| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | Self assessments were not completed until 12/11/2020. There is no documentation that there were assessments completed prior to this date. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agencies certificate of compliance, to measure and record compliance with this chapter. | The new CEO came on board November 19, 2020 and took action regarding compliance. The self assessment was completed, but not within the 3-6 month time frame. To prevent this from happening again, the CEO identified the need for ongoing internal monitoring that shall occur by March 30, 2022, June 2021 and on or before September 2021 which would be three motnhs prior to the annual inspection. The CEO will monitor for progress, areas that require systemic changes and further training. Thereafter, the CEO will initiate the self-assessment process three to six months prior to the annual visit for 2022.
The CEO will send reminders to Administrative staff at least a month before each date listed for them to begin preparations for a review. At the completion of the self-assessments, the CEO will evaluate progress, areas that need to be addressed systemically and provide training.
|
03/30/2021
| Implemented |
| 6400.141(c)(3) | Individual #1's physical dated 1/2/2020 does not contain any information about his immunizations. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Although the Physical form includes immunizations, it was not completed. The individual saw the PCP on January 5, 2021 an the immunizations were documented. Going forward, the Program Coordinator will review the form with staff taking the individual on medical appointments to ensure all areas are completed. Upon return to the site, the Program Coordinator and/or CEO will review the document for compliance. A Nurse Practitioner is being contracted for both locations to provide consulting on all medical issues and to ensure that all paper work is accurate, that necessary follow-up occurs and compliance. |
02/01/2021
| Implemented |
| 6400.141(c)(13) | Individual #1's physical dated 1/2/2020 does not contain any information regarding allergies or contradicted medications. | The physical examination shall include: Allergies or contraindicated medications. | Although the Physical form includes allergies and contradicted medications, it was not completed at the time of the examination. Individual #1 saw the doctor Janaury 5, 2021 and the form was updated. Going forward, the Program Coordinator and/or Specialist will ensure that the physical examination form has completed infomraiton about allergies and contradicted medications . Upon return to the site, the Program Coordinator/Specialist and/or CEO will review the form for compliance. In addition, the CEO is contracting with a Nurse (anticipated February 1, 2021) for consulting and review of medical issues , follow -up and compliance. |
02/01/2021
| Implemented |
| 6400.141(c)(14) | Individual 1's physical exam dated 1/2/2020 does not contain medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Although the Physical form includes an area to document medical informationf pertinent to diagnosis and treatment in case of an emergency, it was not completed.. Going forward, the Program Coordinator and/or Specialist will ensure that the physical examination form has completed information.The individual went for the annual exam on January 5, 2021. Going forward, upon returning to the site with the documentation, the Program Coordinator/Specialist and/or CEO will review the form for compliance. In addition, the CEO is contracting with a Nurse Practitioner (anticipated February 1, 2021 for consulting and review of medical issues, follow -up and compliance. |
01/16/2021
| Implemented |
| 6400.141(c)(15) | Individual #1's physical exam dated 1/2/2020 does not include special instructions for the individual's diet. | The physical examination shall include:Special instructions for the individual's diet. | Although the Physical form includes documentation for Special instructions for the individual's diet, it was not completed at the time of the examination last year. The individual went for the annual exam January 5, 2021.and instructions about the diet were included int he documentation. Going forward, upon returning to the site with the documentation, the Program Coordinator/Specialist and/or CEO will review the form for compliance. In addition, the CEO is contracting with a Nurse Practitioner (anticipated February 1, 2021 for consulting and review of medical issues , follow -up and compliance. |
01/16/2021
| Implemented |
| 6400.18(a)(9) | EIM #8770927 for Individual #1 was discovered on 11/18 but was not reported or entered into EIM until 11/22/20. | 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:
Injury requiring treatment beyond first aid.
| The previous CEO was the certified investigator and responsible for reporting information into HCSIS/EIM. Unfortunately, there was no transition when he left. The new CEO came on board November 17, 2020 and was not able to access information. Additionally, there were no other Certified Investigators on staff. Since then, one staff has completed the pre-requisites for the January 19th CI training and two additional staff will be attending the CI course between February and April 2021. In the interim, we identified area CI's who we would contact should an investigation need to occur before this person is certified. We have also obtained access for the Program Coordinator and Specialist to enter HCSIS/EIM. Certified investigation being completed on January 19th, 2021. The CEO is receiving hard copies of a written Incident Repot and is following up with Administrative staff for deadline compliance. Going forward, the CEO intends to designate a staff for the role of QIM (Quality Improvement Manager) who will be the point who ensures timely, accurate completion of documentation. This person will also be the CI. (anticipated March 2021) |
01/30/2021
| Implemented |
| 6400.34(a) | Individual #1's rights were signed however the rights that were reviewed and signed by the Individual were not current and did not address all of the individual's rights. The rights did not address 32 a, b, c, d, e, f, g, h, I, j, k, p, and q. In addition they did not address 32 t 1-5 and 32 v. Individual #1 was not fully informed of their rights. | 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. | The CEO updated the Individual Rights form to be inclusive of all rights. Program Coordinator or Specialist will inform and explain to the individual(s) and designated guardian, parent or advocate, of the individual's rights and the process to report a rights violation. The policy has also been updated to reflect the corrections and process. Individual #1 has been informed of his/her rights. Going forward, the Program Specialist shall maintain a check list of required information for each individual to assist in maintianing timely and accurate documentation. |
01/19/2021
| Implemented |
| 6400.46(b) | Staff #1 last had fire safety training on 11/15/2019. She hasn't had fire safety training since that date, which exceeds the annual requirement. Staff #2's initial fire safety date was 7/5/19 and his annual training did not occur until 9/12/2020, placing Staff #2 out of compliance with annual training requirement. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Administrative team developed a checklist of required and supplemental trainings and corrected the training syllabus. The trainings will be for all staff and will include initial training date as well as expiration of training date so that the training is completed according to regulations. Program Coordinator will maintain this training checklist for staff. The Coordinator/Specialist will provide staff with their individual list of required training and dates for compliance. The CEO will review compliance monthly. Staff #1 has been suspended. so we have not been able to correct this. If returning, fire safety training will be given the first day of his/her return. |
01/16/2021
| Implemented |
| 6400.51(a)(1) | Staff #5's training record does not indicate that orientation trainings were completed. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons. | Administrative team developed a checklist of required and supplemental trainings and corrected the training syllabus. The trainings will be for all staff and will include initial training date as well as expiration of training date so that staff comply with regulations. The Pogram Coordinator/Specialist will maintain this training checklist of all staff. The Coordinator/Specialist will provide staff with their individual list of required training and dates for compliance. The CEO will review compliance monthly. Staff #5 has since been terminated. |
01/16/2021
| Implemented |
| 6400.52(c)(1) | Staff #1, #2, #3, and #4's annual training did not include the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | CEO has created training for the application of person-centered practices, community integration, individual choice, and supporting individuals to develop and maintain relationships. CEO administered the training January 13th and 14th to staff for both locations.
Administrative team developed a checklist of required and supplemental trainings and corrected the training syllabus. The syllabus will be for staff and will include initial training date as well as expiration of training date so that staff comply with regulations. The Program Coordinator/Specialist will maintain this training checklist of staff. The Coordinator/Specialist will provide staff with their individual list of required training and dates for compliance. The CEO will review compliance monthly. |
01/14/2021
| Implemented |
| 6400.52(c)(2) | Staff #1, #2, #3 and #4's annual training did not include the prevention, detection and reporting of abuse, suspected abuse and alleged abuse. | The annual training hours specified in subsections (a) and (b) 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. | Staff have been assigned prevention, detection and reporting of abused, suspected abuse, and alleged abuse and are reminded by Relias about upcoming due dates. The staff identified above will have a training session with the CEO so a discussion can occur about the application of regualtions related to abuse. Going forward, the training syllabus was updated. Staff will be provided with their individual list of training and due dates. Administrative team developed a checklist of required and supplemental trainings and corrected the training syllabus. The syllabus will be for staff and will include initial training date as well as expiration of training date so that staff comply with regulations. The Program Coordinator/Specialist will maintain this training checklist for staff. The Coordinator/Specialist will provide staff with their individual list of required training and dates for compliance. The CEO will review compliance monthly. |
02/01/2021
| Implemented |
| 6400.52(c)(3) | Staff #1, #2, #3 and #4's annual training did not include Individual rights. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Staff have been assigned training on Individual Rights through Relias about upcoming due dates. The staff identified above will have a training session with the CEO so a discussion can occur about the application of regualtions related to abuse. Going forward, the training syllabus was updated. Staff will be provided with their individual list of training and due dates. Administrative team developed a checklist of required and supplemental trainings and corrected the training syllabus. The syllabus will be for staff and will include initial training date as well as expiration of training date so that staff comply with regulations. The Program Coordinator/Specialist will maintain this training checklist for staff. The Coordinator/Specialist will provide staff with their individual list of required training and dates for compliance. The CEO will review compliance monthly. |
02/01/2021
| Implemented |
| 6400.52(c)(4) | Staff #1, #2, #3 and #4's annual training did not include Recognizing and reporting incidents. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Staff have been assigned training on Recognizing and reporting incidents via Relias which also reminds staff of upcoming due dates. The staff identified above will have a training session with the CEO so a discussion can occur about the application of regulations related to Recogizing and reporting incidents. Going forward, the training syllabus was updated. Staff will be provided with their individual list of training and due dates. Administrative team developed a checklist of required and supplemental trainings and corrected the training syllabus. The syllabus will be for staff and will include initial training date as well as expiration of training date so that staff comply with regulations. The Program Coordinator/Specialist will maintain this training checklist for staff. The Coordinator/Specialist will provide staff with their individual list of required training and dates for compliance. The CEO will review compliance monthly. |
02/01/2021
| Implemented |
| 6400.52(c)(5) | Staff #1, #2, #3 and #4's annual training did not include the safe and appropriate use of behavior supports if the person works directly with an individual. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Saff have been assigned training on the Safe and appropriate use of behavior supports via Relias which also reminds staff of upcoming due dates. To correct this violation, Staff# 2,3,4 will review the plan. Staff #1 is suspended indefinitely. The PCM trainer will provide staff with a refresher during annual training and prior to new staff working with an individual. The training syllabus was updated. Going forward, staff will be provided with their individual list of training and due dates. Administrative team developed a checklist of required and supplemental trainings and corrected the training syllabus. The syllabus will be for staff and will include initial training date as well as expiration of training date so that staff comply with regulations. The Program Coordinator/Specialist will maintain this training checklist for staff. The Coordinator/Specialist will provide staff with their individual list of required training and dates for compliance. The CEO will review compliance monthly. |
02/01/2021
| Implemented |
| 6400.52(c)(6) | Staff #1, #2, #3, and #4's annual training did not include implementation of the individual plan. | 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. | The Program Specialist will assume responsibility for training staff on individual plans with the support of the PCM trainer and/or Program Coordinator. Staff 2, 3, 4 have been trained on the individual plan. Staff #1 is suspended indefinitely.
The training syllabus was updated. Going forward, staff will be provided with their individual list of training and due dates. Administrative team developed a checklist of required and supplemental trainings and corrected the training syllabus. The syllabus will be for all staff and will include initial training date as well as expiration of training date so that staff comply with regulations. The Program Coordinator/Specialist will maintain this training checklist for staff. The Coordinator/Specialist will provide staff with their individual list of required training and dates for compliance. The CEO will review compliance monthly. |
02/01/2021
| Implemented |
| 6400.162(c)(3) | Individual 1 is prescribed Pentasa 500 MD Capsule. Take two capsules by mouth two times a day. (Capsules can be opened and mixed with soft food). Omeprazole 40mg CPDR. Take one capsule by mouth two times a day (May open capsule in food). Probiotic 250 MG Caps. Take one capsule by moth two time s a day *May open and sprinkle in soft foods. Alinia 500mg Tab. Take 1 tablet by mouth every 12 hours---Tablets can be crushed and added to applesauce. Linzess 290 MCG Caps. Take one capsule by mouth every day *May open capsule and sprinkle in soft food. All of these meds are being mixed with fish oil and not soft foods or applesauce as prescribed. | Medication administration includes the following activities, based on the needs of the individual: Prepare the medication as ordered by the prescriber. | Historically, the medications were mixed with fish oil due to the preference of the individual. However, to correct this, the prescribing doctor will rewrite the order to indicate that fish oil can be used instead of soft foods or applesauce.
Going forward, the CEO is contracting with a Nurse for both locations (anticipated date-February 1, 2021) to provide consulting on medical issues, medication, and follow-up on paperwork to ensure consistency and compliance.. Additionally, a staff has been designated as a Medication Supervisor to review all medications per regulation and training. |
02/01/2021
| Implemented |
| 6400.165(c) | Individual #1 was prescribed Diflucan until May 21, 2020. The medication is documented to be discontinued on May 21, however it continued to be administered on May 22, 24 and 26.
Individual #1 was prescribed Lamisil until May 21, 2020. The medication is documented to be discontinued on May 21, 2020, however it continued to be administered on May 23, 25 and 27.
Individual 1 is prescribed Ibuprofen 800 MG Tablet. Take one tablet by mouth three times a day for 7 days then use three times a day as needed. The MAR reads: Ibuprofen 800mg Tablet. Take three times a day as needed for inflammation. It is unclear if the medication is being administered as prescribed based on the discrepancy between the label and the MAR. | A prescription medication shall be administered as prescribed. | The MAR has been updated and corrected to reflect current medication administration. Because the CEO recognized a need for additional support, a designated staff has become a Medication Supervisor (for both locations) and a Nurse for both locations) is being contracted with (anticipated February 1, 2021) to provide additional monitoring and guidance. If an order shows a discrepancy, the Nurse will be able to receive a verbal order from the doctor to correct the mistake. |
02/01/2021
| Implemented |
| 6400.165(f) | Individual #1 was prescribed Alprazolam as needed until 11/11/2020. During the time that this was prescribed there was no Social Emotional Environmental Needs protocol in place. | 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. | The psychotropic medication has since been discontinued. For Side B, a current SEEN plan is being developed and we expect to have it by the end of January 2021. The Program Coordinator/Specialist will discuss the plan with the BCBA prior to staff receiving training about the protocol.
Going forward, when reviewing the medications, the Medication Supervisor and Nurse Practitioner (anticipated date February 2021) will ensure that a SEEN plan is available, staff were trained and updated as needed. They will communicate to the Program Specialist if anything is out of compliance for her attention and follow-up. |
02/01/2021
| Implemented |
| 6400.165(g) | Individual #1 was prescribed Alprazolam as needed until 11/11/2020. Throughout the duration of this medication being prescribed, three month reviews of the medication did not occur. | 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. | Psychotropic medication has since been discontinued. If medication is prescribed to treat a psychiatric illness , a licensed physician will review the medication and document the reason for prescribing the medication, the need to continue the medication and the necessary dosage at least every 3 months. A psychotropic medication follow up form will be used to document the quarterly reviews. Terrapin House is contracting with a nurse who will add another layer of review. However, it is the Program Specialst who will schedule the appointments ahead of time to ensure they are done quarterly. The target dates will be listed on the shared calendar. |
02/01/2021
| Implemented |
| 6400.166(a)(16) | Individual #1 is taking the following medications: Fish oil, Pour one layer on spoon before pouring medication and pour 1 layer on top of spoon on medication. Vega Protein. Magnesium Pill (1) Break capsule and pour contents into liquid. Gluconic DMG Liquid 300mg 1.0ml 2x daily into liquid. Nutiva Hemp Proteoin Powder, 1 tbsp. with liquid. Vitamin D3 pill (1) break capsule and pour contents into liquid. Green Superfood 1 scoop into liquid and Chia Seed 1 1/2 scoop with 3/4 tsp. into liquid. All of these medications are over the counter with no prescription. There is no documentation of potential side effects or review by a physician indicating that these medications are safe and will not contradict any of Individual 1's prescribed medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Side effects of the medication, if applicable. | Primary Care Physician has reviewed medications on January 5th 2021 as well as supplements including fish oil, magnesium, vega protein, gluconic dmg liquid, nutiva hemp protein powder, vitamin d3, green superfood, and chia seeds to make sure there are no side effects or contradictions with his current medications. Documentation is included with the Medication record and medication supervisor will ensure this document remains up to date and with current medication record moving forward. Going forward, the Medication Supervisor and /or Nurse will review medications and orders for consistency and compliance. |
01/30/2021
| Implemented |
| 6400.166(c) | Individual #1 periodically refuses his medications. Documentation of the refusal is maintained on the Medication Administration Record. The prescriber is not contacted to make them aware of the refusals. | If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual. | A refusal form has been created for use anytime the individual(s) refuse (s) to take medications. The form will be scanned and sent to the prescribing physician for additional instructions. Bringing a Nurse on board will assist in obtaining orders for next administration and/or side effects to watch for in case there are any. Staff trained in medication administration will continue to document refusals on the MAR. Program Coordinator will obtain documentation from prescribing doctor on how to handle a refusal in the future. The Nurse and Medication Supervisor will review paperwork for compliance and add another layer of review. |
02/01/2021
| Implemented |
| 6400.167(a)(1) | Individual #1's Medication Administration Record for November 2020 and December 2020 includes Zyrtec 10mg tablet: Take on tablet once daily; do not take more than one tablet in 24 hours. The medication was not administered for days 1-30 of November or days 1-17 of December. | Medication errors include the following: Failure to administer a medication. | Zyrtec has since been discontinued on MAR as over the counter medication and has been prescribed as an as needed medication by Individual 1's PCP. Documentation is attached to current medication record. All future PRN medications will be prescribed by appropriate licensed physician for instructions. A Medication Supervisor and/or Nurse will review medications and records at both locations to ensure accuracy and compliance at least weekly. |
12/24/2020
| Implemented |
| 6400.195(a) | Individual #1 does not have access to the water in the shower of his bathroom. It is controlled by a light switch that turns the shower on and off. The light switch is maintained in a locked closet that staff access when Individual 1 takes a shower. There no restrictive procedure plan regarding use of water in the shower for Individual #1. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | Because of the individual's history of flooding homes, it is essential that we plan carefully. Human Rights Committee will be reviewing this regulation and determining if the locked closet is necessary any longer. If it is determined that the locked closet is no longer necessary, staff will run a trial of leaving closet unlocked for Individual #1 to access freely. If there are no incidents, the closet will remain unlocked. Data will be collected for one week on this trial and submitted to the Human Rights Committee. If the committee recommends continuation of the locked closet, this will be added to restrictive procedure plan and Individual #1 will be informed of this addition to the plan. This is the only location where access to the water for the shower was locked. |
02/12/2021
| Implemented |
| 6400.196(a) | Staff #1, #2, #3, #4 or #5 were not trained on Individual #1's Restrictive Procedure Plan. | 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. | Administrative team has developed a checklist of all trainings and corrected the training syllabus for staff that includes the trainings required by 6400 regulations. Restrictive Procedure Plan training will occur during orientation for staff. If a change is made to the restrictive procedure plan, staff will complete updated training on Individual 1's restrictive procedure plan. Program Coordinator will ensure that staff completed this training. The staff identified above have completed training on the individual's Restrictive Procedure Plan. |
01/22/2021
| Implemented |
| 6400.207(4)(I) | Until 11/11/2020, Individual #1 was prescribed Alprazolam (1mg three times daily as needed ). This medication was utilized when Individual #1 experienced behavioral issues. The prescription does not include the symptoms of the specific mental, emotional, or behavioral condition to be treated which would determine when this medication should be administered. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition. | The psychotropic medication has since been discontinued. In the future, when psychotropic medications are prescribed, the order will be reviewed by the Medication Supervisor and/or Nurse to ensure it contains the symptoms of the mental, emotional or behaviroal condition for which it is being prescribed and when the medication should be administered. The Nurse will also be able to receive verbal orders from the prescribing physician to ensure accuracy in documentation. The Medication Supervisor will also monitor for compliance with documentation and report issues to the nurse to address. |
02/01/2021
| Implemented |