|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(13) | Individual #1's current, 12/11/19 physical examination states he has seasonal allergies. According to the Individual's 12/5/19 Diabetes and Endocrinology medical documentation, Individual #1 is allergic to Penicillin. This individual's allergy to Penicillin was not included on his 12/11/19 physical examination record nor is there evidence of the agency's attempt to clarify Individual #1's allergy to Penicillin in the record. | The physical examination shall include: Allergies or contraindicated medications. | 6400.141.c13: Consumers Physical Examination Form:
o LSS revised the physical examination form to include all current allergies (see supporting documentation).
Wellness Coordinator & LSS Compliance Coordinator will review all individuals Annual Physical Examination forms upon submission from the group home ensuring the physical examination form is following regulation 6400141.c13.
If regulation 6400141.c13 is not met, the WC & CC is NOT to sign off on the form for verification until the form follows the regulation. WC & CC will verify allergies identified match all clinical documentation in the medical chart.
o 11/20/20
Keynote:
Individual was not allergic to Penicillin as per the legal guardian at any time. The allergy was a documentation error on the part of the physician. |
11/20/2020
| Implemented |
| 6400.143(a) | The individual's refusals to comply with medical recommendations and physician's orders were not documented for every refusal, and the continued attempts to train the individual about the need for health care was not documented in the individual's record. The following are examples of medical recommendations and orders that were refused by the individual.
· Individual #1 refused to attend his 11/29/19 physical therapy appointment.
· The agency reported that Individual #1 refused to wear his physician's ordered CPAP machine nightly. After the Department initiated the unannounced monitoring on 6/15/2020 and requested said information, then the agency documented the individual's refusal of utilizing the CPAP machine after 6/19/2020. However, staff's monitoring of the individual's refusals and the training provided to him after 6/19/2020.
· On 5/7/2020, Individual #1's primary care physician and his podiatrist on 5/12/2020 both state that the individual is to wear 20-30mmhg compression stockings. There is no records maintained that the individual wears or refuses to wear his compression stocking until 6/19/20. | 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. | 6400.143a: Consumer refusals:
LSS developed a generalized consumer refusal form to be completed by RSWs and/or House Supervisors (see attached refusal form). House staff are to email WCs, Program Specialist (PS) when a refusal occurs followed by an entry into care tracker pending topic making them aware of the refusal.
Refusals forms are to be sent to WC & PS for review and filed in consumers medical books.
How to prevent?
o LSS WC & PS will check email and care tracker daily identifying any refusals.
o WC ensure consumer refusal forms have been completed and submitted as directed.
o Once a refusal has been identified, WC will provide education with consumer & follow up with consumers PCP and/or specialized doctor when warranted.
o CC will ensure all consumer refusals have been follow-up with education as well as with necessary paperwork/signature pages verifying education had occurred.
Implementation date of correction?
o 11/20/20
Who is responsible for each step?
o House staff to complete and submit refusal forms.
o WC to educate consumers on refusals,
o CC to ensure all consumers have received the necessary follow-up for refusals with documentation. |
11/20/2020
| Implemented |
| 6400.144 | The following are examples of health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services, planned for or prescribed that were not completed as prescribed.
· According to LifeStyle Support Services' medical appointment summary record for Individual #1, on 8/15/19 the individual was prescribed Mupirocin ointment to apply twice a day for 7 days for mild folliculitis treatment. Mupirocin wasn't administered for seven days as prescribed. The individual's record also did not include if the medication was refused by the individual.
· Individual #1's record includes a prescription from his physician on 8/1/2018 that reads, "check blood sugar fasting daily and record result." Throughout his record his blood sugar was not taken due to either the home not having the needed equipment needed or his blood sugar was not taken while fasting. The following are times when his blood sugar was not taken daily as prescribed: 9/14/19, 2/13/2020 and 3/10/2020.
1. 3/15/2020, 3/16/2020, and 5/12/2020 blood sugar was not taken due to the home not having necessary equipment (pen needles).
2. 4/8/2020, 4/10/2020, 4/11/2020 and 4/22/20 blood sugar levels were not obtained until after breakfast (not fasting) with no indication of the individual refusing to allow blood sugar check to be done prior to breakfast.
· Individual #1 has routine counseling appointments. He was seen on 6/6/19 with a return appointment scheduled for 7/11/19 per agency appointment summary. He was not seen on 7/11/19.
· He was seen for his counseling appointment on 9/19/19 and was to return on 9/26/19. Individual #1 did not return for his appointment on 9/26/19. The agency reported that on 9/26/19 they canceled Individual #1's 9/26/19 counseling appointment due having another appointment that day. However, the agency does not have record of the individual attending any appointments on 9/26/19 or the individual's refusal to attend an appointment on 9/26/19. He did not return to his counselor until 10/3/19.
· On 5/12/2020 Individual #1's podiatrist stated the individual is to return on 7/21/2020. There is no evidence of this return appointment.
· Individual #1's record contained a recent hospitalization discharge summary report from 6/16/2020. The discharge instructions included medications that should continue to be taken upon discharge on 6/16/2020 and "if there are any questions on the medications, the agency is to contact the individual's provider." The hospital summary stated Individual #1 was to continue to take Divalproex Sodium 250mg at bedtime, Divalproex Sodium 250mg twice a day, and Hydroxyzine Pamoate 25mg every 6 hours as needed upon his 6/16/2020 discharge, among many other medications. Staff person #4 confirmed via 6/22/2020 email that she documented on the discharge summary that medications Hydroxyzine Pamoate and the Divalproex 250mg bedtime dosage was discontinued. However, Staff person #4 also confirmed on 6/22/2020 that she confirmed with the hospital that said medications were not discontinued. Staff person #4 then documented on the discharge summary that Hydroxyzine and the bedtime 250mg dose of Divalproex was not discontinued. Individual #1's bedtime, 250mg dose of Divalproex was never administered to him after his 6/16/2020 discharge. The individual's prescribed Hydroxyzine wasn't available to him after his 6/16/2020 discharge. There is no evidence that the agency contacted the individual's provider regarding any medications ordered from the hospital upon discharge. | 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.
| 6400.144: Health Services, such as medical, nursing, pharmaceutical, dental, dietary & psychological services that are planned or prescribed for consumers shall be provided.
What we did to correct?
o LSS will develop an individualized tracker identifying consumer recommendations made by doctors based on the original appointment summary to ensure health services are provided as prescribed.
o
¿ How to prevent?
o Wellness Coordinator (WC) & LSS Compliance Coordinator (CC) will review all individuals appointment summaries upon submission from the group home ensuring recommendations are follow-up with as prescribed following regulation 6400.144.
¿ Implementation date of correction?
o 11/20/20
¿ Who is responsible for each step?
o LSS Wellness Coordinators will develop individualized trackers identifying doctor recommendations based on consumers appointment summaries.
o CC is to monitor the WC tracker daily ensuring WCs are entering doctor recommendations on the tracker.
o to review consumer appointment summaries upon submission ensuring doctor recommendations have been followed up with. |
11/20/2020
| Not Implemented |
| 6400.212(a) | Individual #1's 11/14/19, 3/17/20, 5/20/20, and 6/17/2020 restrictive procedure plans reference another individual's name and their behaviors, twice within each plan and only once on 6/17/2020. Separate records and behavior support plans must be kept for each individual. | A separate record shall be kept for each individual.
| 1. 212a
Concern: Another individual first name within the Behavior Support Plan on one occasion
a. Behavior Specialist/Clinical Coordinator/Program Specialist
b. What: there was a first name of an individual in the plan for this individual. The BSP for 6.14.2020 had 1 occurrence of this. This was completely fixed on 9.11.2020. This individual, everyone from the treatment team, and the Legal Guardian signed that they reviewed the plan in full, with no comments for corrections. It is clear that this plan is for this individual as it is listed on the 1st page with his name and identifying information, then at the bottom of every page of his plan has the individuals name. The top of the Behavior Support Plan states the following all parties listed below have read the behavior support plan and support its use in its current form.
c. Moving forward: The plan for this individual has already been corrected on 9.11.2020. For all the individuals within the agency, after the Behavior Specialist has reviewed the plan, the Clinical Coordinator will review, and then followed by the Program Specialist in efforts to catch any errors. There will be an additional signature page completed to show that the Behavior Specialist, Clinical Coordinator, and Program Specialist have reviewed and read the plan.
d. The updates will start for the plans being reviewed on 12.16.2020. |
12/16/2020
| Implemented |
| 6400.18(b)(2) | Medication errors described in violation 6400.167(b) of this report, were never reported to the Department through the Department's information management system or on a form specified by the Department. | 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. | 6400.18b2: Medication Errors in HCSIS.
What we did to correct
LSS will re-educate WCs on LSS incident Management policy identifying reporting timelines for HCSIS incidents.
How to prevent
o LSS Incident Manager will re-train WC on the LSS incident management policy.
o WC will enter all medication errors within 72hrs.
¿ Implementation date of correction?
o 11/20/20
Who is responsible for each step?
o LSS Incident Manager is responsible to train WCs on LSSs incident management policy.
o WC are responsible to enter medication errors in HCSIS within 72hrs. of error. |
11/20/2020
| Not Implemented |
| 6400.32(r) | Individuals #1 and #2 were not offered their right to lock their individual bedroom door via any locking mechanism described under 6400.3(r)(1) that would permit the individuals to lock and unlock their door. During the 6/30/2020 remote inspection (virtual, onsite inspection due to COVID-19 national pandemic) of the home, both individuals confirmed that they were never offered the ability to lock their individual door nor were they offered a key to their bedroom door. Neither Individuals' Individual Plans state that they were offered the ability to have a locked bedroom door and their wishes and/or their guardian's wishes if they wanted a locked bedroom door. | An individual has the right to lock the individual's bedroom door. | Individuals will be provided with door lock and key if guardian of individual 1 approves (individual 2 already provided with door lock and key). All individuals and/or guardians will be provided with a consent form to approve or disapprove a lock being placed on their bedroom door. If individuals choose a lock, they will be provided with a key. |
12/30/2020
| Implemented |
| 6400.34(a) | Individual #1 and his legal guardian were informed of Individual #1's rights on 4/1/2019 and again on 2/27/2020. However, the Department issued updated individual rights effective 2/3/2020. The individual's rights reviewed with Individual #1 and his legal guardian on 2/27/2020 did not include a review of the individuals rights defined in 6400.32(d), (e)-(i), and (p)-(v). | 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. | New individual rights form was created. Individual 1 guardian reviewed and signed. LSS will implement the form to all individuals/guardian at LSS.
Program Specialists will work with Compliance Coordinator to ensure all individuals and guardians sign updated individual rights form. |
12/11/2020
| Implemented |
| 6400.163(d) | Per agency report, Individual #1 is assessed to be unable to administer his own medications and fully capable of using a key to unlock a padlock or door lock in the home. During the 9/2/2020 onsite inspection of the home, Individual #1's Trulicity medication was stored in a locked box in the refrigerator in the kitchen of the home. However, the key to access the locked box, was stored in an unlocked and accessible compartment on the locked box itself, making the medication accessible to Individual #1 with the capability to use a key to unlock the box. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | 6400.163d: Medication kept in locked areas or containers.
What we did to correct?
o LSS provided a locked box and keys the consumers staff in order to store medications and syringes.
How to prevent?
o House staff will keep the locked box key with them when working ensuring the consumers meds & syringe is locked in the locked box.
o WC will verify the consumers meds and syringe are locked and not accessible to the consumer due to the consumer not being able to self-administer medications.
Implementation date of correction?
Who is responsible for each step?
o WC are responsible to ensure a lock box is provided to the consumers home with keys so medications and syringes can be locked up as per regulation 6400.163d. |
11/06/2020
| Implemented |
| 6400.165(c) | The following are examples of Individual #1's medications not being administered as prescribed by his physicians.
· According to Individual #1's October 2019 medication administration record (mar), he was prescribed Mupirocin ointment to be applied 1 gm to affected area twice a day as needed for 7 days. This medication was applied daily for 10 consecutive days from 10/10-19/2019 for an open wound on the individual's shoulder, neck, back, and arm. The medication was administered for more consecutive days than prescribed and there is no evidence that the individual's physician was informed of the length of time this medication was administered and the reason for administering it.
· Individual #1 is prescribed Lamotrigine 150mg at 8PM, Metformin 1,000mg at 5PM, Perphenazine 16mg at 8Pm, and Ropinirole .5mg at 8PM on 12/9/19. Staff person #5 initialed the individual's electronic mar as administering all said medications at their corresponding times on 12/9/19 to Individual #1. However, Staff person #5 also initialed as administering the individual the same medications again on the individual's paper, 12/9/19 mar. There is no evidence to clarify the double-dosage of medication administration recorded.
· On 12/16/19 at 2:43PM, Staff person #7 administered Individual #1 50mg of Chlorpromaz and 50mg of Diphenhydramine for agitation. However, Individual #1 was prescribed to take 75mg of Chlorpromaz and 50mg of Diphenhydramine taken together for agitation. Staff person #7 administered the incorrect dosage of Chlorpromaz. This was evidenced by Staff person #7 documenting she administered one, 50mg tablet of Chlorpromaz. The order was to administer 1 and ½ tablets (1.5 tablets= 75mg total) of Chlorpromaz.
· On 1/10/2020 Keflex was ordered to take 1 capsule by mouth 3 times a day for 10 days. Keflex was administered to Individual #1 three times a day from 8AM on 1/11/2020 to 8PM on 1/20/2020 (10 days) plus two additional administrations at 8AM and 4PM on 1/21/2020, the 11th day. The individual's record does not contain evidence from the individual's physician of a change of order extending the medication administration.
· According to Individual #1's February 2020 medication administration record (mar), he is prescribed Sumatriptan 100mg, take 1 tablet by mouth at onset of migraine headache, may repeat in 2 hours if needed, for a diagnosis of Migraine headaches. Staff person #8 administered Sumatriptan to Individual #1 at 9:42PM on 2/21/2020 for back pain, the incorrect reason for prescribing the medication.
· Additionally, Staff person #9 recorded that he administered 2 tablets of Sumatriptan at 8:04PM on 3/7/2020 to Individual #1 for back pain. According to the doctor's order written above, Staff person #9 administered Individual #1 the incorrect dosage of Sumatriptan medication and for the incorrect diagnosis or purpose for administering the medication.
· Individual #1 had an upper Gastrointestinal Endoscopy completed on 3/10/2020. Per agency medication error report and the individual's medication administration record (mar), Individual #1 was to receive all of his morning medications (Docusate Sodium 100mg, Losartan Pot 100mg, Divalproex 250mg, Gabapentin 300mg, Lamotrigine 150mg, Pantoprazole 40mg, Perphenazine 12mg) but Staff person #9 failed to administer the individual his medications.
· Individual #1's Metformin 500mg was not administered on 3/19/2020. Staff person #8 recorded that the medication was held due to doctor's order. However, there isn't a doctor's order to hold the individual's Metformin on 3/19/2020.
· Individual #1 was prescribed Gabapentin 300mg, take 2 pills at bedtime. Individual #1's medication Gabapentin was not administered as ordered on 5/28/2020 and 5/29/2020 at bedtime. The agency reported the medication error stating that staff only administered 150mg of Gabapentin each night, on 5/28 and 5/29, and not the prescribed 600mg dosage nightly. | A prescription medication shall be administered as prescribed. | 6400.165c: Prescription Medication shall be administered as prescribed.
What we did to correct?
o LSS will monitor Quick Mar daily to ensure consumer medications are being administered as prescribed.
How to prevent?
o WC will enter all med errors in HCSIS with 72 hours.
o WC will utilize LSS Med Error Protocol (point system) in educating staff when medication errors occur.
o WC will file all follow-up action documentation in consumers record.
Implementation date of correction?
o 11/20/20
Who is responsible for each step?
o WC is responsible to enter medication errors in HCSIS within 72hrs. of error.
o WC is responsible to utilize LSS Med Error Protocol (point system) in educating staff when medication errors occur.
o WC will file all follow-up action documentation in consumers record.
o (WC) & (CC) are responsible to ensure LSS is following regulation 6400.165c. |
11/20/2020
| Implemented |
| 6400.165(g) | Individual #1 saw his psychiatrist on 8/5/19 for a review of his psychotropic medications and was to return on 10/7/19. The individual did not return on 10/7/19 and there is no evidence for the missed appointment. The individual did not return to his psychiatrist to have his medications reviewed until 12/4/2019. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | 6400.165g: If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes documentation of reason for prescribed medication.
5. What we did to correct?
a. LSS will follow up all psychiatric appointments ensuring the doctor or licensed physician reviewed and documented reason for prescribed medications. appointment summaries are completed and sub mitted to LSS medical department.
6. How to prevent?
a. LSS house staff is required to complete and submit a consumer appointment summary for consumers who see a psychiatrist outside of LSS.
b. LSS WC is required to follow-up with group homes the next business day ensuring the appointment summary was sent to the office.
c. LSS WC is required to review the psychiatric appointment summary ensuring all necessary information is documented to meet the 6400.165g regulation.
d. LSS CC is required to review all appointment summaries ensuring a licensed physician reviewed and documented reason for prescribed medications on the appointment summaries at least every 3 months.
7. Implementation date of correction?
a. 11/20/20
8. Who is responsible for each step?
a. LSS WC is responsible to complete a psychiatric appointment summary for consumers meeting with the psychiatrist. LSS house staff is required to complete and submit a consumer appointment summary for consumers who see a psychiatrist outside of LSS.
b. LSS WC is required to follow-up with group homes the next business day ensuring the appointment summary was sent to the office.
c. LSS WC is responsible to review the psychiatric appointment summary ensuring all necessary information is documented to meet the 6400.165g regulation.
d. LSS WC is responsible to submit all completed psychiatric appointment summaries to LSS CC.
e. LSS CC is responsible to review all psychiatric appointment summaries ensuring a licensed physician reviewed and documented reason for prescribed medications on the appointment summaries at least every 3 months. |
11/20/2020
| Implemented |
| 6400.167(b) | Documentation of the medication errors described in 6400.165(c) of this report, the follow-up action taken, and the prescriber's response were not documented and kept in Individual #1's record. The following are the medication errors not documented:
· Individual #1 was prescribed Mupirocin ointment to be applied 1 gm to affected area twice a day as needed for 7 days. This medication was applied daily for 10 consecutive days from 10/10-19/2019. The medication was administered for more consecutive days than prescribed.
· On 12/16/19 at 2:43PM, Staff person #7 administered Individual #1 50mg of Chlorpromaz and 50mg of Diphenhydramine for agitation. However, Individual #1 was prescribed to take 75mg of Chlorpromaz and 50mg of Diphenhydramine taken together for agitation.
· On 1/10/2020 Keflex was ordered to take 1 capsule by mouth 3 times a day for 10 days. Keflex was administered to Individual #1 three times a day from 8AM on 1/11/2020 to 8PM on 1/20/2020 (10 days) plus two additional administrations at 8AM and 4PM on 1/21/2020, the 11th day.
· On 1/24/2020 Individual #1 was prescribed Amoxicillin 500mg, take three times a day for 10 days. The medication was administered for 10 complete days plus an extra administration on the 11th day.
· The individual is prescribed Sumatriptan 100mg, take 1 tablet by mouth at onset of migraine headache, may repeat in 2 hours if needed, for a diagnosis of Migraine headaches. Staff person #8 administered Sumatriptan to Individual #1 at 9:42PM on 2/21/2020 for back pain, the incorrect reason for prescribing the medication.
· Additionally, Staff person #9 recorded that he administered 2 tablets of Sumatriptan at 8:04PM on 3/7/2020 to Individual #1 for back pain. According to the doctor's order written above, Staff person #9 administered Individual #1 the incorrect dosage of Sumatriptan medication and for the incorrect diagnosis or purpose for administering the medication.
· On 5/12/2020 Individual #1's physician ordered a decrease in the individual's Depakote to 250MG ER, take 1 tablet twice a day for 2 weeks then take 1 tablet at night only for 2 weeks then discontinue. The agency did not administer this medication as prescribed until 5/16/2020, 4 days after the physician's order.
· Staff person #4 confirmed on 6/22/2020 that Individual #1's medication Divalproex 250mg at bedtime was not discontinued upon the individual's 6/16/2020 discharge from the hospital. Staff person #4 documented on the discharge summary that Hydroxyzine and the bedtime 250mg dose of Divalproex was not discontinued. Individual #1's bedtime, 250mg dose of Divalproex was never administered to him after his 6/16/2020 discharge.
· Staff were administering Lamotrigine 150mg to Individual #1 at 8PM from 6/16/2020 until 6/24/2020 without an order to do so.
· Individual #1's medication label for Lamotrigine that was dispensed on 6/10/2020 stated to administer 100mg by mouth twice a day for 10 days for a diagnosis of seizures, take ½ tablet every day for 10 days. At the time of the 6/30/2020 remote inspection, this medication wasn't administered. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | 6400.167b: Medication Errors, documentation of follow-up action as it relates to medications errors.
What we did to correct?
o LSS will monitor Quick Mar daily to ensure consumer medications are being administered as prescribed.
How to prevent?
o WC will enter all med errors in HCSIS with 72 hours.
o WC will utilize LSS Med Error Protocol (point system) in educating staff when medication errors occur.
o WC will file all follow-up action documentation in consumers record.
Implementation date of correction?
o 11/20/20
¿ Who is responsible for each step?
o WC is responsible to enter medication errors in HCSIS within 72hrs. of error.
o WC is responsible to utilize LSS Med Error Protocol (point system) in educating staff when medication errors occur.
o WC will file all follow-up action documentation in consumers record.
o (WC) & (CC) are responsible to ensure LSS is following regulation 6400.167b. |
11/20/2020
| Implemented |
| 6400.186 | Individual #1's 3/18/2020 and 5/20/2020 restrictive behavior support component of his individual plan (Restrictive Procedure Plan = RPP) states that he is to be restricted to an 1800 calorie diet, limit his carbohydrates and increase his vegetable intake. During the 6/15/2020-9/14/2020 unannounced monitoring, the agency provided evidence that they were documenting and tracking his daily calorie diet, or carbohydrate and vegetable intake for every meal, drink, and snack since the plan's 3/18/2020 implementation. The records provided were either missing information or left blank on multiple days. In addition to his behavior support component, his individual plan states that his restricted calorie diet is being monitored daily.
Individual #1's 3/18/2020 and 5/20/2020 RPP also states that for his reward/token incentive restriction, the individual will always have access to his visual of his incentives. During the 6/30/2020 remote inspection (virtual, onsite inspection due to COVID-19 national pandemic), of the home, the individual's visual incentive was not at the home. Staff persons #1-#3 at the home during the inspection, confirmed that the individual's visual incentive is not kept at the home. Staff persons #1-#3 conferred with Staff person #10, staff person responsible for monitoring and implementing Individual #1's RPP, during the 6/30/2020 inspection that Staff person #4 keeps the individual's visual incentive in the agency's main office, not the individual's home. On 9/2/2020 during another onsite visit to the agency, Staff person #11 stated that Individual #1 was telling staff that he didn't know when he was earning any rewards/tokens via his incentive restriction and wanted to visually see how he was doing.
Additionally, both RPP's state that the stickers and play money are to be kept in the staff office of the home. During the 6/30/2020 onsite inspection, Staff #1-#3 and #10 confirmed that neither were kept at the home.
Individual's 3/18/2020 and 5/20/2020 plans states that he is to earn a sticker or token for completing his hygiene, which was defined as showering for the day. The following days, staff documented that Individual #1 showered on multiple days but did not document that the individual received a sticker or a token in 2020: 3/18, 3/21, 3/23, 3/26-27, 3/29-30, 4/1-2, 4/4, 5/23, 5/25, 5/27, 5/29, 6/7, 6/20, 6/26, 6/27, 6/30, 7/10, 7/11, 7/13, 7/15, 7/16, 7/20, 7/28, 7/29, and 8/13.
· Staff did not complete any documented daily showers for Individual #1 on 3/31/2020 as staff failed to record 3/31/2020 date on his weekly shower schedule. Staff then continued to record the incorrect calendar date with the corresponding day of the week for tracking of his shower schedule from 4/1/2020 until 5/20/2020. Staff also failed to document any shower data for Individual #1 on 4/4/2020 and 4/5/2020 as they skipped tracking these days on the shower calendars provided. Therefore, staff did not complete an accurate tracking of the days he completed showers from 4/1/2020-5/20/2020 to know when he should receive a token.
· Additional days staff documented that he took a shower but there's no evidence he received a sticker or token in 2020 was on 4/7, 4/9, 4/11, 4/14, 4/16, 4/18, 4/21, 4/23-24, 4/26, 4/29, 5/2, 5/7, 5/115/13, and 5/16.
· There is no evidence that staff were tracking his showers from 5/17-5/20. Therefore, the agency was not monitoring his daily showers and/or providing him with a stick or token on days that were not tracked. | The home shall implement the individual plan, including revisions. | Concern: Calorie tracking
a. Wellness Coordinator is responsible
b. The monitoring of individuals calorie intake
c. Wellness Coordinator will review the paper calorie tracker weekly. This will start effective 11.16.2020. The review will ensure that all meals with calories are documented and ensuring that the individual is re-educated or staff if the calories exceed what is being recommended.
d. Continued education will occur by the Behavior Specialist on the restrictive component of his 1800 calorie diet. Last training was on 10.27.2020. This will be documented on staff trainings and located in the Behavior Support Services individual record. It has been added to this individuals Individual Functional Assessment for the staff to just list the calories total for the day. This is a safeguard that the Behavior Specialist will review weekly when the sheets are reviewed every Monday.
e. See document # 1
Concern: Token incentive restriction
a. Behavior Specialist is responsible
b. The token economy system in the restrictive plan
c. The Behavior Specialist was receiving a 2-week sticker chart from CC and the Individual Functional Assessment weekly. On this chart has if he showered (yes or no). This then gets compared to the sticker chart. The individual if he earned a token is signing the chart to validate what was provided. These are all located in the Behavior Support Service book for the individual. The team did educate staff on the process on 3.18; 4.7; 5.20; 6.17; 6.18; 6.19; 6.26; 6.30; 7.7; 7.28; 8.26; 9.9; 9.14; 9.17.2020. All training sheets are located in the Behavior Support Service book for the individual.
d. Due to not seeing any progress or regression (no lasting change) with the use of the token economy system, the team is going to be discontinuing that limitation from the Behavior Support Plan on 11.18.2020. Individual has already been educated, regarding this occurring and understands that praise and encouragement will still take place. He will be re-educated, and this documented on 11.12.2020.
e. The staff will be educated that they will still document the showering but will not be following the token economy system by 11.18.2020.
f. Long term plan- anyone who has a token economy system will be monitoring weekly by the Behavior Specialist. If there are errors in the documentation that is currently found, the team will do the best to correct, but team will be re-educated on the process to move forward. The client will sign the chart or IFA directly stating what they earned for the token. The full review of individuals with token economy systems and the review if done effectively will happen by no later then 12.1.2020.
g. See Document # 1 |
12/01/2020
| Implemented |
| 6400.195(c)(6) | - Individual #1's token system restriction included in both his 3/18/2020 and 5/20/2020 behavior support component of his individual plan, does not include the circumstances for how the token system restriction is to be used. Each plan states that if he completes his hygiene (showers) and attends day program 5 days a week, he will receive a sticker for that day. But both plans also state that if he only accomplishes one of these items, his shower or attending day program, he will receive a sticker for the area accomplished. His plans do not define how he is to earn a sticker as the description could allow him to receive one sticker for completing two items, but also receive two stickers for completing the same two items. Additionally, during the 6/30/2020 remote inspection (virtual, onsite inspection due to COVID-19 national pandemic), Staff person #1 confirmed with Staff person #10 and concluded that staff are only to track Individual #1's showers and attendance of day program and provide him a sticker if he completes these items 3 times a week. None of the individual's restrictive components of his behavior support plans/individual plans include this information.
Individual #1's sticker/play money token economy system is a part of his restrictive component of his behavior support plan. However, his 3/18/2020 and 5/20/2020 plans do not include the circumstances for how many stickers and/or play money he must receive in order to obtain an incentive item purchased by the agency, Lifestyle Support Services. On 9/2/2020 during another onsite visit to the agency, Staff person #11 stated that Individual #1 was telling staff that he didn't know when he was earning any rewards, tokens, or reinforcements via his incentive restriction and wanted to know this information. Staff person #11 stated on 9/2/2020 that the agency was not documenting when Individual #1 was provided with a reinforcement or reward based on his sticker/play money earnings. His plan does not include accurate information on when he should receive a sticker/token, when should he receive a reinforcement, and how soon after achieving a reinforcement on paper does he receive the reinforcement. | The behavior support component of the individual plan shall include: Types of restrictive procedures that may be used and the circumstances under which the procedures may be used. | 2. 6400.195c6
Concern: Token system restriction
a. The Behavior Specialist
b. Monitoring the Individual Functional Assessment turned in weekly.
c. The Behavior Specialist was receiving a 2-week sticker chart and the Individual Functional Assessment weekly. On this chart has if he showered (yes or no). This then gets compared to the sticker chart. The individual if he earned a token is signing the chart to validate what was provided. These are all located in the Behavior Support Service book for the individual. The team did educate staff on the process on 3.18; 4.7; 5.20; 6.17; 6.18; 6.19; 6.26; 6.30; 7.7; 7.28; 8.26; 9.9; 9.14; 9.17.2020. All training sheets are located in the Behavior Support Service book for the individual.
d. Due to not seeing any progress or regression (no lasting change) with the use of the token economy system, the team is going to be discontinuing that limitation from the Behavior Support Plan on 11.18.2020. Individual has already been educated, regarding this occurring and understands that praise and encouragement will still take place. He will be re-educated, and this documented on 11.12.2020.
e. The staff will be educated that they will still document the showering but will not be following the token economy system by 11.18.2020.
f. Long term plan- anyone who has a token economy system will be monitoring weekly by the Behavior Specialist. If there are errors in the documentation that is currently found, the team will do the best to correct, but team will be re-educated on the process to move forward. The client will sign the chart or IFA directly stating what they earned for the token. The full review of individuals with token economy systems and the review if done effectively will happen by no later than 12.1.2020.
For the restrictions specifically it stated that the plan on 3.18.2020 and 5.20.2020 did not include the circumstances for how the token system restriction is to be used. For the BSP on 6.17.2020 the following is the information in the plan:
a. Pg 4 lists circumstances
b. Pg. 6- lists measurable goals
c. Pg. 18- the goal is to increase use of independent skills to decrease any negative behaviors so that (individual) can use them in his natural environment eventually without use of the system.
d. Pg 18- once (individual) showers for 3 consecutive days in a row he will receive a token of his choosing |
12/01/2020
| Implemented |
| 6400.196(b) | Individual #1's restrictive behavior support component of his individual plan approves 37 specific physical restraints for staff to use if the situation qualifies for physical restraint intervention per his plan. There are many staff working with the individual that have not experienced the use of 9 of the 37 physical restraints directly on their person; those restraints being, two-person cross grain assist, off the wall assist, punch out arm grab release, diagonal drive clothing grab release, runaway release from a rear choke, shoehorn escape, two-person come along, the catcher arm grab release, and person supine stability hold. The following are staff who are or have worked with Individual #1 and not received training on the 9 restraints listed above.
· Staff persons #4-5, #6-7, #9-11, #15, and #12-30.
The following are staff who have been working with Individual #1 prior to experiencing physical restraints in Individual #1's restrictive behavior support component of his plan on their person.
· Staff persons #8 and #31 worked with Individual #1. | If a physical restraint will be used, the staff person who implements or manages the behavior support component of the individual plan shall have experienced the use of the physical restraint directly on the staff person. | 3. 6400.196b
Concern: CPI training not matching individuals BSP list of restrictions
a. Behavior Support Specialist/Training Coordinator/ and CPI Instructor
b. The training sheets did not match the list of CPI techniques listed in the Behavior Support plan.
c. Training along with the CPI instructor have already altered the training document to ensure that it matches the CPI instructor manual. The implementation of the starting this new form was around 11.1.2020. All re-training and new hires have received this new sign off to CPI training.
d. The CPI instructor will have all individuals within the individuals home completed the updated training and signature verification by no later then 12.25.2020.
e. The CPI instructor will work on having 8 other home locations re-educated with the new training form due to those home having a restrictive plan with the use of CPI.
f. The Behavior Specialist has already discontinued CPI out of the individual plan on 6.17.2020 (due to meeting the fade out plan). Per the regulations, all staff are trained on CPI, but individuals do not need to have a Behavior Support Plan until 2 or more restraints in a 6-month period. This is listed within the plan. The staff will still be re-educated by 12.25.2020 .
g. All Behavior Support Plans that still have CPI within them, will have an addendum created, reviewed by individual or Legal Guardian indicating the changes to the list of techniques that could be used by no later than 12. 16.2020.
UPDATED as of 12.15.20
1. ON 12.16.2020 2 of the 8 plans will be discontinued. These two individuals have met the standards and have gone 1 year no restraints and there plans were up on 12.16.2020. CPI will be taken out of their plans (for central region plans).
2. I'll go back and alter those 6 plans again and only use the 35 techniques on the old CPI training sheet. This then will stop any training needs in efforts to get us to the 39 that is being taught and in the bsp's.
a. The discrepancy that caused this was the BSP's had additional training techniques that are not listed on the training sheet. The training sheet has techniques that are not in the plan.
b. Any of these 6 homes (central region) will be educated on the updated plan as they are completed and what the change was to the plan.
3. Lifestyle Support Services certified Master Level trainer will come up with what he feels safe with and what would show a level of competency within the participants that are new or getting re-trained.
a. Staff completes virtual training (if office is closed and unable to do in person) on techniques and de-escalation (share point in the homes)
b. Staff will watch the video on how to perform the techniques (sharepoint in the homes if needed)
c. Staff will take the test and turn it into Tom to grade (provided in training packet)
d. Certified CPI trainers will then schedule them a in class portion, which would be a competency in the physical interventions as determined by the instructors.
e. Any additional training on techniques will be delivered at a later date if necessary to avoid the risk of transmitting covid-19 infection.
4. All plans that have the CPI training that was already updated to the new training form, will have an addendum to the plan again showing the techniques that match the training sheet that all of our staff have been using. This will occur no later than January 13, 2021. |
12/25/2020
| Implemented |
|
|