Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00226517 Renewal 07/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment for the home completed on 11/8/22 did not assess compliance with the following regulations: 6400.32s3, 6400.32t, 6400.34a, 6400.34b, 6400.64e, and 6400.141c14.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. Associate Directors of Operations and the Director of Operations shall standardize the annual self-assessment process, including assigning point people to ensure that all self-assessment items are marked appropriately. 10/01/2023 Implemented
6400.15(c)(Repeated Violation - 7/11/22) The self-assessment for the home completed on 11/8/22 did not include a written summary of corrections for the following regulations: 6400.18h4, 6400.46b, 6400.50a, 6400.52c1, 6400.82c, and 6400.141c9.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. Director of Operations and Associate Directors of Operations will model after RCG guide to follow the five steps and instruct point people to write an effective Plan of Correction and focus on prevention of citations by 9/1/23. 10/01/2023 Implemented
6400.111(f)The fire extinguishers for the home were inspection on 3/14/22 and not again until 3/16/23, outside of the 1-year time frame required by regulation. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. Director of Operations will train the Associate Director of Facility Services on the expectation of all fire extinguishers needed to be approved annually by a fire safety expert. Training shall be completed by 9/1/23. 10/01/2023 Implemented
SIN-00114506 Unannounced Monitoring 04/12/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.18(c)Staff #1 reported to Staff #2 and Staff #3 allegations of suspected verbal and sexual abuse and a possible rights violation against Individual #1 on August 22, 2016 via email. Staff #1 nor Staff #2 reported the suspected abuse to the Enterprise Incident Management database. The home shall orally notify the county Intellectual Disability program of the county in which the home is located, the funding agency and the appropriate regional office of Intellectual Disability, within 24 hours after abuse or suspected abuse of an individual or an incident requiring the services of a fire department or law enforcement agency occurs. 6400.18 (c)- Immediate Action: On 5/24/17, Abby Morris (Associate Director of Operations) entered incidents of Rights Violation and Verbal Abuse on behalf of Individual #1 into the Enterprise Incident Management System regarding 8/22/16 email received by Staff #1 and Staff #2. On 5/25/17, Abby Morris also verbally informed Lancaster County AE, Kelly Phelan, via phone of the incidents that were entered on behalf of Individual #1. 6400.18 (c)- Future Prevention of Similar Citation: a- On 6/5/17, Abby Morris (Associate Director of Operations) provided retraining to Friendship Community¿s Administrative and Programming Team, which included Staff #2. Note: Staff #1 is no longer employed with the organization. This retraining included Incident Management Guidelines, including required categories of reporting and timeframes required for reporting any observed or reported incident. Additionally, the Administrative and Programming Team was retrained on the requirements for reporting to Adult Protective Services. 06/20/2017 Implemented
6400.18(d)Friendship Community failed to initiate an investigation into the suspected abuse allegations within 72 hours of the initial report on August 22, 2016. An investigation was not completed until February of 2017.The home shall initiate an investigation of the unusual incident and complete and send copies of an unusual incident report on a form specified by the Department to the county Intellectual Disability program of the county in which the home is located, the funding agency and the appropriate regional office of Intellectual Disability, within 72 hours after an unusual incident occurs. b- On 6/27/17, Associate Directors of Operations (Abby Morris, Jayme Crowder, and Gabi Kime Toews) will provide retraining to each Incident Management Point Person regarding Incident Management Guidelines to include the established structure of thorough and timely reporting. 06/27/2017 Implemented
SIN-00097636 Unannounced Monitoring 06/20/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Act Mouthwash and Extra Care Nail Polish Remover were unlocked in the bathroom.Poisonous materials shall be kept locked or made inaccessible to individuals.Poisonous substances were immediately locked on 6/21/2016, when discovered. Individual was assessed to be safe around poisonous substances on 6/21/2016 and a communication was sent to their County Supports Coordinator to update their ISP document to include that information. All Program Managers will be trained on the necessity of having all poisonous substances locked within a home if an Individual is not assessed to be safe around such products. Utilizing Care Tracker, all Program Managers will be trained on the necessity of having all poisonous substances locked within a home if an Individual is not assessed to be safe around such products. Care Tracker documentation will verify that each Program Manager is aware of this and an audit of all records has been completed to ensure compliance with poisonous substances for each Individual. 10/31/2016 Implemented
6400.164(a)Individual #1 was prescribed Hydrocortisone Ointment 0.5%. The medication administration records stated hemorrhoid ointment.A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. Individual # 1 MAR was transcribed correctly and according to the medication label. All Program Managers, Nurses, and Practicum Observers will be retrained on the necessity of transcribing all medications correctly onto the MAR, ensuring the correct name of the medication, according to the medication label, is included in transcription. Using Care Tracker, Program Managers, Nurses, and Practicum Observers will be retrained to make sure all medications are transcribed correctly onto the MAR with the correct name of the medication according to the medication label. Using Care Tracker, Program Managers, Nurses, and Practicum Observers will verify that each Individual¿s MAR Record is transcribed correctly and as per each medication label. 10/31/2016 Implemented
SIN-00245374 Renewal 05/30/2024 Compliant - Finalized
SIN-00176508 Unannounced Monitoring 09/01/2020 Compliant - Finalized
SIN-00040428 Initial review 06/25/2012 Compliant - Finalized