Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00258393 Renewal 01/09/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.162(b)(1)A prescription medication that is not self-administered shall be administered by a licensed HCP or an unlicensed person trained in medication administration. 12/1 medications were omitted with a documented reason of "staff at site was not certified".A prescription medication that is not self-administered shall be administered by one of the following: A licensed physician, licensed dentist, licensed physician's assistant, registered nurse, certified registered nurse practitioner, licensed practical nurse, licensed paramedic or other health care professional who is licensed, certified or registered by the Department of State to administer medications.All employees medication administration training records were reviewed to identify all staff who did not meet the annual practicum requirements as well as initial training documentation including the 4 medication observations for initial certification. Employees who were found to be out of compliance with either initial or annual requirements will be retrained in the full medication administration training course by a certified medication administration trainer. Employee who committed the error was retrained in medication administration on 2/7/2025. Documents included with the POC. 02/07/2025 Implemented
6400.165(b)a prescription medication shall be administered as prescribed. 12/15 medication benzonatate (Tessalon perles) administered for fever- medication prescribed for as needed for cough.A prescription order shall be kept current.The employee responsible for the error is no longer employed with PAHrtners Deaf Services as of January 30th, 2025. 02/25/2025 Implemented
6400.167(a)(1)failure to administer medication 12/3, 12/17, 12/23, 12/27 omitted for community. 12/24 omitted for therapeutic leave. Christmas Eve, possible home visit. Appropriate documentation is needed indicating if the medication was administered in the community. The documentation reflects that it was not administered.Medication errors include the following: Failure to administer a medication.The employees who made the documentation errors were retrained in the ODP Medication Administration certification course. The medications were administered however the MAR was not documented with therapeutic leave indicating that the individual took the mediations with her on therapeutic leave. Medication Administration retraining occurred for all staff on1/29/25, 2/4/25, 2/12/25, 2/25/25. Training documentation is included with this plan of correction. 02/25/2025 Implemented
SIN-00256129 Unannounced Monitoring 11/18/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(f)The bed shaker in Individual #2's bedroom was not functional when the fire alarm was sounded in the home. 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 shaker works with the smoke detector. There are 2 systems in the home. One is integrated with the lights and the other with the bed shaker. The light and alarm can be activated through the panel. The system for the bed shaker is activated through the smoke detector. The system is being upgraded 12/31/2024 Implemented
6400.207(4)(I)Individual #2 is prescribed Hydroxyz Pam Cap 50mg (Generic for Vistaril) to be taken 1 capsule by mouth, once daily as needed (PRN) for severe anxiety. This medication is being prescribed for psychiatric use to treat anxiety on a PRN basis and staff were not able to provide evidence that there are written instructions and protocol in place for allowable administration of this specific PRN medication, as outlined in the ODP Regulatory Compliance Guide, so it is therefore considered a chemical restraint.A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition.The agency¿s policy on the use of PRN psychotropic medications is being reviewed by the Compliance Department. The policy has been updated to include the procedure for determining the prescribing a PRN medication and for approving the administration of a PRN medication per Bulletin 00-02-09. The policy is scheduled to be reviewed by March 21, 2025. Upon approval, this policy will be used as the basis for use of PRN psychotropic medications. 02/21/2025 Not Implemented
SIN-00252254 Unannounced Monitoring 09/23/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(c)The home does not adequately document refusals of medication. On occasions where medications are refused, the corresponding section on the MAR is left blank which leaves it unclear what occurred during that administration time.If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual.The MAR was corrected on 10/4/24 to reflect that the individual refused their 9pm medications on multiple days during the month of September. The refusals for 9/27, 28, and 30 will be corrected when the attestation forms are received on 10/8/24 upon return of the Direct Support Supervisor¿s return from leave. (Attachment 2) 10/05/2024 Implemented
SIN-00247043 Unannounced Monitoring 06/24/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(c)On the date of 6/19/24 none of the 9pm medications for individual #1 were signed for as being administered or refused. The medications prescribed at this time are: Estrilla Tabs 0.25 mg Loratadine Tab 10mg Vitamin D tab 50 mcg The medications were still in the blister packs for this date, however staff stated that they were refused at this administration which is documented as commonplace with this individual.If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual.1.a The MAR record was corrected on 6/27/24 to reflect that the individual refused their 6/19/24 9pm medications. Responsible party: Program Manager 06/27/2024 Implemented
SIN-00223834 Renewal 04/11/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)There was no fire drill for 1/2023 in the record. An unannounced fire drill shall be held at least once a month. Fire drills have been running since January on monthly basis and managers were trained on fire drill procedures. See attachment 29 for fire drill procedures 04/12/2023 Implemented
6400.113(a)Individual 2 had no fire safety training in the records that showed what curriculum used to train the individual. 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. We had the individual and staff sit and review the fire safety training and sign the fire plan on June 8, 2023. See attachment 30 06/08/2023 Implemented
6400.213(1)(i)The individual 2's religion is not noted in the recordEach individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.The individual's FACE sheet has been updated to reflect her religious affiliation. See attachment 31. 06/08/2023 Implemented
SIN-00211258 Unannounced Monitoring 09/12/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(e)The trash can in the kitchen did not have a lid.Trash receptacles over 18 inches high shall have lids. New trashcan with lid was purchased and placed in the kitchen of the home. 10/24/2022 Implemented
SIN-00186237 Renewal 04/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The dryer was not well-maintained. There was a tennis-ball-sized deposit of lint found in the dryer's lint trap.Floors, walls, ceilings and other surfaces shall be in good repair. Provider provided visual reminders on the dryer to have the lint removed after each use. Provider met with the two individuals who live in the home to show how to remove lint and the importance of removing lint after each use. 05/16/2021 Implemented
6400.111(e)The site's only available fire extinguisher---located in the kitchen area---was inaccessible to staff and individuals. The extinguisher was secured within a locked box with a tempered glass pane, and there was hammer attached to the box by a chain. Staff on site explained that this box is integrated into the fire safety system; the hammer would be used to break the glass and access the extinguisher in case of an actual fire emergency, and this would cause the alarm to sound. Staff on site confirmed that the box remains locked except for times when maintenance or routine checks are being performed on the extinguisher. Staff on site stated that a key to the box is not made available to staff or individuals in the home. Fire extinguishers must be accessible to staff and individuals at all times, not only during emergencies. A fire extinguisher shall be accessible to staff persons and individuals. Day of licensing inspection, the glass panel was removed from the fire extinguisher to be accessible to staff and individuals. 04/13/2021 Implemented
SIN-00158884 Renewal 07/11/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(a)There was no fire drill held for this home during the month of January 2019. An unannounced fire drill shall be held at least once a month. A designated person (Denise D'Antonio) will audit every month during the week of 15th to ensure fire drill forms are turned in, and completed. In the event fire drills were not completed, Denise will inform the Operations Director who in turn will ensure fire drills are completed by the team. This is effective August 1, 2019. 08/31/2019 Implemented
SIN-00132607 Renewal 04/10/2018 Compliant - Finalized
SIN-00113970 Renewal 03/13/2017 Compliant - Finalized