| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | There was no indication that a self-assessment was completed for the home. The self-assessment form did not include an address for the home that it was completed for. The legal entity address was recorded on all self-assessment forms. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| 1. The CEO trained Vice President on regulation 6400.15A on 09/04/2018 to have addresses properly identified on the self-assessment.
2. All other locations were not in compliance with this regulation. This violation was addressed by the licensor on 08/29/2018 during on-site inspection.
3. The President and Vice President and house team leads were trained on regulation 6400.15A by the CEO to ensure that all self-assessments will have the proper addresses listed with reference to Regulation 6400.15A. The President, Vice-President and House Team Leads will sign off on signature paper by 12/31/2018.
4. The CEO will review with the Vice President the self- assessments on a yearly basis to ensure compliance. |
10/12/2018
| Implemented |
| 6400.31(b) | There is no date documented for when Individual #1 was informed of his/her rights. The date line next to his/her signature was blank. Individual #1's date of admission to the provider was 1/29/18. | 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. | 1. On 08/30/2018, the Program Specialist wrote the date to accompany individual¿s name on the individual¿s civil rights.
2. On 09/04/2018-09/06/2018, the Program Specialist went through other individual¿s civil rights to make sure that dates accompanied signatures. No other issues were found in other individual¿s civil rights.
3. All staff including Program Specialist will be trained on regulation 6400.31b titled correct signature and dates on Individual¿s Civil Rights by the Vice President. All staff will sign off on signature page by 12/31/2018.
4. The Program Specialist will review all individual¿s civil rights document on a quarterly basis to ensure that dates accompany signatures of all parties involved starting on 01/2019. |
10/12/2018
| Implemented |
| 6400.44(b)(10) | Individual #1's program specialist did not physically date the monthly documentation of Individual #1's participation and progress towards outcomes. The date was prepopulated. | The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of an individual'ss participation and progress toward outcomes. | 1. The Program Specialist was informally trained to not pre-populate dates on 08/31/2018 by Vice President.
2. On 09/04/18 the Program Specialist reviewed all other records and hand wrote in all the dates that were typed in.
3. All office staff including Program Specialist will be trained on regulation 44 b 10 titled not pre-populating dates by the Vice President. All staff will sign off on signature sheet by 12/31/2018.
4. The Program Specialist will review files on a quarterly basis to ensure that dates are not pre-populated. This will begin on 11/01/2018. |
10/12/2018
| Implemented |
| 6400.44(b)(18) | --Individual #1 has a diagnosis of seizures and, according to his/her 12/19/17 physical examination form, is prescribed diazepam rectal gel as needed for prolonged seizures greater than 3 minutes or serial seizures. None of the staff working in Individual #1's home were trained on the administration of diazepam rectal gel by a certified medical professional. There was no documentation that any staff working with Individual #1 were trained in serial seizures and what signs and symptoms are associated with serial seizures. The agency indicated that Staff #1 worked in Individual #1's home however, according to training documents provided by the agency at the time of licensing, Staff #1 never received training in seizures.
--There was no documentation that staff working in Individual #1's home received training on his/her current Individual Support Plan which included his health and safety needs. | The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. | 1. On 8/30/2018, the medical coordinator contacted Michelle Hamula, who is the director of Nursing at Chan Soon-Shiong Medical Center at Windber in which a training was set up for 10/17/18. This training will be on non-oral medications and how to use them properly.
2. On 09/04/2018, the medical coordinator reviewed all other houses to see if they were trained by trained personnel on non-oral medications. The staff were not trained by trained personnel on non-oral medications.
3. All staff will be trained on regulation 6400.44b18 by Michelle Hamula, who is the director of Nursing at Chan Soon-Shiong Medical Center at Windber on 10/17/18 on non-oral medications. Staff will sign off on signature paper on 10/17/18.
4. The Medical Coordinator will review all staff¿s training on non-oral medications on a quarterly basis to ensure compliance starting 01/2019. |
10/12/2018
| Implemented |
| 6400.46(a) | Staff #10's first day working with individuals was 2/24/18 and she didn't receive orientation to job description, orientation to the home, or training on policy and procedures until 2/24/18 when she had contact with individuals. | The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. | 1. On 08/30/2018 the staff signed off on new employment orientation checklist.
2. On 09/04/2018 the Administrative Assistant reviewed all other employee files to make sure that every employee had new employee checklist completed before working with individuals in group home. There were no other violations found.
3. All staff will be trained on regulation 6400.46a titled New Employee Checklist and all staff will sign off on a training sheet by 12/31/2018. The staff will be trained that they must complete eight (8) hours of orientation before working with individuals.
4. The Administrative Assistant will review each home on monthly basis to ensure that new employees are completing eight (8) hours of orientation. This will begin on 11/01/2018. |
10/12/2018
| Implemented |
| 6400.46(i) | --Staff #6's date of hire was 7/21/16 and she never received hands on CPR training. There was training provided in 2017 and 2018 by Staff #9 who was a red cross first aid/CPR trainer. However per the agency, Staff #9 only had Staff #6 complete an online CPR test.
--Staff #10's date of hire was 2/19/18 and she has not completed hands on CPR training yet, at the time of licensing on 8/30/18. She only took online quizzes from a red cross first aid/CPR trainer. | 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. | On 08/30/2018 the staff member was immediately taken off the schedule until she completed her CPR/First Aid training. The staff completed her First/Aid CPR training on 10/02/2018.
2. On 09/04/2018 the Administrative Assistant reviewed all other employee files to make sure that they have completed CPR/First Aid Training. There were not other violations found.
3. All staff will be trained on regulation 6400.46(i) titled ensuring staff are trained in First/aid CPR before working in the group home by First Aid/CPR instructor. All staff will sign off on signature sheet by 12/31/2018.
4. The Administrative Assistant will review individual employee files to ensure that they have completed First Aid/CPR training. This will begin on 11/01/2018. |
10/12/2018
| Implemented |
| 6400.46(j) | It was documented that Staff #6 received training on "program book" for 3 hours on 7/19/17. However, there was no content for which program books she was trained on. The only form attached to the trained was a document that indicated she understood her job duties as reading and reviewing ISP'S and behavior support plans of individuals she works with. Agency staff were unsuccessful at locating any content for Staff #6's program book training when asked during the annual inspection. | 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. | On 08/30/2018 the administrative assistant created a form titled Program Books for reviewing of each individual¿s records. The staff came into the office and signed off on this form.
2. On 09/04/2018- 09/07/2018 the administrative assistant went through each employee file and noticed that there was no form titled Program Book. All staff will come into the office to sign off on the new form by 12/31/2018.
3. All staff will be trained on regulation 6400.46j titled Program Book. All staff will sign off on signature sheet by 12/31/2018.
4. The administrative assistant will review employee files on a quarterly basis to ensure that all employees are signing off on Program Book form. This will begin on 11/01/2018. |
10/12/2018
| Implemented |
| 6400.62(a) | Individual #1 was assessed to be unsafe around poisonous materials. Isopropyl alcohol and Germ-x that contained labels to contact poison control center if ingested were found unlocked and accessible in the bathroom mirror cabinet. | Poisonous materials shall be kept locked or made inaccessible to individuals. | 1. On 8/30/2018 all poisonous items were immediately locked up in the group home after the violation was found.
2. On 09/04/2018, the quality compliance manager checked all other homes that were not reviewed by the state licensor. All other houses outside of homes that were not reviewed by state licensor were found in compliance.
3. All staff will be trained on regulation 6400.62a by the Behavioral Specialist Consultant to ensure that all poisonous materials are kept locked up in house per restrictive plan by 12/31/2018.
4. The Behavioral Specialist will review the restrictive plans with all staff on a monthly basis starting 11/01/2018. |
10/12/2018
| Implemented |
| 6400.67(a) | The carpet on the steps were stained brownish black on every step leading to the individuals' bedrooms. The carpet in Individual #1's room had a strong smell of urine. | Floors, walls, ceilings and other surfaces shall be in good repair. | 1. The staff at the house immediately scrubbed the carpet in the bedroom on 08/30/2018.
2. On 09/04/2018 the quality compliance manager checked all other individual¿s homes to ensure that the homes were clean and sanitary. All other houses outside of McCoy and Christoff house were found clean and sanitary. The carpet was replaced at McCoy house on 09/02/2018.
3. All staff will be trained on regulation 6400.67a Making sure that all homes are clean and sanitary by the quality compliance manager. All staff will sign off on training signature sheet by 12/31/2018.
4. The Quality Compliance Manager will review each home on a weekly basis to make sure that each home is clean and sanitary. This will be documented on a weekly group home checklist starting 11/01/2018. |
10/12/2018
| Implemented |
| 6400.110(a) | The smoke detector in Individual #1's bedroom was not operable. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | 1. On 8-30-18 NSC maintenance installed a battery in the smoke detector in the bedroom.
2. All other homes were checked on 09/04/2018 by the quality compliance manager. The quality compliance manager replaced batteries as deemed necessary.
3. All staff will be trained on regulation 6400.110a, Making Sure All Smoke Detectors are Functionable by the Quality Compliance Manager and sign off on a training signature sheet by 12/31/2018.
4. The Quality Compliance Manager will on a weekly basis check all group homes to make sure that all smoke detectors are operable. This will be documented on a weekly group home checklist starting 11/01/2018. |
10/12/2018
| Implemented |
| 6400.142(f) | Individual #1 requires assistance to complete his/her dental hygiene needs. His/her record did not contain a written plan for his/her dental hygiene needs. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | 1. On 8/30/2018 the Program Specialist immediately updated revised assessment to include Dental Plan of Care.
2. On 09/04/2018- 09/06/2018 the Program Specialist reviewed all individual assessments and made sure all dental plan of cares will outline the level of supervision required, what level of verbal prompting, gestural prompting and physical prompting that each individual requires, with brushing, flossing and rinsing. If an individual has achieved dental hygiene independence that also would be reflected in their ISP and assessment.
3. All staff including Program Specialist will be trained on regulation 6400.142f Implementing Dental Plan of Care in Assessment by Vice President and sign off on training signature paper by 12/31/2018.
4. The Program Specialist will review all assessments on a quarterly basis to ensure that Dental Care of Plan is included and revised as deemed necessary starting 01/2019. |
10/12/2018
| Implemented |
| 6400.144 | REPEAT from 7/12/17 renewal inspection:
-Individual #1's dentist indicated that he/she needed to return at 10am on 8/27/18 for a return 6-month prophy and exam. This did not occur. There was a dateless note in the record indicating that Individual #1's 8/27/18 dentist appointment was rescheduled due to "conflicting schedule due to 1st day of school activities."
--Individual #1 was seen at Conemaugh Health System on 2/4/18 for mild closed head injury, contusion of scalp, contusion of right hand and multiple abrasions due to "hand controls on 2/4/18, 5 mins with Staff #2 and #3 who observed this restraint." The discharge instructions from Conemaugh Health System indicated to follow up with Individual #1's primary care physician (pcp) in 1 day. Individual #1 did not return to his/her pcp until 2/9/18 for which the doctor's record indicated the 2/9/18 appointment was addressing constipation concerns. | 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.
| 1. On 08/30/2018 the Medical Coordinator called physicians and scheduled the appointments at the earliest convenience.
2. On 09/04/2018 the Medical Coordinator reviewed all medical appointments for all the individuals to make sure that they were going to their scheduled appointments. No other violations were found concerning this regulation.
3. All staff will be trained by Medical Coordinator on violation 6400.144 making sure that individuals go to their followed up medical visits. All staff will sign off on training signature paper by 12/31/2018.
4. The Medical Coordinator will review all appointment summaries after individuals attend appointments and will document on an appointment follow up form. This form will be sent to each individual group home. This will start on 11/01/2018. |
10/12/2018
| Implemented |
| 6400.161(a) | According to Individual #1's Individual Support Plan and medication log, he/she is prescribed Diazepam gel 10mg insert rectally as needed for prolonged seizures greater then 3 minutes or serial seizures. This medication was not stored in it's original container. The medication was kept in a Ziplock bag. | Prescription and nonprescription medications shall be kept in their original containers, except for medications of individuals who self-administer medications and keep the medications in personal daily or weekly dispensing containers. | 1. On 08/30/2018 the Medical Coordinator immediately contacted the pharmacy to have a label delivered to the house for the medication. The staff on shift at that location were trained on this regulation on 08/30/2018.
2. On 09/04/2018 the quality compliance manager reviewed medications at all houses to ensure that all medications were in their original labeled container. No other violations were found concerning this regulation.
3. All staff will be trained by Medical Coordinator on violation 6400.161a making sure each medication is in its original labeled container. All staff will sign off on training signature paper by 12/31/2018.
4. The quality compliance manager will review and make sure that each medication is in its original labeled container on a weekly basis and document on group home checklist starting on 11/01/2018. |
10/12/2018
| Implemented |
| 6400.162(a) | Individual #1's Diazepam gel medication, as described in 6400.161(a), did not contain a pharmaceutical medication label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. | The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. | 1. On 08/30/2018 the Medical Coordinator immediately contacted the pharmacy to have a label delivered to the house for the medication. The staff on shift at that location were trained on this regulation on 08/30/2018.
2. On 09/04/2018 the quality compliance manager reviewed medications at all houses to ensure that all medications were in their original labeled container. No other violations were found concerning this regulation.
3. All staff will be trained by Medical Coordinator on violation 6400.162a making sure each medication is in its original labeled container. All staff will sign off on training signature paper by 12/31/2018.
4. The quality compliance manager will review and make sure that each medication is in its original labeled container on a weekly basis and document on group home checklist starting on 11/01/2018. |
10/12/2018
| Implemented |
| 6400.163(c) | REPEAT from 7/12/17 renewal inspection: Individual #1's 5/23/18 medication review didn't include the reason for prescribing Trazodone, Ability and Clonazepam. Abilify is prescribed for mood disorder, Trazodone for mental health and Clonazepam for Anxiety. Individual #1's 5/23/18 medication review didn't review their medication Clonazepam at all. | 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. | 1. On 8/30/2018, an attached copy of the physician¿s orders was attached to the appointment summary on site.
2. On 09/04/2018, to ensure medications administered are matching directions specified by the physician, certified nurse and or LPN, the Residential Service Workers and/or House Teams leads will attach a current copy of the individual's physician's order sheet or medication administration record to the appointment summary so that an accurate and current up to date list of medications are available for the physician to review. Next Step Care Inc. medical department (Medical Coordinator & Medical Administrator) will be responsible for ensuring medications administered are matching the individual's MAR.
3. All staff will be trained on regulation 6400.167b by the Medical Coordinator stating that the physician must review all medications during a psychiatric review. All staff will sign off on training signature paper by 12/31/2018.
4. The Medical Coordinator will review all appointment summaries on quarterly basis starting 01/2019 to comply with this regulation. |
10/12/2018
| Implemented |
| 6400.164(a) | --Individual #1's physician's order medication list located in his/her record that was attached to his/her 12/19/17 physical examination form, indicated he/she was prescribed "Bisacodyl EC 5mg tablet, take 1 tablet by mouth at bedtime as needed for no bm x3 days. Continue to give one tablet nightly until a bm is achieved per patient request." Individual #1's corresponding mediation logs from 1/29/18-3/12/18 indicated to administer "Bisacodyl tab 5mg EC, take 1 tablet orally at bedtime as needed for no bm x3 days for constipation: continue to give one-half (2.5mg) until a bm is achieved for constipation." The physician's order and what was documented on the medication log did not match.
-Staff JS initialed as administered Individual #1's Oxycarbazepin, Vitamin d3, Dok cap, Aripiprazole and Trazodone in February 2018 and did not sign the back of the medication log indicating who Staff JS was identified as. A central medication administration signature sheet did not exist.
-Multiple staff signatures on the back of the medication logs were not legible. Therefore it was impossible to determine who administered medication to Individual #1 on multiple occasions.
-Individual #1 is prescribed Trazodone 25mg every 8am, 1 hour prior to leaving school, and at bedtime for mental health. The May-July 2018 medication logs were blank for the 2pm dose to be administered 1 hour prior to leaving school. The medication log had the time "2pm" was crossed off. The logs did not indicate if the medication was administered or if the Individual was out of program during the time of administration. According to the agency, Individual #1 attended an extended school year which meant the individual attended school during some of the summer months.
--Individual #1's July 2018 medication logs indicated "sc" and "s" for some of the days for medication administration. The medication logs only identified that "sc" was defined as school but did not define "s."
--There were two August 2018 medication logs in Individual #1's record at his/her home. According to the provider, the provider switched pharmacies, thus received a new medication log. However the medication log that was initialed with medication administrations from 8/1/18-8/15/18 did not indicated on that medication log that the medications were rewritten on another medication log.
--Individual #1's new August 2018 medication log indicated to administer Acne Medicat Gel 5%, apply topically to back in shower daily. However, the medication label for Acne Medicat Gel indicated to apply topically to back in shower as directed. | 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. | 1. On 08/30/2018, medical coordinator contacted pharmacy and had them match the physician¿s orders with the medication log. The pharmacy then sent them to the house.
2. On 09/04/2018- 09/07/2018 the medical coordinator and medical administrator reviewed all other agency MARS and found no other discrepancies.
3. All staff will be trained on regulation 6400.164a by the Medical Coordinator to ensure proper documentation of a MAR. All staff will sign off on signature page by 12/31/2018.
4. The Medical Coordinator will review all MARS on a monthly basis starting 11/01/2018 to comply with this regulation. |
10/12/2018
| Implemented |
| 6400.167(b) | -Individual #1's 3/12/18 medication administration record (mar) initialed by staff JS indicated the individual's medication Bisacodyl was discontinued as written "take 1 tablet (5mg) orally at bedtime as needed for no bm (bowel movement) x3 days for constipation; continue to give one-half tablet (2.5mg) until a bm is achieved for constipation" and was rewritten to "Bisacodyl tab 5mg ec, take 2 tablets orally daily as needed for constipation." However, according to the medication summary appointment form for Individual #1 on 3/12/18 it indicated no medication changes with a mar attached that indicated to administer Bisacodyl 5mg orally at bedtime as needed for no bm x3 days; continue to give ½ tab until bm is achieved for constipation. According to bm chart for Individual #1, a bm was documented on 3/27/18 and not again until 3/31/18. According to the March 2018 mar, Bisacodyl was never administered for the entire month. There's no documentation that the original order for Bisacodyl, as referenced in 6400.164(a), from the individual's 12/19/17 physical was ever changed. The physician's order sheet (that did not contain physician name information) changed in April 2018 and per the agency, they assumed the medication should be administered a different way. April 2018 mar changed Biscodyl 5mg to administer 2 tablets daily as needed for constipation.
--Individual #1's psychiatrist changed the individual's Trazadone to 12.5mg at 8am and 25mg at night on 3/27/18. The morning dose of Trazadone wasn't administered as ordered until 3/30/18. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | 1. From 09/04/2018- 09/05/2018 the medical coordinator and medical administrator reviewed MARS from this location due to the infraction that happened in March 2018.
2. From 09/06/2018- 09/13/2018 the medical coordinator and medical administrator reviewed MARS from all other house locations and found no other infractions on the MARS.
3. All staff will be trained on regulation 6400.167b by Medical Coordinator on making sure the MARS are written as prescribed by the licensed physician. All staff will sign off on training signature page by 12/31/2018.
4. The Medical Coordinator will review MARS from each location on monthly basis starting 11/01/2018 to ensure compliance. |
10/12/2018
| Implemented |
| 6400.168(a) | --Staff #6 had an initial medication administration training completed for her by medication trainer, Staff #11, on 2/7/17. However, it was Staff #6's initial medication training and documentation provided by the agency only indicated that Staff #6 received certification on 2 out of the required 4 medication administration observations by 2/7/17. Staff #6 has been passing medications since 2/7/17. Referenced in 6400.168(c), there were staff signing as practicum observers and medication trainers on Staff #6's 2/7/17 and 2/5/18 annual medication administration trainings, when those staff were not certified as practicum observers or medication administration trainers to do so. Thus Staff #6 has not been certified to pass medications for multiple years.
--Staff #7 was not certified to pass medications and he has been passing medications from 8/4/17 until currently. His initial 8/4/17 medication administration training did not indicate he completed the multiple-choice test as required. This was left blank on his exam form and there was no documentation kept by the agency to indicate he received the training. Staff #8, who did not have the credentials required to certify Staff #7's handwashing and gloving tests until 8/30/17, indicated on Staff #7's annual medication training documentation that she certified Staff #7's handwashing and gloving test on 7/28/17.
-Individual #1 is prescribed Diazepam rectal gel to be administered as needed. There was no staff from the agency that was trained in the administration of medications, outside of the regulatory routes of oral, ear drops, eye drops and topical medications, by a licensed professional. | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | 1. On 08/31/2018 the Medical Coordinator immediately contacted the staff and let them know that their medication passing privileges were suspended until they were properly trained.
2. On 09/04/2018-09/07/2018, medical coordinator and medical administrator went through all other employee files and found that all other staff were properly med trained and observed.
3. Staff #6 was retrained on medication administration on 09/06/2018. Staff #7 multiple choice test was found and place in employee binder on 09/06/2018. Staff #7 was retrained in hand washing and gloving by certified medical administration trainer on 09/06/2018. All office staff will be trained on regulation 6400.168 medication administration training and its requirements. All office staff will sign off on training signature paper by 12/31/2018
4. The Medical Coordinator will review all medication trainings on quarterly basis starting 01/2019 to ensure compliance. |
10/12/2018
| Implemented |
| 6400.168(c) | --Both medication observations from Staff #6's 2/5/17 medication administration training was completed by Staff #9 who was not a certified medication administration trainer or practicum observer. Staff #8 signed as being a practicum observer for Staff #6's 8/2/17 mar review as part of Staff #6's 2/5/18 annual medication training. However, the agency did not have documentation that Staff #8 was ever certified as a practicum observer nor did they have documentation that she was a medication trainer until 8/30/17. Therefore, Staff #8 was not certified to pass Staff #6's mar review for her 2018 medication training.
-- Staff #8 indicated on Staff #7 8/4/17 initial medication administration training documentation that she was a medication trainer and completed the handwashing and gloving test on Staff #7 on 7/28/17. There was no documentation to indicate Staff #8 was a medication trainer certified to complete said documents until 8/30/17. Staff #8 also signed as a practicum observer and completed 4 of Staff #7's medication administration observations on 7/28/17. There was no documentation that indicated Staff #8 was a medication trainer or certified as a practicum observer when she completed those documents for Staff #7. | Medications administration training of a staff person shall be conducted by an instructor who has completed the Department's Medications Administration Course for trainers and is certified by the Department to train staff. | 1. On 08/31/2018 the Medical Coordinator immediately contacted the staff and let them know that their medication passing privileges were suspended until they were properly trained.
2. On 09/04/2018-09/07/2018, medical coordinator and medical administrator went through all other employee files and found that all other staff were properly med trained and observed.
3. Staff #6 was retrained on medication administration on 09/06/2018. Staff #7 multiple choice test was found and place in employee binder on 09/06/2018. Staff #7 was retrained in hand washing and gloving by certified medical administration trainer on 09/06/2018. All office staff will be trained on regulation 6400.168 medication administration training and its requirements. All office staff will sign off on training signature paper by 12/31/2018.
4. The Medical Coordinator will review all medication trainings on quarterly basis starting 01/2019 to ensure compliance. |
10/12/2018
| Implemented |
| 6400.168(e) | --Staff #6's 2/7/17 initial medication training did not include documentation of her written documentation test or multiple-choice test. There also wasn't documentation for two of the four required medication observations being completed on or prior to 2/7/17. Staff #6's 2/5/18 medication administration recertification did not include documentation of 2 full and completed mar reviews.
--Staff #7's 8/4/17 initial medication administration training did not include documentation that he completed the required multiple-choice exam or written documentation test. | Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept. | 1. On 08/31/2018 the Medical Coordinator immediately contacted the staff and let them know that their medication passing privileges were suspended until they were properly trained.
2. On 09/04/2018-09/07/2018, medical coordinator and medical administrator went through all other employee files and found that all other staff were properly med trained and observed.
3. Staff #6 was retrained on medication administration on 09/06/2018. Staff #7 multiple choice test was found and place in employee binder on 09/06/2018. Staff #7 was retrained in hand washing and gloving by certified medical administration trainer on 09/06/2018. All office staff will be trained on regulation 6400.168 medication administration training and its requirements. All office staff will sign off on training signature paper by 12/31/2018.
4. The Medical Coordinator will review all medication trainings on quarterly basis starting 01/2019 to ensure compliance. |
10/12/2018
| Implemented |
| 6400.181(b) | REPEAT from 7/12/17 renewal inspection: Individual #1's 3/29/18 assessment indicated he/she required 2:1 supervision at all times. Recently, Individual #1's supervision level changed at the home to 2:1 staffing during awake hours and 1:1 staffing during sleeping hours. Individual #1's assessment was never updated to indicate this change of service. | If the program specialist is making a recommendation to revise a service or outcome in the ISP as provided under § 6400.186(c)(4) (relating to ISP review and revision), the individual shall have an assessment completed as required under this section. | 1. On 08/30/2018, the Program Specialist revised the assessment supervision level from 2:1 at night to 1:1 at night.
2. On 09/04/2018- 09/07/2018 the Program Specialist reviewed all other assessments to ensure that the supervision levels matched the ISP. All other assessments were found to be in compliance with supervision levels matching ISP.
3. All staff including Program Specialist will be trained by CEO on Regulation 6400.181b to include that all assessments supervision levels match the ISP. All staff will sign off on training signature paper by 12/31/2018.
4. The CEO will review all assessments on a quarterly basis to ensure that they are correct and up to date with the ISP starting 01/2019. |
10/12/2018
| Implemented |
| 6400.181(e)(3)(ii) | Individual #1's 3/29/18 assessment didn't include his/her current level of communication. His/her assessment indicated he/she could express his/her wants and needs when he/she wants something within his/her environment but did not explain how he/she does this. Other documents in his/her record indicate that he/she is nonverbal or that his/her speech is extremely difficult to understand. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. | 1. On 08/30/2018, the Program Specialist revised the assessment to put in current level of communication for individual.
2. On 09/04/2018- 09/07/2018 the Program Specialist reviewed all other assessments to ensure that the communication levels matched the ISP. All other assessments were found to be in compliance with supervision levels matching ISP.
3. All staff including Program Specialist will be trained by CEO on Regulation 6400.181(e)(3)(ii) to include that all assessments communication levels match the ISP. All staff will sign off on training signature paper by 12/31/2018.
4. The CEO will review all assessments on a quarterly basis to ensure that they are correct and up to date with the ISP starting 01/2019. |
10/12/2018
| Implemented |
| 6400.181(e)(3)(iii) | REPEAT from 7/12/17 renewal inspection: Individual #1's 3/29/18 assessment didn't include his/her level of personal adjustment. During the time frame of the initial assessment (from 1/29/18-3/29/18) Individual #1 had 16 reported restraints, one of which he was seen at the hospital for serious head, face and hand contusions due to personal adjustment concerns that were not included in his/her assessment. | The individual's current level of performance and progress in the following areas: Personal adjustment. | 1. On 08/30/2018, the Program Specialist revised the assessment to put in current level of personal adjustment for individual.
2. On 09/04/2018- 09/07/2018 the Program Specialist reviewed all other assessments to ensure that all of the individual¿s personal adjustment matched the ISP. All other assessments were found to be in compliance with personal adjustment matching ISP.
3. All staff including Program Specialist will be trained by CEO on Regulation 6400.181(e)(3)(iii) to include that all assessments of individual¿s personal adjustment match the ISP. All staff will sign off on training signature paper by 12/31/2018.
4. The CEO will review all assessments on a quarterly basis to ensure that they are correct and up to date with the ISP starting 01/2019. |
10/12/2018
| Implemented |
| 6400.181(e)(6) | Individual #1's 3/29/18 assessment doesn't indicate his/her ability to use or avoid poisons. His/her assessment only indicated he/she had a restrictive plan where all poisons are locked. | The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. | 1. On 08/30/2018, the Program Specialist revised the assessment to put in the individual¿s ability to use or avoid poisons.
2. On 09/04/2018- 09/07/2018 the Program Specialist reviewed all other individual assessments to ensure that all of the individual¿s ability to use or avoid poisons are in the assessment. All other assessments were found to be in compliance with indicating the individual¿s ability to use or avoid poisons.
3. All staff including Program Specialist will be trained by CEO on Regulation 6400.181(6) to include that all assessments include the individual¿s ability to use or avoid poisons. All staff will sign off on training signature paper by 12/31/2018.
4. The CEO will review all assessments on a quarterly basis to ensure that they are correct and up to date with the ISP starting 01/2019. |
10/12/2018
| Implemented |
| 6400.181(e)(12) | Individual #1's 3/29/18 assessment doesn't include recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | 1. On 08/30/2018 the Program Specialist revised the assessment to put in the recommendations for specific areas of training, programming and services.
2. On 09/04/2018- 09/07/2018 the Program Specialist reviewed all other individual assessments to ensure that recommendations for specific areas of training, programming and services are in the assessment. All other assessments were found to be in compliance with recommendations for specific areas of training, programming and services be included in the assessment.
3. All staff including Program Specialist will be trained by CEO on Regulation 6400.181(12) to include that all assessments include the recommendation for specific areas of training, programming and services are in the assessment. All staff will sign off on training signature paper by 12/31/2018.
4. The CEO will review all assessments on a quarterly basis to ensure that they are correct and up to date with the ISP starting 01/2019. |
10/12/2018
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's 3/29/18 assessment doesn't indicate his/her current level of health. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| 1. On 08/31/2018, the Program Specialist revised the assessment to indicate the individual¿s current level of health.
2. On 09/04/2018- 09/07/2018 the Program Specialist reviewed all other individual assessments to ensure that the assessment indicated the individual¿s current level of health. All other assessments were found to be in compliance with indicating the individual¿s current level of health.
3. All staff including Program Specialist will be trained by CEO on Regulation 6400.181(13)(i) to include that all assessments include the individual¿s current level of health. All staff will sign off on training signature paper by 12/31/2018.
4. The CEO will review all assessments on a quarterly basis to ensure that they are correct and up to date with the ISP starting 01/2019. |
10/12/2018
| Implemented |
| 6400.181(e)(13)(ii) | REPEAT from 7/12/17 renewal inspection: Individual #1's 3/29/18 assessment doesn't indicate his/her current level of motor and communication skills. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | 1. On 08/31/2018, the Program Specialist revised the assessment to indicate the individual¿s current motor and communication skills.
2. On 09/04/2018- 09/07/2018 the Program Specialist reviewed all other individual assessments to ensure that the assessment indicated the individual¿s current level of motor and communication skills. All other assessments were found to be in compliance with indicating the individual¿s current level of motor and communication skills.
3. All staff including Program Specialist will be trained by CEO on Regulation 6400.181(13)(ii) to include that all assessments include the individual¿s current level of motor and communication skills. All staff will sign off on training signature paper by 12/31/2018.
4. The CEO will review all assessments on a quarterly basis to ensure that they are correct and up to date with the ISP starting 01/2019. |
10/12/2018
| Implemented |
| 6400.181(e)(13)(v) | REPEAT from 7/12/17 renewal inspection: Individual #1's 3/29/18 assessment doesn't indicate his/her current level of socialization skills. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | 1. On 08/31/2018 the Program Specialist revised the assessment to indicate the individual¿s current level of socialization skills.
2. On 09/04/2018- 09/07/2018 the Program Specialist reviewed all other individual assessments to ensure that the assessment indicated the individual¿s current level of socialization skills. All other assessments were found to be in compliance with indicating the individual¿s current level of health.
3. All staff including Program Specialist will be trained by CEO on Regulation 6400.181(13)(v) to include that all assessments include the individual¿s current level of socialization skills. All staff will sign off on training signature paper by 12/31/2018.
4. The CEO will review all assessments on a quarterly basis to ensure that they are correct and up to date with the ISP starting 01/2019. |
10/12/2018
| Implemented |
| 6400.181(e)(13)(vi) | REPEAT from 7/12/17 renewal inspection: Individual #1's 3/29/18 assessment doesn't indicate his/her current level of recreation skills | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | 1. On 08/31/2018 the Program Specialist revised the assessment to indicate the individual¿s current level of recreational skills.
2. On 09/04/2018- 09/07/2018 the Program Specialist reviewed all other individual assessments to ensure that the assessment indicated the individual¿s current level of recreational skills. All other assessments were found to be in compliance with indicating the individual¿s current level of recreational skills.
3. All staff including Program Specialist will be trained by CEO on Regulation 6400.181(13)(vi) to include that all assessments include the individual¿s current level of recreational skills. All staff will sign off on training signature paper by 12/31/2018.
4. The CEO will review all assessments on a quarterly basis to ensure that they are correct and up to date with the ISP starting 01/2019. |
10/12/2018
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's 3/29/18 assessment doesn't indicate his/her current level of financial skills | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| 1. On 08/31/2018, the Program Specialist revised the assessment to indicate the individual¿s current level of financial skills.
2. On 09/04/2018- 09/07/2018 the Program Specialist reviewed all other individual assessments to ensure that the assessment indicated the individual¿s current level of financial skills. All other assessments were found to be in compliance with indicating the individual¿s current level of financial skills.
3. All staff including Program Specialist will be trained by CEO on Regulation 6400.181(13)(vii) to include that all assessments include the individual¿s current level of financial skills. All staff will sign off on training signature paper by 12/31/2018.
4. The CEO will review all assessments on a quarterly basis to ensure that they are correct and up to date with the ISP starting 01/2019. |
10/12/2018
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's 3/29/18 assessment doesn't indicate his/her current level of managing personal property skills | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | 1. On 08/31/2018, the Program Specialist revised the assessment to indicate the individual¿s current level of managing personal property skills.
2. On 09/04/2018- 09/07/2018 the Program Specialist reviewed all other individual assessments to ensure that the assessment indicated the individual¿s current level of managing personal property skills. All other assessments were found to be in compliance with indicating the individual¿s current level of managing personal property skills.
3. All staff including Program Specialist will be trained by CEO on Regulation 6400.181(13)(viii) to include that all assessments include the individual¿s current level of managing personal property skills. All staff will sign off on training signature paper by 12/31/2018.
4. The CEO will review all assessments on a quarterly basis to ensure that they are correct and up to date with the ISP starting 01/2019. |
10/12/2018
| Implemented |
| 6400.181(e)(13)(ix) | Individual #1's 3/29/18 assessment doesn't indicate his/her current level of community integration skills | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community-integration. | 1. On 08/31/2018 the Program Specialist revised the assessment to indicate the individual¿s current level of community integration skills.
2. On 09/04/2018- 09/07/2018 the Program Specialist reviewed all other individual assessments to ensure that the assessment indicated the individual¿s current level of community integration skills. All other assessments were found to be in compliance with indicating the individual¿s current level of community integration skills.
3. All staff including Program Specialist will be trained by CEO on Regulation 6400.181(13)(ix) to include that all assessments include the individual¿s current level of community integration skills. All staff will sign off on training signature paper by 12/31/2018.
4. The CEO will review all assessments on a quarterly basis to ensure that they are correct and up to date with the ISP starting 01/2019. |
10/12/2018
| Implemented |
| 6400.181(f) | Individual #1's 3/29/18 assessment did not indicate the specific team members that received his/her assessment. There was no indication that Individual #1 or his/her school received a copy of his/her assessment. His/her assessment was also indicated as sent on 3/29/18 but that was not 30 days prior to his/her annual Individual Support Plan (ISP) meeting held on 4/19/18. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| 1. On 08/31/2018 the Program Specialist revised the assessment to include the specific team members that received the assessment.
2. On 09/04/2018- 09/07/2018 the Program Specialist reviewed all other individual assessments to ensure that the assessment indicated the name of the specific team members that received the assessment. The Program Specialist made changes to all other assessments to indicate the specific team members name that received the assessment.
3. All staff including Program Specialist will be trained by CEO on Regulation 6400.181(f) to include that the name of the specific team members that received the assessment. All staff will sign off on training signature paper by 12/31/2018.
4. The CEO will review all assessments on a quarterly basis to ensure that they are correct and up to date with the ISP starting 01/2019. |
10/12/2018
| Implemented |
| 6400.183(4) | Individual #1's Individual Support Plan (ISP) indicated he/she only required 1:1 staffing in the community. According to his/her assessment and the agency staff, Individual #1 requires 2:1 staff to individual ratio in the community at all times. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. | 1. On 08/30/2018, the Program Specialist sent an e-mail to the supports coordinator to have the staffing ratio changed from 1:1 to 2:1 in the ISP.
2. On 09/04/2018, the Program Specialist reviewed all other individual¿s ISP¿s to make sure that the staffing ratio was correct in the ISP. All other individual¿s ISP¿s were found to be in compliance with staffing ratios.
3. All staff including Program Specialist will be trained by Vice President on Regulation 6400.183.4 to ensure that the staffing ration is correct in the ISP for all individuals. All staff will sign off on training signature paper by 12/31/2018.
4. The CEO will review individual¿s ISP¿s on a quarterly basis to ensure compliance with the CEO review signature sheet starting 01/2019. |
10/12/2018
| Implemented |
| 6400.195(a) | During the onsite inspection of the home, multiple personal items of Individuals #1 and #2 were found locked in the staff office. Individuals #1 and #2 did not have a restrictive procedure plan to have the items locked. Individual #1's items that were locked included multiple games and puzzles, some clothing items, and other personal items. Individual #2's items that were locked included a computer, computer games, electronic items, electronic cords, and electronic game supplies. | For each individual for whom restrictive procedures may be used, a restrictive procedure plan shall be written prior to use of restrictive procedures.
| 1. On 08/30/2018 all items that were found during in the office during licensing were removed immediately and placed in the individual¿s bedrooms.
2. On 09/04/2018, the Quality Compliance Manager went to all group homes to ensure that there were no other individual¿s items were locked up that was not in a restrictive plan. All other homes were found to be in compliance.
3. The Behavioral Specialist will hold a training by 12/31/2018 to ensure all staff are properly trained on what is restrictive in an individual¿s restrictive plan. All staff will sign off on signature training paper.
4. The Behavioral Specialist will review all restrictive plans with staff on a monthly basis starting 11/01/2018. |
10/12/2018
| Implemented |
| 6400.205 | --Individual #1's record indicated that restraints were placed on Individual #1 on 7/20/18 at 8:23am. However, there was no indication for who placed each restraint and when. The agency incident report summary indicated Staff persons who observed the individual were Staffs #4 and #5, both of whom have initials DG. The section on the incident report summary where it indicated to list the length of each restraint and who administered the restraint was blank for who administered each restraint. The incident report entered into Enterprise Incident Management (EIM) for this restraint only used the initials DG and DG in regards to the staff that administered restraints, not differentiating which staff applied which restraints.
--A note in Individual #1's record dated 2/4/18 indicated "specific behavior addressed: physical aggression, methods of intervention used to address the behavior: hand controls, date, time and duration of each restrictive procedure used and staff that used the procedure: 2/4/18 hand controls 5 mins, staff persons who observed the individual: Staff #2, Staff #3, was exclusion used?: (blank)." This restraint was not entered into EIM nor did it indicate who used the restraint, or the time of the restraint, or if least restrictive measures were used first. The incident of restraint on 2/4/18 was not discussed on the EIM incident report labeled "emergency room visit" that occurred on 2/4/18 either. | A record of each use of a restrictive procedure documenting the specific behavior addressed, methods of intervention used to address the behavior, the date and time the restrictive procedure was used, the specific procedures followed, the staff person who used the restrictive procedure, the duration of the restrictive procedure, the staff person who observed the individual if exclusion was used and the individual's condition following the removal of the restrictive procedure shall be kept in the individual's record.
| 1. On 08/29/2018, the Behavioral Specialist went back and put in the staff¿s names to clearly identify who was involved in the restraint incident.
2. On 09/04/2018 through 09/07/2018, the Behavioral Specialist Consultant went through other incidents for other individuals to ensure that the staff¿s names clearly identify who was involved in any incident.
3. All staff will be trained on regulation 6400.25 by Behavioral Specialist Consultant to ensure that staff are using their full names to clearly identify themselves when involved in any incident. Staff will sign off on training signature page by 12/31/2018.
4. A new tracking form has been created by the Behavior specialist to record the use of any restrictive procedure documenting the specific behavior addressed, methods of intervention used to address the behavior, the date and time the restrictive procedure was used, the specific procedures followed, the staff person who used the restrictive procedure, the duration of the restrictive procedure and this tracking and original reports will be maintained in the individual¿s record starting 11/01/2018. The Behavioral Specialist will make sure that these records will be reviewed and completed in its entirely on a monthly basis starting 11/01/2018. |
10/12/2018
| Implemented |
| 6400.213(11) | REPEAT from 7/12/17 renewal inspection: Individual #1's Individual Support Plan (ISP) update 5/16/18 included allergies to amoxicillin, grapefruit, chronic ringworm and seasonal allergies/sinus infections. His/Her 12/19/17 physical examination form indicated allergies to penicillin and amoxicillin. His/Her identification sheet indicated allergies to amoxicillin, grapefruit and grapefruit juice. Some of Individual #1's medication logs and treatment records list allergies to just amoxicillin, others indicate amoxicillin and grapefruit, and some list allergies to amoxicillin, penicillin and grapefruit.
--Individual #1's 3/29/18 assessment indicated he requires 2:1 supervision at all times due to his intensive behavior issues. His/Her ISP indicated he needs a 2:1 during waking hours and 1:1 during sleeping hours and only needs 1:1 in the community. His/Her restrictive procedure plan (RPP) indicates he/she requires a 1:1 staff ratio.
--Individual #1's ISP under demographics section indicates he/she lives in a 1 person group home. He/She currently is living with one other housemate.
-Individual #1 is prescribed Trazodone for mental health (according to his/her medication logs) but his/her ISP indicates he/she is prescribed Trazodone for insomnia. He is prescribed to take Trazodone in the morning, 1 hour prior to leaving school and at night. His/her ISP indicated to only take Trazodone twice a day.
--Individual #1's medication logs and psychiatric appointments indicated that Individual #1 is prescribed Abilify for episodic mood d/o. Individual #1's ISP indicated that he/she is prescribed Abilify for Bipolar disorder.
-Individual #'1 restrictive procedure plan does not include a reward system or token economy for good behaviors. His/Her ISP under the know and do section indicated "what works for Individual #1: the reward system." | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | 1. On 8/30/2018, the administrative assistant updated the individual¿s demographics to reflect his current allergies.
2. On 09/04/2018, the administrative assistant reviewed all other individual¿s demographics to make sure that all were in compliance with regulation 6400.213.11. All demographics were updated to show current information on all of the individuals.
3. All staff including the administrative assistant will be trained by 12/31/2018 by quality compliance manager on regulation 6400.213.11 to ensure that all documentation is correct and up to date to include but not limited to allergies. All staff will sign off on training signature paper.
4. The administrative assistant will review all demographics on a quarterly basis to ensure compliance with regulation 6400.213.11 starting on 01/01/2019. |
10/12/2018
| Implemented |