| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.53(a) | In room 27 there was a closet that contained various poisons such as nail polish remover. The closet had a lock which was inoperable and the items were removed to avoid accident. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | At time of inspection items were removed from closet. New placement was inside a locking closet in the room. Director, Adult Day Services will retrain all instructors by 1/7/20 to complete a visual scan of their room upon arrival to confirm all poisonous materials are in a located cabinet. They will also be reminded to put away in locked cabinet all poisonous materials after use throughout the day. |
01/07/2020
| Implemented |
| 2380.55(a) | Upper level women's bathroom had substance consistent with urine and feces unflushed in the handicapped stall.
Upper level water fountain was rusted at the spout. | Clean and sanitary conditions shall be maintained in the facility. | "Flushed at time of inspection; email sent to all Holland employees by Supervisor, hourly documented restroom checks are scheduled by the housekeeping staff.
Cleaned of all rust from spout. A line item was added to the weekly environmental check to ensure clean. All housekeepers will be retrained by 1/7/20. The Director will ensure environmental checks are being completed. " |
01/07/2020
| Implemented |
| 2380.111(a) | Individual#1's current exam held on 11/19/18 was completed more than a year from the previous physical dated 11/1/17.
Individual#4's annual physical dated 12/10/18 was completed more than a year from the previous physical dated 7/12/17. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | "APE scheduling to be done by nurse at The Medical Center. Refusals/no-shows will be documented in chart and discussed with team as needed.
The Director, Records Services will assign a designated person who will be responsible for reviewing the chart/resident file with surveyor. This person must communicate any information not able to be found to the Director, Records Services. The Director, Records Services will then try to locate information in the record and supply to the surveyors. " |
02/28/2020
| Implemented |
| 2380.111(c)(1) | individual#4's annual physical dated 12/10/18 did not indicate that medical history was checked. | The physical examination shall include: A review of previous medical history. | "APE form within the medical EHR will be edited to include field for individual's medical history. Going forward Nursing will check that all required fields are completed.
The Director, Records Services will assign a designated person who will be responsible for reviewing the chart/resident file with surveyor. This person must communicate any information not able to be found to the Director, Records Services. The Director, Records Services will then try to locate information in the record and supply to the surveyors. " |
02/28/2020
| Implemented |
| 2380.111(c)(3) | Individual#4's annual physical dated 12/10/18 did not contain immunizations.
Individual #2's annual physical dated 10/26/18 did not contain immunizations.
Individual#6's annual physical dated 1/25/19 did not contain immunizations.
Individual#1's annual physical dated 11/19/18 did not indicate past immunizations.
Individual#3's immunizations were not recorded on the physical dated 11/07/18. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | APE form w/in medical EHR will be updated to include this. Nursing will be responsible to ensure all fields are present prior to uploading |
02/28/2020
| Implemented |
| 2380.111(c)(4) | Individual#4's annual physical dated 12/10/18 did not indicate that a hearing screening was completed. Vision was completed separately on 10/3/19.
Individual#2's last Vision screen was completed on 8/8/19. The last hearing screen completed 4/30/18 which is more than a year from the date of this inspection.
Individual#3 had an eye exam on 5/28/19. The last hearing screening was completed on 3/26/18 which is more than a year from the date of this inspection. | The physical examination shall include: Vision and hearing screening, as recommended by the physician. | "Scheduling to be done by audiology assistant. Refusals/no-shows will be documented in chart and discussed with team as needed.
The Director, Records Services will assign a designated person who will be responsible for reviewing the chart/resident file with surveyor. This person must communicate any information not able to be found to the Director, Records Services. The Director, Records Services will then try to locate information in the record and supply to the surveyors. " |
02/28/2020
| Implemented |
| 2380.111(c)(6) | lndividual#1's annual physical dated 11/19/18 did not indicate if the individual was free of communicable disease.
Individual#4's annual physical dated 12/10/18 did not indicate if the individual was free of communicable disease.
Individual#6's annual physical dated 1/25/19 did not indicate if the individual was free of communicable disease.
Individual#7's annual physical dated 2/1/19 did not indicate if the individual was free of communicable disease. | The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals. | APE form w/in medical EHR will be updated to include this. Nursing will be responsible to ensure all fields are present prior to uploading |
02/28/2020
| Implemented |
| 2380.111(c)(7) | Individual#1's annual physical dated 11/19/18 did not indicate assessment of health maintenance needs.
Individual#4's annual physical dated 12/10/18 did not indicate assessment of health maintenance needs.
Individual#7's annual physical dated 2/1/19 did not indicate assessment of health maintenance needs. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | "APE form within the medical EHR will be edited to include field for individual's health maintenance needs. Going forward Nursing will check that all required fields are completed.
The Director, Records Services will assign a designated person who will be responsible for reviewing the chart/resident file with surveyor. This person must communicate any information not able to be found to the Director, Records Services. The Director, Records Services will then try to locate information in the record and supply to the surveyors. " |
02/28/2020
| Implemented |
| 2380.111(c)(8) | The physical exam for individual #5 dated 2/25/19 did not include the physical limitations of the individual.
The physical exam for individual #6 dated 1/25/19 did not include the physical limitations of the individual.
The physical exam for individual #7 dated 2/1/19 did not include the physical limitations of the individual.
Individual#4's annual physical dated 12/10/18 did not indicate physical limitations. | The physical examination shall include: Physical limitations of the individual. | "APE form within the medical EHR will be edited to include field for individual's physical limitations. Going forward Nursing will check that all required fields are completed.
The Director, Records Services will assign a designated person who will be responsible for reviewing the chart/resident file with surveyor. This person must communicate any information not able to be found to the Director, Records Services. The Director, Records Services will then try to locate information in the record and supply to the surveyors. " |
02/28/2020
| Implemented |
| 2380.111(c)(10) | Individual#1's annual physical dated 11/19/18 did not indicate information pertinent to diagnosis in case of an emergency.
Individual #5's annual physical dated 2/25/19 did not indicate information pertinent to diagnosis in case of an emergency.
Individual #7's annual physical dated 2/1/19 did not indicate information pertinent to diagnosis in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | "APE form within the medical EHR will be edited to include field for information pertinent to diagnosis. Going forward Nursing will check that all required fields are completed.
The Director, Records Services will assign a designated person who will be responsible for reviewing the chart/resident file with surveyor. This person must communicate any information not able to be found to the Director, Records Services. The Director, Records Services will then try to locate information in the record and supply to the surveyors. " |
02/28/2020
| Implemented |
| 2380.111(c)(11) | Individual#1's annual physical exam dated 11/19/18 did not indicate dietary needs.
Individual#2's annual physical exam does not indicate any special dietary needs however the assessment dated 8/27/19 suggests that the individual is to have yogurt three times a day and Ensure Plus four times a day.
The physical exam dated 2/25/19 did not include special diet instructions for individual #5.
The physical exam dated 1/25/19 did not include special diet instructions for individual #6.
The physical exam dated 2/1/19 did not include special diet instructions for individual #7. | The physical examination shall include: Special instructions for an individual's diet. | "APE form within the medical EHR will be edited to include field for individual's diet. Going forward Nursing will check that all required fields are completed.
The Director, Records Services will assign a designated person who will be responsible for reviewing the chart/resident file with surveyor. This person must communicate any information not able to be found to the Director, Records Services. The Director, Records Services will then try to locate information in the record and supply to the surveyors. " |
02/28/2020
| Implemented |
| 2380.113(a) | Staff member #1's physical exam was completed 2/11/19 but not signed until date of inspection 10/23/19. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The representatives of RL Health and Woods nursing met to discuss the required information. Going forward, the residential nurse will ensure all history and current health information is present on the physical. Once the physical is completed nursing will upload the physical into EHR and will ensure that any doctors orders are completed. |
02/28/2020
| Implemented |
| 2380.171(b)(3) | The name, address and phone number of the person able to give consent for emergency medical treatment for individual #7 was not included in record.
The last attempt for consents to family was 4/2019, there was no response from the family. | Emergency information for each individual shall include: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. | The name, address and phone number of person able to give consent was located on the individuals Facesheet. The Director, Records Services will assign a designated person who will be responsible for reviewing the chart/resident file with surveyor. This person must communicate any information not able to be found to the Director, Records Services. The Director, Records Services will then try to locate information in the record and supply to the surveyors. |
12/27/2019
| Implemented |
| 2380.173(1)(ii) | Identifying marks not included in individual#6's record at inspection.
There was no mention of identifying marks in individual#4's record.
Individual#2's record did not indicate identifying marks.
Individual#3's record did not contain identifying marks. | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. | "Identifying marks are located on the day program assessment on page 1 under the heading, Introduction.
The Director, Records Services will assign a designated person who will be responsible for reviewing the chart/resident file with surveyor. This person must communicate any information not able to be found to the Director, Records Services. The Director, Records Services will then try to locate information in the record and supply to the surveyors." |
12/01/2019
| Implemented |
| 2380.173(1)(iv) | There was no mention of religious affiliation in individual#4's record. | Each individual's record must include the following information: Personal information including: Religious affiliation. | AVP and Directors of Care Coordination will train Care Coordinators on the importance of making a selection for Religion even if the information is unknown, they will be trained to select ¿unknown¿ so that every individual has an appropriate response. |
12/27/2019
| Implemented |
| 2380.177 | Written consents for release of information was not found in the record at inspection for individual #7. | Written consent of the individual, or the individual's parent or guardian if the individual is incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it. | "The Records Services Department mailed out consent packets to mother on 12/18/18 and 4/11/19 with no response. Another consent packet was mailed on 11/5/19 Care Coordinator reached out on 11/21/19, Mom returned the signed consents on 11/20/19.
The Care Coordinator will be responsible for calling parent to follow up and ensure documents are signed and returned to Woods." |
12/01/2019
| Implemented |
| 2380.181(a) | Individual#4's most recent assessment dated 9/6/18 was completed more than a year from the date of this inspection. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | Assessment was last signed on 9/6/18, an error was made and the adult day care coordinator was informed to submit a new one. Director, Adult Day Services will ensure all assessments are not done more than 1 year apart by having all dates verified. |
11/11/2019
| Implemented |
| 2380.181(e)(1) | Individual#5"s preferences not listed on assessment dated 3/7/19. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | "Assessment dated 3/7/19 details this area.
The Director, Records Services will assign a designated person who will be responsible for reviewing the chart/resident file with the surveyor. This person must communicate any information not able to be found to the Director, Records Services. The Director, Records Services will then try to locate information in the record and supply to the surveyors. " |
12/27/2019
| Implemented |
| 2380.181(f) | it could not be determined if the assessment was provided to the individual plan team members 30 days prior to the individual plan meeting. No documentation found at inspection. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting. | Assessments will be completed and submitted to records for distribution at least 30 calendar days before ISP meetings by Adult day care coordinator. Moving forward, a tracking sheet will be utilized. In this situation the sheet was updated in error. The Director, Adult day program, will ensure compliance. |
11/08/2019
| Implemented |