|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self-assessment for the home was completed 4-10-16. The Certificate of Compliance has an expiration date of 6-9-16. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| Armstrong Care, Inc. will in-service all Program Specialists and all Supervisors on making sure a self-assessment of each home serving eight or fewer individuals is completed within 3 to 6 months prior to the expiration date of the Armstrong Care, Inc.`s certificate of compliance. This in-service was completed by July 29, 2016. Also, Armstrong Care, Inc. will remind all Program Specialists and Supervisors to begin completing the self-assessment from February 1st of each year and to be completed and turned in no later than February 28, of each year. This process will be monitored by the Program Specialist Manager and the Program Director in order to prevent similar deficiencies from reoccurring in the future. [Documentation of reviews shall be kept. (AS 9/20/16)]
|
08/08/2016
| Implemented |
| 6400.31(a) | Individual #1, date of admission 9-11-15 was informed of individual's rights on 9-14-15. | Each individual, or the individual's parent, guardian or advocate, if appropriate, shall be informed of the individual's rights upon admission and annually thereafter. | Upon admission to Armstrong Care, Inc. each individual, or the individual¿s parent, guardian or advocate, if appropriate, shall be informed of the individual¿s rights upon admission and annually thereafter. Program Specialist has a checklist that will be completed upon admission of each new resident to Armstrong Care, Inc. Direct Care Staff along with Program Specialist have been trained on the importance of all the intake forms that are to be signed and dated upon admission to ACI and the use of the Checklist form. Training was held on July 22, 2016.[Within 30 days of receipt of the plan of correction the program specialist shall review all individuals' records and admission check list to ensure all individuals have been informed of the rights upon admission and annually as required. The program director shall review all new admissions checklists and individual rights documentation to ensure completion by the program specialist and that individuals' are informed of rights as required. Documentation of reviews shall be kept. (AS 9/20/16)] |
08/08/2016
| Implemented |
| 6400.141(c)(3) | The physical examination dated 7-22-15 for Individual #1, date of birth 12/28/59 did not include immunizations. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | IMMUNIZATION RECORDS FOR INDIVIDUAL #1
SCANNED FIRST RECORD CAME WITH INDIVIDUAL #1 UPON ADMISSION TO ARMSTRONG CARE, INC. FROM SOUTHWOOD HOSPITAL, THE SECOND CONTAINS A TRANSFER OF THOSE RECORDS OVER TO THE ELECTRONIC RECORDS OF HIS PCP AND HAS HIS ADDITIONAL ONES ADDED TO IT. THESE WERE ATTACHED TO THE PHYSICAL ON THE DAY OF INSPECTION AND WERE THERE UPON ADMISSION TO ARMSTRONG CARE. A COPY WILL BE SENT TO LICENSING FOR INSPECTION.[Individual #1's physical examination was updated on 7/22/16 to include immunizations. Within 30 days or receipt of the plan of correction and prior to entering in to the individuals' records, the residential supervisor(s) and program specialist(s) shall review the individuals' current physical examination documentation to ensure the physical examination is completed, sign and dated by the physician, certified nurse practitioner or licensed physician's assistant and there are no require areas left blank and missing information shall be obtained. At least quarterly, the program director shall review a 25% sample of physical examination to ensure the physician, certified nurse practitioner or licensed physician's assistant completed, signed and dated as required. (AS 8/18/16)]
|
08/08/2016
| Implemented |
| 6400.141(c)(14) | The physical examination for Individual #1 dated 7-22-15 did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #1 physician was contacted by Armstrong Care, Inc. supervisor to clarify if there was any medical information pertinent to diagnosis and treatment in case of an emergency that needed added to the physical exam for Individual #1. Individual #1¿s physical was completely filled out by his/her PCP and return to his/her Supervisor and it will be forwarded to licensing. Additional safeguards will be implemented to ensure this section, and no other sections of the annual physical form are blank going forward. A Physical Examination Training was held on Monday July 25, 2016 with all Residential Supervisors, and Program Specialist. Emphasis was brought to their attention to not have any section on the physical left blank when leaving the physician¿s office. Medical Information Pertinent to the Diagnosis and Treatment in Case of Emergency along with all other areas of the physical will be completed by the physician before leaving the office the day of the individual¿s appointment. There are Sections that are appropriate for staff to complete prior to the appointment. These sections are demographics, history, medication and allergy type information that the doctor generally asks the patient during the exam. They are also already current on the Emergency Medical Information form that is being shared with the physician at the appointment. These items, the EMI and the sections of the physical completed by staff should ALWAYS match going into the exam. The physician can make changes in these sections as he determines is necessary. Residential Program Supervisors received training on July 25, 2016 for implementation of this form. Training verification will be sent to licensing.[Individual #1's physical examination was updated on 7/22/16 to include medical information pertinent to diagnosis and treatment in case of an emergency. Within 30 days or receipt of the plan of correction and prior to entering in to the individuals' records, the residential supervisor(s) and program specialist(s) shall review the individuals' current physical examination documentation to ensure the physical examination is completed, sign and dated by the physician, certified nurse practitioner or licensed physician's assistant and there are no require areas left blank and missing information shall be obtained. At least quarterly, the program director shall review a 25% sample of physical examination to ensure the physician, certified nurse practitioner or licensed physician's assistant completed, signed and dated as required. (AS 8/18/16)] |
08/08/2016
| Implemented |
| 6400.141(c)(15) | The physical examination for Individual #1 dated 7-22-15 did not include special diet instructions. | The physical examination shall include:Special instructions for the individual's diet. | Individual #1 physical 7/22/2015 from admission to ACI no special diet instructions. Individual #1 was on a Thick-It diet which came with him from the Nursing Home that had cared for him. ACI¿s plan of correction is for Supervisors and Program Specialist to follow the physical training that was given on July 25, 2016, which included in depth the reason for no blanks on the intake physical and all annual physicals. Each area of the physical must follow the regulation as specified in Pa Regulation 6400.141.
¿ A review of previous medical history.
¿ A general physical examination.
¿ Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.
¿ Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician.
¿ Immunizations and screening tests for individuals 17 years of age or younger, as recommended by the Standards of Child Health Care of the American Academy of Pediatrics, Post Office Box 1034, Evanston, Illinois 60204.
¿ Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted.
¿ A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations.
¿ A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. A prostate examination for men 40 years of age or older.
¿ Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals.
¿ An assessment of the individual¿s health maintenance needs, medication regimen and the need for blood work at recommended intervals.
¿ Physical limitations of the individual.
¿ Allergies or contraindicated medications.
¿ Medical information pertinent to diagnosis and treatment in case of an emergency.
¿ Special instructions for the individual¿s diet.[Individual #1's physical examination was updated on 7/22/16 to include special instructions for the individual's diet. Within 30 days or receipt of the plan of correction and prior to entering in to the individuals' records, the residential supervisor(s) and program specialist(s) shall review the individuals' current physical examination documentation to ensure the physical examination is completed, sign and dated by the physician, certified nurse practitioner or licensed physician's assistant and there are no require areas left blank and missing information shall be obtained. At least quarterly, the program director shall review a 25% sample of physical examination to ensure the physician, certified nurse practitioner or licensed physician's assistant completed, signed and dated as required. (AS 8/18/16)] |
08/08/2016
| Implemented |
| 6400.163(c) | The 3 month medication reviews dated 1-18-15, 1-21-16, 4-14-16, and 6-17-16 for Individual #1 did not include the reason for prescribing the medications. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | AT THE TIME OF INSPECTION WE WERE CITED DUE TO THE FACT THAT THE MEDICATION LABEL DID NOT MATCH THE MAR. THE LABEL STATED BY MOUTH WHEREAS THE MAR STATED VIA THE PEG TUBE. INDIVIDUAL #1 HAS A PEG TUBE AND THE MAR WAS RIGHT. THE LABEL WAS FIXED ON SITE THAT DAY. WE WERE NOT CITED FOR MEDICATION REVIEWS AS INDICATED ABOVE. OUR PLAN OF CORRECTION ON WHAT WE WERE CITED FOR WAS A MEDICATION CHECK IN TRAINING. MEDICATION CHECK IN PROCESS WHICH IS INDICATED BELOW.
Medication check in procedure
Upon arrival of medications staff is to
1. Get medication sign in sheet and pen.
2. Compare list from KPS to what has been delivered.
3. If a med is on KPS¿s list but not delivered, make note on KPS list and send with delivery person also make note on sign in sheet.
4. Immediately sign in all meds then lock meds in med cart.
5. Compare old MAR to new MAR and then to Medication labels. If there is any discrepancies make note of medication name and description of discrepancy along with any meds not delivered on the sign in sheet.
Supervisors are to recheck all medications and MAR that has been delivered then compare to sign in sheet. Call KPS with any problems as soon as possible.
Medication change procedure
When there is a change in a medication you must
1. Give prescription to KPS or electronically sent to KPS on SAME DAY
2. Contact KPS to inform them there is a medication change
3. Keep in contact with KPS until they have received new prescription.
4. Fill out medication change form
5. Inform all team members
6. YOU CAN NOT CHANGE MAR WITHOUT NEW PRESCRIPTION LABEL. If the medication does not arrive with new label you cannot add or make changes to MAR nor can you give medication change. You must give medication as per the MAR until you receive new label, medication with label change or new medication.
Plan of correction:
1. Retrain all staff and supervisors on medication check in procedure and medication change procedure. Training was held on July 18, 2016.
2. Post procedures at Med cart and in area of house where med deliveries arrive.
KPS is the pharmacy that we use to supply our blister packs of medication.
[Within 30 days of receipt of plan of correction, the program director and/or president will develop and implement policies and procedures to include a review process to ensure three month medication reviews are completed timely and required information is present. Within 60 days of receipt of the plan of correction, all staff responsible for implementing the policies and procedures shall be trained by the program director on what is required in medication review documentation and the policies and procedures to include a review process. Documentation of policies, procedures, reviews and trainings shall be kept. (AS 9/20/16)] |
08/08/2016
| Implemented |
|
|