| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(4) | Individual #1 had a hearing screening on 1/4/22 and not again until 4/21/23, outside of the annual timeframe. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The PCP typically has, in the past, completed the annual hearing test noted on the annual physical form. An appointment was scheduled for the audiologist for the annual hearing exam, and it was completed on 4/21/2023 which is outside of the required time frame. Going forward, audiology will be scheduled separately and within the year to ensure that the annual hearing test is done timely. |
10/05/2023
| Implemented |
| 6400.141(c)(15) | Individual #1's assessment documented that Individual #1 is currently on an 1800 calorie per day, low fat, low cholesterol diet. Individual #1's current protocol indicates that Individual #1 is currently on a 2200 calorie per day, low fat, low cholesterol diet. Their most recent physical completed on 1/5/23 indicates that Individual #1 is to resume "a normal diet and continue the low fat, low cholesterol diet." | The physical examination shall include:Special instructions for the individual's diet. | An addendum to the Annual Assessment was completed and sent to the SC on 8/25/23(see attachment #1) and the diet was changed in the ISP on 8/28/23(see attachment #2). |
10/05/2023
| Implemented |
| 6400.144 | Individual #1 has a bowel movement protocol in which Individual #1's bowel movements are to be tracked daily. If Individual #1 goes three days with no bowel movements, they are to receive Senna S 8.6mg at bedtime that night. Individual #1's bowel movements are being tracked in their T-Logs and on an intake log. The bowel movement protocol does not identify what steps should be taken if the Individual goes more than 3 days with no bowel movement or what to do if the medication is not successful in treatment. Whether or not Individual #1 had a bowel movement was not tracked at all a total of 6 times from January 2023 through the present (2/23, 3/4, 3/18, 3/20, 5/24, and 5/27). Individual #1 had no bowel movement from 3/7/23 to 3/9/23. No Senna S was administered. Individual #1 had an incident of head banging on 3/5/23; which resulted in redness and slight bruising. The Agency Nurse directed staff to administer Tylenol as needed and to complete neuro checks every two hours. The two-hour neuro checks were not completed. Individual #1 sustained a fall on 6/6/23 and was taken to Med Express. The discharge instructions recommended Individual #1 receive ice/cool compresses to the affected area four to six times a day for 10-15 minutes. This treatment was not completed. Individual #1 was prescribed daily Cetirizine on 4/27/23. Individual #1 did not receive their first dose of the medication until 5/4/23, which was a 7-day delay. Individual #1 has a blood pressure protocol. Their blood pressure is to be checked daily. From January 2023 to the present, there were 35 days in which Individual #1's blood pressure was not checked. | 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.
| Program Managers and their supervisory staff are required to review bowel movements daily. T-Logs, along with Intake and Elimination will be utilized to track and to inform all staff of pending need for intervention when 72 hours has passed without a bowel movement. Since home visits are an integral part of our individual's lives, emphasis will be placed on marking the date and time the person left our care.
Ice/Compresses are to be documented on a paper MAR. Although neither is a medication, documentation is necessary to ensure follow up to all doctor's requests. The Program Managers will be trained on 10/5/23. Program Managers will train all their staff at their next monthly staff meeting. This paper MAR will be scanned and submitted into Therap with the initial Medical Review.
Cetirizine was prescribed by the physician without an appointment or acknowledgment. When the medication appeared on the pharmacy waiting list in the eMAR, the Program Manager immediately contacted the pharmacy where this medication originated. It took the pharmacy, physician, and the program manager 7 days to resolve. The Program Managers will be retrained by 10/5/23 on documenting all contact with the time and date until resolution. This was missed by the Program Manager and an investigation was completed. As a result, the Program Manager understands the necessity of documentation to ensure the treatment is started as soon as possible. |
10/05/2023
| Implemented |
| 6400.181(d) | The program specialist did not sign or date the most current assessment completed for Individual #1 on 3/14/23. | The program specialist shall sign and date the assessment. | The program specialist will complete and sign all assessments. |
10/05/2023
| Implemented |
| 6400.212(b) | The signatures on the ISP trainings completed on 1/6/23 and 3/28/23 are illegible. The signature on the training sheet completed on 3/28/23 for the use of the blood pressure monitor is illegible. | Entries in an individual's record shall be legible, dated and signed by the person making the entry.
| Program Managers, Program Specialists, and all administrators are required to ensure signatures are legible. Each presentation will have a sign in sheet with both the printed name of the participant and a signature. |
10/05/2023
| Implemented |
| 6400.52(c)(6) | Staff #4-Staff #6 did not receive training on the use of the blood pressure monitor for Individual #1. Staff #4 and Staff #5 did not receive training on Individual #1's Constipation Care Protocol. Individual #1's ISP was updated on 7/27/23. The following staff were not trained on the updated ISP: Staff #4 and Staff #6 through Staff #12. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | All training has been completed for the current employees with the exception of staff, #5,#7 and #12 as those DSP's no longer for the agency(see attachment #3). To ensure that all staff are trained in the implementation of all plans, the Quality Assurance Associate will complete training on the blood pressure monitor and constipation care protocol with all current staff. |
09/14/2023
| Implemented |
| 6400.165(c) | Individual #1 was prescribed Cetirizine 10mg to be taken once a day for 30 days on 1/11/23. Individual #1 received their first dose of this medication on 1/13/23. Individual #1 received the medication a total of 31 days; the last dose being administered on 2/15/23. | A prescription medication shall be administered as prescribed. | In reviewing the eMAR, it was noted that the Program Manager accepted the medication but did not clarify in the "scheduling" section that the medication was to be given for only 30 days. The individual only received 30 doses of the medication. Without the stop date in the system, staff began to document the dose not given. However, on the last day prior to the medication entry being corrected, the medication administrator accidentally put successful instead of other with the explanation. The program manager and medication administrators who continued to document will be retrained by a Medication Administration Trainer on checking medications once accepted, and contacting the on-call system when a medication is showing on the eMAR but not available. This training will be completed by 10/05/23. |
10/05/2023
| Implemented |
| 6400.166(a)(4) | Individual #1 took the following PRN medications in January 2023 and the PRN medications were not correctly documented on the Medication Administration Records: Aller-Chor 4mg, Apap, Sore Throat Chloraseptic Spray, Loperamide, Tussin DM Syrup, and Senna S 8.6mg. In June 2023, Individual #1 was administered Acetaminophen on three different days. The PRN medication was not correctly documented on the MAR. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | CaraSolva was chosen as the eMAR for Valley Community Services. The system requires that all prn medications are listed within the system and is organized by symptom. From each person's landing page, an OTC/PRN button is selected and all of the symptoms for medications that can be given on an as needed basis is listed. This ensures that medications such as Acetaminophen, Ibuprofen, and APAP are only available to the correct symptom, Valley Community Services acknowledges that the inner working of the eMAR was not explained or demonstrated to the surveyors during this unannounced visit. VCS is in the midst of Western Region licensing and have not received any feedback. However, this is completed in person and the unannounced was not. |
09/14/2023
| Implemented |
| 6400.166(b) | On 3/5/23, Individual #1 was administered their morning medications at 7:30am. According to the MAR, the medication administrations were not logged immediately. On 4/12/23, Individual #1 was given their morning medications prior to 9am. According to the MAR, the medication administrations were not logged immediately. On 4/14/23, Individual #1 received their 8pm medications at 8pm. According to the MAR, the medication administrations were not logged immediately. On 6/1/23 and 6/3/23, Individual #1's morning medications were administered on time, but according to the medication administration record, they were not logged immediately. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | As Valley Community Services rolled out the eMAR this past year, there were issues with ensuring the documentation was being completed within the allotted timeframe. As we move forward, the number of late entries has diminished. However, there are still medication administrators struggling. The Quality Assurance department will begin to meet with medication administrators across the agency starting in October 2023 and completed by December 2023. An outline and sign in sheets will be kept with Human Resources and a to-be created poster will be hung in the offices of each home to remind the medication administrators. Poster will be distributed to the Program Managers by 12/31/23. |
12/31/2023
| Implemented |
| 6400.181(b) | Individual #1's previous supervision levels were that they were able to receive 1 hour of alone time in the community to go to the gas station. Individual #1 requested their alone time in the community increase. Individual #1 was approved to have up to six hours of alone time in the community with his girlfriend. Individual #1's assessment was not updated to reflect this change. In addition, Individual #1's current assessment indicates that Individual #1 can have up to 1 hour of alone time in the community to go to the gas station, but if Individual #1 is home they require line of sight supervision. This is contradictory as to why Individual #1 would require line of sight supervision at home but be free to have alone time in the community. | If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have an assessment completed as required under this section. | An Addendum to the Annual Assessment was completed on 8/25/2023 by the Operations Director and sent to the SC on 8/25/2023(see attachment #1). The supervision level was corrected as well as the alone time requirements in the ISP by the SC on 8/28/23(see attachment #2). |
08/28/2023
| Implemented |