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55 Pa. Code Chapter 6400 – Community Homes for Individuals with an Intellectual Disability or AutismInspection RecordA. Site Information Legal Entity Name:Service Location Name: Service Location Address: Service Location County:B. Inspection Information Assessment Begin Date:Assessment End Date:Assessors:General Requirements ??CVNANM??CVNANM11Chapter 20????19a6Social Needs????13Max Capacity????19a7Environmental Needs????14aOccupancy Permit????19a8Personal Safety????14bPermit Withdrawn????19bCorrective Plan Implemented????14cRenovations Approval????19cPlan Revised, if Indicated????15aSelf-Assessment ????20a1Confirmed Incident – Analysis of Cause????15bL.I.I. Used????20a2Corrective Action????15cL.I.I. Results????20a3Potential Risk Strategies????16Abuse????20b3-month review/analysis????17Reporting to Childline????20c1Preventative Measures: Reduce incidents????18aIncidents Reported –24 Hrs.????20c2Severity of Risk????18bIncidents Reported-72 Hrs.????20c3Likelihood of Recurrence????18cFamily Notification- 24 Hrs. ????20dEducate Staff????18dNotification Kept????20eMitigate/Manage Risks????18eReport Available????21aPSP Clearance- 5 days????18fImmediate Action????21bFBI Clearance – 5 days????18gInvestigation – 24 Hrs.????21cClearances 1 Year????18h1CI investigate: Death????21dClearances Kept????18h2Inpatient????21eChild Abuse Clearance????18h3Abuse????22aFunds/Property Policy????18h4Neglect????22bInd. Right to manage finance.????18h5Exploitation????22cInd. Funds – Ind. Benefits????18h6Injury: Treatment beyond first aid????22d1Financial/Prop. Record????18h7Theft/Misuse of Funds????22d2Record - Disbursement????18h8Rights Violation????22e1Rec. Dep./Withdrawals????18iFinal Report – 30 days????22e2Record Funds to Ind.????18j1Content of Report – Additional Info????22e3Receipt over $15????18j2Results of Investigation????22fComingling of Funds????18j3Action Taken????22gBorrowing of Funds????18j4Corrective Action????210bPayment for Damages????18j5Responsible Person????23Grievance Procedures????18j6Date of Implementation????24Other Statutes????19a1Potential Risks????25aChild/Parent/Guardian ????19a2Health Care Info.????25bGenerally Accepted Practices????19a3Med History/Current Meds????25cPermanent Caregiving????19a4Behavioral Health History????25dShared Bedroom- Unrelated Child/Adult????19a5Incident History????ments Individual Rights CVNANMCVNANM31aDeprived of Rights????32oManage Finances????31bAccommodations????32pChoice of Roommate????31cExercise Rights - Punishment????32qFurnish/Decorate Bedroom, Common Areas????31eLegal Guardian – Rights/Decisions????32rLock Bedroom Door????31fIndividual Involved with Decision making????32r1Locking Mechanism????31gDesignated Person????32r2 Access to Bedroom????32aDiscrimination????32r3Assistive Technology????32bCivil/Legal Rights????32r4Immediate Access????32cAbuse, Neglect, Mistreatment????32r5Staff Key????32dDignity/Respect????32sEntry Mechanism – Front Door????32eMake Choices/Accept Risks????32s1Assistive Technology????32fRefusal of Activities????32s2Immediate Access????32gControl Schedule????32s3Staff Key????32hPrivacy????32tAccess to Food????32iAccess/Security of Possessions????32uHealth Care Decisions????32jVoice Concerns????32vRights Modified????32kParticipate in Plan Development????33aViolation of Others’ Rights????32lVisitors/Communication????33bResolve Differences????32mMail????34aIndividual Informed????32nTelecommunications????34bSigned Statement????ments StaffingCVNANMCVNANM4218 yrs.????50bRecord Per Person????43aCEO????51a1Orientation: Mngmt/Admin/Prgrm/Fisc????43b1CEO - Policies????51a2Diet/Housekeep/Maint????43b2CEO - Admin./Discharge????51a3Full/Part time DSP????43b3CEO - Safety/Protection????51a4Volunteers????43b4CEO - Compliance????51a5Paid/Unpaid Interns????43c1CEO Qualifications: Masters + 2 years exp????51a6 Consultants????43c2Bachelors + 4 years exp????51b1Orientation includes: Person Centered Practices, Community Integration, etc????44aP. S. 30 Ind.????51b2Prevention, Detection, Reporting of Abuse????44b1P.S. Coordinate/Complete Assessments????51b3Individual Rights????44b2P.S. Participate in Plan Process ????51b4Recognize/Report Incidents????44b3P.S. Provide/Supervise Activities????51b5Job-related skills/knowl????44b4P.S. CommunityIntegration????52a1Training - 24 Hrs: DSW????44b5P.S. Family/Friend Involvement????52a2Direct Sup(s) of DSW’s ????44c1PS Qualifications: Masters + 1-year experience????52a3Program Specialists- ????44c2P.S. Bachelors + 2-year ????52b1Training -12 Hrs: Mngmt/Admin/Prgrm/Fisc-????44c3P.S. Associates/60 credits + 4 years ????52b2Diet/Housekeep/Maint ????45a1:8 Ratio Awake????52b3Consultants????45b1:16 Ratio Sleeping????52b4Volunteers????45cUnsupervised time????52b5Paid/Unpaid Interns ????45dISP Ratio Implemented????52c1Content: Person Centered Practices, Community Integration, etc????45eUnsupervised - Staff Convenience????52c2Prevention, Detection, Reporting of Abuse????46aPrior to Work: Fire Safety????52c3Individual Rights????46bAnnually: F.S Expert????52c4Recognize/Report Incidents????46cInitial First Aid????52c5Use of Behavior Supp????46dF.A/CPR/Heimlich – 6mo????52c6Plan Implementation????50aTraining Records Kept????ments Physical SiteCVNANMCVNANM61aSpecial Accommodations????77bFirst Aid Kit - Content????61bAdaptive Equipment????77cFirst Aid Manual????62aPoisons Locked????78aLiving/Dining Area????62bPoisons Unlocked????78b30 Sq. Ft./90 Sq. Ft.????62cOriginal Containers????79Elevator Approval????62dPoisons Sep. from Food????80aOutside Walkways????63aHeat Sources/Protect????80bOutside Conditions ????63bProtection not required????81aBedroom-Basements????64aClean and Sanitary????81bApts- Below Grnd Level????64bInfestation ????81c60 Sq. Ft./80 Sq. Ft????64cTrash Removal????81d100 Sq. Ft. - Wheelchair????64dCleanable Trash Cans????81e2 Ind. Per Bedroom????64eLids on Trash Cans -18”????81fBedrooms – Access????64fClosed Outside Trash ????81gBedrooms - Passageway????65Ventilation????81hWindow in Bedroom????66Lighting????81iCurtains, Shades????67aSurfaces – Good Repair????81jDoors for Privacy????67bSurfaces – Hazard Free????811k1Bed????67cPaint Tested????81k2Mattress/Foundation????68aWater Under Pressure????81k3Pillow/Linens????68bHot Water - 120°????81k4Chest of Drawers????68cColiform Water Test????81k5Closet Space????69a65° Non-Sleeping????81k6Mirror????69b58° Sleeping????81lCribs w/ Domes/12” sides????69c85° Mechanical Vent????82a1 Toilet: 4 Indiv.????70Telephone ????82bTubs/Showers????71Emergency Numbers????82cBathrooms – Phys. Disability????72aWindows/Doors Screened????82dPrivacy in Bathrooms????72bScreens – Good Repair????82eNonslip Surface ????72cOutside Doors - Locks????82fBathroom Items????73aHandrails????82gTowel, Washcloth, Toothbrush????73bPorch Railings????83aKitchen Area????74Nonskid Surfaces????83bAdaptive Eating Equipment????75aLandings????83cUtensils Washed????75bLanding Width????84aLaundry - Weekly????76aFurnit. Safe, Clean, Sturdy????84bLaundry - Storage ????76bFurniture Appropriate????85aIn ground Pool????76cFurniture Homelike????85bAbove ground Pool????76dAmount of Furniture????86Firearms????76eDining Tables????77aFirst Aid Kit????ments Fire Safety CVNANMCVNANM101Unobstructed Egress????111bFire Ext. – 3000 sq.ft????102Two Exits/Fire Escape????111cFire Ext. – Kitchen Min. 2A-10BC????103Evacuation Procedures????111dUL/FMS Approval????104Notification????111eFire Ext. Accessible????105Combustible Supplies ????111fAnnual Inspection????106Furnace Inspected????112aFire Drills Per Month????107Portable Space Heaters????112bNormal Staff Conditions????108aWood/Coal Stove Insp.????112cFire Drill Records????108bWood/Coal Stove Cleaned????112dEvacuation????109aFireplace Guards????112eFire Drill Sleeping Hours????109bFireplaces Cleaned????112f Alternate Routes????110aSmoke Detector per Floor????112gFire Drills – Days/Times????110bSmoke Detector – 15ft????112hMeeting Place????110cCommon Areas????112iDetectors/Alarms Set Off????110dUL or L&I Approved????113aInd. Trained????110eInterconnected Detectors????113bDoc. If No Training????110fDetect. Hearing Impaired????113cTraining Records????110gInoperative Alarms????114aSmoking Safety Procedures ????110hMonitoring Process????114bWritten Procedure Followed????111a2-A Fire Ext. Per Floor ????ments Individual Health CVNANMCVNANM141aInd. Physical????141c15Diet Instructions????141bPhysician Sign/Date????141dRN/LPN – complete/sign Immun/TB/Hear/Vision????141c1Medical History????142aDental Exam????141c2General Physical????142bMeds - Dental Probs????141c3Immunizations Adults????142cExam Record Content????141c4Vis./Hearing Screen Adults????142dCleaning/Gums/Dentures????141c5Immun. Screening Children????142eFollow Up Completed????141c6TB Testing????142fDental Hygiene Plan????141c7Gyn. Exam????142gRewritten Annually????141c8Mammogram????142hPlan in Record????141c9Prostate Exam????143aRefusal of Treatment????141c10Communicable Disease????143bConsent: Serious Condit????141c11Health Maintenance????144Health Services????141c12Physical Limits????145(1)Med Plan: Hospital????141c13Allergies/Cont. Meds????145(2)Med Plan: Transport????141c14Emergency Info.????145(3)Med Plan: Emergency Staffing????ments Staff Health CVNANMCVNANM151aStaff Physicals????151c4Medical Problems????151bPhysician Sign/Date????152 aCommunicable Disease Auth.????151c1General Physical????152 bSpecific Precautions????151c2TB Testing????152cPrecautions Followed????151c3Communicable Disease????ments Medications CVNANMCVNANM161aSelf-Admin: Assistance????166a6Dosage Form????161bTypes of Assistance????166a7Dose of Med????161cAssistive Technology????166a8Route of Administration????161dSelf-Admin Status in Plan????166a9Frequency of Admin????161e1SA: recognize meds????166a10Administration Times????161e2SA: How much ????166a11Diagnosis/Purpose????161e3SA: When to take????166a12Date/Time of Admin????161e4SA: Assistive Tech.????166a13Name/Initials of Person Administering????162aAdmin by Qualified Staff????166a14Duration of Treatment, If applicable.????162bQualified Staff ????166a15Special Precautions, If Applicable.????162c1Med Admin: Identify Indiv.????166a16Side Effects, if Applicable????162c2Remove from orig. cont. ????166bLogged Immediately ????162c3Prepare Med as Ordered????166cRefusal Documented on Log????162c4Med in Med Cup/Cont.????166dDirections Followed????162c5Vital Signs, if indicated????167a1Med Errors: Failure to administer Med????162c6Injection of insulin/epineph????167a2Wrong Med Admin????163aOriginal Labeled Container????167a3Wrong Dose Admin????163bRemoval from Container????167a4Failure to Admin at Pres. Time????163cInsulin/Epinephrine not individual dose container????167a5Administered -Wrong Person????163dMeds/Syringes Locked????167a6Wrong Route????163eEpinephrine Stored Safe/Accessible????167a7Wrong Position????163fRefrig. Meds – Locked Container????167a8Improper preparation????163gStorage of Meds????167bDoc. of Med Errors????163hDisposal of Meds????167cError Reported as in 18b????165aAuthorized Prescriber????167d1Reported to prescriber: Not Admin as directed????165bCurrent Order????167d2Admin to Wrong person????165cAdministered as Prescribed????167d3Harm to Individual????165dUse of Meds????168aAdv Reaction- Consult Dr.????165eWritten Changes????168bResponse/Action Documented????165fSEEN Protocol in Plan????169aMed Admin Training????165g3-month psych med review????169b1Insulin Admin: Med Admin Course????166a1Med Log: Individual Name????169b2Training by Health Care Professional: 24 Months????166a2Prescriber????169c1Epinephrine Admin: Med Course????166a3Drug Allergies????169c2Training by Health Care Professional- 24 Months????166a4Medication Name????169dTraining Record Kept????166a5Strength of Med????ments Nutrition CVNANMCVNANM171Food Protected????174 Food Groups????1723 Meals Per Day????175Tables – 12 or Fewer Ind.????173Quantity of Food ????176Food Returned????ments Assessments CVNANMCVNANM181aInitial/Annual Assessment????181e9Functional/Med. Limits ????181bAssess/Service Revised????181e10Lifetime Med History ????181cBasis of Assessment????181e11Psychological Evaluation ????181dP.S. Sign Date????181e12Recommendations ????181e1Strengths/Needs/Prefer.????181e13i Progress - Health????181e2Likes/Dislikes/Interests ????181e13ii Motor/Communication ????181e3iFunctional Skills????181e13iii Daily Living ????181e3iiCommunication????181e13iv Personal Adjustment????181e3iiPersonal Adjustment????181e13v Socialization ????181e3ivPers. Needs w/wo Assist. ????181e13vi Recreation????181e4Supervision Needs????181e13vii Financial Independence????181e5Ability to Self-Admin????181e13viii Manage Personal Property????181e6Poisons ????181e13ixCommunity Integration????181e7Heat Sources????181e14Water/Swim Safety????181e8Evacuation????181fCopy to SC/Plan Team????ments Plan Development/Process/ContentCVNANMCVNANM182aPS Coordinate Plan????184(8)Method to request updates????182bDeveloped w/in 90 days????185(1)Plan: strengths/abilities/needs????182cInitial Develop, Revised Annually/Needs Change????185(2)Individual Preferences????182dIndividual/Designees Involved????185(3)Desired Outcomes????183a1Plan Team Includes: Indiv????185(4)Services to Assist Achievement of Outcomes????183a2Designated Persons????185(5)Risks to health/safetyRisk Mitigation Strategies????183a3Direct Care Staff????185(6)Modification of rights????183a4Program Specialist????186Plan Implemented????183a5SC/TSM/Funding Source????195aRestrictive Plan Prior to Use????183a6Day Program PS, If applic????195bHuman rights Team Review – 6 months????183a7Other Specialists as appropriate????195c1Specific Behaviors ????183b3 Members + indiv Present????195c2Assessment of Behavior????183cParticipant List Kept????195c3Desired Outcome????184(1)Plan Process: Individual Directs Plan Process????195c4Methods for Facilitating Positive Behaviors????184(2)Make Choices/Decisions????195c5Restrictions and Circumstance for use ????184(3)Important to Individual????195c6Outcome Target Date????184(4)Occur Timely????195c7Amount of Time????184(5)Understandable Language????195c8Staff Person Responsible????184(6)Cultural Considerations????195dBSP Developed by Certified BS if modifying rights????184(7)Guideline: Solving Disagreements????209Emergency Basis????ments Home Services CVNANMCVNANM188aResidential Home Assist.????188cServ. Specified in ISP????188bCommunity Life????188dAge/Functionally Approp.????ments Day Services/Recreational and Social ActivitiesCVNANMCVNANM189aDay Services Provided????190a2Rec/Soc Activity - Away????189b1Day Services at home: Phys. Approved Annually????190bTime Away from Home????189b2Team Approved Annually????190cDoc of rec/soc activities????190a1Rec/Soc Activity - Home????ments Restrictive Procedures CVNANMCVNANM191Definition ????207(3)Pressure Point Tech.????192Written Policy????207(4)Chemical Restraint????193aRetribution/Convenience????207(5)Mechanical Restraint????193b1Anticipate/Least Restrict????208cPhys. Restraint - Prone Position????193b2Less Restrict. Techs. Fail????208dPhys Rest – Pain, Hyperextension, Humiliation????194aReview Committee????210aFunds/Property as Reward/Punishment????194bCommittee Includes BSP????Permitted Procedures194cMajority Not Providing Services????207(3)Clinically Accepted Bite Release????194dRecord of Meetings????207(4)Prescribed Drug????196aSpecific RP Training????207(5)Prescribed Device????196bExperienced Use of RP????208aPhys. Rest Emergency????196cDoc. Of Training????208bEscort/Guide/Redirect/Physical Prompts????Prohibited Procedures208fPhys Rest: 30min/2Hrs????207(1)Seclusion????210b1Personal Funds - Consent for Restitution????207(2)Aversive Conditioning????210b2Consent obtained w/ indiv or designee????210b3Coercion prohibited????ments Individual Records CVNANMCVNANM211aInd. Emergency Info????213(3)Physical Exams????211b1Contact Info – Designated Person ????213(4)Dental Exams????211b2Contact Info – Physician ????213(5)Dental Hygiene Plans????211b3Contact Info – Consent to Treatment????213(6)Assessments????211b4Copy- Most Recent Phys. Exam????213(7)Individual Plan Docs????212Separate Record????213(8)Psych Eval.????212bEntries legible/dated/signed????214aRecord info kept at home????213(1)iName, sex, DOA, DOB, SSN????214bCurrent copies at home????213(1)iiRace/ht/wt/hair/eye/mark????214cNot Current Kept in home/admin office????213(1)iiiMeans of Communication????215aInformation kept 4yrs.????213(1)ivReligion????216aRecords Locked????213(1)vNext of Kin????216bAccess to Records????213(1)viCurrent, Dated Photo.????217Release of Info????213(2)Incident Reports????ments 9 or More Individuals CVNANMCVNANM231Other regs apply????240cManufacturer’s Instruct????232Awake Staff????241aFood-Covered Containers????233Sewage System????241bFood-Proper Temp.????234Indoor Living Furniture????242Returned Food????235Elevators, Ramps????243aMenus Prepared????236Evacuation Procedures????243bMenus- Accessible 1 day Prior????237aExit Signs????243cMenu Changes????237bDirection of Travel????243dMenus Followed????237cExit Sign Letters????243eWritten Menus Retained????238aSeparate Laundry????244Bedrooms-200ft from bath????238bLaundry Entrance????245a(b)-(d) Supersede 82(a-c)????239aDining Area????245b9-14 - 2 Tub/Shower/toilets ????239bDining Tables – 12 Ind.????245c15+ 1 toilet/10 indiv. 1 shower/20 indiv.????240aDishwater????245dBathrooms- Physical disabilities.????240bHot Water Temp.????ments Emergency Placement CVNANMCVNANM251aNotice: 2 weeks or less????251bPhysical Exam w/in 31 days????ments Respite CareCVNANMCVNANM261aNot to Exceed 31 Days????262b1Not Applicable: 6400.78????261b1Not Applicable: 6400.78????262b2N/A: 6400.87(g)(h)????261b2N/A: 6400.81(g)(h)????262b3N/A: 6400.121-127????261b3N/A: 6400.121-127????262b4N/A: 6400.141 6400.142????261b4N/A: 6400.142????262b5N/A: 6400.213(3-8)????261b5N/A:6400.213(4)(5)(7)(8)????263Other Requirements Apply????262aEmergency Respite: 2 weeks or less notice????ments Semi-Independent Living CVNANMCVNANM271(1) Evacuation????273(2)N/A: 6400.62(a)(b), 6400.63, 6400.68(b)????271(2) Intermittent Training????273(3)N/A: 6400.161(b)(c)????271(3)18 yrs. Or Older????273(4)N/A: 6400.18(b) 6400.192????272Annual Doc. Of Abilities????274(1)1 staff member available????273(1)Not Applicable: 6400.45????274(2)Initial/Annual Fire Safety????275Other requirements apply????ments ` ................
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