|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency's licensing certificate expired on 10/8/19. The agency did not complete a self-assessment of the home. During the 10/9/19 onsite inspection, Staff #2 and #3 confirmed that a self-inspection of the home was never completed. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| Home of Apex Healthcare Services will complete a self assessment, by 2/28/20 to determine the accuracy of the plan of correction.
Another self assessment will be completed during the month of May, 2020 to determine the continued accuracy of the plan of correction. This plan will be submitted to ODP as their pre-licensing self-assessment by 5/31/20. |
| Implemented |
| 6400.16 | As referenced in this report, the agency, through acts and omission of acts, have deprived the individual of their rights that may cause or have caused physical injury or emotional harm to the individual. | 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. | No acts of abuse or neglect were committed intentionally. This plan of extensive correction is intended to correct the failure to provide needed care, failure to provide care as instructed by a healthcare professional or as specified in the Individual Plan, and failure to provide medication management.
Through training the staff appropriately and educating the CEO on the 6400 regulations, many of these issues have been corrected already. Through educating the Apex administrative team, orientation training and on boarding practices have been changed to reflect the 6400 regulations.
The evidence for these changes and the plan for continuous improvement and training in these areas is located throughout this plan of correction and in all of the attachments.
The Program Specialist and the Director of Community Homes will be responsible for the Community Homes on boarding and orientation process for any new staff, beginning 12/23/19.
12/20/19 - This plan of correction was reviewed with the CEO. The Program Specialist and the Director of Community Homes are continuously educating the CEO on the 6400 regulations, introduced the 6100 regulations and reviewed the RCG's with the CEO on multiple occasions to ensure an understanding of the responsibilities to which he must adhere (attachment # 23 a & b). |
| Implemented |
| 6400.22(d)(2) | Individual #1's current financial account included a $10.30 receipt for food purchased at Charley's Cheese Steak. The receipt and funds used for this purchase was never deducted from the individual's financial ledger or total funds available at the home. The individual's financial account and financial ledger should be kept current and up to date. | Individual #1's current financial account included a $10.30 receipt for food purchased at Charley's Cheese Steak. The receipt and funds used for this purchase was never deducted from the individual's financial ledger or total funds available at the home. The individual's financial account and financial ledger should be kept current and up to date. | 10/14/19 - It was determined that the $10.30 belonged to the CEO and therefore should not have been entered into her financial ledger. The Director of Community Homes explained co-mingling of funds in accordance with regulation 6400.22 (f) to the CEO. It was explained that the CEO should never pay for things for an individual. |
| Implemented |
| 6400.43(b)(3) | As referenced under 6400.46(c), Staff #1 was witnessed by Licensing staff to be the only staff person in the agency vehicle while Individual #1 was transported home from her day program on the morning of 10/9/19 around 10:30am. During the annual inspection, there was no evidence to support that Staff #1 received training before working with individuals or providing transportation for individuals, in first aid techniques or Cardio Pulmonary Resuscitation (CPR). Individual #1 is transported 3 days a week, minimum 6 trips per week, to day program with only one staff in the vehicle. It was found that at least one staff providing transportation to the individual was never trained in first aid and CPR techniques. Staff #1 would not be able to render aid or CPR in an emergency situation, should the individual's health and safety depend on it. Staff #3 was aware Individual #1 was being transported with only Staff #1 in the vehicle.
Staff #3, the agency Chief Executive Officer (CEO), has many responsibilities of oversight and direct care within the agency, as well as CEO responsibilities with another health care agency outside of the APEX residential facility. Due to his multiple obligations, he has failed to manage and administer the individual's medication and health regimen as prescribed by the individual's physician's, as referenced in this report.
Staff #3 is the only staff employed with the agency who works in Individual #1's home, who is certified to administer medications to the individual. Staff #3 reports, he only arrives to the home to administer medications in the morning and evening to Individual #1. During the 10/9/19 inspection, Staff #3 reported that should he be unavailable to administer daily or as needed medications to the individual, there is no plan in place to assure the individual receives medication in a timely manner by a medication administration certified staff within the residential agency.
The individual is diagnosed with Diabetes. The individual's blood sugar needs to be monitored daily to ensure she does not exhibit any signs or symptoms related to high blood sugar or low blood sugar. Staff #3 did not monitor the individual's blood sugar levels on a daily basis. Nor did any staff contact the individual's physician to obtain information regarding what the individual's normal blood sugar levels should read, concerning blood sugar levels (high or low), and what staff are to do should the individual have high or low concerning blood sugar levels.
The individual is diagnosed with Chronic Constipation and takes daily medication for this. Staff #3 created a protocol for staff to follow should she experience constipation. However, Staff #3 never contacted the individual's prescribing physician to obtain a protocol for staff to follow should the individual experience constipation and what concerns staff should monitor. Staff #3 is also not the individual's prescribing physician nor has he taken to the individual to any doctor appointments to know what has or has not been recommended for the individual regarding her constipation. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | 10/11/19 - Effective this date, if staff on duty is accompanying Individual #1 to an appointment, Apex transportation services will drive Individual # 1 and the staff to the appointment.
All staff at Evergreen have successfully completed training with the America Red Cross in First Aid/CPR/AED (attachment # 62 a-f).
New employees will successfully complete training with the American Red Cross in First Aid/CPR/AED, prior to working a shift alone in an Apex Community Home. CPR/First Aid/AED training is now a part of the two week orientation syllabus. The Program Specialist and the Director of Community Homes will be responsible for scheduling the training with the Red Cross and obtaining the documentation of successful completion of the course. This documentation will be kept in the employee's file.
12/20/19 - The 6400.46 (c) regulations were reviewed with the CEO to ensure understanding of the importance of having properly trained staff working with the individuals we support. (attachment # 23 a & b). |
| Implemented |
| 6400.43(b)(4) | As referenced in this report, the chief executive officer, Staff #3, has failed to ensure the APEX agency has maintained compliance with this chapter. There was no evidence that Staff #3, who was directly involved with the individual's daily care, made attempts to become compliant with this chapter. During the 10/9/19 onsite inspection, Staff #3 was witnessed by licensing staff to have a lack of understanding of the chapter's regulations. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Compliance with this chapter. | 10/14/19 - The Program Specialist and Director of Community Homes began educating Staff #3 on the 6400 regulations. As each plan of correction was written, it was covered with Staff #3.
11/5/19 - Staff # 3 began attending the orientation training with the staff. To date Staff #3 has completed the following: Incident management, The Fatal 4, Standard Precautions/Blood borne Pathogens, Abuse and Neglect, Adult Protective Services Act, Older Adult Protective Services Act, Mandated Reporting, Diabetes, Behavior Supports, Policies and Procedures, Job related knowledge and skills, Bowel protocol, Diabetic Diet and Wrist brace protocols, reporting Medication Errors, Person Centered Practices, Individual Rights, Fire Safety (attachment # 48 a-w ). Staff # 3 started Medication Administration Training and is expected to complete it by 1/30/20. Staff # 3 will attend Arthritis and Schizophrenia training presented at the house by the HCQU on 2/4/20.
12/20/19 - The entire plan of correction was reviewed with Staff #3 to ensure understanding of the citations and plans of corrections. It was also reviewed with Staff # 3, responsibilities that he is ultimately responsible for as well as responsibilities of compliance with the 6400 regulations. (attachment # 23 a & b) |
| Not Implemented |
| 6400.46(e) | Staff #1, #2, and #3 have all provided direct support care to Individual #1. There is no evidence that Staff #1-#3 received training in the areas of intellectual disability, the principles of normalization, rights and program planning and implementation within 30 calendar days after their day of initial employment, 5/2/19, 8/12/19 and 7/1/15 respectively, or within 12 months prior to initial employment | Program specialists and direct service workers shall have training in the areas of intellectual disability, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. | 10/11/17 - The Director of Community Homes developed and implemented an Orientation Syllabus that encompassed all mandatory training under 6400. 51 (b) (5) (attachment #49 a-e).
10/21/19 - Staff #1-3, as well as all current staff participated in Orientation Training on Individual Rights and HIPAA Training (attachment # 50 a & b) Incident Reporting (attachment # 51 a & b), Fire Safety (attachment # 52 a, b, & c ), Abuse and Neglect (attachment # 53), Person Centered Practices and Everyday Lives (attachment #54 a-e), Individual # 1's and eating protocol (attachment # 17 a & b), Mandated Reporting (attachment # 55 a&b) Positive Behavioral Supports and Behavioral Intervention Plans (attachment # 56 a-c), Policies and Procedures Manual (attachment #57 a) and Monthly Reviews that included Financial management, (attachment #57 b-h and attachment i -1-19), Universal/Standard Precautions and Blood Borne Pathogens (attachment # 58 a-c), Current Medication Protocol and Med Adm. Protocol as of 1/30/20 (attachment # 59 a & b), Medication Change Protocol (attachment # 60 a & b), Bowel Protocol for Individual # 1 (attachment # 61 a & b), Reporting Medication Errors (attachment # 28 a & b), CPR and First Aid (attachment #62 a - f), Supporting Someone With a Hearing Loss (attachment # 63 a-g), Developmental Disabilities (attachment # 64 a-g).
3 staff completed Effective Communication (attachment # 65 a-c).
5 staff completed Depression (attachment # 66 a-e).
4 staff completed Hypertension (attachment # 67 a-d).
5 staff completed Osteoporosis (attachment # 68 a-e)
4 staff completed Dementia (attachment # 69 a-d).
All staff completed Fatal 4 attachment #42 a-e).
2 staff completed Bi-Polar Disorder (71 a, b).
2 staff completed Cholesterol (72 a & b).
2 staff completed Skin Integrity and Pressure Injury (72 a, b)
10/23/19 - All staff began ODP's Medication Administration Training. Their expected completion date is 1/15/20.
1/8/20 - 3 staff completed Medication Administration Training and 4 med pours (attachment # 34 a,b,c).
1/23/20 - Staff are scheduled for training on low fat, low salt, low cholesterol, low carbohydrate cooking.
2/4/20 - All staff are scheduled to attend a HCQU training on Arthritis and Schizophrenia training.
Any new staff working at or any other Apex Healthcare Services Community Home will complete the 2 week training agenda which includes all mandatory orientation training requirements listed in 6400.51 (b) (5). The Director of Community Homes and the Program Specialist will be responsible for this training. New employees will not be assigned to work a shift alone until the orientation syllabus is completed. A newly hired staff is currently in her 2 weeks of training prior to working a shift (attachment 118 a-j).
12/20/19 - The Program Specialist and the Director of Community Homes reviewed the requirements of 6400.51 (a) (1) with the CEO to ensure an understanding of the importance and compliance with training requirements. This Plan of Correction was reviewed with the CEO (attachment # 23). |
| Implemented |
| 6400.72(b) | The latch on the back screen door is broken and the screen door does not stay shut when closed. The front screen door was hard to unlatch and had to be opened with force. | Screens, windows and doors shall be in good repair. | 10/11/19 - The back screen door latch was repaired. The latch closes the door firmly (attachment # 100 a & b).
10/11/19 - The front screen door latch was oiled and loosened and turns easily.
Doors will be checked daily as staff arrive and leave their shifts. They were added to the weekly site checks for the homes. Staff must immediately report any broken items or items that do not work properly to the Program Specialist or Director of Community Homes. This was reviewed at the 10/21/19 staff meeting (attachment #100 c).
The CEO has reviewed the 6400 regulations to ensure understanding of the requirements to run a 6400 home. The Program Specialist and the Director of Community Homes have reviewed the 6400.72 regulations and the Regulatory Compliance Guide with the CEO to ensure an understanding of the importance of the site regulations. The Plan of Correction was also reviewed (attachment # 23 a & b). |
| Implemented |
| 6400.103 | The written emergency evacuation procedure does not include individual and staff responsibilities. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| 12/9/19 - The Emergency Evacuation Plan was revised to include the responsibilities of staff and individuals (attachment #105 a, b, c ). It was reviewed with staff on 12/11/19 (attachment # 105 a & b).
12/20/19 - The regulations in 6400.103 were reviewed with the CEO to ensure understanding of the staff and individual responsibilities in an emergency evacuation attachment # 23 a & b). |
| Not Implemented |
| 6400.104 | The written notification letter sent to the fire department on 9/20/19 states that Individual #1 may require assistance in evacuating the home in the event of a fire. The letter does not include an explanation of the location of the individual's bedroom, nor an attached floor plan. During the 10/9/19 onsite inspection, Staff #2 confirmed that Individual #1 requires 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.
| 10/11/19 - The Program Specialist sent an updated letter to the fire department. It included an attached floor plan with Individual's #1 's bedroom labeled. On 10.23.19 she sent a letter for Individual # 2 who was admitted on October 23, 2019 (attachment #104 a-d).
The Program Specialist will send notification to the fire department for any new individuals admitted to an Apex community home. If the individual requires assistance evacuating, a floor plan will be included that clearly labels the individuals bedroom location.
12/20/19 - The regulations for fire safety in 6400.104 were reviewed with the CEO. He was also trained in fire Safety. The Program Specialist and the Director of Community Homes reviewed the plan of correction with him. (attachment # 23 a & b). |
| Not Implemented |
| 6400.106 | The residential facility had their onsite annual inspection completed on 10/9/19, over a year after the home was opened on 10/8/18. The home was heated by a gas furnace. At the time of the 10/9/19 inspection, the home's furnace was not inspected, cleaned or received a filter change by a professional furnace cleaning company. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| 10/14/19 - The CEO contacted Plumbing, Inc. to have the furnace inspected.
10/24/19 - The furnace at was inspected by Plumbing (attachment #99 a & b).
The CEO will have the furnace inspected annually. The CEO reviewed the 6400 regulations regarding 106 - Furnaces. The Program Specialist and the Director of Community Homes reviewed 6400.106 regulation with the CEO. The Regulatory Compliance guide concerning 106 - Furnaces was also reviewed with the CEO (attachment # 23 a & b). |
| Implemented |
| 6400.110(f) | The agency documented on Individual #1's initial assessment and intake paperwork, that the individual has a hearing impairment and requires an amplification system. The homes smoke detectors and fire alarms are not equipped with strobe lights or a device, such as a bed shaker or body vibration device, that will alert the individual in the event of a fire. | 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 is able to hear the smoke alarm when fire drills are performed. She comes out of her room and listens to staff directives. She evacuates with limited assistance once she comes out of her room.
10/22/19 - Individual #1 was scheduled for and attended a PCP appointment with doctor at Penn State internal medicine. At that time, a referral for an audiologist was obtained (attachment # 90). Ind. #1 was scheduled for the first available audiology appointment on 1/2/2020, to determine the severity of the hearing loss, to clarify what kind of amplification system is required, and to determine the need for adaptive equipment in the home for fire drills (strobes, bed rocker and personal body device).
If indicated, CEO will be responsible for purchasing and installing all adaptive equipment for fire drills to ensure the safety of individual # 1.
11/21/19 through 12/13/19 - Staff was trained in how to support an individual with hearing loss (attachment # 63 a-g).
An amplification devise was obtained on 12/17/19 for individual # 1 to use until further information is gathered at the audiology appointment on 1/2/20 (attachment # 84).
12/17/19 - Amplification protocol was developed (attachment # 85).
12/17/19-12/20/19 - Staff was trained on the amplification protocol (attachment # 86).
12/20/19 - The Program Specialist and the Director of Community Homes have reviewed the regulations and the Regulatory Compliance Guide regarding the requirements of 6400.110 (f) with the CEO to ensure that Individual # 1's medical needs are met (attachment # 23 a & b). |
| Not Implemented |
| 6400.111(f) | The fire extinquishers in the kitchen and attic were not equipped with the date of the inspection by the fire safety expert on the fire extinquisher. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | 10/11/19 - The CEO contacted fire protection (who had previously inspected the fire extinguishers) to and completed the tags for the fire extinguishers with the month and the year of inspection. This was completed on the same day, 10/11/19 (attachment # 98 a, b, c).
The Program Specialist, Director of Community Homes and the CEO will be responsible for ensuring that the date of the inspection is listed on the tags for the fire extinguishers after each yearly inspection.
12/20/19 - The requirements for 6400.111 (f) were reviewed with the CEO by the Program Specialist and the Director of Community Homes. The Plan of Corrections was also reviewed with the CEO (attachment # 23 a & b |
| Implemented |
| 6400.113(a) | Individual #1's date of admission to the home was 7/18/19 and at the time of the 10/9/19 inspection, has not received training 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. Staff #2 and #3 confirmed that the said training has not occurred for the individual yet. | Individual #1's date of admission to the home was 7/18/19 and at the time of the 10/9/19 inspection, has not received training 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. Staff #2 and #3 confirmed that the said training has not occurred for the individual yet. | 10/15/19 - The Program Specialist was tasked with training the individual and staff on general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within a fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the home.
10/15/19 - Individual # 1 was trained in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within a fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the home (attachment # 96).
The PS will be responsible to ensure Fire Safety Training has been completed prior to the admission of any individuals.
10/21/19 - Individual #2 (admission date 10/21/19) was trained in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within a fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the home (attachment # 97).
The CEO will ensure compliance of this training by signing off on the documentation prior to an individuals admission.
The CEO has reviewed the 6400 regulations to ensure understanding of the requirements that must be completed prior to moving an individual into a 6400 home. The Program Specialist and the Director of Community Homes have reviewed the 6400 regulations and the Regulatory Compliance Guide concerning 6400.113 (a) with the CEO (attachment # 23 a & b). |
| Implemented |
| 6400.141(c)(4) | Individual #1's 8/2/19 physical exam did not include a vision or hearing screening. The physical examination documentation did not include a section for this information to be recorded on the physical form. The agency documented on Individual #1's initial assessment and intake paperwork that the individual has hearing difficulties. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | 10/12/19 - In order to gain information and clarification, the most recent audiology report (7/24/18) was reviewed. Individual #1's sister, in conjunction with the doctor decided to discontinue a trial of hearing aides due to the individual losing several pairs of hearing aids. Other options were discussed including an amplifier from a drug store; however, this was not obtained by the sister. The sister reports asking the SC to handle this, but to date, it was not resolved. The recommendations from the audiologist were as follows: 1. Return for annual hearing evaluation and 2. Utilize hearing protection in the presence of hazardous sounds (attachment # 89 b).
10/21/19 - The Program Specialist developed an attachment to the physical for that includes a block for Hearing and vision screening. Individual # 1's PCP completed the new form (attachment #95). These will be completed at future physicals.
1/23/20 - In order to ensure proper completion of the forms, a training is scheduled for 1/23/20. This training will include: how to run a medical appointment, how to properly check if the form is completed properly, and how to complete an annual physical and dental appointment.
10/22/19 - Since the screening was already past due, Individual #1 was scheduled for and attended a PCP appointment with Penn State internal medicine. At that time, a referral for an audiologist was obtained (attachment # 90). Ind. #1 was scheduled for the first available audiology appointment on 1/2/2020, to determine the severity of the hearing loss, to clarify what kind of amplification system is required, and to determine the need for adaptive equipment in the home for fire drills (strobes, bed rocker and personal body device).
If indicated, CEO will be responsible for purchasing and installing all adaptive equipment for fire drills to ensure the safety of individual # 1.
11/21/19 through 12/13/19 - Staff was trained in how to support an individual with hearing loss (attachment # 63 a-g).
An amplification devise was obtained on 12/17/19 for individual # 1 to use until further information is gathered at the audiology appointment on 1/2/20 (attachment # 84).
12/17/19 - Amplification devise protocol developed (attachment # 85).
12/17/19-12/20/19 - staff trained in amplification devise protocol (attachment # 86).
12/20/19 - The Program Specialist and the Director of Community Homes have reviewed the 6400 regulations and the Regulatory Compliance Guide regarding the requirements of 6400.141 (c) (4) with the CEO to ensure that Individual # 1's medical needs are met attachment # 23 a & b).
1/2/20 - Individual # 1 attended the audiology appointment/consult (attachment 119 a, b, c).
1/3/20 - to date, Apex has not received notification from the county that the medical assistance was obtained. An email was sent regarding the urgency of this matter (attachment # 120 a & b). |
| Implemented |
| 6400.141(c)(10) | Individual #1's 8/2/19 physical examination did not include if the individual did or did not have a communicable disease or specific precautions that must be taken to prevent the spread of the disease. The physical examination form also did not include a section for this to be documented and completed by the individual's physician. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | 10/21/19 - The Program Specialist developed an addendum to the physical form that includes a space for documenting the individual is free from communicable disease.
10/22/19 - The new form was taken to the PCP during a regular check-up. While the PCP filled out the rest of the form, that space could not be completed by the physician as she did not complete the PPD test. She instructed us to have the person who administered the test, sign the form.
Individual # 1 was given a 2 step PPD by RN . The first was performed on 7/19/19 and read on 7/31/19. The second was performed on 7/31/19 and read on 8/2/19. Both results were negative. The RN completed this part of the physical form (attachment # 94 a & b).
In the future, PPD tests will only be performed every other year, at the Individuals annual physical by the individuals PCP.
The Program Specialist and the Director of Community Homes reviewed the entire 6400.141 with the CEO to ensure an understanding of the requirements of the Individual Physical Examination (attachment # 23 a & b). |
| Implemented |
| 6400.141(c)(12) | Individual #1's 8/2/19 physical examination did not include physical limitations of the individual. The physical examination form also did not include a section for this to be documented and completed by the individual's physician. | Individual #1's 8/2/19 physical examination did not include physical limitations of the individual. The physical examination form also did not include a section for this to be documented and completed by the individual's physician. | 10/21/19 - The Program Specialist developed an addendum to the physical form that includes a space for documenting the Limitations or restrictions for physical activities.
10/22/19 - The new form was taken to the PCP during a regular check-up. While the PCP filled out the rest of the form, that space was left blank.
12/12/19 - The Director of Community Homes sent the form by email to the PCP, requesting the space to be filled with information on the limitations or restrictions on physical activity.
12/12/19 - The PCP filled in the Limitations portion of the addendum with "No restrictions" (attachment # 93).
1/15/20 - All staff are scheduled to attend a training on how to run an appointment and how to make sure that paperwork is filled out completely and correctly before leaving the doctor's office. This training is taking place in the event that staff need to run an appointment.
12/20/19 - The Program Specialist and the Director of Community Homes reviewed the requirements of 6400.141 (c) (14) with the CEO to ensure understanding of the information needed to comply with the regulations (attachment # 23 a & b). |
| Implemented |
| 6400.141(c)(14) | Individual #1's 8/2/19 physical examination did not include medical information pertinent to diagnosis and treatment in case of an emergency. The information in this section listed some of the individual's diagnoses, as required under 6400.141(c)(1), that had spilled over from the medical history section of the physical. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | 12/27/19 - The Director of Community Homes sent a message to Individual #1's PCP asking for information pertinent to diagnosis and treatment in case of emergency to be added to the physical form (attachment 91 a, b, c ). This was documented in consult log (attachment # 92).
1/15/19 - All staff will be trained on how to run an appointment, how to ensure the forms are completed properly, how to run a psychotropic medication check and how to run an annual physical and dental appointment. This training is taking place in the event that staff need to run the appointment.
12/20/19 - The Program Specialist and the Director of Community Homes reviewed the requirements of 6400.141 (c) (14) with the CEO to ensure understanding of the information needed to comply with the regulations (attachment # 23). |
| Implemented |
| 6400.144 | Individual #1's 7/29/19 physician's medication list in her record stated "glucometer, use daily or as directed by physician to check blood sugars, and one touch ultra, use as directed to check blood sugars." The individual's 9/9/19 physician's medication list states, "glucometer uses daily or as directed by physician to check blood sugars diagnosis 250 diabetes, and one touch ultra glucose use as directed to check blood sugars." The individual's medication logs, created from the pharmacy based on the physician's orders, from July to October 2019 list "one touch ultra test strips use to test blood sugars once daily." In July, the individual's blood sugar was only taken 3 times, August taken 9 times, September taken 9 times and October 3 times.
The Chief Executive Officer (CEO), Staff #3 was responsible for administering the individual's medication and taking the individual's blood sugar as directed since he was the only staff member with qualifications to use a glucometer and test Individual #1's blood sugar. Out of a total of 82 days where the individual's blood sugar should have been taken and monitored once per day, it was only taken 24 times.
On 7/24/19, the individual had a dental examination. The dentist recorded on the examination documentation, the individual "has loose teeth, and uncooperative for x-rays. Needs sedation in order to complete a more comprehensive exam and possibly extraction of loose teeth." The agency waited until 9/26/19 to contact the individuals case worker to see if the individual's insurance will cover the procedure. Through interviews with staff during the 10/9/19 onsite inspection, it was found that a follow up appointment to complete the dental work as ordered, is not scheduled yet. There is no evidence to confirm that additional support has been provided to the individual in attempts to get the follow up work completed.
The agency documented on 7/22/19 that the individual "Needs Amplification system due to hearing loss." During the 10/9/19 onsite inspection, an amplification system has not been installed so that the individual can be alerted in the event of a fire or emergency. The agency has not scheduled a hearing evaluation or an appointment with a physician to further discuss the individual's hearing loss. The agency stated on the individual's 9/16/19 assessment, the Individual has a hearing Impairment.
Individual #1's 8/2/19 physical examination list a diagnosis of Chronic Constipation and takes a medication for this. On the refrigerator in the kitchen of the home there is typed, written instructions for staff not to use prune juice unless Individual has not had a bowel movement in 3 days. Staff #3 confirmed this order is not from the individual's physician, but an order written by Staff #3 himself. The agency has not contacted the individual's physician to determine next steps should the individual's Chronic Constipation reach a stage of concern due to no bowel output.
Individual #1's 9/9/19 current, physician's medication list that states, "please take the following medications: Donepezil (Aricept 10mg oral tablet) special instructions: one in AM by mouth" and "Donepezil (donepezil 5mg oral tablet) 1 tablet by mouth once daily." The individual's Donepezil (Aricept 10mg tablet) was never administered to the individual. The medication was not available at the home. The individual's physician was never contacted regarding the current, 9/9/19 physician's orders to administer an additional 10mg of Donepezil. The individual's Penn State Hershey Medication Group's current, 9/9/19 physician's medication list also states, "if this list does not agree with the medications you are taking or how you are taking them, notify your physician or pharmacist." The agency never contacted the individual's physician or pharmacist.
page 1, continued on next page. | 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.
| Regarding Blood sugar checks:
10/14/19 - Staff # 3 was counseled on the importance of following physician's written orders as well as making sure verbal orders are matching of the written orders. If they are in contradiction, the written orders must be followed until the written change is received.
10/22/19 - Individual # 1 completed an appointment with her PCP. At that appointment, it was explained to the PCP that verbal orders to not follow a previously written order will not suffice. Changes to previously written orders must be put into writing. The PCP discontinued the "one touch ultra strips" along with the glucometer and blood sugar checks (attachment #10), due to a stable and appropriate A1C level. The "one touch ultra strips" and glucometer were removed from Individual 1's medication box.
12/6/19 - Individual # 1 completed a check-up with PCP. Her A1C level continues to decrease through medication, diet and exercise.
12/20/19 - The Program Specialist and the Director of Community Homes reviewed the requirements of 6400.144 with the CEO to ensure understanding of the information needed to comply with the regulations. The Plan of Correction was reviewed with the CEO (attachment # 23 a & b).
Regarding dental health:
10/15/17 - Planned or prescribed health services for individuals that Apex serves were reviewed with the CEO. The responsibilities of arranging and providing these services were reviewed to ensure an understanding of what this entails.
7/24/19 - Individual #1 saw DDS for a new patient exam and cleaning. Recommendation for x-rays and a more comprehensive exam and possible extraction of loose teeth. Recommendation for exam under sedation due to patient being uncooperative (attachment #76 a & b).
7/24/19 - A Dental Hygiene desensitization plan was developed (attachment #77). A Dental hygiene plan was developed (attachment # 78).
9/13-9/26/19 - The Program Specialist, DSP and Individual #1 had several conversations regarding making an appointment for a dental consult and exam under sedation (attachment # 79).
10/17/19 - The Program Specialist did research on providers that accept Individual # 1's insurance. She was referred to an Oral Surgeon. An appointment was made for 12/3/19.
11/22/19 - The Program Specialist and the Director of Community Homes had a meeting with the SC to begin the process of obtaining Medical Assistance to cover the dental appointments under sedation as well as extraction of teeth (attachment # 80 a & b).
12/3/19 - Individual #1 completed an oral surgery consult with doctor. She was referred back to her regular dentist for further evaluation for needed treatment. The Oral surgeon does not complete dental exams under sedation. They were able to take panoramic films of Individual # 1's teeth but not full x-rays (attachment # 81 a).
Individual # 1 is not compliant with full dental exams and x-rays, therefore these will need to be completed under sedation. Her insurance will not cover this. The family is not willing to pay for this at this time.
12/4/19 - New Dental Appointment Summary Forms were developed. This will be used for the first time at her next dental appointment. New Dental hygiene Plan forms were developed. This will be used for the first time at her next appointment (attachment # 82 a & b).
12/19/19 - The Program Specialist and the Director of Community Homes had a Provider meeting with the supervisor of the SC, who is preparing the application for Medical Assistance. She informed us the application would be filed after 12/25/19. (attachment # 83) Upon receipt of the Medical Assistance, the complete exam, x-rays and possible extraction of teeth will be scheduled by the Program Specialist.
The Program Specialist will ensure that annual examinations are scheduled and attended.
12/20/19 -The Program Specialist and the Director of Community Homes reviewed the 6400.144 regulations/POC with the CEO to ensure an understanding of follow-up to medica |
| Not Implemented |
| 6400.144 | page 2
Individual #1's 7/29/19 physician's order medication list states she is to be administered, "Levothyroxine 100mcg tablet, take 1 tablet by mouth every other day alternating with 75mcg," and "Levothyroxine 75mcg, take 1 tablet by mouth every day." The agency was administering Levothyroxine 100mcg and 75mcg tablet together on one day, then administering 75 mcg the next day. Both physician's orders for Levothyroxine could not be administered as prescribed due to how they were written. When Staff # 3, the CEO and only staff responsible for administering medications, was questioned on 10/9/19 about how he was administering both Levothyroxine orders to the individual as prescribed, he reported he did not know which orders were correct. Staff #3 also reported he never contacted the individual's prescribing physician to clarify which order(s) should be followed.
The individual's current, 9/9/19 physician's ordered medication list does not include an order to administer Levothyroxine 75mcg, take one tablet by mouth daily. However, this medication was available at the home and continued to be administered to the individual daily by Staff #3. On 10/9/19, Staff #3 reported to the Department that he was unaware that this medication was not listed on the individual's 9/9/19 current physician's order. Staff #3 did not know if the medication should be administered nor was the individual's physician contacted.
The same 9/9/19 physician's ordered medication list states that the individual is prescribed, "Levothyroxine 100mcg, take 1 tablet by mouth every other day alternating with 75mcg." However, the medication label available at the home, and the current October 2019 medication administration record states, "Levothyroxine Sodium 100mcg, take one tablet by mouth on alternate days (with 75mcg tablet)." The medication was being administered according to the medication label and not the current, physician's orders. Staff #3 confirmed that the individual's prescribing physician was not contacted for clarification for how to administer the medication. | 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.
| Regarding Amplification System:
12/16/19 - An amplification system was obtained for Individual # 1 (attachment # 84). A protocol for the system was developed (attachment #85). Individual # 1 will use this amplification system until further information is gathered from the audiology appointment on 1/2/20.
12/16/19-1/2/19 - Evergreen staff continues to train on the amplification system protocol. Not all staff have completed to date (attachment # 86).
10/12/19 - The most recent audiology report (7/24/18) was reviewed (attachment #87 a-g).
11/26/18 - Appointment for another pair of hearing aids due to Individual #1 loosing them (attachment # 88 a & b).
12/10/18 - Individual #1's sister, in conjunction with the doctor decided to discontinue a trial of hearing aides due to the individual losing several pairs of hearing aids. Other options were discussed including an amplifier from a drug store; however, this was not obtained by the sister. The sister requested that the SC look into this option. No amplification system was obtained. The recommendations from the audiologist were as follows: 1. Return for annual hearing evaluation and 2. Utilize hearing protection in the presence of hazardous sounds (attachment # 89 a, b).
10/22/19 - Individual #1 was scheduled for and attended a PCP appointment with doctor at Penn State internal medicine. At that time, a referral for an audiologist was obtained. (attachment #90 a, b, c ) Ind. #1 was scheduled for the first available audiology appointment on 1/2/2020, to determine the severity of the hearing loss, to clarify what kind of amplification system is required, and to determine the need for adaptive equipment in the home for fire drills (strobes, bed rocker and personal body device).
To date, Individual # 1 has never has difficulty hearing the smoke detector. During fire drills, she immediately comes out of her room and evacuates accordingly. If the results of the audiology exam indicate adaptive devises are needed, the CEO will be responsible for purchasing and installing all adaptive equipment for fire drills to ensure the safety of individual # 1.
Staff was trained in how to support an individual with hearing loss on 11/21/19 (attachment # 63 a-g).
Regarding Levothyroxine:
10/17/19 - Staff # 3 was counseled to ensure an understanding of contacting a prescribing physician when orders are confusing or do not match labels and MARS. staff may not administer medication based on their own understanding. Requirements of 6400.144 were reviewed in order to improve the understanding of what is required to be in compliance and serve individuals in the best way possible.
12/6/19 - Medication errors under 6400.144 were entered into the EIM system (attachment #25 a-f, #26 a-f, #27 a-f).
12/11/19 - The requirements for reporting medication errors and notifying the prescribing physician were reviewed with Evergreen staff and the CEO (attachment # 28 a & b).
12/6/19 - Individual # 1 was seen by her PCP and the medication errors were discussed. (attachment #29a-c, #30, #31,). PCP ordered blood work to check thyroid level to determine if a change needs to be made in future doses of levothyroxine. Blood work was completed.
12/9/19 - Result of the blood work was obtained. Individual # 1"s TSH level is within the reference range. No change in medication was given (attachment # 32).
12/20/19 - The CEO has reviewed the 6400 regulations to ensure understanding of the requirements 6400.144 . The Program Specialist and the Director of Community Homes have reviewed the 6400.144 regulations and the Regulatory Compliance Guide with the CEO, as well as the entire plan of correction attachment # 23 a & b). |
| Not Implemented |
| 6400.145(1) | The home did not have a written emergency medication plan that included (1) the hospital or source of health care that will be used in an emergency, (2) the method of transportation to be used, or (3) an emergency staffing plan. | 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. | 10/14/19 - The Program Specialist updated the Emergency Medical Plan to include (1) the hospital or source of health care that will be used in an emergency (2) the method of transportation to be used, and (3) an emergency staffing plan. (attachment # 75) |
| Implemented |
| 6400.145(2) | The home did not have a written emergency medication plan that included (1) the hospital or source of health care that will be used in an emergency, (2) the method of transportation to be used, or (3) an emergency staffing plan. | The home shall have a written emergency medical plan listing the following: The method of transportation to be used. | 10/14/19 - The Program Specialist updated the Emergency Medical Plan to include (1) the hospital or source of health care that will be used in an emergency (2) the method of transportation to be used, and (3) an emergency staffing plan (attachment # 75 a & b).
The regulations in 6400.145 (2) were reviewed with the CEO to ensure an understanding of the requirements for the Emergency Medical Plan. The Plan of Correction was reviewed with the CEO (attachment # 23 a & b |
| Implemented |
| 6400.145(3) | The home did not have a written emergency medication plan that included (1) the hospital or source of health care that will be used in an emergency, (2) the method of transportation to be used, or (3) an emergency staffing plan. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | 10/14/19 - The Program Specialist updated the Emergency Medical Plan to include (1) the hospital or source of health care that will be used in an emergency (2) the method of transportation to be used, and (3) an emergency staffing plan (attachment # 75 a & b).
The regulations in 6400.145 (3) were reviewed with the CEO to ensure an understanding of the requirements for the Emergency Medical Plan. The Plan of Correction was reviewed with the CEO (attachment # 23 a & b). |
| Implemented |
| 6400.151(a) | Staffs #1-#3 were hired on 5/2/19, 8/12/19, and 7/1/15 respectively, and there was no evidence to support that any of the staff received a physical examination within 12 months prior to employment. All three staff have come into direct contact with Individual #1 since the individual's date of admission on 7/18/19. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The CEO set up an account with Worknet who will provide physicals and PPD's prior to staff working in the home. All current staff must complete a Worknet physical or provide documentation of a physical and PPD.
The CEO and the Human Resources Department immediately adjusted the hiring and on-boarding process for Community Home staff. No staff will be placed on shift until Apex receives physicals (with PPD) stating they are clear of communicable diseases.
10/14/19 - Staff # 1 produced a physical that was completed on 4/5/19 stating the results of her PPD test and that she was free of communicable disease (attachment # 74).
11/19/19 - Staff # 2 completed a physical through the WorkNet account, stating the results of her PPD test and that she was free of communicable disease (attachment # 74).
12/30/19 - Staff # 3 completed a physical through the WorkNet account stating the results of his PPD test and that he was free of communicable disease (attachment # 74).
12/30/19 - The rest of the Staff completed a physical through the WorkNet account. PPD's or Chest X-rays are also attached (attachment # 74 a- g).
The Director of Community Homes will maintain the documentation of completed physicals and inform staff of upcoming physical dates.
12/20/19 - The Program Specialist and the Director of Community Homes reviewed 6400.151 (a) regulations to ensure understanding of the requirement of any staff working in an Apex Community Home will complete a physical, with PPD and indication they are free from communicable disease, prior to working a shift. The Plan of Correction was reviewed with the CEO (attachment # 23 a & b). |
| Implemented |
| 6400.151(c)(2) | Staff #2 and #3 were hired on 8/12/19 and 7/1/15 respectively, and there was no evidence to support that either received a Tuberculin skin test by Mantoux method with negative results or a chest x-ray with results noted within 12 months prior to employment. Both staff have come into direct contact with Individual #1 since the individual's date of admission on 7/18/19.
Staff #1's date of hire was 5/2/19 and she did not have a Tuberculin skin test by Mantoux method with negative results completed until 5/15/19, 13 days after her date of hire | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The CEO set up an account with Worknet who will provide physicals and PPD's, prior to staff working in the home.
The CEO and the Human Resources Department immediately adjusted the hiring and on-boarding process for Community Home staff. No staff will be placed on shift until Apex receives physicals (with PPD) stating they are clear of communicable diseases.
10/14/19 - Staff # 1 produced a physical that was completed on 4/5/19 stating the results of her PPD test and that she was free of communicable disease (attachment # 74 a, 1-3).
11/19/19 - Staff # 2 completed a physical through the WorkNet account, stating the results of her PPD test and that she was free of communicable disease (attachment # 74 b 1, 2).
12/30/19 - Staff # 3 completed a physical through the WorkNet account stating the results of his PPD test and that he was free of communicable disease(attachment # 74 c, 1, 2).
12/30/19 - The rest of the Staff completed a physical through the WorkNet account. PPD's or Chest X-rays are also attached (attachment # 74 a- g).
The Director of Community Homes will maintain the documentation of completed physicals and inform staff of upcoming physical dates.
12/20/19 - The CEO has reviewed the 6400.151 (c) (2) regulations with the PS and DoCH, to ensure understanding of the requirement of any staff working in an Apex Community Home will complete a physical, with PPD and indication they are free from communicable disease, prior to working a shift.The Plan of Correction was reviewed with the CEO (attachment #23 a & b). |
| Implemented |
| 6400.181(e)(10) | Individual #1's current 9/16/19 assessment does not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | The lifetime medical history for Individual #1 will be completed by 1/10/20.
Individual # 2's Lifetime Medical history was completed (attachment # 103 a & b). |
| Implemented |
| 6400.46(a) | Staff #1, #2 and #3 have worked with Individual #1 since her date of admission on 7/18/19. According to Staff #2 and #3 during the 10/9/19 inspection, none of the staff working with Individual #1, or who have ever worked with Individual #1 in the past and are no longer employed, ever received training in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building, smoking safety procedures, 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 #1, #2 and #3 have worked with Individual #1 since her date of admission on 7/18/19. According to Staff #2 and #3 during the 10/9/19 inspection, none of the staff working with Individual #1, or who have ever worked with Individual #1 in the past and are no longer employed, ever received training in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building, smoking safety procedures, 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. | 10/15/19 - Staff # 2 received Fire Safety Training (attachment # 52 c).
10/15/19 - 2 additional staff received Fire Safety Training (attachment # 52 c).
10/21/19 - Staff # 1 and 2 additional staff received Fire Safety Training (attachment # 52 a).
10/23/19 - 1 additional staff received Fire Safety Training (attachment # 52 b).
12/20/19 - Staff # 3 completed fire safety training (attachment 48 r).
10/11/17 - The Director of Community Homes developed and implemented an Orientation syllabus that encompassed all mandatory training under 6400. 51 (b) (5) (attachment # 49 a-e ). This includes Fire Safety Training.
Any new staff working or any other Apex Healthcare Services Community Home will complete the 2 week training agenda which includes all mandatory orientation training requirements listed in 6400.51 (b) (5). The Director of Community Homes and the Program Specialist will be responsible for this training. New employees will not be assigned to work a shift alone until the orientation syllabus is completed.
The Program Specialist and the Director of Community Homes, reviewed with the CEO, the importance of having staff who are fire safety trained working in the community home. In accordance with 6400.46 (a) all new staff must go through the orientation process that includes fire safety training before working alone in the home. The Plan of Correction was reviewed with the CEO (attachment #23 a & b). |
| Implemented |
| 6400.46(c) | Staff #1 was witnessed by Licensing staff to be the only staff person in the agency vehicle while Individual #1 was transported home from her day program on the morning of 10/9/19 around 10:30am. During the annual inspection, there was no evidence to support that Staff #1 received training before working with individuals or providing transportation for individuals, in first aid techniques. Staff #1 has been working with Individual #1 since the individual's date of admission to the facility on 7/18/19.
Staff #2 has been working with Individual #1 since the staff's date of hire, 8/12/19. There is no evidence to verify that Staff #2 received training before working with the individual in first aid techniques. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques. | 10/10/19 - Staff # 2 successfully completed training with the American Red Cross in First Aid/CPR/AED (attachment #62 a-f). All but one of the staff have completed or produced certificates of training. This staff is scheduled to complete the training by 1/30/20.
10/11/19 - Effective this date, if staff on duty is accompanying Individual #1 to an appointment, Apex transportation services will drive Individual # 1 and the staff to the appointment. This will continue until staff successfully completes CPR/First aid training. Staff # 1 completed training on 12/12/19 with the America Red Cross in First Aid/CPR/AED (attachment # 62 e).
10/18/19 - A plan was developed to train all staff at home in First Aid/CPR/AED.
Certificates were obtained for 2 staff who were already trained in American Red Cross First Aid/CPR/AED (attachment # 62 d - Staff # 2 was completed 1/30/19) and (#62 a - expires 1/12/20, This staff (62 a) is Director of Community Homes. They will be scheduled in January to renew their CPR/First Aid training).
11/25/19 - One staff from Home successfully completed training with the American Red Cross in Adult First Aid/CPR/AED (attachment # 62c).
12/12/19 - Staff #1 and another staff successfully completed training with the American Red Cross in First Aid/CPR/AED (Attachment #62 e and # 62 f ).
Per the new orientation syllabus, new employees will successfully complete training with the American Red Cross in First Aid/CPR/AED. The Program Specialist and the Director of Community Homes will be responsible for scheduling the training with the Red Cross and obtaining the documentation of successful completion of the course. This documentation will be kept in the employee's file.
The 6400.46 (c) regulations were reviewed with the CEO to ensure understanding of the importance of having properly trained staff working with the individuals we support (attachment # 23). The Plan of Correction was reviewed with the CEO. |
| Implemented |
| 6400.51(b)(5) | Staffs #1-#3 were expected to performed a variety of daily jobs for Individual #1 that could have included anything in relation to medication management, assisting the individual through symptoms related to her diagnoses, providing assistance to Individual #1 with daily living skills, assuring the individual's rights, privacy and information was protected, secured and not abused or neglected, reporting incidents and emergencies, filing complaints and incidents, general daily operations of the home, assisting with money management, tracking behaviors, health concerns, and financial spending, etc.
Individual #1 was diagnosed with Diabetes Type 2, Hypertension, Hyperlipidemia, Chronic Constipation, Dementia, Mood Disorder, Mild Intellectual disabilities, Depression, Hearing impairment, Acute mania, Alzheimer, arthritis, and required her blood sugar checked daily and blood pressure checked twice weekly.
Staff #1-#3 never received training in any of Individual #1's diagnoses or the symptoms related to each diagnosis in order to provide support to the individual during any symptom of her diagnoses. Staff #1-#3 also did not receive training in incident management, incident recognizing, reporting, and investigation, the daily operations of the home, how to assist the individual with daily living skills, protecting the individual's personal information, tracking of behaviors, financial spending and notes regarding the individual's care, etc. | The orientation must encompass the following areas: Job-related knowledge and skills. | 10/11/17 - The Director of Community Homes developed and implemented an Orientation Syllabus that encompassed all mandatory training under 6400. 51 (b) (5) (attachment #49 a-e).
10/21/19 - Staff #1-3, as well as all current staff participated in Training on Individual Rights and HIPAA Training (attachment # 50 a & b) Incident Reporting (attachment # 51 a & b), Fire Safety (attachment # 52 a,b, &c), Abuse and Neglect (attachment # 53), Person Centered Practices (attachment #54 a-e), Individual # 1's eating protocol (attachment # 17 a & b), Mandated Reporting (attachment # 55 a & b) Positive Behavioral Supports and Behavioral Intervention Plans (attachment # 56 a-c), Policies and Procedures Manual (attachment #57 a) and Monthly Reviews that included Financial management, (attachment #57 b-h and attachment i -1-19), Universal/Standard Precautions and Blood Borne Pathogens (attachment # 58 a-c), Current Medication Protocol and Med Adm. Protocol as of 1/30/20 (attachment # 59 a & b), Medication Change Protocol (attachment # 60 a & b), Bowel Protocol for Individual # 1 (attachment # 61 a & b), Reporting Medication Errors (attachment # 28 a & b), CPR and First Aid (attachment #62 a - f), Supporting Someone With a Hearing Loss (attachment # 63 a-g and 118d), Developmental Disabilities (attachment # 64).
4 staff completed Effective Communication (attachment # 65 a-c and 118 i).
5 staff completed Depression (attachment # 66 a-e).
5 staff completed Hypertension (attachment # 67 a-d and 118j).
5 staff completed Osteoporosis (attachment # 68 a-e)
5 staff completed Dementia (attachment # 69 a-d and 118h).
All staff completed Fatal 4 attachment #42 a-e).
2 staff completed Bi-Polar Disorder (71 a, b).
2 staff completed Cholesterol (72 a & b).
2 staff completed Skin Integrity and Pressure Injury (72 a, b)
10/23/19 - All staff began ODP's Medication Administration Training. Their expected completion date is 1/3/20.
1/23/20 - Staff are scheduled for training on low fat, low salt, low cholesterol, low carbohydrate cooking.
2/4/20 - All staff are scheduled to participate in HCQU training at the house on Arthritis and Schizophrenia.
Any new staff working or any other Apex Healthcare Services Community Home will complete the 2 week training agenda which includes all mandatory orientation training requirements listed in 6400.51 (b) (5). The Director of Community Homes and the Program Specialist will be responsible for this training. New employees will not be assigned to work a shift alone until the orientation syllabus is completed.
1/6/20 - Training for 1 new staff has begun (attachment 118 a-j).
12/20/19 - The Program Specialist and the Director of Community Homes reviewed the requirements of 6400.51 (b) (5) with the CEO to ensure and understanding and compliance with orientation and training. This Plan of Correction was reviewed with the CEO (attachment # 23). |
| Implemented |
| 6400.52(a)(1) | Staff #3 provides direct service to Individual #1 on a daily basis, has been hired with the agency since 7/1/15, and administers the individual's medications multiple times a day. Staff #3 did not have 24 hours of training related to job skills and knowledge during their training year, or within the last year. The agency has never established a training year or ensured that staff hired with their agency for more than a year have received 24 hours of training. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | 10/17/19 - The CEO (staff # 3) established a training year by sending a letter to ODP stating the training year for Apex Healthcare Services Community Homes would be 10/1/19-10/1/20 (attachment # 47).
The CEO (staff # 3) began attending training to meet the requirement of 6400.52 (a) (1) to obtain 24 hours of training.
12/20/19 - The CEO (staff # 3) has completed: Abuse and Neglect, Fatal 4, Incident Management, Policies and Procedures Manual, Medication Administration Protocols for Evergreen, Policy and Procedure Review, Financial Responsibilities, Bowel Protocol, Reporting Medication Errors, Standard Precautions and Blood borne Pathogens, Positive Behavior Supports and Behavior intervention Plans, Diabetes and Eating Plan for control of Diabetes, 6400 Regulations and Regulatory Compliance Guide and 6100 regulations, Plan of Correction for Evergreen home for 2019 licensing, Mandated Reporting, Developmental Disabilities, Person Centered Practices and Individual Rights and HIPAA (attachment # 48 a-w) totaling 18 hours.
The CEO (staff #3) is scheduled to participate in the following future training: Dementia, Depression, Hypertension, Osteoporosis, Schizophrenia and Arthritis, and Medication Administration practicum observer, totaling 11 hours.
12/20/19 - The Program Specialist and the Director of Community homes reviewed the requirements of 6400.52 (a) (1) to ensure compliance with training requirements. The Plan of Correction was reviewed with the CEO (attachment # 23).
1/6/20 - An new employee began. She is completing all training on the new syllabus from 1/6/20-1/17/20. (Attachment of training so far # 118 a-j). |
| Implemented |
| 6400.52(c)(3) | Staff #1-#3 did not have evidence to show they are free from communicable diseases. As referenced under 6400.151(a), neither staff had a physical examination on file for a medical professional to document if the staff had a communicable disease or precautions to take that will prevent the spread of the disease to individuals. All three staff have had direct contact with Individual #1. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | An account was set up with Worknet who will provide physicals and PPD's prior to staff working in the home.
The CEO and the Human Resources Department immediately adjusted the hiring and on-boarding process for Community Home staff. No staff will be placed on shift until Apex receives physicals (with PPD) stating they are clear of communicable diseases.
10/14/19 - Staff # 1 produced a physical that was completed on 4/5/19 stating the results of her PPD test and that she was free of communicable disease (attachment # 74 a, 1-3 ).
11/19/19 - Staff # 2 completed a physical through the WorkNet account, stating the results of her PPD test and that she was free of communicable disease (attachment # 74 b 1, 2).
12/30/19 - Staff # 3 completed a physical through the WorkNet account stating the results of his PPD test and that he was free of communicable disease(attachment # 74 c, 1,2).
12/30/19 - The rest of the Staff completed a physical through the WorkNet account. PPD's or Chest X-rays are also attached (attachment # 74 a- g).
The Director of Community Homes will maintain the documentation of completed physicals and inform staff of upcoming physical dates.
Staff not in compliance will not be put on shift until compliance is documented.
12/20/19 - The CEO has reviewed the 6400.151 (c) (3) regulations with the PS and DoCH, to ensure understanding of the requirement of any staff working in an Apex Community Home will complete a physical, with PPD and indication they are free from communicable disease, prior to working a shift. The Plan of Correction was reviewed with the CEO (attachment # 23 |
| Implemented |
| 6400.163(a) | Individual #1's current, 9/9/19 physician's medication list, along with physician's medication lists from July and August 2019, includes "one touch ultra strips" The lancet devices and test strips at the home do not contain a medication label issued by a pharmacy. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | 10/14/19 - Staff #3 (CEO) contacted the pharmacy to have labels printed for the "one touch ultra strips".
10/22/19 - Individual # 1 completed an appointment with her PCP. At that appointment, the "one touch ultra strips" along with the glucometer and blood sugar checks were discontinued (attachment # 10) due to a stable and appropriate A1C level. The "one touch ultra strips" and glucometer were removed from Individual 1's medication box.
12/6/19 - Individual # 1 completed a check-up with PCP. Her A1C level continues to decrease through diet and exercise. (attachment # 46)
12/20/19 - The Program Specialist and the Director of Community Homes reviewed the requirements of 6400.163 (a) with the CEO to ensure an understanding of the importance of having labels from the pharmacy on all medications and medical equipment that is prescribed in the physician's orders. This Plan of Correction was reviewed with the CEO (attachment # 23). |
| Implemented |
| 6400.165(c) | Individual #1 was prescribed "Linaclotide (Linzess) 145mcg, take one capsule by mouth daily on an empty stomach 30 minutes before breakfast" per the individual's medication logs, the medication label and physician's medication lists. Staff #3 documented that this medication was administered to the individual at 6AM on a daily basis. However, Staff #4 documented in Individual #1's record on 10/6/19, "{the individual} woke up at 910am ate and took her morning meds"; not administering the medication as prescribed.
Furthermore, Staff #5 documented in the individual's record on 10/5/19 and 10/7/19 respectively, " I came in 8am and I met {the individual} in her bedroom. I prepared cereal for her with applesauce. {the individual} took her morning med after her breakfast" and "I arrived at {the individual's} house at 7:50am. {The Individual} was awake and her breakfast has been prepared. She ate breakfast and took her morning pills." Staff #3 documented that he administered the individual's medications to her at 6AM and 7AM before breakfast on 10/5/19 and 10/7/19, when Staff #5 reported this did not occur. Staff #3 reported during the 10/9/19 onsite inspection that sometimes Individual #1 doesn't want to get up at 6 AM and 7 AM, so he doesn't administer medications until the individual wakes up. Staff #3 never contacted the individual's physician to determine if he could administer the medications to the individual outside her scheduled medication administration times.
Individual #1 is prescribed Stool softener 250mg, take one capsule by mouth twice daily. Staff #3 stated on 10/10/19 that he did not administer the 10/8/19 evening dose and the 7AM dose on 10/9/19 of the stool softener to the individual due to her having diarrhea. Staff #3 stated he does not have an order from the individual's physician to hold the medication or not administer the medication during periods of diarrhea.
Individual #1's 9/9/19 current, physician's medication list that states, "please take the following medications: Donepezil (Aricept 10mg oral tablet) special instructions: one in AM by mouth" and "Donepezil (donepezil 5mg oral tablet) 1 tablet by mouth once daily." The individual's Donepezil (Aricept 10mg tablet) was never administered to the individual. The medication was not available at the home. The individual's physician was never contacted regarding the current, 9/9/19 physician's orders to administer an additional 10mg of Donepezil. The individual's Penn State Hershey Medication Group's current, 9/9/19 physician's medication list also states, "if this list does not agree with the medications you are taking or how you are taking them, notify your physician or pharmacist." The agency never contacted the individual's physician or pharmacist.
Individual #1's 7/29/19 physician's order medication list states she is to be administered, "Levothyroxine 100mcg tablet, take 1 tablet by mouth every other day alternating with 75mcg," and "Levothyroxine 75mcg, take 1 tablet by mouth every day." The agency was administering Levothyroxine 100mcg and 75mcg tablet together on one day, then administering 75 mg the next day. Both physician's orders for Levothyroxine could not be administered as prescribed due to how they were written. When Staff # 3, the CEO and only staff responsible for administering medications, was questioned on 10/9/19 about how he was administering both Levothyroxine orders to the individual as prescribed, he reported he did not know which orders were correct. Staff #3 also reported he never contacted the individual's prescribing physician to clarify which order(s) should be followed.
page 1, continued on next page | A prescription medication shall be administered as prescribed. | Regarding Linzess:
12/6/19 - Individual #1 had an appointment with her PCP. Linzess being administered late on 10/5/19, 10/6/19, and 10/7/19 was discussed. The PCP said that "it was fine" (attachment #39).
12/6/19 - The medication error was entered into the EIM system (attachment # 25). The medication error was reviewed with Staff # 3 (CEO) to ensure an understanding of late administration of Linzess.
Regarding the stool softener:
After research was done on standing orders regarding the stool softener, it was emphasized to Staff #3 the importance of knowing about and being able to produce written standing orders regarding the holding of medication.
8/2/19 - Individual #1 saw PCP for a routine appointment. No bowel protocol was given at that time except to hold the Colace for one day if diarrhea (attachment # 40).
10/22/19 - Individual #1 was scheduled for a PCP appointment. At that time, the physician was asked about a bowel protocol due to a diagnosis of chronic constipation. PCP stated that Individual # 1 was having a bowel movement everyday and was doing well on her Linzess and Colace. There is a standing order to hold the Colace if Individual # 1 presents with diarrhea attachment #40).
11/19/19 -The Director of Community Homes reached out to PCP for a bowel protocol. PCP responded - If no BM for 2 days, give 10 ounces of prune juice daily until having daily bowel movements. Call our office if no BM for 3 days for further instructions (attachment #41 a). A written bowel protocol (attachment # 41 b) was developed. This information was shared with Staff #3. At the time he was the only staff administering medications.
12/2/19 and 12/11/19 - and All staff of home were trained in the protocol (attachment # 41c,d).
The bowel protocol was placed in the individuals medical binder and the MAR binder in the protocol section.
10/15/19, 11/22/19, 12/11/19, 12/13/19 - The Fatal Four training was completed by all staff (attachment #42a - e).
Regarding Donepezil:
10/14/19 - The Program Specialist and the Director of Community Homes discussed the medication error with Staff # 3. It was emphasized that staff giving medication must be aware of medication changes and make those changes immediately to the MAR and the pharmacy. Staff # 3 contacted the pharmacy to obtain the correct dosage of donepezil.
Research of Individual #1's record produced verification that the medication change was written in the out patient notes from 8/16/19 by Individual # 1's neurologist (attachment # 43 a & b).
10/15/19 - Individual # 1 began receiving donepezil, 10mg daily. This was added to the MAR and the pharmacy completed new blister packs of the 10 mg tablets.
10/23/19 - A medication change protocol was developed. (attachment # 44) All staff were trained in the protocol (attachment # 45). A copy of the protocol was placed in the Individual MAR binder as well as the policy and procedure manual. |
| Implemented |
| 6400.165(c) | page 2
The individual's current, 9/9/19 physician's ordered medication list does not include an order to administer Levothyroxine 75mcg, take one tablet by mouth daily. However, this medication was available at the home and continued to be administered to the individual daily by Staff #3. On 10/9/19, Staff #3 reported to the Department that he was unaware that this medication was not listed on the individual's 9/9/19 current physician's order. Staff #3 did not know if the medication should be administered nor was the individual's physician contacted.
The same 9/9/19 physician's ordered medication list states that the individual is prescribed, "Levothyroxine 100mcg, take 1 tablet by mouth every other day alternating with 75mcg." However, the medication label available at the home, and the current October 2019 medication administration record states, "Levothyroxine Sodium 100mcg, take one tablet by mouth on alternate days (with 75mcg tablet)." The medication was being administered according to the medication label and not the current, physician's orders. Staff #3 confirmed that the individual's prescribing physician was not contacted for clarification for how to administer the medication.
The individual's prescribed Venlafaxine HCL ER was labeled with a pharmacy label that stated, "75mg tablets, take 2 capsules by mouth daily." The medication was dispensed from the pharmacy in a sheet-style pill packet, with each individual dose in a separate pod where the medication could be popped out and administered. The Venlafaxine pill packets that were examined during the 10/9/19 inspection, showed that two pills were contained within each pod that was packaged from the pharmacy. The agency confirmed that at the start of October 2019, a new pill packed was started. Staff #3 initialed as administering two, 75mg Venlafaxine tablets to the individual on 10/7/19. However, it was witnessed by Licensing staff, Staff #3, and Staff #6 that the 7th pill pod had medications popped out of the pod, yet a single pill remained in the pod. Staff #3 admitted that he is the staff that was to administer the medication and it was his mistake. Two pills were not administered to Individual #1 as prescribed on 10/7/19. | A prescription medication shall be administered as prescribed. | Regarding Medication errors:
12/6/19 - Medication errors under 6400.144 were entered into the EIM system (attachment #25 a-f, #26 a-f, #27 a-f).
12/11/19 - The requirements for reporting medication errors and notifying the prescribing physician were reviewed with staff and the CEO (attachment # 28 a &b).
12/6/19 - Individual # 1 was seen by her PCP and the medication errors were discussed. (attachment #29a-c, #30, #31,) PCP ordered blood work to check thyroid level to determine if a change needs to be made in future doses of levothyroxine. Blood work was completed.
12/9/19 - Result of the blood work was obtained. Individual # 1's TSH level is within the reference range. No change in medication was given (attachment # 32 ).
10/23/19 - All staff began ODP's Medication Administration Training. Everyone is projected to be completely Med trained by 1/3/19. This will enable staff to administer the medication instead of having one person administering medication 3 times every day.
10/23/19 - Staff # 3 began ODP Medication Administration Training to enable an understanding of the ODP regulations surrounding Medication Administration and medication errors.
1/8/20 - 3 staff have completed Medication Administration Training (attachment 34 a, b, c).
12/11/19 - Staff # 3 and All other staff completed training in Reporting Medication Errors (attachment # 28 a & b).
12/20/19 - The Program Specialist and the Director of Community Homes reviewed the requirements of 6400.165 (c) with the CEO to ensure an understanding of the importance of administering medications as prescribed.This Plan of Correction was reviewed with the CEO (attachment # 23). |
| Implemented |
| 6400.165(g) | Individual #1's licensed physician did not document on the individual's 10/8/19 medication review the reason the individual's psychotropic medication is prescribed or the need to continue the medication. This information was missing from the documentation provided at the time of licensing on 10/9/19. | 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. | 10/17/19 - New quarterly medication check form was developed. It includes a section for listing all medications, the dosage and the reason for the medication. The form was sent to the physician to fill out for the 9/3/19 appointment (attachment # 38). This form will be used for all future appointments.
The Program specialist has attended and will attend psychotropic medication quarterly checks.
1/23/19 - All staff will be trained on how to run an appointment, how to ensure the forms are completed properly, how to run a psychotropic medication check and how to run an annual physical and dental appointment. This training is taking place in the event that staff need to run an appointment.
12/20/19 - The Program Specialist and the Director of Community Homes reviewed the requirements of 6400.165 (g) with the CEO to ensure understanding of the information needed to comply with the regulations. This plan of Correction was reviewed with the CEO (attachment #23). |
| Not Implemented |
| 6400.166(a)(4) | Individual #1's July, August and September 2019 physician's medication lists and the Stool Softener medication label states the individual is prescribed, "Stool Softener 250mg, 1 tablet by mouth twice a day." However, the individual's medication administration records from the time of her admission on 7/18/19 to current, 10/9/19, list the name of the medication as "Ducosate Sod 250mg cap." The name of the medication, as it reads from the medication label, is not correctly transposed onto the medication administration record.
The medication label for Individual #1's Vitamin D 2000U states, "Vitamin D 2000U, take one capsule by mouth daily." The individual's mars from 7/18/19-10/9/19 state "Cholecalciferol 2000IU capsule, take one capsule by mouth daily dx: vit d deficiency." The name of the medication as it was listed on the medication label, was not the same name of the medication that was listed on the mar. When discussed onsite on 10/9/19, the agency was unsure if the medication being administered, Cholecalciferol, was the same form of Vitamin D as the intended medication prescribed | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | The names of the medications were clarified with the PCP and the pharmacist.
12/1/19 - The CEO contacted the pharmacy to have the label changed to read "Ducosate Sod 250mg cap" instead of "stool softener" (attachment # 36 a & b).
12/1/19 - The CEO contacted the pharmacy to have the label changed from "Vitamin D3 2000U" to "Cholecalciferol D3 2000IU" (attachment # 37).
12/16/19 - A medication log-in form was created. On the form, there is a place to note if the labels and MAR match. All staff who are medication administration trained will be responsible for checking in medications and ensuring labels and MARs match. The Program Specialist and the Director of Community Homes will ensure that both the MAR and the label match the physician's orders. This form will be used starting with the January medications (attachment # 37 a).
12/16/19 - A review sheet for matching MAR, Labels and Physician orders was created.
12/20/19 - The first review was conducted by the CEO, (Staff#3), the Director of Community Homes and the Program Specialist (attachment # 35 a & b). This form will be used once a month for 6 months. It will be evaluated in February when the first self-assessment is completed. It will be determined at that time, if this is a practical tool to continue to use on a monthly basis or if changes should be made.
12/20/19 - The Program Specialist and the Director of Community Homes reviewed the requirements for 6400.166 (a) (4) to ensure an understanding of compliance of having matching labels on medications, the MAR and the physician's orders. The CEO reviewed this plan of correction (attachment # 23). |
| Implemented |
| 6400.166(a)(7) | Individual #1's 7/29/19 physician's medication list states she is prescribed, "stool softener 250mg 1 tablet by mouth twice a day that was started on 4/29/19." The individual's July 2019 medication administration record (mar) reads that the individuals is prescribed, "ducosate sod 250 mg capsule take 1 capsule by mouth daily." The individual's July 2019 mar did not list the correct, physician's ordered, dose of the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | 10/14/19 - The 6400.166 (a) (7) requirements were reviewed with the CEO. Even though the medications are the same, the label, order and MARs did not match. The importance of following ODP's medication administration protocol was explained.
10/21/19 and 10/23/19 - All Evergreen staff were trained in the current medication administration protocol as well as how it will change when all have completed ODP's medication administration training. Staff began this training on 10/23/19. They are expected to be fully trained by 1/15/20. Through this training, staff will understand the importance of having labels, orders and MARs that match exactly.
12/1/19 - The labels, MARs and physician's orders all match for ducosate. (attachment 36a & b).
12/16/19 - A review sheet for matching MAR, Labels and Physician orders was created.
12/20/19 - The first review was conducted by the CEO, (Staff#3), the Director of Community Homes and the Program Specialist (attachment # 35 a & b). This form will be used once a month for 6 months. It will be evaluated in February when the first self-assessment is completed. It will be determined at that time, if this is a practical tool to continue to use on a monthly basis or if changes should be made.
The CEO has reviewed the 6400.166 (a) (7) regulations to ensure understanding of the requirements of Medication Administration and the reporting of medication errors. The Program Specialist and the Director of Community Homes have reviewed the 6400 regulations and the Regulatory Compliance Guide with the CEO. (attachment # 23) |
| Implemented |
| 6400.166(a)(10) | There are multiple times throughout Individual #1's record, that direct support staff working with the individual document that the individual was administered her morning medications at a different time then what is being documented by Staff #3.
Staff #4 documented in Individual #1's record on 10/6/19, "{the individual} woke up at 910am ate and took her morning meds." However Staff #3 documented on the individual's 10/6/19 medication administration record, that he administered all morning medications to the individual at her scheduled 6AM and 7AM administration times. Staff #3 reported during the 10/9/19 onsite inspection that sometimes the individual doesn't want to get up at 6 AM and 7 AM, so he doesn't administer medications until the individual wakes up. Staff #3 never recorded the actual time of administration.
Staff #5 documented on 10/5/19 in the individual's record, " I came in 8am and I met {the individual} in her bedroom. I prepared cereal for her with applesauce. {the individual} took her morning med after her breakfast." Staff #3 documented that he administered the individual's medications to her at 6AM and 7AM on 10/5/19, when Staff #5 reported this did not occur.
Staff #5 documented on 10/7/19 in the individual's record, that she (Staff #5), "I arrived at {the individual's} house at 7:50am. {The Individual} was awake and her breakfast has been prepared. She ate breakfast and took her morning pills." Staff #3 again documented on Individual #1's 10/7/19 medication administration record that he administered medications to the individual at 6AM and 7AM, when Staff #5 disputes that. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | 10/14/19 - The Program Specialist and the Director of Community Homes discussed medication administration, documentation and reporting medication errors with Staff # 3. Discussion included recording the correct time of administration is essential for the individual's health and safety and necessary for staff, physicians, and emergency personnel to have an accurate picture of the last time medication was administered. The PS and the DoCH began to check the MAR's daily.
10/23/19 - Staff # 3 began ODP Medication Administration Training.
1/8/20 - 3 Evergreen staff completed ODP's Medication Administration Training, including 4 med pours and is certified to give medications in the community Home (attachment # 34 a, b, c).
12/11/19 - Staff # 3, as well as All staff, were trained in recognizing and reporting medication errors (attachment # 28 a & b).
The CEO has reviewed the 6400.166 (a) (10) regulations to ensure understanding of the requirements of Medication Administration and the reporting of medication errors. The Program Specialist and the Director of Community Homes have reviewed the 6400 regulations and the Regulatory Compliance Guide with the CEO (attachment # 23). |
| Implemented |
| 6400.166(b) | Staff #3 initialed as administering Ducosate Sod 250mg tablet to Individual #1 at 18:00 on 10/8/19 and 07:00 on the individual's 10/9/19 medication administration record (mar). Staff #3 also recorded on the back of the mar that the medication was "wasted." When interviewed on 10/10/19, Staff #3 clarified "wasted" to mean that he held the medication. Staff #3 did not administer the medication to the individual even though he documented, by way of signature, on the front of the mar that he did. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | 10/14/19 - The Program Specialist and the Director of Community Homes discussed medication administration, documentation and reporting medication errors with Staff # 3. Discussion included recording the correct time of administration being essential for the individual's health and safety and necessary for staff, physicians, and emergency personnel to have an accurate picture of the last time medication was administered. The PS and the DoCH began to check the MAR's daily.
10/23/19 - Staff # 3 began ODP Medication Administration Training.
10/23/19 - All Evergreen staff began ODP Medication Administration Training. They will all be completed by 1/30/20. This will enable the regular staff of to be administering medications, rather than 1 person, Staff #3, to be administering all medications, 3 times a day.
1/19 - 3 staff have completed ODP's Medication Administration Training, including 4 med pours and is certified to give medications in the community Home (attachment # 106 a, b, c).
12/11/19 - Staff # 3, as well as All staff, were trained in recognizing and reporting medication errors (attachment # 28 a & b).
The CEO has reviewed the 6400.166 (b) regulations to ensure understanding of the requirements of Medication Administration and the reporting of medication errors. The Program Specialist and the Director of Community Homes have reviewed the 6400 regulations and the Regulatory Compliance Guide with the CEO (attachment # 23). |
| Implemented |
| 6400.167(b) | Medication errors as described under 6400.144, 6400.165(c), 6400.166(a)(4), and 6400.166(b) were never documented by the agency. Follow-up action and the prescriber's response was never completed, obtained, or kept in the individual's record. The individual's date of admission to the facility was 7/18/19 and at the time of the inspection on 10/9/19, no one in the agency was aware that the individual's medications were not administered as prescribed or that there were medication errors. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | 12/6/19 - Medication errors under 6400.144 and 6400.165(c) were entered into the EIM system (attachment #25 a-f, #26 a-f, #27 a-f).
12/11/19 - The requirements for reporting medication errors and notifying the prescribing physician were reviewed with staff and the CEO (attachment # 28 a &b).
12/6/19 - Individual # 1 was seen by her PCP and the medication errors were discussed (attachment #29 a-c, #30, #31). PCP ordered blood work to check thyroid level to determine if a change needs to be made in future dose of levothyroxine. Blood work was completed.
12/9/19 - Result of the blood work was obtained. Individual # 1's TSH level is within the reference range. No change in medication was given (attachment # 32).
10/10/2019 The Program Specialist completed training and received her Trainer Certification in DHS Medication Administration (attachment # 33).
10/23/19 - All staff working at home began Medication Administration Training and are targeted to finish by 1/15/20.
1/8/20 - 3 staff completed Medication Administration Training (attachment # 34 a,b,c).
Medication Administration Records will be audited and MAR reviews will be conducted monthly.
Medication practicum observations will be conducted for each staff every 6 months.
The Program Specialist, the Director of Community Home and the CEO will conduct monthly reviews of the MARS, physician orders and medication labels to ensure that all 3 match and that medication is being administered properly. The first of these reviews took place on 12/10/19 (attachment # 35 a & b). These reviews will continue for 6 months.
1/7/20 - A medication error was discovered. The label on the blister pack and the MARs did not match for Individual # 2. The HICSIS administrator was notified, it was entered into EIM, the pharmacist and the PCP were contacted. A medication error review form was completed (attachment #106) and the MARs were corrected.
The CEO has reviewed the 6400.167 (b) regulations to ensure understanding of the requirements of Medication Administration and the reporting of medication errors. The Program Specialist and the Director of Community Homes have reviewed the 6400 regulations and the Regulatory Compliance Guide with the CEO (attachment # 23 |
| Implemented |
| 6400.186 | Individual #1's current, 9/19/19 Individual Support Plan (ISP) states, "twice a week before dinner {the individual's}blood sugar level & blood pressure is checked. The individual's medication administration record (mar) states to check the individual's blood sugar one time per day. There is no evidence that the individual's blood pressure was checked from her date of admission on 7/18/19 to current, 10/9/19. As referenced under 6400.144, the individual's blood sugar levels were not checked as ordered or written in her ISP.
The individual's ISP and current, 9/16/19 assessment do not state that the individual could handle any amount of money independently, but that she needs assistance to manage finances. When conducting a physical site inspection of the home on 10/9/19, a large jar with change in it was found on the individual's dresser. The residential agency confirmed that they do not count and keep an up-to-date financial record of the individual's money in this jar even though she is not assessed to handle money independently. | The home shall implement the individual plan, including revisions. | 10/14/19 - The CEO, Program Specialist and the Director of Community Homes reviewed the instructions from the PCP regarding blood sugar and blood pressure checks. The PCP was contacted to clarify the instructions. She stated that because Individual # 1's A1C level and blood pressure numbers were within acceptable level (with medication) that daily checks for both were not necessary.
10/22/19 - Individual #1 saw her PCP (attachment # 8). At that appointment, written confirmation was received that daily blood pressure checks and twice weekly blood sugar checks were not needed at this time (attachment # 9 & 10). If the need for daily testing arises, a protocol will be obtained from the PCP. Blood work to check A1C and urine micro albumin will be completed prior to regular 4 month check-ups (attachment #11).
The Program Specialist and the Director of Community Homes will review paperwork and instructions from appointments immediately and if changes are needed will develop new protocols. The Program Specialist will contact the Supports Coordinator to make the changes in the ISP so paperwork matches.
This can be evidenced by the following recommendations:
1. At the 10/22/19 appointment, the PCP put in a referral to Ophthalmology for diabetic retinopathy screening. That appointment was completed on 11/25/19 (attachment #12).
2. The PCP put in a referral for a nutritionist. Individual # 1 completed this appointment on 11/8/19. The individual received education on what, when and how much to eat. The individual was given dietary guidelines of between 30-40 carbs per meals (3) and 15-30 carbs per snack (2). (attachment # 13, 14 and 15). The Program Specialist and the DOCH developed an eating protocol and trained the staff (attachment #16 & 17 a, 17 b).
The PS has improved the food supply at the house to include more fruits and vegetables, more protein and low carb/low sugar alternatives as well as sugar free items. At Individual #1's PCP check-up on 12/6/19, her A1C level had decreased and the PCP attributed it to the protocol and training of staff.
3. The PCP put in a referral for a podiatrist for Diabetic foot Care. Individual # 1 completed this appointment on 12/3/19. She is to return in 6 months. No complications noted (attachment # 18 & 19).
4. All staff who work at home were trained in supporting an individual who has type 2 diabetes (attachment # 20 a & 20 b, 21).
The CEO of Apex Healthcare Services has reviewed the 6400.186 regulations to ensure understanding of the importance of following the instructions from medical appointments and ensuring staff understand those directions.
12/20/19 - The Program Specialist and the Director of Community Homes have reviewed the 6400.186 regulations and the Regulatory Compliance Guide with the CEO to strengthen the understanding of the importance of implementing and following the instructions from appointments for an individual who is admitted to an Apex group home (attachment # 23).
12/5/19 - The Program Specialist re-assessed Individual # 1 for the ability to handle money. Individual #1 cannot handle any amount of money independently and continues to need assistance to manage finances. Therefore, the coins were counted, added to the financial ledger, (attachment # 24) and are being stored in a locked area with the rest of her funds. Individual # 1 knows that she can access the coins at any time, just like the rest of her funds. |
| Implemented |
| 6400.213(1)(i) | Individual #1's record does not include their date of admission accurately in all parts of their record. The Individual's record contained an identification data sheet that listed the date of admission as 7/19/19, the individual's Individual Support Plan (ISP) lists 7/17/19, and hospital ER discharge instructions list that Individual #1 was discharged on 7/18/19 to go to the group home.
As required under 6400.213(1)(vi), the individual's dated photograph must resemble the individual. Individual #1's photograph in her record did not currently resemble the individual. The individual was present for the inspection on 10/9/19 and was witnessed by Licensing representatives to not resemble the picture in her record. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | 10/14/19 - Confirmation was obtained that the correct admission date into Apex Healthcare Services community home was 7/18/19 (attachment #1).
10/15/19 - The Program Specialist contacted the Supports Coordinator to have Individual # 1's ISP corrected with the admission date of 7/18/19.
10/14/19 - The Program Specialist corrected the admission date in the Apex records for Individual #1 (attachment # 3 & 4).
10/31/19 - Apex received an updated ISP from the county, however, the admission date was not corrected.
11/5/19 - The Program Specialist spoke with the new Supports Coordinator and her supervisor to request that the ISP for Individual #1 be updated with the correct admission date.
12/4/19 - Apex received the updated ISP with the correct admission date (attachment # 5).
The CEO of Apex Healthcare Services has reviewed the 6400 regulations to ensure understanding of the requirements to run a 6400 home. The Program Specialist and the Director of Community Homes have reviewed the 6400 regulations and the Regulatory Compliance Guide with the CEO to strengthen the understanding of the importance of having matching dates throughout all paperwork for an individual who is admitted to an Apex group home (attachment # 23).
The Program Specialist and the Director of Community Homes will ensure matching dates throughout all paperwork for an individual who is admitted to an Apex group home by completing quarterly reviews of the records specifically to check dates (attachment #6).
6400.213 (1) (vi)
10/15/19 - the Program Specialist placed an updated photograph of Individual # 1 in the Medication Binder, and in her general Record binder (attachment #7 |
| Implemented |
| Article X.1007 | APEX is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including 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 #1 was hired on 5/2/19; the criminal history check wasn't requested until 5/15/19. Staff #1 also resided outside the Commonwealth in the last two years and did not have a FBI clearance record check requested until 10/4/19. At the time of the inspection on 10/9/19, the agency did not have the results of Staff #1's FBI clearance record check.
Staff #2's date of hire was 8/12/19 and the criminal history check wasn't requested until 8/21/19. At the time of the inspection on 10/9/19, the agency did not have the results from Staff #2's criminal history record check. | 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. | Through educating the Apex administrative team and the CEO, orientation training and on boarding practices have been changed to reflect the 6400 regulations. No staff will be hired without first having completed Criminal Background Checks, FBI clearances (if they have not resided in PA for the prior 2 years), physicals stating they are free from communicable diseases, and orientation that meets the standards of the 6400 regulations.
12/20/19 - The entire plan of correction, including the on boarding and orientation practices for Apex Community Home staff was reviewed with the CEO (attachment # 23 a & b).
The evidence for these changes and the plan for continuous improvement and training in these areas is located throughout this plan of correction and the attachments.
Once Apex completes their paperwork and on boarding process for Apex Healthcare Services, the Program Specialist and the Director of Community Homes will be responsible for the new two week Community Homes on boarding and orientation process for any new staff, beginning 12/23/19. New staff will not be permitted in the home, prior to having a physical certifying they are free of communicable diseases, a completed criminal background check and an FBI clearance (if they have not resided in PA for the prior 2 years). New staff will not be permitted to work a shift alone until they have completed the new orientation process for community homes (attachment # 49 a-e |
| Implemented |
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