Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00219611 Renewal 02/27/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)There was a series of small, black, speckled discolorations---consistent in appearance with mold---along the ceiling of the home's bathroom. These discolorations were clustered around the area of the ceiling above the bathtub.Clean and sanitary conditions shall be maintained in the home. Staff cleaned the mold off the ceiling on 2/28/23. A maintenance request was completed and a plan was made to get an fan put into bathroom for proper ventilation. Attachment # 13, 14. 05/04/2023 Implemented
6400.67(a)One of the windows in Individual #2's bedroom was incapable of remaining in the open position. Whenever the window was opened, it quickly slid shut. The window mechanism was not working as intended and, therefore, was not in good repair.Floors, walls, ceilings and other surfaces shall be in good repair. Maintenance customed ordered a new window on 3/10/23 to replace the current window. Attachment # 15 06/16/2023 Implemented
6400.111(f)The fire extinguisher located on the second story of the home had inspection tags indicating that it was last inspected and approved by a fire safety expert in January 2022, over one year ago. This fire extinguisher was not inspected and approved annually by a fire safety expert as required. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. Fire extinguishers were replaced on 2/28/23 to be in compliance with 55 PA Code Chapter 6400.111(f) . Program Specialist will be retrained by 3/24/2023 on how to check monthly fire drills, fire extinguishers, and fire systems. Attachment # 16 04/03/2023 Implemented
6400.181(a)Individual #2 was admitted to the provider's residential program effective 07/15/2022. An initial assessment was not completed for this individual until 09/16/2022, 64 days later. This individual's initial assessment was not completed within 60 days of the admission date as required. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. An admission Checklist was created to ensure Program Specialists meet appropriate deadlines per 55 PA Code Chapter 6400.181. Attachment # 17 04/03/2023 Implemented
6400.46(d)Per staff training records, Staff #2's two most recent trainings on first aid, Heimlich techniques, and cardio-pulmonary resuscitation occurred on 04/04/2019 and 05/13/2021. This training was conducted through the American Red Cross and is noted to remain valid for a period of two years; the interim between these two training certification dates exceeds the allowable two-year validity period specified by the American Red Cross. There is no evidence that this staff received training on these topics from another source. As such, this staff did not receive training in this area at the annual frequency required under this chapter or at the two-year frequency specified by the American Red Cross.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.HR will enter all current staff's Red Cross Adult First Aid/CPR/AED certification dates into an electronic database, and alert staff 2 months prior to their due dates to ensure compliance of 55 PA Code Chapter 6400.46(d). HR will complete this task by 4/14/2023. 04/14/2023 Implemented
SIN-00166284 Renewal 12/03/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The license for this chapter expires on 12/7/2019. The self-assessment was not dated so it couldn't be determined if it was completed 3-6 months prior to the license expiration.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Self-Assessment tool will be scheduled to be completed in July or August in 2020 and each successive year, which is within 3-6 months prior to the expiration date of the agency¿s certificate of compliance. This will be monitored by Martha Gonzalez, Director of IDD Residential Services. 12/21/2019 Implemented
6400.141(c)(3)Individual #2 (DOB: 8/19/1969) had his Tetanus/Diphtheria on 11/2/2009. He didn't have it again until 11/27/2019.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. Threshold will train all medical and medical appointment scheduling staff on requirement of Tetanus/Diphtheria at least every 10 years. Training will be completed by Martha Gonzalez, Director of IDD Residential Services by 1/15/2020. All records will be reviewed to assure compliance of Tetanus/Diphtheria immunization at least every 10 years by 1/31/2020. 01/31/2020 Implemented
6400.181(e)(13)(viii)This area was not assessed in Individual #2's assessment dated 5/16/20019. Repeat Violation: 1/15/2019.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. Program Specialist completed individual¿s current progress and growth in managing personal property by 12/20/2019. See Attachment 4. Director of IDD Residential Services, Martha Gonzalez will assure Program Specialist are retrained in requirements of The Assessment by 1/15/2020. All Assessments will be reviewed and updated for accuracy by Program Specialist by 1/31/2020. A new Annual Assessment form will begin implementation effective 3/1/2020. See Attachment 10. 03/01/2020 Implemented
6400.18(b)(2)A medication error is an incident that needs to be reported in EIM within 72 hours. Individual #2 is prescribed Fish Oil 1000mg BID at 7am & 4pm). This medication was not administered at 7am on 11/19/19, 11/20/19, 11/21/19 and 11/22/19; it also was not administered at 4pm on 11/19/19, 11/20/19 and 11/21/19. EIM's were not completed for these omissions.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person: A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner.EIM report 8628631 was entered to document omissions of Fish Oil 1000mg BID for dates missed. Upon discover of omitted medications, including over-the-counter medications, an EIM report will be filed by Program Specialist. This is effective immediately and will be monitored by Martha Gonzalez, Director of IDD Residential Services. All Program Specialists will be trained on 181 (b)(2). Training will be conducted by Martha Gonzalez, Director of IDD Services by 1/15/2019. At house meetings in January 2019, all staff will be trained on 181 (b)(2). 01/31/2020 Implemented
6400.163(h)On 10/31/2019, Individual #2 was prescribed Bacitracin (500unit/gm) to be applied BID for 10 days to an abrasion on his right hand or until it was healed. This medication was still in Individual #2's med box and was no longer listed on his MAR sheet. Staff reported that the abrasion on his right hand has healed.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Bacitracin (500unit/gm) was removed from the home on 12/4/2019 by Martha Gonzalez, Director of IDD Residential Services. All Program Specialists will be trained that prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. Training will be conducted by Martha Gonzalez, Director of IDD Services by 1/15/2019. At house meetings in January 2019, all staff will be trained to remove unused medications or treatments. 01/31/2020 Implemented
6400.165(c)Individual #2 is prescribed Fish Oil 1000mg BID at 7am & 4pm). This medication was not administered at 7am on 11/19/19, 11/20/19, 11/21/19 and 11/22/19; it also was not administered at 4pm on 11/19/19, 11/20/19 and 11/21/19.A prescription medication shall be administered as prescribed.All medications will be given as prescribed, including over-the-the counter medication. Staff will report medication errors to Program Specialists when observed and Program Specialists will complete Medication Audits weekly to assure compliance. See attachment 3 for a copy of the Medication Audit form. This is effective immediately and will be monitored by Martha Gonzalez, Director of IDD Residential Services. 12/21/2019 Implemented
SIN-00071376 Renewal 11/13/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(b)On the exterior of the house, at the basement exit where the trash is kept has a blacktop surface in need of repair. The blacktop is uneven with dips and potholes as well as moss growing on it, causing a tripping hazard. The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions.1. A plan to fix the immediate problem a. on 11/17/2014 maintenance removed moss and sod from top of asphalt at the door b. on 01/09/2015 low spots were filled. 2. A plan to prevent future occurrences a. During weekly house audits program specialist will continue to monitor physical sites b. Request to repair/replace damages will be complete as soon the issue is discovered. 3. A designation of the person responsible to complete each step The Program Specialist will be responsible for the home 4. Target dates for completion of each step The process is effective immediately and will be ongoing. 01/09/2015 Implemented
6400.112(f)The basement is not being utilized during fire drills. Alternate exit routes shall be used during fire drills. Tthe incident had occurred and cannot be altered,as the fire drill was completed,a fire drill cannot be completed for a past date at this time.CSS Director will train current managers and new managers on Licensing requirements and expectations for compliances.Managers will develop a schedule for all fire drills ensuring compliance with all licensing requirements Fire drills will be scheduled by the manager to assure consistency and accuracy; including Exit used.Informing the staff the day of to comply,whether in person, phone call or in writing.During the weekly house audit after the scheduled fire drill is completed it will be reviewed by manager.If there are mistakes a fire drill still will be done this day and the manager will discuss the mistake with staff to assure compliance.Further training/review will be done with currently working staff during staff meetings to assure compliance.During post orientation training managers,will review the fire drill protocol for new staff.The Program Specialist will be responsible for the home in question.During a managers meeting that was conducted on December 23/2014. Managers will complete schedules by December 30/2014.Effective 1/2015 managers will continue to review completion of fire drills for compliance.Completion of retraining of current staff of fire drills protocols to ensure compliance will be completed by 1/31/2015.Managers will include fire drill protocol training with all new staff this will an ongoing procedure effective 1/2015.Newly completed fire drill will be reviewed by the Program Specialist the of or day after the fire drill is completed. If done correctly, the program specialist will sign off,if not done correctly the fire drill policy will be reviewed with staff and done again the same day or the following day. 01/31/2015 Implemented
SIN-00147632 Renewal 01/15/2019 Compliant - Finalized
SIN-00129463 Renewal 02/12/2018 Compliant - Finalized