| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | Repeat from 6/21/22- Individual #1 had an annual physical examination on 3/4/22 and not again until 3/28/23, outside of the annual timeframe. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual's PCP was unable to accommodate a yearly physical in the required timeframe and failed to document any conversations/attempts to obtain this appointment in the necessary timeframe. TLC staff failed to obtain a physical from an alternate provider when the PCP was not able to meet yearly timeframe. TLC staff failed to utilize the Residential Quality Date monitor and Quality Coordinators did not monitor this document appropriately.
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.
TLC's Annual Physical Exam Form (See attached Annual Physical Exam 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.
Upon completing Annual Physical, Program Specialist will update Residential Quality Date Monitor which is audited by the end of month by Quality Coordinators.
The individual transitioned to a new PCP on 5/10/23 who are a Wellspan provider. TLC as well as Alco Pharmacy holds proxies with Wellspan to allow for communication across all providers to ensure documentation is completed thoroughly and appointments can be accommodated in a timely manner. |
07/15/2023
| Implemented |
| 6400.141(c)(7) | Repeat from 5/10/21, 1/3/22, 6/21/22, and 8/29/22- Individual #1 had a pap test and gynecological exam on 1/28/21. Another examination and test were not attempted until 8/29/22, when the examination was deferred for medical reasons. | 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. | TLC staff failed to ensure yearly pap test and gynecological exam were complete in 1 year timeframe. Documentation discovered for rationale of deferment on 6/23/2023 that had not been previously provided during inspection. Please see attached "Wheatland Gyno Exam Deferred Documentation" for rationale for these procedures being deferred. TLC staff failed to utilize the Residential Quality Date monitor and Quality Coordinators did not monitor this document appropriately. |
07/15/2023
| Implemented |
| 6400.141(c)(11) | The health maintenance needs section of Individual #1's 3/28/23 annual physical examination is blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | This occurred due to lack of Residential Management staff training on reviewing Annual Physicals to ensure all sections were completed thoroughly. 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.
The individual transitioned to a new PCP on May 10, 2023, who are a Wellspan provider. TLC as well as Alco Pharmacy holds proxies with Wellspan to allow for communication across all providers to ensure documentation is completed thoroughly and appointments can be accommodated in a timely manner. In addition, TLC Residential Management received written documentation from the physical exam regarding health maintenance needs, medication regime, and the need for bloodwork at recommended intervals (see attached Wheatland Health Maintenance Needs).
TLC's Annual Physical Form (See attached Annual Physical Form) has been updated to include a section on the bottom where the Program Specialist/Nurse must acknowledge that the form is complete, recommendations have been implemented and all necessary follow-up appointments have been scheduled. |
07/15/2023
| Implemented |
| 6400.142(a) | Repeat from 10/12/21, 1/3/22, 6/21/22, and 8/29/22- Individual #1 had a dental examination on 5/19/22 with a six-month recall. Another dental examination was not completed until 3/2/23, outside of the annual timeframe. | 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 occurred due to the scheduling process with the provider office and TLC staff not maintaining documentation of their attempts to ensure the dental exam was scheduled in the required timeframe. The individual is scheduled on June 27, 2023, to have a deep cleaning and all needed restoration work. TLC Residential Management is looking to secure a new dental provider for the individual; we anticipate this by January 1, 2024.
TLC's Dental Exam Form (See attached Dental Exam Form) has been updated to include a section on the bottom where the Program Specialist must acknowledge that the form is complete, recommendations have been implemented and all necessary follow-up appointments have been scheduled.
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. |
01/01/2024
| Implemented |
| 6400.142(d) | The dental examinations completed for Individual #1 on 5/19/22 and 3/2/23 did not include a teeth cleaning. Both appointments indicated that Individual #1 needed a deep cleaning, and the 5/19/22 appointment specifically indicated that teeth were not cleaned. | The dental examination shall include teeth cleaning or checking gums and dentures. | This occurred due to lack of staff training on the necessity of the dental exam to include a cleaning. The dental exam indicated deep cleaning was necessary; however, this procedure was not scheduled by Residential Staff and documentation was not maintained of any attempts to schedule this procedure. The individual is scheduled to have the deep cleaning on 6/27/23.
TLC's Dental Exam Form (See attached Dental Exam Form) has been updated to include a section on the bottom where the Program Specialist must acknowledge that the form is complete, recommendations have been implemented and all necessary follow-up appointments have been scheduled. |
06/28/2023
| Implemented |
| 6400.142(e) | Repeat from 6/21/22- Individual #1's 5/19/22 dental examination indicated that Individual #1 had a new cavity, needed restoration work, a root canal, and a deep cleaning. The individual's 3/2/23 dental examination indicated that they needed a deep cleaning, 4 cavities required fillings, and required endodontic treatment and crown. There was no documentation verifying that this follow-up work had been scheduled or completed. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | The individual was scheduled on 4/25/23 for the necessary dental procedures however, on the morning of the appointment refused to attend despite education on the importance of the procedures. TLC staff did not maintain documentation of attempts to reschedule this appointment with the provider. The individual is scheduled to have this work complete on 6/27/23.
TLC¿s Dental Exam Form (See attached Dental Exam Form) has been updated to include a section on the bottom where the Program Specialist must acknowledge that the form is complete, recommendations have been implemented and all necessary follow-up appointments have been scheduled.
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. |
07/15/2023
| Implemented |
| 6400.142(g) | Repeat from 6/21/22- Individual #1's most recent dental hygiene plan was confirmed by the dentist on 5/19/22. No documentation was provided verifying that Individual #1's dental hygiene plan was updated in 2023. | A dental hygiene plan shall be rewritten at least annually. | This occurred due to lack of training on what form is to be utilized at dental appointments. The form utilized was a generic form from Therap and not the standardized TLC Dental Exam Form. The generic form from Therap did not include a section for the dental hygiene plan to be verified. The individual's dental hygiene plan will be reviewed and verified at the appointment on 6/27/23.
TLC's Dental Exam Form (See attached Dental Exam Form) has been updated to include a section on the bottom where the Program Specialist must acknowledge that the form is complete, recommendations have been implemented and all necessary follow-up appointments have been scheduled. |
07/15/2023
| Implemented |
| 6400.144 | Repeat from 1/11/21, 4/26/21, 10/12/21, 1/3/22, 6/21/22, and 8/29/22- At the time of the 5/24/23 inspection, Individual #1's PRN Medication Diclofenac Sodium Gel was not available in the home.
At Individual #1's 3/28/23 annual physical examination, the doctor indicated that Individual #1 had a mildly elevated blood pressure. The doctor indicated that caretakers should check some blood pressures at home in the morning and before bedtime and let the doctor know if the blood pressure is above 130/80 so that hypertensive therapy could be added. There is no documentation verifying that this medical recommendation has been followed. | 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 during the transition between Good Day Pharmacy and Alco Pharmacy. There were multiple active orders of the same PRN medications in Good Day's System. Both TLC Residential Management and Alco Pharmacy were in the process of reaching out to prescribing physicians to ensure the accuracy of all medication orders. This occurred due to this process not being complete at time of inspection. As of June 1, 2023, all doctor orders for PRNs have been confirmed and all prescribed PRN medications are present in the home.
In addition, the individual transitioned to a new PCP on 5/10/23 who are a Wellspan provider. TLC as well as Alco Pharmacy holds proxies with Wellspan to allow for communication across all providers to ensure documentation is completed thoroughly and appointments can be accommodated in a timely manner.
TLC Residential Management failed to review Annual Physical Exam and implement recommendation to check blood pressure in the morning and before bedtime in the home. At the individual's appointment on 6/2/23, the PCP provided written documentation: "Please stop checking her blood pressure at the group home, may be checked as needed."
TLC's Annual Physical Form (See attached Annual Physical Form) has been updated to include a section on the bottom where the Program Specialist/Nurse must acknowledge that the form is complete, recommendations have been implemented and all necessary follow-up appointments have been scheduled. |
07/15/2023
| Implemented |
| 6400.211(b)(3) | Repeat from 1/3/22 and 6/26/22- Individual #1's demographic information does not include the name, address, or telephone number for the person who can give consent for emergency medical treatment. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| This occurred due to an error in Therap formatting where the information was not selected to be viewable on the factsheets. On 6/9/23, the face sheets were rectified to include emergency medical consent information. |
07/01/2023
| Implemented |
| 6400.32(c) | Repeat from 1/3/22 and 6/21/22- Individual #1 was diagnosed with COVID-19 on 3/11/23. Individual #1 was prescribed a 5-day treatment of Paxlovid on this same date. This medication was not administered to the individual. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | The individual was diagnosed with COVID-19 on 3/11/23 and prescribed a 5-day treatment of Paxlovid. The medication was not delivered by Good Day Pharmacy on 3/11 or 3/12. TLC staff failed to follow up with the prescribing physician for alternate instructions or recommendations to obtain the medication until 3/13. On Monday 3/13, staff contacted Good Day Pharmacy who stated the medication was not in stock. The prescribing physician was contacted and noted medication would be sent to CVS. When medication was picked up from CVS, medication administration time was missing from the label. TLC staff failed to return to CVS to have label corrected immediately. Due to the label not being corrected, medication was not administered to the individual as prescribed. TLC staff took no further action which resulted in a violation of the individual's rights. This was not reported to TLC's Incident Management Department to be investigated at the time of the incident. Upon discovery, TLC's Incident Management department initiated a certified investigation for Neglect "Failure to Provide Medication Management." The associated EIM number is 9225291, the TLC Administrative Committee met to conclude the investigation on 6/14/2023 where the incident was confirmed.
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. |
07/15/2023
| Implemented |
| 6400.165(b) | At Individual #1's 3/28/23 annual physical examination, the doctor indicated that Individual #1's Meloxicam should be reduced from a daily medication to a PRN medication, to be taken once daily at 8am as needed. This medication was given daily through 4/25/23, then changed to a PRN medication in the home. On 5/10/23, the after-visit summary for Individual #1's doctor appointment the same date, it indicated that Meloxicam should be given once daily. As of 5/24/23, this medication is still being treated as a PRN medication in the home and has only been given on 5/11/23. | A prescription order shall be kept current. | This occurred due to lack of staff training on reviewing Annual Physicals after completion. 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.
The individual transitioned to a new PCP on 5/10/23 who are a Wellspan provider. TLC as well as Alco Pharmacy holds proxies with Wellspan to allow for communication across all providers to ensure documentation is completed thoroughly and appointments can be accommodated in a timely manner.
TLC's Annual Physical Form (See attached Annual Physical Form) has been updated to include a section on the bottom where the Program Specialist/Nurse must acknowledge that the form is complete, recommendations have been implemented and all necessary follow-up appointments have been scheduled.
This provider has launched an internal investigation due to failure to provide medication management. All associated Medication Errors have been entered into the EIM system (9224186, 9224243, 9224247, 9224258, 9224266, 9224274, 9224265, 9224277, 9224279, 9224287, 9224294, 9224306,9224307, 9224322). The associated EIM for the investigation is 9225291.
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. |
07/15/2023
| Implemented |
| 6400.166(a)(11) | Individual #1's Medication Administration Records does not have the diagnosis or purpose for Diclofenac Sodium 1% Gel. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | During the agency-wide transition between Carasolva and Therap, staff utilized paper MARs to documentation medication administration. TLC Residential Management was responsible to create and review paper MARs to ensure necessary components were present which did not occur. TLC has adjusted our medication check-in process to include a Medication Check-in Form for completion that requires to ensure all components of 6400.166 are accounted for on MARs. This form and process will be utilized beginning July 1, 2023. |
07/01/2023
| Implemented |
| 6400.167(a)(1) | Individual #1 did not receive their 8am dose of Meloxicam on 12/1/22. Individual #1 did not receive their 8am dose of Meloxicam, Myrbetriq, Vitamin E, or Vitamin D3 on 1/20/23. Individual #1 was prescribed Paxlovid on 3/11/23 to be taken twice daily for 5 days. This medication was not administered. On 5/10/23, Individual #1's PCP indicated a change to Individual #1's Meloxicam instructions; this medication is now to be given 1 tab by mouth daily. This medication was administered on 5/11/23 and has not been administered since that date. | Medication errors include the following: Failure to administer a medication. | TLC failed to provide medication management on 12/1/22 and 1/20/23. Staff failed to reach out to the prescriber to see if medication should be administered late. Staff also failed to report missed doses of medication to the Incident Management Department so it could be placed into EIM. Residential Management failed to accurately complete Monthly Medication Audit.
The individual was diagnosed with COVID-19 on 3/11/23 and prescribed a 5-day treatment of Paxlovid. The medication was not delivered by Good Day Pharmacy on 3/11 or 3/12. TLC staff failed to follow up with the prescribing physician for alternate instructions or recommendations to obtain the medication until 3/13. On Monday 3/13, staff contacted Good Day Pharmacy who stated the medication was not in stock. The prescribing physician was contacted and noted medication would be sent to CVS. When medication was picked up from CVS, administration time was missing from the label. TLC staff failed to return to CVS to have label corrected immediately. Due to the label not being corrected, medication was not administered to the individual as prescribed. TLC staff took no further action which resulted in a violation of the individual's rights. On 5/10/23, TLC staff failed to implement medication changes made by physician. This was not reported to TLC's Incident Management Department to be investigated. The associated EIM number is 9225291, the completion date for the investigation is 6/14/2023 and was confirmed. TLC entered an additional EIM (EIM#9230440), classified as a medication error omission. |
07/15/2023
| Implemented |
| 6400.167(c) | Repeat from 10/12/21, 1/3/22, and 6/21/22- The medication errors described in 6400.167a1 were not reported as incidents in the department's incident management system. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | Staff failed to report medication error to Incident Management Department so it could be placed into EIM. Residential Management failed to accurately complete Monthly Medication Audit. Upon discovery, TLC incident management department initiated a certified investigation for Neglect "Failure to Provide Medication Management." The associated EIM number is 9225291, the completion date for the investigation is 6/14/2023 and was confirmed. All associated Medication Errors have been entered into the EIM system (9224186, 9224243, 9224247, 9224258, 9224266, 9224274, 9224265, 9224277, 9224279, 9224287, 9224294, 9224306,9224307, 9224322. |
09/01/2023
| Implemented |