Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00223832 Renewal 04/11/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The First Aid Kit did not contain Antiseptic. 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. The first aid kit box has been stocked with all of the above by the Direct Support Supervisor and a check was completed at all other CLA homes to ensure all are stocked with the listed items. 06/07/2023 Implemented
6400.46(a)Staff person (1) was not trained in general fire safety before working with individuals.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.All new hires are to be trained in all mandatory trainings including fire safety prior to working with individuals. This has been ongoing since April 2023 - see attachment 25. 04/12/2023 Implemented
SIN-00211261 Unannounced Monitoring 09/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)Rubber bands were located on multiple cabinets. The agency stated the individuals don't want others to steal their food. However, when the rubber bands were removed, the doors were not secure and did not close completely. Furniture and equipment shall be nonhazardous, clean and sturdy. Work order was submitted to maintenance department to have the cabinets repaired and to be in working/safe order. 11/11/2022 Implemented
6400.46(a)Not able to conduct a fire drill test at this location During the review. The agency staff onsite stated direct care staff do not normally conduct fire drills, management does. We concluded the inspection as staff was not able to reach management to conduct the fire drill nor were they able to sound the test alarm. Fire drills and procedures are to be conducted and tested under normal staffing conditions.Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.All employees at PAHrtners that do not know how to operate a fire drill, will be trained in the next coming days to ensure trained. PAHrtners will ensure all current hires are trained by November 25th. 11/25/2022 Implemented
SIN-00158882 Renewal 07/11/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)The first aid kit in the home did not have the required thermometer available during inspection. 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. Thermometer will be purchased for the first aid kit in the home and all other CLA homes have been inspected to ensure that they have the required items. A signed confirmation statement will be procured by each house manager indicating that the first aid kits are up to par. 09/27/2019 Implemented
6400.31(b)Individual #1 did not have a current rights statement in the record.The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights.The individual has a current rights statement on record dated 3/26/2019. For all future updates, all individuals will have this signed annually. 03/26/2019 Implemented
SIN-00132605 Renewal 04/10/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water temperature in the home was tested and found to be 126.3 Hot water temperatures in bathtubs and showers may not exceed 120°F. The Director of the maintenance department was contacted on 4/10 to check the water temperature. The maintenance department checked twice that day. Then, on 4/12, we contacted again on 4/12 to check again to ensure the water temperature was corrected. The maintenance department checked a couple times and 4/20 the maintenance department submitted the completion note on the maintenance order indicating that 116.2 is the highest it goes to comply with the regulation. 04/20/2018 Implemented
6400.141(a)Individual #2's annual physical exam was held on 11/7/17 which was more than a year from the previous exam held on 9/29/16.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual's next annual physical examination will be scheduled in September/October to ensure that her appointment will not take place after 11/17/18. This was reviewed with the Supervisor of the Case Management program. The Program Specialist will ensure that the case manager schedules an appointment for this individual's annual physical examination. 04/19/2018 Implemented
6400.141(c)(14)Individual 32's annual physical exam dated 11/7/17 did not indicate information pertinent to diagnosis 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 Case Managers have been instructed to check the form prior to leaving the doctor's office to ensure that all information has been filled out. Upon receiving the form, the program specialist or the case management supervisor will review the form to double check to ensure all information has been filled out. If there are missing information, the person who took the individual to the appointment will return to the physician's office to request that the blank information be filled out. 04/19/2018 Implemented
6400.142(a)Individual #2's last dental exam was conducted on 5/12/16 with a recommendation of follow up in six months. there has been no appointment since 5/12/16.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 was scheduled to see her pulmonary physician to obtain clearance to undergo dental work under anesthesia on 4/19/18; however, the staff that was supposed to bring her arrived late and the doctor was not able to proceed with the appointment. Staff was instructed to arrive on time (her appointment was close to her feeding time). 4/25, individual was brought to ER due to chronic wheezing which led to inpatient admission. With her current chronic wheezing, we are unable to schedule a dental appointment which will be under anesthesia until her wheezing is under control. Her case manager brought her to the doctor on 5/15 and the doctor wrote on the medical form that individual is not ready to undergo dental work under anesthesia. Once she is cleared, a dental appointment will be scheduled. 05/15/2018 Implemented
6400.144Individual #2's annual physical was conducted late and there has not been a dental appointment in 23 months.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 Program Specialist met with the Operations Director of the Case Management department and reviewed all medical documents and the due dates. The Program Specialist developed a new tracking system where it contains all required medical appointment including annual physical and dental. The tracking has the date of the last medical visit so we can keep track of the due date of the next medical appointment. 04/19/2018 Implemented
SIN-00113968 Renewal 03/13/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66Individual #2's bedroom had a non-operable light. Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The light bulb was replaced the very same day as the inspection. The agency will ensure that the light bulbs are all in working order. 06/01/2017 Implemented
6400.76(a)The dresser in individual #2's bedroom has a missing door. Furniture and equipment shall be nonhazardous, clean and sturdy. A new dresser was ordered and it was assembled by our maintenance department. 05/31/2017 Implemented
6400.141(c)(7)Individual #2's previous gyn exam was dated 9/8/15 and the most recent exam was dated 10/4/16.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. The Case Management department will ensure that all medical appointments be completed within the time frame from the following year. They currently have a spreadsheet and the Case Manager will review the spreadsheet monthly to see who is due for what appointment for the next 2 months. 06/09/2017 Implemented
6400.181(c)The indiviidual #1 's assessment dated 6/17/16 and individual #2, assessment dated 6/13/16 did not indicate the basis of information in the assessment.The assessment shall be based on assessment instruments, interviews, progress notes and observations. The assessment form was revised to indicate the source of information (Review with individual, Observation, Staff reports, Family, Review Records, and other). 06/12/2017 Implemented
6400.181(d)Individual #2's assessment dated 6/13/16 was not dated by the program specialist. The program specialist shall sign and date the assessment. The program specialist will date the assessment after signing it. 03/14/2017 Implemented
6400.181(e)(13)(i)Individual #2's assessment dated 6/13/16 did not document progress and growth in the area of health.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. The assessment form was revised to include progress and growth by adding a Linkert scale: Improved; Regressed; Same. 03/14/2017 Implemented
6400.181(e)(13)(ii)Individual #2's assessment dated 6/13/16 did not document progress and growth in the area of motor/communication skills.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. The assessment form was revised to include progress and growth by adding a Linkert scale: Improved; Regressed; Same. 03/14/2017 Implemented
6400.181(e)(13)(iii)Individual # 2's assessment dated 6/13/16 did not document progress and growth in activities of residential living. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. The assessment form was revised to include progress and growth by adding a Linkert scale: Improved; Regressed; Same. 03/14/2017 Implemented
6400.181(e)(13)(iv)Individual #2's assessment dated 6/13/16 did not document progress and growth in personal adjustment.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. The assessment form was revised to include progress and growth by adding a Linkert scale: Improved; Regressed; Same. 03/14/2017 Implemented
6400.181(e)(13)(v)Individual #2's assessment dated 6/13/16 did not document progress and growth in socialization.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. The assessment form was revised to include progress and growth by adding a Linkert scale: Improved; Regressed; Same. 3/1217. 03/14/2017 Implemented
6400.181(e)(13)(vi)Indvidual #2's assessment dated 6/13/16 did not document progress and growth in recreation.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. The assessment form was revised to include progress and growth by adding a Linkert scale: Improved; Regressed; Same. 03/14/2017 Implemented
6400.181(e)(13)(vii)Individual #2's assessment daed 6/13/16 did not document progress and growth in financial independence.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. The assessment form was revised to include progress and growth by adding a Linkert scale: Improved; Regressed; Same. 03/14/2017 Implemented
6400.181(e)(13)(viii)Individual #2's assessment dated 6/13/16 did not document progess and growth in the area of managing personal property. 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. The assessment form was revised to include progress and growth by adding a Linkert scale: Improved; Regressed; Same. 03/14/2017 Implemented
6400.181(e)(13)(ix)Individual #2's assessment dated 6/13/16 did not document progress and growth on community integration.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.The assessment form was revised to include progress and growth by adding a Linkert scale: Improved; Regressed; Same. 03/14/2017 Implemented
6400.181(f)Individual # 2's assessment dated 6/13/16 was sent to team members on 12/29/16 wheras the ISP meeting was held 12/28/16.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). The independent assessment will be sent to the supports coordinator at least 30 days prior to the ISP meeting. 06/30/2017 Implemented
6400.185(a)Individual's #1's quarterly dated 3/29/16 crossed 2 plan yrs when the review period extended beyond the annual review update date of 6/30/17. Individual #2 three monh review dated 1/6/16 to 4/6/16 crossed the annual review update date (or start date) on 3/9/16. The ISP shall be implemented by the ISP's start date. The agency will ensure that the quarterly reports are conducted on the date of the ISP annual review update date. IE: If the individual's Annual ISP Review Update is on 4/10/17, then the quarterly report will take place on 7/09/17; then the next quarterly period will be 7/10/17 to 10/09/17. 06/30/2017 Implemented
6400.185(b)Individual #2's monthlies did not mention any strategies used to document progress and growth towards the outcome of independence.The ISP shall be implemented as written.The agency will include strategies used to document progress and growth towards the outcome of independence. 06/30/2017 Implemented
SIN-00087531 Renewal 07/10/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
20.34At the time of the inspection, the facility was unable to provide full access to all medication administration records requested. Electronic records were not able to be printed out to allow thorough review.The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients.The team discovered that the medication administration in the current EMR system, Credible, can be printed. PAHrtners will soon be transitioning to a new EMR system, Quick MAR, that is easier to use. 02/15/2016 Implemented
6400.62(a)Secret deodorant was found unlocked in a bathroom cabinet located to the left of the bathroom sink. The label on the deodorant stated to call poison control if ingestedPoisonous materials shall be kept locked or made inaccessible to individuals. Current individuals residing in PAHrtners CLA program have no history or current behaviors of ingesting personal hygiene supplies. SC's have been contacted requesting to add this information to ISP's and this information will also be documented in individuals assessments. 01/06/2016 Implemented
6400.141(c)(7)Individual # 1 did not have documentation of a current GYN examination.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 noted is unable to make medical decisions for herself. Grandparents, who were previous legal guardians, stated they do not want to remain as legal guardians when the individual turned 21 years of age. Grandparents informed the team that individual has never had a GYN exam and they did not pursue this area. Grandparents were informed of GYN exam requirement and have now agreed to act as health care designees. PAHrtners will follow up with scheduling a GYN appointment. 01/05/2016 Implemented
6400.142(a)Individual # 1 did not have documentation of a current dental examinationAn 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 noted is unable to make medical decisions for herself. Grandparents, who were previous legal guardians, stated they do not want to remain as legal guardians when the individual turned 21 years of age. Grandparents informed the team that individual does not do well attending dental appointments and they never pursued this issue. Grandparents were informed of dental requirement and have now agreed to act as health care designees. PAHrtners will follow up with scheduling a dental appointment. 01/05/2016 Implemented
6400.163(c)Individual # 1 was prescribed Risperdal which is psych medication and the psychological medication review was not done every three months. Last psych med review was done on 3/17/15 and there was no psych med review for 6/17/15. 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.Psych med reviews conducted no later than every 3 months for individuals on psychotropic medications was reviewed with residential managers and case managers. Keeping track of appointments and scheduling appointments ahead of time was discussed. This was reviewed again on January 6, 2016. 01/06/2016 Implemented
6400.164(b)Kionex 15 Glam was administered to individual # 1 on 7/13/15 at 2:00PM but was not logged in the MAR until 7/13/15 The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. There have been times when the wifi may not be working and staff cannot log in the medication administration. Staff will contact the on call supervisor when this occurs. The on call manager will enter the medication administration after physically seeing the medication blister packet and then log in the medication as administered, thus showing a later time. Manager have been notified to enter an explanation in the medication comment box to explain these situations. 07/14/2015 Implemented
6400.168(d)Staff # 1 and staff # 2 administered medication in July of 2015 but did not complete their medication administration practicum. Staff # 3 administered medication in June of 2015 but did not complete medication administration practicum.A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. Procedures and guidelines for completing the medication practicum was reviewed with medication instructors. Instructors reviewed all staff charts. Staff our of compliance took the medication administration course again. Instructor developed a spreadsheet to keep track of the dates medication tests, observations and MAR documentation - indicating dates when future observations and MAR documentation are due. 10/15/2015 Implemented
6400.181(e)(5)Individual # 1"s assessment dated 6/5/15 did not include the individual's ability to self administer medicationThe assessment must include the following information:  The individual's ability to self-administer medications.PAHrtners new Program Specialist was trained in assessment requirements, program specialist was provided with the regulation indicating each area that must be included within the assessment including self administration of medications. 01/06/2016 Implemented
6400.181(e)(7)Individual # 1"s assessment dated 6/5/15 did not include the individual's knowledge and understanding of heat sourceThe assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. PAHrtners new Program Specialist was trained in assessment requirements, program specialist was provided with the regulation indicating each area that must be included within the assessment including knowledge and understanding of heat sources. 01/06/2016 Implemented
6400.181(e)(14)Individual # 1"s assessment dated 6/5/15 did not include the individual's knowledge of water safety and ability to swimThe assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. PAHrtners new Program Specialist was trained in assessment requirements, program specialist was provided with the regulation indicating each area that must be included within the assessment including knowledge of water safety and ability to swim. 01/06/2015 Implemented
6400.186(c)(4)(iii)Individual # 1's ISP dated 5/19/15 does not contain an outcome related to residential services and the program specialist did not notify the SC to modify the outcome. The program specialist shall make a recommendation regarding the following, if applicable: The modification of an outcome or service to support the achievement of an outcome in which no progress has been made. PAHrtners has a new Program Specialist who was trained in ISP outcomes and the responsibility to make contact with the SC when outcomes are not related to the residential services provided. 01/06/2016 Implemented
6400.213(1)(i)Individual # 1's record did not inclede eye color, hair color, identifying marks and religious affiliation.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.PAHrtners Quality Assurance department was informed that eye color, hair color, identifying marks and religious affiliation needed to be added to the EMR face sheet form for easy access. 01/30/2016 Implemented