| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | According to the hospital records, dated 08/30/15, Individual #1 presented with the following injuries: 3 cm partial thickness burn vs. lesion to the left shouldera a bruise to right CVA with mild tenderness at the inferior margin of the ribs, left arm erythema warmth in the left forearm between wrist and the elbow, scattered superficial lesions across left forearm, and superficial abrasion on the right shoulder. Individual #1 was dismissed from the day program on 08/20/2015 and was in the care of Casmir Care until Individual #1's mother discovered the injuries on 08/30/2015.
Staff #1 was aware that numerous staff have engaged in continuous physical abuse of Individual #1.
Staff #4 kicked Individual #1 and hit Individual #1 with a frying pan on the shoulder. Staff #4 hit Individual #1 on the head with a plastic book, pushed Individual #1 into the table, pushed Individual #1 into the wall, and hit Individual #1's arm.
Staff #3 used a belt to hit Individual #1 and strangled Individual #1.
Staff #6 hit Individual #1 in the face with a fist.
Staff #7 yelled, screamed and attempted to knock down Individual #1.
Staff #3 and #4 used intimidation tactics to scare and redirect Individual #1.
Through interviews, it was determined that staff members yell at Individual #2 when the mention of moving to a different location is brought up. Individual #2 is fearful when staff are yelling. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | This violation occurred as a result of direct care staff as well as staff #1 failing to follow through on training on incident management identification and reporting .
As a correction, all direct care staff working at the Residential Site received appropriate disciplinary actions including terminations and suspensions. In addition, all Casmir Cares residential staff has been retained on Incident management identification and reporting by 09/29/2015. The Residential Director and Human Resources Director will ensure that this training remains ongoing.
(The Residential Director is responsible to ensure all staff working in the agency receive training on abuse. The training will be scheduled and conducted by an outside agency within 30 days of receipt of this plan. Training content and a signature sheet will be sent to BHSL within 5 days of completion. The program specialist is responsible to coordinate the training of all staff on all plans relating to the individual served. This training should be a face to face comprehensive training. All staff will be re-trained on the agency's policy on restraints within 30 days of receipt of this plan. The policy and signature pages will be sent to BHSL within 5 days of completion. The training on crisis management will be sent to BHSL including training content and signature pages. All staff in the agency will be trained on the rights of an individual and civil rights within 30 days of receipt of this plan. This will be a face to face training conducted by management staff. Training content and signature pages will be sent to BHSL within 5 days of completion. All staff in the agency will be re-trained on the reporting of incidents and the agency policy on reporting within 30 days of receipt of this plan. Plan content and signature sheets will be sent to BHSl within 5 days of completion. All staff of the agency will receive training on abuse and neglect within 30 days of receipt of this plan of correction. The abuse and neglect training will be conducted by an outside agency. At monthly staff meetings the supervisor will discuss abuse, neglect of Individuals and the importance of reporting abuse or other incidents upon notification. AH 10.26.2015) |
09/29/2015
| Not Implemented |
| 6400.18(c) | Staff #1 was notified of Individual #1's multiple abuse injuries incurred on 08/28/2015. It was not reported in HCSIS until 08/30/2015. | The home shall orally notify the county mental retardation program of the county in which the home is located, the funding agency and the appropriate regional office of mental retardation, within 24 hours after abuse or suspected abuse of an individual or an incident requiring the services of a fire department or law enforcement agency occurs.
| This violation results from staff #1 failing to report individual #1's injuries to her supervisor immediately as required by agency protocol. The incident was promptly reported in hcsis once staff #1's supervisor was informed of the injuries.
As a correction, Staff #1 received appropriate disciplinary action in the form of suspension and then demotion, addition to being retrained like all Residential staff in incident management identification and reporting. The Residential Director and Operations Director will continue to monitor to ensure that the appropriate reporting timelines are kept in accordance with regulations
(The Residential Director is responsible to ensure all staff working in the agency receive training on abuse. The training will be scheduled and conducted by an outside agency within 30 days of receipt of this plan. Training content and a signature sheet will be sent to BHSL within 5 days of completion. The program specialist is responsible to coordinate the training of all staff on all plans relating to the individual served. This training should be a face to face comprehensive training. All staff will be re-trained on the agency's policy on restraints within 30 days of receipt of this plan. The policy and signature pages will be sent to BHSL within 5 days of completion. The training on crisis management will be sent to BHSL including training content and signature pages. All staff in the agency will be trained on the rights of an individual and civil rights within 30 days of receipt of this plan. This will be a face to face training conducted by management staff. Training content and signature pages will be sent to BHSL within 5 days of completion. All staff in the agency will be re-trained on the reporting of incidents and the agency policy on reporting within 30 days of receipt of this plan. Plan content and signature sheets will be sent to BHSl within 5 days of completion. AH 10.26.2015) |
09/14/2015
| Not Implemented |
| 6400.33(a) | Direct care staff reported Individual #1's injuries to the residential supervison, Staff #1. There was no direction given to staff except to document it on an incident form. At no time did staff seek medical attention nor did Staff #1 follow up to ensure Individual #1's health and safety needs were met or care provided for the injuries sustained on 8/28/15. | An individual may not be neglected, abused, mistreated or subjected to corporal punishment. | This violation occurred as a result of direct care staff as well as staff #1 failing to follow through on training on incident management identification and reporting as well as following through with the chain of command.
As a correction, all direct care staff working at the Site as well as staff #1 received appropriate disciplinary actions including terminations, suspensions and demotion. In addition, all Casmir Cares residential staff has been retained on Incident management identification and reporting by 09/29/2015. The Residential Director and Human Resources Director will ensure that this training remains ongoing for current staff as well as incoming staff.
(The Residential Director is responsible to ensure all staff working in the agency receive training on abuse and neglect. The training will be scheduled and conducted by an outside agency within 30 days of receipt of this plan. Training content and a signature sheet will be sent to BHSL within 5 days of completion. The program specialist is responsible to coordinate the training of all staff on all plans relating to the individual served. This training should be a face to face comprehensive training. All staff will be re-trained on the agency's policy on restraints within 30 days of receipt of this plan. The policy and signature pages will be sent to BHSL within 5 days of completion. The training on crisis management will be sent to BHSL including training content and signature pages. All staff in the agency will be trained on the rights of an individual, abuse and neglect within 30 days of receipt of this plan. This training will be conducted directly to all staff by management staff. Training content and signature pages will be sent to BHSL within 5 days of completion. All staff in the agency will be re-trained on the reporting of incidents and the agency policy on reporting within 30 days of receipt of this plan. Plan content and signature sheets will be sent to BHSl within 5 days of completion. At monthly staff meetings the administrator will discuss the importance of treating all Individuals in care and understand that with holding treatment is a form of neglect. AH 10.26.2015) |
09/29/2015
| Not Implemented |
| 6400.44(b)(18) | Through interviews, staff of the home consistently reported not being trained on how to support Individual #1. Staff stated they were told to read the Individual Support Plan (ISP) dated 01/03/2015 which did not include the social, emotional and environmental needs plan, dated 07/13/2015. There is no documentation to indicate that staff received training on this plan. | The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. | Individual #1 joined the agency on 07/13/2015 and at that time, there was limited information on the individual. The Social, emotional and environmental needs plan (SEEP) developed for this individual from his ISP with limited information, was discussed with staff during his initial ISP training on 07/13/2015. However, there is no separate documentation for this SEEP in-servicing.
As a correction, all Residential staff will be retrained in the SEEP of the individuals they work with by the Program Specialist by 11/16/2015. Documentation of this training will be kept. All new hires will be trained in the SEEP of any individual who is prescribed with a medication to treat symptoms of a diagnosed psychiatric illness. In addition, Casmir Care Services has revised it's intake process to ensure that all necessary supports and sufficient information is secured prior to accepting an individual. The Residential Director will ensure compliance.
(The Residential director is responsible to ensure all information regarding an individual's care is received prior to accepting the individual into the program. The residential director is responsible to ensure all staff are trained in all plans relating to that individual. All staff in the agency will be re-trained on all plans associated with the person they work with by 11/26/2015. This training will be a comprehensive training with the program specialist or director. A copy of the training and signature pages will be sent to BHSL within 5 days of completion. Documentation of this training will be kept in the staff's record. All newly hired staff will be trained in all plans relating to the individual prior to working in the home. The residential director will edit the new staff orientation to include training on all plans relating to the individual. The revised orientation packet will be used moving forward. A record review of all individuals in the agency will be completed within 30 days of receipt of this plan to ensure all ISP's include the SEEN plan (if needed) or behavior plan and the people who need to be trained on this plan. AH 10.23.2015) |
11/16/2015
| Not Implemented |
| 6400.144 | Individual #1 received a prescription for an antibiotic on 08/28/2015. The prescription was not filled until 08/31/2015. | 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.
| This violation resulted from the inability of the residential staff to ensure communication with the Residential department to ensure that the script received from the hospital was filled same day. In addition, by the time the appointment was completed, the agency's primary pharmacy had closed and it was already a weekend.
As a correction, Casmir is developing an arrangement with a 24 hour pharmacy as a back up to the agency's primary pharmacy. Usually prescriptions are called in directly to the primary pharmacy, but in addition to this, any prescription that needs to be filled beyond 5 p.m will be sent directly to the 24 hour pharmacy. Physical scripts during regular business hours will continue to be filled at the primary pharmacy however any scripts beyond 5 pm will be filled at the 24 hour pharmacy. Hence,it is now a policy that every accompanying staff must immediately contact the Site supervisor or the medical coordinator with the results or any issues that may arise after every appointment. This communication would include any need for follow-up, new prescription, change of prescription and any other findings. The medical coordinator and residential director will ensure strict compliance.
(The medical coordinator will develop a medical evaluation sheet for staff to utilize when taking an individual to a medical appointment. The medical evaluation sheet will include the reason for the visit, recommended follow up, any changes in medication, new prescriptions, discontinued prescriptions, and a summary of the visit. This medical evaluation sheet will be developed and implemented by 11/26/2015.
the medical evaluation sheet will be sent to the home supervisor for review after a medical appointment. The home supervisor will review and sign. The medical evaluation sheet will be sent to the program specialist for review. The program specialist will review and sign. The sheet will be sent to the medical coordinator for review and and signature. The medical coordinator is responsible to ensure any prescribed medication is received by the pharmacy the same day as ordered. The medical coordinator is responsible to ensure the home has the prescribed medication within 1 day. The home supervisor is responsible to ensure the new medication is written on the medication log immediately after reviewing the medical evaluation sheet. The home supervisor will complete a medication review weekly to ensure the medication listed on the medication log is available in the home. The program specialist will complete a monthly medication review to ensure the medication listed on the medication log is available in the home. AH 10.23.2015)
|
10/02/2015
| Not Implemented |
| 6400.165 | The Inspector arrived at the home at 9:00AM on 09/03/2015. Staff #1 arrived at 9:15AM to dispense medication. The medication administration record for Individual #2 indicated the following medications have a 8:00am administration time: Vistaril 50mg, Topiromte 100mg, Lisinopril 10mg, Amlodipine 10mg, Escitalopram 10mg and Carrington moisture topical cream. | Documentation of medication errors and follow-up action taken shall be kept.
| This violation resulted from the inability of Staff #1 to follow through on the timelines required for medication administration. Staff #1 was only required to dispense medication because all medication certified direct care staff at the Site were placed on administrative leave due to pertinent incident at the Site. However, this is no justification as appropriate medication dispensation arrangement should have been made.
As a correction, an incident report was entered into hcsis for the late administration of the medication as well as staff #1 retrained on medication administration. In addition, It is now a policy of Casmir that any uncertified medication dispensation staff will not be left to work alone at any Residential Site during the 2nd shift (3pm-11p.m). Such staff can only work this shift with a staff who is certified to dispense medication. However, they can be allowed to work overnight shifts (where medication dispensation is not required) or 1st shift (7a.m -3pm) alone provided a staff certified to dispense medication works the overnight shift, and who will be required to dispense medication before they depart the Residential Site. The Residential Director will monitor to ensure compliance to this.
(The residential director is responsible to ensure at least one staff per shift is trained on medication administration. The home supervisor (if med trained) will conduct daily MAR reviews to ensure all medications were administered timely. If the home supervisor is not med trained, the residential director is responsible to ensure daily MAR reviews are conducted by a management staff who is med trained. AH 10.26.2015) |
10/01/2015
| Not Implemented |
| 6400.183(5) | Individual #1's Individual Support Plan, dated 01/03/2015, does not include the social, emotional and environmental needs plan, dated 07/13/2015, and who needs to be trained on the plan. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | This violation resulted from the inability of the program specialist to ensure that the protocol to address the Social, emotional and environmental needs (SEEP) of individual #1 is included in his ISP.
As a correction, all individuals with Casmir Care Services, who has been prescribed a medication to treat symptoms of a diagnosed psychiatric illness has had their SEEP sent to their Supports coordinators to include in their ISP. Going forward, the Program Specialist will ensure that the Supports Coordinators makes the appropriate updates such as the SEEP and who needs to be trained on it,in the ISP as required. Records of all such efforts will also be documented. The Residential director will monitor this process to ensure compliance.
(A record review of all individuals in the agency will be completed within 30 days of receipt of this plan to identify any other records out of compliance with this regulation. Should other records be non-compliant, the program specialist is responsible to notify the Supports Coordinator in writing of the plan that needs updated. The written notification will be kept in the individual's record. The Program specialist will be responsible to ensure all staff members are currently trained on the plan and any new staff members are trained prior to working with individuals. AH 10.26.2015) |
10/02/2015
| Not Implemented |
| 6400.195(a) | There is not a restrictive procedure plan in place for Individual #1 however, staff members are using unauthorized restrictive procedures on Individual #1 in an attempt to control behaviors. Staff #5 physically pressed down on Individual #1's shoulders to force the sitting position. Staff #2 physically held him under the armpits as a method of control. | For each individual for whom restrictive procedures may be used, a restrictive procedure plan shall be written prior to use of restrictive procedures.
| The use of restraints are prohibited at Casmir. The violation is as a result of staff applying unauthorized restrictive procedure on individual #1 in an attempt to control his behaviors which goes against the training they received on incident management identification and reporting.
Casmir has revised its intake process, to ensure that all necessary supports are in place prior to accepting an individual. If at the point of intake or immediately it is determined that a restrictive procedure is necessary to ensure the health and safety of an individual, one will be developed for the individual and the support staff trained accordingly in it. In addition, all Residential staff were retrained on Incident management, identification and reporting as at 09/29/2015.All Residential staff will also be retrained on Crisis management by 11/30/2015 to equip staff with skills necessary to employ in the face of aggression or behavioral emergency with any individual. The Residential, Human Resources and Operations Director will monitor to ensure compliance.
(The Residential Director is responsible to ensure all staff working in the agency receive training on abuse. The training will be scheduled and conducted by an outside agency within 30 days of receipt of this plan. Training content and a signature sheet will be sent to BHSL within 5 days of completion. The program specialist is responsible to coordinate the training of all staff on all plans relating to the individual served. This training should be a face to face comprehensive training. All staff will be re-trained on the agency's policy on restraints within 30 days of reciept of this plan. The policy and signature pages will be sent to BHSL within 5 days of completion. The training on crisis management will be sent to BHSL including training content and signature pages. AH 10.26.2015) |
09/29/2015
| Not Implemented |
| 6400.198 | When Individual #1 exhibited behaviors, Staff #3 beat a frying pan on the counter and Staff #4 used a ladle in a flickering motion in an attempt to redirect Individual #1. | The use of aversive conditioning, defined as the application, contingent upon the exhibition of maladaptive behavior, of startling, painful or noxious stimuli, is prohibited.
| The use of aversive conditioning as a form of restraint is prohibited at Casmir Care Services and is covered under IDD, MH/MR trainings as well as incident management, abuse and neglect identification and reporting training. Hence, this violation is as a result of staff inability to apply essential training received.
As a correction , all staff involved in this violation received appropriate disciplinary actions . In addition, All Casmir Cares Residential staff has been retrained on incident management, reporting and identification as at 09/29/2015. All Residential staff will also receive a retraining in Crisis management by 11/30/2015, where the prohibition of the use of maladaptive behavior will be reiterated. In addition, the agency has revised its Intake process, to ensure that all necessary supports are in place prior to accepting any individual. The Residential, Human Resources and Operations Directors will ensure continuous retraining and re-emphasis on the prohibition of use of all prohibited restraints.
(The Residential Director is responsible to ensure all staff working in the agency receive training on abuse. The training will be scheduled and conducted by an outside agency within 30 days of receipt of this plan. Training content and a signature sheet will be sent to BHSL within 5 days of completion. The program specialist is responsible to coordinate the training of all staff on all plans relating to the individual served. This training should be a face to face comprehensive training. All staff will be re-trained on the agency's policy on restraints within 30 days of reciept of this plan. The policy and signature pages will be sent to BHSL within 5 days of completion. The training on crisis management will be sent to BHSL including training content and signature pages. AH 10.26.2015) |
09/29/2015
| Not Implemented |