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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | During the inspection on 11/29/23 there was a golf ball size amount of lint in the dryer. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The dryer lint trap was not clean at the time of the inspection. The program Manager will be responsible for training the DSPs or individuals served by 1.22.24, to clean the lint trap after every completed load of laundry. |
01/31/2024
| Implemented |
| 6400.144 | Individual #1 has a bowel protocol that they are to use a dose of Senna at bedtime if they do not have bowel movement in three days. Per individual #1's BM tracking, they did not have any BM's from 5/5/23-5/16/23. The individual was not given their PRN dose of Senna until 5/10/23. It was documented in Therap that the individual's PCP was contacted on 5/15/23 because the individual did not have a BM in 5 days. According to the BM tracking, it was 10 days since the individual's last BM and not 5 days as reported to the PCP. Also, per the Therap logs, staff #1 indicated if no BM was had on 5/16/23, that Senna should be administered with bedtime medications. No dose of PRN Senna was documented on this date.
Per the BM tracking individual #1 did not have a BM from 8/31/23-9/2/23. There is no documentation that the PRN Senna was given at bedtime on the third day. | 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 have passed without a bowel movement. |
01/31/2024
| Implemented |
| 6400.181(d) | The annual assessment for individual #1, dated 9/19/23, is signed by the program specialist however it is dated 9/19/22. | The program specialist shall sign and date the assessment. | The annual assessment was completed on 9/19/2023 by the Program Specialist however the date on the annual assessment was dated 9/19/2022. This was a documentation error by the Program Specialist as all other dates on the assessment paperwork were correct. Going forward, the Program Specialist will send the annual assessment to the QA Associate for review at the time of completion. The QA Associate will contact the Program Specialist with any needed corrections. This was corrected at the time of the inspection and the correction was sent to the inspector on 12.1.2023. |
01/31/2024
| Implemented |
| 6400.207(5)(I) | At the time of the inspection on 11/29/23, Individual #2 had bedrails on their bed that are not approved by ODP. | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Post-surgical or wound care. | The regulatory process to use bedrails was not followed and bedrails were in place at the time of the inspection. The bedrails were removed at the time of the inspection and are no longer in use. |
01/31/2024
| Implemented |
| 6400.213(1)(i) | (.213(1)(ii)) For individual #1, the identifying marks section on the pertinent info sheet is left blank. Per individual #1's physical dated 10/12/23 they have several identifying marks such as right arm butterfly tattoo, left arm dragonfly tattoo, right arm skull tattoo. | (.213(1)(i)Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.
(.213(1)(ii) The race, height, weight, color of hair, color of eyes and identifying marks. | The Pertinent Information sheet that was in use at the time of the inspection did not include identifying marks. The Pertinent Information sheet will be updated by the Program Manager on or before 1.22.24, to include the identifying marks. (tattoos) |
01/31/2024
| Implemented |
| 6400.213(1)(i) | (.213(1)(iv)) For individual #1, the religious affiliation section on the pertinent info sheet is left blank. | (.213(1)(i)) - Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.
(.213(1)(iv)) - The religious affiliation. | The Pertinent Information sheet that was in use at the time of the inspection did not include religious affiliation. The Pertinent Information sheet will be updated by the Program Manager on or before 1.22.24, to include the religious affiliation, none or unknown. |
01/31/2024
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.61(a) | Individual #1 is wheelchair bound, has visual impairments, and requires total support from staff when using the restroom, shower, and with transferring. Individual #1 has been injured twice, on 1/7/23 and 1/9/23, while in the restroom of the home attempting to stand and has fallen into the shower causing injuries to their face. The adaptive chair purchased to assist with transfers, use in the shower, and use over the existing toilet, does not fit the needs of Individual #1. On 1/20/23 during the onsite inspection, Staff person #1 reported to the Department that the adaptive chair purchased for the individual is too small for Individual #1 and is not used. | A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. | Prior to admission, Individual #1's adaptive chair was purchased. The chair was rated up to 400 pounds. However, it was uncomfortable for Individual #1, and was replaced with one that is wider and more comfortable. Attachment 1 Review of all wheelchair-bound individuals across the agency's adaptive equipment was accessed and shown to be appropriate. Although this admission was an emergency admission, assessments will be completed on all individuals prior to date of admission. Program Specialists were trained on regulation 6400.61(a) on February 23, 2023, by Central Region Operations Director. Outline and attendance record has been submitted for review. Review of the ISP and meeting the individual, whenever possible, will ensure all adaptive equipment is appropriate for their needs. |
02/23/2023
| Implemented |
| 6400.141(b) | The current physical examination record in Individual #1's record, was not dated by the examining physician. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Individual #1's physical was presented after emergency admission. There was not a review at that time and the date was missed. The Quality Assurance Department is responsible for ensuring all documentation is completed and in compliance for each admission. The Chief Operating Officer retrained the Quality Assurance Department on February 22, 2023. Emergency admissions will be tracked for 31 days after the admission date to ensure compliance. Outline and attendance record has been submitted for review. |
02/22/2023
| Implemented |
| 6400.51(b)(5) | REPEAT from 4/27/22 unannounced inspection:
Staff working directly with Individual #1 did not receive orientation to individual-specific plans, protocols, health and safety needs, and risk mitigation factors to prevent injury to the individual and staff during provisions of services while in the agency home. Staff have been injured trying to assist with transfers after Individual #1 has fallen. The description of the individual's fall/transfer plan submitted on 1/20/23 to the Department, did not contain a date that the plan was written, the author of the plan, or documentation that any staff received training on this plan. | The orientation must encompass the following areas: Job-related knowledge and skills. | Individual #1 has an in-home assessment with Physical Therapy. Attachment 2 Recommendations will be added to the Transfer Protocol which will be both signed and dated by the assigned Program Specialist. Staff will be trained immediately. Upon completion, protocol, and attendance record will be submitted to ODP. All staff working at Thomas CLA have been trained on Individual #1's ISP, protocols, health and safety needs, and risk mitigation factors. Program Managers were trained on regulation 6400.51(b)(5) by the Human Resource Director on February 9, 15, and 16, 2023. The pre-service orientation was revised to include the initials of all individuals living within the home. A completed pre-service orientation, training outline and attendance record has been submitted for review. |
02/16/2023
| Implemented |
| 6400.185(5) | Individual #1 is wheelchair bound and requires staff assistance with transfers in and out of the wheelchair, monitoring of falls, preventing falls, and creating a risk-free environment for staff and Individual #1. The individual's individual support plan (ISP) does not include risks to the individual's health, safety or well-being, behaviors and health needs likely to result in immediate physical harm to the individual or others and risk mitigation strategies to be used to maintain the individual's and staff's safety.
The agency has a social, emotional, and environmental needs plan for Individual #1 . However, this plan is not included in the individual's ISP. | 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. | Individual #1 was admitted to the agency on 11/10/2022 as an emergency admission. Upon admission, it was apparent that the home needed modifications to ensure Individual #1s health and safety. Individual #1 returned on 12/29/2022. Individual #1's assessment was completed prior to the 60-day requirement, and the SEEN Plan was submitted to the Supports Coordinator. The Program Specialist did not receive an undeliverable message; however, the Supports Coordinator assigned no longer worked for the county. The SEEN Plan was sent to the SCO as the agency awaited the emails with assignment of Individual#1's new Supports Coordinator. The 90-day meeting was scheduled for after Central Region Licensing. All Program Specialists were trained on regulation 6400.185(d) on February 23, 2023, by the Central Region Operations Director. Outline and attendance record has been submitted for review. Emails will be filed with documentation until the information can be verified in the ISP, at which time the email can be removed. |
02/23/2023
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | On 10/25/19, per agency report, staff #12 was supposed to be the individual's 1:1 staff that day however, Staff #12 was also conducting staff training in the home for other staff, not providing 1:1 care. It was reported that Individual #1 had stayed home from day program at Valley ADT 10/25/19 due to being ill.
The agency had one to one (staff to individual) supervision tracking logs that were to be signed, dated, and time stamped by every staff who worked with Individual #1 for every 24-hour period of the year. In October 2019, there was no evidence to show who was providing his one on one supervision at least 15 times. The time frames not accounted for varied from 1 hour up to 7 hours. Staff#2 reported to Licensing during the inspection, that the agency does not require any management staff to review these logs to ensure his safety was maintained during every 24-hour period.
Failure to follow nursing recommendations, failure to administer medications as prescribed, failure to seek medical attention over a 10-day period such that an individual presenting with symptoms of illness could receive medical care constitutes neglect. Furthermore, failure to provide needed supervision and implement an Individual's support plans such that a person diagnosed with PICA was able to access and consume 10 drinking straws and coins constitutes mistreatment and neglect. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | Entire response is in first listed cite. |
06/12/2020
| Implemented |
| 6400.16 | On 10/26/2019, Individual #1 was transported by ambulance to Bedford Hospital after he/she was found unresponsive in his/her home. According to ambulance records, on the way to the hospital, Individual #1 suffered a cardiac arrest and required CPR, two epi-pen injections and a ventilator to sustain life. Hospital records state Individual #1 aspirated (occurs when a substance accidentally passes into the windpipe and lungs instead of the esophagus) and had an intestinal obstruction. Individual #1 was flown to Pittsburgh Hospital for further treatment.
Prior to the hospitalization, Individual #1 displayed symptoms of illness on 10/16/19 and 10/17/19. Staff #9 made an entry into the staff communication book that read, "[Individual #1] has a runny nose and we'll keep an eye on it," On 10/18/19, the same staff wrote, "[Individual #1] slept ok last night. You could tell he/she was congested by the way he/she was breathing." On call-notes indicate Staff#4 contacted an on-call staff member at 7:24pm because Individual #1 was "acting odd, afebrile (not feverish), took nap at home, refused dinner, dry heaving." Instructions given by the agency nurse, Staff #4, were to monitor, call the individuals primary care physician. There was no evidence that the nurse's recommendations were completed. There was no follow-up from nursing to ensure the directions where followed.
On 10/24/19 at 7:41pm, Staff #4, again, contacted on-call staff and reported Individual #1 refused his/her 8pm meds. The 10/24/19 incident report indicated 8pm meds were not taken because he/she wasn't feeling well. The report read, "couldn't get no foods or liquids in him/her." During the 11/6/19 inspection, Staff #4 reported to the Department that it was a-typical for him/her to refuse medications, food, or liquids. The on-call note indicated Staff #4 was instructed to "do paperwork/call MD." There was no evidence that the physician was contacted. Staff #4 reported to the Department on 11/6/19 that the physician was never contacted but had left a note for the next staff, on shift the following day, to do it.
Agency staff reported Individual #1 did not attend day program on 10/25/19 because he/she wasn't feeling well.
On-call nursing notes completed by Staff #11 indicate she/he was instructed by Staff #1 on 10/26/19 at 9:31am to take Individual #1 to a walk-in clinic due to persistent flu like symptoms. Staff #11 recorded, "yesterday emesis (vomiting) 2-3 x temp -- Tylenol was given- afebrile since, afebrile-tolerating fluids, more congested today." Individual #1 was not taken to a medical clinic as directed. Individual #1 was taken by ambulance to the hospital at approximately 11:45am, more than 2 hours after originally directed, at which point the individual had turned blue, stopped breathing, and 911 services were rendered at the home and CPR had to be performed by staff.
On 11/6/19, Staff #1 reported she/he called 911 around 10:30am-10:45am. Staff #1 reported she/he called on-call twice before calling 911.
According to Individual #1's October 2019 medication record, was prescribed Bismatrol suspension, 2 tablespoons by mouth every 1 hour as need for nausea/vomiting/indigestion. Witness statements, staff interviews, nursing on-call notes, and incident reports note Individual #1 was not feeling well between 10/24/19 and 10/26/19. Symptoms reported include refusing medications, vomiting, dry-heaving, and nausea. Bismatrol Suspension was not administered to Individual #1 during that time period. Instead, Staff #12 purchased Pedialyte and staff members began administering it on 10/25/19 without consulting his physician. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals | Entire response on first listed cite. |
06/12/2020
| Implemented |
| 6400.16 | Continued..
On 7/31/19 Individual #1's primary care physician recommended the individual take Senna Docusate Sodium, two tablets by mouth at bedtime, if no bowel movement in 3 days as needed for constipation. Individual #1 had a bowel movement on 9/29/19 and not again until 10/3/19, a bowel movement on 10/4/19 and not again until 10/9/19, 10/14/19 and not again until 10/22/19 and then not again until 10/26/19. Senna Docusate Sodium was not administered to Individual #1 as prescribed for any of the occurrences. There was no evidence that Individual #1's physician was notified as requested on 7/31/19.
Staff #2 reported that because Individual #1 lives in a Valley Community Service home and attends their day program, staff at both locations have access to his electronic bowel charts and as such should be able to determine when the medication needs administered. Residential staff members relayed they did not know how to view the bowel charts the day program completed.
Once transferred to Pittsburgh hospital, Individual #1 had an extensive surgery to alleviate the intestinal obstruction. 10 drinking straws and coins were identified in and removed from Individual #1's intestines. Individual #1 is diagnosed with Pica, which is defined as a is a psychological disorder characterized by an appetite for substances that are largely non-nutritive. According to the Individual's 2/7/18 Lifetime Medical History, there is a history of ingesting inedible objects that have required seven surgeries throughout his/her life to remove objects from the digestive tract. Because of the individual #1's Pica diagnosis and history of ingesting objects, Individual #1 required one to one supervision at all times while residing at his/her residence and attending all outside community activities with the residential facility. According to Individual #1's one on one supervision plan, staff are to remain within arms-length distance, at all times, every minute of the day. Individual #1's 7/22/19 Behavior Support plan reads, "if [Individual #1] ingests an inedible object, staff should immediately notify nursing staff. Witness statements provided to the Department from the certified investigator- Staff #3, indicated that Individual #1 ingested inedible substances within the year and nursing staff were never notified. Staff #4's witness statement reads, "On 10/19/19 another staff person, Staff#5, reported to her that while she was the 1:1 with Individual #1 had swallowed a piece of a diaper. Staff #4 asked if it was documented or called and told anyone, the answer was no." There is no evidence to show Individual #1 received medical attention following this event. Continued... | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | Staff communications books have been eliminated and replaced by Therap T-Logs. T-Logs are reviewed by all staff working with the individual, including the agencys day program if the individual attends the ADTC. T-Logs are also reviewed by the Program Manager, Program Specialist, Operations Director, and other Administration, including but not limited to the Quality Management Director, the Incident Management Coordinator, Quality Assurance Director, Director of Nursing, and On-Call.
As of 2/1/2020, all instructions given by the On-Call nurse is placed in Theraps T-Log. T-Logs are also reviewed by the Program Manager, Program Specialist, Operations Director, and other Administration, including but not limited to the Quality Management Director, the Incident Management Coordinator, Quality Assurance Director, Director of Nursing, and On-Call. All house staff, including Program Managers will be retrained on the T-Log process, including follow up to specific instructions given to staff regarding contacting physician, making follow up appointments, taking individuals to Urgent Care and the Emergency Room. The Program Managers will be trained by the Operations Director prior to 05/22/2020. All staff will be trained by the Quality Assurance Department starting 05/25/2020 and will be completed by 06/15/2020 for the entire agency. This training will be conducted first in the Bedford Area, then Central Region, and remainder of the agency, in that order. Operations Directors will be responsible for reviewing the T-Logs and following up, as necessary. The Operations Directors will be trained by the Director of Quality Assurance prior to 6/1/2020.
Valley will ensure all medication administrators in the Central Region are retrained on PRNs, including instructions on when to use each medication, its purpose, and the timeliness of administration. Retraining on only dispensing PRNs with On-Call Nursing will be included. Quality Assurance will begin retraining on 5/25/2020 and will be completed by 6/1/2020. In person training by the Quality Assurance Department will be completed by September 2020 to ensure attentiveness, understanding of the material, and have opportunity for Q and A.
Valley has begun utilizing Therap software as of 01/01/2020. Intake/Elimination information is available to all personnel who work with the participant at the residential home and day program, if they attend our day program at the ADTC. Intake/Elimination was trained by Therap to all staff during the software rollout in December 2020. All staff will be retrained by the Director of Quality Assurance & Training and the Program Specialists on the care plans for each participant, along with appropriate documentation in Therap. Training will include retrieval of bowel movements information and the administration of a PRN medication as specified by the physician, along with a T-Log for individuals who have not had a bowel movement within the past 48 hours. This training will be conducted starting 5/25/2020 and completed prior to 6/12/2020. To ensure compliance, the program manager, assistant manager, and the Operations Director will review T-Logs daily to ensure proper documentation and administration of any PRN medication. Follow Up information will be added by the management if necessary. The Quality Assurance department will review documentation during their bi-annual inspections.
Although Individual #1 is not with Valley at this time, it is expected that Individual #1 will return once an appropriate home is located and licensed. This home will be a 1-person CLA, and Individual #1 will require 2:1 staffing. Once the home is licensed, all staff will be trained on Individual #1s updated behavior plan. Behavior Support will reassess Individual #1. If changes are made to the current behavior plan, all staff will be retrained. At each monthly staff meeting, the guidelines will be reviewed to ensure retention and accuracy of the implementation. All staff working with 1:1 across the agency will be retrained on the 1:1 guidelines by 5/29/2020 by the home¿s assigned Program Specialist. Program Specialists of these homes will be required to review the 1:1 guidelines quarterly in the homes staff meetings. Program Specialist training on this requirement will be completed by 5/21/2020 by the Operations Directors.
Valley Community Services does not permit any staff who is assigned 1:1 for an individual to conduct any other assignments during this time. The Program Manager was removed from her position. Once Individual #1 returns to the 1-person home with 2:1 staffing, a Program Manager will be selected by the Operations Director. The Operations Director, during training prior to opening of the home will trained on the requirements of 1:1 staffing. All Program Managers will be retrained on the 1:1 guidelines by the Operations Director by 06/01/2020 regarding no other activities should be conducted while staff, including Program Manager, is permitted when assigned to an 1:1 individual. To ensure no further infractions, all program managers will submit a weekly schedule to the Operations Director. This begun on 12/01/2019.
Requirement of mandated reporting will be retrained will all staff across the agency by 5/29/2020 by the Quality Management Director. The training will review the On-Call system, along with Passive Abuse. The agency will ensure all Passive Abuse allegations are addressed, including an investigation if required. Program Specialists will be required to review Mandated Reporting on a quarterly basis within the home¿s staff meetings. Trainings will be submitted to the Human Resources Department as completed. The Quality Assurance Department will keep trainings on the Mandated Reporter for one year, starting 5/21/2020 and ending 5/20/2021.
Therap System documents the staff person who is a persons 1:1 in the Time Tracking: One on One Support staff. Program Specialists are required to review the reports to ensure all 1:1 times required are completed. If documentation is missing, the Program Specialist contacts the Program Manager for verification and documentation adjustment. If documentation is missing, the Program Manager is responsible to retrain staff on 1:1 documentation and send the training to the Human Resource department to be filed in the employee¿s record. Continued non-compliance will be subject to discipline, including termination per agency policy. The Quality Assurance department will review documentation in the individuals chart and on Therap during their bi-annual inspections.
The Director of Quality Assurance & Training will meet with all Operations Directors on a bi-monthly basis to discuss program manager and program specialist issues and how to monitor and observe any issues found. Documentation of observations and monitoring of issues will be completed by the Operations Director. This documentation will be included with their minutes from their Program Manager/Program Specialist meetings. The bi-monthly meeting established by the Quality Assurance department will begin on 6/1/2020 and continue until 9/30/2020. The decision will be made on how often the meetings should be held starting 7/1/2020; may include a monthly or quarterly meeting depending on the amount of issues still being addressed. The Quality Assurance Department will keep minutes of these meetings. |
06/12/2020
| Implemented |
| 6400.165(c) | meds admin as prescribed- Individual #1 has 7/31/19 order to administer ibuprofen 200mg, take two tabs every 6 hours as needed for elevated temp above 101. Individual #1 has an order for acetaminophen 500mg, take two tabs for headache/discomfort. Staff #1 reported to department that his/her temp was around 99 degrees and she/he administered Tylenol. Individual #1 didn't have an order for Tylenol. Tylenol is a composed of different medication then Ibuprofen. Doctor's orders and medications not admin per instruction.
· Individual #1 has medical for prn bowel movements, to use bowel charts to show that more than 3 days passed numerous times a month, and prn med never administered. No document of bm at least 8 days prior to incident. (use bowel charts to determine this). Individual #1 has an order to administer Senna-doc 8.6mg/5ml tablet, take two tablets by mouth at bedtime if no bowel movement in 3 days, as needed for constipation. Staff #9 recorded on individual bowel activity chart that Individual #1 has a soft bowel movement at 5:35am on 8/3/19. Staff #8 documented on Individual #1 8/3/19 medication administration record that she administered Senna-doc at 8PM on 8/3/19 even though Staff #9 documented Individual #1 had a bowel movement earlier that same day. | A prescription medication shall be administered as prescribed. | Entire response on first cite. |
06/12/2020
| Implemented |
| 6400.165(c) | Staff #14 documented on Individual #1's bm logs that there was a bowel movement on 8/4/19 at 7:08PM and not again until 8/9/19 until 8:20PM. Individual #1's Senna-doc was never administered until 8pm on 8/8/19, over 3 days after the last bowel movement. Individual #1's Senna-doc was administered again on 8/9/19 at 8PM without an order to do so.
· Individual #1 has an order to administer loperamide 1mg/5ml liquid, take 6 teaspoonfuls by mouth after 1st loose stool then 3 teaspoonfuls after each loose stool, no more than 12 teaspoonfuls in 24hrs for diarrhea. Staff #14 documented that Individual #1 has "loose" stool at 5:56am on 8/15/19. Loperamide was never administered after the loose stool until 7:15am by Staff 16. Staff #14 documented Individual #1 had additional "loose" stools on 8/15/19 at 7:39am, 7:40am, 7:41am. Loperamide was never administered after those additional loose stools until 5pm and again at 8PM by staff #1. There weren't orders to administer the medication 3 hours apart if there isn't documentation of loose stools during that 3-hour time frame. Staff#18 documented Individual #1 had additional "liquid" stools 3 separate times at 8:21pm. The medication was never administered after his liquid stools at 8:21pm. There is no evidence to suggest that the physician was ever notified of the bowel issues.
· Staff #19 documented that Individual #1 had a loose stool at 6:59am on 8/16/19 and loperamide wasn't administered until 3pm by staff #15. The medication was not administered as ordered.
· Staff#14 documented Individual #1 having a loose stool at 3:30pm on 8/18/19. The loperamide was never administered that day.
· Loose stools were also documented for Individual #1 on 8/26/19, 8/27/19, and 8/30/19. Loperamide was never administered on any of those days.
· Staff documented that Individual #1 had a bowel movement on 4/30/19 and not again until 5/4/19. Senna-doc was never administered after the 3rd day of no bowel movement during that time frame. | A prescription medication shall be administered as prescribed. | Entire Response on first cite. |
06/12/2020
| Implemented |
| 6400.165(c) | Staff them document that he/she had a bm at 7:04pm on 5/4/19 and not again until 5/8/19 at 6:22pm. Individual #1 then didn't have another bm until 5/12/19, and another bm until 5/16/19. Senna-doc never administered during the entire months' time frame associated with these stools. Over 3 days had gone between each documented bowel movement and his/her medication wasn't administered. Staff documented individual #1 had a bm on 5/16/19 and that they found paper in his/her stool. Individual #1 didn't have another bm until 5/23/19, 7 days later. Individual #1's Senna-doc medication was never administered until 5/20/19 and again on 5/22/19. The administration of Senna doc on 5/20/19 was not administered in the time frame of the physician's order, nor was there an order to administer the Senna-doc again on 5/22/19. Individual #1 had a bm on 5/26/19 and not again until 5/31/19, 5 days later. Senna-doc was never administered. | A prescription medication shall be administered as prescribed. | Valley will ensure all medication administrators in the Central Region are retrained on the following:
-PRNs, including instructions on when to use each medication, its purpose, and the timeliness of administration.
-Information relayed to on-call nursing regarding medication usage, along with the parameters on contacting the PCP.
-Documentation of directions from the On-Call staff is conveyed on a T-Log within Therap. Program Managers are required to respond to the T-Log and place the date and time the physician was contacted and the physicials instructions.
-Contacting the On-Call system immediately, if an error is found.
Quality Assurance will begin retraining on 5/21/2020 and will be completed by 6/1/2020. In person training by the Quality Assurance Department will be completed by September 2020 to ensure attentiveness, understanding of the material, and have opportunity for Q and A.
Program Managers of each home will be retrained on their responsibility to review MARs and Medical Review Forms on a weekly basis to ensure proper documentation. This training will be completed prior to 5/22/2020 by the Director of Quality Assurance & Training. To ensure no further infractions occur, the Operations Directors will review and document at least one residents PRN section of the MAR for accuracy and the corresponding Medical Review forms monthly, when conducting monitoring of homes. The Operations Director will initial and date the PRN MAR and Medical Review forms as completed, starting 06/01/2020. The Quality Assurance department will review during the bi-annual inspections to ensure compliance.
Valley has begun utilizing Therap software as of 01/01/2020. Intake/Elimination information is available to all personnel who work with the participant at the residential home and day program, if they attend our day program at the ADTC. Intake/Elimination was trained by Therap to all staff during the software rollout in December 2019. Staff will be retrained by the Program Specialists on the care plans for each participant, along with appropriate documentation in Therap. Training will include retrieval of bowel movements information and the administration of a PRN medication as specified by the physician. This training will be conducted starting 5/25/2020 and completed prior to 6/12/2020. To ensure compliance, the program manager, assistant manager, and the Operations Director will review T-Logs daily to ensure proper documentation and administration of any PRN medication. Follow Up information will be added by the management if necessary. Immediate retraining will be conducted and submitted to the Human Resource department to be filed in the employees chart. Continued non-compliance will be subject to discipline, including termination per agency policy. The Quality Assurance department will review documentation in the individuals chart and on Therap during their bi-annual inspections.
Each home is required to have a staff meeting monthly. Care Plans/Fatal 4, Use of PRNs and Documentation will be required training by the Program Specialist and Program Manager quarterly for reinforcement and retention. Training on this requirement will be conducted by the Director of Quality Assurance & Training prior to 6/1/2020. An outline and sign in sheet from the quarterly meeting will be submitted to the Operations Director at the following Management meeting to ensure compliance. |
06/12/2020
| Implemented |
| 6400.167(b) | med errors- Tylenol was administered on 10/25/19, per reports, for a fever that did not qualify to administer the medication. It was administered anyway. Med errors where not entered for the meds listed in 165c | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | Valley will ensure all medication administrators in the Central Region are retrained on PRNs, including instructions on when to use each medication and for what purpose. Training will also include information relayed to on-call nursing regarding medication usage, along with the parameters on contacting the PCP. The training will cover the agencys policy on contacting the On-Call system immediately, if an error is found. Quality Assurance will begin retraining on 5/21/2020 and will be completed by 6/1/2020. In person training by the Quality Assurance Department will be completed in September 2020 to ensure attentiveness, understanding of the material, and have opportunity for Q and A.
Program Managers of each home will be retrained on their responsibility to review MARs on a weekly basis to ensure proper documentation. This training will be completed prior to 5/22/2020 by the Director of Quality Assurance & Training. To ensure no further infractions occur, the Operations Directors will review and document at least one residents PRN section of the MAR for accuracy monthly, when conducting monitoring of homes. The Operations Director will initial and date the PRN MAR as completed, starting 06/01/2020. The Quality Assurance department will review during the bi-annual inspections to ensure compliance.
All medication errors will be removed from the Quality Management office files and placed in the persons individual record. This process will begin on 5/18/2020 and completed by 05/30/2020. The Quality Management department will be retrained on this regulation prior to 05/18/2020 by the Director of Quality Assurance & Training. |
06/01/2020
| Implemented |
| 6400.169(a) | Med administration- Staff#13 last med training was 10/13/18, and should have been completed by 10/13/19. but as of 11/7/19 the training has not been signed off by a certified med trainer. Staff #13 has been administering medication at the CLS. | 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). | Valley Community Services Quality Assurance Associates have been retrained on the updated requirements for annual practicum by the Director of QA & Training on 11/11/2019. The outline and sign in sheet are attached. To ensure no further infractions occur, the Director of QA & Training will review medication administration files on a monthly basis starting 12/1/2019 and ending 2/28/2020. Files that are reviewed are initialed and dated by the Director of Quality Assurance & Training. |
02/28/2020
| Implemented |
| 6400.186 | Plan implemented as written: When reviewing the witness statements that the Staff #3 gave to the Department the witness statement from staff #4- mentions that on 10/19/19 another staff #5 reported to her/him that while she/he was the 1:1 with Individual #1 he/she had swallowed a piece of diaper. Staff#4 asked if she/he documented it or called and told anyone, staff #5 said no. Valley Community Services has in place a behavior plan in place dated 7/22/19 --Individual #1 behavior plan that "if he/she ingest an inedible object, staff should immediately notify nursing staff. There is no documentation that Staff #5 reported this incident to anyone. | The home shall implement the individual plan, including revisions. | Although Individual #1 is not with Valley at this time, it is expected that Individual #1 will return once an appropriate home is located and licensed. This home will be a 1-person CLA, and Individual #1 will require 2:1 staffing. Once the home is licensed, all staff will be trained on Individual #1s updated behavior plan. Behavior Support will reassess Individual #1. If changes are made to the current behavior plan, all staff will be retrained. At each monthly staff meeting, the guidelines will be reviewed to ensure retention and accuracy of the implementation. All staff working with 1:1 across the agency will be retrained on the 1:1 guidelines by 5/29/2020 by the homes assigned Program Specialist. Program Specialists of these homes will be required to review the 1:1 guidelines quarterly in the homes staff meetings. Program Specialist training on this requirement will be completed by 5/21/2020 by the Director of Quality Assurance & Training.
Requirement of mandated reporting will be retrained will all staff across the agency by 5/29/2020 by the Quality Management Director. The training will review the On-Call system, along with Passive Abuse. The agency will ensure all Passive Abuse allegations are addressed, including an investigation if required. Program Specialists will be required to review Mandated Reporting on a quarterly basis within the homes staff meetings. Trainings will be submitted to the Human Resources Department as completed. The Quality Assurance Department will keep trainings on the Mandated Reporter for one year, starting 5/21/2020 and ending 5/20/2021. |
05/29/2020
| Implemented |
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