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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.13 | The licensed capacity of the home is 3. There are 3 individuals residing in the upstairs part of the home and two individuals, not receiving services residing in the lower portion of the home. | The maximum capacity specified on the certificate of compliance may not be exceeded. | The tenants have been issued an eviction notice on 11/1/23. The tenants who reside in the basement apartment will be relocated no later than 1/1/2024. |
01/01/2024
| Implemented |
| 6400.22(c) | The home has had two tenants residing in the basement of the home over the past year, September 2022 to September 2023. The home does not have separate electric, sewer, water, utilities, etc. and Individuals #1-#3's room and board funds have been used to fund all utilities for the entire home, including those that the two tenants are using. Individuals #1-#3 were never informed that their funds were being used for other's benefits or if they consented to this agreement.
Additionally, the home has not ensured the individuals and their legal guardians were aware of and approved of the room and board contract annually. According to records produced by the agency during the 9/26/23 inspection, only room and board contracts for the agreement made on 1/1/22 was provided. The agency does not have any agreement the individuals or their family agreed to for the annual year starting on 1/1/23. The following are the dates and persons agreeing to the 1/1/22 room and board: Individual #1's legal guardian signed in agreement on 2/1/22, Individual #2's legal guardian signed in agreement 12/22/21, and Individual #3's legal guardian signed in agreement on 8/23/22. The room and board contract does not specify what is included in the room and board contract, what items the individual is agreeing to pay for and what the provider is agreeing to pay for with the room and board funds. | Individual funds and property shall be used for the individual's benefit. | The organization has reimbursed the individual's 2/5 of the total utility costs retroactive to the beginning of the tenants' lease, on 9/27/23. The organization will continue reimbursement of 2/5 of the total utility costs for the remainder of the lease, ending on 12/31/2023. The incident of exploitation was entered into EIM and an investigation was initiated.
The Director of Finance will complete an accounting of expenses related to client room & board costs on a monthly basis, ongoing, by November 30th for October and so on.
The room & board contract for individual #1 for January 1, 2023, was signed by the guardian on 1/6/23 but the guardian mistakenly signed that it was signed on 1/6/22. |
01/01/2024
| Implemented |
| 6400.22(d)(1) | Individual #1's record didn't include a personal property record. The agency program specialist reported to the Department on 9/27/23, that property records aren't kept for any individuals.
Individual #1's monies available at the home during the 9/28/23 onsite inspection, was $11.16, which was also confirmed by agency staff with Department. On 9/29/23 Individual #1's monies available in their wallet now has $14.33. All receipts and financial records for Individual #1 are in agreement that $14.33 should be the ending balance of their wallet funds. There are no records for where the $3.17 was the day before.
During the 9/28/23 inspection, Individual #1 had gift cards available, but the home did not have any records of the current funds available on any of the gift cards. Gift cards present were: 2 for Olive Garden, 1 for Subway, 1 for Chick-Fil-A, and 1 for Target. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | The Associate Director of Residential developed an electronic property inventory record form on 10/13/23. The house manager and/or designee will complete an inventory record for each individual in their program and keep it up to date.
The house manager will ensure that money that goes with individual #1's community staff will be signed out and then counted and signed back in with receipts.
The Associate Director of Residential developed a gift card transaction log on 10/31/2023. The house managers were trained on how to use the transaction log on 10/31/23 and will use it moving forward. |
11/14/2023
| Implemented |
| 6400.43(b)(1) | According to the agency's "Individuals finances and Safeguarding Individual Funds policy", the home is to keep personal item inventories maintained for all individuals, and the inventory record will be updated as items are purchased or discarded. As referenced in 6400.22(d)(1) of this report, the home does not keep a personal property inventory record for any individual in their homes, nor keep it updated.
The agency didn't follow or implement the Department's medication administration training course requirements. According to the Department's medication administration training course, staff who complete and pass the initial and annual medication administration training practicum observer course, are certified practicum observers and can completed some portions of staff's annual medication administration training requirements; the two medication administration reviews (mars) and two medication observations. Then a medication administration trainer must document if staff have passed or failed their initial or annual medication administration training to administer medications to individuals.
A medication administration trainer documented that Staff #1 passed the initial medication administration training course on 9/9/23. According to Staff #1's 9/9/23 medication administration training documents, two of the four required medication observations were purportedly completed by Staff #2 on 9/9/23. The medication administration trainer that documented Staff #1 passed all requirements of initial medication training on 9/9/23, reported to the Department on 9/28/23 that they did not view records of the practicum observations completed by Staff #2 on 9/9/23 for Staff #1's initial medication administration training. Documentation of the medication observations completed by Staff #2 were not produced during the inspection. Additionally, Staff #2 is not a medication administration trainer and was never a certified practicum observer, so they could not complete any components of Staff #1's medication administration training. According to Staff #2's initial practicum observer medication training provided during the inspection, the following items that are required, per the initial practicum observer medication training course, were blank and not completed: multiple choice examination and the 3 mar review examinations. The agency's previous medication administration trainer, Staff #5, indicated that Staff #2 was a certified practicum observer on 11/2/22 but never provided or recorded examination documents and passing scores. Therefore, Staff #1 has been administering medications to individuals, but their annual medication administration training was never completed by the properly certified staff.
A medication administration trainer documented that Staff #3 passed the initial medication administration training course on 9/14/23. According to Staff #3's 9/14/23 medication administration training documents, two of the four required medication observations were purportedly completed by Staff #2 on 9/14/23. The medication administration trainer that documented Staff #3 passed all requirements of initial medication training on 9/14/23, reported to the Department on 9/28/23 that they did not view records of the practicum observations completed by Staff #2 on 9/14/23 for Staff #3's initial medication administration training. Documentation of the medication observations completed by Staff #2 were not produced during the inspection. Additionally, Staff #2 is not a medication administration trainer and was never a certified practicum observer, so they could not complete any components of Staff #3's medication administration training. According to Staff #2's initial practicum observer medication training provided during the inspection, the following items that are required, per the initial practicum observer medication training course, were blank and not completed: multiple choice examination and the 3 mar review examinations. The agency's previous medication administration trainer, Staff #5, indicated that Staff #2 was a certified practicum observer on 11/2/22 but never provided or recorded examination documents and passing scores. Therefore, Staff #3 has been administering medications to individuals, but their annual medication administration training was never completed by the properly certified staff. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | Moving forward the Director of Residential will be responsible for ensuring that policies and procedures are implemented as written throughout the residential programs. The Associate Director of Residential developed an electronic property inventory record form on 10/13/23. The house manager and/or designee will complete an inventory record for each individual in their program and keep it up to date. All Practicum Observer paperwork was immediately reviewed on 9/28/23 and all Practicum Observers at Jessica and Friends were removed from their role as a Practicum Observer. Certified Medication Administration Trainer completed a new annual practicum by 10/25/23 for all of the staff that had invalid observations. |
11/14/2023
| Implemented |
| 6400.62(a) | Individual #1 is assessed to be unsafe around poisonous materials. During the 9/28/23 inspection of the home there were multiple items that contained poisonous materials unlocked and accessible to Individual #1, even times when Individual #1 has unsupervised access for hours each day of the poisonous items in their bedroom. Individual #1 has a primary bathroom attached to their bedroom. Their bathroom contained many bathing, hygiene, and personal supplies that were unlocked, accessible and sitting on their bathroom vanity counter, in the drawers and doors, and in their mirrored medicine cabinet.
During the inspection, hand sanitizer with a label to contact poison control center was in a kitchen cabinet, toothpastes and deodorants with a label to contact poison control center if ingested were unlocked and accessible in the half bath by the front door an unlabeled bottle of a cleaning substance was in the hallway bathroom, a decorative soap dispenser was in the kitchen without label of what was inside the container; all unlocked and accessible.
A first aid kit unlocked and accessible in a kitchen cabinet contained poisonous materials and medications. Medications within the first aid kit were aspirin, non-aspirin, burn cream, eye wash, and antacid (multiple individual dose packs of each) unlocked in the first aid kit. Individuals living in the home are assessed to be unable to self-administer medications and not safe with poisonous materials. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The Associate Director of Residential distributed new first aid kits on October 24, 2023, that do not contain medications, and all first aid kits have been placed in locked cabinets. House managers were retrained on October 31, 2023, to ensure that these remain in locked cabinets at all times.
A work order was placed on October 30, 2023, to put locks on all bathroom cabinets in Individual #1's home. The Maintenance Coordinator will install locks on bathroom cabinets throughout the home to ensure poisonous materials are locked when not in use. |
11/02/2023
| Implemented |
| 6400.62(c) | Individual #1 is assessed to be unsafe around poisonous substances, is unable to identify them, and items must be kept locked for their safety. During the 9/28/23 onsite inspection of the home, an unlabeled bottle of a white/clear liquid substance was unlocked and accessible on the sink in the hallway bathroom. The item liquid substance was in a clear, hand pump dispenser with said, hand soap, written on it with blank marker. A blue, square, decorative soap dispenser was unlocked and accessible on the kitchen sink and it did not contain a label identifying the substance within the container. Staff did not know what the substance was inside both containers. | Poisonous materials shall be stored in their original, labeled containers. | On 10/30/23, the Associate Director of Residential purchased new hand soap to replace both containers. The soap ordered is nontoxic and poison safe. The house manager will ensure that all soap within the home is in original containers and that the soap is nontoxic and poison safe. The house manager will also ensure that all poisons are kept in a locked cabinet. |
11/02/2023
| Implemented |
| 6400.67(a) | At the time of the 9/28/23 onsite inspection, the follow was witnessed:
Individual #1's medicine cabinets (2 of them) in their bathroom contain particle board inside the cabinets. Moisture has been exposure to the particle board material and the material is starting to expand and swell on the bottom shelf. There is also rust on the metal components and screws of the cabinets.
The hallway bathroom has a mesh material over the drywall, where there appears to be a hole in the drywall. The patch is not sealed and closed completed. The patch is above the shower head.
There are approximately 16 patches of drywall repairs, purportedly recently fixed with drywall repair materials for holes or scratches in the walls in the living room. They have not been painted over yet.
There was a lot of dirt in the tracks of the sliding screen door, and it didn't open smoothly or easily.
The living room/staff office combination room had scratches in the drywall, approximately 2 feet long below the window on the exterior wall. | Floors, walls, ceilings and other surfaces shall be in good repair. | Associate Director of Residential submitted a work order to repair individual #1's medicine cabinet in their bathroom on 9/29/23. Associate Director of Residential submitted a work order to repair the drywall in the hallway bathroom on 9/29/23. Associate Director of Residential submitted a work order to repaint the patches of drywall in the living room on 9/29/23. Associate Director of Residential submitted a work order to remove dirt and debris from the sliding screen door on 11/2/23. Associate Director of Residential submitted a work order to repair and repaint the scratches in the drywall in the living room/staff office on 11/2/23. The maintenance coordinator will complete the above repairs to ensure the surfaces are in good repair. |
11/30/2023
| Implemented |
| 6400.67(b) | At the time of the 9/28/23 onsite inspection, there was a large trash can in the garage, positioned directly behind the garage side egress door. The trash can was approximately 4 feet tall and 2 feet in diameter and prevented the egress door from opening completely. Staff documented they used this egress for fire drills. Two individuals residing in the home are legally blind and require all surfaces to be free of hazards that would prevent them from easily leaving the home. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Associate Director of Residential submitted a work order to move the trash can that was preventing the egress door from opening completely on 9/29/23. The maintenance coordinator moved the trash can from the door leading from the garage to the outside of the home on 10/19/23. |
10/19/2023
| Implemented |
| 6400.72(b) | REPEAT from 10/4/23 annual inspection: At the time of the 9/28/23 onsite inspection, the sliding screen door that leads to the back deck, had a hole in the screen, approximately 2 feet from the bottom of the door, near the right side of the frame, approximately 1 inch in diameter. | Screens, windows and doors shall be in good repair. | Associate Director of Residential submitted a work order to repair the screen in the sliding door on 11/2/23. The maintenance coordinator will repair or replace the screen in the sliding door. |
11/30/2023
| Implemented |
| 6400.80(a) | Individuals #1 and #2 are legally blind. Over the past year, September 2022 to September 2023, Individual #1 has documented falls, gait difficulties, and requires staff assistance to ambulate. During the 9/28/23 inspection at the home, a crack in the cement front walkway creates a tripping hazard. The crack was approximately 2 foot long by 1"-2" wide in some locations.
The side egress off the side garage door, contained a large flower planter covering 1/3rd of the walkway. Immediately off this walkway was a step down, creating a tripping hazard. The planter was sitting on this step, not allowing the entire step to be used. The step down was onto cement. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Associate Director of Residential submitted a work order to repair the crack in the cement in the front walkway on 10/30/23. The maintenance coordinator will repair the cracks in the walkway to ensure that outside walkways are free from hazards. The Associate Director of Residential submitted a work order on 10/5/23 to remove the pot on the side egress of the house to be moved. The maintenance coordinator removed the pot on 10/16/23. |
11/10/2023
| Implemented |
| 6400.80(b) | At the time of the 9/28/23 onsite inspection, the back deck of the house was covered in dirt, leaves, and sticks. The roof of the house on the backside of the home was covered in sticks, moss, leaves, and dirt. The same items were sitting in some of the gutters attached to the roof on the back of the home. The patio furniture, tables and chairs on the back deck were also covered in the same debris. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The Associate Director of Residential submitted a work order on 11/2/23 to clean the deck and patio furniture of the home. Associate Director of Residential submitted a work order on 9/29/23 to clean the gutters and moss off the roof. The maintenance coordinator will clean the deck and patio furniture and clean the gutters and moss off the roof. |
11/15/2023
| Implemented |
| 6400.104 | The most recent letter sent to the fire department on 6/25/22 states that Individual #1 can evacuate (the home) independently but may need verbal assistance, is legally blind so uneven surfaces can be challenging, will cooperate but does not like to be touched. According to the fire drill records over the previous year, October 2022 to September 2023, Individual #1 refused to go to the meeting place on 10/19/22, refused to evacuate the home once in March 2023, and refused to evacuate the home 3 times in August 2023. At the time of the 9/26/23 inspection, the local fire department was never notified of the individual's refusals to vacate the home during fire drills and the assistance that will need to be provided in the event of an emergency. | 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.
| The Program Specialist updated the notification letter and sent it to the fire department. This letter added Individual #1's history of refusing to evacuate and her fire evacuation counseling plan. The letter also was updated to include the level of assistance needed to evacuate the home. |
11/02/2023
| Implemented |
| 6400.112(c) | According to the floor plan of the home, there is an attic, first floor, and lower level or basement of the home. The following rooms are identified in the lower level/basement of the home: bedrooms, kitchen, bathrooms, family room, dining room, and laundry. According to the fire drill records from October 2022, to current, September 2023, the monthly fire drill records only document the attic, hallway and kitchen smoke detectors are operable. The fire drill records do not record if any smoke detector on the lower level/basement of the home was checked for operability. Additionally, during the 9/28/23 onsite inspection of the home, the attic access was screwed shut. It's unclear how the staff were checking for operability of the attic smoke detector if the staff in the home didn't have access to the attic and it was reported to the Department that staff do not go into the attic. | 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 Associate Director of Residential will retrain the house managers on ensuring that fire drill records are thoroughly completed, including the date, time, the amount of time it took for evacuating, the exit route used, problem encountered and whether the fire alarm or smoke detector was operative. The Associate Director of Residential revised the fire drill record for the home to include the smoke detectors in the lower level/basement of the home. The Associate Director of Residential placed a work order on 11/2/23 to unscrew the attic door and ensure that there is an operable smoke detector and fire extinguisher. |
11/14/2023
| Not Implemented |
| 6400.112(h) | The home only held one fire drill in the month of October 2022, on 10/19/22. According to the fire drill record, Individual #1 refused to go to the meeting place during the fire drill. The home reports the individual evacuated the threshold of the home but refused to go to the meeting place, which was identified as the mailbox. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | The Associate Director of Residential will retrain the house managers on ensuring that fire drill records are thoroughly completed, including the date, time, the amount of time it took for evacuating, the exit route used, problem encountered and whether the fire alarm or smoke detector was operative. The fire drill record must also include whether each individual arrived at the meeting place. |
11/14/2023
| Implemented |
| 6400.141(c)(11) | Individual #1's current, 8/10/23 physical examination record didn't include a review of their full list of daily, and as needed, prescribed medications with their physician at the time of the examination. The examination record stated the medication list was attached. The attached 8/9/23 medication list didn't indicate that the physician reviewed the form for completion and accuracy. Additionally, the attached medication list did not agree with the individual's August 2023 medication administration record (mar) for the medications and supplements that the staff are documenting they administer to the individual daily and as needed. | 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. | The Program Specialist immediately filed a copy of individual #1's current medication regimen behind the 2022 annual physical examination record. Moving forward, all current medication regimens will be reviewed and printed on the annual physical examination records. |
11/14/2023
| Implemented |
| 6400.141(c)(13) | Individual #1's current, 8/10/23 physical examination record didn't include their possible reaction to levothyroxine medication. On 12/29/22 their virtual medical appointment summary form indicated the individual was to stop levothyroxine and discussion at the appointment included a possible reaction to levothyroxine. This possible reaction and the concerns discussed during the appointment, were not included on the individual's physical examination record or their medication administration records (mars). | The physical examination shall include: Allergies or contraindicated medications. | The Associate Director of Residential informed the pharmacy on 11/2/23 of Individual #1's possible reaction to levothyroxine so that it could be added to the allergy section on the medication administration record. The Director of Quality Assurance and Compliance updated Individual #1's physical form for 2024 to include the possible reaction of levothyroxine. |
11/14/2023
| Implemented |
| 6400.143(a) | Individual #1 has refused to evacuate the home 4 times during fire drills for the year. According to a reportable incident, Individual #1 refused to leave the house on 9/8/23 to get blood work. Staff have documented on daily service notes over the previous few months, that the individual is getting confused and occasionally refusing meals throughout the week. The continued attempts to discuss the need to implement health care recommendations, proper and safe evacuation during emergency situations, and eating nutritional meals was not documented in the individual's record. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Associate Director of Residential completed retraining on 10/13/2023 with the house manager on what the expectations are as a manager when it comes to documenting refusals to leave the home during fire drills and medical appointments/testing. |
11/14/2023
| Not Implemented |
| 6400.144 | The agency has failed to provide the following health services to Individual #1 over the previous year, October 2022 to current, September 2023, on the following occasions:
Dietary:
· According to Individual #1's shake chart documentation, on 8/7/23 the individual's primary care physician ordered the individual to drink 1 drink of Kate Farm pediatric standard shake (250mls/8oz) after each meal every day due to some blood sugar concerns, and each shake is 8 ounces. Staff documented on 9/5/23 the home did not have any shakes available in the home to offer the individual. According to the record, staff did not have the shake to offer for breakfast, lunch, and dinner on 9/5/23 and breakfast and lunch on 9/6/23.
· According to the shake chart documentation staff are to offer the individual a shake during each meal and document how many ounces of the drink they consume. The record is blank for lunch on 9/3/23 which no record if the home offered the shake or how much the individual consumed. Additionally, staff documented the individual consumed more than 8 ounces on 13 different occasions in September 2023, when a shake is only 8 ounces. According to the August 2023 shake chart documentation, there are many occasions where staff are document Individual #1 drank more than 8 ounces, documenting 10 ounces, 11 ounces as well on 6 occasions.
· The home did not start administering the physician's ordered shake supplement drink until 8/9/23. There aren't records of offering the shake to Individual #1 for dinners on 8/21, 24, 27, and the 29th; these fields were left blank.
· According to medical records and the current 8/10/23 physical examination record, Individual #1's diet is gluten free, dairy free, low fat and low cholesterol. The home only started monitoring the food intake on 8/28/23. According to food logs, they are giving her cheese or bread for every meal. The food log does not indicate that the individual is to have any specific cheeses (dairy free) or breads (gluten free).
Fluid intake:
· According to medical appointment summaries on 12/29/22 and 2/9/23, Individual #1's physician instructed caregivers to monitor the individual's water intake. They should be encouraged to drink at least 16 ounces minimum daily, and more is better.
· On 4/11/23 Individual #1's physician documented it is important for the individual's health that they drink enough water and requires the individual's water intake to be monitored. The individual is ordered to intake a minimum of 16 ounces per day.
· The home only produced additional fluid intake monitoring charts from April 2023 to August 2023, during the inspection. April's chart does not monitor any fluid intake from 4/1/23-4/10/23, only was offered 10 ounces on 4/12, 12 ounces on 5/15/23, 12 ounces 6/4, 0 on 6/11, 12 ounces 6/5, 6 ounces on 7/6, 14 ounces 7/7, 8 ounces on 8/14, 7 ounces on 8/23, 5.5 ounces on 8/28, 6 ounces on 8/29, and 7 ounces each day on 8/30 and 8/31. The following was documented for ounces consumed/offered in September 2023: only 11 ounces on 9/4, 10 ounces on 9/6, 0 ounces on 9/7, 1 ounce on 9/10, 18 ounces on 9/12, and 0 ounces on 9/14.
Weight:
· Individual #1's record includes a weight chart with instructions for staff to take the individual's weight on the same day of the week. At the time of the 9/26/23 inspection the home has only taken and recorded the individual's weight once per month from November 2022 to May 2023, on 11/18/22, 12/23/22, 1/27/23, 2/3/23, 3/30/23, 4/20/23, and 5/29/23. Nothing has been monitored and recorded for October 2022, and June 2023 to September 2023.
Gastroenterology:
· On 11/15/22, Individual #1's Gastroenterologist wanted the individual to return for a 3 month follow up around 2/15/23 and wanted a report within 3-4 weeks after the 11/15/22 appointment on the assessment plan: xray of abdomen, calprotectin stool sample, complete stool study, abdonminal xray, stool charting with frequency and caliber via Bristol stool scale. There are no records the individual returned to the gastro in 3 months, or that the agency updated the gastro in 3-4 weeks of all items they were to complete.
· On 11/15/22, Gastroenterology said Individual #1 is diagnosed with IBS, Chronic Diarrhea, and Constipation, with chronic irregular bowel habits. The individual's individual support plan states staff are to monitor and track the individual's bowel habits. The home does not have a bowel protocol or plan in place for what to do if the individual experiences constipation or goes days without having a bowel movement. There are days documented where Individual #1 didn't have a bowel movement and no follow up from medical personnel was sought. From November 2022 through June 2023, Individual went with no bowel movement 2 days a total of 6 times. They went with no bowel movement a total of 3 days a total of 6 times. Individual #1 had no bowel movement for a total of four days twice and went five days with no bowel movement one time. Individual #1 went eleven days with no documented bowel movement once. No medical treatment was sought for any of these incidents.
Medications:
· On 11/29/22, Individual #1's physician ordered Voltaren to be applied to the individual's knees and hip for arthritic three times as needed. This medication was never added to the individual's mars.
· Individual #1's January 2023 MAR lists Zyrtec 10mg oral dissolving tablet was administered for the month. There isn't a medication record that lists this as a current medication until 2/13/23.
· A summary of current medications from the primary care physician on 4/21/23 states the individual is currently prescribed Ibuprofen 600mg to take 1 tablet every 6 hours for pain. According to the April 2023 mars, Individual #1 was administered 400mg twice daily for the month. The home has been administering ibuprofen 400mg twice daily since 2/9/23. There isn't clarification for what ibuprofen the individual should be administered in April.
· On 5/3/23, the physician increased Ibuprofen to 600mg twice daily and add Tylenol 650mg as needed 4 times a day. Staff didn't administer Ibuprofen 600mg twice daily until 5/8/23.
· On Individual #1's 7/28/23 primary care visit documentation it says meds individual is prescribed prior to this visit and this included Melatonin 5mg 1 tablet at bedtime. During the 9/28/23 onsite inspection, the home had this crossed off the mar. However, the pharmacy is still dispensing this medication in weekly pill rolls for staff to administer. Staff at the home report that per sister this medication is discontinued. There were 4 pills in a ziplock baggy that were Melatonin and not given. Staff at the home aren't giving this. Home doesn't have a d/c order.
· On 8/27/23, a Registered Nurse wrote note to please obtain Desitin ointment to apply to buttocks daily at bedtime and as needed. The nurse was to obtain an order from the primary care physician. There were recently concerns for incontinence, unusual bowel movements, and individual scratching at groin in August 2023. During the 9/28/23 inspection, Desitin was available in the home and hasn't been administered. The medication label stated to apply a thin layer to buttocks 2 times a day after toileting and bathing. The individual's September 2023 medication administration record (mar), stated to apply 4 times, thin layer to buttocks after toilet and shower, but also listed it as an as needed medication. The written order was never obtained, and the medical label never matched the mar.
· Continued in 144 Part 2 | 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 House Manager will now be responsible for ordering the prescribed shakes so that the home does not run out. The House Manager will add a calendar invite to their Google Calendar each month for a week prior to the last case of shakes being open, to ensure there is an adequate supply at all times. The Associate Director of Residential will retrain House Managers on documentation requirements related to all aspects of the individual's care plans to ensure that the individuals are receiving all services to keep them healthy and safe. The House Managers will also be trained on implementing doctor's orders immediately. The Associate Director of Residential updated Individual #1's food log on 11/2/23 to indicate that the individual is supposed to have specific cheeses (dairy free) or bread (gluten free). The Associate Director of Residential updated the weight chart on 11/3/23 to clarify that Individual #1's weight only needs to be taken once per month and not every week. The Program Specialist and/or House Managers will train the staff on proper documentation on shake charts, food logs, weight charts, Inspire Charts, and any other documentation that the individual has. The Associate Director of Residential will retrain House Managers on completing follow-up visits and reporting as the doctor prescribes. The Nurse will contact the Gastroenterologist and develop a Bowel Movement protocol for the individual. The nurse will also contact all prescribing physicians and obtain updated medications orders. |
11/14/2023
| Not Implemented |
| 6400.144 | Continued from Part 1
· According to Individual #1's September 2023 medication administration record (mar), they are prescribed Tussin DM as needed. This medication wasn't available in the home but a generic medication, chest congestion relief, was. However, the chest congestion relief expired on 9/22/23.
· According to the medication label on Individual #1's Peg 3350 powder available at the home on 9/28/23, they are ordered to take 17gm mixed in water, juice, or applesauce and drink by mouth daily until a bowel movement, then mix 17gm every 3rd day. This medication label stated the medication was dispensed from the pharmacy on 3/9/22. The individual's September 2023 mar states to administer 17grams mixed in 8 ounces of liquid or applesauce and take by mouth as needed on 3rd day without a bowel movement until bowel movement is produced. The home does not know the current order.
Sleep apnea
· On 4/26/23 the individual's physician stated "Individual #1 is a patient under my care and being treated for severed obstructive sleep apnea. They underwent surgery on 5/4/18 to have a hypoglossal stimulator implanted and has had improvements with sleep apnea since. It's important to note that untreated sleep apnea is linked to cardiovascular disease, hypertension, diabetes, strokes and may also increase risk of death. The stimulator should be turned on anytime they are about to go to bed, takes a nap or falls asleep. The remote is set to start therapy 30 minutes after it is turned on, therefore allowing the individual to fall asleep before therapy is activated. However, if Individual #1 falls asleep without the remote being turned on, it is important to immediately turn it on, to assure the sleep apnea is being treated. Finally, the remote should always be turned off if Individual #1 wakes up in the middle of the night. They will struggle to talk or drink with therapy on, and this could result in them biting their tongue or not being able to talk or drink effectively. If the remote is turned off in the middle of the night, it should be turned back on once Individual #1 is back in bed and going back in bed and going back to sleep. The remote should always be turned off first thing in the morning when Individual #1 wakes up to start their day. At the time of the 9/26/23 inspection, the home only started documenting when they turn on and off the stimulator on 9/25/23. The field to indicate when staff turned off the stimulator in the morning on 9/27/23 was blank.
· According to the record, from 8/13/22 to 2/13/23 the stimulator was only used 157 out of 184 nights, was only used more than 4 hours each night for 155 out of the 184 nights, and over the previous three weeks it was not utilized on 2/13, 2/11, 2/5, 2/4, 2/3, and 1/28. | 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 House Manager will now be responsible for ordering the prescribed shakes so that the home does not run out. The House Manager will add a calendar invite to their Google Calendar each month for a week prior to the last case of shakes being open, to ensure there is an adequate supply at all times. The Associate Director of Residential will retrain House Managers on documentation requirements related to all aspects of the individual's care plans to ensure that the individuals are receiving all services to keep them healthy and safe. The House Managers will also be trained on implementing doctor's orders immediately. The Associate Director of Residential updated Individual #1's food log on 11/2/23 to indicate that the individual is supposed to have specific cheeses (dairy free) or bread (gluten free). The Associate Director of Residential updated the weight chart on 11/3/23 to clarify that Individual #1's weight only needs to be taken once per month and not every week. The Program Specialist and/or House Managers will train the staff on proper documentation on shake charts, food logs, weight charts, Inspire Charts, and any other documentation that the individual has. The Associate Director of Residential will retrain House Managers on completing follow-up visits and reporting as the doctor prescribes. The Nurse will contact the Gastroenterologist and develop a Bowel Movement protocol for the individual. The nurse will also contact all prescribing physicians and obtain updated medications orders. |
11/14/2023
| Not Implemented |
| 6400.145(1) | The individual's record doesn't clarify the specific hospital or source of health care that will be used in an emergency. At the time of the 9/26/23 inspection, the individual's written emergency medical plan in the home's fire book states the individual wishes to go to UPMC Memorial hospital. The identification form in the individual's record, that includes emergency medical information, states the individual prefers to receive medical services from York hospital. According to Individual #1's most recent individual support plan (isp) in their record, the individual's legal guardian wants the individual to go to York hospital. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | The Program Specialist will update the fire book with Individual #1's preferred hospital. |
11/14/2023
| Implemented |
| 6400.216(a) | During the 9/28/23 onsite inspection at the home, Individuals #1-#3's record information was unlocked and accessible in the home in multiple locations. The staff office/living room combination room contained tv stand, which was also a filing cabinet. The filing cabinet was broken, not locked, and inside the cabinet was individual communication logs that staff record individual specific information per shift and there was a pharmacy receipt for Individual #3's medications dropped off at the home. There was a clear storage container above the medication cabinet in the kitchen contained the individuals' empty medication administration pouches. These pouches included identifying names and medications prescribed to each individual. Individual #2's constipation plan was written on a sticky note hanging on the wall in the kitchen. | An individual's records shall be kept locked when unattended.
| The Associate Director of Residential will retrain House Managers on locking individual's records when unattended. House Manager will remove all files that contain personal information from the tv stand/filing cabinet. House Manager and/or designee will properly dispose of all empty medication administration pouches. The sticky note with Individual #2's constipation plan will be removed from the cabinet in the kitchen. |
11/14/2023
| Implemented |
| 6400.32(c) | Individual #1 has and is diagnosed with seizures, sleep apnea, and downs syndrome. They are a fall risk. They have stroke-like symptoms, are legally blind, and are assessed to require partial to full assistance with ambulation and all daily living skills. They are unsafe with poisonous materials and need increased supervision. Staff have also recorded and reported that since around April 2023, Individual #1 is confused, angry, paces the home for hours, refuses meals, forgets they already ate meals, is awake at all hours of the night, talks to themselves at night when they should be sleeping, slams doors, kicks items, and curses without any antecedents. As most recently as 7/27/23 the individual's physician did report the individual's gait is off, their cognition waxes and wanes, and they are experiencing some incontinence.
As referenced in this report, the agency failed to protect Individual #1's health and safety over the past year, September 2022 to September 2023, resulting in neglect and mistreatment of care. The following events show a pattern of mistreatment that creates an environment conducive to harm, or near harm, of Individual #1:
Ambulation/Fall risk
· On 11/15/22 the individual's physician recorded the individual is having recent gait issues as well as confusion. The individual was seen at the emergency room for an unwitnessed fall and witnessed seizure like activity on 6/11/2023 and discharged on 6/12/23.
· At the time of the 9/26/23 onsite inspection, the home has not had a fall risk assessment completed for the individual and didn't provide training to staff on Individual #1's increased supervision care needs outlined in their assessments.
Failure to provide supervision:
· On 4/14/23, the home assessed the individual to require line of sight supervision in the home with staff checking on the individual every 15 minutes. There are no records that staff were maintaining line of sight supervision of Individual #1 while at home or were checking on Individual #1 in the home every 15 minutes to ensure their safety.
· On 4/14/23, the home's assessment of Individual #1 states the individual is unsafe around poisonous substances and require staff to be within arm's reach of the individual when they are using Clorox wipes, hand sanitizer, personal hygiene products, or any other poisonous substance. As referenced in 6400.62(a) and 6400.62(c) of this report, the home has allowed the individual to have unsupervised, unmonitored, and complete access to personal hygiene items and poisonous materials throughout the home and in their bedroom and bathroom, daily.
· Individual #1's 7/26/23 supervision care needs plan, included in an updated assessment, states staff must have line of sight vision of Individual #1 and be in arms reach of the individual when they are walking to monitor and aid if necessary due to concerns with the individual's balance. Overnight staff (semi-sleep staff) will get up with the individual if the individual should wake up to use the bathroom. Staff should be in arms reach whenever Individual #1 gets up from a sitting position. There is no documentation that this supervision is occurring.
Seizures
· On 4/8/23, the home delayed medical treatment to Individual #1 for more than 12 hours. The individual was evaluated in the hospital on 4/8/23 for diarrhea. The hospital discharge instructions indicated Staff were to continue to monitor for seizure-like activity and if Individual #1 experienced any unconsciousness, generalized shaking, vomiting, fevers or complaints of pain then they were to return to the emergency room. The home never monitored or documented seizure like activity for the individual immediately after the emergency room's discharge instructions.
· The 4/8/23 hospital discharge instructions also stated the individual was to follow up with their nurse practitioner. The individual was not taken for a follow up visit until 4/21/23.
· On 4/21/23 the individual received a neurology referral to evaluate concerns for TIA (Transient ischemic attack) verses epilepsy and the home was to call if there was a change in the individual's condition. On 5/8/23 the individual had an Electroencephalogram completed. The clinical impression of the test was documented as seizure like activity, abnormal awake, and drowsy EEG study due to mild nonspecific global encephalopathy. The home does not have a seizure protocol implemented nor did they provide training to staff on the individual's condition after the results from this examination.
· On 6/11/23, Individual #1 was evaluated at the emergency department for an unwitnessed fall and witnessed seizure-like activity. When discharged on 6/12/23 the individual was prescribed daily seizure medication. The home was instructed to follow seizure precautions. They were provided seizure care and epilepsy instructions that included how to care for yourself at home and when to call for help. There are no records the staff working with the individual received training on the individual's seizure precautions and 6/12/23 discharge instructions after this incident.
· The seizure care and epilepsy care instructions provided on 6/12/23 stated to call 911 if you are experiencing another seizure, you have trouble walking, speaking or thinking, a seizure doesn't stop as it normally does, or you experience new symptoms.
The following was all documented in the individual's record and there were no indications that 911 was called for any of the symptoms documented: Individual #1 was exhibiting symptoms of jerking, yelling, seizure-like activity, abnormal eyelid movement, fatigue, and mouth twitching. 911 was not called.
· On 7/28/23 the individual's nurse practitioner documented a change in the individual's movements that appear to be concerning for small seizures and instructed the home to take Individual #1 to their neurologist that day. They also provided a provided a seizure protocol that stated, for a change in baseline mental status or signs of stroke to call 911 and for abnormal jerking movements, call the on-call medical provider for advice or neurology specialist. On 7/28/23, they prescribed Individual #1 a seizure rescue medication, Midazolam 5ml, to be administered as needed for break through seizure lasting for 5 minutes or longer. The medication could be used up to twice a day, and after two doses the Individual was to go to the emergency department.
· On 7/28/23 around 7:45pm, staff recognized that Individual #1 was confused. They did not know where they were. They did not know who they were, and they began to cry. Staff contacted Individual #1's legal guardian for Individual #1's confused state, and not 911. Staff documented the individual's legal guardian contacted the individual's physician at approximately 8pm and received instruction to take the individual to Jefferson hospital. The individual's legal guardian arrived at the home at approximately 8:20pm. Individual #1 was still confused. The legal guardian took the individual to the hospital as they reported this was the physician's instructions. The home never contacted 911 or the individual's physician, nor attempted to take the individual to Jefferson hospital after knowledge of this physician's order around 8pm.
· The home did not have a seizure plan or protocol for staff to implement until 8/9/23. The individual's seizure protocol was updated on 9/8/23. The agency was unable to produce records that they provided in-person training to all staff working with Individual #1, on the individual's 8/9/23 or 9/8/23 seizure protocols.
· On 8/19/23, at approximately 1:20pm two staff observed Individual #1 being confused, being pale, and drooling from the left side of their mouth. They had knowledge that a previous incident when the individual was confused, they were having a seizure. Staff contacted Individual #1's legal guardian around 1:30pm and did not contact any medical professional.
Continued 32c part 2 | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | The Nurse submitted a referral to HCQU for a fall risk assessment for Individual #1. The Associate Director of Residential will create a supervision care needs chart that indicates that Individual #1 was checked on every 15 minutes to ensure their safety. The Associate Director of Residential placed a work order on 10/30/23 to have locks placed on all bathroom cabinets in Individual #1's home. The maintenance coordinator completed this work order on 11/2/23. The Nurse provided in-person seizure protocol training for Individual #1 on 10/4/23. The Associate Director of Residential provided all staff that work with Individual #1 in-person training on the inspire remote and corresponding charts on 10/4/23. The Associate Director of Residential will retrain House Managers on the ODP Health Alert and the importance of calling 911 when a life-threatening emergency is occurring. The Nurse will train House Managers on following up with the recommended healthcare practitioner within the recommended time frame following emergency room visits. The Director of Quality Assurance and Compliance will train all House Managers, Program Specialists, and Nurses on immediately implementing and training staff on new health concerns and protocols following emergency room visits. The Associate Director of Residential will retrain all House Managers on the importance of recording the exact time medication is administered with PRN medications. The Associate Director of Residential will also create a MAR signature sheet that will go with each medication administration record that staff will print, sign, and write their initials to ensure that signatures and initials are legible. |
11/14/2023
| Implemented |
| 6400.32(c) | · Nayzilam was administered to Individual #1 on 8/19/23. The name and initials of the staff person who administered the medication was illegible on the individual's medication administration records (mar). Staff recorded on the mar that the medication was administered to the individual at 2pm. However, according to an internal incident report, staff administered the medication sometime between talking to the individual's legal guardian at 1:30pm and EMT's arriving on site at 1:47pm. The exact time is unknown.
Failing to seek medical treatment
· Two staff working with the individual on 4/8/23 documented concerns with Individual #1's health decline. Staff noticed the individual bit their lip sometime during the night, had a bowel movement in their bed. Individual #1 was self-talking to themselves all day. They didn't each much food for breakfast, lunch, or dinner. They seemed to be slurring their words. Staff couldn't get the individual's attention when calling their name and the individual wasn't able to answer questions. They were lethargic. Staff reported Individual #1 woke up at 3:15am and had a fecal matter smeared everywhere and had something in their mouth that looked like blood. The house manager was notified, and staff cleaned the individual. Staff continued to document Individual #1's abnormal behavior and health status decline until 7:10pm on 4/8/23. Staff noticed cuts on the individuals' lips upon waking up for the day on 4/8/23. There was dried blood running down their chin. They looked confused after staff asked them to brush their teeth. They kept pacing in their room. They napped sometime prior to 2pm, took medications at 3pm and laid back down. Staff didn't monitor the individual again until approximately 6pm when Individual #1 walked to the kitchen and kept saying they were going to bed. The individual was mumbling and pacing back and forth, seemed disoriented and lethargic, and after about 10 minutes walked back to their bedroom and went to sleep. At this point staff documented they checked on Individual #1 approximately every 30 minutes, and at each inspection the individual was mumbling incoherently. The home did not notify the individual legal guardian or the individual's physicians of all documents concerns. The home did not notify emergency personnel until sometime prior to 7:10pm on, when EMT's arrived at the home.
Sleep Apnea
· Individual #1 underwent surgery on 5/4/2018 to have a Hypoglossal Stimulator implanted to treat their Severe Obstructive Sleep Apnea. The device comes with an external remote device that is used to activate and deactivate the device when it should and shouldn't be in use. The stimulator is ordered to be activated every night before sleeping, deactivated when they wake up, and activated if the individual is napping as well. The individual's record includes a pamphlet for a battery operated inspire remote that is used to activate and deactivate the stimulator. On 4/26/23 Individual #1's physician stated if the individual falls asleep without their remote being turned on its important to immediately turn it on to ensure sleep apnea is being treated. The physician documented that if the remote is not used to turn the stimulator off when the individual is awake, they will struggle to talk or drink and could result in the individual biting their tongue.
· The agency did not provide in-person trainings to staff working directly with Individual #1 on the inspire remote, stimulator implant, the individual's sleep apnea diagnosis, or any sleep apnea protocols. The agency only produced a sign in sheet that states 11 staff independently read inspire instructions from the individual's physician, between 4/27/23 and 9/17/23.
· The home hasn't monitored and recorded when staff activate or deactivate the stimulator daily, until 9/26/23, the first day of the inspection. The records to document if staff are turning the stimulator on and off were not implemented until 9/25/23 but were still blank at the start of the annual inspection on 9/26/23.
· The home is not monitoring the remote to make sure the device is working properly, or if/when they changed the batteries to the remote. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | The Nurse submitted a referral to HCQU for a fall risk assessment for Individual #1. The Associate Director of Residential will create a supervision care needs chart that indicates that Individual #1 was checked on every 15 minutes to ensure their safety. The Associate Director of Residential placed a work order on 10/30/23 to have locks placed on all bathroom cabinets in Individual #1¿s home. The maintenance coordinator completed this work order on 11/2/23. The Nurse provided in-person seizure protocol training for Individual #1 on 10/4/23. The Associate Director of Residential provided all staff that work with Individual #1 in-person training on the inspire remote and corresponding charts on 10/4/23. The Associate Director of Residential will retrain House Managers on the ODP Health Alert and the importance of calling 911 when a life-threatening emergency is occuring. The Nurse will train House Managers on following up with the recommended healthcare practitioner within the recommended time frame following emergency room visits. The Director of Quality Assurance and Compliance will train all House Managers, Program Specialists, and Nurses on immediately implementing and training staff on new health concerns and protocols following emergency room visits. The Associate Director of Residential will retrain all House Managers on the importance of recording the exact time medication is administered with PRN medications. The Associate Director of Residential will also create a MAR signature sheet that will go with each medication administration record that staff will print, sign, and write their initials to ensure that signatures and initials are legible. |
11/14/2023
| Implemented |
| 6400.32(h) | Individual #1's medical information, including their shakes ordered by their physician, was known by someone from the community, not employed by the agency, and who lives in the lower portion of the home. The person with knowledge of Individual #1's medical information, also walked into Individual #1's home on 9/17/23 without being let into the individual's home by any individual residing in the home. The home does not have documents that allow for this person to reside in the lower level of the home. | An individual has the right to privacy of person and possessions. | The soon to vacate tenants on the lower level of the home have been restricted from access to the individuals' living quarters. The tenants have been issued an eviction notice on 11/1/23. The tenants who reside in the basement apartment will be relocated no later than 1/1/2024. |
01/01/2024
| Implemented |
| 6400.46(a) | Staff #1 was hired on 6/23/23 and their first day working with individuals was 7/2/23. At the time of the 9/26/23 inspection, Staff #1 did not complete fire safety training prior to working with the individuals. | 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. | Moving forward staff will be trained by a fire safety expert prior to working with individuals. All orientation training forms will be forwarded to the Staffing Specialist by the House Manager. Staff #1 completed fire safety training on 10/31/23 and will complete it within an annual timeframe moving forward. |
10/31/2023
| Implemented |
| 6400.46(b) | Staff #4 received fire safety training on 3/4/22 and not again until 3/18/23, outside of the annual timeframe. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Moving forward staff will be trained by a fire safety expert within the annual timeframe. The fire safety training form has been revised to have the fire safety expert sign and date the training immediately upon completion. All annual training forms will be forwarded to the Staffing Specialist by the House Manager. |
11/01/2023
| Not Implemented |
| 6400.46(c) | REPEAT from 10/4/22 annual inspection: Staff #1 was hired on 6/23/23 and first day working with individuals was 7/2/23. Staff #1 did not complete their initial first aid training until 8/29/23. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques. | Moving forward staff will be trained in initial first aid prior to working with individuals. All orientation training forms will be forwarded to the Staffing Specialist by the House Manager. Staff #1 completed first aid/CPR training on 8/29/23 and will complete it within the designated time frame moving forward. |
11/14/2023
| Implemented |
| 6400.51(b)(1) | REPEAT from 10/4/22 annual inspection: Staff #3 was hired on 7/28/23. At the time of the 9/26/23 inspection, Staff #3 had not completed community integration training until 9/1/23. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Moving forward staff will be trained on community integration within 30 days of their hire date to ensure compliance. All orientation training forms will be forwarded to the Staffing Specialist by the House Manager. |
11/14/2023
| Not Implemented |
| 6400.51(b)(2) | Staff #3 was hired on 7/28/23. At the time of the 9/26/23 inspection, Staff #3 had not received orientation training on prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. § § 10225.101---10225.5102), the Child Protective Services Law (23 Pa.C.S. § § 6301---6386), the Adult Protective Services Act (35 P.S. § § 10210.101---10210.704) and applicable protective services regulations. | The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations. | Staff #3 will have prevention, detection, and reporting of abuse, suspected abuse and alleged abuse training completed by 11/14/23. Moving forward staff will be trained on the prevention, detection, and reporting of abuse, suspected abuse and alleged abuse within 30 days of their hire date to ensure compliance. All orientation training forms will be forwarded to the Staffing Specialist by the House Manager. |
11/14/2023
| Not Implemented |
| 6400.51(b)(5) | Prior to working along with Individual #1, there are no records that the home provided in person, individual specific training on all their plans, protocols, health needs, or any current health concerns and plans being addressed and added throughout the year. The individual has the following plans, protocols, medical orders, and medical concerns that staff need orientation on prior to working with Individual #1:
· Fluid intake orders with a fluid chart
· Bowel monitoring chart, bowel medications, IBS, constipation, and chronic diarrhea
· Sleep apnea diagnosis and an inspire implant device.
· Inspire remote used for the stimulator implant device for staff to know how to monitor to ensure it is working correctly.
· Seizure Protocol | The orientation must encompass the following areas: Job-related knowledge and skills. | The agency's registered nurse will create a list of all individual's plans, protocols, and health needs to give to the Staffing Specialist who will ensure training is completed prior to working with Individual #1. Moving forward, the home will provide in person, individual specific training on all individual's plans, protocols, health needs, and any current health concerns. |
11/14/2023
| Not Implemented |
| 6400.162(b)(2)(iii) | Individual #1 ordered Nayzilam nasal spray for seizures over 5 minutes. There wasn't an in-person training component to this new medication or how to administer it during a seizure. The sign in sheet listed staff were to watch a Youtube video and stated by singing I am indicating I watched the training video for Individual #1's prn spray. Another sign in sheet that says "I signed and indicating I have read nasal spray training for Individual #1. See two sign-in sheets on phone. Scanned in". The individual was ordered this medication prior to August 2023. The first staff signed the form on 8/17/23. | A prescription medication that is not self-administered shall be administered by one of the following: A person who has completed the medication administration course requirements as specified in § 6400.168 (relating to medication administration training) for the administration of the following: Eye, nose and ear drop medications. | The Nurse will provide in-person training to all med trained staff that work with Individual #1 on nose spray medication administration as soon as possible. |
11/27/2023
| Implemented |
| 6400.163(g) | Individual #1's September 2023 medication administration records (mars) document that staff are to administer 10ml (1000mg) of levetiracetam twice daily for the individual's seizures. During the 9/28/23 onsite inspection, Individual #1's levetiracetam medication with the pharmacy-issued medication label instructing staff to administer 10ml (1000mg) twice daily, was unopened and dispensed from the pharmacy on 9/9/23. Two bottles of levetiracetam were also located with Individual #1's medications, both of which contained a pharmacy label instructing staff to administer 7.5ml (750mg) twice daily. Both levetiracetam medication bottles with instructions to administer 7.5ml twice daily were open, and staff reporting the medication being used. The individual's old medication orders on the opened levetiracetam medication bottles were still being stored with Individual #1's current medications. Staff reported during the inspection they are still using the outdated, levetiracetam medication bottles with an old medication order to administer to the individual. This storage and usage of old medication orders created confusion and a lack of understanding of the individual's current orders for their seizure medication, or the dosage that is being administered daily.
During the onsite inspection, as needed medications with Individuals #1's and #2's initials written on them in black marker, were stored together in a clear, Tupperware container in a locked, kitchen cabinet. The medications were not stored with their respective individual's prescribed, and as needed, medications in the medication cabinet. Individual #1's initials were written on a bottle of Advil liquid gel, 200mg capsules and Individual #2's initials were written on a bottle of ibuprofen, 200mg capsules. Individual #1's record does not include a written order for Advil liquid gels. | Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions. | The Associate Director of Residential removed the discontinued medication and properly destroyed it on 9/29/23. House Manager and/or Nurse will retrain staff on the importance of the medication administration process of comparing medication labels to the medication administration record. The Associate Director of Residential will retrain the House Manager on storing individual's prescribed medications in their respective organized location. |
11/14/2023
| Implemented |
| 6400.165(b) | REPEAT from 10/4/23 annual inspection: During the onsite inspection, as needed medication, Advil liquid gel 200mg capsules, with Individual #1's initials written on them in black marker, was stored in a clear, Tupperware container in a locked, kitchen cabinet. Individual #1's record does not include a current order for administering Advil liquid gels. | A prescription order shall be kept current. | The House Manager will remove the Advil liquid gel 200 mg capsules from the home that have Individual #1's initials written on in black marker. |
11/14/2023
| Not Implemented |
| 6400.165(c) | On 11/29/22 Individual #1 was ordered mupirocin to be administered to their lips, 3 times daily, for 10 days. The home administered this twice on 11/29/22, and three times a day on 11/30, 12/1-9, and 12/11/22.
In December 2022, the individual was ordered levothyroxine 125mcg, take 1 tablet by mouth daily in the morning on an empty stomach. The agency documented the medication was held on 12/27 and 12/28 per doctor's order. The agency did not produce the doctor's order.
According to Individual #1's medication administration records (mars), the individual is ordered Levetiracetam, take 3ml by mouth twice daily at 8am and 8pm for seizures. There is a mar in their record (reference in this report in other violations as the month and year of administration was absent from the mar) that is blank for the 8pm administration on the 29th of the month. There were no records why the individual didn't receive their medication.
Individual #1's 7/27/23 and 7/28/23 physician consultation records, stated the individual is prescribed melatonin daily to be taken at night to assist with sleep. During the 9/28/23 onsite inspection, the medication is still being dispensed from the pharmacy for daily administration. The home hasn't administered the medication for months. The pills of melatonin that should have been administered for the last week were stored in a Ziplock bag in the home. The individual's medication administration records (mars) have a line drawn through melatonin and staff do not initial as administering the medication. The home doesn't have written discontinue order. Staff document Individual #1 is up all night occasionally, doesn't sleep through the night, or wakes at times in the night they should be sleeping, and this isn't reported to medical professionals.
During the inspection, diclofenac sodium topical gel (voltaren) was available in the home and prescribed to Individual #1 to be administered topically, 4gm to affected areas 4 times a day, max 16gms per joint per day, up to 32gm per day. The medication was never administered. The medication was never recorded on the individual's mars. | A prescription medication shall be administered as prescribed. | The Associate Director of Residential will train House Managers on where to file doctor's orders when a prescription is held for a specific amount of time. The Medication Administration Trainer and Registered Nurse will train House Managers and staff on identifying medication and documentation errors. The Nurse will contact all prescribing physicians and obtain updated medication orders. |
11/14/2023
| Not Implemented |
| 6400.165(e) | Individual #1's 12/29/22 medical appointment summary stated it was a zoom (virtual) appointment with a physician and the individual's legal guardian signed the summary form, not a physician. Written on the summary was "discussed levothyrozine and possible reaction to medication, stop levothyroxine, start armour thyroid 60mg, caregivers monitor water intake 16 ounces minimum daily- more is better." The home never obtained the written orders from the prescribing physician to stop levothyroxine and start armour thyroid medications described on the form.
In December 2022 the individual was ordered levothyroxine 125mcg, take 1 tablet by mouth daily in the morning on an empty stomach. The agency documented the medication was held on 12/27 and 12/28 per doctor's order. The agency did not produce the doctor's order to hold the medication.
According to the individuals January 2023 medication administration records (mars), staff administered armour thyroid 60mg daily until 1/11/23, then administered armour thyroid 30mg daily from 1/12/23 until the end of the month. The individual's records don't include medical appointment summaries or written orders form their prescribers for the medication change.
According to a 3/10/23 phone consult record, completed by Individual #1's guardian, the individual's physician made the following medication changes: change armour thyroid to 60mg, stop 30mg dose, repeat labs in 1 month, add Biz (methylcobalamin) 1-time daily 1000mcg (1mg) at 8am. The physician did not sign or complete the form and the home didn't have the written changes of the medication from the prescriber. The home administered the medication changes. | Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. | The Nurse will contact all prescribing physicians and obtain updated medications orders. The Associate Director of Residential will retrain all House Managers that changes in medication may only be made in writing by the prescriber and that the written notice must be kept and filed accordingly. |
11/14/2023
| Implemented |
| 6400.166(a)(2) | Individual #1's February medication administration record (mar) that listed armour thyoid, vitamin c, Zyrtec, and ibuprofen medications didn't list the name of prescriber for any of the medications.
One of the individual's February mars that lists curcum chewables, doesn't include the name of the prescriber.
Individual #1's September mar that lists Zyrtec, destin, vitamin b6, ibuprofen , nayzilam, and destin doesn't include name of their prescriber.
There are mars in Individual #1's record (between mars for March and April 2023) that list the following medications that were administered: Armour thyroid 30mg tablets, vitamin c 1000mg, Zyrtec 10mg, ibuprofen 400mg, Curcum-Evail chewable, Armour thyroid 60mg, and biz (Methylcolalamin) where the name of the prescribers of the medications weren't included. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | The House Manager will ensure that all of Individual #1's medications have the name of the prescriber listed on the medication administration record. The Associate Director of Residential will retrain all House Managers that the prescribing physician must be listed on the medication administration record for each medication. The agency nurse called the pharmacy who provides the medication administration records, to have them add the prescribing physicians on the MARs. |
11/14/2023
| Not Implemented |
| 6400.166(a)(3) | Individual #1's 12/29/22 medical appointment summary stated it was a zoom (virtual) appointment with a physician and the individual's legal guardian signed the summary form, not a physician. Written on the summary was "discussed levothyrozine and possible reaction to medication, stop levothyroxine, start armour thyroid 60mg, caregivers monitor water intake 16 ounces minimum daily- more is better." The individual's possible reaction to levothyroxine was not included on any medication administration records (mars) for the individual. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Drug allergies. | The Associate Director of Residential informed the pharmacy on 11/2/23 of Individual #1's possible reaction to levothyroxine so that it could be added to the allergy section on the medication administration record. |
11/14/2023
| Not Implemented |
| 6400.166(a)(5) | Individual #1's September 2023 mars state Methylcobalamin 1000mg tablet, chew 1 tablet by mouth for general health. Staff document they administered this daily at 8am. During the 9/28/23 onsite inspection, the vitamin bottle, Methylcobalamin 1000mcg, was empty. Staff were administering the vitamin out of the bottle with the name: Sublingual Methylcobalamin b-12 1000mcg. The individual's mars indicated the tablet in milligram dose and the bottle indicated the tablet in microgram dose, which are not the same. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | The Nurse will contact all prescribing physicians and obtain updated medications orders. The Nurse will also request the physicians to send their orders directly to the pharmacy so that the label matches the medication administration record. |
11/14/2023
| Not Implemented |
| 6400.166(a)(6) | Individual #1's February 2023 (purportedly 2023 as the year was missing from the mar) medication administration record (mar) that listed armour thyroid, vitamin c, Zyrtec, and ibuprofen medication didn't list the dosage form of the ibuprofen.
Individual #1's September 2023 (purportedly 2023 as the year was missing from the mar) mar that recorded nayzilam as needed, didn't include the dosage form. It is a nasal spray. The mar only said, 5mg into nasal cavity up to 2 times a day as needed for seizures lasting 5 minutes. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | The Associate Director of Residential contacted the pharmacy on 11/2/23 and informed them that the dosage form must be listed on Individual #1's medication administration record. |
11/14/2023
| Not Implemented |
| 6400.166(a)(7) | Individual #1's February medication administration record (mar) that documented armour thyoid, vitamin c, Zyrtec, and ibuprofen medication were administered, didn't record the dose of ibuprofen that was administered twice daily from 2/9/23-2/28/23. As referenced in this report, the year is purportedly 2023 as this was missing from the mar.
Individual #1's September 2023 mars that document nayzilam is a prescribed medication, didn't include the full dose prescribed. The mar stated, 5mg into nasal cavity up to 2 times a day as needed for seizures lasting 5 minutes. According to the individual's 8/9/23 medication list attached to their 8/10/23 physical examination record they are prescribed, midazolam 5mg/spray (.1ml) spray/non aerosol, administer 5mg into affected nostrils 2 (two) times a day as needed (seizure) 5ml as needed for breakthrough seizure symptoms for more than 5 minutes up to twice day. During the 9/28/23 onsite inspection, the pharmacy issued medication label stated Nayzilam, instill 5mg into affected nostril up to 2 times a day as needed for breakthrough seizures greater than 5 minutes.
There are mars in Individual #1's record (between their mars for March and April 2023) that list the following medications were administered: armour thyroid 30mg tablets, vitamin c 1000mg, zyrtec 10mg, ibuprofen 400mg, curcum-evail chewable, armour thyroid 60mg, and biz (methylcolalamin) where the dose of Zyrtec that was administered daily for the month is unknown. The record has take 1 tablet, and the one also has a two written on it.
Individual #1's September 2023 mars document that staff are to administer 10ml (1000mg) of levetiracetam twice daily for the individual's seizures. During the 9/28/23 onsite inspection, Individual #1's levetiracetam medication with the pharmacy-issued medication label instructing staff to administer 10ml (1000mg) twice daily, was unopened and dispensed from the pharmacy on 9/9/23. Two bottles of levetiracetam were also located with Individual #1's medications, both of which contained a pharmacy label instructing staff to administer 7.5ml (750mg) twice daily. Both levetiracetam medication bottles with instructions to administer 7.5ml twice daily were open, and staff reporting the medication being used. Staff document with their initials at 8am and 8pm daily, that they administer levetiracetam medication to Individual #1. However, the dose administered is unknown in September 2023 as staff report they are using the levetiracetam medication bottle with instructions to administer 7.5ml twice daily but initialing the mar that include instructions for a different dose administered twice daily. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | The Associate Director of Residential contacted the pharmacy on 11/2/23 to have them correct Individual #1's medication administration record and ensure that the dose of medication on the medication administration record matches the dosage on the medication. |
11/14/2023
| Not Implemented |
| 6400.166(a)(11) | REPEAT from 10/4/22 annual inspection: During the 9/26/23 inspection, Individual #1's record contained a medication administration record (mar), between their mars for March and April 2023, that documents armour thyroid 30mg tablets were administered. The diagnosis or reason for prescribing and administering armour thyroid 30mg wasn't included on mars. | 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. | The Associate Director of Residential will retrain all House Managers on the necessary information that must be on the medication administration record. |
11/14/2023
| Not Implemented |
| 6400.166(a)(12) | During the 9/26/23 inspection, there were many medication administration records (mars) in Individual #1's records where the date and time of medication administration was not included on the mar. Some mar records provided included so little information the agency was unable to determine what month medications were administered. The following was found and missing from the individual's mars:
· A February mar that documented administration for Armour thyroid, vitamin c, Zyrtec, and ibuprofen medications, and another February mar that documented administration of curcum chewables didn't document the year they were referencing.
· A September mar that documents administration of Zyrtec, Destin, vitamin b6, ibuprofen, nayzilam, and Destin didn't include the year.
· A September mar that documented Destin was administered on 9/3 did not include the time or year of administration.
· There are mars in Individual #1's record (between their mars for March and April 2023) that list the following medications were administered: Armour thyroid 30mg tablets, vitamin c 1000mg, Zyrtec 10mg, ibuprofen 400mg, curcum-evail chewable, Armour thyroid 60mg, and biz (methylcolalamin) where the month and year is not recorded on any of the mars. Additionally, the time of administration is not documented for the second daily dose of ibuprofen, or the second daily dose of Armour thyroid 60mg. The mars have the time of administration recorded in pen, and then another time of administration recorded over that time, without clarification for when the second doses of medications were administered for the month. Armour thyroid 60mg medication appeared to have the second dose recorded as 8pm with a 6pm written over it as well (or visa versa) and second dose of ibuprofen had 5pm and 4pm written on top of each other.
· There is a mar in the individual's record that does not include a month or a year, but documents ibuprofen and levetiracetam was administered at 4pm and 8pm, respectively, on the 28th of the month by Staff #6. The mar does not include any identifying name that coincides with Staff #6's initials.
· Individual #1's July mar includes administration of medications but does not include the year it references. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | The Associate Director of Residential will retrain all House Managers on the necessary information that must be on the medication administration record. |
11/14/2023
| Not Implemented |
| 6400.166(a)(13) | During the 9/26/23 inspection, the name and initials of the staff that administer Individual #1 their daily and as needed medications over the previous year, October 2022 to current, September 2023, are illegible on the individual's medication administration records (mars) for some staff each month. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | The Associate Director of Residential will retrain all House Managers on the necessary information that must be on the medication administration record. The Associate Director of Residential will also create a MAR signature sheet that will go with each medication administration record that staff will print, sign, and write their initials. |
11/14/2023
| Not Implemented |
| 6400.166(b) | REPEAT from 10/4/23 annual inspection: Nayzilam was administered to Individual #1 on 8/19/23. The name and initials of the staff person who administered the medication was illegible on the individual's medication administration records (mar). Staff recorded on the mar that the medication was administered to the individual at 2pm. However, according to an internal incident report, staff administered the medication sometime between talking to the individual's legal guardian at 1:30pm and EMT's arriving on site at 1:47pm. The exact time is unknown. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The Associate Director of Residential will retrain all House Managers on the importance of recording the exact time medication is administered with PRN medications. |
11/14/2023
| Implemented |
| 6400.167(a)(1) | REPEAT from 10/4/22 annual inspection: According to Individual #1's February 2023 medication administration records (mars), they are prescribed vitamin c and Zyrtec at 8am. The individual was not administered these prescriptions on 2/1/23. The year was missing from the February mar, but the home purports it was referencing 2023.
Individual #1's 2/13/23, (purportedly 2023 as the year was missing from mar) mar documents an "A" for ibuprofen 4pm administration but doesn't record the staff who administered the medication or an answer key to describe what A references.
There is a mar in the individual's record that does not include a month or a year, but documents ibuprofen and levetiracetam was administered at 4pm and 8pm, respectively, on the 28th of the month by Staff #6. Individual #1 is prescribed levetiracetam daily. This medication wasn't administered on the 29th of this month as the mar is blank. This same mar documents A and H for other administrations of these two medications from the 29th-31st of this month, but doesn't include descriptions for A, H, or staff member with those initials as an identifier. | Medication errors include the following: Failure to administer a medication. | The Medication Administration Trainer and Registered Nurse will train House Managers and staff on identifying medication and documentation errors, specifically on descriptions and identifiers on the medication administration records. |
11/14/2023
| Not Implemented |
| 6400.168(b) | On 12/29/22 Individual #1 had a virtual medical appointment. According to the appointment summary record completed by the individual's legal guardian, the individual was to stop levothyroxine and discussion at the appointment included a possible reaction to levothyroxine. The individual's possible reaction to the medication, the concerns discussed about the possible reaction, the practitioner's response, and the action taken when discovered the possible reaction was not documented in the individual's record. | An adverse reaction to a medication, the health care practitioner's response to the adverse reaction and the action taken shall be documented. | The Nurse will contact Individual #1's physician and request documentation for the possible reaction to levothyroxine. This documentation will include details for what the possible reaction is and the action taken. |
11/14/2023
| Implemented |
| 6400.169(a) | Staff #1's medication administration training documents state they passed the Department's initial medication administration training course and all requirements on 9/9/23. As referenced in 6400.43(b)(1) of this report, their 2023 initial medication training requirements (2 of the 4 medication observations) were completed by a staff without the qualifications or certifications to do so. Therefore, Staff #1's didn't properly pass the initial medication administration training and is administering medications.
Staff #3's medication administration training documents state they passed the Department's initial medication administration training course and all requirements on 9/14/23. However, as referenced in 6400.43(b)(1) of this report, their 2023 initial medication training requirements (2 of the 4 medication observations) were completed by a staff without the qualifications or certifications to do so. Therefore, Staff #1's didn't properly pass the initial medication administration training and is administering medications. | 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). | This staff repeated their annual practicum requirements with a Certified Medication Administration Trainer by 10/25/23. All Practicum Observers who did not meet the proper training requirements were removed from their roles immediately on 9/28/23. |
10/25/2023
| Not Implemented |
| 6400.186 | Individual #1's individual support plan (isp) states they want to work on an outcome of attending social events and participating in residential living activities that they enjoy so that they can increase their independence. According to outcome documentation records, the individual's goal is also to send and color cards. The home has not recorded any social events and outings they are taking the individual to in the community to increase their independence. The home is also not assisting the individual to send and color cards monthly. Documentation of working towards these outcomes in August 2023 is blank, there aren't records for September 2023, the home assisted the individual to color once in July 2023, colored a picture once in June 2023, colored pictures once in May 2023, colored pictures 5 times in April 2023, and no records of completing any outcomes from October 2022 to and including March 2023. | The home shall implement the individual plan, including revisions. | The Program Specialist will review the Individual #1's goal with the House Manager and staff. The Program Specialist will review with the staff the proper documentation process of goals including how to mark a goal successful and proper steps to take if an individual refuses a goal. |
11/14/2023
| Implemented |
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