|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | There were a series of events documented by staff from 4/2/2020-4/7/2020 where Individual #1 was reporting ill health, refusing to perform normal daily activities usually compliant with, and fell out of bed. In response to Individual #1's declining health identified between 4/2-7/2020, the agency, Cambria Residential Services, failed to obtain medical evaluation timely and did not administer medication appropriately or in accordance with a physician's order, which constitutes neglect.
From 4/2-3/2020, Staff persons #19 - #21 documented multiple concerns, over varying shifts, in Individual #1's record stating their awareness of Individual #1's declining health described as: Individual #1 wanted to sleep most of the day, did not want to get out of bed (even at 12:30PM), she was eating very little, she now required staff to feed her which was unusual, she now was uncooperative with exercises that she was compliant with days prior, and the individual herself was reporting to staff multiple times that she did not feel well and wanted to stay in bed.
Staff person #19 documented that she contacted Individual #1's physician on 4/3/2020 due to Individual #1 not wanting to eat or drink and possibly having increased dementia symptoms. The physician suggested that staff contact the individual's neurologist for the increased dementia symptoms. There is no evidence that the individual's neurologist was contacted.
On 4/3/2020, Staff person #20 documented that Individual #1's physician stated to take the individual to the hospital if she gets any worse, regarding her reported symptoms of not wanting to eat or drink and possibly having increased dementia symptoms. During her 4/3/2020 evening shift, Staff person #20 documented that she noticed blood in the front of post-menopausal Individual #1's adult brief, Individual #1 fell out of bed, has a new "mark on her back where she may have hit the bed. 2 inch scraped open area," and is now completely unable to ambulate without assistance. Individual #1 was not taken to the hospital as instructed if symptoms worsened.
On 4/4/2020, Staff person #20 noted at 4AM Individual #1 is now experiencing explosive diarrhea, complaining, and stated that her right knee was hurting. Also, the individual needs complete assistance going to the bathroom, walking, and needs help getting into her bed.
On 4/4/2020, Staff person #19, stated that, "when {Individual #1} stood, she was unable to walk without her legs buckling under her. Staff was afraid she would fall, so got her (Individual #1) back to her bed." Inner-agency telephone calls were made to management staff on-call home supervisor, management Staff person #2, along with an addition telephone call to a UPMC nurse to see if she would come to Individual #1's home and evaluate her. Staff person #19 then obtained vitals, oxygen level, pulse, and blood pressure, on Individual #1 prior to contacting 911.
On 4/4/2020 she was treated and discharged from UPMC Altoona hospital. There is no evidence that medical personnel were notified of Individual #1 falling out of bed on 4/3/2020, her complaints of right knee pain, her new open wounds on her back from the fall, her recent change in ability to ambulate, and her feet buckling underneath her, recent change in ability to feed herself and explosive diarrhea.
Staff person #19 stated Individual #1 reports to staff that she is sore on 4/5/2020 when assisting in cleaning the individual's buttocks area. After inspection of the area, Staff person #19 documented that Individual #1 "has an open sore in her buttocks crack approximately ¾" long by ½" wide." This open wound was not reported to medical professionals or monitored further by agency staff. Staff person #19 reported that she applied Desitin cream to this specific open wound on 4/5/2020. According to Individual #1's medication administration record, Desitin to be applied topically to buttock areas of skin three times daily for skin irritation. Wound care instructions provided to the agency on 3/22/2020 were to apply Nystatin Powder to clean dry skin -- breast folds, groin and abdominal crease twice daily, and apply Aquaphor to gluteal crease twice daily. These instructions were not followed nor were additional orders obtained due to a new open wound identified.
Individual #1 was not administered her initial dose of Levaquin until 4/6/2020, when it was prescribed on 4/4/2020 to treat her Urinary Tract Infection. Staff person #19, stated she received a telephone call from someone at UPMC Altoona hospital on 4/7/2020 to discontinue the individual's Levaquin prior to administering the medication today and start Macrobid. The agency did not obtain written orders from the individual's prescribing physician of the discontinuation of Levaquin or the implementation of Macrobid, thus being unable to provide the Department with said written orders.
During the 9/1/2020 annual inspection, there was no evidence that Staff persons #4-#18, identified as working with Individual #1 over the previous year, received training, either in-person by a trainer or independent reading, in Individual #1's individual plans, specific health needs, how to operate her medical equipment (i.e. daily oxygen use), her current diagnoses, her list of allergies, her diagnosis of Dysphagia and pureed dietary needs, her multiple open wounds and skin condition that need monitored daily, her multiple falls and her physician recording on 3/22/2020 that she is at risk of high harm for falls.
Individual #1 is prescribed 3 liters/minute of oxygen daily since 5/16/18. There were no records-maintained to verify Individual #1's oxygen was administered as prescribed.
Cambria Residential Services failed to follow physician recommendations, advocate medical concerns and train staff members on the individual's current needs. The following areas of noncompliance: 6400.52c6, 6400.61a, 6400.181(e)(3)(i), 6400.181(e)(3)(ii), 6400.181(e)(7), 6400.181(e)(9), 6400.181(e)(13)(i), and 6400.181(e)(13)(ii), creates a situation conducive to injury and harm to the individual. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | Staff will be instructed to read ISP, Medical History, recent medical narratives, and instructions for operation of oxygen equipment, and to note references to specific health needs, current diagnoses, allergies, diagnosis of Dysphagia and pureed dietary needs, wounds and skin condition needs which need daily monitoring, and ambulatory needs including risk of falling. In addition, staff will be retrained on medication administration.
See attachments: #10a, #10b, #10c, #10d (pages 1-8) and #25 |
01/29/2021
| Implemented |
| 6400.22(d)(1) | Individual #1's record does not contain a property record of all personal possessions the individual owns in the home or has purchased. Staff person #3 confirmed during the 9/1/2020 onsite inspection of the home, that Individual #1's record never contained an up-to-date property record. During the onsite inspection, there were approximately 15 large, plastic, unlabeled storage bins that contained holiday decorations that Staff persons #1 and #3 reported to be Individual #1's. However, approximately 3 storage bins, not located with the other 15 large bins, were the only bins labeled as Individual #1's possessions. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | All storage bins were labeled to identify their owner.
See attachments: #11a, #11b, #11c and #11d |
12/14/2020
| Implemented |
| 6400.22(d)(2) | Individual #1's financial record was not kept up to date with exact dates of when disbursements were made to or for the individual and the amount of the disbursements, for the entire previous year from August 2019-August 2020.
Individual #1's financial record stated that on 12/8/19 $18.80 was deducted from her account and spent at KFC. However, the KFC receipt listed $21.20 was spent on 12/8/19. This error was never caught and the incorrect ending balance in her financial record continued to transfer daily.
Cambria Residential Services documented that Individual #1's December 2019 financial record was off 53$. Her financial record listed she has 21.39 left in her account at the end of December 2019 and the agency documented Individual #1 should have had $21.92. However, the agency never corrected the inaccurate financial record documented from 12/8/19 listed above, before determining an amount of money that is missing from Individual #1's record. The agency is unable to determine how much money the individual should have in her record because of this. | (2) Disbursements made to or for the individual.
| An investigation (#8733409) found that from July 2019 to 8/26/20 her in-house counts were off by a combined total of $3.04, plus an expense of $7.00 for parking on 2/6/20. Sylvia was reimbursed $10.04 on 9/16/20. Staff were retrained on the need to diligently count funds once per shift, not assume previous balance is correct, double check math, and to report to supervisory staff if balance does not match count, as well as not to use individual's funds to pay for parking.
See Attachments: #12a (pages 1 ad 2), #12b, #12c and #12d |
09/18/2020
| Implemented |
| 6400.22(f) | On 8/27/2020 Program Specialist, Staff person #3, reported to the Department that it's a standard practice for any staff in the home, if they are off on money counts with the amount of money that should be in the individuals' home accounts, staff are to use a communal jar of coins at the house to add back into the individuals' monies to make the balances match.
This practice was evidenced when reviewing Individual #1's financial records. As described in 6400.22(d)(2), there was numerous occasions where the total sum of the individual's spending monies was incorrectly documented in her financial record, yet her spending money counted onsite, matched the incorrect financial record. | There may be no commingling of the individual's personal funds with the home or staff person's funds. | Staff instructed to discontinue use of spare change container to supplement funds when counts do not match balance and to report to supervisory staff any instance when counts are off, no matter how small the amount. Any discrepancies will be reimbursed by CRS.
See Attachment: #13 |
12/18/2020
| Implemented |
| 6400.61(a) | Individual #1's staff and physicians have noted a decline in the individual's ability to see, ambulate, and comprehend her surrounding due to diagnosis of Dementia, vision impairment (blurred vision near and far reported to her optometrist on 3/19/19 and 6/12/2020), Arthritis in her hip, risk of falls, Osteoporosis, and Kyphoscoliosis. Individual #1's physicians also provided the home with a "fall prevention in the home" checklist in January and June 2020, which indicates what the home should do to ensure the individual can safely move about her home. During the 9/1/2020 inspection of her home, there were many items from the "fall prevent in the home" checklist that were not being implemented by the home. The checklist stated to remove non-skid mats from bathrooms, avoid having rugs and uneven surfaces in the home and outside of the home, steps should have handrails on both sides of the steps, and do not use oversized bedding that drapes onto the floor. During the inspection, many rugs and uneven surfaces were placed throughout the home (front entrance, living room, dining room, kitchen, bathroom) that created tripping hazards, the individual's comforter on her bed draped to the floor on the lower, left side of her bed (closest to her closet), and a handrail was not equipped on both sides of all the steps in and outside the home
Additionally, the individual was assessed to be unable to navigate steps and many steps were found at all egresses of her home making her entrance and exit from the home extremely difficult. There was a step leading into the front entrance of her home, multiple steps leading out the back egress of her home, and steps leading into the garage and a step up leading from garage to outside egress; a ramp or ease of incline was not found at the home. | A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. | All rugs, non-skid mats, and individuals comforter were removed on 9/30/20. As to steps, a contractor will be contacted to assess each stair or step location and rails will be installed. In the meantime, individual will continue to always be assisted by staff when egressing the home. She will be moving from Third St to an assessable home by 1/31/21.
See Attachments: #14a, #14b, #14c, #14d, #14e, #14f and #14g |
01/31/2021
| Implemented |
| 6400.67(a) | The living room carpet contained many black stains over the entire carpeted area. | Floors, walls, ceilings and other surfaces shall be in good repair. | : New flooring, including the carpeting cited, has been agreed upon with a flooring installer. Agency is waiting for COVID numbers to decline before scheduling removal and installation, preferring at this time not to have a crew of outsiders in the home which would increase possibility of infection.
See Attachment #15 |
03/31/2021
| Not Implemented |
| 6400.112(c) | During the 9/1/2020 inspection of the home, two smoke detectors were located on the first floor of the home that were not included in the interconnected fire alarm system. Staff person #1 reported that the two additional smoke detectors (one in kitchen and one near individuals' bedrooms) were not tested on a monthly basis to ensure they are working. All smoke detectors and fire alarm systems must be checked every month to ensure operability in the event they are needed for emergency situations. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Battery operated detectors which were not included in the interconnected fire alarm system were removed.
See attachments: #16a and #16b |
12/09/2020
| Implemented |
| 6400.141(a) | Individual #1's physical examinations were not completed on an annual time frame. She had a physical examination completed on 12/4/18 and not again until 12/23/19. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Physical examination is scheduled on 12/28/20.
See attachment: #17 |
12/28/2020
| Not Implemented |
| 6400.141(c)(1) | Individual #1's 12/23/19 physical examination record does not include a review of her medical history, complete list of diagnoses, and past surgeries that are imperative to know to provide care. Her physical examination record did not include her diagnosis of Lymphocytic Colitis that she's been diagnosed with since 6/21/19, internal hemorrhoids that require colonoscopies, and Lichens Sclerosis. | The physical examination shall include: A review of previous medical history. | Lymphocytic Colitis, internal hemorrhoids, and Lichens Sclerosis are now noted on the pre-populated physical exam form for physical exam scheduled on 12/28/20.
See attachment: #18a (pages 1-5) |
12/28/2020
| Not Implemented |
| 6400.141(c)(7) | Individual #1's 12/23/19 physical examination record did not include if she had an annual gynecological exam to include a PAP smear and breast exam annually, or if the individual's physician did not recommend the tests. The fields on the physical examination record were left blank. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Physical examination is scheduled on 12/28/20.
See attachment: #17 |
12/28/2020
| Implemented |
| 6400.141(c)(13) | Individual #1's 12/23/19 physical examination did not include a comprehensive list of Individual #1's allergies or contraindicated medications that were documented throughout her record. According to her kidney specialist on 10/1/18, Individual #1 needs to continue to abstain from over-the-counter NSAIDS due to the individual only having one kidney and her diagnosis of kidney failure. This information was not included on her physical examination record.
Individual #1's 8/29/18 pulmonary medical record includes allergies to Vancomycin that was not included on her physical examination record. | The physical examination shall include: Allergies or contraindicated medications. | Allergies and contraindicated medications, including instruction to abstain from over the counter NSAIDS and allergy to Vancomycin, are now noted on the pre-populated physical exam form for physical exam scheduled on 12/28/20.
See attachment: #18a (pages 1-5) |
12/28/2020
| Implemented |
| 6400.141(c)(15) | Individual #1's 12/23/2019 physical examination record did not include her dietary needs. Per her 9/1/19 and 8/9/2020 assessments, she is diagnosed with Dysphasia and Acid Reflux and requires a pureed diet and uses Thick-it to prevent aspirations. Her 2019 assessment states she requires the use of Thick-it in all liquids to be a honey thick consistency. Her 12/23/2019 physical examination record only stated she should follow a low-fat diet and use Thick-it to thicken all liquids to honey thickness for Dysphasia. A medical form from 10/15/2019 stated she was to continue to follow a low salt diet. This was not included on her 12/23/2019 physical examination. | The physical examination shall include:Special instructions for the individual's diet. | Dietary needs, including low sodium diet and pureed requirement, are now noted on the pre-populated physical exam form for the physical exam scheduled on 12/28/20.
See attachment: #18a (pages 1-5) |
12/28/2020
| Implemented |
| 6400.144 | During the August/September 2020 annual inspection, there were numerous occasions where Individual #1's health services, such as medical, nursing, dental, dietary, pharmaceutical and psychological services that were planned or prescribed for the individual and not arranged for or provided to the individual by the agency, Cambria Residential Services. The following are examples of the agency's failure to provide health services to Individual #1.
· On 3/18/2019, Individual #1's Pulmonologists states the individual was seen for Restrictive Lung disease due to Kyphoscoliosis and chronic respiratory failure with hypoxia and prescribed oxygen at 3 liters/min via nasal cannula continuously. The agency's current 8/9/2020 assessment of the individual confirms that she has been prescribed this oxygen order since 5/16/18. There is no evidence that the individual is utilizing her oxygen continuously or at the prescribed dosage.
· Individual #1 was seen by her Pulmonologist on 3/18/19 and was to return in a year around 3/18/2020. She was not seen again until 6/24/2020 with no evidence why the appointment was not completed within the annual time frame.
· On 6/11/19 the individual's Kidney specialist and on 10/15/2019 her Nephrologist stated that the individual is to continue monitoring her blood pressure once daily. There is no evidence the individual's blood pressure was monitored daily by the home in March 2020 or September 2019. On 10/20/19, Staff person #19 recorded that Individual #1's blood pressure was 186/86 but that "this number might not be accurate due to the individual moving." Individual #1's blood pressure reading wasn't attempted to be obtained again after staff concern of the documented numbers.
· On 10/25/19, Individual #1's Nulton Diagnostic medical assessment of the individual states that the patient (Individual #1) needs further assessment and referred to their PCP (Primary Care Physician) or a qualified professional in the area of fall risk assessment. At the time of the 8/27/2020 inspection, there is no evidence that the home followed up with the individual's PCP or other qualified professional to have a fall risk assessment completed for the individual.
· The agency's quarterly summary of appointments for Individual #1 states on 1/10/2020 the individual was seen at Conemaugh Urology for an ultrasound and is to be seen again on 3/20/2020. The individual's 3/20/2020 follow up appointment was cancelled due to a hospitalization and the agency reported they will reschedule the appointment later. At the time of the 8/26/2020 annual inspection, there was no evidence that the individual's return Urology appointment was attempted to be rescheduled.
· Individual #1's discharge instructions from her hospitalization from 3/17-22/2020 states she is to apply Nystatin powder to clean dry skin, her breast folds, groin and abdominal crease twice daily then apply Aquaphor to gluteal crease twice daily. There was no evidence of this being administered as prescribed.
· Individual #1 was seen by a gynecologist on 4/8/2020. According to Staff person #2 on 4/8/2020, the individual's gynecologist wants Pimecrolimus ointment to be used two times weekly for her Lichen Sclerosis Et Atrophicus diagnosis. There is no evidence that this medication was administered as ordered or recommended.
· The agency reported that the individual saw her podiatrist on 5/7/2020 and was to return on 7/9/2020. There is no evidence the individual returned to her podiatrist on 7/9/2020 or that there is an appointment scheduled in the future.
· The individual's Gastroenterologist instructed staff on 6/8/2020 to keep a log of the individual's weight weekly, due to the gastroenterologist's concern of the individual having a 20-pound weight loss in the last 4 months. The physician also stated that if there wasn't improvement with her weight, they would consider an EGD (Esophagogastroduodenoscopy). There is no evidence that the home was monitoring and keeping a log of the individual's weight weekly.
· On 6/29/2020, Staff person #19 recorded that Individual #1's physician feels that the individual's lack of interest in eating recently is due to her worsening Dementia. The physician recommended that staff should monitor Individual #1's eating and if the lack of eating were to worsen, the physician might need to add a supplement. There is no evidence that staff are monitoring Individual #1's food intake.
· In 2018 the individual's physicians documented they wanted to look into the option of a feeding tube due to her diagnoses of Dysphagia, Aspiration Pneumonia, and lung disease that could be caused by the continued Aspiration Pneumonia. The follow up information regarding the physician's recommendation after tests were ran, was never provided to the department.
· Per Staff person #1 during the annual inspection, Individual #1 currently has an open wound in her groin area. There is no evidence that the home is monitoring this open wound or attempted to have the individual seek medical attention for the open wound. After instruction from the Department, the individual was seen on 9/8/2020 by her Gynecologist for a skin evaluation of her open wound. Her gynecologist documented that the individual "has known Lichen Sclerosis, has open blisters in outer perineal area where adult brief appears to rub, 2 small open blisters on right outer buttocks area, one about ½ cm and one about ¼ cm, left outer buttocks open blister area about 2 cm, and recommended caregiver (agency) to have patient do frequent position changes and at night sleep without adult brief on an absorbent pad to avoid irritation from adult brief."
· Individual #1 is prescribed Loperamide and Diphen/Atrop medications as needed for diarrhea/loose stools, Fiberlax as needed for constipation, and GNP Best Fiber Supplement daily for stool regularity. She is diagnosed with constipation, diarrhea, Crohn's disease, Primary Sclerosis Cholangitis, Colitis and had a precancerous polyp removed from her colon in June 2019. There is no evidence that the home is monitoring the individual's bowel movements daily to determine if any of her medications above need to be administered as prescribed. | 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.
| Pharmacy was requested to include oxygen on the MAR, which is to begin 1/1/21. Pulmonologist appointment scheduled on 3/18/20 was rescheduled for 6/24/20 because individual #1 was hospitalized from 3/17/20 to 3/22/20. Blood pressure has been taken four times daily since 9/15/20. A fall risk assessment is scheduled with PCP on 12/28/20. An appointment is scheduled with urologist for 1/25/21. Medication administration training is scheduled regarding references to Nystatin power and Pimecrolimus ointment. Reference to language on guardian referral form being attributed to physician has been addressed. Name, address, and phone number of acting consent person is noted on Emergency Medical Information form. Individual seen by podiatrist on 12/18/20. Weight chart was begun on 12/9/20. Food intake has been charted since 9/3/20. On 10/21/20 physician reaffirmed there is no need for feeding tube. As noted in additional information for incident #8737587, staff ask individual #1 to sleep without adult brief, but she either refuses or puts brief back on later. While physician did not recommend charting bowel movements, bowel movement records began being kept on 9/30/20.
See attachments: #19a, #19b (pages 1 & 2), #19c, #19d, #19e, #19f, #19g, #19h (pages 1 & 2), #19i, #19j, #21a, #21b and #25.
MAR with oxygen written in lieu of printed MAR from pharmacy, EIM summary noting hospitalization from 3/17/20-3/22/20, blood pressure chart, memo scheduling medications administration training, guardianship referral form from physician, Emergency Medical Information form, podiatrist notes, weight chart, food intake chart, statement from physician regarding feeding tube, EIM summary of 9/1/20 ER visit with reference to adult briefs, bowel movement chart. |
12/18/2020
| Implemented |
| 6400.181(e)(3)(i) | Individual #1's 8/9/2020 assessment does not include her current level of functional skills. Her current assessment states she has no trouble expressing her needs, wants like and desires and can hold appropriate conversations, she can complete the following with minimal prompts: most hygiene tasks, getting dressed, placing dirty clothes in laundry basket, getting her shoes on, pick out out snacks, etc. However throughout the past year, staff have continued to document that Individual #1 will ask staff their name multiple times each shift because she can't recall who they are, is showing a lot of confusion and unable to comply with simple requests, and has forgotten how to complete simple tasks like following 1 step directions and putting on her socks, having trouble reporting health concerns, throwing depends in the laundry basket, can't feed herself, etc. According to her hospital discharge paperwork on 3/22/2020, she is "high harm" for fall risk and requires assistance in grooming, bathing, dressing, toileting, transfers, home ambulation, stairs, curbs and ramps. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. | Skill assessment was updated to include current level of performance and progress in the area of functional skills regarding dementia.
See attachment: #20 (pages 1-15) |
12/09/2020
| Implemented |
| 6400.181(e)(3)(ii) | Individual #1's 8/9/2020 assessment does not include her current level of communication skills. Her current assessment states she has no trouble expressing her needs, wants like and desires and can hold appropriate conversations. However throughout the past year, staff have continued to document that Individual #1 will ask staff their name multiple times each shift because she can't recall who they are, is showing a lot of confusion and unable to comply with simple requests, and has forgotten how to complete simple tasks like following 1 step directions, putting on her socks, and having trouble reporting health concerns. Her physician documented on 4/29/2020 that "{Individual #1} is nonverbal, unable to answer, she doesn't have good understanding of questions, and that she is totally impaired in her capacity to receive and escalate information effectively and to make and communicate decisions concerning her management of financial affairs or to meet essential requirements for her physical health and safety." | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. | Skill assessment was updated to include current level of performance and progress in the area of communication regarding dementia.
See Attachment: #20 (pages 1-15) |
12/09/2020
| Implemented |
| 6400.181(e)(7) | Individual #1's 8/9/2020 assessment does not include her ability to move away from heat sources. Her assessment states if water from her shower would be too hot, she is not aware to move out of the way and to add cold water. Her assessment also states due to her gross motor skills, she would move out of the way of hot water. These are contradictory statements that do not assess or define her ability to move away from a heat source. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | Skill assessment was updated to include current level of performance and progress in the area of ability to move away from heat sources, specifically hot water.
See attachment: #20 (pages 1-15) |
12/09/2020
| Implemented |
| 6400.181(e)(9) | Individual #1's 8/9/2020 assessment does not include her medical limitation regarding her severe reaction to caffeine. Per her 6/12/2020 vision exam, she has a reaction of anaphylaxis from caffeine. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | Skill assessment was updated to include reaction to caffeine of anaphylaxis.
See attachment: #20 (pages 1-15) |
12/09/2020
| Implemented |
| 6400.181(e)(13)(ii) | Individual #1's 8/9/2020 assessment does not include the individual's current level of motor skills. Her current assessment states she has fair motor skills and does not need the following: gait belt, wheelchair, walker, cane, etc. However, she was taken to medical appointments in June and August 2020 in wheelchairs.
Staff person #3, creator of the assessment, reported on 8/26/2020 that Individual #1 needs a wheelchair sometimes for long distances, he was unaware if Individual #1 required the use of a wheelchair daily, and he would let it up to staff discretion to determine if Individual #1 required a wheelchair daily- instead of assessing her. Staff person #1 stated on 9/1/2020 that Individual #1 cannot safely go up and down steps. According to her hospital discharge paperwork on 3/22/2020, she is "high harm" for fall risk and requires assistance in grooming, bathing, dressing, toileting, transfers, home ambulation, stairs, curbs and ramps. In January and June 2020 physicians provided the agency with fall prevention documents to put in place in the home due to her inability to maintain motor function around the home. None of the documented decline in motor skills were addressed in the individual's current 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: Motor and communication skills. | Skill assessment was updated to include current level of performance and progress in the area of motor skills regarding the use of a wheelchair for longer distances.
See attachment: #20 (pages 1-15) |
12/09/2020
| Implemented |
| 6400.211(b)(3) | Individual #1's record does not contain the name, address, or telephone number of the person able to give consent for emergency medical treatment. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| The emergency medical information was reviewed on 1/21/20 and again on 12/10/20. The designated consent persons name, address, and phone number is included.
See attachments: #21a and #21b |
12/10/2020
| Implemented |
| 6400.216(a) | REPEAT from 10/16/2019 annual inspection: Individuals' #1-#3's financial records, medication records, and incoming mail was not kept locked when unattended during the 9/1/2020 inspection of the home. Per staff in the home, the individuals' record information mentioned, is stored in open trays/bins on the kitchen peninsula, unlocked at all times. | An individual's records shall be kept locked when unattended.
| Trays on kitchen counter no longer contain individuals financial records, medication records, or mail.
See attachments: #22a, #22b, #22c and #22d |
12/15/2020
| Implemented |
| 6400.34(a) | The Department issued updated, regulatory individuals' rights for 55 Pa. Code Chapter 6400 on 2/3/2020, effective immediately. At the time of the 8/26/2020 annual inspection, there is no evidence of the date that Individual #1 has been informed of her regulatory rights defined in § 6400.32.(a)-(v). | 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. | : Individual regulatory rights were updated to include all the rights according to regulations. Individuals rights were reviewed with all individuals in the agency.
See attachments: #23a, #23b, #23c and #23d |
10/21/2020
| Implemented |
| 6400.52(c)(6) | There were 15 staff, staff persons #4-#18, identified as working with Individual #1 over the previous year and there is no evidence of them receiving training, either in-person by a trainer or independent reading, in Individual #1's individual plans, specific health needs, how to operate her medical equipment (i.e. daily oxygen use), her current diagnoses, her list of allergies, her diagnosis of Dysphagia and pureed dietary needs, her multiple open wounds and skin condition that needs monitored daily, her multiple falls and her physician recording on 3/22/2020 that she is of high harm for fall risks. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Staff will be instructed to read ISP, Medical History, recent medical narratives, and instructions for operation of oxygen equipment, and to note references to specific health needs, current diagnoses, allergies, diagnosis of Dysphagia and pureed dietary needs, wounds and skin condition needs which need daily monitoring, and ambulatory needs including risk of falling.
See attachments: #10a, #10b, #10c and #10d (pages 1-18) |
01/29/2021
| Not Implemented |
| 6400.163(a) | Individual #1's August 2020 medication administration record (mar) states she is prescribed Ipratropium Solution, inhale 3 ml by nebulization at 8:30am, 2:30pm, 8:30pm for breathing problems. The medication vials of solution were not kept in their original labeled container. The plastic package/bag that contained all the individual vials of solution was removed from the original labeled container, the top of the plastic package/bag was cut off and the vials were stored in the opened plastic bag. Once stored like this, the packaging did not include the name of the individual who the medication was prescribed for, the dosage, the route of administration, the prescribing physician, the name of the pharmacy that dispensed the medication, the date it was dispensed, or any other identifying information. Staff person #1 confirmed during the annual inspection that the Ipratropium Solution is always stored like this. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Ipratropium nasal solution was returned to original container and remains kept in its original container. Staff will be retrained in medication administration to be completed 1/29/21.
See attachments: #24a, #24b and #25 |
12/11/2020
| Implemented |
| 6400.165(b) | Staff person #1 provided an 8/21/2020 order for the individual's Calcium Polycarbophil (Fibercon or Fiberlax) tablet to be administered 625 mg tablet daily. However, this order does not match the order on the medication label itself, that was dispensed on 6/23/2020, stating to administer 625mg orally as needed for constipation. Also, the current order to administer 625mg daily did not match the written instructions for the medication documented on the individual's medication administration record (mar); which stated to administer one tablet as needed on 3rd day if no bowel movement.
The pharmaceutical script attached to Individual #1's December 2019 mar states Diphen/Atrop tablet is to be administered orally three times daily. The medication was administered three times daily until 12/11/19 when a staff member recorded there was a dosage change. The medication then was documented as being administered twice a day from 12/12/19-12/31/19. The agency did not have evidence of the current order of the medication, or the physician's order when the medication changed.
The individual's August 2020 mar stated to mix 2 teaspoons of GNP Best Powder Fiber into 8 ounces of liquid and take orally daily for regularity. However, the agency never provided the medication to the Department inspectors to examine the medication label or a current physician's order documenting how to administer it. | A prescription order shall be kept current. | Staff will be retrained in medications administration, including ensuring that orders and medication labels match.
See attachment: #25 |
01/29/2021
| Not Implemented |
| 6400.165(c) | The Individual's 3/22/2020 hospital discharge instructions and current, 9/4/2020 physicians record state Zinc Oxide is to be applied to buttock area three times a day and may reapply if it gets wiped off. Per Individual #1's August 2020 medication administration record (mar), this medication is not being administered at all.
Individual #1 is prescribed Ipratropium Albuter solution to inhale 3ml by nebulization at 8:30am, 2:30pm, and 8:30pm for breathing problems. This medication was not administered on 12/31/19 at 8:30pm.
Staff person #1 provided the Department with the individual's physician's order to administer Calcium Polycarbophil (Fibercon or Fiberlax) 625mg tablet once daily, starting 8/21/2020. This medication was not administered daily from 8/21/2020 until the end of August 2020.
Staff person #19 recorded on 4/5/2020 that Individual #1 "has an open sore in her buttock crack approximately ¾ inches long by ½ inch wide. Reapplied her Desitin Cream." According to the Desitin medication, it is to be applied topically to buttock area of skin three times daily for skin irritation. This medication was administered on an open sore and it is not prescribed to be used on an open sore. | A prescription medication shall be administered as prescribed. | Staff will be retrained in medications administration, including administering medication as prescribed, both prn and chronic.
See attachment: #25 |
01/29/2021
| Implemented |
| 6400.165(g) | REPEAT from 10/16/2019 annual inspection: According to Individual #1's 10/25/2019 Nulton Diagnostic assessment, her mental health diagnoses being managed at this appointment is Adjustment Disorder with disturbance of conduct, Unspecified Dementia without behavioral disturbance, and Unspecified Psychosis. The reason for prescribing her psychotropic medication was only documented as "mental health" on the following medication reviews: 1/10/20, 3/27/20, and 6/19/20.
Individual #1's 1/10/2020 medication review does not include the need to continue her psychotropic medications. The field was left blank.
There is no written review of the individual's Seroquel medication review with a licensed physician on 3/27/2020 and 6/16/2020 that documented their recommended prescribed dosage, reason for prescribing the medication or the need to continue the medication. There is no evidence of the agency attempting to obtain written record of the required contents (reason for prescribing the medication, the need to continue the medication and the necessary dosage). | 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. | Quarterly Psychiatric/Psychotropic Drug Review was prepopulated to include reason prescribed, need to continue, and dosage.
See attachment: #26 |
12/17/2020
| Implemented |
| 6400.166(b) | Individual #1's 8/22/2020 and 8/23/2020 mar documented that Staff person #10 administered Oysco supplement to the individual at 3:30pm on both days. Staff person #10 then documented on 8/23/2020, they recorded their initials in the wrong box for administration of Oysco supplement to Individual #1. Staff person #19 crossed off Staff person #10's initials on 8/22/2020 and wrote theirs. There is no evidence that when Oysco was administered to the individual on 8/22/2020, the name and initials of the staff person administering the medication was immediately documented due to the discrepancies documented by staff. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Staff will be retrained in medications administration, including entering initials in correct box on MAR and correction of documentation errors.
See attachment: #25 |
01/29/2021
| Not Implemented |
| 6400.181(f) | REPEAT from 10/16/2019 annual inspection: There is no evidence that Individual #1's 8/9/2020 assessment was sent to herself or any of her team members. According to her assessment, the fields that denotes who and when the assessment were sent to, were left blank. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Skill assessment was updated on 12/9/20 to include addendums. Recipients of assessment are noted on page 15.
See attachments: #20 (pages 1-15) and #27 |
12/09/2020
| Implemented |
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