Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00187229 Unannounced Monitoring 04/21/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #1 is to specifically avoid dry solid foods (anything crunchy, crackers, pretzels), raw fruits (especially apples, pears, papaya, pineapple, grapes, and mango), raw vegetables, nuts, seeds, dried fruit. On numerous occasions in March and April 2021, this individual has had the following foods during meals or snacks: apples, pita chips, dried fruit, raw green peppers, broccoli salad, baked chips, fresh pears, and cucumber onion salad. Individual #2 is to have no hard fruits or vegetables, no fruit juice, and limited sweets. On numerous occasions in March and April 2021, the individual had the following foods during meals or snacks: fruit juice, apple slices, chopped and uncooked veggies, various types of pudding, various types of cookies, brownies, various cakes, and raw green peppers. Individual #4 is to have a mechanical soft low sugar, low cholesterol diet with no tough meats, nuts, seeds, raw fruit or vegetables, dried fruit, pretzels. On many occasions in March and April 2021, meals and snacks included: various cakes, cookies, apple slices, raw green peppers, various puddings and other desserts.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. Current menus implemented in this home do not meet specific dietary needs of individuals served. Agency Nurse will review and update each current menu in ALL homes by 5/11/21, to ensure menus meet dietary needs of all individuals in each home. Specific individual dietary needs will be printed on each menu to assist staff with ensuring dietary needs are being met by 5/11/21. Beginning immediately, all menus for the next month will be completed by the house supervisor/program specialist by the 15th of the current month and reviewed by the Agency nurse (prior to implementation) to ensure that all dietary requirements are satisfied. If new dietary restrictions or choking protocols are recommended by a medical professional, the agency nurse will review orders and the program specialist will update all required documents within 24 hours of receipt. 05/11/2021 Implemented
6400.52(c)(6)Staff person #1 works in this home and has not been trained in Individual #2, Individual #3 and Individual #4's specific dietary needs. Staff person #2 works in this home and has not been trained in Individual #4's specific dietary needs.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.All staff must be trained in an individual's specific dietary needs before working in a home to ensure the health and safety of all individuals. All staff who are currently not trained will be trained by 5/11/21 or will not work with that individual until training is complete. Beginning immediately, ALL staff will be trained in individual dietary needs prior to their first shift in a new home or where a new protocol is implemented. If new dietary restrictions or choking protocols are recommended by a medical professional, the agency nurse will review orders and the program specialist will update all required documents within 24 hours of receipt. Staff will be trained on updates/changes prior to working their first shift with individual. 05/11/2021 Implemented
SIN-00183889 Unannounced Monitoring 02/25/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)The bathroom located off the kitchen does not have a trash receptacle as required by regulation.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. DSP will check each bathroom in the home at the start of their shift to assure the bathroom has all needed items. If items are missing from the bathroom, the DSP will immediately replace the items or notify the supervisor the items need purchased as soon as possible. 03/08/2021 Implemented
SIN-00172071 Unannounced Monitoring 03/03/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(a)The smoke detector in the attic and basement was inoperable during the unannounced inspection. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. The maintenance staff responded to the house immediately after the visit and the smoke detectors were working. Staff were trained on the proper way to set them off. Smoke detector will be checked weekly when the 6400 physical site checklist is completed. 03/04/2020 Implemented
6400.182(c)Individual #1's Individual Support Plan available at her home wasn't current (1/30/19).The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The current isp was place in the proper place in the home. Staff were trained in where to keep the current isp as it was previously in the home and someone must have not filed it correctly. The program specialist will ensure compliance on the monthly house visit. 03/04/2020 Implemented
SIN-00170335 Unannounced Monitoring 01/15/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.74There was a missing nonskid strip on the fourth step on the staircase in the front of the home, to the right of the rampInterior stairs and outside steps shall have a nonskid surface. ShadowFax will abide by the settlement agreement to correct this violation in the future. 01/15/2020 Implemented
SIN-00153434 Unannounced Monitoring 04/10/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)Individual # 1's dresser was missing handle on lower left drawer.Floors, walls, ceilings and other surfaces shall be in good repair. Shadowfax will fix the immediate issue. Then they will complete a walkthrough of all homes to assure compliance. All staff will be retrained on this violation. A member of management will conduct a walkthrough at least quarterly to assure compliance. 04/30/2019 Implemented
SIN-00141792 Unannounced Monitoring 09/17/2018 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(a)Individual #2 displayed symptoms of a cold with a 100-degree fever on 9/14/18 as documented on progress notes detailed on 6400.144. Staff #3 attempted to call an on-call staff person to no avail. Individual #2 was taken to his day program facility ill, and was made to return home because of a high fever. Individual #2 was later transported to the emergency room via ambulance.An individual may not be neglected, abused, mistreated or subjected to corporal punishment. During a meeting at the home on 9/28/18, the Associate Director reviewed regulation 33(b). The content of the discussion surrounding this regulation included that staff should not take individuals to day program if they are exhibiting signs of illness. Instead they should assess the situation, treat all signs and symptoms of illness and follow all training related to obtaining needed medical care. Employees were also trained by the Associate Director that when a symptom is observed or reported, it is the employee¿s responsibility to administer over the counter medications or prescribed PRN medications according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. On 9/21/18, Shadowfax instituted a medical on-call system where staff have access to a LPN to call for medical advice 24/7. Staff were trained on this procedure on 9/28/18 by the Associate Director. During the 9/28/18 meeting staff were also reminded by the Associate Director that it is the responsibility of the on call scheduling department to assure that staffing is in place when an individual is unable to attend day program due to illness and to call them as soon as symptoms are present so they can ensure adequate coverage for individuals to remain home. Moving forward, all staff were trained in September on medication mindfulness and the procedure for contacting the nurse is now in effect so that a medical consult can occur. 09/28/2018 Not Implemented
6400.62(a)REPREATED VIOLATION - 2/20/18. Laundry detergent, Shout, and Window Cleaner were unlocked in the basement. Two containers of disinfectant wipes, Palmolive dish liquid, and a container of dishwasher pods were unlocked under the kitchen sink. Individual #2 was not assessed to be safe with poisons.Poisonous materials shall be kept locked or made inaccessible to individuals. A locked cabinet was purchased on 9/28/18 by the Associate Director to lock laundry detergents in the basement of the home (see receipt). All other poisonous materials were placed in the locked closet on 9/17/18. The staff at the home were trained by the Associate Director on 9/28/18 on regulation 6400.62(a) Auditing/monitoring will be completed by the Associate Directors, QA coordinator, and property manager of this regulation in every home. 09/28/2018 Not Implemented
6400.64(a)The exit sign in the hallway was covered with inches of dust. Cobwebs were on the ceiling. A large puddle of standing water was on the basement floor. Oven mitts stored in the kitchen were covered with food particles.Clean and sanitary conditions shall be maintained in the home. The exit sign was cleaned and the cobwebs were removed. The oven mitts were discarded and the water on the floor was cleaned. The staff at this home were trained by the Associate Director on 9/28/18 on regulation 6400.64(a). The Associate Directors will assure compliance with this regulation by weekly home visits to the home to ensure clean and sanitary conditions. Random unannounced visits will be made by the QA supervisor to ensure cleanliness of the homes See attached completed Home Visit Reports from this home and another home showing clean and sanitary conditions (dated 10-4-18). 10/04/2018 Implemented
6400.64(b)The basement floor was covered with approximately 100 dead bees. Several bees were flying throughout the basement and crawling on the floor.There may not be evidence of infestation of insects or rodents in the home. The dead bees were cleaned up on 9/17/18 and the flying bees were killed on 9/17/18 by the Property manager. A local exterminator was also called in to review the situation and assist the property manager. See attached pictures and bill. The staff at the home were trained on 9/28/18 on regulation 6400.64(b). Weekly home visits by the AD will be conducted to ensure there is no evidence of infestation of insects or rodents of the home. Random unannounced visits will be made by the QA supervisor to ensure no infestation of insects or rodents are in the homes. 09/28/2018 Implemented
6400.66Individual #2's bedroom door leading to the outside was not equipped with a light.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The residential property management manager at Shadowfax equipped this area with a light on 10/1/18. The staff at this home were trained by the Associate Director on 9/28/18 on regulation 6400.66. The Associate Directors will assure compliance with this regulation by regular home visits to the home. Moving forward, staff in the homes will be expected to complete maintenance requests for any area with inadequate lighting to ensure safety of the individuals. Auditing/monitoring will be completed by the Associate Directors, QA coordinator, and property manager. 10/01/2018 Implemented
6400.67(a)The leather covering on the couch was missing, exposing the cushion on the left side and back of the couch. Individual #3's bedroom dresser was severely scuffed. Individual #2's bedroom dresser had a broken handle. There were holes in the wall behind Individual #4's bedroom recliner.Floors, walls, ceilings and other surfaces shall be in good repair. A new couch was purchased on 9/19/18 and will be delivered on 10/19/18. The dressers for individual¿s number 2 and 3 were swapped out with other dressers. The wall for individual #4 was repaired by maintenance. The staff at this home were trained by the Associate Director on 9/28/18 on regulation 6400.67(a) and to ensure maintenance requests are submitted timely. The Associate Directors will assure compliance with this regulation by regular home visits to the home. Periotic unannounced spot checks/QA site visits are being done by the IM and QA supervisor to all homes. See attached pictures (before and after) of repairs being completed and receipts as proof of purchases. 10/19/2018 Implemented
6400.144REPEATED VIOLATION - 2/20/18, 6/12/18. The daily notes for Individual #1 indicated she returned home from a hospital stay on 9/3/18. The 9/4/18 progress note indicated, "Individual #1 still has cough." The 9/5/18 note indicated she "woke up with junkie cough, gave her 2 puffs of inhaler." The 9/6/18 progress note read, "day program states she coughed all day long, didn't eat her lunch, complained of her back hurting, could hardly stand or get in van. At home, still coughing, ate dinner, got around fine w/no back pain." on 9/7/18, Individual #1 had a follow up appointment and received a chest x-ray at Ready Care. X-ray results were negative for pneumonia. The 9/9/18 progress note indicated a mood of "feeling sick/tired" and stated after breakfast, Individual #1 was taken to the hospital for blood in her eye. The 9/10/18 progress note read, "Ref 12mid and 4am inhaler. Refused to go to bathroom. Blew out when given 8am inhaler." On 9/11/18, the daily note indicated during the 12am and 9:30am shift, she "coughed a lot through night, refused inhaler both at 12a and 4a, staff tried many times," Individual #1 was taken to the emergency room for excessive cough and admitted on 9/11/18 around 3pm. An "Approval for over the counter medication form" updated on 6/18/18 and signed by the physician indicated Robitussin and Cough Drops were approved over the counter medications that Individual #1 could be administered for cough. Neither were administered to Individual #1 between 9/4/18-9/11/18. Individual #2 was transported to the York Hospital for unresponsiveness and lethargy on 9/13/18. Staff #2 documented Individual #2 displayed symptoms of a cold on the 9/13/18 daily note. On 9/14/18, the Individual #2's daily note read, "slept, awake coughing and laughing, up and dressed, breakfast, tv. Had a high temp of 100 at 7am. Staff Brenda Cox documented "Individual #2 was running a fever at breakfast, called on call, no answer, so DL transported to day program, but they sent him back with same. I called 911. He was taken to ER around 930." Staff #2 documented "relieved Staff #3 at the hospital at 10:15am. Look at MMR for what went on at hospital. Diagnosed w/Rhino Virus. Being admitted at 1:45pm. Individual #2's record contained an approved over the counter medication form, updated 5/8/18, that indicated Acetaminophen (Tylenol) should be taken for pain/fever, Vicks Vapor was approved for colds, and Robitussin should be taken for a cough. The approved OTC meds were not administered.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. On 9/21/18, Shadow fax instituted a medical on-call system where staff now have access to a LPN to call for medical advice 24/7. The staff were trained in this home on this procedure on 9/28/18 by the Associate Director. The staff were also trained on 9/28/18 on regulation 6400.176(b) by the Associate Director. The training content included a review of the regulation and the over the Counter medication record for individuals at this home by the Associate Director. Employees were also trained that when a symptom is observed or reported, it is the employee¿s responsibility to administer over the counter medications or prescribed PRN medications according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. On 10-1-18, the CEO reiterated to all residential management that they need to ensure staff are giving OTC meds to individuals when symptoms are present. The Associate Directors will assure compliance with this regulation by regular home visits to the homes. Moving forward, the Associate Directors will document and follow up on medical issues as they arise. See revised home visit report (revised 10-3-18)¿ Attachment 7. 10/03/2018 Not Implemented
6400.161(b)Nystatin Cream was unlocked on Individual #3's bedroom dresser.Prescription and potentially toxic nonprescription medications shall be kept in an area or container that is locked, unless it is documented in each individual's assessment that each individual in the home can safely use or avoid toxic materials. The medication was immediately locked up by the Associate Director at the onsite inspection. The staff at the home were trained by the Associate Director on 9/28/18 on regulation 6400.161(b). During the 9/28/18 regulation training it was made clear to the staff at Program 36 that all poisons must be locked. The Associate Director will assure compliance with this regulation by regular home visits to the home. Additionally, QA audits are being completed to homes by the IM and QA supervisors now on a periodic basis. Several Fatal 4 trainings are being offered and all staff from this home are expected to attend to understand the seriousness of health and safety issues. 09/28/2018 Not Implemented
6400.164(b)REPEATED VIOLATION - 2/20/18. Denta 5000 plus was not initialed as administered on Individual #1's 8/26/18 medication administration log. The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. This home currently has a medication administration procedure at the home. This procedure requires one staff to administer all medications during an administration time and a second staff person to observe this process for accuracy. The staff at the home were trained by the Associate Director on 9/28/18 on regulation 6400.164(b). During the 9/28/18 regulation training it was made clear to the staff at the home by the Associate Director that the medication administration procedure includes those prescribed medications that are often administered during bathing and bedtime routines and not just administered during oral medication administration times. The Associate Directors will assure compliance with this regulation by regular home visits to the home and checking MAR¿s and medication packaging. Additionally, QA audits are being completed to homes by the IM and QA supervisors now. 09/28/2018 Not Implemented
6400.167(b)REPEATED VIOLATION - 2/20/18. Individual #1 was prescribed Vitamin D3, 400 units, to be administered twice daily. Staff #1 administered 800 units of Vitamin D3 to Individual #1 at 8am on 8/7/18 and 8/8/18. According to the daily notes referenced in 6400.144, staff members working in the home were treating Individual #1's cough with a Ventolin inhaler, prescribed for wheezing, instead of the physician-approved over the counter medications for a cough. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.Staff #1 received 60 days disciplinary action for the vitamin D medication error. The staff at the home were trained by the Associate Director on 9/28/18 on regulation 6400.167(b) ¿ Attachment 1. The content of this training included a review of the step by step guide to medication administration. In response to the 8/7/18 and 8/8/18 medication error, the previous Medication Administration Procedure that was in place for this home was amended to include a second component. The first Medication Administration Procedure was implemented at this home by the Associate Director in July 2018. The original procedure required only one staff at the home to administer medications during each administration time. This Medication Administration Procedure was amended by the Associate Director after the 8/7/18 and 8/8/18 medication errors to require a second staff person to observe all medication administration passes to ensure accuracy. This process was implemented on 8/17/18 by the Associate Director. All staff were trained and retrained on the procedure on 9/28/18. The staff were also trained on 9/28/18 on regulation 6400.176(b) by the Associate Director. The training content included a review of the regulation and the over the Counter medication record for individuals at the home by the Associate Director. Employees were also trained that when a symptom is observed or reported it is the employee¿s responsibility to administer over the counter medications or prescribed PRN medications according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. The Associate Directors will assure compliance with this regulation by regular home visits to the home as well as QA audits to ensure these matters are handled immediately. Furthermore, Shadowfax has 1 of 2 nurses hired and staff were informed to start contacting the nurse for medical issues and concerns so that she can ensure the best medical care is being provided. Also, a Fatal 4 training is being offered and all staff from this home are expected to attend to understand the seriousness of health and safety issues. 09/28/2018 Not Implemented
6400.171An open bag of waffles was stored in the freezer.Food shall be protected from contamination while being stored, prepared, transported and served. The waffles were disposed of on 9/14/18 by the Associate Director. The staff at the home were trained on 9/28/18 on regulation 6400.171 by the Associate Director. The training content included reviewing food storage safety. In the future to ensure compliance, he Associate Directors will check this regulation on regular home visits to the home -see attachment 7 of revised home visit report (revised 10-3-18) with this line item. 10/03/2018 Implemented
6400.181(a)Individual #2's assessment was completed on 3/30/17 and not again until 4/19/18. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. This specific situation was asked at a previous licensing visit at the exit interview. The Program Specialists asked the Licensing Supervisor: with assessments needing to be mailed 30 days prior to the ISP annual meetings, and those dates fluctuating, how we will ensure that we are being compliant, if our assessments dates change to reflect that? The supervisor of the licensing staff stated that as long as our assessments are mailed 30 days prior to the ISP meeting, the dates did not need to be exact. The assessment was completed on 4/19/18 and mailed on 4/20/18 which was more than 30 days prior to the 5/22/18 ISP meeting date. In addition, individual #2 was set to be discharged prior to the assessment date. When he was not, the PS completed the assessment per the regulation that states the assessment needs to be mailed 30 days prior to the ISP meeting. Based on that conversation, Shadowfax thought we were compliant. Staff at the home were trained on 9/28/18 on regulation 6400.181(a). Moving forward, the PS¿s will ensure all assessments are completed before or on the date of the previous assessment. This will be reviewed at the 10-5-18 PS meeting. See attachment 6 for an assessment cover sheet that was completed prior to the previous year¿s assessment(completed 9-21-18). Note: the individual from this home has been discharged to a nursing home; therefore, he will not have another assessment from this agency. 09/21/2018 Implemented
6400.213(6)Individual #2's record did not include his 4/19/18 assessment.Each individual's record must include the following information: Assessments as required under § 6400.181 (relating to assessment). The current Assessment for individual #2 was located in the home but had not been filed in the correct location. The Program Specialist placed the Assessment in the individual¿s record at the program on 9/18/18. Staff members of the home were trained on 9/28/18 on regulation 6400.213(6) by the Associate Director (see attachment 1). The training content included a review of where the current Assessment should be filed in the home black book. Moving forward, the Program Specialist will assure that Assessments are placed in the home book after each annual update. The Associate Directors will complete checks to ensure that the assessment is in the home book in the correct location (see attachment 2). Additionally, on 10-1-18, the CEO of the company reiterated to all Residential Management (AD¿s and PS¿s) that they need to be checking this on home visits. Shadowfax is going to electronic record keeping. Each home has a computer and staff will be fully trained on how to access records when needed. The most current ISP and assessment will be uploaded in Therap, our electronic record system which will be available to all staff. 09/18/2018 Implemented
6400.213(11)REPEATED VIOLATION - 2/20/18. Individual #2's Individual Support Plan (ISP) indicated there were no awake overnight staff in the home however, the home was staffed with an awake overnight staff member. The ISP indicated Individual #2 can be unsupervised for 15 minutes in his bedroom. The 4/19/18 assessment indicated Individual #2 required 24-hour supervision and could be left in his room or other areas without direct supervision. Staff need to be aware of his whereabouts. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. An e-mail was sent to the Support Coordinator by the Program Specialist for Program 36 on 6/4/18 noting that the changes that were discussed at Individual #2¿s ISP on 5/22/18 had not been made as requested at his ISP meeting (attachment 3). In addition, an e-mail was sent to the Support Coordinator by the Program Specialist on 7/25/18 (attachment 4) that individual #2¿s ISP will need to be changed to 1:6 ratio. Another e-mail has been sent on 9/27/18 (attachment 5) by the Program Specialist to the Support Coordinator requesting the following ¿As discussed at his ISP team meeting on 5/22/18, as well as stated in his residential assessment that was mailed to the SC on 4/20/18, please change the home supervision care needs to state "David can be left alone in his room and other areas of his home, without being in the direct line of site from staff. Staff should be aware of his whereabouts at all times." Please remove the following highlighted section below (HE CAN BE ALONE IN HIS ROOM FOR 15 MINUTES WITH CHECKS, HOWEVER STAFF MUST ALWAYS KNOW WHERE HE IS). All staff members were trained on 9/28/18 on regulation 6400.213(11) (attachment 1) by the Associate Director. Training content included the responsibility of every employee when reviewing an ISP to immediately report any content discrepancy to the Program Specialist In addition, a Residential Program Specialist Assistant was trained on 10/1/18 on regulation 6400.213(11) by a Program Specialist. The Residential Program Specialist Assistant duties will include reviewing all ISPs and Assessments for content discrepancy and notifying the assigned Program Specialist of all content discrepancies. Moving forward, the Program Specialist will check the ISP upon receiving it, and have the PS assistant check as the 2nd set of eyes to review and ensure no content discrepancy. Shadowfax has hired an additional Program Specialist to lighten the workload of all current PS¿s so that more time can be spent on each individuals¿ programming. 09/27/2018 Not Implemented
SIN-00137164 Unannounced Monitoring 06/12/2018 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16Individual # 1 was given Individual # 2's morning medication on 06/10/18 by Staff #4. Staff #2 reported that he/she began the medication pass for the 6 individuals in the home at approximately 6:30 am. The only two individuals who had not been given their medications prior to Staff # 4's arrival were Individual #2 and Individual #4. Staff # 2 stated that a med pass is typically completed by a single staff person. Staff # 4 is not assigned to this home but fills in as needed. Staff # 2 yelled at Staff # 4 to "stop medication process because we have from 8 a.m. until 9 a.m" Staff # 4 took over medication pass as Staff #2 began waking and supporting individuals in morning routine upon direction from Staff # 4. Staff # 4 reportedly asked Staff # 2 which individuals needed medications. Staff # 2 told Staff # 4 that "Individuals #2 and #4 still need medications". A short while later, Staff #4 asked Staff#2 "Is it Individual # 1 and Individual #4? (who still needed meds)" Staff # 2 stated "Individual #2 and #4 need meds". Staff #25 arrived at the home at approximately 8:00 am to relieve staff #2. Staff # 4 reported to Staff # 25 that Individual # 1 was given the wrong medications. Staff # 25 directed staff # 4 to contact the on call AD who then directed Staff # 4 to call the Primary Care Physician. At approximately 8:30am staff # 4 was instructed by PCP to track vital signs, push fluids, watch for sedation and call with any concerns. Staff # 4 failed to track vital signs or relay that information to other staff. Staff #1 arrived for his/her shift at approximately 1:30 pm. Staff # 1 identified that Individual # 1 was lethargic, was coughing with phlegm and "just didn't look right". Staff # 1 contacted AD assigned to home and was instructed to bring Individual # 1 to the ER. Individual # 1 was subsequently brought to the hospital by Staff #1 at approximately 2:00PM. after displaying symptoms of severe coughing, phlegm and lethargy. Individual # 1 collapsed in the ER, was intubated and placed on a ventilator in critical condition due to the medication error. Upon interview, Staff # 4 stated "I don't know how it happened" and "I don't know what I was thinking".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.The A.D. will retrain all Herman Court staff on 7/13/18 of the procedure in which only 1 person will pass meds at med times. Staff in all homes will be retrained in the ODP health alert by the QM coordinator by 8/31/18 & ISP¿s by their PS by 8/31/18. All new hires will now have an additional day of training prior to working in the home. The new procedure will allow a full day to be trained on all ISP's & all plans that staff must know/follow to ensure the safety of individuals. Quizzes are being developed to ensure staff have retained & understand the info from the ISP plan. Quizzes will be completed & instituted for new hires by 7-19-18. As discussed at the onsite inspection, this home is being broken into 2 smaller homes to ensure better individualized care. We are awaiting the paper license from ODP & once received, we will be able to move some of the individuals out of this home to downsize the number of individuals living at the Herman Court site until the 2nd home receives approval to open. This ensures less people in the home as we recognize the difficulty in having 6 individuals in a home. On 7-2-18, the Res Director, the HR Director, CEO, the Sr. Res AD, & the QM Coordinator met to discuss hiring additional positions. We will be hiring an Incident Mgmt. coordinator & 2 nurses for the res department. See meeting notes attached (attach. #1) as well as job descriptions completed 7-3-18 for these positions (attachment # 2 A & B). Ads were posted on the agency website & Indeed.com on 7-3-18 & will be running in the newspaper the weekend of 7-7 & 7-8-18. See attached job description for specific nurse duties. HR is looking for trainings on reactions during emergencies. Nurses will work closely with staff on responding & following protocols during emergencies. Nurses will assist/ensure staff have documented appropriately & follow all Dr. orders. Remediation will occur as necessary. The residential department is looking at schedules to ensure all gaps are covered. No pulling of staff from Herman Court is allowed & has been reiterated to scheduling effective 7/2/18. Due to medical issues, we are running an ad to hire CNA¿s as direct care staff as they will be more aware of medical issues with individuals (see attachment # 7). Management will be assigning schedulers to a set of homes that they will be trained on & have the same trainings as the DSP's with regard to training on ISP¿s and plans, & work in those homes with the DSP Lead or seasoned staff to train them on the person's likes/dislikes, etc. to be thoroughly trained. In the event of a call off & they can't find a suitable replacement, the scheduler(s) will be well versed in the home to ensure proper care. All part time & full time staff will be assigned to 1 supervisor & work in their homes only. There will be no pulling beyond the core team homes, & only in emergency situations if necessary. We are also looking into electronic scheduling & have contacted other agencies to see how they schedule. Schedulers will work proactively to fill openings instead of working in crisis mode. Furthermore, Shadowfax is switching to electronic record keeping (Therap). In Therap, staff are assigned to programs & only have access to the records from that home. Therefore, staff cannot be pulled to work in other homes if they have not been ¿enrolled¿ in the home & can only be enrolled in the home upon successful completion of training in the ISP & plans as well as training working with individ's in the home. We are currently working with Therap to set up electronic record keeping & inputting individuals & staff. A 3rd meeting is set for 7-17-18. A specific implementation plan, a Go Live date for our agency, as well as training schedules for staff to learn how to use the system will be established. A meeting is scheduled for 7-11-18 to discuss scheduling & what else should be addressed to ensure there's adequate coverage for the consistency & health of individuals 08/31/2018 Not Implemented
6400.43(b)(1)Agency Medication policy last updated 07/27/15 is for medication errors to be documented and submitted to agency point person on the following business day. Corrective action procedures indicate medication errors will be addressed in the following way. In a one year period measured back from most current med error. 1 Med error=Verbal warning, 2 med errors=written warning, 3 med errors = required to retake med admin course within 30 days, 4 med errors=30 day disciplinary probation, 5 med errors=60 day probationary discipline, 6 med errors=90 days probationary discipline, 7 med errors=Termination. Staff #5 received only a verbal warning on 08/08/17 for medication errors on 06/26, 27, 28, 29, 30/18 and 07/02/18. He/she also had a medication error on 07/22/17. Corrective action plan not implemented. Staff # 6 was responsible for a medication error on 03/04/17. No documentation of Corrective action procedure implemented. Staff #7 received only a verbal warning on 08/16/17 for medication errors on 07/22&23/17. Additional medication error occurred on 09/13/17. Corrective action plan not implemented. Staff #4 received only a verbal warning on 08/08/17 for a medication error on 07/02/17. Additional medication error occurred on 06/10/18. Corrective action plan not implemented. Staff #8 was responsible for a medication error on 09/28/17. No documentation of corrective action plan implementation. Staff # 1 was responsible for medication errors on 05/11/17, 10/29/17, 08/05 & 08/18. No documentation of corrective action plan implementation or medication administration retraining. Staff # 9 was responsible for a medication error on 02/18/18. No documentation of corrective action plan implementation. Staff # 10 received a verbal warning on 02/07/17 for a medication error on 01/26/17. Additional medication error occurred on 07/02/17. No documentation of corrective action procedure implementation. Staff # 11 received a verbal warning on 08/14/17 for a medication error on 08/06/17. He/She was responsible for a medication error on 08/13/17. No documentation or corrective action procedure implementation. Staff # 12 received a verbal warning on 04/23/18 for a medication error on 04/16/18. He/She was responsible for a medication error on 04/03/18. No documentation of corrective action procedure implementation. Staff # 13 received only a written warning for medication errors on 06/26/17, 08/04 (two errors) & 05/17, 09/09/17 and 09/13/17, instead of 60 day probationary discipline. Corrective action procedure not implemented. Staff # 14 was responsible for a medication error on 09/09/17. No documentation of corrective action procedure implemented. Staff # 15 received a written warning for unsatisfactory work performance on 02/27/18. He/She was responsible for a medication error on 11/19/17. No documentation or corrective action procedure implemented. Staff # 16 received a written warning for unsatisfactory work performance on 02/27/18. He/She was responsible for medication errors on 02/25/18, 03/04/18, 03/14/18. No documentation of corrective action procedure implemented. Staff # 1 transported Individual # 1 to hospital instead of contacting 911 on 06/11/18 as per the agency Emergency Medical Care Policy. Staff # 4 did not contact 911 upon acknowledgement of administering the wrong medications to Individual # 1 and Individual # 1 subsequently becoming lethargic, coughing and bringing up phlegm as per agency policy.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. In some cases of medication errors, the corrective action was not followed because the initial report was filed to ODP within the required time frame and upon investigation, the error was not a medication error for the suspected staff but another staff and the corrective action was adjusted accordingly. Information was put into HCSIS as the required procedure requests and the person responsible for putting in medication error entries has been re-trained on 7/9/18 with providing more detail regarding incidents, including staff education and follow up action regarding medication errors ¿ see attachment # 5. The agency medication policy has been updated as of 6-26-18 (attachment # 4) with regard to medication errors and how each error will be handled. Medication mindfulness training has been developed and staff in homes that have issues will be required to take/re-take the training. The medication training and medication mindfulness trainings have been revised to include medication errors and the difference between errors versus a medication overdose and clearly define this for staff. All staff within the company will be retrained on the health alert from ODP, emergency guidelines, and ensure they understand the difference between medication errors and an overdose by 8/31/18. On 7-2-18, the Residential Director, the HR Director, the Senior Residential Associate Director, CEO, and the Quality Management Coordinator met to discuss hiring additional positions. Shadowfax will be hiring an Incident Management Coordinator and 2 nurses for the residential department. See notes from the meeting on 7-2-18 attached (attachment # 1) as well as job descriptions completed 7-3-18 for these positions (attachment # 2 A & B). Advertisements were posted on the Shadowfax website on 7-3-18 and on Indeed.com and in the newspaper the weekend of 7-7 and 7-8-18). The nurse will be responsible for assessing individuals for baseline health on a monthly basis, follow up from hospital discharges, ensure staff are trained thoroughly on signs of infection, concussion protocol, training on diagnoses, etc. The nurse will also be responsible for following medical protocols established by physicians, ensuring medication labels match MAR¿s, attend medical appointments for medically involved individuals, focus and re-educate/train staff in homes with medication issues and medication errors including plans to decrease errors, serving on the medication task force to reduce medication errors, and be on call for staff to contact with medical issues. The nurse will be the liaison with the 2 pharmacies that Shadowfax uses to resolve issues with refills. The incident management coordinator¿s primary focus will be on all the medical issues and medication errors and all follow up. The nurse and the incident manager coordinator will work together. The IM coordinator will notify the nurse of every medication error and anything medically related to ensure follow up is swift and thorough. The IM coordinator and nurse will talk regarding each medication error and a suitable plan of correction will be established after reviewing how the error occurred which may include (but not limited to) retaking mediation training or additional med pass observations, etc. Furthermore, the Associate Director and the nurse will monitor MAR¿s on home visits to ensure proper administration and to look for any possible issues with regards to medication administration. All training sheets will be forwarded to ODP. 08/31/2018 Not Implemented
6400.43(b)(3)Approximately 327 medication errors occurred agency wide, (27 homes) from 01/01/17- 06/12/18. Staff corrective action plans for medication errors have not been implemented as written in medication policy placing individuals at medication error risk. In home # 36 from January 01, 2017- June 12, 2018, Individual # 1 had 8 medication errors and an additional medication error on 06/11/18 which he/she was given another individuals' medications which led to his/her current hospitalization. Individual # 2 had 8 medication errors including medications not ordered from pharmacy on 03/29/18 and 07/22/17. Individual # 3 had 8 medication errors including medications not refilled on 03/05/17. Individual # 4 had 9 medication errors including medications not refilled on 12/21/17 and 11/21/17.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. On 7-2-18, the Residential Director, the HR Director, the Senior Residential Associate Director, CEO, and the Quality Management Coordinator met to discuss hiring additional positions. Shadowfax will be hiring an Incident Management Coordinator and 2 nurses for the residential department. See notes from the meeting on 7-2-18 attached (attachment # 1) as well as job descriptions completed 7-3-18 for these positions (attachment # 2 A & B). Advertisements were posted on the Shadowfax website on 7-3-18 and on Indeed.com (see attachment # 3) and will be running in the newspaper the weekend of 7-7 and 7-8-18). The nurse will be responsible for assessing individuals for baseline health on a monthly basis, follow up from hospital discharges, ensures staff are trained thoroughly on signs of infection, concussion protocol, training on diagnoses, etc. The nurse will also be responsible for following medical protocols established by physicians, ensuring medication labels match MAR¿s, attend medical appointments for medically involved individuals, focus and re-educate/train staff in homes with medication issues and medication errors including plans to decrease errors, serving on the medication task force to reduce medication errors, and be on call for staff to contact with medical issues. The nurse will be the liaison with the 2 pharmacies that Shadowfax uses to resolve issues with refills and to assist with automatic refills if necessary. The incident management coordinator¿s primary focus will be on all the medical issues and medication errors and all follow up. The nurse and the incident manager coordinator will work together. The IM coordinator will notify the nurse of every medication error and anything medically related to ensure follow up is swift and thorough. With regard to ¿corrective action plans for medication errors have not been implemented as written in medication policy placing individuals at medication error risk,¿ the agency medication policy has been updated as of 6-26-18 (attachment # 4) to include the following actions each time a medication error has occurred: ¿ Evaluate new policy or modify an existing policy ¿ Evaluate new practice or modify an existing practice ¿ Referral to HCQU (Health Care Quality Unit) ¿ Indicator for Quality Improvement Initiative ¿ Feedback to staff member ¿ Monitor medication passes for staff member ¿ Referral to Risk Management for further evaluation ¿ Training/retraining ¿ Disciplinary action ¿ Situation evaluated and no action taken It should be noted that in some cases of medication errors, the corrective action was not followed because the initial report was filed to ODP within the required time frame and upon investigation, the error was not a medication error for the suspected staff but another staff and the corrective action was adjusted accordingly. More explanation will be entered on HCSIS as possible. The person who is currently inputting IM medication error data had a discussion about inputting more detail. See attachment 5. All medication errors will be a focus for the nurse and incident management coordinator. The training department will be re-training all residential staff on the Medication mindfulness training by 8/31/18. See attachment 6 of the training content for this training. 08/31/2018 Not Implemented
6400.44(b)(18)No documentation that the Program Specialist trained all 86 staff assigned to the home in the last 6 months in the health and safety needs of the 6 individuals living in home. Staff #4's witness statement indicates "sometimes they do not receive training when covering a shift." "If you need help···you can call the A.D." During 06/10/18 morning shift, it was reported that Staff # 4 yelled at staff# 2 as he/she thought that Individual #4 needed assistance with getting dressed. Staff # 2 stated that Individual #4 was independent with dressing. Staff #4 stated "Why are you letting Individual # 4 dress him/herself?" (*This statement is evidence that did not know the individuals he/she was caring for). Additionally, Staff #4 reported that there is no routine about medication passing in the home which contradicts Staff #2's report that one staff gives all the medications to individuals during a single medication pass. 36 staff were trained/shadowed at homes other than site of incident.The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. The staff was not truthful in her statements during the investigation. See print out of all the hours she worked in the home. She often picked up open hours or overtime in this home as this was one of her ¿favorite¿ homes to work in and had been trained in the individuals ISP¿s. Despite this, it is evident that staff need to be trained and review ISP¿s more often. The Associate Director will be responsible to review ISPs throughout the year with the staff that works with the individuals by doing unannounced ISP quizzes on staff on a random basis to ensure they know the contents of the ISP and re-educate staff on any issues they may have (see attachment # 8 of a sample quiz). The supervisor will retrain all Herman Court staff on 7/13/18 of the procedure in which only 1 person will pass medications at med times. The core team will be the ones giving medications. Due to 6 people living in the home, Shadowfax has purchased 2 separate homes to move the individuals into that will ensure a smaller setting with less chaos and better care. We are currently waiting on the paper license for the first home and then can enroll in PROMISe and downsize Herman Court. Shadowfax is changing the procedure for how staff are trained on ISP¿s and plans. New staff will go through orientation and the final day will be a day set aside to be trained by the Program Specialist, Nurse, and Associate Director on all plans and medical issues/charts of each individual in the home. Documentation will be kept. A new staff has completed orientation on 7-5-18 and met with the PS and AD on 7-5 and 7-6-18 to receive training on the ISP and all plans (see attachment #¿s 9, 10, 11). Quizzes are being developed and will be instituted 7-19-18 to ensure staff have retained what they have learned during ISP training. Shadowfax is revamping scheduling. All staff will be assigned to one Associate Director and will work in homes of that Associate Director only (cross trained in the 5 homes of that Associate Director to help out by picking up overtime in one of these homes). Schedulers will be assigned to homes and attend meetings at least once a month with the AD and the home staff to ensure all gaps in schedules are covered and to preplan for vacations, etc. In the event of call offs, staff that regularly work in the home will be contacted first to fill the open hours regardless of overtime. Schedulers will meet at least monthly with the home to ensure all gaps are covered. The team will work together to have a filled schedule that best meets the needs of the home. Homes will have a copy of the schedule so people will know who is working. Schedulers were all trained in there is no pulling from Herman Court and that they need to communicate when staff call out sick so staff in the home know what is happening. Furthermore, Shadowfax is switching to electronic record keeping via a program called Therap. In Therap, staff are assigned to programs and only have access to electronic record keeping of these homes. Therefore, staff cannot be pulled to work in other homes if they have not been ¿enrolled¿ in the home and can only be enrolled in the home upon successful completion of training in the ISP and plans for that home. Shadowfax is currently working with Therap in setting up the electronic record keeping program and inputting individuals and staff in the residential department. A 3rd meeting with Therap is set for 7/17/18 and then a specific implementation plan and a Go Live date for our agency will be established as well as training schedules for staff after this date. The Program Specialists are re-training all staff on the ISP's and this will be completed by 8-31-18 08/31/2018 Implemented
6400.144Staff #4 witness statement about investigatory incident on 06/10/18 indicated that the PCP instructed him/her to "keep him/her within sight, watch him/her, have him/her drink lots of water." Staff #4 witness statement indicated "the more water he/she drank, the more phlegm···I told him/her not to drink more water".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. On 7-2-18, the Residential Director, the HR Director, the Senior Residential Associate Director, CEO, and the Quality Management Coordinator met to discuss hiring additional positions -see attachment 1. Shadowfax will be hiring an Incident Management Coordinator and 2 nurses for the residential department. Job descriptions for these positions were created 7-3-18 -attachment # 2 A & B. Advertisements were posted on the Shadowfax website on 7-3-18 and on Indeed.com and in the newspaper.. The nurse will be responsible for assessing individuals for baseline health on a monthly basis, follow up from hospital discharges, ensure staff are trained thoroughly on signs of infection, concussion protocol, training on diagnoses, etc. The nurse will also be responsible for following medical protocols established by physicians, ensuring medication labels match MAR¿s, attend medical appointments for medically involved individuals, focus and re-educate/train staff in homes with medication issues and medication errors including plans to decrease errors, serving on the medication task force to reduce medication errors, and be on call for staff to contact with medical issues. The nurse will be the liaison with the 2 pharmacies that Shadowfax uses to resolve issues with refills. The nurse will also be responsible for following up with staff on all Dr.¿s orders and explaining to staff why it is imperative to relay all symptoms as they occur. The nurse will be the liaison with the Doctor for medical issues. The nurse in conjunction with the Associate Director and Program Specialist will ensure health serves that are planned or prescribed will be arranged. Nurse interviews were started on 7/9/18. All staff are being retrained on the ODP health alert as well as emergency guidelines and will be informed of the necessity of following Dr.¿s orders as prescribed and following up if for some reason the orders cannot be followed or staff are having difficulty following the orders. This training will occur by 8/31/18. The residential nurses will be responsible to develop training or make a referral for HCQU nurses to train staff on what happens during symptoms/why symptoms are happening and what they mean so staff understand the seriousness of symptoms, complications, etc. The nurse will be responsible to ensure all documentation is completed as well to ensure the best overall health for each individual. 08/31/2018 Not Implemented
6400.165On 06/11/18, Individual # 1 was given the medications of Individual #2 by Staff #4 leading to emergency hospitalization.Documentation of medication errors and follow-up action taken shall be kept. The company trainer has added how to report errors and appropriate documenting in medication mindfulness training ¿ see attachment # 6. It will be re-iterated to all new staff during initial medication training as well. Part of this training will be understanding the necessity of detailed documentation for the best overall health care for the individual. All residential staff will be retrained on this by 8-31-18. On 7-2-18, the Residential Director, the HR Director, CEO, the Senior Residential Associate Director, and the Quality Management Coordinator met to discuss hiring additional positions. Shadowfax will be hiring an Incident Management coordinator and 2 nurses for the residential department. See notes from the meeting on 7-2-18 attached as well as job descriptions completed 7-3-18 for these positions. Advertisements were posted on the Shadowfax website and on indeed.com (see attachments). The nurse job duties will include: ¿Coordinating, planning, implementing and evaluating all individuals to maintain the person¿s highest practicable physical, mental and psychosocial wellbeing. This includes ensuring monthly medical assessment of all individuals and updating baseline forms as needed. ¿Assist agency staff throughout illnesses of individuals as needed ¿Ensures Medication labels and MAR¿s are correct on a monthly basis ¿Attends appointments with agency staff for medically involved/individuals/critical appointments ¿Trains and monitors residential sites with medication issues (ex. medication errors) ¿Trains agency staff on medical apparatus (ex. Hoyer lifts) and individual diagnoses. Ensures medical adaptive equipment is functional ¿Serve as the main liaison when individuals are hospitalized. Ensures follow up from hospital discharges including acquiring equipment, medication change management, and training agency staff on medical discharge protocol ¿Serves on the agency medication task force. Following up on all medication errors and working with pharmacies and doctors. ¿Reviews safety /health risk plans for individuals ¿Create and modify charts or documents as needed to ensure medical documentation meets ODP regulations. Assist in creating and modify refusal for treatment plans. ¿Being on call for residential staff with regard to medical issues. It will be a job duty of the nurse to ensure all documentation is completed timely and thoroughly on all medical documents, especially during an emergency event. The Human resources department is researching a training on how to effectively manage yourself during a crisis so that staff can be trained to ensure they remain calm, follow protocols appropriately, and document appropriately. The residential flow chart staff can reference is being revised to include when to call the nurse and when to call 911. The current flow chart only shows when to call scheduling on call versus the Associate Director on call. This chart will be completed and mailed out to all staff once the nurses are hired as well as reviewed at team meetings. The nurse will be notified of every medication error and in conjunction with the IM coordinator will decide on follow up action. The Nurse will also monitor to see if any trends are developing per home or per staff and address the need for remediation. 08/31/2018 Not Implemented
6400.185(b)Individual # 1's ISP last updated 11/30/17 identifies an outcome of Individual # 1 NEEDS A CONSISTENT ROUTINE, OPPORTUNITIES TO ENGAGE IN COMMUNITY ACTIVITIES AND 1:1 OUTINGS AS WELL AS BEING ABLE TO HAVE A SPACE OF HIS/HER OWN TO KEEP HIS/HER BELONGINGS ISP not implemented as written. Documentation from provider demonstrates that over 86 staff worked within the home in a 6 month period. ISP review sign off sheets for home residents demonstrates that approximately 61 Staff did not review Individual # 1's 11/30/17 ISP. Staff testimony about inconsistent staffing and scheduling reflect lack of consistency for Individual # 1 and other residents within the home. Direct support staff report that they are unaware of who is scheduled to work shifts on daily basis. Staff # 3 indicates that the staff schedule which is created by the Executive Residential Director creates a lack of consistency for individuals within the home. Of 86 staff training and orientation documents reviewed, only 14 completed shadowing documentation at Individual # 1's residence. On the date of medication error requiring hospitalization, Staff # 2 reported not knowing that Individual # 4 was independent in dressing him/herself during morning routine and told staff # 1 that he/she should be assisting Individual # 4.The ISP shall be implemented as written.All staff in the res department are being re-trained on the ISP¿s by their PS by 8/31/18. All new hires will now have an additional day of training prior to working in the home. This new procedure will allow a full day to be trained on all ISP¿s/all plans that staff must know & follow to ensure the safety of individuals. Quizzes are being developed to ensure the staff have received the training & understand the info in each individual¿s ISP plan. Quizzes will be completed & instituted for new hires by 7-19-18 and forwarded to Human Resources for inclusion into their training files. Quizzes will be done on a random basis throughout the year by AD¿s with staff on the ISP to ensure staff are fully aware of the content of the ISP. AD¿s will refer staff to the PS if re-training is needed. As discussed at the onsite inspection, this home is being broken into 2 smaller homes to ensure better individualized care. We are awaiting the paper license from ODP & once received, we will be able to move some of the individuals out of this home to downsize the number of individuals living at the Herman Court site until the 2nd home receives approval to open. This ensures less people in the home as we recognize the difficulty in having 6 individuals in a home. Shadowfax is revamping scheduling. All staff will be assigned to one Associate Director and will work in homes of that Associate Director only (cross trained in the 5 homes of that Associate Director to help out by picking up overtime in one of these homes). Schedulers will be assigned to homes by management and attend meetings at least once a month with the AD and the home staff to ensure all gaps in schedules are covered and to preplan for vacations, etc. In the event of call offs, staff that regularly work in the home will be contacted first to fill the open hours regardless of overtime. Schedulers will meet at least monthly with the home to ensure all gaps are covered. The team will work together to have a filled schedule that best meets the needs of the home. Homes will have a copy of the schedule so people will know who is working. Schedulers were all trained in there is no pulling from Herman Court and that they need to communicate when staff call out sick so staff in the home know what is happening. Schedulers will be trained on & have the same trainings as the DSP¿s with regard to training on ISP¿s and plans, & work in those homes with the DSP Lead or seasoned staff to train them on the person¿s likes/dislikes, etc. to be thoroughly trained. In the event of a call off & they can¿t find a suitable replacement, the scheduler(s) will be well versed in the home to ensure proper care. We are also looking into electronic scheduling & have contacted other agencies to see how they schedule. Schedulers will work proactively to fill openings instead of working in crisis mode. The Associate Director of the home will ensure, in conjunction with the scheduler, that copies of the schedule cards are at the home so staff are aware of who is scheduled to work. A meeting is scheduled to discuss scheduling & what else should be addressed to ensure there is adequate coverage for the consistency & health of individuals. Shadowfax is switching to electronic record keeping via a program called Therap. In Therap, staff are assigned to programs and only have access to electronic record keeping of these homes. Therefore, staff cannot be pulled to work in other homes if they have not been ¿enrolled¿ in the home and can only be enrolled in the home upon successful completion of training in the ISP and plans for that home. Shadowfax is currently working with Therap in setting up the electronic record keeping program and inputting individuals and staff in the res department. A 3rd meeting with Therap is set for 7/17/18 and then a specific implementation plan and a Go Live date for our agency will be established as well as training schedules for staff after this date. 08/31/2018 Not Implemented
SIN-00105241 Unannounced Monitoring 12/14/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(k)Individual # 1 was interviewed on 12/14/16. He/She reported that they are unable to attend church regularly due to some staff being unable to drive as well as not enough staff in the home. Individual # 1 reported that he/she has missed about half of the Sunday services in past month due to lack of staff An individual has the right to practice the religion or faith of the individual's choice. Individual #1 reported that she has missed about half of the Sunday services in the past month due to lack of staff and staff being unable to drive. As of today's date, Shadowfax has only hired people that are able to drive. Individual 1 has attended church weekly unless she has been ill. See attached quarterly review and Community activities. As documented, Individual # 1 went to church every week in November (on 11/6, 11/13, 11/20 and 11/27 she attended Action Church). Individual # 1 does not have very good short term memory and her statement that she has missed about half of the Sunday services in past month due to lack of staff was not accurate. Shadowfax staff do ensure individuals practice the religion or faith of their choice and provide documentation. See attached documentation of an individual that has expressed her religious preference and her outings to such choice since ODP's onsite visit in November 2016. .(The residential Associate Director On Call Supervisor will review this policy monthly and sign off on the monthly ratio checklist form. A rights training will be provided to all staff in the agency by 3/1/17)JR 1/31/17 01/12/2017 Implemented
SIN-00106585 Renewal 11/30/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(2)Individual #1 was given $2 soda money on 11/4, 11/7, 11/8, and 11/9 and 10/21, 10/24, 10/25, and 10/27 but not signed of when it was given. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: For a withdrawal when the individual is given the money directly, the record shall indicate that funds were given directly to the individual. This was CDI. To prevent a repeat occurrance, The Program Specialist discussed with staff and left detailed instructions in the individual's wallet of how this is supposed to be documented daily and signed when given. The fiscal department checks all receipts as well. 12/01/2016 Implemented
6400.62(a)Hand sanitzier on the kitchen sink that states call posion control if injested. Poisonous materials shall be kept locked or made inaccessible to individuals.The hand sanitizer was immediately locked while the inspector was on site. (CDI). The program specialist that was on site with the ODP staff discussed with the staff that all poisonous materials must be locked or made inaccessible to individuals and if they show that they are safe around such materials then the ISP needs to be changed to reflect those changes. Moving forward, the house supervisor will make weekly visits to monitor to ensure all poisonous materials are locked or inaccessible and document on the attached house visit report. 12/02/2016 Implemented
6400.67(a)The ceiling in living room had 10 tiles falling down with brown black spots and dust surrounding the tiles. Floors, walls, ceilings and other surfaces shall be in good repair. The Shadowfax maintenance man replaced all the tiles on the ceiling. See attached pictures. Staff were reminded to use maintenance request forms to submit when something is in disrepair. In the future, the home supervisor will use the attached revised home visit report to ensure they are checking that all surfaces are in good repair. See attached blank and completed home visit report; 02/15/2017 Implemented
6400.71The police phone number was not on the kitchen phone. Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The phone number for the police was on the phone but the only part that could be read clearly was the "PO" part of the word police as the rest was worn off. The numbers were replaced on the telephone. See attached picture. The home visit report that supervisors complete on a weekly basis was updated to document that this is being checked weekly. See attached form 12/06/2016 Implemented
6400.144Indiviidual #1 had a dexa scan completed on 1/7/15 and was to return in 1 year. They didnt attempt to schedule the dexa scan until 6/22/16 when Doctor indicated no need to return until 1/2017. 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. The staff responsible for scheduling these appointments had quit and the PS dd not realize the appointment wasn't scheduled. Moving forward, the PS will ensure staff are aware of when appt.'s are due so they can schedule accordingly. Also, we now have a staff working day hours to schedule and run all appointments on time for this home. 12/28/2016 Implemented
6400.183(5)Individual #1's record did not include a SEEN plan. The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. The SEEN plan did match the ISP and all the reviews. One of the quarterly reviews stated that individual # 1 heard voices 1 x on that one day only during the year. This behavior was not listed as a targeted behavior in the SEEN plan (support plan). See attached plan updated 2-6-17 with the added targeted behavior (#4). In the future, all PS's will double check that all behaviors exhibited are documented in the SEEN/Support plan, the ISP, and ISP reviews. 02/06/2017 Implemented
SIN-00158715 Unannounced Monitoring 07/03/2019 Compliant - Finalized