| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | On 12/15/15, a $500 check was written to the Ganister Station day program from Individual #1's account. The memo field on the check reads ¿donation¿ and the check is signed by Staff #1. Staff #1 stated that this donation was not discussed with or approved by Individual #1. This transfer of funds constitutes financial exploitation. | 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. | The Administrator is payee for individual #1 and was responsible for assuring that he/she did not exceed state asset standards. The representative from the PA Blair County Assistance Office stated that Donations to 501(c) organizations was an allowable spenddown to assure he does not retain extra capital. After dicussion with the individual,who is able to understand the idea of money management; and with the Assistance Board representative a decision was made to donate money to the Day Program he/she attends. He / She spends 40 + hours per week there. The Administrator was shocked to learn that by licensing standards this would be considerd financial exploitation. The money was immediately returned to Individual #1 (ATTACHMENT: MP-20) The Administrator is committed to assuring transparency and sound fiscal management for individual's funds and has been trained in the agency policy and regulations. ATTACHMENT: T-1A, T-1B |
11/23/2016
| Implemented |
| 6400.22(d)(1) | The agency does not keep a financial record for Individual #1. He/she is unable to manage his/her funds independently. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | See paper copy. |
11/23/2016
| Implemented |
| 6400.31(b) | The statements that indicated that rights were reviewed with Individual #1 were not dated. The date was not documented for the current review or previous review. | Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | Immediate Correction: Individual #1 had the opportunity to review her rights again and initial and dated them. Prevention: The Emergency Consent form has been redesigned to include a date beside the Individual signature. ATTACHMENT CC-5A The staff have been educated on the need to assure that all signatures are dated. ATTACHMENT: T-1A, T-1B |
11/23/2016
| Implemented |
| 6400.44(b)(18) | Individual #1 has a seizure disorder. He/She is prescribed Diastat 20mg rectally as needed for seizures. Staff Persons #2 and #3 have not received training on the administration of Diastat. | 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. | Immediate Correction: Staff #1 and Staff #2 were educated on the use of diastat by the HCQU nurse on 8-15-2016. ATTACHMENT: MP-16, MP-17. Prevention: The Training Coordinator has been educated on the need to add supplemental training to all Medication Administration Courses.. ATTACHMENT: T-1A, T-1B. |
11/23/2016
| Implemented |
| 6400.67(a) | A foot-long piece of padded sealer was separated from the frame of the door leading from the house to the back covered porch. | Floors, walls, ceilings and other surfaces shall be in good repair. | Immediate Correction: The insulation was replaced on 7/25/2016. ATTACHMENT: MP-15 Prevention: Maintenance was / will be educated on the need to assure that all doorways need to be in good repair. ATTACHMENT: T-2A, T-2B. |
07/25/2016
| Implemented |
| 6400.68(c) | The home had a coliform water test completed on 9/3/15 and not again until 1/4/16, outside the 3-month time period. | 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 3 month Coliform test is an important health measure to assure the consumpsion of safe water. Maintenance was unable to explain why tests had been completed every three months as per the regulation but December's test was completed in January, then resumed the 3 month schedule as per the regulation. Prevention: The Administrative Assistance has added Water tests reminders to her Outlook and developed a new process to assure it is completed along with water temperature tests. ( ATTACHMENT: MP-14) The Maintenance staff is responsible for timely completion of the test and have been trained in their responsibiltiy to meet the regularions. ATTACHMENT: T-1A, T-1B. T-2A, T-2B |
12/12/2016
| Implemented |
| 6400.72(b) | The porch door opening to the outside ramp was stuck and could not be easily opened. | Screens, windows and doors shall be in good repair. | Immediate Correction: Maintenance sanded the wood door to allow it to open easily. This repair occurred on 7/21/2016. ATTACHMENT: MP-13 Prevention: Maintenance have been / will be educated on the importance of ensuring that means of egress are easily accesses to assure that everyone can evacuate safely. ATTACHMENT: T-2A, T-2B. |
07/21/2016
| Implemented |
| 6400.74 | The back porch steps were not equipped with non-skid surfaces. | Interior stairs and outside steps shall have a nonskid surface.
| Immediate Correction: Non Skid tape was added to the newly constructed back porch. It was completed on 7/27/2016. ATTACHMENT: MP-12. Maintenance is responsible for assuring that all exterior steps have a non skid surface to assure safety when used. Maintenacne have been / will be eduated on the importance of assuring exterior surfaces have non skid surfaces. ATTACHMENT: T-2A, T-2B |
07/27/2016
| Implemented |
| 6400.110(a) | There was an accessible attic with pull-down steps located in the hallway of the home. The attic did not have a smoke detector. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | Immediate Correction: The drop down door to the attic was made inaccessable with a lock on 7/27/2016. ATTACHMENT: MP-11 Prevention: Maintenance have been educated on the need to place a smoke detector and fire extinguisher in an attic that is being used. If not used it must be made inaccessable. ATTACHMENT: T-2A, T-2B |
07/27/2016
| Implemented |
| 6400.143(a) | Individual #1 refused a gynecological exam and mammogram on 7/6/16. The agency did not perform or document continued attempts to train Individual #1 about the need for health care. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Immediate Correction: Development of a Plan of Care to support Ind #1. with Gynecological exams and mammograms. It is at present under review and has not been executed. ATTACHMENT: MP-10 A, 10B, 10C, 10D. Prevention: At the present time Ind. #1 completed annual health care training with the Medical support coordinator prior to annual gynecological and mammogram due dates. The training content addressed need for treatment, what will happen, and possible consequences of refusals annually but did not include a plan of support througout the year that was signed by the individual who was refusing examination. The newly developed plan involved input from the Ind #1 but has not yet been review by the PCP or Speciality Physician. Upon completion all staff will be trained in the use of the plan. The Medical Support Staff and Program Specialist have been educated on the need for refusal plans of care development. ATTACHMENT: T-1A, T-1B |
11/23/2016
| Implemented |
| 6400.144 | The physical exam completed for Individual #1 on 7/6/16 indicated he/she was to have a 1200mg daily diet. His/Her Individual Support Plan (ISP) indicated 1200 calorie diet for Individual #1. On 8/4/15 Blair Medical Associates Family Medicine indicated that he/she was to have a low fat, low calorie, 1200 calorie diet. Staff are not tracking his/her calorie intake. (see copies of forms)
¿Individual #1's ISP indicated that staff are to monitor his/her seizure activity. There was no documentation that his/her seizures were being monitored and tracked. Copies obtained.
¿Individual #1 is allergic to adhesive. The first aid kit in the home did not have Band-Aids or tape without adhesive.
| 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.
| Immedicate Correction: Staff are tracking calories for all meals. ATTACHMENT: MP-9. Prevention: Consistency in diet is critical to Individual #1's success. The individual is a strong self advocate and she is currently dicussing some changes she would like to make to her diet and plans to review with her Primary Care Physician. Following a review of her requests the Medical Support Coordinator will update all materials to reflect any changes and the Training Coordinator will assure that all staff are trained. ATTACHMENT: T-1A, T-1B. |
12/22/2016
| Implemented |
| 6400.161(b) | Individual #1 is not able to self-administer medications. Ten Lactaid capsules were unlocked and accessible in a basket on the kitchen counter.
¿Nyamyc pow 100000, Risamine Ointment, and Triamcinolone cream were unlocked and accessible in the tall bathroom cabinet.
¿Ketoconazole cream was not present in the home. Individual #1 was carrying the medication with him/her in an unlocked container.
| Prescription and potentially toxic nonprescription medications shall be kept in an area or container that is locked, unless it is documented in each individual's assessment that each individual in the home can safely use or avoid toxic materials. | Immediate Correction: Medications was removed from the area. Prevention: Individual #1 has chosen not to administer her own medication and has been assessed as safe around poisons - she does not injest anything she does not recognize as safe, she does not injest anything she cannot identify. The Lactaid belonged to the staff on duty. We erronously believed that since Individual #1 was identified as safe around poisonous materials , did not injest unknown materials, and clearly communicated her needs - that keeping her medications unlocked and accessable to her was an acceptable practice. The updated assessment (ATTACHMENT: MP-5A-J clairified her abilities with regard to her medications, over the counter medications, and poisons. The Program Specialist and Supervisor have been been educated on the new expectations with regard to accessibility and persons who do not self administer medications. ATTACHMENT: T-1A, T-1B |
11/23/2016
| Implemented |
| 6400.164(b) | The medication log for Individual #1 was not signed on 3/31/16 for Citalopram 20mg. Staff did not initial after administration. | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | Correction: This error is unable to be corrected - it was discovered to late to do anything. Review of documentation showed that no medications were left over in the blister pack which would indicate an entry error rather than an administration error. Prevention: Documentation is critical to assure the health and safety of the people we support. All supervisors who are responsible to complete weekly reviews of the MAR's and the Medication Certification staff who complete reviews on the MAR's (with feedback to employees) quarterly have been educated on the need to assure completion of documentation. ( ATTACHMENT: T-1A, T-1B) |
11/23/2016
| Implemented |
| 6400.167(b) | Individual #1's medication log indicated that on 5/3/16 and 5/5/16 Metalazone 2.5mg, take 1 tab twice daily 30 minutes before Lasix on Tuesdays and Thursdays, was signed as given at 7am along with the rest of his/her 7am medications.
¿On 4/28/16 he/she was discharged from the ER at 7:30pm according to discharge paperwork. Staff initialed his/her April medication administration record on 4/28/16 as administering his/her daily medications at 7pm, before he/she was discharged out of the hospital¿s care.
| Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Correction: A new MAR was created to reflect the special administration time for the Metalazone 2.5 mg. The new MAR clearly identified the administration time as 30 minutes prior to the Lasiz time. ATTACHMENT: MP-7. Prevention: The MAR for Individual # 1 has a medication that requires administation 30 minutes prior to another Med. The MAR did not clearly demonstrate to the DSP the need for that to occur. After a consult with the pharmacist; the Administration time was changed to clearly define and reflect the need to administer before other meds. The Medication Administration staff have been educated to review MAR administration times and to assure that all special admin instructions are clear. T-1A, T-1B. SECOND ISSUE / ADMIN TIME: Mattern House has adopted the generally accepted policy and practice of Temple Universities Medication Administration Course of defining an Administration Time as 1 hour before the admin time up to 1 hour after. . The Agency policy on Medication Administration reflects the Medication Administration Course Trainers Manual Pg. 47. ATTACHMENT: MP-8 With a 7 pm admin time staff can initial the MAR without alteration from 6 pm to 8 pm. The hospital is less than 4 miles from the individual home. When asked, staff report that they understand the process for a late administration and believe that they arrived home in time to administer the medication. The Medical Support Staff and Supervisors are reminded to review all documentation processes to assure that medication administration standards are met. ATTACHEMENT: T-1A, T-1B. |
11/01/2016
| Implemented |
| 6400.181(e)(4) | Individual #1's assessment completed on 7/1/16 did not include his/her need for supervision at home. | The assessment must include the following information: The individual's need for supervision.
| Correction: The Program Specialist updated the Individual #1's assessment to include her need for supervision at home. That Assessment was provided to the Support Coordinator for ISP updates on 7/29/2016. ATTACHMENT: MP-5A-J. Prevention: There was no explaination as to why the assesment was not changed, it appears that she was pulled away from updating the document and then when returning to it, thought it was completed. 10%of all assessments will be evaluated for accuracy each quarter by the C.E.O. The Program Specialist has been educated on the need to fully review and assess the individual and to change the assessment narritive even if the person does not change to assure that the reader that the assessor reviewed that section. ATTACHMENT: T-1A, T-1B. |
11/23/2016
| Implemented |
| 6400.181(e)(13)(v) | REPEAT from 7/23/15- The assessment for Individual #1 completed on 7/1/16 did not contain progress and growth in socialization. The 2015 and 2016 assessments were verbatim. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | Correction: The Program Specialist updated the Individual #1's assessment to include her progress and growth in maintaining personal property. That Assessment was provided to the Support Coordinator for ISP updates on 7/29/2016. ATTACHMENT: MP-5A-J. Prevention: There was no explaination as to why the assesment was not changed, it appears that she was pulled away from updating the document and then when returning to it, thought it was completed. To ensure that assessments are complete 10 % of individual assessments will be reviewed quarterly by the C.E.O. The Program Specialist has been educated on the need to fully review and assess the individual and to change the assessment narritive even if the person does not change to assure that the reader that the assessor reviewed that section. ATTACHMENT: T-1A, T-1B. |
11/23/2016
| Implemented |
| 6400.181(e)(13)(vii) | The assessment for Individual #1 completed on 7/1/16 did not contain progress and growth in financial independence. The 2015 and 2016 assessments were verbatim. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| Correction: The Program Specialist updated the Individual #1's assessment and her progress and growth in financial independence. That Assessment was provided to the Support Coordinator for ISP updates on 7/29/2016. ATTACHMENT: MP-5A-J. Prevention: There was no explaination as to why the assesment was not changed, it appears that she was pulled away from updating the document and then when returning to it, thought it was completed. 10 % of all assessments each quarter will be evaluated to assess for accuracy by the C.E.O. The Program Specialist has been educated on the need to fully review and assess the individual and to change the assessment narritive even if the person does not change to assure that the reader that the assessor reviewed that section. ATTACHMENT: T-1A, T-1B. |
11/23/2016
| Implemented |
| 6400.181(e)(13)(viii) | REPEAT from 7/23/15- The assessment for Individual #1 completed on 7/1/16 did not contain progress and growth in maintaining personal property. The 2015 and 2016 assessments were verbatim. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | Correction: The Program Specialist updated the Individual #1's assessment to include her progress and growth in maintaining personal property. That Assessment was provided to the Support Coordinator for ISP updates on 7/29/2016. ATTACHMENT: MP-5A-J. Prevention: There was no explaination as to why the assesment was not changed, it appears that she was pulled away from updating the document and then when returning to it, thought it was completed. To ensure that assessments are complete 10 % of individual assessments will be reviewed quarterly by the C.E.O. The Program Specialist has been educated on the need to fully review and assess the individual and to change the assessment narritive even if the person does not change to assure that the reader that the assessor reviewed that section. ATTACHMENT: T-1A, T-1B. |
11/23/2016
| Implemented |
| 6400.181(e)(13)(ix) | REPEAT from 7/23/15- The assessment for Individual #1 completed on 7/1/16 did not contain progress and growth in community integration. The 2015 and 2016 assessments were verbatim. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | Correction: The Program Specialist updated the Individual #1's assessment to include her potential to progress and grown in community integration. That Assessment was provided to the Support Coordinator for ISP updates on 7/29/2016. ATTACHMENT: MP-5A-J. Prevention: There was no explaination as to whay the assesment was not changed, it appears that she was pulled away from updating the document and then when returning to it, thought it was completed. To ensure that assessments are complete 10 % of individual assessments will be reviewed quarterly by the C.E.O. The Program Specialist has been educated on the need to fully review and assess the individual and to change the assessment narritive even if the person does not change to assure that the reader that the assessor reviewed that section. ATTACHMENT: T-1A, T-1B. |
11/23/2016
| Implemented |
| 6400.183(7)(iii) | Individual #1's Individual Support Plan (ISP) did not include her potential to advance in vocational programming. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. | Correction: The Program Specialist updated the Individual #1's assessment to include her potential to advance in vocational Programming. That Assessment was provided to the Support Coordinator for ISP updates on 7/29/2016. ATTACHMENT: MP-5A-J. Prevention: There was no explaination as to whay the assesment was not changed, it appears that she was pulled away from updating the document and then when returning to it, thought it was completed. 10 % of all assessments each quarter will be evaluated to assess for accuracy by the C.E.O. The Program Specialist has been educated on the need to fully review and assess the individual and to change the assessment narritive even if the person does not change to assure that the reader that the assessor reviewed that section. ATTACHMENT: T-1A, T-1B. |
11/23/2016
| Implemented |
| 6400.185(b) | According to the 7/1/16 assessment, Individual #1 is only able to handle small amounts of money. The 6/7/16 Individual Support Plan (ISP) for Individual #1 indicates that he/she ¿needs assistance with managing [his/her] money.¿ Per CEO and Staff #4, the Mattern House fiscal department is giving Individual #1 $80 monthly and that he/she has always handled whatever amount of money he/she wanted. | The ISP shall be implemented as written. | Current Corrective Action: The Individual's Assessment was updated and provided to the Support Coordinator with regard to her ability to manage her personal spending money. ATTACHMENT: MP-4, MP-5, MP-5A-J Prevention: It is important that all team members understand their responsibiltiy in maintaining an accurate assessment of personal skills. The supervisor also has a role is alerting the program specialist to any discrepancies. ATTACHMENT: T-1A, T-1B |
11/23/2016
| Implemented |
| 6400.211(b)(3) | The name, address, and contact information of someone able to give consent for emergency medical treatment for Individual #1 was not in his/her record. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. | Corrective Action: Individual #1's Emergency Record has been updated to identify the Administrator as the person able to give consent. ATTACHMENT: MP-6. Issue: Prior recommendations for this regulatory requirement directed us to list the person themself if they did not have a legal guardian. We now have a new understanding of the use / need for this information and going forward will identify the Administrator here when no guardian has been indicated. Staff have been trained with this new information. The Administrator has been educated in the content of emergency medical consent as per ODP Bulletin 6000-11-01 . (ATTACHMENT: T-1A, T-1B) |
11/23/2016
| Implemented |
| 6400.213(9) | The Individual Support Plan (ISP) in the record for Individual #1 was last updated on 9/10/15. Since that update, the ISP has been updated 3 times for a critical revision, general update, and fiscal renewal. The most current copy was not in the record. | Each individual's record must include the following information: A copy of the current ISP. | Immediate Correction: The most recent ISP (fiscal year renewal dated 6-7-2016) was obtained and provided to staff on 7/25/2016. ATTACHMENT: MP-1A, MP-1B. Prevention: Mattern House met with the Blair County ISP Workgroup which is made of up Program Specialists and Support Coordinators, to develop a plan to assure that all ISP's were reviewed and that the most current copy was in the persons record. The Administrative Assistant will notify Program Specialists of any alerts in HCSIS during her weekly check. On 10-25-16 a General Update was completed and provided to staff. ATTACHMENT MP-3 They will be provided with the most recent updates as they occur. The Program Specialist is responsible for comparing the documents using the Word Comparison Process to identify those changes. (ATTACHMENT: MP-2). The Program Specialist and Supervisor have been educated on their responsibiltieis to assure that the most recent ISP is provided to staff. (ATTACHMENT T-1A, T-1B). |
11/23/2016
| Implemented |
| 6400.213(11) | Individual #1's medical consult form from 8/4/15 indicated that his/her current allergies were adhesive tape, aspirin, blaxin, avelox (moxifloxacin), duricet (cefadroxil), and Lortab (hydrocodone-acetaminophen). His/Her 7/6/16 physical indicated thathe/ she was allergic to adhesive tape, opiods, aspirin, and Biaxin. His/Her Individual Support Plan (ISP) indicated that he/she was allergic to aspirin, Biaxin, avelox, and adhesive tape. Allergies were not consistent throughout his/her record.
¿His/Her ISP indicated that he/she can be unsupervised in his/her home for up to 15 minutes. His/Her current assessment did not indicate that he/she could have any unsupervised time at home.
¿His/Her ISP indicated that he/she was to be on a low fat, low sodium, 1200 calorie diet. His/Her 7/6/16 physical indicated he/she was on a low sodium, 1200 mg diet. The agency indicated that Individual #1 has a restrictive behavior support plan because they are restricting calories. The agency isn¿t restricting calories. His/Her ISP indicated that the behavior support plan isn¿t restrictive.
¿His/Her ISP indicated that he/she is diagnosed with Intermittent Explosive Disorder. His/Her psychotropic medication Citalopram is being reviewed with his/her primary care physician as prescribed for Depression. His/Her ISP indicated that he/she takes Citalopram for ¿mental health¿. His/Her ISP does not indicate that he/she has a diagnosis of Depression.
| Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | Individual #1 and the Medical Support Staff will review with her Primary Care Physician the following information for accuracy. List of Allergies, Diagnosis, and Diet. The information will be available by 12/21/2016. Immediate Correction: The Program Specialist has updated Ind. #1 Assessment on 7/27/2016 to reflect her current Supervision Needs and has provided that update to the Support Coordinator to assure accuracy. ATTACHMENT: MP-5 The new assessment (ATTACHMENT 5A-K). Prevention: We have two new Program Specialist this year. In order to improve and assess staff performance; every quarter a 10% sampling of assessments will be reviewed by the C.E.O. to assess for accuracy. Feedback will be provided to each Program Specialist regarding the accuracy of the document. The Administrative Assistant, Program Specialist, and Medical Support Coordinator have been educated regarding their responsibilities to assure that the content is consistent between documents. ATTACHMENT: T-1A, T-1B |
12/13/2016
| Implemented |