| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.18(c) | Individual #1's financial cash-on-hand record indicated on 9/2/18 that the individual's "money bag is short $.30, note to adjust sent to house." As defined under 6400.18(a), an unusual incident is alleged misuse or misuse of individual funds or property. The residential home was aware of the missing funds on 9/2/18 and did not orally notify the county intellectual disabilities program in which the home is located, the funding agency and the appropriate regional office of the department within 24 hours after abuse or suspected abuse of an individual. The home also never initiated an investigation into the unusual incident or submitted the incident report and its findings on the appropriate incident form that is required under 6400.18(d).
--On 10/1/18 staff recorded on Individual #1's financial cash-on-hand ledger that $9.87 was added to their total funds due to "extra found in bag due to not doing receipts properly. Re-training will be scheduled." The agency did not orally notify the county intellectual disabilities program in which the home is located, the funding agency and the appropriate regional office of the department within 24 hours after abuse or suspected abuse of an individual was identified on 10/1/18. The hoe also never initiated an investigation into the unusual incident or submitted the incident report and its findings on the appropriate incident form that is required under 6400.18(d) as well. | The home shall orally notify the county intellectual disability program of the county in which the home is located, the funding agency and the appropriate regional office of intellectual disability, within 24 hours after abuse or suspected abuse of an individual or an incident requiring the services of a fire department or law enforcement agency occurs.
| Accuracy in disbursments is important to assure that all monies are accounted for. Accountabiltiy in processes for staff will assure the safe handling of all funds and prevent any type of fraud on the part of staff. The Client Account Manager is responsible for checking individual accounts monthly. She has a policy of requiring reciepts for any expenditures over $ 10.00 , exceeding licensing standards to assure compliance. The discovery of an additional $9.87 present in the Individuals Money Bag was not properly logged into the account monthly ledger. Staff report that it was an oversight, they wanted to safely secure the money and return to log it back into the ledger but forgot. Staff could only guess at the penny error. Oversight or The single cent error may have been because vendors frequently return who coins rather than deal with pennies and the individal simply returned what they had recieved from the individual. The Supervisors have been educated on the new Financial Process (3 23 A,B Financial Process and record of training. There was no money missing but money that had been put into the back but not properly added into the total. The Incident Management Representative was contacted regarding the potential incident but after review of the incident managment process it was determined that this event did not meet the criteria for Misuse of Funds which in the bulletin is described as: "An intentinal act or course of conduct, which results in the loss or misuse of an individuals's money or personal property." Entry and addition errors do not meet this criteria. However, accuracy is important and the Client Account Manager had been clear with the support staff that there needs to be closer attention paid to the monthly ledgers. Attachment: Reference: PA ODP Incident Managment Bulletin 6000-04-01. The House Supervisors are responsilbe for assuring regular oversight. (Attachment: T-1 Supervisor Taining. The Program Specialist is responsible for assuring regulatory compliance. |
01/18/2019
| Implemented |
| 6400.22(d)(2) | On 6/29/18 Individual #1 had $75 in their cash-on-hand account, spent $16.51 at Applebees restaurant and should have had $58.49 left in their record. However according to their record, there was $58.50 left in their account. The account has been a penny off until 8/11/18.
--On 8/11/18 the individual's cash-on-hand record indicated they had $50.74 however they should have had $51.03 in their account. The account has been off by 29 cents from then until 10/1/18.
--On 10/1/18 staff indicated that $9.87 was found in the individual's cash-on-hand cash bag due to "not doing receipts properly" but did not indicate the inaccurate receipts that were logged. | (2) Disbursements made to or for the individual.
| Accuracy in disbursments is important to assure that all monies are accounted for. Accountabiltiy in processes for staff will assure the safe handling of all funds and prevent any type of fraud on the part of staff. The Client Account Manager is responsible for checking individual accounts monthly. She has a policy of requiring reciepts for any expenditures over $ 10.00 , exceeding licensing standards to assure compliance. Her focus was assuring compliance with collection of reciepts but did not hold staff accountable for errors in calculation. The Client Account Manager and House Supervisor were educated on the expected standard of this regulation. A new process was developed (Attachment: # 23 A,B Financial Process and record of Training) and all House Supervisors were educated ont he process on 12/10/2018. Additional training was provided on assuring regulatory compliance. The Program Specilaist is responsible to assure regulatory compliance. |
01/18/2019
| Implemented |
| 6400.44(b)(18) | Individual #1 has been having constipation issues since last licensing. In October 2017 the individual's doctor recommended introducing prunes/prune juice into their diet. There was no documented training that occurred for direct support staff that indicated staff were trained on increasing prunes/prune juices into the individual's diet after it's recommendation in October 2017. | The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. | Supports and services must be monitored to assure they are being provided in accordance with the orders of the physician . Current practice was for Medical Support Staff to arrange training . MSS reported that the addition of prunes / prune juice to Indivudal#1 diet was a recommendation from the indivudals psychiatrist to offset constipation that may occur as a result of a medicaion change. The suggestion was short term and ineffective because this person already had prunes and juice to her diet as a preference it was noted by physician during a visit log. The notation did not indicate the short term nature of the recommendation. Medical Support Staff have been educated on the need to clairify trial periods vs permanent change when documentating. In the future staff will be using Medical Contact logs 1-4 to identify various stages of a physician appointment (Attachment: # 38 Medical Contact Process Logs 1 - 4) This process will help DSP understanding and documentation. The House Supervisors have been educated to undersatnd the Medical contact process and assist DSP with use of the document. The Program Specialist has been educated on their role in the regulatory process. Attachment: T-2 PS / MSS Training ) They will be reviewing all documentation relevant to the indiviudal's supports. The addition of the new role of Program Specialist Supervisor will assure that all Program Specialists understand their role of coordinating the training of direct support staff. The presence of two Licensed Practical Nurses will act as additional resources for the staff in providing appropriate training. The Program Specialist is responsible for regulatory compliance. |
01/18/2019
| Implemented |
| 6400.46(f) | Staff #3 did not receive fire safety training on an annual basis; 3/31/17 and not again until 4/4/18. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Staff must receive Fire Safety Training each year in order to assure they know how to respond during an emergency. Annual is defined as less than 365 days. The training was delayed due to an ice storm and this caused that particular staff to exceed the 365 days. Human Resourse / Training are responsible for offering training in a timely manner so that delays that may occur do not cause the training to exceed the annual due date (Attachment: T-5 Human Resourse Training Log) H.R. was educated on the need to meet the identified timelines. In order to assure additional oversight Matten House created a new positon of Human Resourse Support Staff to assist with monitoring timelines. All records were review and were within annual timeframes. The Training Supervisor is responsible for monitoring all trainings to assure they are provided within regulatory requirements. Attachment: T-1 Supervisor Training. The program Specilaist is responsible for regulatory oversight. |
01/18/2019
| Implemented |
| 6400.67(a) | The bathroom sink located in the handicapped accessible bathroom was not equipped with a drain stopper. In addition, the same sink was draining very slow. | Floors, walls, ceilings and other surfaces shall be in good repair. | All the equipment in the home must be in good repair. Maintenance was unaware there was an issue and have no record of a repair order for the sink. The sink was repaired (Attachment: #36 Photo of Sink) and the drain is now draining normally. The House Supervisor was educated on the need to maintain the good repair of the home and how and when t to use a work order (Attachment: # 36 Work Order) Attachment : See Supervisor Training. Maintenance and the House Supervisor will be responsible for monitoring equipment in the home to assure it is in good repair. the Program Specialist is responsible for assuring regulatory compliance. |
01/18/2019
| Implemented |
| 6400.68(c) | The home is not connected to a public water system and did not have a coliform water test completed every 3 months; 11/14/17 and not again until 2/20/18. | A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept. | The testing of water in the home is to assure that it is staff for use by the people living there. The test was completed 11 days after its due date. The maintenance person offered no explaination why it was not completed and ultimately left this position . The current process is to complete the process every 60 days. The system is working for the current maintenance persons. All homes requiring coliform water tests were completed on 12/12/18. (Attachment: # 17 Completed Water Test. Results are reviewed by the Administrative Secretary . The Maintenance Staff has been educated on the need to maintain a strict schedule (Attachment: # T-3 Maintenance Training. The Maintenance Supervisor is responsible for assuring regulatory compliance. The Program Specialist is responsible for regulatory compliance as well. |
01/18/2019
| Implemented |
| 6400.103 | REPEAT from 8/29/17 renewal inspection: The written emergency evacuation procedure did not include the means of transportation and an emergency shelter location. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| It is important to have a clear process identified in the event of an emergency to assure that care is provided, staff know exactly where they are to go without having to get direction from a supervisor. The current policy was written without a specific emergency shelter location in order to allow administration flexibilty in deciding an appropriate emergnecy shelter on a person by person basis according to their current needs . On 12- 1-2019 the Mattern House emergency medical plan policy has been corrected to identify the specific emergency shelter location to be used. MH/ Attachment: #1 a-g) Prevention through education. On 1-9-2019 and 1-16-2019 Program Specialist and Supervisors will be educated on the need to specify the specifice emergency shelter location to be used. (MH/FT Attachment # 2 ) (MH / Attachment #3 ) All policies have been reviewed for accuracy by 12-31-18 by the Chief Executive Officer and annually thereafter. |
01/18/2019
| Implemented |
| 6400.104 | REPEAT from 829/17 renewal inspection: The home did not keep the notification to the fire department of the individuals who live in the home, their exact bedroom location since they need assistance or the location of the home current at the time of inspection on 10/31/18. The most current letter addressed to the local fire department was dated for 8/22/16 however it indicates that 4 individuals live at the home when there has only been three individuals living there since last licensing. The 2016 notification letter also indicates that the 4 individuals live at a different residential location then they currently do. There was no documentation sent with the 2016 notification letter to indicate the exact location of the bedrooms of the individuals since Individual #3 needs assistance with evacuation. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Notification to local fire companies is important to make them aware of our location and the needs of the people living there in the event of an emergency. The error appears to have been made when a completed fire notification letter was used to create the "new" letter for Blair Township. The return address infomation and the information about the indivudals in the home was correct but the address listed in the body of the text was from a different home. A corrected letter has been sent to the fire company (Attachment: #35 Fire Company Notification). The Program Specialist is responsible for fire company notifications and any changes in support levels and have been trained on their responsibilties. (Attachemnt : T-1 PS Training) The Program Specialist is responsible for notifying the Inc. team as well as the local fire company should be notified of any changes in support levels / needs in an emergecy .The Program Specialist Supervisor is responsible for review of all materials completed by the Program Specialist. |
01/18/2019
| Implemented |
| 6400.106 | REPEAT from 8/29/17 annual inspection: The oil furnace cleaned, inspected and received a filter change on 2/24/17 and not again until 3/28/8, outside the annual time frame. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Furnace's are a potential cause of fire and must be in good operating condition to assure safety. The maintenance person who was assigned this home was unable to complete his duties in a timely manner as evidenced by another citation. A review by the Program Specialist shows that the two other maintenance persons are completing the job as assigned. The maintenance person is not longer employed by Mattern House. To prevent reoccurance Furnace Cleanings have been scheduled in advance with our Service provider rather than relying on the maintenance staff to schedule. (Attachment: # 27 A,B Furnace Cleaning Schedule) The Maintenance Supervisor will monitor the furnace cleanings. Mainenance Staff have been edcated on the need to maintain the schedule. The House Supervisor , Maintenance, and Program Specialist have all been trained on the policy. Attachment: T-2 Supervisor / PS Training; T-3 Maintenance Training. Maintenance Supervisor is responsible for assuring regulatory compliance |
01/18/2019
| Implemented |
| 6400.110(a) | The two smoke detectors located in the kitchen and the hallway were not operable when the test button was engaged. The smoke detectors did operate on the interconnected system when other smoke detectors were set off in the two individual's bedrooms. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | The fire safey equiment must be in good working order to ensure safety. I contacted the maintenance staff for this home and was informed that the two detectors listed as inoperable because they did not sound are not audable alarms but flashers only. (they did flash when tested but no alarm at the time of licensing) They were installed to assist a staff with a hearing loss when the home was intially licensed. The Maintenance staff checked the fire alarm system and assured that the interconnected fire alarm did sound and was audible through the entire home. In order to prevent this error from occuring Program Specialist need to be made aware of the distinction and to add this inforamtion to the fire safety documentation. (Attachment: T-3 Maintenance Training) The Program Specialist is responsible for assuring regulatory compliance. The Maintenance Supervisor is responsible for oversight as well. |
01/18/2019
| Implemented |
| 6400.113(a) | REPEAT from 8/29/17 annual inspection: Individuals #1-#3 were instructed in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building and smoking safety procedures on 11/5/16 and not again until 11/24/17, outside the annual time frame. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Annual Fire Safety Training is important to assure a quick response in the event of a fire and for staff to have an understanding of support needs in an emergency. The House Supervisor is responsible for planning the Annual Fire Safety Training. In this situation the Supervisor of the home changed and as a result the annual training occured late. All House Suervisors were educated on the need to be aware of the Annual training date (Training: T-1 House Supervisors; T-2 PS/MSS Training ) In order to prevent reoccurance the Program Specialists are responsible for oversight of all Fire Safety Training dates and include those dates in the three month review. Fire Safety Training is scheduled for 2-2-19 and documentation will be provided. The Program Specialist Supervisor is responsible for assuring that the annual training date is met and documented. |
02/08/2019
| Implemented |
| 6400.141(c)(1) | Individual #1's 7/3/18 physical examination form did not include a review of her complete medical history. The individual has been diagnosed with cataracts since least 5/19/17 at which that appointment, 5/19/17, indicated the individual would probably need surgery in 2 years; not on physical. The individual has had noted thyroid cysts since at least 2016 and continues to need scans to monitor them which was not recorded on the physical form. The lifetime medical history that was attached to the physical form did not include all recent appointments and follow up on since last licensing. The individual had a 11/21/17 gastroenterologist appointment that indicated findings and diagnosis of rectal bleeding, history of chronic polyps, change in bowels, history of cholecystectomy, dilated bile duct, family history of colorectal cancer, primary biliary cirrhosis which were not on physical the physical form. The individual's eye exams every 6 month indicate diagnosis of cataracts, astigmatism, and history of amblyopia in right eye that are not included on the physical form. The individual's physician also indicated throughout medical appointment records that the individual is incontinent sometimes but this wasn't included on the physical form. | The physical examination shall include: A review of previous medical history. | The indivudal's physical must reflect the persons complete medical history in order for appropriate medical care to be provided. Medical Support Staff stated that it was an oversight that this information was not on the physical or in the medical history. Medical Support Staff were trained on the regulation and how to meet the requirement. (Attachment: T-2 PS/MSS Training ) Individual #1's 7/3/18 physical examination was corrected to include the following information: Review of her complete medical history, Adding cataracts to the history with the probility of surgery in 2 years. Medical History has thyroid cysts since at least 2016 and need for regular scans. Attachment: #29 A-E . The Lifetime Med History was updated to include all history and recent appointments . (Attachment: # 29 A-E) The gastroenterologist updates were included in the Lifetime Medical History. as well due to physical form limitations. The individual's eye history was added as well as occasional incontenance. Medical Support Staff and Program Specialists were trained on the regulatory requiremens (Attachment: T-2 PS/ MSS training). The Program Specialist is responsible for oversight of the Medical Support staff and their documentary requirements. In order to allow for improved quality care we have created a new position for additional Medical Support staff to allow for smaller caseload. Additional oversight will be provided by the new position of Program Specialist Supervisor. |
01/18/2019
| Implemented |
| 6400.142(f) | REPEAT from 8/29/17 annual inspection: Individual #1's dentist indicated on 11/22/17 that staff need to help the individual with brushing the individual's teeth because the individual isn't brushing their gum-line properly. The agency did not have a written plan for dental hygiene to support the individual with the type of assistance needed to achieve dental hygiene independence. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Each person who needs assistance with dental care must have a dental hygiene plan so that staff have clear and consise direction on support needs of people they provide care for. The Program Specialist stated that the lack of a dental hygiene plan was an oversight and Ind. #1 Support Coordinator has been asked to update the ISP and add the Dental Hygiene plan as a Health Promotion. (Attachement: Request to SC). In order to prevent reoccurance the House Supervisor and Program Specialist have been trained on the regulation and understand the importance of providing DSP with clear direction. (Attachment: Training PS, sup). Supervisors have been directed to notify Program Specialist of any individuals who need assistance with oral hygiene and do not have dental hygiene plans in their file. Review of all Assessments, ISP, 3 month reviews completed by the Program Specialist will be reviewed by the new position of Program Specialist Supervisor to assure they content of the documentation accurately reflect the services being provided to the people we support. |
01/18/2019
| Not Implemented |
| 6400.144 | Individual #1's 7/3/18 physical examination form indicated the individual follow a recommended diet of "high fiber diet, 1800 calories per day, <54 grams of fat per day". The agency did not start tracking the individual's dietary information until 7/6/18 and it hasn't' been consistently tracked for every meal since then. Some examples of missing information includes: dietary information was blank on 7/9/18 for dinner, blank for every meal on 7/10/18 and 7/11/18, blank for lunch on 7/13/18, blank for half of dinner on 7/13/18, the same amount of calories is recorded inaccurately when the individual has just "toast" and "toast with butter", blank for breakfast and lunch on 7/16/18, blank for dinner on 7/18/18, only days recorded for September 2018 were 9/1/18, 9/2/18, and 9/26-9/30/18, the forms don't indicate "grams" next to "fat" to indicate what staff should be measuring and recording, blank for dinner on 9/28/18, only documented two days of attempted dietary recording information for October 2018 on 10/14/18 and 10/15/18, and there was no documentation of calories or carbs or grams of fat on 10/14/18 and 10/15/18. | 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.
| It is important for staff to clearly and consistently track an indivudals diet so that their health and safety needs are met. At the present time when a new diet is prescribed the Medical Support Staff would develop the diet as prescribed, create materials for staff to use for tracking and then train staff. Because of the existing caseload at that time three days until formal start of the diet would be as fast as could be expected. Medical Support staff report that continued oversite of the diet would primarily be left to House Supervisors. In order to prevent a repeat of this regulation we have added additional oversight. 1. The Medical Support staff now have the abiltiy to seek assistance from the two new Licensed Practical Nurses to assist with diet and training which will improve the initial response time. 2. We have hired additional Medical Support Staff to reduce caseload so that quality time can be spent with indivudals and staff. 3. House Supervisors have been educated on the need to review individual diets . Attachment: T-1 Supervisor Training) 4. LPN's will be reviewing all indivudal who have diets recommended by their physician monthly and will provide immediate feedback to direct support staff to assure the diet is being adhered to.. The Program Specialist is responsible for oversight of all services being provided to people we support and will be reviewing all aspects of individuals daily life. (Attachment: T-2 PS / MS training) All foods will be logged seperately to assure accurately. In order to imporve oversight we have added the position of Program Specialist Supervisor whois responsible for regulatory oversight. |
01/18/2019
| Not Implemented |
| 6400.145(2) | The written emergency medical plan does not include the method of transportation to be used in a medical emergency. | The home shall have a written emergency medical plan listing the following: The method of transportation to be used. | It is important to have a clear process identified in the event of an emergency to assure that care is provided. The current policy was written without a specific mode of transportation (any available) because vehicles frequently change at the homes. On 12- 1-2019 the Mattern House emergency medical plan policy has been corrected to identify the specific vehicle to be used. (Attachment: # 26 Emergency Policy and Procedure BT. Prevention through education. On 1-9-2019 and 1-16-2019 Program Specialist and Supervisors will be educated on the need to specify the method of transportation to be used. Attachment: T-1 Supervisor TRaining; T-2 Program Specilaist and Medical Support Training. All policies have been reviewed for accuracy by 12-31-18 by the Chief Executive Officer and annually thereafter |
01/18/2019
| Implemented |
| 6400.151(c)(2) | --Staff #1's 9/21/18 physical form indicated that she received a chest xray in place of a Tuberculin skin test in February 2016. However the physical form did not indicate the results of her chest xray.
--Staff #2's date of hire was 8/23/17 and he did not have a Tuberculin skin testing with negative results completed until 8/25/17. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The presence of a valid TB test for all Direct Support Staff is to assure the health and safety of both the indivudal and staff. All staff new hires are required to complete Mantoux TB testing prior to reporting for work in a home. Human Resourse attempted to secure an Xray confirmation as per the regulation in the case of a positive reactor but were unfamiliar with the document, since this does not happen often, and failed to realize the results of the xray were not present. (Attachment: #34 Xray report They have been trained in the regulation and what to look for in the associated document. (Attachment: T-5 Human Resource Training ) In the case of Staff #2 , this was a scheduling miscommunication, HR scheduled his testing date and he rescheduled it without informing them. HR told scheduling the date he would be availalbe based on the original appointment. HR staff have completed training on the regulation. (see above) In order to prevent this from happening in the future we have created a new position of Human Resourse Support Staff to add additional oversight in the orientation process. |
01/18/2019
| Implemented |
| 6400.151(c)(3) | Staff #3's physician indicated on the staff's 2/21/18 physical examination form that yes "the individual possess any medical problems or communicable diseases which might pose a threat to the health safety and well-being of the individuals they serve." The physician only indicated "she is under care of dr maserati for back pain and requires upcoming surgery." The physician did not further clarify the statement to indicate if Staff #3 was free from communicable disease or the specific precaution that need to be taken to prevent the spread of the disease to the individuals. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | It is important for the health and safety of the indivudal and staff to be aware of any illnesses that could jeopardize people we support. HR staff reported that they did not notice that the physician did not indicate the status of the person with regard t communicable diseases. In order to prevent a repeat of this error the form was change to include only the question regarding communicable diseases. (Attachment: # 53 A, B Updated Staff Physicial) (Attachment: # 54 Statement for Staff #3) HR has been educated on the regulation so that all future staff physicals provide clear information. (Attachment: T-5 HR Training) |
01/18/2019
| Implemented |
| 6400.163(c) | REPEAT from 8/29/17 annual inspection: Individual #1's 7/10/17, 1/8/18, 4/2/18 and 7/2/18 medication reviews did not include the reason for prescribing the individual's psychotropic medications. Individual was supposed to be seen for their 3 month follow up medication review appointments on 10/2/17 and 10/1/18 however there was no documentation of these appointments in Individual #1's record. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | It is important to understand the reason psychiatric medications are prescribed so that the indiviudals response to the medications can be assessed. The Medical Support Staff stated that the individual saw the doctor on 1/7/19 . In order to assure that the reason medications are prescribed all MAR's will be reviewed by the Licensed Practical Nurses each month and all physician orders will be confirmed annually. (Attachment: # 33 # Month Review) All MAR include the reason prescribed (Attachment: #30 MAR) The Program Speciaiist is responsible to assure that all services are provided as per the regulations (Attachment: T-2 PS / Medical Support Training) |
01/18/2019
| Implemented |
| 6400.164(a) | Individual #1's medication administration records (mars) from September 2017 until current, November 2018, read "easy fiber add the appropriate dose (2tsp) to 4 to 8oz of beverage or soft food." The current medication label indicated "Clear Soluble fiber powder, for individuals 12 year of age and up, were to take 2 teaspoons 3x/day not to exceed 6 tsp in a day." This medication name and dosage amount did not match. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | The fiber was being administered as per the doctors orders but not as per the label. All medications, including PRN's and Over the Counters must have a doctors order. Medical Support Staff were unable to locate the order and stated it was a filing oversite and contacted the doctor for new orders. The order for the correct administration was obtained. Medical Support Staff were trained on the need to maintain doctor's orders (Attachment: T-2 Program Specialist / Medical Support Training). In order to imporve oversite of Medicaion Administation we have created two new positions of Licensed Practical Nurses who are directly responsible for all medicaion administration. All MAR's are reviewed before they are provided to staff and reviewed monthly when completed. Attachment: # 30 completed MAR) The Program Specialist has been trained to understand their role in the process to monitor all services to the indivudal including Medicaion Managment and are responsible for regulatory compliance. |
01/18/2019
| Implemented |
| 6400.165 | REPEAT from 8/29/17 annual inspection: There were numerous instances since the last annual inspection where Individual #1's medication administration record (mar) was not initialed by staff after administration of the individual's medication or medication errors entered for the missed administration. The following are examples of medication errors that were not documented and follow up action not taken: equate clear soluble fiber powder not initialed on 7/16/18, Gavilax not initialed on 7/1/18, staff included a written explanation that Gavilax was not administered on 7/2/18 at 7am, easy fiber not initialed on 7am on 6/18/18, omega 3 fish cap 100mg not initialed on 7am on 5/20/18, Quentiapine 100mg not initialed on 8pm on 4/30/18, Ursodiol not initialed on 7pm on 4/30/18, Ursodiol, Lithium Carb 300mg and Lithium Carb 150mg not initialed on 4pm on 4/30/18, Quentiapine 100mg not initialed for evening dose on 3/31/18, and Quentiapine 150mg not initialed for morning dose on 3/26/18.
--The medication label for Individual #1's over the counter Soluble Fiber indicated to administer 3 times a day. This medication was documented as administered to Individual #1 once per day. There was no documentation of a different doctor order since this was an over the counter medication. There weren't any medication errors entered for this incident.
--Individual #1's November 2018 mars listed Levothyroxine 75mcg administer at 7am, listed twice on the mars. Staff initialed as administering Levothyroxine 75mcg on both 7am spots of the mar for 11/1/18 and 11/2/18 for a total of 150mcg administered on 11/1/18 and 11/2/18. There was no indication if either of the signatures were a mistake and also no documentation of the medication error and follow up action taken.
--According to Individual #1's mar, they were prescribed Levothyroxin 25mcg 1 tablet daily. On Sunday 7/1/18, staff initialed as administering the medication, then crossed off every day from 7/1/18-7/4/18 for 7am. Then on 7/5/18 the 7am dose of Levothyroxin was crossed off but below a signature was added with an arrow pointing to 7/5/18. There was no explanation for any of the signatures with x's over them, medication errors or follow up action taken for the medication errors.
--Individual #1's Lithium Carb 300mg and 150mg was initialed as administered by staff on 4pm on 8/5/18. It was then crossed off and "h" for hold was written above the 4pm documentation on 8/5/18. There was no documentation from a licensed physician to hold the medication, documentation of the medication error or follow up action taken.
--Individual #1's Lithium Carb 300mg and 150mg, and Gavilax were noted as "h" for hold on 4pm on 9/14/18 and 9/25//18 and not administered. There is no documentation in writing from a licensed physician to hold the medication. A copy of text messages were in the individual's record but there was no indication who the texts were from, names, or phone numbers attached to the documentation. Documentation of the medication error and follow up action was not completed.
(continued on next page) | Documentation of medication errors and follow-up action taken shall be kept.
| The Medication Administration Log for Individual #1 Bisacodyl 5 mg was prescribed for being administered two days then hold for day three. On the 13th of the month there was an error in adminsitration and from that point on staff were administering two days holding on third but because of the error on the 13th , while they were administering it correctly , they were now off one day for the entire month. This error should have been caught by DSP when it occured, House Supervisor when they reviewed the MAR, the Medical Support staff , when they do a review. All staff stated the error occured because of an oversite. The House Supervisors and Medical Support Staff have been educated on proper documentation when they review an MAR (Attachment: T-1 Supervisor Training) and the Program Specialist was trained in their responsibiltiy in reviewing all documentation. There is additional training planed following review if the ISP by 2-8-19 in order to train staff on updated ISP. In order to prevent this error from occuring again we have hired two Licensed Practical Nurses to oversee Medication Management . The medications that were "Hold" were held on the order of Dr. V who prefers to text orders to Medical Support Staff and then fax the order to hold. The role of the LPN's will be to take orders directly from Dr. V in the furture and assure that all documentation is present for the correct administration of the medication. The Program Specialist is responsible for all regulatory compliance. |
01/18/2019
| Accepted |
| 6400.165 | REPEAT from 8/29/17 annual inspection: (page 2, continued from previous 165 violation)
--Individual #1 was prescribed "Bisacodyl 5mg take 1 tablet once daily for 2 days then hold for one day then restart 2 days/hold for 1 day continue cycle." This medication cycle was not administered correctly for almost the entire month of August 2018 and there was no documentation of medication errors and the follow up action taken for every instance Bisacodyl was not administered correctly in August 2018. The medication was initialed as administered to the individual on the 10th, 11th and held 12th. Then the medication was initialed as administered on 13th but also crossed out with no explanation of what occurred. The medication was initialed as administered on the 16th but also crossed out with an X over the 16th and no explanation of what occurred. The medication should have been administered on the 16th. Bisacodyl was not administered on the 19th, 22nd, 28th, 31st and should have been. Bisacodyl was administered on the 15th, 18th, 21st, 24th, 27th, 30th and it shouldn't have been.
--Individual #1's Lithium 300mg, Lithium 150mg, and Gavilax were noted on the individual's medication administration record as "h" for hold at 4pm on 7/27/18 and the medications were not given. There is no documentation in writing from licensed physician to hold the medication. The individual's record contained copies of text messages about these medications but there was no indication who the texts were from, phone numbers attached of anyone involved, or a date of when messages were sent. Medication errors were never documented and follow up action never taken. | Documentation of medication errors and follow-up action taken shall be kept.
| The Medication Administration Log for Individual #1 Bisacodyl 5 mg was prescribed for being administered two days then hold for day three. On the 13th of the month there was an error in adminsitration and from that point on staff were administering two days holding on third but because of the error on the 13th , while they were administering it correctly , they were now off one day for the entire month. This error should have been caught by DSP when it occured, House Supervisor when they reviewed the MAR, the Medical Support staff , when they do a review. All staff stated the error occured because of an oversite. The House Supervisors and Medical Support Staff have been educated on proper documentation when they review an MAR (Attachment: T-1 Supervisor Training) and the Program Specialist was trained in their responsibiltiy in reviewing all documentation. There is additional training planed following review if the ISP by 2-8-19 in order to train staff on updated ISP. In order to prevent this error from occuring again we have hired two Licensed Practical Nurses to oversee Medication Management . The medications that were "Hold" were held on the order of Dr. V who prefers to text orders to Medical Support Staff and then fax the order to hold. The role of the LPN's will be to take orders directly from Dr. V in the furture and assure that all documentation is present for the correct administration of the medication. The Program Specialist is responsible for all regulatory compliance. |
01/18/2019
| Implemented |
| 6400.167(b) | --The medication label for Individual #1's over the counter Soluble Fiber indicated to administer 3 times a day. This medication was documented as administered to Individual #1 once per day. There was no documentation of a different doctor order since this was an over the counter medication.
--Individual #1's November 2018 medication administration record (mar) listed Levothyroxine 75mcg administer at 7am, listed twice on the mars. Staff initialed as administering Levothyroxine 75mcg on both 7am spots of the mar for 11/1/18 and 11/2/18 for a total of 150mcg administered on 11/1/18 and 11/2/18.
--According to Individual #1's mar, they were prescribed Levothyroxin 25mcg 1 tablet daily. This medication was not administered at all from 7/1/18-7/4/18.
--Individual #1's Lithium Carb 300mg and 150mg was not administered by staff on 4pm on 8/5/18. It was then crossed off and "h" for hold was written above the 4pm documentation on 8/5/18. There was no written documentation, script or order from a licensed physician to hold the medication.
--Equate clear soluble fiber powder was not administered on 7/16/18 at 7am as prescribed.
--Individual #1's Lithium Carb 300mg and 150mg, and Gavilax were noted as "h" for hold on 4pm on 9/14/18 and 9/25/18 and not administered. There is no documentation in writing from a licensed physician to hold the medication. A copy of text messages were in the individual's record but there was no indication who the texts were from, names, or phone numbers attached to the documentation.
--Individual #1 was prescribed "Bisacodyl 5mg take 1 tablet once daily for 2 days then hold for one day then restart 2 days/hold for 1 day continue cycle." This medication cycle was not administered correctly for almost the entire month of August 2018. The medication was initialed as administered on the 16th but also crossed out with an X over the 16th and no explanation of what occurred. The medication should have been administered on the 16th. Bisacodyl was not administered on the 13th, 19th, 22nd, 28th, and 31st but should have been. Bisacodyl was administered on the 15th, 18th, 21st, 24th, 27th, and 30th but shouldn't have been.
--Individual #1's Lithium 300mg, Lithium 150mg, and Gavilax were noted on the individual's medication administration record as "h" for hold at 4pm on 7/27/18 and the medications were not given as prescribed. There is no documentation in writing from licensed physician to hold the medication. The individual's record contained copies of text messages about these medications but there was no indication who the texts were from, phone numbers attached of anyone involved, or a date of when messages were sent.
--The following are examples of medications that were not administered as ordered: equate clear soluble fiber powder not administered on 7/16/18, Gavilax not administered on 7/1/18, staff included a written explanation that Gavilax was not administered on 7/2/18 at 7am, easy fiber not administered on 7am on 6/18/18, omega 3 fish cap 100mg not administered on 7am on 5/20/18, Quentiapine 100mg not administered on 8pm on 4/30/18, Ursodiol not adminsitered on 7pm on 4/30/18, Ursodiol, Lithium Carb 300mg and Lithium Carb 150mg not administered on 4pm on 4/30/18, Quentiapine 100mg not administered for evening dose on 3/31/18, and Quentiapine 150mg not administered for the morning dose on 3/26/18.
--Starting at 8pm on 3/1/18, Individual #1's daily dosages of Quentiapine was administered as 150mg in the morning and 100mg at night. There is no documentation from the individual's physician in writing or from a medical staff that the individual's Quentiapine dosages were increased to 150mg in the morning and 100mg at night. The individual was originally prescribed Quentiapine 100mg twice daily. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | The Medication Administration Record must be accuratly completed to assure safe administration of medicaion. Documentation on the MAR must include clear demonstration of administration by initialing the MAR and clear explaination of any PRN admins or entry errors through use of the back of the document. When asked about the errors staff report that it is an oversite. Ind #1 has been known to refuse the Soluable Fiber which she takes with her breakfast. They wait to assure she tkes it then forget when cleaning up for breakfast. The DSP also report tha they also rely on staff marking the blister pack with day and date administered. If they see that a staff failed to initial a block they look to see if the medicaion was given. If the medicaion was still in the blister pack they file a medication error, if the blister pack indicates the medication was given they notify the supervisor. The proper documentation for Holding a Medicaion is part of the ongoing MAR retraining. The House Supervisors have been trained on proper MAR review techniques and what to do in the event of an entry error vs an administration error. (Attachment: T-1 Supervisor Training). In order to prevent the errors on the MAR Mattern House has added two new positions for Licensed Practical Nurses whos responsiblility is to review MAR monthly and to provide immediate feedback to staff. Attachment: #30 Medication Administration Records / reviewed by LPN) Any staff person who has ANY type of error on the MAR must attend a MAR retraining class which is going to be held quarterly Attachment: #31 Email with Scheduling Plan for MAR review. If House Supervisors or LPN review shows any type of mistake by staff including documentation they will need to attend the MAR refresher course held every three months. House Supervisors have been educated on the process and their responsibilty in assuring that staff who need assistance with medication administration documentation. ( Attachment: T-1 Supervisor Training) The Soluable Fiber was being administered daily. The Primary Care physician was contacted and orders were obtained. (Attachment: # 32 Fiber Orders. . Medical Support have been educated to assure that orders are obtained for all over the counter medications (Attachment: T-2 Medical Support Staff Training). The LPN's are responsible for development of policy and oversight of Medication Administration and are working to standardize all documentation. The program Specialist is responsible for assuring regulatory compliance. |
01/18/2019
| Implemented |
| 6400.181(e)(9) | Individual #1's 3/26/18 assessment doesn't include all of their documented disabilities including functional and medical limitations. Missing information included cataracts, doctor indicated in 2017 the individual potentially needs eye surgery in 2 years, thyroid cysts since at least 2016 and continues to need scans to monitor them, past rectal bleeding, history of chronic polyps, change in bowels, history of cholecystectomy, dilated bile duct, family history of colorectal cancer, primary biliary cirrhosis, astigmatism, history of amblyopia in right eye, and occasional incontinence.
-dietary restrictions/recommendations not on assessment | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | It is important to provide all document, including three month reviews, in order to keep the team inforamed on the effectiveness of services. . The Program Specialist said it was an oversight, forgetting to add Behavior Support once they joined the team. The PS have been trained on the proper documentation required at a three month review and who recieves that. They also understand that they are responsible for assuring that all team members recieve (Attachment : T-2 Program Specialist Training) The Program Specialist understand they are responsible for including the entire team in communications ( Attachment: # 2 a.Cover Letter)The Program Specialist Supervisor is responsible for reviewing all documentation and will review all completed three month reviews to assure all team members recieve the inforamtion. |
01/18/2019
| Not Implemented |
| 6400.181(e)(10) | Individual #1's assessment was completed on 3/26/18 and did not include a lifetime medical history. The lifetime medical history attached to the 3/26/18 assessment was completed by a medical staff, whom did not have the qualifications of a program specialist, on 7/3/18, four months after the completion of the assessment. | The assessment must include the following information: A lifetime medical history. | The Assessment is completed each year and is the direct line from direct support professionals to the team. A through Assessment will assist the team in developing an ISP that the team can use to support the individual. The Program Specialist responsible for this individual had no explaination for the lack of medical inforamtion in the assessment . The current practice was to have medical support staff complete an ISP and attach that document to the Assessment. Mattern House has provided training for the Program Specialist to understand their role. (Attachment: T-2 Program Specialist Training In order for a complete understanding the new Program Specialist will meet with the Team in order to develop a comprehensive assessment. The Team meeting will be held prior to 2-8-19 In order to prevent this in the future we have created a new position of Program Specialist Supervisor who responsibiltiy is to assure taht the required content is present in the ISP. |
02/08/2019
| Implemented |
| 6400.181(e)(12) | Individual #1's 3/26/18 assessment did not include recommendations for specific areas of training, programming and services. The assessment indicated "no recommendations." | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The Assessment is completed each year and is responsible for the accurate development of the ISP. The Program Specialist had medical Support staff complete the Lifetime Medical History and then attached that history to the Assessment without review. The Program Specialist has been trained on the role they play in the development of the ISP. As a Program Specialist they are resposible for reviewing and coordinating all services provided. (Attachment: T-2 PS TRaining) . The Program Specialist have included the Lifetime Medical History directly in the Assessment. (Attachment: 2 A-J Assessment.) In order to assure the role of the Program Specialist in the furture we created a new position: Program Specialist Supervisor. The Program Specialist Supervisor will review the completed assessment and will assure that all parts of the individal services are monitored. |
01/18/2019
| Not Implemented |
| 6400.186(b) | Individual #1 did not date their 4/14/18 Individual Support Plan (ISP) review. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | It is important to sign and date all documents in order to show that documentation was completed and reviewed with all parties in a timely manner. The missing date was an oversight by the Program Specialist. The PS have been trained on the proper documentation required at a three month review. (Attachment : T-2 Training. ) The next three month review for Ind # 1 is due for completion by 2-5-19 and documentation will be provided upon completion. The Program Specialist Supervisor is responsible for reviewing all documentation and will review all completed three month reviews. |
01/18/2019
| Implemented |
| 6400.186(d) | Individual #1's Individual Support Plan (ISP) reviews were not sent to either of their behavior support persons, 2 different people. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | It is important to provide all document, including three month reviews, in order to keep the team inforamed on the effectiveness of services. . The Program Specialist said it was an oversight, forgetting to add Behavior Support once they joined the team. The PS have been trained on the proper documentation required at a three month review and who recieves that. They also understand that they are responsible for assuring that all team members recieve (Attachment : T-2 Program Specialist Training) The Program Specialist understand they are responsible for including the entire team in communications ( Attachment: # 2 a.Cover Letter)The Program Specialist Supervisor is responsible for reviewing all documentation and will review all completed three month reviews to assure all team members recieve the inforamtion. |
01/18/2019
| Not Implemented |
| 6400.213(11) | REPEAT from 8/29/17 annual inspection: Individual #1's 7/11/18 physical indicated the individual should follow a "high fiber diet, 1800 calories per day, <54 grams of fat per day". The Individual's Individual Support Plan (ISP) indicates the individual should follow a low fat diet, limit desserts to once a week and eat fruit at other times as recommended Dr. Vanacore. In the fall 2017 the individual was order by their doctor to increase prune and prune juice and this was not included on the physical examination form or in their ISP. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | All documents related to the person we support must be consisten and accurate in order for staff to provide quality , safe care. The Medical Support staff completing the physical failed to provide an update to the Program Specialist and Support Coordinator when the change occured. Individual 1 is prescribed "high fiber diet, 1800 calories per day, <54 grams of fat per day". The Individual's Individual Support Plan (ISP) indicates the individual should follow a low fat diet, limit desserts to once a week and eat fruit at other times as recommended Dr. Vanacore. This information has been provided to the Support Coordinator by the Program Specialist. (Attachment: # 28 a-c Email and Track Changes) The Individual's Physical and Medical History have been updated to assure consistent information. ( Attachment: #29 Ind #1 Physical with Medical History) Blair County requests that providers complete Track Changes on the ISP. The document is over 75 pages. I have provided the Meals and eating section , the rest of the document is availble on request and includes similar updates throughout the document. Failure to provide the information was an oversight by the Medical Support. The recommendation of prunes and prune juice was not entered as a change in the ISP because it was a short term recommendation (1 week ) to see if that helped with constipation. After a short trial it was determined that it did not impact significantly partly because the individual eats prunes as a choice most mornings. There are no doctor orders for the prunes and they are not included in any upate at this time. Medical Support failed to add the short term trail and its results to the ongoing medical log and failed to specify a clear time frame for the prune trial. Clear direction to staff are critically important in supporting the individual. Medical Staff were educated on the need to update the SC and Program Specialist on permanent changes and to clearly outline "trials" and their results in a manner easily followed by caregivers. ( Attachment: T-2 Medical Support / Program Specialist Training ) The program specialist have reviewed and compared all content between physicals and ISP to assure content accuracy. In order to adequately complete this task we have added an additional Program Specialist position to allow for them to focus on quality documentation. An additional two staff have been added as Medical Support Staff in order for enough time to complete quality documentation. Mattern House has also added tow LPN positions in order for consistency in care and documentation. The Program Specialist is responsible for regulatory compliance. |
01/18/2019
| Implemented |