|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(3) | At the time of the 3/22/22 onsite inspection, Individual #1's record information at their home did not include current information available to staff, plans were not being implemented, and a lack of staff training on Individual #1's current mental and physical health information and plans was identified that creates an environment of failing to protect the health and safety of Individual #1.
Current information not available:
· Referenced in 6400.181(a) of this report, the individual's current health, safety, and medical needs were last assessed by the agency, Excentia Human Services, on 3/19/2021, over a year prior to the inspection and not available in the home.
· Referenced in 6400.214(b) of this report, the individual's current record information wasn't kept at the home or available to staff providing service provisions to Individual #1 at the time of service.
· Individual #1's communication binder at the home included a behavior support plan from 2014 and a social, emotional, environmental needs plan (SEEN), per Staff person #1 was updated a few years ago. There were no records maintained indicating which plan to implement or if either plans were relevant to the individual's current needs. The 2014 behavior support plan and SEEN plan contained differing information of support to provide to Individual #1, yet both were included as information for the agency staff to be trained on and implement.
· An assessment of Individual #1's current supervision needs was not available in the home. Referenced in 6400.181(a) of this report, the last time a program specialist assessed the individual's supervision has been a few years ago. This is corroborated by Individual #1's documented supervision needs in their 3/19/2021 and 3/20/2020 assessments being verbatim.
Plans not implemented:
· A "social/emotional/environmental/needs (SEEN)" plan and incident reporting protocol were located in Individual #1's record onsite. The SEEN plan states, Individual #1's mood changes quickly and most commonly engages in hitting, kicking, scratching staff and housemates, throwing objects at housemates and staff, threatening staff and housemates, yelling, and cursing and its not uncommon for them to be laughing one moment and crying the next. The plan states staff will document any concerns or information related to this plan in Foothold (agency electronic tracker). There are no records maintained that the home was documenting any of Individual #1's behaviors described in the above plan. Per staff interviews conducted on 3/22/22 and 3/23/22, Individual #1 did self-isolate a lot within the home, withdrew from people, had what was described as experiencing severe anxiety with changes in staff or a favored staff no longer worker with them, and had extreme changes in their mood weekly, if not daily. The SEEN plans states the program supervisor is responsible for collecting and summarizing the plan on a monthly basis then it will be reviewed by the program specialist. There are no records maintained that the program supervisor collected and summarized the Individual's daily/weekly behaviors and provided them to the program specialist for review.
· The SEEN plan states if Individual #1 tells a falsehood by recanting a previously made accusation, staff are to reference the individual's protocol. The protocol in their record, Incident Reporting Protocol for staff members when {Individual #1} makes verbal accusations, states the program supervisor will check in with the individual once a week to go over any concerns the individual may have to help diminish their need to make up information about staff. There are no records this is being completed as written.
· Individual #1's SEEN plan and incident reporting protocol collectively state that there is an increase in Individual #1 telling falsehoods for the last few months and every incident of verbal accusation/allegation by Individual #1 will be recorded regardless of the outcome for behavior supports. During the 3/22/22 the only documented report of allegations completed for Individual #1 was completed on 3/14/22. There are no other records of the increased reports of verbal accusations/allegations.
· The incident reporting protocol lists steps for the agency to implement, "for {Individual #1's} health and safety." Steps documented were: 1) all accusations made by the individual will be brought to the attention of the residential program supervisor and associate director, 2) {Individual #1} will complete an incident report worksheet regarding the accusations (with management staff assistance, 3) accusations made by the individual will be address with the individual after one hour (or as soon as they are willing to talk with the management level staff of their choice). Steps 1-3 were not completed or followed as written.
Lack of staff training
· Referenced in 6400.51(b)(5) of this report, there are no records maintained that an in-person training was provided to all staff who worked with Individual #1's over the previous 6 months on the individual's current health and safety needs, current plans, and current protocols prior to working with Individual #1. Onsite Individual #1's record information contained a sign-off sheet that stated the staff read the contents of the individual's binder in the home. Staff person #5 reported to the Department on 3/22/22 that there are no records to indicate if or what staff received training on prior to working with Individual #1 and that it's the staff's responsibility to read individual-specific information independently. The contents of the individual's binder at the home included old, outdated, and irrelevant information per agency management staff; for example, the binder had a document titled "Getting to know {Individual #1}" dated 12/6/2019. Staff person #7, on 3/22/22 all current record information for Individual #1 is stored in binders at the agency office and not all of the individual's record is stored in their home. Both record locations contained different information within the individual's binders. As the training sign-off sheets state, staff documenting their signature "read the contents of this book." There are no records maintained of the specific content contained within each book, or which locations of the book they read the contents of. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | At the time of the 3/22/22 onsite inspection, Individual #1's record information at their home did not include current information available to staff, plans were not being implemented, and a lack of staff training on Individual #1's current mental and physical health information and plans was identified that creates an environment of failing to protect the health and safety of Individual #1.
Current information not available:
· Referenced in 6400.181(a) of this report, the individual's current health, safety, and medical needs were last assessed by the agency, Excentia Human Services, on 3/19/2021, over a year prior to the inspection and not available in the home.
· Referenced in 6400.214(b) of this report, the individual's current record information wasn't kept at the home or available to staff providing service provisions to Individual #1 at the time of service.
· Individual #1's communication binder at the home included a behavior support plan from 2014 and a social, emotional, environmental needs plan (SEEN), per Staff person #1 was updated a few years ago. There were no records maintained indicating which plan to implement or if either plans were relevant to the individual's current needs. The 2014 behavior support plan and SEEN plan contained differing information of support to provide to Individual #1, yet both were included as information for the agency staff to be trained on and implement.
· An assessment of Individual #1's current supervision needs was not available in the home. Referenced in 6400.181(a) of this report, the last time a program specialist assessed the individual's supervision has been a few years ago. This is corroborated by Individual #1's documented supervision needs in their 3/19/2021 and 3/20/2020 assessments being verbatim.
Plans not implemented:
· A "social/emotional/environmental/needs (SEEN)" plan and incident reporting protocol were located in Individual #1's record onsite. The SEEN plan states, Individual #1's mood changes quickly and most commonly engages in hitting, kicking, scratching staff and housemates, throwing objects at housemates and staff, threatening staff and housemates, yelling, and cursing and its not uncommon for them to be laughing one moment and crying the next. The plan states staff will document any concerns or information related to this plan in Foothold (agency electronic tracker). There are no records maintained that the home was documenting any of Individual #1's behaviors described in the above plan. Per staff interviews conducted on 3/22/22 and 3/23/22, Individual #1 did self-isolate a lot within the home, withdrew from people, had what was described as experiencing severe anxiety with changes in staff or a favored staff no longer worker with them, and had extreme changes in their mood weekly, if not daily. The SEEN plans states the program supervisor is responsible for collecting and summarizing the plan on a monthly basis then it will be reviewed by the program specialist. There are no records maintained that the program supervisor collected and summarized the Individual's daily/weekly behaviors and provided them to the program specialist for review.
Providers Plan of Correction: The following items have been implemented.
· Medical Tracking system in place to alleviate missed appointments. This will be overseen by Director of Residential in conjunction with nursing.
· Nursing meeting with staff occurs weekly to review medical concerns of individuals and any issues regarding scheduling of medical appointments.
· Associate Directors and Supervisors will have a checklist in place to ensure all documents in staff binder is up to date and accurate. It will be checked on a weekly basis at minimum.
· ISPs along with any other pertinent information will be reviewed with staff prior to working with the individual.
· Individual files will be moved to the individual's home to ensure all current information is on site and one binder will be utilized for an individual and not two separate finders.
· Documentation will be reviewed on a weekly basis at minimum by AD and/or supervisor to ensure documentation regarding behaviors, changes, etc. are occurring and filed in a timely manner.
· Program specialists will be retrained on expectations of plans, documentation, supervision needs, etc.
Providers Plan to Maintain Compliance: The following has been implanted.
· Medical Tracking system in place to alleviate missed appointments. This will be overseen by Director of Residential in conjunction with nursing.
· Nursing meeting with staff occurs weekly to review medical concerns of individuals and any issues regarding scheduling of medical appointments.
· Associate Directors and Supervisors will have a checklist in place to ensure all documents in staff binder is up to date and accurate. It will be checked on a weekly basis at minimum.
· ISPs along with any other pertinent information will be reviewed with staff prior to working with the individual.
· Individual files will be moved to the individual's home to ensure all current information is on site and one binder will be utilized for an individual and not two separate finders.
· Documentation will be reviewed on a weekly basis at minimum by AD and/or supervisor to ensure documentation regarding behaviors, changes, etc. are occurring and filed in a timely manner.
· Program specialists will be retrained on expectations of plans, documentation, supervision needs, etc. |
05/27/2022
| Implemented |
| 6400.141(c)(4) | Individual #1's 8/17/2020 and 8/18/2021 physical examination appointments did not include a hearing examination. The 8/17/2020 examination record stated the individual refused the hearing examination and the 8/18/2021 examination record was left blank in the field indicating if a hearing examination was completed. There are no records maintained that the individual's physician deferred the examination.
Individual #1's 8/18/2021 physical examination did not include a vision examination. The examination record stated Individual #1 refused their vision examination. There are no records maintained that the individual's physician deferred the examination. Staff person #5 reported during the 3/22/22 inspection that Individual #1 had a vision examination completed in January 2022 however, there are no records maintained that this appointment occurred. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual #1's 8/17/2020 and 8/18/2021 physical examination appointments did not include a hearing examination. The 8/17/2020 examination record stated the individual refused the hearing examination and the 8/18/2021 examination record was left blank in the field indicating if a hearing examination was completed. There are no records maintained that the individual's physician deferred the examination.
Individual #1's 8/18/2021 physical examination did not include a vision examination. The examination record stated Individual #1 refused their vision examination. There are no records maintained that the individual's physician deferred the examination. Staff person #5 reported during the 3/22/22 inspection that Individual #1 had a vision examination completed in January 2022 however, there are no records maintained that this appointment occurred.
The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician.
Providers Plan of Correction: Documentation for the vision appointment on 1-5-2022 has been obtained from the Optometrist. An appointment for a hearing exam had been scheduled for 5-23 but the physician's office called and stated that due to illness of the doctor they had to reschedule the appointment. A plan of refusal documentation form has been created and staff are documenting daily the conversations they are having with individual #1 in regards to the importance of her attending her medical appointments. |
05/27/2022
| Implemented |
| 6400.141(c)(7) | Individual #1's current, 8/18/2021 physical examination record did not include documentation of a Gynecological examination to include a breast examination and PAP smear and the results. There are no records maintained that the individual's physician defers these examinations for the individual. As referenced in 6400.143(a) of this report, the individual reportedly refuses these examinations on an annual basis. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Individual #1's current, 8/18/2021 physical examination record did not include documentation of a Gynecological examination to include a breast examination and PAP smear and the results. There are no records maintained that the individual's physician defers these examinations for the individual. As referenced in 6400.143(a) of this report, the individual reportedly refuses these examinations on an annual basis.
The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations.
Providers Plan of Correction: An appointment was made with Individual #1's physician where paperwork was obtained regarding the recommended frequency of GYN examinations including pap smear. |
05/27/2022
| Implemented |
| 6400.143(a) | Individual #1 refuses routine vision, hearing, and gynecological examinations as referenced in 6400.141(c)(4) and 6400.141(c)(7) of this report. All of Individual #1's refusals of health care services and the continued attempts to train Individual #1 about the need for healthcare were not documented in the individual's record. Additionally, the individual's record did not include any plans in place or protocols to implement to explore other alternative examinations, nor are there any desensitization plans in place to attempt to prepare Individual #1 to complete these health examinations. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Individual #1 refuses routine vision, hearing, and gynecological examinations as referenced in 6400.141(c)(4) and 6400.141(c)(7) of this report. All of Individual #1's refusals of health care services and the continued attempts to train Individual #1 about the need for healthcare were not documented in the individual's record. Additionally, the individual's record did not include any plans in place or protocols to implement to explore other alternative examinations, nor are there any desensitization plans in place to attempt to prepare Individual #1 to complete these health examinations.
If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record.
Providers Plan of Correction: A Plan of Refusal documentation chart has been created and staff are documenting daily the conversations between them and Individual #1 regarding their attempts to train. |
05/27/2022
| Implemented |
| 6400.144 | The home failed to implement health services to Individual #1 over the previous year in the following areas.
Medication:
· Individual #1 has a standing order to be administered over-the-counter pain medication for pain as needed. At the time of the 3/22/22 inspection the only over-the-counter, as needed, pain medication available to Individual #1 was Tylenol that expired in April 2021. Staff documented as administering an over-the-counter pain medication to the individual throughout the previous year. Staff onsite were unable to locate the over-the-counter medication administered to the individual or an applicable as needed pain medication that wasn't expired.
Dental:
· Individual #1's dentists orders semi-annual dental examination and cleanings. Individual #1 had a dental appointment on 8/28/19 and not again until 3/31/21, outside the dentist's recall instructions. There are no records maintained that the home attempted to schedule the next 6-month dental examination and cleaning for the individual until 9/1/21; almost 6 months after their 3/31/21 appointment. Due to the delay in attempting to schedule the appointment, on 9/1/21 the agency was told that the earliest appointment available to complete a dental cleaning and examination for the individual was 11/8/21. There are no records this appointment was completed, rescheduled, missed, or refused. At the time of the 3/22/22 inspection, there are no records that another dental appointment was scheduled or completed for Individual #1.
· On 3/31/21 Individual #1's dentist stated, "See Endodontist for R.C.T on 13 or 14. Referral given." As of the 3/22/22 inspection, this follow-up examination and appointment has not been scheduled or completed.
Vision:
· Staff person #5 reported during the 3/22/22 inspection that Individual #1 had a vision examination completed in January 2022 however, there are no records maintained that this appointment occurred. | 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.
| - The home failed to implement health services to Individual #1 over the previous year in the following areas.
- Medication:
- · Individual #1 has a standing order to be administered over-the-counter pain medication for pain as needed. At the time of the 3/22/22 inspection the only over-the-counter, as needed, pain medication available to Individual #1 was Tylenol that expired in April 2021. Staff documented as administering an over-the-counter pain medication to the individual throughout the previous year. Staff onsite were unable to locate the over-the-counter medication administered to the individual or an applicable as needed pain medication that wasn't expired.
- Dental:
- · Individual #1's dentists orders semi-annual dental examination and cleanings. Individual #1 had a dental appointment on 8/28/19 and not again until 3/31/21, outside the dentist's recall instructions. There are no records maintained that the home attempted to schedule the next 6-month dental examination and cleaning for the individual until 9/1/21; almost 6 months after their 3/31/21 appointment. Due to the delay in attempting to schedule the appointment, on 9/1/21 the agency was told that the earliest appointment available to complete a dental cleaning and examination for the individual was 11/8/21. There are no records this appointment was completed, rescheduled, missed, or refused. At the time of the 3/22/22 inspection, there are no records that another dental appointment was scheduled or completed for Individual #1.
- · On 3/31/21 Individual #1's dentist stated, "See Endodontist for R.C.T on 13 or 14. Referral given." As of the 3/22/22 inspection, this follow-up examination and appointment has not been scheduled or completed.
- Vision:
Staff person #5 reported during the 3/22/22 inspection that Individual #1 had a vision examination completed in January 2022 however, there are no records maintained that this appointment occurred.
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.
Providers Plan of Correction: Tylenol has been purchased. The dental appointment occurred on 5-25-22. A teeth cleaning and exam occurred during this appointment. The dentist stated that there were no apparent concerns seen and no endodontist referral was needed. The record of the vision screening on 1-5-2022 has been obtained by the optometrist. Program Supervisor, Program Specialist and all staff were retrained in the documentation of refusals. |
05/27/2022
| Implemented |
| 6400.181(a) | At the time of the 3/22/22 inspection, Individual #1's most recent assessment was completed on 3/19/21 and was not updated annually. Staff person #1 confirmed Individual #1's assessment was not completed in 2022.
Additionally, Individual #1's current 10/28/21 individual support plan (ISP) lists a plan to assist the individual through their social, emotional, and environmental needs (SEEN plan) relating to their psychiatric diagnoses. On 3/22/22 Staff person #1, the staff responsible for assessing the individual's current needs, abilities, and services, indicated the individual's SEEN plan has not been updated in years. Staff person #1 reported they haven't assessed the individual's current mental health needs described in their SEEN plan or updated their SEEN plan in years.
Individual #'1 3/19/2021 assessment stated that the individual could have up to 2 hours of alone time in the home. This supervision level has been in place for a few years, prior to Staff person #1 becoming the individual's program specialist. Staff person #1 reported they have never reassessed the individual's supervision needs in a few years. When the Department's staff arrived onsite on 3/22/22, Individual #1 was home alone, opened the front door of their home before the Department's staff knocked on the door, Individual #1 stepped back into their home appearing to allow entry if the Department wished without asking any identifying information, and reported to the Department's staff that they were home alone. Individual #1 appeared to be letting complete strangers into their home while they were home alone creating a safety concern. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | At the time of the 3/22/22 inspection, Individual #1's most recent assessment was completed on 3/19/21 and was not updated annually. Staff person #1 confirmed Individual #1's assessment was not completed in 2022.
Additionally, Individual #1's current 10/28/21 individual support plan (ISP) lists a plan to assist the individual through their social, emotional, and environmental needs (SEEN plan) relating to their psychiatric diagnoses. On 3/22/22 Staff person #1, the staff responsible for assessing the individual's current needs, abilities, and services, indicated the individual's SEEN plan has not been updated in years. Staff person #1 reported they haven't assessed the individual's current mental health needs described in their SEEN plan or updated their SEEN plan in years.
Individual #'1 3/19/2021 assessment stated that the individual could have up to 2 hours of alone time in the home. This supervision level has been in place for a few years, prior to Staff person #1 becoming the individual's program specialist. Staff person #1 reported they have never reassessed the individual's supervision needs in a few years. When the Department's staff arrived onsite on 3/22/22, Individual #1 was home alone, opened the front door of their home before the Department's staff knocked on the door, Individual #1 stepped back into their home appearing to allow entry if the Department wished without asking any identifying information, and reported to the Department's staff that they were home alone. Individual #1 appeared to be letting complete strangers into their home while they were home alone creating a safety concern.
Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home.
Providers Plan of Correction: The annual assessment was sent out 3-22-22. While the assessment was not within one year of the previous assessment, it was three days overdue which falls under the 15 day grace period. An annual assessment has been sent out to the team annually where the supervision needs of the individual have been assessed. A team meeting has been requested by the Program Specialist that will occur on 5-27-22 to discuss Individual #1's alone time. |
05/27/2022
| Implemented |
| 6400.214(b) | The current copies of Individual #1's record information defined in 6400.213(4), 6400.213(5), 6400.213(6), and 6400.213(7), are not kept at the home. Upon arrival on 3/22/22, the documents were not at the home and Staff persons #2 and #5 confirmed that this information is never kept at the home, only daily information. Staff person #5 reported that most of Individual #1's current medical and record information is always kept at the agency office and the staff in the home don't always have access to these documents. The individual plan at the home on 3/22/22 was last updated on 6/22/21. According to the electronic system where the individual plan is created, HCSIS, the most recent individual plan was last updated 10/28/21. The plan had been updated twice since 6/22/21; on 9/30/21 and 10/28/21 and staff did not have access to this. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The current copies of Individual #1's record information defined in 6400.213(4), 6400.213(5), 6400.213(6), and 6400.213(7), are not kept at the home. Upon arrival on 3/22/22, the documents were not at the home and Staff persons #2 and #5 confirmed that this information is never kept at the home, only daily information. Staff person #5 reported that most of Individual #1's current medical and record information is always kept at the agency office and the staff in the home don't always have access to these documents. The individual plan at the home on 3/22/22 was last updated on 6/22/21. According to the electronic system where the individual plan is created, HCSIS, the most recent individual plan was last updated 10/28/21. The plan had been updated twice since 6/22/21; on 9/30/21 and 10/28/21 and staff did not have access to this.
The most current copies of record information required in § 6400.213(2)(14) shall be kept at the residential home.
Providers Plan of Correction: Individual #1's records are being moved to the home where they will be kept and maintained. The program specialist will be responsible for maintaining these records. |
05/27/2022
| Implemented |
| 6400.50(a) | The training record provided did not include hours of training for each training provided to Staff persons #1-#6. There are no records that staff received 24 hours annual training. | 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. | The training record provided did not include hours of training for each training provided to Staff persons #1-#6. There are no records that staff received 24 hours annual training.
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.
Providers Plan of Correction: The training record requested was provided during the licensing, but the record printed did not include all of the information required. The Training Lead was able to print a different version of the training records from the Relias Training Program that includes the training source, length of training/credit hours and the names of the staff persons attending. This training record has been uploaded as Attachment #1. |
05/27/2022
| Implemented |
| 6400.51(b)(1) | Staff person #4 was hired on 3/31/21. There are no records maintained that they received orientation training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships until 9/29/21.
Staff person #2 was hired in January 2022. The agency never produced orientation training on the above topics for said staff. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Staff person #4 was hired on 3/31/21. (MM) There are no records maintained that they received orientation training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships until 9/29/21.
Staff person #2 (MU) was hired in January 2022. The agency never produced orientation training on the above topics for said staff.
The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.
Providers Plan of Correction: Staff person #4 did complete orientation in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. These were all competed within 30 days of hire. As part of our annual training, he completed again on 9-29-21. When the training dates were requested for licensing, the Training Lead printed the September dates and not the April 2021 dates.
Staff Person #2 was a former employee who was re-hired in January 2022. She was incorrectly reinstated in our training program (Relias) when she should have been added as a new hire. |
05/27/2022
| Implemented |
| 6400.51(b)(2) | Staff person #4 was hired on 3/31/21. There are no records maintained that they received orientation training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. § § 10225.101---10225.5102), the Child Protective Services Law (23 Pa.C.S. § § 6301---6386), the Adult Protective Services Act (35 P.S. § § 10210.101---10210.704) and applicable protective services regulations until 9/28/21.
Staff person #2 was hired in January 2022. The agency never produced orientation training on the above topics for said staff. | The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations. | Staff person #4 was hired on 3/31/21.(MM) There are no records maintained that they received orientation training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. § § 10225.101---10225.5102), the Child Protective Services Law (23 Pa.C.S. § § 6301---6386), the Adult Protective Services Act (35 P.S. § § 10210.101---10210.704) and applicable protective services regulations until 9/28/21.
Staff person #2 was hired in January 2022. The agency never produced orientation training on the above topics for said staff.
The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations.
Providers Plan of Correction: Staff person #4 did complete orientation training in the prevention, detection, and reporting abuse, suspected abuse and alleged abuse. These were all competed within 30 days of hire. As part of our annual training, he completed again on 9-28-21. When the training dates were requested for licensing, the Training Lead printed the September dates and not the April 2021 dates.
Staff Person #2 was a former employee who was re-hired in January 2022. She was incorrectly reinstated in our training program (Relias) when she should have been added as a new hire. |
05/27/2022
| Implemented |
| 6400.51(b)(3) | Staff person #4 was hired on 3/31/21. There are no records maintained that they received orientation training in individual rights until 9/28/21.
Staff person #2 was hired in January 2022. The agency never produced orientation training on the above topics for said staff. | The orientation must encompass the following areas: Individual rights. | Staff person #4 was hired on 3/31/21. (MM) There are no records maintained that they received orientation training in individual rights until 9/28/21.
Staff person #2 was hired in January 2022. The agency never produced orientation training on the above topics for said staff.
The orientation must encompass the following areas: Individual rights.
Providers Plan of Correction: Staff person #4 did complete orientation training in individual rights. These were all competed within 30 days of hire. As part of our annual training, he completed again on 9-28-21. When the training dates were requested for licensing, the Training Lead printed the September dates and not the April 2021 dates.
Staff Person #2 was a former employee who was re-hired in January 2022. She was incorrectly reinstated in our training program (Relias) when she should have been added as a new hire. |
05/27/2022
| Implemented |
| 6400.51(b)(4) | Staff person #4 was hired on 3/31/21. There are no records maintained that they received orientation training in recognizing and reporting incidents until 9/29/21.
Staff person #2 was hired in January 2022. The agency never produced orientation training on the above topics for said staff. | The orientation must encompass the following areas: recognizing and reporting incidents. | Staff person #4 was hired on 3/31/21. )MM) There are no records maintained that they received orientation training in recognizing and reporting incidents until 9/29/21.
Staff person #2 was hired in January 2022. The agency never produced orientation training on the above topics for said staff.
The orientation must encompass the following areas: recognizing and reporting incidents.
Providers Plan of Correction: Staff person #4 did complete orientation training in recognizing and reporting incidents. These were all competed within 30 days of hire. As part of our annual training, he completed again on 9-29-21. When the training dates were requested for licensing, the Training Lead printed the September dates and not the April 2021 dates.
Staff Person #2 was a former employee who was re-hired in January 2022. She was incorrectly reinstated in our training program (Relias) when she should have been added as a new hire. |
05/27/2022
| Implemented |
| 6400.51(b)(5) | There are no records maintained that prior to working with Individual #1, Staff persons #2, received in-person orientation training specific to Individual #1's needs and plans, for the staff to perform their job duties.
Staff person #5 reported to the Department on 3/22/22 that there are no records to indicate if or what staff received training on prior to working with Individual #1 and that staff are to independently read individual-specific information available in the individuals' binders at the home. The contents of Individual #1's record onsite included old, outdated, and irrelevant information per agency management staff; for example, the binder had a document titled "Getting to know {Individual #1}" dated 12/6/2019.
A note written by Staff person #5 on 1/5/2022, located in Individual #1's communication binder at their home, instructed new Staff person #2 to start reading 6 individuals' binders of information on their own and sign the acknowledgement forms that this was completed.
The agency was asked on 3/23/22 and 3/24/22 to produce records of the in-person training component provided to Staff persons #2 on Individual #1's specific health and safety needs prior to working with Individual #1.
· Staff person #6's 8/28-29/2020 in-home orientation training sheet provided did not include documentation that it was specific to Individual #1 or Individual #1's home, or that it included training on the individual's current needs. Additionally, the agency reported Staff person #6 didn't start working with Individual #1 until approximately the fall of 2021.
· Staff person #4's 4/1/21 in-home orientation training sheet provided did not include documentation that it was specific to Individual #1 or Individual #1's home, or that it included training on the individual's current needs. Additionally, the agency reported Staff person #4 just started working with Individual #1 on approximately 1/14/22.
· Staff person #5's 7/13/16 in-home orientation training sheet provided did not include documentation that it was specific to Individual #1 or Individual #1's home, nor was a training on the individual's current needs provided.
· Staff person #3's 5/14/09 in-home orientation training sheet provided did not include documentation that it was specific to Individual #1, Individual #1's home, or Individual #1's current needs, but did indicate that it was orientation to another home location. Agency reported Staff person #3 started working with Individual #1 on approximately 1/18/22.
· Staff person #2's 1/5/22 in-home orientation training provided did not include documentation that it was specific to Individual #1, Individual #1's home, or Individual #1's current needs.
The agency purported that Staff persons #9 and #10 worked with Individual #1 on at least one occasion over the previous 6 months. There are no records they received orientation to the individual's specific needs and abilities to properly perform their job duties.
During a 5/3/22 phone interview with Staff person #3, they had no knowledge if Individual #1 had a behavior support plan, SEEN plan, what or if they were to track any behaviors for Individual #1, and specific supervision needs. Staff person #3 reported there was no training provided about Individual #1's specific care, plans, services or needs prior to working with the individual. | The orientation must encompass the following areas: Job-related knowledge and skills. | There are no records maintained that prior to working with Individual #1, Staff persons #2-#6, received in-person orientation training specific to Individual #1's needs and plans, for the staff to perform their job duties.
Per agency CEO, Staff person #7, on 3/22/22 all current record information for Individual #1 is stored in binders at the agency office and not all of the individual's record is stored in their home. Both record locations contained different information within the individual's binders. Training sign-off sheets provided state, staff documenting their signature "read the contents of this book." There are no records maintained of the specific content contained within each book, which locations of the book they read the contents of, or that all information specific to the individual was provided via an in-person training.
Staff person #5 reported to the Department on 3/22/22 that there are no records to indicate if or what staff received training on prior to working with Individual #1 and that staff are to independently read individual-specific information available in the individuals' binders at the home. The contents of Individual #1's record onsite included old, outdated, and irrelevant information per agency management staff; for example, the binder had a document titled "Getting to know {Individual #1}" dated 12/6/2019.
A note written by Staff person #5 on 1/5/2022, located in Individual #1's communication binder at their home, instructed new Staff person #2 to start reading 6 individuals' binders of information on their own and sign the acknowledgement forms that this was completed.
The agency was asked on 3/23/22 and 3/24/22 to produce records of the in-person training component provided to Staff persons #2-#6 on Individual #1's specific health and safety needs prior to working with Individual #1.
· Staff person #6's 8/28-29/2020 in-home orientation training sheet provided did not include documentation that it was specific to Individual #1 or Individual #1's home, or that it included training on the individual's current needs. Additionally, the agency reported Staff person #6 didn't start working with Individual #1 until approximately the fall of 2021.
· Staff person #4's 4/1/21 in-home orientation training sheet provided did not include documentation that it was specific to Individual #1 or Individual #1's home, or that it included training on the individual's current needs. Additionally, the agency reported Staff person #4 just started working with Individual #1 on approximately 1/14/22.
· Staff person #5's 7/13/16 in-home orientation training sheet provided did not include documentation that it was specific to Individual #1 or Individual #1's home, nor was a training on the individual's current needs provided.
· Staff person #3's 5/14/09 in-home orientation training sheet provided did not include documentation that it was specific to Individual #1, Individual #1's home, or Individual #1's current needs, but did indicate that it was orientation to another home location. Agency reported Staff person #3 started working with Individual #1 on approximately 1/18/22.
· Staff person #2's 1/5/22 in-home orientation training provided did not include documentation that it was specific to Individual #1, Individual #1's home, or Individual #1's current needs.
The agency purported that Staff persons #9 and #10 worked with Individual #1 on at least one occasion over the previous 6 months. There are no records they received orientation to the individual's specific needs and abilities to properly perform their job duties.
During a 5/3/22 phone interview with Staff person #3, they had no knowledge if Individual #1 had a behavior support plan, SEEN plan, what or if they were to track any behaviors for Individual #1, and specific supervision needs. Staff person #3 reported there was no training provided about Individual #1's specific care, plans, services or needs prior to working with the individual.
The orientation must encompass the following areas: Job-related knowledge and skills.
Plan of correction: The in-home orientation form has been updated to include the name of the individual, the name of the trainer and the date of completion.
Acknowledgement of responsibility form signed by staff person #3 on 1-18-22 shows that he signed off acknowledging that he was trained in Individual's plans.
Staff will be trained in person by the person they are relieving on shift and signing off on this training. In some cases, staff will be trained virtually by on-call supervisor if after hours. |
05/27/2022
| Implemented |
| 6400.52(c)(2) | There are no records maintained that Staff persons #1, #3, #5, and #6 received annual training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. § § 10225.101---10225.5102), the Child Protective Services Law (23 Pa.C.S. § § 6301---6386), the Adult Protective Services Act (35 P.S. § § 10210.101---10210.704) and applicable protective services regulations. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | There are no records maintained that Staff persons #1, #3, #5, and #6 received annual training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. § § 10225.101---10225.5102), the Child Protective Services Law (23 Pa.C.S. § § 6301---6386), the Adult Protective Services Act (35 P.S. § § 10210.101---10210.704) and applicable protective services regulations.
The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.
Providers Plan of Correction: Staff person #1, 3 5 and 6 did complete orientation training their annual training in the prevention, detection and reporting of abuse and alleged abuse. When the training dates were requested for licensing, the Training Lead printed the incorrect dates. |
05/27/2022
| Implemented |
| 6400.52(c)(5) | There are no records maintained that Staff person #3 received annual training in the safe and appropriate use of behavior supports, as they work directly with Individual #1 that requires behavior supports. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | There are no records maintained that Staff person #3 received annual training in the safe and appropriate use of behavior supports, as they work directly with Individual #1 that requires behavior supports.
The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.
Providers Plan of Correction: Staff person #3 completed the annual training in the safe and appropriate use of behavior supports on 10-1-21. When the training dates were requested for licensing, the Training Lead printed the incorrect dates. |
05/27/2022
| Implemented |
| 6400.165(g) | Individual #1 is prescribed psychotropic medications for their psychiatric diagnoses. Individual #1's 3/3/21 review of their psychotropic medications did not include the reason for prescribing their medications. Individual #1's 6/17/21, 10/7/21, and 1/26/22 reviews did not include the reason for prescribing medications, the necessary dosage, or the need to continue medications. The 6/17/21, 10/7/21, and 1/26/22 reviews are only documented via the staff "health services log." There is no documentation verifying that a licensed physician completed these reviews. Additionally, there was more than 3 months between the 10/7/21 and 1/26/22 reviews with no exceptional circumstances to explain the delay. | 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. | Individual #1 is prescribed psychotropic medications for their psychiatric diagnoses. Individual #1's 3/3/21 review of their psychotropic medications did not include the reason for prescribing their medications. Individual #1's 6/17/21, 10/7/21, and 1/26/22 reviews did not include the reason for prescribing medications, the necessary dosage, or the need to continue medications. The 6/17/21, 10/7/21, and 1/26/22 reviews are only documented via the staff "health services log." There is no documentation verifying that a licensed physician completed these reviews. Additionally, there was more than 3 months between the 10/7/21 and 1/26/22 reviews with no exceptional circumstances to explain the delay.
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.
Providers Plan of Correction: Staff person #3 completed the annual training in the safe and appropriate use of behavior supports on 10-1-21. When the training dates were requested for licensing, the Training Lead printed the incorrect dates. |
05/27/2022
| Implemented |
| 6400.166(a)(2) | Staff person #3 reported on 5/3/22 that they administered Tylenol to Individual #1 on 3/11/22 because the individual was experiencing stomach pain from period cramps. Individual #1 was purportedly ordered Tylenol as needed for pain. There are no records maintained of the requirements defined in 6400.166(a)(1)-(16) for the administration of Tylenol on 3/11/22 to Individual #1. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | Staff person #3 reported on 5/3/22 that they administered Tylenol to Individual #1 on 3/11/22 because the individual was experiencing stomach pain from period cramps. Individual #1 was purportedly ordered Tylenol as needed for pain. There are no records maintained of the requirements defined in 6400.166(a)(1)-(16) for the administration of Tylenol on 3/11/22 to Individual #1.
A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.
Providers Plan of Correction: Staff person # 3 was retrained in regard to administering and documenting a PRN medication on 5-25-22. |
05/27/2022
| Implemented |
| 6400.166(a)(4) | Staff person #3 reported on 5/3/22 that they administered Tylenol to Individual #1 on 3/11/22 because the individual was experiencing stomach pain from period cramps. Individual #1 was purportedly ordered Tylenol as needed for pain. There are no records maintained of the requirements defined in 6400.166(a)(1)-(16) for the administration of Tylenol on 3/11/22 to Individual #1. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Staff person #3 reported on 5/3/22 that they administered Tylenol to Individual #1 on 3/11/22 because the individual was experiencing stomach pain from period cramps. Individual #1 was purportedly ordered Tylenol as needed for pain. There are no records maintained of the requirements defined in 6400.166(a)(1)-(16) for the administration of Tylenol on 3/11/22 to Individual #1.
A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.
Providers Plan of Correction: Staff person # 3 was retrained in regard to administering and documenting a PRN medication on 5-25-22. |
05/27/2022
| Implemented |
| 6400.166(a)(5) | Staff person #3 reported on 5/3/22 that they administered Tylenol to Individual #1 on 3/11/22 because the individual was experiencing stomach pain from period cramps. Individual #1 was purportedly ordered Tylenol as needed for pain. There are no records maintained of the requirements defined in 6400.166(a)(1)-(16) for the administration of Tylenol on 3/11/22 to Individual #1. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | Staff person #3 reported on 5/3/22 that they administered Tylenol to Individual #1 on 3/11/22 because the individual was experiencing stomach pain from period cramps. Individual #1 was purportedly ordered Tylenol as needed for pain. There are no records maintained of the requirements defined in 6400.166(a)(1)-(16) for the administration of Tylenol on 3/11/22 to Individual #1.
A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication.
Providers Plan of Correction: Staff person # 3 was retrained in regard to administering and documenting a PRN medication on 5-25-22. |
05/27/2022
| Implemented |
| 6400.166(a)(6) | Staff person #3 reported on 5/3/22 that they administered Tylenol to Individual #1 on 3/11/22 because the individual was experiencing stomach pain from period cramps. Individual #1 was purportedly ordered Tylenol as needed for pain. There are no records maintained of the requirements defined in 6400.166(a)(1)-(16) for the administration of Tylenol on 3/11/22 to Individual #1. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | Staff person #3 reported on 5/3/22 that they administered Tylenol to Individual #1 on 3/11/22 because the individual was experiencing stomach pain from period cramps. Individual #1 was purportedly ordered Tylenol as needed for pain. There are no records maintained of the requirements defined in 6400.166(a)(1)-(16) for the administration of Tylenol on 3/11/22 to Individual #1.
A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form.
Providers Plan of Correction: Staff person # 3 was retrained in regard to administering and documenting a PRN medication on 5-25-22. |
05/27/2022
| Implemented |
| 6400.166(a)(7) | Staff person #3 reported on 5/3/22 that they administered Tylenol to Individual #1 on 3/11/22 because the individual was experiencing stomach pain from period cramps. Individual #1 was purportedly ordered Tylenol as needed for pain. There are no records maintained of the requirements defined in 6400.166(a)(1)-(16) for the administration of Tylenol on 3/11/22 to Individual #1. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Staff person #3 reported on 5/3/22 that they administered Tylenol to Individual #1 on 3/11/22 because the individual was experiencing stomach pain from period cramps. Individual #1 was purportedly ordered Tylenol as needed for pain. There are no records maintained of the requirements defined in 6400.166(a)(1)-(16) for the administration of Tylenol on 3/11/22 to Individual #1.
A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication.
Providers Plan of Correction: Staff person #3 was retrained in regard to administering and documenting a PRN medication on 5-25-22. |
05/27/2022
| Implemented |
| 6400.166(a)(9) | Staff person #3 reported on 5/3/22 that they administered Tylenol to Individual #1 on 3/11/22 because the individual was experiencing stomach pain from period cramps. Individual #1 was purportedly ordered Tylenol as needed for pain. There are no records maintained of the requirements defined in 6400.166(a)(1)-(16) for the administration of Tylenol on 3/11/22 to Individual #1. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Staff person #3 reported on 5/3/22 that they administered Tylenol to Individual #1 on 3/11/22 because the individual was experiencing stomach pain from period cramps. Individual #1 was purportedly ordered Tylenol as needed for pain. There are no records maintained of the requirements defined in 6400.166(a)(1)-(16) for the administration of Tylenol on 3/11/22 to Individual #1.
A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration.
Providers Plan of Correction: Staff person # 3 was retrained in regard to administering and documenting a PRN medication on 5-25-22. |
05/27/2022
| Implemented |
| 6400.166(a)(11) | Staff person #3 reported on 5/3/22 that they administered Tylenol to Individual #1 on 3/11/22 because the individual was experiencing stomach pain from period cramps. Individual #1 was purportedly ordered Tylenol as needed for pain. There are no records maintained of the requirements defined in 6400.166(a)(1)-(16) for the administration of Tylenol on 3/11/22 to Individual #1. | 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. | Staff person #3 reported on 5/3/22 that they administered Tylenol to Individual #1 on 3/11/22 because the individual was experiencing stomach pain from period cramps. Individual #1 was purportedly ordered Tylenol as needed for pain. There are no records maintained of the requirements defined in 6400.166(a)(1)-(16) for the administration of Tylenol on 3/11/22 to Individual #1.
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.
Providers Plan of Correction: Staff person # 3 was retrained in regard to administering and documenting a PRN medication on 5-25-22. |
05/27/2022
| Implemented |
| 6400.166(a)(13) | Staff person #3 reported on 5/3/22 that they administered Tylenol to Individual #1 on 3/11/22 because the individual was experiencing stomach pain from period cramps. Individual #1 was purportedly ordered Tylenol as needed for pain. There are no records maintained of the requirements defined in 6400.166(a)(1)-(16) for the administration of Tylenol on 3/11/22 to Individual #1. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Staff person #3 reported on 5/3/22 that they administered Tylenol to Individual #1 on 3/11/22 because the individual was experiencing stomach pain from period cramps. Individual #1 was purportedly ordered Tylenol as needed for pain. There are no records maintained of the requirements defined in 6400.166(a)(1)-(16) for the administration of Tylenol on 3/11/22 to Individual #1.
A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.
Providers Plan of Correction: Staff person # 3 was retrained in regard to administering and documenting a PRN medication on 5-25-22, specifically name and initials of the person administering the medication. |
05/27/2022
| Implemented |
| 6400.169(a) | An agency (Excentia Human Services) staff medication trainer indicated that Staff person #8 completed the Department's annual medication administration training on 1/25/2020 and not again until 1/25/2022. There are no records that Staff person #8 completed additional medication training requirements due to their late recertification. Staff person #8 administered medications to Individual #1 in June 2021.
An agency staff medication trainer indicated that Staff person #6 completed the Department's initial medication administration training on 11/9/2020. At the time of the 3/23/2022 onsite review of staff's records, there are no records maintained that Staff person #6 completed and passed the Department's annual medication administration training or activities, that was due by 11/9/2021. Staff person #6 administered medication to Individual #1 on the following dates: 3/10/22, 3/13/22, 3/14/22, 3/16/22, 3/21/22, and 3/22/22. Additionally, Staff person #6 hasn't completed a training course, provided by a medical professional, to administer medication via other routes: transdermal patches. Staff person #6 administered a transdermal patch to Individual #1 on 3/16/22. | 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). | An agency (Excentia Human Services) staff medication trainer indicated that Staff person #8 completed the Department's annual medication administration training on 1/25/2020 and not again until 1/25/2022. There are no records that Staff person #8 completed additional medication training requirements due to their late recertification. Staff person #8 administered medications to Individual #1 in June 2021.
An agency staff medication trainer indicated that Staff person #6 completed the Department's initial medication administration training on 11/9/2020. At the time of the 3/23/2022 onsite review of staff's records, there are no records maintained that Staff person #6 completed and passed the Department's annual medication administration training or activities, that was due by 11/9/2021. Staff person #6 administered medication to Individual #1 on the following dates: 3/10/22, 3/13/22, 3/14/22, 3/16/22, 3/21/22, and 3/22/22. Additionally, Staff person #6 hasn't completed a training course, provided by a medical professional, to administer medication via other routes: transdermal patches. Staff person #6 administered a transdermal patch to Individual #1 on 3/16/22.
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).
Providers Plan of Correction: Staff person #8 was added to a med training course and re-took the entire med training course. Staff person #8 has been added to the alternate route med training course on 6-9-22. The program supervisor and program specialist have been retrained on this regulation. |
05/27/2022
| Implemented |
| 6400.185(5) | As referenced in 6400.143(a) of this report, Individual #1 refuses many routine medical examinations. The individual's record did not include any plans or protocols to implement to explore other alternative examinations, nor are there any desensitization plans in place to attempt to prepare Individual #1 to complete these health examinations. | The individual plan, including revisions, must include the following: Risks to the individual's health, safety or well-being, behaviors likely to result in immediate physical harm to the individual or others and risk mitigation strategies, if applicable. | As referenced in 6400.143(a) of this report, Individual #1 refuses many routine medical examinations. The individual's record did not include any plans or protocols to implement to explore other alternative examinations, nor are there any desensitization plans in place to attempt to prepare Individual #1 to complete these health examinations.
The individual plan, including revisions, must include the following: Risks to the individual's health, safety or well-being, behaviors likely to result in immediate physical harm to the individual or others and risk mitigation strategies, if applicable.
Providers Plan of Correction: The ISP for Individual #1 states the following Plan of Refusal of Medical Treatment: Whenever Individual #1 has an appointment coming up, staff will talk with her about the importance of cooperating for needed health care. Staff will be sure to schedule exams with familiar doctors that is in her preference. Staff will share details about what will occur at the appointment, how long it will take, who she is seeing, and the need for her to cooperate. Staff will also remind her to practice relaxation techniques (slow, deep breathing, squeezing a stress ball, etc) before and during appointments. Once she gets to the appointment, staff will reassure her and continue to remind her to utilize relaxation techniques. Staff will inform her doctor of her apprehension and ask the doctor to talk softly and calmly to help her relax. Staff will continue to talk to her to try to help her relax through the procedure. Staff will praise her on all efforts towards a successful exam or procedure.
The Program Specialist has asked the Supports Coordinator to add the following phrase: Individual #1 is at a risk for health conditions not being diagnosed by medical professionals in a timely manner if she refuses medical related appointments. Alternative examination options will be discussed with her. |
05/27/2022
| Implemented |
| 6400.186 | Individual #1's 10/28/21 current individual support plan (ISP) states that they can be unsupervised at home without staff on the premises for up to 2 hours and staff should physical check on the individual every 2 hours for 10 minutes. During the 3/22/22 onsite inspection, Staff person #1 confirmed there are no records maintained when the individual utilizes their unsupervised time, when the unsupervised time starts and ends, or when staff check on the individual to determine the individual's safety during the unsupervised time.
Individual #1's ISP states, "{the individual} has shown a marked increase in telling of falsehood for the last few months. These falsehoods have increased to making false accusations. The individual later recants the accusations, telling the investigator that it was said because the individual wanted a specific staff's attention. When this occurs or is suspected to have occurred, reference {the individual's} protocol. Staff will be trained in this plan prior to working with {the individual}. Staff will document any concerns or information related to this plan. The program supervisor will be responsible for collecting and summarizing the plan on a month basis and then it will be reviewed by the program specialist."
· There are no records of the individual's telling of falsehoods or marked increases in telling of falsehoods.
· Individual #1's protocol was not followed on 3/13/22 when they informed staff of an alleged sexual abuse allegation.
· As referenced in 6400.51(b)(5) of this report, there are no records that staff received training on this plan or protocol. Staff person #6, who was the initial reported of Individual #1's alleged sexual abuse allegation on 3/13/22, reported to the Department on 3/23/22 they were not aware of Individual #1's plan or additional protocol for incident reporting when the individual makes a verbal accusation. Staff person #6 stated they are now aware that they should have contacted management staff via phone (on-call since it was the weekend) to make a report as the agency has now informed Staff #6 of this.
· There are no records maintained of staff reporting and documenting any incidents or concerns related to their plan and protocol (SEEN and incident reporting protocol) mentioned above.
· There are no records maintained that the program supervisor collects and summarizes information about the plan on a monthly basis and reviewed by the program specialist. During onsite interviews on 3/23/22, Staff persons #1, and #4-#6, were aware the individual experienced symptoms of their mental health diagnoses on a weekly basis and would exhibit behaviors identified with the individual's plan.
Individual #1's incident reporting protocol for when Individual #1 makes a verbal accusation, states that the program supervisor will check in with the individual once a week to go over any concerns the individual may have to help diminish the individual's needs to "make up" information about staff. There are no records maintained that this was completed.
The same incident reporting protocol states that all accusations made by the individual will be brought to the attention of the residential program's program supervisor and associate director, and Individual #1 will complete an incident report worksheet regarding the accusation (with management staff assistance). Staff person #6 reported they texted their program supervisor who was on leave, on 3/13/22 when Individual #1 initially reported an alleged sexual abuse incident. The associate director, Staff person #1, was not informed of the alleged incident until 3/14/22. There are no records that any other staff were informed of the initial reporting of the alleged incident on 3/13/22. There are no records maintained that the individual, with the assistance of staff if needed, completed and incident report worksheet regarding the accusation.
Individual #1's current ISP states, "At times, {the individual} will get frustrated and may need behavior supports. This may be because {the individual} is not able to express or convey the issue. Determining the accuracy of their communication requires support." At the time of the 3/22/22 inspection, the agency had not attempted to obtain behavior or communication supports for Individual #1 or have an appropriate plan in place to support the individual's behavior and communication needs. | The home shall implement the individual plan, including revisions. | Individual #1's 10/28/21 current individual support plan (ISP) states that they can be unsupervised at home without staff on the premises for up to 2 hours and staff should physical check on the individual every 2 hours for 10 minutes. During the 3/22/22 onsite inspection, Staff person #1 confirmed there are no records maintained when the individual utilizes their unsupervised time, when the unsupervised time starts and ends, or when staff check on the individual to determine the individual's safety during the unsupervised time.
Individual #1's ISP states, "{the individual} has shown a marked increase in telling of falsehood for the last few months. These falsehoods have increased to making false accusations. The individual later recants the accusations, telling the investigator that it was said because the individual wanted a specific staff's attention. When this occurs or is suspected to have occurred, reference {the individual's} protocol. Staff will be trained in this plan prior to working with {the individual}. Staff will document any concerns or information related to this plan. The program supervisor will be responsible for collecting and summarizing the plan on a month basis and then it will be reviewed by the program specialist."
· There are no records of the individual's telling of falsehoods or marked increases in telling of falsehoods.
· Individual #1's protocol was not followed on 3/13/22 when they informed staff of an alleged sexual abuse allegation.
· As referenced in 6400.51(b)(5) of this report, there are no records that staff received training on this plan or protocol. Staff person #6, who was the initial reported of Individual #1's alleged sexual abuse allegation on 3/13/22, reported to the Department on 3/23/22 they were not aware of Individual #1's plan or additional protocol for incident reporting when the individual makes a verbal accusation. Staff person #6 stated they are now aware that they should have contacted management staff via phone (on-call since it was the weekend) to make a report as the agency has now informed Staff #6 of this.
· There are no records maintained of staff reporting and documenting any incidents or concerns related to their plan and protocol (SEEN and incident reporting protocol) mentioned above.
· There are no records maintained that the program supervisor collects and summarizes information about the plan on a monthly basis and reviewed by the program specialist. During onsite interviews on 3/23/22, Staff persons #1, and #4-#6, were aware the individual experienced symptoms of their mental health diagnoses on a weekly basis and would exhibit behaviors identified with the individual's plan.
Individual #1's incident reporting protocol for when Individual #1 makes a verbal accusation, states that the program supervisor will check in with the individual once a week to go over any concerns the individual may have to help diminish the individual's needs to "make up" information about staff. There are no records maintained that this was completed.
The same incident reporting protocol states that all accusations made by the individual will be brought to the attention of the residential program's program supervisor and associate director, and Individual #1 will complete an incident report worksheet regarding the accusation (with management staff assistance). Staff person #6 reported they texted their program supervisor who was on leave, on 3/13/22 when Individual #1 initially reported an alleged sexual abuse incident. The associate director, Staff person #1, was not informed of the alleged incident until 3/14/22. There are no records that any other staff were informed of the initial reporting of the alleged incident on 3/13/22. There are no records maintained that the individual, with the assistance of staff if needed, completed and incident report worksheet regarding the accusation.
Individual #1's current ISP states, "At times, {the individual} will get frustrated and may need behavior supports. This may be because {the individual} is not able to express or convey the issue. Determining the accuracy of their communication requires support." At the time of the 3/22/22 inspection, the agency had not attempted to obtain behavior or communication supports for Individual #1 or have an appropriate plan in place to support the individual's behavior and communication needs.
The home shall implement the individual plan, including revisions.
Providers Plan of Correction: Individual #1 is not being left alone currently until a team meeting takes place. A team meeting is scheduled for 5-27-22. If the team feels that she could continue to safely remain home alone, a documentation form has been created where staff would document when the unsupervised time starts and ends or when staff checked on the individual. An email has been sent from the Program Specialist to the Supports coordinator with an update to the SEEN Plan. Staff person #6 has been assigned to take incident management training again. The SEEN Plan and/or any behavior documentation required is being documented under the Behavioral Section of our online documentation system, MITC. The incident reporting protocol regarding the supervisor checking in weekly with Individual #1 was an old protocol that has been removed from the record. A referral has also been sent from the Program Specialist requesting behavioral supports. |
05/27/2022
| Implemented |
|
|