| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | There was no light on the exterior door of the property's balcony at point of inspection. The agency submitted a photograph showing a light was installed after the conclusion of the site inspection. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The day following inspection. The facility manager had solar lights installed on the balcony of the property. |
08/14/2021
| Not Implemented |
| 6400.113(a) | No documentation was provided at inspection which verified that Individual 1 received a fire safety training at the time of 8/10/20 admission. [Repeated Non-Compliance from 3/9/20] | 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. | Fire safety training is part of the new hire orientation. The trainer reviews general fire safety, smoking policy, and fire drills (procedures, locating smoke detectors, evacuation, meeting place and completion of the fire drill form). The details of this training will be added to the on-site training form. |
10/29/2021
| Not Accepted |
| 6400.141(c)(12) | Individual 1's 12/23/20 physical did not address physical limitations or restrictions. | The physical examination shall include: Physical limitations of the individual. | The agency followed up with the consumer¿s PCP to have the physical form updated. Our multiple requests were not fulfilled. |
10/29/2021
| Not Accepted |
| 6400.141(c)(14) | Individual 1's 12/23/20 physical did not address information pertinent to diagnosis in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The agency followed up with the consumer¿s PCP to have the physical form updated. Our multiple requests were not fulfilled. |
10/29/2021
| Not Accepted |
| 6400.141(c)(15) | Individual 1's 12/23/20 physical did not address special instructions for diet (and as this individual is a diabetic, there are dietary considerations). | The physical examination shall include:Special instructions for the individual's diet. | The agency followed up with the consumer¿s PCP to have the physical form updated. Our multiple requests were not fulfilled. |
10/29/2021
| Not Accepted |
| 6400.143(a) | A dental exam has not been completed for Individual 1 since their 8/10/20 admission, as they have refused them, per provider statement. There is no documentation in the record of his refusal or continued attempts to train about the need for health care. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Consumer refused to attend the scheduled medical appointment and stated that he was not interested in seeing a dentist because he was not experiencing any pain. Staff and members of the administrative team explained the importance of routine maintenance, but the individual still refused. |
10/29/2021
| Not Implemented |
| 6400.144 | Basaglar insulin was found in a locked box in Individual 1's refrigerator. This medication does not appear on the individual's July or August 2021 MARs, but the individual is diabetic and their August 2021 ISP indicates they can inject insulin with assistance from staff. Staff member 1 indicated at point of inspection, during the medication review, that the individual does not take insulin now, may take it again in the future, and the medication was kept because it is expensive. Further, alcohol prep 70% pads were listed on the individual's August 2021 MAR but only a bottle of 70% isopropyl alcohol was found with his medications at time of inspection. After the inspection, through a video call, staff presented alcohol disinfectant packets that they indicated were found in the property's first aid kit. They carried no label beyond the manufacturer's. Without a prescription label for the pads, it cannot be determined if the pads are expired, current, or if they meet the prescriber's specifications, and without records of administration or discontinuation of the insulin, it is unclear if the individual's diabetic medication needs are being met. As such, it cannot be determined that pharmaceutical services are being fully rendered for the individual. [Repeated Non-Compliance from 3/9/20] | 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.
| In June, the individual's doctor discontinued his insulin on a trial basis. The individual had made changes to his diet and maintained stable blood sugar levels. Therefore, the medication didn't appear on the MAR for July or August. The medication box was moved off-site the same day of the inspection. |
10/29/2021
| Not Accepted |
| 6400.151(a) | It could not be determined that Staff Member 6 has had a physical within the past two years. [Repeated Non-Compliance from 3/9/20] | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The agency has reviewed the employees physical forms. In order to have the physicals completed timely, the agency contracted with an UrgentCare. Employees are scheduling appointments for physicals and ppd tests. |
11/30/2021
| Not Accepted |
| 6400.151(c)(2) | Staff Member 6's TB clearance is not current. The most recent documented TB test observed during inspection was dated 6/6/17. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The agency has reviewed the employees physical forms. In order to have the TB tests completed timely, the agency contracted with an UrgentCare. Employees are scheduling appointments for physicals and TB tests. |
10/29/2021
| Not Accepted |
| 6400.46(b) | It could not be determined that Staff Member 6 received an annual fire safety training in 2020. [Repeated Non-Compliance from 3/9/20] | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Fire safety training is part of the new hire orientation. The trainer reviews general fire safety, smoking policy, and fire drills (procedures, locating smoke detectors, evacuation, meeting place and completion of the fire drill form). The details of this training will be added to the on-site training form. |
10/29/2021
| Not Accepted |
| 6400.166(b) | Administration of individual 1's Cetirizine was not documented in their MAR on the date of 8/17/21. The medication order was that it was to be given for a week. The blister pack for the Cetirizine shows dates ranging from 8/17/21 - 8/23/21, and all seven slots in the pack are empty, whereas the MAR only recorded administrations between 8/18/21 - 8/23/21, accounting for the administration of only six of the seven pills. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Staff was retrained on the proper administration and documentation of a medication. The on-call supervisors have begun random reviews of the MAR throughout the month. Additional staff training is conducted, as needed. |
10/29/2021
| Not Implemented |
| 6400.169(a) | The agency did not retain documentation of staff completing medication administration training or practicum from 2020 - 2021. As it cannot be determined that staff has completed their practicum and agency training, all staff except for the agency's nurse are not permitted to administer medications until staff trainings are remediated. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Following the inspection, the agency engaged a licensed practical nurse (LPN) to administer medication. The LPN administered medication to all consumers until the staff completed the required observations. She continues to administer medication when staff hasn't completed the required training. |
10/29/2021
| Not Accepted |
| 6400.169(b)(2) | Staff who assist individual 1 with their insulin injections did not receive training in a Department-approved diabetes patient education program within the past twelve months. The agency provided certificates from online PCHC diabetes trainings completed during the inspection for seven staff members (Staff Member 2, Staff Member 3, Staff Member 4, Staff Member 5, Staff Member 6, Staff Member 7, and Staff Member 8), all dated 8/24/21, but this is a general information training on diabetes. The training must include specifics on drawing and administering insulin. [Repeated Non-Compliance from 3/9/20] | A staff person may administer insulin injections following successful completion of both: A Department-approved diabetes patient education program within the past 12 months. | Currently, we don't support any individual that receives injections. The insulin injections for the individual mentioned were discontinued in June 2021. |
10/01/2021
| Not Accepted |