| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.82(f) | At the time of the inspection, there was no hand soap present in the downstairs half bathroom or the individuals' upstairs bathroom. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | During the inspection, all homes run by Greater Hearts were inspected. Each of the homes had handwashing soap in all bathrooms except for the home referenced in this violation. The individuals at this location are generally safe with chemicals. However, following a team meeting for one of them in January 2021, the individuals assessment was updated to reflect that chemicals /poisons should be locked when he is exhibiting certain symptoms. It is for this reason that staff had lock the hand soaps that were in the bathrooms during the inspection. This notwithstanding, we acknowledge that non-poisonous soaps should have been made available after the assessment was updated. This violation was corrected on 1/22/21. Non-poisonous hand soaps were added to both bathrooms (See attachments # 14a & 14b). To prevent similar situations in future, all residential supervisors were informed on 1/27/21 and again on 2/4/21 to only purchase non-poisonous hand washing soaps for the various homes under their supervision. Program Specialist and COO during their visits to the homes will ensure that this directive is being followed. |
01/22/2021
| Implemented |
| 6400.141(c)(4) | Individual #1's 1/19/21 physical did not include a vision/hearing screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual #1 uses glasses and sees an ophthalmologist / optometrist for his vision care. His last vision appointment was 11/17/20 (see attachment #15) and he is supposed to have an annual follow up in November 2021. Regarding hearing exams, during the individuals 2020 physical examination, it was recorded that he did not hear when the test was done at the PCPs office as such the individual followed up with an audiologist who currently provides the needed hearing exams. The individual had a hearing appointment on 9/21/20 (see attachment #16) and an annual follow up is due in September 2021. Copies of the individuals vision and hearing tests were available to the PCP during his 1/19/21 physical appointment. Program specialist and the residential supervisor for individual #1 will ensure that all follow up appointments are completed. |
01/19/2021
| Implemented |
| 6400.141(c)(10) | Individual #1's 1/19/21 physical did not include whether or not Individual #1 has a communicable disease. | 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. | Individual #1 had his annual physical appointment on 1/19/21 as evidenced by attachment # 17c. When going for the appointment the staff member mistakenly took the regular medical appointment forms (attachment # 17a) instead of the required physical examination form (attachment #17b). To correct this mistake, the staff returned to the PCPs office on 1/19/21 and delivered the correct forms for it to be completed. A follow up phone call by the program specialist and residential supervisor confirms that the PCP office has received the correct form, but the doctor is yet to complete it. Once completed, the form will indicate whether Individual #1 has a communicable disease or not. To ensure that correct appointment forms are used for each appointment in future, Microsoft Outlook Groups have been created for each house ran by Greater hearts. Residential supervisors are uploading all required appointment forms on the group page for each house. This will ensure that each form is available to staff both in print and electronically. On the day before a scheduled annual physical examination for each individual, the residential supervisor for that individual will ensure that the correct form is prepared and is available to the staff who will be accompanying the individual to the appointment. After each appointment, residential supervisors and/or program specialist will review the appointment form used to ensure among other things that the form was completed accurately. Residential Supervisors were trained with regards to this responsibility on 2/4/21. |
01/19/2021
| Implemented |
| 6400.141(c)(12) | Individual #1's 1/19/21 physical did not include any physical limitations. | The physical examination shall include: Physical limitations of the individual. | Individual #1 had his annual physical appointment on 1/19/21 as evidenced by attachment # 17c. When going for the appointment the staff member mistakenly took the regular medical appointment forms (attachment # 17a) instead of the required physical examination form (attachment #17b). To correct this mistake, the staff returned to the PCP¿s office on 1/19/21 and delivered the correct forms for it to be completed. A follow up phone call by the program specialist and residential supervisor confirms that the PCPs office has received the correct form, but the doctor is yet to complete it. Once completed, the form will indicate any physical limitations and will be filed placed in records upon receipt.
To ensure that correct appointment forms are used for each appointment in future, Microsoft Outlook Groups have been created for each house ran by Greater hearts. Residential supervisors are uploading all required appointment forms on the group page for each house. This will ensure that each form is available to staff both in print and electronically. On the day before a scheduled annual physical examination for each individual, the residential supervisor for that individual will ensure that the correct form is prepared and is available to the staff who will be accompanying the individual to the appointment. After each appointment, residential supervisors and/or program specialist will review the appointment form used to ensure among other things that the form was completed accurately. Residential Supervisors were trained with regards to this responsibility on 2/4/21. |
01/19/2021
| Implemented |
| 6400.141(c)(14) | Individual #1's 1/19/21 physical did not include medical information pertinent to diagnosis or treatment in the event of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | This violation occurred because of the circumstances described when addressing violation 55 PA Code Chapter 6400.141(c)(12). The individuals PCP currently has the correct form which upon completing will include any medical information pertinent to diagnosis or treatment in the event of an emergency. The correct physical form upon receipt will be filed as part of the individuals records.
To ensure that correct appointment forms are used for each appointment in future, Microsoft Outlook Groups have been created for each house ran by Greater hearts. Residential supervisors are uploading all required appointment forms on the group page for each house. This will ensure that each form is available to staff both in print and electronically. On the day before a scheduled annual physical examination for each individual, the residential supervisor for that individual will ensure that the correct form is prepared and is available to the staff who will be accompanying the individual to the appointment. After each appointment, residential supervisors and/or program specialist will review the appointment form used to ensure among other things that the form was completed accurately. Residential Supervisors were trained with regards to this responsibility on 2/4/21. |
02/04/2021
| Implemented |
| 6400.142(b) | On Individual #1's dental examination dated 10/19/20, the question regarding medications causing dental issues is not answered. | An individual who is using medication known to cause dental problems shall have a dental examination by a licensed dentist at intervals recommended in writing by the dentist. | DSPs usually accompany individuals supported to dental appointments. To ensure that dentists have the necessary medication information to accurately answer all the required sections of the dental form, DSPs will be retrained on the need to attach a copy of an individual current medication list to appointment forms. Also, as part of the retraining, DSPs will be educated on how to check appointment forms prior to leaving the dentists office for completeness and accuracy. This retraining will be done between 2/15/21 and 3/31/21 as part of the monthly house meetings. Additionally, residential supervisors and / or program specialists will also review all dental and medical appointment forms to ensure accuracy once the forms brought to the house before filing them as part of the individual¿s record. A meeting has been scheduled for Greater Hearts program team to meet on 2/15/21. At this meeting, the dental appointment form for Greater Hearts will be updated to include sections for DSPs and residential supervisors / program specialist to document their review of dental appointment forms after each appointment. |
03/31/2021
| Implemented |
| 6400.165(g) | There is no indication that a licensed physician has completed a 3 month medication review for Individual #1 since 8/25/20. There are 2 other appointment forms provided, but both of them were completed by Greater Hearts, not the physician. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | A licensed psychiatrist completed a 3-month medication review for individual #1 on 10/20/20 @ 3:00pm and 12/01/20 @ 11:30am. However, due to the Covid-19 pandemic, these appointments were done virtually and there was a delay in receiving the necessary documentations from Penn State Hershey Outpatient Psychiatry Department. The unsigned Greater Hearts appointment forms which were placeholders for the documentation from the psychiatrists office has since been replaced with the appointment summaries received from Penn State Hershey (see attachments # 18 and # 19). Since the beginning of the COVID-19 pandemic, it has been our experience that some doctors offices take a longer time to complete the forms that we fax to them for virtual/telephone visits. Where applicable, individuals and/or their guardians have been encouraged to sign up onto their providers electronic health records platform so that appointment summaries can be downloaded for the individuals records at Greater Hearts. In cases when this is not an option, we have had to wait on the doctors offices to get the documentations to us. While we might not be able to control how long it takes doctors to complete forms for virtual visits, the program team will make continuous follow ups until the appropriate documentations are received. Copies of fax or email messages will be kept as placeholders as well as documentations of attempts to get the appropriate documentations. |
01/22/2021
| Implemented |
| 6400.166(a)(11) | There is not a diagnosis or purpose listed for the following medications on Individual #1's Medication Administration Records: Aripiprazole, Benztropine, Divalproex 500mg, Divalproex 250mg, Melatonin, Trazodone, Venlafaxine, Imodium. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Cognizant of this violation, the program specialist and residential supervisors are reviewing the current MARs for everyone supported. It appears that this is also a problem for other individuals besides individual#1.The pharmacy that serves the individuals supported by Greater Hearts has been contacted regarding the need to include the diagnosis or purpose for each medication on the MARs they provide. However, it appears that the actual prescriptions from the prescribers are the cause of this error. Some did not indicate the reason or diagnosis for the medications. According to the pharmacy, they cannot include diagnoses on the medication labels or MARs unless such diagnoses or reasons are stated as part of the prescriptions. To help rectify this, the program team at Greater Hearts is sending letters (see attachment # 11 for sample) to the various prescribers for scripts to be rewritten to include the purpose for each medication. Once the pharmacy receives the new scripts from the prescribers, they would be able to update the MARs accordingly. Going forward, program specialist and residential supervisors in reviewing new scripts will take the necessary steps to ensure compliance with 55 PA Code Chapter 6400.166(a)(11). |
02/04/2021
| Implemented |
| 6400.167(a)(1) | Individual #1's Medication Administration Record does not indicate that the following medications were administered on 11/1/20: Benzotropine (8:00pm dose), Divalproex (8:00pm dose), and Trazodone (10:00pm dose). | Medication errors include the following: Failure to administer a medication. | The medications mentioned above were administered as evidence from the medication count on the MAR for October 31st, 2020 and November 2nd, 2020 as well as the shift change notes (also referred to as Cross Over form at Greater Hearts) for November 1st, 2020. However, the staff forgot to document on the MAR. At the time the documentation error was discovered the staff concerned had resigned from Greater Hearts and as such could not recertify it. Staff members have been reminded to report documentation errors when they discover them timely so that appropriate steps could be taken to address them. To prevent medication related errors including documentation errors, Greater Hearts will be mandating all DSPs to take annual refresher course in medication administration (beginning in 2021 calendar year) as part of the annual recertification reprocess. Also, all supervisors, program specialists and/or COO will be required to be pass the practicum observer training so that they can provide the necessary monitoring and coaching to DSPs. All current program specialists and residential supervisors are expected to complete the training by April 15th, 2021. Additionally, to ensure earlier detection of medication related errors, practicum observers and medication administration trainers will review the MAR for everyone supported on a bi-weekly basis. |
04/15/2021
| Implemented |
| 6400.167(b) | There is no documentation that there was a failure to administer Individual 1's medications on 11/1/20. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | The medications mentioned above were administered on 11/1/20 as evidence from the medication count on the MAR for October 31st, 2020 and November 2nd, 2020 as well as the shift change notes (also referred to as Cross Over form at Greater Hearts) for November 1st, 2020. However, the staff forgot to document on the MAR. At the time the documentation error was discovered the staff concerned had resigned from Greater Hearts and as such could not recertify it. Staff members have been reminded to report documentation errors when they discover them timely so that appropriate steps could be taken to address them. To prevent medication related errors including documentation errors, Greater Hearts will be mandating all DSPs to take annual refresher course in medication administration (beginning in 2021 calendar year) as part of the annual recertification reprocess. Also, all supervisors, program specialists and/or COO will be required to be pass the practicum observer training so that they can provide the necessary monitoring and coaching to DSPs. All current program specialists and residential supervisors are expected to complete the training by April 15th, 2021. Additionally, to ensure earlier detection of medication related errors, practicum observers and medication administration trainers will review the MAR for everyone supported on a bi-weekly basis. |
04/15/2021
| Implemented |