| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(10) | The annual physical completed for Individual #1 on 3/9/20 did not address if the individual was free and clear from communicable diseases. | 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. | Regulation 141(c)(10)
Plan to Fix Immediate Problem
Program Specialist will obtain written documentation from Primary Care Physician regarding physical information missing from March 2020 physical.
Program Specialist will ensure PCP provides documentation to ensure that Individual #1 is free of communicable diseases.
Program Specialist received documentation from PCP on 2/11/2021 (Physical Addendum 3-2020) verifying that at the time of physical in March 2020; Individual #1 was free from communicable disease.
Program Specialist reviewed all prior physicals with Executive Director on 2/15/2021 to ensure no further missing information was noted for other residents within the organization.
Plan to prevent future occurrences
Due to missing portions of the physical, Faithful Homes LLC. has now implemented a Physical Checklist (see attachment) that mirrors the physical examination regulatory requirements that the program specialist must complete after each physical is completed confirming that all portions and regulatory requirements are completed. This was implemented on 2/18/2021.
Attachment
Physical Addendum 3-2020
Physical Examination Checklist 2-18-2021 |
02/18/2021
| Implemented |
| 6400.141(c)(14) | The information pertinent to diagnose in case of an emergency section of the annual physical completed for Individual #1 on 3/9/20 was blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Regulation 141(c)(14)
Plan to Fix Immediate Problem
Program Specialist will obtain written documentation from Primary Care Physician regarding physical information missing from March 2020 physical.
Program Specialist will ensure PCP provides documentation on information pertinent to diagnose in the event of an emergency.
Program Specialist received documentation from PCP on 2/11/2021 (Physical Addendum 3-2020) verifying information pertinent to diagnose in the event of an emergency.
Program Specialist reviewed all prior physicals with Executive Director on 2/15/2021 to ensure no further missing information was noted for other residents within the organization.
Plan to prevent future occurrences
Due to missing portions of the physical, Faithful Homes LLC. has now implemented a Physical Checklist (see attachment) that mirrors the physical examination regulatory requirements that the program specialist must complete after each physical is completed confirming that all portions and regulatory requirements are completed. This was implemented on 2/18/2021.
Attachment
Physical Addendum 3-2020
Physical Examination Checklist 2-18-2021 |
02/18/2021
| Implemented |
| 6400.18(a)(5) | Incident occurred on 10/5/20 with Individual #1 in which a counseling appointment was rescheduled for her due to staff keeping an appointment of their own to get their vehicle fixed. Individual #1 was reportedly left alone in the vehicle. The discovery date of this incident was on 10/7/20; however this incident was not entered into EIM until 10/13/20. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Neglect.
| Regulation 18(a)(5)
Plan to Fix Immediate Problem
Agency reviewed incident reports for entire licensing year to gauge need for training/retraining on incident reporting on 2/18/2021.
Plan to Prevent future occurrences
Faithful Homes Executive Director will complete agency wide training with all direct care staff, management and executive management on timeliness of incident reporting and critical incident reporting as outlined in the ODP Training. This will be completed by 3/31/2021.
Attachment(s)
Critical Incident Reporting Sign-in |
03/31/2021
| Implemented |
| 6400.18(b)(2) | Individual #1 was not given Quetiapine Fumarate (Seroquel) on 4/14/20 as prescribed. She was not given Vitamin D3 nor Paroxetine HCL 40 on 6/21/20 as prescribed. She was given two doses of Quetiapine Fumarate on 6/28/20. None of these medication errors were reported within 72 hours. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | Plan to Fix Immediate Problem
Executive Director will submit Medication Errors for the three medication errors that were not reported into the EIM system.
Executive Director submitted all three medication errors on 2/11/2021 (please see all attachments) for omission on 4/14/2020 and 6/21/2020 for individual #1. Also, medication error submitted for wrong dose for individual #1 on 6/28/2020.
Executive Director, Compliance Officer and Operations Managers reviewed all MARs for previous licensing year for any other medication errors not reported. This was completed on 2/16/2021.
Plan to Prevent future occurrences
Executive Director will complete training with all direct care staff, management staff and executive staff on reporting medication errors (within 72 hours), chain of command on reporting medication errors and the different types of medication errors.
This training for all staff and management will be completed by March 31st, 2021.
Attachment(s)
Ind #1 Medication Error Omission 4-14-20
Ind #1 Medication Error Omission 6-21-20
Ind #1 Medication Error Wrong Dose 6-28-20 |
03/31/2021
| Implemented |
| 6400.51(a)(3) | Staff #2's date of hire was 12/15/20. As of the date of inspection, there was no documentation that Staff #2 has completed her orientation training, which is more than 30 days past her date of hire. Staff #3's date of hire was 7/14/20. She did not complete her orientation trainings until 9/25/20. | 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. | Regulation 51(a)(3)
Plan to Fix Immediate Problem
Staff #2 completed orientation on 2/19/2021.
Compliance officer reviewed all employee files for training records and completed this on 2-19-2021 to ensure no further non-compliances.
Plan to Prevent future occurrences
In order to keep track of employee training more effectively upon hire, a new form was created to be able to audit training at time of hire to ensure that trainings are being completed within the regulatory requirements (please see attachment). This was put into practice effective 2-19-2021 and will be utilized moving forward.
Faithful Homes, LLC will provide the next training classes audit form(s) to show the use of the form by 3/12/2021. |
03/12/2021
| Implemented |
| 6400.51(b)(1) | There is no documentation that Staff #2 received any training in person centered practices, community integration, individual choice, or supporting individuals to develop or maintain relationships. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Regulation 51(b)(1)
Plan to Fix Immediate Problem
Staff #2 completed orientation on 2/19/2021.
Plan to Prevent future occurrences
In order to keep track of employee training more effectively upon hire, a new form was created to be able to audit training at time of hire to ensure that trainings are being completed within the regulatory requirements (please see attachment). This was put into practice effective 2-19-2021 and will be utilized moving forward.
Faithful Homes, LLC will provide the next training classes audit form(s) to show the use of the form by 3/12/2021.
Attachment(s)
Staff #2 Completed Orientation 2-19-2021
Faithful Homes Training Audit Sheet 2-19-2021 |
03/12/2021
| Implemented |
| 6400.51(b)(5) | There is no documentation that Staff #2 received training in job related knowledge or skills. There is no documentation that she received ISP training for 2 of the individuals with whom she works. | The orientation must encompass the following areas: Job-related knowledge and skills. | Regulation 51(b)(5)
Plan to Fix Immediate Problem
Staff #2 completed orientation on 2/19/2021
Plan to Prevent future occurrences
In order to keep track of employee training more effectively upon hire, a new form was created to be able to audit training at time of hire to ensure that trainings are being completed within the regulatory requirements (please see attachment). This was put into practice effective 2-19-2021 and will be utilized moving forward.
Faithful Homes, LLC will provide the next training classes audit form(s) to show the use of the form by 3/12/2021.
Attachment(s)
Staff #2 Completed Orientation 2-19-2021
Faithful Homes Training Audit Sheet 2-19-2021 |
03/12/2021
| Implemented |
| 6400.166(a)(11) | The purpose for Individual #1 taking the Quetiapine Fumarate Seroquel, Levocetrizine, and the Triamcinolone is not reported on the MAR. | 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. | Regulation 166(a)(11)
Plan to Fix Immediate Problem
Operations Manager contacted provider for individual #1 and requested diagnoses be forwarded to Pharmacy to be attached to the labels and subsequently put onto the MARs.
Operation Managers and Program Specialist will complete a reconciliation of all medications and MARs to identify any other non-compliances.
A new form was created that will be completed by each healthcare provider for each individual listing the medications they prescribe and the diagnosis for taking the medication. (See attachment section).
Plan to Prevent Future Occurrences
To avoid similar errors in the future, Faithful Homes LLC. has updated their Medical Appointment Form (see attached) to include a section specific to medication changes which specifically asks the healthcare provider to list the exact medication, dosage, instructions and indication/diagnosis for the medication. This information will then be forwarded to the Pharmacy and input onto the labels and MARs.
Completion of all of these items for this corrective action will be completed by March 31st, 2021.
Attachment(s)
Diagnosis and Med Reconciliation Form
Medical Appointment Form Updated 2-16-2021 |
03/31/2021
| Implemented |
| 6400.167(a)(1) | Individual #1 was not administered Quetiapine Fumarate on 4/14/20 as prescribed. On 6/21/20, Individual #1 was not administered Vitamin D3 nor Paroxetine HCL 40 as prescribed. | Medication errors include the following: Failure to administer a medication. | Regulation 167(a)(1)
Plan to Fix Immediate Problem
Executive Director will be responsible for entering EIMs for both omissions of medications
Executive Director will enter the EIMs to provide documentation that medication errors of omission occurred for individual #1 on 4/14/20 and 6/21/20.
Executive Director entered two separate incident reports for medication errors. These EIMs were entered on 2/11/2021. EIM #8807315 for omission of medication on 6/21/2020. EIM #8807307 for omission of medication on 4/14/2020.
Plan to Prevent Future Occurrences
Executive Director will complete training with all direct care staff, management staff and executive staff on reporting medication errors (within 72 hours), chain of command on reporting medication errors and the different types of medication errors.
This training for all staff and management will be completed by March 31st, 2021.
Attachments via email
Ind #1 Medication Error Omission 4-14-20
Ind #1 Medication Error Omission 6-21-20 |
03/31/2021
| Implemented |
| 6400.167(a)(3) | Individual #1 was administered Quetiapine Fumarate twice on 6/28/20 as opposed to once at bedtime. | Medication errors include the following: Administration of the wrong dose of medication. | Regulation 167(a)(3)
Plan to Fix Immediate Problem
Executive Director will be responsible for entering EIMs for the wrong dose of medication.
Executive Director will enter the EIM to provide documentation that a medication error of wrong dose occurred for individual #1 on 6/28/2020.
Executive Director entered an incident report for a medication error. This EIM was entered on 2/11/2021. EIM #8807313 for wrong dose of medication on 6/28/2020.
Plan to Prevent Future Occurrences
Executive Director will complete training with all direct care staff, management staff and executive staff on reporting medication errors (within 72 hours), chain of command on reporting medication errors and the different types of medication errors.
This training for all staff and management will be completed by March 31st, 2021.
Attachments
Ind #1 Medication Error Wrong Dose 6-28-20 |
03/31/2021
| Implemented |
| 6400.213(1)(i) | Photo for Individual #1 was last taken on 4/19/19. In order to be a current photo, it must be updated annually. | Each individual's record must include the following information: Current, dated photograph. | Regulation 213(1)(i)
Plan to Fix Immediate Problem
Program Specialist will review all ISP books to identify which individuals photos are over a year old in relation to regulation 213(1)(i)
Program Specialist will take photographs of all individuals whose photos are greater than 1 year old.
Program Specialist identified eleven (11) individuals that needed photos updated including original citation from individual #1. All photographs for these individuals were updated and placed into their ISP Books on 2/11/2021.
Plan to Prevent Future Occurrences
As part of our compliance checklist, which includes consents, individual rights, etc. resident photos will be taken every April and October to ensure compliance with this regulation and submitted to the Compliance Officer by the House Managers of each residential location.
Attachments via email
Updated Photos (Annual 2-11-2021) |
02/18/2021
| Implemented |