| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Individual #1's current 5/4/23 physical examination record states they have active genital herpes. Individual #1 and #2 Individual #2 reside in the same home and use the same shower in the first-floor hallway. The shower had two bars of soap and one wash cloth. Individual #2 requires additional support from staff to help bathe, while Individual #1 is independent. The bars of soap were not in covered, labeled, containers preventing the spread of any bacteria or disease, or to assist with identifying which bar of soap belongs to which individual. | Clean and sanitary conditions shall be maintained in the home. | Each individual will have a caddy labeled with their name. All personal care items will be placed in the caddy and kept either in their bedroom or in the cabinet in the bathroom. No items will be kept in the shower |
06/02/2023
| Implemented |
| 6400.104 | The current, written notification letter sent to the fire department on 5/1/23, states Individual #1 and Individual #2 reside in the home. The letter doesn't indicate the level of assistance needed for either individual. According to the fire drill record for April 2023, Individual #2 required physical assistance on 4/29/23. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Program specialist and coordinators were retrained on all information needed in a fire safety letter so that letters always meet regulatory guidelines. |
06/02/2023
| Implemented |
| 6400.141(c)(11) | Individual #1's current, 5/4/23 physical examination record didn't include a full list of their medications. The milligram dose of Ativan to be administered as needed when experiencing anxiety or agitation is not documented. There are two medications prescribed as needed for anxiety and no indication that they can or should be administered together or if one needs offered before the other, etc. | 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. | Program specialists and coordinators were retrained on completing the annual physical paperwork, all physicals will be completed by respite coordinators and program specialists prior to sending them out for review by the nurse3. The Doctor has been contacted and medication administration instructions for PRN medications have been received. Medication list was updated immediately to include dosage of Ativan. |
06/02/2023
| Implemented |
| 6400.144 | On 4/20/23 Individual #1 was evaluated at the emergency department after experiencing a mental health crisis. Upon discharge they were provided instructions that stated therapy and counseling can help assist with their adjustment disorder, and were provided a number of locations throughout Cumberland, Perry, and Dauphin counties to contact for therapy and counseling services.
On 4/26/23 Individual #1 was evaluated at the emergency department again for a chief complaint of behavioral health evaluation and reported they were seeking counseling. They were to follow up with their primary care physician.
At the time of the 5/9/23 inspection, the agency produced a "memo" stating all therapist and counselors were contacted and an appointment was scheduled for August 2023. The memo does not record when and which counselors were contacted to determine if the attempts to obtain support for Individual #1 was timely. | 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.
| Program specialists and coordinators to be retrained on how to read and understand discharge summaries and follow up requirements. Also to be trained on maintaining an accurate call log to ensure that all information is documented correctly. |
06/02/2023
| Implemented |
| 6400.151(c)(2) | Staff person #5's date of hire is 11/21/22 and they started orientation on this date. They did not have their Tuberculin skin test read with negative results until 11/22/22. | 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. | This citation cannot be corrected. Below is the plan to stop recurrence. |
06/02/2023
| Implemented |
| 6400.181(e)(5) | Individual #1's current, 4/28/23 assessment doesn't include a full and accurate description or assessment of their ability to administer medications. Their assessment says the individual can independently take medications but also needs assistance with as needed medications for anxiety when facing conflict or stress. At the time of the 5/9/2023 inspection, Individual #1's record doesn't include a full list of prescribed medications for the program specialist to use to assess the individual's ability to self-administer their medications. The individual's current, 5/4/23 physical examination record doesn't include a dosage of Ativan to use as needed for anxiety. The same physical record also lists Hydroxyzine 50mg as needed for anxiety. The record doesn't indicate if both medications can be administered together, or if they should be administered separately, or a few hours apart from each other.
Individual #1's 4/1/23 SEEN plan states staff will assist the individual in ensuring that they are taking their medications accurately at all times to assist them with maintaining their emotional wellbeing. During the 5/10/23 inspection at the home, staff report they give Individual #1 their daily container of medications for morning, evening, as needed, and bedtime and let the individual take the medications to their bedroom. Staff report there are times Individual #1 doesn't take their medications accurately. During the inspection an Oxcarbazepine pill was found on Individual #1's nightstand. Staff do not know when this pill was missed. Staff are not talking with the individual during every medication administration to confirm they took their medications or determining if they are choosing to not take their scheduled medications. There isn't documentation of the support being provided to Individual #1 during daily and as needed medication administration.
The SEEN plan states if Individual #1 is presenting to be unstable staff will monitor the individual with medications to ensure they are being safe with them. Every morning staff give Individual #1 a full days' worth of medications and some of their as needed medications to keep in their bedroom. Staff have documented behaviors from 4/26/23-current, that Individual #1 has gotten upset and been aggressive, breaking mirrors, hitting staff, throwing items, and going into their bedroom to continue the escalation. Staff do not document that they go to the individual's bedroom to monitor for medication safety since the medications are available to the individual in their bedroom during times when they are unstable. Staff at the home on 5/10/23 report they don't knock on the individual's door because that will upset them more. The SEEN plan states the individual has attempted to commit suicide and self-harm with medications in the past.
Information included in the SEEN plan, and current reports from staff are not included in the individual's assessment or used as information to assess the individual's ability to self-administer medications. | The assessment must include the following information: The individual's ability to self-administer medications. | Doctor has been contacted and medication administration instructions for PRN medications have been received. Medication list was updated immediately to include dosage of Ativan. Assessments will be updated by program specialist to include the individual's current skill level in medication administration as individuals needs change. |
06/30/2023
| Implemented |
| 6400.216(a) | All record information for individuals who have stayed at the home over the previous year were unlocked and accessible in the home, downstairs in the basement. The cabinet with all the records were unlocked and the key to lock and unlock the cabinet was in the lock of the cabinet. There was 50+ individual records in the cabinet. An individual's record was unlocked laying on the table in the basement. Individual medical records were unlocked and laying in a box next to the shredder in the basement. | An individual's records shall be kept locked when unattended.
| All coordinators and program specialist will be retrained on the importance of HIPAA guidelines to ensure compliance. |
06/02/2023
| Implemented |
| 6400.51(b)(5) | Staff person #5's date of hire was 11/21/22 and Staff #5 started working with individuals on 11/24/22. The documentation of individual specific training provided to Staff person #5 was online training or independent readings, without an in-person orientation training component to the training. | The orientation must encompass the following areas: Job-related knowledge and skills. | All employees will be trained in person on all ISP, BSP, and related documents prior to admitting someone into residential services. Documentation of training will be kept and monitored by training department. Respite guests will be scheduled at least a month in advance so that training on ISP can occur at monthly house meetings. In regards to emergency admissions, it is the coordinator and program specialist role to ensure that every employee received training on prior to working with new individuals. |
07/21/2023
| Implemented |
| 6400.52(c)(6) | Staff person #2 started working as a program specialist full time on 1/9/23 and first worked with individuals on 1/9/23. Individual #1 moved into the home on 3/1/23. Staff person #4 started working with Individual #1 when they moved to the home on 3/1/23. Staff #2 and Staff #4 only received training on Individual #1's individual support plan, but not until 4/4/23. Additionally, the signed training record states that Staff #2 and Staff #4 indicated they read the Individual Support Plan, but it doesn't indicate an in-person training component occurred. Additionally, Individual #1 has a SEEN plan, a medication administration plan, an emergency medical plan, a desensitization plan for refusal of medical appointments, a plan for the community, and a supervision plan. None of these plans are in the individual's Individual Support Plan. There are no records that Staff #2 nor Staff #4 received training in the individual's additional plans and how to ensure they are being implemented. | 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. | All employees will be trained in person on all ISP, BSP, and additional plans prior to admitting someone into residential services. Training on any new or changed plans will be reviewed with all team members by the program specialist at monthly team meetings. Documentation of training will be kept and monitored by training department. |
07/21/2023
| Implemented |
| 6400.163(d) | Individual #2 resides at the home and cannot self-administer medications, requiring medications to be locked for their safety. During the 5/10/23 onsite inspection of the home, Individual #1 was not home and their bedroom door was unlocked. Sitting on Individual #1's bedside table, right inside their bedroom door, there were medications unlocked and accessible. One of the medications was not in a container and laying independently on the stand. The other medications were stored in a daily, flip top medication container. A few medications were left in the evening medications compartment. Individual #2 is able to ambulate the home and use their fine and gross motor skills to open items throughout the home. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | All persons who are self medicating will have the option of how to maintain their medications locked and out of reach for other guests. They can have a locked box in their bedroom, they can lock their bedroom door or they can ask to have their meds kept in the locked medication closet. All team members to be trained of proper medication storage. |
06/02/2023
| Implemented |
| 6400.165(f) | Individual #1 is prescribed psychotropic medications for psychiatric diagnosis. Their Individual Support Plan does not include a current, up-to-date plan to address their social, emotional, and environmental needs (SEEN) relating to the symptoms of their diagnosis. The ISP states the individual does not have any behavioral support plans. The home was able to produce a SEEN plan for the individual, however there are no records this plan was sent to the team member responsible for adding it into the individual's ISP.
Additionally, the SEEN plan produced was created on 4/1/23, but states information was updated on 4/19/23. The plan does not include the current dosage of medication prescribed to the individual to assist with their symptoms of their psychiatric diagnoses.
The 4/1/23 SEEN plan states Individual #1 also "needed assistance to self-administer as needed medications to help them calm down when they began feeling anxious. They have been able to use their as needed medication independently and it has assisted in maintaining their emotional well-being and behavior." Since the plan's creation, Individual #1 has experienced two behavioral crisis events on 4/21/23 and 4/26/23; both events escalating and there are no records the individual recognized their increased agitation/aggression or administered their as needed medication appropriately. The individual's recent behavioral events were not included in their SEEN plan, or ISP. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | All cover letters will be updated to include all documentation (assessment, LMH, SEEN/BSP, plans). SEEN plan will be updated to include new and current behaviors. Medication list was updated immediately to include dosage of Ativan. |
06/30/2023
| Implemented |
| 6400.169(a) | Staff person #6 documented that Staff person #4 passed the Department's modified medication administration training course and 4 medication observations on 6/3/21. There are no records that Staff person #4 received training on the agency's medication administration record documentation (mars) for how to document administration. This is a requirement per ODP announcement during the pandemic.
The ODP announcement confirmed that additional annual documentation for medication training needs to be completed for any staff that had the modified administration course training before the initial examinations. The annual requirements identified in the ODP announcements were that staff is required to have 4 medication administration record (mar) reviews and 4 medication observations by the annual date. Staff person #6 documented Staff person #4 passed annual requirements but not until 6/8/22, outside the annual time frame. Additionally, Staff person #6 documented that Staff person #4 only had 3 mars and 4 observations completed in the annual time frame, no additional remediation completed, and missing 1 mar review. Staff person #4 has been administering medications in April 2023 and has been administering since 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). | Employee was immediately suspended from administering medications. Since this employee was leaving the agency , retraining did not occur in this instance. Retraining would be mandatory if employee continued employment. |
08/31/2023
| Implemented |
| 6400.186 | Individual #1's current, 4/28/23 assessment and current, 4/1/23 SEEN plans state they have had a great increase in mania, anxiety, aggression, anger, and challenging behaviors recently. The SEEN plan describes some de-escalation techniques to use with the individual when they are experiencing some of these behaviors. The individual's record doesn't document the support provided by staff during and after behavior events.
Individual #1's 4/1/23 SEEN plan states staff will assist the individual in ensuring that they are taking their medications accurately at all times to assist them with maintaining their emotional wellbeing. During the 5/10/23 inspection at the home, staff report they give Individual #1 their daily container of medications for morning, evening, as needed, and bedtime and let the individual take the medications to their bedroom. Staff report there are times Individual #1 doesn't their medications accurately. During the inspection an Oxcarbazepine pill was found on Individual #1's nightstand. Staff do not know when this pill was missed. Staff are not talking with the individual during every medication administration to confirm they took their medications or determining if they are choosing to not take their scheduled medications. There isn't documentation of the support being provided to Individual #1 during daily and as needed medication administration.
The SEEN plan states if Individual #1 is presenting to be unstable staff will monitor the individual with medications to ensure they are being safe with them. Every morning staff give Individual #1 a full days' worth of medications and some of their as needed medications to keep in their bedroom. Staff have documented behaviors from 4/26/23-current, that Individual #1 has gotten upset and been aggressive, breaking mirrors, hitting staff, throwing items, and going into their bedroom to continue the escalation. Staff do not document that they go to the individual's bedroom to monitor for medication safety since the medications are available to the individual in their bedroom during times when they are unstable. Staff at the home on 5/10/23 report they don't knock on the individual's door because that will upset them more. The SEEN plan states the individual has attempted to commit suicide and self-harm with medications in the past. | The home shall implement the individual plan, including revisions. | The ABC tracking form that was being used at time of inspection has been updated to include documentation staff actions during each phase of ABC. There have not been any behaviors since adaption to this form to show documentation. Support staff will use a form to document their observations during self-administration of medications. Assessments will be updated by program specialist to include the individual's current skill level in medication administration as individuals needs change. |
06/30/2023
| Implemented |