| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | At the time of the inspection, baseboard molding is missing from a few locations in the kitchen. The subfloor is exposed in the locations that the baseboard is missing.
The carpet covering the steps to the second floor contains many carpet rips, fabric snags, stains, and smells of urine the more one ascends the steps. | Floors, walls, ceilings and other surfaces shall be in good repair. | The baseboard molding has been replaced. Attachment 17
The carpet on the stairs has been removed, the stairs cleaned and non-skid treads have been installed. Attachment 18 |
09/04/2023
| Implemented |
| 6400.67(b) | Individual #1 has an unsteady gait, balance issues, and is to use a walker for ambulation. The home has a fall protection prevention plan for the individual, knowing the individual has accommodations that need made to protect them from falls. During the 8/22/23 onsite inspection, there were tripping hazards present in the home. The following was witnessed:
· The exposed areas (corner and sides) of the large carpet in the living room was curling up in the air, not lying flat on the floor.
· The floor transitions into the kitchen (two separate transition locations) are not level. The kitchen flooring sits above the transition pieces, has a noticeable lip, and creates a tripping hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The living room carpet has been secured with adhesive and tacked into place to eliminate any trip hazards. Attachment 19 The floor transitions into both entrances to the kitchen have been replaced to eliminate potential trip hazards. Attachment 20a,20b |
09/04/2023
| Implemented |
| 6400.71 | The telephone numbers to the nearest hospital, police department, fire department, ambulance, and poison control were not on the telephone/fax machine in the dining room. The numbers to these locations were partial rubbed off and illegible. The home staff did rectify this onsite by placing a sticker with all the telephone numbers on the telephone on site on 8/22/23. | 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.
| As indicated in the citation, the telephone/fax in the dining room now has legible emergency numbers attached to the machine. |
09/11/2023
| Implemented |
| 6400.104 | The fire department notification letter dated 9/12/22 indicates that there are 4 individuals in the home, however, as of the 8/22/23 inspection, there are only 2 individuals residing in this home. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| An updated letter has been sent to the local Fire Department which includes the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. Attachment 21 |
08/24/2023
| Implemented |
| 6400.141(c)(15) | Individual #1's current 10/6/2022 physical examination record does not clearly define their dietary needs. The following statements were all included in the record, but discrepancies were not rectified.
The physician documented dietary needs were minced diet and what appeared to be written, "ensure with every meal." During the 8/22/23 inspection, the home did not have clarification on the order for administering ensure. The physician documented the individual has silent aspirations with thin liquids but did not include an order for the type of liquids the individual should have.
The physician signed the individual's medical history document attached to the physical examination record, and it included "current health status" dietary orders from 3/16/21. The dietary orders from 2021 stated the individual is recommended to have pureed diet, nectar thick liquid via cup and to remain upright for 30 minutes after meals.
The physician signed the provider agency's prepopulated appointment summary that stated as of 3/16/21 the individual's Barium Swallow Study noted silent aspirations with thin liquids. The individual is recommended to follow a pureed diet, nectar thick liquid via cup and to remain upright for 30 minutes after meals.
Thick-it powder was included on a medication list attached to the physical examination record and stated to use as directed per nectar thickened directions. This record didn't indicate if it was only for liquids. | The physical examination shall include:Special instructions for the individual's diet. | Clarification has been obtained from Individual #1's physician regarding their dietary needs which are to have minced food with thin liquids, stop using Thick it for the liquids. The use of Ensure or like products as needed for dietary assistance. Attachment 22 |
09/11/2023
| Implemented |
| 6400.143(a) | Per Individual #1's 10/6/22 physical examination record, the individual requires a walker due to balance issues. Per the individual's 7/6/23 Individual Support Plan (ISP), as of 2021 the individual uses a walker at all times when at home and in the community. During the 8/22/23 inspection, Staff person #1 reported to the Department that Individual #1 doesn't use their walker or their cane sometimes at the home. Staff person #1 reports that the home does not have any records of documenting the individual's refusals to use their walker in the home to prevent falls, or continued attempts to train the individual in the need to use their assistive devices to prevent fall injuries.
During the 8/22/23 onsite inspection at the home, Individual #1 was in the community with staff. The individual's walker was at the home, and not with them. It was reported to the Department that the individual refuses to use their walker in the home and out in the community. The individual's refusal to use the walker in the community and the continued attempts to train the individual in the need to use their assistive devices to prevent fall injuries was not documented.
Individual #1's dentist documented that the individual requires hand over hand assistance for most of their dental hygiene care and additional verbal assistance. Staff have documented on dental hygiene charts that the individual frequently refuses to brush their teeth, floss, and swab their mouth. The attempts to assist the individual with hand over hand assistance and training on the need for good dental hygiene practices is not documented in the record. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | A statement from the physician dated August 29, 2023, has been obtained that states that Individual #1 is to use the walker as needed for balance disorder. This information has been provided to the Supports Coordinator to be included in his ISP. Attachment 22 Attachment 23 |
09/11/2023
| Implemented |
| 6400.144 | (Repeated Violation -- 2/1/23) Individual #1's current 10/6/22 physical examination record states the individual is to have ensure with every meal. Individual #1's 7/6/23 Individual Support Plan (ISP) states the individual has experienced significant weight loss and they are working with staff and physicians to maintain their weight. During the 8/22/23 inspection, the home did not produce records that they were administering or offering the ensure as ordered, did not have record of a discontinue order of ensure if that occurred, and didn't have records of monitoring the individual's weight frequently.
Individual #1 is prescribed docusate sodium daily as a stool softener for constipation. The home does not have a plan in place to indicate next steps should the individual be constipated or not have a bowel movement. The home documents that the individual went 4 days without a bowel movement in August and no additional medical advice was sought.
Individual #1 has a history of aspiration pneumonia and has silent aspirations with thin liquids. As referenced in 6400.141(c)(15) of this report, the individual's dietary needs are not clearly identified on their current 10/6/22 physical examination record. The record states the individual should follow a minced diet, has silent aspirations with thin liquids, needs to have ensure with every meal, had thick-it (a substance used to change the consistency of food and liquids) prescribed with an order to use for nectar thick preparations, but also their current health status listed as: as of 2021 they were ordered a pureed diet with nectar thick liquids via cup and to remain upright for 30 minutes after meals. During the 8/22/23 inspection, provider agency staff had not clarified the specifics regarding the individual's prescribed dietary needs with their medical professionals. During the 8/22/23 onsite inspection at the home, direct support staff report Individual #1's food is pureed, and thick-it was not found in the home.
According to daily notes from June to August 2023, staff documented the individual ate breakfast, lunch, or dinner and either took a nap, laid down, or "kicked back on their recliner." The home does not document attempts to keep the individual upright for 30 minutes after meals.
Individual #1's physician stated on 10/6/22 that the individual needs to use a walker due to balance issues. The home reports the individual refuses to use the walker in the home and in the community. The home has not reported the individual's refusals to use the assistive devices to the individual's physician for further recommendations of devices, trainings, or referrals needed due to the individual's balance issues. The home has a fall protection prevention plan. However, this fall protection prevention plan is not specific to the individual's needs and does not include the individual's specific adaptive equipment needed for use in the home and in the community. For example, the fall protection prevention plan states staff are to use aids to help lift and transfer the individual such as a Hoyer lift, gait felt, slide board, etc. At the time of the 8/22/23 inspection, these aids have not been prescribed to the individual.
Staff documented on 8/14/23 that Individual #1 reported to staff their right foot hurt while walking. At the time of the 8/22/23 inspection, further medical advice, counsel, or attention has not been sought for the pain in their foot they reported. | 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.
| Clarification has been obtained from the PCP regarding the need for Ensure with every meal.
Staff have been instructed to enter Individual #1's weight monthly into the record.
The bowel protocol for Individual #1 has been updated to include criteria for additional treatment and when to contact the PCP for further instructions.
Clarification has been obtained from the physician regarding Individual #1's dietary needs and have been implemented by staff. Staff will document attempts to have Individual #1 remain upright. Attachment 22 Attachment 34
Individual #1's fall protection prevention plan has been updated to be specific to their needs and includes the physician recommendation that the walker be used as needed. Attachment 24
Individual#1 indicated that their foot no longer hurt the following day. There was no visible sign of injury and no indication of difficulty ambulating. |
09/11/2023
| Implemented |
| 6400.32(c) | (Repeated Violation -- 2/1/23) Individual #1 has a history of aspiration pneumonia and has silent aspirations with thin liquids. As referenced in 6400.141(c)(15) and 6400.144 of this report, the individual's dietary needs are not clearly identified on their current 10/6/22 physical examination record. The record states the individual should follow a minced diet, has silent aspirations with thin liquids, and needs to have Ensure with every meal. The record also documents Individual #1 had Thick-it prescribed with an order to use for nectar thick preparations. Their current health status listed as: as of 2021 they were ordered a pureed diet with nectar thick liquids via cup and to remain upright for 30 minutes after meals. During the 8/22/23 inspection, provider agency staff had not clarified the specifics regarding the individual's prescribed dietary needs with their medical professionals. During the 8/22/23 onsite inspection at the home, direct support staff report Individual #1's food is pureed, and thick-it was not found in the home. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | Clarification has been obtained from Individual #1's physician regarding their dietary needs which is to have minced food with thin liquids, do not use Thick it for the liquids. The use of Ensure or like products as needed for dietary assistance. This is consistent with the last annual physical of 10/6/22. Attachment 22 |
09/01/2023
| Implemented |
| 6400.46(a) | Staff person #4's date of hire was 6/20/23. This staff person first worked with individuals on 6/27/23. Staff person #4 did not receive training in general fire safety until 6/29/23. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Staff person #4 received training in general fire safety 6/29/23 |
09/11/2023
| Implemented |
| 6400.51(b)(1) | Staff person #4's date of hire was 6/20/23. As of the 8/22/23 inspection, there is no documentation verifying that staff person #4 completed the training required in person-centered practices, community integration, individual choice, or supporting individuals to develop and maintain relationships. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Staff person #1 has completed all required trainings for the current training year. Attachment 26 |
08/25/2023
| Implemented |
| 6400.51(b)(2) | Staff person #4's date of hire was 6/20/23. As of the 8/22/23 inspection, there is no documentation verifying that staff person #4 completed the training required in the prevention, detection, and reporting of abuse. | The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations. | Staff person #1 has completed all required trainings for the current training year. Attachment 26 |
08/25/2023
| Implemented |
| 6400.51(b)(3) | Staff person #4's date of hire was 6/20/23. As of the 8/22/23 inspection, there is no documentation verifying that staff person #4 completed the training required in individual rights. | The orientation must encompass the following areas: Individual rights. | Staff person #1 has completed all required trainings for the current training year. Attachment 26 |
08/25/2023
| Implemented |
| 6400.51(b)(4) | Staff person #4's date of hire was 6/20/23. As of the 8/22/23 inspection, there is no documentation verifying that staff person #4 completed the training required in recognizing and reporting incidents. | The orientation must encompass the following areas: recognizing and reporting incidents. | Staff person #1 has completed all required trainings for the current training year. Attachment 26 |
08/25/2023
| Implemented |
| 6400.163(a) | (Repeated Violation -- 2/1/23) During the 8/22/23 onsite inspection at Individual #1's home, two medications, Alka-Seltzer and Miralax powder, were not stored in their original containers. Two individually packaged Alka-Seltzer doses and two individually packaged Miralax doses were stored in separate, clear, plastic Ziplock bag. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | The Alka-Seltzer and Miralax powder in their original individual labeled packages were removed from the home. |
09/11/2023
| Implemented |
| 6400.165(a) | (Repeated Violation -- 2/1/23) Staff person #2 administered Tylenol extra strength medication to Individual #1 at 4:30pm on 8/2/23 for complaints of a headache. The home doesn't have a written order for the medication from an authorized prescriber. | A prescription medication shall be prescribed in writing by an authorized prescriber. | Individual #1's Approval for Over-the-Counter Drug Form, signed by the physician on 10/6/22 includes Tylenol for pain and/or fever. Attachment 27 |
09/15/2023
| Implemented |
| 6400.165(c) | (Repeated Violation -- 2/1/23) Individual #1 is prescribed docusate sodium 100mg every day and is to hold the medication for 2 days if more than 2 bowel movements occur in one day. The medication was not held per the physician's orders, but was administered daily, on the following days when the individual had two or more bowel movements in one day: 8/3, 8/4, 8/5, 8/6, 7/1, 7/2, 7/21, 7/22, 7/28, 7/29, 6/2, 6/3, 6/10/ 6/11, 6/12, 6/14, 6/15, 6/16, 6/20, 6/21, 6/22, 6/23, 6/25, 6/26, 6/27, and 6/30 of 2023.
Individual #1 is to have their Vitamin B12 supplement at 6am per the individual's Medication Administration Records (MARs). According to their July 2023 MARs, the 6am administration wasn't documented on the mar within an hour before or after 6am for every day of the month except on the 9th, 15th, 23rd, and 28th. | A prescription medication shall be administered as prescribed. | Individual#1's bowel management protocol has been updated. Attachment 28
Staff have been retrained in the documentation of bowel activity and the necessity of recent bowel activity being reviewed to determine if medication is needed. Attachment 29
Written communication has been sent to all staff stressing the requirement that all medications be given and documented within 1 hour before or after the prescribed time. Attachment 11
The Health Coordinator is reviewing the Therap report daily to identify staff who have violated this requirement and reinstructing them on the proper procedure. Staff who are repeat offenders after being contacted have received written disciplinary action. Attachment 12 |
09/11/2023
| Implemented |
| 6400.165(f) | In 2022, Individual #1 was experiencing increased sexual behaviors, obsessive thoughts, and outbursts. In 2023, their psychiatrist documented the individual has major depressive disorder with a review of their medications on 6/22/23, documenting this diagnosis but that the individual hasn't had signs of depressive episodes lately. On 6/22/23, the individual's psychiatrist documented the individual's review of their medication was for major depressive disorder and mild intellectual disabilities.
During the 8/22/23 inspection at the home, staff report that Individual #1 is combative when they attempt to have them use their walker, gets agitated when their housemate talks constantly, and tends to not interact with their housemate as they agitate them. According to daily notes, recently the individual has been argumentative with their housemate, staff, was up all night in their room, and was witnessed throwing items in their room.
The individual's Individual Support Plan does not include a written protocol to address the social, emotional, and environmental needs of the individual that includes their diagnosis of major depressive disorder, or the behaviors and symptoms of their diagnoses the home has witnessed over the previous year: obsessive thinking, agitation, depression, argumentative, outbursts, sexual fixation behaviors, and other items the staff have witnessed. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | Individual#1's protocol for addressing the social, emotional, and environmental needs of the individual has been updated and a copy has been provided to the Supports Coordinator for inclusion in the ISP. Attachment 30 Attachment 23 |
09/11/2023
| Implemented |
| 6400.165(g) | Individual #1's psychiatrist documented they were seen for a review of the individual's psychotropic medication, Sertraline, on 6/22/23 for major depressive disorder and mild intellectual disabilities. The provider agency's prepopulated medical appointment summary listed the reason for prescribing Sertraline as "reduce obsessive behavior." The reason for prescribing the medication was not clarified and included on their 6/22/23 medication review appointment information, since three different diagnoses and/or reason for prescribing the medication were documented on this date. | 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. | The omission of specific diagnosis on subsequent reviews has been addressed by written correspondence to the physician and will be further addressed at the next appointment. Attachment 31 |
09/01/2023
| Implemented |
| 6400.166(a)(4) | Individual #1's June, July, and August 2023 Medication Administration Records (MARs) do not record the specific medication name [or any requirements defined in 6400.166(a)(1)-(16)] of the as needed medications prescribed to the individual for anti-diarrheal, constipation, cough and cold, medicated powders and creams, nausea and/or vomiting, pain and/or fever, poison ivy, and sun preparations. The home has not attempted to clarify which medications, along with their specific orders, are prescribed for the individual within those categories of reasons for prescribing medications. The MARs list multiple over the counter medications and treatments that can be used for various as needed diagnoses, however, leaves it up to the non-medical direct support staff to determine which over the counter medication to use for which diagnosis. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | The Medication Administration Record has been updated to include specific over the counter medications permissible for specific diagnosis in accordance with the written approval of the physician. Attachment 32
All OTC medications that do not have a specific written order have been removed from the home. |
09/15/2023
| Implemented |
| 6400.166(a)(15) | Individual #1 is prescribed Systane complete .6% eye drops in both eyes daily. The pharmacy issued a sticker on the medication indicating to shake the medication well before using. The special precautions to shake the medical well when preparing the medication for administration, was not recorded on Individual #1's June-August 2023 Medication Administration Records. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable. | The MAR has been updated to include the instruction Shake Well for the Systane. Attachment 32 |
09/15/2023
| Implemented |
| 6400.166(b) | Staff person #3 administered Individual #1 their Vitamin B12 supplement at 6am on 7/9/23 but did not initial the administration and all requirements until 8:47am.
Staff person #2 administered two 500mg tablets of Tylenol extra strength to Individual #1 at 4:30pm on 8/2/23 but didn't record the administration immediately after administration. They recorded the information on the Medication Administration Record at 5:29pm on 8/2/23. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Written communication has been sent to all staff stressing the requirement that all medications be given and documented within 1 hour before or after the prescribed time. Attachment 11 The Health Coordinator is reviewing the Therap report daily to identify staff who have violated this requirement and reinstructing them on the proper procedure. Staff who are repeat offenders after being contacted have received written disciplinary action. Attachment 12 |
09/11/2023
| Implemented |
| 6400.167(a)(4) | According to Individual #1's Medication Administration Records (MARs) for June-August 2023, there are numerous times the individual wasn't administered multiple mediations at their scheduled times. The MARs do not include any notes from staff if they administered the medication at the correct time or if they didn't complete and initial the MARs immediately after administration. The home has never had anyone from the agency monitor Individual #1's MARs over the last three months to ensure that staff were administering the medications on time and per physician's orders. Per the agency during the 8/22/23 inspection, the office secretary reviews some MARs to ensure there are signatures for completion, but never monitors or reviews the MARs to see the time of administration to determine if it was administered on time.
The following were found on the individual's MARs:
June 2023:
· Individual #1 is to have their Vitamin B12 supplement at 6am. According to their July 2023 MARs, the 6am administration wasn't documented on the MAR within an hour before or after 6am for every day of the month.
July 2023:
· Sertraline 50mg 8pm administration: 7/23/23 8pm dose not administered until 7:05am 7/24/23.
· Individual #1 is to have their Vitamin B12 supplement at 6am. According to their July 2023 MARs, the 6am administration wasn't documented on the MAR within an hour before or after 6am for every day of the month except on the 9th, 15th, 23rd, 28th, 2023.
· Systane complete .6% eye drop: 7/6/23 8am dose wasn't administered until 9:49am and 7/24/23 8am dose wasn't administered until 9:19am.
August 2023:
· Docusate sodium 100mg 8am administration: 8/21/23 8am dose wasn't administered until 9:34am.
· Nitrofurantoin MCR 100mg capsule: 8pm dose on 8/9/23 wasn't administered until 8/10/23 at 8:19am, which was also the same time their regularly schedule 8am dose was administered on 8/10/23.
· Oxybutynin 5mg 8pm administration: 8pm dose on 8/4/23 wasn't administered until 8:22am on 8/5, 8/13/23 8pm dose wasn't administered until 12:14am on 8/14/23, and 8/20 and 8/21 8pm doses were administered at 9:34am on 8/21/23 together.
· Sertraline hcl 50mg 8pm administration: 8pm dose on 8/3/23 wasn't administered until 8/4 at 8:31am, 8pm dose on 8/4/23 wasn't administered util 8/5 at 8:22am, 8pm dose on 8/13 was administered at 12:14am on 8/14, and 8pm doses on 8/20 and 8/21 were administered at 9:34am on 8/21 together.
· Individual #1 is to have their Vitamin B12 supplement at 6am. According to their August 2023 MARs, the 6am administration of the supplement wasn't completed within an hour before or after 6am on the 1st, 3rd, 9th, and 10th.
· Systane complete .6% eye drop 8am administration: wasn't administered until 9:38am on the 7th and 9:34am on the 21st. | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | Written communication has been sent to all staff stressing the requirement that all medications be given and documented within 1 hour before or after the prescribed time. Attachment 11 The Health Coordinator is reviewing the Therap report daily to identify staff who have violated this requirement and reinstructing them on the proper procedure. Staff who are repeat offenders after being contacted have received written disciplinary action. Attachment 12 |
09/11/2023
| Implemented |
| 6400.167(b) | The medication errors described in 6400.167(a)(4) of this report were not documented, follow-up action was never taken, and the prescriber was never contacted to determine what their response may be. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | The Program Specialist has been trained in entering medication errors into the General Event Record section of the individual record. |
09/11/2023
| Implemented |
| 6400.167(c) | The medication errors described in 6400.167(a)(4) of this report were not documented and reported to the Department as incidents as specified in § 6400.18(b) (relating to incident report and investigation). | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | Medication errors have been entered into EIM for all of the above where there was no documentation that the medication was administered one hour before or after the prescribed time. |
09/11/2023
| Implemented |