| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The self-assessment of the home completed on 11/10/16 did not include a summary of the corrections made to the violations. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| The self-assessment of the home completed on 11/10/16 did not include a summary of the corrections made to the violations. On 11/17/16 the agency was reviewing documents and requested help via email to licensing and AE on the scoring of the instrument with no response. Although known violations were noted and corrected, it was not scored as Raphael House needed help as a new provider. The CEO/Program Specialist has been trained on regulation 6400.15(c) Attachment #56 Three months prior to the scheduled licensing renewal, the office records compliance manager will check the office records for compliance and the house supervisor will check the site and the house records for compliance. The checklist will then be scored and rescored by the CEO/Program Specialist. The agency¿s current self assessment will be rescored by Target date of 5/30/17. |
05/30/2017
| Implemented |
| 6400.22(d)(2) | Individual #1's financial record contained a receipt titled ¿Chinese massage¿ for the amount of $20, however there wasn't a date recorded on the receipt. Staff recorded on the 2/25/17 receipt for Five Below for the amount of $8.18 that "Individuals #1 and #2 both paid some¿. None of the $8.18 was documented as a purchase on Individual #1's record. Individual #1's financial record contained a 2/18/17 Dick's receipt for $1, $1, $2, $5, and $3. According to Individual #1's financial log, only $2 was subtracted from his/her account on 2/18/17 to Dick¿s. | (2) Disbursements made to or for the individual.
| The home¿s ledger review was conducted on 4/18/17. Individual #1¿s financial record did include a receipt entitled ¿chinese massage¿ for 20 dollars but the masseuse did not put the date on the receipt. The 5 below receipt stated MD (Raphael House Staff ) not Individual #2 paid some, and Individual #1 paid some as Individual #1 only had 51 cents left at the time and staff treated Individual #1. Staff did put the receipt in Individual #1¿s record but crossed it out on the ledger as staff paid for the item (staff should have subtracted 51 cents bringing Individual #1¿s balance down to zero). Regarding the Dick¿s receipt, after an interview of the the staff who took Individual #1 to pick up his/her medications, there is no violation here. The copays were 1 dollar, and 1dollar , for a total of 2 dollar copay, a 5 dollar bill was handed to the cashier and 3 dollars was the change. The staff was correct in subtracting 2 dollars from the ledger. February¿s ledger was messy and when staff made mistakes they scribbled. Individual #2¿s ledger was neat and in order. On 4/19/17 all direct support staff were trained on regulation 6400.22(d)(2) and the importance of accurate and neat ledger keeping. Attachment #55 If any receipts are handwritten, they will ensure the merchant records the date. To prevent this from occurring in the future, the new house supervisor will be monitoring all Individual records and ledgers in the home for compliance and for neatness. Corrected 4/19/17 |
04/19/2017
| Implemented |
| 6400.43(b)(1) | Staff #1 failed to provide general management of the home to include implementation of policies and procedures, admission and discharge of individuals, safety and protection of individuals, and compliance with this chapter. Staff #1 allowed Individuals #1 and #2 to be admitted to the facility without completed physicals, Tuberculin skin tests, and fire safety training. Individuals #1 and #2 were never accurately assessed in the areas of functional skills, strengths, needs, need for supervision, ability to use and avoid poisons, ability to self-administer medications, personal adjustment, needs with or without assistance, knowledge of heat sources, and knowledge of water safety. Current copies of assessment and Individual Support Plans for Individuals #1 and #2 were never kept in their record at the home for residential staff to access. Staff #1 did not ensure that hired staff received criminal background checks, physicals, Tuberculin skin tests, orientation to their job responsibilities, daily operations of the facility, policy and procedures, and health and safety needs of the individuals, including restrictive procedure plans. Staff whom did not pass the Department¿s Medication Administration Training were found to be administering medications to Individuals #1 and #2. Staff #1 did not ensure that staff were properly trained in medication administration. Individuals #1 and #2's medication labels and medication logs indicated regulatory violations. The residential home had several physical site non-compliances. The agency was found to be out of compliance with an abundant amount of 6400 regulations. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | The CEO/Program Specialist is now equipped to perform the duties needed as he/she has been given the tools necessary to complete the tasks accurately. The root cause of most of the violations stemmed from an insufficient assessment template and not having the LIS for guidance. Since the inspection on 3/2/17, the CEO has reached out to other I.D. Providers, Peers and Stakeholders in Blair County and received the necessary guidance through collaboration, extensive 6400 training and studying the LIS. Although there were not several physical site violations, there were several records violations. The CEO has reviewed the regulation 6400.43(b)(1) and has implemented it by opening up up two new positions in the Agency that will prevent deficiencies such as this going forward : Office Records Compliance Manager and House Records Compliance Manager. The Medications Administrations Trainer has been re-trained on his/her duties and responsibilities of training, accurate scoring and records keeping. No medications will be administered by anyone other than the licensed nurses on staff or the meds trainer till all records are reviewed for compliance. All med tests are to be rescored by 5/30/17. The office records compliance manager will ensure all TB¿s, Physicals, Backgrounds of staff are in accurate and meet compliance. The house records compliance manager will ensure that all records of Individuals, including fire safety training, fire drills, assessments, physicals, ISPs/Discrepancies, financial records and all records required to be in the file are there and in compliance. Corrected 5/30/17 |
05/30/2017
| Implemented |
| 6400.44(b)(2) | Staff #1 was never oriented to his/her responsibilities of program specialist. Staff #1 has been performing program specialist duties from license certification date of 2/11/16 until licensing on 3/2/17. | The program specialist shall be responsible for the following: Providing the assessment as required under § 6400.181(f) (relating to assessment). | After review of the Program Specialist¿s training relating to the assessment the Program Specialist was not properly oriented to all his/her specific duties. He/she is now properly trained 4/4/17 Attachment 1. The CEO/Program Specialist has also hired two other staff in management positions for records compliance. Attachment #1. Corrected 4/4/17 |
04/04/2017
| Implemented |
| 6400.44(b)(18) | Individual #1 is diagnosed with a seizure disorder in which he/she is prescribed Dilantin and Tegretol. Staff #1 and #2 indicated that about a month prior to Individual #1's date of admission he/she reportedly had a 30 minute long seizure. Staff #1 and #2 reported to licensing on 3/2/17 that staff working directly with Individual #1 are not trained in the type of seizures he/she is diagnosed with, a seizure protocol, or signs and symptoms of seizures. There was no documentation that any staff working with Individuals #1 and #2 were trained in their Individual Support Plans, Individual #1's restrictive behavior support plan, 1:1 staffing protocol, or Individual #2's behavior support plan. | The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. | After a review of staff records and Individual records, all staff at orientation read each respective Individual¿s ISP (Attachment #50), however the training syllabus is not specific - it just states ¿how to read an ISP¿. The newly hired office records compliance manager will have this corrected by the target date of 5/15/17. The updates were not in the file at inspection so each staff has read the updated ISP¿s (that include behavior support plans and 1:1 staffing protocol) and signed the signature sheets. Attachment #4 and Attachment #5. All Raphael House staff were trained on Individual #1¿s seizure plan created by the CSRU 5/13/16 which includes the method/approach for direct support care staff but did not name the type. Attachment #35. Direct support monitors daily for seizure activity and writes every day his/her progress notes. After review of Individual #1¿s record there was not a sign off sheet for the seizure record, only the daily progress notes verifying the monitoring for seizures. On 4/21/17 Raphael House contacted Individual #1¿s neurologist to have him write a new updated seizure protocol for direct support staff to be on and to follow since the dr. who approved the current protocol was a PA not a neurologist. All staff will be trained on it when it is given to us and a signature sheet will be created. Target date for completion will be 5/15/17/ All staff trained on restrictive procedure before its use however there was no record so on 4/19/17 all staff were retrained on it, (including the use of ethics). The Program Specialist has been trained on regulation #6400.44(b)(18) regarding staff training. Attachment #1 The office records compliance manager will assist the Program Specialist with the compliance of the training syllabus. Corrected 5/15/17 |
05/15/2017
| Implemented |
| 6400.46(a) | Staff #3's date of hire was 1/5/17. He/She was never oriented to his/her job responsibilities, daily operations of the home, and policies and procedures of the home. Staff #2 indicated to licensing that there wasn¿t a training she gives to staff regarding these topics.
¿Staff #1 provides direct support to Individuals #1 and #2. Staff #1 was never oriented to his/her job responsibilities, daily operations of the home, and policies and procedures of the home.
¿Staff #2 provides direct support to Individuals #1 and #2. Staff #2 was never oriented to his/her job responsibilities, daily operations of the home, and policies and procedures of the home.
| The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. | A review was conducted of staff #3, #2, and #1¿s files. Staff #1 wrote the Policy and Procedures manual. Staff #1 trained Staff #2 , #7 and #8 on 10/17/16 prior to enrolling Individual #1. The documentation and signed training syllabus was located in the licensing inspection binder prepared for licensing by request. Attachment # 57 and #58. Staff #1,#2, and #3 were re-orientated according to 6400.46(a) on 4/19/17. Staff #1 will be responsible for implementing the Policy and Procedures manual including the trainings. Attachment #50 The office records compliance manager will re-write the training syllabus to include all information necessary for compliance by target date of 5/10/17. This will also include all training assigned to staff from the college of direct support. Corrected 3/2/17 |
04/19/2017
| Implemented |
| 6400.46(e) | Staff #1 and #2 have been hired with the company by the licensing start date of 2/11/16. Staff #1 and #2 never received training in the areas of intellectual disability, the principles of integration, rights and program planning and implementation within 30 calendar days after the day of initial employment/licensing start date.
¿Staff #3's date of hire was 1/5/17. At the time of licensing on 3/2/17 he still never received training in the areas of intellectual disability, the principles of integration, and rights within 30 calendar days after his 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. | For staff #3, Intellectual disability, the principles of integration, and rights are always covered at every Raphael House orientation. Staff #1 was mandated by ODP to attend New Provider Orientation training on 5/18/16 prior to being allowed to open for business. It was 6.5 hours. This was reported to inspector at the time of inspection. The certificate of completion from the new provider orientation testing is Attachment #49. The certificate number is Staff #1¿s last four digits of the CEO¿s social security number, as the CEO was required to take a test and pass afterwards. As per the conversation with licensing last week, Raphael House will request a sign in sheet verifying attendance of staff #1, 2, and 7 and the content of the all day training. The source was ODP. Staff #3 was retrained on 4/19/2017 attachment #59 and #60. The newly hired office records compliance manager will revise the training syllabus by 5/15/17. Corrected 4/19/17. |
04/19/2017
| Implemented |
| 6400.46(f) | Staff #1 and #2 provided direct support to Individuals #1 and #2 from the Individuals¿ dates of admission to the facility on 10/19/16 and 11/29/16 respectively. At the 3/2/17 annual inspection, neither Staff #1 or #2 have received fire safety training. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | fter review of the staff records, staff #1 and #2 were at the trainings on 11/25/16 and 12/5/16. Although they were there, it needs to be documented. Attachments #45 and #46. The office records compliance manager will ensure all office records are compliant. The CEO will be conducting a training on May 2nd 2017 for all office clerical staff on records compliance 6400. 46(f), 6400.46(h), and 6400.46 (i). Target date: 5/2/17 Corrected 3/6/17 |
03/06/2017
| Implemented |
| 6400.46(h) | Staff #2 provided direct support to Individuals #1 and #2 from the Individuals¿ dates of admission to the facility on 10/19/16 and 11/29/16 respectively. Staff #2 has never received training in first aid techniques.
¿Staff #1 received training in first aid on 1/20/15 and not again until 2/23/17.
| 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. | Staff #1 had first aid training on file at the time of inspection. This does not expire. Staff #2 has received 1st aid from past employment and other sources, however there is no record of it in his/her file. Staff #2 will obtain 1st aid training by May 30 and the source will be the college of direct support.Staff #4 was promoted to Office Records Management and will ensure all office records are compliant. The CEO will be conducting a training on May 2nd 2017 for all office clerical staff on records compliance 6400. 46(f), 6400.46(h), and 6400.46 (i). Target date May 30, 2017 Corrected 4/28/17 |
04/28/2017
| Implemented |
| 6400.46(i) | Staff #1 and #2 provided direct support to Individuals #1 and #2 from the Individuals¿ dates of admission to the facility on 10/19/16 and 11/29/16 respectively. At the 3/2/17 annual inspection, Staff #2 never received training in first aid, Heimlich techniques, and cardio-pulmonary resuscitation. Staff #1's training in Heimlich techniques and cardio-pulmonary resuscitation was late; 1/20/15 and not again until 2/23/17. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Staff #2 will not work direct support and will have another CPR class by 5/30/17. Staff #2 CPR was late due to a blizzard (the trainer could not travel due to the weather). Staff #4 was promoted to Office Records Management and will ensure all office records are compliant. The CEO will be conducting a training on May 2nd 2017 for all office clerical staff on records compliance 6400. 46(f), 6400.46(h), and 6400.46 (i). Target date 5/30/17 Corrected 4/28/17 |
04/28/2017
| Implemented |
| 6400.68(b) | The water temperature in the upstairs bathtub was 122.7 degrees Fahrenheit. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | All Staff will be retrained on regulation 68(b) by May 19th 2017. A physical site inspection will be conducted of each home to correct the issue immediately. A home checklist will be created that will have a water temp check every month completed by Raphael House¿s new house manager. Attachment # 47. This form will be reviewed and signed off on by CEO. Target date: 5/19/2017 Corrected 3/3/17 |
03/03/2017
| Implemented |
| 6400.101 | Access to the basement was completely blocked due to the refrigerator sitting directly in front of the basement door. The basement door was locked with a latch and padlock with the key inaccessible to the individuals. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| At the time of inspection, the basement door was locked with a latch and padlock but the key was accessible to the individuals. The refrigerator was blocking the basement door.This is not an exit to the home. The key was located on on the refrigerator in the magnate box that Individual #1 purchased her/himself. On 3/3/17 the door to the basement was unlocked, cabinets were removed from the wall and the refrigerator was moved, as instructed by the licensing inspectors. All staff will be trained on May 19th 2017 on home compliance and that in case of a fire, staff/Individuals will not be able to escape that way. Raphael House¿s new house manager will be responsible for routine checks to ensure compliance. |
03/03/2017
| Implemented |
| 6400.103 | The written emergency evacuation plan for the residential facility did not include the means of transportation and an emergency shelter location. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The written emergency evacuation plan did not specify in great detail the means of transportation and emergency shelter location. Upon review, Raphael House will revise the plan to include addresses of local emergency shelter locations and means of transportation in more detail. The CEO will be responsible for the revision and implementation of the plan.The revision will be completed and staff will be retrained during the May 19th 2017 staff meeting. Targeted date: 5/19/17 |
05/19/2017
| Implemented |
| 6400.104 | Staff #1 and #2 indicated to licensing on 3/2/17 that both individuals living at the residence may require assistance to evacuate in the event of a fire. The agency did not 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 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.
| It is part of Raphael House¿s Policy that all Individuals whether they need assistance or not, be registered with the County of Blair¿s Department of Emergency Services 911 Center & Emergency Management Agency need assistance evacuating in the event of an actual fire. Staff #1 stated to licensing that Individual¿s #1 and #2 ambulate fine but doesn¿t know how Individual #1 would do (psychologically) in the event of an actual fire. Staff #1 stated that if Individual #1 needed prompting it would be verbal cues only. During the fire drills, Individuals #1 and #2 evacuate the home and make it to the designated meeting place regularly without fail (which is on top of a hill) in under a minute during awake drills and 1.5 minutes during sleep drills. A notification to local fire department in writing of the address of the home and the exact location of the bedrooms of individuals #1 will sent by 5/10/17. It will be the responsibility of the house supervisor to keep notification current. 6400.104 will also be covered during the 5/2/17 training for office clerical staff. Target date: 5/10/17 |
05/10/2017
| Implemented |
| 6400.110(b) | There wasn¿t an operable automatic smoke detector located within 15 feet of Individual #1's bedroom at the time of the physical site inspection. The smoke detector located in his/her bedroom was inoperative and another smoke detector was not within 15 feet of her room. | There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. | The smoke alarm in Individual #1¿s bedroom was not operable during licensing inspection. Although there was an operable smoke detector 12 feet 10 inches from Individual # 1¿s bedroom to the hallway, the CEO replaced the alarm. The new house manager will be responsible to inspect all alarms, replace batteries if needed, and report to the Program Specialist if any will not operate. A home compliance staff meeting will be conducted by the house supervisor on 5/19/17 to cover regulations 6400.110(b), 6400.101, 6400.68(b) 6400.67(b), 6400.64(f), 6400.66, 6400.67(a), 6400.64(b), 6400.64(a) and 6400.64(d). Target date 5/19/17 |
05/19/2017
| Implemented |
| 6400.112(c) | The written fire drill record for the residential facility did not include if the alarm was operative or if all smoke detectors in the home were operative. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | After review of the fire drill form, it was found that it did not state if the alarm was operative. The fire drill form was revised on 3/15/17 and utilized on the next fire drill conducted 3/27/17. The newly hired office records compliance manager will ensure that all templates that go to the home, including fire drill forms, have the correct information on them. The house supervisor/home records compliance manager is responsible for fire drills being conducted for compliance (awake/sleep/utilizing both exits etc). Corrected 3/15/17 |
03/15/2017
| Implemented |
| 6400.112(h) | The written fire drill record for the residential facility did not include if individuals (#1 and #2) evacuated to a designated meeting place outside the home. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | The written fire drill record template has been revised to show whether or not Individuals #1 and #2 make it to the designated meeting place and if all Individuals are able to evacuate the entire building. Attachment # 48. The new fire drill form has been introduced to staff and is being used. The house records compliance manager will ensure that Raphael House continues to perform fire drills in a timely manner. Corrected 3/15/17 |
03/15/2017
| Implemented |
| 6400.113(a) | Individuals #1 and #2 never received fire safety training to the residential facility. There dates of admission were 10/19/16 and 11/29/17 respectively. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Although it was written in other records that Individual #1 and #2 had training in fire safety, it was noticed during records review that there was not a separate record stating who was in attendance . This was corrected on 3/6/17. Attachment #45 and Attachment #46. Training was conducted on 4/4/17 for the new home records compliance manager, office records compliance manager, clerical staff and the Program specialist regarding the requirements of records to be kept in the house files. Attachment #1. Corrected 3/6/17 |
03/06/2017
| Implemented |
| 6400.141(a) | Individual #1's date of admission to the facility was 10/19/16. He/She had a physical exam completed on 12/7/15 prior to admission however, failed to receive a physical exam annually thereafter by 12/7/16. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | After reviewing Individual #1¿s record, he/she had a physical in his/her binder the time of inspection from the CSRU dated 5/12/16. An updated physical was completed 12/6/17 but was not in the individual¿s file. Raphael House had it faxed over on 3/6/17 from his/her physician¿s office and it was placed in the house binder. The Program Specialist has been trained on regulation 6400.141(a) Attachment #1 Attachment #41. The newly hired office records compliance manager will ensure that all medical records meet regulation and make it to the Individual¿s record at the home in a timely manner. Corrected 3/6/17 |
03/06/2017
| Implemented |
| 6400.141(c)(2) | The 12/7/15 physical exam for completed for Individual #1 was almost completely blank indicating to ¿see attached¿ for documentation of what occurred on 12/7/15. The agency did not have any attached documents to the 12/7/15 physical exam form. The form did not indicate that an actual physical exam was completed and the agency was not aware if one was, due to the date being prior to Individual #1's date of admission. | The physical examination shall include: A general physical examination. | After reviewing Individual #1¿s record, he/she had a physical in his/her binder the time of inspection from the CSRU dated 5/12/16. An updated physical was completed 12/6/17 but was not in the individual¿s file. Raphael House had it faxed over on 3/6/17 from his/her physician¿s office and it was placed in the house binder. The Program Specialist has been trained on regulation 6400.141(c)(2) Attachment #1 Attachment #41. The newly hired office records compliance manager will ensure that all medical records meet regulation and make it to the Individual¿s record at the home in a timely manner. Corrected 3/6/17 |
03/06/2017
| Implemented |
| 6400.141(c)(3) | Individual #1's 12/7/15 physical form did not indicate his/her immunizations. The field was blank. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | After reviewing Individual #1¿s record, he/she had a physical in his/her binder the time of inspection from the CSRU dated 5/12/16. An updated physical was completed 12/6/17 but was not in the individual¿s file. Raphael House had it faxed over on 3/6/17 from his/her physician¿s office and it was placed in the house binder. The Program Specialist has been trained on regulation 6400.141(c)(3) Attachment #1 Attachment #41. The newly hired office records compliance manager will ensure that all medical records meet regulation and make it to the Individual¿s record at the home in a timely manner. The CSRU has gotten back to Raphael House on the status of the Hep and Tetanus. They do not have records so Individual #1 has been scheduled for both Immunizations at Primary Health June 8th. Targeted date 6/8/17. |
06/08/2017
| Implemented |
| 6400.141(c)(4) | Individual #2's 1/27/17 and 11/29/16 physical forms did not contain a vision and hearing screening. The agency never had a physical form completed for him/her. The agency indicated that the doctor appointment on 1/27/17 was a physical exam although the physician record only indicated the 1/27/17 appointment was an initial appointment to set him/her up with a doctor in the area.
¿Individual #1's 12/7/15 physical form did not indicate his/her vision and hearing screenings. The field was blank.
| The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | After reviewing Individual #1 and #2¿s record, #1 had a physical in his/her binder the time of inspection from the CSRU dated 5/12/16. An updated physical was completed 12/6/17 but was not in the individual¿s file. Raphael House had it faxed over on 3/6/17 from his/her physician¿s office and it was placed in the house binder. Attachment #41. Individual #2 did not have the physical form completed on his first visit as thought by staff #2 when asked. The physical for Individual #2 was completed and it is compliant Attachment #40. Training was held on 4/4/17 for the Program Specialist, office clerical staff and the newly hired records compliance managers to review policy 6400.141(c)(4) including all requirements of physical forms for Individuals and employees. A new standard form that includes all requirements for Individual¿s physicals was created for all Raphael House Individuals and employees going forward for compliance. Corrected 3/38/17 Corrected 4/10/17 |
04/10/2017
| Implemented |
| 6400.141(c)(6) | Individual #1's 12/7/15 physical form did not indicate his/her Tuberculin skin testing with negative results. The field was blank. The agency did not attempt to have a Tuberculin skin test completed for Individual #1 since his/her date of admission on 10/19/16. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Individual #1 had a physical in his/her record at the time of inspection from the CSRU (part of his/her discharge packet) dated 5/12/16. An updated physical was completed 12/6/17 but was not in the individual¿s file. Raphael House had the current physical faxed over on 3/6/17 and placed in his/her record. Attachment #41 Both physicals include the TB via Mantoux method. Training was held on 4/4/17 for the Program Specialist, office clerical staff and the newly hired records compliance managers to review policy 6400.141(c)(6) including all requirements of physical forms for Individuals and employees. A new standard form that includes all requirements for Individual¿s physicals was created for all Raphael House Individuals and employees going forward for compliance. Corrected 3/6/17 |
03/06/2017
| Implemented |
| 6400.141(c)(7) | Individual #1's 12/7/15 physical form did not indicate his/her gynecological examination. The field was blank. The agency did not attempt to have a Tuberculin skin test completed for Individual #1 since his/her date of admission on 10/19/16. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | After review of Individual #1¿s record, Individual #1 had a physical in his/her record at the time of inspection from the CSRU (part of his/her discharge packet) dated 5/12/16. As reported to licensing at inspection, an updated physical was completed 12/6/17 but was not in the individual¿s file. Raphael House had it faxed over on 3/6/17 and placed in his/her record. Both records included breast examinations and paps. (multiple) Attachment #1 Attachment #41 Attachments #42 Attachment #43. The Program Specialist has been trained on regulation 6400.141(c)(7) to ensure that all physicals include paps and breast exams for women. Attachment #1 The newly hired office records compliance manager will ensure that all medical records meet regulation and make it to the Individual¿s record at the home in a timely manner. Corrected 3/6/17 |
03/06/2017
| Implemented |
| 6400.141(c)(10) | Individual #2's 1/27/17 and 11/29/16 physical exams did not include if he/she was free from communicable diseases. The agency did not get a physical exam form completed for Individual #2. The agency was not aware of any requirements needed for individual physicals.
¿Individual #1's 12/7/15 physical form did not indicate if he/she was free from communicable diseases. The field was blank.
| 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. | After review of Individual #1 and #2¿s physicals, Individual #2 had another exam to meet licensing requirements on 3/28/17. Attachment #40. Individual #1¿s physical completed 12/6/16 included if he/she was free from communicable diseases but was not in the file at the time of inspection. Raphael House had the physical faxed over to the office on 3/6/17 and it was placed in the Individual¿s house binder. Training was held on 4/4/17 for the Program Specialist, office clerical staff and the newly hired records compliance managers to review policy 6400.141(c)(10) including all requirements of physical forms for Individuals and employees. A new standard form that includes all requirements for Individual¿s physicals was created for all Raphael House Individuals and employees going forward for compliance. Corrected 3/6/17 |
03/06/2017
| Implemented |
| 6400.141(c)(11) | Individual #2's 1/27/17 and 11/29/16 physical exam forms and Individual #1's 12/7/15 physical exam form didn¿t include an assessment of their health maintenance needs, medication regimen, and the need for blood work at recommended intervals. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | After review of Individual #1 and #2¿s physicals, Individual #2 had another exam to meet licensing requirements on 3/28/17. Attachment #40. Individual #1¿s physical completed 12/6/16 had all of the necessary requirements for compliance but was not in the file at the time of inspection. Raphael House had the physical faxed over to the office on 3/6/17 and it was placed in the Individual¿s house binder. Training was held on 4/4/17 for the Program Specialist, office clerical staff and the newly hired records compliance managers to review policy 6400.141(c)(11) including all requirements of physical forms for Individuals and employees. A new standard form that includes all requirements for Individual¿s physicals was created for all Raphael House Individuals and employees going forward for compliance. |
03/06/2017
| Implemented |
| 6400.141(c)(12) | Individual #1's 12/7/15 physical form did not indicate his/her physical limitations. The field was blank. | The physical examination shall include: Physical limitations of the individual. | A review was conducted of Individual #1¿s physical. Individual #1¿s physical Attachment #41 is the most current physical and includes his/her physical limitations. This was not in the Individual¿s record at the home at the time of inspection. The CSRU physical dated 5/12/16 which was in the file at the time of inspection Attachment #39. Training was held on 4/4/17 for the Program Specialist, office clerical staff and the newly hired records compliance managers to review policy 6400.141(c)(11) including all requirements of physical forms for Individuals and employees. A new standard form that includes all requirements for Individual¿s physicals was created for all Raphael House Individuals and employees going forward for compliance. Corrected 3/6/17 |
03/06/2017
| Implemented |
| 6400.141(c)(13) | Individual #1's 12/7/15 physical form did not include his/her allergy to raw tomatoes. | The physical examination shall include: Allergies or contraindicated medications. | A review was conducted of Individual #1¿s physical. Individual #1¿s physical Attachment #41 is the most current physical and includes his/her allergy to raw tomatoes. This was not in the Individual¿s record at the home at the time of inspection. The CSRU physical dated 5/12/16 which was in the file at the time of inspection. Attachment #39. Training was held on 4/4/17 for the Program Specialist, office clerical staff and the newly hired records compliance managers to review policy 6400.141(c)(13) including all requirements of physical forms for Individuals and employees. A new standard form that includes all requirements for Individual¿s physicals was created for all Raphael House Individuals and employees going forward for compliance. Corrected 3/6/17 |
03/06/2017
| Implemented |
| 6400.141(c)(14) | Individual #2's 1/27/17 physical exam form and Individual #1's 12/7/15 physical exam form did not include medical information pertinent to diagnosis and treatment in case of an emergency. The fields were left blank. Individual #1 has a diagnosis of seizures and it was reported to the agency that he/she had a 30+ minute seizure within the year prior to his/her admission. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | A review was conducted of Individual #2 and #1¿s physical. Individual #1¿s physical Attachment #41 is the most current physical. It does not include Medical information pertinent to diagnosis and treatment in case of an emergency. It has been placed in the house binder. Training was held on 4/4/17 for the Program Specialist, office clerical staff and the newly hired records compliance managers to review policy 6400.141(c)(14) including all requirements of physical forms for Individuals and employees. A new standard form that includes all requirements for Individual¿s physicals was created for all Raphael House Individuals and employees going forward for compliance. Once Raphael House receives the new seizure protocol from the neurologist, all staff will be trained on it and the information will be added to the PCP record for an updated physical. Target date 5/10/17. Corrected 3/6/17 |
03/06/2017
| Implemented |
| 6400.141(c)(15) | Individual #1's 12/7/15 physical form did not include his/her special dietary instructions. The field was left blank. | The physical examination shall include:Special instructions for the individual's diet. | A review was conducted of Individual #1¿s physical. Individual #1¿s physical Attachment #41 is the most current physical. It includes Individual #1¿s dietary instructions. It has been placed in the house binder. Training was held on 4/4/17 for the Program Specialist, office clerical staff and the newly hired records compliance managers to review policy 6400.141(c)(15) covering the dietary needs of Individuals to be included on the physicals forms. The training/discussion included all areas of non-compliance on physical forms for Individuals and employees. A new standard form that includes all requirements for Individual¿s physicals was created for all Raphael House Individuals and employees going forward for compliance. Corrected 3/6/17. |
03/06/2017
| Implemented |
| 6400.142(c) | A written record of Individuals #1 and #2 dental examinations were not kept in either of their records. At the time of licensing, the agency contacted the dental office to have dental exam records faxed to the agency office. Upon review of the dental records, the forms did not indicate who the dentist was, when Individuals #1 and #2 were advised to follow up with a cleaning or what information was explained to either Individual during the visit. | A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. | A Dental cleaning was performed by University Dental for Individual #1 in October 2016. This record is in his/her file but it was not in the file at the time of inspection. Individual #2 had a cleaning scheduled for 4/3/17 but it was postponed by the dentist till 6/27/16. Attachment #38. Training was held on 4/4/17 for the Program Specialist, all clerical staff and the new records compliance managers on regulation 6400.142(c) Attachment #1. The new house records compliance manager will check all house files for compliance. The office records compliance manager will check for compliance of medical records. Corrected 4/4/17 |
04/04/2017
| Implemented |
| 6400.142(d) | Individual #2 had a dental exam completed on 2/7/17 however it did not include a teeth cleaning. | The dental examination shall include teeth cleaning or checking gums and dentures. | The dentist did not clean Individual #2¿s teeth at the first visit. Raphael House scheduled the cleaning for the dentist¿s next possible appointment 4/3/17. Raphael House was contacted by the dentist saying he had to postpone the cleaning till 6/27/17. Attachment #38. Training was held on 4/4/17 for the Program Specialist, all clerical staff and the new records compliance managers on regulation 6400.142(d) Attachment #1. The new house records compliance manager will check all house files for compliance. The office records compliance manager will check for compliance of medical records. Corrected 4/4/17 |
04/04/2017
| Implemented |
| 6400.142(f) | Individuals #1 and #2's records did not have a written plan for dental hygiene independence. Both Individuals required assistance with dental hygiene skills. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | After review of the assessment, Individual¿s #1 and #2 do need a written dental plan since they require prompting at times to brush their teeth. This plan will be incorporated into each Individual¿s progress note template by 5/5/17. All staff will be trained on the plan which will read ¿Raphael House staff will encourage Individual to brush his/her teeth twice daily.¿ Target Date 5/5/17 |
05/05/2017
| Implemented |
| 6400.144 | Individual #1 is diagnosed with a seizure disorder in which he/she is prescribed Dilantin and Tegretol. Staff #1 and #2 indicated to licensing that about a month prior to his/her date of admission he/she reportedly had a 30 minute long seizure. Staff #1 and #2 reported to licensing on 3/2/17 that Individual #1 does not have a seizure protocol for staff to follow that includes signs and symptoms of seizures, protocol for monitoring seizures, or when to contact emergency services. -Individual #1 is prescribed Perphenazine (Lorazepam) as needed for acute agitation. The residential facility did not have a protocol for when to administer the medications, signs and symptoms of acute agitation, documentation of behaviors, or when to contact management or a physician if symptoms worsen. | 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.
| Individual #1 did have a seizure protocol for staff to follow (Attachment #35 ) that included signs and symptoms of seizures, protocol for monitoring seizures (daily progress notes) and when to contact emergency services laid out for staff in Individual #1¿s Behavior Support Plan but it was not created by Raphael House. On 4/21/17 Raphael House contacted Individual #1¿s neurologist to have him write a new updated seizure protocol for direct support staff to be trained on and to follow since the dr. who approved the current protocol was a PA not a neurologist. All staff will be trained on it when it is given to us and a signature sheet will be created. Target date for the new plan and the training of staff will be 5/15/17 Corrected 5/15/17 |
05/15/2017
| Implemented |
| 6400.145(2) | The residential facility¿s written emergency medical plan did not include the means of transportation. | The home shall have a written emergency medical plan listing the following: The method of transportation to be used. | During Inspection, the Emergency Disaster/Fire and Relocation Policy was reviewed. It states on page 2 that ¿Transportation will be any vehicle including emergency vehicles under the event of a serious fire but not medical emergency. Attachment #34. Training on regulation 6400.145(2) will be held for all staff 5/19/17 by the Program Specialist and home supervisor. Target date for this plan revision will be 5/19/17 Corrected 5/19/17 |
05/19/2017
| Implemented |
| 6400.151(a) | Staff #2's date of hire was 2/11/16 and she did not have a physical completed at the time of licensing, 3/2/17. Staff #2 indicated that a previous employer refused to give her a copy of her physical form, however never attempted to get another physical completed prior to her date of hire.
¿Staff #3's date of hire was 1/5/17 and he did not have a physical completed. There was no physical form on file for him and the residential facility did not ensure he had a physical completed prior to his date of hire.
¿Staff #4's date of hire was 11/25/16 and she did not have a physical completed. There was no physical form on file for her and the residential facility did not ensure she had a physical completed prior to her date of hire. | 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. | After review of records, Staff #2 had a physical and TB test completed on 8/10/15 which was not in his/her file at inspection. A new physical and tb was completed Attachment #29 and Attachment #30. Staff #4 had a physical completed to prior to hire dated 1/27/16 and ppd dated 2/2/16 from the hospital which he/she also currently works but it was not in his/her file. It was emailed to licensing on 3/13/17. Attachment #32. Staff #3 was out of compliance. He/she had a physical and TB completed and is now in compliance. Attachment #31 The Program Specialist was trained on this regulation on 4/4/17 Attachment 1.1 (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). Corrected 4/1/17 |
04/01/2017
| Implemented |
| 6400.151(c)(2) | Staff #2's date of hire was 2/11/16 and she did not have a Tuberculin skin test completed at the time of licensing, 3/2/17.
¿Staff #3's date of hire was 1/5/17 and he did not have a Tuberculin skin test completed.
¿Staff #4's date of hire was 11/25/16 and she did not have a Tuberculin skin test completed. | 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. | After review of the employee files, Staff #2 had another TB test and physical completed, Staff #4 provided the proof of current physical and PPD from the hospital where he/she works, and staff #3 had his/her TB completed. Attachments 29-32. Training was given to the Program Specialist on regulation 6400.151(c)(2) Attachment #1 to make sure the required documentation is in each respective employee file, an office records compliance manager has been hired. Corrected 4/4/17 |
04/04/2017
| Implemented |
| 6400.151(c)(3) | Staff #2, #3, and #4 do not have a physical exam that includes a signed statement indicating they are free from communicable disease or that they are able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | After review of staff #2,3, and 4¿s physicals, it was required of staff to produce current physicals with statements indicating they were free from communicable diseases. Staff #2, #3 and #4 completed physicals include the statement indicating that they are free from communicable disease or they are able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Attachments #29-32. For quality, all other employee physicals were reviewed and are compliant. Training was given to the Program Specialist on regulation 6400.151(c)(3) Attachment #1 to make sure the required documentation is in each respective employee file, an office records compliance manager has been hired. Corrected 4/4/17 |
04/04/2017
| Implemented |
| 6400.162(a) | Individual #2 was prescribed QC Earwax Removal 6.5%. At his/her residence, he/she had two different medication labels on two different bottles of QC Earwax Removal indicating how QC Earwax Removal was to be administered. One bottle indicated ¿place 4 drops into R ear daily for 1 week,¿ while the other medication label indicated ¿place 4 drops into each ear 1 time weekly.¿ | The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. | Staff did not throw the old bottle of earwax away. The administration of QC Earwax Removal 6.5 percent to Individual #2 by placing 4 drops into his/her right ear once daily one time per week is correct. Attachment #54. Individual #1 had an appointment the day before inspection and hours after the MARS was printed. The MARS was printed with an error and not corrected. Staff #2 will be responsible for the compliance of MARS. The Program Specialist and house records compliance manager will ensure that all staff who accompany the Individuals physician¿s appointments, have the Individual bring back the discontinue orders for all medications administration. All medical staff including #2 will be trained on regulation 6400.162(a) along with medication disposal/MARS compliance including signing the back on the 1st of the month/discontinue orders - training target date of 5/8/17. Corrected 5/8/17 |
05/08/2017
| Implemented |
| 6400.163(c) | Individual #2 was prescribed Divalproex Sod and Risperidone for Mood Disorder and Hydroxyzine Pam for Anxiety. Individual #1 was prescribed Sertraline for depression and Perphenazine for anxiety/acute agitation. Neither Individual #1 or #2 had a review with documentation by a licensed physician at least every 3 months that included his/her reason for prescribing the medication, the need to continue the medication and the necessary dosages. Staff #1 and #2 indicated they were not aware medication reviews and documentation was needed. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Since the licensing inspection Raphael House has scheduled meds reviews for Individuals #1 and #2. Individual # 1 Med review was completed on April 19th 2017. Attachment #68. Individual # 2 Med review was completed on April 28th 2017 attachment #67. The CEO will be conducting a training on May 2nd 2017 and will include 6400.162(c). Corrected 4/28/17 |
04/28/2017
| Implemented |
| 6400.164(a) | Staff #5 administered medications to Individual #1 at 8pm on 3/1/17 and did not sign the back of the medication administration record. Individual #1's March 3017 medication administration record (MAR) for his/her prescribed Perphenazine did not match the medication label. The medication label for Perphenazine indicated that Individual #1 was prescribed ¿1 tablet by mouth as needed for acute agitation, may repeat every hour- no more than 3 doses in 24 hours.¿ The MAR only indicated ¿take 1 tablet by mouth as needed for acute agitation may repeat.¿
¿Individual #2 had two different medication labels on two different bottles of QC Earwax Removal indicating how QC Earwax Removal was to be administered. One bottle indicated ¿place 4 drops into R ear daily for 1 week,¿ while the other medication label indicated ¿place 4 drops into each ear 1 time weekly.¿ His/Her March 2017 MAR only indicated to ¿place 4 drops into R ear daily for one week.¿ | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | Staff #5 corrected this error right away as he/she was working direct support during inspection. He/she signed the back of the MARS immediately. Individual #1¿s MARS was corrected to include ¿every hour no more than 3 doses in 24 hours¿ for his/her PRN since this gets cut off every month. It has to be manually written on the MAR (the Pharmacy we use cannot print all of that information in one box). This will now be the sole responsibility of staff #2 when the new MARS come in from the pharmacy to be checked for accuracy. Inspection was 3/2/17 and this should have been caught and corrected on 3/1/17 when the MAR was printed. Staff did not throw away the old medication when the dosage of the same medication was changed. The error on the MARS that was printed by the pharmacy on 3/1/17 was not corrected on 3/1/17. The MARS was corrected. The administration of QC Earwax Removal 6.5 percent to Individual #2 by placing 4 drops into his/her right ear once daily one time per week is correct. Attachment #54. Individual #1 had an appointment the day before inspection and hours after the MARS was printed. All staff responsible for administering medications will be trained on regulation 6400.167(b). Staff #2 will be responsible for the compliance of MARS. The Program Specialist and house records compliance manager will ensure that all staff who accompany the Individuals physician¿s appointments, have the Individual bring back the discontinue orders for all medications administration. All medical staff including #2 will be trained on regulation 6400.164(a) along with medication disposal/MARS compliance including signing the back on the 1st of the month/discontinue orders - training target date of 5/8/17. Corrected 5/8/17 |
05/08/2017
| Implemented |
| 6400.167(b) | Individual #2 had two different medication labels on two different bottles of QC Earwax Removal indicating how QC Earwax Removal was to be administered. One bottle indicated ¿place 4 drops into R ear daily for 1 week,¿ while the other medication label indicated ¿place 4 drops into each ear 1 time weekly.¿ Staff #2 indicated to licensing staff on 3/2/17 that staff are administering QC Earwax Removal 6.5% to Individual #2 by placing 4 drops into his/her right ear once daily one time per week.¿ Staff #2 indicated there wasn¿t a medical label to indicate this was the prescribed dosage nor was there a discontinue order for the other two administration orders on the medication labels. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Staff did not throw away the old medication when the dosage of the same medication was changed. The error on the MARS that was printed by the pharmacy on 3/1/17 was not corrected on 3/1/17. The MARS was corrected. The administration of QC Earwax Removal 6.5 percent to Individual #2 by placing 4 drops into his/her right ear once daily one time per week is correct. Attachment #54. Individual #2 had an appointment the day before inspection and hours after the MARS was printed. All staff responsible for administering medications will be trained on regulation 6400.167(b). Staff #2 will be responsible for the compliance of MARS. The Program Specialist and house records compliance manager will ensure that all staff who accompany the Individuals physician¿s appointments, have the Individual bring back the discontinue orders for all medications administration. Staff training on medication disposal/MARS compliance/discontinue orders will be held 5/8/17 Corrected 5/8/17. |
05/08/2017
| Implemented |
| 6400.168(a) | Medication trainer Staff #2 certified Staff #4 to pass the Department¿s Medication Administration training on 1/30/17. However Staff #4 did not pass the cumulative written, multiple choice, handwashing and gloving tests with a passing score of 90 points or higher. Also, 3 of the 4 required medication observations were completed after Staff #4's certification date 1/30/17. Staff #4 has been passing medications without a certification.
¿Medication trainer Staff #2 certified Staff #6 to pass the Department¿s Medication Administration training on 1/30/17. However Staff #6 did not pass the cumulative written, multiple choice, handwashing and gloving tests with a passing score of 90 points or higher. Only 3 of the required 4 medication observations were completed in the initial training. The last medication observation was not completed until 2/11/17, after the certification date 1/30/17. Staff #6 has been passing medications without a certification. | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | After the review of staff #2 and #4¿s employee files, staff #2 improperly scored Staff #4 and #6¿s certification forms. Also, Staff #2 mistakenly entered the date of the face to face class (1/30/17) on the certification line instead of entering the dates for the fourth observations on the certification line. To be eligible to pass meds staff #4 and #6 will be re-trained, re-tested, pass with an accumulated score of 90, and pass four successful observations. Staff #2 will be retrained on the scoring lesson online (train the trainer), regulation 6400.168(a), and work closely with the office records compliance manager to ensure that all observations that are recorded are in the proper employee file - and by 5/5/17 all staff¿s records will be checked for compliance to this regulation. Target date of correction 5/5/2017 |
05/05/2017
| Implemented |
| 6400.168(e) | Documentation of Staff #4's medication observations completed on 2/8/17 and 2/22/17 were not kept. | Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept. | To be eligible to pass meds staff #4 will be re-trained, re-tested, pass with an accumulated score of 90, and pass four successful observations. Staff #2 will be retrained on the scoring lesson online (train the trainer), regulation 6400.168(e) - (regarding documentation of the dates and locations of medications administration training of staff persons) Staff #2 will work closely with the newly hired office records compliance manager to ensure that all observations once recorded, are kept in the employee file - and by 5/5/17 all staff¿s records will be checked for compliance to this regulation. Target date of correction 5/5/17 |
05/05/2017
| Implemented |
| 6400.181(b) | Individual #1 required 1:1 supervision at all times starting 12/19/16. His/Her 12/10/16 assessment was not updated to indicate the revised need for service. | If the program specialist is making a recommendation to revise a service or outcome in the ISP as provided under § 6400.186(c)(4) (relating to ISP review and revision), the individual shall have an assessment completed as required under this section. | After an assessment review, Individual #1 required 1:1 supervision at all times starting 12/19/16. His/Her 12/10/16 assessment was not updated to indicate the revised need for service. The recommendation to revise the service arose mid November 2016, prior to the 60 day initial assessment completion and due date. Individual #1¿s behaviors were quickly escalating and eventually led to police activity. The finalization of the 1:1 service approval happened 12/19/17. If the program specialist is making a recommendation to revise a service or outcome in the ISP as provided under § 6400.186(c)(4) (relating to ISP review and revision), the individual shall have an assessment completed as required under this section. (in this case it should have been done immediately) Attachment #23 is Individual #1¿s revised Initial assessment which is also updated to show the behavior/need for service (all in one). The Program Specialist was trained on his/her duties on 4/4/17. Attachment #1 and on 6400.181(b) on 4/18/17. Attachment #52. Both of the records compliance managers will work closely with the Program Specialist to relay discrepancies and/or missing information from the assessment and house record, including the need for updates in assessments to be in the house file when services are recommended or revised. Individual #2 came with 1:1 supports and his/her initial assessment included this need. His/her assessment revision target date under the new template is 5/1/17. Corrected 04/16/2017. |
05/01/2017
| Implemented |
| 6400.181(c) | Individual #2's 12/29/16 initial assessment and Individual #1's 12/10/16 initial assessment did not indicate if it was based on assessment instruments, interviews, progress notes, and observations. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | After review of the assessments, the Program Specialist did base the assessments of Individual #1 and #2 off of observations, progress notes and interviews, however the assessment did not state what the instruments were based off of. This was corrected with the revision of Individual #2¿s assessment. Attachment #23. Individual #2's assessment will use the same format and will be submitted to licensing as attachment #24. The agency¿s target date for Individual #2's assessment completion is 5/1/17. The Program Specialist has been trained on regulation 6400.181(c). Attachment #52. Both of the records compliance managers will work closely with the Program Specialist to relay discrepancies and/or missing information from the assessment and house record. Corrected 5/1/17 |
05/01/2017
| Implemented |
| 6400.181(d) | The program specialist did not sign or date Individual #1's 12/10/16 assessment. | The program specialist shall sign and date the assessment. | After a review of the assessment, The program specialist did not sign or date Individual #1's 12/10/16 assessment. Individual #1's assessment has been revised entirely Attachment #23 and Individual #2's will use the same format/template. It was signed and dated. Individual #2¿s assessment was signed and dated. The CEO/Program Specialist has been trained on regulation 6400.181(d) Attachment #52 and the importance of signing and dating the assessment. Both of the records compliance managers will work closely with the Program Specialist to relay discrepancies and/or missing information from the assessment and house record. Target date for Individual #2's assessment revision is 5/1/17. Corrected 4/16/17 |
04/16/2017
| Implemented |
| 6400.181(e)(1) | Individual #2's 12/29/16 assessment and Individual #1's 12/10/16 assessment did not include their strengths, needs, and preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | After a review of the assessments, Individual #2's 12/29/16 assessment and Individual #1's 12/10/16 assessment did not include their strengths, needs, and preferences after a review of assessment records. Individual #1¿s assessment now includes his/her strengths, needs and preferences. Attachment#23 The Program Specialist was trained on regulation 6400.181(e)(1) Attachment #52 and the importance of having strengths needs and preferences included in the assessment. Raphael House has consulted with other agencies/stakeholders and has constructed an assessment that is now satisfactory for compliance with all 6400.181 regulations. Individual #2¿s assessment will be revised by 5/1/17. Both of the records compliance managers will work closely with the Program Specialist to relay discrepancies and/or missing information from the assessment and house record. Corrected 04/16/2017. |
04/16/2017
| Implemented |
| 6400.181(e)(2) | Individual #2's 12/29/16 assessment and Individual #1's 12/10/16 assessment did not include his/her likes, dislikes, and interests. | The assessment must include the following information: The likes, dislikes and interest of the individual. | After reviewing the assessments on 4/7/17, it was found that the template of the assessment used for Individual #1 and #2 prior to inspection did included interests and likes but not dislikes. Raphael House has consulted with other agencies/stakeholders and the Licensing Instrument and on 4/11/17 constructed an assessment template that is now satisfactory for compliance with all 6400.181 regulations. Individual #1¿s assessment has been revised using the new template to include likes, interests and dislikes. Attachment #23. Target date for Individual #2¿s correction is 5/1/17. The Program Specialist was trained on regulation 6400.181(e)(2) Attachment #52 and the importance of having likes, interests and dislikes included in the assessment. Both of the records compliance managers will work closely with the Program Specialist to relay discrepancies and/or missing information from the assessment and house record. Corrected 4/16/2017 |
04/16/2017
| Implemented |
| 6400.181(e)(3)(i) | Individual #2's 12/29/16 assessment and Individual #1's 12/10/16 assessment did not include his/her current level of acquisition of functional skills. | The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. | After a review of both assessments, Individual #2's 12/29/16 assessment and Individual #1's 12/10/16 assessment did not include his/her current level of acquisition of functional skills. Individual #1's assessment has been revised entirely Attachment #23 and Individual #2's will use the same format. The new assessment template includes the current level of acquisition of functional skills for each Individual. Target date for Individual #2's assessment completion is 5/1/17. The Program Specialist was trained on regulation 6400.181(e)(3)(i) Attachment #52 Both of the records compliance managers will work closely with the Program Specialist to relay discrepancies and/or missing information from the assessment and house record. Corrected 4/16/17 |
04/16/2017
| Implemented |
| 6400.181(e)(3)(ii) | Individual #1's 12/10/16 assessment did not include his/her current level of communication skills. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Communication. | After the assessments review, Individual #1's 12/10/16 assessment did not include his/her current level of communication skills A new template was created by Raphael House on 4/11/17 that adheres to all 6400.181 regulations. Individual #1's assessment has been revised entirely. Attachment #23 and Individual #2's will use the same format. It includes the current level of communication skills for each Individual. Target date for Individual #2's assessment completion is 5/1/17. The Program Specialist was trained on regulation 6400.181(e)(3)(ii) Attachment #52. Both of the records compliance managers will work closely with the Program Specialist to relay discrepancies and/or missing information from the assessment and house record. Corrected 4/16/17 |
04/16/2017
| Implemented |
| 6400.181(e)(3)(iii) | Individual #2's 12/29/16 assessment and Individual #1's 12/10/16 assessment did not include his/her current level of personal adjustment skills. | The individual's current level of performance and progress in the following areas: Personal adjustment. | After review of the assessments of Individuals #1 and #2, they did not address his/her current level of personal adjustment skills. Individual #1¿s assessment has been revised to include his/her current level of person adjustment skills Attachment #23 and Individual #2¿s will use the same template. The target date for his/her assessment revision is 5/1/17. The Program Specialist has been trained on regulation 6400.181(e)(3)(iii) Attachment #52 Both of the records compliance managers will work closely with the Program Specialist to relay discrepancies and/or missing information from the assessment and house record. Corrected 4/16/17 |
04/16/2017
| Implemented |
| 6400.181(e)(3)(iv) | Individual #1's 12/10/16 assessment did not include his/her current level of needs with or without assistance. | The assessment must include the following information: The individual¿s current level of performance and progress in the following areas: Personal needs with or without assistance from others. | After review of both assessments, Individual #1's 12/10/16 assessment did include his/her current level of needs with or without assistance on page 11 but not in acceptable detail. Individual #1's assessment has been corrected in it¿s entirety Attachment #23 and Individual #2's will use the same template (target date 5/1/17). The new template includes the current level of needs with or without assistance. The Program Specialist has been trained on regulation 6400.181(e)(3)(iv) Attachment #52. Both of the records compliance managers will work closely with the Program Specialist to relay discrepancies and/or missing information from the assessment and house record. Corrected 4/16/17 |
04/16/2017
| Implemented |
| 6400.181(e)(4) | Individual #2's 12/29/16 assessment and Individual #1's 12/10/16 assessment did not include his/her need for supervision. | The assessment must include the following information: The individual's need for supervision.
| After a review of both assessments,Individual #2's 12/29/16 assessment and Individual #1's 12/10/16 assessment did not include his/her need for supervision. Individual #1's assessment has been corrected Attachment #23 and Individual #2's will use the same format. The new template includes the current need for supervision for each Individual. Target date for Individual #2's assessment completion is 5/1/17. The Program Specialist has been trained on regulation 6400.181(e)(3)(4) Attachment #52. Both of the records compliance managers will work closely with the Program Specialist to relay discrepancies and/or missing information from the assessment and house record. Corrected 4/16/17 |
04/16/2017
| Implemented |
| 6400.181(e)(5) | Individual #1's 12/10/16 assessment did not include his/her ability to self-administer medications. | The assessment must include the following information: The individual's ability to self-administer medications. | After a review of the assessments Individual #1's assessment has been revised entirely Attachment #23 and Individual #2's will use the same format. It includes his/her ability to self-administer medications for each Individual. Target date for Individual #2's assessment completion is 5/1/17. The Program Specialist has been trained on regulation 6400.181(e)(3)(4) Attachment #52. Both of the records compliance managers will work closely with the Program Specialist to relay discrepancies and/or missing information from the assessment and house record. Corrected 4/16/17 |
04/16/2017
| Implemented |
| 6400.181(e)(9) | Individual #1's 12/10/16 assessment didn¿t include his/her functional and/or medical limitations. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | Both assessments were reviewed. Individual #1's assessment has been revised entirely Attachment #23 and Individual #2's will use the same format. It includes his/her functional and/or medical limitations for each Individual. Target date for Individual #2's assessment completion is 5/1/17. The Program Specialist has been trained on regulation 6400.181(9) Attachment #52. Both of the records compliance managers will work closely with the Program Specialist to relay discrepancies and/or missing information from the assessment and house record. Corrected 4/16/17 |
04/16/2017
| Implemented |
| 6400.181(e)(12) | Individual #2's 12/29/16 assessment and Individual #1's 12/10/16 assessment did not include recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Individual #1's assessment has been revised entirely Attachment #23 and Individual #2's will use the same format. It includes recommendations for specific areas of training, programming and services for each Individual. The Program Specialist has been trained on regulation 6400.181(12) Attachment #52. Target date for Individual #2's assessment completion is 5/1/17. Both of the records compliance managers will work closely with the Program Specialist to relay discrepancies and/or missing information from the assessment and house record. Corrected 4/16/17 |
04/16/2017
| Implemented |
| 6400.181(e)(14) | Individual #1's 12/10/16 assessment did not include her knowledge of water safety. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Both assessments were reviewed. Individual #1's assessment has been revised entirely Attachment #23 and Individual #2's will use the same format. It includes the current knowledge of water safety and ability to swim for each Individual. The Program Specialist has been trained on regulation 6400.181(14) Attachment #52. Target date for Individual #2's assessment completion is 5/1/17. Both of the records compliance managers will work closely with the Program Specialist to relay discrepancies and/or missing information from the assessment and house record. Corrected 4/16/17 |
04/16/2017
| Implemented |
| 6400.181(f) | Individual #2's 12/29/16 assessment and Individual #1's 12/10/16 assessment was not sent to any team members. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| After review of each Individual¿s house records, there was no written documentation showing evidence that the supports coordinators received the initial assessments. Individual #1¿s revised assessment was emailed on to the SC by the Program Specialist on 4/17/17. Attachment #53. The Program Specialist has been trained on regulation 6400.181(f) Attachment #52. Target date for Individual #2's assessment completion is 5/1/17. Both of the records compliance managers will work closely with the Program Specialist to relay discrepancies and/or missing information from the assessment and house record. Corrected 4/17/17. |
04/17/2017
| Implemented |
| 6400.183(1) | Individual #1's Individual Support Plan (ISP) did not include an expected residential outcome chosen by the individual and individual¿s plan team. His/Her ISP indicated that ¿goals will be developed following an assessment period. (residential)¿ | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Services provided to the individual and expected outcomes chosen by the individual and individual's plan team. | Individual #1's Individual Support Plan (ISP) did not include an expected residential outcome chosen by the individual and individual¿s plan team. His/Her ISP indicated that goals will be developed following an assessment period. (residential). The ISP that was viewed at the time of licensing inspection was not the current ISP. Training on regulation 6400.183(1) was completed by the Program Specialist. Attachment #22.1. The assessment information is comprehensive and includes all information needed for compliance to all 6400 regulations. Attachment #23. The assessment was to be presented to Individual #1¿s SC at the 4/20/17 DDTT and Restrictive Policy meeting but the transfer from McKean to Blair county happened. A new SC was appointed since the meeting. His/Her new Supports coordinator from Blair was given the revised assessment and all pertinent information needed for an accurate and complete ISP. An introduction meeting is scheduled for 4/27/17 at 9:00 am where Individual #1 will meet his/her new SC along with the Program Specialist, the Office Records Compliance Manager, and the House Supervisor/House Records Compliance Manager. A plan will be made to set up a team meeting for a complete revision of Individual #1¿s ISP. The house records compliance manager will report any missing information from the Individual record, including the current ISP, or ISP updates to the Program Specialist for correction. Discrepancies/missing information and documentation will be reported and noted in a log in the back of each Individual¿s house binder under the ¿compliance¿ tab. Target date for revision of ISP 5/30/17 |
05/30/2017
| Implemented |
| 6400.183(4) | Individual #1's ISP did not indicate his/her need for 1:1 intensive supervision or a protocol and schedule outlining the method of evaluation used to determine progress towards a high level of independence. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. | After review of Individual #1¿s record on 4/18/17, Individual #1's current ISP did indicate his/her need for 1:1 intensive supervision and a protocol and schedule outlining the method of evaluation used to determine progress towards a high level of independence. The need is on the bottom of page 22 and the schedule is top of page 23 but at the time of inspection the new revised current ISP was not in the file nor was there an assessment that met all of the requirements necessary for compliance. The current revised ISP was placed in the house file. The newly hired office records compliance manager will ensure that all ISPs meet compliance before they leave the office. The Program Specialist and office records compliance manager have been trained on regulation 6400.183(4) Attachment #22.1 Corrected 4/5/17 |
04/05/2017
| Implemented |
| 6400.183(5) | Individual #2 was prescribed Divalproex Sod and Risperidone for Mood Disorder and Hydroxyzine Pam for Anxiety. His/Her Individual Support Plan (ISP) did not contain a protocol to address his/her social, emotional and environmental needs. The agency was not aware that a protocol was required.
¿Individual #1 was prescribed Sertraline for depression and Perphenazine for anxiety/acute agitation. His/Her Individual Support Plan (ISP) did not contain a protocol to address his/her social, emotional and environmental needs. The agency was not aware that a protocol was required.
| The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | After a records review, Individual #1 and Individual #2¿s ISP¿s did not include a protocol to address his/her social, emotional and environmental needs, they did have behavior support plans neither of which included SEEN. Both ISP¿s will need revision due to the recent assessment revisions and also due to the recent updates to each Individual¿s BSP¿s. (typo on Individual #1's revised assessment - seen plan not included - team is working on it) A scheduled team meeting for revision of Individual #1¿s ISP is May 9, 2017 at 9am (and if all parties cannot make it that day, the rescheduled date will be May 11, 2017). The Program Specialist and office records compliance manager have been trained on regulation 6400.183(5) Attachment #22.1 and the importance of all necessary documents (ISP¿s, Assessments) having the social, emotional and environmental needs of the individual addressed.
Individual #2¿s next behavior support meeting is 4/27/17 at 1:00pm where the specialist will train the house supervisor, Program Specialist, and direct support staff on Individual #2¿s needs and discuss the discrepancies found in the updated April BSP/need for more plan revisions or a SEEN plan. Expected target date for both ISP¿s to be corrected by SC¿s is 5/30/2017 Corrected 5/30/17 |
05/30/2017
| Implemented |
| 6400.183(6)(i) | Individual #1's Individual Support Plan (ISP) did not include a protocol to eliminate the use of restrictive procedures. His/Her ISP did not include an assessment to determine the causes or antecedents of his/her behaviors. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: An assessment to determine the causes or antecedents of the behavior. | After a review of Individual #1's Individual Support Plan (ISP), it did not include a protocol to eliminate the use of restrictive procedures. His/Her ISP that was in the file did not include an assessment to determine the causes or antecedents of his/her behaviors. After the 4/20/17 team meeting the team and Individual #1 has decided to abolish the restrictive procedure all together. Also since the inspection, Individual #1 has been assigned a new SC and will be revising the ISP to conform to the revised, compliant assessment. Any time a restrictive procedure is used, the ISP must include a protocol to eliminate the use of restrictive procedures, and a revised assessment to address the causes or antecedents of his/her behaviors. The Program Specialist and office records compliance manager has been trained on regulation 6400.183(6)(i). Attachment #7.4. The office records compliance manager will check each ISP and assessment for compliance and report to the Program Specialist if any areas of noncompliance are found prior to the document being placed in the home record. Corrected 4/19/17. |
04/19/2017
| Implemented |
| 6400.183(6)(ii) | Individual #1's Individual Support Plan (ISP) did not include a protocol for addressing the underlying causes or antecedents of the behavior. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: A protocol for addressing the underlying causes or antecedents of the behavior. | After review of Individual #1's Individual Support Plan (ISP), it did not include a protocol for addressing the underlying causes or antecedents of the behavior. After the 4/20/17 team meeting the team and Individual #1 has decided to abolish the restrictive procedure all together. Also since the inspection, Individual #1 has been assigned a new SC and will be revising the ISP to conform to the revised, compliant assessment. Any time a restrictive procedure is used, the ISP must include a protocol for addressing the underlying causes or antecedents of the behavior. The Program Specialist has been trained on regulation 6400.183(6)(ii). Attachment #22.1. The office records compliance manager will check each ISP for compliance before it is placed at the home. Corrected 4/19/17 |
04/19/2017
| Implemented |
| 6400.183(6)(iii) | Individual #1's Individual Support Plan (ISP) did not include a method and timeline for eliminating the use of restrictive procedures. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following: The method and timeline for eliminating the use of restrictive procedures. | After review of Individual #1's Individual Support Plan (ISP), it did not include a method and timeline for eliminating the use of restrictive procedures. After the 4/20/17 team meeting the team and Individual #1 has decided to abolish the restrictive procedure all together. Also since the inspection, Individual #1 has been assigned a new SC and will be revising the ISP to conform to the revised, compliant assessment. Any time a restrictive procedure is used, the ISP must include a method and timeline for eliminating the use of the procedure and the Program Specialist has been trained on regulation 6400.183(6)(iii). Attachment #22.1. The office records compliance manager will check each ISP for compliance before it is placed at the home. Corrected 4/19/17 |
04/19/2017
| Implemented |
| 6400.183(6)(iv) | Individual #1's Individual Support Plan (ISP) did not include a protocol for intervention or redirection without utilizing restrictive procedures. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to eliminate the use of restrictive procedures, if restrictive procedures are utilized, and to address the underlying causes of the behavior which led to the use of restrictive procedures including the following A protocol for intervention or redirection without utilizing restrictive procedures. | |
| Implemented |
| 6400.186(c)(1) | Individual #1's 12/19/17 Individual Support Plan (ISP) review did not include a review of his/her monthly documentation of his/her participation and progress towards an ISP outcome. | The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. | After a records review on 4/18/17, Individual #1¿s 12/19/17 Individual Support Plan (ISP) review did not include a review of his/her monthly documentation of his/her participation and progress towards an ISP outcome. The Program Specialist was trained on regulation 6400.186(c)(1) on 4/19/17 Attachment #22.1. The review will be corrected and submitted to licensing as Attachment #13.1. The review of the documentation of his/her participation and progress towards and ISP outcome will be added to the ISP review by the target date of 5/10/17. The Program Specialist will ensure that documents are compliant and contain all necessary information from the office to the Individual¿s record books. The office and home records compliance managers will also be checking the records for ISP/ISP review compliance. Corrected 5/10/17 |
05/10/2017
| Implemented |
| 6400.186(c)(2) | Individual #2's 1/29/17 Individual Support Plan (ISP) review did not include a review of his/her behavior support plan or 1:1 supervision needs.
¿Individual #1's 12/19/16 Individual Support Plan (ISP) review did not include a review of his/her 1:1 supervision or restrictive behavior supports plan.
| The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | After review of Individual #2¿s record on 4/18/17, his/her ISP review did not include a review of his/her behavior support plan. His/Her behaviors only were noted. The Program Specialist and the office records compliance manager were trained on regulation 6400.186(c)(2) Attachment #22.1 and all that is required in an ISP Review on 4/19/17. At the request of the Program Specialist, on 4/19/17 Kaleidescope Behavior Services revised Individual #2¿s behavior support plan. On 4/21/17 the SC added the updated plan to his/her ISP (Attachment #16.2 showing behavior support and 1:1). After further review of the BSP, the Program Specialist noticed that it did not include some relevant, more current information related to Individual #2¿s behavior and the safety of Individual #1 and, Individual #2, and support staff. On 4/27/17 at 1:00 there is a face to face meeting at the home to discuss possible additions to the BSP including the need for a SEEN plan. Individual #2¿s ISP review will be revised by the Program Specialist to include the updated plan and more detailed information regarding his/her 1:1 supervision needs by the target date of 5/30/17. The office records compliance manager will ensure that ISP¿s meet compliance prior to being filed at the home. If any missing information or discrepancies are found, the he/she will report them to the Program Specialist for correction. Target date 5/30/17 |
05/30/2017
| Implemented |
| 6400.186(d) | Individual #2's 1/29/17 Individual Support Plan (ISP) review and Individual #1's 12/19/16 review was not sent to any team member. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | After review of Individual #1 and #2's records, there was no proof that ISP review documentation was sent to his/her teams. The Program Specialist was trained on regulation 6400.186(d) on 4/19/17 Attachment #22.1. as was the office records compliance manager. The current Program Specialist will be responsible for sending the reviews out to each respective Individual¿s team and the home records compliance manager will ensure that the proof is kept in the Individual¿s house file. Attachment #13, Attachment #14 and Attachment #17 Corrected 4/19/17 |
04/19/2017
| Implemented |
| 6400.186(e) | The program specialist did not notify Individuals #1 or #2's plan team members of the option to decline the Individual Support Plan (ISP) review documentation. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | After a review of Individual #1 and #2¿s record, the Program Specialist did not notify Individuals #1 or #2's plan team members of the option to decline the Individual Support Plan (ISP) review documentation. The Program Specialist was trained on his/her job responsibilities on 4/4/17 and trained on regulation 6400.186(e) along with the office records compliance manager on 4/19/17. Attachment #1 and Attachment #22.1. The corrected options to decline have gone out Attachment #14 and Attachment #17 and the office records compliance manager will work closely with the CEO/Program Specialist Corrected 4/13/17 |
04/13/2017
| Implemented |
| 6400.194(b) | Individual #1's restrictive review committee was comprised of 2 members who provided direct services to him/her, Staff #1 and #2, and 2 members who did not provide direct services him/her. His/Her restrictive procedure review committe does not include a majority of persons who do not provide direct services to him/her. | The restrictive procedure review committee shall include a majority of persons who do not provide direct services to the individual.
| After review of the document on 3/10/17, we found this to be a clerical error. The restrictive policy committee did include a majority of persons who do not provide direct services to the individual. All members of Individual¿s DDTT team (except for her/his Psychiatrist) were part of the restrictive procedure review committee. Staff #2 was trained on regulation 6400.194(b) on 4/19/17 Attachment # 7.4 and the importance of accurate attendance records pertaining to restrictive procedure committee meetings. The restrictive clerical error has been corrected to show all who were in attendance. Attachment #11. There will be a separate sign in sheet and/or email confirmations of all parties who participated via conference call. If there is any content missing from the Individual¿s house record, including the restrictive procedure plan, the house records compliance manager will report it to the writer of the plan (he/she will have a checklist of required content). Restrictive procedure review committee met again 4/20/17. Attachment #11.1 and Attachment #11.2 Corrected 3/10/17 |
03/10/2017
| Implemented |
| 6400.194(d) | Individual #1's restrictive procedure committee met via conference call on 12/13/16 for 1 hour and 47 minutes. There was no written record of the meeting and activities of the restrictive procedure review committee for the 12/13/16 meeting. | A written record of the meetings and activities of the restrictive procedure review committee shall be kept.
| After a document review on 4/18/17, Individual #1's restrictive procedure committee met via conference call on 12/13/16 for 1 hour and 47 minutes. There was a written record of the meeting included in the plan at the bottom but not on a separate form and not in great detail. And there was not a sign in sheet. The activity of the meeting was to implement the restrictive procedure plan as written. The target date for the re-writing of the separate record of minutes of the 12/13/17 meeting will be 5/10/17. On 4/19/17 the house compliance manager and staff #2 were trained on regulation 6400.194(d) and the importance of minutes. Attachment #7.4. The team met again on 4/20/17, minutes were kept and a signature sheet was created. Those who were present via conference call emailed in confirmation of their attendance. Attachments #11.1 and 11.2 The office records compliance manager will now be responsible for committee minutes if ever a restrictive policy procedure plan is needed. Corrected 4/19/17 |
04/19/2017
| Implemented |
| 6400.195(d) | Individual #1's restrictive procedure review committee meeting completed on 12/13/16 was not dated by the program specialist. | The restrictive procedure plan shall be reviewed, approved, signed and dated by the chairperson of the restrictive procedure review committee and the program specialist, prior to the use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least every 6 months.
| After a records review of Individual #1¿s restrictive procedure review committee meeting documentation conducted 3/10/17, it was found that it was not dated by the Program Specialist. On 3/10/17 the Program Specialist dated the document. Attachment #11. The Program Specialist was trained on 4/19/17 on regulation 6400.195(d) and the importance of dating the the review committee meeting documentation. Attachment #22.1. The house records compliance manager will check for missing signatures and missing dated documents in the Individual¿s house binders. Corrected 4/19/17. |
04/19/2017
| Implemented |
| 6400.195(e)(1) | Individual #1's restrictive procedure plan did not include the specific behavior to be addressed and the suspected antecedent or reason for the behavior. | The restrictive procedure plan shall include: The specific behavior to be addressed and the suspected antecedent or reason for the behavior.
| After re-review of Individual #1¿s restrictive procedure plan on 4/18/17, Individual #1¿s restrictive procedure plan did not include the specific behavior to be addressed and the suspected antecedent or the reason for the behavior. It addressed the incident itself and only that the behavior was ¿risky¿. The plan failed to go into enough detail to include the actual behavior, antecedent and reason. On 4/19/17 staff #2 was trained on regulation 6400.195(e)(1) Attachment #7.4 and on 4/20/17 staff #2 met with Individual #1¿s team including the behavior specialist to get clarification on the antecedent and reason for the behavior. Although these things were clarified so that the plan could be revised for compliance, Individual #1 and the team agreed that enough progress had been made that Individual #1 would not need the time restraint on the tablet. Any time there is a restrictive procedure plan written for an individual the writer will review regulations 6400.192-6400.206 prior to writing it. If there is any content missing from the Individual¿s house record, including the restrictive procedure plan, the house records compliance manager will report it to the writer of the plan. Attachment #11 Corrected 4/19/2017 |
04/19/2017
| Implemented |
| 6400.195(e)(2) | Individual #1's restrictive procedure plan did not include the single behavioral outcome desired stated in measurable terms. | The restrictive procedure plan shall include: The single behavioral outcome desired stated in measurable terms. | After re-review of Individual #1¿s restrictive procedure plan on 4/18/17, it did not include the single behavioral outcome desired stated in measurable terms. Although the plan addressed the behavior and the desired outcome, and outcome date of May 10th 2017 the outcome was not shown in measurable terms. On 4/19/17 staff #2 was trained on regulation 6400.195(e)(2). Attachment #7.4 Although a meeting was set in place so that the plan could be revised for compliance, Individual #1 and the team agreed that enough progress had been made that Individual #1 would not need the time restraint on the tablet. Any time there is a restrictive procedure plan written for an individual the writer will review regulations 6400.192-6400.206 prior to writing it. If there is any content missing from the Individual¿s house record, including the restrictive procedure plan, the house records compliance manager will report it to the writer of the plan. Attachment #11 Corrected 4/19/2017 |
04/19/2017
| Implemented |
| 6400.195(e)(3) | Individual #1's restrictive procedure plan did not include methods for modifying or eliminating the behavior, such as changes in his/her physical and social environment, changes in his/her routine, improving communications, teaching skills and reinforcing appropriate behaviors. | The restrictive procedure plan shall include: Methods for modifying or eliminating the behavior, such as changes in the individual's physical and social environment, changes in the individual's routine, improving communications, teaching skills and reinforcing appropriate behavior.
| After review of the plan on 4/19/17, Individual #1¿s restrictive procedure plan included teaching skills in staff helping Individual #1 to calculate the age of a person she encounters on FB, reinforcing appropriate behavior, appropriate conversations with the online community, respecting his/herself and others, and changes in the individual¿s routine as he/she would have use of the tablet one hour per day, however, it did not go into detail about the method used for modifying/eliminating his/her behavior which was a positive approach. Staff #2 was trained on regulation 6400.195(e)(3) on 4/19/17 Attachment #7.4. Any time there is a restrictive procedure plan written for an individual the writer will review regulations 6400.192-6400.206 prior to writing it. If there is any content missing from the Individual¿s house record, including the restrictive procedure plan, the house records compliance manager will report it to the writer of the plan Corrected 4/19/2017 |
04/19/2017
| Implemented |
| 6400.196(a) | Individual #1's restrictive procedure plan was implemented on 12/29/16 according to Staff #1 and #2. Staff #1 and #2 indicated to licensing on 3/2/17 that staff working with Individual #1 weren¿t trained in the use of ethics of using restrictive procedures including the use of alternative positive approaches. | If restrictive procedures are used, there shall be at least one staff person available when restrictive procedures are used who has completed training within the past 12 months in the use of and ethics of using restrictive procedures including the use of alternate positive approaches.
| Before the writing of the restrictive procedure plan and before its implementation, staff #2 and #1 consulted Individual #1¿s AE, SC and the Region¿s Risk Manager. After review of Staff #2 and #1¿s files on 4/18/17 there was nothing in the file that showed this specific training. All employee files were reviewed that day. All had positive approaches and ethics but not ¿ethics of using restrictive procedures¿. On 4/19/2017 all Raphael House direct support staff, clerical staff, including the Program Specialist/CEO were trained on the use of ethics of using restrictive procedures and the regulation 6400.196(a). The (Attachment #7.3) Since all staff have been trained on this regulation, there will always be a staff available who is trained on the use of and ethics of using restrictive procedures . On 4/4/17 Raphael House hired staff B.A as office records compliance manager who will ensure that all proof of training records necessary for compliance are kept at the office. Corrected 04/19/17 |
04/19/2017
| Implemented |
| 6400.196(b) | Staff #2 is responsible for developing, implementing and managing Individual #1's restrictive procedure plan. Staff #2 did not have documentation that she was trained in the specific techniques or procedures that are used in Individual #1's restrictive procedure plan. | A staff person responsible for developing, implementing or managing a restrictive procedure plan shall be trained in the use of the specific techniques or procedures that are used.
| Staff #2 is responsible for developing, implementing and managing individual #1¿s restrictive procedure plan. After another record review of staff #2¿s file, he/she did not have documentation that he/she was trained in the specific techniques of how to use the specific techniques or procedures that are used (facebook, how to view an internet history, being vigilant by keeping a close eye on Individual #1 during tablet time, calculating the age of a person by what year they say they were born) Although Staff #2 was one of the trainers in the procedures used for individual #1¿s restrictive procedure plan, a signed document was not present at inspection stating such. On 4/19/17 staff #2 was trained on regulation 6400.196(b) including the importance of accurate records keeping (Attachment #22.1.) Raphael House has hired staff B.A. who is the new office records compliance manager who will be responsible for all employee training record forms and sign off sheets for compliance. Attachment #1.1 Corrected 4/19/2017 |
04/19/2017
| Implemented |
| 6400.211(b)(1) | Individual #1's record did not include the name, address, and telephone number and relationship of designated person to be contacted in case of an emergency. | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. | Individual #1's record did not include the name, address, and telephone number and relationship of designated person to be contacted in case of an emergency. After a records review on 3/6/17, an emergency contact sheet was created for inclusion into Individual #1¿s record. Individual #2¿s emergency contact information was found to be in compliance. On March 27, 2017, Raphael staff M.F. was hired as house supervisor and compliance manager for all home documents. He/She, was trained on regulations 6400.213(1)-(14) and will ensure that the most current copies of all record information required, including that required in 6400.211(b)(1) will be kept at the residential home as instructed (Attachment #1.1). If the compliance manager finds that the emergency contact information in an Individual¿s house file is missing or not up to date, they will contact the Program Specialist to have it corrected. Attachment #8 and Attachment #1 Corrected 3/6/2017 |
03/06/2017
| Implemented |
| 6400.211(b)(3) | Individual #1's record did not include the name, address, and telephone number of the person able to give consent for emergency medical treatment. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. | After review of Individual #1's record on 3/10/17 it was found that it did not include the name, address, and telephone number of the person able to give consent for emergency medical treatment. Individual #2¿s emergency contact information was found to be in compliance. Individual #1¿s emergency contact sheet was corrected to include the address, name and telephone number of the person able to give consent for emergency medical treatment. The house supervisor/records compliance manager was trained on regulation 6400.211(b)(3) and is responsible to make sure that all Individual¿s records are in compliance. Attachment #8, Attachment 1.1 Corrected 3/10/2017 |
03/10/2017
| Implemented |
| 6400.213(1)(i) | Individuals #1 and #2's records did not contain (ii) their identifying marks, (iv) their religious affiliation, (v) their next of kin, and (vi) a current, dated photograph. Individual #1's record did not include his/her (iii) primary language spoken or understood. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | It is important that all Individual¿s demographic information is present in the record to assure that they are being supported with current and correct information. On 3/10/17 a records review of the Individual #1 and #2¿s demographics sheets was conducted. Individuals #1 and #2's records did not contain (ii) their identifying marks, (iv) their religious affiliation, (v) their next of kin, and (vi) a current, dated photograph. Individual #1's record did not include his/her (iii) primary language spoken or understood. Both Individual¿s demographic sheets were updated that day to include their language, next of kin, identifying marks if any, and religious affiliation. Although there were current photographs in each record, there were no dates on them. The dates were added. On March 27, 2017, Raphael staff M.F. was hired as house supervisor and compliance manager for all home documents. He/She and the Program Specialist has been trained on regulations 6400.213(1)-(14) and will ensure that the most current copies of all record information required, including that required in 6400.213(1)(i) will be kept at the residential home as instructed. If the compliance manager finds that the demographic information in an Individual¿s house file is missing or not up to date, they will contact the Program Specialist to have it corrected. Attachment #2, Attachment #3, Attachment 1.1 Corrected 3/10/2017 |
03/10/2017
| Implemented |
| 6400.213(9) | Individual #2's most current Individual Support Plan (ISP) was recently updated on 1/3/17. The ISP in Individual #2's record was last updated on 6/10/16 before he/she started services with Raphael House on 11/29/16.
¿Individual #1's ISP in his/her record was last updated on 10/25/16. He/She had an ISP update completed on 2/6/17 that was not included in his/her record.
| Each individual's record must include the following information: A copy of the current ISP. | After a records review on 4/4/17, Individual #2¿s most current ISP dated 1/3/17 was placed in his/her house binder. All staff have read and understand it. Attachment #4. Individual #1¿s ISP update from 10/25/16 was also placed in the house binder and reviewed by all staff. Attachment #5. On March 27, 2017, Raphael staff M.F. was hired as house supervisor and compliance manager for all home documents. He/She and the Program Specialist has been trained on regulations 6400.213(1)-(14) Attachment #1.1 and will ensure that the most current copies of all record information required, including that required in 6400.213(9) will be kept at the residential home as instructed. If the compliance manager finds that the demographic information in an Individual¿s house file is missing or not up to date, they will contact the Program Specialist to have it corrected. There will be an inspection log kept in the back of each Individual¿s record under the ¿compliance¿ tab. Corrected 4/5/2017 |
04/05/2017
| Implemented |
| 6400.213(11) | On 1/18/17, PA-C Jolene Still from Primary Health Altoona indicated on a form for Individual #1 that ¿due to Bactrim making patient ill, he/she should stop taking the medication.¿ Individual #1's Individual Support Plan (ISP) and March 2017 medication administration record only indicated he/she was allergic to Penicillin and raw tomatoes. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | It is imperative that all allergies and contraindications to medications are included in all assessments and ISP¿s. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. After a review of Individual #1's ISP and the March 2017 medication administration record, it was found that only penicillin and raw tomatoes was noted under allergies. There were no content discrepancies found in Individual #2¿s record. The Program Specialist is responsible for relaying discrepancies in the ISP to the SC. If it is a medication discrepancy the meds trainer will report. An email went out to the SC on 4/13/17 requesting the addition of Bactrim to the allergy record. (Attachment #7) On March 27, 2017, Raphael staff M.F. was hired as house supervisor and compliance manager for all home documents. He/She, Program Specialist, and the meds trainer were trained on regulations 6400.213(1)-(14) and will ensure that content discrepancies required in 6400.213(11) will be kept at the residential home as instructed (Attachment #1.1). If the house records compliance manager finds medication discrepancies in an Individual¿s house file, they will contact the meds trainer or report directly to the Program Specialist to have it corrected. At Raphael House, it is the responsibility of the Medication Administration Trainer to make sure that all MARS are correct. Bactrim was added as allergy to MARS (Attachment #6) On 4/14/17, the SC corrected Individual #1¿s record to include the contraindication to Bactrim. The update was placed in Individual #1¿s record at the home. (Attachments 7.1 and #7.2). Corrected 4/14/2016 |
04/14/2017
| Implemented |
| 6400.214(b) | Individual #1's 12/10/16 assessment and Individual #2's 12/29/16 assessment were kept at the agency office location, not at their residential home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. | To ensure the best level of care, it is important that Individual records, including assessments be kept at the home. Individual #1's 12/10/16 assessment and Individual #2's 12/29/16 assessment were kept at the agency office location, not at their residential home. Individual #1 and #2¿s assessments were removed from the office filing cabinet on 03/02/17 and placed into each individual¿s respective house binders by office personnel during inspection when it was brought to office staff¿s attention by licensing. The records review was immediate during inspection. On March 27, 2017, Raphael staff M.F. was hired as house supervisor and compliance manager for all home documents. He/She and the Program Specialist has been trained on 6400.213(1)-(14) and will ensure that the most current copies of all record information required, including that required in 6400.214(b) will be kept at the residential home as instructed. On 4/4/17 an intensive training was conducted for M.F. on regulation 6400.214(b) and everything that is required to be in each Individual¿s binder at the home. If the compliance manager finds that there is no assessment in an Individual¿s house file, they will contact the Program Specialist to have the assessment added.. Attachment #1 and Attachment 1.1 Corrected 4/4/17 |
04/04/2017
| Implemented |
| Article X.1007 | Raphael House is required to maintain criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 ¿ 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff #5¿s date of hire was 11/28/16 and her criminal history background check was not completed until 12/1/16. The following staff did not have a criminal history background check completed Staff #1, #2, #4, #7 and #8. | 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. | The CEO/Program Specialist is now equipped to perform the duties needed as he/she has been given the tools necessary to complete the tasks accurately. The root cause of most of the violations stemmed from an insufficient assessment template and not having the LIS for guidance. Since the inspection on 3/2/17, the CEO has reached out to other I.D. Providers, Peers and Stakeholders in Blair County and received the necessary guidance through collaboration, extensive 6400 training and studying the LIS. Although there were not several physical site violations, there were several records violations. The CEO has reviewed the regulation 6400.43(b)(1) and has implemented it by opening up up two new positions in the Agency that will prevent deficiencies such as this going forward : Office Records Compliance Manager and House Records Compliance Manager. The Medications Administrations Trainer has been re-trained on his/her duties and responsibilities of training, accurate scoring and records keeping. No medications will be administered by anyone other than the licensed nurses on staff or the meds trainer till all records are reviewed for compliance. All med tests are to be rescored by 5/30/17. The office records compliance manager will ensure all TB¿s, Physicals, Backgrounds of staff are in accurate and meet compliance. The house records compliance manager will ensure that all records of Individuals, including fire safety training, fire drills, assessments, physicals, ISPs/Discrepancies, financial records and all records required to be in the file are there and in compliance. Corrected 5/30/17 |
05/30/2017
| Implemented |