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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | REPEAT from 6/12/18 unannounced inspection, 2/20/18 annual inspection, and 12/14/16 unannounced inspection: Individual #1's record indicated two recent falls on 8/2/18 and 8/22/18 while living at his residential facility with Shadowfax corporation. According to residential documentation, the individual is diagnosed with edema-lower extremity swelling, ambulatory dysfunction, macular degeneration, obesity, arthritis in both knees, venous insufficiency of both extremities, anemia, aneurysm, bruise, yeast infection of the skin, eczema, osteoarthritis (arthritis due to wear and tear of joints), degenerative joint disease of lower leg and degenerative arthritis of lumbar spine, history of type II diabetes mellitus and required the use of medical stockings and a walker to physically assist him during ambulation. Individual #1's medical appointment records, that the agency has access to, indicated a fall risk screening was completed by his medical provider as early as 3/20/18. The individual's residential facility was not aware of this fall risk screening nor was it kept in the individual's record. Given the individual's diagnosis and ambulation dysfunction, the agency never had a fall prevention plan or fall risk assessment completed for the individual.
On 8/2/18, Staff #1 recorded on Individual #1's daily logs that she worked from 10pm on 8/1/18 until 6am the next day as the sleep staff. Staff #1 then indicated while she was working on 8/2/18 from 6am-9:30am, Individual #1 had a "bruise on his right forearm" and that his "right lower arm had a small laceration, red and swollen." According to day program records, Staff #1 drove the individual to day program facility on 8/2/18 and did not notify other Shadowfax staff of Individual #1's red, swollen, lacerated arm. An agency incident report indicated that once Individual #1 returned home from day program on 8/2/18, his visiting nurses/physical therapist noticed his arm was swollen and advised the direct support staff he should be seen due to possible cellulitis. The incident report indicated it wasn't until 3:43pm, approximately 7 hours after initially recognizing the swollen arm, that staff took him to an urgent care center for his arm to be evaluated.
On 8/4/18 Staff #2 indicated on Individual #1's daily log, that she worked from 7am-8pm and that the individual's bruise is spreading on right arm. An incident report completed by Staff #2 on 8/4/18 indicated that "bruising on his right arm appeared to be spreading up and down his arm. He complained of pain in his hand. I notified AD at 3:40pm. I notified medical on call, Staff #3 came and took Individual #1 to the urgent care." Staff noticed the individual was having additional swelling with associated pain in his arm and medical follow up treatment was delayed approximately 8 hours after noticing additional concerns. Individual #1 was diagnosed with Cellulitis and swelling of right upper extremity on 8/4/18.
According to the individual's medical appointment reviews from 8/4/18, he was to keep the area washed with antibiotic soap and use triple antibiotic cream and bandage 3times daily. The individual was also to take antibiotics 3 times day for seven days, follow up with PCP in 3-4 days, elevate arm above heart and apply ice. There is no documentation to indicate that his arm was elevated, ice was applied, or that the area was washed with antibiotic soap and triple antibiotic cream and new bandages were applied 3 times per day.
On 8/8/18 Individual #1's doctor had to extend the antibiotic treatment for an additional week for his diagnosed Cellulitis of right upper extremity "given the severity of the infection."
(page 1, continued on next page) | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | Concerning the statement "The individual's physician completed fall risk assessments on him as early as 3/20/18"; the record that was reviewed reflects what actually occurred with the physician & he did NOT complete a fall risk assessment on 3/20/18. Attached is what occurred at that appointment (See: 3/20/18 appointment and assessments fax). The Management team, Specialist, & the Nursing staff created a falling plan on 10/15/18 (See: Falling plan & also a fall risk is included. (See: Fall Risk PDF) The Management team & the Nursing staff also created new charts that will make sure sufficient documentation & follow up occur. The charts include: an edema chart and briefing, a bruise chart, a treatment administration record form, yearly tracking form for appointments, a carb counting form, and a caloric counting form (See: edema information, edema chart Page 1 & 2, bruise Chart 1 & 2, treatment administration record PDF file, yearly tracking form for appointments, carb counting form, and food intake chart). The physician actually discontinued the caloric chart on 10/15/18 (See: Elimination of caloric count). The Associate Director emailed the bruise chart and edema chart to the day program to assist in collaborating more for medical concerns (see email attachment). On 10/13/18, the Associate Director/PS Proxy was trained by the Nursing staff on all the above mentioned charts (See: A.D. training by Nurse 10.13.18). On 10/13/18, the Associate Director/PS Proxy in turn trained the staff on those same charts (See: Staff Training on 10.13.18). The nursing staff also set up an Edema Training through the HCQU, which will be held on 10/25/18. The Associate Director will make certain that staff from this home attend. Furthermore to address the eczema, skin issues, and incontinence for individual #1, the organization has started the hiring process of awake over staffing to provide overnight support (See: Awake over hires). The nurse purchased tapes and measuring devices on 10-15-18 to accurately document swelling & bruising (see attached receipt). Finally, staff were trained companywide on emergency guidelines and health alert choking (See: Emergency guidelines 1, 2, & 3 PDF). The Residential Management Team has been doing core meetings which involve teams under each Associate Director that meet every three weeks. For the upcoming year, the Associate Directors will sync their core team meetings to occur during the same week so that info can be coordinated in a more efficient manner amongst all core teams and team members. This will be done by January 2019. Along with that there will be a unified Agenda that will be gone over in those meetings. On 10/11/18 and on 10/13/18, the Associate Director trained the staff on the necessity of taking care of medical issues immediately for our individuals and the need for being proactive (See: Staff Training 880 10/11/18). The training included Edema information, which the Associate Director/PS Proxy was trained on by the nursing staff. (See: A.S. training by Nurse 10/13/18). The Nursing staff trained the Associate Director/PS Proxy also on Bruising (See: Bruise Chart Page 1 and Bruise Chart page 2). The Associate Director/PS proxy then trained the staff on the bruising chart on 10/13/18 (See: Staff Training 880 10/13/18). Discipline was completed for the staff at fault on 10/18/18 (she was out of the country for the last month and just returned on 10/15/18). She was trained on emergency guidelines (See: Emergency guidelines PDF files). Moving forward, a Treatment Administration form was developed and will be utilized in all homes to document all follow up medical documentation. (continued) |
10/25/2018
| Not Implemented |
| 6400.16 | (page 4) Individual #1 has had many appointments over the past year with medical diagnosis relating to ambulatory dysfunction and unsteady gait. The agency never provided medical support to the individual as prescribed and recommended to prevent injuries from a fall or to monitor his deteriorating health condition.
Those appointment are:
· 4/13/18 Wellspan appointment where issues addressed were: chronic pain of right knee. Ongoing health issues identified were: anemia, aneurysm, yeast infection of the skin, eczema, high cholesterol, osteoarthritis (arthritis due to wear and tear of joints), degenerative joint disease of lower leg and thyroid nodule. This appointment indicated a fall risk assessment was completed on 3/20/18 but the residential facility did not have this fall risk assessment in Individual #1's record. This appointment also indicated that the individual was to do his best to walk daily, chart his daily ability to walk and get a massage therapist for the individual. There was no documentation that any of these recommendations were completed.
· 5/25/18 Wellspan appointment where issues addressed were: edema-lower extremity swelling, ambulatory dysfunction and venous insufficiency of both extremities. Ongoing health issues addressed were: ambulatory dysfunction, anemia, aneurysm, bruise, yeast infection of the skin, eczema, osteoarthritis (arthritis due to wear and tear of joints), degenerative joint disease of lower leg and venous insufficiency of both lower extremities. This appointment indicated to wrap his leg and use compression stocking and for his feet to be elevated any time he is not ambulating. There was no documentation that the agency was elevating his feet or wrapping his legs while using compression stockings. Staff #4 stated during the inspection that Individual #1 discontinued the use of the compression stocking after this appointment, but there was no discontinue order to stop the TED stockings in Individual #1's record.
· 7/13/8 Wellspan appointment where issues addressed were: osteoarthritis (arthritis due to wear and tear of joints), degenerative joint disease of lower leg and degenerative arthritis of lumbar spine. Ongoing health issues identified were: ambulatory dysfunction, anemia, aneurysm, bruise, yeast infection of the skin, eczema, osteoarthritis (arthritis due to wear and tear of joints), degenerative joint disease of lower leg, degenerative arthritis of lumbar spine and venous insufficiency of both lower extremities. This appointment indicated he should lower calorie intake to 1600 kcal per day in order to lose approximately 1 pound per week. There was no documentation that the residential facility was monitoring his food intake.
· 8/1/18 Wellspan follow up appointment for blood work indicated that another fall risk assessment was completed on 6/21/18 but the agency was not aware of this assessment. Ongoing health issues addressed were: ambulatory dysfunction, anemia, BMI, bruise, yeast infection of the skin, eczema, high cholesterol, ID, osteoarthritis (arthritis due to wear and tear of joints), degenerative joint disease of lower leg, degenerative arthritis of lumbar spine, thyroid nodule, venous insufficiency of both lower extremities and weight loss counseling. According to the appointment summary form, Individual #1 was to cut down on carbohydrates to include potatoes, bread and anything else with refined flour. There was no documentation that staff were aware of this dietary change or that it was being followed. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | Continued from page 3 - Individual #1 does in fact have a walking goal, which he is on step 2 (See: Quarterly Review 3-26-18 to 6.26.18 done.doc). There was no fall risk assessment done on 3/20/18 (see previous licensing page and attachment from physician stating as such. On 3/21/18, the appointment was not a fall risk assessment according to the records that were reviewed. In fact, it was his physical. According to the appointments from 7/13/18, 8/8/18, and 9/29/18 individual #1 lost a total of twenty pounds. While documentation was not followed through with, the diet was being followed by staff, as evidenced by his weight loss (See: 3.20.18 appointment.pdf). For individual #1, his caloric tracking was cancelled on 10/15/18. (See: Elimination of caloric PDF). Also, the physician confirmed that what was thought to be a fall risk assessment was actually a screening tool, not a PT assessment. (See: assessment fax.PDF) On 10/4/18, individual #1 received a massage session, and that is occurring every two weeks. A treatment Administration Record from has been developed and is now being utilized to show medical issues are being followed up on. (see TAR attached). Moving forward Shadowfax is hiring Awake Overnight staff for this home (see attachment) and is looking at other homes that would benefit from awake overnight staffing. A second nurse has been offered a position to help with health and safety of all individuals' medical concerns. All homes will utilize the new Treatment Administration Record (TAR) form to document all medical follow up. |
10/25/2018
| Not Implemented |
| 6400.16 | (page 2) During the onsite inspection, Staff #2 indicated that Individual #1 wears two adult briefs at night and bed pads are positioned under his body due to excessive urinary incontinence throughout the night. Staff #2 indicated that almost every morning she wakes Individual #1 up, if she was working the overnight shift, Individual #1 is soaked through both briefs, bed pads, and is laying in his urine. Individual #1 is diagnosed with ambulatory dysfunction and needs some assistance at night to get out of his bed if he was to use the bathroom. The agency never staffed he individual's house with an awake overnight staff to help him use the bathroom at night or attend to his soiled bed as needed. Individual #1 is diagnosed with continued health issues of Candidal intertrigo (yeast infection) and eczema. On 8/9/18 Individual #1 was seen at Wellspan for his routine hip injections for osteoarthritis of right hip. However, the doctor indicated that there was slight fungal infection at the injection site and skin overlying the right groin is erythematous with skin breakdown. Individual #1 did not have another medical appointment to address the fungal infection or right groin erythematous with skin breakdown that his physician witnessed on 8/9/18.
On 8/14/18 Individual #1's physical therapist recommended "bed rails on right side of bed, remove box spring to lower bed to enable the individual to get in and out easier, continue home exercises and continue walking -cue to stay close to walker." At the time of licensing on 9/20/18 the individual did not have bed rails on the right side of his bed, his box spring was still under his mattress and there was no documentation of home exercises he was doing. The physical therapy instructions were not available in Individual #1's record at the home for staff to view.
According to Individual #1's 8/20/18 Wellspan follow up appointment, staff were to continue to monitor the wound on the individual's arm, clean the dressing at least 2 or 3 times per day and be on the look out for red flags such as increased warmth in the area, spreading of the redness around the wound, or pus draining from the wound. There is no documentation that the dressing on his arm was cleaned and redressed at least 2-3 times per day. There also wasn't completed documentation that the staff were monitoring the arm. Individual #1 has a daily bruise chart in his record. However, staff document bruises on multiple parts of his body almost every day, but they do not record the color, size, etc. Only twice did staff document the size of the bruise, all other days were blank for monitoring the size of the bruise to indicate if spreading is occurring.
On 8/22/18 Staff #1 recorded on Individual #1's daily logs that she worked from 6am-9:30am and noticed scrapes on the individual's right knee. According to day program documentation, Individual #1 arrived at day program on 8/22/18 "with a cut on the top of his head, which a chunk of hair was missing, and it was bloody. Staff did not come in the room with him, so we had no idea what happened. Individual #1 said he fell this morning. So, his staff (Staff #1) was called and she came back to take him to be checked. She stated he slipped at home." Staff #1 did not provide medical support to Individual #1 when she was aware of new scrapes on his knee and that he fell in the morning prior to transporting him to day program.
(continued on next page) | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | continued from page 1 -The organization has started the hiring process of awake over staffing to provide overnight support (See: Awake over hires). The Associate Director purchased a side bed rail on 9-21-18 and set it up in the home. (See: Picture- Bed Rail). The Associate Director also purchased a low profile box spring on 9/21/18 (See: Low Profile Box Spring receipt 1, Low Profile Box Spring receipt 2, Low Profile Box Spring Purchase Order, and Picture- low profile box spring). The individual has had a health walking goal, as well as having daily physical therapy exercises he participates in (See: Quarterly Review.doc, and PT exercise 8-2014.doc). The Nurse trained the Associate Director/PS Proxy on Bruising and edema on 10/13/18 (See: Edema information, Edema chart Page 1 & 2, Bruise Chart 1 & 2, and A.D. training by nurse 10/13/18). The AD/PS Proxy then trained the staff on those same topics (See: Staff Training 880 10/13/18). The Associate Director/PS proxy was trained by the nurse on the treatment administration record on 10/12/18 (See A.D. training by Nurse 10/12/18). The Nurse will train the rest of the management team and they in turn will train their core teams on this record to guarantee that the treatments that are prescribed are initiated and tracked (See: Treatment Admin Record PDF). The staff involved was disciplined for not providing medical support. Moving forward, the nurse has purchased tapes on 10-15-18 to measure bruises, etc. in all homes for more efficient documentation (see attached receipt). (continued) |
10/25/2018
| Not Implemented |
| 6400.16 | (page 3) According to York Hospital emergency department discharge instructions on 8/22/18, Individual #1 was diagnosed with "hematoma or contusion over the forehead" and there was "concern for contusions from soft tissue injury. Recommend applying ice packs to affected areas 15 minutes on 15 minutes off throughout the day to help with pain and swelling, rest. Use walker to assist with walking and to provide more assistance to prevent falls." There was no documentation to indicate that the individual was offered and/or applied ice to affected areas 15 minutes on and 15 minutes off throughout the day. There is also no documentation that the agency provided more assistance to Individual #1 to prevent falls.
According to 8/23/18 medical appointment summary for the month, Individual #1 was seen again on 8/23/18 "fell and hit head on headboard of bed, has gash on top of head, no sutures, black swollen right eye." Individual #1 was to ice the eye about 20 minutes on and off. This was only documented as being completed as ordered from 6am-8:30am on 8/24/18.
Individual #1 was seen on 8/29/18 for a follow up appointment to the fall on 8/22/18 in which the doctor indicated "cherry size area of swelling at right proximal forearm, not involving the elbow joint." Patient instructions indicated to "apply a warm compress for about 20 minutes at a time to the area of swelling on your right elbow." There was no documentation that this was completed for the individual.
Individual #1 was admitted to the York Hospital from 9/1/18-9/13/18 for severe right hip pain. He was discharged with new medications: Diclofenac sodium 1% gel apply 2 g. topically two times a day, Diclofenac sodium 1% gel apply 1 g. topically two times a day as needed (apply to right hip and right knee twice daily as needed for pain refractory to Tylenol), and Lidocaine 4% adhesive patch apply 1 patch topically daily -- apply to right hip if pain not responding to Voltaren. The residential facility never sent the new medications and as needed medications with the individual to his day program facility, where he spends hours of his day, should he experience pain while at the day program.
According to Individual #1's monthly medical appointment chart, on 9/15/18 physical therapy indicated that he needed a prescription for a shower chair with arms from his primary care physician. At the time of licensing on 9/20/18, this was not completed.
(continued on next page) | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | continued from page 2 - The Associate Director/PS Proxy was trained by the Nursing staff on 10/13/18 concerning bruising, edema (See: A.D. training by Nurse 10/12/18). The AD/PS Proxy then trained the staff at 880 on the topics from the nurses training as well as the importance of handling medical issues immediately and understanding the importance of completing treatment administration as it is prescribed (See: Staff training 880 10.11.18 & Staff training 880 10/13/18). The staff that did not handle the medical situation effectively received discipline on 10/18/18. She was out of the country for the last month and just returned on 10/15/18. She was previously trained on emergency guidelines (See: Emergency guidelines PDF files). The Management team, Specialist, and the Nursing staff also created a falling plan on 10/15/18 (See: Fall Plan). The Management team and the Nursing staff also created new charting mechanisms that will make sure sufficient documentation and follow up occur. The charts include: edema chart and briefing, bruise chart, a treatment administration record form, yearly tracking form for appointments, a carb counting form (See: edema chart and edema information, edema chart Page 1 & 2, bruise Chart 1 & 2, treatment administration record PDF file, yearly tracking form for appointments, carb counting form, and food intake chart). The Nurse will train the rest of the management team and they in turn will train their core teams on this record to guarantee that the treatments that are prescribed are initiated and tracked (See: T.A.R. PDF). The Associate Director has devised a communication log for information flow between the Day program and the Residential Department. This communication log will be instituted solely for people that are medically involved to keep all parties privy of all needs. This was implemented 10/19/18. The communication log will make clear between departments what is needed for the health of the individual (See: Communication log.PDF). The Associate director purchased a shower chair for individual #1. (See: picture- shower chair) Furthermore, the Nursing staff has instituted a HCQU training that will happen on 10/25/18 to enlighten the staff further on edema issues. The Associate Director will make certain that staff from home #880 attend. continued |
10/25/2018
| Not Implemented |
| 6400.67(b) | Individual #1 is diagnosed with edema-lower extremity swelling, ambulatory dysfunction, venous insufficiency of both extremities, anemia, macular degeneration, arthritis to both knees, bruise, osteoarthritis (arthritis due to wear and tear of joints), degenerative joint disease of lower leg and degenerative arthritis of lumbar spine and required the use of medical stockings and a walker to physically assist him during ambulation. The individual's physician completed fall risk assessments on him as early as 3/20/18. During the onsite inspection, the accessible ramp outside of the front of the home had approximately a 2"-3" drop in the threshold of the ramp to the front porch. The ramp was bowing, leaving room to trip on the threshold from the ramp to the porch. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The Maintenance Department fixed the entrance way ramp on 9/26/18. (See Pictures: Ramp finished 1, 2, & 3) Going forward, the Associate Director and Incident Management Team will complete house visits to guarantee 55 PA code Chapter 6400.67(b) is followed. On 10/11/18, the Associate Director trained the staff on the importance of all floors, walls, ceilings and other surfaces being free of hazards. (See: Staff Training 880 10/11/18) Concerning the statement ¿The individual's physician completed fall risk assessments on him as early as 3/20/18.¿; the record that was reviewed reflects what actually occurred with the physician and he did NOT complete a fall risk assessment on 3/20/18. Attached is what occurred at that appointment (See: 3/20/18 appointment). The primary care physician elaborated that he actually did not have a PT assessment, and in fact it was a screening in which the nurse asked if he fell and the individual had to answer yes or no (See: assessments fax dated 10-15-18). |
10/11/2018
| Not Implemented |
| 6400.141(c)(12) | Individual #1's 6/20/18 and 6/16/17 physical examination forms both indicate "independent" for physical limitations in walking, transferring, toileting and dressing. However, he has utilized a walker daily and required assistance from staff to complete the above tasks since 2017. | The physical examination shall include: Physical limitations of the individual. | The physical examination forms were updated by the Program Specialist on 10-4-18
The Program Specialist made a copy of those updates to place in the home and sent them out to all the team members that serve individual #1 (see attachment physical and cover sheet). Moving forward, the Program Specialists Team will ensure that all physicals are updated and accurate for all individuals served. A physical examination is scheduled for another individual on 10-25-18 and that will be forwarded to ODP licensing to show accuracy on physical examinations. |
10/25/2018
| Implemented |
| 6400.162(a) | REPEAT from 2/20/18 annual inspection: Individual #1's medication label for Mupirocin ointment is not legible. Half of the label was rubbed off and the instructions for how to administer the medication were missing. | The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. | The Associate Director had the Pharmacy update individual #1¿s medication labels on 9/29/18 so that the labels are legible, include the individual¿s name, the name of the medication, the date the prescription was issued, the prescribed dose, and the name of the prescribing physician. (See Pictures: Labeled Medications pictures 1, 2, & 3) On 10/11/18, the Incident Management Team instituted a medication storage process that will be effective on 10/22/18. (See: Memo - Medication Containers) Moving forward, this process will ensure that all prescriptions lotions, creams, shampoo, toothpaste, eye drops, etc. will have a clear label on both the container and the box the prescription comes in. This has been implemented at home #62 to start the process. (See File: Staff: Individual #1 medications picture 1 and 2). On 10/11/18, staff members at 880 were trained on regulation 6400.162(a) by the Associate Director. The Training included the medication labeling process (See: Staff Training 880) Also going forward, The Associate Director and the Incident Management Team will complete home visits to ensure the new labeling practices are being adhered to. |
10/11/2018
| Not Implemented |
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