| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | (continued. page 2)
until it was pointed out to them during the annual inspection on 11/1/18.
---According to the Walgreen pharmacist via phone call on 11/1/2018, Individual #1 was prescribed Ciprofloxacin 500mg for 10 days by the emergency room (ER) doctor on 8/31/2018. The first dose of the medication was not administered until 9/7/2018. The residential program did not discuss with the ER doctor or the pharmacist that the individual is allergic to Ciprofloxacin. The residential facility also administered said medication to the individual even thought they were allergic to the medication. | 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. | Client Accounts must be maintained in a clear, consistent manner in order to assure that all funds are secure and handled with the utmost care. The Client Account Manager will inform House Supervisors of any disbursements and they are responsible to enter those into the account log. The monthly account log is audited monthly by the Client Account Manager for accuracy. During the discussion of the licensing issue it was determined that the Client Account Manager misunderstood the concept of having receipts for any expenditure over $15.00 to mean that any expense under 15.00 did not need tracked . The Client Account Manager provided the missing documentation for Ind. # 1. ( Attachment: # 22Ind #1 Monthly Account Log with receipts.) The Client Account Manager was educated on the regulation and developed a new process for all Supervisors. Training for the Supervisors occurred on 12-10-18. (Attachment: #23 Financial Process; Attachment T-4 Financial Training) . Please note: each staff person signed an individual policy. The Supervisor and staff signature are documented. Additional staff have been trained and are available. The Program Specialist is responsible to assure that all individuals have sufficient spending money and that there are no discrepancies. |
01/18/2019
| Not Implemented |
| 6400.16 | --Individual #1's date of admission to the facility was 7/20/2017. There was a lifetime medical history in Individual #1's record, created by the residential medical coordinator on 7/24/17, that indicated Ciprofloxacin was an allergy for the individual. Individual #1's 1/4/18 physical form indicated that Ciprofloxacin was an allergy for the individual.
Individual #1's Individual Support Plan (ISP) indicated that the individual is allergic to Ciprofloxacin. The reaction indicates "not known" and the required response indicates "do not give this medication".
Individual #1's medication administration record indicates that Ciprofloxacin and Cephalexin are allergies.
On 9/7/2018 Individual #1 was prescribed and administered Ciprofloxacin 500mg for 10 days.
During the onsite inspection on 10/31/18, the program specialist was not aware that Ciprofloxacin was indicated in Individual #1's record as an allergy.
--Individual #1's CRNP indicated on 4/20/18 that the individual should be seen by a speech therapist for swallowing issues. The individual was never taken for speech therapy consult. Individual #1 was seen at the emergency room on 8/31/18 due to a choking incident that occurred at the agency's day program. From that incident, there was no documentation to indicate that the individual's dietary needs were evaluated by a doctor or that choking concerns were discussed with the individual's physician. The Individual's Individual Support Plan (ISP) indicates that the individual must be monitored while eating to prevent choking incidents. The agency indicated that Individual #1 is currently not monitored while the individual eats to prevent any other future choking incidents.
-- On 12/22/17 Individual #1 was seen by their physician for right-side face swollen with diagnosis of salivary stones infection. The individual was prescribed Keflex (Cephalexin) 250mg four times a day for 7 days with the initial dose being administered on 12/22/17 at 8pm. The Doctor's order also indicated side effects and concerns to look for that included rash, nausea, vomiting, and diarrhea.
On 12/24/17 staff document an "unusual event" on the individual's daily log, "the individual was going to the bathroom and had real tears and crying the whole time. he/she has been refusing to eat lunch and dinner." The individual's 12/25/17 daily note completed by staff indicated, "the individual did not have any food, just liquids, and refused to eat anything today. The individual did not seem to feel good. The individual did not want to eat food. Did a lot of coughing and sneezing." Individual #1's 12/26/17 daily note indicated the individual "woke up with a bad cough and did not want to eat or was barely even able to open their mouth. They were in bed a lot and no appetite. Very bad cough." The individual's 12/27/17 daily note indicated "spent half the day in bed. Refused all meals, cough a lot towards the evening also had a lot of bowel movements. Refused to eat, only jello. Did drink plenty of fluids." The individual's 12/28/2017 daily notes indicated "not feeling well at all this morning, was on toilet for 30 minutes, kept trying to sit while walking; sat on floor. Seemed confused for about ten minutes today as ambulanced was called. Day got better towards the evening. Still refusing to eat, ate jello with strawberries and pudding."
Residential staff documented on Individual #1's daily logs from 12/24/17-12/28/17 very severe health concerns that the individual's physician indicated on 12/22/18 to look for and follow up with if any are noted. Individual was not taken to the emergency room until 12/28/17 in which their labs showed dehydration, was diagnosed with diarrhea and was ordered to stop the antibiotic due to the individual's reaction to the medication.
The individual's program specialist and medical coordinator were not aware of the medication allergic reaction to Cephalexin/Kelfex (continued on next page...) | 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. | Failure or omission of an act constitutes Neglect and we recognize that the failure of our staff to maintain safety for an individual in unacceptable. 1. Medication: The Program Specialist, when developing the ISP, Medical History and overseeing the Individual #1's Plan failed to identify Ciproflaxin as a contraindicated medication due to allergy. She could not offer any explanation why she failed to discover during her monthly and her 3 month reviews and preparation for annual that the administration had occurred. The event has been referred to Incident Management Representative has been notified of the issue being recognizing it as possible neglect . The preventative aspect of this issue has been address in another portion of this Plan of Correction. The Medication Administration Records were reviewed by LPN's each month for potential Med Errors. (Attachment: 24 a-f Medication Administration Records Ind #1) 2. Recommendation: The recommendation of Speech Therapy on 4/3/18 and failure for follow-up after a choking incident on 8/31/18 . It is the responsibility of the Program Specialist to assure that all recommended services are obtained and completed as per the physician. There was no explanation why this occurred other that it was an oversite. How to prevent reoccurrence was addressed in an earlier cite. The events will be referred to the Incident Management Representative. 3. Possible reaction : On 12-17-2017- This citation , recognizing and responding to a potential interaction of Keflex. After Review of the timeline involved we would like to request that the licensing review reconsider this as potential neglect based on the review. Attachment: #25 Reaction Timeline / Individual #1 Dec Summary Incident. |
01/18/2019
| Not Implemented |
| 6400.44(b)(9) | Individual #1's date of admission to the facility was 7/20/2017. There was a lifetime medical history in Individual #1's record, created by the residential medical coordinator on 7/24/17, that indicated Ciprofloxacin was an allergy for the individual. Individual #1's 1/4/18 physical form indicated that Ciprofloxacin was an allergy for the individual.
Individual #1's Individual Support Plan (ISP) indicated that the individual is allergic to Ciprofloxacin. The reaction indicates "not known" and the required response indicates "do not give this medication".
Individual #1's medication administration record indicates that Ciprofloxacin and Cephalexin are allergies.
On 9/7/2018 Individual #1 was prescribed and administered Ciprofloxacin 500mg for 10 days.
During the onsite inspection from 10/31/18-11/2/18, the program specialist was not aware that Ciprofloxacin was indicated in Individual #1's record as an allergy since 7/24/17. | The program specialist shall be responsible for the following: Supervising, monitoring and evaluating services provided to the individual. | The Program Specialist must provide oversite in order for comprehensive services to be provided. When asked , The Program Specialist was unable to state why there was no oversite and review of all the services for Ind #1 including Medical. Upon admission the Program Specialist reviews all available information (ISP, Medical) and develops a compreshesive medical history and develops a current ISP. The MAR in question was reviewed by the House Supervisor and Medical Support and no one noticed that the indiviudal had been prescribed a medication they were allergic to. When the primary care physician was contacted they reported that they did not have this listed as an allergy. The pharmacy did not have it listed as an allergy. The team attempted to locate the source of the information was the ISP but the Support Coordinator could not determine where it had originated. There is no family left alive to interview. In October, the guardian made a decision to change Primary Care Physicians which left us unable to research the information. The new PCP (visited on 1-8-19) was advised of the issue and is electing at this time to keep the medication as an allergy due to Ind #1 discomfort with needles. (Attachment: #20 New Physician Recommendation). To prevent reoccurance the Supervisors were educated on how to properly review Medication Administration Records and to review the alleries listed. The Licensed Practical Nurses have updated all pharmacies to assure that all allergies are listed. They have reviewed all Medication Administration Records and have transfered any prescriptions filled by different pharmacies all going to the same pharmacy to assure that there is interaction review. The LPN will be reviewing the MAR each month to check for any issues with regard to administration or interactions. (Attachments: # 21 PDC Pharmacy Process) The Program Specialist is responsible for assuring all regulatory processes. See Program Specialist Training) |
01/18/2019
| Implemented |
| 6400.46(a) | Staff #1 was working at Individual #1's residential home during the onsite inspection on 11/2/2018. Staff #1 has not worked in the home in a few weeks and was not re-oriented to the home and the changes in the home and the individual's needs. Staff #1 had not been trained in the individual's updated Individual Support Plans (ISP) or where the first aid kit was located. | The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. | Orientation to the home for staff must occur regularly to assure all health and safety needs are met. When speaking with this particular staff it was not that she felt she was unable to provide care, she was simply nervous about the licensing person being present and was hoping to avoid being questioned. We work dilligently to have staff recognize that Licensing personnel are great resources for information and best practice. Staff #1 is by her nature, very shy. This particular staff was orientated to the home and support needs on 10-17-18(Attachment # 3- Ind #1 Eating Protocol) both indivudals (Attachment: #18 - Medical Service Care Note for Bear Wallow Ind #2) ( Attachment: #1 Emergency response / updates for BW). these documents were dated just two weeks prior to Licensing. All Supervisors are responsible to assure that staff feel comfortable and well educated about the people they are supporting. Supervisors have been educated on their role in assuring that staff are oriented to the home , are comfortable to answer questions and able to provide competant care. See Supervisor Training. The Program Specialist is responsible for assuring regulatory compliance. |
01/18/2019
| Implemented |
| 6400.62(a) | REPEAT from 8/29/17 annual inspection: Individuals at the home were assessed to not be able to use and/or avoid poisonous materials. Purex and Germ-x that contained a label to contact poison control center if ingested was unlocked and accessible in the kitchen. Other poisonous materials that contained labels to contact poison control center if ingested were found unlocked and accessible throughout the home; Bathroom Bona hardwood cleaner, nail polish remover, hydrogen peroxide, Coppertone sunscreen, Alocane emergency burn gel, Dr, Sheffields anti itch cream, and all of Individual #3's personal care items. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Direct Support Staff must have a clear understanding of the ablities of the people we support in order to keep them safe in their home. Individual #1 moved into the home 4 weeks prior to licensing. The other persons in the home are considered safe and Ind 1 had no reported attempts to injest poisons. She came to Mattern House after the passing of her family caregiver and there was incomplete information on her. . If the indiviudals are safe around poisons then this is important information for the Program Specialist to assure that the information in the Assessment and ISP is accurate. Immediately following licensing review all poisons were removed by the Supervisor and all poisons are locked pending review of assessment / skill levels. On 1-16-19 the Program Specialist has scheduled a team meeting to develop a comprehensive assessment. theProgram Specialists are responsible for updating the indiviudals Assessment and ISP to reflect their current ability in relation to the ability to safely useor be around poisons. ( Attachment: # 2 a-j Cover Letter and Assessment ) The Supervisors were educated on the need to keep poisons in their original labeled containers and understanding the assessed need of the people they support and how it relates their their enviroment. (Attachment: T-1 Supervisor Training ; Program Specialist is responsible to assure regulatory compliance. |
01/18/2019
| Implemented |
| 6400.68(c) | The home is not connected to a public water system and the coliform water test was not 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 |
| 6400.71 | The telephone number to the nearest hospital was not located on or by the cordless and wall mounted telephones downstairs in Individual #2's apartment. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| In an emergency there is no time to be looking for an emergency number and especially with a cordless phone which is mobile around the home, it must have the number on the portable handset. The Supervisor of the home stated that it was simply an oversight on her part. A sticker was placed on the phone with the emergency numbers present. (Attachment: # 16 Photo Phone ). The supervisor was educated on the need to keep the number on the hand set. (Attachment: T-1 Supervisor Training Log) |
01/18/2019
| Not Implemented |
| 6400.73(a) | The steps leading down to Individual #2's apartment were not equipped with a handrail for every step. The handrail did not extend to the top 4 steps. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | The presence of a hand rail is a safety precaution to prevent a fall down the steps. Maintenance reported that the failure of the rail to extend up along the stair banister was an oversight. All maintenance were trained on the need to have railings. (Attachment: # T-3 Maintenance Training. The Maintenance Supervisor will tour homes biannually to assure compliance with the regulation. Attachment: # 17 - BW Photo of Handrail. The Program Specialist is responsible for monitoring regulatory compliance. |
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.
| t 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. (Attachment: # 12 a - f Emergency Policy - Bear Wallow) 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. Attachment: #3 Supervisor Training. All policies have been reviewed for accuracy by 12-31-18 by the Chief Executive Officer and annually thereafter. |
01/18/2019
| Implemented |
| 6400.144 | --Individual #1's CRNP recommended on 4/20/18 that the individual should follow up with speech therapy for swallowing issues. At the time of licensing on 10/31/18, the agency had no arranged for the individual to be seen by a speech therapist for swallowing issues. Individual #1 was seen in the emergency room on 8/31/18 due to a choking incident that occurred at the residential's day program facility. The residential program has not put a chocking protocol in place for the individual or additional monitoring requirements due to the choking incident.
--On 10/8/18 Individual #1's doctor indicated to continue warm compresses BID (twice per day) and the OCU Soft pads BID. There was no documentation kept to indicate that warm compresses and OCU soft pads were used twice a day as indicated. The daily logs kept at the home only state "eye care" and for staff to check off if it was completed or not. It gives no information on the pads or warm compresses.
--Individual #1 was seen by their CRNP on 2/19/18 with a recommendation to try ear flushes to clear the wax. Currently staff are administering Debrox earwax removal to Individual #1 3 times a week, every week. There was no documentation that Debrox earwax removal was to be administered 3 times weekly.
--According to the Walgreen pharmacist via phone call on 11/1/2018, Individual #1 was prescribed Ciprofloxacin 500mg for 10 days by the emergency room (ER) doctor on 8/31/2018. The first dose of the medication was not administered until 9/7/2018. The residential program did not discuss with the ER doctor that the individual is allergic to Ciprofloxacin and also administered said medication to the individual even thought they were allergic to the medication. | 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.
| All health services must be provided in order to assure health and safety are secured for the people we support. Medical Support staff stated that the follow up for speech was an oversite. At the time licensing discovered the oversite the Individual #1 Guardian requested a change in Primary Care Practioners. The new PCP would not address the speech therapy referral until they had seen Individal #1. That initial PCP appointment was held on 1/8/2019. The Medical Support Staff addressed the speech therapy recommendation and the PCP stated he would get back to us. (Attachment: #6 Physical), Attachment: 7History and Attachment # 8 OTC. By Thursday 1/10/19 we had not recieved the scheduled referral / any information abut the speech thereapy from the PCP office. Medical Support called the office and are awaiting a response. In order to assure that all contacted with the physicans office are followed up, all calls will be logged into the ongoing physican contact log. (Attachment: # 12 Ongoing Log). The Eye Care order 10/8/18 (Attachment: #13 Physician Orders - Eye Care. ) At the present time staff are documenting the eye care on the individual Treatment Log. Previously it stated only "Eye Care". It has been updated to identify both lid clensing and Warm compresses as per the order by Medical Support Staff (Attachment: # 14 Ind #1 Treatment Log) . Ear Cleaning: At the Annual Physical the OTC care was reviewed for Individual #1's Ear Care. (Attachment: #8 New OTC orders. The Ear Care is has been identifed as a PRN and the Supervisor was trained to recognize and document ear care. Attachment: # T-1 Supervisor Training . All medical contacts will be overseen by the Medical Support Supervisor and the assigned LPN to assure consistency. All Medical Support contacts will be reviewed by the Program Specialist to assure regulatory compliance. The oversight by the Program Specialist Supervisor will assure follow through. |
01/18/2019
| Implemented |
| 6400.145(2) | The written emergency medical plan did 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. MH Attachment # 12 a-f Emergency Policy Bear Wallow. 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 ) All policies have been reviewed for accuracy by 12-31-18 by the Chief Executive Officer and annually thereafter |
01/18/2019
| Implemented |
| 6400.166-1 | According to Individual #1's appointment record summary form, the individual was prescribed an antibiotic Cephalexin (Keflex drug) starting on 12/22/17 at 8pm. From 12/22/17-12/28/17 staff documented on daily notes that the individual was crying all day, refusing to eat for days on end, not feeling well, a lot of coughing and sneezing, barely able to open their mouth, remaining in bed all day, confusion, and going to the bathroom a lot -- in excess of spending up to 30 minutes on the toilet.
According to the individual's appointment record summary form, he/she was taken to the emergency room (ER) on 12/28/17 "due to crying, sitting while walking and dehydration, diarrhea. stop medication." The first and only documented information in the individual's record that indicates the agency informed the individual's prescribing physician of the adverse reaction to Cephalexin/Keflex was not done until 1/4/18. | If an individual has a suspected adverse reaction to a medication, the home shall notify the prescribing physician immediately. Documentation of adverse reactions shall be kept.
| It is critical that staff recognize an adverse reaction to a medicaion and staff inform the prescribing physician immediately. In order to determine the "why this occurred" the team reviewed all the documentation available to establish the timeline for the adverse reaction.(Attachment: Dec 2018 timeline) The Daily Progress Notes , Notice of Concern documents, and actions taken by medical support staff. Upon review the DSP did not recognize the coughing and cold symptoms as a possible adverse reaction and attributed the diarrhea on day 7 as part of what they saw as a new illness. In order to avoid a reoccurance of this event Mattern House has hired two Licensed Practical Nurses to act as resouce to Direct Support Staff and Oversite for Medical Support Staff. Attachment: #9 Policy #10 Chain of Command. Documentation of adverse reactions and education for staff is also part of the Medication Administration Record and educating staff on proper documentation. The House Supervisors have been trained by the LPN's on the propers documentation of adverse reactions and protocol to contact LPN's. (Attachment: #3 Training Supervisors) The program Specialist is responsible for monitoring the documentation and reporting to the team. |
01/18/2019
| Implemented |
| 6400.167(b) | Individual #1 is being administered Debrox earwax flushes three time weekly without a script or order from their doctor to do so. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Correct application / usage of ear wax flushes to assure health and safety of Individual #1 and to assure that no PRN is used without orders of the physicians. This individual had orders for the use of Debrox dated 7/20/18 (Attachment: #5 OTC medication orders). Order's on the label allow for use up to twice daily for four days repeat as necessary. ( Individual #1 has a long history of issues with wax build up which can cause hearing loss and infection. Individual #1 had recieved her Annual Physical completed on 1/8/19 Attachment: # 6 a-d Physical; Attachment #7 a,b,c, Medical History; Attachment #8 a,b OTC orders. In order to better supervise all medical issues with indivudals Mattern House has hired two Licensed Practical Nurses on 12/15/2019. Their role will be to supervise all Medical Support Staff , and provide a resourse and training to Direct Support Staff and to develop and monitor all medications and develop best practice Medical Policy ( Attachment: # 9 a,b Individual Health Policy Attachment: # 10 Chain of Command. In order to assure regulatory compliance we have created a position of Medical Support Supervisor as well as add 2 Licensed Practical Nurses to monitor and assure care. |
01/18/2019
| Implemented |
| 6400.181(e)(4) | Individual #1 currently requires 1:1 staff to individual supervision in the home and in the community. The individual's current assessment only indicated that he/she required staff to be within hearing distance in the home with 15 minute checks and direct super in the community. | The assessment must include the following information: The individual's need for supervision.
| It is critical that Direct Support Staff have clear supervison levels in order to keep Individual #1 safe. Individual #1 is a recent admission who lived at home until living with Mattern House approx 18 months. Her only caregiver has passed away and Indivudal #1 struggles to communicate her wants and wishes to staff. The Program Specialist responsible for Individual #1 was gathering alot of information but was unable to develop a clear support document - including supervision levels. This Program Specialist responsible is no longer employed at Mattern House. In addition to replacing Individual #1's Program Specialist we have added another Program Specialist to reduce caseload and as a result will allow the PS time to create quality work and to connect with Direct Support Staff as a strong team leader. In order to prevent a reoccurance of this issue Mattern House created a new position of Program Specialist Supervisor who will review supervision levles. The team is meeting on 1/16/2019 to review the updated assessment and to update the ISP. (Attachment: # 2 A-I JS Assessment, #2 J Cover Letter. Review of the ISP shows conflicting or confusing direction and the team will be meeting to clairify all safety and eating processes by 1/31/2019 . Because the Program Specialists are new they will be working with the team to create a new assessment by the meeting date. The Direct Care Staff will be trained on the ISP revisions by 2/10/19 by the Program Specialist. |
02/10/2019
| Implemented |
| 6400.181(f) | There was no documentation to indicate that Individual #1's assessment was sent to the individual or other team members; excluding their supports coordinator whom there was documentation of dissemination for. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| The Program Specialist is responsible for providing all documentation on the ISP process to all team members so that the team can assure qualtiy supports and that the individual's health and safety are assured. The program specialist responsible did not have a clear understanding of regulations and is not currently employed. In order to prevent a reoccurance of this issue Mattern House created a new position of Program Specialist Supervisor who will review outcomes that are measurable. In addition to replacing Individual #1's Program Specialist we have added another Program Specialist to reduce caseload and as a result will allow the PS time to create quality work and to connect with Direct Support Staff as a strong team leader. Review of the ISP shows conflicting or confusing direction and the team will be meeting to clairify all safety and eating processes by 1/16/2019 . A new Assessment and Cover Letter has been provided to the team. Attachment: 2 a-j Cover Letter and Assessment). All information will be distributed to the entire team as per the regulation. The Program Specialist Supervisor is responsible for assuring all regulatory issues are met. |
01/18/2019
| Implemented |
| 6400.183(3) | Individual #1's Individual Support Plan (ISP) did not include a method of evaluating their "living their life" outcome. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome. | It is important for the team to create a measurable , relevant outcome so that staff have direction on how we can help Individual #1 have an Everyday Life. The Program Specialist did not deveop a clear action plan for staff to follow in order to achieve an outcome for Individual #1 "Living My Life". This Program Specialist responsible is no longer employed at Mattern House. In order to prevent a reoccurance of this issue Mattern House created a new position of Program Specialist Supervisor who will review outcomes that are measurable. In addition to replacing Individual #1's Program Specialist we have added another Program Specialist to reduce caseload and as a result will allow the PS time to create quality work and to connect with Direct Support Staff as a strong team leader. The Program Specialist updated the Progress Note / Outcome Action Plan for JS . Attachment: #5 a, b JS Daily Progress Notes. The team will be meeting to clairify the information including assuring Action Plan is measurable on 1/16/2019 . Because the Program Specialists are new they will be working with the team to create a updated ISP from the new assessment. Attachment: #2 a-j Cover Letter and Assessment. In order to prevent a reoccurance of the violation a new position was created , Program Specialist Supervisor who is responsible to monitor all isp development and training and assure regulatory requirements. |
01/18/2019
| Implemented |
| 6400.185(b) | Individual #1's Individual Support Plan (ISP) indicated that "staff must sit with the individual while the individual eats. Individual #1 should be monitored while eating to prevent choking." According to the individuals program specialist on 11/1/18, Individual #1's staff is not sitting with the individual to monitor the individual while eating to prevent choking. | The ISP shall be implemented as written. | It is important that staff follow the ISP as written to assure health and safety and provide consistent processes for staff to follow. At the present time Individual #1 ISP states ".STAFF ENCOURAGE HER TO EAT HER MEALS AT THE KITCHEN TABLE. STAFF SIT WITH IND #1 WHILE SHE EATS TO ASSIST IF NEEDED" and "SHE NEEDS TO BE CLOSELY MONITORED WHILE EATING TO HELP PREVENT CHOKING". The ISP annual was dated 9-27-18 with a Critical revision on 10-15-18. The inital ISP had staff sitting with Ind. #1 to "encourge her""assist if needed" when at the table and not identified as a choking issue or safety concern.. Subsequent ISP's stated "closely monitored" which is not well defined. Ind # 1 situation is evolving with annual updates on 9-27-18 and 10-15-19 with rapidly changing information but there is not a clearly detailed direction for staff. Additional updates regarding Ind. #1 eating states that "she likes eating in her chair (recliner)" with no instruction for DSP. The inconsistencies occured because the Program Specialist was not completing documentation or training in a timely manner and is no longer employed at Mattern House. Bear Wallow Staff Supervisor was trained on the Eating Protocol on 9-28-2018. Attachment: #3 JS Eating Protocol Training. Two new Program Specialists have been hired as of 1.1.19 and are currently completing orientation. We have created a new position of Program Specialist Supervisor who is responsible for reviewing all materials and assuring the timeline for development and training is completed to prevent a reoccurance of this situation. Review of the ISP shows conflicting or confusing direction and the team will be meeting to clairify all safety and eating processes on 1/16/2019 . Attachment: #4 JS Meeting Signature sheet. We have created a new position of Program Specialist Supervisor who is responsible for reviewing all materials and assuring the timeline for development and training is completed to prevent a reoccurance of this situation. |
01/18/2019
| Implemented |
| 6400.186(c)(2) | Individual #1's Individual Support Plan (ISP) reviews over the annual review year does not review the status and progress of the individual's behavioral support plan or if it was utilized over each previous three month review. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | The three month review of each individual we support is important to assessing the impact of services provided. The Behavior Support staff completes a montly report that was provided to the team so the Program Specialist assumed that met the standard for keeping the team informed. The Program Specialist has recieved training regarding the three month review and the contents. (Attachment T-2 Program Specialist/Medical Support Training) In order to prevent a reoccurance a new position of Program Specialist Supervisor who is responsible for oversite. A 10% sampling of files will be reviwed biannually by the Program Specialist Supervisor. |
01/18/2019
| Implemented |
| 6400.213(11) | REPEAT from 8/29/17 renewal inspection: Individual #1's Individual Support Plan (ISP) indicated they are receiving 1:1 staff to individual supervision in the home and community. Individual #1's assessment indicated they required staff supervision to be within hearing distance at home and required 15 minute checks. Individual #1's current assessment indicated they only required direct supervision in the community.
--Individual #1's ISP indicates that the individual has a bed alarm and door alarms in the home. The individual's assessment does not indicate this need.
-- Individual #1's ISP indicates that staff must sit with the individual when he/she eats for monitoring to prevent choking. The individual's ISP indicates that they have difficulty eating blueberries and oranges. This is not documented anywhere else in the individual's record. The individual's assessment only indicates that the individual need some assistance with all meals.
--Individual #1's assessment indicates that a family member is the individual's rep payee. However, the individual's ISP indicates Karen Bubier, who is not a family member, is the individual's rep payee. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | This regulation is important to ensure the individual is provided consistent care and support and that staff have consistent guidelines to follow. As of 1/8/2019 Individual #1 Support Coordinator requested updates to her ISP and Assessment have been updated to reflect: a. Ind #1 can be in hearing distance of staff and maintains 1:1 staffing support. b. Individual #1 uses bed and door alarms at night to assure safety becasue Ind. #1 has a history of wandering. c. Eating: Ind #1 is having some difficulty swallowing blueberries and oranges. Ind #1 is showing a preference for finely ground food. This is a preference not doctor ordered. Payee: Individual #1 has a close family friend acting as payee at this time. Staff have been trained on the existing ISP (Attachmen #1 : Training Log ) but the team feels the ISP needs more detail. The Program Specialist responsible for Individual #1 was unable to meet the required timelines and is not longer employed at Mattern House. In order to assure this does not happen again we have created a new position of Program Specialist Supervisor and have hired two Program Specialists. Review of the ISP shows conflicting or confusing direction and the team will be meeting to clairify all safety and eating processes on 1/16/2019 . An updated assessment will be provided to the team Attachment: # 2 a-j Cover Letter and Assessment. The Supervisor's and Program Specialist have been educated to assure compliance to the regulation. Attachment: T-1 Supervisor TRaining T-2 Program Specialist Training. The Program Specialist Supervisor is responsible to assure all Program Specialists complelte regulatory documentation. |
01/18/2019
| Implemented |