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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | During the 10/19/23 onsite inspection, Individual #1's financial records included the following gift cards: Dunkin Donuts, Mastercard, Visa, and Arby's. The home does not have an up-to-date record of any of the gift cards, when they were received, any purchases made, and the total ending balance on the gift cards. Additionally, a sticky note was on the Arby's card activation part stating the card is with the individual's sister. There are no records of when the individual's sister took the card in their possession. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | Staff will utilize the agency petty cash tracking form labeled for each gift card. The Regional Director (RD) will train the Residential Supervisors (RS) and DSPs on November 10th how to use the tracking form. |
11/30/2023
| Implemented |
| 6400.43(b)(1) | The agency AIMED failed to follow proper incident reporting and investigation procedures for cases involving treatment beyond first aid and neglect of care, despite their own policies and the Department's guidelines. Incidents of neglect were not properly investigated. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | The plan of correction consists of re-training the incident management coordinator on reporting incidents and conducting investigations in a timely manner.Why:
The incidents weren't initiated because the PS didn't use proper protocol and incident management reporting. She thought that a voluntary incident was sufficient.
The regulation is important because it designates the person responsible for the overall operation of the agency and each home operated by the agency and who is accountable for meeting the requirements to operate the agency.
POC: (plan, training by whom date and supportive documentation.
The RD will conduct a training on Friday, November 10, 2023, at 4 PM for the York region staff in Incident Management to review how to identify and report abuse, neglect, and exploitation. |
12/08/2023
| Implemented |
| 6400.43(b)(3) | AIMED failed to ensure Individual #1's health and safety in their residential setting from 9/20/22 to 10/20/23. This report highlights gross negligence, including neglecting daily hygiene, failing to create protective plans, inadequate supervision to prevent falls, disregarding medical orders, and not reporting or investigating neglect incidents. Furthermore, on 10/20/23, the agency provided false shift note data for a non-existent shift. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | Why:
The staff working the overnight shift entered a shift note on the 20th rather than the 19th, so it appears to be a duplicate. There is a shift note for 12a-6a on the 20th; the staff worked Thursday 10p-11:59p and didn't change the date if entering the note after midnight on the 20th. Making it look like a duplicate shift, it was not a false shift note.
It is important to record shift notes to keep record of the individuals progress and/or concerns.
POC:
The staff, including the PS, in Individual #1's home requires additional training on supporting daily living skills, fall prevention, following medical orders, incident management, and accurate data collection. The RD will conduct training sessions for the applicable staff by December 8, 2024.
The RS is responsible for checking Therap every morning to ensure that daily the progress note is complete and accurate. |
12/08/2023
| Implemented |
| 6400.62(a) | Individual #1 is assessed to be unsafe around poisonous materials. During the 10/19/23 onsite inspection, Safeguard Chloroxylenol Antibiotic Handwashing Soap, that contained a label to contact poison control center if ingested, was unlocked and accessible sitting next to the kitchen sink. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Although Individual #1's ISP does not state they are unsafe around poisonous materials, the RS staff ensured only non-toxic hand soap was purchased. The PS inadvertently purchased a hand soap, believing it was safe because they did not see the poison control message on the bottle. The regulation is important because it decreases the likelihood of anyone being harmed by exposure to or ingesting poisonous materials. The hand soap was immediately replaced with non-toxic hand soap on 10/18/2023. |
11/30/2023
| Implemented |
| 6400.66 | -Individual #1 is a fall risk and received instructions in 2023 from medical professionals to ensure the home is well lit for the individual's safety. During the 10/19/23 onsite inspection, the only hallway light outside Individual #1's bedroom was very dim, not ensuring the hallway was well lit. The hallway light appeared to be missing a light bulb and the light covering was opaque, contributing to the dimness. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The hallway light is fluorescent and gradually gets lighter. It does not remain as dim. Although Individual #1 hasn't fallen in the hallway, the hallway light fixture, which can house two light bulbs, had only one light bulb. It is important to maintain adequate lighting in hallways of the home to prevent accidents and to protect the safety of individuals. On Monday, November 6, 2023, the second lightbulb was added to the fixture. |
11/30/2023
| Implemented |
| 6400.77(b) | Individual #1 has an allergy to latex and adhesives. During the 10/19/23 onsite inspection, the first aid kit did not have latex or adhesive free bandages or first aid kit materials for the individual's use. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Hypoallergenic bandages were in the first aid kit. A picture of the bandages was uploaded to ODP on October 26, 2023. The regulation is important because it ensures homes have the appropriate supplies to provide first aid. On October 24, 2023, the RD contacted Individual #1's primary care physician, who wrote a letter confirming the allergies were incorrectly noted. Individual #1 does not have an allergy to latex or adhesive. The letter was uploaded to ODP on October 26, 2023. |
11/30/2023
| Implemented |
| 6400.103 | REPEAT from 10/17/22 annual inspection: The written emergency evacuation procedure does not include individual responsibilities for evacuation procedures in an emergency. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The Emergency evacuation plan was updated during last year's inspection and was approved and accepted. AIMED followed the instructions at that time. The regulation is important because it ensures quick response to emergencies and delegates responsibilities. The CEO updated the emergency evacuation plan with Uploaded to ODP on 10/26/23. |
11/30/2023
| Implemented |
| 6400.104 | The home notified the local fire department on 2/22/23 of locations of bedrooms in the home, and the assistance needed for two individuals residing in the home. The letter stated one individual required verbal and physical assistance to evacuate the home and the other individual was independent with evacuation of the home. However, the letter didn't document which individual resided in which bedroom or provide a floor plan with the 2/22/23 notification letter that listed the exact locations of the bedrooms of those that need assistance. Additionally, Individual #1 residing in the home requires physical assistance to evacuate the home monthly as the home does not have a ramp to accommodate their adaptive needs so staff must physically assist the individual. Individual #1 has also refused to evacuate the home during the past year. The notification letter was not updated and sent to the fire department for Individual #1's increase need of support and assistance during fire drills. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| The RD completed the task, believing the required information was included in the notification letters. It is important to have this information in the letter to the fire department in the event of actual fire and the person needs assistance. The RD updated the notification letters on 10/18/23 and sent the letter by email to the York Area United Fire and Rescue chief. Verification was uploaded to ODP on 10/26/23. |
11/30/2023
| Implemented |
| 6400.112(c) | The written fire drill records from September 2023- October 2022, do not indicate if individuals and staff went to the meeting place during the fire drills. The fire drill records record the meeting place location but do not indicate if all participants met there. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | AIMED form contains all the information in the regulation. However, the specific information was not separately listed on the form. This regulation is important because it confirms fire drills occurred and allows providers to correct issues with the evacuation. The CEO updated the fire drill form on 10/18/2023 to include the meeting place and what kind of assistance was needed to evacuate: verbal prompt, physical assist, visual prompt, or none. The updated drill form was uploaded to ODP on 10/26/2023. |
11/30/2023
| Implemented |
| 6400.142(a) | -Individual #1 has not been seen or examined annually by a licensed dentist in 2022 or 2023. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Individual #1 is edentulous, and the staff mistakenly believed a dental appointment wasn't necessary. It is important to ensure the gums are examined to ensure there are no issues. Individual #1 had a dental exam on 10/19/2023, and an appointment was made for 2024. |
11/30/2023
| Implemented |
| 6400.142(f) | Individual #1 requires full physical assistance with dental hygiene care. At the time of the 10/18/23 inspection has never had Individual #1's gums examined by a licensed dentist since their date of admission, 9/20/22. On 1/18/23 the individual's primary care physician stated the individual has poor oral hygiene and ordered mouth swabs twice daily. The individual's record does not have a written plan for dental hygiene. | 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. | Individual #1 is edentulous, and the staff mistakenly believed a dental appointment wasn't necessary. It is important to ensure the gums are examined to ensure there are no issues. Individual #1 had a dental exam on 10/19/2023. The dentist's instructions include swishing the mouth with warm water at night and using the "Toothettes." The dental hygiene plan also states that "the individual is capable of brushing his/her teeth/dentures independently" and recommends an annual dental checkup. The checkup is scheduled for 10/17/2024. |
11/30/2023
| Implemented |
| 6400.144 | The home failed to provide health services to Individual #1 in the following areas: Allergies The individual's physical examination records from 2/7/22, 8/31/22, and 1/18/23 mention allergies to latex and adhesives. Staff communicated with the physician on 8/3/23, confirming the use of latex and adhesive-containing bandages and stickers without reactions. However, the physician was never informed when these allergens were administered. On 8/3/23, the physician didn't deny the allergies, but did indicate staff could use adhesives moving forward, but should be cautious due to psoriasis. Medications · As documented throughout this report, the home failed to provide medications as prescribed, failed to report and investigate omission of medications, and failed to properly document medication administration over the previous year. Ambulation: - Since at least March 2023, Individual #1 needed assistance with ambulation due to 23 diagnoses making them prone to falls. - On 6/16/23, Individual #1 fell out of their chair, and staff couldn't assist safely. The incident wasn't reported until 6/17/23, and the evaluation occurred after 4:15 pm on 6/17/23. - The home never assessed the individual's supervision needs despite documented fall risk and ambulation assistance requirements. Incontinence: - Staff reported increased incontinence on 1/18/23 but didn't contact medical professionals until that date. - On 1/18/23, the physician ordered adult depends and urine culture tests, which were obtained on 2/7/23. - The physician ordered the use of adult briefs, but there are no records of assistance. - In July 2023, the physician ordered pads instead of briefs, but there are no records of assistance. Sleep apnea: - Individual #1 has severe sleep apnea and requires CPAP use, but there are no records of staff assistance with proper CPAP use, cleaning, and storage. Dietary: - Speech language pathologist and the physician ordered mouth cleaning after every meal, but there are no records of this practice being followed after each meal. | 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.
| Why:
There were unnecessary delays from the RS and PA in following up with health professionals and their recommendations. Individual #1 did transition from briefs to pad and did use the Cpap. However, the documentation of changes were lacking and did not require specific documentation by ODP.
Health services are a necessary part of the individual's planned healthcare maintenance.
POC:
The RD will schedule monthly chart /Therap reviews to ensure that medical documentation is present and follow up by the physician is completed and documented.
The RS and PS will review all medical services received to ensure recommendations are implemented.
Allergies: The PS contacted Individual #1's primary care physician, who wrote a letter confirming the allergies were incorrectly noted. Individual #1 does not have an allergy to latex or adhesive. The letter was shared with the Individual's team.
Medications: The PS will enter the medication errors into EIM.
On Tuesday, October 30, 2023, the RS staff began taking pictures of the MARs (front and back) and then sending them (via email) to the RD and PS daily, after reviewing them first.
The RD will instruct the PS to enter med errors within 72 hours of the error. Any staff making repeated, continuous med admin errors will be referred to the agency Medication Trainer for medication administration remediation classes and will not be allowed to administer meds until the class is completed and passed. This means the RS staff will be responsible for ensuring there is someone to give the individual medications until the staff completes the class.
Ambulation: The PS will recategorize the ambulation incidents in EIM, and the agency will investigate for neglect.
By November 17, 2023, the RD will amend Individual #1's annual assessment to include her supervision needs, and redistribute the assessment to Individual #1 and her team.
Incontinence: The delay in the provision of adult depends in January 2022 is unexplainable. There is no doctor's order to document the use and assistance provided to Individual #1 while wearing the adult Depends and protective pads.
Sleep apnea: The RD will reach out to Individual #1's doctor for directions on how to properly clean and store the individual's CP machine. The RD is responsible for training staff on how to properly clean and store the CPAP machine by 12/13/23.
Dietary: Individual #1's oral care is documented on the MAR after administering the Toothette per doctor's orders.The Program Specialist will correct the MAR, add the missing medication, and follow up on the
administration of PRN Senokot-S in September 2023 by December 8, 2023. On Wednesday, October 25, 2023, the RD taught the staff how to use the Intake/Elimination feature in Therap, and reviewed the doctor's orders for administering the Senokot after three days with no bowel movement. |
12/08/2023
| Implemented |
| 6400.145(1) | REPEAT from 10/17/22 annual inspection: The written emergency medical plan for the home lists 3 hospitals to use in an emergency, two of them located in Pittsburgh, and one located in Philadelphia. During the 10/18/23 inspection, Staff #1 reported to the Department that the hospital the home is to use is one located in York. The hospital in York is not included in the home's written emergency medical plan. A separate written emergency medical plan was provided during the inspection that was stored electronically. This plan includes the local hospital source to use. However, the home has two emergency medical plans with no clear delineation which plan is to be used in an emergency and which plan is accessible to staff. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | AIMED staff provided the incorrect emergency medical plan. The form was removed and the correct form was provided. This regulation is important because it ensures people are protected during emergencies. The correct emergency medical plan form was provided during the inspection 10/18/2023, which contained the hospital location specific to the individual #1. This form will be provided again. |
11/30/2023
| Implemented |
| 6400.181(a) | -Individual #1's date of admission to the home was 9/20/22. They did not have an assessment of their skills, abilities, and needs for all categories defined in Pa Code 55 Chapter 6400.181(a)-(f), until 12/18/22, outside the required time frame. Individual #1's 12/18/22 assessment includes many contradictory statements and it's unclear what their assessed needs were at the time of the assessment. There were many areas within the assessment requirements, where the individual's current needs and abilities were not assessed: Lifetime Medical History, Supervision, Functional/Medical Limitations, Recommendations, and Progress made. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The lifetime medical was completed and in the chart. The inspector apparently didn't see it. The individuals ISP didn't have current and correct information at the time of admission. There was inconsistent information that was translated from the ISP to the initial assessment. This regulation is important because it guarantees prompt completion of the assessment and team notification. An updated assessment will be completed by 11/30/23. The PS will use the Assessment/ISP crosswalk to ensure that information is consistent in both documents. |
11/30/2023
| Implemented |
| 6400.18(a)(5) | The agency failed to properly report incident IDs 9233825, 9245180, 9266158, 9272097, and 9283908 to the Department under the correct incident category, neglect. Each incident was entered into EIM as "optionally reportable." | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Neglect.
| The staff in the York region need additional training in Incident Management to review how to identify and report abuse, neglect, and exploitation. This regulation is important because properly categorizing incidents identifies health and safety issues. The incidents were recategorized in EIM and investigations occurred. The outcomes denote the staff requires additional training on incident management. The RD will conduct a training on Friday, November 10, 2023, for the York region staff in Incident Management to review how to identify and report abuse, neglect, and exploitation. |
11/30/2023
| Implemented |
| 6400.18(g) | The agency did not investigate the neglect described in incident IDs 9233825, 9245180, 9266158, 9272097, and 9283908. | The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person. | The staff in the York region need additional training in Incident Management to review how to identify and report abuse, neglect, and exploitation. This regulation is important because properly categorizing incidents identifies health and safety issues. The incidents were recategorized in EIM and investigations occurred. The outcomes denote the staff requires additional training on incident management. The RD will conduct a training on Friday, November 10, 2023, for the York region staff in Incident Management to review how to identify and report abuse, neglect, and exploitation. |
11/30/2023
| Implemented |
| 6400.31(b) | Individual #1 entered residential services with the agency, AIMED, on 9/20/22 without a Power of Attorney. They obtained a POA on 1/20/23. However, from 9/20/22 to 1/20/23, Individual #1 was not educated or given choices regarding their rights, room and board contract, or release of information. On 9/20/22, the sister signed a blanket authorization for AIMED to access Individual #1's medical information without the individual's consent. Various forms were only discussed with the sister on 9/20/22, and the individual was not given the option to consent or deny. During an inspection on 10/18/23, it was discovered that the consent for handling finances wrongly mentioned the sister's name. AIMED later altered the document without specifying who made the change, but there's no record of the individual being informed about this consent. | The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights. | Why: Although not properly documented, Individual #1's sister signed the forms in the presence of Individual #1, and the Rights were explained to the individual.
The regulation ensures that people understand their rights and decision-making choices. The participant's mother was the legal guardian. Individual #1's mother passed away and the sister became the primary family support. During the admission, the participant's mother signed all documentation and during admission, both Mom and participants were given documentation and explained the rights.
The PS will be sure to obtain the Individual's signature after explaining the Rights. The admission forms will, again, be presented to Individual #1 for signature attainment by November 10, 2023. |
12/08/2023
| Implemented |
| 6400.32(c) | Part two for additional POC's. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | Individual #1 cannot use a shoehorn or the toileting aids. The attempts to use these items and their subsequent failures should have been documented. The bedside commode was believed to suffice as a raised toilet seat. A raised toilet seat was purchased on 10/25, and the staff were reminded to supervise Individual #1 while they use the toilet and ask them to wait for help before getting up when they are done. The home assessment was scheduled per the medical provider's availability and completed in May, and the results were provided in June 2023.
RE: From 3/22/23 to 5/25/23- On 5/17/23, the RD reminded the Residential Supervisor and Program Specialist with the therapist's recommendations and YouTube videos to show the staff.
SEATED MARCH: https://www.youtube.com/watch?v=xxf93bq9-vA
SEATED LONG ARC QUAD: https://www.youtube.com/watch?v=MVDRCyVqekA
SEATED HIP ADDUCTION ISOMETRICS WITH BALL https://www.youtube.com/watch?v=muBqkAeu8WE
The exercises were not documented until recently (see attached). Staff reported holding onto the individual's clothing to assist with steps, which is not safe. The home lacks an accessible entrance for the individual's rollator walker.
Incident ID 9233825: Individual #1 was taken to urgent care after the incident was discovered and reported. Individual #1 only owns the recommended shoes; they are Velcro closures that fit snugly on their feet. Incident ID 9245180: Individual #1 only owns the recommended shoes; they are Velcro closures that fit snugly on their feet. The AIMED staff aren't responsible for the actions of EMTs. On October 24, 2023, the RD contacted Individual #1's primary care physician, who wrote a letter confirming the allergies were incorrectly noted. Documenting cleaning the Individual #1 was not required.
RE: 7/11/23 The sensor alarm and gait belt were purchased on 10/20/23 (see attached) after the licensing inspectors clarified that the item is not restrictive because a medical professional recommended it. The Fox Rehab agency will contact the RPD to schedule the gait belt training in the home.
RE: 7/30/23 The sensor alarm and gait belt were purchased on 10/20/23 (see attached) after the licensing inspectors clarified that the item was not restrictive because a medical professional recommended it. The staff are completing 15-minute checks to ensure Individual #1 receives assistance to use the restroom when needed (see Awake/Sleep Tracking data).
RE: 1/18/23 Hygiene/incontinence: The delay in providing protective undergarments in January 2022 is unexplainable. The current staff has ensured the provision of protective undergarments since February 2023. There is no doctor's order to document the use and assistance provided to Individual #1 while wearing the protective pads.
RE: 1/18/23 Oral care: Individual #1 is edentulous, and the staff mistakenly believed a dental appointment wasn't necessary. Individual #1 had a dental exam on 10/19/2023. The dentist's instructions include swishing the mouth with warm water at night and using the "Toothettes." The dental hygiene plan also states that "the individual is capable of brushing his/her teeth/dentures independently" and recommends an annual dental checkup. The checkup is scheduled for 10/17/2024.
RE: 1/18/23 Skin issues: Individual #1's PCP was contacted about skin issues in July 2023 (see attached communication from the WellSpan portal). No regulation states the requirement to document encouragement to stand and walk. The recommended skin products are administered per the doctor's orders per the MARs. Information about the cushion (recommended by the PCP on 9/20/23) was provided to the PS on September 21, 2023. The cushion was finally purchased on 10/31/23. RE: 10/18/23 Before 10/18/23, a regulation or health professional didn't order or require hygiene monitoring. As of 10/24/23, Individual #1's showers are tracked via a form to indicate if she showered or refused and why. Ongoing issues are reported to the Residential Supervisor and followed up by the Program Specialist. RE: 10/18/23 Before 10/18/23, a regulation or health professional didn't order or require hygiene monitoring. As of 10/24/23, Individual #1's showers are tracked via a form to indicate if she showered or refused and why. Individual #1 has chronic skin issues that are addressed by the current medication orders. On 9/28/23, the staff addressed the pain and ongoing rashes by helping Individual #1 shower and applied the prescribed skin treatments, including Gold Bond Powder, Desitin, Betamethasone 0.05 % cream, and Eucerin calming cream.
RE: Supervision: The March 2023 assessment will be amended to incorporate Individual #1's supervision care needs by November 15, 2023. As of 10/26/23, the staff completes 15-minute checks to ensure Individual #1's health and safety (see health/safety check Tracking data).
RE:Medication management: To ensure medication errors are quickly identified, on Tuesday, October 30, 2023, the RS staff began taking pictures of them (front and back) and then sending them (via email) to the RD and PS daily after reviewing them first. The RD will instruct the PS to enter med errors within 72 hours of the error. Any staff making repeated, continuous med admin errors will be referred to the agency Medication Trainer for medication administration remediation classes and will not be allowed to administer meds until the class is completed and passed. This means the RS staff will be responsible for ensuring there is someone to give the individual medications until the staff completes the class.
RE: Incident reporting-
The PS will notify the RD about all incidents to ensure correct reporting is happening.
The PS will consult with the RD within the required timeframe before entering incidents into EIM. If necessary, the RD will consult with the Director of Training and Compliance and CEO for additional guidance. The incidents were recategorized in EIM and investigations occurred. The outcomes denote the staff requires additional training on incident management. The RD and/or Director of Training will conduct a training on Friday, November 10, 2023, for the York region staff in Incident Management to review how to identify and report abuse, neglect, and exploitation.
RE: Health information- On October 24, 2023, the RPD contacted Individual #1's primary care physician, who wrote a letter confirming the allergies were incorrectly noted. Individual #1 does not have an allergy to latex or adhesive. The letter was uploaded to ODP on October 26, 2023. The March 2023 assessment will be amended to incorporate Individual #1's supervision care needs by November 15, 2023. Individual #1 can communicate pain symptoms, as noted in the statement about what occurred on 9/28/23, and on the MARs when the PRN Acetaminophen is given after Individual #1 complains of pain. |
12/08/2023
| Implemented |
| 6400.32(c) | -Individual #1 had multiple medical diagnoses in 2022 and 2023. Despite these conditions and recommendations for therapy and safety assessments, AIMED agency failed to provide basic health care, dietary, ambulation, hygiene, supervision, incontinence care, emergency information, and medication management over the past year. These failures create an environment prone to neglect and mistreatment, with potential harm to Individual #1. The following failures were discovered during the 10/18/23 inspection: Diet On 3/16/23, Staff #1 assessed the individual, finding a need for moderate eating assistance, soft food to prevent choking, and continuous supervision during meals. However, the home lacked medical dietary guidance until 3/22/23, with no clear record of when the eating difficulty was recognized. On 3/22/23, a speech language pathologist evaluated Individual #1, recommending an IDDSI level 6 diet with thin liquids due to cognitive deficits. The protocol involved full meal supervision, alternating solids and liquids, small bites/sips, and post-meal oral care. Medications were to be administered with liquid and puree. Meat preparation was specified at IDDSI level 5, minced and moist with supervision. Dietary records weren't fully updated to reflect these changes. The agency established a choking protocol on 4/11/23 but failed to align it with the 3/22/23 swallow evaluation. This protocol wasn't communicated to the primary care physician. Consequently, on 8/17/23, the home served the individual food inconsistent with the prescribed diet, leading to choking, necessitating EMT intervention, and a hospital evaluation was neglected. The 4/11/23 choking plan outlined post-choking incident procedures, including documentation. However, on 10/18/23, the home didn't follow these guidelines, and staff #1 was unaware of internal incident reports. On 9/15/23, Individual #1 received a fluoroscopy video swallow study, suggesting a potential shift to an IDDSI level 5 diet due to cognitive decline. The home acknowledged this decline but didn't clarify the appropriate diet level, leading to uncertainty. Ambulation · On 2/22/23, a bedside commode was purchased for Individual #1 before the 3/13/23 Advocacy Alliance's recommendation for a physical therapy assessment. There's no documentation that a medical professional ordered the specific commode available during the 10/19/23 inspection. On 3/16/23, Staff #1 assessed that Individual #1 needs maximum assistance with bathing and meal preparation, moderate assistance with toileting and dressing, and relies on a walker. They have mobility issues and struggle with stairs. On 3/13/23, a nurse from the Advocacy Alliance completed a fall risk report for Individual #1, identifying 23 risk factors and providing recommendations. The home only addressed the use of a shower chair and slip-proof mat, obtained physical therapy, and had slip-proof socks available. Individual #1 fell on 7/10/23 without wearing slip-proof socks. On 4/11/23, an occupational therapist recommended adaptive equipment including a long-handled shoehorn, toileting aids, and a home assessment. During an inspection on 10/19/23, the recommended raised toilet seat and handles were missing. On 9/25/23, Individual #1 had an accident using a bedside commode. No professional assessment of the commode was made, and no alternative equipment was sought. From 3/22/23 to 5/25/23, therapists provided home exercise recommendations, but staff failed to document compliance or refusals. They only started documenting after therapy ended. Staff reported holding onto the individual's clothing to assist with steps, which is not safe. The home lacks an accessible entrance for the individual's rollator walker. Incident ID 9233825 on 6/16/23 reported a fall without adaptive equipment or a safety plan. The incident was discovered late, and urgent care evaluation was delayed. Incident ID 9245180 on 7/10/23 involved another fall due to lack of proper footwear. EMTs applied a Band-Aid without considering allergies, and there's no record of the individual being cleaned after the incident. On 7/11/23, the physician suggested a sensor pad, but the home failed to follow up, and one was never purchased. Another fall occurred on 7/30/23 during ambulation without staff assistance. Hygiene/incontinence · On 1/18/23, Individual #1's physician noted increased incontinence issues, but staff didn't seek medical help. The physician ordered tests and adult briefs, but they weren't provided until 2/7/23. No records show assistance with briefs. In July 2023, the physician recommended pads, but no records indicate their use. On 1/18/23, the physician also advised oral care, but no dentist visit occurred in 2022 or 2023. Medications were administered for skin issues, but follow-up was lacking. New skin concerns were documented on 8/29/23 and 9/19/23, but the physician wasn't contacted. Skin condition details weren't recorded. The home failed to encourage standing and walking, lacked a cushion, and delayed using recommended skin products. During a 10/18/23 inspection, poor monitoring of hygiene was revealed, and records showed inconsistencies in shower assistance. On 9/28/23, pain and ongoing rashes were not reported. On 10/19/23, staff neglected to provide care as ordered. Supervision Individual #1's assessments on 12/18/22 and 3/16/23 did not include supervision levels, especially for ambulation support. Despite documented falls and ambulation concerns, the home didn't assess or increase supervision. There are no records of the individual's unsupervised time in the home during the 10/18/23 inspection. Medication management Individual #1 relies entirely on the agency for medication administration. The home's failures to properly administer, document, and investigate medication errors, as outlined in various sections of this report, indicate negligence and mistreatment. Additionally, per incident ID 9169874, the home lacked an as-needed medication for skin concerns for four months. Incident reporting The agency failed to properly report incident IDs 9233825, 9245180, 9266158, 9272097, and 9283908 to the Department under the correct incident category, neglect. The agency failed to investigate all incidents of neglect. Health information All failures outlined in 6400.144 of this report constitute mistreatment. The individual's allergies to latex and adhesives were initially reported but later clarified by the physician, stating the individual can use adhesives with caution. The home failed to include the individual's inability to communicate true symptoms of pain in their assessments on 12/18/22 and 3/16/23. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | Why: Individual #1 received several medical diagnoses in the last six months that weren't addressed in an orderly or timely manner. This regulation protects the person receiving services from harm.
Diet: During a ZOOM training on 3.24.23, Individual #1's dietary assessment results were reviewed with the staff, in addition to the International Dysphagia Diet Initiative (IDDSI) videos on how the food should be prepared.
The staff were informed that line-of-sight supervision was required while Individual #1 is eating. Confirmation of the staff gathering and training was uploaded to ODP on 10/26/23.
The choking protocol was reviewed and updated by the Individual's doctor and uploaded to ODP on 10/26/23.
The speech pathologist updated the diet to Level 5 minced and moist and the info was uploaded to ODP on 10/25/23. Internal incident reports are not the agency's process, and the statement was removed from the choking protocol. An updated choking protocol that includes the recent update for solids and liquid recommendations, and medication administration. The protocol also has been amended to read, "After calling 911, Contact the supervisor and follow the instructions given.
Document the incident in the Progress Notes and the Enterprise Incident Management System (EIM)."
Ambulation: The bedside commode was purchased as a proactive measure to protect Individual #1 from falling when they attempted to use the bathroom during the night. The commode is currently not in use while awaiting an order from a medical professional on a specific commode. The staff are completing 15-minute checks to ensure Individual #1 receives assistance to use the restroom when needed (see Awake/Sleep Tracking data).
-Individual #1 can and will often remove their slip-proof socks independently. To ensure their safety, the staff completes 15-minute safety checks to ensure they have them on and encourages the individual to wear them. Any refusals to wear the socks will be documented in Therap. Properly fitting shoes were recommended, and the sister purchased and delivered the shoes to the home. The recommendation for an alarm to alert staff when they are awake, and walking was delayed because of the mistake of understanding that such an item was restrictive and data collection would be needed. The sensor alarm and gait belt were purchased on 10/20/23 after the licensing inspectors clarified that the item is not restrictive because a medical professional recommended it. The recommendation to keep "important items on a bedside table, including water, tissues, phone to help prevent wandering at night" is implemented. Individual #1 will move the items from the bedside table to the dresser across the bedroom.
-The bedside commode was purchased as a proactive measure to protect Individual #1 from falling when she attempted to use the bathroom during the night. The commode is currently not in use while awaiting an order from a medical professional on a specific commode. The staff are completing 15-minute checks to ensure Individual #1 receives assistance to use the restroom when needed (see Awake/Sleep Tracking data). Individual #1 cannot use a shoehorn or the toileting aids. The attempts to use these
items and her subsequent failures should have been documented. The bedside commode was believed to suffice as a raised toilet seat. A raised toilet seat was purchased on 10/25, and the staff were reminded to supervise Individual #1 while she uses the toilet and ask her to wait for help before getting up when she's done. The home assessment was scheduled per the medical provider's availability and completed in May, and the results were provided in June 2023.
RE: From 3/22/23 to 5/25/23- On 5/17/23, the RD reminded the Residential Supervisor and Program Specialist with the therapist's recommendations and YouTube videos to show the staff.
SEATED MARCH: https://www.youtube.com/watch?v=xxf93bq9-vA
SEATED LONG ARC QUAD: https://www.youtube.com/watch?v=MVDRCyVqekA
SEATED HIP ADDUCTION ISOMETRICS WITH BALL https://www.youtube.com/watch?v=muBqkAeu8WE
The exercises were not documented until recently (see attached). Staff reported holding onto the individual's clothing to assist with steps, which is not safe. The home lacks an accessible entrance for the individual's rollator walker.
The home is not equipped with a ramp to make entering and exiting easier. This was not an issue at admission but Individual #1 has gotten progressively worse.
Incident ID 9233825: Individual #1 was taken to urgent care after the incident was discovered and reported. Individual #1 only owns the recommended shoes; they are Velcro closures that fit snugly on her feet. Incident ID 9245180: Individual #1 only owns the recommended shoes; they are Velcro closures that fit snugly on her feet. The AIMED staff aren't responsible for the actions of EMTs. On October 24, 2023, the RD contacted Individual #1's primary care physician, who wrote a letter confirming the allergies were incorrectly noted. Documenting cleaning the Individual #1 was not required.
RE: 7/11/23 The sensor alarm and gait belt were purchased on 10/20/23 (see attached) after the licensing inspectors clarified that the item is not restrictive because a medical professional recommended it. The Fox Rehab agency will contact the RPD to schedule the gait belt training in the home.
RE: 7/30/23 The sensor alarm and gait belt were purchased on 10/20/23 (see attached) after the licensing inspectors clarified that the item was not restrictive because a medical professional recommended it. The staff are completing 15-minute checks to ensure Individual #1 receives assistance to use the restroom when needed (see Awake/Sleep Tracking data).
RE: 1/18/23 Hygiene/incontinence The delay in providing protective undergarments in January 2022 is unexplainable. The current staff has ensured the provision of protective undergarments since February 2023. There is no doctor's order to document the use and assistance provided to Individual #1 while wearing the protective pads.
RE: 1/18/23 Oral care: Individual #1 is edentulous, and the staff mistakenly believed a dental appointment wasn't necessary. Individual #1 had a dental exam on 10/19/2023. The dentist's instructions include swishing the mouth with warm water at night and using the "Toothettes." The dental hygiene plan also states that "the individual is capable of brushing his/her teeth/dentures independently" and recommends an annual dental checkup. The checkup is scheduled for 10/17/2024.
RE: 1/18/23 Skin issues: Individual #1's PCP was contacted about skin issues in July 2023 (see attached communication from the WellSpan portal). No regulation states the requirement to document encouragement to stand and walk. The recommended skin products are administered per the doctor's orders per the MARs. Information about the cushion (recommended by the PCP on 9/20/23) was provided to the PS on September 21, 2023. The cushion was finally purchased on 10/31/23. RE: 10/18/23 Before 10/18/23, a regulation or health professional didn't order or require hygiene monitoring. As of 10/24/23, Individual #1's showers are tracked via a form to indicate if she showered or refused and why. Ongoing issues are reported to the Residential Supervisor and followed up by the Program Specialist. RE: 10/18/23 Before 10/18/23, a regulation or health professional didn't order or require hygiene monitoring. As of 10/24/23, Individual #1's showers are tracked via a form to indicate if she showered or refused and why. Individual #1 has chronic skin issues that are addressed by the current medication orders. On 9/28/23, the staff addressed her pain and ongoing rashes by helping Individual #1 shower and applied the prescribed skin treatments, including Gold Bond Powder, Desitin, Betamethasone 0.05 % cream, and Eucerin calming cream.
RE: Supervision: The March 2023 assessment will be amend |
12/08/2023
| Implemented |
| 6400.34(a) | Individual #1 started receiving services from the agency, AIMED, on 9/20/22. At the time of the 10/18/23 inspection, the agency has not informed the individual of their regulatory rights defined in Pa Code 55 Chapter 6400.31-33, or the process to report a rights violation. Individual #1 obtained a Power of Attorney (POA) which was their family member on 1/20/23. The signed statement of review of individual's rights with the individual's POA on 9/20/23, is only a signed statement that individuals rights defined in 6400.32(r)-32(u) were reviewed with them. Individual #1's POA was not informed of all Individual #1's regulatory rights defined in Pa Code 55 Chapter 6400.31 and 33, on 9/20/22 or 9/20/23. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Why: Although not properly documented, Individual #1's sister signed the forms in the presence of Individual #1, and the Rights were explained to the individual.
The regulation ensures that people understand their rights and decision-making choices. The participant's mother was the legal guardian. Individual #1's mother passed away and the sister became the primary family support. During the admission, the participant's mother signed all documentation and during admission, both Mom and participants were given documentation and explained the rights.
The PS will be sure to obtain the Individual's signature after explaining the Rights. The admission forms will, again, be presented to Individual #1 for signature attainment by November 10, 2023. |
12/08/2023
| Implemented |
| 6400.51(b)(5) | -Individual #1 is ordered the use of a continuous positive airway pressure machine nightly, uses a rollator walker daily, was ordered various dietary instructions for their dysphagia and choking concerns over the previous year. They received physical therapy, occupational therapy, and modifications to the home. It was recommended the individual obtain a fall risk assessment to assess the individual's safety in and around the home. Individual #1 was ordered a pressure sensor to notify staff when the individual gets up from a seated position, and a seat cushion to use to prevent pressure sores. Individual #1 received changing dietary guidelines on 3/22/23, 4/11/23, and 9/15/23. Individual #1 experienced an episode of choking in their home and numerous falls or unwitnessed falls over the previous year.
On 3/16/23 the agency assessed Individual #1 to require full assistance with personal care and daily living skills.
Individual #1 has a 4/11/23 choking protocol, individual support plan, agency assessment, and a 3/13/23 Advocacy Alliance fall data collection report.
During the 10/18/23 inspection, the home couldn't provide in-person orientation training for staff working with Individual #1 on their plans, health status, physician's recommendations, and dietary changes. A sign-in sheet from 4/12/23 to 9/20/23 indicated that staff had read and understood Individual #1's choking protocol, but there were no records of the training details or trainer. An agency meeting agenda mentioned a virtual meeting on 4/12/23, but staff signed the choking protocol record months later.
On 10/26/23, after the conclusion of the inspection, the agency produced an email reminder sent to staff on 3/24/23 reminding them of dietary training that is to occur at 5pm on 3/24/23. Records of the trainer who conducted the training, attendees, content, and length of training was never produced.
During the inspection, a signature sheet for "Individual #1's Fall Risk Assessment training" indicated staff affirmed they had read and understood the recommendations, but there were no records of the trainer or content provided. The agency couldn't produce a Fall Risk Assessment. After the inspection, the agency provided meeting agendas for Zoom meetings on 4/6/23 and 7/7/23 about "HCQU Fall Risk Assessment," but no trainer or attendance records were available, and no HCQU Fall Risk Assessment was produced. They also provided a training sign-in sheet for "Individual #1's Fall Risk Protocol" without trainer details, content, or a HCQU Fall Risk Data Collection Report. Some staff didn't read the fall data collection report until later dates. | The orientation must encompass the following areas: Job-related knowledge and skills. | Why: Staff are trained on daily responsibilities and the ISP prior to working with the individual, as documented in the HR/training file. AIMED does not have clarity on why this was a violation.
This regulation ensures the staff understand the best practices and laws related to caring for people with IDD or autism.
POC: Advocacy Alliance provided Hypoxia/Sleep Apnea/CPAP training in February 2023. The sensor alarm and cushion were purchased on 10/20/23. The staff certificates were uploaded to ODP on 10/26/23. During a ZOOM training on 3.24.23, Individual #1's dietary assessment results were reviewed with the staff, in addition to the International Dysphagia Diet Standardization Initiative (IDDSI)videos on how the food should be prepared.
https://www.youtube.com/watch?v=piC6Uuua97A https://www.youtube.com/watch?v=9e9AN6LkX_U
The staff were informed that line-of-sight supervision was required while Individual #1 is eating. Confirmation of the staff gathering and training was uploaded to ODP on 10/26/23.
The choking protocol was reviewed and updated by the Individual's doctor and uploaded to ODP on 10/26/23. The speech pathologist updated the diet to Level 5 minced and moist and the info was uploaded to ODP on 10/25/23. Internal incident reports are not the agency's process and the statement was removed from the choking protocol. An updated choking protocol that includes the recent update for solids and liquid recommendations, and medication administration. The protocol also has been amended to read, "After calling 911, Contact the supervisor and follow the instructions given. Document the incident in the Progress Notes and the Enterprise Incident Management System (EIM)."
RE: 10/19/23 comment- The Program Specialist provides the training on recommendations from a health professional. The PS reviewed the choking protocol with the staff and ensured they watched the IDDSI videos. Future training sessions will be completed during in-person lunch and learn or zoom. The training will be documented using a sign-in form and maintained in the individual's chart. |
12/08/2023
| Implemented |
| 6400.163(h) | The medication disposal form for Individual #1 showed that on 8/4/23, Staff #1 and #2 disposed of 3 "stress form tabs" by either flushing or placing them in the garbage. The dosage was not recorded, and neither disposal method complies with Federal and State regulations. On 10/18/23, Staff #1 reported that they did not dispose of the medication in that manner, but the agency CEO could not provide any records of proper medication disposal. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | This regulation is important because it prevents potential adverse reactions to expired or discontinued medications and decreases the likelihood of medication theft or misuse. The CEO updated the medication disposal form on 10/18/2023 and uploaded the form to ODP on 10/26/23, and the RD ensured the form was distributed to the homes. |
11/30/2023
| Implemented |
| 6400.165(c) | In January 2023, Individual #1's physician prescribed Levothyroxine to be taken at 7am, but staff administered it at 8am. They also made medication errors in administering Nitrofurantoin, Fluconazole, Polytrim B-Tmp eye drops, Cephalexin, Eucerin calming crème, Calcium-mag-zinc-vit D supplement, methylprednisolone, Hydroxyz HCL, and SSDI cream. Multiple instances of double doses, missed doses, and incorrect timings were noted, as well as confusion in medication administration. | A prescription medication shall be administered as prescribed. | Why: This regulation prevents medication errors and injury.
POC: On Tuesday, October 30, 2023, the RS staff began taking pictures of the MARs (front and back) and then sending them (via email) to the RPD and PS daily, after reviewing them first.
The RPD will instruct the PS to enter med errors within 72 hours of the error. Any staff making repeated, continuous med admin errors will be referred to the agency Medication Trainer for medication administration remediation classes and will not be allowed to administer meds until the class is completed and passed. |
12/08/2023
| Implemented |
| 6400.166(a)(12) | Individual #1's record contained a medication administration record (mar) that documented the following medications were administered: Methylprednisolone, Fluconazole, Nystatin-triamcinolone cream, and Betamethasone cream. The month and year of administration was not recorded on the mar. | 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. | This regulation is important because it ensures the staff understand the medication order. On Tuesday, October 30, 2023, the RS staff began taking pictures of the MARs (front and back) and then sending them (via email) to the RPD and PS daily, after reviewing them first. The RPD will instruct the PS to enter med errors within 72 hours of the error. Any staff making repeated, continuous med admin errors will be referred to the agency Medication Trainer for medication administration remediation classes and will not be allowed to administer meds until the class is completed and passed. |
11/30/2023
| Implemented |
| 6400.166(b) | REPEAT from 10/17/22 annual inspection: Staff failed to sign, initial, date, and time stamp Individual #1's medication administration records (MARS) immediately after administering medications on various occasions, leading to documentation errors and omissions. These instances include the omission of medication documentation on specific dates, missing staff names on entries, and instances where staff's initials were not linked to the medication administered. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | This regulation prevents errors and protects the individuals.The staff rushed the administration process, which resulted in documentation errors. On Tuesday, October 30, 2023, the RS staff began taking pictures of the MARs (front and back) and then sending them (via email) to the RD and PS daily, after reviewing them first. The RD will instruct the PS to enter med errors within 72 hours of the error. Any staff making repeated, continuous med admin errors will be referred to the agency Medication Trainer for medication administration remediation classes and will not be allowed to administer meds until the class is completed and passed. |
11/30/2023
| Implemented |
| 6400.167(a)(1) | REPEAT from 10/17/22 annual inspection: At the time of the 10/18/23 inspection, Individual #1 was never administered the following prescribed medications, as record of the administration was left blank their medication administration records (mars) without documentation of what occurred: · On 8/17/23 she was prescribed fluconazole 200mg once daily for 7 days due to candidiasis of skin. She was only administered this for 6 days: 8/19/23-8/24/23. · 8/21/23 nystatin cream to abdominal folds and groin · Destin apply to groin daily blank crossed off as not administered 8/31/23. · Nyamyc powder 8pm on 9/10/23 · L is recorded on December 2022 mars without explanation for the letter or documentation that the individual received their daily medications on those days. · Famotidine 20mg at 8am on 12/21/22. · 8pm dose of quetiapine 200mg and toothettes for gum cleaning on 12/31/22. · Erythromycin opth ointment 8pm on 12/30/22 · Fluconazole 8pm on 2/23/23 not given as it "wasn't available in the home." · 11/5/22 Calcium-mag-vit D tablet 8am administration wasn't given. Staff documented they signed as administering in error, but there's no record of the individual receiving the prescribed supplement. · 11/15/22 9pm polymyxin eye drops and 11/15/22 8pm quetiapine 200mg, refresh optive advanced eye drops, and toothettes. | Medication errors include the following: Failure to administer a medication. | -This regulation ensures the proper handling of med errors. On Tuesday, October 30, 2023, the RS staff began taking pictures of the MARs (front and back) and then sending them (via email) to the RD and PS daily, after reviewing them first. The RD will instruct the PS to enter med errors within 72 hours of the error. Any staff making repeated, continuous med admin errors will be referred to the agency Medication Trainer for medication administration remediation classes and will not be allowed to administer. |
11/30/2023
| Implemented |
| 6400.167(b) | REPEAT from 10/17/22 annual inspection: The medication errors described in this report, were not documented, follow up action wasn't taken, and the prescriber's response wasn't sought. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | It is important to a medication error and to monitor the individual for any adverse reactions. On Tuesday, October 30, 2023, the RS staff began taking pictures of the MARs (front and back) and then sending them (via email) to the RD and PS daily, after reviewing them first. The RD will instruct the PS to enter med errors within 72 hours of the error. Any staff making repeated, continuous med admin errors will be referred to the agency Medication Trainer for medication administration remediation classes and will not be allowed to administer meds until the class is completed and passed. |
11/30/2023
| Implemented |
| 6400.167(c) | The medication errors described in this report weren't reported to the Department as an incident specified in 6400.18(b). | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | This regulation ensures med errors are managed appropriately to prevent injury because of an error The PS will enter the medication errors into EIM by November 12, 2023. |
11/30/2023
| Implemented |
| 6400.181(f) | There are no records that Individual #1's 12/18/22 or 3/16/23 assessments were provided to the individual and their individual support plan team members. There are no records for disbursement of their 12/18/22 assessment. On 3/17/23 Staff #1 included an email that Individual #1's assessment was sent to team members, but the attached assessment was a "2020 assessment." There are no records that a lifetime medical history was ever sent to team members for either 2022 or 2023 assessment. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | This regulation is important because it guarantees prompt completion of the assessment and team notification. The March 2023 assessments were provided to the team and a copy of the email verifying the distribution was in Individual #1's binder, directly behind the assessment. The attachment contained the wrong title, but the correct assessment and lifetime medical history (3/2023) were sent on time. The RD will provide the PS with a refresher training on November 17, 2023. |
11/30/2023
| Implemented |
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