| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Individual #2 is assessed to be unsafe around poisonous substances and requires them to be locked when not in use. During the 1/22/2021 remote inspection of the home, multiple items poisonous items that contained a label stating contact poison control center if ingested were found in areas unlocked and accessible to Individual #2. These items and locations were: multiple containers of person hygiene supplies (soaps, wipes, toothpaste, deodorant, sunscreen) accessible to the individual in the cabinet above the toilet in her bathroom as the individual can manipulate items with her hands to open the cabinet, and Vaseline under her bathroom sink. | Poisonous materials shall be kept locked or made inaccessible to individuals. | 629a) violation was reviewed. Items were removed from Individual #2 bathroom that were deemed unsafe. Clear code lock boxes were ordered from Amazon, the personal care items were relocated into the locked box, staff were trained on the new boxes, what items are safe and unsafe and given the code for the box. Items submitted will be labeled POC62A 1-6 |
03/05/2021
| Implemented |
| 6400.112(c) | The written fire drill records for the fire drills held on 11/13/19 and 12/26/19, the only fire drills held in those two months, did not include the amount of time the evacuation took. Both written fire drill records were blank in the field, "total evacuation time," and did not record an evacuation time anywhere else on the forms. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Violation 112(c) was reviewed. MOCAFA updated our current Fire Drill form and Policy with changes.. We used the new form for the February Fire Drill. A new fire drill review form was created for monitoring purposes to make sure the forms are completed fully and correctly. File that will be uploaded will be POC-112c (pages 1-8) |
03/05/2021
| Implemented |
| 6400.112(d) | Individual #1's 11/11/19 and 11/10/2020 assessments both state that she can have up to 3 hours of unsupervised time in her home and that she chooses to use this unsupervised time when her staff and her housemate leave the home to run errands. Even though staff are not always present at the home when Individual #1 is home, staff still provided assistance to Individual #1 during fire drills from September 2019 to present, January 2021. According to the fire drill records, Individual #1 required verbal and physical assistance to evacuate the home on 9/9/19 and 10/5/19 and required verbal assistance to evacuate the home on 11/13/19 and 5/16/20. Staff assistance may only be provided to an individual only if staff persons are always present at the home while the individual is at home. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Violation 112d was reviewed. Individual #1 was evaluated for alone time by going over and assessing what and emergency is, who to call in an emergency, where phones are located, how to lock and unlock the doors to the home. Individual # 1 has completed her sixth fire drill in a row with the most recent being on 2/11/21 and had not required any assistance from her staff or reminders. A team meeting was conducted to review her current needs and how she will be evaluated moving forward in the even she needs assistance that alone time would return to zero. Files uploaded will be labeled POC-112d |
04/02/2021
| Implemented |
| 6400.141(c)(1) | Individual #2's physician confirmed on 4/29/2020 in a pre-operation appointment that the individual was diagnosed with basal cell carcinoma. The individual's current, 5/22/2020 physical examination record did not include a review of this recently added medical history information. | The physical examination shall include: A review of previous medical history. | Violation 141(c)(1) was reviewed. A letter from the Program Specialist was sent to Individual #2 Primary care doctor addressing the missing diagnosis. Individual #2 SEEN Plan, Assessment were updated with the diagnosis. A request to update the individual plan as well. Individual #2 will be seen on 3/2/21 by her physician to go over the letter and complete a new physical for the year. An upload of all corrected documents will be labeled POC-141c1 |
04/02/2021
| Implemented |
| 6400.141(c)(11) | Individual #2's 5/22/2020 physical examination record did not include the physician's review of the individual's health maintenance needs at the time of her physical examination. The sections on the physical examination to complete instructions for health maintenance needs and the use of medical treatments/therapies and other recommended tests, was completed by Staff person #2 sometime after the physical examination appointment. Its documented that Staff person #1 attended Individual #2's physical examination appointment with her but did not record information on the physical examination record or complete a medical consultation record. The medical consultation record and information on the physical was completed by Staff person #2 after Staff person #1 returned home with the individual, per Staff person #2 report during the 1/21/21 annual inspection. The physical examination record was not returned to the physician after staff completed an assessment of the individual's health maintenance needs. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Violation 141(c)(11) The Program Specialist sent a letter to the Primary Care doctor of Individual #2 reviewing the information that needed to be completed on the annual physical and addressed the health maintenance are specifically. Individual #2 is scheduled to see her physician on 3/2/21 to complete a new physical for the year and address all concerns. Staff #1 and #2 were retrained on completion of forms, having to submit for review if additions are made, and created new consult forms with areas for staff to update and make reports of information. Items uploaded will be labeled POC-141c11 |
04/02/2021
| Implemented |
| 6400.141(c)(13) | Individual #1's 5/21/2020 physical examination record stated she was allergic to Ceftin. However, her foot and ankle specialist recorded on 11/1/19, 1/3/2020, 3/6/2020, and 5/8/2020 that individual #1 had an allergy to grapefruit due to the medication she was prescribed. This allergy or sensitivity is not recorded on the individual's physical examination record. There are no records maintained that the agency attempted to clarify this allergy with the individual's primary care physician who completed her physician examination.
Individual #2's 5/22/2020 physical examination record stated she had allergies to Zithromax, Nimitop, Zyprexa, Augmentin, Keppra, Abilify, Saphris and was to avoid caffeine, aspartame, and grapefruit juice. The individual attended a medical appointment on 4/29/2020 that listed the individual also had an allergy to Cipro which caused hives and swelling. This information was not included on her 5/22/2020 physical examination record. | The physical examination shall include: Allergies or contraindicated medications. | Violation was reviewed 141(c)(13). Individual #1 Legal Guardian along with MOCAFA Program Specialist wrote a letter addressing the discrepancies on the Foot and Ankle Specialist records indicating an allergy to grapefruit and grape fruit juice. This was never removed by there office after the medication as no longer prescribed. Individual #1 will be seen for an appointment on 3/26/2021 for her appointment. Will provide documentation that the changes were made and corrected.
MOCAFA's Program Specialist addressed the allergy to Cipro for Individual #2 by letter to the Primary Care doctor verifying no allergy and also to the doctor that stated there was an allergy on 4/29/20. The letter also specified that Individual #2 Legal Guardians are the ones who request that caffeine and aspartame be avoided due to their preference. It was asked to be explained that there is no allergy and that it would cause no harm if the Individual does have it. All plans will be updated to match this statement. Appointment with Primary Care doctor on 3/2/21 to go over letter, corrections and complete a new annual physical.
Files uploaded will be labeled POC-141c13 |
04/02/2021
| Implemented |
| 6400.141(c)(14) | Individual #2 attended a pre-operation appointment on 4/29/2020 with Staff person #1. The appointment summary listed that pertinent history of Individual #2 includes pre-medicating prior to surgeries. Individual #2's current, 5/22/2020 physical examination record does not include the pertinent history of pre-medicating prior to surgeries and that this is possibly a need for individual #2 in the event of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Violation 141(c)(14) was reviewed. Staff person #1 who is the Program Specialist wrote a letter to Individual #2 Primary Care doctor going over the specified information from the appointment on 4/29/20. It was requested that the need to possibly premedication due to surgeries, in the event of an emergency or if it was a procedure deemed necessary be added to the individuals medical record and physical. An appointment with the primary care doctor was scheduled for 3/2/21 to go over the letter, corrections and to complete the annual physical. Corrections will be uploaded and labeled POC-141c14 |
04/02/2021
| Implemented |
| 6400.141(c)(15) | Individual #2's 3/4/2020 and 3/10/19 assessments both state that the individual's food needs cut up into smaller pieces to reduce the risk of choking. This information was not included on either of her 5/21/19 or 5/22/2020 physical examination records. Staff person #1 created the individual's assessments and attended her physical examinations with her. There are no records maintained that Staff person #1 discussed the individual's dietary needs he recorded on Individual #2's assessments with any medical professional. Individual #2's current individual plan also echoes that her "food needs to be cut up into bite-sized pieces (quarter sized) to prevent her from choking and also required constant supervision during meals and snacks." This is not included on her physical examination records. | The physical examination shall include:Special instructions for the individual's diet. | Violation 141(c)(15) was reviewed. Staff #1 who is the Program Specialist created a letter addressing Individual #2 dietary needs to have her food cut up as precaution. This letter also included several other areas that needed addressed for medical records and annual physical forms moving forward. Individual #2 SEEN Plan, Assessment, and ISP all were reviewed to make sure the statement on food and dietary concerns were clear and matched. An appointment was created for Individual #2 for 3/2/21 with the primary care physician to go over the letter, corrections and to complete annual physical.
When items are uploaded they will be labeled POC-141c15 |
04/02/2021
| Implemented |
| 6400.142(d) | Individual #1 is to be seen by her dentist every 6 months for cleanings and examinations. There are no records maintained for the services that were rendered to Individual #1 at her 2/3/2020 dental appointment. The record states that this was a "dental check up" but does not indicate if a cleaning or examination took place. | The dental examination shall include teeth cleaning or checking gums and dentures. | Violation 142(d) was reviewed. MOCAFA has created new Consult forms to be used for appointments. The next step was Individual #1 had a follow up dental examination nd cleaning completed on 2/8/21 where the form was filled out correctly. All dental information including the dental diagnosis was listed. The MOCAFA Program Specialist completed a dental plan, the House Supervisor created a monthly dental chart for implementation. The dental plan sent to Individuals #1 team and plans are being updated. File uploaded will be POC-142d |
04/02/2021
| Implemented |
| 6400.142(f) | Individual #1's record does not include a dental hygiene plan. There are no records maintained stating that she has achieved dental hygiene independence and does not need a dental hygiene plan. The individual's 2020 and 2021 assessments state she does have periodontal gum disease and avoids hard or crunchy food if her teeth are being sensitive. | 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. | Violation 142(f) was reviewed. MOCAFA has created new Consult forms to be used for appointments. The next step was Individual #1 had a follow up dental examination nd cleaning completed on 2/8/21 where the form was filled out correctly. All dental information including the dental diagnosis was listed. The MOCAFA Program Specialist completed a dental plan, the House Supervisor created a monthly dental chart for implementation. The dental plan was sent out to Individuals #1 team and plans were updated. |
02/26/2021
| Implemented |
| 6400.144 | continued..
Individual #2's physician has ordered the individual to take a multivitamin capsule daily since 5/22/2020. The home has been administering a multivitamin gummy all of 2020 and 2021 with no records maintained that this was an applicable substitute and could be administered in place of the multivitamin capsule.
On 5/22/2020 Individual #2's physician continued the order to administer Trifluoperazine 1mg, take by mouth daily. There are no records that this medication has been discontinued or shouldn't be administered. This medication was not available in the home nor being administered.
Additionally, on 5/22/2020 Individual #2's physician stated the individual is to continue to have CBD oil, ¼ dropper administered via other route daily. There are no records maintained that this medication was discontinued. This isn't available in the home nor is it being administered.
On 9/9/2019 Individual #2's psychiatrist ordered lab work to be completed on 11/18/2019, prior to the individual's next appointment with her psychiatrist on 12/2/19. The blood work ordered was: CBC, CMP, Neurontin, DVP T and F, Zonisimide, and Prolactin levels. Individual #2 had this blood work completed on 10/22/2019 prior to the psychiatrist's recommendation to complete the orders on 11/18/2019. There are no records maintained that the psychiatrist agreed to completion of blood work order prior to 11/18/2019. Again on 3/2/2020 the individual's psychiatrist ordered the same blood work as above to be completed on 6/22/2020. There are no records of the individual's Prolactin levels being checked after 2/17/2020. The individual had their blood drawn on 5/21/2020 to check the specific levels order by their psychiatrist. However, again there are no records maintained that the psychiatrist wanted the individual's blood drawn early, on 5/21/2020 and not as ordered on 6/22/2020.
On 3/2/2020 Individual #2's psychiatrist stated the individual had a return visit scheduled for 4/6/2020. Individual #2 did not return to her psychiatrist until 5/29/2020 without record for why the appointment was late.
Individual #2 saw her psychiatrist on 10/5/2020 and was to return on 1/4/2021. At the time of the 1/19/2021 annual inspection, there is no record the individual returned for a visit.
Individual #2's current 3/4/2020 assessment and current Individual Support Plan (ISP) states that she needs staff assistance with brushing her teeth twice a day, once in the morning and at night and that staff will brush her teeth. There are no records maintained that this is completed.
On 10/10/19 Individual #2's physician recommended a referral to a neurologist. The individual did not see a neurologist until 3/7/2020, 5 months later. This was held with a new neurologist and they only addressed the individual's seizure disorder, not the same issues that were addressed at her previous neurologist on 6/4/2019 that were: seizure disorder, dementia associated with other underlying disease with behavioral disturbance and bipolar affective disorder with autism. There are no records maintained that the new neurologist was informed by the agency of Individual #2's current neurological conditions that were being addressed by the previous neurologist.
On 4/29/2020 individual #2 saw the keystone dermatology center for a pre-operation appointment. The doctor stated that Individual #2 has been diagnosed with basal cell carcinoma on the nasal dorsum that has been present for 4 months and pertinent history includes pre-medicating prior to surgeries. The doctor also stated that the plan is to do excision with possible frozen section and reconstruction at the surgery center and discussed the individual taking Ativan prior to surgery. The doctor indicated they reviewed the individual's medications with changes noted on 4/29/2020 to include "Valium 5mg oral tablet and Zonisamide 100mg capsule." There are no records maintained for when the individual received her surgery, what medications she was to take the day of surgery, if she was to take Valium before her surgery, if she and/or her guardians were offered the medication prior to surgery, no records of refusal of medications, or post-surgery instructions. Staff person #2, who never attended the pre-operation appointment, surgery appointment or any surgery follow-up appointments, wrote a note that surgery occurred on 5/29/2020, she had a return appointment on 6/1/2020 for bandage change/removed/check, a follow up on 6/12/2020 for stitches removed/checked, and was to return as needed. Staff person #1 attended all above appointments with Individual #2 and did not obtain medical documentation for any of the above events or physician's orders/recommendations/directions. | 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.
| Reviewed violation in this part. Individual #2 medications have been corrected during her Neurological appointment on 2/2/21 they were faxed and updated in the Portal, a letter was sent to her Primary Care doctor as well requesting areas of concern to be corrected. She will be seen on 3/2/21 by her Primary Care doctor to get her files updated and to complete her yearly physical then instead of May. Change of medication forms were created to be used when medications are changed.
Individual #2 Psychiatrist was contacted by email to have her labs work grace period documented instead of a verbal discussion.
The appointment on 4/6/20 documents were uploaded but may have been missed in the review. There were emails regarding the cancellation and will be uploaded. Change of appointment forms will be used from here on out.
The Neurologist that Individual #2 was seeing retired and was still seen in the same Neurologist practice where she continues to been seen. Her Primary Care referred her to be seen even though she was already being seen there. She was seen by the Neurologist practice on 2/2/21 and the issues regarding medication clarification for him to update his records for what she is currently taking and the medications she takes from her psychiatrist. It was also addressed that a dementia diagnosis was put on her file. He was in agreement and her diagnosis for her in their office is for seizures. The form is updated as well.
Individual #2 will be seen by her psychiatrist on 4/5/21, medications, lab orders, behavior and sleep charts will be reviewed. Files uploaded will be labeled POC-144-Indv2 |
04/19/2021
| Implemented |
| 6400.144 | Health services such as medical, nursing, pharmaceutical, dental, dietary, psychological and other medical treatments and therapies that are planned for or prescribed shall be arranged for or provided. There were numerous occasions from September 2019 to present, January 19, 2021, where such services were not arranged for Individuals #1 and #2. Below are examples of such occasions.
At Individual #1's 3/31/2020 medication review appointment, her physician stated the next appointment to review the individual's current medications was to be held on 4/28/2020. This appointment wasn't completed until 4/30/2020 without an explanation of why it was late.
On 1/20/17 Individual #1's physician recommended that the individual should have annual mammograms completed and gynecological examinations with a pap test every three years. There are no records maintained that the individual continued to receive mammograms yearly or if a physician deferred the examinations. According to the individual's 5/21/19 physical examination record, the physician recorded the results of a mammogram were negative but did not record the date a mammogram was completed as it is not completed at the physical examination. The individual's 5/21/2020 physical examination record stated her mammogram was normal but again did not state when the examination was completed as this is not completed at her physical examination appointment. The agency had documentation that a mammogram screening occurred on 6/12/2020 but no results included in the record.
According to Individual #1's 1/22/2020 appointment record, she had a follow up radiology appointment on 4/10/2020. There are no records maintained that this appointment was completed.
Individual #1 attended an appointment at her sleep lab on 1/22/2020 and had a return appointment scheduled for 7/22/2020, as the physician recommended 6-month recall appointments. There are no records maintained to show she attended this appointment, refused the appointment, or if it was canceled and why. Individual #1 didn't return to the sleep clinic until 8/26/20.
Throughout the year, Individual #1's physicians have provided the agency with a printed summary of the entire list of medications prescribed to the individual. At the individual's 5/21/2020 physical examination appointment and recently at a 12/17/2020 appointment, the individual's physician provided the home with a current list of the individual's medications that included Ketoconazole 2% cream apply to affected area twice a day, Metronidazole .75% cream apply topically 2 times a day to rosacea, Nystatin-emollient combo cream apply topically, and Triamcinolone .1% topical cream apply to affected area 2 times a day as needed for itchy rash on thigh. These creams were never available in the home for Individual #1 to apply, nor are there records maintained that the home attempted to discuss with the individual's physician the applicability of these creams for the individual or if they should be discontinued. During the 1/19/2021 inspection, the home was unaware that these creams were on a current physician's order for prescribed medications to Individual #1.
On 5/21/2020 Individual #1's physician state the individual had a return appointment scheduled on 8/4/2020. There are no records maintained that this appointment was completed, refused, or canceled and why.
Individual #1 is ordered to use a bipap machine every night due to her sleep apnea. There are no records maintained that individual #1 uses her bipap machine nightly or if she refuses to wear it.
Individual #1 last saw her dentist on 8/3/2020 for a routine appointment. The individual's dentist did not document that he was aware of the individual having any dental disease diagnoses or problems with loose teeth. The individual's 2020 and 2021 assessments state she does have periodontal gum disease and avoids hard or crunchy food if her teeth are being sensitive. Individual #1 is a 53-year-old female and teeth falling out because they are "loose" at this age is not normal. Some point after her 8/3/2020 dental appointment, Individual #1 lost a tooth (according to financial ledger she received $1 from the tooth fairy on 8/5/2020). There is no record that the individual's dentist, primary care physician, or any medical professional was contacted to determine the reasoning behind losing a tooth or if follow up with a medical professional was recommended due to her tooth falling out.
continued on next 144 violation. | 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.
| Violation was reviewed. Individual #1- a change of appointment form was created for all cancelled appointments to keep clear and complete documentation. Individual #1 had to cancel her eye appointment on 2/15/21 due to the weather and was rescheduled for 2/23/21. The form was then updated to show the time and date that appointments are canceled for even better documentation purposes.
Individual #1 did have her yearly mammograms complete and attached to the physical appointments.
Individual #1 mammogram was delayed this year from April 2020 to June 12, 2020 due to COVID-19. Her next mammograms is scheduled for 6/14/21. A letter addressing the physicals, to review and document her mammogram results so the documentation is complete on the physicals. This letter also addresses updating her medication lists as well.
Individual #1 BiPap charting for usage was adjusted to show a refusal of wearing it. Staff were retrained on the charts and her machine usage.
Individual #1 was seen by her dental provider on 2/8/21 for an examination and dental cleaning . The consult shows the correct diagnosis, instructions for brushing, a dental plan, and charting for brushing. All plans will be update to reflect the dental area.
All documents uploaded will be labeled POC-144-Indv1 |
04/02/2021
| Implemented |
| 6400.181(e)(4) | Individual #1's 11/10/2020 and 11/11/19 assessments do not clearly state her level of supervision needs or abilities when in the community. Her assessments include contradictory statements about the type of supervision needs she has when in the community and walking around the block at her house. Her assessments state, "she is able to walk to the mailbox and to the end of her block without her support staff. She is familiar with her neighborhood and is able to be within eye sight from her support staff. Her support staff will monitor her from the front porch or side walk" and "she is able to walk independently to the mailbox at the end of her road and around her block in front of her house. When she does this she is able to be observed from her staff from the front porch or sidewalk area." One statement states her house staff monitor her when she does this and one statement gives staff the option to monitor her visually when she does this.
Individual #2's current, 3/4/2020 assessment states she can have up to 15 mins unsupervised time in a room in her house but must be within hearing of staff. Her assessment also says the individual "will pick up stuff that is laying around her home and carry them around. Sometimes she may put them in her mouth. She needs to be monitored and observed closely when working with her and using all cleaning products." However, her individual plan (different from her assessment) states that during times of mania, she picks up any object around her and puts/or attempts to put it in her mouth. Additionally, Staff person #1 who creates the assessments, also created the individual's 2019, 2020, and 2021 social, emotional and environmental needs plans (SEEN) that state Individual #2 needs to be within eye sight of staff at all times when she is eating snacks or meals due to potentially eating too fast and choking. The specific supervision needs addressed in her individual plan and SEEN plans are not included in her assessments. | The assessment must include the following information: The individual's need for supervision.
| violation 181(e)(4) Individual #1 was assessed on her ability to notify, cross the street and walk to the mailbox to mail items. She had no issues with the assessment . Individual #1 SEEN Plan, Individual Plan and assessment will all be updated for clear documentation purposes. Staff were retrained on the plans as well.
Individual #2 SEEN Plan and assessment were update with the individuals walking ability, going up and down the steps, getting in and out of the car. All Plans will be updated to make sure that all information is clear and correct. Files uploaded will be labeled POC-181e4 |
04/02/2021
| Implemented |
| 6400.181(e)(5) | As referenced in 165(b) of this report, the agency, MOCAFA, never obtained a current list of medications prescribed to Individual #1. The agency is required to assess the individual's ability to administer their medications on an annual basis or more frequently if needed, which requires the agency to asses the individual's ability to recognize and distinguish their own medications, know how much medication is to be taken, know when the medication is to be taken, and take or apply their medication with or without the use of assistive technology. Due to the agency being unaware of the specific medications prescribed to Individual #1, they did not accurately assess the individual's ability to administer their own medications based on the specific medications prescribed to the individual.
The agency documented in the individual's 11/11/19 and 11/10/2020 assessments that the individual administered her medications independently but required staff to assist her with medication administration when her medications changed dosages, colors, shapes, reason for prescribing the medications, the medications themselves changed, and a different time of day changed throughout. Throughout the year, the individual's physician changed the individuals medications, dosages, and orders for administration many times. Yet the agency continued to allow the individual to administer the medications herself. Discussion with Staff person #2 during the 1/19/2021 inspection, confirmed that Individual #1 did not know how much medication to take or understand her physician's change of medication orders independently when this occurred throughout the year.
On 1/22/2020 the individual was prescribed Azithromycin for a time-limited medical event. The individual was not assessed to know her abilities to self-administer this new medication.
On 12/11/2020 the individual's podiatrist added a new medicated cream, Ammonium Lactate 12%, to be applied to affected area of dry skin on feet daily. A new assessment of the individual's abilities to administer this new medication was never completed. | The assessment must include the following information: The individual's ability to self-administer medications. | Violation 181e5 reviewed. Individual #1 medications updated, MARS completed, Individual #1 needs to self administer evaluated, reviewed at team meeting and came up with a plan over the next 6 months for staff to administer medications and to help retrain the individual. After 6 months the individual will then be reevaluated and then if passes the individual will be able to self administer her medications again. Plans will be updated to match the individuals needs. Files uploaded will be labeled POC-181e5 |
04/02/2021
| Implemented |
| 6400.181(e)(8) | According to the fire drill records, Individual #1 required verbal and physical assistance to evacuate the home on 9/9/19 and 10/5/19 and required verbal assistance to evacuate the home on 11/13/19 and 5/16/20. The agency notified the local fire department on 10/10/18 stating that Individual #1 may require guidance by verbal and physical prompting to exit the home and remain outside the home and safe during fire drills or evacuation in an emergency. However, her 11/11/19 and 11/10/20 assessments do not clarify her ability to evacuate the home. Both assessments state she can self-evacuate the home within 2 and ½ minutes of hearing the fire alarm but also that she "may require help at times." The specifics of the help needed are not addressed in her assessments | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | Violation 181(e)(8) was reviewed. Individual #1 was assessed on her ability to exit the home during the February 2021 Fire drill. She did not require any verbal prompts or assistance form staff. A new form was created to review the fire drills after each one is completed to verify that the individual was able to exit on her own. In the event she would need or require any type of assistance from staff all plans will be updated with he new information. Assessments will be sent out to the team and staff will be retrained on the assessment changes. Fire drill form included as well for documentation proof. Files uploaded will be labeled POC-181e |
04/02/2021
| Implemented |
| 6400.181(e)(9) | Individual #2's neurologist stated on 6/4/19 that she is seen by the neurologist for management of seizure disorder, dementia associated with other underlying disease with behavioral disturbance and bipolar affective disorder with autism. The individual's physician again noted on 5/22/2020 that the individual has dementia. The individual's dementia and autism diagnosis is not included on the individual's current, 3/4/2020 assessment.
Individual #2's 4/29/2020 medical appointment record listed that the individual's allergies were reviewed and documented as the individual having an allergy to cipro which caused hives and swelling. This wasn't included in her current assessment.
Individual #2's assessment states she walks with no difficulty and does not require any assistive devises to help her walk. However, her individual plan states "she can walk and run and sometimes has difficulty going up and down stairs, getting in and out of the car and needs assistance, her gait is very unsteady and has a problem walking in a straight line." The agency confirmed during the 1/19/2021 inspection that the latter is true occasionally if there are problems noted with her medications. This was not included in her current assessment. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | Violation 181(e)(9) was reviewed. Individual # 2 had an annual Neurology appointment and the dementia diagnosis was addressed. The Neurologist addressed the issues and the dementia diagnosis was removed from his note and form. A letter was sent to the Primary Care doctor addressing several areas of concern and the dementia and autism diagnosis was addressed and requested to be reviewed and fixed. An appointment is scheduled for 3//2/21 to go over the requested changes, complete an annual physical.
Individual #2 allergy to Cipro is not known to her Legal Guardians and MCOAFA. A formal letter was sent to the doctor that was seen on 4/29/20 addressing the concern. Updated documentation form the doctor correcting the allergy. The letter stated above that was sent to the Primary Care Doctor also addressed the Cipro allergy and the need for clarification to make sure that all documentation is complete and accurate.
Individual #2 Assessment and Individual Plan will be compared and updated according to review of the individuals current needs. The SEEN plan was also update for clear and accurate documentation purposes. Files uploaded will be labeled POC-181e9 |
04/02/2021
| Implemented |
| 6400.181(e)(12) | Individual #1's current, 11/10/2020 assessment does not include recommendations for training or programming. The only recommendation included for services was that she is to continue to attend CARES day program five days per week. The rest of the recommendation sections describes the individual's current skills in certain areas and what staff do to help her on a daily basis.
Individual #2's current 3/4/2020 assessment doesn't include recommendations for areas of training, programming, or services for her. The recommendations listed in her assessment included recommendations for staff to continue to work on certain areas with Individual #2. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Reviewed violation 181(e)(12). Individual #1 and Individual #2 assessments were updated with training/programing/service information. Once all corrections have been made staff will be retrained on the assessments. Assessments will be sent out to the teams, and the documentation will be uploaded for proof that it was corrected will be labeled POC-181e12 |
04/02/2021
| Implemented |
| 6400.181(e)(13)(vi) | Individual #1's 11/10/2020 and 1/11/2019 assessments do not include how much money she is currently able to handle independently. Both assessments state that she can handle small amounts of money but do not clarify the total amount. Both assessments also state that she can carry small amounts of money such as denominations up to $20. However, the assessments do not clarify if the denominations of money she carries added up must be $20 or less or if she can carry multiple bill denominations ($1, $5, $10, $20's) at once that may be more than $20 when totaled. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | Violation 181(e)(13)(vi) was reviewed. Individual #1 was assessed on her knowledge on money, she reviewed what each bill was, identified change, and counted bills. The assessment will be updated for clear documentation purposes. Staff will be retrained on the updated assessment. The updated assessment, training proof, and individual assessment will be submitted. Files uploaded will be labeled POC-181evi |
04/02/2021
| Implemented |
| 6400.212(b) | Individual #1's 9/11/19, 11/6/19, 1/7/20, 2/4/2020, 3/3/2020, 4/30/2020, 6/10/2020, 8/5/2020, and 9/17/2020 medication review appointment summary records include information written on the Altoona Behavioral Health Clinical Summary printed report. The information added in pen onto this form included the reason for prescribing medications, and answers to if medications were reviewed, updated, added, or removed, current problems listed and if any procedures were completed at the appointment. There are no records maintained for who added this information to the physician's forms and when it was added. Staff person #2 confirmed during the inspection that direct support staff working for the agency add information to the forms but the name of the staff making the addition and the date of the addition was not included in the individual's record.
Individual #2's 5/22/2020 physical examination contains information regarding what the physician's recommendations are for further health maintenance needs and the recommended follow up for blood work. However, the information recorded in these sections, was completed by Staff person #2, who did not attend the 5/22/2020 physical examination appointment with the individual. There is no date or initials/signature to indicate the date and person who added said information onto the individual's physical examination record.
Individual #2's sleep chart listed the May 2020 chart had "May" crossed off and "June" written above it. There is no records maintained for the name of the staff person making the entry or when the change was made.
Individual #2's September 2019 medication administration record listed Staff person #4 initialing as administering medication to the individual at 7am and 8am on 9/31/19. This was crossed off with error written above but the name and date of the person making this entry into the record and when, was not documented. | Entries in an individual's record shall be legible, dated and signed by the person making the entry.
| Violation 212(b) was reviewed. Retraining was completed with all staff on the importance of accurate, complete and clear documentation. The review and training included how to sign for added information, submitting for review, MARS documentation, consult form completion, change of appointment, and individual #1 and Individual #2 daily charting records.
A new form for Individual #1 medication review appointments was created and will now be sent ahead of time for review at the appointment. The form will indicate who is filling out the form and the date it was filled out The form will then be signed off by the doctor or CRNP at the appointment for clear documentation purposes.
A letter was sent to Individual #2 Primary Care doctor requesting proper completion of the annual physical and what information was missed or needed to be updated. Files uploaded will be labeled POC-212b |
04/02/2021
| Implemented |
| 6400.34(a) | The Department issued updated, regulatory, individuals' rights effective immediately on 2/3/2020 to inform individuals residing in residential facilities. Individual #1 was not informed of her rights defined in 6400.32(d), (e), (f), (g), (h), (i), (j), (p), (q), (r)(1)-(5), (s)(1)-(3), (t), (u), and (v) during her annual reviews on 12/12/19 and 12/7/2020.
Individual #1's has had a legal guardian since 12/12/19. There are no records maintained that Individual #1's legal guardian was informed of Individual #1's rights and the process to report a rights violation.
The agency did not review individual #2's rights (old or new rights effective 2/3/2020) with her in 2019 or 2020. The individual's rights reviewed with individual #2's guardian on 4/23/19 and 4/7/2020 do not include a review of the above-mentioned specific regulations that were effective immediately on 2/3/2020. The agency has no records maintained of this occurring. | The 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. | Violation 34(a) was reviewed. MOCAFA has created a new Individual Rights Policy to reflect the current policy that was implemented on 2/3/2020. The policy was reviewed by Individual #1 and Individual #2, and both Individual #1 legal guardian and Individuals #2 legal guardian as well. Attachments include the new policy, completed individual rights for both Individuals. Another form was created in the event that the Legal Guardians decline the use of locks on the bedroom doors or keys to the home. Files uploaded will be labeled POC-34a |
03/05/2021
| Implemented |
| 6400.45(c) | At the time of the 1/20/21 annual inspection Individual #1 was allotted and using up to 3 hours of unsupervised time in her home on occasion from September 2019 until current, when her staff and housemates would leave the premises. The individual's individual plan did not include the specific periods of time where the individual is able to be left without direct supervisor as an outcome that required the achievement of a higher level of independence. | 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. | Individual #1 was assessed on her ability to be have alone time. Her team held a meeting to address any areas of concern and to create an outcome to address the individuals current needs. This will be uploaded to view for approval and once approved will be added to the Individual's plans and corrected in all plans for clear documentation purposes. Alone time will also be documented when the Individual choses to stay home and the amount of time. Files uploaded will be labeled POC-45c |
04/02/2021
| Implemented |
| 6400.46(d) | Staff person #1 received training in CPR (Cardio Pulmonary Resuscitation) and AED (Automated External Defibrillator) on 4/8/18 and not again until 9/2/2020 due to COVID-19 pandemic. However, there are no records maintained that stated that his trainings on said dates also included trainings in first aid and Heimlich techniques which are regulatory required. The American Heart Association instructor of the course confirm via letter on 1/25/21 that the training on 9/2/2020 covered the use of personal protective equipment, basic life support CPR, basic life support AED, care of choking for adults, children and infants, and opioid overdose treatment with naloxone. The instructor indicated that Staff person #1 is scheduled for the first aid course on 2/6/21 as this was not covered in the 9/2/2020 training. There are no records maintained that Staff person #1 received training in first aid in 2018, 2019, or 2020. | 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. | Violation 46(d) was reviewed. Staff #1 immediately scheduled First Aid training and it was completed on 2/6/21. The attachments will include a letter from the instructor for verification purposes, the content of the training, training certificate, and proof of payment. Files unloaded will be labeled POC-46d |
03/05/2021
| Implemented |
| 6400.50(a) | Training content for Staff person #1's 9/2/2020 CPR and AED training was not kept. The agency obtained this information from the CPR/AED trainer on 1/26/21 after the Department requested the specific emergency training content that was provided to Staff person #1 on 9/2/2020. | 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. | Retraining on violation 50(a) . Since the inspection Staff #1 was able to complete First Aid training on 2/6/21 and received the content of the training for Staff person #1 file. This content will be attached along with the certification and proof of payment. Uploads will be labeled POC-50a |
03/05/2021
| Implemented |
| 6400.51(b)(5) | Individual #2's physician recorded on the individual's 5/22/2020 physical examination record that the individual's nervous system was abnormal and indicating that the individual's abnormality was Dementia. Additionally, Individual #2's neurologist previously stated on 6/4/19 that she is regularly seen by the neurologist for management of seizure disorder, dementia associated with other underlying disease with behavioral disturbance and bipolar affective disorder with autism. During the 1/21/2021 annual inspection, the home supervisor, Staff person #2, was unaware that the individual's physician and neurologist indicated the individual had Dementia and also reported that all staff providing direct support to Individual #2 were unaware of the individual's diagnosis and how to monitor the individual's dementia. There are no records maintained that the staff providing direct support to Individual #2 were instructed on the specific job skills and knowledge regarding the individual's Dementia diagnosis and how to monitor symptoms. | The orientation must encompass the following areas: Job-related knowledge and skills. | Violation51(b)(5) was reviewed. Individual # 2 was seen on 2/2/21 for her annual Neurology appointment. During this appointment the concern regarding the dementia diagnosis was addressed by individual #2 parents and staff #2. This was removed from the Neurological side. The Neurologist mailed us the corrected form from her appointment that shows no diagnosis of Dementia. A letter was written to Individual #2 Primary Care doctor addressing the information that was placed onto the physical form. This letter was sent by the Program Specialist and addressed several other areas needing fixed as well. Individual #2 will be seen by her primary care physician on 3/2/21 to go over the items of concern and have an annual physical completed. Uploads will be labeled POC-51b5 |
04/02/2021
| Implemented |
| 6400.165(b) | Individual #2's record did not include the current prescriber's medication orders as they are prescribed to Individual #2 to determine what medications she should be administered. There were multiple lists of medications throughout her record that contained varying physician's orders for medications and dosages prescribed to the individual. There are no records maintained that the agency attempted to obtain documentation from the individual's physicians of her current order of medications she was prescribed. Individual #2's medications listed on her 5/22/2020 physical examination record were not the same list of medications and dosages provided by the physician on their appointment summary for 5/22/2020, which also did not match the agency-created medication list of current list of medications, which also did not match the current list of medications recorded on the psychiatrist's medication reviews or the medication labels on the medications at the home.
Individual #1's record did not include a current list of her prescriber's medication orders. The individual's record contained multiple different physician's medication orders throughout the year. There were no records maintained that the individual's medications they were administering to themselves, were current physician's orders. The individual's physician provided identical lists of medications on 5/21/2020 and 12/17/2020 to the home that included orders for multiple creams and medications at specific dosages, that was different from an agency-created list of physician's medication orders from 5/21/2020, and that was also different from the individual's medication reviews completed throughout the year. Staff person #2 reported during the 1/19/2021 inspection that Individual #1 was not applying medicated creams to their person, even though multiple medicated creams were listed on medical appointment summary reports from her physician as recently as 12/17/2020. There are no records maintained that the agency attempted to obtain a current list of physician's medication orders for Individual #1 from September 2019 to current, January 2021. | A prescription order shall be kept current. | Reviewed violation 165b. Individual #1 physician was sent a letter regarding medication changes, new medication lists, and will be seen for annual physical on 3/2/21 due to corrections needing made to several areas on her medical records and physical.
Individual #1 physician was sent a letter from her legal guardian requesting changes and updating her medications. Medications were reviewed on 2/24//21 at her psychiatric appointment. Files will be uploaded to verify the changes, documentation and MAR records. Corrections will be labeled POC-165b |
04/02/2021
| Implemented |
| 6400.165(c) | Individual #2 wasn't administered her Zonisamine 100mg at 5pm on 2/20/2020 and 11/30/2020. Staff did not initial as administering this medication on the individual's medication administration record (mar) and there is no record that the medication was administered.
Individual #2 wasn't administered her Depakote 250mg, Zonisamide 100mg, and Gabapentin 200mg at 5pm on 6/9/2020. The individual's mar was left blank. There are no records to indicate that the individual received the medications.
Individual #2 wasn't administered her multivitamin, Methyl-folate 1000mcg, or Levocarnitine 3ml at 7am on 6/15/2020 as the mar was left blank, without record of the medications being administered.
Staff person #4 initialed as administering Levocarnitine twice to Individual #2 on 10/1/2020, but it is only prescribed to be administered once per day.
Individual #2's 10/5/2020 psychiatric medication review with her physician listed that she was prescribed Zonisamide 50mg. At the time of the 1/19/21 annual inspection, the home has been administering Zonisamide 50mg at noon and 100mg at 8am, 5pm and 8pm since that appointment. There are no records maintained that the agency attempted to clarify the dosage prescribed on 10/5/2020 and how much Zonisamide the home should be administering to the individual.
Individual #2's Depakote 250mg at noon on 11/4/2020 wasn't administered. This was left blank on her mar without explanation for what occurred. | A prescription medication shall be administered as prescribed. | Violation 165c reviewed. Medication documentation guidelines were reviewed, individuals #1 and #2 medications were reviewed, created a new medication error form, change of medication forms, central log form, disposal of medication forms, pill count forms, reviewed who to call in the even of an error on the MAR is found. All staff completed Recognizing and reporting incidents. Also weekly review of MAR will be done for the next three months to verify that the staff had completed the MAR forms correctly and no errors are found. Will submit two full months review for correction purposes. If any errors are found they will be reported appropriately. All forms, training forms and completed MARS will be submitted to show completion as well. Files uploaded are labeled 165c |
04/09/2021
| Implemented |
| 6400.165(f) | Individual #1's written social, emotional and environmental needs plan included as part of the individual's plan, does not include her diagnosis of obsessive compulsive disorder and bipolar disorder, the symptoms she exhibits related to both diagnosis, or a plan to assist her through these symptoms. According to the individual's psychiatric medication reviews from 2019 to December 2020, the individual's prescribing physician has stated the individual has these diagnoses for which they are prescribed psychotropic medications. Additionally, both of the individual's social, emotional and environmental needs plans completed on 1/14/2020 and 1/3/2021 do not include these diagnoses or their symptoms or how to address them. | 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. | Violation reviewed. Individual #1 SEEN Plan was updated with the Bipolar Diagnosis and OCD diagnosis. The assessment, SEEN Plan, and Individual Plans were reviewed to make sure all diagnosis were correct in all areas. A letter was sent by Individual #1 guardian to her Primary Care Doctor to make sure he is aware of the diagnosis as well. Files uploaded will be labeled POC-165f |
04/02/2021
| Implemented |
| 6400.165(g) | Psychiatric medication reviews: Individual #1's medication reviews do not include the need to continue the medications. The individual's prescribing physician does not include this on written documentation at the time of the appointments. Per agency Staff person #2, the need to continue the medications is added on a separate form by Staff person #2 for the individual when she returns home from her appointment, even if Staff person #2 doesn't attend the medication review appointment. The date this information is recorded by agency Staff person #2 is unable to be determined due to the information described in 6400.212(b) of this report.
Individual #1's 11/6/19 medication review did not include the reason for prescribing the medications. Staff person #2 reported she added this information onto the physician's record, and other medication review consultation records, after the 11/6/19 appointment due to no agency staff attending the medication review appointment with the individual. The required information that was missed, was never faxed back to the physician to confirm the reason they are prescribing the medication.
Individual #1's prescribing physician changed the individual's Fluvoxamine Maleate dosage at the individual's 1/7/2020 medication review appointment. However, the prescribing physician did not include a dosage for how to administer the change of medication. On 1/7/2020 the physician wrote: "add Fluvoxamine Maleate 25mg oral tablet, take 1 tablet by mouth in the morning with 50mg tablet and add Fluvoxamine Maleate 50mg tablet, take 1 & 2 tablets, by mouth at night (increased from 75mg at night)". The second order to "take 1 & 2 tablets by mouth at night" is not a definitive dosage the defines how the individual should administer their medication. There are no records maintained to clarify what the physician prescribed and reviewed during the 1/7/2020 appointment. The prescriber recorded that the two new psychotropic medications were added (two different orders for Fluvoxamine Maleate) but also didn't indicate the reason for prescribing them. According to the agency these are prescribed for Anxiety/Mood Disorder/Obsessive Compulsive Disorder (OCD).
Individual #1's 3/31/2020, 4/30/2020, and 6/10/2020 medication reviews completed via conference call did not document the individual's psychotropic medications prescribed, dosages that were reviewed, the reason for prescribing the medications or the need to continue the medications. The medications and dosages reviewed on 4/30/2020 and 6/10/2020 were not obtained in writing form the prescribing physician by the agency until 10/20/2020, but the documentation still didn't include the reason for prescribing medication and need to continue the medications.
Individual #1's 8/5/2020 and 9/17/2020 medication review appointment did not include the need to continue the medication. The medications reviewed and the dosages reviewed during the appointments was not documented in the individual's record until 10/20/2020, when the provider obtained this information from the physician. The physician recorded on their appointment summary records that the individual was seen on 8/5/2020 and 9/17/2020 for management of the individual's bipolar. Agency Staff person #2 added the reason for prescribing the psychotropic medications Fluvoxamine Maleate and Lamictal as "anxiety/mood/ocd" and Lamictal as "anxiety/mood", on 8/5/2020 and 9/17/2020 respectively, sometime after she received this documentation on 10/20/2020. There are no records maintained that the physician reviewed and approved the reason for prescribing the medications after they were added to each form, as she recorded a different reason for the visit on her summary of the appointments.
Individual #1's 12/16/2020 medication review records does not include the medications prescribed, prescribed dosage, the reason for prescribing the medications or the need to continue the medications. The provider indicated this review was held via a zoom conference call due to the COVID-19 pandemic. However, Staff person #2 attending the meeting with the individual and their physician did not record the required information that was reviewed during this visit.
Individual #2's 10/5/2020 psychiatric medication review appointment with her physician listed that she was prescribed Zonisamide 50mg. At the time of the 1/19/21 annual inspection, the home has been administering Zonisamide 50mg at noon and 100mg at 8am, 5pm and 8pm since that appointment. There are no records maintained that the agency attempted to clarify the dosage prescribed on 10/5/2020 and how much Zonisamide the home should be administering to the individual. | 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. | Violation 165(G) was reviewed. A new consult form for Individual #1 was created. This form was filled out ahead of time and dated by staff. It was then sent ahead of time to her prescribing physician for review and during her appointment on 2/24/21. During her zoom appointment on 2/24/2021 the entire progress note was reviewed. We requested that this form be used and signed off from now on by the prescribing physician for the psychiatric consult note. The physician will then sign off on the note once they reviewed and are in agreement with it. Items reviewed included current medication list, the need to continue the medications, symptoms, medical, diagnosis.
Individual #2 medications were updated, diagnosis for medications were confirmed, and Individuals #2 progress note will be sent prior to her April 5, 2021 appointment for review by her physician to complete a review and then sign off on it once in agreement. The progress note will review the correct medications, diagnoses, symptoms, medical information, and the need to continue the medications.
Files uploaded will be labeled POC-165g |
04/19/2021
| Implemented |
| 6400.166(a)(4) | As referenced in 6400.181(e)(5) of this report, Individual #1 was found to be unable to self-administer her medications. The agency did not administer the individual's medication to her or record the requirements defined in 6400.166 at the time of the administration for the individual. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Violation 166a4 was reviewed. Individual #1 had MARS created, staff began administering medications to her. Individual #1 team met and discussed a plan moving forward. Individual #1 self administering needs were assessed, a six month plan for staff to work and go over medication administration needs with the individual in the hopes to have the individuals being able to self administer after that. Plans will be update and staff retrained on all plans. Items uploaded will be labeled POC-166a4 |
04/02/2021
| Implemented |
| 6400.166(a)(7) | Individual #2's August 2020 medication administration record does not include the dose of the individual's Zonisamide medication, as the order copied onto the mar is incomplete. The mar stated "zonisamide 50mg capsule, take 2 capsules by mouth at 8am a(missing information) 5Pm and at bedtime take 1 capsule by mouth at 12pm." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Reviewed violation 166(a)(7) Documentation was corrected and will be shown for the February 2021 MAR record. All staff were retrained on documentation guidelines, transferring medication information to MARS, and proper completion. Medications will be compared to the labels after transferred to the MARS and form will be uploaded for review. Medication error forms, all staff completed recognizing and reporting incidents. Files uploaded will be labeled POC-166a7 |
04/02/2021
| Implemented |
| 6400.166(a)(11) | Individual #2's medication administration records do not include the reason for prescribing each medication, next to the medications themselves to be able to distinguish the purpose behind each medication order. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Violation 166(a)(11) was reviewed. Individual #2 MARS were corrected after verification from the CRNP. The diagnosis was added to the February 2021 MARS. The MARS will be uploaded to show that the addition was added. The email will be uploaded showing that the medications prescribed and the reasoning was verified. |
03/12/2021
| Implemented |
| 6400.166(a)(13) | The name and initials of the staff person who administered Individual #2 her Gabapentin 100mg at noon on 5/12/2020 is completely illegible. There are no records clarifying the name and initials of the staff person who administered this medication. The medication record appears to have multiple initials on top of each other along with many circle and swirl marks.
The name and initials of the staff person who administered Individual #2 their Gabapentin 200mg at 5pm on 12/15/2020 is illegible. There are no records clarifying the name and initials of the staff person who administered this medication. The medication record appears to have many circles and swirl marks in the square to document who administered this medication.
The medication records for Individual #2 are very sloppy and hard to distinguish who is administering medications from September 2019 to current, January 2021. Staff person #4's initials look like LP, LD, CD, and CP on numerous occasions. Staff person #5's initials looks like U, V, L, and W on various occasions. A lot of the staff's initials are overlapping and running into other squares to document administration and it's difficult to distinguish who administered medications and when. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Medication documentation guidelines were reviewed, individuals #1 and #2 medications were reviewed, documentation training, central log form, med error form, who to call in the even of an error on the MAR is found. All staff completed Recognizing and reporting incidents. Also weekly review of MAR will be done for the next three months to verify that the staff had completed the MAR forms correctly and no errors are found. Two months of completion will be uploaded If any errors are found they will be reported appropriately. All forms, training forms and completed MARS will be submitted to show completion as well. These will be labeled POC-166a13 |
04/02/2021
| Implemented |
| 6400.166(b) | Individual #2's 7/9/2020 medication record states that she was on leave from program for her 5pm administration of medications. Staff recorded that her 5pm doses of Depakote 250mg and 100mg Zonisamide were not administered due to being out of program. However, Staff person #6 initialed Individual #2's medication record as administering the individual their 200mg of Gabapentin at 5pm on 7/9/2020. This administration didn't occur as the individual was out of program, but the staff initialed the record as if the individual received the medication. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Violation 166(b) was reviewed. Medication documentation guidelines were reviewed, individuals #1 and #2 medications were reviewed, medication error form, central log form, disposal of medication forms, pill count forms, reviewed who to call in the even of an error on the MAR is found. All staff completed Recognizing and reporting incidents. Also weekly review of MAR will be done for the next three months to verify that the staff had completed the MAR forms correctly and no errors are found. Two full months of reviews will be uploaded. If any errors are found they will be reported appropriately. All forms, training forms and completed MARS will be submitted to show completion as well. |
04/02/2021
| Implemented |
| 6400.167(b) | Individual #2 wasn't administered her Zonisamine 100mg at 5pm on 2/20/2020, 6/9/2020, 11/30/2020, wasn't administered her Depakote 250mg and Gabapentin 200mg at 5pm on 6/9/2020, was administered her Levocarnitine twice on 10/1/2020 instead of once per day as ordered, and wasn't administered her Depakote 250mg at noon on 11/4/2020. The documentation of the medication errors, the follow up action taken and the prescriber's response to the medication errors were not kept in the individual's record, or reported to the department. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | Violation 167(b) was reviewed. Medication documentation guidelines were reviewed, individuals #1 and #2 medications were reviewed, medication error form, change of medication forms, central log form, disposal of medication forms, pill count forms, reviewed who to call in the even of an error on the MAR is found. All staff completed Recognizing and reporting incidents. Also weekly review of MAR will be done for the next three months to verify that the staff had completed the MAR forms correctly and no errors are found. Two full months will be uploaded to view. If any errors are found they will be reported appropriately. All forms, training forms and completed MARS will be submitted to show completion as well. Files uploaded will be labeled POC-167b |
04/02/2021
| Implemented |
| 6400.169(a) | Staff person #2 was certified to administer medications (by Staff person #3) on 1/5/2019 and not again until 2/14/2020, outside the annual time frame requirement. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Violation 169(a) was reviewed. Staff #2 Annual medication packet was due to be finalized by 2/14/21. This packet was completed on time and will be attached to show completion within the time frame. Another Medication Administration packet due date form was created to avoid future lapses in training. |
02/26/2021
| Implemented |
| 6400.181(f) | There are no records maintained that Individual #1's behavior support person was provided a copy of the individual's 11/10/2020 assessment. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Retraining on the violation 181(f). A new cover letter was composed and Individual #1 Behavior Support Specialist was added to correct the error. The Behavior Specialist was included in all updated and corrected plans and cover letters attached to show the corrected areas. |
03/01/2021
| Implemented |
| 6400.186 | Individual #1's Individual Support Plan (ISP) and 2019 and 2020 assessments do not include a specific amount of money that the individual can carry on their person independently. The individual does carry money on her person frequently to deliver to her day program for them to hold when they have certain activities and outings planned. Examples of when this occurred is when the individual carried $30 with her to her day program on 10/13/2020 and $20 with her on 8/11/2020.
Individual #1's ISP states that she saw a physician in the sleep lab on 5/1/19 but the physicians were unable to get readings on her sleep due to her old c-pap machine. The ISP states she was to be seen again in December to recheck the machine and her sleep. There are no medical records maintained that she returned to the sleep lab as ordered in December 2019.
Individual #1's ISP states they could use up to 3 hours of unsupervised time at home when staff and housemate left the premises. Per agency Staff person #2, this was utilized throughout the year. There are no records maintained of the times she used her unsupervised time and the amount of time was used, each time it was used.
Individual #1's ISP states that she has a SEEN plan in place that residential and day program staff are to implement. According to Individual #1's 1/14/2020 SEEN plan, the individual's behavior support data and sleep charts are compiled and reviewed at the individual's psychiatric appointments with her physician at least every 3 months or as needed. There are no records to show that this information was reviewed with the individual's physician at said appointments from September 2019 to present, January 2021.
Individual #1's 1/14/2020 and 1/3/2021 SEEN plans state that if the individual is experiencing any of the symptoms described in her plans, staff are to: 1) offer her the change to be away from other or a group of people, 2) offer her the opportunity to change the current activity, 3) monitor her symptoms and document any changes; report changes or concerns to team leader, 4) share all documented information with the individual's prescribing physician, and 5) help her set limits or boundaries within her daily routine. Throughout the year the agency has recorded, by check marks or staff initials next to specific symptoms on a behavior chart, that some form of that symptoms described in her SEEN plan occurred. The behaviors recorded occurred a few times a month to almost daily some months from September 2019 to November 2020. There are no records to indicate that numbers 1-5 described above were completed for every recorded behavior on the individual's behavior chart. The behavior charts also do not define what a check mark or staff initials mean, when this was recorded next to behaviors. There are no records maintained of the behavior event being described in detail.
Individual #2's 3/4/2020 and 3/10/19 assessments state that the individual's rights and responsibilities are maintained by reviewing them with her annually or sooner if needed. As described in 6400.34(a) of this report, there are no records maintained that indicate individual #2's rights and responsibilities were reviewed with her on an annual basis, or at all.
Individual #2's 2019 and 2020 assessments (and 2019, 2020, and 2021 SEEN plans) state that her sleep is tracked on sleep charts to track her mental health concerns. The following are examples of then her sleep was not tracked. Her August 2020 sleep chart appears to have a liquid spilled on the form making it illegible to determine what was tracked for the month; August 28th and 31st of 2020 appear to be blank without anything monitored from approximately 12am to 8:30am both days. July 31st sleep chart was blank from 7:30am to midnight with no records of sleep or awake being monitored/tracked. Her sleep chart is blank from 7/28/2020 from 7:30pm-11pm, 7/29/2020 from 7:30pm-9pm, and 7/30/2020 from 9pm-11pm. Her sleep chart for May does not indicate a year it was completed with no records maintained for when it was completed. Her sleep chart for April 2020 included a key at the bottom that stated if she was sleeping staff are to put an s in the box, if she wakes for the bathroom but goes back to sleep they are to put a b, and if she is sleeping staff are to fill in the square with marker for the time slot she was witnessed being awake. April 2020 had blanks and no monitoring recorded for 4/23/2020 from 11pm to midnight and 4/29/2020 from 9:30pm to 11pm. Staff also recorded numerous times on the log with either an A for awake or S for sleeping in the same box as a they filled in with marker to indicate she was awake. There are no records maintained to clarify if she was sleeping or awake on many of the occasions this occurred in April 2020. March 2020 sleep chart was blank on 3/29/2020 from 9:30pm until 8:30am on 3/30/2020 and from 9:30pm on 3/30/2020 until 9am on 3/31/2020. Her February 2020 sleep chart contained many blanks with no records maintained of monitoring her sleep.
Individual #2's current ISP (and 2019, 2020, 2021 SEEN plans) states due to the amount of medication she takes, she needs to be given drinks often. There are no records maintained that this occurs in the home from provider staff.
Individual #2's current ISP states that staff will brush Individual #2's teeth in the morning and before bed. There are no records maintained that this is completed.
Individual #2's ISP states her complete SEEN plan is on file at her home. According to her 1/19/21, 1/19/2020, and 1/22/19 SEEN plans, all symptoms of the individual's bipolar described in the plan [(1) excessive smiling/laughing/crying/drooling/screaming/running, (2) irritability-the manifest behavior may be physical aggression, verbal aggression, sib, yelling, over-arousal, property damage, elopement, (3) psychomotor agitation- inability or difficulty siting still, walking, rocking, swaying (or any movement) performed with speed or driven ness, (4) pressured speech- any incrased in rate, volume, or quantity of speech or vocalizations, (5) excessive drive- the individual pursues activities, especially favored ones, with excessive energy and zeal. Often called "lots of wanna", (6) distractibility, (7) increased/decreased sleep or fatigue] will be documented by all support staff on daily symptom charts. There are no records of daily symptoms charts provided to the Department.
Additionally, the individual's SEEN plans also state that her daily symptom charts and sleep charts are reviewed with her psychiatrist at least every 3 months or more frequently if needed during the individual's psychotropic medication reviews. According to the individual's 3/2/2020, 5/29/2020, 7/3/2020, and 10/5/2020 psychotropic medication reviews, all symptoms of her bipolar described in 1-7 above, were not reviewed with her physician at every medication review appointment. | The home shall implement the individual plan, including revisions. | Violation 186 was reviewed. Individual #1 was evaluated for her skills with identifying money. The assessment will be included and her plans will be update for clear documentation. The sleep lab that Individual #1 goes to was able to provided us with her last progress note showing the need to continue to use her BiPap machine. Staff were retrained on an update chart with adding a refusal of usage, and a general review of usage and the SO Clean machine.
Individual # 1 was reevaluate on her ability to stay home alone, evacuation during a fire drill, and emergency numbers. Her team held a meeting to discuss outcomes and a plan to assess her needs moving forward in the even she is unable to be alone. A new chart was created instead of using her daily notes for documentation purposes.
Individual # 1 psychiatric progress note was created to reflect all behavior symptoms on her behavior charts. These were reviewed at her appointment on 2/24/21 and is a place showing they were reviewed at the appointment. The blank progress note and a completed note will be update.
Individual #1 and #2 Individual rights were reviewed, updated to match current policy.
Individual #2 sleep charts were corrected, staff were retrained. A new dental chart was created instead of using the daily notes for documentation purposes, a dental plan was created and plans were update. Individual #2 was seen for a dental examination on 1/25/21 and these need to brush and dental needs were addressed. Plans will be update.
Individual #2 symptoms were created into a monitoring chart and how to address them accordingly. Staff will be retrained on the forms and plans.
Individual #2 will be seen by he psychiatrist on April 5, 2021 for her next appointment and documentation will be shown that the sleep charts and behavior charts were reviewed at the appointment. |
04/19/2021
| Implemented |