| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.17(b) | The home's certificate of compliance expires on 2/25/23. The home did not complete full self-assessment of the home 3-6 months prior to the license expiration date using the correct licensing inspection instrument. The home did complete partial self-assessment of the home using the inspection instrument tool identified to open a home. However, the home opened on 2/25/22. | The agency shall use the Department's licensing inspection instrument for this chapter to measure and record compliance. | Fixing the Immediate Problem:
WHO: The CEO will be responsible for implementing this plan of correction.
WHAT: Focus Behavioral Health will complete the Self-Assessment Tool on the proper form.
WHEN and HOW: The FLS will complete the Self-Assessment Tool on the proper form by March 17, 2023, which will allow Focus Behavioral Health to implement other plans of corrections prior to the completion. The FLS will complete this plan of correction by re-reviewing and re-inspection individual files and site locations. The proper form will be obtained from ODP's direct website. |
03/17/2023
| Implemented |
| 6500.24(d)(1) | The individual' #1's property record was last updated on 11/1/22. The individual's tv in their bedroom reportedly cannot connect to the internet. This electronic device was not added to the individual's property record.
During the 2/1/23 inspection, it was reported that staff take Individual #1 back to another home to retrieve some of their belongings on occasion. There are some of the individual's belongings stored at someone else's home, and not available to the individual in their current residence. The individual's items that are stored at another location and the items they have in their possession at their current residence are not reflected on the individual's property record. | An up-to-date financial and property record shall be kept for each individual that includes the personal possessions and funds received by or deposited with the family or agency. | Fixing the Immediate Problem:
WHO: The Family Living Specialist, will be responsible for implementing this plan of correction.
WHAT: Focus Behavioral Health will complete a new personal belongings inventory template for all individual #1. This will show the most up to date personal inventory that is currently with individual #1 at the residence and/or if other personal belongings are in other locations being stored. If Individual #1 has belongings at other locations, the belongings will be moved to the same home that Individual #1 is living at by 3/17/23. Focus Behavioral Health will review personal belongings inventory template with all individuals.
WHEN and HOW: The FLS will complete the updated personal belongings inventory by February 27th, 2023. The FLS will complete this plan of correction by revisiting all homes to complete an accurate personal belongings inventory template. |
02/27/2023
| Implemented |
| 6500.42(b)(1) | The home did not implement their prescription medications policy or their storage and disposal of medications policy. As referenced throughout this report, Individuals #1's and #2's medications were not administered, stored, documented, and disposed of properly. Failure to adhere to the medication policies creates an environment where potential harm or death could occur. | The chief executive officer shall be responsible for the administration and general management of the agency, including the following: Implementation of policies and procedures. | Fixing the Immediate Problem:
WHO: The CEO will be responsible for implementing this plan of correction.
WHAT: FLP needs to be re-trained on medication policies and procedures and have proper storage systems in place.
WHEN and HOW: The FLS will retrain Staff #1 on medication policy and procedures by 02/10/23. On 2/2/23, all expired medications in the home were disposed of properly per instructions with medication policy. Also, storage of medication was implemented by adding lockable safes where the medication can be locked up and/or double locked if required due to the safety of Individual #1. |
02/27/2023
| Implemented |
| 6500.121(a) | Individual #1 was admitted to the agency, Focus Behavioral Health Inc, on 11/1/22. The home was informed on 10/17/22 that the individual would be moving in with them. As of 2/2/23 the individual has not had a physical examination completed. The agency did document on 11/16/22 the individual refused to obtain a physical examination and Tuberculin skin test. However, as referenced on 123(a) of this report, the home did not document the continued attempts to train the individual on the need to complete this health evaluation. Additionally, the home had more than two weeks' notice prior to the individual moving in as respite services, then did not attempt to discuss a physical examination requirement with the individual until they were in the agency's services for 15 days. | An individual shall have a physical examination within 12 months prior to living in the home and annually thereafter. | WHO: The Family Living Specialist will be responsible for implementing this plan of correction.
WHAT: Focus Behavioral Health will discuss with individual #1 the importance of obtaining a physical exam and Tuberculin skin test despite an individual's refusal. This will be implemented by 02/17/23.
WHEN and HOW: The Family living specialist, will discuss with individual #1 the importance of obtaining a physician exam and Tuberculin skin test. If individual #1 decides that he would like to schedule an appointment to complete these, family living provider will help schedule appointments to have these completed. If individual #1 continues to decline getting these completed, family living specialist will document the refusal form as well as complete another section of the form of how individual #1 was educated on the importance of completing these tests by his primary care provider. |
03/17/2023
| Implemented |
| 6500.121(c)(6) | Individual #1 was admitted to the agency, Focus Behavioral Health Inc, on 11/1/22. As of 2/2/23 the individual has not had a Tuberculin skin test by Mantoux method, or a chest x-ray completed. The agency did document on 11/16/22 the individual refused to obtain a physical examination and Tuberculin skin test. However, as referenced on 123(a) of this report, the home did not document the continued attempts to train the individual on the need to complete this health evaluation. Additionally, the home had more than two weeks' notice prior to the individual moving in as respite services, then did not attempt to discuss a physical examination requirement with the individual until they were in the agency's services for 15 days. | Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if a tuberculin skin test is positive, an initial chest x-ray with results noted. | WHO: The Family Living Specialist, will be responsible for implementing this plan of correction.
WHAT: Focus Behavioral Health will discuss with individual #1 the importance of obtaining a physical exam and Tuberculin skin test despite an individual's refusal. This will be implemented by 02/17/23.
WHEN and HOW: The Family living specialist, will discuss with individual #1 the importance of obtaining a physician exam and Tuberculin skin test. If individual #1 decides that he would like to schedule an appointment to complete these, family living provider will help schedule appointments to have these completed. If individual #1 continues to decline getting these completed, family living specialist will document the refusal form as well as complete another section of the form of how individual #1 was educated on the importance of completing these tests by his primary care provider. |
02/17/2023
| Implemented |
| 6500.123(a) | Individual #1 was seen at an urgent care medical center due to a mass that was found in their mouth that reportedly looked like a flap of skin on their cheek/gum area. It was recommended that Individual #1 see a dentist for follow up to discuss treatment. Individual #1 refused to follow up with any medical professional to discuss further treatment. According to the individual's 11/10/22 assessment, the individual refuses routine dental care by a dentist or daily dental hygiene care. The refusals for all dental care and recommendations for follow up and the continued attempts to train the individual about the need for health care was not documented in their record.
Individual #1 was admitted to the facility on 11/1/22. On 11/16/22 it was documented that Individual #1 refused to obtain a physical examination, Tuberculin skin test, psychiatric medical evaluation, dental examination, and eye doctor appointment. The continued attempts to train the individual in the need to obtain these medical evaluations was not documented in their record.
The individual is prescribed psychotropic medications for psychiatric diagnoses. They refuse to have their medications reviewed every 3 months by a licensed physician. The refusals or attempts to train the individual in the need for this health service was not documented in the records.
The individual's assessment states they have adaptive equipment to use because they are a fall risk but refused to wear the adaptive equipment. The refusals and retraining are 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. | WHO: The Family Living Specialist will be responsible for implementing this plan of correction.
WHAT: Focus Behavioral Health will discuss with individual #1 the importance of obtaining an exam regarding the mass in mouth despite an individual's refusal. This will be implemented by 02/17/23.
WHEN and HOW: The Family living specialist will discuss with individual #1 the importance of obtaining a physician exam and Tuberculin skin test. If individual #1 decides that they would like to schedule an appointment to complete these, the family living provider will help schedule appointments to have these completed. If individual #1 continues to decline getting these completed, family living specialist will document the refusal form as well as complete another section of the form of how individual #1 was educated on the importance of completing these tests by their primary care provider. |
03/17/2023
| Implemented |
| 6500.151(e)(4) | Individual #1's 11/1/22 and 1/27/23 assessment do not include their current supervision level needs and court orders that include supervision requirements. | The assessment must include the following information: The individual's need for supervision. | Fixing the Immediate Problem:
WHO: The CEO will be responsible for implementing this plan of correction.
WHAT: The individual assessment did not include up to date individual's supervision needs.
WHEN and HOW: The FLS will re-review and update Individual Assessments by 3/17/22. |
03/17/2023
| Implemented |
| 6500.151(e)(5) | Individual #1 moved in with the agency on 11/1/22. They were never properly assessed to be self-administering of medication since their admission to the agency. The agency never obtained medical records for the proper list of medications prescribed to Individual #1 when they moved in. However, the agency (Staff person #3) documented that on 11/1/22, Individual #1 was assessed to be able to self-administer Albuterol, 1-2 puffs every 4 hours as needed, Budesonide, 1-2 puffs up to twice a day, and Bupropion 150mg daily. Staff person #3 completed Individual #1's initial assessment on 11/10/22 documenting that the individual was able to self-administer their medications: Wellbutrin 100mg once a day, Symbicort 1 puff twice a day, and Ventolin 2 puffs as needed. According to a medical print out on 11/30/22 Individual #1 was ordered Albuterol inhale 1-2 puffs every 4 hours as needed for wheezing, Budesonide inhale 1 puff two times a day, and Bupropion 150mg every morning. Bupropion was then increased on 12/13/22 to 300mg every morning.
During the 2/1/23 inspection of the home, Staff persons #1 reported to the Department they did not know what the requirement were to assess an individual to be self-administering of medications. Staff person #1 reported they assumed that if someone could hold a cup of medications and physically put the cup to their mouth and take the medications, even though all other steps of medication administration needed completed by someone else, this was still a good assessment that one would be able to be self-administering of their own medications. | The assessment must include the following information: The individual's ability to self-administer medications. | Fixing the Immediate Problem:
WHO: The CEO will be responsible for implementing this plan of correction.
WHAT: The individual assessment did not include the individual's ability to self-administer medications.
WHEN and HOW: The FLS will re-review and update Individual Assessments by 3/17/22. |
03/17/2023
| Implemented |
| 6500.151(e)(9) | Individual #1's 11/30/22 medical appointment summary states the individual has an allergy to penicillin. This allergy was not included on their assessment or any other document in their record.
11/30/22 med appointment record lists dx of: mild intermittent asthma, autism spectrum disorder, anxiety, dysthymia, adhd predominantly inactive type, Arnold-chiari syndrome without spina bifida or hydrocephalus, Asperger's disorder, ataxic gait, chronic pain of both knees, degenerative disc disease, dermatitis, spasm, overweight, allergies to penicillin. Instructed to follow a moderate low carb diet, limit concentrated sweets and drinks, exercise daily, walk 30 mins per day or 15 mins 2 times per day, strengthening exercised 3 days per week, drink plenty of water.
The 1/27/23 updated assessment did not include the new diagnoses recorded on 1/9/23 and 1/17/23 medical records from their recent hospitalizations. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | Fixing the Immediate Problem:
WHO: The CEO will be responsible for implementing this plan of correction.
WHAT: The individual assessment did not include new diagnoses, medications, and limitations.
WHEN and HOW: The FLS will re-review all medical files and update Individual Assessments by 3/17/22. |
03/17/2023
| Implemented |
| 6500.182(b) | Individual #1's medication administration record for Hydroxyzine as needed medication had the strength of the medication recorded as 30. Then it was crossed off and 25mg was placed next to it. The name of the person making the change and the date the change was made was not recorded in the record. | Entries in an individual's record must be legible, dated and signed by the person making the entry. | Fixing the Immediate Problem:
WHO: The Family Living Specialist will be responsible for implementing this plan of correction.
WHAT: FLP must be trained to ensure Medication Administration Records are properly completed and maintained.
WHEN and HOW: The FLS will retrain the FLP by 2/10/23 on proper completion and maintenance of Medication Administration Records. |
03/17/2023
| Implemented |
| 6500.182(c)(1)(iv) | Individual #1's record did not record their religious affiliation. Their face sheet stated n/a. | Each individual's record must include the following information: Personal information, including: The religious affiliation. | Fixing the Immediate Problem:
WHO: The CEO will be responsible for implementing this plan of correction.
WHAT: Focus Behavioral Health will require an Individual Record Template to be completed in its entirety.
WHEN and HOW: The FLS will complete new Individual Record Templates for all individuals by 3/17/23. The FLS will re-review all Individual Record Templates for completion for all individuals by 3/17/23. |
03/17/2023
| Implemented |
| 6500.124 | Individual #1 was admitted to the agency on 11/1/22.
On 12/13/22 Individual #1's physician ordered the individual to obtain blood work on 12/13/22: CBC and differential, comprehensive metabolic panel, and lipid panel. There are no records this was completed.
Individual #1 had a suicide attempt by overdosing on medications on 12/21/22. They were ordered Tramadol on 1/17/23. The pharmacy-issued medication label for tramadol has a sticker stating it's an "opioid-risk for addiction." The medication was not double locked in the home for protection The label states it was dispensed from the pharmacy on 1/20/23 with only 7 pills in the container with zero refills. However, Staff person #1 documented that they administered the medication to the individual 8 times from 1/17/23-2/1/23. Additionally, at the home, there was one Tramadol pill left in the pill container that was dispensed from the pharmacy with only 7 pills. There is no explanation or documentation of appropriate medication administration of this medication that aligns with the evidence provided and witnessed during the inspection.
On 12/20/22 Individual #1 was charged with a crime and is ordered to have no access to any device that has internet access. Individual #1 moved in with the primary caregiver, Staff person#1, on 1/9/23. On 2/1/23 Staff person #1 reported to the Department that the television in the living room has access to the internet and is accessible to all persons in the home. On 2/1/23 Staff person #1 reported to the Department that since the individual has moved into the home, there have been occasions were Staff person #1 left the home to run errands, leaving Individual #1 at home unsupervised and access to internet on the living room television. Staff person #1 reported there is usually another staff in the home and that's why they leave the home. However, the other staff in the home is providing service provisions to another individual living in the home and is not a qualified staff to provide service provisions to Individual #1.
Staff person #1 reported to the Department on 2/1/23 that Individual #2 has choked recently on one of their large prescription pills. Staff person #1 reported they just break the pill in half and administer the medication in an altered state. The primary caregiver, nor the agency, has attempted to contact any medication professionals, or the prescribing physician, to notify the prescriber the individual choked on a pill, or if the medication can and should be altered for administration. There is no written order from the prescribing physician or any medical professional, that the medication can be altered. | 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. | WHO: The Family Living Specialist, will be responsible for implementing this plan of correction.
WHAT: Focus Behavioral Health will get documentation of refusing a blood work panel from Individual #1 or help schedule an appointment to complete these tests.
WHEN and HOW: The Family living specialist, will educate Individual #1 on the importance of blood work that was prescribed for them. If individual #1 declines, the FLS will get documentation that individual #1 was educated on the importance and document that individual #1 is still refusing to complete. |
03/17/2023
| Implemented |
| 6500.31(d) | On 12/20/22, Individual #1 was as ordered by the court to not have access to any device that can access the internet. During the 2/1/23 inspection of the home, Staff person #1 reported the living room television, that all in the home have access to, connects to the internet. Staff person #1 also reported that they have on occasion left the home and Individual #1 was home with access to the tv. Staff person #1 reported there usually was another individual home at the time, but the identified person is a support staff providing service provisions to another individual in the home, not to Individual #1 for supervision and monitoring. | A court's written order that restricts an individual's rights shall be followed. | Fixing the Immediate Problem:
WHO: The Family Living Specialist, will be responsible for implementing this plan of correction.
WHAT: Focus Behavioral Health will implement a passcode pin on the living room television to ensure that Individual #1 does not have access to any device in the home containing access to the internet.
WHEN and HOW: The FLS installed a passcode pin onto the living room television on 02/02/23. This enables any internet access to the living room television to be required to enter a passcode pin in order to access the internet apps on the television. The information for the passcode pin was not provided to Individual #1. |
02/27/2023
| Implemented |
| 6500.34(a) | Individual #1 was informed of their individuals rights on 11/1/22. However, the review of rights with them did not include a review of individual's regulatory rights defined in Pa Code 55 Chapter 6500.32(l)-(o), 32(r)(1)-(v), and 33(a) and (b). | Individual rights and the process to report a rights violation shall be explained to the individual, and persons designated by the individual prior to moving into the home and annually thereafter. | WHO: The CEO will be responsible for implementing this plan of correction.
WHAT: The following rights were not reviewed with Individual #1 on 6/30/22- 32(l), 32(m), 32(n), 32(o), 32r(1), 32r(2), 32r(3), 32r(4), 32r(5), 32s(1), 32t, 32u, 32v, 33a, 33b.
WHEN and HOW: The FLS will review the above individual rights with all individuals by 2/27/23. |
02/27/2023
| Implemented |
| 6500.47(b)(1) | Staff person #1 had individuals live with them starting on 3/24/22. There are no records that prior to individuals living with Staff person #1, they received orientation training on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. Their records indicate training on person-centered practices didn't occur until 8/28/22 and training on relationships didn't occur until 4/30/22. There were no records produced those other trainings related to these topics occurred. | 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. | Fixing the Immediate Problem:
WHO: The Family Living Specialist, will be responsible for implementing this plan of correction.
WHAT: Staff #1 requires new orientation training due to not meeting 6500 requirements.
WHEN and HOW: Focus Behavioral Health will train Staff #1 on the following training for orientation that are required: the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships.) This will be implemented by 03/17/23. |
03/17/2023
| Implemented |
| 6500.47(b)(2) | Staff person #1 had individuals live with them starting on 3/24/22. There are no records that prior to individuals living with Staff person #1, they received orientation training on 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 | 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. | Fixing the Immediate Problem:
WHO: The Family Living Specialist will be responsible for implementing this plan of correction.
WHAT: Staff #1 requires new orientation training due to not meeting 6500 requirements.
WHEN and HOW: Focus Behavioral Health will train Staff #1 on the following training for orientation that are required: prevention, detection, and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act, The Child Protective Services Law, the Adult Protective Services Act, and applicable protective services regulations.This will be implemented by 03/17/23. |
03/17/2023
| Implemented |
| 6500.47(b)(3) | Staff person #1 had individuals live with them starting on 3/24/22. There are no records that prior to individuals living with Staff person #1, they received orientation training on individual rights. | The orientation must encompass the following areas: Individual rights. | Fixing the Immediate Problem:
WHO: The Family Living Specialist, will be responsible for implementing this plan of correction.
WHAT: Staff #1 requires new orientation training due to not meeting 6500 requirements.
WHEN and HOW: Focus Behavioral Health will train Staff #1 on the following training for orientation that are required: individual rights.This will be implemented by 03/17/23. |
03/17/2023
| Implemented |
| 6500.47(b)(4) | Staff person #1 had individuals live with them starting on 3/24/22. There are no records that prior to individuals living with Staff person #1, they received orientation training on recognizing and reporting incidents. | The orientation must encompass the following areas: Recognizing and reporting incidents. | Fixing the Immediate Problem:
WHO: The Family Living Specialist, will be responsible for implementing this plan of correction.
WHAT: Staff #1 requires new orientation training due to not meeting 6500 requirements.
WHEN and HOW: Focus Behavioral Health will train Staff #1 on the following training for orientation that are required: recognizing and reporting incidents.This will be implemented by 03/17/23. |
03/17/2023
| Implemented |
| 6500.47(b)(5) | Staff person #1 had individuals live with them starting on 3/24/22. There are no records that prior to individuals living with Staff person #1, they received orientation training on job-related knowledge and skills related to individual-specific plans, protocols, and health and safety needs. Staff person #1 had 5 different individuals reside with them since 3/24/22, currently Individuals #1 and #2 still reside in the home. There are no records that prior to any of the individuals residing with Staff person #1, they were oriented to individual-specific needs and plans.
Individual #1 has a functional behavior assessment, behavior support plan, court orders, and other plans that defines parameters that need to be met when providing care to the individual to protect their health and safety. There weren't records that Staff person #1 received training on the individual-specific plans and needs. | The orientation must encompass the following areas: Job-related knowledge and skills. | Fixing the Immediate Problem:
WHO: The Family Living Specialist, will be responsible for implementing this plan of correction.
WHAT: Staff #1 requires new orientation training due to not meeting 6500 requirements.
WHEN and HOW: Focus Behavioral Health will train Staff #1 on the following training for orientation that are required: job related knowledge and skills.This will be implemented by 03/17/23. |
03/17/2023
| Implemented |
| 6500.49(a) | Content of training, training source, and total hours earned for the trainings was not provided during the inspection for all of Staff person #1's trainings from February 2022 to current, January 2023. A training record for all trainings provided to Staff person #1 was not provided. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept. | WHO: The CEO will be responsible for implementing this plan of correction.
WHAT: Though Focus Behavioral Health tracks training, the training tracking record does not include all required information from 6500 Regulations.
WHEN and HOW: The CEO will update the training record template to include all requirements by 3/17/23. |
03/17/2023
| Implemented |
| 6500.133(a) | During the 2/1/23 inspection of the home, an Albuterol inhaler was found sitting on a stand in Individual #1's bedroom. The original container for the medication was not at the home, nor did the primary caregiver know where the medication came from. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | WHO: The Family Living Specialist, will be responsible for implementing this plan of correction.
WHAT: Focus Behavioral Health will inspect all areas in the home to ensure that there is no medication in the home left out as well as ensuring that the medication is in the original labeled containers that it came in from the pharmacy.
WHEN and HOW: The Family living specialist, went to the home on 02/02/23 to inspect all areas of the home to ensure that there was no medication left out in any areas due to the safety of individual #1. Family living specialists also disposed of any medication expired in the home properly per medication policy. Family living providers will also be trained on proper medication storage of the medications in the home. |
02/10/2023
| Implemented |
| 6500.133(d) | Staff person #1 reported to the Department on 2/1/23 that Individuals #1 and #2 are no longer able to self-administer their medications. The agency confirmed that due to Individual #1 now being unsafe with medication administration, has not been able to self-administer their medications since 1/9/23. Multiple medications were found unlocked and accessible to Individuals #1 and #2 throughout the home during the 2/1/23 inspection. The following was found unlocked and accessible: 325mg of aspirin and 420mg of antacid in the first aid kit in the kitchen cabinet, 7 inhalers of Albuterol Sulfate and one bottle of nasal mist unlocked in Individual #2's bedroom, one Albuterol inhaler in Individual #1's bedroom, a clear, plastic cup of what was reported as Hydroxyzine 25mg, Hydroxyzine 10mg, and Bupropion 300mg was sitting on Individual #1's dresser in their bedroom. Individual #1 was in their bedroom, unsupervised with the medications from sometime prior to 10am to 11:10am when the bedroom door was opened to witness the medications. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | WHO: The Family Living Specialist, will be responsible for implementing this plan of correction.
WHAT : Focus Behavioral Health will retrain Staff #1 on medication policy and procedures by 02/10/23. On 2/2/23, all expired medications in the home were disposed of properly per instructions with medication policy. Also, storage of medication was implemented by adding lockable safes where the medication can be locked up and/or double locked if required due to the safety of Individual #1.
WHEN and HOW : The Family living specialist, will be implementing a new storage of medication and the MAR logs. A new filing cabinet storage system will be implemented. The filing cabinet will have 3 drawers that are locked on it. This will ensure that all of the medication is in one location and is able to be locked from the outside. The family living specialist and the family living provider will have a key to access the filing cabinet. In one drawer, a safe with a lock on it will be inside for Individual #1, in one drawer, a safe with a lock on it will be inside for Individual #2, and the third drawer will allow for any other medication in the home such as advil, tylenol ect as well as the MAR log forms to be located in. The filing cabinet is ordered and will be implemented by 02/27/23. Also, each individual residing in the home will have their own binder with their MAR log inside of them. In the front of the binder will have the most up to date medication list for the individual, as well as the medication policy to ensure that all the information is in one location for the family living provider. The binders have been ordered and will be implemented by 02/27/23. |
02/27/2023
| Implemented |
| 6500.133(h) | Staff person #1 reported to the Department on 2/1/23 that Individual #2 is no longer able to self-administer their medications. Staff person #1 produced a one-gallon Ziplock bag of Individual #2's medications that they reported are discontinued. Staff person #1 had all discontinued medications still available at the home, did not dispose of them properly, they were stored with current ordered medications, and Staff person #1 was not aware of how to dispose of the medications. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | WHO: The Family Living Specialist will be responsible for implementing this plan of correction.
WHAT: Focus Behavioral Health will retrain Staff #1 on medication policy and procedures by 02/10/23. On 2/2/23, all expired medications in the home were disposed of properly per instructions with medication policy. Also, storage of medication was implemented by adding lockable safes where the medication can be locked up and separated for individual #1 and individual #2.
WHEN and HOW: On 2/2/23, the FLS disposed of any expired medications that were in the home properly per medication policy. The Family living specialist will be implementing a new storage of medication. A new filing cabinet storage system will be implemented. The filing cabinet will have 3 drawers that are locked on it. This will ensure that all of the medication is in one location and is able to be locked from the outside. The family living specialist and the family living provider will have a key to access the filing cabinet. In one drawer, a safe with a lock on it will be inside for Individual #1, in one drawer, a safe with a lock on it will be inside for Individual #2, and the third drawer will allow for any other medication in the home such as Advil, Tylenol etc. as well as the MAR log forms to be located in. The filing cabinet is ordered and will be implemented by 02/27/23. In the front of the binder will have the most up to date medication list for the individual, as well as the medication policy to ensure that all the information is in one location for the family living provider. Family living provider will also be trained on medication policy and procedures. The binders have been ordered and will be implemented by 02/27/23. |
02/27/2023
| Implemented |
| 6500.135(c) | Individual #1 has a few as needed medications ordered: Cetirizine, Hydroxyzine, Tramadol, melatonin, and albuterol. Staff person #1 has administered cetirizine daily, hydroxyzine almost daily, melatonin daily, and tramadol without documenting if the individual was in pain or requesting the medications. The individual's records do not indicate that they were requesting their as needed medications to be administered daily. Staff person #1 was not asking the individual if they needed their as needed medications but was administering them daily. | A prescription medication shall be administered as prescribed. | WHO: The Family Living Specialist will be responsible for implementing this plan of correction.
WHAT: Focus Behavioral Health will retrain Staff #1 on medication policy, documenting MARs accurately, and procedures by 02/10/23.
WHEN and HOW: The FLS will train family living provider on medication policy, documenting MARS accurately, and procedures by 02/10/23. Family living provider will document when a PRN is given and state why it was requested to be given. Family living provider will contact primary care physician if individual #1 is requesting medication daily that is prescribed for PRN as it may need to be reevaluated into a daily prescribed medication. |
02/10/2023
| Implemented |
| 6500.136(a)(1) | The medication administration records (mars) for Individual #1 from January 9, 2023, until January 28, 2023, did not all contain the individual's name. Four of the mars only identified the name of the individual by recording initials.
Out of the 4 pages of mars for Individual #1 from 1/29/23-2/1/23, only one page and one medication Cetirizine, contained the individual's name. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Individual's name. | Fixing the Immediate Problem:
WHO: The Family Living Specialist, will be responsible for implementing this plan of correction.
WHAT: FLP, must be trained to ensure Medication Administration Records are properly completed and maintained. FLP must include individual's full name in designated place.
WHEN and HOW: The FLS will retrain the FLP by 2/10/23 on proper completion and maintenance of Medication Administration Records. |
03/17/2023
| Implemented |
| 6500.136(a)(3) | According to Individual #1's 11/30/22 medical appointment summary, they have an allergy to Penicillin. The individual's allergy wasn't included on any medication administration records from January 9, 2023, until February 1, 2023. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Drug allergies. | Fixing the Immediate Problem:
WHO: The Family Living Specialist will be responsible for implementing this plan of correction.
WHAT: FLP must be trained to ensure Medication Administration Records are properly completed and maintained. FLP must include drug allergies in designated place.
WHEN and HOW: The FLS will retrain the FLP by 2/10/23 on proper completion and maintenance of Medication Administration Records. |
03/17/2023
| Implemented |
| 6500.136(a)(5) | The strength of the daily and as needed medications administered to Individual #1 from 1/29/23-2/1/23 was not recorded on the medication administration records. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | Fixing the Immediate Problem:
WHO: The Family Living Specialist will be responsible for implementing this plan of correction.
WHAT: The FLP must be trained to ensure Medication Administration Records are properly completed and maintained. FLP must include strength of medication in designated place.
WHEN and HOW: The FLS will retrain the FLP by 2/10/23 on proper completion and maintenance of Medication Administration Records. |
03/17/2023
| Implemented |
| 6500.136(a)(7) | The dose of daily and as needed medications administered to Individual #1 from 1/29/23-2/1/23 was not recorded on the medication administration records. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Fixing the Immediate Problem:
WHO: The Family Living Specialist will be responsible for implementing this plan of correction.
WHAT: FLP, must be trained to ensure Medication Administration Records are properly completed and maintained. FLP must include dose of medication in designated place.
WHEN and HOW: The FLS will retrain the FLP by 2/10/23 on proper completion and maintenance of Medication Administration Records. |
03/17/2023
| Implemented |
| 6500.136(a)(9) | Individual #1's 1/9/23-2/1/23 medication administration records (mars) do not record the frequency to administer cetirizine and melatonin. The medications are ordered as needed but the mars incorrectly state to administer the medication daily.
The frequency of administration of daily and as needed medications administered to Individual #1 from 1/29/23-2/1/23 was not recorded on the medication administration records. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Fixing the Immediate Problem:
WHO: The Family Living Specialist will be responsible for implementing this plan of correction.
WHAT: FLP, must be trained to ensure Medication Administration Records are properly completed and maintained. FLP must include frequency of administration in designated place.
WHEN and HOW: The FLP will retrain the FLS by 2/10/23 on proper completion and maintenance of Medication Administration Records. |
03/17/2023
| Implemented |
| 6500.136(a)(10) | The time of administration was never documented for any daily or as needed medication administration for Individual #1 from 1/9/23-current, 2/1/23. The medication administration records listed the medication administration times as "am", "eve," or "pm." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | Fixing the Immediate Problem:
WHO: The Family Living Specialist will be responsible for implementing this plan of correction.
WHAT: FLP, must be trained to ensure Medication Administration Records are properly completed and maintained. FLP must include administration times in designated place.
WHEN and HOW: The FLP will retrain FLS by 2/10/23 on proper completion and maintenance of Medication Administration Records. |
03/17/2023
| Implemented |
| 6500.136(a)(11) | Individual #1's 1/9/23-1/28/23 medication administration records (mars) did not include the reason for prescribing Albuterol as needed. The medication label on Albuterol stated the medication is to be administered as needed for wheezing or shortness of breath. The mar only stated the medication was to be administered for shortness of breath.
Individual #1's 1/9/23-1/28/23 medication administration records (mars) did not include the reason for prescribing Tramadol as needed. The medication label on Tramadol states to administer for moderate to severe pain. The mar states for pain.
Individual #1's 1/9/23-1/28/23 medication administration records (mars) did not include the reason for prescribing Trazodone. The medication label states the medication is prescribed for insomnia associated with depression. The mars state the medication is prescribed for depression.
The reason for prescribing vitamin D2 wasn't included on the individual's mars.
The reason for prescribing all of the individual's daily and as needed medications was not documented on their 1/29/23-2/1/23 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. | Fixing the Immediate Problem:
WHO: The Family Living Specialist, will be responsible for implementing this plan of correction.
WHAT: FLP, must be trained to ensure Medication Administration Records are properly completed and maintained. FLP must include diagnosis/purpose including pro re nata in designated place.
WHEN and HOW: The FLS will retrain the FLP by 2/10/23 on proper completion and maintenance of Medication Administration Records. |
03/17/2023
| Implemented |
| 6500.136(a)(12) | Individual #1's 1/9/23-1/28/23 medication administration records (mars) did not include the date for all administrations. The Mar for Trazodone, Bupropion, and cetirizine did not include the month or year of administration. Additionally, only a 9 and 28 was listed for administration days for Trazodone and Cetirizine, even though the family member put an X for administration on many more locations of the mar for both medications.
The Mar's for Hydroxyzine didn't include the month and year of administration. Additionally, the Hydroxyzine as needed medication had numerous "x"'s for administration but the only date recorded was a 10 and 28. The family member indicated this mediation was administered 18 times sometime between the 10th and 28th.
The Mars for melatonin and Vitamin D2 do not include the month and year of administration.
Three of the pages of mars for 1/29/23-2/1/23 do not include the month or year of administration. | 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. | Fixing the Immediate Problem:
WHO: The Family Living Specialist, will be responsible for implementing this plan of correction.
WHAT: FLP, must be trained to ensure Medication Administration Records are properly completed and maintained. FLP must include date and time in designated place.
WHEN and HOW: The FLS will retrain the FLP by 2/10/23 on proper completion and maintenance of Medication Administration Records. |
03/17/2023
| Implemented |
| 6500.136(a)(13) | Staff person #1 did not record their name and initials for every medication administration to Individual #1 from 1/9/23-2/1/23 for daily and as needed medications. Staff person reportedly documented administration via an "x" on the record. | 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. | Fixing the Immediate Problem:
WHO: The Family Living Specialist, will be responsible for implementing this plan of correction.
WHAT: FLP, must be trained to ensure Medication Administration Records are properly completed and maintained. FLP must include initials on MAR in designated place.
WHEN and HOW: The FLS will retrain the FLP by 2/10/23 on proper completion and maintenance of Medication Administration Records. |
03/17/2023
| Implemented |
| 6500.136(a)(14) | The duration of treatment for the daily and as needed medications administered to Individual #1 from 1/29/23-2/1/23 was not recorded on the medication administration records. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Duration of treatment, if applicable. | Fixing the Immediate Problem:
WHO: The Family Living Specialist will be responsible for implementing this plan of correction.
WHAT: FLP must be trained to ensure Medication Administration Records are properly completed and maintained. FLP must include duration of treatment on MAR in designated place.
WHEN and HOW: The FLS will retrain FLP by 2/10/23 on proper completion and maintenance of Medication Administration Records. |
03/17/2023
| Implemented |
| 6500.136(a)(15) | The special precautions of daily and as needed medications administered to Individual #1 from 1/29/23-2/1/23 was not recorded on the medication administration records. The medication bottle for Tramadol came packaged with a warning label that it is an opioid and there is risk of addiction. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable. | Fixing the Immediate Problem:
WHO: The Family Living Specialist will be responsible for implementing this plan of correction.
WHAT: FLP must be trained to ensure Medication Administration Records are properly completed and maintained. FLP must include special precautions on MAR in designated place.
WHEN and HOW: The FLS will retrain the FLP by 2/10/23 on proper completion and maintenance of Medication Administration Records. |
03/17/2023
| Implemented |
| 6500.136(a)(16) | The side effects of the medication of daily and as needed medications administered to Individual #1 from 1/29/23-2/1/23 was not recorded on the medication administration records. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Side effects of the medication, if applicable. | Fixing the Immediate Problem:
WHO: The Family Living Specialist, will be responsible for implementing this plan of correction.
WHAT: FLP, must be trained to ensure Medication Administration Records are properly completed and maintained. FLP must include side effects on MAR in designated place.
WHEN and HOW: The FLS will retrain the FLP by 2/10/23 on proper completion and maintenance of Medication Administration Records. |
03/17/2023
| Implemented |
| 6500.136(b) | Staff person #1 documented they administered Tramadol 8 times to the individual between 1/17/23 and 2/1/23. During the inspection of the home on 2/1/23, there was one Tramadol still in the original container. The Pharmacy dispensed the Tramadol on 1/20/23 with only 7 pills in the container. There are no records or explanation for how staff person signed as administering the medication 8 times.
As referenced in 137(a(1) of this report, staff person #1 documented they administered medications to individual #1 in the morning on 2/1/23. However, the pills were found in the individual's bedroom in a clear plastic cup, not administered by 11:10am.
During the 2/1/23 inspection, prior to lunchtime, staff person #1 documented they already administered Melatonin to Individual #1 at night on 2/1/23.
All of individual #1's medication administration records from 1/9/23-2/1/23 (mars) do not include the name or signature of the person administering any daily or as needed medications. Per Staff person #1, they put an "x" on the mar to document administration. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Fixing the Immediate Problem:
WHO: The Family Living Specialist, will be responsible for implementing this plan of correction.
WHAT: FLP must be trained to ensure Medication Administration Records are properly completed and maintained.
WHEN and HOW: The FLS will retrain FLP by 2/10/23 on proper completion and maintenance of Medication Administration Records. |
03/17/2023
| Implemented |
| 6500.137(a)(1) | Staff person #1 recorded they administered medications Hydroxyzine 10mg, 25mg and Bupropion 300mg to Individual #1 in the morning on 2/1/2023. However, during the 2/1/23 inspection of the home, the medications were found in a clear, plastic up sitting on the individual's dresser in their bedroom at 11:10am. The individual did not take their medications and the primary caregiver responsible to administer the medications did not ensure the medications were administered, constituting of a medication error. | Medication errors include the following: Failure to administer a medication. | WHO: The Family Living Specialist, will be responsible for implementing this plan of correction.
WHAT: FLP failed to administer medication.
WHEN and HOW: The FLS will retrain FLP on medication administration policy by 2/10/23 including proper disposal and recording of medication errors. |
02/27/2023
| Implemented |
| 6500.151(b) | Individual #1 was hospitalized from 12/21/2022-1/9/2023 for attempted suicide by overdose of medication. The individual moved into their current home on 1/9/23. An assessment was not completed until 1/27/23 to document any of the change in needs and services. According to the primary caregiver and agency, Individual #1 can no longer safely administer their medications due to the suicide attempt. The assessment updated on 1/27/23 states the individual is currently unable to administer medications due to safety concerns of attempted suicide. However, the individual's 1/27/23 assessment still states they are still able to self-medicate, but it's best practice for the family caregiver to distribute the medication. At the time of the 1/29/23 inspection the assessment was still not updated to clarify their current level of needs with medication administration.
The individuals 11/1/22 assessment was not update when there was a change in their needs for electronic devices. On 12/20/22 the individual received court orders that they were not to have access to electronic devices. The individual's 11/10/22 assessment stated the individual continue to use social media. The individual's assessment wasn't updated until 1/27/23, but not all sections were included in the update to make the court ordered change.
Individual moved to a new home with the agency on 1/9/23. The individual's assessment wasn't updated to include an assessment of their current needs, skills and abilities since moving to the new home, and | If the life sharing specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have an assessment completed as required under this section. | Fixing the Immediate Problem:
WHO: The CEO will be responsible for implementing this plan of correction.
WHAT: Life sharing specialist did not update assessment revision to outcome/service was required.
WHEN and HOW: The FLS will review and update as necessary by 3/17/23. |
03/17/2023
| Implemented |
| 6500.151(d) | Individual #1's initial 11/10/22 and updated, 1/27/23 assessments were not signed or dated by the life sharing specialist. | The life sharing specialist shall sign and date the assessment. | Fixing the Immediate Problem:
WHO: The CEO will be responsible for implementing this plan of correction.
WHAT: Life sharing specialist did not sign and date the assessment.
WHEN and HOW: The CEO is to ensure all assessments are signed and dated by FLS by 3/17/23. |
03/17/2023
| Implemented |
| 6500.151(f) | The home did not provide Individual #1's initial, 11/10/22 or updated, 1/27/23 assessments to any team member. | The life sharing specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Fixing the Immediate Problem:
WHO: The Family Living Specialist will be responsible for implementing this plan of correction.
WHAT: The individual plan distribution was not documented.
WHEN and HOW: Individual plans will be distributed to the teams via email to the team by 2/27/23. |
02/27/2023
| Implemented |
| 6500.155(5) | Individual #1 resided with the agency from 11/1/22-12/21/22 when they were then hospitalized for attempted suicide by overdosing. The individual was discharged from the hospital on 1/9/23 with as assessment from the agency that the individual is not able to self-administer their medications due to the attempted suicide. The individual's individual plan (last updated on 1/25/23) states the individual is able to self-administer their medications, has had no incident/injuries the past year, and has not had any mental health hospitalizations, significant behaviors or psychiatric issues in the past year. These statements do not reflect the individual's current health status, current needs, current level of assessment of needs, and current level of support to provide. The individual's individual plan also states the individual requires medications to be locked. The two statements do not match.
Individual #1's plan says they are a fall risk but doesn't include mitigation strategies to prevent harm to the individual or others if they fall.
The individual's individual support plan does not include a full list of their prescribed medications and the physician's orders for the medications. | The individual plan, including revisions, must include the following: Risks to the individual's health, safety or well-being, behaviors likely to result in immediate physical harm to the individual or others and risk mitigation strategies, if applicable. | Fixing the Immediate Problem:
WHO: The CEO will be responsible for implementing this plan of correction.
WHAT: The individual support plan is inaccurate. The plan must be updated with correct medications, show recent attempts of self-harm, include the inability to administer medication, and state mitigation strategies for falling.
WHEN and HOW: The FLS will notify the Supports Coordinator requesting all plan updates no later than 3/17/23. |
03/17/2023
| Implemented |
| 6500.156 | Individual #1's behavior support plan states that the individual's medications including but not limited to over the counter and prescription medications will be locked up and the house parent will distribute the medications. During the 2/1/23 onsite inspection, multiple medications were found unlocked and accessible to Individual #1 and the houseparent did not ensure that the individual's morning medications were administered, but gave them the medications to have independently in a cup in their room.
The individuals' behavior support plan states data is collected for the behaviors of using or attempting to use the internet, and during any times of stress. The behavior support plan documents how the house parent is to support the individual during any times indicated on the behavior support plan. The behavior support plan data produced does not indicate the specific antecedent they engaged in, the support offered to the individual during any behaviors identified within the plan, or the outcome of the situations. | The home and the agency shall implement the individual plan, including revisions. | Fixing the Immediate Problem:
WHO: The CEO will be responsible for implementing this plan of correction.
WHAT: FLP, must be trained on the individual plan. Specific antecedent data needs to be collected.
WHEN and HOW: The FLS will retrain staff on implementation of the individual plan. The FLS will update behavioral plan and documentation to include specific antecedent data. This is to occur no later than 2/10/23. |
02/10/2023
| Implemented |