Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00242070 Unannounced Monitoring 03/08/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The loveseat in the living room is in poor condition with rips in the fabric on the back, seat, and arm.Floors, walls, ceilings and other surfaces shall be in good repair. On Friday 03/29/2024 the loveseat in the living room was removed. (See attached picture, replacement chair). 05/10/2024 Implemented
6400.144At the time of the physical inspection of the home on 3/12/24, the following PRN medications were listed on the MAR but not available in the home: Loperamide, Robafen, and a heating pad. Individual #1 is prescribed Polyethylene glycol to take once a day as needed for constipation. The bowel protocol outlined in individual #1's ISP indicates that if they go without a bowel movement for 48hrs, the polyethylene glycol should be administered. Per staff documentation, Individual #1 did not have a bowel movement on 12/14/23, 12/15/23, 12/16/23, or 12/17/23. The corresponding MAR does not indicate the PRN dose of polyethylene glycol was administered. Individual #1 also did not have a bowel movement on 3/10, 3/11, or 3/12. No PRN was administered.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. To immediately address the areas of non-compliance cited the Loperamide, Robafen, and a heating pad was replaced (see pictures). 05/10/2024 Implemented
6400.18(f)The provider agency received the report of neglect on 3/8/24 and reported this in EIM on the same date. The incident report indicates that a wellness check would be performed by the SC and adult protective services however does not mention any action the provider was taking/would take to protect the health, safety, and wellbeing of the individual.The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident.To prevent recurrence of this citation, in the absence of a physical Administrator not being able to get to the home due to the distance and proximity of the home versus the home office location in (Hershey, PA 2 hours' drive) the following will occur for timely response to secure the health and safety and well-being: The Team Facilitator or Designee will conduct a virtual review of the home to examine the individual and other infractions noted in the notice of an incident. Upon completion of the review the Team Facilitator of Designee will take any necessary steps to ensure the safety of the individual. This includes but is not limited to immediately removing the alleged targets from the home and having additional staff report to the home to cover the shift as needed. 05/10/2024 Implemented
6400.32(c)Individual #1 requires the assistance of 2 female staff for showering. According to the hygiene tracking, individual #1 had a shower on 2/29/24 and not again until 3/5/24. Also in October 2022 the individual had a shower on 10/22/23 and not again until 10/26/23.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.Immediate course of action, retraining all DSPs and Lead Staff and or Designees on the Individualized Service Plan and Recognition, Response, and Reporting. A shower protocol will be developed for Individual #1 that details how bathing will be completed if there is only one female staff available. Upon development of the protocol the Agency nurse will train staff. 05/10/2024 Implemented
6400.32(d)Staff are routinely documenting that hygiene cannot be completed due to staffing. Individual #1 requires the physical assistance of 2 female staff to safely bathe/shower. Staff #3 documented that on 3/4/24 individual #1 could not bathe due to staff #3 being the only female there 7a-3p. The individual also is not able to shower/bathe when preferred. Per documentation provided, individual #1 typically is having to bathe/shower early in the am or at night due to needing the assistance of 2 female staff. For example on 1/7/24 individual #1 had to shower before the overnight staff left their shift as this was the only available time and on 1/20/24 individual #1 had to wait until 9pm to shower as this was the only time 2 females were on shift together. On 11/1/23 the individual requested a shower and was told this could not be done due to only 1 female being on shift. Staff documentation notes the following reasons individual #1 could not bathe/shower: 12/30 staff was by themselves all day 12/28 only 1 female 12/27 no help to give bath 12/25 staffing 2/3/24 no staffing 2/12 no assistance 2/13 no bath, need 2 people -- staff noted they did wash her with a washcloth.An individual shall be treated with dignity and respect.Immediate course of action, retraining all DSPs and Lead Staff and or Designees on the Individualized Service Plan and Recognition, Response, and Reporting. A shower protocol will be developed for Individual #1 that details how bathing will be completed if there is only one female staff available. Upon development of the protocol the Agency nurse will train staff. 05/10/2024 Implemented
6400.165(c)Individual #1 had an ER visit on 10/16/23. The discharge instructions included a prescription for prednisone 20mg to take 1 tab by mouth in the morning for 3 days. The corresponding MAR does not show that this medication was ever added to the MAR or that the medication was ever administered.A prescription medication shall be administered as prescribed.For corrective action and clarification purposes, individual #1's discharge summary for the ER visit on 10/16/23 included a prescription for prednisone 20 mg to take 1 tablet by mouth in the morning for 3 days was never ordered per the ordering Physician, hence why it was never administered or added to the MAR. Please see attachments from the portal (attachment) and (from email - Pharmacist) indicating a script was never received. Staff will review the discharge summary at time of discharge and make sure all recommendations are followed and completed. 05/10/2024 Implemented
SIN-00207437 Renewal 07/05/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(f)At the time of the physical site walkthrough conducted on 7/6/22, the smoke detectors were set off and the bed shakers in Individual #1 and Individual #2's bedrooms were not operable. If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. The bed shakers were immediately moved to a more suitable temporary location so as to not become disconnected. Staff at the home were informed by the Team Facilitator of the concern and directed for the staff to monitor the bed shakers until a permanent solution was found. 09/30/2022 Implemented
6400.112(h)The designated meeting place for this home is at the end of the driveway. On 9/19/21 and 6/16/22, the Individuals did not meet at the designated meeting place during the fire drills. They met in the back yard. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.All staff were informed by the Team Facilitator that moving forward we are to be only meeting at the primary designated meeting place, not the alternate locations, when conducting fire drills. 09/30/2022 Implemented
6400.216(a)At the time of the onsite walkthrough conducted on 7/6/22, Individual #1's bowel movement tracking chart was unlocked and out in the open in the bathroom. An individual's records shall be kept locked when unattended. Individual #1's bowel movement tracking chart was immediately removed from the unsecure location and locked in the home office. The Team Facilitator informed the staff of the non-compliance concern and stated that the tracking chart was to be kept locked in the office until a permanent solution could be determined. 09/30/2022 Implemented
SIN-00194013 Renewal 08/18/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The 08/09/21 self-assessment has a violation indicated for 76a, there is no POC associated with that violation in the record.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. 1. To address this area of non-compliance in, a training for all the admins Lead Staff, Health and Wellness Admins, Team Facilitators, Program Specialists and Associate Directors, who complete the self- assessment tool will be trained on this violation by the Residential Director during the Residential Team Meetings scheduled for 11/15/21, 11/16/21 and 11/19/21 this requirement is met by all. 12/31/2021 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# revised fire drill form # 5) 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 end of the driveway. 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# 5 revised fire drill form) 01/31/2022 Implemented
6400.113(a)There are no records maintained that Individuals #1 , #2 , and #3 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. 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. 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 & 11 revised client's rights packet fire safety and add annual power point) 01/31/2022 Implemented
6400.141(c)(9)Individual #1 6/15/21 Annual Physical states that the prostate exam result is "N/A', indicating that the exam was not completed as required for males over 40 years of age. There is no medical justification given for the decision, nor was a prostate specific antigen (PSA) test ordered.The physical examination shall include: A prostate examination for men 40 years of age or older. 1. An appointment with individual #1's PCP was made on 9/3/21for the PCP to complete the full evaluation including A prostate examination, at that time it was deemed not necessary to preform a prostate exam. . Please find attached #_20_ 01/31/2022 Implemented
6400.141(c)(14)Information pertinent to diagnosis and treatment in case of emergency was not reviewed at Individual #1 6/15/21 annual physical.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. 1. An appointment with individual #1's PCP was made on 10 for the PCP to complete the full evaluation including Medical information pertinent to diagnosis and treatment in case of an emergency. 01/31/2022 Implemented
6400.181(e)(7)Individual #1 Annual Assessment does not indicate if Individual #1 can move away from heat sources quickly. The document states that Individual #1 "will move away from anything that can burn the individual".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 9/20/2021 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 # 21 Individual #1's annual assessment updated 9/20/2021) 01/31/2022 Implemented
6400.181(e)(10)Individual #1 Annual Assessment states that the "lifetime medical history is attached", however, the attached medical document only includes health records in 2020 and 2021.The assessment must include the following information: A lifetime medical history. 1. The lifetime medical form is attached to the assessment on 9/20/2021 (See attachment 21 Individual #1's Annual Assessment for updated Lifetime medical 8/21/21 last updated) 01/31/2022 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 7/28/2020 annual inspection, Individual #1 was not informed of all 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 new Regulatory Compliance Guidelines (RCG), including the individual's right to lock their bedroom door (Attachment# lock assessment) 17 01/31/2022 Implemented
6400.165(g)Individual #1 is prescribed "Thioridazine 25mg tablet" for "mood disorder". There is no record of review by a physician every 3 months.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.1. To address the area of non-compliance cited above, the CI Lead Staff reached out to the prescribing physician of Thioridazine 25 mg tablet, which had been ordered after a sleep study was conducted in 1986. (attachment 21) An appointment to see this physician has been scheduled for 11/18/21 at 1:45 PM. 01/31/2022 Implemented
6400.166(a)(2)Individual #1 current Medication Administration Record (MAR) for August 2021 that is kept in the home does not include all of the prescriber's names, only the name of the Primary Care Physician. Individual #1 is prescribed medications from three different prescribers.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.1. To address the concerns observed and noted during the licensing exercise, all the staff working in the home will be retrained by Medication Administration Trainer, the name of prescribing physician(s) will appear in all MARs. 01/31/2022 Implemented
6400.181(f)Staff #2 sent the 2018 Annual Assessment to the ISP team on 01/10/21 to prepare for a meeting on 01/19/21 to create the current Annual Assessment for Individual #1. The current Annual Assessment was a signed by Staff #2 on 01/19/21, which makes 01/19/21 the date the Annual Assessment was created. The updated, current Annual Assessment was not sent to the ISP team 30 days prior to the 02/16/21 ISP meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.1. The Program Specialist addressed this area of non-compliance by revising the current annual assessment to meet the compliance as per the attached document ¬¬21_. 01/31/2022 Implemented
SIN-00176451 Renewal 09/09/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(c)The first aid kit did not have a first aid manual. A first aid manual shall be kept with the first aid kit.1. The manual in the First Aid kit was replaced on 9/11/2020. (Attachments #8, #9) 2. Direct Support Professionals (DSPs) will be trained to keep all contents of the first aid kit in one box. The training will be completed by the Team Facilitator or designee. 3. On a weekly basis, the House Manager/Lead staff or Cluster Administrators will complete the Weekly Quality Assurance checklist (PA-QA) to ensure first aid kit has all its contents. (PA-QA Attachment #3) 4. The monthly Quality Assurance checklist will be completed by the Team Facilitator or designee assigned to the cluster. (Attachment #4) 5. All House Manager/Lead Staff, Team Facilitators and Program Specialists will be re-trained on following the new guidelines/expectations to ensure compliance regarding First Aid Kit contents. This training will be completed by the Associate Residential Director. 6. This will be completed by 12/31/2020 12/31/2020 Implemented
SIN-00157429 Renewal 08/27/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.61(b)Individual #1's current assessment dated 03/12/19 states that Individual #1 needs raised buttons on the microwave, washer and dryer to be able to use them independently and the new stove needs dials marked for Individual #1 to see settings clearly. Upon site inspection, there were missing raised buttons on the microwave, no markings on the stove and no raised buttons on the washer or dryer.A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have adaptive equipment necessary for the individuals to move about and function at the home.1. The buttons were added on 9/11/2019 (attachment #6) 2. Our Weekly and Monthly PA /QA Audit forms have been revised to read raised button-appliance (visual adaptable equipment) . These forms will be completed by the Lead Staff, Team Facilitator and Program Coordinator/Specialist. 3. The Associate Director or designee will be reviewing the Monthly PA QA Audit on a Quarterly basis beginning March 2020. 4. The Residential Director will train everyone on the new forms before 12/31/19. 5. The newly revised forms will become effective in 1/15/20. 01/15/2020 Implemented
6400.64(a)Individual #1's bathtub is a jet tub. The jets have a black residue around the two jets which appears to be mildew and was able to be removed with a pen tip during the site inspection.Clean and sanitary conditions shall be maintained in the home. 1. The jets were changed on 9/11/2019 (attachment #5) 2. Our Weekly and Monthly PA /QA Audit forms have been revised to read Tubs/ sinks/shower heads/ free of mildews/molds residue. These forms will be completed by the Lead Staff, Team Facilitator and Program Coordinator/Specialist. 3. The Associate Director or designee will be reviewing the Monthly PA QA Audit on a Quarterly basis beginning March 2020. 4. The Residential Director will train everyone on the new forms before 12/31/19. 5. The newly revised forms will become effective in 1/15/20 01/15/2020 Implemented
6400.141(c)(11)Individual #1's 02/21/19 physical exam did not include health maintenance needs. Space left blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.1. Individual went to an annual physical, to ensure compliance of all areas that were not included on the previous annual physical exam. The doctor was able to fill in the all the information required and attached on the Physical examination form. 2. All Annual Physical records in the agency will be reviewed by Program Coordinator/Specialist, to ensure that if such an issue is found, corrections are done before 12/31/19 3. Each Annual Physical will be reviewed by the Healthcare Team RN/LPN to make sure the physical form is accurate and fully completed before being filed. 4. The RN/LPNs will use a checklist to ensure that the regulatory requirements for an annual physical form are met. This checklist will be created by 12/31/19 by the Director of Healthcare and Clinical Services. The Director of Healthcare and Clinical Services will train all the Nurses and how to complete the form by 12/31/19. 5. The Health and Wellness Admin/designee will complete a quarterly report for all the medical appointments done within that quarter and will also review the all the documents to ensure compliance ¿ including that all documents are completed. This quarterly form will be developed by the Director of Healthcare and Clinical Services by 12/31/19. Director of Healthcare and Clinical Services train Admins by 12/31/19. 6. By January 15, 2020; Community Interactions will start implementing the new tracking system. 01/15/2020 Implemented
6400.181(a)Individual #1's current assessment was signed by the Program Specialist on 03/12/19. Individual #1's previous assessment was signed by the Program Specialist on 01/03/18. 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. 1. 90 days prior to ISP meeting the Program Coordinator/Specialist will coordinate with the Support Coordinator on the date, time, and location of the ISP meeting. 2. 60 days prior to the ISP meeting the CI team will start preparing the assessments and sending invitations for the ISP meeting. 3. 45 days prior to the ISP meeting the assessment will be sent out by the Program Coordinator/ Specialist to all team members. 4. A checklist will be developed by the Residential Director on how to track the dates and the process; before 12/31/19 5. The Residential Director will train all the Admins before 12/31/19 12/31/2019 Implemented
6400.181(e)(4)Individual #1's 03/12/19 assessment is not clear as to the level of supervision needed within the home and community. The assessment states "...Individual #1 can be left alone outside of his home for 4 hours. Individual #1 prefers assistance with traffic safety. Individual #1 can be left alone for 4 hours unsupervised. Individual #1 can be left unsupervised for 1.5 hours at a time. Staff will check in with Individual #1 via cell phone or VP. The time will restart after the check in···" The assessment must include the following information: The individual's need for supervision. 1. A revision on the assessment for the individual was done on by the Program Specialist to reflect that he can be alone for up to 4 hours both at home and in the community and the staff would check him using the phone or the VSP. 2. All staff who work with the consumer were on trained on the changes made in the assessment by the Program coordinator ¿on supervision while the individual is in both at home and in the community. The training was completed on 9/10/19 3. Moving forward the all the ISPs in the agency will have the supervision section reviewed to ensure that there are no discrepancies by the Program Coordinator/Specialist. 4. If a discrepancy is detected, corrections on both the ISP and the Assessment will be the Program Coordinator/Specialist and then all staff trained all staff by 12/31/19 5. The Residential Director will develop a Quarterly ISP check list by 12/31/19 that ensures supervision is reviewed on a continuous basis and that both the ISP and the assessments are consistent. 6. All Admins will be trained on the new checklist before 12/31/19 by the Residential Director or Designee. 12/31/2019 Implemented
6400.181(f)Individual #1's current assessment was signed by the program specialist on 03/12/19. The ISP meeting was held on 03/12/19. Individual #1's signed assessment was not sent to team members 30 days prior to the ISP meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.1. 90 days prior to ISP meeting the Program Coordinator/Specialist will coordinate with the Support Coordinator on the date, time, and location of the ISP meeting. 2. 60 days prior to the ISP meeting the CI team will start preparing the assessments and sending invitations for the ISP meeting. 3. 45 days prior to the ISP meeting the assessment will be sent out by the Program Coordinator/ Specialist to all team members. 4. A checklist will be developed by the Residential Director on how to track the dates and the process; before 12/31/19 5. The Residential Director will train all the Admins before 12/31/19 12/31/2019 Implemented
SIN-00135381 Renewal 08/01/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(h)The fire drill records did not indicated if individuals evacuated to a designated meeting place outside the building or within the fire safe area during each fire drill.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 Coordinators will be trained on the approved forms. (attachments 2&3) 09/11/2018 Implemented
SIN-00112363 Renewal 05/16/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(f)Staff #1's 10/15/16 fire safety training was completed late. The previous fire safety training was completed on 9/11/15.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. 05/07/2017 Implemented
6400.46(i)REPEATED VIOLATION- 5/16/16. Staff #1's 10/18/16 CPR/first aid training was completed late. The previous training was completed on 9/9/15 with a one year expiration.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. All applicable staff will complete CPR/First Aid training by a certified trainer within six months after the day of initial employment and annually thereafter. 05/07/2017 Implemented
6400.112(e)An asleep drill was held on 3/29/16 and not again until 10/15/16.A fire drill shall be held during sleeping hours at least every 6 months. Our 6400.112 (e) protocol has been updated and the following procedures have been instituted; ¿ All staff will be re- trained on responsibilities of completing monthly fire drills and the importance of ensuring forms are filled out at the completion of the drill. All completed monthly fire drill forms will be turned into the program coordinator and/or program specialist for review. ¿ Target date 6/30/2017. ¿ Person Responsible: Program Coordinator and/or Program Specialist. 06/30/2017 Implemented
6400.141(c)(14)REPEATED VIOLATION- 5/16/16. Individual #1's 8/15/16 physical exam did not include information pertinent to diagnosis and treatment in case of an emergency. The section was not completed by the physician.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The Healthcare Team will monitor our tracking system more closely to ensure that all physical examination shall include medical information pertinent to diagnosis and treatment in case of an emergency. 05/05/2017 Implemented
6400.142(d)Individual #1's 4/26/17 dental exam did not include checking of the gums. The dental examination shall include teeth cleaning or checking gums and dentures. Plan of Correction: Our 6400.142 (d) protocols has been updated and the following procedures have been instituted: ¿ Challenge Violation: Individual #1 dental exam noted that a comprehension was performed on 4/26/17. ¿ See attachment #2 04/26/2017 Implemented
6400.144REPEATED VIOLATION- 5/16/16. On 1/3/17, Individual #1 was not administered 30mg of Duloxetine. 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. All staff working in Elm Drive will be re-trained in Medication Administration. 05/05/2017 Implemented
6400.164(b)The April 2017 medication log did not include intiails of the staff person administering QC Saline Nasal Spray between 4/1/17 and 4/4/17. The 8pm administration of Saline Nasal Spray was not initialed on 4/3/17. The 8am administration of Gabapentin, Duloxetine, Calcium, Omeprazole, and Senexon S on 4/30/17 was not intialed by the staff member administering the medication. The February 2017 medication log did not inclue the intiials of the staff person administering Saline Nasal Spray between 2/25/17 and 2/28/17. The 8am, 5pm, and 9pm dose of QC Antacid was not initialed by the staff person administering the medications between 2/22/17 and 2/28/17. The 2/27/17 noon dose of Gabapentin was not initialed by the staff person administering the medication. 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; ¿ Staff will be retrained on how to properly document medication administration of the medication records. ¿ Target Date- 06/30/2017. ¿ Person Responsible: CI Medication Administration Trainer 06/30/2017 Implemented
6400.181(e)(3)(iv)Individual #1's 8/17/16 assessment did not include personal needs with or without assistance.The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others. Our 6400.181 (e) (3) (iv) 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 needs with or without assistance from others.. 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. ¿ Target Date- 06/30/2017. ¿ Person Responsible: Program Specialist. 06/30/2017 Implemented
6400.181(e)(6)Individual #1's 8/17/16 assessment does not include her ability to safely use or avoid poisonous materials.The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. Our 6400.181 (6) 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 Safely Use Poisonous Materials. See attachment # 3. under Ability to Safely Use Poisonous Materials ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Target Date- 06/30/2017. ¿ Person Responsible: Program Specialist. 06/30/2017 Implemented
6400.181(e)(7)Individual #1's 8/17/16 assessment did not include his/her knowledge of 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; ¿ Assessment documentation has been updated to clearly specify and indicate individuals supported current level of the danger of heat source and ability to sense and move away quickly from heat sources which exceed 120 degrees and are not insulated. See attachment # 3. under Heat Source ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Target Date- 06/30/2017. ¿ Person Responsible: Program Specialist. 06/30/2017 Implemented
6400.181(e)(8)Individual #1's 8/17/16 assessment did not include her ability to evacuate in a fire.The assessment must include the following information: The individual's ability to evacuate in the event of a fire. Our 6400.181(8) 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 the individual ability to evacuate in the event of a fire. 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. ¿ Target Date- 06/30/2017. ¿ Person Responsible: Program Specialist. 06/30/2017 Implemented
6400.181(e)(13)(i)REPEATED VIOLATION- 5/16/16. Individual #1's 8/17/16 assessment did not include progress or regression over the past year in health.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. Our 6400.181(13) (i) protocol has been updated and the following procedures have been instituted; ¿ Assessment documentation has been updated to clearly specify and indicate individuals progress in Health over the last 365 calendar days.. See attachment # 3. under Health ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Target Date- 06/30/2017. ¿ Person Responsible: Program Specialist. 06/30/2017 Implemented
6400.181(e)(13)(ii)REPEATED VIOLATION- 5/16/16. Individual #1's 8/17/16 assessment did not include progress or regression over the past year 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 of performance in Motor and Communication Skills. See attachment # 3. Motor and Communication Skills ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Target Date- 06/30/2017. ¿ Person Responsible: Program Specialist. 06/30/2017 Implemented
6400.181(e)(13)(iii)REPEATED VIOLATION- 5/16/16. Individual #1's 8/17/16 assessment did not include progress or regression over the past year in residential living. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. 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 current level of Activities of Residential Living. See attachment # 3. Under Activities of Residential 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- 06/30/2017. ¿ Person Responsible: Program Specialist. 06/30/2017 Implemented
6400.181(e)(13)(iv)REPEATED VIOLATION- 5/16/16. Individual #1's 8/17/16 assessment did not include progress or regression over the past year in personal adjustment.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. 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 current level of performance in personal adjustment. See attachment # 3. 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- 06/30/2017. ¿ Person Responsible: Program Specialist. 06/30/2017 Implemented
6400.181(e)(13)(v)REPEATED VIOLATION- 5/16/16. Individual #1's 8/17/16 assessment did not include progress or regression over the past year in socialization.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. 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 current level of performance in Socialization. See attachment # 3. under 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- 06/30/2017. ¿ Person Responsible: Program Specialist. 06/30/2017 Implemented
6400.181(e)(13)(vi)REPEATED VIOLATION- 5/16/16. Individual #1's 8/17/16 assessment did not include progress or regression over the past year in recreation.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. 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 current level of performance in Recreation. See attachment # 3. under 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- 06/30/2017. ¿ Person Responsible: Program Specialist. 06/30/2017 Implemented
6400.181(e)(13)(vii)REPEATED VIOLATION- 5/16/16. Individual #1's 8/17/16 assessment did not include progress or regression over the past year in financial independence.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. 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 current level of performance in Financial Independence. See attachment # 3. under 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- 06/30/2017. ¿ Person Responsible: Program Specialist. 06/30/2017 Implemented
6400.181(e)(13)(viii)REPEATED VIOLATION- 5/16/16. Individual #1's 8/17/16 assessment did not include progress or regression over the past year in managing personal property.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. Our 6400.181(13) (viii) 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 Managing Personal Property. See attachment # 3. under Managing Personal Property ¿ The Program Specialist will update the Assessment yearly or in the event of any changes in the status of the individual supported. ¿ Target Date- 06/30/2017. ¿ Person Responsible: Program Specialist. 06/30/2017 Implemented
6400.181(e)(13)(ix)REPEATED VIOLATION- 5/16/16. Individual #1's 8/17/16 assessment did not include progress or regression over the past year in community integration.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.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 current level of performance in Community Integration. See attachment # 3. under 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- 06/30/2017. ¿ Person Responsible: Program Specialist. 06/30/2017 Implemented
6400.186(c)(1)REPEATED VIOLATION- 5/16/16. Individual #1's 7/18/16 Indiviudal Support Plan review did not include progress towards the ISP outcome of budgeting.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; ¿ Individual Monthly report form has been updated to reflect information that is required to document in the report. See attachment #8 ¿ Team Lead (s) will be retrained on how to complete monthly reports. ¿ Target Date- 06/30/2017. ¿ Person Responsible: Program Specialist and/Program Coordinator 06/30/2017 Implemented
6400.186(c)(2)REPEATED VIOLATION- 5/16/16. Individual #1's 10/18/16 Indiviudal Support Plan review did not include a review of his/her behavior plan or an update on the progress made. 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(d) protocol has been updated and the following procedures have been instituted; Violation Challenge Individual #1 ISP review 10/18/16 did note the behavioral plan along with the progress. The information is stated under personal adjustment. Please attachment #9 06/30/2017 Implemented
SIN-00094879 Renewal 05/16/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(1)The program specialist did not complete Individual #1's 1/20/16 assessment. It was completed by a direct support staff. 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
6400.44(b)(10)Staff #2 did not review, sign, or date Individual #1's monthly documentation for April 2016.The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of an individual'ss participation and progress toward outcomes.Our 6400.44 (b)(10) 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 reviewing, signing and dating monthly progress notes related to individuals supported progress on outcomes. ¿ Target date of completion; 06/20/2016. ¿ Person Responsible: Residential Director and Assistant Residential Director 06/20/2016 Implemented
6400.44(b)(18)Individual #1 wore a nebulizer every night and was prescribed daily nebulizer treatments. All staff working at the home never received training on the nebulizer apparatus nor how to administer the nebulizer treatments. The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. Our 6400.44 (b)(18) 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 of the training of staff in the content of health and safety needs of the individuals supported. ¿ Target date of completion; 06/20/2016. ¿ Person Responsible: Residential Director and Assistant Residential Director 06/20/2016 Implemented
6400.61(b)Individual #1's bed shaker was not positioned properly under his mattress. The bed shaker was on the floor underneath his bed. A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have adaptive equipment necessary for the individuals to move about and function at the home.Our 6400.61 (b) protocol has been updated and the following procedures have been instituted; ¿ Our Quality Assurance tool has been updated to include daily checks of bed vibrators where applicable to ensure the bed vibrators are securely fasten to the mattress/bed. See attachment # 10. Item # 4. ¿ All staff will be trained on how to utilize the Quality Assurance tool. ¿ Target date 7/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.67(a)All four corners of the kitchen island countertop had pieces of the counter 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; ¿ Our Quality Assurance tool has been updated to include daily checks of walls, ceilings and other surfaces and their condition. See attachment # 10. Item # 1 (b). ¿ All staff will be trained on how to utilize the Quality Assurance tool. ¿ Target date 7/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.72(b)The bottom metal frame of the front screen door was hanging off the door. Two, two-inch rips were noticed in the bottom corners of the front screen door. Screens, windows and doors shall be in good repair. Our 6400.72 (b) protocol has been updated and the following procedures have been instituted; ¿ Our Quality Assurance tool has been updated to include daily checks of screens, windows and doors condition. See attachment # 10. Item # 1 (a). ¿ All staff will be trained on how to utilize the Quality Assurance tool. ¿ Target date 7/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.141(c)(6)Individual #1 had a Tuberculin skin test completed on 2/27/13 and not again until 3/27/15. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. 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
6400.141(c)(9)REPEAT: Individual #1's physical examination completed on 9/24/15 did not contain a current prostate exam. The last exam completed was on 9/16/14. The physical examination shall include: A prostate examination for men 40 years of age or older. 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
6400.141(c)(11)Individual #1's 9/24/15 physical examination did not contain an assessment of health maintenance needs, medication regimen and the need for blood work at recommended intervals. The field was left blank on the physical form. The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. 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
6400.141(c)(14)Individual #1's physical examination completed on 9/24/15 did not contain 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. 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
6400.144REPEAT: On 1/25/16, Individual #1 was prescribed Doxycyline 100mg and it was recommended they eat yogurt daily while on the medication. A physician's order requires that the home's staff track the individual's yogurt intake while on the Doxycycline. There was no tracking form located in his record.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. Our 6400.144 protocol has been updated and the following procedures have been instituted; ¿ Our Quality Assurance tool has been updated to include Physician special instructions related to medication administration. See attachment # 10. Item #21 ¿ All staff will be trained on how to utilize the Quality Assurance tool. ¿ Target date 7/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.162(a)The medication label for Ipratropium prescribed to Individual #1 stated to administer one vial via nebulizer every 4-6 hours as needed. There was no specific time for administration listed on the medication label. The medication label for Mupirocin 2% ointment prescribed to Individual #1 stated to administer to infected area twice daily. According to the provider this medication is now an as needed medication and the medication label has not been updated. The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. Our 6400.162(a) protocol has been updated and the following procedures have been instituted; ¿ Our Quality Assurance tool has been updated to include daily checks of medication labels to the medication log. See attachment # 10. Item #20 ¿ All staff will be trained on how to utilize the Quality Assurance tool. ¿ Target date 7/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.164(a)REPEAT: The medication label for Pepto Bismol prescribed to Individual #1 stated to administer 2 tbsp every hour as needed but no more than 8 doses in 24 hours. The medication log for Pepto Bismol indicated that it was to be administered every 30 minutes to 1 hour as needed but no more than 8 doses in 24 hours. The medication log did not match the medication label for 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 has been updated to include daily checks of medication labels to the medication log. See attachment # 10. Item # 22. ¿ All staff will be trained on how to utilize the Quality Assurance tool. ¿ Target date 7/30/2016. ¿ Person Responsible: Assistant Residential Director and Program Specialist. 06/20/2016 Implemented
6400.168(a)REPEAT: Staff #4 completed the Department-approved medication administration course on 11/1/13 but not again until 11/30/15. Staff #5 completed the Department-approved medication administration course on 1/6/14 and not again until 1/28/16. Both staff were administering medications to individuals during the time they were not certified to administer prescription medications. In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. Our 6400.168(a) protocol has been updated and the following procedures have been instituted; ¿ An Annual Medication Training Calendar that has time frames for when Medications Administration Records ( MAR) needs to be reviewed and Medication Practicums completed to recertify all staff in medication administration based on specific initial medication pass dates has been instituted. (See attachment 16). ¿ All Medication trainers and Practicum observers will be trained on how to utilize the Annual Medication training calendar. Target Date 6/30/2016. ¿ The Annual Medication Training Calendar will be reviewed every 3 months by a designated Medication Trainer or Certified Medication Administration Practicum Observer during the quarterly MAR review to ensure that all staff who administer medication are current in their Medication Administration recertification. ¿ Human Resources Department will be tracking all staff certification records. ¿ Person Responsible: Medication trainers, Practicum observers and Human Resources Department. 06/20/2016 Implemented
6400.181(d)REPEAT: The assessment for Individual #1 dated 1/20/16 was not signed and dated by the program specialsit. The program specialist shall sign and date the assessment. Our 6400.181(d) 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. ¿ Upon completion of the Assessment, The Program Specialist will date the Assessment and send the Assessment out to the Team Members. ¿ Target date of completion; 06/20/2016. ¿ Person Responsible: Residential Director and Assistant Residential Director 06/20/2016 Implemented
6400.181(e)(1)The assessment for Individual #1 dated 1/20/16 did not indicated any preferences of the individual. 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 for Individual #1 dated 1/20/16 did not contain 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)(13)(i)The assessment for Individual #1 dated 1/20/16 did not contain their progress in health. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. Our 6400.181( 13)(i) 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 health.See attachment # 6. Current Health and Progress in health. ¿ 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 for Individual #1 dated 1/20/16 did not contain 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 for Individual #1 dated 1/20/16 did not contain their progress in activities of residential living. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. 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 current level in activities of residential living. See attachment # 6. Under, Current level in Activities of residential living and Progress in Activities of residential 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 for Individual #1 dated 1/20/16 did not contain their progress in personal adjustment. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. 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 for Individual #1 dated 1/20/16 did not contain their progress in socialization. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. 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 for Individual #1 dated 1/20/16 did not contain their progress in recreation. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. 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 for Individual #1 dated 1/20/16 did not contain their progress in financial independence. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. 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)(viii)REPEAT: The assessment for Individual #1 dated 1/20/16 did not contain their progress in managing personal property. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. Our 6400.181(13) (viii) 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 managing personal property. See attachment # 6 under Current managing of personal property and Progress in managing of personal property. ¿ 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 for Individual #1 dated 1/20/16 did not contain their progress in community-integration. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration.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. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.183(4)Individual #1's current assessment completed on 1/20/16 indicated that they were able to be without direct supervision for 2 hours at home and 4 hours in the community. Individual #1's Individual Support Plan (ISP) did not contain a protocol and schedule outlining specific periods of time for the individual to be without direct supervision and the method of evaluation used to determine progress. 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
6400.186(a)REPEAT: The program specialist did not complete any Individual Support Plan (ISP) reviews for Individual #1. They were completed by a direct support staff. 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(c)(1)Individual #1's Individual Support Plan (ISP) reviews did not review their participation and progress during the prior 3 months towards their ISP outcome "exploring mediums."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: Assistant Residential Director and Program Specialist. 06/20/2016 Implemented
6400.186(c)(2)REPEAT: Individual #1's Individual Support Plan (ISP) reviews did not review their nebulizer procedure or their utilized hours of unsupervised time at home and in the community. 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)The Individual Support Plan (ISP) reviews for Individual #1 did not indicate the specific team member they were sent to after the review. 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
6400.186(e)REPEAT: The option to decline Individual #1's Individual Support Plan (ISP) reviews was not offered to any of his team members. 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; ¿ Option to Decline form has been updated. See attachment # 13. ¿ The option to Decline form will be offered to all Team members offering them the option to decline ISP reviews. ¿ Target date of completion; 06/20/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.213(11)The assessment completed on 1/20/16 for Individual #1 indicated that they were safe to utilize 4 hours of unsupervised time in the community and 2 hours at home. Individual #1's Individual Support Plan (ISP) indicated that they were independent with supervision for short periods of time up to 2 hours at home and the community. Individual #1's ISP in the record indicated that they were prescribed Carbamazepine for anxiety. However, the ISP also indicated that Carbamazepine was prescribed to control seizures/nerve pain. The social/emotional section of the ISP indicated that Individual #1 did not have any social or emotional issues at this time. However they are prescribed psychotropic medications for current psychiatric diagnosis. 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
SIN-00074481 Renewal 10/23/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(a)Staff person #1 had medication training on 9/18/13 and not again until 9/23/14. In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. Our 6400 168 (a) protocol has been updated and the following procedures have been instituted; ¿ An Annual Medication Training Calendar that has time frames for when Medications Administration Records (MAR) needs to be reviewed and Medication Practicums completed to recertify all staff in medication administration based on specific initial medication pass dates has been instituted. (See attachment 1-hard copy to follow). ¿ All Medication trainers and Practicum observers will be trained on how to utilize the Annual Medication training calendar. ¿ The Annual Medication Training Calendar will be reviewed every 3 months by a designated Medication Trainer or Certified Medication Administration Practicum Observer during the quarterly MAR review to ensure that all staff who administers medication are current in their Medication Administration recertification. 05/30/2015 Implemented
6400.168(c)Medication administration trainer -staff person #2 certification expired 12/13 and continued to train staff. 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; ¿ An Annual Medication Trainer Tracking Sheet has been instituted. (See attachment 1-hard copy to follow). ¿ All Medication trainers will be trained on how to utilize the Annual Medication Trainer Tracking Sheet. ¿ 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. 05/30/2015 Implemented
SIN-00058966 Renewal 11/12/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)There was not a ledger completed for $10 that staff was holding for Individual #1 in order to pay for her medications. (d) The home shall keep an up-to-date financial and property record for each individual that includes the following: (1) Personal possessions and funds received by or deposited with the home. Partially Implemented, Adequate Progress. JW 3/17/14 Our 6400 protocol has been updated and the following procedures will be instituted; ¿ A running up to-date financial report has been instituted. (See attachment 1). After each purchase and as soon as staff returns from an outing the purchase details will be recorded on to the financial report. ¿ The financial report will also be completed on the Bank Account side to include funds received by or deposited with the home. ¿ Disbursements made to or for the individual will be documented in both the personal account and Bank account. ¿ At the end of each month an audit will be completed by the Program Specialist via the completion of the audit form. (See Attachment 2). 03/31/2014 Implemented
6400.161(e)Fluconide USP 0.05%, prescribed to Individual #1, was to be discarded on 10/16/13, but it still remained in the home.(e) Discontinued prescription medications shall be disposed of in a safe manner. Partially Implemented, Adequate Progress. JW 3/17/14 Our 6400.161(e) protocol has been updated and the following procedures will be instituted; ¿ As soon as a medication is discontinued and upon return to the program. Staff will document the change on the medication as per the physician¿s order. Staff will then remove the discontinued medication from the medication box. ¿ Staff will then complete a discontinuation form (See Attachment 3) and take the discontinued medication to the pharmacy for disposal. 03/31/2014 Implemented
6400.165Calcium + D was prescribed to Individual #1 but was not given from March 7th to April 23rd. According to staff (Todd), the physician never sent the script to the pharmacy. According to documentation, follow-up on attempting to obtain the Supplement was not done until April 22nd. Also, there was no documentation on the medication log including this medication error.Documentation of medication errors and follow-up action taken shall be kept. Partially Implemented, Adequate Progress. JW 3/17/14 Our 6400.161(e) protocol has been updated and the following procedures will be instituted; ¿ As soon as a medication is prescribed by a physician staff will take the prescription to the pharmacy and have it filled. ¿ Upon returning to the program, staff will add the new medication onto the MAR with the start date and all the medication particulars to include the right medication, dosage, time and route. ¿ In the event that the medication is not administered, staff will complete the medication error or omission and complete a medication error form (See Attachment 4(1and 2). 03/21/2014 Implemented
6400.181(f)The annual assessment for Individual #1 was not sent to Hope Enterprises who are part of her plan team. (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). PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 3/17/14 Our 6400.161(e) protocol has been updated and the following procedures will be instituted; Our Assessment preparation checklist has been updated to include the following step by step guidelines. . ¿ The Program Specialist will initiate and send out to the entire team, including the Supports Coordinator, an assessment 90 days prior to the end date of an existing plan. ¿ When the individual and their Team members decide on an ISP date, if there is any need for any updates in the assessment the Program Specialist will provide the updated assessment to the SC and all team members. This will be done at least 30 days prior to the ISP meeting to enable the development of the ISP, the annual update and revision of the ISP. 03/31/2014 Implemented
6400.183(5)Individual #1 is on medication for depression and there is no Social/Emotional plan in place to help support her. (5) A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 3/17/14 Our 6400.161(e) protocol has been updated and the following procedures will be instituted; ¿ A Social/Emotional plan was formulated and the plan put in place for medication prescribed to treat symptoms of a diagnosed psychiatric illness. (See Attachment 5). ¿ The plan will be reviewed during Psychiatric visits to include information regarding decrease or increase of challenging behaviors to enable the psychiatrist make an accurate prescription of medications if needed. 03/31/2014 Implemented
6400.186(c)(2)The ISP reviews for Individual #1, dated 7/19/13 and 10/19/13, do not review the current outcomes: Healthier Living and Crafts.(2) A review of each section of the ISP specific to the residential home licensed under this chapter. PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 3/17/14 Our protocol has been updated and the following procedures will be instituted: ¿ All current outcomes specific to the ISP will be updated and reviewed every 90 days. ¿ Progress will be monitored via completion of daily notes, monthly progress notes and quarterly review by the Program Specialist. ¿ The Program Specialist will then utilize the 3 monthly progress notes to complete ISP reviews and indicate progress or need to review the current outcomes. 03/31/2014 Implemented
6400.186(d)ISP reviews for Individual #1 are not being sent to Hope Enterprises who are part of her plan team.(d) 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. PARTIALLY IMPLEMENTED, ADEQUATE PROGRESS. JW 3/17/14 Our 6400.186(d) protocol has been updated and the following procedures will be instituted: ¿ After 30 calendar days of the ISP review meeting the Program Specialist shall provide the entire team with ISP Review documentation and retain record of date sent (See Attachment 6). ¿ The Program Specialist shall notify the plan team members of the option to decline the ISP Review documentation and record will be kept of any such decline. 03/31/2014 Implemented
SIN-00225471 Renewal 06/13/2023 Compliant - Finalized