| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.33(a) | There was a content discrepancy in Individual #1's ISP which stated that the individual's food consistency should be "soft foods/pureed." The Individual's annual assessment dated 2/22/18 stated that the Individual's food should be "finely cut." Additionally, the ISP stated that staff were trained in the individual's feeding protocol, but staff were not trained. These discrepancies led to confusion for staff, and went uncorrected until Individual #1 choked on 10/12/18. By not ensuring that Individual #1's feeding needs were accurately assessed, correctly documented, and staff trained in the feeding protocol, Individual #1's health and safety needs were neglected and resulted in a life-threatening choking incident on 10/12/18. | An individual may not be neglected, abused, mistreated or subjected to corporal punishment. | There was a content discrepancy in Individual #1's ISP which stated that the individual's food consistency should be "soft foods/pureed." The Individual's annual assessment dated 2/22/18 stated that the Individual's food should be "finely cut." Additionally, the ISP stated that staff were trained in the individual's feeding protocol, but staff were not trained. These discrepancies led to confusion for staff, and went uncorrected until Individual #1 choked on 10/12/18. By not ensuring that Individual #1's feeding needs were accurately assessed, correctly documented, and staff trained in the feeding protocol, Individual #1's health and safety needs were neglected and resulted in a life-threatening choking incident on 10/12/18.
1. The provider shall ensure that all individuals are free from harm/neglect and that a best practice standard of care is met.
2. Response to the citation began prior to inspection as the related incident occurred on 10/12/18. Care was provided, an investigation was started, suspensions and corrective action began to occur immediately following notification.
3. To prevent reoccurrence of this issue all staff shall be trained on company policy ¿Abuse Prohibited¿ annually and as deemed necessary by any member of the individual¿s team. Additionally all company members of the individuals team shall be trained by the appropriate department (nursing, BSS etc.¿) when new or changes in current diagnoses occur. This training shall occur upon hire and at time of change as well as when critical revisions are necessary. Nursing and BSS will be updated by the Program Specialist when a new or change to a current diagnosis is made, this shall include being made aware of upcoming appointments so attendance by the appropriate parties can be assured. Additionally training support is now offered by a nurse dedicated to the training needs of staff. This position works closely with the nurses dedicated to care and management staff so that new or changing needs are addressed and education provided timely.
4. The Program Specialist shall work closely and with open lines of communication with all other departments to ensure that staff are adequately trained and tooled to provide best practice standard of care. The Operations Director shall monitor communication and care to ensure all is provided. The Regional Director will provide feedback quarterly, after Directors meetings and as otherwise available, as to the success of the conjoined departments. Any deficiency noted in any step shall be addressed immediately so that continuation of quality care is provided. |
11/01/2018
| Implemented |
| 6400.104 | The most current notification letter sent to the local fire department was dated 5/04/18 and stated that one individual lived in the home. A new notification letter was not sent to the fire department when a second individual moved into the home in September of 2018. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| 1. The provider will ensure that the local fire department is consistently provided with current information regarding the address of the home, exact location of bedrooms of individuals who need assistance in evacuating in the event of an actual fire.
2. Written notification was provided to the local fire department.
3. The provider shall ensure that proper notification is made to the local fire department by maintaining a file of the current letters. The Office Manager, working closely with the Operations Director, will review all letters on an annual basis to ensure that the most current information is captured. Additionally the Program Specialist will be responsible for ensuring that new letters are completed during expected times of new admissions, consumer transfer between houses and change in independent evacuation status.
4. The Operations Director will monitor the status of letters during routine supervision sessions. |
01/09/2019
| Implemented |
| 6400.163(c) | The most recent psychiatric medication review for Individual #1 occurred on 4/13/18; the individual has not had a psychiatric medication review since that date. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | . The provider shall ensure that all medication prescribed to treat a diagnosed psychiatric illness are reviewed by a licensed physician every three months according to regulation.
2. An appointment was immediately scheduled for 11/20/2018 although not attended because he was hospitalized. As was the case for previous appointments. The Site Supervisor will ensure proper scheduling. Should there be a compelling reason for the appointment to be missed the Site Supervisor/Program Specialist will ensure that proper documentation and rescheduling occurs promptly.
3. To prevent reoccurrence of this issue the provider shall utilize a chart that maintains all past and current appointment dates.
4. The Site Supervisor will be responsible for maintaining this appointment schedule on a weekly basis; updating as necessary. The Program Specialist will review this document on a monthly basis to ensure compliance and proper scheduling. Additionally the Operations Director will provide weekly supervision that includes discussion on maintaining all appointments to requirements. |
10/18/2018
| Implemented |
| 6400.168(d) | Staff #1's medication training expired on 7/12/18 and was not recertified by successfully completing the Medications Administration Course Practicum until 9/21/18. Between 7/12/18 and 9/21/18, when the staff's training had lapsed, they continued to administer medication. | A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | 1. The provider will ensure that all staff are properly trained to administer medications according to regulation.
2. Corrective action was completed on 9/21/18 with the completion of the Medications Administration Course Practicum.
3. The provider will ensure compliance by proper tracking and training. The training department shall ensure that adequate notice is given to the employees and trainer that the specific training is required. Dates shall be manually entered and maintained by the training department. Once date is established it shall be entered into Time Forge, our time keeping method. Should the employee expire they would then become ineligible to work and not able to clock in. Built in expiry warnings are also set within the weeks prior to expiration and are sent to the employee in question. The training department shall also notify the appropriate supervisor/Program Specialist of the upcoming deadline at least one month prior to expiry.
4. The Program Specialist/Operations Director shall be responsible for ensuring that notification is received and attended to. Any employees noted to be out of compliance shall be suspended according to policy and not reinstated until such time that the employee is current with training and properly prepared to return to the workforce. |
01/10/2019
| Implemented |
| 6400.213(1)(i) | Identifying marks were not included in Individual #1's record. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.
| 1. The provider will ensure that all individual records are up to date with accurate and complete information.
2. Program Specialist reviewed citation and met with consumer to determine any identifying marks. Consumer has a scar on his right forearm. Program Specialist completed new face sheet and placed it in the home.
3. Upon admission, annually and at such times updates are found to be required the Program Specialist will review consumer records with Site Supervisor and team where applicable to make sure all individual records are up to date.
4. The Program Specialist of the home shall be responsible for ongoing education and ensuring all documentation is complete and up to date. Documentation of such will continue on a monthly and quarterly basis. |
01/08/2019
| Implemented |
| 6400.213(11) | There was a content discrepancy in Individual #1's ISP which stated that the individual's food consistency should be "soft foods/pureed." The Individual's annual assessment dated 2/22/18 stated that the Individual's food should be "finely cut." Additionally, the ISP stated that staff were trained in the individual's feeding protocol, but staff were no trained. These discrepancies led to confusion for staff, and went uncorrected until Individual #1 choked on 10/12/18. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | 1. The provider shall ensure that the information captured in the individuals ISP shall be clearly stated and accurate.
2. Corrective action began on 10/18/18 with Jeanetta Twardzik, DON, sending updated information to the SC for the purpose of updating/correcting the ISP.
3. The Program Specialist will be responsible for ensuring that all aspects of the ISP are factual and correct as written by attending the ISP meetings, review meetings and updating appropriate SC at times when critical revisions to the plan are needed. The Program Specialist shall be responsible for reviewing the content of the ISP as soon as it is received and providing input to the SC in writing of the revisions required within 48 business hours. Record of the communication should be maintained in the individuals file with the ISP.
4. The Operations Director shall be responsible for maintaining a record of when all plans are due. This schedule shall be maintained and reviewed monthly with Program Specialists. Each Program Specialist will be responsible for providing accurate dates to maintain compliance. The Operations director will assist the PS in communication with the SC when required. |
01/09/2019
| Implemented |