Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00224481 Renewal 05/23/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65There was no ventilation either by window or operational mechanical method. The fan was not operational at time of inspection.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. On 5/24/2023, maintenance company PRM went onsite and replaced a faulty motor in the fan in question. The fan is currently operational as evidenced in Video footage and e-mail from maintenance company (Exhibit A) confirming the repair. 05/24/2023 Implemented
6400.32(e)The staff or individuals has no access to the thermostat in event the need arises.An individual has the right to make choices and accept risks.The key to the thermostat had been misplaced. New keys were made per photos and work order in Exhibit C. 06/07/2023 Implemented
SIN-00205645 Renewal 05/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)The bathrooms had antibacterial soaps in the bathrooms that are potentially poisonous when ingested, all other household cleaners and soaps were locked.Poisonous materials shall be kept locked or made inaccessible to individuals. Locking poisons was a new change to the ISP for one of the residents of this home due to his severity of dementia symptoms. Prior to this time, all residents were capable of having poisons out and unlocked. Antibacterial soaps had been recommended during the COVID-19 pandemic as part of safety protocols. The anti-bacterial soaps have been placed in locked closet and the soaps that are available on the sinks of the bathrooms accessible to the resident with dementia are not poisonous if ingested. Staff have been retrained in this topic and the need to keep poisons locked in the home. 05/31/2022 Implemented
6400.63(a)The stainless-steel shower handle flex tubing attached to the showerhead measured at approximately 138 degrees Fahrenheit to the touch when water was turned on the hot position on 5/26/2022.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. Upon inspection during a 5/27/22 service call, the plumber discovered that there was a problem with the hot-water heater that resulted in above-normal hot water temperatures throughout the home. A mixing valve was installed on 05/27/2022 to prevent temperatures of the hot water going to any source throughout the home from exceeding 120 degrees. In addition, the shower fixture was also replaced with plastic tubing that is less likely to conduct heat from the hot water that is flowing through it. 06/24/2022 Implemented
6400.67(a)The lower cabinet near the sink was missing a handle on its left door panel. The light in individual #1's closet did not turn on and work consistently when turning on. When the light did work it flickered.Floors, walls, ceilings and other surfaces shall be in good repair. The new supervisor began on 05/09/2022. Staff had not been consistently reporting maintenance concerns to upper management (Residential Director). These concerns had not been noticed by upper management in order to be addressed. The loose screw was replaced on the door handle (Appendix G) and maintenance was called to fix the closet light (Appendix H). Supervisor has reminded staff to inform her of maintenance concerns and reshown them where to place them in the communication log. 06/27/2022 Implemented
6400.68(b)The hot water in the bathroom tub measured 148 degrees Fahrenheit during water test on 5/26/2022. The water temperature was corrected within 24 hours to read 113.1 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. Upon inspection during a 5/27/22 service call, the plumber discovered that there was a problem with the hot-water heater that resulted in above-normal hot water temperatures throughout the home. A mixing valve was installed on 05/27/2022 to prevent temperatures of the hot water going to any source throughout the home from exceeding 120 degrees. A fire drill was held on 5/31/22 and 6/23/22 (Appendix K) and water temperatures were taken at several locations which were all well under 120 degrees. 05/27/2022 Implemented
6400.81(k)(6)There were no mirrors in individual #1 or #2's bedroom.In bedrooms, each individual shall have the following: A mirror. Repair work had been done in the home including full painting of all bedrooms on 5/24 and 5/25. The mirrors that were in each bedroom had been stickers on the wall due to behaviors. The mirrors were removed for the painting and not located by the time of the inspection for replacement. Mirrors were since reinstalled in both bedrooms. 05/31/2022 Implemented
6400.112(e)Over the past 12 months there has only been one drill conducted during sleeping hours.A fire drill shall be held during sleeping hours at least every 6 months. The Residential Supervisor resigned on 02/28/22 and there was a two-month gap before a new supervisor was hired. This may have contributed to assuring that this was covered adequately. A fire drill was held on 6/23/22 (Appendix K) and at 3 AM and all residents evacuated safely in under 2 minutes and 30 seconds. The monthly fire drill log already had a monthly rotation on it that the Residential Supervisor will now assure is adhered to. Actual dates to target each monthly drill were added through the end of 2022. 06/24/2022 Implemented
6400.141(c)(1)On individual #1's annual physical dated 7/7/21 there was no space to indicate if medical history was checked.The physical examination shall include: A review of previous medical history. The scanned version of the physical for this individual was missing the middle page which was not discovered until it was submitted to licensing. The office at the residence had the floor replaced and was repainted on 05/24 and 05/25/2022. The binder with the original copy was not located until after the exit interview due to records still being in boxes from the repair work. Attempts to contact the physicians office for a replacement on the day of licensing were unsuccessful to get a replacement on time. The original was located and copy is able to be provided (Appendix M). The missing page included a review of previous medical history. 05/31/2022 Implemented
6400.141(c)(4)On individual #1's annual physical dated 7/7/21 there was no space to indicate if a vision or hearing screen was completed.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. The office at the residence had the floor replaced and was repainted on 05/24 and 05/25/2022. The scanned version of the physical for this individual was missing the middle page which was not discovered until it was submitted to licensing. The binder with the original copy was not located until after the exit interview due to records still being in boxes from the repair work. Attempts to contact the physician¿s office for a replacement on the day of licensing were unsuccessful to get a replacement on time. The original was located and copy is able to be provided (Appendix M). The missing page includes a review of vision/hearing screening. 05/31/2022 Implemented
6400.141(c)(14)On individual #1's annual physical dated 7/7/21 an N/A for info pertinent to diagnosis in case of emergency is written. The individual is a diabetic.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. At the time of the physical, there was no nurse employed by the agency to review the physical when it was returned to assure accuracy. It is believed that the nurse practitioner who conducted the physical was aware of the Health Promotion Activities Plan for his Diabetes assumed that this was sufficient and no additional information was necessary on this form. A new primary physician was found. He issued an order to follow the Health Promotion Activities plan that was developed and signed by the endocrinologist dated 04/13/22. 06/27/2022 Implemented
6400.144Documentation that the nurse was contacted per medication record instructions when individual's blood sugar exceeded 300 on 5/10, 5/11, 5/14 and 5/19/2022 was not completed. The record was left blank.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. The previous form did not clearly have a space/manner to indicate that the nurse had been contacted on the MAR itself, even though this is a necessary step in the diabetes protocol and the nurse was keeping records of every time he was called. A simpler log was added and staff were trained in it as of 5/31/22 to list every time the nurse is contacted. 05/31/2022 Implemented
6400.181(d)The current assessment for individual #1 dated 5/24/22 was not signed and dated by the PS.The program specialist shall sign and date the assessment. There were several issues with uploading correct documents to the Microsoft Sharepoint drive. This was a situation where the file uploaded was not a scan of the finalized copy, but rather the original computer version. A signed copy is provided. All assessments were reviewed for signatures of both the Program Specialist and Individual. 05/31/2022 Implemented
6400.166(b)Naltrexone 50 mg tablet prescribed to individual #1 to be taken twice a day was not logged immediately after administration on 5/4/2022 at 8amThe information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Individual #1 went to the hospital on 5/4 due to symptoms and ended up being hospitalized for several days. The missing signature should have been caught during the Residential Health Coordinators weekly MAR audit, but he was consumed that week with caring for an entire house which had COVID-19. All staff reminded to record medication at time of giving. MAR audit continued to be performed weekly by Residential Health Coordinator (nurse) (Appendix Q). 06/26/2022 Implemented
SIN-00195358 Unannounced Monitoring 11/01/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144The following medications prescribed to individual one as needed, docusate 100mg per capsule, 2 capsules by mouth to be taken as needed and Ibuprofen 400mg tablets were not available on site at the time of review but were listed on the medication administration record. Antacids prescribed to individual 2 to be taken as needed were not present on site at the time of inspection. Hydrocortisone cream 1% to be taken as needed for individual 3 up to twice a day for a rash on the neck was not available to the individual on site at the time of inspection.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. On 11/1/2021, the nurse contacted pharmacy to refill missing PRN medications. Some required new prescriptions from the physicians. On 11/1/2021, the Docusate arrived onsite for Individual 1. On 11/9/2021 the Ibuprofen arrived onsite for Individual 1. On 11/10/2021, both the Calcium Antacid for Individual 2 and the Hydrocortisone 1% for Individual 3 arrived onsite. Therefore, as of 11/10/2021, all PRN medications for all 3 individuals were onsite and available (Appendix H). 11/16/2021 Implemented
6400.50(b)A complete training record was not kept for medication administration and diabetes training for staff members 1,2,3 and 4. Certification dates were missing from annual practicums from prior administrative staff medication trainer. Staff 4 who left agency on 10/8/2021, per agency statement, did not have a training file for diabetes and medication administration kept by agency.The home shall keep a training record for each person trained.In May 2021, the then Residential Director, who had also been lead Medication Administration trainer resigned. She did not leave specific instructions of where staff records were filed. A new Medication Administration trainer was not hired until 09/22/2021. At the time of his hiring, discrepancies in completion of annual practicums had been found and medication errors had been numerous in the preceding weeks, so management decided to require all staff of this home to attend a 2-day remediation Medication Administration training in October of 2021 (Appendix J). At the time the inspector identified the record discrepancies, Employee 1 was put on a remediation plan (Appendix J-1) , Employee 2 was already out on medical leave (J-2), Employee 3 was suspended from administering medications (J-3), and employee 4 had already resigned (J-4). A full audit was performed of all Medication Administration trainings for all employees administering medications within the home (Appendix L). Any employees with deficiencies were put on remediation plans and/or suspended from medication administration duties. A mandatory Diabetes Education session was scheduled for 11/17/2021 and all employees from the home were required to attend. 8 Employees Attended. A remediation in-person Medication Administration training is planned for 11/18/2021 for employees with deficiencies. 11/17/2020 Implemented
6400.165(c)Vitamin B-12 tablets (100mcg) to be taken once every other day by individual 2 at 8am was not administered as of 11:15am on 11/1/2021. The last documented administration was on 10/30/2021.A prescription medication shall be administered as prescribed.The medication in question requires that the agency call the pharmacy to inform the pharmacist whether or not the medication should be packaged on the odd days or the even days in the blisterpack, since the vitamin is prescribed every other day (and not daily). Despite being trained to do this ordering the previous month by the Executive Director, the new nurse neglected to do the manual ordering and missed that the medication was not present when he did the medication audit at the beginning of the month to compare the medications that arrived from the pharmacy with the MARs for the new month. On the day in question, the pharmacy was contacted, the pharmacist gave permission for the late administration, and the vitamin was picked up (Appendix M) and was administered at 12:00 PM (Appendix M), but not documented properly. The staff person was retrained in how to properly document a late administration by the nurse Nana Nuakoh. The medication continued to be administered throughout the month of November per the MAR (Appendix M). 11/08/2021 Implemented
6400.166(b)The medications Naltrexone and Mirtazapine were not logged immediately after administration at 8pm on 10/15 for individual 1. The Medication Naltrexone prescribed to individual 1 was not logged after administration on 10/15/2021. On 10/22/2021, The Novalong INJ flex pen injection was not logged as administered before lunch for individual 1, the area on the log was partially left blank for blood sugar levels and initials. Time of administration was filled out incorrectly without initials to show adjusted time. Trazadone 50mg tablet prescribed to individual 2, to be taken 3 times a day, was not logged immediately after administration for 8pm's final dose on 10/31/2021. Multivitamin Tablets prescribed to individual 3 to be taken once daily at 8am was not logged immediately after use on 10/8/2021. The fields were left blank on the aforementioned dates and times.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Medication logging errors likely resulted from a lack of regular checks and accountability of staff by management. Executive Director worked with the Director of Quality LifeCare, to retrain the new nurse LPN (Appendix N) to understand the establish that MARs should be audited daily as well as retraining him in assuring that missed signatures can/should be logged immediately upon discovery as long as administration is confirmed and that medication errors must be reported in EIM. Most of the Medication Log entries could not be corrected because the staff whose signatures were missing were no longer employed, but the nurse did confirm the 10/22/21 administration of insulin and indicated the on-time administration and late logging on the MAR for Individual 1 for October 2021. 11/15/2021 Implemented
6400.169(a)Staff 1's Medication administration training was last completed 4/8/2020.. Staff 1's certification to administer medication expired on 4/8/2021. Staff 2's Medication administration training was last completed 2/21/2020. Staff 2's certification to administer medication expired on 2/21/2021. Staff 3's Medication administration training was last completed 5/17/2020. Staff 3's certification to administer medication expired on 5/17/2021. The aforementioned staff did not meet the renewal requirements in accordance to the documents provided during review and all staff were actively administering medication as of October 2021.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).In May 2021, the then Residential Director, who had also been lead Medication Administration trainer resigned. She did not leave specific instructions of where staff records were filed. A new Medication Administration trainer was not hired until 09/22/2021. At the time of his hiring, discrepancies in completion of annual practicums had been found and medication errors had been numerous in the preceding weeks, so management decided to require all staff of this home to attend a 2-day remediation Medication Administration training in October of 2021 (Appendix J). At the time the inspector identified the record discrepancies, Employee 1 was put on a remediation plan (Appendix J-1) , Employee 2 was already out on medical leave (J-2), Employee 3 was suspended from administering medications (J-3), and employee 4 had already resigned (J-4). A full audit was performed of all Medication Administration trainings for all employees administering medications within the home (Appendix L). Any employees with deficiencies were put on remediation plans and/or suspended from medication administration duties. A mandatory Diabetes Education session was scheduled for 11/17/2021 and all employees from the home were required to attend. 8 Employees Attended. A remediation in-person Medication Administration training is planned for 11/18/2021 for employees with deficiencies. 11/17/2021 Implemented
6400.169(b)(2)Staff 1, 2 and 3 did not complete a department approved diabetes patient education program within the past 12 months. Individual 1 requires daily Insulin injections. Staff 1, 3 and 4 administered Insulin injections per medication log the month of October 2021.A staff person may administer insulin injections following successful completion of both: A Department-approved diabetes patient education program within the past 12 months.The Diabetes education documentation for Employee 1 was located as having taken place on 02/09/2021 (Appendix O-1), making her current. No updated documentation was located demonstrating Diabetes education during the past 12 months for Employees 2, 3 or 4. At the time the inspector identified the record discrepancy and as of today, Employee 2 was/is out on medical leave (K-2), Employee 3 was/is suspended from administering medications including insuling (K-3), and Employee 4 had already resigned (K-4). A full audit was performed of all Diabetes Education trainings for those administering insulin within the home was completed (Appendix L). Any employees with deficiencies were suspended from insulin administration duties. A mandatory Diabetes Education session was held on 11/17/2021 and all employees from the home were required to attend (Appendix O-2). 8 staff attended. Staff without training within the last 12 months who did not attend, including Employee 3, are still not permitted to adminster insulin. 11/17/2021 Implemented
SIN-00188080 Renewal 05/24/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.76(a)There was a missing knob on top right drawer of INDIVIDUAL #1's nightstand at time of inspection. There was a missing knob on top right drawer of INDIVIDUAL 2's nightstand at time of inspection. Furniture and equipment shall be nonhazardous, clean and sturdy. Prior to 05/2021, the Residential Director had not been conducting self-inspections during the required timeframes over the past 18 months. Despite weekly check-ins, the Executive Director was not holding the Residential Director adequately accountable for conducting self-inspections and other oversight within the agency. After learning of the missing knob, a knob was purchased and installed on 06/08/2021 (See Attachment A). A staff communication was done on 06/01/2021 reminding staff of the need to report maintenance concerns to the House Supervisor (Attachment B). A visual inspection of both homes was conducted on 06/01/2021 and no additional furniture needs were identified (Attachment C). 06/08/2021 Implemented
6400.181(a)INDIVIDUAL #1's most recent assessments were dated 8/8/19 and 5/14/21. Greater than 1 year elapsed between these two assessments Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. In our agency, the Program Specialist role is fulfilled by the Residential Director. Prior to 2020, the Residential Director had demonstrated regular on-time submission of such documents. The Executive Director had not specifically required evidence of compliance, assuming that it was being completed. This Residential Director resigned on 05/11/2021. Upon discovering that this document was out of date, the Executive Director completed the assessment on 05/14/2021 for this indivdiual as well as the other two individuals in the home.. 06/21/2021 Implemented
6400.166(b)There were no initials on the MAR for IDNVIDUAL #1's 10pm Mirtazapine 45mg on 5/13/21.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.An investigation found that the pill had been administered, but that the staff person had failed to initial for its administration. A review of medication logs conducted by the Excutive Director on 05/31/2021 for all 3 residents for May 2021 did not reveal any additional medication documentation errors (Appendix E). The LPN who had been responsible for training staff and assuring proper medication administration had not been conducting MAR reviews on a regular basis and there was no mechanism for ongoing training. The LPN was terminated from employment for this and other failures to perform work duties as of 06/14/2021. 06/21/2021 Implemented
SIN-00162380 Renewal 09/11/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)The fire safety training was not completed annually upon review of the record for individual #1. Fire safety training dated 1/8/19 was the most recent training found in record, however , there was no record of training for fire safety in the 2018 training calendar year. 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. A schedule has been developed to ensure fire safety training is completed annually for all individuals living in the home. The residential director will ensure the training is completed within the required timeframe. 11/11/2019 Implemented
SIN-00136283 Renewal 05/29/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The hot water in the home was tested and found to be 128 degrees Fahrenheit. Hot water temperatures in bathtubs and showers may not exceed 120°F. The water temperature was adjusted and the reinspection took place on 6/8/2018. This lapse was caused because a Program Manager was not in place to monitor such issues. A thermometer was purchased and this issue is included in the monthly compliance checklist for the new program manager. 06/08/2018 Implemented
6400.106There was not a current furnace inspection. Last completed 3/14/17.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. Why: The annual inspection was due in March the same month that the Program Manager when out on leave and then did not return. This would have been part of her responsibilities to assure it was done. Current: Furnace was inspected on 6/4/2018. Future: This is included in the Program Manager Monthly Site Complaince Checklist (Attachment #13). 06/04/2018 Implemented
6400.112(f)The front door of the home was used 9 out of 10 times.Alternate exit routes shall be used during fire drills. Why: Although the Fire Drill log explicitly provided a schedule to vary the exits (along with time of day), the manner in which it did was confusing and therefore not executed by staff. Current: The form was modified to make it less confusing and is included in Attachment #12. Staff will be retrained at staff meeting on. Future: This was added to the Program Manager's monthly compliance checklist. 07/31/2018 Implemented
6400.141(c)(10)Individual #1's physical dated 9/28/17 did not indicate whether or not he was free of 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. WHY: As a first inspection, staff were not aware of how to review the physical after the physician fills it out to assure compliance. Current: Fax was sent to Individual's Physician on . Response is included in Attachment #11. Future: Nurse Regan was trained on 5/31/18 on how to review physicals and assure that all sections are filled out. 06/22/2018 Implemented
6400.151(a)Staff #1 did not have a current physical. 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. WHY: Many employees of this program, including Employee #1, were already employees of Holy Redeemer Health System, HRHS before transferring or adding job responsibilities to this program. Since services with ODP are new to the Health System, Occupational Health was not aware that a new physical and current TB test was required upon transferring into work in the residence, as it was not required by HRHS policy. Current: Occupational Health staff person Terry Smigley (TeSm) was educated on 5/31/2018 of the need for all employees to immediately have both a current physical and TB test. Attachment #10 shows that all employees working are now up to date. A new physical form, specific to work in this program was also provided to TeSm on 5/31/2018, as the current occupational health physical form was confusing and did not specifically follow 6400 regulations. Employee #1 is on leave. A copy of his new physical and TB test results will be provided upon his return and he will not have contact with residents until its completion. Future: Occupational Health staff person Terry Smigley will assure compliance with all new hires. 07/31/2018 Implemented
6400.151(c)(2)Staff #1 did not have a current TB test. 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. WHY: Many employees of this program, including Employee #1, were already employees of Holy Redeemer Health System, HRHS before transferring or adding job responsibilities to this program. Since services with ODP are new to the Health System, Occupational Health was not aware that a new physical and current TB test was required upon transferring into work in the residence, as it was not required by HRHS policy. Current: Occupational Health staff person Terry Smigley (TeSm) was educated on 5/31/2018 of the need for all employees to immediately have both a current physical and TB test. Attachment #10 shows that all employees working are now up to date. A new physical form, specific to work in this program was also provided to TeSm on 5/31/2018, as the current occupational health physical form was confusing and did not specifically follow 6400 regulations. Employee #1 is on leave. A copy of his new physical and TB test results will be provided upon his return and he will not have contact with residents until its completion. Future: Occupational Health staff person Terry Smigley will assure compliance with all new hires. 07/31/2018 Implemented
6400.164(b)Individual#1's MAR for the month of May 2018 has several medications that were not logged as of the date of inspection. These included; Novolog Injection Flexpen 7:30am on 5/10/18, 5/24/18, 5/31/18. 12:30pm on 5/7/18, 5/9/18, 5/17/18, 5/23/18, 5/30/18. Clonaxepam 5mg- 2:00pm on 5/9/18 The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. WHY: The omissions were identified to have occurred during home visits when family administered the medication. The former Program Manager LaWh did not fully understand and execute her responsibilities in the role of assuring Med Administration compliance. LaWh officially left the position in March. CEO Anne Marie Collins (AmCo) then discovered several deficiencies in LaWh¿s work and subsequently hired a nurse to oversee all aspects of the healthcare of the residents, including review of the MAR¿s. CURRENT: A procedure (Attachment #7) was developed for families to sign out their individuals when they take them home in which they commit to providing medications on the home visit and returning all medications to the residence after the visit. This procedure also recommends separate packaging and MAR¿s when vacations and home visits are planned in advance to lessen the chances for med errors. The nurse Regan will re-train all med trained staff on and carefully review the way to document when the individual is out of program so that there does not have an appearance of a missed dose. In addition, the necessity for HCSIS reporting of medication errors will be reviewed as well as the new internal document for documenting Medication Errors (Attachment #8). FUTURE: Besides the family sign-out form, a Medication Error Document was created and will assist in identifying these issues in the future. This compliance responsibility was added to the Program Specialist (Attachment #3) and Nurse¿s (Attachment #9) Job Descriptions. 07/10/2018 Implemented
6400.181(a)Individual #1 did not have a current assessment. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. WHY: The former Program Specialist LaWh did not fully understand and execute her responsibilities in this role. LaWh officially left the position in March. CEO Anne Marie Collins (AmCo) then discovered several deficiencies in LaWh¿s work and subsequently hired Maleita Olson, LCSW (MaOl) to fulfill the role as acting Program Specialist as on 5/1/2018. CURRENT: MaOl completed an annual assessment for individual #1, provided in attachment #6. Annual assessments were already present and up to date for other 2 individuals in the home. FUTURE: The Program Specialist job description was modified to more clearly delineate responsibilities related to 6400 compliance, including annual assessments, as seen in Attachment #2. In addition, MaOl created a handout for her upcoming training of the new program specialist which is scheduled for 7/10/2018, as seen in Attachment #3 which clearly indicates and reviews the documentation responsibilities. Finally, an ISP Required Assessments-Review Log (Attachment #4) was created to document and recognize timely submission errors at a glance. 07/10/2018 Implemented
6400.186(a)Individual #1's record did not have a 90 day review since his admission.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. WHY: The former Program Specialist LaWh did not fully understand and execute her responsibilities in this role. LaWh officially left the position in March. CEO Anne Marie Collins (AmCo) then discovered several deficiencies in LaWh¿s work and subsequently hired Maleita Olson, LCSW (MaOl) to fulfill the role as acting Program Specialist as on 5/1/2018. CURRENT: MaOl completed a quarterly review for individual #1, provided in attachment #1. Quarterly reviews were also completed for the other two residents. FUTURE: The Program Specialist job description was modified to more clearly delineate responsibilities related to 6400 compliance, including Quarterly Reviews, as seen in Attachment #2. In addition, MaOl created a handout for her upcoming training of the new program specialist which is scheduled for 7/10/2018, as seen in Attachment #3 which clearly indicates and reviews the documentation responsibilities. Finally, a Monthly/Quarterly ISP Review Log (Attachment #4) was created to document and recognize timely submission errors at a glance. 07/10/2018 Implemented
6400.186(c)(1)Individual#1's record did not have monthly reviews for the ISP dated 11/23/18.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. WHY: The former Program Specialist LaWh did not fully understand and execute her responsibilities in this role. LaWh officially left the position in March. CEO Anne Marie Collins (AmCo) then discovered several deficiencies in LaWh¿s work and subsequently hired Maleita Olson, LCSW (MaOl) to fulfill the role as acting Program Specialist as on 5/1/2018. CURRENT: MaOl completed a monthly review for individual #1, provided in attachment #5. Monthly reviews for May were also completed for the other two residents. FUTURE: The Program Specialist job description was modified to more clearly delineate responsibilities related to 6400 compliance, including monthly reviews, as seen in Attachment #2. In addition, MaOl created a handout for her upcoming training of the new program specialist which is scheduled for 7/10/2018, as seen in Attachment #3 which clearly indicates and reviews the documentation responsibilities. Finally, a Monthly/Quarterly ISP Review Log (Attachment #4) was created to document and recognize timely submission errors at a glance. 07/10/2018 Implemented
SIN-00111804 Initial review 04/06/2017 Compliant - Finalized