| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | SODA ASH, which is poisonous if ingested was stored in the laundry room which was unlocked. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Why is the regulation important?
This regulation is important to ensure that the individuals being served are protected from dangerous and poisonous substances that could easily be misinterpreted as something else.
How was the regulation violated?
Soda Ash was left in the laundry room instead of being locked up.
What caused the violation?
Manager overlooked the laundry room when doing her walkthrough and therefore did not see the Ash sitting out.
What can be done right away to fix the violation?
Soda Ash was locked up on 8/22/19 (attachment #10)
What can be done to prevent future violations?
Safety maintenance checklist that is performed on a monthly basis (minimally) by resident managers as well as program directors has been updated to include information on materials that should remained locked and inaccessible to individuals(attachment #4). This will be trained at the next admin meeting on 9/23/19 and then with all managers by 9/27/19. Training on the this regulation will occur with all staff by 9/27/19
Who will be responsible for preventing future violations?
Resident Manager and Program Directors |
09/27/2019
| Implemented |
| 6400.67(a) | The floor in the shower stall used for wheel chairs had damaged tiles. | Floors, walls, ceilings and other surfaces shall be in good repair. | Why is the regulation important?
This regulation is important to ensure that surfaces are in good repair and free of hazards in order to ensure safe environments for our individuals.
How was the regulation violated?
During the inspection at West Sadsbury, there were shower stall tiles that were damaged/cracked.
What caused the violation?
Resident manager and Program Director did not notice these damaged tiles during their safety and maintenance checks or during the site's self-assessment inspection.
What can be done right away to fix the violation?
Maintenance was notified of the damaged tiles on 9/16/19. The site has 2 wheelchair accessible showers and therefore the other shower will be used till the other shower is fixed.
What can be done to prevent future violations?
Safety maintenance checklist that is performed on a monthly basis (minimally) by resident managers as well as program directors has been updated to include information on surfaces being in good repair(attachment #4). This will be trained at the next admin meeting on 9/23/19 and then with all managers by 9/27/19.
Who will be responsible for preventing future violations?
Resident Manager and Program Directors |
09/27/2019
| Implemented |
| 6400.112(a) | There was no drill held in the month of January 2019. | An unannounced fire drill shall be held at least once a month. | Why is the regulation important?
This regulation is important because it ensures that all consumers are able to evacuate in a timely matter and that staff are able to assist as needed. It also tests the interconnected system to ensure it is working properly and the signal is being received by the Protection Bureau.
How was the regulation violated?
No fire drill was completed in January 2019.
What caused the violation?
Staff that was assigned did not complete the fire drill before the end of the month and the Resident Manager and Program Support Specialist did not notice that the drill had not been completed until the next month.
What can be done right away to fix the violation?
There is no short term solution as the drill was due January 2019.
What can be done to prevent future violations?
Managers are assigned to complete fire drills by the 3rd Monday of each month. The Manager is then to submit the Fire Drill record to the Program Director for review. The PD then forwards it to the Quality Assurance Specialist to be filed in the main office. If the PD does not have the completed fire drill by the 4th Monday of the month, the PD will follow up with the Manager to ensure the fire drill is completed and faxed in to the PD within 48 hours
Who will be responsible for preventing future violations?
Resident Mangers and Program Directors |
08/23/2019
| Implemented |
| 6400.141(b) | Individual #'2's annual physical exam was held on 5/9/19, but the doctor did not sign off on the physical until 6/6/19. The previous physical was held on 5/8/18. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Why is the regulation important?
Annual physical exams are essential to your ongoing health. Providing thorough and accurate information allows for the physician to assess, diagnosis, and treatment the individual properly.
How was the regulation violated?
The date of the appointment listed on the annual physical did not match the date the doctor wrote causing the actual appointment date to be misrepresented.
What caused the violation?
Initial physical exam was scheduled for 5/9/19 but individual refused. Appointment was rescheduled for 6/6/19 however the initial annual physical documentation was not updated to reflect this change in appointment.
What can be done right away to fix the violation?
There is no fix to this specific violation as the annual physical has already been completed.
What can be done to prevent future violations?
The annual physical has been updated and a case note report from the individuals electronic health record always accompanies therefore this information will pre-populated and reviewed by the resident manager and the kelsch nurse before the appointment to check for accuracy.
Who will be responsible for preventing future violations?
Resident Manager and Kelsch Nurse |
08/23/2019
| Implemented |
| 6400.141(c)(6) | Individual #2's last TB test was held on 4/24/17. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Why is the regulation important?
TB screening tests help to determine whether a person has become infected with Mycobacterium tuberculosis bacteria which is highly airborne. Screenings allow for immediate treatment which promote the health and safety of our individuals.
How was the regulation violated?
Individual has not had a TB test since 4/24/17.
What caused the violation?
Individual receives her TB shot on 6/6/19 during her annual physical, but then refused to go back 48 hours later to have it read. Another test was scheduled for 9/5/19 however individual refused to go to doctor.
What can be done right away to fix the violation?
Another appointment has been scheduled for 9/27/19 and alternative arrangements have been made so that if she refuses to go back to have it read it can be read by a licensed medical professional at the site.
What can be done to prevent future violations?
Meeting requested to this individual¿s team was sent on 9/19/19 due to their chronic history of appointment refusals. Mantoux screenings are tracked on the medical appointment planner form so that appointments to have these done are completed accordingly.
Who will be responsible for preventing future violations?
Resident Manager, Nursing, and Program Director. |
09/27/2019
| Implemented |
| 6400.141(c)(12) | Individual #2's last annual physical on 6/6/19 did not indicate physical limitations. | The physical examination shall include: Physical limitations of the individual. | Why is the regulation important?
Annual physical exams are essential to your ongoing health. Providing thorough and accurate information allows for the physician to assess, diagnosis, and treatment the individual properly.
How was the regulation violated?
On the annual physical the section regarding physical limitations was left blank.
What caused the violation?
This section was left blank as the information was on the accompanied case note report that comes from the electronic health record.
What can be done right away to fix the violation?
There is no fix to this specific violation as the annual physical has already been completed.
What can be done to prevent future violations?
Case notes from the individuals electronic health record is printed and accompanies the individual on all appointments. The case note includes specific medical information regarding the individual such as physical limitations, emergency information, etc . Therefore the annual physical documents were updated to reflect if that information would be available on the accompanied case note (attachment #9). Updated form was implemented and sent to all sites 8/28/19
Who will be responsible for preventing future violations?
Resident Manager, Nursing, and Program Director. |
08/28/2019
| Implemented |
| 6400.141(c)(14) | Individual #2's last annual physical on 6/6/19 did not indicate information pertinent to diagnosis in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Why is the regulation important?
Annual physical exams are essential to your ongoing health. Providing thorough and accurate information allows for the physician to assess, diagnosis, and treatment the individual properly.
How was the regulation violated?
On the annual physical the section regarding pertinent information in case of emergency was left blank.
What caused the violation?
It was assumed that if blank this communicated that there was no specific protocol outside of 911. .
What can be done right away to fix the violation?
There is no fix to this specific violation as the annual physical has already been completed.
What can be done right away to fix the violation?
There is no fix to this specific violation as the annual physical has already been completed.
What can be done to prevent future violations?
Case notes from the individuals electronic health record is printed and accompanies the individual on all appointments. The case note includes specific medical information regarding the individual such as physical limitations, emergency information, etc . Therefore the annual physical documents were updated to reflect if that information would be available on the accompanied case note (attachment #9). Updated form was implemented and sent to all sites 8/28/19
Who will be responsible for preventing future violations?
Resident Manager, Nursing, and Program Director. |
08/28/2019
| Implemented |
| 6400.143(a) | Individual #2 has had refusal for many appointments over the past year including Gynecological, psychotropic medication reviews and dental, however the refusal documentation has not met the standard of regulatory measures. Staff have documented refusals but the documentation does not indicate follow up measures that have been taken. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Why is the regulation important?
Visiting your primary care provider for regular preventive care is one of the best ways to identify and treat health issues before they get worse. These visits also help you track your progress toward your health goals therefore documentation of supports and measures being taken to help the individual are needed.
How was the regulation violated?
Documentation was not available to show the measures being taken to education individual on the consequences of her refusals or the measures the agency is taken to help the individual in regards to this.
What caused the violation?
Individual refuses appointment and the documentation fails to show the follow up and measures being taken to support health.
What can be done right away to fix the violation?
Protocol and tracking chart was created, trained, and implemented on 8/23/19 (attachment #8)
What can be done to prevent future violations?
Protocol notes the steps that staff are to take when appointments are refused. Review of this chart will be done by the program director and behaviorist and the team so that other interventions such as the involvement of PCHC and etc., are sought.
Who will be responsible for preventing future violations?
Program Director |
08/23/2019
| Implemented |
| 6400.181(a) | Individual #2's last annual assessment was completed on 10/11/18. There was no assessment prior to that in the file. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Why is the regulation important?
This regulation is important to ensure the timely assessment of individuals we serve and so the information being used to develop and update ISPs are current.
How was the regulation violated?
There was no assessment in the file for the previous year.
What caused the violation?
The program director that was responsible for the site in 2017 did not follow the policies and procedures in place regarding assessment completion.
What can be done right away to fix the violation?
The violation can not be immediately corrected as it was due over a year ago.
What can be done to prevent future violations?
An assessment tracking form is sent out to personnel involved in completing the assessment 2 months before the due date. Follow up from the Program Director and the Director of Services will occur to ensure completion of the assessment.
Who will be responsible for preventing future violations?
Clerical, Resident Manger, Program Director, and Director of Services. |
08/23/2019
| Implemented |
| 6400.181(e)(1) | Individual #2's last annual assessment dated 10/11/18 did not mention strengths. It was left blank. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | Why is the regulation important?
The regulation is important as it ensure that the ISP is taking into account all information regarding the individual and therefore supporting them properly.
How was the regulation violated?
In the individuals last assessment the section on the individual's strengths was left blank.
What caused the violation?
The current template for assessments is not a locked and completed in Microsoft Word. Due to the template not being locked as information was being inputted the document shifted moving and therefore missed.
What can be done right away to fix the violation?
This specific violation cannot be remedy as the assessment was submitted a year ago. The current program director is working on the new assessment for upcoming annual ISP meeting.
What can be done to prevent future violations?
The template that is currently used for assessments is being edited so that the textboxes are locked which will prevent the shifting of categories. This will be completed by 9/30/19 and then immediately implement.
Who will be responsible for preventing future violations?
Director of Services and Director of Residential Services. |
09/27/2019
| Implemented |
| 6400.167(b) | Individual #2's medication, FLUPHENAZINE DECANOATE INJ. 25mg was to be given every 2 weeks. The medication was given and signed for on 8/02/19 and then on 8/18/19, the medication was to be administered on 8/16/19. The agency stated the medication was given but logged incorrectly. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | Why is the regulation important?
It¿s important that medication is given as instructed by the prescribing doctor as it aids in controlling chronic conditions, treatment of temporary conditions, and overall long-term health and well-being.
How was the regulation violated?
Individual Fluphenzine decanoate inj 25 mg was prescribed to be given every 2 weeks. Per MAR it was given and signed for on 8/2/19 and then on 8/18/19 which was past the 2 week time frame.
What caused the violation?
Agency nurse documented the wrong date which resulted in the misrepresentation of when this medication was administered.
What can be done right away to fix the violation?
Nurse Kim McCarthy confirmed her schedule (Attachment #7) and it was shown on her timesheet that she had indeed been at West Sadbury to administer individual¿s injection on 8/16/19 and therefore corrected the documentation error on the MAR on 8/21/19 (Attachment #6)
What can be done to prevent future violations?
Nurse will complete additional documentation check after administration and should any documentation error occur the forms showing the response to this will be maintained in the individual record.
Who will be responsible for preventing future violations?
Nurse Kim McCarthy |
08/21/2019
| Implemented |