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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(15) | REPEAT from 1/3/22 annual inspection and 8/29/22 unannounced monitoring: Individual #1's current, 4/19/23 physical examination record did not include the individual's complete dietary needs or instructions regarding food and medication administration needs. According to the individual's individual support plan, the individual is ordered Level 1 pureed diet with thin liquids, liquids should be presented via a cup, medications should be crushed and pureed. Individual #1 is a choking risk. They are also diagnosed with PICA. The pureed diet should be pudding consistency and free of lumps. The staff are to follow the doctor's recommendations of 5, 8 oz glasses of fluid per day. Staff are required to sit with the individual while eating. The individual's April 2022 physical examination record stated the individual's medications were to be crushed and administered with applesauce.
Individual #1's current physical examination record only lists instructions for medication was to give in applesauce or yogurt, and to puree food. | The physical examination shall include:Special instructions for the individual's diet. | TLC's physical form allowed for the provider to write open ended instructions for dietary recommendations/modifications. It was discovered that physicians would often write N/A and/or not include specific dietary instructions. In addition, the Quality monitoring team was responsible to review all physicals to ensure that all areas had been completed and filled out; this was an error on both the residential manager who ran the appointment and the quality monitor who reviewed the form. TLC contacted the individual's PCP on 6/6/2023 for clarification and thorough instructions regarding the individual's dietary need and medication administration needs. On 6/7/2023, the PCP provided clarification that the individual should be on a ¿Level 1 pureed diet with thin liquids and that thin liquids should be presented via cup.
An ISP change form was submitted on 6/9/2023 to reflect clarification from Annual Physical regarding special instructions for the individual's diet.
TLC modified the Annual Physical Exam Form (see attached Annual Physical Exam Form), to include specific checkboxes for dietary recommendations and limitations. We have included a regular/no limitations option, as well as a recommended option with a prompt to include specific units of intake. We have also separated the diet and diet modifications to prompt physicians to be more thorough and allow for management to ensure that all recommendations are implemented.
In addition, the Annual Physical Exam Form (See attached Annual Physical Exam Form) has been updated to include a section on the bottom to be signed by the Program Specialist that reads: I have reviewed this form and acknowledge it is complete and all recommendations have been implemented and all applicable follow up appointments are scheduled and have been added to the appointment calendar.
Upon completing of Annual Physical, Program Specialist will update Residential Quality Date Monitor which is audited by the end of month by Quality Coordinators.
Program Specialists will complete an audit of all most current Annual Physical Exams for individuals in their service area by September 30, 2023, to ensure that all recommendations are in place (i.e. there are corresponding protocols, trackers, applicable follow-ups) and that all parts of the Annual Physical Exam are aligned with the ISP and Annual Assessment. Any discrepancies will be resolved by completing an addendum to the Annual Assessment and/or submitting an ISP change form. |
09/30/2023
| Implemented |
| 6400.142(e) | REPEAT from 6/21/22 unannounced monitoring: On 10/5/22, Individual #1's dentist stated the individual is to get treatment for radiographs, dental restorations, and cleaning under general anesthesia as there are areas of decay noted. There are no records that the individual's team consulted to get the Individual seen for the issues identified by the individual's dentist on 10/5/22.
Individual #1 did not return to a dentist until 4/10/23. At this time, their dentist noted there is still decay and cavities noted from the previous appointment and new areas needing treatment found today; patient needs to go to York Hospital for treatment. Further recommendations noted were fillings needed at York Hospital after x-rays are taken and treatment plan is updated.
Individual #1 was seen at the York Hospital dental center on 4/27/23 and it was noted there are obvious cavities and the individual needs full mouth rehabilitation performed in an operating room. On 4/27/23 the home did schedule a sedation cleaning and restoration for Individual #1 in the York Hospital for 5/30/2024. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | TLC staff was unable to obtain an appointment with York Hospital for dental treatment and failed to document attempts to obtain appointment until 4/27/23 when rehabilitation work and sedation cleaning was scheduled for 5/30/24. Due to wait times for appointments at this provider, TLC Residential Management received confirmation that Individual #1 is added to a cancellation list in effort to obtain these procedures sooner (see attached Dental Cancellation).
TLC Residential Management immediately received retraining on the importance of maintaining written documentation in the form of collateral notes when making calls with all providers, pharmacies, or applicable natural supports to serve as documentation. |
05/30/2024
| Implemented |
| 6400.144 | REPEAT from 1/3/22 annual inspection and 6/21/22 and 8/29/22 unannounced monitorings: Individual #1's physician had ordered the individual to have at least 40 ounces of fluid per day over the previous year. The individual's individual plan also documented the individuals doctor recommends 40 ounces of fluid per day. The individual has a fluid tracking form and protocol indicating the individual is to drink 40 ounces of fluid daily and staff are to track this. According to the fluid tracking records, there are many days where the amount of fluid the individual drank did not equal 40 ounces and there weren't records produced that additional ounces were offered in attempts to provide the individual with 40 ounces of fluid. There are some days where the fluid was not tracked for the entire day. Examples of the home's failures to provide the individual with the recommend amount of fluid are: 1/12/23 only 16 ounces of fluid was consumed by the individual, 1/30/23 only 16.45 ounces consumed, 2/27/23 only 26.45 ounces consumed, 3/9/23 only 21.45 ounces consumed, for April 2023 only 36.42 ounces was consumed for the month, and from 5/1/23-5/25/23 only 102 ounces consumed.
Individual #1's physician ordered Nutren 2.0 supplement to be administered at 9am and 5pm from September 2022 to April 19, 2023. The home documents the nutritional supplement on the individual's medication administration records (mars). The home was unable to produce any mars for administration of Nutren from 9/1/22 -- 11/30/22.
· Nutren wasn't administered at 9am, per physician's orders, on 12/5/22 (10:17am), 12/7/22 (10:11am), 12/11/22 (10:28am), 12/13/22 (10:34am), 12/14/22 (10:08am), 12/17/22 (2:19pm), 12/20/22 (10:02am), 1/8/23 (12:26pm), 1/9/23 (10:35am), 1/14/23 (10:35am), 1/19/23 (10:04am), not administered 1/23/23 in the morning, and 3/30/23 (11am).
· Nutren wasn't administered at 5pm, per physician's orders, on 12/5/22 (6:03pm), 12/7/22 (8:29pm), 12/10/22 (6:38pm), 12/12/22 (6:02pm), 12/18/22 (3:47pm), 12/19/22 (6:52pm), 12/23/22 (6:44pm), 12/28/22 (6:21pm), 12/29/22 (7:50pm), 12/30/22 (6:33pm), 12/31/22 (6:39pm), 1/4/23 (6:06pm), 16/23 (6:03pm), 1/17/23 (6:55pm), 2/25/23 (8pm), not administered on 2/7/23 in evening, 2/12/23 (9:30pm), 2/16/23 (8:38pm), and 2/27/23 (7:15pm). | 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.
| Individuals Nutren 2.0 physicians order indicated administration time is at 9am and 5pm with a 2-hour window both before and after. On several occasions, staff administered the medication outside of the 2-hour window. Staff did not complete a GER (General Event Report / Incident Report) or contact Incident Management to notify of error. Residential management staff did not indicate an error during weekly medication audits. It was discovered that some staff were utilizing the fluid tracker to document that the Nurten was given while other staff utilized the MAR. This was due to a lack of tracking.
On 4/19/23 the individuals Nutren 2.0 supplement was discontinued by the physician.
As of 6/13/2023, Medication Error(s) Wrong Time EIMs have been entered, the corresponding EIM numbers are 9231252, and 9231289. |
07/07/2023
| Implemented |
| 6400.181(e)(8) | Individual #1's current, 12/29/22 assessment does not assess and include the individual's most updated needs and abilities for evacuating the home during fire drills. According to fire drill records from September 2022 to current, May 2023, the individual has required verbal and physical assistance to evacuate the home. The individual's assessment states they can evacuate the home independently. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | Program Specialist did not utilize ISP or recent fire drill forms to ensure the Annual Assessment did not have contradictory information. The Current Program Specialist complete an addendum to the Annual Assessment that accurately reflects the individual's ability to evacuate during a fire and what their present needs are during fire drills. The Annual Assessment was complete and provided to the team on 6/13/2023. |
06/28/2023
| Implemented |
| 6400.181(e)(9) | Individual #1's current, 12/29/22 assessment does not assess and include the individual's specific dietary needs, or all their medical diagnoses that require assistance and monitoring from agency staff. Individual #1 is prescribed a Level 1 pureed diet with thin liquids. Liquids should be presenting via a cup. Medications should be crushed and pureed. Individual #1 is a choking risk. The pureed diet is to be a pudding consistency and free of lumps. Staff are to follow doctor's recommendations of 5, 8 oz glasses of fluid per day. Staff are required staff assistance when eating. Diagnoses missing from the individual's current assessment are other specified eating disorder, chronic gingivitis, mild dry eyes, ocular allergies, and seizure disorder. The individual also has a restrictive procedure plan for identified restrictions due to behaviors in the home and in the community. The individual's assessment does not include the functional limitations held upon their services from their restrictive procedure plan. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | Program Specialist did not include dietary needs, or a list of current functional and medical limitations in the Annual Assessment. The Current Program Specialist complete an addendum to the Annual Assessment that accurately reflects the individual's dietary needs and a list of their current functional and medical limitations. The Annual Assessment was completed and provided to the team on 6/13/2023. |
06/28/2023
| Implemented |
| 6400.181(e)(13)(ii) | Individual #1's current, 12/29/22 assessment does not assess and include the individual's most recent needs and abilities and progress with communication. The assessment includes contradictory statements about the individual's current abilities. The assessment indicates they make their wants and needs known, usually through gestures, facial expressions, vocalizations, and body language. It also documents Individual #1 needs assistance to communicate when they are not feeling well, and does not include specifics of their gestures, facial expressions, vocalizations and body language. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | Program Specialist did not utilize ISP or Annual Physical to ensure the Annual Assessment did not have contradictory information. The Current Program Specialist complete an addendum to the Annual Assessment that accurately reflects individual's current abilities and needs in regard to motor and communication skills. The Annual Assessment was complete and provided to the team on 6/13/2023. |
06/28/2023
| Implemented |
| 6400.163(g) | Individual #1 had a quarterly Psych Med Review on 9/19/22, 11/16/22, 2/13/23, and 5/23/23. Individual #1's quarterly psychiatric mediation reviews with a licensed physician did not include documentation of all required components of 6400.165(g). The following was noted as missing from the records: reason for prescribing the medications. | Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions. | TLC previously utilized AWARDS/Carasolva as an electronic health record/medication administration system. Appointment forms in AWARDS pre-populated medication information from Carasolva however there was a flaw in the system and AWARDS and Carasolva did not communicate with one another. TLC now uses Therap as an electronic health record/medication administration system and presently utilize an updated Psychotropic Medication Review Form (See Attachment Psychotropic Medication Review Form) at all quarterly appointments which requires provider to include the reason for prescribing the medication, the need to continue the medication, and the necessary dosage.
At the most recent quarterly psych review on 5/16/2023, the provider confirmed both frequency of doses and reason for all prescribed psychotropic medications including PRN Ativan specifically used for medical appointments.
The Psychotropic Medication Review Form has been updated to include a section on the bottom to sign that reads: I have reviewed this form and acknowledge it is complete and all recommendations have been implemented and all applicable follow up appointments are scheduled and have been added to the appointment calendar. |
07/01/2023
| Implemented |
| 6400.165(c) | REPEAT from 1/3/22 annual inspection and 6/21/22 and 8/29/22 unannounced monitorings: Individual #1 is ordered Gavilax powder to be administered Mondays, Wednesdays, and Fridays and to hold for diarrhea. Staff documented the individual had two loose stools at 6:25am and sometime between 8am-4pm on 3/24/23 and one bout of diarrhea at 1:25pm on 3/31/23. However, staff administered the individual's Gavilax at noon on 3/24/23 and 3/31/23. | A prescription medication shall be administered as prescribed. | This occurred due to the design of Bowel Tracking in Therap which did not allow staff to review previous entries to determine if a bowel movement took place. Additionally, not all staff were utilizing the electronic health record (Therap) as some staff were using the former paper tracking's. TLC identified this error and transitioned from using an ISP Goal Tracker to the Health Tracking Forms in Therap which now allows staff to readily view updates within the past 7 days. All paper tracking has been removed from all TLC residences. |
06/28/2023
| Implemented |
| 6400.166(a)(4) | Individual #1's February and March 2023 medication administration records (mars) did not include a list of all prescribed as needed medication that are prescribed and to be available to the individual in the home. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | This occurred because a directive was provided by former Sr Director of Quality to utilize MARs that were developed based upon Medication Administration Training Samples. The MARs did not include the regulatory required PRN section. TLC recognized this discrepancy and implemented the use of paper MARs obtained from Therap beginning April 1, 2023. On May 1, 2023, TLC transitioned to our new pharmacy, Alco, and we began using their paper MARs which includes all components of 6400.166. |
06/28/2023
| Implemented |
| 6400.166(a)(6) | Individual #1's physician orders the individual's medications to be crushed and mixed with applesauce or yogurt. The individual's May 2023 medication administration records (mars) do not include this order for the individual's medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | When TLC transitioned to Alco MARs, special instructions were not included that medication should be crushed but instead said they needed to be taken in food. TLC will complete an audit of MARs by July 1, 2023, to ensure special instructions are present and accurate on all MARs. |
06/28/2023
| Implemented |
| 6400.166(a)(7) | Individual #1 was administered Lorazepam on 4/10/23 and 4/11/23 prior to a medical appointment for anxiety. The dosage that was administered each time was not documented on the medication administration records (mars). | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | This occurred during the transition between Good Day Pharmacy and Alco Pharmacy when paper MARs were in use. TLC failed to provide training to staff completing paper version of PRN MARs on the necessity of including dose of medication administered. TLC has completed their transition to electronic medication administration documentation via Therap effective June 1, 2023. |
08/01/2023
| Implemented |
| 6400.166(a)(12) | Individual #1's May 2023 medication administration record does not record the time of administration of Gavilax powder on Mondays, Wednesdays, and Fridays. The record only states, "3x a week" in the field to document the time of administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | The individual's Gavilax powder did not indicate a specific time to administer only 3x a week. TLC staff failed to identify this in Weekly Medication Audits. The individual's Program Manager received written confirmation for the medication to be administered Monday, Wednesday and Friday at Noon. This has been corrected for the individual's June 2023 MAR.
The individual's prescribed toothpaste did not indicate specific times for AM and PM administration. On 6/8/2023, Program Manager received written confirmation from the individual's prescribing dentist that reads: "Prevident 5000 Booster Plus-Fruitastic prescription instructions: Use daily for toothbrushing. Put a pea size amount on the toothbrush, 2 times a day, in the morning between 8am and 10am, and in the evening, between 7pm and 9pm, spit afterwards. If patient cannot spit, no harm in swallowing if it is a pea size amount on the toothbrush." |
06/28/2023
| Implemented |
| 6400.186 | REPEAT from 6/21/22 and 8/29/22 unannounced monitorings: Individual #1's current individual plan states that there is plexiglass over the television in the home for safety purposes. During the 5/24/23 inspection of the home, the plexiglass was not placed over the television in the home but was placed below the television. | The home shall implement the individual plan, including revisions. | A plexiglass covering has been installed over the cable box due to the individual breaking the cable box on multiple occasions. When this information was added to the individual's ISP, the wording noted the plexiglass covered the television which is inaccurate as the individual has not attempted to destroy the television. This discrepancy was not caught by TLC staff. On 5/25/2023 Program Specialist submit an ISP change form to Supports Coordinator to resolve the discrepancy; by end of day on 5/25/2023, the ISP was updated. |
09/30/2023
| Implemented |
| 6400.213(1)(i) | Individual #1's record does not include their religious affiliation. Their record stated their affiliation was other but did not define other. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The individual's face sheet listed "other" as their religious affiliation with no description as to what "other" entails. This occurred because of a formatting issue with Therap. When this was discovered on 5/25/2023, Director of Residential was able to resolve formatting issues in Therap so all fields appear on face sheet. The individual's religious affiliation reads as non-denominational on their face sheet. |
07/01/2023
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Typical Life Corporation (TLC) created a detrimental environment where punishment and seclusion were used as tools to control individuals' behavior and dangerous conditions conducive to severe bodily injury were established as evidenced by the following:
Use of prohibited procedures. On numerous occasions, Individual #1, Individual #2, and Individual #3 were sent to their rooms as punishment or secluded within their home as evidenced by the following events:
· On 1/27/21, 3/3/21 and 3/19/21. staff #2 and staff #18 documented in progress notes that Individual #1 was "redirected to [their] room" as a punishment for behaviors. In all 3 instances, staff documented that Individual #1 was pinching or grabbing at staff, and the individual was redirected to their room as punishment for these behaviors.
· Between 1/1/21 and 4/27/21 staff #3 noted in progress notes that Individual #2 was "redirected to [their] room" for walking around the home. In all instances, staff #3 documented that Individual #2 was sent to their room as punishment for walking around the home.
· Between 1/1/21 and 4/27/21 staff #3 noted in daily progress notes that Individual #3 was "redirected to [their] room", isolated from others in the front room, or sent to the couch as punishment for behaviors. Staff #3 documented that Individual #3 was sent to their room or another location in the home because of behaviors such as disrespect to staff, refusing to use the restroom, or attempted to steal food. On 10 of these occasions, staff #3 documented that the individual was not allowed to leave the area that staff redirected the individual to until staff gave verbal permission.
Punishing an individual for exhibiting behaviors and/or secluding individuals to portions of the home with verbal direction to stay put until otherwise told is prohibited and constitutes mistreatment.
Unauthorized use of restraints. Individual #2 currently has a suprapubic catheter that requires changing every 2 weeks by a VNA nurse. Numerous staff reported that they have assisted in or witnessed staff member's restraining individual #2 so that the nurse can complete catheter changes. According to the staff, one staff member will hold Individual #2's shoulders or chest while the second staff member will hold the individual's legs. The unauthorized use of restrictive procedures by untrained staff members creates an unsafe environment, violates Individual #2's rights, and constitutes mistreatment.
Failure to properly train staff member/supply vital medications -- Individual #1 has grand mal seizures on a frequent basis. Individual #1 wears a helmet most hours of the day and has a VNS magnet device for staff to treat seizures. Individual #1 has a PRN prescription for rectal diazepam to be administered if the individual has a cluster seizure lasting longer than 5 minutes, more than 2 cluster seizures in 24 hours, or a single seizure lasting longer than 3 minutes. Individual #1 has resided in this home since 5/5/13. As of 4/30/21, staff members working in Individual #1's home were not trained in the administration of diazepam. Untrained staff administered this medication 5 times between 1/1/21 and 4/26/21. Furthermore, this medication is not made available when the staff and individual are participating in community activities.
Failure to ensure staff members are trained by a medical professional before administering rectal medications and failure to ensure critical medications are always available to the person create perilous conditions such that a person requiring a critical medication cannot receive it immediately when required or may be severely harmed during administration. | 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. | During weekly supervisions with the Associate Directors of Service (ADOS), the Director of Services (DOS) will ensure training is provided to new and existing staff. The training shall include the individual Health and Safety, Individual Plan, and Behavior Plan, as applicable, to guarantee the residents are free of physical, mental, verbal, and punishment, mental and physical neglect, and involuntary seclusion. The Associate Directors will document the training of staff on the weekly supervision report. In addition, the Associate Directors will ensure staff document their training in AWARDS by signing the training logs at the beginning of scheduled training. In addition, the ADOS, numerous staff and the Program Manager are no longer with the company. Training on individual rights has taken place and additional training on reporting of incidents has taken place. The Clinical ADOSs in every home in TLC's organization is reviewing, editing and working with local county representatives to amend Health and Safety Plans and ISPs so they are congruent. Training records for staff on documents related to people we support are to be not just read, but reviewed with staff members to make sure there is an understanding of expectations for staff members for each person supported by the organization |
08/13/2021
| Not Implemented |
| 6400.144 | Individual #1 has a PRN prescription for rectal diazepam. This medication is to be administered if the individual has a cluster seizure lasting longer than 5 minutes, more than 2 cluster seizures in 24 hours, or a single seizure lasting longer than 3 minutes. Individual #1 participates in outings outside of the home. Typical Life Corporation does not take the medication when Individual #1 leaves the home, putting Individual #1 at risk of harm if a seizure requiring this medication were to occur.
Individual #1 is on a medically ordered 2000 calorie, low sugar diet as individual is diabetic. There have been instances where staff person #2 will order food to the home that does not meet Individual #1's diet recommendations and share this food with Individual #1. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Staff and management have been relieved of their positions, training has taken place, staff has been made aware of the needs and proper use of the device and the necessity of the medication being available. The RN has provide appropriate training and the CADOS has been made aware that new staff must have this professionally led training before working with individuals with specific, possibly unique medication needs |
10/30/2021
| Not Implemented |
| 6400.18(a)(4) | Staff person #1 was alerted of an Adult Protective Services Report of Need for Individual #1 - #3 at the residence on 4/23/21 at 9:22am via e-mail. Staff person #1 documented in progress notes for Individual #1-#3 that they spoke to Adult Protective Services regarding the Report of Need at 10:25am on 4/23/21. The incidents reported were not entered in the Enterprise Incident Management system until 4/26/21 beginning at 3:56pm. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Abuse, including abuse to a individual by another client.
| The Quality Assistant and the Director of Compliance trained the ADOS staff and the Director of Residential Services on the regulations regarding reporting of incidents. It is the responsibility pending assigned training by the Education Coordinator to inform and track a conversation/training in each house explaining the process, the time constraints and the expectations that everyone has a responsibility to report incidents, when they are seen. |
11/30/2021
| Not Implemented |
| 6400.18(f) | Staff person #2 and Staff Person #3 were identified as targets of suspected abuse in incidents reported to Typical Life Corporation by Adult Protective Services on 4/23/21. Staff #2 and #3 were not separated from Individual #1 - #3, identified in the incident as victims of suspected abuse, until 4/26/21. | The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident. | Staff and management have been relieved of their positions, training has taken place, staff has been made aware of the needs and proper use of the device and the necessity of the medication being available. The RN has provide appropriate training and the CADOS has been made aware that new staff must have this professionally led training before working with individuals with specific, possibly unique medication needs Specific training has been developed and all ADOS personnel have been trained on appropriate reporting. |
01/31/2022
| Not Implemented |
| 6400.18(g) | Staff person #1 was made aware of an incident in the home by Adult Protective Services on 4/23/21 at 9:22am. A certified investigator was not assigned to investigate this incident until 11:40am on 4/26/21. | The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person. | Staff and management have been relieved of their positions, training has taken place, staff has been made aware of the needs and proper use of the device and the necessity of the medication being available. The RN has provide appropriate training and the CADOS has been made aware that new staff must have this professionally led training before working with individuals with specific, possibly unique medication needs Specific training has been developed and all ADOS personnel have been trained on appropriate reporting. |
01/31/2022
| Not Implemented |
| 6400.32(c) | On numerous occasions, Individual #1, Individual #2, and Individual #3 were sent to their rooms as punishment or secluded within their home as evidenced by the following events:
· On 1/27/21, 3/3/21 and 3/19/21, staff #2 and staff #18 documented in progress notes that Individual #1 was "redirected to [their] room" as a punishment for behaviors. In all 3 instances, staff documented that Individual #1 was pinching or grabbing at staff, and the individual was redirected to their room as punishment for these behaviors.
· Between 1/1/21 and 4/27/21 staff #3 noted in progress notes that Individual #2 was "redirected to [their] room" for walking around the home. In all instances, staff #3 documented that Individual #2 was sent to their room as punishment for walking around the home.
· Between 1/1/21 and 4/27/21 staff #3 noted in daily progress notes that Individual #3 was "redirected to [their] room", isolated from others in the front room, or sent to the couch as punishment for behaviors. Staff #3 documented that Individual #3 was sent to their room or another location in the home because of behaviors such as disrespect to staff, refusing to use the restroom, or attempting to steal food. On 10 of these occasions, staff #3 documented that the individual was not allowed to leave the area that staff redirected the individual to until staff gave verbal permission.
Punishing an individual for exhibiting behaviors and/or secluding individuals to portions of the home with verbal direction to stay put until otherwise told is prohibited and constitutes mistreatment.
Individual #2 currently has a suprapubic catheter that requires changing every 2 weeks by a VNA nurse. Numerous staff reported that they have assisted in or witnessed staff member's restraining individual #2 so that the nurse can complete catheter changes. According to the staff, one staff member will hold Individual #2's shoulders or chest while the second staff member will hold the individual's legs. The unauthorized use of restrictive procedures by untrained staff members creates an unsafe environment, violates Individual #2's rights, and constitutes mistreatment. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | During weekly supervisions with the Associate Directors of Service (ADOS), the Director of Services (DOS) will ensure training is provided to new and existing staff. The training shall include the individuals Health and Safety, Individual Plan, and Behavior Plan, as applicable, to guarantee the residents are free of physical, mental, verbal, and punishment, mental and physical neglect, and involuntary seclusion. The Associate Directors will document the training of staff on the weekly supervision report. In addition, the Associate Directors will ensure staff document their training in AWARDS by signing the training logs at the beginning of scheduled training. In addition, the ADOS, numerous staff and the Program Manager are no longer with the company. Training on individual rights has taken place and additional training on reporting of incidents has taken place. The Clinical ADOSs in every home in TLC's organization is reviewing, editing and working with local county representatives to amend Health and Safety Plans and ISPs so they are congruent. Training records for staff on documents related to people we support are to be not just read, but reviewed with staff members to make sure there is an understanding of expectations for staff members for each person supported by the organization |
05/28/2021
| Not Implemented |
| 6400.32(d) | The events and subsequent punitive actions and/or seclusion, dictated by Typical Life Corporation staff members, described in 6400.32(c) do not support or promote an individual's right to be treated with dignity and respect. | An individual shall be treated with dignity and respect. | During weekly supervisions with the Associate Directors of Service (ADOS), the Director of Services (DOS) will ensure training is provided to new and existing staff. The training shall include the individuals Health and Safety, Individual Plan, and Behavior Plan, as applicable, to guarantee the residents are free of physical, mental, verbal, and punishment, mental and physical neglect, and involuntary seclusion. The Associate Directors will document the training of staff on the weekly supervision report. In addition, the Associate Directors will ensure staff document their training in AWARDS by signing the training logs at the beginning of scheduled training. In addition, the ADOS, numerous staff and the Program Manager are no longer with the company. Training on individual rights has taken place and additional training on reporting of incidents has taken place. The Clinical ADOSs in every home in TLC's organization is reviewing, editing and working with local county representatives to amend Health and Safety Plans and ISPs so they are congruent. Training records for staff on documents related to people we support are to be not just read, but reviewed with staff members to make sure there is an understanding of expectations for staff members for each person supported by the organization |
10/30/2021
| Not Implemented |
| 6400.45(d) | Individual #1 requires 1:1 supervision during daylight hours due to the regular occurrence of seizures. There have been numerous occasions where the staff member assigned to Individual #1's care has left individual #1 alone for 10-15 minutes at a time to assist with Individual #2's catheter change. Staff #9 reported that they witnessed this failure to provide required supervision at least one time in April 2021. | The staff qualifications and staff ratio as specified in the individual plan shall be implemented as written, including when the staff ratio is greater than required under subsections (a), (b) and (c ). | The Operational and Clinical ADOS, both newly assigned to this area, have trained people on the different plans and set specific levels of expectations for staff members, including medications, safety plans, ISPs and any Behavioral Plans |
10/30/2021
| Not Implemented |
| 6400.51(b)(5) | Typical Life Corporation could not provide any evidence to the Department to demonstrate that Staff #2 and #3 were trained on the health and safety plans and individual plans for Individual #1-#3 as part of their orientation prior to working with these individuals.
Typical Life Corporation could not provide any evidence to the Department to demonstrate that Staff #5, #6, #8, #9 and #10 were trained in the health and safety plans or ISPs for individual #1 - #3.
Typical Life Corporation could not provide any evidence to the Department to demonstrate that staff #4 was trained in the health and safety plans for individual #1 and #2.
Typical Life Corporation could not provide any evidence to the Department to demonstrate that staff #7 was trained in the ISPs for individual #1 - #3. | The orientation must encompass the following areas: Job-related knowledge and skills. | Retrieving data. Wait a few seconds and try to During weekly supervisions with the Associate Directors of Service (ADOS), the Director of Services (DOS) will ensure training is provided to new and existing staff. The training shall include the individuals Health and Safety, Individual Plan, and Behavior Plan, as applicable, to guarantee the residents are free of physical, mental, verbal, and punishment, mental and physical neglect, and involuntary seclusion. The Associate Directors will document the training of staff on the weekly supervision report. In addition, the Associate Directors will ensure staff document their training in AWARDS by signing the training logs at the beginning of scheduled training. In addition, the ADOS, numerous staff and the Program Manager are no longer with the company. Training on individual rights has taken place and additional training on reporting of incidents has taken place. The Clinical ADOSs in every home in TLC's organization is reviewing, editing and working with local county representatives to amend Health and Safety Plans and ISPs so they are congruent. Training records for staff on documents related to people we support are to be not just read, but reviewed with staff members to make sure there is an understanding of expectations for staff members for each person supported by the organization. Each CADOS will provide a training log for staff indicating their retraining by July 31, 2021. |
11/30/2021
| Not Implemented |
| 6400.162(a) | Individual #1 is prescribed rectal diazepam for cluster seizures lasting longer than 5 minutes, more than 2 cluster seizures in 24 hours, or a single seizure lasting longer than 3 minutes. Staff member #11, the former Assistant Director of Operations for the residence, reported to the Department on 4/30/21 that there were no staff working in the home who have been trained by a medical professional on administering this medication. Furthermore, Typical Life Corporation could not provide any evidence to demonstrate that the staff members working in this home were trained by a medical professional in the administration of rectal diazepam. Individual #1 required this medication 5 times between 1/1/21 and 4/26/21. Each time it was administered by staff who were not trained in its administration. | A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication. | Numerous staff, the PM and the ADOS were relieved of their employment. The RN provided in person training to all staff members during the departmental investigation. |
07/30/2021
| Not Implemented |
| 6400.165(c) | Individual #2 is prescribed a 1 mg tablet of Lorazepam 30 minutes before catheter changes. On 11/27/20, staff person #3 administered ½ tablet, .5mg, of Lorazepam before Individual #2's catheter change.
On 1/7/21 and 4/22/21, Individual #2 received catheter changes. Individual #2 was not administered the prescribed dose of Lorazepam. | A prescription medication shall be administered as prescribed. | Numerous staff, the PM and the ADOS were relieved of their employment. TLC has undertaken a retraining of everyone in the organization providing direct support in medication administration. This is being accomplished with a certified trainer who established methodologies of training and record keeping at another provider This process began during the inspection and will be completed by September 1, 2021. The staff were trained over three sessions as this retraining of all TLC personnel was undertaken. The OADOS is responsible for staffing the delivery of Medications by only trained staff. In most cases until the staff were trained and observations were made (4) one person was going from location to location to deliver meds. This happened at Oakleigh and other residences, including other facilities. As of today, over half of the necessary staff have been trained and just slightly less than half have done the observations necessary according to the ODP training. By the end of the next week, the expectation is to be at 60%. With 20 open slots each week, TLC does about 10% of their work population weekly. It is the intention of HR and leadership, to not allow people to work until they are trained after September 1, 2021. The Education Coordinator is managing the list of trained personnel. I am expecting an up to date list on July 9 and can provide to the Dept. |
09/01/2021
| Not Implemented |
| 6400.169(a) | Staff persons #2-#10, and #12-#24 administered medications between 11/1/2020 and 5/12/2021. Typical Life Corporation could not provide evidence that these staff members received the Department's medication administration training. | 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). | TLC has undertaken a retraining of everyone in the organization providing direct support in medication administration. This is being accomplished with a certified trainer who established methodologies of training and record keeping at another provider This process began during the inspection and will be completed by September 1, 2021. |
09/01/2021
| Not Implemented |
| 6400.186 | Individual #1 requires 1:1 supervision during daylight hours due to the regular occurrence of seizures. There have been numerous occasions where the staff member assigned to Individual #1's care has left individual #1 alone for 10-15 minutes at a time to assist with Individual #2's catheter change. Staff #9 reported that they witnessed this failure to provide required supervision at least one time in April 2021
As referenced in 6400.32(c), Individual #1-#3 are frequently sent to their rooms or secluded within their home as punishment for behaviors. If Individual #1 is presenting behaviors, staff are to ensure that all the individual's physical needs are met and then direct Individual #1 to another activity, such as feeding the fish, going for a walk in the community, watching a television show, or shaking a water bottle for self-stimulation. If Individual #2 is presenting behaviors, staff are to engage the individual in another activity, such as taking a walk, having a snack, listening to music, or watching television. If Individual #3 is presenting behaviors, staff are directed to "ignore the behavior but not [the individual]." | The home shall implement the individual plan, including revisions. | The Operational and Clinical ADOS, both newly assigned to this area, have trained people on the different plans and set specific levels of expectations for staff members, including medications needed, ISPs, Health and Safety Plans and any applicable Behavioral Plans |
11/30/2021
| Not Implemented |
| 6400.193(a) | On numerous occasions, Individual #1, Individual #2, and Individual #3 were sent to their rooms as punishment or secluded within their home as evidenced by the following events:
· On 1/27/21, 3/3/21 and 3/19/21. staff #2 and staff #18 documented in progress notes that Individual #1 was "redirected to [their] room" as a punishment for behaviors. In all 3 instances, staff documented that Individual #1 was pinching or grabbing at staff, and the individual was redirected to their room as punishment for these behaviors.
· Between 1/1/21 and 4/27/21 staff #3 noted in progress notes that Individual #2 was "redirected to [their] room" for walking around the home. In all instances, staff #3 documented that Individual #2 was sent to their room as punishment for walking around the home.
· Between 1/1/21 and 4/27/21 staff #3 noted in daily progress notes that Individual #3 was "redirected to [their] room", isolated from others in the front room, or sent to the couch as punishment for behaviors. Staff #3 documented that Individual #3 was sent to their room or another location in the home because of behaviors such as disrespect to staff, refusing to use the restroom, or attempting to steal food. On 10 of these occasions, staff #3 documented that the individual was not allowed to leave the area that staff redirected the individual to until staff gave verbal permission.
Punishing an individual for exhibiting behaviors and/or secluding individuals to portions of the home with verbal direction to stay put until otherwise told is prohibited and constitutes mistreatment. | A restrictive procedure may not be used as retribution, for the convenience of staff persons, as a substitute for the program or in a way that interferes with the individual's developmental program. | During weekly supervisions with the Associate Directors of Service (ADOS), the Director of Services (DOS) will ensure training is provided to new and existing staff. The training shall include the individuals Health and Safety, Individual Plan, and Behavior Plan, as applicable, to guarantee the residents are free of physical, mental, verbal, and punishment, mental and physical neglect, and involuntary seclusion. The Associate Directors will document the training of staff on the weekly supervision report. In addition, the Associate Directors will ensure staff document their training in AWARDS by signing the training logs at the beginning of scheduled training. In addition, the ADOS, numerous staff and the Program Manager are no longer with the company. Training on individual rights has taken place and additional training on reporting of incidents has taken place. The Clinical ADOSs in every home in TLC's organization is reviewing, editing and working with local county representatives to amend Health and Safety Plans and ISPs so they are congruent. Training records for staff on documents related to people we support are to be not just read, but reviewed with staff members to make sure there is an understanding of expectations for staff members for each person supported by the organization |
10/30/2021
| Not Implemented |
| 6400.207(1) | There were 15 different instances between 1/1/21 and 4/27/21 where staff #3 documented in progress notes that Individual #3 was "redirected to [their] room", isolated from others in the front room, or sent to the couch for staff convenience or punishment for behaviors. On 10 of these occasions, Individual #3 was not allowed to leave the area where he was "redirected" to until staff verbally approved. Staff person #3 specifically noted this direction in individual #3's daily progress notes as follows:
· The 1/20/21 progress note read, "[Individual #3] was redirect to [Individual #3's] room until staff take [individual #3] to the table"
· In progress notes dated 3/9/21, Individual #3 was sent to the living room, "because [individual #3] was having a bad behavior with staff until another staff take [individual #3] to [Individual #3's] appointment."
· In progress notes dated 3/11/21, it was documented that, "staff sit [individual #3] at litter couch until [individual #3] start acting right and [individual #3] stay there until staff shift end it."
· In progress notes dated 3/24/21, Individual #3 attempted to take another individual's food at breakfast so, "[individual #3] was again redirect to [Individual #3's] room until lunch."
· In progress notes dated 4/6/21, it was documented that Individual #3 was showing disrespect to staff at lunch so, "staff take [Individual #3] to [Individual #3's] room until [Individual #3] decide to act right." Individual #3 was in their room until staff #3's shift ended.
· In progress notes dated 4/7/21, Individual #3 "had a behavior" at breakfast so, "staff redirect [Individual #3] to [Individual #3's] room [individual #3] stay there until lunch." At lunch, individual #3 was asked if they were done with their behavior, but "[Individual #3] continue with the same behavior and was redirect back to room until staff shift end it."
· In progress notes dated 4/9/21, staff #3 arrived for 8am shift where Individual #3 was sitting on the couch. Individual #3 then "had a behavior" and, "staff redirect [Individual #3] to [Individual #3's] room because of [Individual #3's] behavior." Individual #3 was "redirected to eat lunch" and "[Individual #3] decide to keep their behavior so [Individual #3] stay in [Individual #3's] room until [Individual #3] decide to calm down but [Individual #3] stay with [Individual #3] behavior until staff shift end it."
· In progress notes dated 4/19/21, Individual #3 attempted to take food from another individual at lunch so "staff redirect [individual #3] to [Individual #3's] room until staff decide that [individual #3] was done with [Individual #3's] behavior."
· In progress notes dated 4/20/21, Individual #3 attempted to touch other individuals' food at lunch so, "[individual #3] was redirect to the from room until [Individual #3] decide to change [Individual #3's] behavior but [Individual #3] were acting all afternoon the same even staff try to take [Individual #3] to the bathroom and [individual #3] start trying throwing [Individual #3] to the floor so staff decide to leave [Individual #3] there and [individual #3] stayed in the from room until staff shift end it."
· In progress notes dated 4/22/21, Individual #3 was touching other individuals' food at lunch so, "staff clean [Individual #3] up and take [Individual #3] to the from room so [individual #3] can have some time to [Individual #3] and [individual #3] stay there until staff redirect [Individual #3] to the couch." | The following procedures are prohibited: Seclusion, defined as involuntary confinement of an individual in a room or area from which the individual is physically prevented or verbally directed from leaving. Seclusion includes physically holding a door shut or using a foot pressure lock. | During weekly supervisions with the Associate Directors of Service (ADOS), the Director of Services (DOS) will ensure training is provided to new and existing staff. The training shall include the individuals Health and Safety, Individual Plan, and Behavior Plan, as applicable, to guarantee the residents are free of physical, mental, verbal, and punishment, mental and physical neglect, and involuntary seclusion. The Associate Directors will document the training of staff on the weekly supervision report. In addition, the Associate Directors will ensure staff document their training in AWARDS by signing the training logs at the beginning of scheduled training. In addition, the ADOS, numerous staff and the Program Manager are no longer with the company. Training on individual rights has taken place and additional training on reporting of incidents has taken place. The Clinical ADOSs in every home in TLC's organization is reviewing, editing and working with local county representatives to amend Health and Safety Plans and ISPs so they are congruent. Training records for staff on documents related to people we support are to be not just read, but reviewed with staff members to make sure there is an understanding of expectations for staff members for each person supported by the organization |
10/30/2021
| Not Implemented |
| 6400.208(d) | Individual #2 requires a suprapubic catheter that involves biweekly changing by a VNA nurse. Staff have been assisting the VNA nurse with these catheter changes by applying unauthorized restraints to the individual, with one staff holding Individual #2's shoulders or chest while the second staff hold the individual's legs. A physical restraint that inflicts pain, inhibits respiration, or applies pressure to the chest or joints is prohibited. | A physical restraint that inhibits digestion or respiration, inflicts pain, causes embarrassment or humiliation, causes hyperextension of joints, applies pressure on the chest or joints or allows for a free fall to the floor is prohibited. | The VNA, under the direction of the physician and the insistence of the TLC RN, has and will continue to send two personnel and manage the change of this person's suprapubic catheter without intervention of the TLC staff. This occurred with the first change of catheter after the inspection/investigation, but was delayed four days, again at the order of the physician, while alternative solutions were explored. |
05/28/2021
| Not Implemented |
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