|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(2) | Prior to admission, the agency is required to obtain specific documents and train staff in individual specific health and safety needs to ensure the care provided to the individual is appropriate. As evidenced by this report, there were multiple documents that weren't obtained by the agency prior to the individual's admission nor were there individual specific trainings provided to staff to equip them with the knowledge and job skills they will need to provide proper care. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Admission and discharge of individuals. | Protocols for new admissions has been updated (#12) to include review of the ISP sections that would be significant for the admission physical, the information that would require trainings prior to admission, and any follow up information to be obtained by the Supports Coordinator. Protocol has been submitted for review. The admission packet contains a Valley Community Services blank physical form, which will be required for all admissions, except emergency admissions. A team meeting, to include but not limited to the Program Manager, Program Specialist, Operations Director, Director of Quality Assurance & Training will be documented. The meeting, scheduled by the Director of Quality Assurance & Training, will address all trainings required prior to the individuals admission to the home. The meeting notes and completed physical will be submitted by the Director of Quality Assurance & Training to the chief executive officer for approval prior to an approved move in date. The Program Specialist will be responsible for all trainings prior to admission. Completed trainings will be reviewed by the Operations Director for compliance. To ensure no further infractions occur, the Director of Quality Assurance & Training will review all documentation prior to setting an admission date. |
03/09/2021
| Implemented |
| 6400.141(c)(4) | Individual #1's 9/17/2020 physical examination did not include a vision or hearing screening or recommendations for such as these sections were crossed off the physical examination record and not completed by the physician, or documentation that they were reviewed with the physician. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Program Managers and Program Specialists were trained on regulation 6400.141(c)(4) by the Director of Quality Assurance & Training on 03/09/21. Outline and attendance record are submitted for review. (#13) Program Managers are responsible for scheduling Vision and Hearing examines when the Primary Care Physician is unable/unwilling to perform testing during the annual physical. Program Specialists will review all physicals upon completion and ensure any ancillary appointments have been scheduled by the Program Manager. To ensure no further infractions occur, the Quality Assurance & Training Associate will verify annual requirements are completed in a timely manner during their biannual inspections. |
03/09/2021
| Implemented |
| 6400.141(c)(12) | Individual #1 started receiving services with the agency, Valley Community Services, on 1/2/2020. Upon admission, the individual must have a physical examination completed with all requirements defined in 6400.141. The individual's records maintained, state that he had a physical examination completed on 6/5/19, prior to admission. However, the physical examination record did not include physical limitations. The physical examination record contained illegible information in the section titled, "physical limitations."
The agency did not have the individual's physical limitations documented on a physical examination record until 9/17/2020. However, Individual #1's 9/17/2020 physical examination record listed "none" in the section to include his physical limitation or restrictions for activities. "None" was reportedly added onto the individual's physical examination record at some point, by agency staff. According to the agency, the individual wears adult briefs daily, uses a waterproof wheel chair every time he takes a shower, has Cerebral Palsy and requires a wheelchair for movement around his home and community and is diagnosed with Cortical Visual Impairment (CVI) that severely impacts his vision. This information is not included on his 9/17/2020 physical examination record nor are there records maintained that the agency reviewed the individual's physical limitations with the physician during or after his 9/17/2020 examination. | The physical examination shall include: Physical limitations of the individual. | Protocols for new admissions has been updated (#12) to include review of the ISP sections that would be significant for the admission physical, including but not limited to physical limitations, and any follow up information to be obtained by the Supports Coordinator. Protocol has been submitted for review. The completed physical will be submitted by the Director of Quality Assurance & Training to the chief executive officer for approval prior to an approved move in date.
The Program Managers were trained on 6400.141(c)(12) by the Director of Quality Assurance & Training on 03/09/2021 regarding the importance and totality of all physical limitations of the person served. Outline and attendance record are submitted for review. (#13) This information will be added to the annual physical form and reviewed with the primary care physician for accuracy. Any additional information will be included as needed prior to the physician's signature on the annual physical. Program Managers will submit the completed annual physical to the Program Specialist for review upon completion and follow up with the primary care physician must be completed as soon as they are available. Review of the annual physical by the Program Specialist will start as of 03/09/2021 and end on 06/30/2021. To ensure no further infractions occur, the Quality Assurance & Training Associate will review both the current ISP and annual physical for compliance. |
03/09/2021
| Implemented |
| 6400.141(c)(14) | Individual #1 started receiving services with the agency, Valley Community Services, on 1/2/2020. Upon admission, the individual must have a physical examination completed with all requirements defined in 6400.141. The individual's records maintained, state that he had a physical examination completed on 6/5/19, prior to admission. However, the physical examination record did not include medical information pertinent to diagnosis and treatment in case of an emergency. The field on the examination record was left blank. The agency did not review the individual's medical information pertinent to diagnosis and treatment in case of an emergency with the individual's physician at a physical examination appointment until 9/17/2020. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Protocols for new admissions has been updated (#12) to include review of the ISP sections that would be significant for the admission physical, the information that would require trainings prior to admission, and any follow up information to be obtained by the Supports Coordinator. Protocol has been submitted for review. The admission packet contains a Valley Community Services blank physical form, which will be required for all admissions, except emergency admissions. A team meeting, to include but not limited to the Program Manager, Program Specialist, Operations Director, Director of Quality Assurance & Training will be documented. The meeting, scheduled by the Director of Quality Assurance & Training, will address medical information pertinent to diagnosis and treatment in case of emergency. Information missing or unclear will be required to be clarified by the Supports Coordinator prior to admission approval. To ensure no further infractions occurs, the Director of Quality Assurance & Training will review all admission paperwork prior to setting an admission date. |
03/09/2021
| Implemented |
| 6400.141(c)(15) | Individual #1 started receiving services with the agency, Valley Community Services, on 1/2/2020. Upon admission, the individual must have a physical examination completed with all requirements defined in 6400.141. The individual's records maintained, state that he had a physical examination completed on 6/5/19, prior to admission. However, the physical examination record did not include special instructions for the individual's dietary needs. The agency did not attempt to have the individual's physician clarify the individual's dietary needs until 3/6/2020. On 3/6/2020 the individual's physician stated he needs to follow a diet of bite-sized, 1 inch by 1 inch bites and ground moist due to concerns of the individual choking when eating. | The physical examination shall include:Special instructions for the individual's diet. | Protocols for new admissions has been updated (#12) to include review of the ISP sections that would be significant for the admission physical, the information that would require trainings prior to admission, and any follow up information to be obtained by the Supports Coordinator. Protocol has been submitted for review. The admission packet contains a Valley Community Services blank physical form, which will be required for all admissions, except emergency admissions. A team meeting, to include but not limited to the Program Manager, Program Specialist, Operations Director, Director of Quality Assurance & Training will be documented. The meeting, scheduled by the Director of Quality Assurance & Training, will address dietary needs and special instructions. Information missing or unclear will be required to be clarified by the Supports Coordinator prior to admission approval. To ensure no further infractions occurs, the Director of Quality Assurance & Training will review all admission paperwork prior to setting an admission date. |
03/09/2021
| Implemented |
| 6400.143(a) | Individual #1 often refuses routine medical appointments, treatments, and medications. The continued attempts to train the individual about the need for health care is not documented in the individual's record for every time he refuses routine medical appointments, treatments, and medications. Examples of the individual refusing said items are:
· He refused to attend his 6/9/2020 physical examination appointment and refused to wear a mask (Government mandate due to COVID-19 pandemic) into the physician's office.
· He refused to attend his follow-up Neurologist visit on 7/29/2020 for continued monitoring of his seizures and medications.
· He refused to attend his Neurologist appointment that was rescheduled to 8/5/2020.
· He refused to have staff administer medications to him on:
- 12PM on 3/30/2020 refused his ensure drink and Fiber choice tablets
- 7AM, 8AM and 12PM on 4/18/2020 he refused Loratadine, Omeprazole, SM Clearlax powder, Lamotrigine, Fiber choice chewable tablet, and Ensure drink.
- 8AM on 4/20/2020 he refused Loratadine, Omeprazole, Lamotrigine and Fiber choice chewable tablets.
- 8PM on 5/2/2020 he refused Lamotrigine, Fiber choice, and Melatonin.
- 8PM on 5/16/2020 he spit out Fiber-lax capsules.
- 7AM and 8AM on 7/30/2020 he refused SM Clearlax Powder, Loratadine, Omeprazole, Lamotrigine, Fiber-lax, and Ensure.
- 8AM on 8/17/2020 he refused Loratadine, Omeprazole, Lamotrigine, and Fiber lax.
- 8AM on 12/12/2020 he refused Omeprazole, Loratadine and Lamotrigine. | 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. | Program Specialists and Program Managers were trained on regulation 6400.143(a) by the Quality Assurance & Training Associate on 03/09/21. The outline and attendance record were submitted for review.(#14) Program Specialists were trained on a standard ISP Program within Therap by the Quality Assurance & Training Associate. Program Specialists are required to add/update the new program to ensure documentation of the following: training the individual of the importance of attending medical appointments and training the individual of the importance of taking medication as prescribed. The new program will be added and trained to all staff serving the individuals by the Program Specialist prior to 04/01/2021. The Quality Assurance department will review all individual programs within the Therap system by 04/05/2021 for the inclusion of the program. The Program Specialists are required to submit staff training to the Operations Director by 04/05/2021 for verification. Documentation will be added to the Quarterly Reports by the Program Specialist. To ensure no further infractions occur, the Quality Assurance & Training Associate will review 10% of all Quarterlies and feedback will be given to the Program Specialist. The Director of Quality Assurance & Training and the Operations Directors will be cc: on emails. Monitoring will be completed by the Quality Assurance & Training Associate during the biannual inspections. |
03/12/2021
| Implemented |
| 6400.144 | There were occasions throughout the year, from the individual's admission on 1/2/2020 to current 1/25/2021, where such services were not arranged for or provided. Examples of such occasions include:
· On 1/29/2020 Individual #1's Neurologist recommended the individual take Melatonin 5mg at 9PM as the individual was having trouble waking in the morning. The agency, Valley Community Services, did not administer this medication to the individual until 3/6/2020. There are no records maintained that the agency attempted to immediately obtain the order for the medication from the individual's primary care physician or Neurologist after it was recommended on 1/29/2020.
· Staff noted that Individual #1's 6/9/2020 physical examination appointment was canceled, and they need to call and reschedule the appointment. The agency documented that they did not attempt to call the individual's physician's office to reschedule his annual physical examination until 8/3/2020, two months after his original appointment. Individual #1 did not attend a physical examination appointment until 9/17/2020, more than 3 months after his originally scheduled appointment.
· Staff person #10 administered Bismatrol to the individual on 8/8/2020 for stomach ailments. Staff #10 stated the agency, Valley Community Services, nurse ordered the staff to administer the medication until the individual's stomach feels better. Staff #10 documented that the single dose administered on 8/8/2020 was not effective and the individual threw it up. There are no records maintained that the agency nurse was contacted again for additional instructions, attempts to administer the medication again due to the physicians order stating it can be administered every hour as needed, nor is there records of contacting the individual's physician for further instructions to help ease the individual's stomach ailments.
· Individual #1 is diagnosed with Constipation, takes daily constipation medications, and is prescribed as needed medication should he experience constipation and be unable to have a bowel movement or if he experiences diarrhea and needs medication, is prescribed as needed medications for that. He is prescribed Loperamide, take 2 caplets (4mg) by mouth after loose bowel movement then may take 1 caplet after each subsequent loose stool, not to exceed 4 caplets per 24 hours and also prescribed. He is also prescribed Docusate Sodium 8.6/50mg, take 2 tablets by mouth at bedtime if no bowel movement in 3 days as needed for constipation. The agency has documented the individual's bowel movements from January 2020 to January 2021, reporting there are multiple times throughout the year that he was experiencing constipation and diarrhea. There are no records maintained that Loperamide or Docusate Sodium was administered when it met the criteria prescribed to administer it. There are no records maintained that the individual's physician was notified of how often he is experiencing loose stools or diarrhea. The agency documented the individual's bowel movement charts documented the type (d=diarrhea, h=hard, i=independent, l=loose, s=soft, n=normal, t1=type 1, t2=type2, t3=type3, t4=type4, t5=type5, t6=type6, t7=type7), the amount (s=small, m=medium, l=large, xl=extra large), and if bowel aids (e=enema, l=laxative, s=suppository, o=other) were administered. Examples of when staff documented constipation and diarrhea but did not administer his prescribed as needed medications were:
- Loose stools were documented once on 1/2/20, 1/15/20, 2/2/20, 2/8/20, 2/15/20, 3/13/20, 3/22/20, 3/27/20, 4/3/20, 4/5/20, 4/6/20, 4/11/20, 4/15/20, 4/20/20, 4/25/20, 4/28-29/20, 5/2/20, 5/5/20, 5/7-8/20, 5/10-13/20, 5/15/20, 5/21/20, 5/23/20, 6/1/20, 6/3/20, 6/7/20, 6/9/20, 6/11-12/20, 6/16-18/20, 6/21/20, 6/24/20, 6/28/20, 6/30/20, 7/2/20, 7/5-6/20, 7/8-9/20, 7/11/20, 7/13-14/20, 7/16/20, 7/7/19/20, 7/29-30/20, 8/3/20, 8/6-7/20, 8/15/20, 8/19/20, 8/28/20, 8/31/20, 9/4/20, 9/11/20, 9/21/20, 10/2/20, 10/5/20, 10/8-9/20, 10/21/20, 10/25/20, 10/28/20, 11/7/20, 11/13-14/20, 11/19-21/20, 11/23/20, 11/28/20, 12/23-24/20, 12/26/20, 12/30/20, 1/7/21, 1/18/21, twice on 4/10/20, 4/13/20, 4/23-24/20, 4/27/20, 5/3/20, 5/8-9/20, 5/17/20, 5/17/20, 5/19/20, 5/26/20, 5/31/20, 6/2/20, 6/5/20, 6/19/20, 6/23/20, 6/26/20, 6/29/20, 7/1/20, 7/3-4/20, 7/6/20, 7/22/20, 7/24/20, 8/8/20, 8/23/20, 8/26-27/20, 9/5/20, 9/8/20, 9/12/20, 9/18-19/20, 9/28/20, 9/30/20, 10/7/20, 10/12/20, 10/16/20, 10/23/20, 11/18/20, 12/21/20, three times on 5/6/20, 5/25/20, 7/25/20,8/21/20, 9/7/20, diarrhea on 4/21/20, 7/31/20, 9/19/20, and his Loperamide was never administered.
- He had a bowel movement on 2/8/20 and not again until 2/12/20, a bowel movement on 2/17/20 and not again until 2/21/20, a bowel movement on 3/4/20 and not again until 3/10/20, and his Docusate Sodium wasn't administered on the 3rd day of no bowel movement. | 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 were trained on regulation 6400.144 by the Director of Quality Assurance & Training on 03/09/21. The outline, guidelines, and attendance sheet were submitted for review.(#15) Follow ups and recommendations from appointments must be completed and/or scheduled within one week. Attempts to schedule appointments require a medical review form with the date of the attempt. Documentation will be reviewed by the Program Specialist assigned on an ongoing basis. Monitoring will be completed by the Quality Assurance & Training Associate during the biannual inspections.
Program Managers were trained on the Over the Counter (PRN) orders. Outline and attendance record are submitted for review. (#16) The orders have been adjusted to ensure clearly defined parameters for administration and length of use as defined by the signing physician. Program Managers will review the PRN orders with all staff members who are medication administration trained.
Program Specialists and Program Managers were trained on 03/09/21 and, in turn, will train all staff by 04/01/2021 on the Therap¿s Intake & Elimination section, which has now been clearly defined for data entry purposes. Outline and attendance record are submitted for review. (#17) Guidelines were reviewed and placed on the agencys OneDrive for easy access. Routine medication prescribed by the physician for maintaining regularity will not be documented within the Therap Intake/Elimination section. Only when the PRN medication prescribed by physician is required by the parameters set, the Bowel Aids drop down in Therap¿s Intake/Elimination is to be completed. The on-call system, which includes a nurse, will be contacted to confirm the physicians orders are properly followed. Attendance records from the staff trainings must be submitted to the Operations Director prior to 04/02/2021.
Program Managers are responsible to ensure staff have entered in correct data and that documentation of the PRN constipation medication matches the data. To ensure no further fractions occur, Program Specialists will run monthly reports of the intake/elimination data. Monitoring will be completed by the Operations Director by reviewing the submitted monthly reports. Monitoring will also be completed by the Quality Assurance & Training Associate during the biannual inspection. |
04/02/2021
| Implemented |
| 6400.145(3) | The home's written emergency medical plan does not include a staffing plan to be used in the event of an emergency. There are two individuals in the home that require full assistance in most all areas of daily living. The plan states that staff are to drive the individual(s) or accompany them to the hospital emergency room or other healthcare facility. However, a plan to continue to provide staffing to the other individual living in the home is not included in this plan, should staff leave the home with the other individual. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | Program Managers were trained on regulation 6400.145(3) by the Director of Quality Assurance and Training on 03/09/21. The outline and attendance record are submitted for review (#3). The emergency medical plan was placed in pdf format to ensure no information is inadvertently omitted. The form and Individual #1 form have been submitted for review. Program Managers were instructed to review each person we serves emergency medical plan to ensure accuracy. All updated forms are to be sent to the Quality Assurance department by 03/11/21. To ensure no further infractions occur, the Program Specialist will review each plan for assigned persons. An email will be sent to the Operations Director by 03/12/21 with completion of the task. Monitoring of the document will be completed by the Quality Assurance & Training Associate during biannual inspections. |
03/12/2021
| Implemented |
| 6400.18(b)(2) | The medication errors described below for Individual #1 were never reported to the Department through the Department's information management system or on a form specified by the Department.
· SM Clearlax powder, Lamotrigine 200mg, and his Ensure drink was not administered at 7AM and 8AM on 3/5/2020. Agency staff recorded that the medications were missed due to the individual having a sedation dental appointment that day. There are no records maintained that the individual attended a dental appointment on 3/5/2020 where he was sedated or instructed to not administer morning medications.
· On 4/18/2020 he refused his 7AM Ensure drink, 8AM Loratadine, Omeprazole, SM Clearlax powder, Lamotrigine, Fiber choice chewable tablet, and 12PM Ensure drink. The individual's medication administration record (mar) states that he was administered Loratadine, Omeprazole, SM Clearlax Powder, Lamotrigine, Fiber choice, and Ensure drink at 10AM on 4/18/2020 "per nurses order." There are no records maintained of a nurses or physician's order to administer these medications and supplements at 10AM on 4/18/2020. The physician's order on 4/18/2020 states to resume administering Ensure at the next scheduled time, not attempt to administer a missed dosage at 10AM.
· The individual's Lamotrigine 200mg was not administered to the individual as prescribed at 8AM on 11/30/2020. The individual's mar was left blank.
· The individual's physician stated on 12/12/2020 at 10:30AM that due to the individual refusing their 8AM dose of Lamotrigine 200mg, the agency was to administer the morning dose at lunch. Staff person #14 administered Lamotrigine 200mg at 10:30AM on 12/12/2020 and didn't wait until lunch as the physician's order stated. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | Program Managers were trained on regulation 6400.18(b)(2) by the Director of Quality Assurance & Training on 03/09/21. The outline and attendance sheet were submitted for review.(#15) Program Managers are required to complete a Medical Review form for all appointments and procedures. Program Managers will obtain written instructions, including instructions regarding not administering medications prior to appointments or procedures. If the appointment or procedure is cancelled for any reason, written orders by the physician are required to administer medications outside of the allotted window. Only prescribing physicians, with received written orders, can extend a window for medication administration. If the appointment or procedure are kept, required documentation from the physician will be obtained to ensure discharge instructions, including the administration of any held medications.
Individuals have the right to refuse medications. The prescribing physician must be contacted with the refusal and staff will follow instructions by the physician. If the physician is wanting to have medications administered after the allotted time, the home must receive written orders from the prescribing physician to administer the medications. All medication errors must be relayed to the Incident Management Coordinator or On Call system upon discovery. Modification of orders is not permitted and constitutes a medication error.
Program Managers are required to review this information regarding 6400.18(b)(2) to staff who are medication administration trained prior to 04/01/21. The Program Manager must submit attendance sheet to the Operations Director by 04/02/21.
The Director of Quality Assurance & Training met with Medication Administration Trainers to review this information on 03/10/21 and are required to discuss during Medication Administration courses. The outline and attendance sheet are attached.(#24)
To ensure no further infractions occur, the Program Manager will review all MARs prior to the 5th of the following month when filing in the permanent chart as required. Any discovered medication errors found at this time must be called into the Incident Management Coordinator. Program Specialists will review a sample MAR each month for accuracy and place their initials on the back of reviewed MARs. Monitoring will be conducted by the Quality Assurance & Training Associate during biannual inspections.
Program Specialist will review Medical Review forms monthly to ensure all follow up documentation has been completed. Monitoring will be conducted by the Quality Assurance & Training Associate during biannual inspections. |
04/02/2021
| Implemented |
| 6400.34(a) | Individual #1 moved into the home and started receiving agency (Valley Community Services) services on 1/2/2020. Individual #1 wasn't informed or explained his rights defined under PA code 55, Chapter 6400.32(a)-(v) and the process to report a rights violation until 3/30/2020, almost three months after his admission to the agency and outside the regulatory time-frame requirement.
Additionally, the agency did not inform and explain Individual #1's regulatory individual rights and the process to report a rights violation to Individual #1's legal guardian upon the individual's admission to the facility, annually thereafter, or after the Department's implementation of updated individual regulatory rights effective immediately on 2/3/2020. When individuals' rights were explained to Individual #1 on 3/30/2020, there is a field for the legal guardian to sign off on receiving this review, and the field is left blank. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Protocols for new admissions has been updated (#12) to include requirements for day of admission. Protocol has been submitted for review. The admission packet will contain a copy of the Individual Rights with Watermark containing Sample which gives the individual and legal guardian, if one is appointed, time to review prior to admission. The date and time of the admission to the home will be decided once all paperwork and trainings are completed, and the legal guardian designates a specific time to arrive at the home. The Program Manager is required to review the rights with the Individual and guardian, answer any questions, and obtain signatures. To ensure no further infractions occur the Program Specialist will verify the signatures prior to the guardians departure.
The Program Managers & Program Specialists have been trained on 6400.34(a) by the Director of Quality Assurance & Training on 03/09/21. The outline and attendance sheet have been submitted for review. |
03/09/2021
| Implemented |
| 6400.44(b)(2) | The program specialist is responsible to ensure that Individual #1's plan are created, developed, updated as needed and implemented as written. As referenced in 6400.186 of this report Individual #1's plans were found to not be implemented as written, he had an behavior support plan that contained inaccurate information, and the home did not have a seizure plan or protocol specific to the individual, as he recently started experiencing seizures again, for staff to know what his seizures looked like. | The program specialist shall be responsible for the following: Participating in the individual plan process, development, team reviews and implementation in accordance with this chapter. | Program Managers, Program Specialists and Behavior Specialists were trained on regulation 6400.44(b)(2) by the Director of Quality Assurance & Training on 03/09/21. The outline and attendance record are submitted for review. (#12) Protocols for new admissions has been updated to include review of the ISP sections that would be significant and any information that would require trainings prior to admission. Missing or incomplete information, and any follow up information is to be obtained by the Supports Coordinator. Protocol has been submitted for review. A team meeting, to include but not limited to the Program Manager, Program Specialist, Operations Director, Director of Quality Assurance & Training will be documented. The meeting, scheduled by the Director of Quality Assurance & Training, will address all trainings and further information required prior to the individuals admission to the home.
The Program Manager is responsible for updating the Program Specialist by email with any changes in the care of the individual, including but not limited to dietary changes, immediately following appointments. The Program Specialist is required to email the Behavior Specialist with any changes in the care of the individual that impacts current behavior plans. The Behavior Specialist will adjust the behavior plan as necessary and submit to the Human Rights Committee for approval at the next scheduled meeting. Once the adjusted Behavior Plan is approved, the Behavior Specialist will train all staff on the plan immediately. Outline and attendance record are submitted for review (#10) To ensure no further infractions occur, the Operations Director, as part of the individuals team will follow the changes to ensure all parties have completed their assigned requirement. Monitoring will be completed by the Quality Assurance & Training Associate during biannual inspections, ensuring no lag in time and that all trainings have been completed. |
03/09/2021
| Implemented |
| 6400.46(d) | Staff person #6 was hired on 3/19/2020 and didn't receive training by an individual certified as a trainer by a hospital or other recognized healthcare organization, in initial first aid, Heimlich techniques, and Cardio-Pulmonary Resuscitation (CPR) until 10/28/2020, outside the time frame requirement. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | The Human Resource Specialists were trained on regulation 6400.46(d) by the Director of Quality Assurance & Training on 03/10/21. The outline and attendance record are submitted for review.(#20) Documentation of the delay in face-to-face trainings was not available at the time of inspection. The Human Resources Director has initiated CPR training for all new hires within the allotted 6-month requirement, ensuring the health and safety of the staff by limiting the number of participants and utilizing CDC recommended COVID-19 precautions, including masking, social distancing, and sanitation requirements. The Human Resource department will adjust the policy when/if ODP requirements and limitations change.
To ensure no further infractions occur, the Human Resource Specialists will submit new hire report, including the date of hire and the completion of the required CPR training to the Director of Human Resources monthly, during the COVID-19 restrictions. |
03/10/2021
| Implemented |
| 6400.51(b)(5) | Individual #1 moved into the home on 1/2/2020 after previously living with his mother. Prior to admission with the residential facility, the individual was receiving services through the agency, Valley Community Services, day program facility for a few months. The agency had documentation via the individual's individual support plan, prior to his admission to the residential home, that discussed a recent development of Seizures that landed the individual in the hospital, approximately 6 months prior to his admission. Additionally, the individual's plan states that the individual's seizures that have recently occurred, came after years of not experiencing a seizure. During the 1/28/2021 remote inspection of the home, none of the staff working in the home that day (3 staff) knew what Individual #1's seizures looked like if he were having them or was to have them while at the residence. Staff were not oriented to knowledge and skills specific to the individual and his seizures. Additionally, the individual had a generic seizure plan, that was not reviewed with his neurologist, created on 1/2/2020 by the agency. There are no records maintained that staff working with him were trained on this generic seizure plan until 11/24/2020. Also, the records state that the training that took place on 11/24/2020 covered "Care plans" but did not stated that it was a training on Individual #1's 1/2/2020 seizure plan.
Staff working with the individual are also to document the individual's bowel movements using his bowel movement chart. The individual's bowel movement chart defines the specific types of stool (d=diarrhea, h=hard, i=independent, l=loose, s=soft, n=normal, t1=type 1, t2=type2, t3=type3, t4=type4, t5=type5, t6=type6, t7=type7), the amount (s=small, m=medium, l=large, xl=extra large), and if bowel aids (e=enema, l=laxative, s=suppository, o=other) were administered. There are no records maintained that staff working with the individual have received training on specific job knowledge and skills needed to properly monitor and document the individual's bowel movements, the descriptions of the specific categories on his bowel chart, or how to report a problem with the individual's bowels.
Individual #1's dietary needs have been defined by his physician multiple times throughout the year due to the individual's difficulty with chewing and swallowing food that places the individual at risk for choking. His physician stated on 9/17/2020 that the individual should follow a ground moist diet. There are no records maintained that all staff working with the individual were trained on his updated dietary needs prior to working with the individual again. Staff persons #10, 11, 12, and 13 did not receive training in the individual specific dietary needs until 9/21/20 while staff person #14 didn't receive training until 11/22/2020. Additionally, the Department issued instructions effective immediately on 2/3/2020 that any training provided to staff regarding individual specific job knowledge and skills needed to perform their job must be completed in person. The agency's training records document that a trainer was only present for a training on Individual #1's specific dietary needs on 9/17/2020, but did not list that a trainer was present for any other time a staff signed the training record. | The orientation must encompass the following areas: Job-related knowledge and skills. | Protocols for new admissions has been updated (#12) to include review of the ISP sections that would be significant for the admission, the information that would require trainings prior to admission, and any follow up information to be obtained by the Supports Coordinator. Protocol has been submitted for review. The seizure protocol for Individual #1 was reviewed and is at the neurologist for approval. Added information on the expectations of seizure presentation will be reviewed and trained with staff upon receipt. To ensure no further infractions occurs, the Director of Quality Assurance & Training will review all admission paperwork prior to setting an admission date.
Program Specialists and Program Managers were trained on regulations 6400.51(b)(5) by the Director of Quality Assurance & Training on 03/09/21. Outline and attendance sheet are submitted for review.(#21) Program Specialists and/or Program Managers are required to be present for all staff trainings, including Teams trainings during the COVID-19 restrictions. Care Plans, including but not limited to seizures and dietary needs, are trained on a quarterly basis for a year as a response to a previous plan. This training require outlines specific to the individuals, with listed care plans attached. Care plans needing clarification, including seizures and dietary needs, must be submitted to the physician to ensure accurate protocol.
Staff person #14 worked at Woodbury CLA for the first time on 11/22/2020. Orientation trainings and transfer orientation trainings which have separate signature sheets with outlines are to begin on 03/10/21 as proof of live trainings by the Program Manager and/or Program Specialist. Staff unable to attend any training must be trained at the beginning of the shift of their first workday with an individual. (#21)
Program Managers, Program Specialists, and Operations Directors were trained on the Intake/Elimination documentation on Therap on 03/09/21 by the Quality Assurance & Training Associate. The outline and attendance sheet were submitted for review. (#17) Program Specialists are required to train staff on the appropriate documentation utilizing both the training outline and developed guidelines, which include descriptions of specific types of stool. Individual # 1 has not had loose stool, but soft stool which does not require any medication. Attendance records from staff trainings must be submitted to the Operations Director prior to 04/01/21. Program Managers are responsible to ensure staff have entered in correct data and that documentation of the PRN bowel medication matches the data. To ensure no further fractions occur, Program Specialists will run monthly reports of the intake/elimination data. Monitoring will be completed by the Operations Director by reviewing the submitted monthly reports. Monitoring will also be completed by the Quality Assurance & Training Associate during the biannual inspection. |
03/09/2021
| Implemented |
| 6400.165(c) | Individual #1's medications were not administered as ordered throughout the previous year, January 2020 to January 2021, on multiple occasions. Examples of when the agency, Valley Community Services, failed to administer the individual's medications as ordered were:
· The physician's order for Tussin DM Syrup is to take 2 teaspoonfuls by mouth every 4 hours as needed for cough. This medication was administered to individual at 7am, 11am, 3pm, and 7pm from 2/16-18/2020. The individual's medication administration record (mar) for said administrations didn't record the physician's ordered frequency to administer the medication. The mar listed the medication was to be administered 2 teaspoonfuls by mouth every 4 hours as needed for cough for 3 days. The individual's record does not have a physician's order to only administer the medication for 3 days.
· SM Clearlax powder, Lamotrigine 200mg, and Ensure drink was not administered at 7AM and 8AM on 3/5/2020. Agency staff recorded that the medications were missed due to the individual having a sedation dental appointment that day. There are no records maintained that the individual attended a dental appointment on 3/5/2020 where he was sedated and instructed to not administer morning medications.
· On 4/18/2020 he refused his 7AM Ensure drink, 8AM Loratadine, Omeprazole, SM Clearlax powder, Lamotrigine, Fiber choice chewable tablet, and 12PM Ensure drink. The individual mar states that he was administered Loratadine, Omeprazole, SM Clearlax Powder, Lamotrigine, Fiber choice, and Ensure drink at 10AM on 4/18/2020 "per nurses order." There are no records maintained of a nurses or physician's order to administer these medications and supplements at 10AM on 4/18/2020. The physician's order on 4/18/2020 states to resume administering Ensure at the next scheduled time, not attempt to administer a missed dosage at 10AM. There are no records maintained that the physician was notified of any refused medications and supplements on 4/18/2020; the only exception being his physician was notified of his 12 noon missed dose of Ensure.
· His Ensure drink was not administered at 12noon on 5/31/2020 nor are there records that the individual refused this prescribed supplement.
· Staff person #15 documented on the individuals September 2020 mar that the individual's physician discontinued the individual's Fiber-lax caplets at the afternoon appointment on 9/17/2020. Staff #15 also documented that the medication was not removed from the individual's medications or discontinued off the individual's mar, thus the staff working the evening shift on 9/17/2020 continued to administer the medication after the physician's discontinuation order earlier in the day.
· The individual's Lamotrigine 200mg was not administered to the individual as prescribed at 8AM on 11/30/2020.
· The individual's physician stated on 12/12/2020 at 10:30AM that due to the individual refusing their 8AM dose of Lamotrigine 200mg, the agency was to administer the morning dose at lunch. Staff person #14 administered Lamotrigine 200mg at 10:30AM on 12/12/2020 and didn't wait until lunch as the physician's order stated.
· Individual #1 is diagnosed with Constipation, takes daily constipation medications, and is prescribed as needed medication should he experience constipation and be unable to have a bowel movement or if he experiences diarrhea and needs medication, is prescribed as needed medications for that. He is prescribed Loperamide, take 2 caplets (4mg) by mouth after loose bowel movement then may take 1 caplet after each subsequent loose stool, not to exceed 4 caplets per 24 hours also prescribed. He is also prescribed Docusate Sodium 8.6/50mg, take 2 tablets by mouth at bedtime if no bowel movement in 3 days as needed for constipation. The agency has documented the individual's bowel movements from January 2020 to January 2021, reporting there are multiple times throughout the year that he was experiencing constipation and diarrhea. There are no records maintained that Loperamide or Docusate Sodium was administered when it met the criteria prescribed to administer it. There are no records maintained that the individual's physician was notified of how often he is experiencing loose stools or diarrhea. The agency documented the individual's bowel movement charts documented the type (d=diarrhea, h=hard, i=independent, l=loose, s=soft, n=normal, t1=type 1, t2=type2, t3=type3, t4=type4, t5=type5, t6=type6, t7=type7), the amount (s=small, m=medium, l=large, xl=extra large), and if bowel aids (e=enema, l=laxative, s=suppository, o=other) were administered. Examples of when staff documented constipation and diarrhea but did not administer his prescribed as needed medications were:
- Loose stools were documented once on 1/2/20, 1/15/20, 2/2/20, 2/8/20, 2/15/20, 3/13/20, 3/22/20, 3/27/20, 4/3/20, 4/5/20, 4/6/20, 4/11/20, 4/15/20, 4/20/20, 4/25/20, 4/28-29/20, 5/2/20, 5/5/20, 5/7-8/20, 5/10-13/20, 5/15/20, 5/21/20, 5/23/20, 6/1/20, 6/3/20, 6/7/20, 6/9/20, 6/11-12/20, 6/16-18/20, 6/21/20, 6/24/20, 6/28/20, 6/30/20, 7/2/20, 7/5-6/20, 7/8-9/20, 7/11/20, 7/13-14/20, 7/16/20, 7/7/19/20, 7/29-30/20, 8/3/20, 8/6-7/20, 8/15/20, 8/19/20, 8/28/20, 8/31/20, 9/4/20, 9/11/20, 9/21/20, 10/2/20, 10/5/20, 10/8-9/20, 10/21/20, 10/25/20, 10/28/20, 11/7/20, 11/13-14/20, 11/19-21/20, 11/23/20, 11/28/20, 12/23-24/20, 12/26/20, 12/30/20, 1/7/21, 1/18/21, twice on 4/10/20, 4/13/20, 4/23-24/20, 4/27/20, 5/3/20, 5/8-9/20, 5/17/20, 5/17/20, 5/19/20, 5/26/20, 5/31/20, 6/2/20, 6/5/20, 6/19/20, 6/23/20, 6/26/20, 6/29/20, 7/1/20, 7/3-4/20, 7/6/20, 7/22/20, 7/24/20, 8/8/20, 8/23/20, 8/26-27/20, 9/5/20, 9/8/20, 9/12/20, 9/18-19/20, 9/28/20, 9/30/20, 10/7/20, 10/12/20, 10/16/20, 10/23/20, 11/18/20, 12/21/20, three times on 5/6/20, 5/25/20, 7/25/20,8/21/20, 9/7/20, diarrhea on 4/21/20, 7/31/20, 9/19/20, and his Loperamide was never administered.
- He had a bowel movement on 2/8/20 and not again until 2/12/20, a bowel movement on 2/17/20 and not again until 2/21/20, a bowel movement on 3/4/20 and not again until 3/10/20, and his Docusate Sodium wasn't administered on the 3rd day of no bowel movement. | A prescription medication shall be administered as prescribed. | Program Managers were trained on regulation 6400.165(c) by the Director of Quality Assurance & Training on 03/09/21. The outline and attendance sheet were submitted for review.(#16) Over the Counter Medication list has been updated to include specific length of time the medication may be used prior to contacting the physician. Program Managers will obtain Primary Care Physicians signature for all individuals by 05/01/21 and placed in the permanent chart and MAR binder. Program Specialist assigned will ensure completion by 05/02/21 and email the Operations Directors upon completion of review. Monitoring will be completed by the Quality Assurance & Training Associate during the biannual inspections.
Program Managers are required to obtain written orders from the physician for holding medications prior to all required, scheduled procedures. Upon completion, or if the procedure was cancelled and/or refused, written orders for resuming/administering the medications from the physician are to be obtained.
Program Managers trained all current medication administrators on the requirement to contact the prescribing physician for all refusals and omissions. Any directions for administration of medications beyond the defined window of administration must be obtained in writing by the prescribing physician. On call system, including the on-call nurse are to be utilized only as clarification, if needed, with prescribing physicians¿ instructions. Program managers will train all current medication administrators on proper discontinuation of medications, highlighting the steps to remove the medication from the individual¿s locked storage area, reviewing the MAR prior to medication administration each time for current medications, and contacting the Incident Management Coordinator and submission of medication errors on a GER in the Therap system. Outline and attendance records are to be submitted to the Quality Assurance Department prior to 05/01/21. To ensure no further infractions occur, the Program Manager and/or the supervisory staff will review the MARs daily for compliance. The Director of Quality Assurance & Training trained all Medication Administration Trainers regarding the medication administration issues within the plan of correction, requiring emphasis during subsequent face-to-face medication administration trainings for new medication administrators. Monitoring by the Quality Assurance & Training Associates will be completed during biannual inspections, along with immediate retraining for medication errors.
Program Managers were trained on the Over the Counter (PRN) orders. Outline and attendance record are submitted for review, (#16) The orders have been adjusted to ensure clearly defined parameters for administration and length of use as defined by the signing physician. Program Managers will review the PRN orders with all staff members who are medication administration trained by 04/01/21. The on-call system, which includes a nurse, will be contacted to confirm the physicians orders are properly followed.
Program Managers and supervisory staff are responsible to ensure staff have entered in correct data in Therap and that documentation of the PRN medications matches the data and are documented on the MAR. To ensure no further fractions occur, Program Specialists will run monthly reports of the intake/elimination data. Monitoring will be completed by the Operations Director by reviewing the submitted monthly reports. Monitoring will also be completed by the Quality Assurance & Training Associate during the biannual inspection |
05/02/2021
| Implemented |
| 6400.166(a)(4) | According to Individual #1's bowel chart, staff document if a bowel aid was administered to the individual. The chart defines bowel aids as E for Enema, L for Laxative, S for Suppository and O for other form of treatment/medication applied or administered. Staff documented that another form of medication/treatment was administered on 2/28/20, 6/7/20, and laxatives were administered on 6/12/20, 6/13/20 (twice), 6/15/20 (twice), 6/16/20 (twice), 6/18/20, 6/20/20, 7/13/20, 7/15/20, 7/17/20 (twice), 7/18/0, 7/20/20, 10/8/20, 10/16/20, 10/27/20, 11/2/20, 11/5/20, 11/14/20, 11/17/20 (twice), 12/8/20, and 12/13/20. There are no records maintained for the name of the medication that was administered to Individual #1 for each documented date above that staff indicated a medication was administered. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Program Managers, Program Specialists, and Operations Directors were trained on the Intake/Elimination documentation on Therap on 03/09/21 by the Quality Assurance & Training Associate. The outline and attendance sheet were submitted for review. (#17) Program Specialists are required to train staff on the appropriate documentation utilizing both the training outline and developed guidelines. When a bowel aid is used, the medication administrators will document the name of the PRN (laxative) and note it on the back of the medication administration record, including time and date given. A data entry will also be written in Therap under Intake/Elimination to note that the PRN laxative was given, which will include the name of the medication. Attendance records must be submitted to the Operations Director prior to 04/01/21. Program Managers are responsible to ensure staff have entered in correct data and that documentation of the PRN constipation medication matches the data. To ensure no further fractions occur, Program Specialists will run monthly reports of the intake/elimination data. Monitoring will be completed by the Operations Director by reviewing the submitted monthly reports. Monitoring will also be completed by the Quality Assurance & Training Associate during the biannual inspection. |
04/01/2021
| Implemented |
| 6400.166(a)(5) | On 5/15/2020 Individual #1's physician ordered Fiberlax 625mg tablets, take 2 tablets three times a day. The individual's medication administration record (mar) in May-June 2020 did not record the strength of the medication. The mar stated to take two tablets but did not list that the tablets were 625mg tablets. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | Staff #19 entered the information into the MAR. The Quality Assurance & Training Associate who is a Medication Administration Trainer completed a one-on-one training with Staff #19 on 03/10/21 regarding adding medication to the MAR, including the strength of medication.
The Quality Assurance & Training Associate who is a Medication Administration Trainer completed a one-on-one training with the Program Manager, Staff #11 requiring the Program Manager and/or supervisory staff review of the MAR daily.
Program Managers, Program Specialists, and Operations Directors were trained on regulation 6400.166(a)(5) by the Director of Quality Assurance & Training on 03/09/21. (#18) (#22) Program Managers will train all current medication administrators on the correct process of adding a medication into the MAR prior to 04/01/21. Outline and attendance sheet will be submitted to the Program Specialists for review and submit an email to the Operations Director confirming completion by 04/02/21. To ensure no further infractions occur, the Quality Assurance & Training Associate will monitor during biannual inspections. |
04/02/2021
| Implemented |
| 6400.166(a)(6) | Individual #1 was administered a fiber powder on 9/18/2020 at 9PM. However, the medication administration record (mar) did not list the dosage form for how it was administered. The mar stated "take by mouth once daily 1 rounded tsp in 8oz" but did not explain what the item was to be mixed with prior to administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | Staff #16 entered the information into the MAR. The Quality Assurance & Training Associate who is a Medication Administration Trainer completed a one-on-one training with Staff #16 on 03/10/21 regarding adding medication to the MAR, including the medication dosage form. Outline and attendance record are submitted for review. (#22)
The Quality Assurance & Training Associate who is a Medication Administration Trainer completed a one-on-one training with the Program Manager, Staff #11 on 03/10/21 requiring the Program Manager and/or supervisory staff review of the MAR daily. (#22)
Program Managers, Program Specialists, and Operations Directors were trained on regulation 6400.166(a)(5) by the Director of Quality Assurance & Training on 03/09/21. Program Managers will train all current medication administrators on the correct process of adding a medication into the MAR. (#22) Outline and attendance sheet will be submitted to the Program Specialists for review by 04/01/21 and submit an email to the Operations Director by 04/02/21 confirming completion. To ensure no further infractions occur, the Quality Assurance & Training Associate will monitor during biannual inspections. |
04/02/2021
| Implemented |
| 6400.166(a)(7) | According to Individual #1's bowel chart, staff document if a bowel aid was administered to the individual. The chart defines bowel aids as E for Enema, L for Laxative, S for Suppository and O for other form of treatment/medication applied or administered. Staff documented that another form of medication/treatment was administered on 2/28/20, 6/7/20, and laxatives were administered on 6/12/20, 6/13/20 (twice), 6/15/20 (twice), 6/16/20 (twice), 6/18/20, 6/20/20, 7/13/20, 7/15/20, 7/17/20 (twice), 7/18/0, 7/20/20, 10/8/20, 10/16/20, 10/27/20, 11/2/20, 11/5/20, 11/14/20, 11/17/20 (twice), 12/8/20, and 12/13/20. There are no records maintained for the dose of the medication that was administered to Individual #1 for each documented date above that staff indicated a medication was administered. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Program Managers, Program Specialists, and Operations Directors were trained on the Intake/Elimination documentation on Therap on 03/09/21 by the Quality Assurance & Training Associate. The outline and attendance sheet were submitted for review.(#17) Program Specialists are required to train staff on the appropriate documentation utilizing both the training outline and developed guidelines, which include descriptions of specific types of stool. Individual #1 has not had loose stool, but soft stool which does not require any medication.
Documentation of the dose of medication is required each time a bowel aid is utilized. Medications prescribe by a physician on a routine basis for regularity are not considered bowel aids. The guidelines address the requirement to add the PRN medication information to the comment section each time a bowel aid is used, along with documentation on the MAR. Attendance records must be submitted to the Operations Director prior to 04/01/21. Program Managers are responsible to ensure staff have entered in correct data and that documentation of the PRN bowel medication matches the data. To ensure no further fractions occur, Program Specialists will run monthly reports of the intake/elimination data. Monitoring will be completed by the Operations Director by reviewing the submitted monthly reports, starting April 2021, and ending October 2021. Monitoring will also be completed by the Quality Assurance & Training Associate during the biannual inspection. |
04/01/2021
| Implemented |
| 6400.166(a)(8) | According to Individual #1's bowel chart, staff document if a bowel aid was administered to the individual. The chart defines bowel aids as E for Enema, L for Laxative, S for Suppository and O for other form of treatment/medication applied or administered. Staff documented that another form of medication/treatment was administered on 2/28/20, 6/7/20, and laxatives were administered on 6/12/20, 6/13/20 (twice), 6/15/20 (twice), 6/16/20 (twice), 6/18/20, 6/20/20, 7/13/20, 7/15/20, 7/17/20 (twice), 7/18/0, 7/20/20, 10/8/20, 10/16/20, 10/27/20, 11/2/20, 11/5/20, 11/14/20, 11/17/20 (twice), 12/8/20, and 12/13/20. There are no records maintained for the route of administration of the medication that was administered to Individual #1 for each documented date above that staff indicated a medication was administered. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | Program Managers, Program Specialists, and Operations Directors were trained on the Intake/Elimination documentation on Therap on 03/09/21 by the Quality Assurance & Training Associate. The outline and attendance sheet were submitted for review.(#17) Program Specialists are required to train staff on the appropriate documentation utilizing both the training outline and developed guidelines, which include descriptions of specific types of stool. Individual #1 has not had ¿loose¿ stool, but soft stool which does not require any medication.
Documentation of the route of medication is required each time a bowel aid is utilized. Medications prescribe by a physician on a routine basis for regularity are not considered bowel aids. The guidelines address the requirement to add the PRN medication information to the comment section each time a bowel aid is used, along with documentation on the MAR. Attendance records must be submitted to the Operations Director prior to 04/01/21. Program Managers are responsible to ensure staff have entered in correct data and that documentation of the PRN bowel medication matches the data. To ensure no further fractions occur, Program Specialists will run monthly reports of the intake/elimination data. |
04/01/2021
| Implemented |
| 6400.166(a)(9) | Individual #1's physician's order for Tussin DM Syrup is to take 2 teaspoonfuls by mouth every 4 hours as needed for cough. This medication was administered to individual at 7am, 11am, 3pm, and 7pm from 2/16-18/2020. The individual's medication administration record (mar) for said administrations didn't record the physician's ordered frequency to administer the medication. The mar listed the medication was to be administered 2 teaspoonfuls by mouth every 4 hours as needed for cough for 3 days. The individual's record does not have a physician's order to only administer the medication for 3 days.
Additionally, the individual's record documents that Chlorpheniramine 4mg tablet was administered to him at 7am, 1pm, and 7pm from 2/16-18/2020. The mars recorded the frequency was to administer the medication every 6 hours as needed for cold symptoms for 3 days. However, the frequency for how to administer this medication is prescribed by the individual's physician to administer Chlorpheniramine 4mg by mouth every 6 hours as needed for cold symptoms. There are no records maintained for an order to administer the specific medication for only 3 days. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Program Managers were trained on regulation 6400.166(a)(9) and the Over the Counter (PRN) orders by the Director of Quality Assurance & Training on 03/09/21. The outline and attendance sheet are submitted for review. (#16) The PRN orders have been adjusted to ensure clearly defined parameters for administration and length of use as defined by the signing physician. Program Managers will review the PRN orders will all staff members who are medication administration trained by 04/01/21. The on-call system, which includes a nurse, will be contacted to confirm the physicians orders are properly followed, including the written frequency of administration. Program Managers will submit training outlines and attendance sheet to the assigned Program Specialist by 04/01/21 and will send an email to the Operations Director by 04/02/21 for confirmation. To ensure no further infractions occur, the Quality Assurance & Training Associate will monitor during biannual inspections. |
04/01/2021
| Implemented |
| 6400.166(a)(11) | The diagnosis or purpose for prescribing Individual #1's daily medications and treatments were not recorded on the individual's medication administration records (mars) from January 2020 to January 2021. Medications listed on his mars that did not include a reason for prescribing the medications included Omeprazole, Loratadine, Lamotrigine, SM Clear Powder, Ensure drink, Fiber choice tablets, Melatonin, Fiber powder, and Fiber lax.
Additionally, there are multiple times throughout the year when time-specific medication was prescribed and administered to the individual. The diagnosis or purpose for prescribing the medication was not recorded on the mar for the time-specific administrations of medications. Examples of when this occurred was: Bismatrol administered on 8/8/2020, Hydrocortisone cream administered from 1/13-28/2021, and Prednisone administered from 1/13-17/2021. According to the 1/13/2021 physician's record, Individual was ordered Prednisone daily for 5 days and Hydrocortisone cream twice daily for Allergic Dermatitis. | 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. | Director of Quality Assurance & Training reviewed the MARs and requested technical support from the surveyor. With the information given, the Director of Quality Assurance & Training met with Client Services Manager at Health Direct, the pharmacy utilized by Valley Community Services, on February 24, 2021. This meeting was to ensure that the diagnosis or purpose of the medication could be added to the MARs with each individual medication. This would replace the current listing of all diagnoses on the MARs.
.
Program Managers Directors were trained on regulation 6400.166(a)(11) by the Director of Quality Assurance & Training on 03/09/21. Program Managers will train all current medication administrators on the correct process of adding a new or time-limited medication into the MAR, which will include the diagnosis or purpose of the medication. (#22)
As of April 2021, all MARs will list all the diagnosis or purpose of the medication with the medication. Program Managers will submit the completed April 2021 MAR to the Quality Assurance department prior to 05/05/21. Outline and attendance record are submitted for review (#7) To ensure no further infractions occur, the Quality Assurance & Training Associate will review the MARs for diagnosis or purpose of medication during biannual inspections. |
05/05/2021
| Implemented |
| 6400.166(a)(12) | Staff person #10 administered Bismatrol to Individual #1 on 8/8/2020. The time of administration is illegible on the individual's medication administration record (mar). | 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. | Staff #10 entered the information into the MAR. The Quality Assurance & Training Associate who is a Medication Administration Trainer completed a one-on-one training with Staff #10 on 03/10/21 regarding adding information on the MAR which is legible. including the time of administration. Outline and attendance record are submitted for review. (#22)
The Quality Assurance & Training Associate who is a Medication Administration Trainer completed a one-on-one training with the Program Manager, Staff #11 requiring the Program Manager and/or supervisory staff review of the MAR daily, ensuring legibility.(#22)
Program Managers, Program Specialists, and Operations Directors were trained on regulation 6400.166(a)(12) by the Director of Quality Assurance & Training on 03/09/21. Program Managers will train all current medication administrators on the correct process of adding a medication into the MAR and ensuring legibility. Outline and attendance sheet will be submitted to the Program Specialists for review by 04/01/21 and submit an email to the Operations Director confirming completion by 04/02/21.
The Director of Quality Assurance & Training trained all Medication Administration Trainers regarding the medication administration issues within the plan of correction, requiring emphasis during subsequent face-to-face medication administration trainings for new medication administrators on 03/10/21. The outline and attendance sheet are submitted for review.(#24) Monitoring by the Quality Assurance & Training Associates will be completed during biannual inspections. |
04/02/2021
| Implemented |
| 6400.166(b) | The name and initials of the staff person administering medications to Individual #1 over the past year (January 2020-January 2021) is extremely difficult to read based on what is recorded on the individual's medication administration records (mars). The name and initials of the staff person administering the medication to the individual should be legible to determine who was administering medications after each administration. The staff's initials after administrations run into the next day's documentation of medication administration, and overlap other staff's initials of administration. Additionally, staff signatures on the mars are often illegible thus making it impossible to know the staff name who administer the medication. Multiple times a month, it cannot be determined who administered medications to the individual and when.
Staff person #16 initialed as administering Individual #1 his Loratadine 10mg and Omeprazole 20mg tablets at 8AM on 4/5/2020. However, Staff person #17 documented that the 8AM doses of Omeprazole and Loratadine were missed on 4/5/2020. Medications were signed as administered when they were not.
Staff person #18 initialed as administering Fiberlax tablets to Individual #1 multiple times in May 2020 but did not record their name on the medication administration record for purposes of identifying who administered the medication.
Staff person #16 administered triple antibiotic ointment to Individual #1 three times in July 2020. She did not record her name on the mar to identify the staff who administered the medication. She also administered Fiber powder to the individual on 9/19 and 9/20 without recording her name on the mar to identify herself.
There are no records maintained for who administered Prednisone 20mg to the individual at 8PM on 1/16/2021. The individuals mar list initials for Staff person #19 as who administered the medication. However, this was crossed out and two different sets of initials were written above and below Staff person #19's initials for administration. There are no records for who the initials belonged to, if they administered the medication, or if the medication was omitted.
According to Individual #1's bowel chart, staff document if a bowel aid was administered to the individual. The chart defines bowel aids as E for Enema, L for Laxative, S for Suppository and O for other form of treatment/medication applied or administered. Staff documented that another form of medication/treatment was administered on 2/28/20, 6/7/20, and laxatives were administered on 6/12/20, 6/13/20 (twice), 6/15/20 (twice), 6/16/20 (twice), 6/18/20, 6/20/20, 7/13/20, 7/15/20, 7/17/20 (twice), 7/18/0, 7/20/20, 10/8/20, 10/16/20, 10/27/20, 11/2/20, 11/5/20, 11/14/20, 11/17/20 (twice), 12/8/20, and 12/13/20. There are no records maintained for the name and initials of the staff person who administered the medication or the date and time that the medications were administered to Individual #1 for each documented date above that staff indicated a medication was administered. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The Quality Assurance & Training Associate who is a Medication Administration Trainer completed a training with medication administrators #16, #18, and #19 on 03/10/21 regarding legibility, proper documentation of mistaken entries, and signing the back of each MAR where the person has passed a medication. Staff #17 no longer is employed with the agency. Outlines and attendance records have been submitted for review. Outline and attendance record are submitted for review, (#22)
The Quality Assurance & Training Associate who is a Medication Administration Trainer completed a one-on-one training with the Program Manager, Staff #11 on 03/10/21 requiring the Program Manager and/or supervisory staff review of the MAR daily, ensuring legibility, accuracy, and completion of medication administration. Outline and attendance record were submitted for review. (#22)
.
All staff at Woodbury CLA were trained by the Quality Assurance & Training Associate on 03/10/21 regarding medication errors, including the requirement to relay to the Incident Management Coordinator or On Call system upon discovery. Outline and attendance record were submitted for review. Outline and attendance record are submitted for review (#18)
Program Managers, Program Specialists, and Operations Directors were trained on regulation 6400.166(b) by the Director of Quality Assurance & Training on 03/09/21. Outline and attendance record are submitted for review. (#22) Program Managers will train all current medication administrators by 04/01/21 on legibility, proper documentation of mistaken entries, and signing the back of each MAR where the person has passed a medication. Outline and attendance sheet will be submitted to the Program Specialists by 04/02/21 for review and submit an email to the Operations Director confirming completion.
The Director of Quality Assurance & Training trained all Medication Administration Trainers regarding the medication administration issues within the plan of correction, requiring emphasis during subsequent face-to-face medication administration trainings for new medication administrators on 03/10/21. The outline and attendance sheet are submitted for review. (#24) Monitoring by the Quality Assurance & Training Associates will be completed during biannual inspections. |
04/02/2021
| Implemented |
| 6400.167(b) | Documentation of the medication errors described in 165(c) and 18(b)(2) of this report, the follow up action taken, and the prescriber's response was not kept in the individual's record. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | Program Managers were trained on regulation 6400.167(b) by the Director of Quality Assurance & Training on 03/09/21. The outline and attendance sheet were submitted for review. (#18) Medication errors are placed in a GER in the Therap system and the Incident Management Coordinator contacted.
All staff at Woodbury CLA were trained by the Quality Assurance & Training Associate on 03/10/21 regarding medication errors, including the requirement to relay to the Incident Management Coordinator or On Call system upon discovery. Outline and attendance record are submitted for review (#18) Each medication error that is not a documentation error must be conveyed to the prescribing physician for response. Program Managers are required to review this information regarding 6400.167(b) to staff who are medication administration trained prior to 04/01/21. Outline and attendance sheet will be submitted to the Program Specialists by 04/02/21 for review and submit an email to the Operations Director confirming completion.
Medication Administrators are retrained on medication errors. (#22) The outline and signature sheet are placed in the medication administrators medication file.
To ensure no further infractions occur, the Program Specialist and Operations Directors review GERs and verify documentation in the follow up section including prescribing physicians response and medication administrator retraining. Monitoring will be completed by the Quality Management Director during finalization of GERs in Therap. |
04/02/2021
| Implemented |
| 6400.181(f) | There are no records maintained that Individual #1 was provided a copy of his initial assessment completed on 2/24/2020, within 30 days prior to his 3/25/2020 annual individual plan meeting. The individual's record contains a notification letter addressed to his supports coordinator on 2/24/2020 stating there is an enclosed assessment for Individual #1. This letter also lists several team members who were sent this letter and the 2/24/2020 assessment, none of which were Individual #1. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Program Specialists were retained on regulation 6400.181(f) by the Director of Quality Assurance & Training on 03/09/21. Outline and attendance record are submitted for review. (#10) All initial and annual assessments will have the individual added to the list of persons receiving the assessment to review at least 30 days prior to the Annual Individual Plan meeting. This requirement begins on 03/10/21. Each Program Specialist will submit their next assessment to the Quality Assurance department for review. Monitoring will be completed by the Quality Assurance & Training Associate during biannual inspections. |
03/10/2021
| Implemented |
| 6400.186 | Individual #1's current, individual support plan (ISP) states that when the individual is at his residential home, he requires eye-sight supervision. During the 1/28/2021 remote inspection of his home, he was found to be in his bedroom, with his bedroom door shut, and not in eye-sight supervision of staff as there was not staff in his bedroom with him.
Individual #1 also has a 7/17/2020 behavior support plan created and last approved by the agency behavior specialist, program specialist, executive director, human rights chairperson, and the individual's mother. This plan states the size of the individual's food and how he can drink is restricted (but does not explain what his drink restriction is), his food will be cut into one inch pieces, and the team who created the plan believe the plan needs implemented to decrease the frequency of choking/aspirating. The plan states that the individual's behavior support plan is monitored monthly by a psychologist and/or a behavior specialist. The individual's dietary needs changed on 9/17/2020 by his physician to state the individual needs to follow a ground moist diet. The individual's behavior support plan to monitor his choking/aspiration concerns was never updated. Yet the agency staff continued to monitor the outdated plan monthly, stating that the individual's dietary needs addressed in the 7/17/2020 plan were being followed.
The individual's ISP states that OVR (Office of Vocational Rehabilitation) is assisting with a bill reader and an eye specialist appointment with a physician in State College due to the individual's diagnosis of Cortical Vision Impairment (CVI). The agency was unaware that the individual's ISP stated this and did not know if the individual received a bill reader or eye specialist appointment. | The home shall implement the individual plan, including revisions. | Protocols for new admissions has been updated (#12) to include review of the ISP sections that would be significant for the admission, the information that would require trainings prior to admission, and any follow up information to be obtained by the Supports Coordinator, which would include both the OVR statement and the eye specialist. Protocol has been submitted for review. A team meeting, to include but not limited to the Program Manager, Program Specialist, Operations Director, Director of Quality Assurance & Training will be documented. The meeting, scheduled by the Director of Quality Assurance & Training, will address all items in the ISP requiring clarification prior to the individuals admission to the home. The Program Specialist will be responsible for all trainings prior to admission. Completed trainings will be reviewed by the Operations Director for compliance. To ensure no further infractions occur, the Director of Quality Assurance & Training will review all documentation prior to setting an admission date.
Individual #1¿s Supports Coordinator has been contacted and a Team meeting is being schedule to clarify the eye-sight supervision in the home. ISP states immediately following that Individual #1 would need eye-sight supervision in most situations. Individual #1 is not a One-On-One. Eye-sight supervision at all times at home would remove any private time in his bedroom. If deemed necessary during the team meeting, the agency would submit request for one-on-one support and a new SIS assessment as this would require behavior plan and Human Rights approval for regulations 6400.32(h), 6400.32(l), and 6400.32(m).
The Program Manager is responsible for updating the Program Specialist by email with any changes in the care of the individual, including but not limited to dietary changes, immediately following appointments. The Program Specialist is required to email the Behavior Specialist with any changes in the care of the individual that impacts current behavior plans. The Behavior Specialist will adjust the behavior plan as necessary and submit to the Human Rights Committee for approval at the next scheduled meeting. Once the adjusted Behavior Plan is approved, the Behavior Specialist will train all staff on the plan immediately. To ensure no further infractions occur, the Operations Director, as part of the individuals team will follow the changes to ensure all parties have completed their assigned requirement. Monitoring will be completed by the Quality Assurance & Training Associate during biannual inspections, ensuring no lag in time and that all trainings have been completed. |
03/09/2021
| Implemented |
|
|