Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.21(a) | Ten staff members, identified as "security guards", had no dates of hire listed or even information as to when they were assigned to working with Individual #3 in the home. The agency was unable to produce Pennsylvania criminal history record checks which are required to be submitted within 5 working days after the person's date of hire. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| At this time the current home/residence is licensed under 6400 Regulations
Per Corporate Protective Services, LLC security team are not part of Supreme Care staff, they are a contracted service provider for LCOCYS. They should not be included in an ISP or considered part of Supreme care staff ratio of 2:1 staffing.
Security Staff are not at anytime to be in the role of a caregiver. They are there to provide support and protection if needed. |
12/02/2022
| Not Implemented |
6400.21(e) | Individual #3 is the only individual residing in the home. Individual #3 is 17 years of age. None of the staff working in the home completed background checks relating to 23 Pa.C.S. § § 6301---6384 (relating to the Child Protective Services Law). | If the home serves primarily individuals who are 17 years of age or younger, 23 Pa.C.S. § § 6301¿6384 (relating to the Child Protective Services Law) applies. | All staff are currently getting their background checks updated as needed. |
11/30/2022
| Not Implemented |
6400.62(a) | Individual #3's Individual Service Plan indicates that the individual is not safe with poisons and poisons need to be kept locked in the home. Poisons including, Members Mark dish soap, Degree Advanced men's deodorant, Dermasil Cocoa Butter Moisturizing Lotion, Colgate toothpaste, Aim toothpaste, Febreze air freshener, Argon shampoo, Selson Blue shampoo, Head and Shoulders advanced series shampoo, Dial hand soap and Dermasil Aloe Fresh Moisturizing Body Lotion were not locked or made inaccessible to the individual. All items indicated to contact poison control or seek medical care if ingested. | Poisonous materials shall be kept locked or made inaccessible to individuals. | All of the above mentioned items have been removed and replaced with poison safe items. |
11/30/2022
| Implemented |
6400.64(a) | The vent in the living/dining room area was covered in a significant amount of dust. | Clean and sanitary conditions shall be maintained in the home. | Staff took a broom and rag and cleaned the dust. |
11/30/2022
| Implemented |
6400.77(b) | The first aid kit did not contain a thermometer. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | A new first aid kit is on site and has all required items. A new electronic thermometer is also on site. |
11/30/2022
| Implemented |
6400.113(a) | Individual #3 moved into a home operated by Supreme Nursing Care on 6/30/2022. The individual then moved into a new home also operated by Supreme Nursing Care on 9/6/2022. Individual #3 was not instructed in the individual's primary language or mode of communication, upon initial admission or upon moving to a new home 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. | 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. | Director of Residential services along with lead staff who interpreted to Spanish for individual went over 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. Individual had prior fire safety training however the date could not be confirmed at this time. This will be confirmed or individual retrained by 12.2.22. |
12/02/2022
| Implemented |
6400.141(a) | Individual #3 was admitted to Supreme Nursing Care on June 30, 2022, and the current home on September 6, 2022. Individual #3 did not have a physical examination within 12 months prior to admission. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Lead staff and CEO scheduled a physical for individual and this will be confirmed by 12.2.22. Also at that time the annual for next year will be scheduled for next year. |
12/02/2022
| Not Implemented |
6400.144 | Health services, such as pharmaceutical, are not being arranged for or provided. Individual #3 is prescribed Trazadone HCL 150mg tab, Take two tablets by mouth at bedtime. This medication was not administered as prescribed on October 12, 2022. The Medication Administration Record (MAR) indicated that the medication had been discontinued. Documentation on the back of the MAR indicated that the medication had not been discontinued and the pharmacy had not delivered the medication resulting in the medication not being administered.
Individual #3 is prescribed Fluticasone Propiona 50mcg, two sprays into each nostril daily. The bottle available in the home is ¾ full and was last filled on 6/8/22. There are 120 metered sprays in the bottle and based on the prescribed dosage, the medication would need to be refilled monthly. The medication is not documented on the Medication Administration Record and there is no record that the medication is being administered as prescribed. Staff reported that the medication may have been discontinued, there is no documentation of a discontinuation order.
Individual #3 is prescribed Loratadine10mg tab, take 1 tablet, (10mg total) by mouth daily. This medication was last filled on 6/8/22 with 30 tablets and there were 15 tablets remaining in the bottle. Based on the number of tablets dispensed on 6/8/22, the medication would need to be refilled monthly. The medication is not documented on the Medication Administration Record and there is no record that the medication is being administered as prescribed or refilled since 6/8/22. Staff reported that the medication was as needed and also may have been discontinued, there is no documentation of a discontinuation order. | 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.
| Between the dates of 10.27.22 and 11.4.22 CEO and Director of residential updated the MARs and medications to reflect appropriate times. Staff have also had a brief unofficial medication overview. An official refresher training will be done by 12.2.22 |
12/02/2022
| Implemented |
6400.181(a) | Individual #3 was admitted to the home on 6/30/22 and did not have an initial assessment completed within 1 year prior to or 60 calendar days after admission to the residential home. | 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. | Individual now has a current assessment written by the new Director of Residential Services. |
11/30/2022
| Not Implemented |
6400.212(a) | A separate record was not kept in the home for Individual #3. | A separate record shall be kept for each individual.
| Residential director separted the files for individual. |
11/18/2022
| Not Implemented |
6400.18(c) | The individual and persons designated by the individual were not notified within 24 hours of discovery of the medication errors including: Individual #3 not receiving Trazadone Trazadone HCL 150mg tab, 2 tablets at bedtime on 10/12/22, Individual #3 receiving Propanol Hydrochl 20mg tab, (take one tablet by mouth twice day). At 4PM instead of 8PM as documented on the Medication Administration Record. Fluticasone Propiona 50mcg, two sprays into each nostril daily and Loratadine10mg tab, take 1 tablet, (10mg total) by mouth daily. | The individual and persons designated by the individual shall be notified within 24 hours of discovery of an incident relating to the individual. | Between the dates of 10.27.22 and 11.4.22 CEO and Director of residential updated the MARs and medications to reflect appropriate times.
Staff have also had a brief unofficial medication overview. An official medication and incident management refresher training will be done by 12.2.22. |
12/02/2022
| Not Implemented |
6400.18(b)(2) | Medication errors are not reported through the Department's information management system or on a form specified by the Department with 72 hours of discovery by a staff person. Individual #3 is prescribed Trazadone HCL 150mg tab, Take two tablets by mouth at bedtime. This medication was not administered as prescribed on October 12, 2022. The Medication Administration Record (MAR) indicated that the medication had been discontinued. Documentation on the back of the MAR indicated that the medication had not been discontinued but that the pharmacy had not delivered the medication resulting in the medication not being administered. Individual #3 is prescribed Propanol Hydrochl 20mg tab, take one tablet by mouth twice day. This medication was documented on the Medication Administration Record (MAR) as administered at 8AM and 8PM until 10/11/22. Beginning on 10/12/22, the medication was being administered at 8AM and 4PM. Staff in the home indicated that the individual had an appointment on 10/8/22 and the physician changed the administration times at the time of the appointment. There was no documentation to support a change in the time that the medication is being administered and there is a failure to administer the medication at the prescribed time. Individual #3 is prescribed Oxcarbazepine 600mg, this takes one tablet by mouth twice a day. This medication is documented on the MAR as administered at 8AM, 4PM and 8PM. There is not documentation of a medication change and there is not an additional dose of medication available in the home. The medication and there a failure to administer the medication at the prescribed time. Individual #3 is prescribed Fluticasone Propiona 50mcg, two sprays into each nostril daily. The bottle available in the home is ¾ full and was last filled on 6/8/22. There are 120 metered sprays in the bottle and based on the prescribed dosage, the medication would need to be refilled monthly. The medication is not documented on the Medication Administration Record and there is no record that the medication is being administered as prescribed. Staff reported that the medication may have been discontinued, there is no documentation of a discontinuation order. Individual #3 is prescribed Loratadine10mg tab, take 1 tablet, (10mg total) by mouth daily. This medication was last filled on 6/8/22 with 30 tablets and there were 15 tablets remaining in the bottle. Based on the number of tablets dispensed on 6/8/22, the medication would need to be refilled monthly. The medication is not documented on the Medication Administration Record and there is no record that the medication is being administered as prescribed. Staff reported that the medication was as needed and also may have been discontinued, there is no documentation of a discontinuation order. | 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. | All medications were updated and put onto MAR. |
11/30/2022
| Not Implemented |
6400.34(a) | Individual #3 was admitted on June 30, 2022. The home did not inform and explain individual rights and the process to report a rights violation to the individual, and person designated by the individual, upon admission to the home. | 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. | Director of residential services sat with individual and lead staff who served as a translater for spanish to inform and explain individual rights and the process to report a rights violation to individual on 10.27.22 |
10/27/2022
| Implemented |
6400.46(a) | At least ten staff members, identified as "security guards" working in the home with Individual #3 did not receive training in General fire safety. While it was stated they are not Supreme Care employees, these ten individuals were, at times, counted as staff in the Individual's required supervision ratios. | 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. | Per Corporate Protective Services, LLC security team are not part of Supreme Care staff, they are a contracted service provider for LCOCYS. They should not be included in an ISP or considered part of Supreme care staff ratio of 2:1 staffing.
Security Staff are not at anytime to be in the role of a caregiver. They are there to provide support and protection if needed. |
11/30/2022
| Not Implemented |
6400.46(c) | At least ten staff members, identified as "security guards," did not receive training in first aid techniques before working with individuals. While it was stated they are not employees, these ten individuals were, at times, counted as staff in the Individual's required supervision ratios. | 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. | Per Corporate Protective Services, LLC security team are not part of Supreme Care staff, they are a contracted service provider for LCOCYS. They should not be included in an ISP or considered part of Supreme care staff ratio of 2:1 staffing.
Security Staff are not at anytime to be in the role of a caregiver. They are there to provide support and protection if needed. |
11/30/2022
| Not Implemented |
6400.50(a) | Records of orientation and training, including the training source, content, dates, length of training, nor copies of certificates received and staff persons attending, are maintained for least ten staff members identified as "security guards." working with Individual #1. While it was stated they are not Supreme Care employees, these ten individuals were, at times, counted as staff in the Individual's required supervision ratios. | 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. | Per Corporate Protective Services, LLC security team are not part of Supreme Care staff, they are a contracted service provider for LCOCYS. They should not be included in an ISP or considered part of Supreme care staff ratio of 2:1 staffing.
Security Staff are not at anytime to be in the role of a caregiver. They are there to provide support and protection if needed. |
11/30/2022
| Not Implemented |
6400.51(b)(1) | At least ten staff members with names, dates of hire, and when assigned to Individual #3 unavailable, that are identified as "security guards" working in the home with Individual #1 did not receive training in the application of Person-centered practices, community integration, individual choice and to develop and 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. | Per Corporate Protective Services, LLC security team are not part of Supreme Care staff, they are a contracted service provider for LCOCYS. They should not be included in an ISP or considered part of Supreme care staff ratio of 2:1 staffing.
Security Staff are not at anytime to be in the role of a caregiver. They are there to provide support and protection if needed. |
11/30/2022
| Not Implemented |
6400.51(b)(2) | At least ten staff members, names, dates of hire or when assigned to Individual #3 unavailable, that are identified as "security guards" working in the home with Individual #3 did not receive training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S.§§ 10225.101-10225-5102), the Child Protective Service Law (23 Pa.C.S §§ 6301-6386), the Adult Protective Services Act (35 P.S. §§ 10210.101-10210.704) and applicable protective services regulations. | The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations. | Per Corporate Protective Services, LLC security team are not part of Supreme Care staff, they are a contracted service provider for LCOCYS. They should not be included in an ISP or considered part of Supreme care staff ratio of 2:1 staffing.
Security Staff are not at anytime to be in the role of a caregiver. They are there to provide support and protection if needed. |
11/30/2022
| Not Implemented |
6400.51(b)(3) | At least ten staff members whose names, dates of hire, or when assigned to Individual #3 unavailable, that are identified as "security guards" working in the home with Individual #3 did not receive training in Individual rights. | The orientation must encompass the following areas: Individual rights. | Per Corporate Protective Services, LLC security team are not part of Supreme Care staff, they are a contracted service provider for LCOCYS. They should not be included in an ISP or considered part of Supreme care staff ratio of 2:1 staffing.
Security Staff are not at anytime to be in the role of a caregiver. They are there to provide support and protection if needed. |
11/30/2022
| Not Implemented |
6400.51(b)(4) | At least ten staff members whose names, dates of hire, or when assigned to Individual #3 are unavailable, that are identified as "security guards" working in the home with Individual #3 did not receive training in Recognizing and reporting incidents. | The orientation must encompass the following areas: recognizing and reporting incidents. | Per Corporate Protective Services, LLC security team are not part of Supreme Care staff, they are a contracted service provider for LCOCYS. They should not be included in an ISP or considered part of Supreme care staff ratio of 2:1 staffing.
Security Staff are not at anytime to be in the role of a caregiver. They are there to provide support and protection if needed. |
11/30/2022
| Not Implemented |
6400.51(b)(5) | At least ten staff members whose names, dates of hire, or when assigned to Individual #3 are unavailable, that are identified as "security guards" working in the home with Individual #3, did not receive training in job related knowledge and skills specifically implementation of the individual service plan in if the staff works directly with an individual. | The orientation must encompass the following areas: Job-related knowledge and skills. | Per Corporate Protective Services, LLC security team are not part of Supreme Care staff, they are a contracted service provider for LCOCYS. They should not be included in an ISP or considered part of Supreme care staff ratio of 2:1 staffing.
Security Staff are not at anytime to be in the role of a caregiver. They are there to provide support and protection if needed. |
11/30/2022
| Not Implemented |
6400.165(c) | Prescription Medications are not being administered as prescribed. Individual #3 is prescribed Trazadone HCL 150mg tab, Take two tablets by mouth at bedtime. This medication was not administered as prescribed on October 12, 2022. The medication. The Medication Administration Record (MAR) indicated that the medication had been discontinued. Documentation on the back of the MAR indicated that the medication had not been discontinued and the pharmacy had not delivered the medication resulting in the medication not being administered as prescribed.
Individual #3 is prescribed Fluticasone Propiona 50mcg, two sprays into each nostril daily. The bottle available in the home is ¾ full and was last filled on 6/8/22. There are 120 metered sprays in the bottle and based on the prescribed dosage, the medication would need to be refilled monthly. The medication is not documented on the Medication Administration Record and there is no record that the medication is being administered as prescribed. Staff reported that the medication may have been discontinued, there is no documentation of a discontinuation order.
Individual #3 is prescribed Loratadine10mg tab, take 1 tablet, (10mg total) by mouth daily. This medication was last filled on 6/8/22 with 30 tablets and there were 15 tablets remaining in the bottle. Based on the number of tablets dispensed on 6/8/22, the medication would need to be refilled monthly. The medication is not documented on the Medication Administration Record and there is no record that the medication is being administered as prescribed or refilled since 6/8/22. Staff reported that the medication was as needed and also may have been discontinued, there is no documentation of a discontinuation order.
Individual #3 is prescribed Propanol Hydrochl 20mg tab, take one tablet by mouth twice day. This medication was documented on the Medication Administration Record (MAR) as administered at 8AM and 8PM until 10/11/22. Beginning on 10/12/22, the medication was being administered at 8AM and 4PM. Staff in the home indicated that the individual had an appointment on 10/8/22 and the physician changed the administration times at the time of the appointment. There was no documentation to support a change in the time that the medication is being administered and there is a failure to administer the medication at the prescribed time.
Individual #3 is prescribed Oxcarbazepine 600mg, this takes one tablet by mouth twice a day. This medication is documented on the MAR as administered at 8AM, 4PM and 8PM. There is not documentation of a medication change and there is a failure to administer the medication at the prescribed time. | A prescription medication shall be administered as prescribed. | Between the dates of 10.27.22 and 11.4.22 CEO and Director of residential updated the MARs and medications to reflect appropriate times. Staff have also had a brief unofficial medication overview. An official refresher training will be done by 12.2.22
Effective immediately (11.18.22) direct care staff, Director of Residential and CEO will ensure Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. |
12/02/2022
| Not Implemented |
6400.165(g) | Individual #3 is prescribed medications to treat symptoms of a psychiatric illness. Review of these medications by a licensed physician were not completed at least every 3 months. | 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. | Director of residential and CEO are currently working with individuals psychiatrist and PCP to schedule the next year of reviews this will be done by 12.2.22. |
12/02/2022
| Not Implemented |
6400.166(b) | Individual #3 is prescribed Oxcarbazepine 300mg tab, Take one tablet by mouth at bedtime. This medication is included in the blister packs of medication; however, it is not documented on the Medication Administration Record (MAR). Individual #3 is prescribed Loratadine10mg tab, take 1 tablet, (10mg total) by mouth daily, and Fluticasone Propiona 50mcg, two sprays into each nostril daily. Ibuprofen 400mg, take one tablet by mouth every 6 hours as needed for mild pain, this medication was administered on 10/18/22 in the presence of inspectors. Individual #3 is prescribed Haldol by injection monthly. This medication was not listed on Individual #3's medication administration record. These medications are not documented on the documented on the MAR. Missing information includes the Individual's name, the name of the prescriber, drug allergies, the name of medication, strength of medication, dosage form, dose of medication, route of medication, frequency of administration, administration times, diagnosis or purpose for the medication, including pro re nata, date and time of medication administration, name and initials of the person administering the medication, duration of treatment, if applicable, special instructions if applicable and side effects of the medication, if applicable. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Between the dates of 10.27.22 and 11.4.22 CEO and Director of residential updated the MARs and medications to reflect appropriate times. Staff have also had a brief unofficial medication overview. An official refresher training will be done by 12.2.22 |
12/02/2022
| Implemented |
6400.167(a)(1) | Individual #3 is prescribed Trazadone HCL 150mg tab, Take two tablets by mouth at bedtime. This medication was not administered as prescribed on October 12, 2022. The medication. The Medication Administration Record (MAR) indicated that the medication had been discontinued. Documentation on the back of the MAR indicated that the medication had not been discontinued and the pharmacy had not delivered the medication resulting in the medication not being administered. Individual #3 is prescribed Fluticasone Propiona 50mcg, two sprays into each nostril daily. The bottle available in the home is ¾ full and was last filled on 6/8/22. There are 120 metered sprays in the bottle and based on the prescribed dosage, the medication would need to be refilled monthly. The medication is not documented on the Medication Administration Record and there is no record that the medication is being administered as prescribed. Staff reported that the medication may have been discontinued, there is no documentation of a discontinuation order.
Individual #3 is prescribed Loratadine10mg tab, take 1 tablet, (10mg total) by mouth daily. This medication was last filled on 6/8/22 with 30 tablets and there were 15 tablets remaining in the bottle. Based on the number of tablets dispensed on 6/8/22, the medication would need to be refilled monthly. The medication is not documented on the Medication Administration Record and there is no record that the medication is being administered as prescribed. Staff reported that the medication was as needed and also may have been discontinued, there is no documentation of a discontinuation order. | Medication errors include the following: Failure to administer a medication. | Between the dates of 10.27.22 and 11.4.22 CEO and Director of residential updated the MARs and medications to reflect appropriate dosage, times and medication. Staff have also had a brief unofficial medication overview. An official refresher training will be done by 12.2.22 |
12/02/2022
| Implemented |
6400.167(a)(4) | Individual #3 is prescribed Propanol Hydrochl 20mg tab, take one tablet by mouth twice day. This medication was documented on the Medication Administration Record (MAR) as administered at 8AM and 8PM until 10/11/22. Beginning on 10/12/22, the medication was being administered at 8AM and 4PM. Staff in the home indicated that the individual had an appointment on 10/8/22 and the physician changed the administration times at the time of the appointment. There was no documentation to support a change in the time that the medication is being administered and there is a failure to administer the medication at the prescribed time. | 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. | Between the dates of 10.27.22 and 11.4.22 CEO and Director of residential updated the MARs and medications to reflect appropriate times. Staff have also had a brief unofficial medication overview. An official refresher training will be done by 12.2.22 |
12/02/2022
| Implemented |
6400.167(b) | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, is not kept in the individual's record. Individual #3 is prescribed Trazadone HCL 150mg tab, Take two tablets by mouth at bedtime. This medication was not administered as prescribed on October 12, 2022. The medication. The Medication Administration Record (MAR) indicated that the medication had been discontinued. Documentation on the back of the MAR indicated that the medication had not been discontinued and the pharmacy had not delivered the medication resulting in the medication not being administered. Individual #3 is prescribed Fluticasone Propiona 50mcg, two sprays into each nostril daily. The bottle available in the home is ¾ full and was last filled on 6/8/22. There are 120 metered sprays in the bottle and based on the prescribed dosage, the medication would need to be refilled monthly. The medication is not documented on the Medication Administration Record and there is no record that the medication is being administered as prescribed. Staff reported that the medication may have been discontinued, there is no documentation of a discontinuation order.
Individual #3 is prescribed Loratadine10mg tab, take 1 tablet, (10mg total) by mouth daily. This medication was last filled on 6/8/22 with 30 tablets and there were 15 tablets remaining in the bottle. Based on the number of tablets dispensed on 6/8/22, the medication would need to be refilled monthly. The medication is not documented on the Medication Administration Record and there is no record that the medication is being administered as prescribed. Staff reported that the medication was as needed and also may have been discontinued, there is no documentation of a discontinuation order.
Individual #3 is prescribed Propanol Hydrochl 20mg tab, take one tablet by mouth twice day. This medication was documented on the Medication Administration Record (MAR) as administered at 8AM and 8PM until 10/11/22. Beginning on 10/12/22, the medication was being administered at 8AM and 4PM. Staff in the home indicated that the individual had an appointment on 10/8/22 and the physician changed the administration times at the time of the appointment. There was no documentation to support a change in the time that the medication is being administered and the medication is not being administered as prescribed. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | Between the dates of 10.27.22 and 11.4.22 CEO and Director of residential updated the MARs and medications to reflect appropriate times. Staff have also had a brief unofficial medication overview. An official refresher training will be done by 12.2.22
Effective immediately (11.18.22) direct care staff, Director of Residential and CEO will ensure Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. |
12/02/2022
| Implemented |
6400.167(c) | Medication errors including Individual #3 not receiving Trazadone HCL 150mg tab, 2 tablets at bedtime on 10/12/22, and Individual #3 receiving Propanol Hydrochl 20mg tab, (take one tablet by mouth twice day) at 4PM instead of 8PM as documented on the Medication Administration Record, are not being reported as incidents as specified in §6400.18(b) (relating to incident report and investigation). | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | Between the dates of 10.27.22 and 11.4.22 CEO and Director of residential updated the MARs and medications to reflect appropriate times. Staff have also had a brief unofficial medication overview. An official refresher medication training and ncident management training will be done by 12.2.22
Effective immediately (11.18.22) direct care staff, Director of Residential and CEO will ensure Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. |
12/02/2022
| Not Implemented |
6400.186 | Individual #3's Individual Service Plan (ISP) is not being implemented. Individual #3's ISP dated 9/4/22 states "he is not safe handling poisons. He is not safe handling poisons as he does not understand the dangers of poisons if used improperly. Poisons need to be locked." All poisons are easily accessible and not locked in Individual #3's home. Individual #3's ISP indicates that the individual requires 3:1 staffing. There were four people working in the home with the individual, only two were identified as staff through Supreme Nursing Care. The other people working in the home were identified as "security guards" and not employed through Supreme Nursing Care and are not counted in staffing ratios. | The home shall implement the individual plan, including revisions. | All current staff working with individual will review ISP and sign off on its understanding.
Per Corporate Protective Services, LLC security team are not part of Supreme Care staff, they are a contracted service provider for LCOCYS. They should not be included in an ISP or considered part of Supreme care staff ratio of 2:1 staffing.
Security Staff are not at anytime to be in the role of a caregiver. They are there to provide support and protection if needed. |
11/30/2022
| Not Implemented |
6400.196(a) | Individual #3 has a behavior support plan in place. Staff working in Individual #3's home implement and manage a behavior support component of Individual #3's individual plan. Staff working in Individual #3's home are not trained in the use of the specific techniques or procedures that are used. | A staff person who implements or manages a behavior support component of an individual plan shall be trained in the use of the specific techniques or procedures that are used. | Residential Director is working with behavior services to get supreme staff trained in accordance to current behavior by 12.2,22. |
12/02/2022
| Not Implemented |