus by manager/director regarding the timeliness of medication practicums. A spreadsheet has been developed to assure that all practicums will be completed on a timely basis. See attached. 03/15/2018 Implemented
6400.181(e)(1)Individual # 1's 10/16/17 assessment did not identify his/her needs. The assessment must include the following information: Functional strengths, needs and preferences of the individual. The assessment has been attached to Lifetime Medical history and the Psychological assessment. The coordinator/ Supervisors were retrained on 2/21/18 see attached syllabus- by the Manager/Director on the importance of having the Psychological assessment attached to the assessment. 02/21/2018 Implemented
6400.181(e)(2)Individual # 1's 10/16/17 assessment did not identify his/her dislikes.The assessment must include the following information: The likes, dislikes and interest of the individual. When the assessment was redone using the correct form, for individual number 1, dislikes were indicated. Use of the correct Biosycosoccial form corrected this issue on 1/23/18. The coordinator/ Supervisors were retrained on 2/21/18 see attached syllabus- by the Manager/Director on the importance of using the correct form, and making sure dislikes are on the assessment. See attached assessment 02/21/2018 Implemented
6400.181(e)(10)A lifetime medical history was not attached to 10/16/17 assessment. No documentation that lifetime medical history was included as part of assessment.The assessment must include the following information: A lifetime medical history. The assessment has been attached to Lifetime Medical history and the Psychological assessment. The Coordinator/ Supervisors were retrained on 2/21/18 see attached syllabus- by the manager/Director on the importance of having the lifetime medical history attached to the assessment. 02/21/2018 Implemented
6400.181(e)(11)Individual # 1's 10/0-6/17 assessment does not include psychological evaluation. No documentation that psych evaluation information included in assessmentThe assessment must include the following information: Psychological evaluations, if applicable. The assessment has been attached to Lifetime Medical history and the Psychological assessment. The coordinator/ Supervisors were retrained on 2/21/18 see attached syllabus- by the Manager/Director on the importance of having the Psychological assessment attached to the assessment. 02/21/2018 Implemented
6400.185(b)Individual # 1's current ISP last updated 01/09/18 states outcomes of Health and safety, Independence and Community Integration and Participation. These outcomes have not been implemented. His/her current ISP also indicates that Individual # 1 needs supervision on stairs when going up and down to prevent falls due to loosing his/her balance at times. This is a result of his/her loss of coordination since Neuroleptic Malignant Syndrome. He/She also should avoid being in the sun when it is warm, (Hx of dehydration) and limit the eating of bulky vegetables. He/She has an elopement history and requires a high level of prompting during manic episodes.The ISP shall be implemented as written.A critical revision meeting was held on 1/31/18 to address outcomes for health and safety, independence, and community integration. See attached ISP critical revision and current quarterly which address supervision on stairs, and uneven surfaces. She continues to spend limited time in the sun due to dehydration and continues to need additional fluids. Her concerns of elopement have significantly decreased since her admission to East Petersburg. See current Quarterly report. 03/08/2018 Implemented
6400.186(c)(1)Individual # 1's monthly documentation did not include outcomes identified in his/her ISP.The ISP review must include the following: 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. When the critical revision meeting was held on 1/31/2018, the team was able to list functional outcomes to report on daily, monthly, and quarterly basis. Please see correct quarterly report form now in use. The coordinator/ Supervisors were retrained on 2/21/18 see attached syllabus- by the Manager/Director on the importance of having ISP outcomes included in the monthlies. 03/08/2018 Implemented
6400.186(c)(2)Individual # 1's ISP review dated 12/08/17 did not include a review of outcomes identified in his/her ISP. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. -- When the critical revision meeting was held on 1/31/2018, the team was able to list functional outcomes to report on daily, monthly, and quarterly basis. Please see correct quarterly report form now in use. The coordinator/ Supervisors were retrained on 2/21/18 see attached syllabus- by the Manager/Director on the importance of including a review of outcomes identified in her ISP. 03/08/2018 Implemented
6400.188(a)Individual # 1 is diagnosed with a seizure disorder and does not have a seizure protocol in place.The residential home shall provide services including assistance, training and support for the acquisition, maintenance or improvement of functional skills, personal needs, communication and personal adjustment. - Individual number 1 needed a Seizure protocol prior to admission. An appointment was made with her PCP Dr. Elizabeth Messick on February 1st 2018 to see if a seizure protocol was necessary. Dr. Messick indicated that a seizure protocol was unnecessary. An assessment marked 188 (a) has been added into the supporting documentation. 02/01/2018 Implemented
6400.213(1)(i)Individual # 1's photo is not dated. Individual # 1's record does not indicate identifying marks.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. After a visual check from a staff member on 3/9/18, it was noted that Individual number 1 had mole on her left breast, and freckles on her back and arms. This change was documented on her Emergency medical sheet as noted on the supporting documentation marked 213 (1(ii)) as of 3/9/18. The coordinator/ Supervisors were retrained on 2/21/18 --- see attached syllabus- by the manager/Director on the importance of having documentation of identifying marks listed in the client record. 03/09/2018 Implemented
6400.213(9)Individual # 1 did not have a copy of the current ISP in the record. Each individual's record must include the following information: A copy of the current ISP. The correct ISP was not included in Individual number 1¿s record. After a critical revision on 1/31/2018, the correct ISP was put into her record. Staff were informed that Individual number 1¿s ISP was updated (See sign in sheet). Any time in the future when a critical revision/ updated ISP occurs, this same process will be followed to inform staff. The coordinator/ Supervisors were retrained on 2/21/18 see attached syllabus- by the manager/Director on the importance of having a current ISP in the residential record. 03/05/2018 Implemented
6400.213(11)Individual # 1's 06/08/11 psych evaluation states that he/she had an allergic reaction, rash from the medication Depakote. This allergy is not indicated in her lifetime medical history. It is in his/her ISP. The back up emergency plan states that he/she has been shown where the phone list is and how to call the numbers. Individual # 1 is unable to complete phone calls independently. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. Depakote was added as an allergy to her Physical and Lifetime Medical History. If any further allergies are discovered for her, the program supervisor will make sure the allergies are added to the Lifetime Medical History, and well as the physical. The coordinator/ Supervisors were retrained on 2/21/18 see attached syllabus- by the manager/Director on the importance of making sure all allergies are listed on the lifetime medical history. 02/21/2018 Implemented
6400.216(a)Individual progress notes for Individual # 1 and #2 were left unlocked and unattended near the kitchen area. An individual's records shall be kept locked when unattended. All staff signed a memo stating that the Progress notes need to be locked up when they are not in use on 2/27/18. The Supervisor was retrained on 2/21/18 see attached syllabus- by the Manager/Director on the importance of having all programming books locked away when they are not in use. 02/27/2018 Implemented
SIN-00263222 Unannounced Monitoring 03/26/2025 Compliant - Finalized
SIN-00209486 Renewal 08/15/2022 Compliant - Finalized
SIN-00193702 Unannounced Monitoring 09/27/2021 Compliant - Finalized
SIN-00184965 Unannounced Monitoring 03/19/2021 Compliant - Finalized
SIN-00183307 Unannounced Monitoring 02/04/2021 Compliant - Finalized
SIN-00181186 Unannounced Monitoring 01/06/2021 Compliant - Finalized
SIN-00175352 Unannounced Monitoring 08/13/2020 Compliant - Finalized
SIN-00173709 Unannounced Monitoring 06/30/2020 Compliant - Finalized
SIN-00173094 Unannounced Monitoring 05/05/2020 Compliant - Finalized
SIN-00172872 Unannounced Monitoring 04/10/2020 Compliant - Finalized
SIN-00170484 Unannounced Monitoring 02/05/2020 Compliant - Finalized
SIN-00165867 Unannounced Monitoring 11/06/2019 Compliant - Finalized