|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(9) | There are no records maintained that Individual #1 received a prostate examination annually at his physical examination appointment or documentation on his physical examination records that this is deferred or completed by a specialist. At the time of the 1/4/2021 inspection, the agency, Penn-Mar Human Services, had documentation that the individual's PSA blood test was completed on 7/20/20 but no records of any prostate examination or PSA blood test completed in 2019. | The physical examination shall include: A prostate examination for men 40 years of age or older. | It is important to meet each individuals needs by following recommendations made by physicians and following state regulations concerning the health of the people we support.
Program managers and agency nurses have been retrained on the need to thoroughly review medical documents and ensure there is follow up for each recommendation noted. The nurses and program managers were retrained on the need to coach or provide feedback to the program supervisor if there is missing documentation on submitted appointment records.
Reviewing documents following a medical appointment has always been an expectation of the agency nurses and program managers. They have been reminded on several occasions since this licensing for the need for them to thoroughly review medical documents and to do so as the appointments occur. Effective immediately, the Administrator and Community Living Manager will conduct weekly audits of appointments to ensure follow up appointments and recommendations occur as recommended.
Since the licensing in January 2021, there have been physical examinations completed in other CLAs that included proper documentation for a prostate examination for men 40 years of age or older. See Attachment # 5 02.25.2021 annual Physical - prostate exam. |
04/01/2021
| Implemented |
| 6400.144 | Health services such as medical, nursing, pharmaceutical, dental, dietary, psychological, etc. that are planned for or prescribed for the individual shall be arranged and provided. There were a few occasions from September 2019 to January 2021 where such services that were ordered were not provided to Individual #1. Examples of this are as follows:
· The agency is to track the individual's bowel movements on a bowel movement chart due to concerns regarding the individual's bowel movements. There are numerous dates over the time period above, where the individual's chart was not completed, and his bowel movements weren't tracked. Additionally, there were many occasions where staff noted the individual had gone more than 3 days without a bowel movement, with at least one occasion stretching 10 days in between bowel movements. There are no records maintained that the individual's physician or a medial professional were notified of the individual's inability to have a regular bowel movement, or that any additional treatments/medications were administered to the individual to assist with his constipation.
· Individual #1 was to have his temperature taken prior to going into the community. On 8/15/2020 and 12/5/2020 he had community outings completed and there are no records maintained that his temperature was taken prior to going into the community.
· The individual is ordered to have his blood pressure checked daily. His blood pressure was not taken on 9/22/20, 12/5/20, 12/18/20, 12/26/20, 12/27/20, and 12/30/20 as recommended.
· Individual #1 is to have Triple Antibiotic ointment available at his home as a pro re nada (PRN) medication should he need it. As of 1/6/21, there was no triple antibiotic ointment 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.
| This citation was received because direct support staff did not follow the individuals bowel protocol and there was lack of oversight from the program manager. In addition, he had a prescribed PRN medication that staff did not ensure was present in the home.
In the description of the citation, the following is noted:
Individual #1 was to have his temperature taken prior to going into the community. On 8/15/2020 and 12/5/2020 he had community outings completed and there are no records maintained that his temperature was taken prior to going into the community. On 8/15/2020, the individual went on a van ride. He did not leave the van prior to returning home. On 12/5/2020, the individual went to the hospital. It is noted in the service note that on 12/4/2021, 911 was called because he had a temperature of 101.9. See Attachment #6 of individual #1s service notes.
It is important to meet each individuals needs by following recommendations made by physicians, following protocols, ensuring team members are thoroughly trained and reporting incidents in a timely manner to ensure the individuals health and safety needs are met.
All individuals that are prescribed a medication to aid in bowel movements or have a history or diagnosis of constipation have bowel charts where staff are to document whether the individual had a bowel movement. The bowel chart tracking form was updated to include each individuals bowel protocol, the Bristol Stool Chart, when the PRN should be given and the time the bowel movement occurred. The new bowel chart was implemented starting February 1, 2021. Supervisors were trained on how to complete the updated form via email on 1/28/2021. The new form was also reviewed with supervisors during a virtual meeting on 2/10/2021. Supervisors have reviewed the updated bowel charts with direct support staff that report directly to them. All direct support staff have reviewed the bowel chart training through our online training system. Supervisors are required to review bowel charting during each shift and managers are required to review bowel charts at least weekly to ensure bowel protocols are followed and that documentation is completed thoroughly. See attachment #7- the bowel chart.
Program managers will ensure required charting such as monitoring vital signs or other recommendations is entered as a task in our electronic medication records where staff are required to sign-off on the task when completed. The nurses and program managers were retrained on the need to coach or provide feedback to the program supervisor if there is missing documentation on submitted appointment records. We also started to implement that all team members review and sign discharge documents following an emergency room visit or hospitalization immediately upon their next shift following the hospital visit. Our training department will store these documents so that we are able to provide documentation of the training as required. When an individual returns from an emergency room visit or hospitalization, staff immediately forward the discharge documents to the program manager and nurse for review. This process was set in place to ensure documentation is reviewed in a timely manner, ensure staff are following the discharge instructions, and to ensure that follow up appointments are scheduled as recommended. Program managers trained the supervisors for each program on these new requirements during their individual supervision meetings held between 12/18/2020 and 1/8/2021. Retraining will occur on 04/14/2021 during the residential supervisor meeting.
Program Managers and nurses will continue to review medical appointment records for each individual as appointments occur and ensure recommendations from physicians and follow up appointments are followed through. Reviewing documents following a medical appointment has always been an expectation of the agency nurses and program managers. They have been reminded on several occasions since this licensing for the need for them to thoroughly review medical documents and to do so as the appointments occur. Effective immediately, the Administrator and Community Living Manager will conduct weekly audits of appointments to ensure follow up appointments and recommendations occur as recommended.
Immediately upon notification from the state licensing staff that the order for Triple Antibiotic ointment was not available for the individual, staff ordered the medication from Minnichs Pharmacy and the triple antibiotic ointment was delivered on 1/6/2021. See attachment # 8-prescription label. Program Managers are to monitor PRN medications during monthly site monitoring. If a manager is unable to monitor the site, they will assign the task to another team member to ensure all PRN medications are available. |
04/01/2021
| Implemented |
| 6400.211(b)(3) | Individual #1's record did not include the name, address, and telephone number of the person able to give consent for emergency medical treatment. | 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.
| The program manager failed to ensure the individuals medical contact information on the Emergency Medical form and the individuals face sheet.
This regulation is important to ensure that medical emergency contacts are able to be reached in a timely manner.
Emergency contact information for the individual was added to the individuals face sheet and medical emergency form. See attachment # 9.1 - Individual #1 face sheet and Attachment # 9.2 medical emergency form with the emergency contact information included.
Program managers and nurses have had training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. Program Managers conducted an audit of the face sheets and emergency medical forms to ensure all the individuals supported in Penn-Mar CLAs have emergency contact information on the documents. All residential supervisors and program managers have been retrained on this regulation via email. see attachment #2 of the email sent to all residential team members. A review of this regulation will also be completed with the Residential Supervisors again at their next team meeting on April 14, 2021. |
04/14/2021
| Implemented |
| 6400.50(a) | Staff persons #3-#5's training records did not include the content of the trainings, the trainer(s), or the training source for all of their trainings. For example, the information was not kept for specific trainings, individual's protocols to define what content was reviewed, which individual's plans were reviewed, etc. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | Penn-Mar failed to keep on file the content of trainings along with the signature sheets that show the source, dates, and length of training.
This regulation is important to ensure team members are properly trained to support the individuals they are working with and are able to meet their needs.
Program Managers and Supervisors were retrained on the need to ensure all team members review ISPs, protocols, support plans, behavior plans, and assessments prior to working with individuals. A new process was put in place in November 2020 to have Program Managers review weekly training reports for team members that have worked in each program to ensure all team members have completed the training requirements for each program. Weekly audits are also conducted by the Director and Administrator to provide another level of oversight to ensure that staff working have completed all required individual specific training prior to working with individuals.
A new process was put into place in November requiring Managers and Nurses to meet with teams to review protocols together. These meetings are held virtually and recorded. The protocol videos along with a Microsoft Word document of the protocol will then be uploaded into UltiPro (training platform). This will show the content of each protocol training. Protocol trainings include content, dates, length of training and staff persons attending. If team members are unable to attend the team meeting, they are required to review the recorded training at the start of their next shift. New protocols or updated protocols are immediately written and reviewed with team members. See attachment # 11 Protocol Training Guide.
For staff training on things such as hospitalization discharge documents, the Learning and Development department will save staff signature sheets with the content they reviewed so they we are able to provide training information when required. See attachment # 12- in-person training guide. |
04/01/2021
| Implemented |
| 6400.51(b)(5) | Staff person #4 started working independently with Individual #1 and his housemates on 5/30/2020. There are no records maintained that Staff person #4 received orientation specific to Individual #1, his specific plans, and his health and safety needs prior to working with him. Individual #1's specific plans and protocols provide staff with the knowledge and job skills needed to ensure the individual's health and safety is properly managed while living at the residence. Staff person #4 didn't receive training in Individual #1's Choking, Fall, Seizure, and Supra Catheter plan until 12/4/2020, his agency assessment until 7/1/2020, or his individual support plan (isp) until 12/2/2020. | The orientation must encompass the following areas: Job-related knowledge and skills. | The program manager failed to ensure the staff was properly trained to support the individual prior to working with him.
It is important to ensure staff are thoroughly trained on plans and protocols for an individual prior to working with them to ensure they have the knowledge and job skills needed to ensure the individuals health and safety is properly managed.
Program Managers and Supervisors were retrained on the need to ensure all team members review ISPs, protocols, support plans, behavior plans, and assessments prior to working with individuals. Supervisors have been retrained on the need to email their Program Manager to let them know when new substitute team members are scheduled to work at a group home. The Program Manager will then ensure that team members are assigned all trainings that team member is required to complete prior to working with individuals. A new process was put in place in November 2020 to have Program Managers review weekly training reports for team members that have worked in each program to ensure all team members have completed the training requirements for each program. Previously, the training system used did not allow managers to see the training records of the people who did not directly report to them. We have since discovered a work around to this and these reports are now sent weekly via email from the Director of PA programs to the Program Managers. Weekly audits are also conducted by the Director and Administrator to provide another level of oversight to ensure that staff working have completed all required individual specific training prior to working with individuals. |
04/01/2021
| Implemented |
| 6400.166(b) | Staff person #6 administered Individual #1 his Amlodipine, Nystatin cream, Phenobarbital, and Vimpat at 8AM on 11/22/2020. However, she recorded that she did not initial the individual's medication administration record (mar) immediately after administration. She didn't record the administration of medications until 9:07AM and 9:08AM.
Individual #1 is to be administered Vimpat 100mg, Phenobarbital 64.8mg and Nystatin cream at 8PM on 10/8/2020. Staff person #6 reported that these medications were administered at 8PM however, she did not immediately initial the individual's mar after she administered said medications. According to the individual's 10/8/2020 mar, Staff person #6 did not initial as administering the medications until 9:45PM and 9:46PM. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | This citation was received because staff failed to document medication administration on time.
It is important to ensure documentation of the medication administration is completed at the time the medication is administered to prevent potential medication errors.
All team members administering medication are also required to take a video training created by an agency nurses regarding medication administration documentation by 4/16/2021. See attachment #4-medication documentation training.
All staff will be retrained on the expectation to utilize the paper MAR when they do not have internet access. In addition, all staff will be retrained on how to properly document on the electronic MAR when documentation of a medication administration is written on the paper MAR. This training has occurred via email. see attachment # 3 - email regarding medication administration documentation.
Program managers and nurses have had training regarding this regulation during the exit conference with state licensing team on January 11, 2021. Program managers will continue to monitor MARs during monthly site monitoring at each group home. Site monitoring completed by Program Managers are monitored monthly for completion by the Community Living Administrator and the Director of PA Program. Effective 3/22/2021, the nurses will start to complete weekly audits of MARs to ensure medications are being administered as ordered. |
04/01/2021
| Implemented |
| 6400.167(a)(4) | Individual #1 was prescribed Furosemide 40mg and Vitron C 325mg at 8AM in November 2020. Staff person #6 failed to administer each medication at the prescribed time, which exceeded more than 1 hour before or after the prescribed time. Staff person #6 documented that she administered the medications to Individual #1 on 11/22/2020 at 9:07AM and 9:09AM respectively.
Individual #1 is prescribed Nystatin cream to be applied at 8PM. Staff had the individual on an outing, away from the home and without his medications to be administered at the prescribed times, on 11/28/2020. Staff reported that they didn't bring the individual home until 9PM and thus didn't administer the individual his Nystatin cream until 9:30PM.
Staff person #6 administered the individual his Nystatin cream at 10:45PM on 10/26/2020 when it is to be administered at 8PM.
Individual #1 was to be administered Nystatin cream 30gm at 8AM on 12/26/2019. According to his 12/26/219 mar, he was not administered the medication until 1:30PM without record for why the medication wasn't administered at the correct time. | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | This citation was received because staff failed to document medication administration or administered the medications late on several occasions.
It is important to ensure documentation of the medication administration is completed at the time the medication is administered to prevent potential medication errors.
There are times when the internet connection in the program does not work well due to the location of the home being in a rural area. Our IT team is working on a solution for this and is currently piloting a new internet connection in our rural programs. During the times that staff are unable to connect to the internet, they are expected to administer medications using the paper MAR and add a note in the electronic MAR when internet access is available, stating that the paper MAR was used to administer medications.
All staff will be retrained on the expectation to utilize the paper MAR when they do not have internet access. In addition, all staff will be retrained on how to properly document on the electronic MAR when documentation of a medication administration is written on the paper MAR. This training has occurred via email. see attachment # 3 - medication administration documentation. All team members administering medication are also required to take a video training created by an agency nurses regarding medication administration documentation by 4/16/2021. See attachment #4- medication documentation training.
Program managers and nurses have had training regarding this regulation during the exit conference with state the state licensing team on January 11, 2021. Program managers will continue to monitor MARs during monthly site monitoring at each group home. Site monitoring completed by Program Managers are monitored monthly for completion by the Community Living Administrator and the Director of PA Program. Effective 3/22/2021, the nurses will start to complete weekly audits of MARs to ensure medications are being administered as ordered. |
04/01/2021
| Implemented |
| 6400.167(b) | The medication errors described in 6400.167(a)(4) of this report were not documented in the individuals record, follow-up action wasn't taken, and the prescriber's response to the medication errors was not documented. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | This citation was received because staff failed to document medication administration or administered the medications late on several occasions and program managers failed to follow up with the staff regarding late administration and file reports if necessary.
It is important to ensure documentation of the medication administration is completed at the time the medication is administered to prevent potential medication errors. If a medication error occurs, it is important for staff to follow up with the prescribing physician and follow their recommendations. It is also important for the manager to provide retraining to the team member that had the medication error. All medication errors are required to be filed by the program manager in the EIM system.
There are times when the internet connection in the program does not work well due to the location of the home being in a rural area. Our IT team is working on a solution for this and is currently piloting a new internet connection in our rural programs. During the times that staff are unable to connect to the internet, they are expected to administer medications using the paper MAR and add a note in the electronic MAR when internet access is available, stating that the paper MAR was used to administer medications.
All staff will be retrained on the expectation to utilize the paper MAR when they do not have internet access. In addition, all staff will be retrained on how to properly document on the electronic MAR when documentation of a medication administration is written on the paper MAR. This training has occurred via email. see attachment # 3 - medication administration documentation. All team members administering medication are also required to take a video training created by an agency nurses regarding medication administration documentation by 4/16/2021. See attachment #4- medication documentation training.
Program managers and nurses have had training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. Program managers will continue to monitor MARs during monthly site monitoring at each group home. Site monitoring completed by Program Managers are monitored monthly for completion by the Community Living Administrator and the Director of PA Program. Effective 3/22/2021, the nurses will start to complete weekly audits of MARs to ensure medications are being administered as ordered. |
04/16/2021
| Implemented |
| 6400.169(a) | The agency documented that Staff person #2 completed the initial medication administration training and was certified to administer medications to individuals on 7/9/2020. However, according to the information documented by the agency's (Penn-Mar Human Services) medication administration trainer, Staff person #2 never completed the Department's approved medication administration course correctly in order to be certified to administer medications.
In order to correctly pass the Department's initial medication administration training course, staff must take and complete with passing grades a serious of in-class examinations (multiple choice, written, handwashing, and gloving examinations) then pass four observations within 30 days of passing the in-class examinations. The initial medication administration training course also defines parameters to meet should the staff taking the course be unable to have four observations completed within 30 days of passing their in-class examinations. The parameters are defined as: 6 observations need to be completed within 75 days of passing the examinations, or 7 observations need to be completed within 105 days of passing the examinations, or 8 observations need to be completed within 135 days of passing the examinations, or 9 observations need to be completed within 175 days of completing the examinations, and if not completed by then, the student would have to retake all in-class examinations again.
Staff person #2 completed all in-class examinations on 3/12/2020. The agency documented she was certified to administer medications to individuals on 7/9/2020, but they only completed 6 observations with her. 7/9/2020 is 119 days after 3/12/20. She should have had 8 observations completed prior to a medication trainer certifying her to administer medications. At the time of the 1/4/2021 annual inspection, Staff person #2 has been administering medications to individuals since July 2020.
Staff person #3 was documented as passing the Department's medication administration training course on 7/29/18 and not again until 7/24/2020, outside of the requirements to complete the training annually. In addition, there are no records maintained that the staff's 7/24/2020 medication training was completed with all requirements. The agency only had documentation of Staff person #3 completing 1 and 1/2 of the 2 required medication administration record (mar) reviews and 1 out of the 2 required observations.
There were no records maintained that Staff person #2 or #3 completed the Department's modified medication administration training course and it's requirements during the COVID-19 pandemic in leu of the complete medication administration training course. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | This citation was received because the medication administration trainer did not follow the requirement of ensuring 8 medication passes were completed prior to certifying staff #1 to administer medications. Also, Penn-Mar was unable to locate the 2019 annual medication administration certification packet for a team member.
It is important for medication administration trainers ensure that staff completed their medication administration observations on time to keep their medication certification current. It is also important for medication administration trainers to observe medication administrations to ensure staff are properly trained to administer medications in an effort to prevent medication errors.
Program managers and nurses have had training regarding this regulation during the exit conference with the state licensing team on January 11, 2021. The nursing department will continue to monitor medication administration passes to ensure they are completed within the required timeframe. Effective 3/22/2021, the Community Living Administrator will begin to conduct monthly audits of medication administration certifications.
Following the licensing exit on January 11, 2021, the agency nurses completed an audit to ensure all medication administration certifications are in compliance. Also, upon being alerted to this issue, the staff did not administer medications until she was completed the medication administration course and became recertified to administer medications. |
04/01/2021
| Implemented |
| Article X.1007 | Penn-Mar Human Services (the agency) is required to maintain criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff person #2 was hired by the agency, Penn-Mar Human Services, on 3/2/2020. An application for a Pennsylvania criminal history record check was never submitted to the Pennsylvania State Police. At the time of the 1/4/2021 inspection, the agency only had records of a third-party background check, that did not meet the regulatory requirements of submitting an application to the Pennsylvania State Police, was completed. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | This citation was received because Penn-Mar had records of a third-party background check instead of a physical copy of the Pennsylvania criminal history check that was submitted to the Pennsylvania State Police on file.
Penn-Mar understands the importance of completing criminal record checks on staff. The vendor that we used HireRight, did submit background checks to PA State Police and would indicate on the report that they sent us the outcome of the PATCH report, however they did not send us a copy of the actual PATCH document. Since this was brought to our attention during our licensing, Penn-Mar Director of HR has been working closely with our vendor to change the terms of our agreement so that we will not only receive their comprehensive report but also a copy of the PA PATCH report. He has talked to numerous people at this company in an attempt to get copies from previously submitted staff but has not been successful. We have been successful at changing our agreement moving forward and have started to receive the PA PATCH document for all staff who have been extended offers of employment. Please see attachment #10, which is the actual PA PATCH document for a new staff recently hired.
Moving forward we will receive the PA PATCH report from HireRight for all new staff. We are also in the process of submitting for a PA background check (PATCH) through the PSP system for any staff previously hired that we only have the comprehensive report for, given our previous arrangement with HireRight. We anticipate this to be completed by May 15th at the very latest. |
05/15/2021
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | 16-Neglect - Individual #1 had an ongoing history of aspiration and issues with eating leading back to 2017 which lead to being put on hospice. In 2017, he was removed from hospice but continued to have issues with eating. He was again placed on hospice in October 2020, due to issues with aspiration. Individual #1 passed away on 10/13/20. During the inspection initiated on 10/21/20 it was discovered that Penn Mar had multiple systematic failures of training staff in plans and protocols, following protocols developed to eliminate risk, reporting incidents of concern, reporting falls and not following doctor recommendations which created conditions conducive to serious injury or death as depicted below:
Failure to ensure all staff are trained in plans. Individual #1 had the following protocols in place: Choking Protocol, Fall Protocol, Bed Alarm/Railings Protocol, MRSA protocol, and a seizure protocol. The following staff providing care to Individual #1 were not trained on Individual #1's Individual Support Plan dated 7/14/20 or all of the protocols mentioned above: Staff #3, #4, #5, #6, #8, #10, #11, #12, and #13.
Failure to follow the choking protocol. An LPN employed with Penn-Mar first developed a choking protocol for Individual #1 on 4/5/10, due to Individual #1 being edentulous, having a large tongue, and having ongoing issues with aspiration. The choking protocol remained in effect with updates from that date forward. The choking protocol updated on 6/22/20 for Individual #1 included training which detailed foods that he should avoid: ice cream, gelatin, sherbet, water ices, smoothies, or shakes. The choking protocol also required notification to the supervisor and supporting nurse for a choking assessment to be completed when Individual #1 experienced reoccurring coughing episodes. Below are instances where the choking protocol was not followed:
· According to the service logs, Individual #1 had a protein shake on 5/1/20, 5/2/20, 5/11/20, and 5/31/20 and given ice cream on 5/23/20, 6/13/20, and 7/28/20.
· Based on interviews held from 11/4/20 to 11/6/20 by Licensing Representative, Staff #2, 3, 4, 5, 7, 8, 9 confirmed Individual #1 would hiccup, spit-up, aspirate, experience coughing fits, refuse to eat by pushing out his tongue and overall displayed eating issues frequently. Staff did not report/notify these concerns as outlined in the choking protocol and therefore a choking assessment was not completed.
Failure to follow doctor recommendations. Staff #3 made an appointment with Individual's #1 Primary Care Physician (PCP) due to lack of eating and weight loss concerns. At the appointment on 8/27/20, the primary care physician recommended that Individual #1's blood pressure be monitored and to be contacted if Individual #1's blood pressure remained low. There were no records maintained verifying Individual #1's blood pressure was being monitored.
· On 9/10/20, Individual #1 returned to his PCP for a follow-up from the appointment dated 8/27/20. It was recommended that Individual #1 follow-up with Gastroenterology to discuss possible treatments and to receive an evaluation due to his weight loss and ongoing issues with aspiration and vomiting. The Gastroenterology appointment was scheduled for 9/24/20; but was canceled due to staffing issues. This appointment was not rescheduled.
Failure to report unexplained injuries. On 9/30/20, Individual #1 was taken to the hospital due to concerns of throwing up and possible aspiration. A forehead abrasion was discovered during the assessment completed at the hospital. The cause of the injury to his forehead was never discovered or reported prior to going to the hospital.
· On 9/30/20, a CT was completed of Individual #1's spine. It was discovered that he had a fracture of T8 that had occurred sometime between January 2020 and September 2020. Upon discovering of the fracture that no one was previously aware of, an investigation wasn't initiated, and the injury was not reported in the Enterprise Incident Management (EIM) System. | 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. | It is important to meet each individuals needs by following recommendations made by physicians, following protocols, ensuring processes are in place and followed, and ensuring team members are thoroughly trained and reporting incidents in a timely manner to ensure the individuals health and safety needs are met.
During the licensing process for the Ridge Meadow Rd home, areas on non-compliance were brought directly to the attention of the Director. As these issues surfaced, the Director had discussions with the administrator, program managers and nurses and made plans to correct the areas where we were not in compliance with regulations. During this time, program managers and agency nurses were retrained on the need to thoroughly review medical documents and ensure there is follow up for each recommendation noted. The nurses and program managers were retrained on the need to coach or provide feedback to the program supervisor if there is missing documentation on submitted appointment records. The preliminary citations received during the licensing exit on 12/14/2020 were reviewed with the program managers and nurses on 12/18/2020.
We started to implement that all team members review and sign discharge documents following an emergency room visit or hospitalization. Our training department will store these documents so that we are able to provide documentation of the training as required. When an individual returns from an emergency room visit or hospitalization, staff immediately forward the discharge documents to the program manager and nurse for review. This process was set in place to ensure documentation is reviewed in a timely manner, ensure staff are following the discharge instructions, and to ensure that follow up appointments are scheduled as recommended. Program managers trained the supervisors for each program on these new requirements during their individual supervision meetings held between 12/18/2020 and 1/8/2021.
During a meeting that occurred on 2/10/2021, program managers, supervisors and nurses were retrained on the definition of Abuse and the need to report any type of abuse and unusual incidents immediately. In addition, they were retrained on each specific issue discovered that lead to this citation regarding regulation 6400.16. Program Managers and nurses will continue to review medical appointment records for each individual as appointments occur and ensure recommendations from physicians and follow up appointments are followed through. - See attachment #1 Residential Supervisors meeting Agenda 2/10/2021
Reviewing documents following a medical appointment has always been an expectation of the agency nurses and program managers. They have been reminded on several occasions since this licensing for the need for them to thoroughly review medical documents and to do so as the appointments occur. Effective immediately, the Administrator and Community Living Manager will conduct weekly audits of appointments to ensure follow up appointments and recommendations occur as recommended.
Program Managers and Supervisors were retrained on the need to ensure all team members review ISPs, protocols, support plans, behavior plans, and assessments prior to working with individuals. Supervisors have been retrained on the need to email their Program Manager to let them know when new substitute team members are scheduled to work at a group home. The Program Manager will then ensure that team members are assigned all trainings that team member is required to complete prior to working with individuals. A new process was put in place in November 2020 to have Program Managers review weekly training reports for team members that have worked in each program to ensure all team members have completed the training requirements for each program. Previously, the training system used did not allow managers to see the training records of the people who did not directly report to them. We have since discovered a work around to this and these reports are now sent weekly via email from the Director of PA programs to the Program Managers. Weekly audits are also conducted by the Director and Administrator to provide another level of oversight to ensure that staff working have completed all required individual specific training prior to working with individuals.
All protocols for individuals residing in residential programs have been reviewed and retraining of each protocol occurred for all team members from November through December 2020. A new process was put into place in November requiring Managers and Nurses to meet with teams to review protocols together. These meetings are held virtually and recorded. If team members are unable to attend the team meeting, they are required to review the recorded training at the start of their next shift. New protocols or updated protocols are immediately written and reviewed with team members. See attachment # 2 Protocol Training Guide
All direct support staff will be retrained on reportable incidents and the requirement to report any unusual incidents or medical concerns immediately to the program manager or agency nurse. This training will occur during staff meeting for each program through March. Each direct support staff, program manager and nurse will also be required to review reportable incidents noted in the Incident Management Bulletin by March 15, 2021 to ensure they have clear understanding of incidents that require reporting. |
02/23/2021
| Implemented |
| 6400.144 | As per Individual #1's ISP, he has a bowel movement chart that is to be recorded daily by staff. Individual #1's bowel movement chart was not completed on 8/6/20, 8/7/20, 8/8/20, 8/15/20, 8/28/20, 8/29/20, 9/7/20, 9/8/20, 9/13/20, 9/14/20, 9/19/20, 9/20/20, 9/21/20, 9/27/20, or 9/29/20.
· Staff #3 made an appointment with Individual's #1 Primary Care Physician (PCP) due to lack of eating and weight loss concerns. At the appointment on 8/27/20, the primary care physician recommended that Individual #1's blood pressure be monitored and to be contacted if Individual #1's blood pressure remained low. There were no records maintained verifying Individual #1's blood pressure was being monitored.
· On 9/10/20, Individual #1 returned to his PCP for a follow-up from the appointment dated 8/27/20. It was recommended that Individual #1 follow-up with Gastroenterology to discuss possible treatments and to receive an evaluation due to his weight loss and ongoing issues with aspiration and vomiting. The Gastroenterology appointment was scheduled for 9/24/20; but was canceled due to staffing issues. This appointment was not rescheduled.
· An LPN employed with Penn-Mar first developed a choking protocol for Individual #1 on 4/5/10, due to Individual #1 being edentulous, having a large tongue, and having ongoing issues with aspiration. The choking protocol remained in effect with updates from that date forward. The choking protocol updated on 6/22/20 for Individual #1 included training which detailed foods that he should avoid: ice cream, gelatin, sherbet, water ices, smoothies, or shakes.. According to the service logs, Individual #1 had a protein shake on 5/1/20, 5/2/20, 5/11/20, and 5/31/20 and given ice cream on 5/23/20, 6/13/20, and 7/28/20.
· The choking protocol updated on 6/22/20 required notification to the supervisor and supporting nurse for a choking assessment to be completed when Individual #1 experienced reoccurring coughing episodes Based on interviews held from 11/4/20 to 11/6/20 by Licensing Representative, Staff #2, 3, 4, 5, 7, 8, 9 confirmed Individual #1 would hiccup, spit-up, aspirate, experience coughing fits, refuse to eat by pushing out his tongue and overall displayed eating issues frequently. Staff did not report/notify these concerns as outlined in the choking protocol and therefore a choking assessment was not completed. | 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 to meet each individuals needs by following recommendations made by physicians, following protocols, ensuring team members are thoroughly trained and reporting incidents in a timely manner to ensure the individuals health and safety needs are met.
All individuals that are prescribed a medication to aid in bowel movements or have a history or diagnosis of constipation have bowel charts where staff are to document whether the individual had a bowel movement. The bowel chart tracking form was updated to include each individuals bowel protocol, the Bristol Stool Chart, when the PRN should be given and the time the bowel movement occurred. The new bowel chart was implemented starting February 1, 2021. Supervisors were trained on how to complete the updated form via email on 1/28/2021. The new form was also reviewed with supervisors during a virtual meeting on 2/10/2021. Supervisors have reviewed the updated bowel charts with direct support staff that report directly to them. All direct support staff are also required to review the bowel chart training through our online training system by 3/15/2021. Supervisors are required to review bowel charting during each shift and managers are required to review bowel charts at least weekly to ensure bowel protocols are followed and that documentation is completed thoroughly. See attachment #3 of the bowel chart.
During the licensing process for the Ridge Meadow Rd home, areas of non-compliance were brought directly to the attention of the Director. As these issues surfaced, the Director had discussions with the administrator, program managers and nurses and made plans to correct the areas where we were not in compliance with regulations. During this time, program managers and agency nurses were retrained on the need to thoroughly review medical documents and ensure there is follow up for each recommendation noted. The preliminary citations received during the licensing exit on 12/14/2020 were reviewed with the program managers and nurses on 12/18/2020.
Program managers will ensure required charting such as monitoring vital signs is entered as a task in our electronic medication records where staff are required to sign-off on the task when completed. The nurses and program managers were retrained on the need to coach or provide feedback to the program supervisor if there is missing documentation on submitted appointment records. We also started to implement that all team members review and sign discharge documents following an emergency room visit or hospitalization immediately upon their next shift following the hospital visit. Our training department will store these documents so that we are able to provide documentation of the training as required. When an individual returns from an emergency room visit or hospitalization, staff immediately forward the discharge documents to the program manager and nurse for review. This process was set in place to ensure documentation is reviewed in a timely manner, ensure staff are following the discharge instructions, and to ensure that follow up appointments are scheduled as recommended. Program managers trained the supervisors for each program on these new requirements during their individual supervision meetings held between 12/18/2020 and 1/8/2021.
During a meeting that occurred on 2/10/2021, program managers, supervisors and nurses were retrained on the definition of abuse and the need to report any type of abuse or unusual incidents immediately. In addition, they were retrained on each specific issue discovered that lead to this citation regarding regulation 6400.144. - See attachment #1 Residential Supervisors meeting Agenda 2/10/2021
Program Managers and Supervisors were retrained on the need to ensure all team members review ISPs, protocols, support plans, behavior plans, and assessments prior to working with individuals. Supervisors have been retrained on the need to email their Program Manager to let them know when new substitute team members are scheduled to work at a group home. The Program Manager will then ensure that team members are assigned all trainings that team member is required to complete prior to working with individuals. A new process was put in place in November 2020 to have Program Managers review weekly training reports for team members that have worked in each program to ensure all team members have completed the training requirements for each program. Previously, the training system used did not allow managers to see the training records of the people who did not directly report to them. We have since discovered a work around to this and these reports are now sent weekly via email from the Director of PA programs to the Program Managers. Weekly audits are also conducted by the Director and Administrator to provide another level of oversight to ensure that staff working have completed all required individual specific training prior to working with individuals.
All protocols for individuals residing in residential programs have been reviewed and retraining of each protocol occurred for all team members from November through December 2020. A new process was put into place in November requiring Managers and Nurses to meet with teams to review protocols together. These meetings are held virtually and recorded. If team members are unable to attend the team meeting, they are required to review the recorded training at the start of their next shift. New protocols or updated protocols are immediately written and reviewed with team members. See attachment # 2 ¿ Protocol Training Guide
Program Managers and nurses will continue to review medical appointment records for each individual as appointments occur and ensure recommendations from physicians and follow up appointments are followed through. Reviewing documents following a medical appointment has always been an expectation of the agency nurses and program managers. They have been reminded on several occasions since this licensing for the need for them to thoroughly review medical documents and to do so as the appointments occur. Effective immediately, the Administrator and Community Living Manager will conduct weekly audits of appointments to ensure follow up appointments and recommendations occur as recommended.
All direct support staff will be retrained on reportable incidents and the requirement to report any unusual incidents or medical concerns immediately to the program manager or agency nurse. This training will occur during staff meeting for each program through March. Each direct support staff, program manager and nurse will also be required to review reportable incidents noted in the Incident Management Bulletin by March 15, 2021 to ensure they have clear understanding of incidents that require reporting. |
02/23/2021
| Implemented |
| 6400.212(a) | Individuals in the home are to have separate records. However, Individual #2's compression sock protocol was incorporated into Individual #1's record as if it were Individual #1's protocol. Individual #1 has never had a compression sock protocol and yet staff were trained on a compression sock protocol for Individual #1. | A separate record shall be kept for each individual.
| It is important to follow this regulation to ensure that the care provided to an individual is specific to their needs.
This regulation was not met because the nurse that wrote the protocol included information in an individual protocol that did not pertain to them. The nurse blended medical information pertaining to one individual into another individual protocol. This likely happened because the two individuals resided in the same home. Program managers review protocols for individuals prior to staff being trained. In this case, the program manager missed this error made by the nurse and proceeded to include this information in the individuals record.
When this issue was brought to the attention of the Director, the nurses and program managers were immediately retrained on the need to thoroughly review medical documentation and ensure that information in each individuals medical record remains separate.
All protocols for individuals residing in residential programs have been reviewed and retraining of each protocol occurred for all team members from November through December 2020. A new process was put into place in November requiring Managers and Nurses to meet with teams to review protocols together. This allows for all staff that support an individual the opportunity to ask questions about the implementation of the protocol. These meetings are held virtually and recorded. If team members are unable to attend the team meeting, they are required to review the recorded training at the start of their next shift. New protocols or updated protocols are immediately written and reviewed with team members. See attachment # 2 Protocol Training Guide
Program managers supervisors, and nurses have had retraining regarding regulation 6400.212 (a) and the issue that lead to this citation during a meeting on February 10, 2021. - See attachment #1 Residential Supervisors meeting Agenda 2/10/2021 |
02/23/2021
| Implemented |
| 6400.18(a)(4) | · On 7/23/20, Individual #3 walked into Individual #4. Individual #4 started hitting Individual #3 on his left thigh. Individual #3's big left toe was black & blue. It was believed Individual #4 may have run over Individual #3's toe with his wheelchair. This incident was not reported in EIM. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Abuse, including abuse to a individual by another client.
| It is important for all team members to follow this regulation to ensure the health and safety needs of the individual is met. It is important that reportable incidents are reported in a timely manner and filed in EIM within the required timeframe.
This incident was reported by direct support staff. However, the program manager responsible for filing the incident in EIM failed to do so. When this issue was brought to our attention during the licensing process in November 2020, the program manager responsible for reporting this incident in EIM was counseled and provided specific training regarding incidents that need filed in EIM. Additionally, all other program managers were retrained in this area.
All program managers, supervisors and nurses were retrained on the definition of Abuse, specifically as it relates to individual-to-individual abuse within support services. Supervisors were retrained on the need to report any type of abuse and unusual incidents immediately to their Program Manager.
Program Managers are responsible for reporting incidents through the Departments information management system within the specified time frames for that specific incident. The Community Living Administrator, Director of PA Programs and the Chief Operations Officer are responsible for ensuring reports are filed, completed, and investigated as required. The Community Living Manager files incident reports in Doc Star, which is the system we use for electronic record keeping. When filing incident reports, the Community Living Manager will ensure incidents that require reporting in EIM are filed. |
02/23/2021
| Implemented |
| 6400.18(a)(9) | Individual #1 was taken to the emergency room on 9/30/20 due to vomiting. While at the ER, Staff #4 reported to hospital officials, it was believed Individual #1 may have had an unwitnessed fall due to having an unexplained abrasion on his forehead. There was no mention of the unexplained abrasion reported in EIM.
· As of 1/15/20, Individual #1 had three prior compression fractures of his spine at T3, T6 and T7. As of 9/30/20, an additional "older" fracture was found in his spine at T8. This fracture occurred sometime between January 15, 2020 and September 30, 2020. When this information was discovered, this incident was not entered into EIM and an investigation was not initiated. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Injury requiring treatment beyond first aid.
| It is important for all team members to follow this regulation to ensure the health and safety needs of the individual is met. It is important that reportable incidents are reported in a timely manner and filed in EIM within the required timeframe and investigated as needed.
During the licensing process for the Ridge Meadow Rd home, there were discussions of the issues brought to the attention of the Director of PA Programs with the nurses and program managers as they surfaced. During this time, program managers and agency nurses were retrained on the need to thoroughly review medical documentation and follow up with concerns, as necessary. They were also retrained on the need to file reportable incidents and conduct investigations as required.
When an individual returns from an emergency room visit or hospitalization, staff immediately forward the discharge documents to the program manager and nurse for review. This process was set in place to ensure documentation is reviewed in a timely manner, ensure staff are following the discharge instructions, ensure medical concerns are addressed, and that follow up appointments are scheduled as recommended. Program managers trained the supervisors for each program on these new requirements during their individual supervision meetings held between 12/18/2020 and 1/8/2021.
The preliminary citations received during the licensing exit on 12/14/2020 were reviewed with the program managers and nurses on 12/18/2020. Specifically, managers have been retrained on the need to file EIM reports for incidents requiring treatment beyond first aid.
During a meeting that occurred on 2/10/2021, program managers, supervisors and nurses were retrained on the need to report any type of unusual incidents immediately to their program manager. In addition, they were retrained on each specific issue that contributed to the citation for not meeting regulation 6400.18 (a) (9). - See attachment #1 Residential Supervisors meeting Agenda 2/10/2021
Supervisors, Program Managers, and agency Nurses were retrained on the need to thoroughly review medical paperwork and ensure changes in an individuals health is noted and that we are following through with required actions. |
02/23/2021
| Implemented |
| 6400.52(c)(6) | Staff #5, #8, #10, #11, #12, and #13 did not receive training on Individual #1's ISP dated 7/14/20. Staff #4, #5, #10, #11, #12, and #13 did not receive training on Individual #1's MRSA protocol dated 6/22/20. Staff #3, #4, #5, #10, #11, #12, and #13 were not trained on Individual #1's Bed Alarm/Bed Railing Protocol dated 7/17/20, nor his Fall Protocol dated 7/17/20. Staff #3, #10, #11, #12, and #13 were not trained on Individual #1's Seizure Protocol. Staff #3, #4, #5, #6, #10, #11, #12, and #13 were not trained on Individual #1's Choking Protocol dated 6/22/20. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | This regulation is important to follow so that team members can meet the needs of the individuals they are supporting.
Program Managers and Supervisors were retrained on the need to ensure all team members review ISPs, protocols, support plans, behavior plans, and assessments prior to working with individuals. Supervisors have been retrained on the need to email their Program Manager to let them know when new substitute team members are scheduled to work at a group home. The Program Manager will then ensure that team members are assigned all trainings that team member is required to complete prior to working with individuals. A new process was put in place in November 2020 to have Program Managers review weekly training reports for team members that have worked in each program to ensure all team members have completed the training requirements for each program. Previously, the training system used did not allow managers to see the training records of the people who did not directly report to them. We have since discovered a work around to this and these reports are now sent weekly via email from the Director of PA programs to the Program Managers. Weekly audits are also conducted by the Director and Administrator to provide another level of oversight to ensure that staff working have completed all required individual specific training prior to working with individuals.
All protocols for individuals residing in residential programs have been reviewed and retraining of each protocol occurred for all team members from November through December 2020. A new process was put into place in November requiring Managers and Nurses to meet with teams to review protocols together. These meetings are held virtually and recorded. If team members are unable to attend the team meeting, they are required to review the recorded training at the start of their next shift. New protocols or updated protocols are immediately written and reviewed with team members. See attachment # 2 Protocol Training Guide
Program managers, supervisors and nurses have had training regarding regulation 6400.52 and the issues discovered that lead to this citation during a meeting on February 10, 2021. Supervisors and Program Managers are responsible for ensuring all staff are trained on necessary documents such as protocols, assessments, ISPs, SEEN plans or Behavior plans prior to working with individuals. |
02/23/2021
| Implemented |
|
|