| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | On 6/25/22 staff documented that Individual #1 was upset, Staff person #4 told the individual to calm down, took the individual's personal phone and tablet, and only gave the items back when Individual #1 asked for them nicely. The individual continued to escalate after this interaction with staff by attempting to jump off the back deck, and eventually stated a suicidal ideation and jumped off the back deck of the home on 6/25/22. Taking away individual #1's personal items from them is not a part of a restrictive plan or mitigation strategy to help the individual de-escalate.
Emmaus home reported to the Department via an incident report, on 6/25/22 at approximately 7pm Individual #1 became aggressive towards Staff person #4 with no clear antecedent. Individual #1 expressed suicidal ideations, stated a clear plan, the individual attempted to jump off the side deck of their residence multiple times and succeeded once, after continual efforts from Staff person #4 to prevent the individual from doing so. The home reported the individual fell approximately 10 feet from the deck and continued to attempt to jump off the deck after the fall. The home reported that Staff person #4 contacted Staff person #5 for support to which they arrived at the home shortly after being contacted. Staff person #5 then contacted an ambulance after arriving to the residence and Individual #1 was taken to the York hospital via ambulance for medical evaluation. The agency provided contradictory information to the Department via the incident report by also indicating Individual #1's housemate, not agency staff, was the point person who contacted agency management staff to notify them that Individual #1 had jumped off the back deck. The incident management section of the incident report requests that the agency clarify and provide information about supports the individual currently has in place. At the time of the 8/8/22 inspection, the agency has not provided the Department with information of supports that are in place for the individual.
Staff have documented from June 2022 to August 2022 that Individual #1 continues to use objects in the home to throw when upset, breaking the objects and windows and glass within the home multiple times. Staff person #1 reported that Individual #1 has a suicide safety plan to assist with these behaviors. Staff person #1 didn't produce documentation that all staff working in the home with Individual #1 were trained on Individual #1's suicide safety plan.
The suicide safety plan reportedly created 6/27/22, states that when Individual #1 is displaying property destruction, aggression, crying/yelling, pain, communication difficulties and communicating suicidal ideations/plan, the staff are to remove and secure any hazardous items within reach, remain within arm's reach of the individual and alert the warning signs to the supervisor and program specialist. Staff documented the following incidents and there is no documentation of attempts to notify the supervisor and program specialist, remove hazardous items within reach, and remain within arm's reach of the individual for every incident.
· On 6/30/22 the individual threw various items throughout the home, from the front porch to the back deck, including items they were wearing, broke windows, slammed doors, reported stomach pain, was aggressive towards staff, and yelling in the home and up and down the sidewalks in the neighborhood. The incident lasted a minimum of 1 and a half hours.
· On 7/13/22 the individual was throwing objects in their bedroom and reported to Staff person #4 they were upset because Staff person #4 was at the home.
· On 7/22/22 Individual #1 was yelling and swearing at staff. Staff left the individual unsupervised at home for approximately one hour after this event. Staff noted that when they arrived back home, the phone in the home was broken and the individual reported they threw it against the wall.
During the 8/11/22 inspection of the home, the back deck railing appears to be more than 10 feet from the railing to ground level. Additionally, the deck does hang over a solid stone wall and stone patio. The individual's individual support plan (isp) still states they can be left home alone for up to 3 hours, even after the team is aware of the 6/25/22 attempted suicide at the home. The agency created an assessment on 8/6/22 that still states Individual #1 can have up to 2 hours alone time at the home. The agency does not have a behavior support plan or SEEN plan that addresses the individual's suicidal attempt on 6/25/22, interventions and/or methods to prevent this from occurring again. Not providing Individual #1 with behavior supports, not re-assessing the individual's supervision levels, not implementing the suicide safety plan as outlined, failing to train staff on the individual's suicide safety plan, and continuing to allow the individual unsupervised access to the location where they attempted suicide creates conditions conducive to further harm which is neglectful to individual #1's health and safety. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | Immediately following the on-site inspection on 8/11/22, staff person #4 was removed from the schedule and a Rights Violation was entered into the EIM. The Incident was investigated by a Certified Investigator and the Rights Violation was confirmed. For corrective action, during Staff Person #4's leave of absence, the following trainings were assigned and completed: Doc #27 Crisis Intervention Training, Doc #28 PS Documentation Training, Document #30 Guidelines for effective Documentation Document #31 ID Crisis Interventions, Document #32 Individual Rights, Document #33 IDD Mental Health Conditions, Document #34 Restricting Rights, and Document #35 Suicide Prevention.
Following the on-site inspection, the Program Specialist implemented a new behavior tracking form (document #37) and Incident Reporting form (document #36) to ensure proper reporting guidelines within the Organization and to outside Entities. All location's staff were trained on documenting on the Trackers (document #41).
On 8/16/22, the Program Specialist updated Individual #1's SEEN, which includes Individual #1 suicidal history, and all staff were trained on Individual #1 updated SEEN & Suicide Safety Plan (Document #1, Document #6)
The Incident Report entered on 6/25/2022 has been extended to ensure appropriate corrective action, EIM documentation, and follow up. |
10/07/2022
| Implemented |
| 6400.22(d)(2) | Individual #1 requires assistance to manage their finances; assistance is needed for all transactions and deposits made to or for the individual. The facility reported that Individual #1 has a debit card and can use cash to make purchases monthly. The facility staff do not have access to the debit card funds, even though they are responsible for assistance with purchases made using the debit card. The facility only has an up-to-date record of the funds in this account once or twice a month when Individual #1's mother provides this information to the facility.
During the 8/10/22 onsite visit to the home, there were no records of the current amount in Individual #1's debit card account.
Individual #1's December 2021 cash financial record ended on 12/21/21 with a balance of $22.43. The individual's January 2022 cash record had a starting balance of $33.67 with no records or receipts of the deposits and/or withdrawals that occurred between the dates.
An entry on Individual #1's 2/23/22 financial cash record states $6.87 of "excess funds" was added into the account with no explanation of what occurred, or where the excess funds originated from.
Individual #1's ending balance for February 2022 cash record was $50.30 on 2/23/22. The starting balance in March 2022 was $29.85. There are no records or receipts of the deposits and/or withdrawals that occurred between the dates.
Individual #1's ending balance for their March cash record was recorded as $31.81 on 3/13/22. Their April 2022 starting balance was recorded as $31.56. There are no records or receipts of the deposits and/or withdrawals that occurred between the dates.
Individual #1's April 2022 cash record documented the individual had $26.03 cash on hand on 4/28/22. The individual's May 2022 cash record said "no money spent." The agency did not produce any cash on hand records for Individual #1 after April 2022. On 8/10/22 the home reported there was no cash in the home that belonged to Individual #1. | (2) Disbursements made to or for the individual.
| On 8/16/22, Individual #1 staff received re-training on proper documentation for the Individual, including expense/ledger records (document #6) and the Individual #1 received and was supported in reviewing/signing the updated Individual Rights policy/consent, informing her of her rights to be supported in managing her finances (document #3). |
08/29/2022
| Implemented |
| 6400.101 | Individual #2's bedroom door did not open completely during the 8/11/22 inspection of the home. There was a standing, coat rack behind the door, preventing it from opening completely. The door opened approximately to a 45 degree angle. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Immediately following the on-site Inspection, Administrators relocated the Individuals coat rack (picture #1) to a location of the Individual's choosing and one that would not compromise an entrance/exit pathway. |
09/29/2022
| Implemented |
| 6400.103 | The home provided two different, written evacuation procedures for the home. One procedure doesn't include individual's responsibilities, the other does. The records for individual fire safety training state the curriculum is to review the written evacuation procedure. However, there are two, both containing different information. During the 8/8/22 inspection, the home was unaware that they had two different, written procedure plans, that one plan did not contain all regulatory requirements, or which plan(s) were included and used for fire safety training. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The non-compliant evacuation plan was removed from the home on 8/8/22. The compliant evacuation plan (document #13) originally posted contained all regulatory requirements. Individuals' responsibilities were confirmed to be listed on the plan. Staff were informed that the correct evacuation plan has been posted. |
08/08/2022
| Implemented |
| 6400.104 | At the time of the 8/8/22 inspection the home is comprised of 3 adults, that according to the fire drills held throughout the year, require physical and verbal assistance to evacuate the home in the event of a fire. The dates of admission to the home for the individuals are as follows: Individual #3 10/7/21, Individual #1 11/12/21, and Individual #2 3/19/22. The home notified the local fire department on 10/1/21 but did not include the number of individuals residing in the home, the locations of their bedrooms, or that they require physical assistance to evacuate the home. | 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.
| Due to individual#1 needing staff assistance in the overnight (sleep) evacuations, Fire Department was notified of the need of the individual in the home on 9/21/22. |
10/15/2022
| Implemented |
| 6400.110(f) | According to multiple fire drill records, Individual #1 is unable to hear the smoke detectors/fire alarms in the home. On 12/23/21 staff record that they had to tell Individual #1 the fire alarm was activated as Individual #1 didn't have their hearing aid in. On 5/5/22 staff recorded they assisted Individual #1 out of bed for the fire drill. On 7/29/22 staff recorded they had to wake Individual #1 up for the fire drill as they weren't notified by the smoke detector or alarms in the home. The home is only equipped with 2 strobe lights- Individual #1's bedroom and the living room in the home. All other locations of the home accessible to Individual #1 are not equipped with strobe lights: garage, kitchen, sunroom, basement, bathroom, and stairwell. Additionally, the strobe lights in Individual #1's bedroom did not work to alert Individual #1 of the need to evacuate the home on more than one occasion. During the 8/10/22 inspection of the home, it was confirmed that Individual #1 did not have or wear a personal body device nor did they have a bed shaker installed in their bedroom. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | Individual #1 team meeting held on 8/23/22 discussed the individual's level of need in terms of evacuation. Team is in agreement to include additional resources to assist individuals in awaking during the night hours. Bed shaker was identified to be used. Ordering of bed shaker and installation shall be completed by 10/1/22. |
10/15/2022
| Implemented |
| 6400.112(c) | According to the 7/23/22 fire drill record, the time the drill was held was not recorded. The record stated, "5:40" but did not include AM or PM to indicate the time of day.
According to the monthly fire drill records from October 2021 to May 2022, staff only indicated that 2 smoke detectors were operative in the home during the drill. Staff then recorded on the fire drill records from June 2022 to July 2022 that 3 smoke detectors in the home were operative during the drill. Staff documented as activating smoke detectors titled, first floor, living room, upstairs hallway, and upstairs for the fire drills. There are no records that all smoke detectors were operative during the fire drills. The home is equipped with 6 smoke detectors. The home never indicated that the smoke detectors were all operative during the time of the drill. | 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. | Emmaus Home implemented a new fire drill form to ensure the time is accurately documented on the fire drill. Staff were trained and a new fire drill form was implemented on 8/29/22. See training document # 8. |
10/01/2022
| Implemented |
| 6400.112(d) | According to the fire drill records, there were many fire drills where individuals did not evacuate the home in 2 and ½ minutes. A successful fire drill was not held within the month to ensure the individuals could evacuate the home in 2 and ½ minutes. The following is when this occurred: 2/16/22 fire drill took 2 minutes and 55 seconds for evacuation, 4/20/22 fire drill took 3 minutes and 33 seconds for evacuation, 5/5/22 fire drill took 2 minutes and 55 seconds for evacuation, and the 7/29/22 fire drill took 3 minutes and 18 seconds for evacuation. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | On 8/16/22, administrative staff met with the Residential employees to discuss the Individuals ability to evacuate within 2 and 1/2 minutes. All residential staff reported over-recording the length of the drill time due to confusion with the Organizations' Fire Drill form. Residential employees were re-trained in accurate time-recording (document #8). |
08/29/2022
| Implemented |
| 6400.112(h) | According to the monthly fire drill records from October 2021 to July 2022, the records don't indicate if all individuals and participants evacuated to the meeting place during the fire drill. The records listed the meeting location as the "safe fire designated area" but didn't indicate if all participants met there. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | On 8/16/22, administrative staff met with the Residential employees to discuss the fire safe designated areas. All residential staff reported confusion with the Organizations' Fire Drill form. Residential employees were re-trained in accurate and appropriate documentation on the Organization's new Fire Drill Form (document #42, #8). |
08/29/2022
| Implemented |
| 6400.112(i) | The 6/23/22 fire drill record did not indicate if a smoke detector was activated during the drill. The field to indicate which detector was activated for the drill was left blank. The home is equipped with 6 smoke detectors and the record doesn't indicate that all 6 detectors were operative or activated | A fire alarm or smoke detector shall be set off during each fire drill. | Following the on-site inspection, a new Fire Drill form was implemented, and staff received training on appropriate documentation (document #8). The new Fire Drill form (document #42) includes sections & questions for staff to document the following: number of detectors, method of activating the alarm, location of smoke detector pull-station used, all smoke detectors/alarms activated question. |
09/22/2022
| Implemented |
| 6400.113(a) | Individual #1's date of admission to the home was 11/12/21 and fire safety training did not occur until 12/14/21. Additionally, there are no records that the fire safety training included general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. Their record states fire safety training was completed by Tri-State on 12/14/21 and "meets the requirements for 55 PA Code Chapter 6400."
Individual #3's date of admission to the home was 10/7/21. The fire safety training they received on 10/7/21 does not indicate any content that Individual #3 received during this training. The record states fire safety training was completed via a Zoom conference call on 10/7/21 and no other information was produced. Individual #3 did not receive fire safety training again until 12/14/21 by Tri-State. Again, the content they received during said training was not documented or produced.
Individual #2's date of admission to the home was 3/19/22. The agency produced a prepopulated document stating Individual #2 received "fire safety" training via zoom conference call on 2/1/22, prior to their admission to the home, and was unable to produce the content reviewed with the individual during this training. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | The Individuals were retrained on 8/16/22 (document #2, #8) in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place, smoking safety procedures, and the fire department notification. |
08/16/2022
| Implemented |
| 6400.141(c)(7) | The results of Individual #1's 2/1/21 gynecological examination was not included or reviewed by their primary care physician during the individual's 1/18/22 physical examination. The examination record to indicate the date and results of the examination were left blank and nothing was attached. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | The Organization hired and employed a new Program Specialist. The new Program Specialist updated the Individual's Lifetime Medical record to include gynecological exam results, and all other current medical information. The updated Life-time medical was uploaded to the Individual's portal and made available to the PCP. The House Supervisor has scheduled a PCP appointment with the Individual to ensure the PCP has received, reviewed, and documented the Life-Time medical and gynecologic exam. The PCP appointment has been scheduled for the first available appointment. |
10/25/2022
| Implemented |
| 6400.142(c) | Individual #1's 7/11/22 and 1/12/22 dental appointment records do not include the name of the dentist that completed the dental work. | A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. | New dental form created to ensure all required documentation (physician, work completed and follow up treatment required) implemented on 8/29/22. |
10/01/2022
| Implemented |
| 6400.142(h) | Individual #1's dental hygiene plan in their record created by Emmaus Home, on 10/5/21 prior to the individual receiving services, states the individual needs assistance but doesn't clarify the assistance. The dentist recommended the individual brush and floss twice daily on 4/7/22 and this isn't included in the dental hygiene plan. The individual's individual support plan (isp) includes a dental hygiene plan that their previous residential provider is working on with them and not applicable. The Emmaus Home dental hygiene plan doesn't include Individual #1's use of their retainer and the assistance needed to keep that clean. | The dental hygiene plan shall be kept in the individual's record. | New dental form created to ensure dental plan of care is completed by dentist with all required actions for dental care. New form implemented on 8/29/22. |
10/01/2022
| Implemented |
| 6400.144 | The agency, Emmaus Home, failed to provide Individual #1's health services on numerous occasions from August 2021 to current, August 2022. The follow are examples of the home's failures:
· On 1/24/22 Individual #1's physician recommended the individual to use baking soda mouth rinses 3 times daily and call the physician if there were any problems. The record of when the individual completed or refused the baking soda rinses was blank.
· On 3/21/22 Individual #1's physician ordered a PAP smear, HPV screening, and mammogram screening to be completed. Emmaus Home was unable to produce records that the individual received an HPV screening. Emmaus Home was unable to produce records that a mammogram screening was completed or needed after the 3/21/22 order; they provided a mammogram screening completed on 2/17/22, prior to the order on 3/21/22. Individual #1's results from their 3/24/22 PAP smear flagged the specimen for high grade squamous intraepithelial lesion. There were no records provided of additional follow up with Individual #1's physician.
· On 3/31/22 Individual #1's ENT (Ear, Nose, Throat specialist) recommended the individual contact OVR for new hearing aids. At the time of the 8/8/22 inspection, this was not completed.
· Individual #1 is prescribed Amoxicillin prior to dental appointments to prevent infections. Individual #1 had a dental appointment on 7/11/22 and Amoxicillin wasn't administered, nor was there an order from the prescriber to hold or discontinue the medication.
· According to Individual #1's medication administration record, they are prescribed Fiberlax daily for diarrhea. According to their agency assessment, Individual #1 is prescribed Fiberlax for constipation. The home has administered over-the-counter medication as needed to Individual #1 multiple times for stomach pain. | 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.
| Emmaus Home included a new medical service report on 8/29/22 (document #21) to ensure documentation and follow-ups, discharge of medications, and other physician orders are being documented. All MSRs are to be reviewed by admin, entered into a medical spreadsheet (document #44) to ensure follow-up is completed. Individual#1 is scheduled for PCP appt 10/12/2022, Gyno Exam 1/10/23 (First Available). New hearing aide was purchased by Individual#1 hearing aide in April 2022. Document #50 |
10/01/2022
| Implemented |
| 6400.181(a) | According to agency staff during the August 8th-11th, 2022 inspection, Individual #1's initial 1/11/22 assessment did not include an accurate assessment of the individuals needs and abilities at the time of completion. The following are examples of how the individual's assessment did not portray their accurate needs:
· The assessment states the individual is self-medicating, or able to administer their own medications without any staff assistance. Staff have had to assist the individual from November 2021 to current, August 2022, daily with all medication administrations. Individual #1 was never able to safely administer their medications independently.
· The assessment states the individual can evacuate the home in the event of an emergency, independently. According to records and staff recount, Individual #1 requires physical assistance from staff and adaptive equipment, along with occasional verbal and gestural assistance to evacuate the home.
· The assessment states the individual is independent with dental hygiene. However, they have dental hygiene plans in place due to the individual's inability to complete all aspects of dental hygiene independently.
· The assessment states the individual does not have to be evaluated for elopement risks, labeling this category as, "n/a" as not applicable. However, the individual's records detail the individual's previous and recent history of elopement.
· The assessment states the individual does not require supervision overnight but did require supervision support during the day. The individual does require supervision 24/7. The assessment also states the individual requires eye-sight supervision during the day, but the agency allowed the individual to be unsupervised at home for short periods of time. At the time of the 8/8/2022 inspection, the agency has not re-assessed the individual's supervision needs to reflect the individual's current needs.
· The assessment never included an assessment of the individual's previous medical history or their financial needs and abilities.
Additionally, Individual #1's needs changed throughout the year and an assessment of their current and changing needs was never completed to include the changes in needs, abilities, and services. The individual experienced a new cancer diagnosis in December 2021 that also brought about new treatments, challenges, and changing needs that was not included in the initial or any updated assessments. Staff documented that Individual #1 started experiencing behaviors that included property destruction, elopement, yelling, making threats towards staff and themselves, including an attempted suicide on 6/25/22. The individual's assessment was never updated to include this information, or the individuals needs when each situation arose.
The individual's current, 8/6/22 assessment still doesn't include an assessment of the individual's supervision needs after they attempted suicide at home on 6/25/22. Their current assessment also doesn't include the behaviors listed above they have exhibited in the home. The current assessment still doesn't include the individual's financial needs and abilities. | 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 former Program Specialist, responsible for accurate Assessment completion, has been terminated and replaced by a new, experienced, and qualified professional. Individual #1 Assessment (document #46) has been updated to include all current and applicable information. |
10/15/2022
| Implemented |
| 6400.211(b)(3) | Individual #1's record did not identify the specific name, address, and telephone number of the person able to give consent for emergency medical treatment. Their individual support plan, the only location in their record where this is identified, states the individual's family member will make health care decisions and also states the agency CEO designee/CFO/COO will make health care decisions on behalf of the Individual. The individual's record does not clarify who to contact and what order for medical decisions. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| Emmaus home face sheet has been updated to include Emergency information for each individual including the name, address and telephone as to who can give consent for medical treatment. Implemented 9/1/2022 |
10/01/2022
| Implemented |
| 6400.216(a) | Individuals #1-#3's personal records and identifying information was left unlocked and accessible on a table in the basement, on the television stand in the living room, and on shelves in the basement. | An individual's records shall be kept locked when unattended.
| Following the on-site Inspection, the home's Supervisor immediately secured Individual's records (picture #4) in the appropriate designated locking areas. On 8/18/22, staff were trained in securing and storing documentation. |
08/18/2022
| Implemented |
| 6400.18(a)(12) | The missing funds from Individual #1's financial account identified in 6400.22(d)(2) of this report summary, were never reported to the Department and the agency never initiated an investigation into the incidents. | 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:
Theft or misuse of individual funds. | The Organization entered a Rights Violation into the EIM on 9/28/2022 (document #49) and has assigned a CI. |
10/21/2022
| Implemented |
| 6400.32(i) | On 6/25/22 Staff person #4 documented that during an incident at the home, they took Individual #1's personal phone and tablet from them, told Individual #1 to calm down, and did not give Individual #1 their personal items back until Individual #1 asked nicely for them. This shows undignified treatment of Individual #1's right to their own personal belongings and possessions. | An individual has the right of access to and security of the individual's possessions. | Emmaus Home updated their Individual Rights Consent form. All staff in the home were retrained on individual rights in the home 8/23/22 and again on Relias by 8/30/22.
Immediately following the on-site inspection on 8/11/22, staff person #4 was removed from the schedule and a Rights Violation was entered into the EIM. The Incident was investigated by a Certified Investigator and the Rights Violation was confirmed. For corrective action, during Staff Person #4's leave of absence, the following trainings were assigned and completed: Doc #27 Crisis Intervention Training, Doc #28 PS Documentation Training, Document #30 Guidelines for effective Documentation Document #31 ID Crisis Interventions, Document #32 Individual Rights, Document #33 IDD Mental Health Conditions, Document #34 Restricting Rights, and Document #35 Suicide Prevention.
Following the on-site inspection, the Program Specialist implemented a new behavior tracking form (document #37) and Incident Reporting form (document #36) to ensure proper reporting guidelines within the Organization and to outside Entities. All location's staff were trained on documenting on the Trackers (document #41).
On 8/16/22, the Program Specialist updated Individual #1's SEEN, which includes Individual #1 suicidal history, and all staff were trained on Individual #1 updated SEEN & Suicide Safety Plan (Document #1, Document #6)
The Incident Report entered on 6/25/2022 has been extended to ensure appropriate corrective action, EIM documentation, and follow up. |
10/07/2022
| Implemented |
| 6400.32(r)(1) | According to Emmaus Home's individual rights, choices and services policy and procedure, all participants living in the home are allowed to lock their bedrooms and bathroom as they choose for personal privacy. During the 8/10/22 inspection of the home, Individual #1-#3's bedroom doors did not have a locking device that would allow the individuals to lock their bedroom door from the outside if they wished. The home staff reported they would use a pin lock device to lock the bedroom door, which does not meet regulation. Staff persons #2, #5 and #6 reported on 8/10/22 that they did not know what the individuals', or their legal guardians if applicable, wishes were regarding wanting a locking device on their bedroom door. The individuals' records did not include documentation of their wishes regarding a locking mechanism to their bedroom doors. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | Options to Lock consent form was created and reviewed with all individuals. Consents were signed as they were given to lock private areas including their bedroom, key(code) to the front door, and lock on the bathroom door. Forms were signed as of 8/16/22. |
10/01/2022
| Implemented |
| 6400.32(s) | According to Emmaus Home's, individual rights, choices and services policy and procedure, all participants living in the home are given a personal key or key code to their home. During the 8/10/22 inspection of the home, Individual #1-#3 doors did not have a locking/unlocking device that would allow the individuals access to an entry door of their home. Staff persons #2, #5 and #6 reported on 8/10/22 that they did not know what the individuals', or their legal guardians if applicable, wishes were regarding wanting a key or unlocking device to an entry door of their home. The individuals' records did not include documentation of their wishes regarding a locking mechanism to their home. | An individual has the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home. | Options to Lock consent form was created and reviewed with all individuals. Consents were signed as they were given to lock private areas including their bedroom, key(code) to the front door, and lock on the bathroom door. Forms were signed as of 8/16/22. |
10/01/2022
| Implemented |
| 6400.34(a) | Upon admission to the home, Individual #1 did not have their individual rights defined in 55 Pa. Code 55 Chapter 6400.32(a), (g), (j), (q), and (t) reviewed with them. The rights reviewed with the individual on 11/12/21 did not include a full review of their rights defined within 6400.31-33. | 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. | New individual rights form was created and implemented. Individual rights form was reviewed with individuals as of 8/16/22. Individual Rights consent will be completed annually hereafter. |
10/01/2022
| Implemented |
| 6400.46(a) | Staff person #3 started working with individuals on 10/7/21 but did not receive training in fire safety until 12/14/21. Additionally, there are no records that their 12/14/21 fire safety training included all training requirements of 6400.46(a). Their documentation was a certificate stating the training on 12/14/21 reviewed requirements of "55 PA Code Chapter 6400 (ODP)." Staff person #3 received fire safety training from Relias on 9/30/21 but there are no records that the training included all topics required in 6400.46(a). The documentation only stated fire safety training.
Staff person #2's 8/3/22 Relias fire safety training did not include training in evacuation procedures of the home, responsibilities during home fire drills/evacuation, the home's meeting place, smoking safety procedures, the use of smoke detectors and fire alarms, and notification of the local fire department. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Staff person #3 started working with individuals on 10/7/21 but did not receive training in fire safety until 12/14/21. Additionally, there are no records that their 12/14/21 fire safety training included all training requirements of 6400.46(a). Their documentation was a certificate stating the training on 12/14/21 reviewed requirements of "55 PA Code Chapter 6400 (ODP)." Staff person #3 received fire safety training from Relias on 9/30/21 but there are no records that the training included all topics required in 6400.46(a). The documentation only stated fire safety training.
Staff #3 received appropriate fire safety training upon orientation, prior to working with any individuals, through training partner Relias Learning Systems, in conjunction with on-site orientation trainings (document #46). Proof of training record was submitted post on-site inspection and not accepted by the Department.
Staff person #3 annual fire safety training curriculum, conducted by training partner Tri-State Training, sent to the Department as document #46
Staff person #2's 8/3/22 Relias fire safety training did not include training in evacuation procedures of the home, responsibilities during home fire drills/evacuation, the home's meeting place, smoking safety procedures, the use of smoke detectors and fire alarms, and notification of the local fire department. |
10/01/2022
| Implemented |
| 6400.51(b)(5) | Staff person #1 reported that Individual #1 has a suicide safety plan, reportedly created on 6/27/22. Staff person #1 never provided documentation that all staff working in the home with Individual #1 were trained on Individual #1's suicide safety plan prior to working with the individual after plan creation. | The orientation must encompass the following areas: Job-related knowledge and skills. | All staff were retrained on 8/16/22 on suicide plan and SEEP by the program specialist. Document#6 Staff will be trained annually and prior to working with Individual#1. Sign in sheet for training archived and HR entered training on staff training logs. |
10/01/2022
| Implemented |
| 6400.165(b) | Individual #1's Amoxicillin was dispensed from the pharmacy on 1/5/22 and 7/7/22 with the current orders to administer the medication 1 hour prior to appointments and continue to administer the medication every 6 hours for 2 days after the appointment.
Staff person #5 recorded a note on Individual #1's April 2022 medication administration record (mar) stating the individual's dentist reported the individual "didn't need to take the other capsule for 2 days at appointments." There are no records from the prescribing physician on this change of order. The current medication at the home stated to continue to take the medication for two days after the appointment. | A prescription order shall be kept current. | New medical service report implemented to include detailed comments of medication being added and discontinued. House Manager retrained on MAR documentation and physician orders. MARS training 8/16/22 & 9/15/22. New Medication Checklist is implemented to ensure all medications, dosages, and MAR is completed to its fullest. Implementation of Checklist 10.1.22. Checklist will be conducted monthly by the house manager and another time by designated staff as assigned throughout the month. |
10/01/2022
| Implemented |
| 6400.165(c) | The home failed to administer multiple medications to Individual #1, on multiple occasions, as prescribed by the individual's prescribing physicians. The following are examples of when this occurred:
· According to the current pharmacy-issued medication label, Individual #1 is ordered, Amoxicillin 500mg capsules, take 4 capsules 1 hour prior to appointment then administer 1 capsule every 6 hours for 2 days after. Per Emmaus Home, "appointment" refers to dental appointments. Two pill packets were located at the home: one dispensed from the pharmacy on 1/5/22 and the other on 7/7/22. Individual #1 had dental appointments on 1/12/22, 4/7/22, and 7/11/22. According to the pill packets and the individual's medication administration records (mars), only 4 Amoxicillin capsules were administered on 1/12/22 and 4/7/22. At no other time was this medication administered as ordered prior to and after dental appointments.
· Per Individual #1's mars, they are prescribed QC Bismuth tablets for diarrhea. Staff administered this medication 13 times in July 2022 for "stomach pain", with most of the results indicating the medication was ineffective.
· On 3/8/22 a nurse stated to give Individual #1 Tylenol by mouth, as needed, if stomach pain continues. Staff continued to administer QC Bismuth for stomach pain in July 2022.
· Individual #1's Hydrocortisone is to be applied 3 times daily. Individual #1's 2pm dose of Hydrocortisone was not administered on August 1st, 3rd-5th, 8th, and 10th of 2022. The mar states, "A" but does not provide a description of A, or document that the individual was absent from program for the day thus unable to receive 3 doses of the medication daily.
· Individual #1's Cephalexin was ordered to be administered 3 times daily. Mimicking Hydrocortisone above, the 2pm dose was not administered on August 1st, 3rd, and 5th 2022. Staff recorded "A" but did not provide a description of A, or document that the individual was absent from program for the day thus unable to receive 3 doses of the medication daily.
· Individual #1 missed their 8pm dose of Cephalexin on 8/3/22. There are no records of attempts to contact their medical professional to determine next steps.
· On 5/17/22 Individual #1's physician ordered Clindamycin 300mg, 3 times daily for a labia boil. According to the individual's May 2022 mar, Clindamycin 150mg was administered 3 times a day for 7 days. The home never contacted the individual's prescribing physician to report the incorrect milligram administration nor did the home attempt to obtain clarification between the two different milligram doses ordered and administered with the prescribing physician. | A prescription medication shall be administered as prescribed. | New medical service report implemented to include detailed comments of medication being added and discontinued.
New Medication Checklist (document #5) is implemented to ensure all medications, dosages, and MAR is completed to its fullest. Implementation of Checklist 10.1.22. Checklist will be conducted monthly by the house manager and another time by designated staff as assigned throughout the month.
Staff were trained (8/16/2022) on IM bulletin and what to do if a missed medication were to occur. Staff will write an incident report and missed medication will be filed in EIM. |
10/01/2022
| Implemented |
| 6400.166(a)(2) | Individual #1 has multiple physician's that have and/or are currently prescribing medications for them. However, Individual #1's November 2021 to current, August 2022, medication administration records only document one of the prescribing physicians. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | MAR is updated upon arrival to the home to ensure accuracy of the medications, diagnoses, and physicians. New Medication Checklist (document #9 & 4) is implemented to ensure all medications, dosages, and MAR is completed to its fullest. Implementation of Checklist 10.26.22. Checklist will be conducted monthly by the house manager and another time by designated staff as assigned throughout the month. |
10/01/2022
| Implemented |
| 6400.166(a)(10) | The time of administration for multiple medications administered to Individual #1, was not recorded. The following are examples of then the time of administration was never recorded:
· Acetaminophen on 1/12/22
· Benzonatate on 7/20/22 and 7/22/22
· QC Pink Bismuth on 7/4/22, 7/5/22, and 7/11/22
· Ibuprofen on 7/12/22 | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | Staff were retrained on MARS PRNs and documentation of the time for administration is required on 9/15/22 (document #9). New Medication Checklist is implemented to ensure all medications, dosages, and MAR is completed to its fullest. Implementation of Checklist 10.1.22. Checklist will be conducted monthly by the house manager and another time by designated staff as assigned throughout the month. |
10/01/2022
| Implemented |
| 6400.166(a)(11) | In August 2022, Individual #1 was prescribed Risperidone for agitation and upset and Trazadone for insomnia. Staff person #4 administered both medications, Risperidone and Trazadone, to Individual #1 on 8/8/22 at 8pm. However, they recorded Risperidone was administered on 8/8/22 for insomnia and Trazadone was administered for "upset."
The reason for prescribing Individual #1's medications is not included for every medication administered, including as needed medications, on every medication administration record (mar) for the individual. Examples of medications administered when the reason for prescribing the medication wasn't recorded is: Amoxicillin, Abreva, Debrox, Loratadine, Prednisone, Daily-vite tablet, Levothyroxine, Omeprazole, Oxcarbazepine, Hydrocortisone, Doxycycline Hyclate, Cephalexin, Clindamycin, and Polymyxin B/TMP eye drops. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Staff were retrained on MARS PRNs and documentation of the reason for administration is required to be accurate on 9/15/22 (document # 9). New Medication Checklist is implemented to ensure all medications, dosages, and MAR is completed to its fullest. Implementation of Checklist 10.1.22. Checklist will be conducted monthly by the house manager and another time by designated staff as assigned throughout the month. |
10/01/2022
| Implemented |
| 6400.166(b) | Staff person #7 documented they administered Amoxicillin to Individual #1 on 1/1/22. Staff person #7 then recorded on the back of the individual's medication administration record (mar), Amoxicillin was administered by Staff person #7 on 1/12/22. Staff person #7 did not attempt to document the actual date and time of administration on the back of the individual's mar until at least after 1/29/22. Staff person #7 recorded the clarifying information in the next line available on the back of Individual #1's mar, which was after the staff person above recorded a medication administration on 1/29/22.
Staff person #5 documented on the front of Individual #1's mar that they administered Amoxicillin to the individual on 4/1/22. Staff person #5 recorded on the back of the individual's mar the medication was administered on 4/7/22. However, Staff person #5 did not record the actual date and time of administration until after 4/29/22, as the information was recorded on a line after a staff made an entry for a medication administered on 4/29/22. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Staff were retrained on MARS PRNs and documentation of the time and reason for administration is required at the time of administration to ensure accuracy on 9/15/22 (document # 9). New Medication Checklist is implemented to ensure all medications, dosages, and MAR is completed to its fullest. Implementation of Checklist 10.1.22. Checklist will be conducted monthly by the house manager and another time by designated staff as assigned throughout the month. |
10/01/2022
| Implemented |
| 6400.167(b) | Staff recorded Individual #1 missed their 8pm dose of Cephalexin on 8/3/22. The home did not attempt to contact the individual's prescribing physician to determine next steps for medication management due to the missed dose. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | All staff were trained on medication administration on 9/15/2022. New Medication Checklist is implemented to ensure all medications, dosages, and MAR is completed to its fullest. Implementation of Checklist 10.1.22. Checklist will be conducted monthly by the house manager and another time by designated staff as assigned throughout the month to ensure medications are being given properly. When a medication is missed, physician will be documented immediately for further directions. Documentation of physician's conversation shall be documented and filed in the medical chart. |
10/01/2022
| Implemented |
| 6400.167(c) | Individual #1 missed a dose of Cephalexin on 8/3/22. The medication error was never reported to the Department as an incident nor was the incident investigated to determine cause of the missed dose.
All medication errors described in this report were never reported to the Department, or Individual #1's prescribing physicians, and subsequently investigated as required for Pa. Code 55 Chapter 6400.18. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | All staff were trained on medication administration on 9/15/2022. New Medication Checklist is implemented to ensure all medications, dosages, and MAR is completed to its fullest. Implementation of Checklist 10.1.22. Checklist will be conducted monthly by the house manager and another time by designated staff as assigned throughout the month to ensure medications are being given properly. |
10/01/2022
| Implemented |
| 6400.181(f) | There are no records that either Individual #1's initial, 1/11/22 assessment or 8/6/22, updated assessments were sent to the individual and all their plan team members. Individual #1 had a critical revision individual support plan meeting on 2/1/22 and an annual individual support plan team meeting on 5/3/22. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Assessments will be completed 30 days prior to ISP and sent to the SC & team members. Updated Assessments will be sent to SC and team member. Document #20 |
10/15/2022
| Implemented |
| 6400.183(a)(1) | A critical revision individual plan meeting was held for a revision of services for Individual #1 on 2/1/22. Individual #1 was not in attendance. There are no records of why they were not in attendance of the meeting. The record indicates Individual #1 was not informed of results of the meeting until 2/19/22. | The individual plan shall be developed by an interdisciplinary team, including the following: The individual. | The Individual was present for the 2/1/2022 via Zoom (document #51). |
09/28/2022
| Implemented |
| 6400.183(c) | A list of persons who attended and participated in Individual #1's 5/3/22 annual individual support plan meeting was never kept or produced during the 8/8/22 inspection. | The list of persons who participated in the individual plan meeting shall be kept. | Program Specialist has requested sign-in sheet multiple times from SCO (document # 19) Executive Assistant has been designated to ensure Program Specialist compliance through developing tool that includes ISP Sign-in sheet verification. Tool scheduled for use by 10/15/22. |
10/15/2022
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include their hair color or identifying marks. Their hair color was never identified throughout their record. Their identifying marks was recorded as, "none." However, Individual #1 has facial pigmentation patches specifically to them. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Following the on-site inspection, Program Specialist updated Individual #1 to be compliant with the Department and include missing identifying marks (document #11) |
09/01/2022
| Implemented |
| Article X.1007 | Emmaus Home is required to maintain criminal history checks and hiring policies for the hiring, retention, and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff person #3 was hired on 9/24/21 as direct support professional to have contact with individuals, lived in the state of Maryland at least until 8/2/2021 and a Federal Bureau of Investigation (FBI) background record check wasn't completed. Staff person #1 confirmed during the inspection on 8/8/22 that an FBI background check was not completed for Staff person #3.
Staff person #2 was hired on 7/27/22 as a program specialist to have direct contact with individuals and a Pennsylvania criminal history background check was never initiated by the agency until 8/9/22, after the 2022 annual inspection was initiated, and after their date of hire. As of 8/10/22, the agency did not have the results of Staff person #2's Pennsylvania criminal history background check as the record indicates, "request under review for control." | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | Immediately following the 8/8/22 on-site inspection, staff person #3 was informed of schedule pending fbi background results. On 8/09/22, staff person #3 resigned from the Organization. On 8/17/2022, staff person #2 FBI background results were received and filed (document #48). |
08/17/2022
| Implemented |