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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | Individual #1's blood pressure protocol states, "if/when dizziness occurs check blood pressure and record. If blood pressure is greater than 160/90 take prn {Pro Re Nata; "as needed"} dose of Clonidine. Check blood pressure again in 1 hour. If blood pressure is still over 160/90, please call PCP {Primary Care Physician} office and follow directions given by provider or nurse. If they say go to ER {Emergency Room}, call 911, do not bring him/her yourself."
The individual's record contained a note from a 6/8/19 hospital EIM (Electronic Incident Management) report where Staff #1 recorded the individual's blood pressure reading at 7pm then, "staff checked the bp an hour later and it was 170/102. Staff called PCP office and they asked staff to check it again and it was 170/108 at 8:45pm." The individual's blood pressure protocol requires the staff to contact the PCP office an hour after the first high reading if there is a continued high blood pressure reading. Staff #1 documented there was an additional high reading an hour after the first high reading, but did not contact the physician's office until an additional 45 minutes had passed.
On 6/9/19 the individual's blood pressure was documented at 180/89 at 6pm and Clonidine HCL .1mg was administered at 6pm. Per EIM report: "At 7pm Staff #1 rechecked his bp to be 176/95. She called the pcp office at 7pm and they said to administer evening meds and recheck bp in an hour. She administered evening meds at 7:20pm and rechecked bp at 8:30. Bp was 175/98 and pcp was called and he said to go to hospital. Staff called 911 at 8:40." Per the individual's handwritten 6/9/19 blood pressure protocol log: "pcp said to give night time meds and call 911 if bp doesn't change an hour later." Staff #1 was to recheck the individual's blood pressure by 8pm and staff did not until 8:30pm. Staff was also to call 911 an hour after 7pm if blood pressure didn't change. Staff called the individual's PCP office first, prior to calling 911 per the handwritten staff note from the physician's office. Staff did not call 911 until 8:40pm.
On 6/10/19 Staff #1 administered Clonidine per the individual's protocol at 7pm due to 170/102 blood pressure reading. Staff #1 documented that it was checked again at 8 to read 166/85. One of the numbers is higher than 160/90, which required either an additional medication or a phone call to the physician, per protocol. The individual's physician was not contacted. Staff noted that the individual was left to go to sleep. | 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.
| October 23, 2019-Individual #1 had a medical appointment with his primary care physician. At that time, Individual #1¿s blood pressure protocol and prn medication, Clonidine, were reviewed by the doctor. The doctor notes due to weight loss, exercise program and stable blood sugar and blood pressure, the blood pressure protocol and Clonidine were discontinued effective 10/23/19. (Attachment #7)
November 8, 2019-All Program Specialists were trained on their responsibilities that 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. A training record was signed indicating their attendance and understanding. (Attachment #1) Program Specialists will continue to arrange for and provide all health services that are planned or prescribed for individuals. All Program Specialists have reviewed and verified that all health services are currently in compliance. |
11/08/2019
| Implemented |
| 6400.165(c) | Individual #1's December 2018 medication administration record listed, "Acetaminophen 500mg, take 2 caplets every 6 hours while symptoms last." Staff #2 recorded that she/he only administered one, 500mg caplet instead of two on 12/29/18 at 12:45pm due to the individual having knee pain | A prescription medication shall be administered as prescribed. | November 6, 2019-Individual #1¿s over the counter medication record was reviewed to ensure all over the counter medications were administered as prescribed. Program Specialists and/or Strawberry Fields, Inc.¿s LPN will review medication logs monthly to ensure that all medications are administered as prescribed and documented accurately on the medication record, even over the counter medications. The Program Specialists or LPN will sign off on the Medication Administration Sign off Sheet verifying medications have been signed off correctly. (Attachment #6) Program Specialists reviewed all current over the counter medication records to ensure they are correct and in compliance.
November 8, 2019-All Program Specialists were trained on their responsibilities that a prescription medication shall be administered as prescribed. A training record was signed indicating their attendance and understanding. (Attachment #1) |
11/08/2019
| Implemented |
| 6400.165(g) | Individual #1's 6/14/19 psychiatric medication review listed a new medication added to their current medication regimen, "Hydroxyzine 25mg for anxiety." However, the mediation review did not review or include the frequency of administration of the medication. It wasn't until the individual's 7/2/19 medication review where the frequency, "take 1 tablet by mouth twice daily as needed for anxiety" is recorded.
The individual's 8/28/19 medication review stated that he was prescribed Hydroxyzine HCL .1mg as needed for anxiety. The medication form attached to the review stated, Hydroxyzine HCL 25mg, take 1 tablet by mouth twice daily as needed for anxiety. The dosage of medication reviewed was not clear.
The individual's 12/6/18 medication review stated that he was to administer Citalopram 20mg, 1 tablet in the evening. For the entire month of December 2018, staff administered Citalopram 40mg, 1 tablet once a day. He was prescribed 40mg once per day and the medication review documented the incorrect dosage. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | November 8, 2019-All Program Specialists were trained on their responsibilities that if a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every three months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. A training record was signed indicating their attendance and understanding. (Attachment #1)
November 6, 2019-The Psychiatric Consult Form that is used for psychiatric appointments was updated to include a review of current medications and signature by the Program Specialist and frequency of a medication if a new medication is prescribed. Program Specialists reviewed all current psychiatric consult forms to ensure they are correct and in compliance.
November 14, 2019-There is a scheduled psychiatric appointment on 11/14/19. The new psychiatric consult form will be used at that appointment. |
11/06/2019
| Implemented |
| 6400.166(a)(12) | - Individual #1 was in the emergency room on 5/18/19 during the time of the evening medication administration of medications, 7PM. According to the Mount Nittany medical Center patient visit information, a summary of his visit was reviewed and received by the patient on 5/18/19 at 21:08. The report states, "continue your home medications including taking evening medicines tonight even if they are a little bit late." According to the medication administration record, all evening medications on 5/18/19 were initialed as administered at 7pm, when he was in the Emergency Room. The medication administration record does not include the actual time of administration of his evening medications, as he received them late due to being in the Emergency Room over his regular scheduled time of administration of evening medications. | 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. | November 7, 2019-Individual #1¿s medications are now documented electronically on an EMar system. If a medication is given late, the system requires an ¿exception¿ to be made and staff must document in the exception specific details regarding the medication administration, including if a medication was given late and why. Individual #1¿s medication record for October 2019 was reviewed and medications were documented correctly on the EMar. Any exceptions that occurred throughout the month are documented directly on the EMar.
November 8, 2019-All Program Specialists were trained on their responsibilities that a medication record shall be kept, including the following for each individual for whom a prescription medication is administered: date and time of medication. A training record was signed indicating their attendance and understanding. (Attachment #1) All medication records have been reviewed by the Program Specialists to ensure they are correct and in compliance. |
11/08/2019
| Implemented |
| 6400.166(b) | Staff who administered Omeprazole 20mg to Individual #1 on 4/20/19 did not initial immediately after administering the medication. The medication administration record listed Staff #3 as administering the medication to the individual on 4/20/19. However, Staff #4 recorded that Staff #3 initialed as administering the medication to the individual on 4/20/19 and did not. Staff #3 administered the individual's Omeprazole to him on 4/21/19 and the administration time for Omeprazole on 4/20/19 was blank, allowing Staff #3 to sign her initials in it the next day.
Staff #5 did not initial after administering all 7 of the individual's 7pm medications on 3/11/19. Staff #6, who did not administer the individuals 7pm medications to them on 3/11/19 but worked and administered 7pm medications on 3/12/19, initialed as administering the medications on 3/11/19 and 3/12/19. Staff #5 then returned the medication log to cross off Staff #6 initials on 3/11/19 and recorded his own. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | November 6, 2019-Medication records from Individual #1 were reviewed and it was confirmed by the Program Specialist that all the medications were administered and documented correctly on the medication record. All medication records have been reviewed by the Program Specialists to ensure they are correct and incompliance.
November 8, 2019-All Program Specialists were trained on their responsibilities that information in subsection (a) (12) and (13) shall be recorded in the medication record at the time the medication is administered. Subsection (a)(12)states: Date and time of medication administration and subsection (a)(13) states: Name and initials of the person administering the medication. A training record was signed indicating their attendance and understanding. (Attachment #1)
November 8, 2019-Program Specialists and/or Strawberry Fields, Inc.¿s LPN will review medication logs monthly to ensure that all medications are administered as prescribed and documented accurately on the medication record. The Program Specialists or LPN will sign off on the Medication Administration Sign off Sheet verifying medications have been signed off correctly. (Attachment#6) Medications are now administered through an emar system at that program. When medications are administered at the home, the medications are automatically signed off through the system. |
11/08/2019
| Implemented |
| 6400.186 | - Individual #1's current 10/16/19 assessment states that he/she is given $10 at a time and is independent with $10. However, per the financial ledger and Staff #4's report, the individual is given $20 to handle independently weekly over the last year. | The home shall implement the individual plan, including revisions. | November 4, 2019- Individual #1¿s assessment was updated to include Individual #1 can handle up to $20 at a time. (Attachment #4) Individual #1¿s isp was also updated to include this information. (Attachment #5)
November 6, 2019-The Quarterly ISP Review form was updated to include a review to the Learning/Cognition-Financial Indpendence section of the isp. This section will specifically address all individuals¿ abilities in handling specific amounts of money independently.
November 8, 2019-All Program Specialists were trained on their responsibilities that the home shall implement the plan, including revisions. A training record was signed indicating their attendance and understanding. (Attachment #1)
November 8, 2019-Financial information for all individuals within the agency have been reviewed by the Program Specialists to ensure they are correct and in compliance. |
11/08/2019
| Implemented |
| 6400.213(1)(i) | Individual #1's record does not include his/her identifying marks. The record listed that "glasses" was an identifying mark. However, glasses can be removed and are not a permanent identifier | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Plan of Correction:
November 5, 2019-Individual #1¿s record was updated to include identifying marks, if applicable. Individual #1¿s does not have any specific identifying marks so the statement, ¿no identifying marks¿ was included in Individual #1¿s record. (Attachment #2) All individuals¿ records have been reviewed by the Program Specialists to ensure identifying marks are correct and within compliance.
November 6, 2019-The Personal Data Information Sheet was updated to specifically address each item in 213(1)i-vi on the form. The identifying marks section of the form is to list identifying marks or state none if none, with the clarification that glasses should not be indicated as an identifying mark due to the fact that they can be removed.
November 8, 2019-All Program Specialists were trained on their responsibilities that each individual¿s record must include the following information: personal information, including: (i) the name, sex, admission date, birth date and social security number. Program Specialists were trained that all information in 213(1)i-vi, which specifically includes identifying marks, need to be in the individual¿s record. A training record was signed indicating their attendance and understanding. (Attachment #1)
November 15, 2019-All individual records within the agency will be using the new updated Personal Data Information sheet to specifically address each item in 213(1)i-vi. (Attachment #3) |
11/15/2019
| Implemented |
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