| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.18(c) | Individual #1 was prescribed Simvistatin 40 mg one tablet at 8 pm daily. Individual #1's Simvistatin medication was not administered on 8/7/17 as indicated on the August 2017 MAR due to not having the prescription filled. On 8/8/17 it stated that the Simvistatin medication was not administered and the point person was notified. There was no medication error entered into HCSIS. | The home shall orally notify the county intellectual disability program of the county in which the home is located, the funding agency and the appropriate regional office of intellectual disability, within 24 hours after abuse or suspected abuse of an individual or an incident requiring the services of a fire department or law enforcement agency occurs.
| Incident 8416433 was filed 4/2/18 by the IM point person for the 8-8-17 medication not being given. Staff # 2 is no longer with the company. Staff # 1 was re-educated on the proper procedures with medication administration training and reporting errors to the IM person on 3-28-18. See attachment 28. To prevent future occurrences, the Associate Director will be responsible to check all MAR's on visits to the home to ensure proper documentation and reporting procedures are followed by contacting the IM person. Disciplinary action will occur for staff that do not adhere to the IM training, policies & procedures. |
04/02/2018
| Implemented |
| 6400.46(i) | Staff #1 had cardio-pulmonary resuscitation training on 9/2/15 and not again. Staff #2 was hired on 5/3/17 and has not yet received CPR training as of 2/23/18. | 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 trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | The explanation of this regulation states that the requirement does not require formal certification; it only requires training. As our training department was short staffed, the trainer trained people in CPR prior to working in the homes and annually as specified. However, formal training was not completed. This licensing administration's interpretation of this regulation is that the compressions must be demonstrated even though formal certification is not required. Therefore, our training department has been training all staff that have completed CPR during the past year to get them officially formally trained. Staff # 2 is no longer employed. Staff # 1 is slated to have CPR training on April 5, 2018. Moving forward, all staff will have the formal CPR training and be certified by the Red Cross by the company trainer on or before their due dates. |
04/05/2018
| Implemented |
| 6400.68(c) | A coliform water test was completed on 3/2/17 and not again until 6/6/17. | A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept. | Prior licensing personnel (Carol Chalick, John Shankweiler, Bob Robinson, Dale Erb, Bill Foltz) had stated that this regulation is every 3 months. They informed us that the 3 month mark meant if it was due in February, so long as it was done in February, it was compliant. This licensing administration is stating that the 3 month mark means every 90 days and there is no leeway. Therefore, according to this licensing representative, we were 4 days late with the water test.The Director contacted the company that does our water testing on 2-27-18 and changed the water testing to every 2 months instead of 3 months (see attached email - attachment 20). The Director will continue to monitor that the water is being tested every 2 months. As the first water testing that is coming due will be in April 2018, a copy will be forwarded to ODP licensing personnel as soon as the results are obtained. |
02/27/2018
| Implemented |
| 6400.106 | The furnace was cleaned on 9/22/16 and not again. The furnace was replaced on 10/25/17. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Shadowfax had the plumbing company out and they inspected the furnace and deemed it needed replaced. We did not think to have the plumbing company put anything in writing as far as inspection and cleaning as we knew we would be incurring the cost of a new furnace. Moving forward, even if a furnace needs to be replaced and the date of the inspection and cleaning is coming due, Shadowfax will incur the cost of inspection and cleaning and the cost again to install a new furnace. Furnaces will now be cleaned every 9 months - see attached email (attachment # 15) sent 2-28-18 to the owner of the plumbing business that Shadowfax utilizes. The owner conversed with the Shadowfax maintenance man that this will occur as per our request. Moving forward, the Shadowfax maintenance man will keep track of the 9 month mark to ensure it is completed for every home, instead of assuming the plumbing contractor is doing them as specified. There will also be spot checks from the Director at the 9 month mark to ensure all furnace inspections are done and if not done, that it is arranged to occur before the 12 month mark. Our first inspection will be due by 5-28-18 so the documentation of the inspection will be forwarded upon receipt. |
05/28/2018
| Implemented |
| 6400.112(d) | The fire drill logs indicated that a fire drill was held on 12/29/17 and 12/31/17. During both drills all of the individuals did not evacuate within the two and a half minute time period. The fire drill log noted on 12/29/17 Individual #2 refused to evacuate and the fire drill held on 12/31/17 was longer than five minutes. No other fire drills were held in December of 2017. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Shadowfax is changing practice to prevent future occurrences by having all fire drills completed prior to the 15th of the month. This will allow ample time for drills to be repeated in case of difficulties with evacuation or to notify the fire department for assistance. During the on site inspection, licensing personnel reviewed the 3 goal plans that were instituted to educate and teach individual # 2 to evacauate. This had been an acceptable plan of correction in previous inspections. Monthly monitoring is being completed by the Associate Director and by the administrative assistant as a double check that all drills are completed and completed with everyone evacuating. See attachment 28 for training with staff # 1 (Staff # 2 is no longer employed). See attachment # 29 for a successful drill done in this home since licensing. |
| Implemented |
| 6400.142(a) | Repeat 11/30/16: Individual #1 had a dental appointment on 5/13/16. It is documented at this appointment that the dentist recommended Individual #1 to see the dentist every six months. Individual #1 did not see the dentist again until 12/15/17. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Documentation was not completed to show that this was the earliest appointment available. A documentation training was completed 3-26-18 with all Associate Directors. See attachment 6. The next dental appointment for this individual is scheduled 6-22-18 at 9am. See attachment 12 for a dental examination completed 3-23-18 since inspection that is on time. Furthermore, all Associate Directors met to go through individuals charts to gather all due dates of appointments to ensure they are scheduled on time and met. To prevent reoccurrence, Shadowfax also hired an administrative assistant to oversee the appointment database and remind Associate Directors of appointments that need scheduled. |
03/26/2018
| Implemented |
| 6400.142(c) | Individual #1's dental form completed at his/her dental appointment on 12/15/17 did not include all of the necessary documentation. There was no documentation of the name of the dentist performing the cleaning/exam and follow-up treatments that were recommended. | A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. | We respectfully disagree with this citation as Shadowfax has a completed dental form that includes the dentist performing the exam and the recommendations (see attachment 30). This form was in the home book at the time of inspection. His next cleaning/examination is scheduled 6-22-18 at 9am for his semi-annual examination. We are waiting on the dental center to call about cleaning under anesthesia as they are backed up by approximately 1 year. See attachment 12 for a dental examination since inspection that is on time (completed 3-23-18). Moving forward, the staff will continue to ensure the form is completed and the Program Specialist and the Associate Director will be the double check to ensure the forms and all documentation is accurate. |
03/23/2018
| Implemented |
| 6400.144 | Repeat 11/30/16: Individual #1 saw his/her primary care physician (PCP) on 3/3/17 due to external hemorrhoids according to the monthly medical review documentation. On the monthly med review documentation it stated that a prescription would be faxed over however there is no documentation of the prescription or that the medication was administered to Individual #1. Individual #1's lifetime medical history signed by his/her PCP on 8/3/16 indicates that he/she sees the podiatrist on a quarterly basis for routine clipping. According to the monthly medical review forms Individual #1 saw the podiatrist on 5/10/16 and not again until 1/29/18. There is another podiatry appointment scheduled for 4/3/18. Individual #1 is prescribed to follow a ground, mashed or mechanical soft diet according to his/her choking protocol updated 7/5/17. On Individual #1's daily logs it is indicated on 8/22/17 that day program staff reported to residential staff that Individual #1's lunch was not chopped all the way and nuts were accidentally in his/her lunchbox. | 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.
| Staff called the doctor and asked for hemorrhoid cream to be prescribed. The nurse responded she would have the doctor call it in to the pharmacy. The staff documented on the monthly med review and the daily logs. The doctor would not prescribe it without seeing the individual. The PCP saw the individual on 3-13-17 and no hemorrhoid cream was prescribed. Staff failed to document the follow up information. There was no oversight to catch this lack of documentation. It is the responsibility of the Associate Director to be checking these charts on their home visits. During March 2017 this home had no Associate Director. Currently there is an Associate Director for this home and she has been providing oversight on documentation. To prevent reoccurrence when there is an Associate Director opening, another manager will be responsible to visit to monitor and provide oversight. Associate Directors were all re-trained on the importance of documentation on 3-26-18. With regard to appointments, all Associate Director met to obtain all appointment dates and the frequency to ensure they are scheduled and run on time. Furthermore, Shadowfax has hired an administrative assistant to double check all appointment dates. Staff 2 is no longer employed. Staff 1 was re-trained on 3-28-18 since inspection to double check lunches prior to leaving the home to ensure individuals have not packed items that are not prepared according to their choking prevention care plans. The Associate Director will give reminders at team meetings to ensure lunches are checked each morning and are prepared according to their plans. Day program staff also monitor this daily and inform residential management if a lunch is not prepared correctly. Staff will receive performance feedback if choking plans are not adhered to. |
03/28/2018
| Not Implemented |
| 6400.164(a) | Individual #1's February 2017 MAR does not indicate what time his/her 8 am dose of Lorazepam was administered on 2/16/17. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | A medication error training is being held 4-10-18 to re-train staff on proper administration and documentation. The staff did not properly document the administration time as it was a one time only entry and staff failed to document the time on that date when it was administered. The medication error training will cover proper documentation. Shadowfax is hiring additional program specialists so that the work load is minimized so that Program Specialists can spend more time checking paperwork with more accuracy and detail. The 4-10-18 training signature sheet will be forwarded to licensing upon completion. Moving forward, the Associate Director and Program Specialists will work cohesively to ensure all documentation is thorough. The Director will conduct routine examinations of random samples of paperwork to also ensure compliance with this regulation. |
04/10/2018
| Implemented |
| 6400.164(b) | According to Individual #1's June 2017 medication administration records (MAR), the following 8 am doses were administered but not logged immediately by staff: Depakote 2 tabs 500 mg, Seroquel 200 mg 1 tablet, Hydrochlorothiazide 25 mg 1 tablet. On 6/25/17 Individual #1's June 2017 MAR did not have a staff signature for his/her 8 am dose of Ativan 1 mg. | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | On April 10, 2018 a medication error training is being held to retrain staff and educate them on the importance of signing immediately after administration. It is the responsibility of the Associate Director to be checking these charts on their home visits. During June 2017 this home had no Associate Director. Since that time an Associate Director was hired and she has been providing oversight on this issue. To prevent reoccurrence when there is an Associate Director opening, another manager will be responsible to visit to monitor and provide oversight. Furthermore, staff who do not follow established medication administration protocol will be disciplined. Associate Directors were all re-trained on the importance of documentation on 3-26-18. |
04/10/2018
| Implemented |
| 6400.167(b) | Individual #1 saw his/her primary care physician on 10/18/17 for a follow up appointment. At the appointment it is documented on the monthly medical review that he/she was prescribed Gavilax to take as needed for constipation. According to Individual #1's October 2017 medication administration record, he/she was administered this medication at 8 am on 10/19/17, 10/20/17 and 10/21/17 as a daily medication. The Gavilax medication was then crossed out on the MAR and added back to the MAR stating it was an only as needed medication as this is what was prescribed by the doctor. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | A medication error training is being held 4-10-18 to re-train staff on proper administration and documentation. Shadowfax has medication questionnaire's that the physician complete on what to do if the person vomits their medications. Unfortunately, the staff did not properly document this. The medication error training will also cover re-ordering medication. 2 additional staff and an Associate Director have been hired for this home to provide consistency and to ensure refills are called in promptly. Per medication administration training, medications are not to be started or discontinued until written documentation is acquired which is why staff continued to administer the medication. There was no oversight to ensure the follow up documentation was received. Shadowfax is hiring additional program specialists so that the work load is minimized. The training signature sheet will be forwarded to licensing upon completion. |
04/10/2018
| Implemented |
| 6400.181(d) | Individual #1's assessment completed on 5/5/17 was not signed by the program specialist. | The program specialist shall sign and date the assessment. | The Program Specialist that was responsible for this assessment is no longer in the program specialist position. Correction can not be made since the date due is already past and the signature cannot be obtained by the former program specialist. This individuals' assessment is coming due within the next 2 months and will be signed by the current program specialist. Program Specialists were re-trained on 2-23-18 on the importance of signing all documentation and know that they are to sign and date each assessment at the time of completing the assessment (signed by the individual and program specialist). The Director will conduct routine examinations of random samples of assessments to ensure the Program Specialists sign and date the assessments. Any non-compliance will be reported to the Program Specialists for correction. Additionally, an administrative assistant was hired to be a double check in ensuring documentation all matches and all documents are appropriately signed. |
02/23/2018
| Accepted |
| 6400.181(e)(4) | Individual #1's assessment completed on 5/5/17 does not clearly state his/her supervision needs. It indicates that Individual #1 requires periodic checks but does not say how often the periodic checks need to occur. | The assessment must include the following information: The individual's need for supervision.
| The Program Specialist created an addendum to the assessment. This addendum was mailed out on March 30, 2018 to all team members. See attachment 36. Additional program specialist are being hired so that the PS's can spend more time ensure accurate thorough documentation. Current Program Specialists were re-educated on 2-23-18 about specific time frames, not stating periodic. The Director will monitor for compliance to ensure specific time frames are listed in assessments. |
03/30/2018
| Accepted |
| 6400.181(e)(14) | Individual #1's assessment dated 5/5/17 does not include his/her ability to swim. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | The Program Specialist created an addendum to the assessment. This addendum was mailed out on March 30, 2018 to all team members. See attachment 36. Additional program specialist are being hired so that the PS's can spend more time ensure accurate thorough documentation. Current Program Specialists were re-educated on 2-23-18 about ensuring all sections are thoroughly and accurately completed in the assessment. The Director will monitor for compliance to ensure each section of the assessment is completed in its entirety. |
03/30/2018
| Accepted |
| 6400.186(a) | Individual #1's Individual Support Plan (ISP) review that was completed on 6/20/17 was late. The ISP review period covered from 3/2/17-6/2/17 but the review was not done until 6/20/17. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | The program specialist that completed the late ISP review is no longer in the Program Specialist position. The Program specialists were re-trained on 2-23-18 of the 15 day time frame to complete and review ISP Quarterly reviews and mail them to the team members. Additionally, Shadowfax is hiring additional Program Specialists so that the work load is lessened and Program Specialists can meet all deadlines. See attachment 33 of individual # 1's 3-2-18 ISP Quarterly Review review mailed out since licensing within the correct time frame (reviewed 3-9-18 and mailed the same day) as well a review from an individual from another home (attachment 34). The Director has also made an addition to the Program Specialist position training packet for all newly hired program specialists- see attachment 35. The Driector will monitor that all ISP reviews are reviewed within the time frame by putting all review dates on a master calendar and checking to ensure they are reviewed on time and subsequently mailed to all team members. |
03/09/2018
| Accepted |
| 6400.186(c)(2) | Repeat 5/9/17: Individual #1's ISP reviews completed on 3/16/17, 6/20/17, 9/15/17 and 12/15/17 did not review his/her social, emotional, environmental support plan. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | Program Specialists were re-trained on 2-23-18 on this regulation and ensuring SEEN information is present on ISP reviews. See individual # 1's ISP Quarterly Review completed since licensing and reviewed and mailed 3-9-18 (attachement 33) for the inclusion of the SEEN information. Additional Program Specialists are being hired so more time can be spent by each Program Specialist checking their work to be sure all sections of the ISP are reviewed /included. SEEN plans is on the agenda for the 4-6-18 Program Specialist meeting so that we can brainstorm on ways to ensure the SEEN information is included on all Reviews. To prevent re-occurrence, the Quarterly ISP reviews will include the typed heading for the social, emotional, and environmental needs so that this section is not overlooked. The Director will provide oversight to ensure ISP quarterly reviews are completed thoroughly for each section through routine reviews of random samples. |
03/09/2018
| Accepted |
| 6400.188(a) | The residential home did not provide training and assistance for the improvement of functional skills and personal needs for Individual #1. Individual #1's goal progress notes indicate that Individual #1 is not choosing to bathe often sometimes for 11 to 12 consecutive days. It is documented that Individual #1 did not bathe from 1/8/18 to 1/15/18 and 12/6/17 to 12/17/17. There is only documentation from one staff per day stating that he/she chose not to bathe. It is not consistently documented in the goal progress notes how often verbal prompts and education on the importance of bathing are provided. There is no documentation in Individual #1's record that residential staff informed day program staff of Individual #1's updated choking protocol which lists his/her new diet. Individual #1's choking protocol was updated on 7/5/17 to state that he/she is to follow a ground, mashed or mechanical soft diet. | The residential home shall provide services including assistance, training and support for the acquisition, maintenance or improvement of functional skills, personal needs, communication and personal adjustment. | A refusal plan & chart was developed by the Program Specialist for staff to educate individual 1 on the health benefits of bathing and to chart attempts to have him bathe. As part of this plan, if this individual refuses a shower, all attempts will be made by staff to have him wash himself thoroughly at the sink. See attachment 32 for refusal plan and chart. All Associate Directors & Program Specialists were re-trained on regulation 188a as well as the regulation if an individual refuses any personal care need or appointment and how to handle refusals and follow up planning that should occur. Staff # 2 is no longer employed but staff # 1 was re-trained on documentation and refuslas. Shadowfax is hiring additional Program Specialists, with a new PS to start 4-23-18 so that the work load of the current program specialists is lessened so they have more time to check documentation and institute necessary plans. Furthermore, Associate Directors will be responsible on home visits to check goal progress notes for progress and refusals and work cohesively with the program specialist to institute a plan to address the issue. In the past as individual #1's day program is also Shadowfax, we have shared information via interoffice mail. Moving forward the Program Specialist will scan and attach to email or attach a memo to the choking prevention care plan and all other necessary medical information so proof is provided that all team members have received the documentation timely. The program specialists were trained on this change in practice on 2-23-18. |
03/30/2018
| Accepted |
| 6400.213(11) | Repeat 11/30/16: Individual #1's January 2018 medication administration record (MAR) states that he/she takes Ativan for anxiety however his/her physical dated 7/10/17 states he/she is prescribed Ativan for impulse control. Individual #1's assessment completed on 5/5/17 indicates he/she may be left alone in a room at home with periodic checks from staff. In Individual #1's assessment completed on 5/5/17 it indicates that he/she needs constant supervision while in the community and is not able to be left alone in a vehicle. Individual #1's ISP updated on 11/27/17 states that he/she requires checks in the home every 30 minutes, that he/she can be left alone outside the home with 5 minute checks and that he/she may be left alone in a van while staff are taking housemates into day program. Individual #1's choking protocol dated 7/5/17 states that he/she is to follow a ground, mashed or mechanical soft diet. Individual #1's ISP updated 11/27/17 indicates that he/she is to have all food mechanically pureed. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | On 2-22-18, The Director of Residential/Proxy PS notified the Supports coordinator to update the ISP to match the current assessment. See attachment ______ DFGFSRRET$#TEAGFADAEVSZ.........Shadowfax is hiring additional Program Specialists so the PS's have less work load in order to spend more time ensuring accurate and thorough documentation. Going forward the Director will provide ongoing monitoring by checking records to ensure all documentation matches. Additionally, Shadowfax has hired a resid admin assistant to be a 3rd check for discrepancies. |
| Accepted |