Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00242365 Renewal 04/22/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)At the time of the 04/24/24 inspection, there was a golf ball sized amount of lint in the clothes dryer lint trap. The appliance was not in use at the time of the inspection. Floors, walls, ceilings and other surfaces shall be free of hazards.During the inspection, the lint was removed on 04/24/2024 in the from the dryer lint trap. 06/30/2024 Implemented
6400.82(f)At the time of the 04/24/24 inspection, the second floor bathroom did not contain a trash receptacle.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. During the inspection, the trash receptacle was replaced on 04/24/2024 in the second-floor bathroom. 06/30/2024 Implemented
SIN-00225470 Renewal 06/13/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(f)The home was unable to produce the date the fire extinguishers were inspected and approved in 2022. The home produced an invoice that was created on 5/7/2022 stating payment is required for the inspection of fire extinguishers, indicating the inspection happened sometime prior to 5/7/2022. The home did not have the fire extinguishers inspected and approved again until 5/23/23, more than 365 days after an inspection prior to 5/7/2022. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The agency scheduled next year's appointments for all sites for the fire extinguisher inspections. The appointment is scheduled for May 13, 2024 at 8:00 am. The company will also give a courtesy call 30 days prior as a reminder or if a rescheduled date will be needed. (Email attachment) 08/20/2023 Implemented
6400.151(c)(2)REPEAT from 7/5/2022 annual inspection: At the time of the 6/12/23 inspection, Staff person #1 had record of a negative Tuberculin skin test by Mantoux method on 01/29/21 and not again until 03/08/23, outside of the two-year requirement. 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. The Human Resources Department (HR) notifies staff via email of upcoming expiration of Physical at 120, 90, 60, 30, 15 days prior to the expiration date of the physical, at the expiration of the physical. Supervisor is also notified at 90, 30, 15 and at expiration. At the expiration of the physical HR notifies the Employee and the Primary Supervisor that the employee does not have a valid physical and that the employee should be removed from schedule without pay until a valid physical is provided. All advance notification sent to the employee and supervisor, include in part: Employees with expired physicals, PPDs or Chest X-rays will not be eligible to remain on the staffing schedule. Physical Forms: PA Staff: Physicals must be completed on CI Physical form. A copy of this form will be added to your Paycom profile via checklist. You will need to print and bring the form with you. You can also request a copy electronically or pick up a hard copy at your local office. Where to complete: Employees may complete their Physicals / PPD / Chest X-rays with any medical provider. Physicals can be provided free of cost by your PCP. We encourage you to make an appointment as soon as possible. If you do not have a PCP or are unable to schedule an appointment prior to your expiration date, you may have your physical completed at Patient First. You will be required to pay for your physical via payroll deduction. The payroll deduction form is included in the checklist containing the physical form. Employees who do not submit timely physicals will forfeit eligibility for the next approved across the board increase. 08/20/2023 Implemented
SIN-00207436 Renewal 07/05/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(h)From August 2021 through June 2022 there were eight fire drills conducted in which it was not documented whether the individuals met at the meeting place. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.The agency Fire Drill Form will be redrafted to include the necessary updates. All staff will be retrained on the new form by the Program Specialist and Team Facilitator. 09/30/2022 Implemented
6400.141(c)(14)The annual physical 1/20/22 completed for Individual #1 does not contain information pertinent in diagnosis and treatment in case of an emergency. This section is left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The physical form will be resent to the Doctor to request to add the missing information. 09/30/2022 Implemented
6400.151(a)Staff person # 4 had a physical examination completed on 7/3/19 and not again until 8/2/21. 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. Our research indicates that the identified employee made every effort to make an appoint with her primary care physician, and due to limited in-person appointments, the employee was unable to confirm an appointment within the appropriate timeline from her last bi-annual physical examination as outlined in the 55 PA Code Chapter 6400 regulations. To prevent future compliance violations concerning the completion and submission of bi-annual employee physical examinations, a representative from Human Resources will ensure that appropriate follow up measures are implemented, including communications of expiring regulatory documentation, i.e., bi-annual employee physical examination through remainders, which will begin at least 90, 60 and 30 days prior to the expiration of the physical through currently communication opportunities, i.e., email and others means of employee community as they become available. All communication of upcoming expiration of bi-annual employee physical examination will also be shared the employees direct supervisor. 09/30/2022 Implemented
6400.151(b)Staff person #4's 8/2/21 physical examination was completed and signed by a radiology technician. The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. In response to the finding that our contracted medical provider authorized by an employee that was not a licensed physician, certified nurse practitioner or licensed physicians assistant to sign the bi-annual employee physical examination, stating that is their companys practice. It was determined that an alternative service provider would be needed to be identified to avoid future violations concerning the completion of bi-annual employee physical examinations, PDD placement and readings, and chest x-rays as indicated. Community Interactions, Inc. will now utilize Patient First. As a contracted service provider, Patient First has agreed to follow Community Interactions, Inc. policy and procedures and 55 PA Code Chapter 6400 regulatory expectations. 09/30/2022 Implemented
6400.151(c)(2)Staff person # 4 had a tuberculin test on 7/6/19 and not again until 8/2/21. Additionally, Staff person #4's 8/2/21 Tuberculin test was read and signed by a radiology technician. 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. In response to the finding that our contracted medical provider authorized by an employee that was not a licensed physician, certified nurse practitioner or licensed physicians assistant to complete the Tuberculin skin testing by Mantoux, stating that is their companys practice. It was determined that an alternative service provider would be needed to be identified to avoid future violations concerning the completion of bi-annual employee physical examinations, PDD placement and readings, and chest x-rays as indicated. Community Interactions, Inc. will now utilize Patient First. As a contracted service provider, Patient First has agreed to follow Community Interactions, Inc. policy and procedures and 55 PA Code Chapter 6400 regulatory expectations. 09/30/2022 Implemented
6400.34(a)The Department issued updated regulatory rights, effective 2/3/2020, stating that individuals have additional rights they need to be informed of. At the time of the 7/6/2022 annual inspection, Individual #1 was not informed of all of the individual rights as described in 6400.32.The home 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 home and annually thereafter.Upon completion of the Individuals Rights Packet being updated the assigned Program Specialists will complete and review with the individuals and their teams and gather any necessary signatures in the updated format for their assigned caseloads. 09/30/2022 Implemented
6400.166(a)(2)March, April, May, June 2022, medication administration records for Individual #1 did not contain the prescribing physician for the medications prescribed.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.The assigned agency nurse will add the prescribing physicians for the medication prescribed for all medications for all individuals on their caseload. 09/30/2022 Implemented
6400.166(a)(11)Aug, Sept, Oct, Nov, Dec 2021, Jan, Feb 2022: The following medications on Individual #1's medication administration records did not indicate the diagnosis or purpose for each medication: Duloxetine HCL Dr 30mg 1 cap 8am, Lamotrigine 200mg 1 tab 8am, Vitamin B-12 100mg 1 tab 8am, Vitamin D3- 2,000unit (50mcg) 1 cap 8am.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.This violation has already been remediated and addressed internally. The MAR that were reviewed for this date range are no longer in use. The agency currently uses Electronic MARs. 09/30/2022 Implemented
6400.166(b)On 7/7/22 when the inspector was reviewing Individual #1's medication to the medication record it was noticed that Individual #1 was administered the following medication, but staff did not initial the following medication as being administered. Duloxetine 30 mg Dr. cap 8am, Lamotrigine 200mg tab 8am, Quetiapine 50mg tab 8am, Vitamin B-12 100mcg tab 8am, Vitamin D3200 IU (50mcg) C 8am.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.It is the agency's opinion that this violation is not a systematic concern but an individual employee performance concern. This performance concern will be documented in writing with the employee. 09/30/2022 Implemented
6400.169(a)Staff person #4's completed the online portion of the Modified Medication Administration Training Course on 3/17/21, however, they did not complete the required number of observations within the established timeframes, nor did they complete the handwashing and gloving requirements. Staff person #4 has administered medications since their 3/17/21 initial training.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).Staff person #4 was immediately removed from administering any medications. The staff was then scheduled for Medication Administration retraining and certification. 09/30/2022 Implemented
SIN-00194012 Renewal 08/18/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Individual #1 is assessed by the agency to not be safe around any poisonous materials. During the 8/19/21 physical site inspection of the home, multiple poisonous materials, that contained a label to contact poison control center if ingested, were fund unlocked an accessible throughout the home. The following are examples of the poisonous materials found at the home and their location: a bottle of Soft Soap hand soap, a bottle of generic hand sanitizer and a container of Lysol disinfectant wipes were located on the countertop pin the kitchen and on the kitchen sink, and the first aid kit containing sanitizer wipes, burn cream and after bite cream were in the first aid kit under the kitchen sink.Poisonous materials shall be kept locked or made inaccessible to individuals. 1. This area of non-compliance was addressed during licensing and since that time the Soft Soap, hand sanitizer and Lysol disinfectant were locked under the kitchen sink during before the inspection was over. 01/31/2022 Implemented
6400.67(a)Individual #1's bathtub in their upstairs bathroom, did not drain water quickly out of the bathtub. During the 8/19/21 inspection of the home, when the bathtub water was turned on, the bathtub quickly filled with water and drained extremely slow. A few inches of water stayed in the bathtub even after the water had been shut off for a few minutes.Floors, walls, ceilings and other surfaces shall be in good repair. 1. This area of non-compliance was addressed the same day when the Team Facilitator contacted the landlord who sent a professional person to unclog the drainage in the bathtub on 9/3/21. See attachment - 13 01/31/2022 Implemented
6400.112(e)There are no records maintained that a fire drill was held when the individuals were sleeping, during sleeping hours, from September 2020 to current, August 2021, outside the requirement to be completed every 6 months. The fire drill records do not indicate if the individuals were sleeping during any of the monthly fire drills to meet the requirement of fire drills being held during sleeping hours.A fire drill shall be held during sleeping hours at least every 6 months. 1. The fire drill form was revised to address whether the individual was awake or asleep during the monthly fire drill. (Attachment# 5revised fire drill form) 01/31/2022 Implemented
6400.112(h)There are no records maintained that all individuals evacuated to the meeting place during every monthly fire drill held from September 2020 to current, August 2021. According to the fire drill records, the meeting place is documented on the records as the lamp post or stop sign. There is no indication on the records if individuals evacuated to the meeting place during every monthly drill. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.1. The fire drill form was revised to reflect that all individuals evacuated to the meeting place during monthly fire drill. (Attachment# revised fire drill form) 01/31/2022 Implemented
6400.113(b)There are no records maintained that Individuals #1 and #2 received training defined in 55 PA Code. Chapter 6400.113(a) on an annual basis. At the time of the 8/18/21 inspection there were no records of said fire safety training for 2019, 2020, or 2021.If an individual is medically or functionally unable to participate in the fire safety training, documentation shall be kept specifying why the individual could not participate. 1. The fire safety training forms was revised to reflect that all individuals received training upon initial admission or 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 (Attachment# 10 revised client's rights packet fire safety and add annual power point) 01/31/2022 Implemented
6400.145(1)There are no records maintained that the home had a written emergency medical plan that include the hospital or source of health care to use in the event of an emergency.The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. 1. The Program Specialist addressed this area of non-compliance - written emergency medical plan that include the hospital source of health care in case of an emergency as per the attached document 15 & 16 01/31/2022 Implemented
6400.32(r)Individuals #1 and 2's individual plans and assessments do not include their decision if they would want to enact their right to lock their bedroom door by any locking mechanism that is deemed fit for their abilities. According to the agency staff on site on 8/19/21, they had no knowledge of the individual's being asked specifically if they would like to have a locking mechanism placed on their bedroom door for their ability to lock their bedroom doors if they wish.An individual has the right to lock the individual's bedroom door.1. The Client's Rights Packet was revised to include the new Regulatory Compliance Guidelines (RCG), including the individual's right to lock their bedroom door (Attachment# 17 lock assessment) 01/31/2022 Implemented
6400.186Individual #1's plans state that the individual requires sharp objects to be stored in locked compartments due to their suicidal threats. During the 8/19/21 inspection of the home, a pair of scissors and sharp, metal tweezers were unlocked and accessible in the first aid kit under the kitchen sink.The home shall implement the individual plan, including revisions.1. This area of non-compliance was addressed the same day during the inspection by having the First Aid Kit been taken to the office area which is locked and only staff have a key to access the area. 01/31/2022 Implemented
SIN-00176450 Renewal 09/09/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The hot water temperature measured at the kitchen sink was 126.1 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. 1. On 9/11/ 2020 the hot water heater was adjusted by maintenance to not exceed 120°F (Attachment #10) 2. Direct support professionals (DSP) will be re-trained on the dangers of not reporting temperatures exceeding 120°F. In case the condition of the water exceeds 120°F, the DSP¿s will report immediately to their Supervisor or on call during non-business hours. The training will be completed by the Team Facilitator or designee. 3. On a daily basis, the DSP¿s will check and document water temperatures using the Daily Overnight checklist to ensure compliance with CI¿s temperature checks guidelines. (Attachment #2) 4. On a weekly basis, the Cluster Administrator or designee will complete the Weekly Quality Assurance checklist (PA-QA) to ensure compliance with temperature checks. (Attachment #3) 5. The monthly Quality Assurance checklist will be completed by the Team Facilitator or designee assigned to the cluster. (Attachment #4) 6. If an area of non-compliance is identified, a Maintenance request will be completed by the Team Facilitator or designee. 7. House Manager/Lead Staff, Team Facilitators and Program Specialists will be re-trained on following the new guidelines/expectations to ensure compliance. This training will be completed by the Associate Residential Director. 8. This will be completed by 12/31/2020 12/31/2020 Implemented
6400.141(c)(11)"Current Medications" section of the 10/08/19 physical states "see attached"; there is no medication list attached, and other documents in the file indicate that Individual #1 does take medications. No medication regimen review was completed during the annual physical.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. 1. In March 2020, Community Interactions Inc. hired a Nurse to provide and implement healthcare supports to the Central, PA team. This will ensure that all documentation for medical appointments will be completed correctly prior to the appointment, which includes attaching current medication regime. 2. Prior to attending any medical appointment, the Nurse or designee will complete and review all medical records (Annual Physical Examination or routine medical appointments) to ensure compliance to avoid reoccurrence of such noncompliance 3. A THERAP Medical Consultation Form will be included in all medical appointment¿s documentation (Attachment #11) 4. On a quarterly basis, the Program Specialist will review the medical appointments using the attached form (Attachment #12) 5. Training on the new documents and process will be completed by the Associate Residential Director 6. This will be completed by 12/31/2020 12/31/2020 Implemented
6400.181(e)(7)11/20/19 Assessment indicates that Individual #1 can identify heat sources but does not indicate if Individual #1 can move away quickly from heat sources which exceed 120 degrees Fahrenheit.The 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. 1. On 9/20/2020 Individual #1 was documented and revised on the assessment to identify heat sources and indicates Individual #1 can move away quickly from heat sources. (Attachment #13) 2. All Program Specialists will be retrained on utilizing the Residential Quarterly Assessment Tool which covers the area of non-compliance in this citation. (attachment #14) 3. The Program Specialists will be required to review all the assessments of the individuals in their caseload to ensure that this concern is addressed on or before 12/31/2020 4. This training will be completed by the Associate Residential Director 5. This will be completed by 12/31/2020 12/31/2020 Implemented
6400.34(a)The Department issued updated regulatory rights, effective 2/3/2020, stating that individuals have additional rights they need to be informed of. At the time of the 9/09/2020 annual inspection, Individual #1 was never informed of the individuals rights as described in 6400.32.The home 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 home and annually thereafter.1. The Client¿s Rights Packet was revised to include the Regulatory Compliance Guidelines (RCG), about the individual¿s right to lock their bedroom door (Attachment #15) 2. The Program Specialist will inform all the individuals of their rights and review the newly revised Client¿s Rights Packet to meet the regulatory requirements. Thereafter, on an annual basis or as needed the Client¿s Rights Packets will be reviewed with the individuals and signed. 3. All DSP¿s and Cluster Administrators will be re-trained on new additional rights as per the RCG and Client¿s Rights Packet. 4. The Associate Residential Director will retrain all Cluster Administrators, who will in turn train the DSP¿s. 5. This will be completed by 12/31/2020 12/31/2020 Implemented
6400.213(1)(i)Individual #1 is edentulous. This is not indicated as a distinguishing mark or feature in the record.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.1. On 10/01/2020 the Emergency Data Form was updated identifying he does not have any teeth. (Attachment #16) 2. All Program Specialists will be retrained on how to identify other distinguishing marks while completing the Residential Quarterly Assessment Tool (Attachment #14) 3. The Program Specialists will review all Emergency Data Forms to ensure compliance and to avoid reoccurrence of such noncompliance 4. The Associate Residential Director will review the Residential Quarterly Assessment Tool on quarterly basis to provide oversight (Attachment #14) 5. This training will be completed by the Associate Residential Director 6. This will be completed by 12/31/2020 12/31/2020 Implemented
SIN-00135380 Renewal 08/01/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106Furnace inspected and cleaned in May 2017 and not again until 8/2/2018.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 Maintenance Team will come up with a routine/preventative environmental checklist for all the homes. The checklist will identify the areas that need to be checked, how often and who will complete the task. The checklist will be completed by 10/31/18. 10/31/2018 Implemented
6400.112(h)Fire drill records did not indicate whether or not individuals evacuated to a designated meeting place outside the building or within the fire safe area during each fire drill (June 2017 to July 208). Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.A new user friendly fire drill report form was created as well as a new fire drill review form. It was developed in order to ensure all fire drill related regulations are met, including the designated meeting place. All personnel and Program Coordinator will be trained on the approved forms (attachments #2 and #3) 09/11/2018 Implemented
6400.145(3)The written emergency medical plan did not list the following: An emergency staffing plan.The home shall have a written emergency medical plan listing the following: An emergency staffing plan.A written emergency medical plan was updated to include an emergency staffing plan (attachment #1) 09/11/2018 Implemented
SIN-00112362 Renewal 05/16/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)REPEATED VIOLATION- 5/16/16. Individual #1's financial ledger was not up-to-date. The beginning balance of the November 2016 log had a balance of $52.51. The end balance of October 2016 was $27.51. The end balance of the January 2017 log was $12.28 which didn't match the beginning balance of the February 2017 log which was $12.98.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. Our 6400.22(d)(1) protocol has been updated and the following procedures have been instituted; ¿ At the beginning of each month the lead staff/team leader will create the individual financial ledger. The lead staff/team leader will verify that the amounts match from the previous months ending balance to the next months beginning balance. ¿ All staff will retrained on how to complete individual¿s financial ledger ¿ Person Responsible: Program Coordinator 06/20/2017 Implemented
6400.31(b)Individual #1 was admitted to the program on 9/20/16. Individual #1 was not informed of his rights until 10/7/16.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. A consumer intake checklist will be created and utilized moving forward. 06/30/2017 Implemented
6400.44(b)(1)REPEATED VIOLATION- 5/16/16. Individual #1's 12/20/16 assessment was completed by Staff #1. Staff #1 is not a program specialist. The program specialist shall be responsible for the following: Coordinating and completing assessments. Our 6400.44 (b) (1) protocol has been updated and the following procedures have been instituted; ¿ Staff #1 job responsibilities have been redefined to exclude writing and completing assessments. ¿ Program Specialist and/or Program Coordinator will coordinate and complete all assessments as directed. The assessment form has been update to reflect only the Program Specialist who completed the assessment form. ¿ Person Responsible: Program Coordinator 05/20/2017 Implemented
6400.46(a)REPEATED VIOLATION- 5/16/16. Staff #2 was hired on 10/7/16 and began working his/her first shift in the home on 10/7/16 from 4pm-12am. Staff #2 did not receive orientation training prior to working his/her appointed position.The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. All newly hired staff will receive on-site orientation related to their responsibilities, and policies and procedures/daily operation of the home before working with individuals. 05/01/2017 Implemented
6400.46(e)Staff #2 was hired on 10/7/16 and worked his/her first shift in the home from 4pm-12a, according to his/her timesheet, on 10/7/16. Staff #2 received 14.5 hours of training on 10/7/16 during his/her 8 hour shift. It cannot be determined if Staff #2 was trained on intellectual disabilities, normalization, rights, and program planning.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. All program specialists and direct service workers will receive training in intellectual disability, normalization (our Therapeutic Options curriculum), rights and program planning and implementation within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. In most cases, training will be conducted by the Director of Staff Development. 05/01/2017 Implemented
6400.46(f)Staff #2 was hired on 10/7/16 and worked his/her first shift in the home from 4pm-12a, according to his/her timesheet, on 10/7/16. Staff #2 received 14.5 hours of training on 10/7/16 during his/her 8 hour shift. It can not be determined if Staff #2 was trained on fire safety.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 program specialists and direct service workers will receive training in fire safety and accompanying responsibilities prior to working with individuals and annually thereafter. 05/01/2017 Implemented
6400.104REPEATED VIOLATION- 5/16/16. The notification letter to the fire department did not indicate Individual #1's assistance needs with evacuation.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. Our 6400.104 protocol has been updated and the following procedures have been instituted; ¿ A revised letter was sent to the local fire department to notify of the address of the home and the exact location of individuals #1 bedroom and the assistance needed to evacuate in the event of an actual fire. #6 ¿ Program Specialist will notify the fire department annually of the individual¿s address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. See attachment # ¿ Person Responsible: Program Coordinator and/or Program Specialist Fire Letter 21 Westminster Building Hershey PA, 17033 717-259-1159 May 22, 2017 Never Sink Fire Company 1912 Center Street Lebanon PA, 17042 (717)273-5819 Dear Chief Mathews: Dear Fire Chief Jack Gresch: This letter is to inform you of the community living arrangement located at 2001 Greystone Drive Lebanon, PA. The CLA houses two individuals with an intellectual disability. In the case of a fire emergency: Individual #1's bedroom is located at the top of the second floor level facing the back of the home. Individual #1 can ambulate independently and evacuated the home independently in case of an emergency. John¿s bedroom is located on second floor, the second door on your left hand side facing the front of the townhouse. John can ambulate independently but requires verbal assistance to exit the home. He can meet at the designate at the meeting place. All of the above individuals participate in monthly fire drills and overnight fire drills during the course of the year. All of the individuals are aware of the evacuation procedures for their home in the event of an actual emergency. Sincerely, Stephanie Simmons Program Coordinator 05/20/2017 Implemented
6400.112(c)The smoke detector in Individual #2's bedroom was not tested in June, July, August, or September of 2016. An asleep drill conducted on 7/16/16 at 2:05am had an evacuation time of 8 seconds. The other asleep drills had evacuation times of at least one minute. 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 or smoke detector was operative. Our 6400.112(c) protocol has been updated and the following procedures have been instituted; ¿ Fire drill form has been updated that includes a review of the form by the program specialist and/or senior program specialist. See attachment # 5 ¿ Staff will be retrained on how to properly complete fire drill form. ¿ Person Responsible: Program Coordinator/Program Specialist/Senior Program Specialist 06/05/2017 Implemented
6400.113(a)Indiviudal #1 was admitted to the program on 9/20/16. Individual #1 did not receive fire safety training until 10/7/16. 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. Our 6400.164(b) protocol has been updated and the following procedures have been instituted; ¿ An initial fire safety training document has been added into the initial paperwork packet that is to be completed upon admissions to instruct 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. See attachment #4 ¿ Person Responsible: Program Coordinator/Program Specialist MB 2016-3/1/16 2017- 3/1/17 2018- 3/1/18 Date completed; Date Signed; mailed to Team; JR 2016- 11/20/16 2017- 11/20/17 2018- 11/20/18 Date completed; Date Signed; mailed to Team; 06/05/2017 Implemented
6400.164(a)REPEATED VIOLATION- 5/16/16. Individual #1's 1/1/17 medication log indicated Trazadone 50mg, and Olanzapine 5mg were administered. The medication log did not include the time of administration.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. Our 6400.164(a) protocol has been updated and the following procedures have been instituted; ¿ Our Quality Assurance tool will include daily checks of medication labels to the medication log. ¿ All staff will be retrained on how to utilize the Quality Assurance tool. ¿ Person Responsible: Program Coordinator and/or Team Lead 06/12/2017 Implemented
6400.164(b)On 10/2/16, Lorazepam 1mg was administerd to Individual #1. The staff member adminsitering the medication did not intiital the medication log. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. Our 6400.164(b) protocol has been updated and the following procedures have been instituted; ¿ The Quality Assurance tool will be used to complete daily medication log checks. ¿ All staff will be trained on how to utilize the Quality Assurance tool. ¿ Person Responsible: Program Coordinator. 06/05/2017 Implemented
6400.181(a)Individual #1 was admitted to the program on 9/20/16. The initial assessment was not completed until 12/20/16. 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. Our 6400.181(a) protocol has been updated and the following procedures have been instituted; ¿ Program Specialist/Program Coordinator will complete assessments within the regulatory time frame as stated in 181 (a). See attachment #1 ¿ Upon completion of the Assessment, The Program Specialist will date the Assessment and send the Assessment out to the Team Members. ¿ Person Responsible: Program Specialist. MB 1) Start Date 07/23/16-------- to-------- End date 10/22/16 Date completed; Date Signed; mailed to Team; 2) Start Date 10/23/16-------- to--------End date 01/22/17 Date completed; Date Signed; mailed to Team; 3) Start Date 01/23/17-------- to-------- End date 04/22/17 Date completed; Date Signed; mailed to Team; 4) Start Date 04/23/17-------- to-------- End date 07/23/17 Date completed; Date Signed; mailed to Team; JR 1) Start Date 09/20/16-------- to-------- End date 12/19/16 Date completed; Date Signed; mailed to Team; 2) Start Date 12/20/16-------- to--------End date 03/19/17 Date completed; Date Signed; mailed to Team; 3) Start Date 03/20/17-------- to-------- End date 06/19/17 Date completed; Date Signed; mailed to Team; 4) Start Date 06/20/17-------- to-------- End date 09/19/17 Date completed; Date Signed; mailed to Team; 06/05/2017 Implemented
6400.181(e)(3)(i)Individual #1's 12/20/16 assessment did not include acquisition of functional skills.The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. Our 6400.181(e)(3)(i) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly define and specify individuals supported current level of performance and progress in the following areas. See attachment #3. Under, Acquisition of functional skills. ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Person Responsible: Program Specialist. COMMUNITY SERVICES INDIVIDUAL ASSESSMENT Prepared with: _______________ On: _______________ Revision date: __________________ CC: Family (Name/s)¿¿¿¿¿¿¿¿¿¿¿¿.. Support Coordinator (Name)¿¿¿¿¿¿¿¿ Advocates (Name/s)¿¿¿¿¿¿¿¿¿¿¿ Day Program (Name/s)¿¿¿¿¿¿¿¿¿¿. This assessment shall be based on assessment instruments, interviews, progress notes and observations. This is a document that is written collaboratively with the contributions and input of the planning team and incorporates information provided and services and supports as agreed upon. Attachments: Lifetime Medical History Self-Medication Administration Assessment Individual: Date: Program Specialist: Date: FUNCTIONAL STRENGTHS AND NEEDS: What are ¿s functional strengths and needs in the following areas? BASELINE INFORMATION¿LEVEL OF PROMPTING, VERBAL, GESTURE, PHYSICAL ________________________________________ LEVEL OF PERFORMANCE AND PROGRESS: What is `s current level of performance and what progress has she/he made in the past year in the follow areas? Health: Current: Progress: Motor and Communication: Current: Progress: Activities of Residential Living: Current: Progress: Personal Adjustment: (How does the individual get along with housemate, staff and community? Current: Progress: Socialization: Include progress with stranger awareness Current: Progress: Recreation: Current: Progress: Financial Management/Independence: Current: Progress: Management of Personal Property: Current: Progress: Community Integration: Current: Progress: Water Safety: Current: Progress: ________________________________________ POISINOUS MATERIAL: Are poisonous materials kept unlocked in home? (181e6) Yes Describe his abilities to avoid such materials. Are there sources of heat in the home that exceed 120 degrees F, are not insulated, and are accessible to him or her? ___ YES / __ NO HEAT SOURCE: Does have safety awareness of heat sources? Heat: (the ability to sense and move away from heat source quickly) (181e7) __ YES / ___ NO Water safety (181e14) Ability to temper water including bathing water? __ YES / ___ NO Notes: _____________ Ability to swim? __ YES / ___ NO Notes: ___________ Stranger Awareness: Does the individual have knowledge of stranger danger? __ YES /___ NO Comments: ______ SUPERVISION: ¿ Does have unsupervised time? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ Can be with direct supervision? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ What supports does need in order to be to have unsupervised time or be without direct supervision? ¿ Describe ¿s progress in developing the ability and/or desire to be without direct supervision, since her/his last assessment. ________________________________________ SELF-ADMINISTRATION OF MEDICATION ¿ Can recognize and distinguish her medication? (Note: To be considered capable of self-administration she must be able to recognize both the container and the medication itself from other medications.) 0 NO 0 YES ¿ Does know how much medication is to be taken? (Note: To be 06/05/2017 Implemented
6400.181(e)(7)Individual #1's 12/20/16 asssessment does not include his/her ability to move away from heat sources.The 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. Our 6400.181(7) protocol has been updated and the following procedures have been instituted; ¿ Individual #1 assessment was updated to include 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. The standard assessment document has been updated to add section for knowledge of ¿heat source.¿ See attachment # 3 ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Person Responsible: Program Specialist. COMMUNITY SERVICES INDIVIDUAL ASSESSMENT Prepared with: _______________ On: _______________ Revision date: __________________ CC: Family (Name/s)¿¿¿¿¿¿¿¿¿¿¿¿.. Support Coordinator (Name)¿¿¿¿¿¿¿¿ Advocates (Name/s)¿¿¿¿¿¿¿¿¿¿¿ Day Program (Name/s)¿¿¿¿¿¿¿¿¿¿. This assessment shall be based on assessment instruments, interviews, progress notes and observations. This is a document that is written collaboratively with the contributions and input of the planning team and incorporates information provided and services and supports as agreed upon. Attachments: Lifetime Medical History Self-Medication Administration Assessment Individual: Date: Program Specialist: Date: FUNCTIONAL STRENGTHS AND NEEDS: What are ¿s functional strengths and needs in the following areas? BASELINE INFORMATION¿LEVEL OF PROMPTING, VERBAL, GESTURE, PHYSICAL ________________________________________ LEVEL OF PERFORMANCE AND PROGRESS: What is `s current level of performance and what progress has she/he made in the past year in the follow areas? Health: Current: Progress: Motor and Communication: Current: Progress: Activities of Residential Living: Current: Progress: Personal Adjustment: (How does the individual get along with housemate, staff and community? Current: Progress: Socialization: Include progress with stranger awareness Current: Progress: Recreation: Current: Progress: Financial Management/Independence: Current: Progress: Management of Personal Property: Current: Progress: Community Integration: Current: Progress: Water Safety: Current: Progress: ________________________________________ POISINOUS MATERIAL: Are poisonous materials kept unlocked in home? (181e6) Yes Describe his abilities to avoid such materials. Are there sources of heat in the home that exceed 120 degrees F, are not insulated, and are accessible to him or her? ___ YES / __ NO HEAT SOURCE: Does have safety awareness of heat sources? Heat: (the ability to sense and move away from heat source quickly) (181e7) __ YES / ___ NO Water safety (181e14) Ability to temper water including bathing water? __ YES / ___ NO Notes: _____________ Ability to swim? __ YES / ___ NO Notes: ___________ Stranger Awareness: Does the individual have knowledge of stranger danger? __ YES /___ NO Comments: ______ SUPERVISION: ¿ Does have unsupervised time? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ Can be with direct supervision? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ What supports does need in order to be to have unsupervised time or be without direct supervision? ¿ Describe ¿s progress in developing the ability and/or desire to be without direct supervision, since her/his last assessment. ________________________________________ SELF-ADMINISTRATION OF MEDICATION ¿ Can recognize and distinguish her medication? (Note: To be considered capable of self-administration she must be able to recognize both the container and the medication itself from other medications.) 0 06/05/2017 Implemented
6400.181(e)(10)Individual #1's 12/20/16 assessment did not include a lifetime medical history.The assessment must include the following information: A lifetime medical history. Our 6400.181(10) protocol has been updated and the following procedures have been instituted; ¿ Individual #1 assessment was update to add within the assessment the lifetime medical history. The standard assessment has been updated to include lifetime medical history information within the assessment document. See attachment #3 ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Person Responsible: Program Specialist. COMMUNITY SERVICES INDIVIDUAL ASSESSMENT Prepared with: _______________ On: _______________ Revision date: __________________ CC: Family (Name/s)¿¿¿¿¿¿¿¿¿¿¿¿.. Support Coordinator (Name)¿¿¿¿¿¿¿¿ Advocates (Name/s)¿¿¿¿¿¿¿¿¿¿¿ Day Program (Name/s)¿¿¿¿¿¿¿¿¿¿. This assessment shall be based on assessment instruments, interviews, progress notes and observations. This is a document that is written collaboratively with the contributions and input of the planning team and incorporates information provided and services and supports as agreed upon. Attachments: Lifetime Medical History Self-Medication Administration Assessment Individual: Date: Program Specialist: Date: FUNCTIONAL STRENGTHS AND NEEDS: What are ¿s functional strengths and needs in the following areas? BASELINE INFORMATION¿LEVEL OF PROMPTING, VERBAL, GESTURE, PHYSICAL ________________________________________ LEVEL OF PERFORMANCE AND PROGRESS: What is `s current level of performance and what progress has she/he made in the past year in the follow areas? Health: Current: Progress: Motor and Communication: Current: Progress: Activities of Residential Living: Current: Progress: Personal Adjustment: (How does the individual get along with housemate, staff and community? Current: Progress: Socialization: Include progress with stranger awareness Current: Progress: Recreation: Current: Progress: Financial Management/Independence: Current: Progress: Management of Personal Property: Current: Progress: Community Integration: Current: Progress: Water Safety: Current: Progress: ________________________________________ POISINOUS MATERIAL: Are poisonous materials kept unlocked in home? (181e6) Yes Describe his abilities to avoid such materials. Are there sources of heat in the home that exceed 120 degrees F, are not insulated, and are accessible to him or her? ___ YES / __ NO HEAT SOURCE: Does have safety awareness of heat sources? Heat: (the ability to sense and move away from heat source quickly) (181e7) __ YES / ___ NO Water safety (181e14) Ability to temper water including bathing water? __ YES / ___ NO Notes: _____________ Ability to swim? __ YES / ___ NO Notes: ___________ Stranger Awareness: Does the individual have knowledge of stranger danger? __ YES /___ NO Comments: ______ SUPERVISION: ¿ Does have unsupervised time? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ Can be with direct supervision? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ What supports does need in order to be to have unsupervised time or be without direct supervision? ¿ Describe ¿s progress in developing the ability and/or desire to be without direct supervision, since her/his last assessment. ________________________________________ SELF-ADMINISTRATION OF MEDICATION ¿ Can recognize and distinguish her medication? (Note: To be considered capable of self-administration she must be able to recognize both the container and the medication itself from other medications.) 0 NO 0 YES ¿ Does know how much medication is to be taken? 06/05/2017 Implemented
6400.181(e)(12)Individual #1's 12/20/16 assessment did not include recommendations for specific areas of training, programming, and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. Our 6400.181(12) protocol has been updated and the following procedures have been instituted; ¿ Individual #1 assessment was updated to update recommendations for specific areas of training, programming and services. The assessment form has been update to reflect a description of the information to be captured recommendations for specific areas of training, programming and services. See attachment #3 ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. COMMUNITY SERVICES INDIVIDUAL ASSESSMENT Prepared with: _______________ On: _______________ Revision date: __________________ CC: Family (Name/s)¿¿¿¿¿¿¿¿¿¿¿¿.. Support Coordinator (Name)¿¿¿¿¿¿¿¿ Advocates (Name/s)¿¿¿¿¿¿¿¿¿¿¿ Day Program (Name/s)¿¿¿¿¿¿¿¿¿¿. This assessment shall be based on assessment instruments, interviews, progress notes and observations. This is a document that is written collaboratively with the contributions and input of the planning team and incorporates information provided and services and supports as agreed upon. Attachments: Lifetime Medical History Self-Medication Administration Assessment Individual: Date: Program Specialist: Date: FUNCTIONAL STRENGTHS AND NEEDS: What are ¿s functional strengths and needs in the following areas? BASELINE INFORMATION¿LEVEL OF PROMPTING, VERBAL, GESTURE, PHYSICAL ________________________________________ LEVEL OF PERFORMANCE AND PROGRESS: What is `s current level of performance and what progress has she/he made in the past year in the follow areas? Health: Current: Progress: Motor and Communication: Current: Progress: Activities of Residential Living: Current: Progress: Personal Adjustment: (How does the individual get along with housemate, staff and community? Current: Progress: Socialization: Include progress with stranger awareness Current: Progress: Recreation: Current: Progress: Financial Management/Independence: Current: Progress: Management of Personal Property: Current: Progress: Community Integration: Current: Progress: Water Safety: Current: Progress: ________________________________________ POISINOUS MATERIAL: Are poisonous materials kept unlocked in home? (181e6) Yes Describe his abilities to avoid such materials. Are there sources of heat in the home that exceed 120 degrees F, are not insulated, and are accessible to him or her? ___ YES / __ NO HEAT SOURCE: Does have safety awareness of heat sources? Heat: (the ability to sense and move away from heat source quickly) (181e7) __ YES / ___ NO Water safety (181e14) Ability to temper water including bathing water? __ YES / ___ NO Notes: _____________ Ability to swim? __ YES / ___ NO Notes: ___________ Stranger Awareness: Does the individual have knowledge of stranger danger? __ YES /___ NO Comments: ______ SUPERVISION: ¿ Does have unsupervised time? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ Can be with direct supervision? 0 NO 0 YES (If YES, describe how long/where?) o While in the home? o While asleep? o In the community? ¿ What supports does need in order to be to have unsupervised time or be without direct supervision? ¿ Describe ¿s progress in developing the ability and/or desire to be without direct supervision, since her/his last assessment. ________________________________________ SELF-ADMINISTRATION OF MEDICATION ¿ Can recognize and distinguish her medication? (Note: To be considered capable of self-administration she must be able to recognize both the container and the medication itself from other medications.) 0 NO 0 YES ¿ Does know how much 06/05/2017 Implemented
6400.185(b)REPEATED VIOLATION- 5/16/16. Individual #1's Individual Support plan indicated a behavior plan would be implemented by 4/12/17 and staff members working with Individual #1 would be trained on this plan. A behavior plan was not created and implemented as of the date of the inspection.The ISP shall be implemented as written.Our 6400.185(b) protocol has been updated and the following procedures have been instituted; ¿ The Program Specialist will review individual¿s ISP every three months in alignment with each individual¿s Plan start date and end date. Any content discrepancies noted will be shared with the individual¿s Supports Coordinator to ensure the information in the ISP is current and up to date. See attachment # 1. ¿ Program Specialist/Program Coordinator Support Coordinator will notify Support Coordinator to make the appropriate changes and recommendation to individual #1 ISP to reflect accurate staff training dates. ¿ Person Responsible: Program Specialist. MB 1) Start Date 07/23/16-------- to-------- End date 10/22/16 Date completed; Date Signed; mailed to Team; 2) Start Date 10/23/16-------- to--------End date 01/22/17 Date completed; Date Signed; mailed to Team; 3) Start Date 01/23/17-------- to-------- End date 04/22/17 Date completed; Date Signed; mailed to Team; 4) Start Date 04/23/17-------- to-------- End date 07/23/17 Date completed; Date Signed; mailed to Team; JR 1) Start Date 09/20/16-------- to-------- End date 12/19/16 Date completed; Date Signed; mailed to Team; 2) Start Date 12/20/16-------- to--------End date 03/19/17 Date completed; Date Signed; mailed to Team; 3) Start Date 03/20/17-------- to-------- End date 06/19/17 Date completed; Date Signed; mailed to Team; 4) Start Date 06/20/17-------- to-------- End date 09/19/17 Date completed; Date Signed; mailed to Team; 06/02/2017 Implemented
6400.186(d)REPEATED VIOLATION- 5/16/16. There was no documentation to indicate Individual #1's 12/20/16 Individual Support Plan review was sent to plan 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. Our 6400.186(d) protocol has been updated and the following procedures have been instituted; ¿ Program Specialist/Program Coordinator will provide supporting documentation that ISP review documentation was sent to all plan team members. The ISP review documentation will include how the plan team members were informed and the date the information was shared with all plan team members. Attachment #2 ¿ Upon completion of the Assessment, The Program Specialist will date the Assessment and send the Assessment out to the Team Members. ¿ Person Responsible: Program Specialist. COMMUNITY SERVICES QUARTERLY PROGRESS REVIEW Name: Address: Date of Report: Reporting Period: Date of Last Quarterly Review: Date of Annual Plan: Person Planned For: ______________________________ Date: ______ Program Specialist: ______________________________ Date: ______ Signature Required CC: Family (Name/s)¿¿¿¿¿¿¿¿¿¿¿¿.. Support Coordinator (Name)¿¿¿¿¿¿¿¿ Day Program (Name/s)¿¿¿¿¿¿¿¿¿¿. You have the option to decline to receive this information. If you would like to decline to receive this information in the future, please contact Stephanie Simmons, Program Coordinator at ssimmons@ciinc.org or call us at 717-259-1159. HEALTH: MEDICAL SERVICES: (List appointments completed during this quarter. Provide a summary of each appointment and target dates for follow-up care, if necessary.) MEDICAL SERVICES (Continued): MEDICATION CHART: NAME STRENGTH DOSAGE TIMES PURPOSE PHYSICIAN COMMUNITY INCLUSION PLAN/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan is no longer appropriate or if plan(s) need to be added, please document revisions below. SUPERVISION PLAN/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan is no longer appropriate or if plan(s) need to be added, please document revisions below. PERSONAL ADJUSTMENT/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan is no longer appropriate or if plan(s) need to be added, please document revisions below. PROTOCOL (S) /OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan(s) is no longer appropriate or if plan(s) need to be added, please document revisions below. SPECIALIZED PLAN (S)/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan(s) is no longer appropriate or if plan(s) need to be added, please document revisions bel Recommendations to delete, add or modify an outcome or service to support the achievement of an outcome: ISP Quarterly Review Meeting completed on: _______________________ See attached ISP Quarterly Review Meeting Attendance Sheet 05/22/2017 Implemented
6400.186(e)REPEATED VIOLATION- 5/16/16. Individual #1's plan team members did not receive an option to decline the Individual Support Plan review documentation. The program specialist shall notify the plan team members of the option to decline the ISP review documentation. Our 6400.186(e) protocol has been updated and the following procedures have been instituted; ¿ The option to decline will be added within the ISP review documentation form. See attachment #2 ¿ Person Responsible: Program Specialist/Program Coordinator COMMUNITY SERVICES QUARTERLY PROGRESS REVIEW Name: Address: Date of Report: Reporting Period: Date of Last Quarterly Review: Date of Annual Plan: Person Planned For: ______________________________ Date: ______ Program Specialist: ______________________________ Date: ______ Signature Required CC: Family (Name/s)¿¿¿¿¿¿¿¿¿¿¿¿.. Support Coordinator (Name)¿¿¿¿¿¿¿¿ Day Program (Name/s)¿¿¿¿¿¿¿¿¿¿. You have the option to decline to receive this information. If you would like to decline to receive this information in the future, please contact Stephanie Simmons, Program Coordinator at ssimmons@ciinc.org or call us at 717-259-1159. HEALTH: MEDICAL SERVICES: (List appointments completed during this quarter. Provide a summary of each appointment and target dates for follow-up care, if necessary.) MEDICAL SERVICES (Continued): ¿ MEDICATION CHART: NAME STRENGTH DOSAGE TIMES PURPOSE PHYSICIAN COMMUNITY INCLUSION PLAN/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan is no longer appropriate or if plan(s) need to be added, please document revisions below. SUPERVISION PLAN/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan is no longer appropriate or if plan(s) need to be added, please document revisions below. PERSONAL ADJUSTMENT/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan is no longer appropriate or if plan(s) need to be added, please document revisions below. PROTOCOL (S) /OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan(s) is no longer appropriate or if plan(s) need to be added, please document revisions below. SPECIALIZED PLAN (S)/OUTCOME PROGRESS: Please provide a summary of the team¿s efforts and the person¿s progress during the past 90 days. If there has been no progress, if the plan(s) is no longer appropriate or if plan(s) need to be added, please document revisions bel Recommendations to delete, add or modify an outcome or service to support the achievement of an outcome: ISP Quarterly Review Meeting completed on: _______________________ See attached ISP Quarterly Review Meeting Attendance Sheet 05/22/2017 Implemented
6400.213(11)REPEATED VIOLATION- 5/16/16. Individual #1's 9/13/16 physical exam indicated allergies to Zyprexa and Depakote. Contraindicated medications were listed as Relan, Bsupar, Lamicatal, Risperdal, Latuda, Seroquel, Geodon and Rexulti. Individual #1's Individual Support Plan indicated allergies to Reglan, Buspar, Lamictal, Risperdal, and Prilosec. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. Our 6400.213(11) protocol has been updated and the following procedures have been instituted; ¿ The Program Specialist will review individual¿s ISP every three months in alignment with each individual¿s Plan start date and end date. Any content discrepancies noted will be shared with the individual¿s Supports Coordinator to ensure the information in the ISP is current and up to date. See attachment # 1. ¿ Person Responsible: Program Specialist. MB 1) Start Date 07/23/16-------- to-------- End date 10/22/16 Date completed; Date Signed; mailed to Team; 2) Start Date 10/23/16-------- to--------End date 01/22/17 Date completed; Date Signed; mailed to Team; 3) Start Date 01/23/17-------- to-------- End date 04/22/17 Date completed; Date Signed; mailed to Team; 4) Start Date 04/23/17-------- to-------- End date 07/23/17 Date completed; Date Signed; mailed to Team; JR 1) Start Date 09/20/16-------- to-------- End date 12/19/16 Date completed; Date Signed; mailed to Team; 2) Start Date 12/20/16-------- to--------End date 03/19/17 Date completed; Date Signed; mailed to Team; 3) Start Date 03/20/17-------- to-------- End date 06/19/17 Date completed; Date Signed; mailed to Team; 4) Start Date 06/20/17-------- to-------- End date 09/19/17 Date completed; Date Signed; mailed to Team; 05/22/2017 Implemented
6400.216(a)REPEATED VIOLATION- 5/16/16. Individual finance logs were unlocked in a black cabinet in the basement. An individual's records shall be kept locked when unattended. The locker was immediately locked on the date of the physical inspection. All staff in the home will be retrained on HIPPA protocols. 06/30/2027 Implemented
SIN-00094878 Renewal 05/16/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)On 4/22/16 Individual #1 received a paycheck in the amount of $352.97. On the same day, he deposited his pay check into his financial account. However the amount recorded by staff as deposited into his account was only $352.00. Individual #1's financial ledger was off by $.97 starting 4/22/16. 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. ¿ Our 6400.22 (d)(1) protocol has been updated and the following procedures have been instituted; ¿ All staff will be re-trained on financial and property up keep of individuals supported. Target date of completion 06/30/2016. ¿ Monthly audit has been instituted and will be completed monthly. See attachment 11. ¿ Target date of completion; 06/30/2016. ¿ Person Responsible: Program Specialist./Assistant Residential Director and Residential Director. 06/20/2016 Implemented
6400.22(e)(2)According to staff, on 11/7/14 Individual #1 was given $20 directly. The record did not indicate that money was given directly to him. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: For a withdrawal when the individual is given the money directly, the record shall indicate that funds were given directly to the individual. Our 6400.22( e) (2) protocol has been updated and the following procedures have been instituted; ¿ All staff will be re-trained on financial and property up keep of individuals supported. Target date of completion 06/30/2016. ¿ Receipt of funds to individuals supported has been instituted and will be completed any time an individual supported is given money directly. See attachment 12. ¿ Target date of completion; 06/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.44(b)(1)The program specialist did not complete the assessments for Individual #1. A direct support staff without program specialist qualifications was completing the assessments for all individuals in this region. The program specialist shall be responsible for the following: Coordinating and completing assessments. Our 6400.44 (b)(1) protocol has been updated and the following procedures have been instituted; ¿ Program Specialist will be re-trained on the Program Specialist responsibilities. Target date of completion 06/20/2016. See attachment # 2. ¿ The Program Specialist will be responsible for the coordination and completion of Individual Assessments. ¿ Target date of completion; 06/20/2016. ¿ Person Responsible: Residential Director and Assistant Residential Director 06/20/2016 Implemented
6400.46(j)Record of training content was not kept for trainings from Staff #1-#3. Some examples of training topics where content was not kept includes multiple staff meetings, communication enhancement, and understanding and supporting families. 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.Employee Development Coordinator will retain copy of all training content before acceptance of training hours. 06/20/2016 Implemented
6400.67(a)Carpet at the residence was supposed to be tan. The entire carpeted area of the house was a dark brown color with many large black stains throughout the whole house. A two foot wide strip of carpet running vertically up the 20 steps to the second floor, was black. Drywall was chipped off the corner of wall at the top of the second floor steps and the corners of the walls in the kitchen. The wall in the upstairs hallway contained many black scuff marks and about 3, two inch scrapes on the wall where drywall was missing. Floors, walls, ceilings and other surfaces shall be in good repair. Our 6400.67( a) protocol has been updated and the following procedures have been instituted; ¿ Work order has been placed to have the entire home repainted and carpet changed. Work order placed. 05/18/2016. ¿ Floors, walls, ceilings and surfaces check has been added to our environmental check list. See attachment # 10. ¿ Staff will be trained on how to utilize the tool. Target Date 6/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.101An extra large love seat was positioned behind the front door entrance, preventing the front door from opening entirely. The door would not open even half of the way. Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Our 6400.101 protocol has been updated and the following procedures have been instituted; ¿ The love seat has been moved from it¿s initial position and away from the exit. Completed during inspection 05/18/2016. ¿ Exit and passage way check has been added to our environmental check list. See attachment # 10. ¿ Staff will be trained on how to utilize the check list. Target Date 6/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.141(c)(14)Individual #1¿s physical form dated 12/21/15 did not include information pertinent to diagnosis and treatment in case of an emergency. The field was left blank on the physical form.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Our 6400.141 ( c) (14) protocol has been updated and the following procedures have been instituted; Staff will be reminded and retrained to point out to the Physician to complete the noted section on page 2 of the Physical form. Page 2 section of the Physical form is normally completed by the Physician at time of an annual examination. 06/20/2016 Implemented
6400.143(a)Individual #1 refuses hygiene skiils on a daily basis. He will refuse to shower, brush his teeth, wash his hands, and care for any other hygiene needs. Individual #1 did not have a plan to train the individual about the need for caring for his hygiene. If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. Our 6400.143( a) protocol has been updated and the following procedures have been instituted; ¿ Medical/ Dental/ Hygiene Refusal and Desensitization tool has been formulated. See attachment # 9. ¿ Staff will be trained on how to utilize the tool as they provide support to the individuals supported. Target Date 7/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.144REPEAT: Individual #1 had a vision exam completed on 9/18/14. His doctor recommended he follow up in one year on 9/21/15. The appointment was not completed until 10/2/15. He had a hearing exam completed on 3/11/15 and was to follow up in one year on 3/9/16. Individual #1 did not return to his hearing appointment until 3/18/16. Individual #1 had a counseling appointment on 10/6/14 and it was recommended that he return in 2 weeks. He did not return until 11/10/14. The agency did not know why any of these appointments were late. On 3/14/16 Individual #1's physician recommended that he use a finger splint for 3 days, ice the area for 20 minutes on and 1 hour off for two days, and take tylenol as needed for his finger sprain. A physician¿s order requires that the home's staff track the individual's usage of the splint, ice, and tylenol. There was no documentation to show that the recommendations were followed. 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. Program staff that assist with medical appointments will scan completed medical paperwork and email to their Health and Wellness administrator to include copying PA Healthcare staff. Staff will be asked to document follow up appointments on the home calendar. Health and Wellness administrator will manage appointment schedules and notify staff and individual to their upcoming follow up appointment. 06/20/2016 Implemented
6400.151(a)REPEAT: Staff #2 had a physical exam completed on 5/8/12 and not again until 10/21/14. 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. Employee Development Coordinator will enter and track physical completion dates. Staff with expired physical exam will be removed from schedule until completed. 06/20/2016 Implemented
6400.151(c)(2)REPEAT: Staff #2 had a Tuberculin skin test completed on 5/1/12 and not again until 10/1/14. 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. Employee Development Coordinator will enter and track tuberculin skin testing completion dates. Staff with expired tuberculin skin tests will be removed from schedule until completed. 06/20/2016 Implemented
6400.168(c)REPEAT: Staff #4 did not pass either initial practicum observer trainings dated 6/23/14 and 8/26/15 and is not qualified to train other staff persons in medication administration. Medications administration training of a staff person shall be conducted by an instructor who has completed the Department's Medications Administration Course for trainers and is certified by the Department to train staff. Our 6400.168(c) protocol has been updated and the following procedures have been instituted; ¿ Staff # 2 is no longer administering medications and is scheduled to re-take the Department¿s Medications Administration Course. ¿ Target Date 7/30/2016. ¿ Staff # 4 is scheduled to undertake practicum observer training class ¿ Target date 7/30/ 2016168 c ¿ Human Resources Department will be tracking the Practicum Observers certification records ¿ Person Responsible: Residential Director, Assistant Residential Director( Certified Medication Trainers) Human Resources Department. 06/20/2016 Implemented
6400.181(e)(1)The assessment completed on 4/4/16 for Individual #1 did not include individual preferences. The assessment must include the following information: Functional strengths, needs and preferences of the individual. Our 6400.181( e) (1) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly specify and indicate individuals supported Functional strengths, needs and preferences. See attachment # 6 under Functional strengths, needs and preferences. ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Target Date- 07/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.181(e)(3)(iii)The assessment completed on 4/4/16 for Individual #1 did not include their current level of performance in personal adjustment.The individual's current level of performance and progress in the following areas: Personal adjustment. Our 6400.181( e) (3)(iii) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly specify and indicate individuals supported current level of performance in personal adjustment. See attachment # 6. under Personal Adjustment ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Target Date- 07/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.181(e)(4)The assessment completed on 4/4/16 for Individual #1 did not include their need for supervision. Their assessment indicated that Individual #1 had zero hours of unsupervised time in the community. However Individual #1 was able to be unsupervised to walk within one fourth of a mile around his home. The assessment must include the following information: The individual's need for supervision. Our 6400.181(e) (4)) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly specify and indicate individuals supported need for supervision. See attachment # 6. Under Supervision. ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Target Date- 07/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.181(e)(5)The assessment completed on 4/4/16 for Individual #1 did not include their ability to self administer medications. The assessment must include the following information:  The individual's ability to self-administer medications.Our 6400.181(5) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly specify and indicate individuals supported ability to self- administer medications. See attachment # 6 under Ability to Self-Administer medications. ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Target Date- 07/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.181(e)(9)The assessment completed on 4/4/16 for Individual #1 did not include their functional and medical limitations. Individual #1 was diagnosed with Mood Disorder, Depression and Anxiety which created some functional concerns with his ability to be unsupervised. The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. Our 6400.181(9) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly specify and indicate individuals supported disability, functional and medical limitations. See attachment # 6 under Disability, Functional and medical limitations. ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Target Date- 07/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.181(e)(13)(ii)REPEAT: The assessment completed on 4/4/16 for Individual #1 did not include their progress in motor and 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. Our 6400.181(13) (ii) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly specify and indicate individuals supported current level in motor and communication and progress. See attachment # 6. Under, Motor communication current level and Progress in Motor communication. ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Target Date- 07/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.181(e)(13)(iii)REPEAT: The assessment completed on 4/4/16 for Individual #1 did not include their progress in activities of residential living. The 2016 and 2015 assessments were verbatim. 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. Our 6400.181 (13) (iii) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly specify and indicate individuals supported progress in the area of residential living. See attachment # 6. Under, Current activities of residential living and Progress in activities of daily living. ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Target Date- 07/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.181(e)(13)(iv)REPEAT: The assessment completed on 4/4/16 for Individual #1 did not include their progress in personal adjustment. The 2016 and 2015 assessments were verbatim. 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. Our 6400.181 (13) (iv) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly specify and indicate individuals supported personal adjustment. See attachment # 6 under Current personal adjustment; Progress in personal adjustment. ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Target Date- 07/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.181(e)(13)(v)REPEAT: The assessment completed on 4/4/16 for Individual #1 did not include their progress in socialization. The 2016 and 2015 assessments were verbatim. 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. Our 6400.181(13) (v) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly specify and indicate individuals supported progress in socialization. See attachment # 6 under Current Socialization and Progress in socialization. ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Target Date- 07/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.181(e)(13)(vi)REPEAT: The assessment completed on 4/4/16 for Individual #1 did not include their progress in recreation. The 2016 and 2015 assessments were verbatim. 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. Our 6400.181(13) (vi) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly specify and indicate individuals supported progress in the area of recreation. See attachment # 6 under Current Recreation and Progress in recreation. ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Target Date- 07/30/2016. ¿ Data collecting tool has been formulated and will be used to measure progress See attachment # 7. ¿ Staff will be trained on how to utilize the tool as they provide support to the individuals supported. Target Date 7/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.181(e)(13)(vii)REPEAT: The assessment completed on 4/4/16 for Individual #1 did not include their progress in financial independence. The 2016 and 2015 assessments were verbatim. 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. Our 6400.181 (13) (vii) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly specify and indicate individuals supported progress in financial independence. See attachment # 6 under Current Financial independence and Progress in financial independence. ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Target Date- 07/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.181(e)(13)(ix)REPEAT: The assessment completed on 4/4/16 for Individual #1 did not include their progress in community integration. The 2016 and 2015 assessments were verbatim. 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.Our 6400.181(13) (ix) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly specify and indicate individuals supported progress in community integration. See attachment # 6 under Current community integration and Progress in community integration. ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Target Date- 07/30/2016. ¿ Data collecting tool has been formulated and will be used to measure progress See attachment # 7. ¿ Staff will be trained on how to utilize the tool as they provide support to the individuals supported. Target Date 7/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.181(e)(14)The assessment completed on 4/4/16 for Individual #1 did not include their knowledge of water safety.The 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. Our 6400.181(14) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly specify and indicate individuals supported progress in financial independence. See attachment # 6 under Current knowledge of water safety and Progress in knowledge of water safety. ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Target Date- 07/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.181(f)REPEAT: There was no documentation for who the assessment, completed on 4/4/16 for Individual #1, was sent to or when. There was a letter indicating that the assessment was sent. However the letter included genergic departments to which the assessment was sent. This letter listed that Individual #1's assessment was sent to day program team members. Individual #1 has never attended a day program. (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). Our 6400.181(f) protocol has been updated and the following procedures have been instituted; ¿ Upon completion of an individual¿s Assessment, The Program Specialist will share the Assessment with the team at least 30 days prior to an ISP meeting. ¿ The specific names of the Team Members the Assessment is sent to and the date sent will be documented on the cover page of the Assessment. See attachment # 8. ¿ Target date of completion; 06/15/2016 moving forward. ¿ Person Responsible: Program Specialist. 06/23/2016 Implemented
6400.183(3)The Individual Support Plan (ISP) for Individual #1 did not include a method of evaluation used to determine progress towards his outcomes. His outcomes were independent living, transportation, working, social appropriateness, hygiene, and positive strategies. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome. Our 6400.183(3) protocol has been updated and the following procedures have been instituted; ¿ The methodology of collecting data and evaluating outcome progress has been formulated as it relates to each individual¿s specific outcomes. See attachment # 4. ¿ Staff will be trained on how to collect data while working directly with the individuals supported. Target Date- 7/30/2016. ¿ The Program Specialist will review the data related to an individual¿s outcome and complete monthly progress notes indicating progress, or lack of progress and recommendations. ¿ The data pertaining to outcome progress will be shared to the individual¿s Team members and the ISP updated by the Support Coordinator accordingly. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.183(4)Individual #1 was assessed to have 3 hours of unsupervised time at home. The Individual Support Plan (ISP) for Individual #1 did not include a protocol to determine a higher level of independence with supervision. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. Our 6400.183(4) protocol has been updated and the following procedures have been instituted; ¿ Protocol and schedule of any individual with unsupervised time has been formulated. See attachment # 5 ¿ Staff will be trained on how to utilize the protocol and schedule when working with the individuals supported. Target Date- 7/30/2016. ¿ The Program Specialist will review the protocol and schedule of unsupervised time and complete monthly progress notes indicating progress, or lack of progress and recommendations geared to achievement of a higher level of independence to the individual supported. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.185(b)Individual #1's Individual Support Plan (ISP) indicated that he was assessed to have 0 hours of unsupervised time in the community. Individual #1 reported that in Febuary 2016, he went to the hospital with one staff person and sat in the waiting room unsupervised while the staff was in the hospital room with his housemate. His ISP also indicated that he was unable to independently handle any amount of money. However on 8/8/15 Michael was given $153.65 to use for personal spending money. On 9/10/15 he was given $127.79.The ISP shall be implemented as written.Our 6400.185 (11) protocol has been updated and the following procedures have been instituted; ¿ The Program Specialist will be reviewing individuals ISP every 3 months or sooner in the event that there are any changes in an individual¿s status to ensure the information in the ISP is current and up to date. ¿ The Program Specialist will communicate any content discrepancies noted with the individual¿s Supports Coordinator to ensure the information in the ISP is current and up to date. See attachment # 1(a) and attachment # 1(b). ¿ In the event of any changes to an individual status, staff will be trained on the changes and the support and services needed to ensure an individual¿s plan is implemented as written. ¿ Target date of completion; 07/15/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.186(a)REPEAT: The program specialist was not completing the Individual Support Plan (ISP) reviews for Individual #1. They were completed by a direct support staff. The program specialist was not completing any ISP reviews for individuals in this region. There wasn't any ISP reviews for Individual #1 in his record that were completed prior to 7/18/15. 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. Our 6400.186( a) protocol has been updated and the following procedures have been instituted; ¿ Program Specialist will be re-trained on the Program Specialist responsibilities. Target date of completion 06/20/2016. See attachment # 2 ¿ The Program Specialist will be responsible of completing and reviewing all individuals ISP reviews following the dates on each individual¿s ISP start date and end date. See attachment # 1. ¿ Target date of completion; 06/20/2016. ¿ Person Responsible: Residential Director and Assistant Residential Director 06/20/2016 Implemented
6400.186(b)REPEAT: The program specialist didn't sign and date Individual #1's 7/18/15 Individual Support Plan (ISP) review. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. Our 6400.186(b) protocol has been updated and the following procedures have been instituted; ¿ Program Specialist will be re-trained on the Program Specialist responsibilities. Target date of completion 06/20/2016. See attachment # 2 ¿ The Program Specialist will be responsible of completing and reviewing all individuals ISP reviews following the dates on each individual¿s ISP start date and end date. See attachment # 1. ¿ The Program Specialist will then update the ISP Review checklist. See attachment #1 ¿ Target date of completion; 06/30/2016. ¿ Person Responsible: Assistant Residential Director and Program Specialist. 06/20/2016 Implemented
6400.186(c)(1)All Individual Support Plan (ISP) reivews for Individual #1 did not review their participation and progress towards any ISP outcome. Individual #1's outcomes included independent living, transportation, working, social appropriateness, hygiene, and positive strategies. 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. Our 6400.186 ( c )(1) protocol has been updated and the following procedures have been instituted; ¿ The methodology of collecting data and evaluating outcome progress has been formulated as it relates to each individual¿s specific outcomes. See attachment # 4. ¿ Staff will be trained on how to collect data while working directly with the individuals supported. Target Date- 7/30/2016. ¿ The Program Specialist will review the data related to an individual¿s outcome and complete monthly progress notes indicating progress, or lack of progress and recommendations ¿ The Program Specialist will utilize 3 monthly progress notes toward each outcome to complete ISP reviews. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.186(c)(2)REPEAT: All Individual Support Plan (ISP) reivews for Individual #1 did not review their dental plan, unsupervised time, and behavior support plan. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. Our 6400.186 ( c) (2) protocol has been updated and the following procedures have been instituted; ¿ The methodology of collecting data, evaluating and reviewing outcome progress has been formulated as it relates to each individual¿s specific outcomes and specified plan in the ISP. See attachment # 4. ¿ Staff will be trained on how to collect data while working directly with the individuals supported. Target Date- 7/30/2016. ¿ The Program Specialist will review the data related to an individual¿s outcome and complete monthly progress notes indicating progress, or lack of progress and recommendations ¿ The Program Specialist will utilize the data collected monthly to complete monthly progress notes and ISP reviews every 3 months. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.186(d)There was no documentation for who the Individual Support Plan (ISP) reviews, completed for Individual #1, were sent to. There was a letter indicating that the ISP reviews were sent. However the letter included genergic departments to which the reviews were sent. This letter listed that Individual #1's reviews were sent to day program team members. Individual #1 has never attended a day program.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. Our 6400.186(d) protocol has been updated and the following procedures have been instituted; ¿ Upon completion of an individual¿s ISP review and within 30 calendar days, the Program Specialist will send out ISP reviews to the SC and all the Plan Team Members. ¿ The specific names of the Team Members the ISP review is sent to will be documented on the cover page of the ISP review. See attachment # 3. ¿ Target date of completion; 06/15/2016 moving forward. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.213(11)Individual #1's 4/4/16 assessment indicated that poisonous materials were locked at his home. Individual is aware of poisonous materials and they do not need to be locked. The same assessment indicated that he did not have a job however he has a job. The assessment indicated that did not have any hours of unsupervised time in the community but that he could walk around the block of his home unsupervised. His Individual Support Plan (ISP) indicated that he was allotted 3 hours of unsupervised time in the community to work on taking public transportation to the mall. The assessment indicated that he had 3 hours of unsupervised time at home per day. However his ISP indicated that he had 3 hours of unsupervised time at home, and that he could do the 3 hours unsupervised multiple times per day at home. The ISP indicated that he was now prescribed Sertraline 200mg however that medication was discontinued in September 2015. His ISP indicated that he was on probation and shouldn't work on his transportation independence outcome. He hasn't been on probaion since September 2015. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. Our 6400.213(11) protocol has been updated and the following procedures have been instituted; ¿ The Program Specialist will be reviewing individuals ISP every 3 months in alignment with each individual¿s Plan start date and end date. Any content discrepancies noted will be shared with the individual¿s Supports Coordinator to ensure the information in the ISP is current and up to date. See attachment # 1. ¿ Target date of completion; 07/15/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.216(a)Individuals #1 and #2's daily logs and record information from 2012 until present was kept unlocked and accessible in the basement. An individual's records shall be kept locked when unattended. Our 6400.216(a) protocol has been updated and the following procedures have been instituted; ¿ Purchase request for locking storage cabinets has been placed ¿ All individuals¿ records will be stored in locked cabinets in their respective programs. ¿ Target date of completion; 06/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
SIN-00074480 Renewal 10/23/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.66There were 2 light bulbs not working in Individual #1's bathroom above the sink. Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Our 6400.66 protocol has been updated and the following procedures have been instituted; ¿ A Daily Overnight Quality Assurance Tool has been instituted (See attachment 4, item # 6). ¿ The Daily Overnight Quality Assurance Tool will be completed daily by the overnight /evening staff and reviewed monthly by the Program Specialist/Lead Staff to ensure all rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes are lighted to assure safety and to avoid accidents. Any problems noted will be communicated to the Program Specialist and corrected within 24hrs. 08/03/2015 Implemented
6400.77(b)The first aid kit was missing the tweezers. 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. Our 6400.77(b) protocol has been updated and the following procedures have been instituted; ¿ A Quality Assurance Tool has been instituted (See attachment 4, item # 5). ¿ The Daily Overnight Quality Assurance Tool will be completed daily by the overnight/evening staff and reviewed monthly by the Program Specialist/Lead Staff to ensure all required first aid kit contain all needed tools including tweezers, assortment of adhesive bandages, sterile gauze pads, thermometer, tape, scissors etc. Any problems noted will be communicated to the Program Specialist and corrected 24hrs. 08/03/2015 Implemented
6400.113(a)Individuals #1 & #2 had fire safety on 6/3/13 and none in 2014. This was not completed annually, 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. Our 6400.113(a) protocol has been updated and the following procedures have been instituted; ¿ An Annual Fire Safety Training has been updated. (See attachment 3). ¿ The Annual Fire Safety Training will be completed every January of the New Year. ¿ The completed Annual Fire Safety Training and Signature Sheet will then be filed in the individual¿s records book. 08/03/2015 Implemented
6400.168(c)Staff person #1 medication trainer certification expired December 2013 and had not been re-newed. Staff person #1 continued to train other staff with an expired certificate. Medications administration training of a staff person shall be conducted by an instructor who has completed the Department's Medications Administration Course for trainers and is certified by the Department to train staff. Our 6400.168(c) protocol has been updated and the following procedures have been instituted; ¿ A certified trainer has been assigned to train other staff members on the Medication Administration Course (See attachment 1.) ¿ An Annual Medication Trainer Tracking Sheet has been instituted to ensure Medication Trainers are always current in their training. (See attachment 2). ¿ The Annual Medication Trainer Tracking Sheet will be reviewed annually and signed by all Medication Trainers. ¿ The signed Annual Medication Trainer Tracking Sheet will then be filed with the Medications Trainers Annual Practicum Recertification package. ¿ Twelve months prior to expiration of the Medication Trainers certification, the medication trainer will proceed and sign up for the recertification class using the Department of Social Services/ Department of Public Welfare guidelines. 08/03/2015 Implemented
SIN-00058965 Renewal 11/12/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(9)The prostate exam was complete for Individual #1 on 6/22/11, but then not again until 1/9/13. This exceeds the regulatory annual requirement. (9) A prostate examination for men 40 years of age or older. PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 3/17/14 Our protocol has been updated and the following procedures will be instituted: Appointment list has been instituted to ensure return dates are maintained as appointments occur to include prostate examinations (See attachment 8). 03/31/2014 Implemented
6400.163(c)The following 3-month psych medication reviews for Individual #1 did not include all medications and dosages: 5/22/13; 6/19/13; 7/31/13; 9/4/13 and 11/6/13. (c) 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. PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 3/17/14 Our protocol has been updated and the following procedures will be instituted: ¿ A list of table of medications has been formulated and will accompany individuals to all appointments to include Psychiatric appointments (See attachment 9) 03/31/2014 Implemented
6400.181(a)The assessment for Individual #1 was completed late. It was done on 3/20/12, but then not again until 6/1/13.(a) 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. PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 3/17/14 Our protocol has been updated and the following procedures will be instituted: ¿ An Assessment completion list specific to each individual will be instituted and maintained with the individual records. (See attachment 8) ¿ The Program Specialist will update assessment annually 03/31/2014 Implemented
6400.213(6)The complete current assessment for Individual #1 was not located in his record.(6) Assessments as required under § 6400.181 (relating to assessment). PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 3/17/14 Our protocol has been updated and the following procedures will be instituted: ¿ Upon completion of an Assessment the Program Specialist will ensure that updated Assessment is filed in the individual record. ¿ Book and Record reviews will be maintained quarterly by the Program Specialist and a check list (See attachment 8) will be completed to ensure a current Assessment is maintained with the individuals records at all times. 03/31/2014 Implemented
SIN-00157428 Renewal 08/27/2019 Compliant - Finalized