| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | Individual #1's 5/6/22 ISP indicates that "[They] do not require adaptive equipment to eat," and that they need help cutting up their food. Individual #1's assessment dated 5/11/22 completed by Typical Life Corporation indicates that Individual #1 needs reminders to eat slowly and needs help cutting up their food. An order was placed from Amazon on 5/26/22 for 2 Ableware Scooper Bowls with suction cups and a 3 pack of Scoop Plate High-Low adaptive bowls, totaling $52.35 for Individual #1. Typical Life Corporation was reimbursed for this purchase from Individual #1's financial account on 6/15/22. Individual #1 does not require this adaptive equipment, and Typical Life Corporation should not have been reimbursed from Individual #1's funds for this purchase. | Individual funds and property shall be used for the individual's benefit. | As a result of this violation, an EIM report has been filed and the IM team is investigating this. Individual #1 was refunded for $52.35 on 06/24/2022. The admin review for this investigation occurred 07/12/2022. Please see attachment Nightlight 6400.22c Corrective Actions. |
08/03/2022
| Implemented |
| 6400.22(d)(2) | Individual #1's mother is currently their representative payee and provides cash to Typical Life Corporation for Individual #1 to utilize as spending money. This money is deposited into Individual #1's register account. A check was written to Individual #1 in the amount of $20 on 3/31/22 to use as spending money, however, there is no record of how this money was spent or if this money was given directly to Individual #1. Individual #1 is not financially independent. | (2) Disbursements made to or for the individual.
| Individual #1's $20 that is referenced in the violation is still in their account, and it was not spent. At this time, there have been no additional requests for any funds.
On March 24th, there was a SharePoint (online) balance sheet that was implemented so that the fiscal department and the program managers/ specialists have access to the same electronic form for the time lapse where the physical balance sheet is in limbo between fiscal and the program. This discrepancy occurred due to the program manager using the balance sheet for the house account for additional funds provided by Individual #1's parent (who is their rep payee).
Due to this violation, the fiscal department will audit Individual #1's financial records for April and May by 07/27/2022. |
07/27/2022
| Not Implemented |
| 6400.111(a) | (Repeated Violation -- 1/10/22) During the inspection completed on 6/23/22, the fire extinguisher located in the attic was 1-A rating as opposed to the required 2-A rating. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | This occurred due to the Program Manager not checking the required size of the fire extinguisher, only ensuring that there was an inspected fire extinguisher present. Maintenance request was submitted to request the correct size fire extinguisher. A 2A rating fire extinguisher has been placed in the attic of this home (see attachment 6400.111a Fire Extinguisher). The Quality Department has requested Program Managers inspect all fire extinguishers in all programs by 07/25/2022 to ensure that the fire extinguishers are in compliance. Should any additional fire extinguishers be found to not be a 2A rating they will be replaced immediately. The Quality Department will ensure that Program Managers complete this inspection of all homes by 7/25/2022. |
07/27/2022
| Implemented |
| 6400.113(a) | (Repeated violation -- 1/10/22) Individual #1's date of admission was 1/31/22. Individual #1's initial fire safety training was completed on 2/1/22. Initial fire safety training is to be completed prior to admission or the date of admission. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | This occurred due to the staff receiving no guidance on what was expected to be completed prior to Individual #1 returning to TLC. Staff were not advised to treat this as a new admission as opposed to Individual #1 returning to TLC. New Admission Checklist was developed on 04/27/2022 to check that all requirements are completed prior to move in. As a result of this violation, quality will be checking to ensure all individuals are up to date with their Fire Safety Training requirements by 07/25/2022. (Please see attachment New Admission Checklist). |
07/27/2022
| Implemented |
| 6400.141(a) | Individual #1's date of admission was 1/31/22. They did not have an annual physical examination until 2/14/22. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | This occurred due to the staff receiving no guidance on what was expected to be completed prior to Individual #1 returning to TLC as well as struggling to gain any records from their previous placement. New Admission Checklist & Transfer/ Emergency Placement Checklists were developed on 04/27/2022 to check that all requirements are completed prior to move in, including ensuring that there has been an annual physical exam completed within 12 months prior to admission. As a result of this violation, quality will be checking to ensure all individuals are in compliance with their annual physical assessments. |
07/27/2022
| Implemented |
| 6400.141(c)(4) | (Repeated Violation -- 1/10/22) Individual #1's 2/14/22 annual physical examination did not include a vision or hearing examination. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | This occurred due to staff not being trained appropriately on the use of the Annual Physical Form, along with the form not focusing on the completion of all necessary regulatory requirements. Quality is checking all individual¿s annual physical exams to ensure all fields of the exam were completed entirely by 07/25/2022, if there is any information missing, the physician will be contacted to complete this form. |
07/27/2022
| Implemented |
| 6400.141(c)(6) | Individual #1's date of admission was 1/31/22. Individual #1 did not have a tuberculin test completed and read until 2/17/22. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | This occurred due to staff not being trained appropriately on the use of the Annual Physical Form, along with the form not focusing on the completion of all necessary regulatory requirements. Quality is checking all individual¿s annual physical exams to ensure all fields of the exam were completed entirely by 07/25/2022. |
07/27/2022
| Implemented |
| 6400.141(c)(7) | (Repeated Violation -- 1/10/22) Individual #1's date of admission was 1/31/22. As of the 6/23/22 inspection, Individual #1 has not had a gynecological exam completed, and there is no documentation on file verifying when Individual #1's last exam was completed. Individual #1's 2/14/22 annual physical examination states that a breast examination could not be completed and that a referral to gyn was being completed. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | This had occurred due to Individual #1 not having medical insurance at the time, so staff had a difficult time with obtaining an appointment with a provider. The gyn appointment had been scheduled for 06/28/2022, however, prior to this appointment, Individual #1 broke their ankle and has been out of program so this appointment needed to be cancelled. Quality will complete a check of all individuals to ensure that their annual required appointments are scheduled, or that there is documentation of attempts to schedule, by 07/25/2022. |
07/27/2022
| Not Implemented |
| 6400.141(c)(14) | (Repeated Violation -- 1/10/22) The medical information pertinent to diagnosis and treatment in the event of an emergency section of Individual #1's 2/14/22 annual physical examination is blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | This occurred due to the format of the physical exam form and the lack of training staff received. Quality will check other individual¿s annual physical exam form to ensure this is completed entirely by 07/25/2022. |
07/27/2022
| Not Implemented |
| 6400.142(a) | (Repeated Violation -- 1/10/22) Individual #1's date of admission is 1/31/22. There is no record on file of Individual #1 having a completed dental examination. Individual #1 was scheduled to have a dental appointment on 5/4/22, however, this was cancelled by staff due to Individual #1 not having dental insurance and has not been rescheduled. According to Individual #1's daily notes, Individual #1's mother stated on 2/2/22 that insurance may not cover the dental exam, but that their mother would pay the difference. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | This non-compliance occurred due to an issue with Individual #1's insurance, mixed messages from Individual #1's parent (their rep payee) stating that they are tired of paying medical bills for Individual #1 and lack of intervention on the part of TLC management to resolve the issue. Quality has been monitoring all individuals¿ dental exam appointments and communicating with the Program Managers and Program Specialists to ensure that these are being scheduled. The Quality department communicates on a weekly basis with the program management team to ensure attempts are being made to schedule appointments. Quality will complete a check of all individuals to ensure that their dental exams are scheduled, or that there is documentation of attempts to schedule, by 07/25/2022. |
07/27/2022
| Not Implemented |
| 6400.143(a) | (Repeated Violation -- 1/10/22) Individual #1 has refused to follow their dental hygiene plan at least 27 times since admission. There is no record of the continued attempts to train the individual about the need for health care. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | This occurred due to behavior supports not following through with completing an FBA, developing, and implementing a behavior support plan. As a result of the violations 6400.143 & 6400.144, TLC has separated from the director of behavior supports and is updating the internal referral process for behavior supports. Also, a result of this violation, the behavior specialist will be completing an FBA and developing an appropriate behavior support plan as soon as Individual #1 returns to TLC. Also, the Program Specialists were requested to develop a list of required protocols to be tracked and submit this to quality by 08/15/2022. Quality will update the auditing spreadsheet to reflect these changes and complete a dental tracking monitor and bowel tracking for all individuals by 07/27/2022 |
08/15/2022
| Not Implemented |
| 6400.144 | (Repeated Violation -- 1/10/22) On 2/11/22, Dr. Eike indicated that Individual #1 should have a behavior support plan that "must contain items to address high risk of injury to staff (risks to eyes especially) and risk resulting from inappropriate sexual touching." As of the 6/23/22 inspection, Individual #1 does not have a Behavior Support Plan in place.
Individual #1 has a dental hygiene plan that indicates they are to brush their teeth with staff assistance twice daily. This is to be tracked by staff. There is no documentation provided indicating that Individual #1's dental hygiene plan was followed for the following dates: 2/4/22 AM, 2/3/22 AM, 2/4/22 AM, 2/7/22, 2/9/22 AM, 2/11/22 PM, 2/14/22, 2/18/22 -- 2/23/22, 2/25/22 -- 2/28/22, 3/10/22 -- 3/15/22, 3/22/22 -- 3/26/22, 3/29/22 PM, 4/7/22, 4/8/22, 4/15/22 -- 4/25/22, 5/7/22 -- 5/12/22, 5/19/22 -- 5/24/22, 6/12/22 PM.
Individual #1 was scheduled to have a 3/10/22 Orthopedics appointment which was to be a follow-up from a 7/9/21 injury if Individual #1's injury did not improve or got worse. This appointment was cancelled by the doctor's office, however, there is no documentation provided by Typical Life Corporation verifying that this appointment has been rescheduled or completed.
Bowel tracking for Individual #1 was started on 5/26/22. Per tracking protocol, staff is to contact the TLC nurse if an individual does not have a bowel movement within 24 hours. Between 5/26/22 and 6/22/22, Individual #1 only had bowel movements on the following dates: 5/29/22 between 12am and 8am, 6/3/22 between 10pm and 8am, 6/10/22 between 12am and 8am, 6/12/22 between 12am and 8am, 6/16/22 between 4pm and 12am, 6/17/22 between 12am and 8am, 6/18/22 between 12am and 8am and 4pm and 12am, 6/19/22 between 12am and 8am, and 6/21/22 between 12am and 8am. Typical Life Corporation did not report this information to nursing or the doctor's office until 6/4/22, when Colace was changed to a daily medication as opposed to a PRN medication. Typical Life Corporation did not report the continued constipation to Individual #1's doctor until 6/20/22. | 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 occurred due to behavior supports not following through with completing an FBA, developing, and implementing a behavior support plan. As a result of the violations 6400.143 & 6400.144, TLC has separated from the director of behavior supports and is updating the internal referral process for behavior supports. Also, a result of this violation, the behavior specialist will be completing an FBA and developing an appropriate behavior support plan as soon as Individual #1 returns to TLC. Also, the Program Specialists were requested to develop a list of required protocols to be tracked and submit this to quality by 08/15/2022. Quality will update the auditing spreadsheet to reflect these changes and complete a dental tracking monitor by 07/27/2022.
Another factor to why this has occurred is because TLC has not developed a specific practice for developing and implementing protocols. Beginning in June, following the announcement of the new residential structure, the Director of Residential began working with all Program Specialists to create specific protocols for all applicable individuals per their needs in their ISP and develop tracking protocols. The Program Specialist has reviewed all Individual #1's physician notes to ensure all plans have been documented, implemented, and trained on. Program Specialists and Nurses will review all protocols and tracking/ documentation requirements to ensure that they align with the physician¿s orders by 07/27/2022.
TLC transported Individual #1's to the appointment where the orthopedic doctor stated that the individual did not need to be seen since there was improvement, so the appointment was cancelled by the provider at that time. |
08/15/2022
| Not Implemented |
| 6400.181(a) | (Repeated Violation -- 1/10/22) Individual #1's date of admission was 1/31/22. Their initial assessment was not completed until 5/11/22, after the required 60-day timeframe. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | This occurred due to TLC not having a process for new admissions/transfers. As a result of this violation, Program Specialists reviewed annual assessments/ dates to ensure all assessments were updated. All out of compliance are required to be completed by 08/01/2022. |
08/01/2022
| Implemented |
| 6400.181(e)(10) | Individual #1's 5/11/22 assessment does not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | This occurred due to the Program Specialist not including the lifetime medical history. Perhaps this could have been avoided if there was an index attached to the assessment that shows what all needs to be included in the assessment. As a result of violation, Program Specialists are auditing each individuals most recent Annual Assessments to ensure that all Assessments include a lifetime medical history for each individual by 08/01/2022. If the previously completed Annual Assessment does not include the lifetime medical history and addendum to the assessment will be sent to all team members, which will include a copy of the most recent lifetime medical history. |
08/01/2022
| Implemented |
| 6400.32(d) | (Repeated Violation -- 1/10/22) Individual #1's 5/6/22 ISP indicates that "[They] do not require adaptive equipment to eat," and that they need help cutting up their food. Individual #1's assessment dated 5/11/22 completed by Typical Life Corporation indicates that Individual #1 needs reminders to eat slowly and needs help cutting up their food. An order was placed from Amazon on 5/26/22 for 2 Ableware Scooper Bowls with suction cups and a 3 pack of Scoop Plate High-Low adaptive bowls, totaling $52.35 for Individual #1. The use of un-needed adaptive equipment at mealtime infantilizes Individual #1. | An individual shall be treated with dignity and respect. | As a result of this violation, an EIM report has been filed and the IM team is investigating this. Individual #1 was refunded for $52.35 on 06/24/2022. The admin review for this investigation occurred 07/12/2022. Please see attachment Nightlight 6400.22c Corrective Actions. |
08/03/2022
| Implemented |
| 6400.34(a) | (Repeated Violation -- 1/10/22) Individual #1's date of admission was 1/31/22. Their individual rights were not reviewed with them until 2/8/22. | 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. | This occurred due to TLC not having a process for new admissions/transfers. All individuals had their individual rights reviewed with them in June 2022, as part of a previous POC. However, due to this violation, the Quality Department will review each individuals records by 07/15/2022 to ensure that all people supported had the individual rights forms reviewed and signed in June 2022. If any individuals were missed in June, the Quality Department will ensure that this is completed by 7/25/22. |
07/27/2022
| Implemented |
| 6400.165(c) | (Repeated Violation -- 1/10/22) On 2/11/22, Dr. Eike prescribed Divalproex 325mg twice daily to Individual #1. From 2/11/22 through the end of February 2022, Individual #1 was administered (increased dose) of 375mg of Divalproex twice daily. | A prescription medication shall be administered as prescribed. | TLC believes that this issue continues to occur due to the lack of communication between our internal psychiatric services and TLC. Due to concerns with the internal psychiatric provider, TLC has decided to separate from outpatient services tentatively effective 12/31/2022. The tentative plan is to have all individuals who receive care at TLC be transferred to an alternative psychiatric provider with a continuity of care plan. The TLC nurses will look at the most recent psychiatric appointment and compare the medications that were prescribed to the medications that are in Carasolva and the medications that are in the homes by 07/27/2022. |
07/27/2022
| Not Implemented |
| 6400.165(g) | (Repeated Violation -- 1/10/22) Individual #1's 3/9/22 medication review did not document the reason for prescribing any medications. Individual #1's 6/2/22 medication review did not document the reason for prescribing Lorazepam. | 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. | TLC believes that this issue continues to occur due to the lack of communication between our internal psychiatric services and TLC. The Program Specialists are required to sign off on the psychiatrist¿s appointment summary, compare the notes and prescriptions to what has been prescribed in Carasolva. TLC will look at the most recent psychiatric appointment and compare the medications that were prescribed to the medications that are in Carasolva and the medications that are in the homes for all individuals. TLC is working with PennMar to determine which form the psychiatrist sends to them and TLC will request that the same form be used to ensure consistency. TLC will look at the most recent psychiatric appointment and compare the medications that were prescribed to the medications that are in Carasolva and the medications that are in the homes by 08/15/2022. |
08/15/2022
| Implemented |
| 6400.166(b) | (Repeated Violation -- 1/10/22) Individual #1 was given medications on the following dates and the administration was not documented immediately:
· 2/28/22 -- PRN Lorazepam 1mg was administered at 6:30am, but not documented until 7:25am
· 3/28/22 -- all 8pm medications
· 3/29/22 - 4pm dose of Risperidone 3mg
· 4/4/22 -- all 8pm medications
· 4/7/22 -- all 8am medications
· 5/7/22 -- 4pm dose of Risperidone 3mg
· 5/28/22 -- all 8pm medications
· 5/29/22 -- 12pm dose of Risperidone 3mg
· 6/1/22 -- 12pm dose of Risperidone 3mg
· 6/2/22 -- all 8am medications
· 6/4/22 -- all 8pm medications | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | This occurred due to staff not completing the 15 steps of medication administration. As a result of TLC's self-assessments that were completed in April, beginning May 2, 2022, the nurses were delegated the task of auditing the May MARs for all individuals in the organization (they completed one service area per week from May 2 - June 3). Following the completion of the MAR reviews, reminders were sent to all management staff to remind all direct care staff to follow the 15 steps of medication administration when they are administering medications to ensure documentation is completed at the time of administration. Due to the documentation and omission errors that were identified, all Program Specialists and Program Managers participated in the Medication Administration training held on June 15, 16, and 17, 2022. As a result of this violation, the nurses are currently reviewing and auditing the MARs for June with the completion date of 07/31/2022. If during the end of month audit it is discovered that medications were not documented within the needed window feedback will be provided to staff responsible. Staff will be trained to add a note to Carasolva if there is a valid reason why a medication was not marked as successful within the required timeframe. |
10/03/2022
| Not Implemented |
| 6400.166(d) | (Repeated Violation -- 1/10/22) Individual #1 has an order for PRN Lorazepam 1mg that is to be administered as needed 2 hours before medical/dental/lab appt. The dose can be repeated in 1 hour if needed. On 2/28/22, Individual #1 was administered a dose of Lorazepam at 6:30am that staff indicated was "not effective." Individual #1 was not administered a repeat dose before their lab appointment at 8:30am.
Individual #1 was administered Lorazepam 1mg on 3/10/22 at 12:54pm because of a 2:45pm ortho appointment. This administration was not effective. A follow-up dose was administered at 1:56pm, however, this appointment was cancelled by the doctor's office per a signed form that was printed at 1:09pm that same day. | The directions of the prescriber shall be followed. | For the first part of this violation, the staff administered the first dose of the PRN. Staff tried to be proactive in attempting to get Individual #1 in the car, more than an hour prior to her appointment, however, Individual #1 refused to get in the car. The doctor who ordered the bloodwork was contacted and told staff to forgo trying to get the bloodwork at that time and to try again before their next appointment in a week or so. Therefore the 2nd dose was not given. Staff failed to document all aspects of this situation. This also occurred during the time where Individual #1 was very new to TLC and staff were still trying to build rapport with them, currently, Individual #1 is much more willing to attend appointments, and participate in day program and community outings.
For the second part of this violation, the staff proactively printed out the paperwork from TLC¿s laptop at 1:09 pm in preparation for the appointment, staff then administered the PRN at the correct designated time and upon arrival to the appointment it was determined that the physician cancelled the appointment, so staff were advised to have the Medical Assistant sign the form stating the appointment was cancelled so TLC had documentation that the appointment was cancelled and not needed. Individual #1 is only to follow up if there are any concerns. |
07/27/2022
| Implemented |
| 6400.167(a)(1) | (Repeated Violation -- 1/10/22) Individual #1 did not receive the following doses of medication:
· February
o 2/1/22 -- All prescribed 8am medications
o 2/5/22 -- 8pm dose of Risperidone .25mg
o 2/6/22 -- 8am dose of Risperidone .25mg, 8pm dose of Risperidone .25mg
o 2/7/22 -- 8am dose of Divalproex 250mg, Ergocalciferol, Latuda 120mg, Risperidone .25mg ; 8pm dose of Divalproex 250mg, Risperidone 2mg and Risperidone .25mg
o 2/8/22 -- 8am dose of Risperidone .25mg and Latuda; 8pm dose of nitrofurantoin
o 2/13/22 -- 12pm dose of Risperidone 3mg
o 2/17/22 -- 8am dose of Latuda 60mg; 12pm dose of Risperidone 3mg; 4pm dose of Risperidone 3mg
· March
o 3/7/22 -- 8am dose of Vitamin D
· April
o 4/28/22 -- all 8pm medications | Medication errors include the following: Failure to administer a medication. | Since this inspection, the Incident Management team reported the medication errors in EIM. The TLC team has recognized medication administration as an area needing improvement based on the Self-Assessment licensing tools which were completed throughout the month of April 2022. As a result of this, TLC has increased the amount of medication administration trainers, adopted a new residential structure as of 06/06/2022 which created more management in each of the homes, and updated our medication procedures to include if a staff member has a medication error, it is required that remediation occurs and is documented; after 2 medication errors, the staff will need to complete medication administration training again with the Senior Director of Quality/ Staff Development. All management staff were also required to attend Incident Management Training again by 07/31/2022 due to the fact that these errors were not reported in EIM. |
10/03/2022
| Implemented |
| 6400.167(a)(3) | On 2/11/22, Dr. Eike prescribed Divalproex 325mg twice daily to Individual #1. From 2/11/22 through the end of February 2022, Individual #1 was administered 375mg of Divalproex twice daily. | Medication errors include the following: Administration of the wrong dose of medication. | This error occurred due to lack of management oversight to ensure that medications received from the pharmacy match current doctor orders. TLC, specifically the Quality Department will look at the most recent psychiatric appointment paperwork for all individuals supported and compare the medications that were prescribed to the medications that are in Carasolva and the medications that are in the homes by 08/15/2022.
The TLC team has recognized medication administration as an area needing improvement based on the Self-Assessment licensing tools which were completed throughout the month of April 2022. As a result of this, TLC has increased the amount of medication administration trainers, adopted a new residential structure as of 06/06/2022 which created more management in each of the homes, and updated our medication procedures to include if a staff member has a medication error, it is required that remediation occurs and is documented; after 2 medication errors, the staff will need to complete medication administration training again with the Senior Director of Quality/ Staff Development. |
08/15/2022
| Implemented |
| 6400.167(a)(4) | (Repeated Violation -- 1/10/22) Individual #1 received the following medications more than 1 hour after the prescribed time:
· February
o 2/3/22 -- All prescribed 8am medications were administered at 9:05am; All prescribed 8pm medications were administered 2/4/22 at 3:58am
o 2/8/22 -- The following 8pm medications were administered at 9:30pm: Divalproex 125mg, Divalproex 250mg, Melatonin 10mg, Risperidone 2mg
o 2/13/22 -- 4pm dose of Risperidone 3mg was administered at 6:19pm
o 2/14/22 -- 12pm dose of Risperidone 3mg was administered at 1:06pm
o 2/15/22 -- 12pm dose of Risperidone 3mg was administered at 1:36pm
o 2/17/22 -- 4pm dose of Neomyc-polym-dexameth eye drops not administered until 5:51pm
o 2/20/22 -- 4pm dose of Neomyc-polym-dexameth eye drops and Risperidone 3mg not administered until 6:50pm
o 2/22/22 -- 12pm dose of Neomyc-polym-dexameth eye drops and Risperidone 3mg not administered until 1:02pm
· March
o 3/17/22 -- 12pm dose of Risperidone 3mg not administered until 1:10pm
o 3/27/22 -- 12pm dose of Risperidone 3mg not administered until 1:04pm
· April
o 4/14/22 -- 12pm dose of Risperidone 3mg not administered until 1:03pm
o 4/26/22 -- 12pm dose of Risperidone 3mg not administered until 1:03pm
o 4/28/22 -- 12pm dose of Risperidone 3mg not administered until 1:27pm | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | The TLC team has recognized medication administration as an area needing improvement based on the Self-Assessment licensing tools which were completed throughout the month of April 2022. As a result of this, TLC has increased the amount of medication administration trainers, adopted a new residential structure as of 06/06/2022 which created more management in each of the homes, and updated our medication procedures to include if a staff member has a medication error, it is required that remediation occurs and is documented; after 2 medication errors, the staff will need to complete medication administration training again with the Senior Director of Quality/ Staff Development. All management staff were also required to attend Incident Management Training again by 07/31/2022 due to the fact that these errors were not reported in EIM. |
08/22/2022
| Implemented |
| 6400.167(b) | (Repeated Violation -- 1/10/22) With the exception of the following errors: 2/7/22 8pm failure to administer Risperadone .25mg, 2/13/22 12pm failure to administer Risperidone 3mg, 2/17/22 12pm failure to administer Risperidone 3mg and 3/7/22 8am failure to administer Vitamin D, Typical Life Corporation did not document the errors, follow up action, or the prescriber's response for all medication errors described in 6400.167a1, 6400.167a3, and 6400.167a4. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | The TLC team has recognized medication administration as an area needing improvement based on the Self-Assessment licensing tools which were completed throughout the month of April 2022. As a result of this, TLC has increased the amount of medication administration trainers, adopted a new residential structure as of 06/06/2022 which created more management in each of the homes, and updated our medication procedures to include if a staff member has a medication error, it is required that remediation occurs and is documented; after 2 medication errors, the staff will need to complete medication administration training again with the Senior Director of Quality/ Staff Development. |
07/27/2022
| Implemented |
| 6400.167(c) | (Repeated Violation -- 1/10/22) With the exception of the following errors: 2/7/22 8pm failure to administer Risperadone .25mg, 2/13/22 12pm failure to administer Risperidone 3mg, 2/17/22 12pm failure to administer Risperidone 3mg and 3/7/22 8am failure to administer Vitamin D, the medication errors described in 6400.167a1, 6400.167a3, and 6400.167a4 were not reported as incidents. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | Since this inspection, the Incident Management team reported the medication errors in EIM. The TLC team has recognized medication administration as an area needing improvement based on the Self-Assessment licensing tools which were completed throughout the month of April 2022. As a result of this, TLC has increased the amount of medication administration trainers, adopted a new residential structure as of 06/06/2022 which created more management in each of the homes, and updated our medication procedures to include if a staff member has a medication error, it is required that remediation occurs and is documented; after 2 medication errors, the staff will need to complete medication administration training again with the Senior Director of Quality/ Staff Development. All management staff were also required to attend Incident Management Training again by 07/31/2022 due to the fact that these errors were not reported in EIM. |
08/22/2022
| Implemented |
| 6400.181(f) | (Repeated Violation -- 1/10/22) Individual #1's initial assessment was due 4/1/22 but was not completed and signed by the program specialist until 5/11/22. Individual #1's ISP meeting was conducted on 5/6/22. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | This occurred due to lack of management in the homes, and the Program Specialists in the organization not having direction or guidance on a new admission. There has been Program Specialists designated for each house with the new residential structure change. As a result of this violation, Program Specialists reviewed annual assessments/ dates to ensure all assessments were updated. All out of compliance are required to be completed by 07/31/2022. |
07/31/2022
| Not Implemented |
| 6400.183(c) | (Repeated Violation -- 1/10/22) Individual #1's plan meeting was conducted on 5/6/22. Typical Life Corporation does not have a record of who attended this meeting. | The list of persons who participated in the individual plan meeting shall be kept. | This occurred due to TLC Program Specialist not receiving the ISP Approval Packet (including the attendance sheet) from the SC. The SC was contacted on 07/13/2022 to obtain the packet (please see attachment 6400.183c Email to SC) and will send TLC the ISP packet upon completion. As a result of this violation, the Program Specialists will be auditing all individual¿s file cabinets to ensure ISP Approval Packet is filed by 08/15/2022. Any missing attendance sheets will be obtained from SC¿s. |
08/15/2022
| Implemented |
| 6400.186 | Per Individual #1's ISP, their home should be equipped with electrical outlet covers. During the inspection completed on 6/23/22, said items were not present in Individual #1's home. | The home shall implement the individual plan, including revisions. | This occurred due to the ISP not being updated, the program specialist requested that this be changed. As a result of this violation, ISPs are being audited to ensure they are reflective of the most up to date information. ISPs will be audited throughout the month of August with the expectation that all necessary changes be sent to the assigned SC by August 22, 2022. |
08/22/2022
| Not Implemented |