Inspection Reports for
Chandler Hall Health Services, Inc. – Hicks
99 BARCLAY STREET,, NEWTOWN, PA, 18940
Back to Facility Profile34 Reports
Inspection Report — Feb 2, 2026
Renewal
Date: Feb 2, 2026
Visit Reason
The inspection was a full, unannounced renewal inspection conducted to review compliance and verify the submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including failure to timely refund a resident's charges after death, incomplete staff training on required topics, missing emergency telephone numbers, inoperable equipment, medication documentation errors, lack of resident education on medication refusal rights, and absence of required written approval for locked exit doors. Plans of correction were accepted and implemented with specified completion dates.
Citations (8)
28e - Death of a Resident: The facility failed to issue a refund timely for a deceased resident's personal property, resulting in a delayed refund of $876.00.
65f - Training Topics: Direct care staff persons A and B did not receive required training on care for residents with mental illness or intellectual disability for the 2025 training year.
65g - Annual Training Content: Staff persons A and B did not receive fire safety and emergency preparedness training during the 2025 training year, a repeat violation from 3/6/2025.
91 - Telephone Numbers: Emergency telephone numbers for the nearest hospital and fire department were not posted on or by the telephone in resident #2's bedroom.
95 - Furniture and Equipment: The commercial dryer in the laundry room was not operable for several weeks and the carbon monoxide detector in the main kitchen was hanging off the ceiling.
185a - Implement Storage Procedures: Medication documentation errors were found for resident #3's insulin administration, with glucometer readings not matching recorded values.
191 - Resident Right to Refuse: Residents #4 and #5 were not educated about their right to refuse medication if they believed there was a medication error, and documentation was missing.
233a - Lock Approval: The facility lacked written approval from relevant authorities for keypad and electronic card operated locking systems on exit doors from the secured dementia care unit.
Report Facts
Refund amount: 876
Residents served: 22
Total daily staff: 44
Waking staff: 33
Current hospice residents: 3
Notice — Jan 2, 2026
Date: Jan 2, 2026
Visit Reason
The document serves to notify Chandler Hall Health Services Inc.-Hicks that their request to waive the requirement for direct care staff to have a high school diploma, GED, or active registry status was granted under specified conditions.
Findings
The waiver is granted with conditions including documentation of education and training to be maintained and made available upon request. The Department will review compliance with the waiver annually during inspections.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Dec 22, 2025
Monitoring
Date: Dec 22, 2025
Visit Reason
The inspection was an unannounced partial visit conducted for monitoring purposes to review compliance and the implementation of a plan of correction.
Findings
The facility had multiple deficiencies including incomplete training records, missing fencing creating hazards, unsigned support plans, incomplete cognitive preadmission screenings, missing directions for key-locking devices, and late admission support plans. All deficiencies had plans of correction accepted and were implemented by March 2, 2026.
Citations (6)
65i - Training Record: The home's record of direct care staff training does not include the date and length of each course.
100a - Exterior - Free of Hazards: Two large sections of fencing were missing from the secured unit patio area, posing a tripping hazard due to loose dirt and debris.
227g - Support Plan Signatures: A resident's assessment and support plan was not signed by the resident and did not indicate if the resident declined or was unable to participate.
231c - Preadmission Screening: A resident's written cognitive preadmission screening was not completed within 72 hours prior to admission to the secured dementia care unit.
233c - Key-Locking Devices: Directions for operating the home's locking mechanism were not conspicuously posted near the main dining room exit door to the Secure Dementia Care Unit.
234a - Admission Support Plan: A resident's initial support plan was completed late, after admission to the Secure Dementia Care Unit.
Report Facts
Residents Served: 19
Current Residents in Hospice: 4
Residents Age 60 or Older: 19
Residents with Mental Illness: 8
Residents with Mobility Need: 19
Inspection Report — Oct 27, 2025
Follow-Up
Date: Oct 27, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including failure to provide required assistance with activities of daily living, missing resident signatures on contracts and rights acknowledgments, neglect resulting in a resident fall with injury, and failure to educate residents on their right to refuse medication. Plans of correction were accepted and implemented by March 2, 2026.
Citations (5)
23a - Activities of Daily Living Assistance: A resident requiring total physical assistance with toileting was left unattended, resulting in a fall and closed head injury.
25b - Contract Signatures: Several resident-home contracts were not signed by the residents as required.
41e - Signed Statement: Resident records lacked signed statements acknowledging receipt of resident rights and complaint procedures.
42b - Abuse: A resident was neglected when left alone during toileting assistance, resulting in a fall and injury; staff member was suspended and re-educated.
191 - Resident Right to Refuse: Multiple residents were not educated on their right to refuse medication if they believed there was a medication error.
Report Facts
Residents Served: 22
Current Residents: 5
Staff Count: 44
Waking Staff: 33
Inspection Report — Sep 22, 2025
Follow-Up
Date: Sep 22, 2025
Visit Reason
The inspection was an unannounced partial incident review conducted on 09/22/2025 to follow up on a submitted plan of correction related to prior deficiencies.
Findings
The facility was found to have fully implemented the submitted plan of correction. Deficiencies included failure to immediately report suspected resident abuse, delayed incident reporting to the department, failure to provide required assistance with activities of daily living, and unlocked poisonous materials accessible to residents.
Citations (4)
Failure to immediately report suspected abuse of a resident with a large skin tear requiring sutures.
Failure to report the incident to the department within 24 hours.
Resident did not receive required assistance with eating during breakfast, waiting 15 minutes for help.
Poisonous materials (toothpaste and mouthwash) were unlocked and accessible to residents not assessed as safe to use them.
Report Facts
Residents Served: 23
Current Residents in Hospice: 5
Residents Diagnosed with Mental Illness: 8
Residents Aged 60 or Older: 23
Sutures Required: 8
Staff Total Daily: 46
Waking Staff: 35
Notice — May 14, 2025
Date: May 14, 2025
Visit Reason
This document serves to notify Chandler Hall Health Services Inc.- Hicks that their request to waive the requirement for direct care staff to have a high school diploma, GED, or active registry status was granted under specified conditions.
Findings
The waiver is granted based on submitted documentation showing equivalent education obtained outside the United States. The Department will review this waiver annually during inspections to ensure compliance with conditions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Notice — May 12, 2025
Date: May 12, 2025
Visit Reason
The document serves to notify the facility that a waiver request to waive the high school diploma or GED requirement for a direct care staff person was granted under 55 Pa.Code § 2600.19.
Findings
The waiver is granted with conditions requiring documentation of education and training to be kept on file and made available upon request. The Department will review this waiver annually during inspections to ensure compliance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Mar 6, 2025
Renewal
Date: Mar 6, 2025
Visit Reason
The inspection was conducted as a renewal inspection of the facility license.
Findings
The inspection found multiple deficiencies related to staff training, food safety, medication management, fire drill evacuation, and preadmission screening. All deficiencies had plans of correction submitted and were determined to be fully implemented by the follow-up date.
Citations (8)
Staff person A did not receive training in emergency preparedness procedures and recognition and response to crises and emergency situations during training year 2024.
There was an uncovered, unsealed bag of herbs stored in the walk-in refrigerator.
There was a tray of peeled bananas and a black trash bag said to contain loaves of bread in the walk-in freezer; both were unlabeled and undated.
All residents in the home did not evacuate to a designated meeting place away from the building or within the fire-safe area during fire drills on 9/20/2024 and 11/20/2024.
Guaifenesin Oral Solution and Milk of Magnesia prescribed for individual 1 were in the medication cart but not listed on resident 1's current medication orders.
An Insulin Glargine Pen prescribed to resident 2 was in the medication cart with no open date indicated. Olopatadine .1% eye drops and Latanoprost solution .005% eye drops prescribed to resident 3 were in the medication cart with open dates from 12/20/2024, exceeding manufacturer discard timeframes.
Resident 2's prescribed Acetaminophen 325 mg tablets were not available in the home at the time of inspection.
Resident 4's written cognitive preadmission screening was not completed as of admission to the Secure Dementia Care Unit.
Report Facts
Residents Served: 22
Residents in Secured Dementia Care Unit: 22
Current Hospice Residents: 10
Residents Age 60 or Older: 22
Residents Diagnosed with Mental Illness: 3
Residents with Mobility Need: 22
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 0
Staffing Hours - Total Daily Staff: 44
Staffing Hours - Waking Staff: 33
Fire Drill Evacuation - 9/20/2024: 16
Fire Drill Evacuation - 11/20/2024: 9
Notice — Dec 5, 2024
Date: Dec 5, 2024
Visit Reason
The document serves to grant a waiver request for a direct care staff person at Chandler Hall Health Services Inc.- Hicks to waive the requirement of having a high school diploma, GED, or active registry status due to education obtained outside the United States.
Findings
The waiver is granted under conditions that the staff member's education is equivalent to a U.S. high school diploma as validated by a credential evaluation, and documentation must be maintained and available for review. The Department will review this waiver annually during inspections to ensure compliance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Notice — Aug 24, 2024
Date: Aug 24, 2024
Visit Reason
The document serves to notify Chandler Hall Health Services Inc.-Hicks that their request to waive the requirement for direct care staff to have a high school diploma, GED, or active registry status has been granted due to education obtained outside the United States.
Findings
The waiver is granted with conditions including documentation of education and training to be maintained and available for review. The Department will review this waiver annually during inspections to ensure compliance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Feb 15, 2024
Renewal
Date: Feb 15, 2024
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing regulations at Chandler Hall Health Services, Inc. - Hicks.
Findings
The inspection found multiple deficiencies related to contract signatures, signed statements, locking poisonous materials, bathroom ventilation, medical evaluations, medication management, resident rights, support plan documentation, preadmission screening, and staff training. Plans of correction were accepted and implemented to address these issues.
Citations (13)
The resident-home contract for resident #1 was not signed by the resident or payor.
Resident #1's record did not contain a statement signed by the resident acknowledging receipt of a copy of the resident rights and complaint procedures.
Bathroom cabinets in resident rooms #409 and #600 contained unlocked poisonous materials accessible to residents who have not been assessed capable of recognizing and using poisons safely.
The bathroom in resident room #409 does not have an operable window and the ventilation fan is inoperable.
Resident #2's medical evaluation did not include special health or dietary needs of the resident.
Expired medication prescribed for resident #3 was found in the home's medication cart.
Resident #4 had a missing pill from prescribed medication; pharmacy confirmed fewer pills dispensed than ordered.
Resident #4's medication administration record did not include initials of staff who administered certain medications.
Resident #5's controlled medication log indicated medication was not signed out/administered on a date, but the MAR documented it as administered.
Resident #1 was not educated on the right to refuse medication if a medication error is suspected.
Resident #2's support plan did not document notation of inability or refusal to sign the support plan.
Resident #2 and Resident #6 did not have timely completed written cognitive preadmission screenings prior to admission to the secured dementia care unit.
Direct care staff B and C working in the secured dementia care unit did not meet the required 6 hours of annual dementia care training during the 2023 training year.
Report Facts
Residents Served: 23
Current Residents in Hospice: 4
Residents Diagnosed with Mental Illness: 5
Residents Aged 60 or Older: 23
Residents with Mobility Need: 23
Total Daily Staff: 46
Waking Staff: 35
Deficiencies Cited: 13
Training Hours Deficiency: 2
Notice — Aug 31, 2023
Date: Aug 31, 2023
Visit Reason
The document serves to notify Chandler Hall Health Services, Inc.-Hicks that their request to waive the high school diploma or GED requirement for a direct care staff person has been granted under specified conditions.
Findings
The waiver is granted based on documentation of educational equivalency from outside the United States. The Department will review this waiver annually during inspections to ensure compliance with conditions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Harman | Bureau Director, Human Services Licensing | Signed the waiver approval letter. |
Inspection Report — Jan 4, 2023
Complaint Investigation
Date: Jan 4, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at the facility.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 31
Current Hospice Residents: 1
Total Daily Staff: 62
Waking Staff: 47
Notice — Dec 7, 2022
Date: Dec 7, 2022
Visit Reason
The document serves as an approval letter from the Department of Human Services for Chandler Hall Health Services Inc. to participate in a research study assessing the Tango Belt device for fall injury mitigation.
Findings
The Department approves the facility's request contingent on use of the submitted consent form and adherence to resident privacy and rights policies. The letter clarifies that this approval is not an endorsement and may be revoked at any time.
Inspection Report — Oct 5, 2022
Plan of Correction
Date: Oct 5, 2022
Visit Reason
The visit was conducted to review the submitted plan of correction for the facility.
Findings
The submitted plan of correction was determined to be fully implemented, and continued compliance must be maintained.
Inspection Report — Jul 7, 2021
Renewal
Date: Jul 7, 2021
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing regulations for CHANDLER HALL HEALTH SERVICES, INC. - HICKS.
Findings
The inspection identified several deficiencies including failure to post the current license inspection summary, untimely criminal background check for a staff member, unlocked poisonous materials accessible to residents, missing closet doors in a resident bedroom, damaged window shades, lack of evidence for timely submission of emergency procedures to the local emergency management agency, and failure to post emergency procedures in a conspicuous place. Plans of correction were submitted and fully implemented.
Citations (7)
License Inspection Summary dated 12/9/2019 was not posted in a conspicuous and public place in the home.
Criminal History Check for Staff A was not completed timely.
Cleaning solution labeled 'Hazard' was unlocked, unattended, and accessible to residents in the food pantry closet.
Closet doors were missing in bedroom 503.
Window shade in bedroom 410 had adhesive peeling off the window frame.
No evidence that 2019 and 2020 written emergency procedures were submitted in a timely manner to the local emergency management agency.
Emergency procedures were not posted in a conspicuous and public place in the home.
Report Facts
Residents Served: 24
Current Hospice Residents: 3
Total Daily Staff: 48
Waking Staff: 36
Notice — Jan 25, 2021
Date: Jan 25, 2021
Visit Reason
This document serves as a license renewal notification and certificate of compliance for Chandler Hall Health Services, Inc. - Hicks, confirming the facility's authorized operation as a Personal Care Home with a maximum capacity of 36 residents.
Findings
The Department has issued a regular license in response to the renewal application and advises that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal notification letter |
Inspection Report — Mar 23, 2020
Routine
Date: Mar 23, 2020
Visit Reason
The Department’s Bureau of Human Services Licensing Representatives conducted an inspection of the facility to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
No regulatory citations were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Parker | Human Services Licensing Supervisor | Signed as the Human Services Licensing Supervisor conducting the inspection. |
Inspection Report — Dec 9, 2019
Follow-Up
Date: Dec 9, 2019
Visit Reason
The inspection was a follow-up review to verify that the submitted plan of correction was fully implemented following an incident-related partial inspection.
Findings
The submitted plan of correction was determined to be fully implemented. The facility addressed training deficiencies related to resident care, medication self-administration, and falls prevention.
Citations (3)
Direct care staff person A did not receive training on meeting residents' needs as described in preadmission screening, assessment, and care plans during 2018 training.
Direct care staff person C did not receive training in medication self-administration, resident care needs, and safe management techniques during 2018 training.
Staff person C did not receive training in falls and accident prevention during 2018 training.
Report Facts
Residents Served: 28
Current Hospice Residents: 7
Total Daily Staff: 56
Waking Staff: 42
Inspection Report — Nov 15, 2019
Renewal
Date: Nov 15, 2019
Visit Reason
The document is a renewal license issued in response to the November 14, 2019 renewal application to operate the Personal Care Home Chandler Hall Health Services, Inc. - Hicks. The Department will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It is a license renewal certificate and accompanying letter confirming the issuance of a regular license.
Report Facts
Inspection Report — Nov 13, 2019
Renewal
Date: Nov 13, 2019
Visit Reason
The inspection was conducted as a renewal inspection of Chandler Hall Health Services, Inc. on November 13, 2019.
Findings
The submitted plan of correction was reviewed and determined to be fully implemented. Continued compliance must be maintained.
Report Facts
Residents Served: 30
Current Residents in Hospice: 4
Inspection Report — Nov 7, 2019
Routine
Date: Nov 7, 2019
Visit Reason
The Department’s Bureau of Human Services Licensing conducted an inspection of Chandler Hall Health Services, Inc. on November 7, 2019, to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report — Apr 24, 2019
Complaint Investigation
Date: Apr 24, 2019
Visit Reason
The inspection was conducted as a result of an incident (reason: Incident) and was an unannounced partial inspection to investigate violations related to Personal Care Homes regulations.
Complaint Details
The inspection was complaint-related due to an incident involving Resident #1. The violation concerned incomplete resident assessments and was substantiated by the findings.
Findings
Violations of 55 Pa. Code Ch. 2600 were found, specifically related to additional resident assessments and Resident Assessment Support Plans (RASP). The resident #1's assessment did not include key incidents and patterns of wandering. A plan of correction was partially implemented as of June 28, 2019.
Citations (1)
225.c Additional Assessment: Resident #1's assessment dated 12/5/18 did not include the resident's pattern of wandering into other residents' rooms or the incident where Resident #1 slapped another resident.
Report Facts
Residents Served: 33
Current Hospice Residents: 3
Staffing Hours - Total Daily Staff: 66
Staffing Hours - Waking Staff: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nora Alba | PC Administrator | Signed the Plan of Correction related to the resident assessment violation |
Inspection Report — Jan 28, 2019
Annual Inspection
Date: Jan 28, 2019
Visit Reason
The inspection was an annual licensing inspection conducted by the Department’s Bureau of Human Services Licensing on January 28-30, 2019, to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
Multiple violations of 55 Pa. Code Chapter 2600 were found related to medication administration, storage, and adherence to prescriber orders. Plans of correction were partially implemented with ongoing monitoring and staff education.
Citations (4)
2600.185(a) - The home failed to ensure a scheduled blood sugar check was performed for resident #3 on 1/1/19 at 4:30pm.
2600.185(b) - During a narcotic count on 12/16/18, staff found resident #7 was missing a dose of Lorazepam and could not determine its disposition.
2600.186(b) - On 12/4/18, resident #1 was administered Ducolax prescribed for another resident.
2600.187(d) - The home failed to follow prescriber orders for multiple residents, including incorrect dosages and missed medications.
Report Facts
Number of Residents Served: 29
Total Daily Staff: 58
Walking Staff: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nora Alba | PC Administrator | Signed multiple plans of correction and legal entity representative. |
Inspection Report — Nov 28, 2018
Routine
Date: Nov 28, 2018
Visit Reason
The Department's Bureau of Human Services Licensing representatives conducted an inspection of Chandler Hall Health Services, Inc. - Hicks facility on November 28, 2018.
Findings
No regulatory citations with 55 Pa. Code Ch. 2600 (relating to Personal Care Homes) were identified as a result of this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shawn Parker | Human Services Licensing Supervisor | Signed the inspection report letter. |
Notice — Nov 13, 2018
Date: Nov 13, 2018
Visit Reason
Notification of license renewal application and information about the Department's requirement to conduct an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application.
Report Facts
Inspection Report — Oct 24, 2018
Annual Inspection
Date: Oct 24, 2018
Visit Reason
The inspection was an annual licensing inspection conducted by the Department's Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
The inspection identified multiple violations including failure to post video surveillance signage, lack of chairs in resident rooms, inadequate lighting sources, and lint accumulation in the laundry dryer lint trap. Plans of correction were submitted and partially implemented with ongoing education and monitoring.
Citations (4)
55 Pa.Code §2600.42(s): The home had multiple cameras monitoring entrances and parking lots but failed to post a video surveillance sign.
55 Pa.Code 2600.101(j)(2): Resident room #403 A did not have a chair in the bedroom as required.
55 Pa.Code 2600.101(j)(7): The bed in room #403 A lacked an operable lamp or other source of light that can be turned on/off from bedside.
55 Pa.Code 2600.135(g)(1): There was an accumulation of lint in the lint trap of the second dryer in the laundry room, posing a fire hazard.
Report Facts
Total Daily Staff: 50
Waking Staff: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nora Alba | PC Administrator | Named as legal entity representative and involved in plan of correction implementation. |
| Youn Hie Chung | Department representative on-site during inspection. | |
| Dean Gray | Department representative on-site during inspection. |
Inspection Report — Jan 24, 2018
Annual Inspection
Date: Jan 24, 2018
Visit Reason
The inspection was conducted as part of the Department's Bureau of Human Services Licensing annual inspection of Chandler Hall Health Services, Inc.
Findings
Violations of 55 Pa. Code Ch. 2600 relating to Personal Care Homes were found during the inspection. All violations must be corrected by the dates specified on the enclosed License Inspection Summary to maintain compliance.
Inspection Report — Nov 22, 2017
Routine
Date: Nov 22, 2017
Visit Reason
The inspection was a licensing inspection conducted by the Department of Human Services on November 22, 2017, related to Personal Care Homes regulations under 55 Pa.Code Chapter 2600.
Findings
Violations were found related to blocked egress routes and prohibited procedures such as involuntary confinement and mechanical restraints. Plans of correction were submitted and partially implemented to address these issues.
Citations (2)
Regulation 55 Pa.Code 2600.121(a): Stairways, hallways, doorways, passageways, and egress routes must be unlocked and unobstructed. On 11/05/17, staff blocked an exit door with furniture preventing resident egress.
Regulation 66 Pa.Code 2600.202: Prohibited procedures include involuntary confinement, aversive conditioning, pressure point techniques, chemical restraint, mechanical restraint, and manual restraint. On 11/06/17, staff barricaded an exit door with a dresser, two chairs, and a shopping cart to prevent resident egress.
Report Facts
Number of Residents Served: 31
Number of Current Hospice Residents: 2
Number of Hospice Residents in Past Year: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nora Alba | PC Administrator | Named in plan of correction and signature on violation reports. |
Inspection Report — Nov 14, 2017
Renewal
Date: Nov 14, 2017
Visit Reason
The document concerns the renewal application and license issuance for Chandler Hall Health Services, Inc. - Hicks, a Personal Care Home, and notifies that an onsite inspection will be conducted within twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It serves as a license renewal notification and confirmation of license issuance.
Inspection Report — May 8, 2017
Complaint Investigation
Date: May 8, 2017
Visit Reason
The inspection was conducted as a complaint investigation following allegations related to medication administration at Chandler Hall Health Services, Inc.
Complaint Details
The inspection was triggered by a complaint. The violation involved a resident's medication (Lexapro) where leftover pills were found despite a recent fill. The home lacked documentation of receipt and accountability for the medications.
Findings
The facility was found to have violations related to medication management, specifically lacking documentation for receipt of prescription medications and accountability for medications given. A resident was found to have leftover pills despite medication being filled previously.
Citations (1)
REGULATION 55 Pa.Code §2600.185(b) requires procedures for documenting receipt of controlled substances and prescription medications, investigating missing medications, limiting access to medication storage, and documenting administration of medications. The facility failed to document receipt of prescription medications and accountability for medications given, as evidenced by leftover pills in a resident's medication bottle.
Report Facts
Number of Residents Served: 30
Total Daily Staff: 56
Waking Staff: 42
Number of Current Hospice Residents: 2
Number of Hospice Residents in past year: 10
Number of Residents 60 Years or Older: 30
Number of Residents with a Mobility Need: 26
Number of Residents with a Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anda Durso | Personal Care Administrator | Named in plan of correction and legal entity representative |
Inspection Report — Dec 12, 2016
Renewal
Date: Dec 12, 2016
Visit Reason
The inspection was a renewal visit conducted on December 12 and 13, 2016, as part of the Department of Human Services' annual licensing inspections for Chandler Hall Health Services, Inc.
Findings
Two violations were found related to medical evaluations and medication storage/use. The facility was required to correct these violations and maintain compliance with 55 Pa.Code Chapter 2600.
Citations (2)
Regulation 55 Pa.Code §2600.141(b)(1): Resident #1 did not have a medical evaluation completed annually, exceeding one year between evaluations.
Regulation 55 Pa.Code §2600.185(a): Resident #2's glucose 15 mg oral 40% gel PRN was not present in the home as required.
Report Facts
Number of Residents Served: 30
Number of Current Hospice Residents: 2
Number of Hospice Residents in past year: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anda Durso | Personal Care Administrator | Named in relation to violations and plan of correction |
| Lauren Kazimer | Department representative conducting the inspection | |
| Shawn Parker | Department representative conducting the inspection |
Notice — Apr 14, 2016
Date: Apr 14, 2016
Visit Reason
This document serves as a renewal notification and issuance of a regular license for Chandler Hall Health Services, Inc. - Hicks Personal Care Home following the receipt of a renewal application dated March 1, 2016.
Findings
The Department advises that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable laws and regulations. No inspection findings are reported in this document.
Inspection Report — Apr 13, 2016
Renewal
Date: Apr 13, 2016
Visit Reason
The inspection was conducted as a renewal and incident investigation of Chandler Hall Health Services Inc. Hicks facility, including licensing inspections on April 13, 14, and July 20, 2016.
Findings
Multiple violations were found related to glucometer use, fire drill evacuation, medication administration, and medication storage. Plans of correction were submitted and partially implemented with ongoing monitoring.
Citations (7)
Regulation 2600.85(a): Sanitary conditions were not maintained as Resident #2's glucometer was used to check Resident #3's and Resident #4's blood sugar on multiple dates.
Regulation 2600.132(d): During the fire drill on 8/31/15, two residents did not evacuate to a public thoroughfare or fire safe area as required.
Regulation 2600.182(c): Medication administration records for Resident #3 were not properly initialed for Ferrus Sulfate and Trazadone on 4/1/16.
Regulation 2600.183(f): Resident #4's Olanzapine 5mg medication was discontinued but still remained in the medication cart on 4/14/16.
Regulation 2600.186(a): Procedures for safe storage, access, security, and distribution of medications were not fully implemented; Resident #3's Antacid Chewable 500mg was not properly documented.
Regulation 2600.187(d): The home did not follow prescriber directions for blood sugar checks and insulin administration for Residents #2, #3, and #4, with missing or incorrect documentation.
Regulation 2600.190(a): Staff member A had not completed the required Department-approved medication administration course and annual practicum by the survey date.
Report Facts
Number of Residents Served: 30
Number of Residents Served: 32
Number of Current Hospice Residents: 3
Number of Current Hospice Residents: 2
Number of Hospice Residents in past year: 12
Total Daily Staff: 59
Waking Staff: 44
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