Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00195597 Unannounced Monitoring 11/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(9)Individual #1 had a prostate exam completed on 10/1/21. Individual #1 did not have a prostate exam nor a PSA test in 2020.The physical examination shall include: A prostate examination for men 40 years of age or older. At the date of the inspection the PSA test for Individual #1 had been completed. All individual files will be evaluated for compliance with the PSA or prostate exam guidelines for testing by 12/31/21. All staff working in this home will be re-trained in this regulation by the Associate Director before 12/15/21. Documentation of this training will be kept. 01/01/2022 Implemented
6400.144(Repeat from Inspection dated 7/27/20 and 8/4/20) Individual #1's seizure protocol dated 2/26/21, notes that when the individual has a seizure, the individual has a blank stare more than their normal gaze and that their body stiffens up. It also states to call 911 for any seizure that is different or abnormal in presentation. Shadowfax staff documented on 6/28/21 that Individual #1 had a seizure that lasted for 2 mins and that the individual was unresponsive and did not talk for 1 hour after the seizure. Shadowfax staff did not follow the seizure protocol and call 911. Individual #1 is diagnosed with constipation. The individual's bowel movement protocol noted in the current ISP dated 9/9/21, states "if no BM in 3 days begin Miralax at 8pm on day 3". On 8/25/21, the individual had an instance of no BM in three days and the prescription for Miralax was not administered at 8pm as specified in the protocol.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. An EIM (892932) was initiated, and an investigation is in process to evaluate where the root cause of the failure to identify the need to call 911 arose. All staff working with Individual #1 will be retrained, by the program specialist, on the seizure protocol by 12/31/21.Assistance from the PCP has been requested and the Bowel Movement (BM) protocol for Individual #1 will be clarified, and updated as needed, by 12/15/21. All staff working with Individual #1 will be retrained, by the program specialist, on the BM protocol by 12/31/21 01/01/2022 Implemented
6400.34(a)The Department issued updated regulatory rights, effective 2/3/2020, stating that individuals have additional rights they need to be informed of. At the time of this insepction, Individual #1 was never informed of the individual rights as described in 6400.32The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.The current Individual Rights have been acquired and every individual receiving residential services from Shadowfax are being informed of the individual rights as described in 6400.32. The Program Specialists will confirm that these have been reviewed and signed by the individuals by 12/31/21. 01/01/2022 Implemented
SIN-00187352 Unannounced Monitoring 04/07/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144On 4/5/21 Staff person #1 did not follow Individual #1's Choking Preventative Plan dated 2/24/21. Individual #1 was choking on a piece of ham at 12:45pm. Staff #1 contacted Staff #2 at 12:45pm who instructed Staff #1 to call 911. The Choking Preventative Plan states that staff are to call 911 first, before calling a supervisor. Staff person #1 signed the training sheet on 2/25/21 indicating they reviewed the Choking Preventative Plan for Individual #1.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 agency will re-train all staff working directly with individual #1 on the current choking plan and the steps staff should take when presented with an emergency. This training will be completed by 5/17/21. 06/01/2021 Implemented
SIN-00174686 Unannounced Monitoring 08/04/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #1's physical examinations completed on 3/21/19 and 7/23/20 note that his blood sugar levels and carbohydrates should be monitored. This information is also documented in his current ISP dated 7/1/20. As of 8/4/20 records of these recommendations are not maintained.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. Why did the violation happen? The Program Specialist overlooked the recommendation and failed to create supporting documentation to show that recommendations were followed. To fix the immediate problem: The residential management team, met on 09/29/2020 to discuss root causes. The following actions will be implemented as follows: * The LPN contacted the PCP on 08/04/2020, for Individual #1, and discussed the need for the monitoring of the sugar and carbohydrates intake and the pcp said due to improved health, there was no need for any monitoring to occur. * Management was trained on regulation 6400.144(b)(3) on 09/29/2020. * DSP's and LPN's will be trained on regulation 6400.144 (b) (3) by 10/9/2020. JR 10/2/2020 * The nurse will attend all individual plan meetings and in conjunction with the Program Specialist to ensure the accuracy and documentations of all medical recommendation. To prevent this from happening again: * All individual's physicals will be reviewed by a LPN or RN before the annual physical appointment and after the appointment to ensure all recommendations made by the medical professional are being followed. They will communicate any of their recommendations to the Associate Director and Program Specialist. * The LPN, Associate Director and Program Specialist will meet on a bi-weekly basis to discuss upcoming physicals, appointments, health issues and what is being done to address. Attachment #2 = Training signature sheet for management Attachment #8 = Addendum to ISP, Physical and Assessment for individual #1 09/30/2020 Implemented
6400.181(e)(4)Individual #1's 10/26/2019 assessment states he can be in any area of his home without direct line of sight supervision from staff. Individual #1 is safe within his home and safe in his yard as long as staff are with in the vicinity. It also states he can be alone in the car if doors are locked, adequate ventilation, the car is not running, and keys are not in the ignitions. Staff can leave him in the car for up to five minutes. Individual #1 should not be left unsupervised without checks from staff. Individual #1 should not be locked in a car alone. The assessment must include the following information: The individual's need for supervision. Why did the violation happen? Program specialist did not include enough detail for supervision by not adding how much time he can be safe when in yard & can be left unattended in the vehicle. To fix the immediate problem: The residential management team, met on 09/29/2020 to discuss root causes. The following actions will be implemented as follows: * An addendum was completed to change the supervision for Individuals #1. * Management was trained on regulation 6400.181(e) (4) on 09/29/2020. * A review of all assessments was completed and addendums completed for all that stated individuals were allowed to remain unsupervised in a vehicle, when they are not independent in the community. To prevent this from happening again: *1/4ly content discrepancy reviews of all records by Program Specialist. *A program specialist position has been created that will be responsible to do record checklists and content 1/4ly discrepancy checks. This will be to take sme work load off of the current program specialists and also to have another set of eyes in reviewing the records. Attachment #2 = Training signature sheet for management Attachment #11 = Addendum to ISP 09/30/2020 Implemented
6400.181(e)(10)181e10 Individual #1's LMH 3/5/2020 is not updated. Medical information stops at the 2013 and 2014 years, respectively.The assessment must include the following information: A lifetime medical history. Why did the violation happen? The program specialist failed to include enough detail. To fix the immediate problem: The residential management team, met on 09/29/2020 to discuss root causes. The following actions will be implemented as follows: * The LMH was updated to include more detail * Management was trained on regulation 6400.181(e) (10) on 09/29/2020. To prevent this from happening again: * 1/4ly each LPN, will review 4 of the Lifetime Medical Histories from their caseload. This review will ensure that the LMH is a thorough detailed history of all medical information. All recommendations will be communicated to the appropriate Program Specialist and the director of residential. The residential director will ensure that the corrections to the LMH are made in a timely manner. * Shadowfax is in the process of implementing a new electronic health record (EHR) system, Setworks. This system will make it easier to track all appointment and medical issues, to then compile in the Lifetime Medical History. Attachment #2 = Training signature sheet for management Attachment #9 = Updated Lifetime Medical History Attachment #10 = LPN 1/4ly tracking chart for LMH 09/30/2020 Implemented
6400.44(b)(3)Individual #1's physical examinations completed on 3/21/19 and 7/23/20 note that his blood sugar levels and carbohydrates should be monitored. This information is also documented in his current ISP dated 7/1/20. As of 8/4/20 records of these recommendations are not maintained.The program specialist shall be responsible for the following: Providing and supervising activities for the individuals in accordance with the individual plans.Why did the violation happen? The Program Specialist overlooked the recommendation and failed to create supporting documentation to show that recommendations were followed. To fix the immediate problem: The residential management team, met on 09/29/2020 to discuss root causes. The following actions will be implemented as follows: * The LPN contacted the PCP on 08/04/2020, for Individual #1, and discussed the need for the monitoring of the sugar and carbohydrates intake and the pcp said due to improved health, there was no need for any monitoring to occur. * An addendum was completed on 8/20/2020 to update the ISP, Physical, and assessment. * Management was trained on regulation 6400.44(b)(3) on 09/29/2020. * DSP's and LPN' s will be trained on regulation 6400.44 (b) (3) by 10/9/2020. JR 10/2/2020 * The nurse will attend all individual plan meetings and in conjunction with the Program Specialist to ensure the accuracy and documentations of all medical recommendation. To prevent this from happening again: * All individual's physicals forms will be reviewed by a LPN or RN before the annual physical appointment to ensure all information on the form is accurate. They will also be reviewed after the appointment to ensure all recommendations made by the medical professional are being followed and there is accurate documentation of these recommendations. * The LPN, Associate Director and Program Specialist will meet on a bi-weekly basis to discuss upcoming physicals, appointments, health issues and what is being done to address. * In the future if there is any newly hired program specialists, all of the individuals physical forms that they complete within the first year, will be reviewed by the director to ensure accuracy and allow the Program specialist adequate time for adequate training. With the director reviewing the physical form it will prevent any errors to be corrected before the physical appointment and if there are errors, the director can use this as a learning tool to train the program specialist. Attachment #2 = Training signature sheet for management Attachment #8 = Addendum to ISP, Physical and Assessment for individual #1 09/30/2020 Implemented
6400.46(d)Staff #1 last completed CPR certification on 03/09/18. The certification document states that the training is valid for two years. Staff #2 completed CPR training on 11/02/16 and not again until 12/07/18. The certification document states that the training is valid for two years.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.Why did the violation happen? Staff #1 last completed CPR certification on 3/9/18. A review of the monthly training due dates reports generated from the training tracking system reflects that CPR was listed on the February 2020 due date report for Staff #1 but not the reports generated March 2020 and thereafter. Therefore, an administrator must have removed CPR as a training requirement for staff #1 sometime between February and March 2020. However, the dashboard of the tracking system does not indicate who made the change or a specific date that it occurred. To fix the immediate problem: The HR training team met on 9/3/20 to discuss root causes. The following actions will be implemented as follows: * Staff #1 was certified in Red Cross First Aid and CPR on 9/4/20. * The training tracking system was updated on 9/4/20 to reflect that First Aid/CPR is required for this staff member. * All staff members who manage the tracking software will be trained by 10/2/20 to verify with the Training Manager or Assistant Training Manager before changing the training criteria for any staff member. * HR staff who are involved with training will receive training on the regulations related to training requirements. This will be completed no later than 10/2/20. * The Training Manager will review the list of due dates for accuracy on a quarterly basis. To prevent this from happening again: * Shadowfax is in the process of vetting several Learning Management Systems (LMS). The selected LMS will be able to generate a training report for each staff member which contains the information required by regulations. By January 2021 (start of new training year) we will have a LMS system in place Attachment#7: Staff #1 CPR certification 09/30/2020 Implemented
6400.50(a)Staff #3's date of hire was 3/26/2020. His orientation training record does not include the training source for the different areas of orientation trainings. The documentation states orientation trainings were "completed online" and/or that it was blank.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.Why did the violation happen? Due to COVID-19, Shadowfax staff members who were able to work from home began doing so on Wednesday 3/18/20. This included the Training Manager. One of the two HR Administrative Assistants took a leave effective 3/18/20 due to being at increased risk for complications from the virus. As a result, one HR Administrative Assistant and the Training Assistant were the only HR staff on-site handling training documentation. The orientation program shifted from being on-site to online training effective 3/23/20. Typically, the two HR Administrative Assistants complete all training documentation. In this case, the Training Assistant completed the New Hire Orientation Checklist and did not properly document the training source. To fix the immediate problem: The HR training team met on 9/3/20 to discuss root causes. The following actions will be implemented as follows: * The new hire orientation checklist was revised on 9/3/20 to include a place in the upper right corner that two HR staff have reviewed the document for accuracy. * The orientation checklist for staff #3 was corrected on 9/8/20 to include the source of the training and the name of the instructor. * An audit of all New Hire Orientation Checklists for staff hired since 3/23/20 will be completed by HR Admin Assistants by 10/2/20. * HR Staff who are involved with training will receive training on the regulations related to training documentation. This will be completed no later than 10/2/20. * The Training Manager will be responsible to ensure this practice is followed with each new employee beginning immediately. To prevent this from happening again: * Shadowfax is in the process of vetting several Learning Management Systems (LMS). The selected LMS will be able to generate a training report for each staff member which contains the information required by regulations. By January 2021 (start of new training year) we will have a LMS system in place Attachment #5: New Staff Orientation Checklist Attachment #6: Staff #3 corrected Orientation Checklist 09/30/2020 Implemented
6400.165(e)165e- Individual #2's dose of "Bisacodyl Tab 5mg EC" was dispensed by the pharmacy on 11/05/19 and not added to the MAR until December 2019. The December 2019 MAR stated that the prescription was to be administered "Take 4 tablets (20 mg total) by mouth daily for 2 days. Please take 20 mg at 4pm on 1 day and two days before colonoscopy". There was no written order documenting the discontinuation of this medication located in the file at the time of the inspection.Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received.Why did the violation happen? When the medication was delivered, the DSP on duty did not add the medication to the November 2019 MAR. Upon preparing December MAR, the DSP added it to the MAR. When the colonoscopy was cancelled due to other health issues, the staff did not return the medication to be disposed. To fix the immediate problem: The residential management team, met on 09/29/2020 to discuss root causes. The following actions will be implemented as follows: * 8/6/2020 " Bisacodyl Tab 5mg EC" for Individual #2 was removed from the house. * Management was trained on regulation 6400.165(e) on 09/29/2020. * DSP's and LPN's will be trained on regulation 6400.165 (e) by 10/9/2020. JR 10/2/2020 * During weekly medication checks by the LPN, they will ensure all medications in the home are documented on the MAR and document it on their form, that is then reviewed by the RN. To prevent from happening again: * Shadowfax is in the process of implementing a new electronic health record (EHR) system, Setworks. This system is connected with the pharmacy and all new medications will automatically be entered on the electronic MAR's, as well as a paper back up will be delivered with the medication. Attachment #2 = Training signature sheet for management Attachment #4 = Nurses weekly medication check form 09/30/2020 Implemented
6400.165(g)Individual #1's quarterly psychiatric medication review appointment was never scheduled for January 2020. The next appointment was on 2/14/2020. His last appointment was October of 10/16/2019.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Why did the violation happen? At the 10/16/19 quarterly psychiatric medication review appointment, the next quarterly appointment was scheduled for 1/14/2020. A DSP was assigned to take individual to the appointment and due to a lack of communication the appointment was missed. When discovered, the appointment was rescheduled for the first available appointment. To fix the immediate problem: The residential management team, met on 09/29/2020 to discuss root causes. The following actions will be implemented as follows: * All appointment dates were entered into the database by management. From this point forward, all appointment dates will be entered and tracked by management. Monthly, the director will review upcoming appointment due dates and distribute to the associate directors. * On 09/29/2020, Management was trained on regulation 6400.165 (g). * DSP `s will receive training on regulation 6400.165 (g) by 10/9/2020. JR 10/2/2020 To prevent from happening again: * Shadowfax is in the process of implementing a new electronic health record (EHR) system, Setworks. * This EHR will give notifications of upcoming due dates of appointments. * The position of the lead DSP (house supervisor) has been reviewed and the lead DSP positions schedules will be revised to be Monday through Friday, to enable them to be available to accompany individuals to all scheduled appointments. They will be responsible to schedule and take all individuals on appointments. Their responsibility will include to ensure all paperwork from the appointment is completely correctly and scanned to the associate director and program specialist for immediate review and to follow up on all medication changes, follow-up appointments and any communication that needs to take place concerning the appointment. This will create a continuity of care to better serve the needs of the individuals and eliminate missed appointments. This will also be create consistency for the individuals and build better rapport with medical professionals. Lead DSP's will meet with their supervisor 1x weekly for assistance and support. Attachment #2 = Training signature sheet for management 09/30/2020 Implemented
6400.213(1)(i)The most recent photograph for individual #2 in the record was dated for July 2013.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.Why did the violation happen? The program specialist was given the picture of individual #2 on 02/24/2020 to place into the office record. The program specialist placed into his files and failed to file into the individuals record. To fix the immediate problem: The residential management team, met on 09/29/2020 to discuss root causes. The following actions will be implemented as follows: * 8/5/2020- A recent photograph of individual #2 was placed in his record. * On 09/29/2020, Management was trained on regulation 6400.213 (1) 1-v. * DSP `s will receive training on regulation 6400.213(1)i-v by 10/9/2020. JR 10/2/2020 * New pictures will be taken of each individual by the Associate Directors. The Associate Directors will be responsible to place the new pictures in the records at the office and at the home by 10/9/2020. JR 10/2/2020 * By 10/9/2020, the Sr. Associate Director will check all office books to ensure individuals pictures are current and filed correctly. JR 10/2/2020 * Quarterly, the Sr. Associate Director and/or the Director will check the pictures to ensure they are current and filed correctly. To prevent this from happening again: * Shadowfax is in the process of implementing a new electronic health record (EHR) system, Setworks. * This EHR will give notifications of upcoming due dates, including annual pictures. * A program specialist position has been created that will be responsible to do record checklists and content 1/4ly discrepancy checks. Attachment #1 = New picture of individual #1 Attachment #2 = Training signature sheet for management Attachment #3 = Checklist to check all pictures by 10/9/2020/2020 & 1/4ly JR 10/2/2020 09/30/2020 Implemented
SIN-00177631 Unannounced Monitoring 07/27/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16On June 30, 2020, Individual #1 was taken to the emergency room after consuming approximately one to one and a half ounces of shaving cream. Individual #1 was discharged the same day with instructions that read, "return with any new or worsening symptoms including not limited to persistent nausea and vomiting, worsening severe abdominal pain, fevers greater than 100.4." The discharge instructions included a directive to "schedule an appointment with Certified Registered Nurse Practitioner (CRNP), as soon as possible for a visit in 2 days (around 7/2/2020)." The Shadowfax Corporation (Shadowfax) failed to schedule the appointment with Individual #1's primary care physician and communicated such with the Department in incident report #8709703. On July 5, 2020, progress notes completed by Staff #1 noted Individual #1 "had diarrhea and throw ups." Staff #1 contacted Staff #5, the agency's licensed practical nurse (LPN), who instructed Staff #1 to monitor Individual #1 and to contact her if emesis continued. On July 6, 2020, Staff #1 noted Individual #1 was weak and documented that Individual #1 "woke up looking tired. His bed had throw ups. Gave him breakfast but looked like he wanted to throw up···" Staff #2 mentioned Individual #1 was throwing up, sick all day, weak, and exhausted. Staff #3 remarked Individual #1 was weak, throwing up and sick all day. Neither Staff #1, #2, or #3 contacted Staff #5. Staff #1, #2, #3, and the agency LPN, had knowledge of Individual #1's symptoms, yet failed to return Individual #1 to the emergency room as directed in the hospital discharge notes nor was medical attention or consultation sought from Individual #1's physician. Failure to seek prompt medical attention, failure to schedule follow-up appointments, and failure to follow hospital discharge instructions, such that an individual displaying symptoms of illness may receive medical attention and treatment constitute mistreatment and neglect.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.Why did violation happen? The staff that accompanied Individual #1 to the ER did not scan the discharge paperwork to the appropriate people to be reviewed. Staff #1 & Staff 2 that were present when he went to ER and when he should have returned to the ER due to symptoms are day program staff that were reassigned to work in residential homes during the closing of day program due to COVID. The day program staff receive the appropriate training to deal with situations of this kind, but do not deal with it often as a residential program staff, so they are not as familiar with the procedures. The staff that received the paperwork during the ER visit is responsible for follow-up instructions and appointments and to communicate them to the nurse and Associate Director. The staff failed to communicate this information so there was no follow-up from the Associate Director or Nurse in this incident. To prevent this from happening again? *Management and DSPs will receive training in the procedures of when an individual has physicians orders from a hospital stay, an ER visit or a Doctors appointment. They will be educated that the instructions are to be followed until you have new medical directives from a physician. They will be educated that if instructions are not followed, it may be a neglect investigation. * Management and staff will be trained in the Shadowfax Emergency Guidelines that gives instructions on what to do during medical situations. *When staff get the discharge paperwork, they will scan it to the Associate Director, the assigned LPN and Incident Management. With the Associate Director and LPN being informed of the discharge instructions, they will follow them if they receive any notification from staff about the individual. The Associate Director will ensure all appointments, or any other follow-up is completed. * Whenever the nurses receive a phone concerning an individual having any symptoms of illness, the nurse will follow-up in the next 12 hours to see how the individuals is doing and see if symptoms are still present and direct staff with further instructions. * The discharge instructions will be put the front of the individuals records so that all staff working with the individual has access to the information. The staff will read and sign off that they reviewed the instructions. * The Quality Management team, who submits all reportable incidents, will ensure that they receive all discharge paperwork from a reportable incident within 48 hours and they will confirm with management that any follow-up appointment is scheduled and then completed. If failure to receive this information, they will inform the Residential Director or the Sr Residential Associate Director if Director is unavailable. *Shadowfax is in the process of implementing a new electronic health record (EHR) system, Setworks. When this is in place, staff will scan the discharge paperwork into the system and all management and staff will have access. ATTACHMENT #1 = Shadowfax Emergency Guidelines 11/06/2020 Implemented
6400.144Shadowfax failed to provide health services to Individual #1 as follows: · On June 30, 2020, Individual #1 was taken to the emergency room after consuming one to one and a half ounces of shaving cream. Individual #1 was discharged the same day with instructions that read, "return with any new or worsening symptoms including not limited to persistent nausea and vomiting, worsening severe abdominal pain, fevers greater than 100.4." The discharge instructions included a directive to "schedule an appointment with CRNP, as soon as possible for a visit in 2 days (around 7/2/2020). Shadowfax failed to schedule the appointment with Individual #1's primary care physician and communicated such with the Department in incident report #8709703. · On July 5, 2020 and July 6, 2020, Individual #1 displayed symptoms of illness, described in 6400.16, that warranted a return visit to the emergency room per the 6/30/2020 hospital discharge instructions. Individual #1 was not taken to the emergency room nor was medical attention or consultation sought with Individual #1's physician. · According to Individual #1's Individual Support Plan dated 3/26/20, Individual #1 should be offered prune juice regularly to prevent constipation. There was no evidence that prune juice was offered to Individual #1.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. Why did the violation happen? The staff that accompanied Individual #1 to the ER did not scan the discharge paperwork to the appropriate people to be reviewed. Staff #1 & Staff 2 that were present when he went to ER and when he should have returned to the ER due to symptoms are day program staff that were reassigned to work in residential homes during the closing of day program due to COVID. The day program staff receive the appropriate training to deal with situations of this kind, but do not deal with it often as a residential program staff, so they are not as familiar with the procedures. The staff that received the paperwork during the ER visit is responsible for follow-up instructions and appointments and to communicate them to the nurse and Associate Director. The staff failed to communicate this information so there was no follow-up from the Associate Director or Nurse in this incident. The staff offered prune juice to Individuals #1 but was not documenting that he was given prune juice. To prevent this from happening again? * Management and DSPs will receive training in the procedures of when an individual has physicians orders from a hospital stay, an ER visit or a Doctors appointment. They will be educated that the instructions are to be followed until you have new medical directives from a physician. They will be educated that if instructions are not followed, it may be a neglect investigation. * Management and staff will be trained in the Shadowfax Emergency Guidelines that gives instructions on what to do during medical situations. *When staff get the discharge paperwork, they will scan it to the Associate Director, the assigned LPN and Incident Management. With the Associate Director and LPN being informed of the discharge instructions, they will follow them if they receive any notification from staff about the individual. The Associate Director will ensure all appointments, or any other follow-up is completed. * Whenever the nurses receive a phone concerning an individual having any symptoms of illness, the nurse will follow-up in the next 12 hours to see how the individuals is doing and see if symptoms are still present and direct staff with further instructions. * The discharge instructions will be put the front of the individuals records so that all staff working with the individual has access to the information. The staff will read and sign off that they reviewed the instructions. * The Quality Management team, who submits all reportable incidents, will ensure that they receive all discharge paperwork from a reportable incident within 48 hours and they will confirm with management that any follow-up appointment is scheduled and then completed. If failure to receive this information, they will inform the Residential Director or the Sr Residential Associate Director if Director is unavailable. *Shadowfax is in the process of implementing a new electronic health record (EHR) system, Setworks. When this is in place, staff will scan the discharge paperwork into the system and all management and staff will have access. * All dietary recommendations for individuals will be documented in the individuals record in chart form. *The LPN, Associate Director and Program Specialist will meet on a bi-weekly basis to discuss upcoming physicals, appointments, health issues and new recommendations and what is being done to address. At this meeting records will be reviewed to ensure that all recommendations are being followed and documented. *The nurse will attend all individual plan meetings and in conjunction with the Program Specialist to ensure the accuracy and documentations of all medical recommendation. *Train management and staff that all dietary recommendation must be implemented, and documentation provided to prove the recommendations was followed. ATTACHMENT #1 = Shadowfax Emergency Guidelines ATTACHMENT #2 = Example of chart for dietary recommendations ATTACHMENT #3 = Example of chart for dietary recommendations ATTACHMENT #4 = Example meeting notes from nurse, AD & PS meeting 11/06/2020 Implemented
6400.32(c)On June 30, 2020, Individual #1 was taken to the emergency room after consuming approximately one to one and a half ounces of shaving cream. Individual #1 was discharged the same day with instructions that read, "return with any new or worsening symptoms including not limited to persistent nausea and vomiting, worsening severe abdominal pain, fevers greater than 100.4." The discharge instructions included a directive to "schedule an appointment with CRNP, as soon as possible for a visit in 2 days (around 7/2/2020)." The Shadowfax Corporation (Shadowfax) failed to schedule the appointment with Individual #1's primary care physician and communicated such with the Department in incident report #8709703. On July 5, 2020, progress notes completed by Staff #1 noted "throwing up" as a health concern. Moreover, Staff #1 documented that Individual #1 "had diarrhea and throw ups." Staff #1 contacted Staff 5 the agency's licensed practical nurse (LPN), who instructed Staff #1 to monitor Individual #1 and to contact her if emesis continued. On July 6, 2020, Staff #1 noted Individual #1 was weak and documented that Individual #1 "woke up looking tired. His bed had throw ups. Gave him breakfast but looked like he wanted to throw up···" Staff #2 noted Individual #1 was throwing up, sick all day, weak, and exhausted. Staff #3 noted Individual #1 was weak, throwing up and sick all day. Staff #1, #2, #3, and the agency LPN, had knowledge of Individual #1's symptoms, yet failed to return Individual #1 to the emergency room as directed in the hospital discharge notes nor was medical attention or consultation sought from Individual #1's physician. Failure to seek prompt medical attention and failure to follow hospital discharge instructions such that an individual displaying symptoms of illness may receive medical attention and treatment does not support or protect an individual's right to be free of neglect and mistreatment. See violation description of 6400.16 & 6400.144An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.Why did the violation happen? The staff that accompanied Individual #1 to the ER did not scan the discharge paperwork to the appropriate people to be reviewed. Staff #1 & Staff 2 that were present when he went to ER and when he should have returned to the ER due to symptoms are day program staff that were reassigned to work in residential homes during the closing of day program due to COVID. The day program staff receive the appropriate training to deal with situations of this kind, but do not deal with it often as a residential program staff, so they are not as familiar with the procedures. The staff that received the paperwork during the ER visit is responsible for follow-up instructions and appointments and to communicate them to the nurse and Associate Director. The staff failed to communicate this information so there was no follow-up from the Associate Director or Nurse in this incident. To prevent this from happening again? *Management and DSPs will receive training in the procedures of when an individual has physicians orders from a hospital stay, an ER visit or a Doctors appointment. They will be educated that the instructions are to be followed until you have new medical directives from a physician. They will be educated that if instructions are not followed, it may be a neglect investigation. * Management and staff will be trained in the Shadowfax Emergency Guidelines that gives instructions on what to do during medical situations. *When staff get the discharge paperwork, they will scan it to the Associate Director, the assigned LPN and Incident Management. With the Associate Director and LPN being informed of the discharge instructions, they will follow them if they receive any notification from staff about the individual. The Associate Director will ensure all appointments, or any other follow-up is completed. * Whenever the nurses receive a phone concerning an individual having any symptoms of illness, the nurse will follow-up in the next 12 hours to see how the individuals is doing and see if symptoms are still present and direct staff with further instructions. * The discharge instructions will be put the front of the individuals records so that all staff working with the individual has access to the information. The staff will read and sign off that they reviewed the instructions. * The Quality Management team, who submits all reportable incidents, will ensure that they receive all discharge paperwork from a reportable incident within 48 hours and they will confirm with management that any follow-up appointment is scheduled and then completed. If failure to receive this information, they will inform the Residential Director or the Sr Residential Associate Director if Director is unavailable. *Shadowfax is in the process of implementing a new electronic health record (EHR) system, Setworks. When this is in place, staff will scan the discharge paperwork into the system and all management and staff will have access. ATTACHMENT #1 = Shadowfax Emergency Guidelines 11/06/2020 Implemented
6400.32(u)On June 30, 2020, Individual #1 was taken to the emergency room after consuming approximately one to one and a half ounces of shaving cream. Individual #1 was discharged the same day with instructions that read, "return with any new or worsening symptoms including not limited to persistent nausea and vomiting, worsening severe abdominal pain, fevers greater than 100.4." The discharge instructions included a directive to "schedule an appointment with CRNP, as soon as possible for a visit in 2 days (around 7/2/2020)." There was no evidence that Individual #1 was offered the choice to visit the primary care physician or return to the emergency room after symptoms of illness presented, as noted in 6400.16. Failure to offer choice or involve Individual #1 in health care decisions does not support or encourage the exercise of rights.An individual has the right to make health care decisions.Why did the violation happen? The staff that accompanied Individual #1 to the ER did not scan the discharge paperwork to the appropriate people to be reviewed. Staff #1 & Staff 2 that were present when he went to ER and when he should have returned to the ER due to symptoms are day program staff that were reassigned to work in residential homes during the closing of day program due to COVID. The day program staff receive the appropriate training to deal with situations of this kind, but do not deal with it often as a residential program staff, so they are not as familiar with the procedures. The staff that received the paperwork during the ER visit is responsible for follow-up instructions and appointments and to communicate them to the nurse and Associate Director. The staff failed to communicate this information so there was no follow-up from the Associate Director or Nurse in this incident. To prevent this from happening again? * Management and DSPs will receive training in the procedures of when an individual has physicians orders from a hospital stay, an ER visit or a Doctors appointment. They will be educated that the instructions are to be followed until you have new medical directives from a physician. They will be educated that if instructions are not followed, it may be a neglect investigation. * Management and staff will be trained in the Shadowfax Emergency Guidelines that gives instructions on what to do during medical situations. *When staff get the discharge paperwork, they will scan it to the Associate Director, the assigned LPN and Incident Management. With the Associate Director and LPN being informed of the discharge instructions, they will follow them if they receive any notification from staff about the individual. The Associate Director will ensure all appointments, or any other follow-up is completed. * Whenever the nurses receive a phone concerning an individual having any symptoms of illness, the nurse will follow-up in the next 12 hours to see how the individuals is doing and see if symptoms are still present and direct staff with further instructions. * The discharge instructions will be put the front of the individuals records so that all staff working with the individual has access to the information. The staff will read and sign off that they reviewed the instructions. * The Quality Management team, who submits all reportable incidents, will ensure that they receive all discharge paperwork from a reportable incident within 48 hours and they will confirm with management that any follow-up appointment is scheduled and then completed. If failure to receive this information, they will inform the Residential Director or the Sr Residential Associate Director if Director is unavailable. *Shadowfax is in the process of implementing a new electronic health record (EHR) system, Setworks. When this is in place, staff will scan the discharge paperwork into the system and all management and staff will have access. ATTACHMENT #1 = Shadowfax Emergency Guidelines 11/06/2020 Implemented
6400.186According to Individual #1's 3/26/20 Individual Support Plan (ISP), Individual #1 should be offered prune juice on a regular basis to prevent constipation. There was no evidence that Individual #1 was offered prune juice.The home shall implement the individual plan, including revisions.Why did the violation happen? Staff were providing prune juice to Individual #1, but not documenting that prune juice was provided. To prevent this from happening again? *Train management and staff that all dietary recommendation must be implemented, and documentation provided to prove the recommendations was followed. *The LPN, Associate Director and Program Specialist will meet on a bi-weekly basis to discuss upcoming physicals, appointments, health issues and what is being done to address. At this meeting records will be reviewed to ensure that all recommendations are being followed and documented. *The nurse will attend all individual plan meetings and in conjunction with the Program Specialist to ensure the accuracy and documentations of all medical recommendation. ATTACHMENT #2 = Example of chart for dietary recommendations ATTACHMENT #3 = Example of chart for dietary recommendations ATTACHMENT #4 = Example meeting notes from nurse, AD & PS meeting 11/06/2020 Implemented
6400.188(a)On June 30, 2020, Individual #1 was taken to the emergency room after consuming approximately one to one and a half ounces of shaving cream. Individual #1 was discharged the same day with instructions that read, "return with any new or worsening symptoms including not limited to persistent nausea and vomiting, worsening severe abdominal pain, fevers greater than 100.4." Individual #1 displayed symptoms of illness, as described in 6400.16, that warranted a return visit to the emergency room, per the hospital discharge instructions. Shadowfax failed to aid and support Individual #1 to seek and receive medical treatment to improve his medical circumstance.The home shall provide services, including assistance, training and support for the acquisition, maintenance or improvement of functional skills, personal needs, communication and personal adjustment.Why did the violation happen? The staff that accompanied Individual #1 to the ER did not scan the discharge paperwork to the appropriate people to be reviewed. Staff #1 & Staff 2 that were present when he went to ER and when he should have returned to the ER due to symptoms are day program staff that were reassigned to work in residential homes during the closing of day program due to COVID. The day program staff receive the appropriate training to deal with situations of this kind, but do not deal with it often as a residential program staff, so they are not as familiar with the procedures. The staff that received the paperwork during the ER visit is responsible for follow-up instructions and appointments and to communicate them to the nurse and Associate Director. The staff failed to communicate this information so there was no follow-up from the Associate Director or Nurse in this incident. To prevent this from happening again? * Management and DSPs will receive training in the procedures of when an individual has physicians orders from a hospital stay, an ER visit or a Doctors appointment. They will be educated that the instructions are to be followed until you have new medical directives from a physician. They will be educated that if instructions are not followed, it may be a neglect investigation. * Management and staff will be trained in the Shadowfax Emergency Guidelines that gives instructions on what to do during medical situations. *When staff get the discharge paperwork, they will scan it to the Associate Director, the assigned LPN and Incident Management. With the Associate Director and LPN being informed of the discharge instructions, they will follow them if they receive any notification from staff about the individual. The Associate Director will ensure all appointments, or any other follow-up is completed. * Whenever the nurses receive a phone concerning an individual having any symptoms of illness, the nurse will follow-up in the next 12 hours to see how the individuals is doing and see if symptoms are still present and direct staff with further instructions. * The discharge instructions will be put the front of the individuals records so that all staff working with the individual has access to the information. The staff will read and sign off that they reviewed the instructions. * The Quality Management team, who submits all reportable incidents, will ensure that they receive all discharge paperwork from a reportable incident within 48 hours and they will confirm with management that any follow-up appointment is scheduled and then completed. If failure to receive this information, they will inform the Residential Director or the Sr Residential Associate Director if Director is unavailable. *Shadowfax is in the process of implementing a new electronic health record (EHR) system, Setworks. When this is in place, staff will scan the discharge paperwork into the system and all management and staff will have access. ATTACHMENT #1 = Shadowfax Emergency Guidelines 11/06/2020 Implemented
SIN-00170969 Unannounced Monitoring 02/06/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The shared, hallway bathroom sink drained very slow which allowed the sink to fill up with water, nearing the overflow part of the sink. The sink should be in good, working order and drain properly to prevent water over flowing from the sink.Floors, walls, ceilings and other surfaces shall be in good repair. The ShadowFax will comply with settlement agreement for compliance with this POC. 02/06/2020 Implemented
6400.110(a)The smoke detector located in the living room area of the home did not sound with an alarm that would alert those in the vicinity from that smoke detector. The smoke detector was still operable with the interconnected system and would sound the rest of the alarms throughout the home if activated. The smoke detector/alarm itself did not sound. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. The ShadowFax will comply with settlement agreement for compliance with this POC. 02/06/2020 Implemented
SIN-00148993 Unannounced Monitoring 01/22/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The trash can lid in the kitchen has orange residue.Clean and sanitary conditions shall be maintained in the home. Agency will correct the immediate issue. Agency will review the issue for violation and correct. Then agency will train all staff on the violation. Program specialist will review monthly and supervisor will review quarterly and complete tracking form. 02/01/2019 Implemented
SIN-00145390 Unannounced Monitoring 11/07/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(i)Unopened mail was found on the staff desk in the living room areaAn individual has the right to unrestricted mailing privileges. Agency will correct the immediate issue. Agency will review the issue for violation and correct. Then agency will create policy on mail privileges and train all staff on the violation. Program specialist will review monthly and supervisor will review quarterly and complete tracking form. 12/31/2018 Implemented
6400.141(a)Individual # 2 's last physical in his record was completed on 9/21/2017.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Agency will correct the immediate issue. Agency will review the issue for violation and correct. Then agency will develop plan to ensure physical exams are tracked and scheduled. Agency will train all staff on the violation. Program specialist will review monthly and supervisor will review quarterly and complete tracking form. 12/31/2018 Implemented
6400.216(a)Individual # 1 's goal plans and progress notes were unlocked on the staff's desk. An individual's records shall be kept locked when unattended. Agency will correct the immediate issue. Agency will review the issue for violation and correct. Then agency will train all staff on the violation. Program specialist will review monthly and supervisor will review quarterly and complete tracking form. 12/31/2018 Implemented
SIN-00128596 Renewal 02/20/2018 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace was cleaned on 9/27/16 and not again until 10/24/17.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. Furnaces will now be cleaned every 9 months - see attached email (attachment # 15) sent 2-28-18 to the owner of the plumbing business that Shadowfax utilizes. The owner conversed with the Shadowfax maintenance man that this will occur as per our request. Moving forward, the Shadowfax maintenance man will keep track of the 9 month mark to ensure it is completed for every home, instead of assuming the plumbing contractor is doing them as specified. There will also be spot checks from the Director at the 9 month mark to ensure all furnace inspections are done and if not done, that it is arranged to occur before the 12 month mark. Our first inspection will be due by 5-28-18 so the documentation of the inspection will be forwarded upon receipt. 02/28/2018 Implemented
6400.142(a)Repeat 11/30/16: Individual #1 had a dental exam completed on 7/10/17 with an order for a six month recall. Individual #1's next dental appointment is not scheduled to occur until 4/23/18.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. A new management staff canceled the January dental appointment due to a conflict. This staff was given performance feedback on the importance of medical appointments being scheduled and run on time. The senior Associate Director re-trained all management on 3-12-18 on the regulations pertaining to the frequency of medical appointments and the importance of meeting these on time. Each manager went through the records of the indivduals on their caseload to gather all dates and ensure appointments are scheduled on time. Furthermore, the data base was revised to include only medical appointments. A res admin assistant is checking for the 3rd time to ensure dates are correct. 03/12/2018 Implemented
6400.144Repeat 11/30/16: Individual #1 has a bowel protocol to be given prune juice for constipation on the fifth day he/she does not have a bowel movement. This protocol is not being implemented correctly as there was documentation stating that on 12/3/17 through 12/7/17 Individual #1 did not have a bowel movement but was given prune juice on 12/5/17, 12/6/17 and 12/7/17. It is documented on 11/1/17 through 11/10/17 Individual #1 did not have a bowel movement but was given prune juice daily during this time period.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 Program Specialist developed a chart to document all bowel movements and prune juice. The individual has no dietary restrictions with regard to prune juice and enjoys drinking it. It is his right to have prune juice when he chooses, not to limit to when he needs to have a bowel movement. The Program Specialist also sent a note to the Doctor on 3/27/18 for clarification and advice of what to do when the individual has no BM and is drinking prune juice as advised. ____________ need result. See attachments ----- and ______. Moving forward with this individual and with other individuals in the same situation, the PS will ensure there are charts to document all bowel movements and review the bowel protocol with the PCP on a yearly basis at the physical examination to ensure the bowel regimen is still the most effective, clear protocol Not Implemented
SIN-00070190 Renewal 06/30/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(d)Staff person #1 did not have at least 24 hours of training. Her training hours totaled 23.5 hours.Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. The trainer was counting every Med practicum being done quarterly as training. On 7/7/14, this was discussed with the Human Resources department. Med Practicums will no longer be counted toward training hours. 07/07/2014 Implemented
6400.71Individual #1 did not have emergency numbers by the telephone.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 emergency numbers were replaced on the telephone. Furthermore, staff discussed with the individual the importance of not removing the numbers (he doesn't like them on the phone). The house supervisor will check this on house visits in the future to ensure the numbers are on or by the phone. 07/05/2014 Implemented
SIN-00068632 Renewal 06/30/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(d)Staff person #1 did not have at least 24 hours of training. The training hours where 23.5 Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. previously submitted 10/31/2014 Implemented
6400.71Individual #1 did not have emergency numbers by the telephone. 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. previously submitted 10/31/2014 Implemented
SIN-00226865 Unannounced Monitoring 06/08/2023 Compliant - Finalized
SIN-00224666 Unannounced Monitoring 04/25/2023 Compliant - Finalized
SIN-00215868 Unannounced Monitoring 12/05/2022 Compliant - Finalized
SIN-00211285 Unannounced Monitoring 09/12/2022 Compliant - Finalized
SIN-00202705 Unannounced Monitoring 03/31/2022 Compliant - Finalized
SIN-00192065 Unannounced Monitoring 08/30/2021 Compliant - Finalized
SIN-00182621 Unannounced Monitoring 01/25/2021 Compliant - Finalized
SIN-00165802 Unannounced Monitoring 11/01/2019 Compliant - Finalized
SIN-00158723 Unannounced Monitoring 07/03/2019 Compliant - Finalized
SIN-00106586 Renewal 11/30/2016 Compliant - Finalized