Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00242368 Renewal 04/22/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(a)At the time of the 04/24/24 inspection, there was a crack in the front concrete porch that was deep enough to be a tripping hazard. Outside walkways shall be free from ice, snow, obstructions and other hazards. A maintenance request was submitted on 05/07/2024 to fix the crack in the front concrete porch that was deep enough to be a tripping hazard. 06/30/2024 Implemented
6400.144Individual #1 is prescribed polyethylene glycol 510gm to be taken as 17grams mixed into 4-8 oz of water or liquid and drank once daily for 14 days as needed for constipation. There was no bowel protocol or bowel tracking in place for Individual #1 to determine when the medication should be administered. (Repeat from 06/13/23 and 03/08/24)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 a bowel protocol was created for individual #1. 06/30/2024 Implemented
6400.145(3)The emergency medical plan does not include an emergency staffing plan that reflects the additional staffing that may be needed in an emergency.The home shall have a written emergency medical plan listing the following: An emergency staffing plan.The Program Specialist has corrected this area of non-compliance - written emergency medical plan to reflect the emergency staffing plan that reflects if additional staffing may be needed in an emergency. 06/30/2024 Implemented
6400.165(g)The 02/01/24 quarterly psychiatric medication review for Individual #1 does not include the "need to continue the medication".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.The 02/01/2024 quarterly psychiatric medication review for individual #1 was incomplete. Individual #1 has an upcoming appointment for May 2024 to update and complete the behavioral health form. The doctor has agreed to complete the proper documentation. 06/30/2024 Implemented
6400.166(a)(11)Individual #1's prescribed medication Macrobid was prescribed from 02/21/24 until 02/28/24. The Medication Administration Record (MAR) does not include a diagnosis or purpose for the medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.All MARS were reviewed and corrected, moving forward the diagnosis or purpose for the medication will be included. 06/30/2024 Implemented
6400.181(f)Individual #1's 2024 Annual Assessment states that the Assessment was forwarded to Individual Support Plan (ISP) team members, but not the manner that it was delivered or date of the delivery.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Moving forward, The all annual assessments for individuals will have a reminder section on ensuring it was delivered or date of delivery are attached to the annual assessment. 06/30/2024 Implemented
6400.186The 08/10/23 ISP states that Individual #1 should have no more than $40 on hand at any given time to avoid overspending. On 08/16/23 Individual #1 was given $30 in "pocket money" and the next day, 08/17 23, Individual #1 was given $26.49. With no record of monies spent, Individual #1 was given more than $40 in a 2-day period. (Repeat from 06/13/23)The home shall implement the individual plan, including revisions.The team members, including the Direct Support Staff, were verbally reminded about the amount of money that the consumer can have on hand as identified in the Individualized Support Plan. 06/30/2024 Implemented
6400.213(1)(i)Individual #1's hair color, eye color, and identifying marks are not stated in the record.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.Individual #1 hair color, eye color, and identifying marks are now corrected as of 5/10/2024. 06/30/2024 Implemented
SIN-00225473 Renewal 06/13/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)A few items within the home were found to be in disrepair during the 6/15/23 onsite inspection. The following was witnessed: -The third drawer down of the kitchen cabinets, located on the same side as the kitchen sink, was broken and not sliding on the tracks. -The upper, left, drawer of the kitchen cabinets, located on the same side as the stove, was broken and not sliding on the tracks. -The vinyl floor in the spare, hallway bathroom was peeling up by the bathtub. -The rubber baseboard was starting to peel off the wall, and the wall was soft to the touch, by the bathtub in the hallway bathroom. -The wall above the shower in Individual #1's bathroom was soft, squishy, the wallpaper was peeling off, and the seam was exposed and splintering apart. -Individual #1's shower had a lot of black spots on the caulking around the bottom of the shower.Floors, walls, ceilings and other surfaces shall be in good repair. A maintenance request was submitted on 07/19/2023. (email of maintenance request) to Briarcrest Gardens Supervisor to repair the drawers, kitchen cabinet, side of the stove, vinyl floor in spare, hallway bathroom was peeling by tub, rubber baseboard, walls that seem to be soft to touch, wallpaper, and individual #1 bathroom has black spots and caulking. 08/20/2023 Implemented
6400.71The telephone number to the nearest hospital and the one used in an emergency was not located on or near the telephone in the living room. The emergency numbers by the living room phone stated Muncy hospital and listed the Muncy hospital telephone number. This is the emergency numbers list for another home and hospital located over 2 hours away.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The contact list was immediately replaced with the current emergency numbers posted near the device (see attachment -contact list near phone). 08/20/2023 Implemented
6400.111(f)The home was unable to produce the date the fire extinguishers were inspected and approved in 2022. The home produced an invoice that was created on 5/7/2022 stating payment is required for the inspection of fire extinguishers, indicating the inspection happened sometime prior to 5/7/2022. The home did not have the fire extinguishers inspected and approved again until 5/23/23, more than 365 days after an inspection prior to 5/7/2022. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The agency scheduled next year's appointments for all sites for the fire extinguisher inspections. The appointment is scheduled for May 13, 2024 at 8:00 am. The company will also give a courtesy call 30 days prior as a reminder or if a rescheduled date will be needed. (Email attachment) 08/20/2023 Implemented
SIN-00207439 Renewal 07/05/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)At the time of the inspection, there was an accumulation of lint in the dryer vent. Floors, walls, ceilings and other surfaces shall be free of hazards.The lint accumulation was immediately removed from the dryer and disposed of. 09/30/2022 Implemented
6400.103The Emergency Evacuation plan does not include Individual #1 responsibilities in an emergency.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. The Team Facilitator informed the direct support team of this non compliance issue and what Individual #1 responsibilities are in an emergency. 09/30/2022 Implemented
6400.34(a)The Department issued updated regulatory rights, effective 2/03/2020, stating that individuals have additional rights they need to be informed of. At the time of the 7/05/2022 annual inspection, Individual #1 was never informed of the individual rights as described in 6400.32.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Upon completion of the Individuals Rights Packet being updated the assigned Program Specialists will complete and review with the individuals and their teams and gather any necessary signatures in the updated format for their assigned caseloads. 09/30/2022 Implemented
6400.166(a)(2)Individual #1 Medication Administration Record (MAR) does not list the prescriber for each listed medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.The assigned agency nurse will add the prescribing physicians for the medication prescribed for all medications for all individuals on their caseload. 09/30/2022 Implemented
SIN-00194015 Renewal 08/18/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The "future call" picture phone did not have the emergency numbers posted on or near the device.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. 1. The future call picture phone was replaced with the emergency numbers posted near the device on 09/20/2021 (see attachment # 8 future phone call picture). 01/31/2022 Implemented
6400.106At the time of the 8/18/21 inspection, there are no records maintained that the home received a furnace cleaning and inspection by a professional furnace cleaning company in 2019, 2020, or 2021. The home provided a written document from the apartment complex that the furnace filters were changed at the home on 7/8/2020 and not again until 8/5/21, outside the annual time frame requirement. Additionally, the document from the apartment complex does not document who completed the filter change, their qualifications, or if the furnaces were cleaned and inspected.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. 1. To bring this concern of non-compliance, CI has hired a Company to do the annual cleaning of the furnace for the apartments. The Apartment Complex was unable able to provide the certifications of the person who completed the cleaning in in a timely manner as the person is out of the office until later in November 2021.The cleaning will be completed on 11/24/21 and thereafter every year. (See attachment #_9_) 01/31/2022 Implemented
6400.112(e)At the time of the 8/18/21 inspection, the fire drill records stated that a fire drill was held while the individuals were sleeping, during sleeping hours, in April 2021 and not again since then; outside the regulatory requirement to be completed every 6 months. According to all monthly fire drill records, April 2021 was the only month were it was indicated that a drill was held while the individuals were sleeping, 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# 5 revised fire drill form) 01/31/2022 Implemented
6400.112(h)There are no records maintained that all individuals evacuated to the meeting place during every monthly fire drill held from September 2020 to current, August 2021. According to the fire drill records, the meeting place is documented on the records as the lamp post. 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# 5revised fire drill form) 01/31/2022 Implemented
6400.113(a)There are no records maintained that Individuals #1 and #2 received training defined in 55 PA Code. Chapter 6400.113(a) on an annual basis. At the time of the 8/18/21 inspection there were no records of said fire safety training for 2019, 2020, or 2021. 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
SIN-00157431 Renewal 08/27/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(6)No mirror in Individual#1's bedroom.In bedrooms, each individual shall have the following: A mirror. 1. Mirror was replaced on 9/5/2019, in MH¿s room behind his door (see attachment #3) 2. All bedrooms in the agency will be checked by the team facilitator to ensure that each bedroom has a mirror by 12/31/19. This will be documented on the quarterly furnishing review check list, that will be submitted to the Associate Residential Director 3. The team facilitator will inspect each home and bedroom to check for a mirror and show 4. Moving forward, the team will not assume a mirror in a bathroom within the bedroom, should not be counted as a mirror in the bedroom for individual #1 5. The Residential Director will develop a quarterly check list that ensures all licensing standards including a mirror in the bedroom will be verified for compliance with regulations 6. The Residential Director will train all administrative staff on the use of the check list by 12/31/19 7. On a quarterly basis the team facilitator will inspect each home using the checklist ensuring that there is a mirror in each bedroom, those checklists will be submitted to the Associate Residential Director quarterly. 8. Full completion date 12/31/2019 12/31/2019 Implemented
6400.141(c)(14)Individual#1's physical 6/19/19 the section information pertinent to diagnosis and treatment in case of an emergency was blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. 1. Individual #1 went to an annual physical on 9/5/19, 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(e)(4)Individual#1's supervision in his current assessment is not clear. It does not contain the level of detail of his ISP update 6/25/19. The ISP states Individual#1 can be in deferent rooms of his home with 30-minute checks, he is never left unsupervised in the community, arm's length in traffic, staff must stay outside the door in community bathrooms, and staff can be out of a non-running car for 3 minutes. The assessment must include the following information: The individual's need for supervision. 1. ISP and assessment were corrected by the Supports Coordinator and the Program Coordinator on 9/10/19 and 9/3/19 respectively¿ see attachments. 2. All staff who work with the consumer were on trained on the changes made in the ISP and the assessment by the Program coordinator ¿ especially on supervision while the individual is in the community. The training was completed on 9/12/19 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. 12/31/2019 Implemented
6400.46(a)Staff #3 DOH 5/1/19 did not have fire safety training to date. Staff #3 works at the Elm home in and is deaf; he works with wit the deaf individuals at the home He has been removed from schedule until trained.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.1. Staff was removed from schedule until completing the fire safety training on 8/28/19 2. All staff will get retrained on fire safety by 12/31/19 3. The Training Specialist will develop a process that will track and monitor training compliance and be distributed every 30 days to the Residential and Associate Residual Director to ensure compliance. 4. This process will be developed, implemented and staff will be trained by 1/15/2020 01/15/2020 Implemented
6400.50(a)Staff #1 and Staff #2 training files did not include complete records of orientation and training; including the training source, content, dates, length of training, copies of certificates received. The records were unorganized and incomplete.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.1. Staff was removed from schedule until completing the fire safety training on 8/28/19 2. All staff will get retrained on fire safety by 12/1/19 3. The Training Specialist will develop a process that will track and monitor training compliance and be distributed every 30 days to the Residential and Associate Residual Director to ensure compliance. 4. Included in this is will be validation of training documentation, including source, content, date, length of training as well who attended 5. This process will be developed, implemented and staff will be trained by 1/15/2020 01/15/2020 Implemented
6400.51(a)(1)Staff #1 and Staff #2 training record did not have documentation of training and orientation relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions.Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons.1. Both staff 1 and 2 have completed the trainings on 10/31/19 and 11/1/19. 2. The Associate Residential Director will review all staff training files to ensure that thy have a current orientation to each home they work at by 12/31/19 3. The Training Specialist will develop a process that will track and monitor training compliance and be distributed every 30 days to the Residential and Associate Residual Director to ensure compliance. 4. This process will be developed, implemented and staff will be trained by 1/15/2020 01/15/2020 Implemented
6400.186Individual#1's current ISP 6/25/19 states he can handle up to $15 on his person; however, his ISP also documents he cannot identify the correct change or denominations. If Individual#1 cannot identify the value of money, he should not be independently handling money.The home shall implement the individual plan, including revisions.1. ISP and assessment were corrected by the Supports Coordinator and the Program Coordinator on 9/10/19 and 9/3/19 respectively¿ see attachments. 2. All staff who work with the consumer were on trained on the changes made in the ISP and the assessment by the Program coordinator ¿,as well as how they will assist him spend the money. The training was done on 9/12/19 2. Moving forward all the ISP¿s across the agency have the financial section reviewed to ensure that there are no discrepancy by the Program Coordinator/Specialist. 3. 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 4. the Residential Director will develop an ISP check list by 12/31/19, that quarterly ensures that the program is adhering to the ISP and the assessments (please see #1-attachment ISP) 12/31/2019 Implemented
SIN-00135383 Renewal 08/01/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106Furnace was inspected and cleaned on 10/6/2016 and not again until 11/9/2017.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The Maintenance Team will come up with a routine/preventative environmental checklist for all the homes. The checklist will identify the areas that need to checked, how often and who will complete the task. The checklist will be completed by 10/31/18 10/31/2018 Implemented
6400.112(h)The fire drill records did not indicate whether or not individuals evacuated to a designated meeting place outside the building or within the fire safe area during each fire drill. 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 (attachments #2&3). It was developed in order to ensure all fire drill related regulations are met, including the designated meeting place. All personnel and Program Coordinator will be trained on the approved forms. 09/11/2018 Implemented
6400.145(3)The written emergency medical plan did not list the following: An emergency staffing plan.The home shall have a written emergency medical plan listing the following: An emergency staffing plan.A written emergency medical plan was updated to include an emergency staffing plan (attachment #10) 09/11/2018 Implemented
SIN-00112365 Renewal 05/16/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106There was no documentation that the furnace was inspected and cleaned in 2015 or 2016. Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. May 30, 2017 To Whom It May Concern: This letter serves as confirmation that the following services have been performed on the HVAC unit at 11 Willimasburg, Hershey, PA, which is part of Briarcrest Gardens Rental Community. This is apartment is currently leased by Community Interactions Group. November 23, 2015-filter was changed October 6, 2016-filter was changed 2017-To be completed in the fall If you have any questions or concerns, please contact our office. Thank you, Melissa Nottke Property Manager mnottke#horstreality.com 05/30/2017 Implemented
SIN-00094881 Renewal 05/16/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(a)REPEAT: Staff #3's date of hire was 4/4/16. At the time of licensing on 5/16/16, she had not received training in policies and procedures of the home. Staff #3 was currently working with individuals in the home. The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. All staff will receive basic orientation and on-site orientation before working with individuals. An new orientation packet has been designed to include a basic orientation to be completed before the on-site orientation. The Program Coordinator will be responsible for overseeing completion of new staff orientation. The Employee Development Coordinator will be responsible for tracking and retaining new staff orientation packets. 06/20/2016 Implemented
6400.46(h)Staff #3's date of hire was 4/4/16. At the time of licensing on 5/16/16, she had not received training in first aid techniques. Staff #3 was currently working independently with individuals in the home. Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home, shall be trained before working with individuals in first aid techniques. All staff will receive basic orientation and on-site orientation before working with individuals. An new orientation packet has been designed to include a basic orientation to be completed before the on-site orientation. First Aid techniques is included in the basic orientation portion. The Program Coordinator will be responsible for overseeing completion of new staff orientation. The Employee Development Coordinator will be responsible for tracking and retaining new staff orientation packets. The Employee Development Coordinator will ensure that First Aid and CPR courses by a certified professional are offered at minimum quarterly for all staff. 06/20/2016 Implemented
6400.46(j)Content of training was not kept for Staff #1 and #2. Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.Employee Development Coordinator will retain copies of all course content. Training hours without course content will not be accepted. 06/20/2016 Implemented
6400.66REPEAT: The lightbulb outside the front door to the residence was not functioning. Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. Our 6400.66 protocol has been updated and the following procedures have been instituted; ¿ Work order has been placed to have the outside bulb replaced ¿ All staff will be trained on how to utilize the environmental check list related to lighting and safety. See attachment # 10, Item # 7. ¿ Target Date 7/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.67(a)Individual #2's bedroom door and doorframe was missing many chunks of wood near the bottom of the door. The corner of the wall outside of the the staff office was chipping drywall, exposing the metal corner underneath. Floors, walls, ceilings and other surfaces shall be in good repair. Our 6400.67( a) protocol has been updated and the following procedures have been instituted; ¿ Work order has been placed to have the door and walls repaired. ¿ Floors, walls, ceilings and surfaces check has been added to our environmental check list. See attachment # 10, Item # 1 (b). ¿ All staff will be trained on how to utilize the environmental check list. ¿ Target Date 7/30/2016. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.104Individual #1 required physical assistance to evacuate the home in the event of a fire. The home sent a notification letter to the fire department on 10/15/15. However the letter did not indicate the evacuation needs of Individual #1. The floor plan attached to the letter did not indicate which bedroom belonged to Individual #1. The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. Our 6400.104 protocol has been updated and the following procedures have been instituted; ¿ The notification letter and floor plan indicating rooms and assistance needed in the event of an actual fire has been updated and sent to the local Fire Department. See attachment # 14. Target Date 6/24/2016. ¿ The Program Specialist will review notification to the local fire department yearly to ensure it is current or in the event of change of status of individuals supported. ¿ Person Responsible: Program Specialist. 06/20/2016 Implemented
6400.112(h)The 7/30/15 fire drill record did not indicate if Individuals #1 and #2 went to the meeting place during the evacuation. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Our 6400.112(h) protocol has been updated and the following procedures have been instituted; ¿ All staff will be re- trained on responsibilities during Fire drills and the importance of ensuring individuals meet at the designated meeting place. ¿ Target date 7/15/2016. ¿ Quality assurance check list will be reviewed daily to ensure all documentation is completed accurately. See attachment # 10. Item # 4. ¿ All staff will be trained on how to utilize the Quality assurance check list. Target date 7/30/2015. ¿ Person Responsible; Program Specialist. 06/20/2016 Implemented
SIN-00090514 Unannounced Monitoring 10/19/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32The agency is using the Individual #1 & #2's home to conduct trainings such as medication administration, first aid & CPR , fire safety and house meetings while the Individuals are home. This prevents the Individuals from moving freely due to a number of staff in the home sitting on the living room furnature and in kitchen area. Individuals have to listen to what is going on in their home since there is nowhere for them to go except in their bedroom when trainings are conducted. These trainings can be hours long. An individual may not be deprived of rights. Moving forward all training will take place in separate location from the individuals residences.(P.S. and service director will be responsible in making sure this violation does not occur again.)JR 3/15/16 03/14/2016 Implemented
6400.144Tylenol 325mg tablets had expired on 8/7/15 but were still being used for the Individual #1. Tylenol was administered on 8/8/15 & 8/17/15. 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. Weekly Medication Inspection will be conducted to assure that medications have not passed the expiration date. CI Weekly Medication Inspection form will be utilized (see attached). Overnight Medication checks will be initiated so that daily check will occur in which all medication administration for the previous 24 hours is verified and documented. 03/14/2016 Implemented
6400.164(a)Medication log for Individual #1- on 7/30/15-8am Celexa 10mg, 8am Flonase, 8am Align 4mg, 8am Colace 100mg, 8am Multi Day tab where not initialed on the medication log as given. Tylenol (PRN)- administered on 8/8/15 & 8/17/15 but was not documented on the medication log, the blister packet had initials. Zyrtec 10mg administered 8/17/15 & 8/30/15 at 8pm where not initialed on the medication log. 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. Effective 3/21/16 Community Interactions will implement a documented daily overnight medication inspection to be completed by the Community Support Associate. The Program Specialist will also complete documented weekly medication inspections. 03/14/2016 Implemented
6400.181(e)(13)(ii)There was no progress and growth in motor and communication skills in the annual assessment for Individual #1. The information was the same as the prior year.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. Effective immediately Community Interactions will utilize a new assessment tool that will be completed on an annual basis by the Program Specialist that will note relevant progress in all required areas (see attachment 3). 03/14/2016 Implemented
6400.181(e)(13)(iii)There was no progress and growth in activities of residential living for Individual #1 in the annual assessment. The information was the same as the prior year.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. Effective immediately Community Interactions will utilize a new assessment tool that will be completed on an annual basis by the Program Specialist that will note relevant progress in all required areas (see attachment 3). 03/14/2016 Implemented
6400.181(e)(13)(iv)There was no progress and growth in personal adjustment for Individual #1 in the annual assessment. The information was the same as the prior year.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. Effective immediately Community Interactions will utilize a new assessment tool that will be completed on an annual basis by the Program Specialist that will note relevant progress in all required areas (see attachment 3). 03/14/2016 Implemented
6400.181(e)(13)(v)There was no progress and growth in socialization for Individual #1 in the annual assessment. The information was the same as the prior year.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. Effective immediately Community Interactions will utilize a new assessment tool that will be completed on an annual basis by the Program Specialist that will note relevant progress in all required areas (see attachment 3). 03/14/2016 Implemented
6400.181(e)(13)(vi)There was no progress and growth in recreation for Individual #1 in the annual assessment. The information was the same as the prior year.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. Effective immediately Community Interactions will utilize a new assessment tool that will be completed on an annual basis by the Program Specialist that will note relevant progress in all required areas (see attachment 3). 03/14/2016 Implemented
6400.181(e)(13)(vii)There was no progress and growth in financial independence for Individual #1 in the annual assessment. The information was the same as the prior year.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. Effective immediately Community Interactions will utilize a new assessment tool that will be completed on an annual basis by the Program Specialist that will note relevant progress in all required areas (see attachment 3). 03/14/2016 Implemented
6400.181(e)(13)(viii)This section was missing from the assessment for Individual #1 & Individual #2- There was no progress and growth from the annual assessment. 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. Effective immediately Community Interactions will utilize a new assessment tool that will be completed on an annual basis by the Program Specialist that includes a section on the individual's abilities in managing personal property (see attachment 3). 03/14/2016 Implemented
6400.181(e)(13)(ix)There was no progress and growth in community intergration for Individual #1 in the annual assessment. The information was the same as the prior year.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.Effective immediately Community Interactions will utilize a new assessment tool that will be completed on an annual basis by the Program Specialist that will note relevant progress in all required areas (see attachment 3). 03/14/2016 Implemented
6400.181(f)The Program specialist did not provide the annual assessment to all team members 30 days prior to the ISP meeting for Individual #1 (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). Our 6400.181(f) protocol has been updated to include an ISP/Assessment preparation checklist with the following step by step guidelines. 1) 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. 2) When the individual and their Team members decide on an ISP date, if there is any needed 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. 3) The protocols will be used in conjunction with the ISP /Assessment tracking sheet attached (see attachment 1). 03/14/2016 Implemented
SIN-00074483 Renewal 10/23/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(c)The medication trainer certificate had expired 12/13 and had been training staff currently 10/14. 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
6400.181(e)(13)(viii)Individual #1's annual assessment did not include progress on 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: ¿ The annual assessment has been updated to include progress on Managing Personal property (see attachment 7 Pg 11-hard copy to follow) ¿ The Program Specialist will review and sign that the assessment has included Managing Personal property 05/30/2015 Implemented
6400.187There was no documentation of Individual #1's 3/20/14 ISP review being sent to all plan team members.A copy of the ISP, including the signature sheet, shall be provided to plan team members within 30 calendar days after the ISP, annual update and ISP revision meetings. Our 6400.187 protocol has been updated and the following procedures have been instituted: ¿ The Program Specialist will send out a copies of ISP annual update or ISP review including signature sheet, to all team members within 30 days after the ISP, annual update, and ISP revision meetings. ¿ Documentation showing the ISP review was sent out to all team members 30 days after the ISP meeting will be filed in the individuals records. (See attachment 7 -hard copy to follow) 05/30/2015 Implemented
SIN-00058968 Renewal 11/12/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water temperature at the home was 120 degrees Fahrenheit which exceeds the regulatory requirement. (b) Hot water temperatures in bathtubs and showers may not exceed 120°F. Fully Implemented. JW 3/17/14 Our protocol has been updated and the following procedures will be instituted: Staff training completed and form updated to include monitoring of water temperature to ensure hot water temperature in bathtubs and showers do not exceed 120 degrees F. (See attachment 7) 03/31/2014 Implemented
SIN-00176453 Renewal 09/09/2020 Compliant - Finalized