| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.20 | According to staff documentation, Individual #1 had 14 seizures on 4/29/16. On 4/30/16, staff recorded that she had a "vast amount of motor seizures throughout the morning. After given 2 (PRN) doses of Lorazepam, seizures did not stop." On another staff note from 4/30/16, Individual #1 "had cluster of motor seizures." On 5/1/16 staff recorded that she "continued to have a cluster of motor seizures. Program Director gave permission for 2nd dose prn Lorazepam at 1:51pm. She continued to have seizures." The length of each seizure and any intervention required was not recorded. | The home shall maintain a record of individual illnesses, seizures, acute emotional traumas and accidents requiring medical attention but not inpatient hospitalization, that occur at the home.
| New Documentation forms implemented for staff to record the specifics of the seizures experiences rather general statements and to record the specifics of the required intervention that takes place. (Documents 3-6)
The deficiencies in reporting the detailed information required for the cited dates cannot be corrected after the fact.
Franklin Office Director created the forms and will train the staff in their use starting 7/11/2016 (sign in sheets for training completed so far attached Documents 6a ¿ 6e)
There have only been 2 seizure incidents since licensing ¿ documentation attached. The most recent was documented on the new forms.(documents 6L to 6p) Although not formally trained until 7/11/2016, the staff completing the form on 7/10/2016 was supervised by the Director.
All future consumer documentation will be copied and sent to home office to be reviewed monthly by the record clerk at the main office in Clarion PA to make sure all required information is present and correct
|
08/05/2016
| Implemented |
| 6400.44(b)(18) | Individual #1 had a seizure protocol for when to administer Lorazepam as needed and when to seek medical attention for seizures. All twelve staff work that work in the home were not trained on Individual #1's seizure protocol. | The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. | Seizure protocol training is part of every orientation and annual update. Retraining was held on May 20, 2016 for the protocol dated May 13, 2016 (Document 1 and 2) Trainer was the Director. HR at the main office will monitor training records and coordinate Records and the Director to make sure that all staff are trained at orientation, annually and when the protocol is updated. |
08/05/2016
| Implemented |
| 6400.46(j) | Training content for Anxiety Disorder, Obsessive Cumpulsive Disorder, Overview of Intellectual Disabilities, and Skin Disorder was not kept for Staff #1. | 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. | The Staff Verification Forms for the cited items (Document 16-19) are attached.
Human Resources will review personnel files after each training to make sure that all training verification forms are present and completed in their entirety. A sign in sheet will also be kept to compare to the Form to make sure nothing is missing.
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08/05/2016
| Implemented |
| 6400.103 | The written emergency evacuation procedure did not include individual responsibilities during an evacuation. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The correct Evacuation Procedure is attached (Document 7). It will be reviewed and reissued annually.
The consumer involved in the citation is completely dependent on others for all functions of movement and care. This procedure was written in the only reasonable wording that seemed possible.
The Director will make sure that the form is issued at admission and reissued annually upon update.
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08/05/2016
| Implemented |
| 6400.104 | Two individuals who require assistance to evacuate the home, reside at the residence. The fire notification letter sent on April 4, 2013 only indicated that one individual lived at the home. The letter did not indicate that individuals needed assistance or where their bedrooms were located. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| A corrected letter to the Fire Chief (Document 8) and a diagram of the house (Document 8a) was sent on July 1, 2016. The Director will make sure that this is updated/sent upon admission and annually. |
08/05/2016
| Implemented |
| 6400.141(c)(14) | Individual #1's 11/4/15 physical examination did not include information pertinent to diagnosis and treatment in case of emergency. Individual #1 has a severe seizure disorder. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The cited physical (Document 9 and 10) has been corrected by the Director as instructed.
The Records Clerk at the main office will review the initial physical form and make sure all fields are completed properly.
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08/05/2016
| Implemented |
| 6400.144 | Individual #1's neurologist signed her seizure protocol on 1/8/16 which indicated that "if her seizure lasts more then 1 minute or she has greater than 2 seizures in a cluster of seizures, she must be given Lorazepam 1 mg via PEG tube. If seizures persist, Lorazepam 1 mg via PEG tube may be repeated once in 15 minutes. If her seizures continue dispite the above treatment, medical attention must be sought." On 4/29/16 staff recorded on an unusual incident report, that Individual #1 had seizures at 8:16am, 8:28am, 8:34am, 8:50am, 8:56am, 9am, 9:10am, 9:18am, 9:26am, 9:32am, 9:40am, 9:45am, 10:02am, and 11:40am. Length of each seizure was not noted. Lorazepam 1mg via PEG tube was administered at 8:45am after a cluster of 3 seizures. She had another cluster of 3 seizures within 15 minutes from the first administration of Lorazepam. However Lorazepam was not administered again until 10am. On 4/30/16 staff recorded that Individual #'1 had a "vast amount of motor-seizures throughout the morning." Accroding to the April 2016 medication administration record, she was administered Lorazepam 1mg via PEG tub at 11:20am and 11:50am on 4/30/16. Medical attention was not sought until after 1:30pm when, according to the incident report, the agency decided to take Individual #1 to the hospital. | 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.
| New Documentation forms implemented for staff to record the specifics of the seizures experiences rather general statements and to record the specifics of the required intervention that takes place. (Documents 3-6)
The deficiencies in reporting the detailed information required for the cited dates cannot be corrected after the fact.
Franklin Office Director created the forms and will train the staff in their use starting 7/11/2016 (sign in sheets for training completed so far attached Documents 6a ¿ 6e)
There have only been 2 seizure incidents since licensing ¿ documentation attached. The most recent was documented on the new forms.(documents 6L to 6p) Although not formally trained until 7/11/2016, the staff completing the form on 7/10/2016 was supervised by the Director.
All future consumer documentation will be copied and sent to home office to be reviewed monthly by the record clerk at the main office in Clarion PA to make sure all required information is present and correct
|
08/05/2016
| Implemented |
| 6400.167(b) | On 4/29/16 staff recorded on an unusual incident report, that Individual #1 had seizures at 8:16am, 8:28am, 8:34am, 8:50am, 8:56am, 9am, 9:10am, 9:18am, 9:26am, 9:32am, 9:40am, 9:45am, 10:02am, and 11:40am. Length of each seizure was not noted. Lorazepam 1mg via PEG tube was administered at 8:45am after a cluster of 3 seizures. She had another cluster of 3 seizures within 15 minutes from the first administration of Lorazepam. However Lorazepam was not administered again until 10am. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | New Documentation forms implemented for staff to record the specifics of the seizures experiences rather general statements and to record the specifics of the required intervention that takes place. (Documents 3-6)
The deficiencies in reporting the detailed information required for the cited dates cannot be corrected after the fact.
Franklin Office Director created the forms and will train the staff in their use starting 7/11/2016 (sign in sheets for training completed so far attached Documents 6a ¿ 6e)
There have only been 2 seizure incidents since licensing ¿ documentation attached. The most recent was documented on the new forms.(documents 6L to 6p) Although not formally trained until 7/11/2016, the staff completing the form on 7/10/2016 was supervised by the Director.
|
08/05/2016
| Implemented |
| 6400.213(11) | Individual #1's 11/4/15 physical indicated that she was allergic to flu vax and moxiflaxacin. Individual #1's identification sheet indicated that she was allergic to flu vax, moxiflaxacin, and vancomycin. Their Individual Support Plan (ISP) indicated that they were only allergic to flu vax. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | The Personal Identification Sheet and the Physical have been corrected (Document 9-15)
All future consumer documentation will be copied and sent to home office to be reviewed monthly by the record clerk at the main office in Clarion PA to make sure all required information is present and correct
The SC has been notified that the ISP needs to be updated. As of July 15,2016, the ISP has not been corrected. Document 17/18 ¿ monthly and quarterly reports for December 2015 and January2016 notifying her of the information that needed updated
The physical did not contain the allergy for the Vancomycin because at the time of the Physical, there had been no sign of allergy.
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08/05/2016
| Implemented |