| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | Individuals #1 and #2 had fire safety training on 4/24/15. At the time of licensing on 7/21/16, they had not received annual fire safety training yet. | 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. | Corrective Action: On 8-2-16 Fire Safety training was conducted for individuals #1 and #2 immediately . Documentation of training is secured in the fire drill book. (ATTACHMENT: EM-9A-C; EM-10A-C). Prevention: We want to create a network of persons who are aware this must be completed annually. The dates of the annual training have been added to the Administrative Assistance Outlook calendar. Supervisor and Program Specialist have / will complete training to understand their regulatory responsibilties. ATTACHMENT: T-1A, T-1B . |
12/13/2016
| Implemented |
| 6400.144 | Individual #2 was prescribed Nystatin 100000 susp twice a day as needed. The medication was not available in the home.
¿Individual #2 was prescribed Floucinonide .5% sol twice a day as needed and the medication was not in the home.
Individual #1, was prescribed (the name of medication was unable to be determined) ¿hemorrhoid ointment use 4x¿s daily prn¿ and the medication was not available in the home.
1.Individual #1's Metronidazole 75% cream to be applied to face at bedtime as needed was not available in the home.
2.Individual #1's Topirmax oint twice daily as needed for redness in eyes was not available in home.
3.Individual #1's Tessasion pearls medicine, give every 8 hrs as needed for cough was not available in the home. | 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.
| Analysis: Review of all of Individual #2's medications, creams, and supplements showed that up to date MAR's were not kept and that Medication that were no longer in use were never removed from the MAR. MAR's were produced by the LPN at the home. Corrective Action to Fix: Individal #2 and her family elected to have all medications and necessary forms provided by a local Pharmacy that is familiar with 6400 regulations. All medications were reviewed with her doctor and a comprehensive Mediation Administration Record has been produced by the pharmacy. Newly trained staff understand how to enter New Orders use the MAR appropriately. ATTACHMENT: 8A,8B, 8C. Reviews showed that Nystatin 100000 was not a medication that Ind. 2 was using, it was never removed from the MAR. The Supervisor and Program Specialist understand their responsibiities in monitoring medicaitons and have / will complete the appropriate training. ATTACHMENT: T-1A, T-1B |
12/13/2016
| Implemented |
| 6400.164(a) | Individual #2's July 2016 medication logs indicated the medication Senakote 50mg, 1 tablet, was to be administered twice a day. The medication label for Senakote indicated 1 tab, 50mg, every day as needed.
¿Individual #2's Clydamicine 1% gel medication label indicated to apply to affected area twice per day. The July 2016 medication log indicated apply twice a day as needed.
¿Individual #2's July 2016 medication log indicated the medication ¿black drawing salv¿ was prescribed. The actual medication tin said ¿krestol salv.¿
¿Individual #2's Topirmax oint indicated to apply to both eyes at bedtime. The July 2016 medication log for him/her indicated to apply twice a day as needed.
¿Individual #2's May 2016 medication log indicated he/she was taking, ¿allergy 10mg 1 tab qd.¿ The actual medication being administered is Loratidine 10mg once per day for allergies.
Staff #1 administered medication to Individual #1 on 7/21/16 and his/her full name was not indicated anywhere on the medication administration record or a master list.
¿Individual #1's July 2016 medication log indicated the medication Acetaminophen 325mg was to be administered 2 tablets every 4 hours as needed. The medication label indicated the medicine was Pain and Fever 325mg.
¿Individual #1's July 2016 medication log indicated "amoisture ipm oint" was prescribed. The medication label indicated that the medication was a Sooth Night ointment 4gm.
¿Individual #1's July 2016 medication log indicated that the medication Triamycalon .025% cream was to be applied to face as needed for dryness. The label indicated the medicince was to be applied to face twice a day as needed, not more than 7 days at a time.
¿Individual #1's July 2016 medication log indicated a medicine ¿ayr¿ was to be administered 2-3 drops in both nostrils 3-4 times per day. There medication log did not include a dosage. The medication label indicated "ayr .65 spr" place 2 drops in each nostril 3-4 times as needed. | 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. | Fix : All medications were reviewed and a new and complete MAR is being used. Prevention for Future: The LPN responsible for the medications in the home is no longer employed here. The team reviewed Individuals #1 & #2 to identify issues. Multiple pharmacies as well as lack of review for added medications was occuring. The new process is that ALL medications are processed at the same pharamcy, the pharmacy is familiar with our regulatory requirements, and all staff and family understand that all medications and supplements must be approved by the Individuals Physician first. Attachment : Training 1 To assure consistency we explained the process to a very involved family member. Attachment - EM-5 |
11/18/2016
| Implemented |
| 6400.168(a) | Staff #2 was ¿certified¿ to pass medications on 8/27/14. However, he/she did not complete the department¿s Medication Administration Course in its entirety. He/She only completed 3 out of the 4 medication administration record (MAR) reviews. He/She was again ¿certified¿ to pass medications on 8/15/15 however the training was incomplete again. The 8/15/15 training did not include a practicum summary sheet or any MAR reviews. He/She is not trained to pass medications and has been since at least 2014.
¿Staff #3 was ¿certified¿ to pass medications on 4/12/16 but he/she didn¿t complete observations until 4/13/16. He/She was ¿certified¿ by Staff #4 who was not certified to be a practicum observer or medication trainer. Staff #3 is not certified to pass medications and has been passing medications.
¿Staff #5 had an initial medication training completed on 3/8/16. However Staff #4 who was not certified to be a practicum observer or medication trainer was who ¿certified¿ Staff #5 on 3/8/16. Staff #5's last observation in his/her 3/8/16 ¿certification¿ packet was not completed until June 2016. He/She was not certified to pass medication. | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | Analysis: The medication management was under the direction of an LPN. The Medication Administration processes and regulations were not adheared to. Immediate Corrective Action: The LPN handling the medications no longer provides that service. It was also important to help family members understand the role of the Medication Administration process. Staff #2 and Staff #5 have been trained with the Medication Administration Course.. All components have been completed. ATTACHMENT: (EM-1 (A-L) ATTACHMENT : EM-2 (A-F) Staff #3 is not availalble for retraining. Staff were retrained by the program speciaist, who is a certified trainer. (ATTACHMENT: EM-3) A practicum summary sheet was completed with all testing components. The Program Specialist is responsible for continued monitoring of all regulations and will assure observations will be completed timely, and within regulatory reuirements. The Medication Administration / Training Coordinator is responsible for the timely completion of the training components as per Communication 039-16. Family education was an important component in developing an understanding of the Medicaion Administration process. (ATTACHMENT: 4) Program Specialist and Supervisors will be educated in the need to maintain the process (ATTACHMENT TRAINING: T-1A,1B. ) |
12/13/2016
| Implemented |
| 6400.168(c) | Staff #6's medication trainer certification expired the end of March 2016. He/She did not pass the Department¿s Medication Administration Course for trainers again until May 2016. During the time frame where he/she did not have a current medication trainer certificate, he/she ¿certified¿ Staff #3 to be able to pass medications.
¿Staff #6 also ¿certified¿ Staff #4 to be a practicum observer. The practicum observer test that Staff #6 gave to Staff #4 was not the Department¿s certified Initial Practicum Observer test.
¿Staff #4 signed Staff #3's medication training as being a certified practicum observer and medication trainer however he/she was neither. | Medications administration training of a staff person shall be conducted by an instructor who has completed the Department's Medications Administration Course for trainers and is certified by the Department to train staff. | Immediate Corrective Action: Staff from outside the home administered the medication until all staff in the home completed the Medication Administration Course. ATTACHMENT EM-1 (A-L) STAFF #2 ; EM-2(A-F) STAFF #5 Staff #3 in not currently wtht the agency. To improve our monitoring skills Mattern House has three persons scheduled for the Medication Administration Course on 11-18-16 . (Attachment : EM-5, EM-6, EM-7) The Training Coordinator understands that she is responsible for management of Trainer Certificate valid dates and has added them to her Outlook calender. Recommendation from Temple University is to start 6 months prior to Certificate Valid date in order to register and complete the process of the class. Attachment: T - 1A, T-1B. |
11/23/2016
| Implemented |
| 6400.168(e) | Staff #2's 8/15/15 medication training packet did not include any of the 4 Medication Administration Record (MAR) review forms. | Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept. | Current Analysis: When reviewing the situation the team identified several issues that lead to the failure at this site. Failure to adhere to the Medication Administration Course training, failure to use the Med Admin current review forms, failure to track Certification dates (the trainer was responsible to maintain his or he certification). As stated above all relevant persons were retrained using the most recent review forms. Staff #2 was retrained using the Medicaiton Administration Course (ATTACHMENT EM-1A-L) The Training Coordinator and the Program Specialist are responsible to maintain information regarding all certifications and are trained in Medication Administration processes. (ATTACHMENT: T-1A, T-1B). |
11/23/2016
| Implemented |