| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Individual #1 Assessment dated 3-28-23 indicates that Individual #1 "Poisons are locked personal care items not locked" and Individual Support Plan (ISP) last updated on 7/10/23 notes that "[Individual #1] does not fully understand the dangers posed by poisonous substances; therefore all such substances and cleaning products are locked." Poisons were found unlocked in the basement and bathroom of the home at time of inspection. Lysol power cleaning gel and Ajax with bleach were unlocked in the bathroom sink cabinet. The Lysol label contains directions to "call Poison Control Center or doctor immediately for treatment advice" if swallowed or if in eyes. Directions on the Ajax indicate "seek medical attention" if ingested. There were approximately 12 gallons of paint, two five-gallon buckets of paint and approximately six quarts of paint from various makers unlocked in the basement where a few of Individual #1's sensory items were found on the floor. Paint labels had various warnings such as "If swallowed get medical attention immediately" and "If swallowed, seek medical advice immediately and show the container or label." Poisonous substances must be locked in the home. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The agency conducted an investigation into the overall operations of the home, including the Director's role for oversight. The staff have been re educated in the principals of locking all Poisons to include the paint, cleaning items etc. Staff were re educated to not leave items unlocked at any time. The agency has Supervisory and Director level audits with an increase of frequency to include unannounced auditing. |
07/12/2023
| Implemented |
| 6400.64(a) | The toothbrush identified by Staff #15 as belonging to Individual #1 was found lying unprotected against packages of individual wipes in the bathroom closet. | Clean and sanitary conditions shall be maintained in the home. | The agency conducted an investigation into the overall operations of the home, including the Director's role for oversight. The staff have been re educated in the principals of clean and sanitary conditions through storage of individuals personal care items. The agency has Supervisory and Director level audits with an increase of frequency to include unannounced auditing. |
07/12/2023
| Implemented |
| 6400.67(a) | The ceiling lights in the two spare bedrooms of the home did not have the necessary covering over the lightbulbs. The ceiling fan and light in Individual #1's bedroom did not have a covering for the lightbulbs in the hanging fixture and was missing a bulb. The metal piece that covers the hole in the kitchen ceiling where the light fixture hangs was loose and hanging on the chain. The metal covering of the heat on the living room front wall of the home was bent on the right side. The left end piece of this same heat register was bent and askew. | Floors, walls, ceilings and other surfaces shall be in good repair. | The agency has replaced the 2 spare bedroom light fixtures, the individuals light fixture, replaced the missing bulb, repaired the metal hanging plate in the kitchen, and repaired the heating element covers to align and cover the heat conductors properly. |
07/27/2023
| Implemented |
| 6400.67(b) | The HVAC unit for the home is located in the upstairs recreation room occasionally visited by Individual #1. The HVAC unit was recessed in the wall but without covering to ensure the safety of Individual #1. Electrical wires and other mechanical workings of the unit were easily accessible causing a potential hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The HVAC Unit panel has been secured in the home. The agency conducted an investigation into the overall operations of the home, including the Director's role for oversight. The staff have been re educated in the principals of hazards being properly addressed in the home including the open HVAC unit. Staff were re educated to check for this panel and be sure it is not open. The agency has Supervisory and Director level audits with an increase of frequency to include unannounced auditing. |
07/12/2023
| Implemented |
| 6400.70 | The telephone for the home is located in the upstairs recreation area. The telephone was not operable at the time of the inspection. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| The agency has the telephone in working order. |
07/13/2023
| Implemented |
| 6400.71 | At time of inspection there were no emergency numbers located next to the phone in the home as required. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| The agency has taped the 911 emergency phone number to the phone itself. |
07/13/2023
| Implemented |
| 6400.76(a) | The paint on the surface of the only dining table in the home was flaking and peeling leaving small particles of paint on the surface as well as items laid upon the surface. At time of inspection Individual #1 was witnessed eating breakfast during which they would eat with their hands, place hands on the surface of the table and begin eating again. The chipping paint creates a hazard to Individual #1. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The agency has replaced the table with a table with a safe surface. |
07/15/2023
| Implemented |
| 6400.81(k)(6) | No mirror was found in Individual #1's bedroom. No documentation to explain or justify the absence of the mirror was found in the individual's Individual Support Plan (ISP.) | In bedrooms, each individual shall have the following: A mirror. | The agency has provided a mirror that is attached to the wall and not made of glass due to the individual previously damaging the previous mirrors provided in the home. This eliminates the potential of a safety hazard for the individual when causing property destruction. |
07/12/2023
| Implemented |
| 6400.101 | At time of inspection the single door exit on the left side of the enclosed back porch of the home was locked with a pad lock and blocked by a outdoor lounge chair. All egresses from the home shall remain unobstructed. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The agency removed the lock from the door and re educated staff as to the regulation for obstructed egress at every door. The agency conducted an investigation into the overall operations of the home, including the Director's role for oversight and increased the frequency of on site audits at the home to include unannounced. |
07/13/2023
| Implemented |
| 6400.181(a) | Assessment dated 3/28/23 for Individual #1 notes that "[Individual #1] Steven has limited verbal skills, and uses gestures to make his needs known." This statement uses the wrong name and gender as well as inaccurate description of skill level when describing the verbal skills for Individual #1. In the "Communication" section of the 3/28/23 assessment for Individual #1 it is marked a "1" or "unable" for "Is verbal." This rating would not be correct as Individual #1 has limited, but understandable, speech. Providers must develop assessments that are meaningful, accurate and useful. | 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. | The agency assessment has been corrected to name, gender and speech rating. The agency is utilizing a cross audit process of Director's auditing homes, other than their own regularly assigned homes, to ensure proper documentation and protocols are in place. |
08/20/2023
| Implemented |
| 6400.214(b) | The assessment dated 3/28/22 for Individual #1 located in the home at the time of monitoring on 7/12/23 was not the most current copy. Upon request an additional assessment for Individual #1 dated 3/28/23 was produced. The assessment in the home shall be the most current. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The agency home copy was retrieved from the office and placed in the home as required. The agency is utilizing a cross audit process of Director's auditing homes, other than their own regularly assigned homes, to ensure proper documentation and protocols are in place. |
07/13/2023
| Implemented |
| 6400.18(b)(2) | Individual #1 is prescribed the birth control "Blisovi FE Tab 1/20 Take 1 tablet by mouth daily" which is packaged in a manner that denotes the day of the week each tablet is to be taken on and contains 28 tablets in four rows of seven tablets. At time of inspection on Wednesday, 7/12/23 the package in use had been filled on 6/15/23 and started on Sunday 6/18/23. There were six tablets remaining in the packet. The first row of tablets contained a tablet in the MON 6/19/23 blister and a tablet in the SAT 6/24/23 blister. The second row contained a tablet in the SUN 6/25/23 blister. The third row was empty and the fourth row contained three tablets in the THU, FRI and SAT blisters to be administered on 7/13, 7/14 and 7/15/23. There were no notations on the Medication Administration Record (MAR) to indicate a reason for the missed doses of medication. All doses had been initialed as though administered on the MAR. Medication errors, such as failure to administer a medication, must be 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. | The agency has filed an EIM in the Commonwealth's HCSIS platform for this specific incident. The agency conducted an investigation into the overall operations of the home, including the Director's role for oversight. The staff have been re educated in the principals of proper medication administration and management through supervisor's audit on site and to increase that audit frequency. We have purchased an eHR that includes an e MAR. That system is due to begin on September 18, 2023. |
08/20/2023
| Implemented |
| 6400.32(c) | Provider neglected to ensure the proper staffing support for Individual #1 on the evening of 7/9/23 leading into 7/10/23 which resulted in Individual #1 leaving the home unsupervised and being found near a traffic light on front of the home. Provider reports indicate that Staff #10 and Staff #13 were scheduled for the 12:00am until 8:am shift but Staff #13 called off for the shift. It could not be determined who Staff #13 notified that they would not be in attendance nor who was responsible for ensuring proper staffing. Attendance records indicate that Staff #1 and Staff #5 were at the home until Staff #5 departed the home at 11:59pm leaving Staff #1 at the home alone and not in compliance. Staff #10 arrived at the home at 12:31am and Staff #1 left at 12:36am leaving only Staff #10 at the home alone and not in compliance. Staff #10 then fell asleep at an undetermined time allowing Individual #1 to elope from the home where she was later found in wet clothing and near a signaled intersection by a member of the community. Provider was neglectful in not ensuring proper staffing at the home for Individual #1.
At time of inspection on 7/12/23 at approximately 9:05am Provider neglected to ensure proper staffing support as only one Provider staff was at the home providing supervision to Individual #1. Staff #4 arrived at the home at approximately 9:55am; the home was then providing the proper 2:1 staffing ratio required. Individual #1 has the right to be free from neglect.
At time of inspection an expired blister pack of Lorazepam 2mg was found in use and in the medication box belonging to Individual #1. The expiration date on the pharmacy label of the Lorazepam was 1/26/23. Documentation on the blister pack indicates that the medication in the #16 blister was administered on 3/3/23 and the medication in the #15 blister was administered on 5/23. Pills in the #14-#9 blisters appear to have been popped after the #15 on 5/23 however the blisters lacked dates and initials. Staff were neglectful in administering the expired medication potentially exposing Individual #1 to harm on 3/3/23, 5/23 and possibly six additional times. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | The agency has increased the frequency of Director's audits to include monitoring of staff in home clock in's and additional phone checks as another layer of staff counts and attendance. The agency has implemented email print outs and retention of ISP changes and updates to ensure proper care and up to date protocols are presented to the staff.
The agency has audited the homes operations for medication administration, documentation and disposal of expired medications. Corrections to the medications were taken by correcting the MAR information, disposing of expired medications and re educating the staff as to locking the medications administering medications and documenting administration of medications immediately. |
07/13/2023
| Implemented |
| 6400.32(r) | At the time of inspection on 7/12/23 there was no lock on Individual #1's bedroom door. Individual #1's Assessment dated 3/28/23 states that Individual #1 has "refused a lock on their bedroom door and does not wish to have a lock on their bedroom door." However, a declination of the lock or indication of team discussion of the necessity of a lock was not included in Individual #1's Individual Support Plan. | An individual has the right to lock the individual's bedroom door. | Agency has replaced the current door lock and a key is provided to the staff and administration in order to prevent any incident of the individual locking themselves in the room. The individual does not have the capability to understand the use of a key but has potential to lock themselves in the room as they are familiar with using a door handle and lock. |
07/12/2023
| Implemented |
| 6400.45(d) | Investigation conducted by Licensing Representative (LR) determined that Individual #1 eloped from their home on 7/10/23 and was found near the traffic light at the end of the driveway of the home unsupervised at approximately 7:33am when the 911 call was received by authorities. LR investigation determined that only one staff person was present at the home from 12:36am until 8:00am when Staff #2 arrived for their scheduled shift. It was also determined that management Staff #7 arrived just prior to Staff #2. The Individual Support Plan (ISP) for Individual #1 last updated on 7/10/23 notes the supervision level required for Individual #1's safety to be "is supervised at a 2:1 ratio at all times to ensure their health and safety. When [Individual #1] is in common areas of the home they needs to be within eye sight. When [Individual #1] is in their bedroom staff need to be within auditory range of them, and do 15 minute visual checks to maintain their safety." The staffing ratio as specified in Individual #1's plan was not implemented as written at the time of Individual #1's elopement. At time of inspection 7/12/23 LR arrived at the home at approximately 9:05am. Only Staff #2 was present until the arrival of Staff #4 at approximately 9:55am. The required 2:1 staffing was not in place during this timeframe. Staff ratio as specified in the individual plan shall be implemented as written. | The staff qualifications and staff ratio as specified in the individual plan shall be implemented as written, including when the staff ratio is greater than required under subsections (a), (b) and (c ). | The agency has increased the frequency of Director's audits to include monitoring of staff in home clock in's and additional phone checks as another layer of staff counts and attendance. The agency has implemented email print outs and retention of ISP changes and updates to ensure proper care and up to date protocols are presented to the staff. |
07/12/2023
| Implemented |
| 6400.51(b)(5) | Individual #1 has a behavioral support plan (BSP) in place that was most recently updated on 8/10/22.
Records of training on the BSP submitted for Individual #1 did not document that initial orientation training of the essential job-reated knowledge and skills such as the BSP for Individual #1 occurred for Staff #8 hire date 1/31/23 or Staff #11 hire date 6/14/23.
Records of training on the Individual Support Plan (ISP) submitted for Individual #1 did not document that initial orientation training of the essential job-reated knowledge and skills such as the ISP for Individual #1 occurred for Staff #8 hire date 1/31/23, Staff #10 hire date 8/8/22 and Staff #11 hire date 6/14/23.
Training on job-related knowledge and skills such as the ISP and BSP is required. | The orientation must encompass the following areas: Job-related knowledge and skills. | These staff have been trained in the proper BSP by the agency. |
08/07/2023
| Implemented |
| 6400.163(d) | Individual #1's medications are kept in a pantry closet in the kitchen of the home. The pantry closet door was unlocked upon arrival and remained unlocked during the inspection. The pad lock used to secure the medications remained sitting on the side counter in the kitchen. The controlled substances in the home were presented in a small black box with a cylinder type numerical lock. After reviewing, the medications were placed into the box, the lid shut and the lock closed. Staff #2 quickly stated that the locking device did not work and was concerned that the box would not be able to be opened again. Staff #2 shook the box and the lid popped open. Staff #2 then explained and demonstrated how the locking device on the box does not work leaving the controlled substances not double locked. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | The medications are properly locked according to the regulatory requirements of single and double locking. The agency conducted an investigation into the overall operations of the home, including the Director's role for oversight. The staff have been instructed to immediately report any and every issue in the home that is not in compliance with the regulations. The staff have been re educated in the principals of proper medication administration including auditing for medication expiration dates, and contacting the pharmacy for needed refills of that medication, and management through supervisor's audit on site and to increase that audit frequency. |
07/13/2023
| Implemented |
| 6400.163(h) | A blister pack of Lorazepam 2mg "Take 1 tablet by mouth as needed 1 hour prior to any kind of medical appointment" was located with Individual #1's medications at the time of inspection on 7/12/23. The expiration date listed on the pharmacy label on the blister pack in use was 1/26/23. The expired medication remained in Individual #1's medication box after it had expired and was not disposed of in a safe manner according to applicable Federal and State statutes and regulations. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The expired medication was properly disposed of by the Director. The agency conducted an investigation into the overall operations of the home, including the Director's role for oversight. The staff have been re educated in the principals of proper medication administration including auditing for medication expiration dates, and contacting the pharmacy for needed refills of that medication, and management through supervisor's audit on site and to increase that audit frequency. |
07/12/2023
| Implemented |
| 6400.166(a)(11) | The diagnosis or purpose for each medication was not included with each medication entry on the July 2023 Medication Administration Record (MAR) for Individual #1. The bottom of the July 2023 MAR contained a section noted as "Diagnosis: Autism Spectrum Disorder; Intermittent Explosive Disorder; Moderate IDD." The following medications were noted on the MAR without the diagnosis or purpose: Quetiapine Tab 400mg, Trazodone 300mg, Divalproex 500mg, Lactulose SOL 10mg and Mirtazapine 15mg. | 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. | The agency has corrected the MAR to include the reason for each medication listed on the MAR. The agency conducted an investigation into the overall operations of the home, including the Director's role for oversight. The staff have been re educated in the principals of proper medication administration and management through supervisor's audit on site and to increase that audit frequency. We have purchased an eHR that includes an e MAR. That system is due to begin on September 18, 2023. |
07/13/2023
| Implemented |
| 6400.166(b) | The July 2023 Medication Administration Record (MAR) for Individual #2 did not contain the initials of the person administering the following medications: Quetiapine 400 mg: 8pm 7/1/23 and 8pm 7/10/23, Trazadone 300mg: 8pm on 7/1/23 and 8pm on 7/10/23, Lactulose SOL 10mg: 8pm on 7/1/23, Mirtazapine Tab 15mg: 8pm on 7/1/23, 7/2/23 and 7/3/23. The July 2023 MAR did not contain notation that the medication had not been administered as prescribed. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The agency conducted an investigation into the overall operations of the home, including the Director's role for oversight. The staff have been re educated in the principals of proper medication administration including signing the MAR after administration of medication. The management, through supervisor's audit on site has to increased in frequency. We have purchased an eHR that includes an e MAR. That system is due to begin on September 18, 2023. The eMAR's can be monitored remotely from outside of the home. |
07/13/2023
| Implemented |
| 6400.167(a)(1) | Individual #1 is prescribed the birth control "Blisovi FE Tab 1/20 Take 1 tablet by mouth daily" which is packaged in a manner that denotes the day of the week each tablet is to be taken on and contains 28 tablets in four rows of seven tablets. At time of inspection on Wednesday, 7/13/23 the package in use had been filled on 6/15/23 and started on Sunday 6/18/23. There were six tablets remaining in the packet. The first row of tablets contained a tablet in the MON blister and a tablet in the SAT blister. The second row contained a tablet in the SUN blister. The third row was empty and the fourth row contained three tablets in the THU, FRI and SAT blisters. The June 2023 Medication Administration Record (MAR) for Individual #1 included staff initials in the appropriate slots to indicate administration of the medication although the medication remained in the blister pack for the 6/19/23, 6/24/23 and 6/25/23 doses. The June 2023 MAR did not contain a notation that the medication was refused or not administered as prescribed. The medication was not administered on 6/19, 6/24 and 6/25/23 as evidenced by the pills remaining in the blister pack. | Medication errors include the following: Failure to administer a medication. | The medication was audited and counted for compliance with disposal as needed of by the Director. The agency conducted an investigation into the overall operations of the home, including the Director's role for oversight. The staff have been re educated in the principals of proper medication administration including the administration itself of those medications. Increased management through supervisor's audit on site and to increase that audit frequency. |
07/13/2023
| Implemented |
| 6400.167(b) | Individual #1 is prescribed the birth control "Blisovi FE Tab 1/20 Take 1 tablet by mouth daily" which is packaged in a manner that denotes the day of the week each tablet is to be taken on and contains 28 tablets in four rows of seven tablets. At time of inspection on Wednesday, 7/13/23 the package in use had been filled on 6/15/23 and started on Sunday 6/18/23. There were six tablets remaining in the packet. The first row of tablets contained a tablet in the MON (6/19/23) blister and a tablet in the SAT (6/24/23) blister. The second row contained a tablet in the SUN (6/25/23) blister. The third row was empty and the fourth row contained three tablets in the THU, FRI and SAT blisters. The June 2023 MAR did not contain a notation that the medication was refused or not administered as prescribed and was initialed to indicate that the medication had been administered. Medication errors by omission occurred on 6/19/23, 6/24/23 and 6/25/23. There was no documentation of the error including follow-up action taken as required. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | The agency has filed an EIM in the Commonwealth's HCSIS platform for this specific incident. The agency conducted an investigation into the overall operations of the home, including the Director's role for oversight. The staff have been re educated in the principals of proper medication administration and management through supervisor's audit on site and to increase that audit frequency. We have purchased an eHR that includes an e MAR. That system is due to begin on September 18, 2023. |
08/20/2023
| Implemented |
| 6400.167(c) | Individual #1 is prescribed the birth control "Blisovi FE Tab 1/20 Take 1 tablet by mouth daily" which is packaged in a manner that denotes the day of the week each tablet is to be taken on and contains 28 tablets in four rows of seven tablets. At time of inspection on Wednesday, 7/13/23 the package in use had been filled on 6/15/23 and started on Sunday 6/18/23. There were six tablets remaining in the packet. The first row of tablets contained a tablet in the MON (6/19/23) blister and a tablet in the SAT (6/24/23) blister. The second row contained a tablet in the SUN (6/25/23) blister. The third row was empty and the fourth row contained three tablets in the THU, FRI and SAT blisters. The June 2023 MAR did not contain a notation that the medication was refused or not administered as prescribed and was initialed to indicate that the medication had been administered. Medication errors by omission occurred on 6/19/23, 6/24/23 and 6/25/23. There was no documentation to support that the medication errors had been reported as required. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | The agency has filed an EIM in the Commonwealth's HCSIS platform for this specific incident. The agency conducted an investigation into the overall operations of the home, including the Director's role for oversight. The staff have been re educated in the principals of proper medication administration and management through supervisor's audit on site and to increase that audit frequency. We have purchased an eHR that includes an e MAR. That system is due to begin on September 18, 2023. |
08/20/2023
| Implemented |
| 6400.186 | The Individual Support Plan (ISP) last updated on 7/10/23 for Individual #1 notes their supervision level to be "[Individual #1] is supervised at a 2:1 ratio at all times to ensure their health and safety. When [Individual #1] is in common areas of the home they needs to be within eye sight. When [Individual #1] is in their bedroom staff need to be within auditory range of them, and do 15 minute visual checks to maintain their safety. At the time of the incident on 7/10/23 a 2:1 ratio was not provided. Testimony of all staff supports that only Staff #10 was at the home. Further reports indicate that Staff #10 was asleep at the time Individual #1 eloped from the home and wandered near the traffic light. At the time of inspection on 7/12/23 at approximately 9:05am only one provider staff member was providing supervision to Individual #1. An additional provider staff member, Staff #4, did not arrive at the home until approximately 9:55am.
The Behavior Support Plan (BSP) portion of the ISP for Individual #1 states that "The following strategies are being implemented to assist [Individual #1] in meeting their sensory needs/concerns: visual picture exchange communication system (pecs) schedule of sensory and fine motor/leisure activities for [Individual #1] to engage throughout their day when not at school; deep pressure protocol where deep pressure sensory input will be done with a brush and a massager to [Individual #1] arms/hands/back/legs; lotion massage; weighted vest protocol where staff will guide [Individual #1] arms into the arm holes of the vest; theraband to gain deep pressure into their arms/body; table activities and water play; and household activities where [Individual #1] will learn to engage in various household tasks." At the time of inspection on 7/12/23 Staff #2 and Staff #16 noted that there was no schedule of sensory and fine motor/leisure activities in use at the home, no proprioceptive activities, there was no deep pressure protocol or deep pressure being provided and there was no weighted vest protocol or weighted vest. The BSP further outlines that ABC charts, sleeve tying trackers and proprioceptive activity trackers should be kept. The trackers and charts were not completed as outlined in the BSP. | The home shall implement the individual plan, including revisions. | The agency has increased the frequency of Director's audits to include monitoring of staff in home clock in's and additional phone checks as another layer of staff counts and attendance. The agency has been discussing the needed edits in the ISP starting with the previous SC when Abby first came to the agency. We have sent previous emails and most recently an email for edits on 9/1/23. The agency has implemented email print outs and retention of ISP changes and updates to ensure proper care and up to date protocols are presented to the staff. The BSP was updated and corrected by the BSS, staff were trained as well in the BSP. |
09/01/2023
| Implemented |