| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | The personal inventory sheet for individual #1stopped at July 2017. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | Critical Analysis of cause of violation:
The current procedure for the monitoring of and accounting for individual finances and personal property lacks an effective means of monitoring personal inventories. While the transactions that the individuals make to purchase all personal items are clearly documented on their financial ledgers with accompanying receipts and their finances are reconciled on no less than a monthly basis, the updating of the itemized list of possessions is not properly monitored.
Immediate Correction:
Individual #1s personal inventory has been updated to include her current personal possessions. Attachment J
All individuals personal inventories are being reviewed and updated accordingly
Changes to Procedures:
The House Supervisors will submit the personal inventories to the Office Manager along with the weekly expenditure reports that are currently submitted. The Office Manager will continue to reconcile the expenditure reports and will now compare the items purchased on that report to the personal inventory sheet to insure that all personal possessions are listed.
Specific Steps to be taken:
The House Supervisors will continue to review the weekly expenditure reports for accuracy prior to submitting them to the Office Manager for reconciliation and posting into the accounting system.
Staff have been instructed to record any new purchases as they occur and to remove any items that are being discarded. Attachment J
The House Supervisors will review and if necessary enter any new purchases onto the inventory sheet and document any possessions that have been discarded including the date and reason for their removal. Effective November 1, 2020, the inventory sheet will be submitted to the Office Manager along with the weekly expenditure report for each individual.
The Office Manager will compare the weekly expenditure purchases with the updated personal inventory sheets to insure accuracy. Any discrepancies will be immediately reported to the Executive Director for further investigation.
The Executive Director will conduct interviews, review all relevant documentation and conduct on site inspections to resolve any discrepancies and insure the accuracy of the personal inventory sheets. In the event of any unaccounted for personal possessions, the agency will provide restitution to the affected individual. |
10/27/2020
| Implemented |
| 6400.62(c) | Underneath the kitchen sink of individual #1's home, an unknown cleaner was in a clear, unmarked spray bottle. | Poisonous materials shall be stored in their original, labeled containers. | Critical Analysis of cause of violation:
Direct Support Staff had filled a generic spray bottle with cleaning solution from a properly labeled container which is sold as a refill product and placed it among the other cleaning supplies underneath the kitchen sink.
Immediate Correction:
The spray bottle was removed during the inspection.
Change in Procedure:
Direct Support Staff will no longer be permitted to purchase refill cleaning products. The use of generic spray bottles will be limited to non poisonous material such as water and will be clearly labeled.
Specific Steps to be Taken:
House Supervisors have been reinstructed as to the requirement that all cleaning materials and all poisonous materials must be kept in their original labeled containers and be kept separate from food. Attachment K1 Attachment K2
The House Supervisors will immediately inspect all household containers to insure that there are no instances of poisonous materials that are not in their original labeled containers.
If there are generic spray bottles in the home, (such as for use to water plants, etc.).the House Supervisor will clearly label them as to what they contain.
House Supervisors will instruct Direct Support Staff that the purchase of poisonous cleaning refill products is no longer permitted. House Supervisors will examine all cleaning products purchased for the home to insure compliance.
The Office Manager will review bi-weekly company expenditure receipts to insure that no poisonous cleaning refill materials have been purchased.
The Executive Director will conduct random unannounced inspections of the home and insure that all poisonous materials are in their original labeled containers and immediately rectify any occurrences of noncompliance with this requirement. |
10/27/2020
| Implemented |
| 6400.141(c)(10) | Individual #1's Physical 8/21/20 is listed as "not free from communicable diseases". Licensing has not yet received confirmation from provider that this is false. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Critical Analysis of cause of violation
(See 6400.141(c) (14) Analysis and cause are identical
In the instance of the citation for 6400.141 c (10) PCP inadvertently checked off the incorrect box on the form which indicated BD was not free from communicable disease. This error was not noticed prior to the overall document being placed in the individuals record book by HAP Personnel.
Immediate correction:
The PCP was contacted by the Registered Nurse with a request made for correction of this error. A copy of letter received from PCP acknowledging error in checking box and certifying that BD is free from communicable diseases is included in our attachments for review. Attachment L
Change in procedure:
While Direct Support Staff will still transport individuals to annual physical appointments, the Registered Nurse will also attend these annual visits to ensure that clear and concise direction is both given and received. It will also be the Registered Nurse¿s responsibility to review all medical documentation issued by physicians for completeness and accuracy.
Specific steps to be taken:
The current software being used for documentation regarding health and medical information is being re-evaluated for potential transition to electronic health information in order to develop more precise record-keeping and exchange of information between doctors and service providers. Agency policy will be developed and distributed to all support staff re procedure for reporting medical visit results and documentation to Registered Nurse for review within 24 hours of all visits. Training will be provided within 7 days to house supervisors and support staff by Registered Nurse on reviewing medical documentation for accuracy before, during, and after all medical appointments and implementation of physician¿s instructions therein.
A signed acknowledgement for this instruction will be maintained at the administrative office. |
10/27/2020
| Implemented |
| 6400.142(f) | Individual #1 does not have a dental hygiene plan in place to meet her needs. There is also no current documentation provider is supporting individual #1 to care for her oral care as prescribed. Current oral hygiene tracking sheet address verbal, physical, or independent with brushing and flossing. Individual #1's 8/10/20 dental appointment states she is edentulous. She has dentures and requires physical assistance to care for them and to swab her gums. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Critical Analysis of cause of violation
Due to physician office closures because of COVID-19, prior dental appointments (May and August 2020) had been cancelled and rescheduled by the Dentist. The Dental Dreams office began scheduling/accepting patients in September of 2020, so Individual #1's next appointment was not until 10/7/20. The Direct Support Provider did not have a pre-printed form with them for that visit. The Dental Provider used a generic form from their office to record the visit however no additional written instruction was given. Individual #1 is edentulous and new dentures were last made for her in November 2017. A Dental Treatment plan was executed by her dental provider on 11/25/2019 that directs Care Providers to rinse and keep dentures clean. Her choice has been to not wear dentures as noted by her PCP in her Lifetime Medical History Summary dated 8/21/20.
Immediate correction:
Individual #1 requires physical assist for oral care. The oral hygiene plan utilized by the Direct Support Providers indicates that assistive oral care is being provided twice a day, however it does is not specifically labeled to provide for Individual #1's needs. A new treatment sheet requiring Direct Support Providers to sign off that they have provided gum care twice a day has been created to address this and will go into effect on 11/1/2020. Attachment N
Change in procedure:
A new specific care plan and verification process will be created to address Individual #1's oral care needs.
Specific steps to be taken:
Create new treatment sheet to specifically include swabbing gums.
Instruct staff on utilization of the new form and review of gum care procedure.
A signed acknowledgement for this instruction will be maintained at the administrative office.
A review of being prepared with documentation prior to appointments will be completed for Direct Care Personnel by the Registered Nurse to be completed within 7 days. A signed acknowledgement for this instruction will be maintained at the administrative office. |
10/27/2020
| Implemented |
| 6400.144 | Individual #1 had an incident on 9/11/2020 where she fell off her bed and injured her left shoulder. The personal care physician gave individual #1 a treatment order to wash the left shoulder abrasion daily with soap and water and apply Neosporin with band aid with a response time of 5-7 days; revisit only if any puss, redness, or pain increases. This order was not documented on the individual's medication administration record (MAR). Also, individual #1 is allergic to band aids per her medical records and they should not have been used.
Individual #1's medication Gabapentin 100mg 1cap 3X day for Intermittent Explosive Disorder was not given September 21st and 22nd, 2020 @ 4PM.
Individual #1's current 2/17/2020 A&D Ointment medication order does not give the reason for ointment or where to apply this ointment. Individual #1's September 2020 medication administration record (MAR) states staff are applying this ointment daily. The MAR also states it is a PRN.
Per Individual #1's current lifetime medical history and assessment, she is diagnosed with chronic kidney disease and has her fluid intake monitored daily. A Hydration Chart must be kept offering fluid intake of 2000cc daily, including 1000cc free water daily. A hydration chart is currently kept, however, it is marked in ounces, does not state what individual #1 drank, and does not give the conversion totals from ounces to cc's. There is also no documented training on file that staff have been trained on this protocol.
Individual #1 does not have a dental hygiene plan in place to meet her needs. There is also no current documentation Provider is supporting individual #1 to care for her oral care as prescribed. Current oral hygiene tracking sheet address verbal, physical, or independent with brushing and flossing. Individual #1's 8/10/20 dental appointment states she is edentulous. She has dentures and requires physical assistance to care for them and to swab her gums.
Individual #1's current September 2020 Medication Administration Record (MAR) states staff are to check her blood pressure prior to taking her medication. There is no current order in individual #1's record explaining the reason why this is in place. Provider states this order goes back a long time and the order must have been purged. | 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.
| Critical Analysis of cause of violation
Individual #1 fell out of bed which resulted in a superficial abrasion to her left shoulder. The Registered Nurse was notified of the incident and instructed Direct Support Provider to take individual to physician to be evaluated as a precaution. Primary Care Physician prescribed Treatment order which included washing with soap/water, application of Neosporin and use of a Band-Aid. Pt does have a documented reaction to adhesives, and this is listed on Individual's Medication Administration Record. This treatment was not logged onto the Medication Administration Record which resulted in the violation.
Immediate correction:
Direct Support Staff will be trained to review individual allergies and current medications prior to attending individuals' medical appointments to be attentive to potential physician oversights. Direct Support Staff will begin using newly formatted Treatment Record that is maintained at residences to record treatment processes ordered by physicians and are separate from prescribed medications. Attachment P
Change in procedure:
After all medical related appointments, all Direct Support Staff are to immediately record any changes to the current medication and/or treatment orders on the Medication Record. They are also to scan documentation into the office electronic Medical files within 24 hours if said documentation is available.
Specific steps to be taken:
The Registered Nurse and Program Specialist will create a new Treatment Record document which will distributed with the November Medication Administration Record.
Staff will be instructed on the utilization of the new Treatment Record form and scanning process. A signed acknowledgement for this instruction will be maintained at the administrative office. |
10/27/2020
| Implemented |
| 6400.145(1) | Individual #1 does not have a written emergency medical plan. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | Critical Analysis of cause of violation:
It is unclear as to why this document was not located in the individual's record. The individual records are being reviewed quarterly by the Executive Director and any omissions are noted and returned to the House Supervisor for correction. The document did exist in the administrative computer system however there was a breakdown in the procedure to insure its presence in the individual record at the home.
Immediate correction:
A written emergency medical plan has been added to Individual#1's record. All records have been reviewed to insure inclusion of written emergency medical plans. Attachment Q
Change in Procedure:
To insure the presence of an easily accessible written Emergency Medical Plans in all individual records, a checklist of required documents is being developed within fourteen days to be used by the House Supervisors prior to the record review by the Executive Director.
Specific Steps to be taken:
The House Supervisors will review each individual record on a monthly basis and use the checklist as a tool to verify and record the presence of all required documents.
The completed checklist signed by the House Supervisor will be submitted monthly to the Executive Director for review.
The Executive Director will inspect the individual records quarterly to insure compliance with regulations and insure that all relevant information is accessible to the Direct Support Staff working in the home. |
10/27/2020
| Implemented |
| 6400.145(2) | Individual #1 does not have a written emergency medical plan. | The home shall have a written emergency medical plan listing the following: The method of transportation to be used. | Critical Analysis of cause of violation:
It is unclear as to why this document was not located in the individual's record. The individual records are being reviewed quarterly by the Executive Director and any omissions are noted and returned to the House Supervisor for correction. The document did exist in the administrative computer system however there was a breakdown in the procedure to insure its presence in the individual record at the home.
Immediate correction:
A written emergency medical plan has been added to Individual#1's record. All records have been reviewed to insure inclusion of written emergency medical plans. Attachment Q
Change in Procedure:
To insure the presence of an easily accessible written Emergency Medical Plans in all individual records, a checklist of required documents is being developed within fourteen days to be used by the House Supervisors prior to the record review by the Executive Director.
Specific Steps to be taken:
The House Supervisors will review each individual record on a monthly basis and use the checklist as a tool to verify and record the presence of all required documents.
The completed checklist signed by the House Supervisor will be submitted monthly to the Executive Director for review.
The Executive Director will inspect the individual records quarterly to insure compliance with regulations and insure that all relevant information is accessible to the Direct Support Staff working in the home. |
10/27/2020
| Implemented |
| 6400.145(3) | Individual #1 does not have a written emergency medical plan. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | Critical Analysis of cause of violation:
It is unclear as to why this document was not located in the individual's record. The individual records are being reviewed quarterly by the Executive Director and any omissions are noted and returned to the House Supervisor for correction. The document did exist in the administrative computer system however there was a breakdown in the procedure to insure its presence in the individual record at the home.
Immediate correction:
A written emergency medical plan has been added to Individual#1's record. All records have been reviewed to insure inclusion of written emergency medical plans. Attachment Q
Change in Procedure:
To insure the presence of an easily accessible written Emergency Medical Plans in all individual records, a checklist of required documents is being developed within fourteen days to be used by the House Supervisors prior to the record review by the Executive Director.
Specific Steps to be taken:
The House Supervisors will review each individual record on a monthly basis and use the checklist as a tool to verify and record the presence of all required documents.
The completed checklist signed by the House Supervisor will be submitted monthly to the Executive Director for review.
The Executive Director will inspect the individual records quarterly to insure compliance with regulations and insure that all relevant information is accessible to the Direct Support Staff working in the home. |
10/27/2020
| Implemented |
| 6400.181(e)(7) | Individual #1's current assessment 5/8/2020 addresses that she has has an understanding of heat sources, however, it does not address her ability to sense and move away from it quickly. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | Critical Analysis of cause of violation:
The Program Specialist failed to include Individual #1's ability to sense and move away from heat sources quickly. The assessment included her understanding of heat sources however the implication that her having that understanding does result in her ability to respond appropriately was not specifically stated. This error may have been due to the Program Specialist's familiarity with the individual over many years and her abilities specific to this situation however it does not document that she has no physical or cognitive limitations that would interfere with her ability to avoid harm from sources of heat in her environment.
Immediate Correction:
The assessment has been updated to address her ability to sense and move away from heat sources quickly. All records have been reviewed to insure that the individuals ability to sense and move away from heat sources quickly is documented. Attachment R
Change in Procedure:
The Program Specialist will review a checklist of all areas of the assessment that require specific actions that need to be taken by an Individual and include these actions on each assessment. He will complete this checklist for each assessment of an Individual.
Specific Steps to be taken:
The Executive Director will provide a checklist that includes the regulations of the assessments for Individuals and instruct the Program Specialist on the proper way to complete this list. Each list will be completed by the Program Specialist for each assessment that is written. This will be completed by October 31, 2020. |
10/31/2020
| Implemented |
| 6400.214(a) | Provider did not keep the following record books relating to individual #1 at her home: 6400.213(2) - Incident reports relating to the individual. 6400.213(6). Assessments as required under §6400.181(relating to assessments). 6400.213(7) Individual plan documents as required by this chapter 6400.213(8). Copies of psychological evaluations, if applicable. These records were also not accessible electronically while at individual #1's home. | Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home. | Critical Analysis of cause of violation:
It is unclear as to why the documents were not located in the individual's record. The individual records are being reviewed quarterly by the Executive Director and any omissions are noted and returned to the House Supervisor for correction. The document did exist in the administrative computer system however there was a breakdown in the procedure to insure its presence in the individual record at the home.
Immediate correction:
Copies of all required documents have been placed in a locked area of each respective home. In the absence of clarification from the inspector, the agency has defined the term current as contained in the regulation to be that information which still applies or in the case of incidents, a period of one year
Change in Procedure:
To insure the presence of all required documents in the home all individual records, a checklist of required documents is being developed within fourteen days to be used by the House Supervisors prior to the record review by the Executive Director.
Specific Steps to be taken:
The House Supervisors will review each individual record on a monthly basis and use the checklist as a tool to verify and record the presence of all required documents.
The completed checklist signed by the House Supervisor will be submitted monthly to the Executive Director for review.
The Executive Director will inspect the individual records quarterly to insure compliance with regulations and insure that all relevant information is accessible to the Direct Support Staff working in the home. |
10/27/2020
| Implemented |
| 6400.44(b)(2) | Staff #1 did not ensure the implementation of trainings related to violations cited under regulation 6400.144.
Also, there is no formal documentation he addressed any trainings on individual #1's diet protocol as per her updated September 2020 Individual Plan; and also the blood pressure cuff trainings as implemented. | The program specialist shall be responsible for the following: Participating in the individual plan process, development, team reviews and implementation in accordance with this chapter. | Critical Analysis of cause of violation:
The agency hired a full time registered nurse whose duties, among other things include insuring that health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual and that such services are arranged for or provided. During the transition of those duties being performed by the agency nurse, the Program Specialist is working virtually due to compromised health conditions that prohibit his physical presence at the work site during the COVID-19 pandemic. The oversight responsibility of the Program Specialist was not fulfilled, in part due to communication deficiencies resulting from the intermittent virtual interactions with the Nurse as opposed to the more continuous face to face access with agency personnel to which he had become accustomed and the fact that the expectation that he would actively insure that the training related to the above referenced services was not adequately communicated to him by the agency administrative staff.
Immediate correction:
The Program Specialist has been instructed to insure that the agency nurse provides training necessary for Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual and that such services are arranged for or provided.
Attachment S
Changes in Procedures:
The Program Specialist job description has been amended to clarify the responsibility of insuring the implementations of trainings relevant to health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual and that such services are arranged for or provided.
Specific Steps to be taken:
The Program Specialist will now schedule weekly communication with the agency Nurse to specifically review any training needs specific to health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual and that such services are arranged for or provided and insure that any such training is provided by the Nurse or arranged to be provided by an appropriate outside source such as HCQU. These interactions will be documented by the Program Specialist in a written summary to be provided to the Nurse and a copy sent to the Executive Director via e-mail. |
10/27/2020
| Implemented |
| 6400.45(c) | Individual #1's 5/8/2020 assessment and her individual plan 9/28/2020 do not address her supervision needs in the home. Documents state individual #1 is always supervised at home, however, she may be without direct supervision in all areas of the home. After further review, this is false. Also, there is also no outcome which requires the achievement of a higher level of independence at this time. | An individual may be left unsupervised for specified periods of time if the absence of direct supervision is consistent with the individual's assessment and is part of the individual plan, as an outcome which requires the achievement of a higher level of independence. | Critical Analysis of cause of violation:
There is a lack of clarity in the assessment relevant to Individual #1's need for supervision in her home. The assessment inadequately documents that she does require support staff to be present at any time she is in the home however she is capable of being out of line of sight when sleeping or when seated in the living room or at the dining table. Individual#1's mobility limitations are medically related and require that she be supervised when she is ambulating or performing personal hygiene tasks to minimize the risk of her falling. It is not expected that her medical condition will improve to the extent that she will achieve a higher level of independence in her home. This need for support was not clearly identified in the assessment.
Immediate correction:
Individual #1's assessment has been amended to reflect her supervision needs in her home. It contains documentation that achievement of a higher level of independence is not a foreseeable outcome for her at this time. Attachment R
Changes in Procedures:
The Program Specialist has been instructed by the Executive Director to expand the detailed description of individual's need for supervision in their homes to include any specific limitations that may be present due to medical, cognitive or behavioral challenges.
Specific Steps to be taken:
The Program Specialist will incorporate any specific limitations that impact on the individuals need for supervision in their home into the narrative description contained in the assessment. This shall include specific areas of the home that present challenges as well as specific tasks with which the individual requires supervision and support. Examples will include the person's ability to use the telephone, to ambulate safely, to operate appliances and identify any environmental considerations that are relevant to the level of support needed. |
10/27/2020
| Implemented |
| 6400.165(b) | Individual #1's current September 2020 Medication Administration Record (MAR) states staff are to check her blood pressure prior to taking her medication. There is no current order in individual #1's record explaining the reason why this is in place. Provider states this order goes back a long time and the order must have been purged. | A prescription order shall be kept current. | Critical Analysis of cause of violation:
The Registered Nurse monitors every individual under HAP care that is currently on anti-hypertensive medications as a safety precaution based on Commonwealth of PA State Board of Nursing established nursing practice. This nursing action which is an element of assessing an individual's current health condition does not require a physicians order.
All Primary Care Physicians who have patients under HAP care that are on daily blood pressure medications were contacted by the Registered Nurse who requested blood pressure parameters (i.e. if blood pressures below/above indicated levels, take this action)
for individuals taking daily anti-hypertensives. Some PCPs do not require blood pressure monitoring, while those that did, their patients BP monitoring was placed on the MAR for monitoring by the nurse. If and when an individual's pressure may be trending high, staff notifies the Registered Nurse and nurse will give direction to staff or contact physician as necessary.
Immediate Action to correct violation:
The Agency will continue current practice as defined above.
Changes to Procedures:
There are no changes to this procedure at this time. The current procedure is consistent with current Nursing practices and serves to promote the health and safety of the individuals involved.
Specific Steps to be taken:
Agency will continue to monitor blood pressure as described above. |
10/27/2020
| Implemented |
| 6400.165(c) | Individual #1's current 2/17/2020 A&D Ointment medication order does not give the reason for ointment or where to apply this ointment. Individual #1's September 2020 medication administration record (MAR) states staff are applying this ointment daily. The MAR also states it is a PRN. | A prescription medication shall be administered as prescribed. | Critical Analysis of cause of violation
Written orders on the Appointment Form from the 2/17/20 Primary Care Physician visit do not include any new orders for A&D ointment; a box on this form is checked to state no changes to current medications¿. The medication list that is prepared by the Program Specialist as a part of the HAP appointment documentation packet that is brought to the visit does not have A&D ointment included on the list of Current Medications.
A separate Clinical Visit Summary form was generated by the physicians office and given to staff along with the Appointment Form from HAP at the end of the appointment. That form documents the fact that Individual #1 is incontinent and wears adult briefs/diapers and also lists an undated historical order for A&D ointment to be used daily that was issued by an additional provider. There is no reason written for its use nor does it state a site for the ointment. Frequency is recorded as to apply daily. This order was among a list of 5 additional historical providers with orders that the PCP has continued.
New medication orders created for Individual #1 after any medical appointment are immediately hand-written on the current Medication Administration Record by Direct Support Staff and prior to the printing of the following month's MAR, the new medication is included electronically after being reviewed by the Program Specialist. PRN use of the A&D ointment was inadvertently placed on this ointment which is used daily during changes.
Immediate correction:
A request for a new order for A&D ointment was sent to the Primary Care Physician. The PCP responded to request for new order for A&D ointment and purpose. Per PCP office on follow-up call, the order was sent to the Medicine Shoppe on 10/7 and we were notified by PCP office of this on 10/13. Attachment P
Change in procedure:
All post-appointment forms will be reviewed for accuracy prior to medical appointments by Direct Support Staff, the Program Specialist, and Registered Nurse. Accompanying Staff will review Medication lists during appointments, so the physicians¿ and HAP records agree as to medication, purpose, dosage, frequency, site, and prescribing physician.
Specific steps to be taken:
The Registered Nurse is reviewing current and past years medical records across multiple specialties (PCP, Psychiatrists, Neurologists, etc.) and comparing to pharmacy orders which in some cases has highlighted differences between how information is written on our paperwork by a physician as a result of an office visit and how it is e-scribed and ultimately labeled on the bottle, tube, or package. Physician offices are also contacted for medication confirmation which at times highlights differences in physician office records and our historical records such as older or unintended continuation of older prescriptions. |
10/27/2020
| Implemented |
| 6400.166(a)(2) | There name of the prescriber is not listed for all medications on individual #1's September 2020 Medication Administration Record (MAR). | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | Critical Analysis of cause of violation
Medical Administration Records (MAR) are developed and updated monthly by Program Specialist. Information on these forms is updated by the Program Specialist based on new orders, changes, or modifications by physicians during the previous month. At the end of the month, the new MAR for the upcoming month is printed in the office for distribution to individual residences. While an individual¿s medical records, which includes all signed orders, are kept at the residence, the MAR template was erroneously constructed without including the name of prescribing physician for each individual medication.
Immediate correction:
Updating of the Medication Administration Record has been completed to now include Prescribing Physician for each listed medication and treatment. Attachment I
Change in procedure:
A monthly review of all MAR will now be performed by company Nurse for accuracy and updates including prescribing physician. This has been completed for all November MARs
Specific steps to be taken:
An investigation by the Registered Nurse has been undertaken to match each prescribed medication to the correct prescriber in the Medication Administration Records for all individuals. This process involves reviewing current and past years medical records across multiple specialties (PCP, Psychiatrists, Neurologists, etc.), reviewing pharmacy orders which in some cases has highlighted differences between how information is written on our paperwork by a physician as a result of an office visit and how it is e-scribed and ultimately labeled on the bottle, tube, or package. Physician offices are also contacted for medication confirmation which at times highlights differences in physician office records and our historical records such as older or unintended continuation of older prescriptions. This should be completed for all 27 individuals receiving services.
The current software being used for MAR development and maintenance is currently being re-evaluated for potential transition to electronic medication records in order to develop a more precise record-keeping and exchange of information between doctors and HAP service providers. |
10/27/2020
| Implemented |
| 6400.167(a)(1) | Individual #1's medication Gabapentin 100mg 1cap 3X day for Intermittent Explosive Disorder was not given September 21st and 22nd, 2020 @ 4PM. | Medication errors include the following: Failure to administer a medication. | Critical Analysis of cause of Violation:
The Direct Support Staff responsible for administering this medication in accordance with the procedure contained within the Medications Training, failed to do so.
The Medication Administration Record was not reviewed for errors and/or omissions in a timely manner.
Immediate correction:
An incident report was completed and submitted to the Commonwealth of Pennsylvania through the Home and Community Services Information System (HCSIS). An investigation was instigated by HAP management to identify the responsible Direct Support Staff member and appropriate disciplinary action was taken. Attachment O
Change in procedure:
House supervisors are to review med logs at a minimum of once a week.
Specific steps to be taken:
Direct Support Staff will review all Medication Administration Records, including Treatment Records at the end of each shift for missed entries.
Any missed entries found from a prior shift are to be immediately reported to pertinent supervisory staff (House Supervisors, On-Call Supervisors) and to the Registered Nurse on the ensuing morning after discovery. |
10/31/2020
| Implemented |
| 6400.167(c) | Individual #1's medication Gabapentin 100mg 1cap 3X day Intermittent Explosive Disorder Medication not given September 21st and 22nd, 2020 @ 4PM was not reported as specified in § 6400.18(b). At exit on 10/9/2020, provider reported that they had yet to report the error. Licensing did ask to get confirmation when this medication error was reported; no confirmation received as of 10/19/2020. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | Critical Analysis of cause of Violation:
The Incident Manager did not insure the entry of the medication error within 72 hours of discovery. The Incident manager is currently on an unexpected medical leave and is unavailable to provide an account of the reason for the late report, The administration failed to insure that all incident reports were entered as required.
Immediate Action to correct violation:
The incident was entered into EIM on October 16, 2020. Attachment O
Change in Procedure:
The responsibility of the Incident Manager relevant to insuring the timely reporting of medication errors has been reassigned to the Executive Director,
Specific Steps to be taken:
The duties of the Agency Incident Manager have been reassigned to the Executive Director. The Executive Director will be notified of any medication errors by the agency Nurse. Refer to Specific Steps to be taken to prevent future violation of 6400.167(a)(1)
The Executive Director will insure all medication errors are entered into the EIM system within the timeframe required. |
10/27/2020
| Implemented |
| 6400.181(f) | Staff #1 did not provide individual #1's 5/8/2020 Assessment to team members. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Critical Analysis of cause of Violation:
The provider was unable to produce documentation that Individual #1's assessment had been provided to all interested team members prior to her annual ISP meeting. The assessment had been provided to the team via email, however a copy of that email was not placed in the individual record.
Immediate Action to correct violation:
The email from the Program Specialist to the team members notifiying them of the attached assessment for Individual#1 was located, printed and placed in the individuals record.
Attachment V
Changes to Procedure:
The Program Specialist will copy in the Executive Director on all emailed assessments to team members.
Specific Steps to be Taken:
The Program Specialist will provide all individuals' assessment to all interested team members within the required timeframe. The majority of these contacts will occur using date and time stamped emails including the attachment.
The Executive Director will be copied in all such emails and insure that a printed copy is entered in the individuals' records. |
10/27/2020
| Implemented |