| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | ·REPEAT VIOLATION from 3/22/22:
Individual #1's dental exam completed on 3/22/21, 6/29/21, 9/30/21, 1/3/22, 4/4/22, and 7/14/22 all state that staff should change the electronic toothbrush head every 3-6 months. There is no record kept of when the Individual's toothbrush head is being changed or was changed last.
Individual #2 began seeing a Physical Therapist on 5/5/2022 for swollen leg. Physical Therapist recommended that Individual be seen 3x/week for up to 12 weeks. Individual was only seen by Physical Therapist 11 times by 7/8/22, (9 weeks). Multiple appointments were missed due to various reasons. The following scheduled appointment dates were missed but not documented as to the reason why: 5/23, 5/25, 5/27, 6/3/22. Additional appointments were noted that they were cancelled due transportation difficulties, but do not appear to have been rescheduled. | 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 protocol to change the head of the toothbrush every 3-6 months was created for individual #1. Staff will document when the head of the toothbrush is changed on the Toothbrush Replacement Tracking Log.
The DSP Lead who was responsible to ensure Individual #2's physical therapy sessions would occur was retrained on his responsibility to ensure all appointments regarding the health and safety of individuals must be attended as recommended by the physician. |
09/16/2022
| Accepted |
| 6400.181(d) | Individual #3's assessment available in the home dated 3/28/2020 was not signed by the program specialist | The program specialist shall sign and date the assessment. | The program specialist who did not sign the assessment no longer works for the organization. All program specialists were retrained on the 6400 regulations pertaining to assessments on 9-15-22 by Director of Residential Services Leo Marcantonis to ensure they understand all of their responsibilities as a program specialist. |
09/15/2022
| Accepted |
| 6400.211(b)(1) | Individual #2's emergency contact did not include their address | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
| Emergency Contact Information for Individual #2 was updated with their address by Program Specialist Shawn Anthony on 9-2-2022. Shawn Anthony was retrained by Director of Residential Services Leo Marcantonis on 9-2-2022 to ensure that the address is included in the emergency contact information. The management team was retrained by Leo Marcantonis on 9-16-22. |
09/16/2022
| Accepted |
| 6400.214(a) | Individual #2's demographics sheet was not available in the home as required in 6400.213(1). | Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home. | Individual #2¿s demographic sheet was placed in the home on 8-23-2022 by Program Specialist Shawn Anthony. The entire management team were retrained by Director of Residential Services on 9-16-2022 to ensure they understand their responsibility to current content of records are kept in the home. |
09/16/2022
| Accepted |
| 6400.214(b) | REPEAT VIOLATION FROM 3/22/22:
· Individual #1's Emergency Medical Authorization form was dated for 3/12/19 (the form states to be updated every 3 years)
· Individual #1's Release and Consent Agreement was dated for 3/18/19 (the form states to be updated every 3 years)
· Individual #1's "Getting to Know Me" document dated 9/3/21 does not mention any issues surrounding foods as described by the Bluff View Drive staff (eating condiments, raw egg, raw meats, etc.) which is the reason staff advised that food is not kept in the kitchen refrigerator or cupboards.
· Individual #3's Emergency Medical Authorization form was dated for 8/11/18 (the form states it is to be updated every 3 years)
· Individual #3's Release and Consent form was dated for 8/11/18 (the form states it is to be updated every 3 years)
· Individual #1's current BSP was not available in the home. BSP available was dated 6/23/20 which is not current
· Individual #3's current BSP was not available in the home. BSP available was dated 5/30/19 which is not current
· Individual #3's assessment available in the home is dated 4/2/2021 (not current).
· Emergency Medical Form kept in the home for Individual #1 is dated 3/12/19 (this form states it is to be updated every 3 years)
Individual #3's Behavior Support Plan updated on 4/25/22 states that they currently reside with one male and one female housemate on home. Individual #3 currently resides on other home since 7/1/19, with two male housemates. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The Emergency Medical Authorization Forms and Release and Consent Forms for Individuals #1 and #3 were updated by Program Specialist Shawn Anthony on 7-20-22 for Individual #1 and 7-21-22 for Individual #3. They were placed in the individuals record in the home on 8-10-22.
Excentia Human Services has updated its procedure for completing Emergency Medical Authorization Forms and Release and Consent Forms. Emergency Medical Authorization Forms and Release and Consent Forms are no longer required to be completed every three years. They are only required to be on file per Chapter 6400 regulations.
Individual #1¿s Diet section from the Getting to Know was removed completely to avoid conflicting information from other documents. We are re-evaluating whether or not we will continue utilizing the Getting to Know document.
Individual #1 and #3¿s current BSPs were placed in the home by Program Specialist Shawn Anthony on 8-3-22. Individual #3¿s BSP was updated to include the correct information on who he lives with Amanda Diehl, Behavioral Specialist on 9-2-22. This BSP was placed in the home by Program Specialist Shawn Anthony on 9-2-22. |
09/02/2022
| Accepted |
| 6400.216(a) | Individual #1, #2, and #3's records were found unattended and unlocked in the staff office at the time of the physical walkthrough. | An individual's records shall be kept locked when unattended.
| Individual #1, #2, and #3¿s records were locked when unattended after the discovery of the unlocked records. All employees were re-trained by Jeff Kepeck, Director of Operations and Quality Assurance, on 9/15/2022 to ensure all Individual¿s Records must be kept locked when unattended. Please see attached email. |
09/15/2022
| Accepted |
| 6400.165(f) | Individual #2 is prescribed medication to treat a diagnosed psychiatric illness, but does not have a written protocol as part of the individual plan to address needs relating to symptoms of the psychiatric illness | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | A SEEN Plan for Individual #2 was created by Shawn Anthony on 9/2/22 and sent to his supports coordinator on 9/2/22 to add his SEEN plan to his ISP. |
09/02/2022
| Accepted |
| 6400.166(a)(12) | REPEAT VIOLATION from 3/22/22 - Individual #1's July MAR has no staff initials for 7/3/22 and 7/8/22 for medication, 30 Nysten. (Staff had no explanation or knowledge of whether a medication error had been recorded in EIM). | 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. | All Management in Residential were re-trained by Leo Marcantonis, Director of Residential Services, on 9-19-22 explaining 6400 regulations regarding administering and documenting medications according to regulatory timeframes. They were retrained to document the administration of medications when they are given. Upon further investigation, the medication was administered but it was not initialed. There was no need to enter an EIM incident report for a medication error. |
09/19/2022
| Accepted |
| 6400.166(a)(13) | REPEAT VIOLATION from 3/22/22 - Individual #1's July MAR has no staff initials for 7/3/22 and 7/8/22 for medication, 30 Nysten. (Staff had no explanation or knowledge of whether a medication error had been recorded in EIM). | 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. | All Management in Residential were re-trained by Leo Marcantonis, Director of Residential Services, on 9-19-22 explaining 6400 regulations regarding administering and documenting medications according to regulatory timeframes. They were retrained to document the administration of medications when they are given. Upon further investigation, the medication was administered but it was not initialed. There was no need to enter an EIM incident report for a medication error. |
09/19/2022
| Accepted |
| 6400.192 | Staff member #1 and #2 state that Individual #1 has ongoing issues regarding consuming raw/undercooked food items, as well as condiments. It has been expressed that the Individual has consumed raw meats, raw eggs, and whole jar of condiments at times. For this reason, staff have resorted to keeping most of the house food in the staff office (refrigerator and cabinets) to prevent Individual #1 from indulging in these unsafe food practices. The restrictive procedure is being utilized without a written plan. | The home shall develop and implement a written policy that defines the prohibition or use of specific types of restrictive procedures, describes the circumstances in which restrictive procedures may be used, the staff persons who may authorize the use of restrictive procedures and a mechanism to monitor and control the use of restrictive procedures. | A restrictive procedures policy was in place at the time of the inspection. |
09/20/2022
| Accepted |