| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.104 | There was a notification to the fire department on 7/26/2020 but the individual's admission date was 6/26/2020. | 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 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.
This regulation is important because it provides advance knowledge of the layout of the home and the needs of the individuals to help first responders evacuate individuals quickly in the event of an emergency.
The notification to the Fire Department was sent late.
The Program Director did not quite understand the time-sensitivity involved in complying with this regulation.
This error cannot be fixed in retrospect. But the importance of sending it on time is learned. The Licensing Representative had explained the importance of registering an advanced notice.
To prevent this error in the future, all notifications will be sent before the individuals move in.
The Program Specialist shall send this notice in advance of the individuals move into the home.
The CEO will supervise the Program Specialist to ensure compliance with this safety regulation. |
11/06/2020
| Implemented |
| 6400.165(f) | Individual #1 is diagnosed with situational anxiety and depressive disorder for which she is prescribed Citalopram for anxiety, and at the time of the inspection, her most recent ISP (Individual Plan) dated 9/18/2020 did not contain a SEEN plan. Also, under section "social/emotional information" it states that Individual #1 is taking Lexapro, which is not the correct medication. It also states that she does not have a mental health diagnosis, which is also inaccurate information and needs to be updated. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.
This regulation is important because the written protocol (SEEN Plan) includes historical data regarding the individual¿s diagnosis and general techniques staff can utilize to assist this individual if symptoms are displayed. It is important that this plan is in place so it can assist staff to respond appropriately when the symptoms of their psychiatric illness manifests.
The SEEN Plan was not sent to the Supports Coordinator (SC). Consequently, it was not incorporated into the individuals ISP.
The Program Specialist failed to send the SEEN Plan to the SC.
To correct this immediately, the SEEN Plan has been sent to the SC (e-mail cover letter attached as Attachment #1).
To prevent this in the future, the Program Specialist will send this type of protocol to the SC on time, and implement it in the home immediately.
The CEO will provide more oversight for the Program Specialist to ensure compliance with this regulation. |
11/07/2020
| Implemented |
| 6400.165(g) | Individual #1 is diagnosed with situational anxiety and Depressive Disorder for which she is prescribed citalopram. Individual #1 was due for a psychotropic medication check up by 9/26/2020. The provider stated they had a tele-visit on 9/11/2020 with the Individual's PCP, however the chart did not contain supporting documentation to verify the appointment occurred nor was there current documentation that indicated the reason for prescribing the medication, the need to continue the medication and the need to continue the medication at the necessary dosage currently being taken. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage.
This regulation is important because many psychotropic medications have sedating side effects; and adhering to this regulation prevents maintenance medications from being used or interpreted as a form of chemical restraint. This medication monitoring serves to confirm that the individual is complying with their medication regimen, while also ensuring they are avoiding potentially dangerous drug interactions and other complications. The review also helps the psychiatrist review/assess the effectiveness of the medication and the need to continue its use. Overall, the review guarantees an optimal medication therapy and improves therapeutic outcomes for the individual.
The individual had a medication check with her PCP, who follows her psychiatrically, on 09/11/2020. The needed documentation was not in the individuals record at the time of the inspection.
The visit was a tele-health visit due to measures imposed by the Medical Center as a result of the coronavirus lockdown. The doctor, however, did not send the needed documentation, following the visit. Despite numerous efforts on the part of the Program Specialist, the doctor would not respond.
To correct this immediately, the Program Specialist was eventually able to obtain a completed form from the doctor. Unfortunately, the documentation was done on a wrong form (attached as Attachment #2).
The Program Specialist has scheduled another appointment for 10/5/2020 so we can have the doctor complete another form, but he cancelled the appointment. The Program Specialist will continue to make the effort to see him so he can fill out the correct form.
A copy of the correct form is attached as attached as Attachment #3).
To prevent this from happening in the future, the staff has established service for the individual with a psychiatrist. An evaluation was done by remote visit on 10/29/2020.
The agencys nurse will take over facilitating these visits.
She will be supervised by the Program Specialist. |
11/07/2020
| Implemented |
| 6400.166(a)(3) | The Electronic Medication Administration Record had a spot to list the individual's allergies, however on individual #1's MAR it was left blank. If the individual does not have any drug allergies, it should be listed as no known allergies, or NKA, or NA, etc. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Drug allergies. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered:
(3) Drug allergies.
This regulation is important because consistent and comprehensive recording of drug allergy status is important to ensure that all patients with confirmed or suspected drug allergy have a full and accurate record of this in their electronic medical record. Accurate recording of drug allergy status will prevent the prescription and administration of drugs inducing allergic reactions and will improve patient safety. Providing this information could help avoid patients with known allergies wrongly receiving drugs that could endanger their health.
The individual's drug allergy status was not documented in her electronic medical record.
This error occurred because the MAR was not reviewed by the agency's Nursing Staff. After the IT Staff had input the basic information, the Clinical staff members did not review it.
To correct this immediately, all MARs have been updated to include all necessary information, including Drug Allergies (Attachment #4 - Individual's current MAR.
This was reviewed with all staff at the post-inspection briefing.
All certified medication administration staff have been asked to look out for this information in all MARs.
To prevent this from happening in the future, a multi-level system of verification has been put in place:
After IT has input all the medications information in the electronic system, it will be reviewed by:
1. The Nursing Supervisor
2. The Director of Nursing Services
This way, all possible errors will be captured and corrected immediately.
The Program Specialist shall be responsible for providing oversight in this area. |
11/07/2020
| Implemented |
| 6400.167(a)(1) | The MAR for individual #1 indicates that medication: Zyrtec (Cetirizine) 10mg was not given on 9/30/2020 at 7:30am for reason, "has not arrived from pharmacy". There was no documentation indicating when the medication arrived or if it had been given later that day. There were no incident reports indicating that the medication was missed in HCSIS and there was documentation in the individual's file, at the time of the inspection, that stated "There has been no unusual incidents in the period under review". | Medication errors include the following: Failure to administer a medication. | Medication errors include the following:
(1) Failure to administer a medication.
This regulation is important because medication errors have the potential to cause harm to the individual. Sometimes, the harm can be life-threatening.
The individuals medication, Zyrtec (Cetirizine), was not documented as administered.
The medication did not arrive in the home along with the usual monthly batch. The staff on duty administered the morning medications with the exception of Zyrtec. The Pharmacist supplied the medication right after Sarah left her home for her Program. Staff took the medication to administer to her immediately, but did not go back to document the administration.
All med admin trained staff have been informed that this kind of errors must be reported immediately, so that the supervisory staff can report it in EIM.
To prevent this type of error in the future, the Nursing Supervisor will review the documentation on a daily basis.
Staff who make errors will be offered re-trainings.
Re-trainings will include a root cause analysis of the medication error, so that specific actions will be taken to prevent recurrence.
The Director of Nursing will supervise the Nursing Supervisor to ensure error-free med administration, and thereby improve outcomes and increase safety for the individuals. |
11/07/2020
| Implemented |
| 6400.181(f) | At the time of the inspection, there was no documentation to support that the PS sent individual #1's assessment to the SC and team 30 days prior to the ISP meeting scheduled for 10/06/2020. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.
The importance of this regulation cannot be overstated. Assessments are essential to maximizing personal growth and development, the persons ability to self-direct through choice and control over decisions affecting them directly while protecting the health and safety of the individual.
Assessments are the foundation for many of the requirements of the residential program. Regulation requires that assessments are completed in a timely fashion and that notification of assessment results are provided to individual plan team member at least 30 calendar days prior to an individual plan meeting. This is important because the assessment would have reflected all changes in the past year which would be relevant to the annual individual plan review.
The individuals assessment was not sent to the plan team members at least 30 calendar days prior to the individual plan meeting of 10/6/2020.
The invitation for the meeting was not sent by the Supports Coordinator on time. The invitation was sent on 9/21/2020 for a 10/6/2020 meeting. This was only 15 days in advance. That did not allow 30 days for the Program Specialist to fulfil the regulation.
This error cannot be rectified retroactively.
To prevent this type of error in the future, the Program Specialist (PS) shall do the following:
The PS will send the Assessments as soon as they are completed, even when a meeting has not been scheduled.
The PS will not consent to a meeting that does not allow enough time to send the Assessment in a timely fashion.
The PS will re-send the Assessment when a meeting invitation is received. |
11/07/2020
| Implemented |
| 6400.182(c) | Individual #1's current ISP dated 9/18/2020 has not been revised to reflect the individual's needs that have changed since moving in with Ideal Services Group. The Assessment has been updated to reflect these changes, however the ISP still states that the individual's mother is responsible for items such as the individual's health and safety. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The individual plan shall be initially developed, revised annually and revised when an individuals needs change based upon a current assessment.
The development and implementation of high-quality Individual Plans is crucial for individuals to live an everyday life. Individual plans must be revised in response to any change identified by an assessment that requires an alteration of the Individual Plan. The Program Specialist ensures that the individual plan is up to date and accurately reflects the individuals needs.
The individual plan was not reviewed by the Program Specialist.
The newly reviewed ISP did not update in HCSIS as of 9/18/2020. In the first place, the ISP Review meeting did not hold until 10/6/2020. It is doubtful that the ISP in question is the reviewed one.
The Program Specialist reviewed the approved ISP and all the information in it is correct as of the time of entering the POCs in LIS (please refer to HCSIS).
To prevent this type of error in the future, the Program Specialist (PS) shall review the ISP immediately.
The CEO will supervise the PS, to ensure compliance. |
11/07/2020
| Implemented |