| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(1) | The agency's medication administration and medication administration training policy states that medication errors, described as failure to administer the medication and failure to administer the medication at the right time, will be reported online within 72 hours. Internal progressive disciplinary actions pertaining to medication errors will be implemented. As documented in this report, the home failed to administer medications to Individual #1 and failed to administer medications on the correct date monthly over the previous year. At no point did the agency report the medication errors to the Department, implement internal progressive disciplinary actions, or implement their medication administration policy. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | On 7/13/23 Staff were trained on the importance of completing the proper medication management when administering meds and how to report errors if they do occur. Management staff including the lead staff and the director were retrained on providing oversight to the home regarding medication administration and the process of reporting medication errors online within the appropriate time frame. Home compliance will be in the form of monthly House checks which include reviews of the MARS and medication within the homes. |
07/24/2023
| Implemented |
| 6400.43(b)(3) | As documented in this report, the home failed to administer medications to Individual #1 and failed to administer medications on the correct date, monthly over the previous year. At no point did the agency, Care Sense Living LLC, report the medication errors to the Department, implement internal progressive disciplinary actions, or implement their medication administration policy.
Additionally, the agency's medication administration and medication administration training policy does not include instructions for the safe practices of managing individual's medications, storage and disposal of medications, the use of prescription medications, the use of as needed psychotropic medications, the agency's medication administration documentation records, who to report medication administration errors to and what is needed for individual's to be able to self-administer medications. It is also lacking who is responsible for management and oversight daily of individual's medications, medication administration records, and medication administration to ensure the individual's health and safety. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | On 7/13/23 Staff were trained on the importance of completing the proper medication management when administering meds and how to report errors if they do occur. management staff (7/13/23) including the lead staff, the director (6/28/23) were retrained on importance of providing oversight to the home regarding medication administration and the process of reporting medication errors online within the appropriate time frame and implementing the medication administration policy. Home compliance will be in the form of monthly House checks which include reviews of the MARS and medication within the homes. The forms committee will be reviewing the medication administration policy on 7/28/23 and will updating the policy to reflect who is responsible for management and oversight daily of individual's medications, medication administration records, and medication administration to ensure the individual's health and safety., the updated policy will also include instructions for the safe practices of managing individual's medications, storage and disposal of medications, the use of prescription medications, the use of as needed psychotropic medications, the agency's medication administration documentation records, who to report medication administration errors to and what is needed for individual's to be able to self-administer medications. |
08/02/2023
| Implemented |
| 6400.62(a) | At the time of the 6/22/23 inspection, there was Lysol spray in the bathroom closet and Clorox wipes under the kitchen sink, both accessible to the individual. Individual #1 is not safe around poisonous items. | Poisonous materials shall be kept locked or made inaccessible to individuals. | On 7/13/23 - Staff were trained on the importance abiding by the individual's safety protocols which includes safety around poisonous materials - Poisonous materials shall be kept locked or made inaccessible to individuals. The management staff including the lead staff (7/13/23) , also the director (6/28/23) were retrained on importance of providing oversight to the home regarding poison safety and the process of reporting any updates to the support's coordination. Home compliance monitoring of poison safety will be in the form of monthly House checks which include reviews of the MARS and medication within the homes. On 7/20/23 an email update to the Supports coordination was sent to reflect current poison safety status of individual #1 which will be reviewed in the upcoming ISP . |
07/28/2023
| Not Implemented |
| 6400.103 | During the 6/21/23 inspection, the agency produced an Emergency Evacuation Policy for the agency. This policy did not include the means of transportation to the emergency shelter location or the emergency shelter location the home is to use in the event of an emergency evacuation.
The home produced an Emergency Evacuation and Temporary Placement plan. This plan did not include the individual's responsibilities or applicable staff responsibilities. This plan states staff on shift are to contact a program coordinator for directions and the process of evacuation, can contact an on-call point person, and is to take further direction for delivery of medications, supplies, and notification of family members by the program coordinator or program specialist. The agency, Case Sense Living LLC., did not provide the Department with any staff member that holds the title of a program coordinator for the direct support staff to know who to contact for further instructions.
Both plans were missing components of the requirements defined in 55 Pa. Code § 6400.103. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| On 7/13/23 Staff person were updated on the updated emergency evacuation and temporary Placement protocol. The emergency evacuation and temporary Placement protocol were updated to reflect the missing components and they now include the means of transportation to the emergency shelter location or the emergency shelter location the home is to use in the event of an emergency evacuation. The Emergency Evacuation and Temporary Placement plan now includes the individual's responsibilities or applicable staff responsibilities. This plan has been updated who the staff and family members should contact in an emergency. Both plans updated to reflect all components of the requirements defined in 55 Pa. Code § 6400.103. |
07/13/2023
| Implemented |
| 6400.112(h) | The electronic and paper fire drill records from July 2022 to June 2023 do not document if individuals went to the meeting place during the monthly fire drills. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | on 7/13/23 staff were retrained on the importance of completing fire drills and all its components that need to be documented including the documentation of the monthly meeting place. Lead staff and the director were both retrained on the importance of monitoring fire drills on a monthly basis and ensuring that it's completed in full. |
08/04/2023
| Not Implemented |
| 6400.112(i) | The electronic and paper fire drill records from July 2022 to June 2023 do not document or report if a smoke detector was activated to simulate the monthly fire drills. | A fire alarm or smoke detector shall be set off during each fire drill. | On 7/13/23 staff were retrained on the importance of completing fire drills and all its components that need to be documented including the documentation of the activation of the smoke detector. Lead staff and the director were both retrained on the importance of monitoring fire drills on a monthly basis and ensuring that it's completed in full including utilizing the smoke detector during drills and documenting which was used. |
08/04/2023
| Implemented |
| 6400.141(a) | Individual #1 did not have an annual physical examination completed in 2022. The only annual physical examination the provider agency was able to produce was dated 2/3/23. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | On 7/13/23 Staff were retrained on the importance of ensuring that An individual shall have a physical examination within 12 months prior to admission and annually thereafter. |
07/07/2023
| Not Implemented |
| 6400.141(c)(6) | The only tuberculin test results provided to the Department for Individual #1 were dated 6/20/22. Individual #1's date of admission is 9/7/20. There is no documentation verifying that Individual #1 had a tuberculin test completed between date of admission and 6/20/22. | 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. | On 7/13/23 staff were retrained on the importance of ensuring that individuals residing at the home have a physical completed annually and 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. Compliance review./training on what annual physical paperwork should require was completed withe lead staff and residential director for Lancaster . |
07/07/2023
| Not Implemented |
| 6400.141(c)(11) | The health maintenance needs, medication regiment, and the need for blood work at recommended intervals section of Individual #1's 2/3/23 annual physical examination was left blank. | 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. | Compliance review /training on what annual physical paperwork should require was completed withe lead staff and residential director for Lancaster and an emphasis on esuring that includes and assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. |
07/07/2023
| Implemented |
| 6400.145(1) | During the 6/21/23 inspection, the agency was only able to produce a Medical Emergencies and Emergency Medical Plan document. This document did not include the hospital or source of heath care the individuals in the home are to utilize in an emergency. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | On 7/13/23 - Staff were trained on the importance of following the medical emergencies and emergency medical plan ad its updated components which includes the hospital or source of health care that will be used in an emergency. |
07/13/2023
| Implemented |
| 6400.145(3) | During the 6/21/23 inspection, the agency was only able to produce a Medical Emergencies and Emergency Medical Plan document. This document did not include the emergency staffing plan the home is to utilize in an emergency. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | On 7/13/23 - Staff were trained on the importance of following the medical emergencies and emergency medical plan ad its updated components which includes the hospital or source of health care that will be used in an emergency as well as the emergency staffing plan the home is to utilize in an emergency. |
07/13/2023
| Implemented |
| 6400.151(b) | Staff person #2's 11/16/21 and 1/3/23 physical examination records are not completed, signed and dated by a licensed physician, certified nurse practitioner, or licensed physician's assistant. The record provided was a printout summary and did not indicate who completed the summary, a signature and date, or electronic signature and date of the licensed medical professional completing the record. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | On 7/13/23 staff were trained on the importance of ensuring that all staff physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner, or licensed physician's assistant. Also reviewed was the physical exam form that should be utilized during all staff physicals and all components completed in full including physicians' signature and date. |
07/13/2023
| Implemented |
| 6400.151(c)(2) | Staff person #2's 11/16/21 and 1/3/23 physical examination records did not include a review or documentation of their most recent Tuberculin skin test by Mantoux method with negative results of a chest x-ray. The agency produced a document that Staff person #2's Tuberculin skin test was read negative on 1/5/23, after the physical examination, but the record does not document the medical certification of the person reading the results.
Staff person #3's 1/18/23 physical examination record did not record if they received a Tuberculin skin test by Mantoux method with negative results, or a chest x-ray with negative results. The field to indicate if this was completed and reviewed by the physician during the examination was left blank. The report of a chest x-ray produced during the 6/21/23 inspection was illegible. | 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. | On 7/13/23 staff were trained on the importance of ensuring that all 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. Also reviewed with staff was the physical exam form that should be utilized during all staff physicals and all components completed in full including TB section that needs to be completed and results documented and the medical certification of the person administering it. |
07/13/2023
| Implemented |
| 6400.151(c)(3) | Staff person #2's 11/16/21 and 1/3/23 physical examination records did not 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. | 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. | On 7/13/23 staff were trained on the importance of ensuring that all 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. Also reviewed with staff was the physical exam form that should be utilized during all staff physicals and all components completed in full including 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. |
07/13/2023
| Implemented |
| 6400.151(c)(4) | Staff person #2's 11/16/21 and 1/3/23 physical examination records and Staff person #3's 1/18/23 physical examination record did not include Information of medical problems which might interfere with the health of the individuals. Staff person #2's record did not include this and the field to indicate this on Staff person #3's record was left blank. | The physical examination shall include: Information of medical problems which might interfere with the health of the individuals. | On 7/13/23 staff were trained on the importance of ensuring that all staff person's physical examination shall include Information of medical problems which might interfere with the health of the individuals. Also reviewed with staff was the physical exam form that should be utilized during all staff physicals and all components completed in full including Information of medical problems which might interfere with the health of the individuals, and nothing should be left blank, and all areas addressed. |
07/13/2023
| Not Implemented |
| 6400.181(a) | Individual #1's annual assessment was completed on 5/3/21 and not again until 11/7/22, outside of the annual timeframe. | 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. | On 7/13/23 staff and program specialist ( 7/21/23) were trained on the importance of ensuring that 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. Dues dates and components and where the assessments are kept in the home were reviewed as well. |
07/13/2023
| Not Implemented |
| 6400.211(a) | Individual #1's emergency information sheet does not contain the correct address of the residence. Individual #1 moved from one home to another home on 1/5/23. The Emergency information sheet was not updated at the time of the move. | Emergency information for an individual shall be easily accessible at the home.
| 0n 7/13/23 staff were retrained on the importance of ensuring that Emergency information for an individual shall be easily accessible at the home and be updated to reflect updated information.
On 7/25/23 the emergency information will be updated for all individuals in the home and updated by 7/26/23. |
07/26/2023
| Implemented |
| 6400.24 | Article X.1007: The agency, Care Sense Living LLC, documents Staff person #3's date of hire is 1/25/23. At the time of the 6/21/23 inspection, Staff person #3 did not complete any records documenting if they are or have been a resident of the state of Pennsylvania for the previous two years. Staff person #3 left all fields on their application to answer this question blank. The agency was unaware that Staff person #3 never reported their residency, and the agency never applied for a Federal Bureau of Investigation background check for Staff person #3. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | On 7/13/23, all staff were trained on the importance of ensuring that the home shall comply with applicable Federal and State statutes and regulations and local ordinances. the staff person #3 has been a resident of Pennsylvania for more than 2 years and had left the field of the application for residency area blank which was an oversite. A driving check had been completed, prior to hire as well that reflects documentation of two years of pa driving history and the staff is scheduled to complete an FBI background check by 7/28/23. The director of residential also had training on the onboarding process and the importance of making sure the employee application is completed in full and how to address the residency section and follow up needed. |
07/28/2023
| Implemented |
| 6400.34(a) | At Individual #1's 1/6/23 annual rights review, the individual's rights defined in 55 Pa Code 6400.31 and 6400.33 were not reviewed with the individual. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | On 7/13/23 staff were retrained on the importance of informing and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. a refresher training will be done with the individual #1 by 7/25/23. |
07/25/2023
| Not Implemented |
| 6400.46(a) | Staff person #3's date of hire is 1/25/23. Staff person #3 started working independently with individuals on 1/29/23. They did not receive fire safety training until 1/30/23.
Staff person #2's date of hire is 6/3/19. There is no record verifying that staff person #2 received fire safety training before 1/26/23. | 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. | On 7/13/23 all staff were trained on the importance of ensuring that the Program specialists and direct service workers are 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. on 6/28/23 director of residential was trained on the onboarding process and what is needed prior to staff working with the individuals once hire also reviewed is the new staff checklist and new hire orientation which breakdown all components needed prior to hire and trainings needed once hired. |
07/13/2023
| Implemented |
| 6400.46(c) | Staff person #3's date of hire is 1/25/23. Staff person #3 started working independently with individuals on 1/29/23. Staff person #3 did not receive training in general first aid until 1/30/23. | 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. | On 7/13/23 all staff were trained on the importance of ensuring that 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. on 6/28/23 director of residential was trained on the onboarding process and what is needed prior to staff working with the individuals once hire also reviewed is the new staff checklist and new hire orientation which breakdown all components needed prior to hire and trainings needed once hired. |
07/13/2023
| Implemented |
| 6400.50(a) | Staff person #3's orientation training record that occurred on 2/7/23 did not list the length of training on all topics they received training on. The field to indicate the length of the training(s) was left blank.
Staff person #1's annual 2022 training record stated that training topics, "community integration, with developing relationships, seizure management, person center practices, and individual choice" occurred on two days (1/10/22 and 1/11/22) but did not define which trainings occurred on which days.
Additionally, these training topics were listed as ODP (Office of Developmental Programs) trainings, but the training source was recorded as Staff person #2, not ODP. ODP trainings produce certificates for documentation of completion of the courses, and ODP certificates were never produced for Staff person #1's ODP trainings. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | On 7/13/23 staff person were trained on the importance of ensuring that Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. The new hire orientation form will be reviewed. During the forms committee meeting on 7/28/23 and scheduled retraining of new forms will be done on 8/4/23. |
08/04/2023
| Implemented |
| 6400.51(a)(3) | Staff person #3's date of hire is 1/25/23. Staff person #3 started working independently with individuals on 1/29/23. Staff person #3 did not complete orientation training described in 6400.51(b)(1) through 6400.51(b)(5) before working with individuals. Staff person #3 completed a list of orientation topics on 2/7/23, but the content of these trainings was not provided to the Department to ensure that this staff person complete all aspects of orientation training. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons. | On 7/13/23 staff person including management /hiring staff were trained on the importance of ensuring that prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons. The director of operations was trained on the onboarding process and orientation of staff. |
07/13/2023
| Implemented |
| 6400.52(a)(1) | The agency reports that their training year is the calendar year. Staff person #4 only received 8 hours of training in the 2022 calendar year. Additionally, staff person #4 did not complete annual training in the areas specified in 6400.52(c)(1) through 6400.52(c)(6) in calendar year 2022. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | On 7/13/23- The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. Annual trainings will be scheduled for the start of CareSense calendar year which will add up to 12 hrs. to start off the calendar year, which is scheduled for January 5th and January 8th, 2024. |
07/13/2023
| Implemented |
| 6400.52(c)(5) | Staff person #2 works directly with individuals. Annual training in the safe and appropriate use of behavior supports that included training on all individuals' specific behavior support plans wasn't provided to Staff person #2 in the agency's 2022 annual training year.
Staff person #2 produced records that they received web-based trainings on challenging behaviors and behaviors as communication in 2022. However, according to the Department's 6400 Regulatory Compliance Guide, any of the annual training topics listed at 6400.52(c) may be delivered through a web-based format except for 6400.52(c)(5)-(6). | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | On 7/13/23 staff were trained on the importance of ensuring that The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. a refresher training of behavior support will done with the staff in the home by 7/28/23 and challenging behaviors will be reviewed as a component. |
07/13/2023
| Implemented |
| 6400.52(c)(6) | Staff person #2 works directly with individuals. Annual training in implementation of the individual plan, training on job-related knowledge and skills relating to individual-specific needs, plans, protocols, health needs, and support to provide to individual's outlined in all their individual-specific plans was not provided to Staff person #2 in the agency's 2022 annual training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | On 7/13/23 staff were trained on the importance of ensuring that the annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. |
07/13/2023
| Implemented |
| 6400.165(g) | Individual #1's 9/722, 12/7/22, 2/7/23, and 4/26/23 psychiatric medication reviews do not list the current medications that were to be reviewed. | 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. | On 7/1/23 staff reviewed the importance of ensuring that 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. An updated/simplified psyche form was implemented as of 7/21/23. |
07/21/2023
| Not Implemented |
| 6400.166(a)(1) | Individual #1's record is missing the Medication Administration Record for July 2022. The provider agency was unable to produce this document. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Individual's name. | On 7/13/23, staff were trained on the regulation that a medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Individual's name. Lead staff and residential director for Lancaster were trained on the importance of reviewing and uploading the MAR's. |
07/24/2023
| Not Implemented |
| 6400.166(a)(12) | Individual #1 was recorded as being administered the following medications, however, a time is not listed for the administrations:
· 12/17/22 -- Acetaminophen
· 12/19/22 -- Acetaminophen
· 12/29/22 - Acetaminophen
· 2/23/23 -- Triamcinolone
· 2/24/23 -- Triamcinolone
· 2/24/23 -- Triamcinolone
· 3/1/23 -- Triamcinolone and Fluticasone
· 3/2/23 -- Triamcinolone
· 3/3/23 - Triamcinolone
· 3/2/23 -- Trazodone 50mg
· 3/14/23 -- Fluticasone
· 3/15/23 - Fluticasone
· 4/1/23 -- Metamucil
· 4/2/23 -- Metamucil
· 4/23/23 -- Trazodone 50mg | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | On 7/13/23 - a retraining was done on the importance of having a medication record that is kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. Home compliance will be in the form of monthly House checks which include reviews of the MARS and medication within the homes. |
07/13/2023
| Not Implemented |
| 6400.167(a)(1) | (Repeated Violation -- 6/21/22) The following medications were not administered to Individual #1:
· 11/28/22 -- 8pm dose of Lisinopril
· 1/6/23 -- 8pm dose of Lamictal
· 1/6/23 -- 4pm and 8pm dose of Flaxseed Oil
· 1/11/23 -- 4pm and 8pm dose of Flaxseed Oil
· 1/22/23 -- 8pm dose of Lamictal
· 2/18/23 -- 8am dose of Amoxicillin
· 3/3/23 -- 8pm dose of Metformin and Flaxseed Oil
· 4/25/23 -- 8pm dose of Lisinopril
· 4/26/23 -- 8pm dose of Lisinopril
· 4/28/23 -- 8pm dose of Lisinopril
· 6/16/23 -- 4pm dose of Flaxseed Oil | Medication errors include the following: Failure to administer a medication. | Medication errors once identified during the licensing were submitted within the allotted time frame. On 7/13/23 staff were trained on the importance of completing the medication administration processing full and giving medications in a timely manner as specified and signing off on the MAR. Also reviewed was the importance of documenting home visits on the MAR. |
08/02/2023
| Not Implemented |
| 6400.167(a)(4) | The following medications were administered to Individual #1 at the wrong time:
· Debrox 6.5% ear drops are to be administered Tuesday and Friday; This medication was administered on 12/31/22, which was a Saturday. | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | Medication errors once identified during the licensing were submitted within the allotted time frame. On 7/13/23 staff were trained on the importance of completing the medication administration processing full and giving medications in a timely manner as specified at the prescribed time and signing off on the MAR. Also reviewed was the importance of documenting home visits on the MAR. |
08/02/2023
| Implemented |
| 6400.169(a) | Staff person #3's 2023 initial medication administration training did not document the date a certified medication administration trainer reviewed the staff's training documents and approved them to administer medications to individuals. The field to indicate the date they passed all examinations and requirement was left blank. Staff person #3 administered medications to individuals in May 2023. | 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). | On 7/13/23 staff were retrained on the importance of having up to date medication admin training records including signoff on reviews since 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). |
07/13/2023
| Implemented |
| 6400.169(d) | The date and documents for Staff person #3's written documentation test (consisting of a script/label examination and mar examination) and the multiple-choice test, part of the 2023 initial medication administration training documents, was not provided or kept in their record.
The date and documents for Staff person #4's written documentation test and multiple-choice test, part of their 6/12/22 initial medication administration training, was not provided or kept in their record. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | On 7/13/23 - Staff were retrained on the importance of ensuring that the record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. |
07/13/2023
| Implemented |
| 6400.181(f) | Individual #1's 11/7/22 was not sent to the team members. The PS indicated on the 11/7/22 annual assessment "CC- as requested," but it did not indicate that the annual assessment was sent to any team members. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The program specialist was retrained on 7/21/23 on the program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. |
07/21/2023
| Implemented |