| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.24(e)(1) | The home documented that multiple gift cards were added to Individual #1's funds on 3/27/22: $20 Target, $20 outback, $25 kohls, $15 Walmart, $160 visa, $25 mastercard, and $15 rutters. The records of the amount used by the gift cards was not kept for all cards. The home recorded some of the transactions with the cards as if they were cash transactions. It is unclear if the money was used from cash or cards for each of the establishments and how much was left on each card during the inspection.
The home recorded that $17.96 cash from Individual #1's spending account was spent at Walmart on 3/28/22. According to the receipt, only $2.96 cash was spent. The incorrect total amount of cash funds available have been continuously carried over from March 2022 until current, discovered during the 10/6/22 inspection.
A target gift card was added to Individual #1's account on 4/17/22. The home documented that $20.12 of cash was used from Individual #1's home financial account on 4/23/22. According to the receipt, cash was not used but a gift card was used. The incorrect amount of cash was reported as being deducted from the financial account and continued to be carried over until the inspection on 10/6/22. | If the agency or family assumes the responsibility for an individual's financial resources, the following shall be maintained: a separate record of financial resources including the dates and amounts of deposits and withdrawals. | This regulation is important because the individual relies on agency or family members to ensure that they're finances are appropriately kept and all funds, whether it is a cash amount or gift card.
The home documented that multiple gift cards were added to Individual #1's funds on 3/27/22: $20 Target, $20 outback, $25 kohls, $15 Walmart, $160 visa, $25 MasterCard, and $15 rutters. The records of the amount used by the gift cards was not kept for all cards. The home recorded some of the transactions with the cards as if they were cash transactions. It is unclear if the money was used from cash or cards for each of the establishments and how much was left on each card during the inspection. The home recorded that $17.96 cash from Individual #1's spending account was spent at Walmart on 3/28/22. According to the receipt, only $2.96 cash was spent. The incorrect total amount of cash funds available have been continuously carried over from March 2022 until current, discovered during the 10/6/22 inspection. A target gift card was added to Individual #1's account on 4/17/22. The home documented that $20.12 of cash was used from Individual #1's home financial account on 4/23/22. According to the receipt, cash was not used but a gift card was used. The incorrect amount of cash was reported as being deducted from the financial account and continued to be carried over until the inspection on 10/6/2022.
When individual #1 received the gift cards, the provider failed to accurately document the gift card and record all transactions made with that gift card. During regular monitoring, the program specialist did not ensure that the individuals finances were being appropriately recorded.
On 10/10/2022, the program specialist and the provider were retrained regarding the importance of ensuring that the individuals funds are appropriately recorded. Attachment #1 is proof of training.
On 10/10/2022, the Program Specialist provided the provider with a gift card transaction form and provided training on how to use the gift card transaction form. The provider began utilizing the gift card transaction form On this date. Attachment #2 is proof of implementation.
On 10/14/2022, the program specialist completed an audit of all individuals' financials to ensure that their gift cards were being recorded appropriately and all transactions were captured. No further errors were found. See attachment #3 for documentation of audit. |
10/14/2022
| Implemented |
| 6500.83(b) | Individual #2 reported on 10/6/22 that they are unable to swim. This was confirmed by Staff person #1 and #2. The above ground pool was not locked and accessible to all individuals and family on 10/6/22. Individual #2's assessment states they need support and assistance when in or around bodies of water.
Individual #1's assessment and individual plan state they can swim however, due to their seizure disorder require supervision around bodies of water. | An aboveground swimming pool shall be made inaccessible to individuals when the pool is not in use. | This regulation is important because it protects the individuals who are unsafe around bodies of water. Failure to ensure that the pool was made inaccessible while it was not in use could lead to injury or even death.
The gate at the entrance of the pool was not equipped with a lock and was accessible to individuals.
After using the pool area, the provider did not ensure that the gate to the pool was locked.
Following the inspection on 10/6/2022, the pool's gate was locked, making it inaccessible to individuals. A new lock was purchased on 10/6/2022 that automatically locks when the gate door is shut. Attachment #9 shows new lock. |
10/14/2022
| Implemented |
| 6500.101 | The rear egress door, leading from the sunroom to the exterior of the home, did not open completely. It only opened approximately 3/4th of the way and hit the couch sitting directly behind the door. | Stairways, halls, doorways and exits from rooms and from the home shall be unobstructed. | This regulation is important because it protects the individuals and providers, ensuring that stairways, halls, doorways, and exits are unobstructed in case of an emergency.
The rear egress door, leading from the sunroom to the exterior of the home, did not open completely. It only opened approximately 3/4th of the way and hit the couch sitting directly behind the door.
The couch that sits directly behind the door was moved when someone sat down and stood up. The couch did not have non-slide grips on the feet, making it easy to move. The provider failed to ensure that the couch remained in a safe location following its use.
Following the inspection on 10/6/2022, the couch was moved to a safe location, allowing the exit door to open completely. On 10/8/2022, the provider purchased non-slide grips for the feet of the sofa. Attachment #10 is a picture of the relocation of the sofa and non-slide grips on the feet. |
10/14/2022
| Implemented |
| 6500.124 | Since 8/23/21, Individual #1's physician has indicated that they must be contacted if the individual's conditions for applying as needed medications, Clotrimazole and Eucerin calming cream, worsen. Individual #1 was administered Eucerin calming cream and Clotrimazole ointment twice daily, approximately 50% (or more) of the days every month, over the previous year. There are no records the individual's physician was contacted to report the worsening conditions that required the primary caregiver to apply the medications on almost a daily basis.
Individual #1 received a Tetanus immunization on 7/18/12 and did not receive another Tetanus immunization until 8/23/22, outside the CDC recommended guidelines. Their home/agency did not attempt to have the immunization completed within 10 years. | 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 regulation is important because staff need to ensure that health services are planned and provided as prescribed. Failing to follow health service orders could lead to further medial issues for the individual.
Since 8/23/21, Individual #1's physician has indicated that they must be contacted if the individual's conditions for applying as needed medications, Clotrimazole and Eucerin calming cream, worsen. Individual #1 was administered Eucerin calming cream and Clotrimazole ointment twice daily, approximately 50% (or more) of the days every month, over the previous year. There are no records the individual's physician was contacted to report the worsening conditions that required the primary caregiver to apply the medications on almost a daily basis.
Individual #1 received a Tetanus immunization on 7/18/12 and did not receive another Tetanus immunization until 8/23/22, outside the CDC recommended guidelines. There home/agency did not attempt to have the immunization completed within 10 years.
When individual #1 began to receive the as needed mediations, Clotrimazole and Eucerin calming cream, more frequently, the provider and Program Specialist failed to recognize the increase in administrations and failed to contacted the doctor as directed.
The provider and Program Specialist failed to ensure that individual #1 receive their Tetanus immunization within the CDC's recommended guidelines.
On 10/13/2022, Individual #1's Primary Care provider was contacted requesting guidance on next steps for the use of the as needed medications, Clotrimazole and Eucerin calming cream. On 10/17/2022, the Program Specialist is still awaiting a response. See attachment #11 for proof of contact. The Program Specialist will continue to contact the PCP daily until direction is received.
Given that Individual #1 had already received the Tetanus Immunization, there was no immediate plan of correction. No one supported in the 6500 program has received immunization since the inspection to show an understanding following regulations and CDC recommendations. |
10/14/2022
| Implemented |
| 6500.32(s) | During the 10/6/22 onsite inspection Staff persons #1 and #2 confirmed that Individual's #1 and #2 hadn't been asked if they wanted a locking mechanism for an entry door of the home but did confirm that the individuals were asked if they wanted a lock on their bedroom door. Individual #1 reported onsite they wanted a key or locking/unlocking mechanism to the home. Individual #1's assessment and individual plan do not include information if they want or does not want a locking/unlocking mechanism to an entry door of their home. | An individual has the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home. | The regulation is important because the individual needs to be made aware that they have the right to have a key, access card, keypad code or other entry mechanisms to lock or unlock the entrance door of their home.
During the 10/6/22 onsite inspection Staff persons #1 and #2 confirmed that Individual's #1 and #2 hadn't been asked if they wanted a locking mechanism for an entry door of the home but did confirm that the individuals were asked if they wanted a lock on their bedroom door. Individual #1 reported onsite they wanted a key or locking/unlocking mechanism to the home. Individual #1's assessment and individual plan do not include information if they want or does not want a locking/unlocking mechanism to an entry door of their home. The Program Specialist did not ensure that this right was reviewed with the individuals.
The Program Specialist did not ensure that all rights were reviewed with Individual #1 and Individual #2 and failed to document their desire to or not to have access lock and unlocking access to their home.
On 10/6/2022, the Program Specialist informed and explained individual#1 and individual #2's rights with them.
The Program Specialist was retrained on 10/14/2022 regarding the importance on reviewing the individual's rights. Attachment #5 is proof of training.
Individual #1 was provided with a key to the exterior door of their home. See attachment #6.
The Program Specialist completed an audit of all rights documentation. Individuals who were missing information regarding the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home received an updated rights review. This audit began and all rights were rereviewed by 10/13/2022. Attachment #7 is proof of notification to the Supports Coordinator regarding Individual #2's choice to not have a key. |
10/14/2022
| Implemented |
| 6500.34(a) | The rights reviewed with Individual #1 on 1/5/21 and 1/12/22 do not include a review of their regulatory rights defined in 6500.32(r)(1)-(r)(5). | Individual rights and the process to report a rights violation shall be explained to the individual, and persons designated by the individual prior to moving into the home and annually thereafter. | The regulation is important because the individual needs to be made aware that they have the right to have a key, access card, keypad code or other entry mechanisms to lock or unlock the entrance door of their home.
The rights reviewed with Individual #1 on 1/5/21 and 1/12/22 do not include a review of their regulatory rights defined in 6500.32(r)(1)- (r)(5)
The Program Specialist did not ensure that all rights were reviewed with Individual #1 upon admission to the facility and annually thereafter.
On 10/6/2022, the Program Specialist informed and explained individual #1 rights with them.
The Program Specialist was retrained on 10/14/2022 regarding the importance on reviewing the individual's rights. Attached #1 is proof of training.
The Program Specialist completed an audit of all rights documentation. Individuals who were missing information regarding the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home received a updated right review. This audit began and all rights were rereviewed by 10/6/2022. Attachment #8 is proof of the updated at rights review. |
10/14/2022
| Implemented |
| 6500.135(b) | Individual #1's physician ordered Eucerin calming cream to be applied 2 times daily as needed to affected areas on arms and legs since at least 8/23/21. During the 10/6/22 onsite inspection, the medication label on Eucerin calming cream (supplied by the pharmacy on 9/26/22) stated to apply twice daily as needed and mix with Triamcinolone. | A prescription order shall be kept current. | This regulation is important because staff need to ensure that the individuals are receiving the correct medications according to the doctors most recent prescription.
Individual #1's physician ordered Eucerin calming cream to be applied 2 times daily as needed to affected areas on arms and legs since at least 8/23/21. During the 10/6/22 onsite inspection, the medication label on Eucerin calming cream (supplied by the pharmacy on 9/26/22) stated to apply twice daily as needed and mix with Triamcinolone.
When individual #1 received a new order, the provider and Program Specialist failed to ensure that the label and MAR matched the current orders. During regular monitoring and check ins of monthly medications, the provider and Program Specialist failed to ensure that the label and MAR matched the current orders.
On 10/13/2022, individual #1's Primary Care provider was contacted requesting guidance on next steps for the use of the as needed medications, Clotrimazole and Eucerin calming cream. On 10/17/2022, the Program Specialist is still awaiting a response. See attachment #11 for proof of contact. The Program Specialist will continue to contact the PCP daily until direction is received.
The Program Specialist will complete an audit of all 6500 programs to ensure that there is a current prescription order and the details of the order match the label and MAR's. This will be completed by November 1st. |
11/01/2022
| Implemented |
| 6500.135(e) | The primary caregiver did not administer Individual #1's Calcium supplement from 3/4/22 until the evening of 3/10/22. The primary caregiver recorded instructions for holding the supplement: "York hospital called, told me to stop {the individual's} calcium on Thursday being last dose. Thursday prior to surgery for 1 week restart after surgery." Written instruction for the change in medication orders were never obtained. The primary caregiver, who is not a medical professional, took verbal orders over the phone from a staff from the hospital. | Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. | This regulation is important because staff need to ensure that the individuals are receiving the correct medications according to the doctors most recent prescription. The doctor must provide written orders to ensure safety.
The primary caregiver did not administer Individual #1's Calcium supplement from 3/4/22 until the evening of 3/10/22. The primary caregiver recorded instructions for holding the supplement: "York hospital called, told me to stop {the individual's} calcium on Thursday being last dose. Thursday prior to surgery for 1 week restart after surgery." Written instruction for the change in medication orders were never obtained. The primary caregiver, who is not a medical professional, took verbal orders over the phone from a staff from the hospital.
When individual #1 received a new order, the provider and Program Specialist failed to ensure that written orders were obtained.
On 10/13/2022, individual #1's Primary Care provider was contacted requesting guidance on next steps for the use of the as needed medications, Clotrimazole and Eucerin calming cream. On 10/17/2022, the Program Specialist is still awaiting a response. See attachment #11 for proof of contact. The Program Specialist will continue to contact the PCP daily until direction is received. |
10/14/2022
| Implemented |
| 6500.136(a)(2) | Individual #1's March 2022 medication administration record (mar) did include the name of the prescriber for their Bacitracin ointment. This was prescribed by their Urologist. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | This regulation is important because staff need to know who the prescribing doctor is and who needs to be contacted in case of an emergency.
Individual #1's March 2022 medication administration record (mar) did not include the name of the prescriber for their Bacitracin ointment. This was prescribed by their Urologist.
The Program Specialist failed to ensure that the monthly MAR contacted the prescribing physician included the name of the prescribing doctor.
On 10/6/2022, the Program Specialist updated Individual #1's MAR to include the prescribing physician. See attachment #12. An audit of all individuals in the 6500 Program was completed on 10/6/2022. |
10/14/2022
| Implemented |
| 6500.136(a)(7) | Individual #1's medication administration records (mars) from December 2021 to current, October 2022 do not record the dose of Eucerin cream that was administered. Per the mar, the cream was applied while being mixed with Triamcinolone. However, Eucerin cream was not applied by mixing with another ointment, and it was only applied by itself. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | This regulation is important because staff need to know the dosage of the medication in order to properly administer the medication.
Individual #1's medication administration records (mars) from December 2021 to current, October 2022 do not record the dose of Eucerin cream that was administered. Per the mar, the cream was applied while being mixed with Triamcinolone. However, Eucerin cream was not applied by mixing with another ointment, and it was only applied by itself.
The Program Specialist and provider failed to ensure that the monthly MAR contained the prescribed dosage.
On 10/6/2022, the Program Specialist updated Individual #1's MAR to include dosage. The PCP was contacted regarding updated instructions. On 10/17/2022, the Program Specialist is still awaiting a response. See attachment #11 for proof of contact. The Program Specialist will continue to contact the PCP daily until direction is received. See attachment #11. |
10/14/2022
| Implemented |
| 6500.136(a)(11) | Individual #1's December 2021 and August -- October 2022 medication administration records (mars) did not include the diagnosis or reason for prescribing Systane eye drops.
Individual #1's March 2022 mar didn't include the diagnosis or reason for prescribing Bacitracin ointment.
Individual #1's July 2022 mar didn't include the diagnosis or reason for prescribing Paxlovid. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | This regulation is important because staff need to know why the medication was prescribed.
Individual #1's December 2021 and August -- October 2022 medication administration records (mars) did not include the diagnosis or reason for prescribing Systane eye drops.
The Program Specialist failed to ensure that the monthly MAR included the reason for the prescribed medication.
On 10/6/2022, the Program Specialist updated Individual #1's MAR to include the prescribing physician. See attachment #12. An audit of all individuals in the 6500 Program was completed on 10/6/2022. |
10/14/2022
| Implemented |
| 6500.136(a)(12) | The primary caregiver administered Acetaminophen to Individual #1 four times on 7/6/2022. The time of administration was not recorded or legible for two of the administrations; 12:30 was recorded but did not include AM or PM, and the last written administration was illegible. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | This regulation is important because staff need to know when the medication was administered, and the documentation needs to be legible. Failing to have this information could result in error and/ or harm to the individual.
The primary caregiver administered Acetaminophen to Individual #1 four times on 7/6/2022. The time of administration was not recorded or legible for two of the administrations; 12:30 was recorded but did not include AM or PM, and the last written administration was illegible.
The provider failed to properly document at the time of the medication administration.
The Program Specialist failed to ensure that the monthly MAR included the legible time entries of the medication administration.
Immediate feedback and retraining was provided to the provider by the Program Specialist regarding proper MAR documentation on 10/6/2022.. An audit of all individuals in the 6500 Program was completed on 10/6/2022. |
10/14/2022
| Implemented |
| 6500.136(a)(15) | On 3/10/22 Individual #1's Urologist prescribed Bacitracin ointment to be applied to their incision twice a day for two weeks. The individual's March 2022 medication administration record did not include the special instructions for where to apply the ointment: the incision. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable. | This regulation is important because staff need to know the route in which to administer the medication. Failing to have this information could result in error and/ or harm to the individual.
On 3/10/22 Individual #1's Urologist prescribed Bacitracin ointment to be applied to their incision twice a day for two weeks. The individual's March 2022 medication administration record did not include the special instructions for where to apply the ointment: the incision.
On 10/6/2022, the Program Specialist updated Individual #1¿s MAR to include the special instructions. See attachment #12. An audit of all individuals in the 6500 Program was completed on 10/6/2022 by the Program Specialist. |
10/14/2022
| Implemented |