| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
|
SIN-00221408
|
Renewal
|
03/13/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(1) | Immunization screening (Influenza/Civid) for Individual #1 was not completed, agency provided a printout stating, "Consent Refused". No follow-up of further documentation for refusal from the parent provided. | The physical examination shall include: A review of previous medical history. | For Individual #1 DON went to the state website (PA DOH) and found documentation of flu vaccine give 1/31/23). Please see scanned attachment. Once this was found, DON went to Point Click Care and added it as historical consent status. Please see second scanned attachment. Admission documentation from St Christopher's Hospital was not accurate. |
03/13/2023
| Implemented |
| 6400.144 | An LPN was observed administering the medication ONFI 20mg tablet to individual #2 on 3/13/23. This medication was ordered to be crushed. A It was observed that this medication was crushed using 'silent knife' and put into a plastic sleeve. Once they crushed medications in the sleeve, it was not fully emptied into the container which was to be administered to the individual. | 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.
| Individual #2 was redirected at the time of preparation and administration of medication. The Nurse expelled the remaining medication into the medication cup to ensure the completed dose was administered. |
05/05/2023
| Implemented |
| 6400.165(b) | Individual #2 is prescribed Polyethylene Glick 3350 Powder. The directions on the medication record states:
-Give 17 Grams via G-tube two times a day for constipation, mix with 240ml water.
However, the label on the medication did not say to mix with 240ml of water.
Individual #2 is prescribed a sliding scale Bolus insulin order. This order was updated on 3/1/23.
The mediation that was on site still had the previous dosing information listed on the label. It included a note attached stating that the medication had been updated but the note did not contain the specifics of the new order. | A prescription order shall be kept current. | On 3/13/23 at the time this was noted, a "change of direction" sticker was placed on the sticker. |
04/10/2023
| Implemented |
|
|
|
SIN-00203091
|
Renewal
|
03/31/2022
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The step leading to the staff breakroom on the second floor was ripped in an area which could cause a tripping hazard. | Floors, walls, ceilings and other surfaces shall be in good repair. | Immediately on 3/31/2022, the tattered carpet was secured to the stair. On 4/20/2022, the ripped carpet on the step leading to the staff breakroom on the second floor was removed and replaced with non-slip tread to prevent it from being a tripping hazard. |
03/31/2022
| Implemented |
| 6400.141(c)(15) | On the annual physical exam dated 4/29/21 for individual #2 the diet section was left blank. | The physical examination shall include: Special instructions for the individual's diet. | On 3/31/2022, the annual physical exam dated for 4/29/21 was immediately reviewed with the Medical Director and Nursing Supervisor to explain the regulation regarding physical exam completion. The annual physical for Individual #2 was corrected immediately to reflect instructions for the Individual's diet. |
03/31/2022
| Implemented |
| 6400.18(b)(2) | Individual #2's Polyethylene glycerin was not administered as prescribed on 3/21/22. This incident was not entered into EIM within 72 hours. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | Immediately education was provided verbally with the Nurse who failed to complete an Incident Report in our EMR which is the trigger for an Incident Report to be entered in EIM. |
05/25/2022
| Implemented |
| 6400.46(b) | Staff #1 was last trained in annual Fire Safety on 02/24/21 and not retrained until 03/21/2022. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Immediately this regulation was escalated to the Clinical Training committee for discussion on the definition and interpretation of "annual" training. It was determined that exact dates of training need to be utilized in order not to exceed a 12 month period. |
05/25/2022
| Implemented |
| 6400.163(h) | Medication Chlorexidine 4% liquid for Individual #1 expired on 12/31/21 and was still in the medication cart. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The expired medication was disposed of immediately and a replacement medication was on hand at the time of the inspection. |
03/31/2022
| Implemented |
| 6400.165(c) | Polyethylene glycerin prescribed to Individual #2 was not administered as prescribed on 3/21/22 for its 8am dose. | A prescription medication shall be administered as prescribed. | Medication was delivered from pharmacy and administered at the next scheduled dose 3/22/2022. |
03/31/2022
| Implemented |
|
|
|
SIN-00193583
|
Renewal
|
09/10/2021
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.101 | The bathroom located in the lobby area had an external latch lock preventing immediate escape in the event of an emergency, if the room was inadvertently locked during use. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The external latch on the lobby area bathroom door was removed. . |
10/04/2021
| Implemented |
| 6400.25(b) | Individual 1 did not have immediate access to the bathrooms in the residential wing should the individual require to use them. The bathrooms had external number keypad locks that the individual would be unable to open. His toileting guidelines notated the individual is able to use the restrooms with assistance and prompting. The Individual is mobile and still in the process of learning but adaptive, age appropriate equipment can be used to assist him and grant him more access and practice in lieu of the current locks. | The provisions of this chapter regarding rights, decision-making and individual plan activities shall be implemented in accordance with generally accepted, age-appropriate parental decision-making and practices for children, including bedtimes, privacy, school attendance, study hours, visitors and access to food and property, and do not require a modification of rights in the individual plan in accordance with §6400.185 (relating to content of the individual plan). | The external number keypad locks were removed from the bathroom doors so that access can be had in accordance with Individual #1 toileting plan. |
10/07/2021
| Implemented |
| 6400.52(c)(4) | The 2020/2021 annual training records for Staff 1 and Staff 2 do not reflect that the staff received training on the following topic: Recognizing and Reporting Incidents. Staff records for these staff do not contain an annual training with this title or description. When information on the contents of the training course relating to this topic was requested from the provider during inspection, the provider supplied a PowerPoint file titled "Recognizing and Reporting Incidents" as a record of course content. This PowerPoint's title slide reads "Child Abuse Overview and Definitions" and contains information relating to recognizing abuse, exploitation, and neglect and how to report these occurrences. The PowerPoint file does not include information on how to recognize and report incidents recognized by the Department of Human Services (DHS) other than child abuse such as hospitalizations, death and law enforcement related events. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | All staff will be assigned the course in our Electronic Training System. A completion date of this training will be expected by 12/15/2021. |
12/15/2021
| Implemented |
|
|
|
SIN-00190244
|
Unannounced Monitoring
|
06/08/2021
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | Individual #1 had an order from 07/17/2018 for PT, OT & SLP to evaluate and treat if necessary/available. And a verbal order from 10/9/2021 to Hold OT Services until available. It was stated OT services were not provided at the PSC Point Pleasant location. PSC had a Rehabilitation Physician assess all of their location and also took into account each facilities census and budgetary requirements when deciding which therapies would be offered at each location. Therefore health services for OT were not provide for individual #1 as ordered. | 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 order for "PT/OT and SP to evaluate and treat if necessary/available" will be modified to remove "OT". |
08/19/2021
| Implemented |
|
|
|
SIN-00182051
|
Renewal
|
12/21/2020
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(k)(5) | Closet wardrobes for individual 1 had child locks over the handles which made them inaccessible for the individual to use if they needed them. Some Wardrobes were too high for the individuals to access and numerous licensed bedrooms also had child locks over wardrobes during inspection. | In bedrooms, each individual shall have the following: Closet or wardrobe space with clothing racks and shelves accessible to the individual. | Wardrobe closets with child safety locks will have the child safety locks removed. Items requiring to be stored securely will be moved. |
03/12/2021
| Implemented |
| 6400.82(e) | The showering area and the single bathub on the main level did not have nonslip surfaces or mats. | Bathtubs and showers shall have a nonslip surface or mat. | In addition to the tile that is non-slip, a rubberized slip resistant floor treatment was completed. |
02/25/2021
| Implemented |
|
|
|
SIN-00172577
|
Unannounced Monitoring
|
02/19/2020
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(e) | Staff #1 was first trained in his floor duties on 11/23/19. He was hired as a Nurse Technician Assistant. Documentation in the file reports he first signed acknowledgement of his duties on 11/19/19. The record could not establish that staff was trained in the individual #1 behavior plan or in his history of biting behaviors. | Program specialists and direct service workers shall have training in the areas of intellectual disability, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. | A new task button will be created in Point Click Care for staff to acknowledge a behavior plan is in place for Individuals. The task button will also include the location of the plan and the access for additional training. Additionally all behavior plans will be reviewed in orientation along with the location of the behavior plan. |
04/26/2020
| Implemented |
| 6400.46(j) | Staff #2, a Registered Nurse, their new hire orientation training was not successfully completed as the nursing orientation skills checklist had not been completely filled out.
Staff #3, a Nurse Technician, It does not appear that this staff was trained in point click care system, which is the agencys internal incident/behavior reporting system, as this section is blank on the nursing technician orientation skills checklist section dated 12/17/19. | 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. | New hire orientation training documents and nursing orientation skills checklist will be reviewed by Nursing Supervisors and ADON during the training process. Once training is complete ADON will review Nursing Training checklist for any omissions. Once Nursing skills checklist is complete ADON will forward to Human Resource Assistant. Human Resource Assistant will review for any omissions prior to filing in employee training file. Orientation training documents and nursing orientation skills check list will not be considered complete until all areas are signed off. |
03/26/2020
| Implemented |
| 6400.141(a) | A physical examination for Individual #1 was not completed annually, last physical was completed 10/25/18 and current physical dated 11/21/19. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1 was sent out to CHOP on 10/25/19 the day the physical was due. He was hospitalized for respiratory distress and fever and did not return to back to us until 11/6/19. The Physician rounded 11/21/19 and completed his physical. Moving forward tracking of annual physicals will be prepared 30 days prior to due date in order to plan for unexpected situations. |
03/26/2020
| Implemented |
| 6400.181(e)(1) | The Assessment dated 12/06/19 did not contain preferences within the resident assessment for Individual #1. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | The assessment document was reviewed and compared to the regulation. It was noted that it listed "Functional Strengths and Needs " in the Individual's assessment. The assessment document will be modified to capture "Functional Strengths, Needs and Preferences of the Individual". |
04/26/2020
| Implemented |
|
|
|
SIN-00164249
|
Renewal
|
10/10/2019
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | A container was found in the back storage rooms. The access door was not able to be locked as well as the storage cabinet. The chemicals included skin cleanser, toothpaste, oil moisturizer, hair lotion and hair conditioner. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Container was removed 10/11/19. All Individuals who have room changes, transfers or are discharged will be monitored to ensure poisonous materials are packed and stored safely. Process will be reviewed with Nursing Supervisors, Program Specialist, Social Worker and Housekeeping staff to ensure all rooms are cleaned and packed appropriately. |
10/11/2019
| Implemented |
| 6400.64(a) | The nurses' office in the day room has a small refrigerator accumulating ice inside. This refrigerator did not have a temperature gauge. The floor mat in room 7 was stored with its edge facing up. The edge of the mat had accumulated dirt. Room #2 and Individual # 3, the voice/noise monitor was found stained and unsanitary. Room # 3, individual # 4 , a sticky substance was found on the floor. | Clean and sanitary conditions shall be maintained in the home. | The refrigerator was replaced on 11/7/19 with a new unit with temperature gauge. The floor mat was replaced with a clean mat 10/11/19. The voice/noise monitor was cleaned on 10/11/19. The floor in room 3 was cleaned on 10/11/19 and sticky substance was removed. Environmental Service Director will review cleaning practices with housekeeping staff. |
12/06/2019
| Implemented |
| 6400.67(a) | The resident bathroom on the left side of the hallway has a broken toilet seat. | Floors, walls, ceilings and other surfaces shall be in good repair. | On 10/11/19 the broken toilet seat was removed and replaced with one in good condition. All Staff are aware that any broken equipment should be escalated during huddle meetings and noted on communication board. Housekeeping staff are aware to inspect equipment during the daily cleaning and will notify Environmental Service Director should equipment need to be repaired or replaced. |
10/11/2019
| Implemented |
| 6400.67(b) | Room 3 has a changing table that has porous, unpainted surfaces which can attract contaminates. The tray table used by individual #1 in the day room has exposed wood surfaces. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The changing table and tray table were discarded. Replacement equipment ordered and awaiting receipt. |
12/06/2019
| Implemented |
| 6400.110(f) | The fire alarm was tested and there were certain rooms that were not equipped with strobe lights. The inspector noticed that in these rooms it was difficult to hear the sound of the alarm. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | On 10/28/2019 Environmental Service Director received a proposal from Keystone Fire Protection for removal and replacement of older strobe lights horns and replace with newer units with a higher decibel reading . Proposal was immediately approved. Keystone Fire Protection completed work on 12/6/2019. |
12/06/2019
| Implemented |
| 6400.144 | Individual #2 has an order for a weighted blanket from 9/12/18 to use up to 30 minutes as a comfort . There was no documentation on the Medical Administration Record (MAR) concerning when it was being used. | 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.
| On 10/11/19 the EMAR System was adjusted to reflect PRN nursing documentation access. It was noted that the initial order under "audit details" did not reflect ability for nursing to document the use of weighted blanket. It was corrected immediately. Education will be given to Nurse Supervisors on order entry specific to PRN treatments or medications. |
12/10/2019
| Implemented |
|
|
|
SIN-00141732
|
Renewal
|
09/13/2018
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff person #3, DOH 5/16/18, had a late criminal history check completed 5/31/18. Staff person #4, DOH 2/11/18, had a late criminal history check completed 5/24/18. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| Going forward new employees will have a criminal history check prior to start of employment. On a monthly basis the HR Coordinator and/or designee will conduct an audit of employee files to ensure their criminal history check was completed before their date of hire, and to ensure ongoing compliance. The HR Coordinator was re-educated on the importance of this regulation. |
11/20/2018
| Implemented |
| 6400.21(c) | Staff person #1, DOH 9/1/18, had a late FBI criminal history check completed 5/22/17. Staff person #2, DOH 6/13/18, had a late FBI criminal history check completed 5/16/17. | The Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person's date of hire. | Going forward new employees will have an FBI check completed prior to the start of employment. On a monthly basis, the HR Coordinator/designee will conduct an audit of employee files to ensure their FBI check was completed no more than 1 year prior to the person's date of hire, and to ensure ongoing compliance. The HR Coordinator was re-educated on the importance of this regulation. |
11/30/2018
| Implemented |
| 6400.64(a) | Individual #1, room 2, has in his bedroom a voice/noise monitor which is stained and unsanitary. Individual #2, room #3 has a sticky substance on the floor. | Clean and sanitary conditions shall be maintained in the home. | Immediately the noise/voice monitor in room #2 was cleaned and the floor in room #3 washed. Going forward daily building rounds will include inspection of noise/voice monitors and floors to ensure clean and sanitary conditions. The building rounds audit sheet was updated to include these items. Results of the audits will be reviewed at safety meeting to ensure ongoing compliance. All staff will be re-educated on the importance of having sanitary conditions via Relias (online learning system) by 11/30/18. |
11/30/2018
| Implemented |
| 6400.67(a) | The nurse's station on the upper level has a formica type strip missing from the desk. | Floors, walls, ceilings and other surfaces shall be in good repair. | The Formica type strip on the nursing station will be replaced. Materials are in the process of being procured. During monthly safety rounds surfaces will be inspected to ensure good repair and ongoing compliance. All staff will be re-educated on the importance of keeping surfaces in good repair via Relias(online learning system) by 11/30/18. |
11/30/2018
| Implemented |
| 6400.69(a) | The upper level bathroom (the one w/o the tub) the temperature was cold. | The indoor temperature may not be less than 65°F during nonsleeping hours while individuals are present in the home. | Immediately the damper in the bathroom was modified to prevent cold air from blowing down into the area. During monthly safety rounds bathroom temperatures will be audited to ensure the room is 65 degrees or warmer. Environmental and maintenance will be re-educated on the importance of air temperatures being above 65 degrees by 11/30/18. |
11/30/2018
| Implemented |
| 6400.76(a) | Room #2., Individual #3 bedroom, has a wheelchair with a torn armrest. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Immediately the physical therapist requested replacement armrests for Individual #3 and awaiting arrival of the equipment. Going forward the physical therapist will complete monthly audits to ensure equipment is in good repair. Results of audits will be reviewed at safety meeting to ensure ongoing compliance. All staff will be re-educated via Relias (online learning system) on what denotes clean and sturdy equipment, how to report issues, and to whom by 11/30/18. |
11/30/2018
| Implemented |
| 6400.80(b) | The exit door in the gym had debris on the ground, the outside door had a mildew-like substance on its surface and in need of cleaning. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Immediately the debris outside the exit door was removed and the door was washed. During monthly safety rounds all exit doors will be audited to ensure the area is well maintained and in good repair. All staff will be re-educated on the importance of keeping exit areas free of debris, clean, in good condition and how to report issues via Relias (online learning system) by 11/30/18. |
11/30/2018
| Implemented |
| 6400.101 | The exit door in the gym was blocked by a table and a red-wheeled apparatus. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Immediately the table and red wheeled apparatus were removed to clear the exit. Daily building rounds will be completed by maintenance and/or designee to ensure exit doors, stairways, halls and doorways are not obstructed. Results of audits will be reviewed at safety meeting to ensure ongoing compliance. All staff will be re-educated on the importance of not blocking egress doors on Relias by 11/30/18. |
11/30/2018
| Implemented |
| 6400.167(b) | Bethanechol 1 mg/ml 4 mg via g-tube 4x's a day for reflux 1 hour prior to bolus feeds. The med log was reviewed at 11 am and it was signed out for the 12 pm dosage administration but individual # 4 was at school at that time. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Going forward individuals with medication administration times assigned while at school, will be signed out according to policy and the appropriate Point Click Care code will be documented. Daily audits will be completed by the Nurse Supervisor and/or designee to ensure medications are given and signed out at administration times. Results of audits will be reviewed at safety meetings to ensure ongoing compliance. All clinical staff will be re-educated on the process of medication documentation including administration codes in Point Click Care via Relias ( Online learning system) by 11/30/18. |
11/30/2018
| Implemented |
|
|
|
SIN-00121226
|
Renewal
|
09/05/2017
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.46(i) | Staff #1's CPR certification expired 3/21/2017.
Staff #2's CPR certification expired 7/25/2017.
| Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Staff #1 (VT) and #2 (DB) were advised of outstanding CPR Certification and instructed to bring in a copy for the file. Both employees provided copies of the cards on 9/15/17. On a monthly basis the HRC will notify employees 60 days in advance of the due date for CPR Certification Renewal. On a monthly basis HRC and/or designee will audit HR files via staff record audit tool to ensure all staff have current CPR training. All staff will be re-educated on the importance of the regulation via Relias by 11/17/17. |
11/17/2017
| Implemented |
| 6400.62(a) | Virex TB disinfectant cleaner and Purell hand sanitizer were found in an unlocked closet in the hall on the lower level. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Immediately on 9/5/17 the magnetic lock on this cabinet was replaced with a sliding child lock to prevent from opening. Going forward on a monthly basis an audit will be completed by the Safety Committee utilizing the Safety Committee Audit form to ensure all poisonous materials are locked, and cabinets with locks can not be pulled open. All Staff will be re-educated on this regulation via Relias (online learning system) by 11/17/17. |
11/17/2017
| Implemented |
| 6400.65 | The exhaust fan in the lower level resident bathroom was inoperable and there were no operable windows in the bathroom. | Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation.
| Immediately a contractor was called and the exhaust fan was fixed and operable as of 9/11/17. Going forward on a monthly basis an audit will be completed by the Safety Committee utilizing the Safety Committee audit form to ensure exhaust fans are operable and physical site is in regulatory compliance. All Staff will be re-educated on this regulation via Relias (online learning system) by 11/17/17. |
11/17/2017
| Implemented |
| 6400.76(a) | A railing located outside the lower level exit across from the resident bathroom had four broken spindles. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The Spindles were immediately fixed on 9/6/17. Going forward on a monthly basis an audit will be completed by the Safety Committee utilizing the Safety Committee audit form to ensure furniture and equipment are nonhazardous, clean and sturdy. All Staff will be re-educated on this regulation via Relias(online learning system) by 11/17/17. |
11/17/2017
| Implemented |
| 6400.141(c)(14) | Individual #3's annual physical examination dated 2/17/2017 did not include information pertinent to diagnosis in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Resident Physical form was revised on June 7, 2017 to include all pertinent information to diagnosis and treatment during an emergency. The Nurse manager and/or designee will audit physicals on a monthly basis to ensure ongoing compliance. Nursing staff will be re-educated on the revised physical form as well as what information needs to be included on the physical form by 11/17/17 via Relias(online learning system). |
11/17/2017
| Implemented |
| 6400.144 | Comparison of Individual #1's glucometer and the glucose-monitoring record showed that many more blood glucose readings were being taken than were recorded on the data collection sheet. | 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.
| Going forward a flow sheet will be utlizied for documentation of blood glucose readings to be entered into PCC ( electronic medical records system). A new blood glucose skills checklist will be implemented and completed by 11/30/17 by all nurses to ensure ongoing compliance.All staff will be re-educated on the Blood Glucose policy via Relias (online learning system) by 11/17/17. |
11/30/2017
| Implemented |
| 6400.151(c)(2) | Staff #1's most recent TB testing was completed 3/14/2015. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Staff #1 was advised of outstanding TB test and instructed to bring in a copy. Subsequently the employee was terminated. Going forward on a monthly basis the HRC will notify employees 60 days in advance of the due date for a TB test via iCIMS (electronic HR system) or personal email. On a monthly basis the HRC and/or designee will audit the HR files via the Staff Records Audit tool to ensure all staff have a TB test completed. All staff will be re-educated on the regulation via Relias (online learning system) by 11/17/17. |
11/17/2017
| Implemented |
| 6400.167(b) | The medication Lotrimin (Clotrimazole 1%) was prescribed on 8/04/2017 for Individual #2 to be applied BID for ten days. The MAR shows documentation that the medication was administered for seven days. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Clotrimazole was ordered for 10 days, but Pharmacy only scheduled it for 7 days, and nurse only approved it for 7 days. Going forward the Nurse supervisor and/or designee will monitor QMAR on a daily basis to ensure all new orders are approved and transcribed as ordered. Chart checks will be performed daily by nurses to ensure proper transcription of medication orders, accurate dosing, strength, and duration are reflected in QMAR and are approved accurately and timely. PSC's Medication Administration and Physician Order policies will be reviewed via Relias (online learning system) by 11/17/17. |
11/17/2017
| Implemented |
| 6400.213(1)(i) | Individual #3's record did not indicate religious affiliation. | Each individual's record must include the following information: Personal information including: (i)The name, sex, admission date, birthdate and social security number. (iii)The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii)The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v)The next of kin. (vi)A current, dated photograph. | Individual #3's records was corrected to reflect a religious affiliation on 9/6/17. On a monthly basis the Social Worker and/or designee will audit all Individual's Face Sheet to ensure religious affiliation is indicated utilizing the Social Service auditing tool. PSC Social Worker was re-educated on the importance of completing each section of the Individual's Face Sheet on 10/20/17. |
10/20/2017
| Implemented |
|
|
|
SIN-00116668
|
Unannounced Monitoring
|
06/20/2017
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | On 05/28/2017, Staff # 1 was providing oral hygiene care to Individual # 1 when maggots were discovered in Individual # 1's oral cavity. Staff # 1, #2, #3 and #4 promptly removed the maggots by scooping and suctioning. Staff # 2 consulted with the physician and Individual # 1 was assessed and monitored. Individual # 1 received medical care via the emergency room to rule out a potential infestation which resulted in no evidence of additional maggots or necrotic flesh. Individual # 1 has an open mouth at rest posture and Pediatric Specialty Care's oral hygiene policy documents "all individuals will have their teeth brushed and entire mouth at least twice daily". According to Pediatric Specialty Care Documentation Survey, Individual # 1 received oral hygiene care once per day. Therefore Pediatric Specialty was not implementing their oral hygiene policy. | 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 evening ADL bundle within Point of Care (POC) which addresses brushing teeth and mouth care was entered as PRN. An audit was immediately completed to determine if this error was in any other Individual¿s record and none were effected. On 6/7/17 all individuals were assigned an oral hygiene button in Point Click Care ( Electronic Medical Record) that requires twice daily documentation of oral hygiene.On a monthly basis Physician orders will be audited by DON/Designee to ensure accuracy and on-going compliance. All Clinical Staff will be re-trained on PSC oral hygiene policy via Relias (online learning system) by 8/31/2017. |
08/31/2017
| Implemented |
|
|
|
SIN-00114791
|
Unannounced Monitoring
|
02/24/2017
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | Individual # 1's physician orders dated 11/01/2016 through 01/31/2017 document a thermovent is not to be utilized in their care. Pediatric Specialty Care's Respiratory Assessment dated 01/07/2017 at 15:57 documents, Individual # 1's respiratory pattern was no apparent distress, oxygen was given to obtain SpO2 % and the mode of oxygen was a thermovent. | 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.
| Nursing and Respiratory Staff were immediately retrained on modes of oxygenation/ventilation and the importance of following Physician orders. The Nurse involved in incident received 1:1 re-training by the Clinical Educator on 2/5/17 and by the Lead Respiratory Therapist on 1/27/17. The Respiratory Therapist involved in incident received 1:1 retraining by the Lead Respiratory Therapist on 1/27/17. Additional re-training was conducted via in-service by the DME company on 1/12/17. Topics reviewed included how to properly ventilate individuals with tracheostomies, properly connecting individuals to the humidifier, use of air compressors, ventilation modes, nebulizer attachments,changing the circuit, troubleshooting, and the importance of following physician orders. On a monthly basis Physician orders will be audited to ensure accuracy and on-going compliance. Going forward, during orientation all new RNs and Respiratory Therapist's will be trained by the Lead RT on modes of ventilation/oxygenation and the importance of following Physician orders via the Respiratory Refresher Training Checklist. |
06/16/2017
| Implemented |
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|
|
SIN-00088093
|
Renewal
|
02/11/2016
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.31(b) | Individual #3's date of admission was 10/14/2015 and the individual rights were signed on 10/15/2015. | Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | All future admissions will sign individual rights on the day of admission. Program Specialist, Nurse, and Social Worker will be instructed on the responsibility to complete all paperwork at the time of the admission. Social Worker will audit new Individual Record within 24 hours to ensure individual rights are signed on the day of admission. Results of the findings will be shared at the Quarterly Quality Assurance Meeting to ensure ongoing compliance. |
04/01/2016
| Implemented |
| 6400.46(g) |
Staff # 1's annual fire safety training dated 01/20/2015 was completed online and a fire safety expert was not present during the training.(Repeat Violation )
Staff # 2's annual fire safety training dated 01/20/2015 was completed online and a fire safety expert was not present during the training.
Staff # 3's annual fire safety training dated 01/21/2015 was completed online and a fire safety expert was not present during the training.
| Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). | Going forward all staff will be trained by a fire safety expert. A review of the fire safety training records will be completed by human resources, and a tracking tool will be created to ensure in person training by a fire expert will occur annually. This review will be completed by 4/1/16. Administrator and Maintenance Assistant (who have been trained by a fire safety expert DS 4.6.16) will conduct fire training 4 times a year (April/July/October/December) on all shifts in order to ensure all staff are trained appropriately. A quarterly audit to ensure ongoing compliance will be completed and reviewed during the Quarterly Quality Assurance meetings. |
04/15/2016
| Implemented |
| 6400.67(b) | A toolbox containing a screwdriver, bolts, nuts, screw, etc was found unlocked in the day room. The items are considered hazardous since they pose a choking risk. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The toolbox was immediately removed from the day room (gym). All hazards will be removed from the environment during daily building rounds and documented on the building rounds checklist. Daily building rounds checklist will be reviewed monthly by the Administrator to ensure ongoing compliance. All staff will be educated on what is considered to be a hazardous item in order to assist in keeping the environment free of all hazards. This education will be completed on Relias (and within 30 days of receipt of this POC (DS 4.6.16) |
04/15/2016
| Implemented |
| 6400.110(e) | The fire alarm is not audible when the fire door closes in the area around Rooms 21, 22, 23, 24.
The fire alarm is not audible once the door closes in the bathrooms located on the lower level.
| If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | The audible component to the fire alarm was corrected so that Rooms 21, 22, 23, 24 and the bathrooms on the lower level can hear the alarms when sounding. BizCom, a provider of fire alarm equipment, completed the work to ensure Rooms 21, 22, 23, 24 and lower level bathrooms can hear the alarms. Going forward we will have a fire alarm that is audible throughout the entire building. |
03/10/2016
| Implemented |
| 6400.110(f) | The bathrooms located on the lower and upper levels do not have strobes lights. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | Strobe lights will be added to the noted areas to alert hearing impaired individuals in the event of a fire. BizCom, a provider of fire alarm equipment, will complete the work necessary to ensure hearing impaired individuals can be alerted in the event of a fire by 3/31/16. Going forward all hearing impaired individuals will be notified of a fire by strobe lights. |
03/10/2016
| Implemented |
| 6400.112(a) | The fire drill records covering the period from 01/27/2015 through 01/30/2016 indicated there are two separate drills being held for the upper and lower level which are in the same building. Therefore, the fire drill is announced to the level that did not participate in the initial drill | An unannounced fire drill shall be held at least once a month. | Going forward every month there will be an unannounced fire drill. Beginning in April 2016, one drill will be held for the entire (single) building. Staff on each floor will be trained appropriately on a response to the fire depending on the location of the fire. Maintenance Director and Fire Safety expert will meet in March to discuss purpose and training to meet the regulation.Monthly audits of the fire drill record by the Maintenance Director will be completed to ensure ongoing compliance. |
04/01/2016
| Implemented |
| 6400.112(h) | The fire drill records covering the period from 01/27/2015 through 01/30/2016 do not indicate the designated meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Going forward all fire drill records will record the designated meeting place. A new architectural drawing of the evacuation map will be obtained to include a designated meeting place. The consultant will then utilize the new map during fire drills to ensure a designated meeting place is indicated.
Maintenance Director will complete a monthly audit of fire drill records to ensure ongoing compliance. All PSC staff will be trained on the designated meeting locations through Relias. |
04/15/2016
| Implemented |
| 6400.113(a) | Individual # 3's date of admission was 10/14/2015 and the fire safety training was completed on 10/15/2015. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | All future admissions will be instructed of fire safety on day of admission. Going forward all individuals will have the safety training upon admission. Social Worker will audit new admission record within 24 hours to ensure fire safety is completed on the day of admission. Results of the findings will be shared at the Quarterly Quality Assurance Meeting to ensure ongoing compliance is maintained. |
04/01/2016
| Implemented |
| 6400.142(a) | Individual #2's is under 17 years of age and had a dental examination completed on 01/13/2015 then again on 08/07/2015. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | No corrective action can happen for Individual #2. All dental appointments will be every 6 months for individuals 17 and younger. All records will be audited to ensure dental appointments are scheduled within a 6 month time frame by 4/1/16. All Nursing staff will be trained through Relias to ensure comprehension that ¿semi-annually¿ is defined by every 6 months and not twice a year. A Quarterly audit of medical charts will be completed to ensure on-going compliance. |
04/01/2016
| Implemented |
| 6400.151(b) | Staff #1's annual physical examination dated 05/21/2014 was not signed by the physician.
Staff #2's annual physical examination dated 05/21/2014 was not signed by the physician.
| The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Staff #1 and Staff #2 will receive an annual examination that is signed by the physician. Going forward all staff will have signed physicals. All employee files will be audited by 4/1/16. The Human Resource coordinator will be educated on the regulation. During the scheduled monthly audits, it will be ensured that all annual physicals have a signed signature from the licensed physician and not a printed signature. All staff will be trained through Relias on the importance of having physicals signed by a licensed physician. |
04/15/2016
| Implemented |
| 6400.161(b) | Pedialyte solution was found unlocked in a kitchen drawer. [The medication cart located outside of Room #5 was unlocked. Pedialyte was found unlocked in the kitchen cabinet located on the lower level. Albuterol solution, Pedialx Enema and schraggers paste was found unlocked in the cabinet located between Room 18 and Room 19. Repeat violation per POC verification conducted on 04/26/2016] | Prescription and potentially toxic nonprescription medications shall be kept in an area or container that is locked, unless it is documented in each individual's assessment that each individual in the home can safely use or avoid toxic materials. | The Pedialyte was moved into a stored locked area on 2/15/16.Daily building rounds will be completed by the Maintenance Director/designee to ensure Pedialyte is stored in a locked area. The building rounds audit results will be shared at the Quarterly Quality Assurance Meeting. Any non-compliance will be brought to the Administrator¿s attention the day it occurs, for immediate action. |
02/15/2016
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not document identifying marks.
Individual #2's record did not document identifying marks.
Individual #3's record did not document identifying marks.
| Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | Individual #s¿ 1, 2, and 3 record were corrected to reflect identifying marks. An audit to review all Individual¿s records will be completed by 4/1/16 in order to assure identifying marks are included. The Social Worker will be educated to the Regulation in order to prevent future occurrence. An audit will be completed quarterly to ensure all records have 2 identifying marks. The results will be shared at the Quarterly Quality Assurance Meeting. |
04/01/2016
| Implemented |
|
|
|
SIN-00090336
|
Unannounced Monitoring
|
11/23/2015
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.33(a) | On 10/02/2015, Individual # 1 unexpectedly passed away. Physician orders indicated to check pulse oximetry continuous unless under direct supervision, high heart rate 170, low heart rate 40, oxygen saturation greater than or equal to 92 percent. Staff interviews verified direct supervision is when the patient is within eyesight of staff. For examples in the day room, when staff is completing ADLs or with a staff person. Neglect is confirmed based on the following: 1)The Video recording shows the nursing cart assigned to Staff #1 was stationed along the wall to the left of the individual's room hence not in direct line of sight of Staff # 1. Staff #1 would have to step to the right or lean their body to the right to be able to see in individual #1's room. In addition, staff walking by Individual #1's room would have to turn their head in order to see the individual while in their room.
2) The pulse oximetry report summary shows no activity after 7:09PM which indicates the probe was not on individual #1 or the machine was turned off.
3) Staff #2's statement indicates they noticed the pulse ox machine was turned off upon entering individual #1's room when Staff #1 yelled for assistance after finding individual #1 unresponsive.
4) According to Staff #3's Certified Investigator's report witness statement dated 10/02/2015 upon entering Individual #1's room after staff #1 called for help, the following was documented, "no pulse ox reading as machine was off" and Staff #6 "turned on the pulse ox and attached probe initial reading of HR67 SPO2 73%".
5) According to Staff #6's certified investigator's individual statement form dated 10/02/2015, they reported "Pt pulse oximeter was not turned on upon arrival into her room. I immediately turned on Pulse Ox machine and HR reading at 67 and PaO2 was 73."
Staff did not follow emergency medical protocol and initially contacted the physician instead of contacting 911 as evidenced by Staff #3's certified investigator's individual statement form dated 10/02/2015. The statement documents Staff # 3 left the room to notify the physician of possible code situation, Order received to call 911. Also in Staff #3¿s certified investigator¿s individual statement form dated 10/08/2015 they recorded, this nurse called the physician (2139) and informed him of a code in progress. He said call 911. The statement indicated Staff # 7 placed call to 911. | An individual may not be neglected, abused, mistreated or subjected to corporal punishment. | All physician pulse oximetry orders will be reviewed with a licensed physician to ensure appropriate utilization based on medical need. All individuals will receive care that follows the licensed physician¿s orders. A checklist to document hourly observation will be initiated to ensure pulse oximetry is continuous as ordered by the physician. A daily Nursing Supervisor checklist will be completed to ensure ongoing compliance. Nursing Supervisors will have a detailed review of the mock code process, documentation and policy. All clinical staff will be trained on the mock code process, responsibilities, roles and interventions during an emergency event. Every quarter a training will be held. All PSC staff will be trained on the emergency medical care policy via Relias. |
04/15/2016
| Implemented |
| 6400.33(g) | There is video cameras/surveillance throughout the facility. The video recording did not have audio and cameras were seen in the hallways, day room, and gym. There is no signage posted indicating video recording and the individuals were not informed that certain areas are subject to video recording.
| An individual has the right to receive scheduled and unscheduled visitors, communicate, associate and meet privately with family and persons of the individual's own choice. | Video cameras in the day room, hallway and gym were disabled from recording. Signage indicating video surveillance was in progress was paced at all entrance/exit access doors. PSC will apply for a waiver due to the medical needs of the individuals we provide care to. |
04/15/2016
| Implemented |
| 6400.33(l) | Individual #1 is diagnosed with encephalopathy of unclear etiology, asthma, tracheostomy, ventilator dependent, gastrostomy, seizure disorder and was prescribed Clonazepam 0.5 mg daily, Clonazepam 2 mg twice daily, Clonidine 0.3 mg patch apply 1 patch topically every 7 days, diazepam 1 mg three times per day, risperidone 0.5 mg at bedtime, olanzapine 10 mg daily and lorazepam 2 mg PRN. Individual # 1 does not have a psychiatric diagnosis and was prescribed Risperidone and Olanzapine which are antipsychotic medications. | An individual has the right to be free from excessive medication. | Individuals will receive the least number of medications possible while still addressing all of their medical needs and conditions as followed by the plan of care. Individuals will have the appropriate diagnosis to match the medications they are taking. An audit will be conducted by the DON/designee to ensure all individuals have the correct diagnosis for medications they are taking. This will be completed by 3/31/16.Individuals will have their records reviewed by a pharmacy consultant twice a year in order to determine excessive medications are not prescribed. Quarterly audits of MARS will be completed to ensure all individuals have the appropriate medications based upon diagnosis and medical need. |
04/15/2016
| Implemented |
| 6400.144 | Physician orders indicated to check pulse oximetry continuous unless under direct supervision, high heart rate 170, low heart rate 40, oxygen saturation greater than or equal to 92 percent. Individual # 1 was in their room and not under direct supervision of staff when they were found unresponsive. Through staff interviews, it was reported the pulse oximetry was turned off when staff entered the room in response to the call for help. | 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.
| All physician pulse oximetry orders will be reviewed with a licensed physician to ensure appropriate utilization based on medical need. A checklist to document hourly observation will be initiated to ensure pulse oximetry is utilized based on the physician orders. A daily Nursing Supervisor checklist will be completed to ensure ongoing compliance. This process will be initiated on 3/31/16. Audits will be reviewed monthly by DON/Administrator to ensure ongoing compliance. All Clinical Staff, RNs, NTs and RTs will be educated through Relias on their responsibility to monitor and ensure the pulse oximetry is being monitored as ordered by the physician. |
04/15/2015
| Implemented |
| 6400.161(b) | The medication cart has a key lock and it was evident through the videotape that the medication carts were not locked. Staff #1 was seen repeatedly opening the drawers on the medication cart without manipulating a key at any point. | Prescription and potentially toxic nonprescription medications shall be kept in an area or container that is locked, unless it is documented in each individual's assessment that each individual in the home can safely use or avoid toxic materials. | Going forward all medication carts will be kept locked. On a daily basis the Nursing Supervisor will complete a Supervisor's checklist which will monitor for observation of locking medication carts. Audits will be reviewed monthly by DON/Administrator to ensure ongoing compliance. All PSC staff will be re-educated on the importance of locking medication carts as this is best practice and ensuring the safety of all individuals. |
04/15/2016
| Implemented |
| 6400.163(c) | Individual # 1 is diagnosed encephalopathy of unclear etiology, asthma, tracheostomy, ventilator dependent, gastrostomy, seizure disorder and was prescribed Clonazeoam 0.5 mg daily, Clonazepam 2 mg twice daily, Clonidine 0.3 mg patch apply 1 patch topically every 7 days, diazepam 1 mg three times per day, risperidone 0.5 mg at bedtime, olanzapine 10 mg dally and lorazapem 2 mg PRN. The medication administration record indicated risperidone was administered from 09/24/2015-10/02/2015 and olanzapine was administered from 09/23/2015-10/02/2015. These medications are antipsychotic medications and individual # 1 did not have a psychiatric diagnosis. The physician also did not completed 3 month reviews to determine the need for the medication.. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Upon admission, medical diagnoses will be reviewed with licensed physician to develop, enhance or correct plan of care. If presence of prescribed antipsychotic medications are noted, adjustments to medical care plan will be modified. All current plans of care will be reviewed with the physician to ensure orders are accurate for each individual. DON/designee will audit all individuals record¿s to ensure antipsychotic medications are not being administered without a diagnosis. Additionally, an audit to ensure that any individual who is receiving antipsychotic medications is being reviewed every 3 months by the licensed physician to ensure there is a reason for prescribing the medication, the need to continue the medication, and the necessary dosage as well as having an appropriate diagnosis. This will be completed by 3/31/16. DON will educate the licensed physician that antipsychotic medications need to have a diagnosis and review detailing the reason for prescribing the medication, the need to continue the medication and the necessary dosage every 3 months to determine the need for the medication. A quarterly audit of physician orders will be completed to ensure ongoing compliance. |
04/15/2016
| Implemented |
| 6400.199(c)(1) | Individual #1 is prescribed Lorazapem 2mg every four hours as needed. It was administered on 09/27/2015 10/01/2015 and 10/02/2015 however there is no documentation the licensed physician examined the individual and gave a written order to administer the medication. | If a chemical restraint is administered as specified in subsection (b), the following apply: Prior to each incidence of administering a drug on an emergency basis, a licensed physician shall have examined the individual and given a written order to administer the drug.
| All MD orders will be reviewed ensuring chemical restraints are PRN "as needed". Due to our RN model of care and physician 24/7 availability and on call status, a licensed physician is not on site 24/7. If an Individual is experiencing acute episodic behavior, a safety plan will be initiated to redirect behaviors. If safety plan is ineffective and episodic behaviors continue an emergency medical plan will be in effect and order will be obtained from licensed physician to send out via 911 for off site evaluation. If a serious life threatening situation is present 911 will be called prior to calling the licensed physician. DON/designee will audit every individual¿s record to ensure medications that are considered chemical restraints are not ordered as routine by 3/31/16. For all new admissions, upon admission, all medications will be reviewed to ensure compliance in accordance with subsection 6400.199(c)(1). DON will educate Physician that he/she may not order a chemical restraint for acute episodic behaviors but instead follow safety plan. All staff will be trained on the Individual¿s current safety plan to ensure redirection of behaviors are effective. All safety plans will be reviewed monthly during the monthly safety meetings. Quarterly Audits will be conducted to ensure ongoing compliance. Ongoing review will continue regarding individual behavior documentation in order to develop needed safety plans. |
04/15/2016
| Implemented |
| 6400.199(e) | Individual # 1 is prescribed Lorazapem 2mg every four hours as needed for severe agitation or seizure activity leading to respiratory distress. Lorazapem 2 mg was administered on 09/27/2015 and 10/01/2015 for agitation which is an episodic behavior. | A Pro Re Nata (PRN) order for controlling acute, episodic behavior is prohibited.
| PRN orders will not be utilized for addressing episodic behavior. DON/designee will audit every individual¿s record to ensure there are no PRN orders written for episodic behavior. Physician will be educated on 6400.199(e) regarding prohibited utilization of chemical restraints. This will be completed by 3/31/16. All RNs will be trained through Relias that PRN orders are prohibited for addressing episodic behaviors. |
04/15/2016
| Implemented |
|
|
|
SIN-00078385
|
Renewal
|
01/15/2015
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.164(a) | The medication log for individual # 1 was not on site for review. Individual #1 went to a wheelchair clinc located at a hospital on 1/15/15. A nurse accompanied this individual and took all her records plus the medication log. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | The medication log of Individual #1 was transported with the resident by a licensed staff member to a scheduled appointment at Children's Hospital of Philadelphia. This was done to comply with regulation 6400.164(b) so that the transporting nurse can log immediately after each individual's dose of medication. Effective June 1, 2015, it will be Pediatric Specialty Care's policy that individual medication logs will be kept at the facility. Pediatric Specialty Care is planning to transition to an electronic medical record. The electronic medical record will have access to the resident's medication log containing a list of the medications prescribed, dosage, time, and date of the medication administration, along with the name of the licensed professional administering the medication. The benefit of transitioning to an electronic medical record is that it will enable paperless accessibility of each resident's medication log via company I-pad. Prior to the transition to electronic medical records, staff will be required to copy necessary medication logs needed while out on transportation with the resident. The Policy and Procedure has been updated to include that individual records shall be kept at the facility. The Director of Nursing and the Quality Assurance Coordinator will perform monthly audits until 100% compliance is achieved for three months to ensure medication records are kept at the facility. The Director of Nursing or designee will be responsible for the ongoing compliance of this regulation. |
06/01/2015
| Implemented |
| 6400.214(a) | Records for Individual # 1 was not at the resiential facility for inspection review on 1/15/15, | Record information required in § 6400.213(1) (relating to content of records) shall be kept at the home. | The medical record of Individual #1 was transported with the resident by a licensed staff member to a scheduled appointment at Children's Hospital of Philadelphia to facilitate communication with medical consultants and to promote continuity of care. Effective June 1, 2015, Pediatric Specialty Care's policy will require individual medical records to be kept at the facility. Pediatric Specialty Care is planning to transition to an electronic medical record system that will continue to facilitate consistency and effective communication among clinicians. A benefit of an electronic medical record is that it will enable paperless accessibility for consult and clinic visits. Each resident's medical information will be available via a company I-pad. The Director of Nursing and Quality Assurance Coordinator will perform monthly audits until 100% compliance is achieved for three months to ensure all charts are left at the facility. The Director of Nursing or designee will be responsible for the ongoing compliance of this regulation.
|
06/01/2015
| Implemented |
|
|
|
SIN-00231983
|
Renewal
|
09/28/2023
|
Compliant - Finalized
|
|