|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | During the Department's inspection of the home from 5/10/2021 until 5/20/2021, the agency, Typical Life Corporation, exhibited multiple systematic failures that create an environment conducive to imminent risk of abuse and neglect for Individuals #1 and #2. The home failed to obtain dietary orders from Individual #2's physician upon admission, did not seek immediate medical attention after Individual #2 choked on food, failed to address all Individual #2's eating concerns with the Individual's physician after said choking incident, did not implement plans, failed to properly assess the Individuals' needs, and failed to follow Department orders effective immediately on 5/13/21.
Failure to obtain dietary orders upon admission:
· Individual #2's physical examination record required upon their admission to the home on 1/25/2021, did not include documentation of the individual's dietary needs. The field was left blank. According to record information, the individual has a diagnosis of Dysphagia, is a choking risk, and has had trouble swallowing food and liquid for years.
Failure to seek immediate medical attention after choking:
· Individual #2 choked on food in the home on 2/10/2021. Staff documented the individual was gasping for air with their arms stretched out, required staff to hit them on the back to dislodge the food item, and was choking for approximately 15 seconds. There are no records maintained that the home sought any type of medical intervention for the choking incident until 2/15/2021.
· Via a medical health alert on 1/4/2015, the Department instructed agencies to contact 911 for an incident of choking. The home never contacted 911.
Failure to address Individual #2's dietary concerns with medical professionals:
· On 2/10/21 Individual #2 choked on food at the home. Staff persons #1 and #2 who witnessed the event, documented the individual "doesn't chew their food when they eat but rather softens the food in their mouth then swallows." Staff also documented that during a phone conversation with the individual's sister on 2/11/21, there was possible concerns the individual has increased gagging and choking while eating and drinking together. There are no records maintained that the agency informed the individual's physician, and requested dietary clarification, of the specific difficulties staff documented above regarding the individual's eating and drinking during meals. During the 5/14/21 onsite inspection at the home, Staff person #1 confirmed that Individual #2 has trouble swallowing food and liquid every day.
· After Individual #2's sister reported to staff on 2/11/21 that the individual has increased risk of choking and gagging while eating and drinking together, the home did not provide liquids to the individual during mealtimes. The home did not seek medical advice if it was safe to withhold liquids from Individual #2 during meals and snacks until 5/5/21. The individual's physician clarified on 5/5/21 that the individual should have frequent sips of water with food.
· Individual #2 is diagnosed with Dysphagia, Spastic Quadriplegic Cerebral Palsy, is documented to have difficulty swallowing, and is a choking risk. During lunch on 5/14/21 the individual was witnessed to be coughing excessively while eating lunch and drinking from a cup and witnessed to cough later in the day when drinking a soda from a cup. The home did not independently initiate contact with a medical professional after the individual was witnessed to be coughing excessively when eating and drinking throughout the day.
· On 5/5/21 Individual #2's physician stated the individual is to have frequent sips of water with food. During lunch on 5/14/21, the individual was gulping/chugging liquids from a cup which resulted in the individual coughing excessively. It was only after the individual started coughing, that staff reminded the individual to drink slower.
· Staff person #1 reported to the Department on 5/14/21 that the last known date an agency staff attending a medical appointment with Individual #2 was on 2/15/21.
Failure to implement plans:
· Individual #2's individual support plan (ISP) states that the individual's food is to be cut into dime-sized pieces and staff always need to be within line of sight and 5-foot reach of the individual when eating and drinking. During the 5/14/21 inspection, Staff person #3 prepared a hot pocket and pears for Individual #2 that were cut into quarter-sized pieces. Staff person #3 was also witnessed to be more than 5 feet away from the individual with their back turned to the individual (not line of sight) while the individual was eating lunch at the kitchen table at one point. Again, staff was not within 5 feet of the individual or visual eye sight when the individual was drinking a soda in the living room after lunch.
· Refer to violation description 6400.186 of this report.
continued on next description... | 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. | The violation occurred because a new staff was involved in the admission process and that person was not properly oriented to the admission process. Nor was their work properly reviewed by their supervisor. / All medical information was reviewed by two staff responsible for the home and the medical provider(s) were contacted for needed information and any clarification. The health and safety plans were then rewritten. A registered nurse will review the health and safety plans, and compare it with all other medical documentation to ensure nothing was missed in supporting the person(s). Also, on 6/28/2021 the HCQU on dysphagia. / A Practice and Guideline will be written to ensure all health and safety needs are met upon admission and as the medical needs change. This will provide a step by step guideline on the responsibilities and actions to be taken by all staff responsible for writing the health and safety plans or those participating in the attendance and communication with health professionals. This group would include but not be limited to the CADOS, Program Manager, RN, OADOS and select members of the DSP staff. In addition a training on the P & G will be developed for DSPs and Program Managers to understand what and how to communicate updates from a medical provider. The training will be developed by 7/30/2021 Training will be completed by 8/13/2021. |
09/30/2021
| Not Implemented |
| 6400.16 | Failure to assess the individual:
· Individual #2's current, 3/18/21 assessment does not include their allergy to adhesives. According to medical documentation from the individual's physician on 2/15/21, the individual is allergic to adhesives and Phenytoin (Dilantin); Dilantin was the only allergy included in the assessment. During the 5/14/21 onsite inspection, the agency management staff responsible for oversight at the home, was not aware that the individual had an allergy to adhesives.
· The 3/18/21 assessment states the individual's food needs cut into dime size pieces, but also states their food needs cut into bite-size pieces. Staff person #2, creator of the assessment, reported on a separate document on 2/10/21 that the individual's food needs cut into dime-sized pieces.
· On 2/10/21 Staff person #2 reported Individual #2 does not chew or chews minimally when eating, only softens the food in their mouth and then swallows. The individual's individual plan states the individual has trouble swallowing food and food collects in their mouth. Staff person #2 did not include this information in the individual's 3/19/21 assessment.
· The individual's current, physical examination record states they are diagnosed with Aphasia. This diagnosis was never included in their assessment as a current diagnoses or medical and functional limitation.
· The individual's assessment states they can "communicate independently, can communicate verbally and is able to express their wants and needs independently." During 5/14/21 inspection, staff had to relay the individual's name to Department representatives as this information was unclear when the individual was introducing themselves. Additionally, the individual's physician noted on their physical examination record, that information pertinent to the diagnosis and treatment in the event of an emergency was that the individual was diagnosed with Aphasia; a condition hindering the individual's ability to communicate.
· The individual's assessment does not accurately reflect the current state of ambulation and needs. The individual's assessment states a strength of theirs is the "ability to walk up and down stairs, needs assistance on uneven surfaces and terrain, can walk on an incline, and sits, stands and walks independently." During the 5/14/21 inspection, the individual needed physical assistance from staff to walk the incline of their smooth, even-terrain, paved driveway. It was reported on 5/14/21 that the basement door is kept locked as the individual has difficulty ambulating stairs. When the individual was ambulating about the home on 5/14/21, they would steady themselves on nearby surfaces on occasion to balance themselves. For example, they would hold onto the kitchen island, walls, and cupboards when walking near them.
· The individual is currently diagnosed with Spastic Quadriplegic Cerebral Palsy. The individual's assessment does not include this diagnosis, but reports they are diagnosed with Cerebral Palsy.
· Individual #2's assessment states they complete their daily hygiene routine independently that includes: toileting, clothing coordination, dressing, brushing/flossing their teeth and bathing. However, the assessment also states that they need assistance with parts of their daily hygiene routine and showering. These statements are contradictory and do not include an accurate understanding of the individual's needs and abilities.
· On 5/5/21 the individual's physician stated that the individual should have frequent sips of water with food, they should increase their water intake, increase fiber in diet, and limit between meal snacking. The individual's current assessment does not include this information. The individual's individual support plan contradicts this by stating the individual is not to have beverages with their meals.
· Refer to violation descriptions in 6400.181(e)(1), 6400.181(e)(3)(i), 6400.181(e)(3)(iii), and 6400.181(e)(9) of this report.
Failure to follow Department's orders:
· On 5/13/21 at 1:38PM the Department instructed the agency, Typical Life Corporation, that effective immediately, 32 staff, including Staff person #3, were not able to administer medications until they have successfully completed the Department's Medication Administration Training course. During the 5/14/21 onsite inspection of Individual #1's medication administration records, Staff person #3 administered all medications to the individual in the morning on 5/14/21 and they had not successfully completed the medication administration training course. | 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. | A Practice and Guideline, listing a step by step method will be developed to ensure all health and safety needs are met upon admission and as the medical needs change. This will be given to all staff responsible for writing the health and safety plans, that is, CADOS, OADOS, Program Manager, RN and select members of the DSP staff actively participating in the care and management of supported persons. In addition a training will be developed for DSPs to understand how to communicate updates from a medical provider to the CADOS. The training will be developed by 7/30/2021 Training will be completed by 8/13/2021. The RN and CADOS will have 24 hours after any change in the medical status to review and implement appropriate measures to meet the orders/recommendations of the medical professional. CADOS personnel The program specialist called the PCP and the PCP provided instructions Seen by PCP on 2/15/21 Health and Safety Plan was updated and the Health and Safety Plan and the PCPs instructions are congruent. The assessment will be updated by 7/2/2021 to be congruent with the Health and Safety Plan. CADOS personnel are responsible for ensuring the training of staff within any location as it relates to the people in support at that location. The RN and the CADOS responsible for a particular location will collaborate on the review of the medical information and they will work together to obtain any information not evident in the initial paperwork. |
09/30/2021
| Not Implemented |
| 6400.22(d)(2) | Individual #1's daily financial spending ledger provided, stated on 5/5/21 they had $30 in their daily spending account. The record stated on 5/13/21 the individual now had $12.29 available to them in the same account. There were no records maintained for what occurred between 5/5 and 5/13. | (2) Disbursements made to or for the individual.
| The Financial Manager and the Program Manager were able to recreate the circumstances and come to a conclusion of what expenditures were made that accounted for the discrepancy. |
06/25/2021
| Not Implemented |
| 6400.22(f) | Individual #1's daily spending money is comingled with staff's personal funds. The agency, Typical Life Corporation, writes checks from Individual #1's account to staff members. Staff members cash the check and deposit the money into the individual's spending account. This occurred on 2 different occasions from 2/12/21 through 5/7/21 with checks #1072 and #1089, both written to Staff person #3. | There may be no commingling of the individual's personal funds with the home or staff person's funds. | [The Director of Operations will retrain all staff in TLC's employ on regulation 6400.22f regarding commingling of funds by 9/30/21. Checks will be written and released to the individual for which the funds are for. Checks will be deposited in the individuals' bank account or taken to the bank for cashing with the assistance of TLC staff, when necessary. The P&G (Policy & Procedure and Practice & Guideline) developed and implemented by TLC will be reviewed and updated, as needed, to reflect the procedure above. All staff will receive training on the updated P&G by 9/30/21. Documentation of training shall be kept. Any funds received by an individual shall be recorded immediately on the financial log. The staff member assisting with the transaction is responsible for documentation on the financial log. Financial records should be reviewed by the home supervisor daily.] BR Licensing Supervisor |
09/30/2021
| Not Implemented |
| 6400.43(b)(3) | Staff person #5 was hired on 2/1/21. On 5/11/21, the agency, Typical Life Corporation, did not have record if Staff person #5 was a resident of the state of Pennsylvania for the previous two years, thus not requiring an FBI record check upon hire. The agency also did not have record that they completed an FBI record check for Staff person #5 upon hire. Staff person #5 has been working directly with individuals. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | [A written statement by the person verifying that they lived in PA for the last two consecutive years (submitted). TLC Human Resource Information System has been updated to ensure that form the potential employee signs must be completed properly prior to the employee beginning employment. The HR Director will designate a staff person within HR to audit each hire's paperwork to ensure the complete nature of the information. No person, will be allowed to begin work, based on this review if information is not complete. The HR Director will randomly check new hire paperwork. This will consist of a 5% sample size each quarter for new hires. The review of all new hires back to January of 2020 was done and completed by June 22.]BR Licensing Supervisor 8/11/21 |
10/15/2021
| Not Implemented |
| 6400.64(a) | A pink bar of soap was witnessed to be sitting on a ledge in the hallway shower/tub combination, accessible to both individuals. The bar of soap was not stored in a labeled container that would maintain sanitary conditions and prevent the individuals from mistaking the bar of soap for their own and possibly spreading diseases. | Clean and sanitary conditions shall be maintained in the home. | Soap containers were purchased for each resident living in a home with two or more people before May 21, 2021. The soap containers will be labeled with the person's name on it and stored in an accessible area for the person to be able to use as needed. The Program Manager, and in the absence of this position, the OADOS, will look at least monthly (this can be done virtually) at the existence and proper use of the soap containers. |
07/30/2021
| Not Implemented |
| 6400.112(c) | REPEAT from 1/11/21 annual inspection: There are no records maintained for the time the 2/9/21 fire drill was conducted at the home. The time of evacuation during the 2/9/21 fire drill was not documented in a comprehensible format. Staff documented that the evacuation time of the drill was, "1;06.09."
The 2/9/21, 4/15/21, and 5/4/21 fire drill records do not indicate if all smoke detectors in the home were activated, or were in working order, during said fire drills. Staff documented that all the smoke detectors were tested and in working order during each fire drill, but also documented that not all smoke detectors and strobes lights activated at the time of the drill. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | The documentation exists and will only be provided from the automated FORMS spreadsheet. |
03/19/2021
| Not Implemented |
| 6400.113(a) | Individuals #1 and #2 moved into the home on 1/25/2021. There are no records maintained that the individuals received training in the specific fire safety requirements defined in 6400.113(a) upon admission or after. It's documented that the individuals received training on fire safety on 1/25/21 and 2/9/21. However, the content of training provided to individuals on 1/25/21 and 2/9/21 was not documented and could not be produced. | 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. | Both individual #1 and #2 were retrained in fire safety and evacuation procedures on 6/30/21. The TLC residential Fire Safety Training form in the record is evidence of this. |
06/30/2021
| Not Implemented |
| 6400.141(b) | REPEAT from 1/11/21 annual inspection: Individual #1's physical examination record was not dated by the physician, certified nurse practitioner, or physician's assistant who completed the physical examination. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | 3/26/2021 a new physical was completed and this was corrected. The CADOS is responsible for the physical information to be complete and correct. If there is a deficiency, they can delegate, but are the responsible position for TLC;s adherence to the regulation. |
11/30/2021
| Not Implemented |
| 6400.141(c)(7) | Individual #1's current physical examination record did not include a gynecological examination to includes a PAP and breast examination, completed within the previous year, or record that it was deferred. At the time of the 5/10/21 inspection, the physical examination record stated that the last known examination was completed in 2019. | 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. | A gynecological and pap test and breast examination on 1/27/2021. Two days after the person was admitted to TLC's service |
08/13/2021
| Not Implemented |
| 6400.141(c)(8) | Individual #1's current physical examination record did not include a mammogram completed within the previous year. The field on the physical examination record to indicate the date and results, or deferment, of the most recent mammogram was left blank. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | A mammogram was completed on 1/21/2021 |
09/30/2021
| Not Implemented |
| 6400.141(c)(10) | Individual #2's physical examination record obtained upon their admission to the home on 1/25/21, did not include if they were free of communicable diseases or precautions that need to be taken to prevent the spread of a communicable disease. This field was left blank until 5/5/21. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | We have put in to place a way to ensure this information is collected at the time of admission via an admission checklist as the responsibility of the CADOS |
09/30/2021
| Not Implemented |
| 6400.141(c)(11) | Individual #2's physical examination record obtained upon their admission to the home on 1/25/21, did not include health maintenance needs. The field was left blank until 5/5/21. | 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. | We have put into place a way to ensure this information is collected at the time of admission via an admission checklist as the responsibility of the CADOS |
09/30/2021
| Not Implemented |
| 6400.141(c)(15) | Individual #2's physical examination record obtained upon their admission to the home on 1/25/21, did not include dietary instructions. This field was left blank until 5/5/21. | The physical examination shall include:Special instructions for the individual's diet. | We have put into place a way to ensure this information is collected at the time of admission via an admission checklist as the responsibility of the CADOS |
09/30/2021
| Not Implemented |
| 6400.144 | REPEAT from 1/11/21 annual inspection: The following are examples where health services planned for or prescribed for Individual #1 that were not arranged for or provided for them:
On 1/26/21 the individual attended aquatic physical therapy. They were instructed to complete home exercises daily, 10 repetitions each, 3 sets each, 1 time daily, 7 days per week: seated long arc quad, supine lower trunk rotation, supine bridge, supine active straight leg raise, and standing hip abduction with counter support. There are no records maintained that these exercises are being completed as ordered. The physical therapist changed the home exercise program on 2/22/21 to include daily exercises, 10 reptations each, 3 sets each, 1 time daily, 7 days per week: tandem walking with counter support, seated long arc quad, seated march, sit to stand, shoulder extension with resistance, standing anti-rotation press with anchored resistance. There are no records maintained that these exercises are completed as ordered.
On 2/2/21 individual #1 reported to their physical therapist that they "fell last night." There are no records that the agency assessed the individual for a fall or followed up with a medical professional for the fall.
In January the individual's physical therapist noted that the that individual had an unstable posture and a fall encounter. On 2/22/21 the physical therapist documented that the patient falls frequently, has abnormal posture, unspecified fall and is unsteady on their feet. The home does not have a fall prevention plan in place to ensure her safety when moving about and in and out of the home.
The individual saw their physician for a full body skin assessment on 2/11/21 due to personal history of melanoma in situ, seborrheic keratosis, multiple benign melanocytic nevi of upper and lower extremities and trunk, and Asteatotic dermatitis. The physician noted that plan is to continue to observe the benign melanocytic nevi of upper and lower extremities and trunk, call for a follow-up appointment and possible steroid prescription if any of the lesions change in size, shape, color or behavior, and to follow a daily specific skin care regimen: short, warm shower/bath once daily to not dry out skin, mild soap such as dove white bar, unscented moisturizers should be applied twice daily and once daily on damp skin out of the shower, apply Vaseline and socks before bed and leave on overnight. There are no records that the individual was assessed to complete all steps of the physician's recommendations independently, that all recommendations are implemented as written, or that the individual was refusing any of the hygiene recommendations.
On 2/23/21 the individual's physician recorded that the individual will benefit from a Behavior Specialist. As of 5/10/21 the individual does not have a behavior support plan that is created and monitored by a Behavior Specialist or receiving support by a Behavior Specialist. During the 5/14/21 onsite visit, a behavior support person was at the home. However, the behavior support person reported to the Department that they were not providing support to the individual, they were only monitoring for behaviors.
On 3/1/21 the individual's podiatrist prescribed daily foot checks. There are no records maintained that the individual's feet are checked daily.
On 3/4/21 the individual's physician recommended the individual consume less than 2 grams of sodium a day and maintain a blood pressure goal of less than 130/80. There are no records that the home is monitoring and recording the individual's sodium intake or blood pressure.
Individual #1 transitioned from aquatic and land physical therapy to a Wellfit program on 3/19/21. The individual attending sessions until 4/13/21. There are no records maintained that the sessions were discontinued, ended, or continued after 4/13/21.
Individual #1 saw their physician on 3/23/21 to review their psychotropic medications and behavioral health. The individual was to return in 4 weeks, on 4/20/21. A note was documented that the appointment was canceled by the "provider" but did not clarify if the provider was the agency, Typical Life Corporation, or the physician.
Individual #1's current physical examination record stated the individual is to use a CPAP (Continuous Positive Airway Pressure) machine. On 4/9/21 the individual's Pulmonary and Sleep specialist confirmed the individual is to continue to use their CPAP machine nightly due to Severe Obstructive Sleep Apnea. There are no records maintained that the individual is using the CPAP machine every night; i.e. no documentation if it was used on 1/30, 2/13, 2/26, 4/3, 4/4 of 2021. Additionally, staff have documented at 4 AM on a particular day that the individual used their CPAP machine for the entirety of the 12 AM to 6 AM shift the same day, prematurely completing record information.
The individual had a Urology appointment scheduled for 4/29/2021. They did not return to their Urologist until 5/5/21, with no explanation for the late appointment. | 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.
| The PCP was consulted about dietary needs and clarifications were obtained. Physical exam information was also completed when made aware of the difficulty. |
09/30/2021
| Not Implemented |
| 6400.151(c)(2) | Staff person #10 has not had a Tuberculin (TB) skin test by Mantoux method completed with negative results since 9/10/18. At the time of the 5/10/21 inspection, there are no records maintained that they had another TB completed, a chest x-ray with results, or documentation from the staff's physician that they were not to have the TB test during a certain time frame due to receiving any other vaccination that could impede the results of a TB test. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The CADOS will schedule a TB skin test at a time indicated by a medical professional that is safe and will provide a good result. The date of said test and its scheduling will be provided as needed when available. This was a result of a conflict with the COVID vaccine. HR is reviewing all staff member's records. This was done before June 25 |
09/01/2021
| Not Implemented |
| 6400.181(e)(1) | Individual #1's functional strengths, needs, and preferences were not accurately assessed in the Individual's current, 3/19/21 assessment. The assessment reports that the individual's strengths are walking independently, avoids obstacles, stands without falling over, and can go up and down stairs. However, the individual was attending physical therapy sessions twice a week for three months during the creation of the assessment. Per their physical therapist the individual was receiving services due to "falls frequently, has abnormal posture, unspecified fall, is unsteady on their feet, high fall risk, one-side weakness, and has some limited range of motion in extremities."
The assessment stated a strength of the individual's was that they were cooperative at dental appointments. At the time of the assessment, the individual had not been to the dentist for a dental appointment with the provider to assess this. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | The program specialist called the PCP and the PCP provided instructions Seen by PCP on 2/15/21 Health and Safety Plan was updated and the Health and Safety Plan and the PCPs instructions are congruent. The assessment will be updated by 7/2/2021 to be congruent with the Health and Safety Plan. |
10/30/2021
| Not Implemented |
| 6400.181(e)(3)(i) | Individual #1's current, 3/19/21 assessment does not clearly define their functional skills regarding their daily life at their residence. For example, their assessment mentions multiple times how they can independently complete daily hygiene routine of toileting, dressing, showering and dental hygiene. But also goes on to state that they need prompting to complete said tasks, monitored to ensure thorough showering and cleaning after a bowel movement, and that they need assistance with fine motor tasks associated with bathing, rinsing their hair and thoroughly cleaning after a bowel movement. Additionally, the individual's physical therapist documented functional concerns for the individual that included: high risk of falls, history of falls, unsteadiness on their feet, abnormal posture, one-side weakness and limited range of motion in some extremities. The individual's assessment did not include these concerns. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. | The program specialist called the PCP and the PCP provided instructions. Health and Safety Plan was updated and the Health and Safety Plan and the PCPs instructions are congruent. The assessment will be updated by 7/2/2021 to be congruent with the Health and Safety Plan. |
10/30/2021
| Not Implemented |
| 6400.181(e)(3)(iii) | Individual #1's current, 3/19/21 assessment does not include their current level of performance in their personal adjustment needs and strengths. The assessment states that the individual is having some behavior concerns and needs to be provided with 1:1 staffing starting on 3/8/21. However, the assessment does not include all behavior concerns or describe what they are. The individual's record notes the individual experiences agitation and hallucinations and has diagnoses of schizophrenia, manic bipolar 1 disorder, mood disorder, psychotic disorder, impulse control disorder, a recent episode of PICA with an attempt to ingest a tag from an article of clothing, and many perseverations. | The individual's current level of performance and progress in the following areas: Personal adjustment. | The program specialist called the PCP and the PCP provided instructions. Health and Safety Plan was updated and the Health and Safety Plan and the PCPs instructions are congruent. The assessment will be updated by 7/2/2021 to be congruent with the Health and Safety Plan. |
10/30/2021
| Not Implemented |
| 6400.181(e)(9) | REPEAT from 1/11/21 annual inspection: Individual #1's current, 3/18/21 did not include a complete list of their diagnoses and functional and medical limitations. Prior to the assessment, the individual's record includes diagnoses and functional and medication limitations of: history of melanoma in-situ, seborrheic keratosis, multiple benign melanocytic mevi of upper and lower extremities and trunk, asteatotic dermatitis, anemia, cerebral artery occlusion, essential hypertension, gerd, hyerlipidemia, manic bipolar 1 disorder, severe obstructive sleep apnea, osteopenia, overactive bladder, overweight, psychotic disorder, scabies, schizophrenia, shoulder pain, mood disorder, impulse control disorder, hallucinations, PICA, falls frequently, has abnormal posture, unspecified fall and is unsteady on their feet, high fall risk, one-side weakness per physical therapist, has partial dentures, intellectual disability, history of a stroke in 2018, should consume less than 2 grams of sodium per day, can have 2 cups of coffee in the morning, has partial dentures, back pain and allergic to grass, seasonal allergies, easter sycamore pollen extract, tree and shrub pollen, and Thorazine (chlorpromazine). However, their assessment only documented diagnoses and functional and medical limitations of: obstructive sleep apnea, bipolar affective d/o, current episode manic, undifferentiated schizophrenia, mild id, anemia, gerd, pica, cerebrovascular disease, hypertension, hyperlipidemia, cva w/o neurological deficits, osteopenia, chronic low back/neck pain, melanoma left lower extremity, cataract surgery, history of agitation due to schizophrenia, seasonal allergies and allergy to Thorazine.
Additionally, the list of medications included in their 3/19/21 assessment did not include the accurate dosage of medications they were prescribed at that time.
The individual's 3/19/21 assessment states they are not considered a choking risk. However, the author of the assessment also created a separate health and safety plan on 2/24/21 stating the individual is a choking risk and that their food must be cut into small pieces. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | The program specialist called the PCP and the PCP provided instructions. Health and Safety Plan was updated and the Health and Safety Plan and the PCPs instructions are congruent. The assessment will be updated by 7/2/2021 to be congruent with the Health and Safety Plan. |
10/30/2021
| Not Implemented |
| 6400.18(b)(2) | The medication errors described in 6400.165(c) and 6400.167(b) of this report, were never reported to the Department. | 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 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | Medication Errors identified in this report will be entered into EIM by the appropriate area ADOS |
06/18/2021
| Not Implemented |
| 6400.32(d) | Individual #1's assessment states they use mouthwash daily. Individual #2's individual support plan (ISP) states they use mouth wash at least two times daily. Only one bottle of mouthwash was found in the hallway bathroom under the sink with no indication who's mouthwash it was. The bottle was almost empty and was heavily used. Individual's should be provided their own personal hygiene products.
Staff documented on Individual #2's current physical examination record that the individual's medications are put in applesauce. Staff person #1 confirmed on 5/14/21 that staff, not the individual's physician, recorded this information. Individual #2's current, 3/18/21 assessment states they are unable to meet the standards to self-medicate. There are no records indicating that the individual is informed of their medications, their names, dosages, reason for prescribing them, and other identifies for every time a medication is disguised in applesauce and administered to the individual. | An individual shall be treated with dignity and respect. | Staff did not realize the need for separate identified containers since each person has their own bathroom facilities. |
06/18/2021
| Not Implemented |
| 6400.32(o) | There were two occasions where Individual #1 has been denied their right to manage their daily spending money. The agency, Typical Life Corporation, writes checks from the individual's financial account to staff persons for staff to cash. This occurred on 2 different occasions from 2/12/21 through 5/7/21 with checks #1072 and #1089, both written to Staff person #3. Individual #1 has not consented to the above method of distributing money and purchasing items requested for them. | An individual has the right to manage and access the individual's finances. | Plan of correction (immediate problem): [All TLC staff will be trained by the Director of Operations on regulation 6400.32o regarding the right to manage and access finances by 9/30/21. The Director of Operations is responsible to review and update the agency's policy on individual funds, ensuring the policy accounts for individual choice and direction. The policy shall be compliant with 6400.22(a). Checks will be written and released to the individual for which the funds are for. Checks will be deposited in the individuals' bank account or taken to the bank for cashing with the assistance of TLC staff, when necessary. The P&G (Policy & Procedure and Practice & Guideline) developed and implemented by TLC will be reviewed and updated, as needed, to reflect the procedure above. All staff will receive training on the updated P&G by 9/30/21. Documentation of training shall be kept. Any funds received by an individual shall be recorded immediately on the financial log. The staff member assisting with the transaction is responsible for documentation on the financial log. Financial records should be reviewed by the home supervisor daily.] BR Licensing Supervisor 8/11/21 |
09/01/2021
| Not Implemented |
| 6400.34(a) | REPEAT from 1/11/21 annual inspection: individual #1 has had an appointed Power of Attorney (POA) since 2014. The individual's rights and the process of reporting a rights violation defined in 6400.32 was never reviewed and explained to Individual #1's POA. | 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. | A meeting will be held by the Clinical ADOS to review the individuals rights with the POA. This meeting will meet with the POA and get a signature by July 9, 2021 |
07/23/2021
| Not Implemented |
| 6400.46(a) | There are no records maintained that the specific fire safety training requirements defined in PA Code 55. Chapter 6400.46(a) were reviewed with Staff person #5 prior to working with individuals. The fields to include this information on his training log were blank. | Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Training was to be completed at the local sites for each person working within each home. They will be reviewed as part of the monthly staff meetings at each location during July |
08/13/2021
| Not Implemented |
| 6400.50(a) | The training records for Staff person #5 and #10 did not include the specific content, the trainer, and the total hours of each training. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | Training was to be completed monthly for annual exposure. A list of courses assigned, to both direct support staff with tenure and new hires is available. The new LMS system will allow for the trainings to be available to any appropriate party with the time spent in the training and the topics assigned to and completed by each staff member |
08/13/2021
| Not Implemented |
| 6400.165(c) | REPEAT from 1/11/21 annual inspection: There were multiple occasions since Individual #1's admission to the facility on 1/25/21 that their medications weren't administered as prescribed. The follow are examples of said occasions.
Individual #1's current list of medications attached to their physical examination record gathered upon admission states they were prescribed: Risperidone 1mg: take 1 tablet by mouth at bedtime, Aspirin 81mg: take 1 tablet by mouth every day, Divalproex sodium 125mg table: take 3 tablets by mouth every day at bedtime, Atorvastatin Calcium 40mg: take 1 tablet by mouth every day, Carvedilol 25mg: take 1 tablet by mouth twice a day, Zyrtec 10mg: take 1 tablet by mouth every day, and take one multivitamin by mouth every day. According to the individual's January 2021 medication administration record (mara), they were only administered Aspirin once a day, Atorvastatin once daily, and Divalproex 375mg nightly.
Additionally, there are no records that Divalproex was administered on 1/27/21, 1/28/21, or 1/31/21 as the mar was left blank.
There are no records that Atorvastatin was administered on 1/28-29/21 and 1/31/21 as the mar was left blank.
On 1/26/21 individual #1's physician documented that they are to take Atorvastatin 80mg once daily at 7 AM. The home has never administered this medication at that prescribed dose.
There are no records that any of the individual's prescribed medications (aspirin, atorvastatin, carvedilol, cetirizine, daily vitamin, divalproex, risperidone, vitamin d3) were administered to them on 2/1/21. The mar was either blank or had an X, defined as "not scheduled", for 2/1/21.
There are no records that the individual's prescribed medications (aspirin, carvedilol, cetirizine, daily vitamin, risperidone, vitamin d3) were administered to them on 2/2/21. The mar was either blank or had an X, defined as "not scheduled," marked on 2/2/21.
Staff person #3 recorded on 2/3/21 that the wrong dose of Carvedilol was administered at 5pm to Individual #1.
There are no records maintained that the individual's Cetirizine was administered on 2/3/21.
There are no records that the individual's Divalproex 375mg was administered on 2/6/21. The mar was left blank.
Staff person #3 documented on 2/24/21 that they administered Divalproex 375mg to Individual #1 with a note about the administration: "the medication dosage changed to 500mg." There are no records maintained for the exact dose administered on 2/24/21.
There are no records maintained that the individual's Carvedilol was administered from 2/4-12/21. All the individual's mars are left blank.
There are no records that the individual's daily multivitamin was administered daily from 2/1-22/21.
On 3/4/21 Individual #1 was prescribed Galvilax powder, to mix 1 capful (17grams) into a beverage and drink once a day as needed for constipation for up to 3 days. Staff documented that the individual had a bowel movement on 4/2/21 and not again until 4/6/21, 4/22/21 and not again until 4/26/21, and 5/6/21 and not again until 5/11/21 and the medication was never administered for any of the occasions listed.
The individual was prescribed Risperidone twice daily. The home only administered the medication once daily on 3/24/21 and 3/26/21 and never administered the medication on 3/25/21. | A prescription medication shall be administered as prescribed. | Medication Audits will be conducted weekly by DSP for each individual at each location. This will be reviewed by ADOS . This will no longer be the responsibility of the Director of Services and will be reviewed weekly by the ADOS personnel to assure the accuracy of the medication audits and allowing for the immediate, real-time identification of errors or difficulties with the medication delivery to the individual. |
09/01/2021
| Not Implemented |
| 6400.165(f) | Individual #1 is prescribed psychotropic medications for psychiatric illnesses. The individual's individual support plan does not include a written protocol to address the social, emotional, and environmental needs (SEEN) of the individual related to the symptoms of all their psychiatric illnesses. The individual's record did include a SEEN plan however, there is no record that this was sent to all team members, specifically the supports coordinator who will add this plan into the individual's individual support plan. Additionally, the SEEN plan did not include a plan to address how, when, and for how long to lock up sharp objects when the individual is displaying signs of hallucinations as they are reportedly a danger to themselves and others during hallucinations. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | The NEW CADOS has created ISP add form to update the ISP including the SEEN. The CADOS has been in touch with the psychiatrist to get specific instructions to provide to staff on the recognition of hallucinations. He will then train the staff on this information, put into place appropriate measures to lock the sharps and protect other staff and individuals |
09/30/2021
| Not Implemented |
| 6400.166(a)(11) | REPEAT from 1/11/21 annual inspection: Individual #1's January 2021 medication administration record (mar) does not include the diagnosis or reason for prescribing Aspirin or Divalproex.
The individual's February 2021 mars do not include the reason for prescribing and administering their Divalproex 125mg tablet and Risperidone .5mg tablet.
The individual's March 2021 mars do not include the reason for prescribing and administering Nitrofurantoin mono, Divalproex, Risperidone, and their daily multivitamin.
The individuals April 2021 mars do not include the reason for prescribing and administering Divalproex, Risperidone, and their daily multivitamin. | 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. | Medication Audits will be conducted weekly by DSP for each individual at each location. This will be reviewed by ADOS . This will no longer be the responsibility of the Director of Services and will be reviewed weekly by the ADOS personnel to assure the accuracy and completeness of the medication audits and allowing for the immediate, real-time identification of errors or difficulties with the medication delivery to the individual. |
10/30/2021
| Not Implemented |
| 6400.166(b) | There were three, handwritten medication administration records (mars) in Individual #1's record where staff have documented multiple medication administrations. However, the date of administration was never recorded. All three mars did not include the month or year that the medications were administered, and the time of administration was not recorded for the administration of Atorvastatin. Additionally, at least 5 different staff initials have documented as administering medications to the individual via the handwritten mars and only two staff have included their name to identify the name of the staff that administered the medications. The initials of many of the staff members who signed as administering medications via the handwritten mars are not legible.
The time of administration for Individual #1's Cetirizine on 5/6/21 was not documented. Staff person #3 recorded a note on 5/6/21 at 7:39am that the medication was given at "&:30pm" but also that the individual was on leave during this time of administration. An accurate time of administration was never recorded.
The time of administration for all Individual #1's pro-re nada (PRN or "as needed") Cetirizine medication was not recorded in April and May 2021. The individual is to be administered this medication 5mg once daily as needed. The mars state the PRN Cetirizine was "administered for allergy symptoms on {included a date and time} by {a specific staff member}," then immediately below each documentation states, "given at {a specific time}." Ten out of the eleven times Individual #1 was administered PRN Cetirizine during these two months, the time of administrations on both lines never agreed. For example, on 5/4/21 Cetirizine was documented as being administered at 7:20am and 7:15am. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Medication Audits will be conducted weekly by DSP for each individual at each location. This will be reviewed by ADOS . This will no longer be the responsibility of the Director of Services and will be reviewed weekly by the ADOS personnel to assure the accuracy of the medication audits and allowing for the immediate, real-time identification of errors or difficulties with the medication delivery to the individual. |
10/30/2021
| Not Implemented |
| 6400.167(b) | REPEAT from 1/11/21 annual inspection: The medication errors documented in 6400.165(c) of this report were not documented, reported to the Department, follow up action taken, and the prescriber's response to the medication errors kept. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | Medication Audits will be conducted weekly by DSP for each individual at each location. This will be reviewed by ADOS . This will no longer be the responsibility of the Director of Services and will be reviewed weekly by the ADOS personnel to assure the accuracy of the medication audits and allowing for the immediate, real-time identification of errors or difficulties with the medication delivery to the individual. To address the lack of knowledge the Quality Assistant and the Director of Compliance trained the ADOS and PM staff on reporting requirements in EIM. This was done twice, once in May and once in June, based on the results that would indicate there was a lack of understanding took place among this population. Numerous hires and some separations have occurred, including the DOS, ADOS and PM personnel. |
07/16/2021
| Not Implemented |
| 6400.169(a) | REPEAT from 1/11/21 annual inspection:
Staff person #2 administered medication to Individual #1 in May 2021. There are no records maintained they have completed and passed the Department's initial or annual medication administration training that would allow them to administer medications to the individual. A medication administration trainer did not document if Staff person #2 passed or failed the initial medication administration training course or the date of the pass or fail. The initial medication administration training requirements indicate that within 30 days of passing all written portions of the examination, 4 medication observations must be completed. If 4 observations cannot be completed within 30 days, additional observations must be completed depending on how long passed the date of written examinations is completed. Staff person #2 completed the written portions of the initial medication training on 11/5/2020. They had 2 observations completed 11/6/2020, and 2 completed 1/4/2020, not meeting the medication training requirements. At the time of the 5/12/2021 inspection, no additional observations were completed as required, nor did the staff person retake the initial medication administration training course again.
Staff person #3 administered medications to Individual #1 in April and May 2021. There are no records maintained they completed and passed the Department's initial or annual medication administration training.
Staff person #4 administered medications to Individual #1 in April 2021. There are no records maintained they completed and passed the Department's initial and annual medication administration training. The staff's 2020 initial medication administration training did not include documentation from a medication trainer if Staff person #4 passed or failed the course, the date of the pass or fail, or that all the required observations were completed in 2020. There are no records for 2021.
Staff person #5 administered medications to Individual #1 in May 2021. There are no records maintained that he completed and passed the Department's initial medication administration training course. He failed to complete 2 out of the 4 required initial medication observations in the proper order. Additionally, there are no records by a medication trainer indicating if Staff person #5 passed or failed the course and a date of when they passed or failed. The fields on practicum summary form were blank.
The Department instructed the agency, Typical Life Corporation, on 5/13/21 that there were no records maintained that Staff person #3 (along with 32 other identified staff, including staff persons #2-#10) completed and passed the Department's initial or annual medication administration training course and they were to cease administering medications effective immediately. Upon review of Individual #1's medication administration records on 5/14/21, Staff person #3 administered medications to Individual #1 on 5/14/21. | 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). | Retraining for all Staff at Autumn, by a certified medication trainer was provided before the end of the month of May. All four observations for that staff was also completed within a week of the training as directed by the Department. |
09/01/2021
| Not Implemented |
| 6400.186 | Individual #1's current, individual support plan (ISP) states that they are to see the dentist every 6 months and their last appointment was completed on 10/8/2020. At the time of the 5/10/21 inspection, there are no records maintained that the individual was examined by their dentist since 10/8/2020.
The individual's ISP states they are to see their Gynecologist yearly with the last visit completed on 3/2/18. Additionally, their ISP states they had a gynecology appointment scheduled for 1/27/21. There are no records maintained that the individual has seen their Gynecologist.
Individual #1's current ISP and 3/19/21 assessment both state that during times when the individual is experiencing hallucinations, it is recommended that sharps (scissors, knives, sharp objects) be put away and not provided to the individual. There are no records of the individual's hallucinations or that all staff working with the individual are aware of any hallucinations the individual has and when, so that sharp objects can be removed from individual's access. There isn't a plan in place to address the individual's hallucinations and when/how long sharp objects should be removed from access. During the 5/14/21 onsite inspection, there were approximately 10, large, knives and sharp objects sitting on the kitchen counter accessible to everyone in the home.
Individual #1 has a health and safety plan that states their blood pressure is to be monitored two times daily until 3/18/21. There is no record maintained of this being completed.
Individual #1 has a health and safety plan that states their physician recommends they consume less than 2 grams of sodium daily and to limit caffeine to 2 cups of coffee daily. There are no records maintained that the home is monitoring this.
Individual #1 has a health and safety plan that states their CPAP mask is to be cleaned daily, hoses to the machine cleaned weekly, filter changed/cleaned monthly and only distilled water to be used to fill reservoir. There are no records maintained this is being completed.
The tracking and documenting of the individual's behaviors identified within their SEEN plan (PICA, hallucinations, symptoms of schizophrenia, agitation and anxiety) are not being tracked and monitored per Staff person #1 on 5/14/21. The SEEN states the program manager is to monitor these symptoms but there's no records maintained that the identified personnel is completing this. | The home shall implement the individual plan, including revisions. | The ISP, Health and Safety Plan and Assessment will all be compared and brought up to date. This will be completed by July 9 |
10/30/2021
| Not Implemented |
| 6400.213(1)(i) | The violation in this description is in reference to regulation 6400.213(1)(ii)-Each individual's record must include the following information: The race, height, weight, color of hair, color of eyes and identifying marks. This regulation number is not accessible at this time in the Certified Licensing System and thus, documented here.
Individual #1's record does not include their identification marks. Their document titled, "individual face sheet" stated the individual's identifying marks were recorded as "wears glasses." However, an object that can be removed from oneself is not an identifying mark that can identify the individual. The individual's physical examination record mentioned the need for denture care. The agency did not indicate the missing teeth in the individual's record as an identifying mark. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The Content of the records will be redone by the current program specialist to ensure all appropriate information is updated/ corrected. This will be completed before July 9, 2021 |
08/13/2021
| Not Implemented |
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