Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00254260 Renewal 11/12/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(3)Individual #1's most recent physical completed on 7/16/24 does not include a current date of when the tetanus/diphtheria was last administered. Individual #3's physical completed on 2/15/23 documented the tetanus/diphtheria was due in February 2024. There is no documentation it was administered in February 2024.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.On 11/14/24, the Day Services Coordinator updated Day Services Physical form to include tetanus/diphtheria. 12/30/2024 Implemented
2380.111(c)(4)Individual #2 had a vision screening on 9/21/23 and not again since, outside of the annual timeframe.The physical examination shall include: Vision and hearing screening, as recommended by the physician.11/14/24- Program Specialist (not listed) received a copy of Individual # 2 (DS) 9.9.24 vision screening. 12/30/2024 Implemented
2380.111(c)(7)Individual #3's most recent physical completed on 2/21/24 does not document the health maintenance needs. This section was left blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.11/14/24 Physical reminder letter will be sent out 3 months prior to physical due date with a reminder to complete the entire physical, leaving no assessment area blank (attachment #2) The Day Services Coordinator emailed Individual #3's physical to their family requesting that they ask physician to complete health maintenance needs section. The Day Services Coordinator informed the Studio Manager (staff #4) that all completed physicals should be sent to the Day Services Coordinator for review. 12/30/2024 Implemented
SIN-00235913 Renewal 12/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.88(f)The facility had the fire extinguishers inspected on 02/28/22 and not again until 03/29/23, outside of the annual timeframe.Fire extinguishers shall be inspected and approved annually by a firesafety expert. The date of the inspection shall be on the extinguisher.The Director of Operations shall train the Assoicate Director of Facilities about the fire extinguishers having no grace period by 1/5/24. 01/05/2024 Implemented
SIN-00219177 Renewal 02/22/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.183(c)A list of participants was not kept for Individual #1's Individual Support Plan (ISP) meeting held on 06/23/2022.The list of persons who participated in the individual plan meeting shall be kept.Program Specialist requested ISP signature sheet from the Supports Coordinator 8/18/22 (attachment #1). An internal audit was conducted 1/5/23 and another ISP signature request was sent to the Support Coordinator 1/5/23 (attachment #2). Program Specialist started ISP Meeting template at 6/23/22 ISP meeting, but full attendance was not noted (attachment # 3). 04/30/2023 Implemented
SIN-00201281 Renewal 03/01/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.91(a)Friendship Community re-opened in August of 2020 and Individual #3 returned to the program on 11/17/21. Friendship Community confirmed there wasn't fire safety training for individual #3 until 1/19/22.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, 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 facility.Individual #3 shall receive fire safety training in their primary language or mode of communication on or before 3/18/2022. Program Manager and Program Specialist shall receive retraining on or before 3/31/2022 on the importance of ensuring Individual fire safety training is completed upon admission and annually thereafter as tracked by the Program Manager. The Program Manager shall conduct an audit on the current status of fire safety training for all Individuals at the program on or before 4/30/2022. 04/30/2022 Implemented
2380.111(a)Individual #2 had a physical completed on 9/24/21. No documentation was provided verifying the individual had a physical completed prior to that date. Individual #2's date of admission was 7/30/17.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Program Manager and Program Specialist shall receive retraining on or before 3/31/2022 on completing Individual physicals within 12 months prior to admissions to the Program as well as annually thereafter as tracked by the Program Specialist. Program Specialist shall contact Individuals' family/guardian prior to due dates to ensure timely completion. 04/30/2022 Implemented
2380.111(c)(5)Individual #2 had a TB test on 9/30/21. No documentation was provided verifying the individual had a TB test completed prior to that date. Individual #2's date of admission was on 7/30/17.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted.Program Manager and Program Specialist shall receive retraining on or before 3/31/2022 on the regulation surrounding TB testing every two years with a negative result or, if positive, an initial chest x-ray with results noted as tracked by the Program Specialist. Program Specialist shall contact Individuals' family/guardian prior to due dates to ensure timely completion. 04/30/2022 Implemented
SIN-00184338 Renewal 03/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.173(1)(v)Individual #1's record did not contain a current photograph of her at the time of the 3/8/2021 inspection. The photograph in her record was last updated on 1/17/2017.Each individual¿s record must include the following information: Personal information including: A current, dated photograph.Immediate: On 3/10/2021 ODPs licensing lead retrained the Heart Studio Manager on the need to have a current dated photograph present in each Individual's record. The Day Services Coordinator contacted Individual 1s residential manager to request a current photograph on 3/10/2021, as her services at the Heart Studio were interrupted in March 2020 and have not yet resumed. The manager replied with a photograph taken that day. The photograph was added to Individual 1s record on 03/10/2021, with the date indicated and submitted to ODPs licensing lead for review. Global Immediate: The Heart Studio Program Manager or designee shall review each Individuals record to ensure that it contains a current dated photograph on or before 03/17/2021. Any Individual whose record does not contain a current dated photograph shall be asked to have their photo taken by a Heart Studio staff member upon their return services at the Heart Studio and it shall be immediately placed in the Individuals record by the Program Manager or designee. Global Preventative: The Heart Studio Program Manager or designee shall ask Individuals to have their picture taken by a Heart Studio staff member annually upon receipt of the Individuals annual assessment. Individuals records shall be updated with the current photo each year. Each Individual's record shall be reviewed annually to ensure that the current dated photograph was taken within the past 365 days, prompted by a reminder contained in Microsoft Office tools that shall be instituted on or before 3/26/2021. Any photos taken more than 365 days prior to this annual review shall be updated upon the Individuals next date of participation and immediately placed in the file by the Program Manager or designee. 03/26/2021 Implemented
2380.21(u)The Department issued updated, regulatory individual's rights effective immediately on 2/3/2020. The agency, Friendship Community informed Individual #1 of her rights on 1/8/2020. However, that review of her rights did not include a review of her regulatory rights defined in 2380.21(c)-(g), (k)-(p), and (r)-(t). Individual #1's mother and brother have a shared guardianship of the individual. There are no records maintained that either her mother or brother were informed of the individual's rights defined in 2380.21. Individual #1 did not have her updated, regulatory rights reviewed with her until 10/8/2020, nine months after they were issued. Individual #2 had her rights reviewed with her on 9/19/19 and not again until 10/7/2020, outside the annual time frame requirement. In addition, the Department issued updated, individual's rights effect immediately on 2/3/2020. The individual was not informed of these updated individual's rights until 10/7/2020. Individual #3 did not have his updated regulatory rights reviewed with him until 10/6/2020.The facility shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the facility and annually thereafter.Immediate: On 3/10/2021 ODPs licensing lead retrained the Heart Studio Manager on the requirement that the updated expanded list of Individual Rights found in 2380.21 shall be reviewed with Individuals in a timely manner upon publication and annually thereafter. Individual 1 signed and dated an updated Individual Rights on 10/8/2020, consistent with regulatory guidelines. Global Immediate: The Heart Studio Program Manager or designee shall conduct a review on or before 3/26/2021 of Individual Rights documentation for all Individuals at the Heart Studio to ensure they have been informed of all Individual Rights found in 2380.21 and that they are aware of the process for reporting a rights violation. Any Individuals who have not been informed of all rights listed in 2380.21 within the past year shall have these rights reviewed with them by the Program Manager or designee, along with the process for reporting a rights violation, upon their return to services at the Heart Studio. Global Preventative: The Heart Studio Program Manager or designee shall ensure that all Individual Rights found in 2380.21 are reviewed with Individuals annually upon receipt of their annual assessment at the Heart Studio. The Heart Studio shall develop a calendar on or before 3/26/2021 to track when Individuals Rights shall be reviewed with them to ensure this is completed in a timely manner. 03/26/2021 Implemented
2380.129(d)Staff person #1's 2019 annual medication training did not include documentation if she passed or failed the annual requirements or the date of which she passed or failed the annual medication training requirements. The practicum summary sheet of the staff's medication administration training was blank in the fields for the medication trainer to document if the staff passed or failed, and the form listed the medication training was done on 1/16/2019. However, the requirements (two medication administration record reviews and two observations) were completed after 1/16/19, not before as required. There are no records maintained for when a medication trainer reviewed Staff person #1's training requirements after they were completed.A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.Immediate: On 3/09/2021 ODPs licensing lead retrained the Day Services Coordinator on the need to indicate whether staff have been recertified or have failed to recertify on the Annual Practicum Summary and Certification form for staffs medication administration training. On 03/09/2021 the Day Services Coordinator consulted with the Friendship Community Training Associate and Medication Administration Trainer to confirm that the identified staff member within the sample had been recertified in medication administration training. After reviewing the relevant documentation and speaking with the Medication Administration Trainer it was determined that the staff had been recertified and the Annual Practicum Summary and Certification form was updated on 03/09/2021 indicating that they had been recertified. Retraining occurred with the Medication Trainer on 3/16/2021 by Nursing Services Coordinator, including the expectation that all Medication Administration paperwork is documented in accordance with ODP requirements for Medication Administration. Global Immediate: The Friendship Community Training Associate reviewed all annual medication administration training for each med trained staff at the Heart Studio on 3/11/2021 to ensure that all med trained staff have proper documentation to verify their certification/recertification. All medication packets reviewed verify that med trained staff have been recertified by a Medication Administration Trainer or Practicum Observer. Global Preventative: The Friendship Community Training Associate shall retrain Medication Administration Trainers on the need to complete the annual medication administration recertification packets by indicating whether or not a med trained staff member has been recertified or has failed to recertify on the Annual Practicum Summary and Certification Form. This training will take place on or before 04/08/2021. The Friendship Community Training Associate shall perform a review of the Annual Practicum Summary and Certification Form before filing each to ensure the outcome of the staff members Annual Medication Administration training has been properly documented. Retraining on this filing practice was provided by the Training Administrator for all Training Associates on 3/12/2021. 04/08/2021 Implemented
SIN-00166951 Renewal 12/03/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.87(b)Individual #7 is Deaf and can not hear the smoke detectors or fire alarms when they are activated in the event of a fire or emergency. The individual does not wear a personal body device to notify her to evacuate the building in the event of a fire or emergency. The fire alarms in the building are not interconnected therefore not activating the strobe lights in every part of the licensed space during a fire or emergency. Individual #7 could be in a room in the facility that does not activate the strobe light during an emergency.If one or more individuals or staff persons are not able to hear the fire alarm system, the fire alarm system shall be equipped so that each person who is not able to hear the alarm shall be alerted in the event of a fire.87 (b) Immediate: ODP's licensing lead retrained the Day Services Coordinator on 12/3/19 regarding the need for the duplicate fire system (accessed by the Gallery/Studio unit only) to be equipped so that each person who is not able to hear the alarm is alerted in the event of a fire on 12/3/19. The Associate Director of Facility and Services at Friendship Community was contacted regarding the need to assess the fire alarm system at the Studio. Global Immediate: On 12/12/19 the Studio Manager updated the schedule to assign a Studio Instructor to assist any individuals who are deaf or have difficulty hearing with evacuating the facility in the event that the fire alarm is triggered. The Studio Manager remained as the designated member of the team responsible for providing immediate support to the hearing impaired individual currently in attendance on a part-time basis at the Studio throughout the time period of 12/3/19 when the deficiency was discovered and the updated schedule on 12/12/19. Friendship Community shall install an interconnected fire alarm system with strobe lights on or before 12/31/19, on the earliest date that the appropriate equipment can be installed. Global Preventative: Following the interconnection of the strobe lights throughout the Heart Studio as required to ensure the safety of hearing impaired individuals, Studio Manager or designee shall monitor the strobes at the time of routine monthly fire alarm checks in each location to ensure they are in good working order, taking follow-up actions needed as applicable. Upon admission of individuals to the Studio at and at least annually thereafter, training on fire evacuation procedures for individuals and team members within the Studio shall occur to include the purpose of strobe lights connected to the alarm system, including appropriate evacuation responses when strobes are flashing. Additionally, if modifications should occur to the physical site of any Day Services location within Friendship Community, there shall be a review of the location of strobe lights in relation to the areas where hearing impaired individuals are being served to ensure that strobes are visible from all program locations. 12/31/2019 Implemented
2380.111(a)Individual #1 had a physical examination completed on 1/9/18 and not again until 1/29/19. She was in attendance during the time period where her physical examination lapsed.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.111 (a) Immediate: On 12/3/19 the ODP licensing lead trained the Day Services Coordinator at the Studio on the need for individuals attending the Studio to have a physical examination completed within 12 months of starting at the Studio and annually thereafter in accordance with PA Code Chapter 2380.111 (a). Global Immediate: The Studio Manager and Program Specialist are conducting an audit of all individual physicals at the Studio to ensure that they have been completed within 12 months of admission and annually thereafter in accordance with PA Code Chapter 2380.111 (a). During the audit process the Studio Manager and Program Specialist will contact designated personal of any discrepancies that shall need corrected, as possible. The audit is to be completed on 1/10/2020. Global Preventative: The Studio Manager in conjunction with the Program Specialist at the Studio will develop physical audit checklist to be used to review new physical examinations of individuals at the Studio and ensure that all information relevant to PA Code Chapter 2380.111 is present and up to date by 12/20/19. The Studio Manager and Program Specialist will then complete the physical audit checklist upon receiving updated physicals examinations from individuals attending the Heart Studio as well as individuals who are being admitted to the Studio to ensure that each physical examination contains up to date information. This is to be completed on an ongoing basis. Additionally, a policy shall be developed to address attendance interruption at the Studio at any time that an individual's physical exam exceeds the annual date that it is required (with a grace period included per regulations). This policy shall be developed by 1/10/2020 and disseminated by 1/31/19 to each individual and their primary caregiver, as well as included in each individual's admission packet to be reviewed upon admission. 01/31/2020 Implemented
2380.111(c)(3)Individual #5's 9/9/19 physical examination record did not include a list of his immunizations or documentation of his most recent Tetanus/Diphtheria as required.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.111 (c)(3) Immediate: On 12/3/19 the Studio Manager contacted the residential provider of Individual to obtain a record of immunizations including their most recent TDap. Individual's residential provider emailed a copy of the PCP visit summary for individual's 2019 physical to the Studio Manager which included a record of current immunizations including a current TDap immunization. On 12/3/19 the Studio Manager filed individual's 2019 physical evaluation's PCP visit summary alongside their 2019 physical. Global Immediate: The Studio Manager and Program Specialist shall conduct an audit of all individual physical evaluations to ensure that they include record of current immunizations as recommended by the United States Public Health Service, Centers for Disease Control and are consistent with information listed in the individual's ISP in accordance with PA Code Chapter 2380.111 (c)(3). During the audit process the Studio Manager and Program Specialist will contact designated personal of any discrepancies that shall need corrected. The audit shall be completed by 1/10/2020. Global Preventative: The Studio Manager in conjunction with the Program Specialist will develop physical evaluation audit checklist to be used to review new physical examinations of individuals at the Studio and ensure that all information relevant to PA Code Chapter 2380.111 is present and up to date by 1/10/20. The Studio Manager and Program Specialist will then complete the physical audit checklist upon receiving updated physicals examinations from individuals attending the Studio as well as individuals who are being admitted to the Studio to ensure that each physical examination contains up to date information relevant; this is to be completed on an ongoing basis. 01/10/2020 Implemented
2380.111(c)(5)Individual #5's 9/9/19 physical examination record did not include the date the individual's Tuberculin (TB) skin test was read. The physical form documented the TB was completed on 9/3/19. However, according to physician's records obtained during the 12/3/19 inspection, the individual's TB test was administered on 9/3/19 and he was to return on 9/6/19 to have the test read by a medical professional. Individual #3's date of admission to the facility was 4/10/19 but she did not obtain a Tuberculin skin test with negative results until 11/1/19. The individual's 3/8/19 did not contain information that she received a Tuberculin skin test. An attached laboratory form confirmed that she did not receive said skin test until 11/1/19 with negative results.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.111 (c)(5) Immediate: ODP Licensing lead retrained Studio Manager on the need to ensure individuals have completed a tuberculin skin test with negative result at least every 2 years in accordance with PA Code Chapter 2380.111 (c)(5). The Studio Manager contacted the residential provider of individual on 12/9/19 in order to obtain a record of when the tuberculin skin test placed on 9/3/19 was read. The Day Services Coordinator followed up on 12/12/19 with the residential provider of individual regarding the date for when the tuberculin skin test placed on 9/3/19 was read and information placed in the individual's file. Global Immediate: The Studio Manager and Program Specialist shall conduct an audit of all individual physicals at the Studio to ensure that they include a record of a tuberculin skins test with a negative result within the past 2 years and are consistent with information listed in the individual's Individual Support Plan in accordance with PA Code Chapter 2380.111 (c)(5). During the audit process the Studio Manager and Program Specialist will contact designated personal of any discrepancies that shall need corrected. The audit is to be completed on 1/10/2020. Global Preventative: The Studio Manager in conjunction with the Program Specialist at the Studio will develop physical audit checklist to be used to review new physical examinations of individuals at the Studio and ensure that all information relevant to PA Code Chapter 2380.111 is present and up to date by 1/10/2020. The Studio Manager and Program Specialist will then complete the physical audit checklist upon receiving updated physicals examinations from individuals attending the Studio as well as individuals who are being admitted to the Studio to ensure that each physical examination contains up to date information. This is to be completed on an ongoing basis. 01/10/2020 Implemented
2380.111(c)(7)Individual #5's 9/9/19 physical examination record did not their health maintenance needs. This section was left blank on the physical form.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.111 (c)(7) Immediate: On 12/3/19 the Studio manager contacted the residential provider of Individual to obtain a current record of health maintenance needs for the individual. Individual's residential provider emailed a copy of the PCP visit summary for individual's 2019 physical which occurred on 9/3/19 to the Studio Manager which included a record of health maintenance needs under the section titled recommended care. The PCP visit summary for individual's 2019 physical was filed in their individual record alongside their 2019 physical. Global Immediate: The Studio Manager and Program Specialist shall conduct an audit of all individual physicals at the Studio to ensure that they include a current record of health maintenance needs for each individual and are consistent with what is listed in the individual's ISP in accordance with PA Code Chapter 2380.111 (c)(7). During the audit process the Studio Manager and Program Specialist will contact designated personal of any discrepancies that shall need corrected. During the audit process the Studio Manager and Program Specialist will contact designated personal of any discrepancies that shall need corrected. The audit is to be completed on 1/10/2020. Global Preventative: The Studio Manager in conjunction with the Program Specialist will develop physical audit checklist to be used to review new physical examinations of individuals at the Studio and ensure that all information relevant to PA Code Chapter 2380.111 is present and up to date by 1/10/2020. The Studio Manager and Program Specialist will then complete the physical audit checklist upon receiving updated physicals examinations from individuals attending the Studio as well as individuals who are being admitted to the Studio to ensure that each physical examination contains up to date information. This is to be completed on an ongoing basis. 01/10/2020 Implemented
2380.111(c)(9)Individual #5's 9/9/19 physical examination record did not include their complete list of allergies, only an allergy to Bactrim. According to his 9/4/18 physical examination record from his physician, and additional physician's physical documentation from 9/3/19 obtained during the 12/3/19 inspection, the individual has allergies to Bactrim, Sulfamethoxazole and Trimethoprim. Individual #4's 2/18/19 physical examination record states, "no known allergies." His current, 5/9/19 assessment and identification sheet in his record all state no known allergies. According to his Individual Support Plan (ISP), he is prescribed two daily medications for allergies.The physical examination shall include: Allergies or contraindicated medication.111 (c)(9) Immediate: On 12/3/19 the Studio manager contacted the residential provider of Individuals to obtain a current record of allergies for the individuals. Individual's residential providers provided Studio Manager appropriate documentation of allergies, which was placed in each Individual's record alongside their 2019 physical exams. The Program Specialist at the Studio then emailed Individual #5's Supports Coordinator on 12/12/19 to request that the individual's ISP be updated to reflect the allergies listed on their 2019 physical examination after visit summary. Global Immediate: The Studio Manager and Program Specialist shall conduct an audit of all individual physicals at the Studio to ensure that they include a current list of allergies for each individual and are consistent with information listed in the individual's ISP in accordance with PA Code Chapter 2380.111 (c)(9). During the audit process the Studio Manager and Program Specialist will contact designated personal of any discrepancies that shall need corrected. The audit is to be completed on 1/10/2020. Global Preventative: The Studio Manager in conjunction with the Program Specialist at the Studio will develop physical audit checklist to be used to review new physical examinations of individuals at the Studio and ensure that all information is present and up to date by 1/10/2020. The Studio Manager and Program Specialist will then complete the physical audit checklist upon receiving updated physicals examinations from individuals attending the Studio as well as individuals who are being admitted to the Studio to ensure that each physical examination contains up to date information. This is to be completed on an ongoing basis. 01/10/2020 Implemented
2380.171(b)(1)Individual #5's record does not contain the name of the person to contact in the event of an emergency. His record only states the emergency contact is the on-call person at the individual's residential provider agency.Emergency information for each individual shall include: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.171 (b)(1) Immediate: On 12/3/19 ODP licensing lead retrained the Studio manager on the requirement that the emergency contact listed for individuals at the Studio must be a specific person and not a service provider in accordance with PA Code Chapter 2380.171 (b)(1). The Studio Manager contacted Individual's residential provider on 12/3/19 to obtain updated information regarding the individual's emergency contact and updated the individual's face sheet immediately. Global Immediate: The Day Services Coordinator directed the Studio Manager at the Studio to conduct an audit of the emergency contact information of all individuals at the Studio to be completed on 1/10/2020. The Studio Manager and Program Specialist shall make updates to emergency contact information to ensure they are in compliance with PA Code Chapter 2380.171 (b)(1) by 1/10/2020. Global Preventative: The Studio Manager shall coordinate an annual review of face sheets for individuals attending the Studio to ensure that the name, address and telephone number of the emergency contacts for individuals at the Studio are readily available in accordance with PA Code Chapter 2380.171 (b)(1). The face sheets for individuals who are newly admitted into program shall be reviewed and approved by the Studio Manager to ensure the name, address and telephone number of the emergency contact for the individual is readily available at the Studio, prior to entering the face sheet into the individual's record, in accordance with PA Code Chapter 2380.171 (b)(1). 01/10/2020 Implemented
2380.171(b)(3)Individual #5's record does not contain the name of the person to contact for consent for emergency treatment in the event of an emergency. His record only states the emergency contact is the on-call person at the individual's residential provider agency.Emergency information for each individual shall include: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.171 (b)(3) Immediate: On 12/3/19 ODP licensing lead retrained the Studio manager on the requirement that the person appointed to give consent for emergency medical treatment listed for individuals at the Studio must be a specific person and not a service provider in accordance with PA Code Chapter 2380.171 (b)(3). The Studio Manager contacted Individual's residential provider on 12/3/19 to obtain updated information regarding the person appointed to give consent for emergency medical treatment for this individual and updated the individual's face sheet immediately. Global Immediate: The Day Services Coordinator directed the Studio Manager at the Studio to conduct an audit of the person appointed to give consent for emergency medical treatment on the face sheets of all individuals at the Studio to be completed on 1/10/2020. The Studio Manager and Program Specialist shall make updates to the person appointed to give consent for emergency medical treatment on the face sheets of individuals at the Studio to ensure they are in compliance with PA Code Chapter 2380.171 (b)(3) by 12/17/19. Global Preventative: The Studio Manager shall coordinate an annual review of face sheets for participants attending the Studio to ensure that the name, address and telephone number of the person able to give consent for emergency medical treatment is readily available at the Studio in accordance with PA Code Chapter 2380.171 (b)(3). The face sheets for individuals who are newly admitted into program shall be reviewed and approved by the Studio Manager to ensure the name, address and telephone number of the person able to give consent for emergency medical treatment is readily available at the Studio, prior to entering the face sheet into the individual's record, in accordance with PA Code Chapter 2380.171 (b)(3). 01/10/2020 Implemented
2380.125(c)Individual #6's prescribed Amphetamine 10mg that is to be administered at 12 noon, was omitted on 11/12/19 due to the medication not being available at the day program and the individual was in attendance.A prescription medication shall be administered as prescribed.125 (c) Immediate: On 12/3/19 ODP licensing lead trained the Studio Manager on the need to ensure medications are available to individuals during times of medication administration, and the need to maintain records of medication omissions in accordance with PA Code Chapter 2380.125 (c). The Studio Manager reviewed the medication supply for individuals who receive medication at the Studio to ensure an adequate supply was available on 12/3/19. Global Immediate: On a weekly basis the Studio Manager shall review the medication supply for individuals who receive medication at the Studio to ensure an adequate supply is available for three months while a tracking system is being developed. Global Preventative: The Studio Manager will develop and implement a tracking system by 2/17/2020 to contact identified personal when medications supplies are to be checked and ordered for individuals attending the Studio to ensure that medications are available at the Studio in accordance with PA Code Chapter 2380.125 (c). 02/17/2020 Implemented
2380.125(f)Individual #5 is prescribed psychotropic medications for his psychiatric diagnoses of Depression, Undifferentiated Schizophrenia, and Obsessive Compulsive Disorder (OCD). The individual's plans in his record does not contain a protocol to address the social, emotional and environmental needs of the individual, for the medication they are prescribed to treat symptoms of their diagnosed psychiatric illness. The individual's plan in their record, last updated 12/27/18, states that the individual has a plan to follow for said symptoms and diagnoses but does not state that the plan is utilized for the day program facility. Individual #3 is prescribed psychotropic medication for psychiatric diagnosis of Anxiety. Her ISP did not include a protocol to address the social, emotional and environmental needs of the individual, for the medication they are prescribed to treat symptoms of their diagnosed psychiatric illness.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.125 (f) Immediate: The Day Services Coordinator contacted the Supports Coordinator for individual to request that their SEEN Plan being used at the Studio be included in his ISP on 12/3/19. The Supports Coordinator responded on 12/3/19 to report that she would update the ISP to include the SEEN Plan linked to the Studio for Individual. An updated ISP was printed from HCSIS was printed and placed in his individual plan on 12/3/19. Global Immediate: The Program Specialist at the Studio shall conduct an audit of individual records to ensure that SEEN Plans linked to the Heart Studio are included in the individual's ISP in accordance with PA Code Chapter 2380.125 (f). The Program Specialist will also conduct an audit of individual records to ensure that the most current ISP is included in their records. Audits shall be completed by 1/10/2020. Global Preventative: The Program Specialist shall conduct a documented biannual review of individual records to ensure that the most up to date Individual Support Plan is included, and to ensure that SEEN Plans linked to the Studio are included in the individual's Individual Support Plan in accordance with PA Code Chapter 2380.125(f). 01/10/2020 Implemented
SIN-00146063 Renewal 12/10/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.21(b)The program has two cameras in the office areas and one camera in the art studio. There are no signs that the there are active cameras.The facility shall develop and implement civil rights policies and procedures. Civil rights policies and procedures shall include the following: 21(b) Immediate: Immediate retraining was provided to the Studio Manager, Gallery & Studio Coordinator and Associate Director of Operations by ODP¿s Licensing Lead while onsite 12/10/2018 to address signage for and individual awareness of video recording equipment located in the studio and office spaces. It is the understanding of the Associate Director of Operations that this citation is related to the requirement to develop and implement civil rights policies and procedures that include nondiscrimination in the provision of services, admissions, placements, facility usage, referrals and communications with individuals who are nonverbal or non-English speaking, physical accessibility and accommodation for individuals with physical disabilities, the opportunity to lodge civil rights complaints and informing individuals on their right to register civil rights complaints as outlined in 21(b)(1-4) of 2380 regulations. Global Immediate: The Studio Manager and Gallery & Studio Coordinator created signage for the office and studio spaces to indicate that there is video recording equipment onsite for the sole purposes of monitoring the Gallery space which is open to the public. Signage was created and hung for awareness in the office and studio spaces by 1/4/2019. Global Preventative: The Associate Director of Operations will update the civil rights policies and procedures for Day Services by 1/14/2019 to include awareness of video recording equipment in the studio and office spaces and its usage by the program. The updated civil rights policies and procedures shall be added to the Day Services intake/referral process guide and Day Services admissions packet by 1/18/2019 to ensure that all future candidates are aware of this process to mitigate risk in public spaces within the Gallery, which adjoins with licensed Studio space. 01/18/2019 Implemented
2380.89(c)The fire drill log completed for dates 12/06/18, 11/30/18, and 09/28/18 did not indicate if the fire alarm tested was operable.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm was operative.89(c) Immediate: Immediate retraining was provided to the Studio Manager and Associate Director of Operations by ODP¿s Licensing Lead during review of records on 12/10/2018 regarding the requirement that a written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm was operative as outlined in 89(c) of 2380 regulations. Global Immediate: The Associate Director of Operations provided retraining on or before 12/21/2018 to the Studio Manager and Gallery & Studio Coordinator on the requirement to check the status of each fire alarm during each monthly fire drill. Documentation of retraining shall be maintained on file. Global Preventative: The Studio Manager and Gallery & Studio Coordinator shall ensure that a fire drill is conducted on a monthly basis by the Studio Manager, Gallery & Studio Coordinator, or properly trained designee. The Gallery & Studio Coordinator shall ensure that each fire drill record has been completed in its entirety, including whether the fire alarm was operative, and verify this information with a signature and date, within 3 business days following each monthly fire drill. In the absence of the Gallery & Studio Coordinator, the Associate Director of Operations shall ensure that each fire drill record has been completed in its entirety, including whether the fire alarm was operative, and verify this information with a signature and date, during each calendar month. The Associate Director of Operations shall review the program¿s fire book on a monthly basis to ensure that each fire drill record has been completed in its entirety and document accordingly, including any actions taken to address areas of concern, as applicable. The Studio Manager and Gallery & Studio Coordinator shall ensure that all fire alarms connected to the internal alarm system are operable as of 1/11/2019. Starting in January 2019, the Studio Manager, Gallery & Studio Coordinator, or properly trained designee, will ensure that the alarm being used, as well as all other alarms connected to the internal alarm system, are operable. This shall be noted on each individual fire drill record by the person conducting the fire drill each month. 01/11/2019 Implemented
2380.91(a)Individual #1 DOA was 12/1/17 and she did not receive fire safety training for the facility until 02/02/18.An individual 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 facility.91(a) Immediate: Immediate retraining was provided to the Studio Manager and Associate Director of Operations by ODP¿s Licensing Lead during review of records on 12/10/2018 regarding the requirement for an Individual to 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 facility as outlined in 91(a) of 2380 regulations. Global Immediate: The Associate Director of Operations provided retraining to the Studio Manager and Gallery & Studio Coordinator on the importance of timely fire safety training upon admission on or before 12/21/2018, and documentation of retraining shall be maintained on file. Global Preventative: The Associate Director of Operations added initial fire safety training to the internal intake/referral process guide for all Day Services on or before 12/21/2018. Additionally, the Associate Director of Operations added initial fire safety training to the admissions packet checklist for all new and incoming Individuals at the Friendship Heart Studio on or before 12/21/2018. The Associate Director of Operations reviewed the updated intake/referral process guide and admissions packet with the Studio Manager and Gallery & Studio Coordinator on 12/21/2018. The updated intake/referral process guide and admissions packet shall require that initial fire safety training is completed by the Studio Manager or Gallery & Studio Coordinator within 3 days of an Individual¿s admission/starting date within the program. 01/31/2019 Implemented
SIN-00200800 Renewal 03/01/2022 Compliant - Finalized
SIN-00122965 Technical Assistance 10/19/2017 Compliant - Finalized
SIN-00122455 Initial review 10/06/2017 Compliant - Finalized