|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | The exit door in the kitchen had a light that was inoperable. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Program director notified maintenance to address the issue (attachment #7) and the lightbulbs were changed and the light found to be operative (attachment #8). To ensure that rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps, and fire escapes are lighted to assure safety and to avoid accidents, the homes will be inspected on a regular basis, and the lights will be switched on to check that they work. Program director updated community home review sheet to include checking for operative lights. Program managers will visit all their sites at least weekly and document all lights are in working order on CHS Review Checklist, and submit the form to co-directors biweekly (attachment # 9). Additionally, the CHS Co-Directors, the Assistant Director, and the Quality Assurance Specialist, on a weekly rotating schedule, will inspect all homes to make sure that all lights are working and compliance is maintained (attachment #4) Visits will be documented. Any/all issues identified with any lights inoperative will be immediately addressed with the program manager and/or Operations as needed. |
04/02/2019
| Implemented |
| 6400.67(a) | Individual #7's bedroom window had missing blinds. | Floors, walls, ceilings and other surfaces shall be in good repair. | Program manager removed broken blind and replaced it with a new mini blind and a curtain, ensuring privacy in individual¿s bedroom (attachments #5 and 6). In order to ensure compliance that all surfaces are in good repair, the homes will be inspected on a regular basis. Program director updated community home review sheet to include blinds. Program managers will visit all their sites at least weekly and document surfaces in good repair on CHS Review Checklist, and submit the form to co-directors biweekly (attachment #3). Additionally, the CHS Co-Directors, the Assistant Director, and the Quality Assurance Specialist, on a weekly rotating schedule, will inspect all homes to make sure that all surfaces are in good repair and compliance is maintained (attachment #4). Visits will be documented. Any/all issues identified with any surfaces not in good repair will be immediately addressed with the program manager and/or Operations as needed. |
04/04/2019
| Implemented |
| 6400.72(a) | Individual #7's bedroom window was missing the screen. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Program director notified maintenance that screen was missing (attachment #1) Screen was replaced (attachment #2). In order to ensure compliance that all windows are securely screened when windows are opened, the homes will be inspected on a regular basis. Program director updated community home review sheet, to include looking for screens. Program managers will visit all their sites at least weekly and document screens being in good condition on CHS Review Checklist, and submit the form to co-directors biweekly (attachment #3). Additionally, the CHS Co-Directors, the Assistant Director, and the Quality Assurance Specialist, on a weekly rotating schedule, will inspect all homes to make sure that all windows are screened and compliance is maintained (attachment #4). Visits will be documented. Any/all issues identified with any windows needing screens will be immediately addressed with the program manager and/or Operations as needed. |
03/29/2019
| Implemented |
| 6400.164(b) | individual #6's medication Enablex was not documented as being given on 3/26/19.
individual #6's medication Risperdal was not documented as being given on 3/26/19. | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | Med certified staff responsible for the error was given a memo, reminding her of the requirement that the information specified on medication log shall be logged immediately after each individual¿s does (dose) of medication is administered (attachment # 10). In order to ensure compliance, practicum observers and trainers will randomly review MAR¿s to ensure administration of medication is immediately logged as required (attachment #11). Any issues with noncompliance will be addressed with med certified staff as warranted. |
04/01/2019
| Implemented |
| 6400.181(e)(2) | Individual #6's assessment dated 8/9/18 did not indicate the individual's dislikes. | The assessment must include the following information: The likes, dislikes and interest of the individual. | Individual # 6¿s assessment was updated to include her dislikes (attachment #12). Assessment was emailed to SC (attachment #13). In order to ensure compliance that each assessment include the likes, dislikes, and interest of the individual, CHS Co-Director updated residential chart audit form to focus on assessment including individual¿s likes, dislikes, and interests (attachment #14). Compliance Officer audited assessments of all residents, to verify that likes, dislikes, and interests of the individual were included, and all other assessments were in compliance with regulation. Going forward, CHS Co-Directors, the Assistant Director, and the Quality Assurance Specialist will conduct semi annual chart audits to ensure that program paperwork is in compliance with regulations (attachment #14) |
04/02/2019
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Continued:
A new assessment was not completed to address the Barium Swallow Study findings, nor was the Individual Support Plan updated to address new eating requirements.
Additionally, Staff Person #2 conducted an audit of individuals' records, including Individual #1's record. Staff Person #2 notified Staff Person #3 by email dated March 12, 2018 of "corrections/follow-ups needed" to the records. The email read, in part: "Please note a Speech Swallow Study was completed on 2/15/18. Diet should be as follows in all documentation (including the physical in the future): Mechanical soft diet: thin liquids. Aspiration Precautions -- Alternate bites and sips. Reflux Precautions -- upright for 30 minutes [after eating]." Staff Person #3's responses were as follows:
o Mechanical soft diet: thin liquids -- "Speech pathology results are Regular diet with thin liquids."
o Aspiration Precautions -- Alternate bites and sips -- "These are FYI instructions."
o Reflux Precautions -- "These are FYI instructions. These instructions will be included in the medical history and on the quick view instructions sheets. Staff have already been instructed on the diet requirements."
Additionally, Staff Person #4 completed monthly summary reports for Individual #1. The February 2018 summary report, signed on March 26, 2018, reads in part, "On 2/15/18 [Individual #1] was seen at Roxborough Hospital for a swallow study as per order placed by [her Primary Care Physician]. Report followed stats that [Individual #1] remains on regular diet solids and thin liquids. Aspirations precautions: alternate bites/sips, slow rate." The March 2018 summary report, signed April 9, 2018, reads in part, "[Individual #1] continued to maintain her regular house diet with limited sweets." | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | Immediate action - A review of all resident records determined no other records out of compliance and needing correction Division vice president & program directors conducted an immediate retraining/review with Program Specialists and nurses regarding their role/responsibility which included staff training regulations updating records & recognizing and preventing abuse/neglect 8 & 9. Program directors ensured program specialists & nurses were retrained on flow of medical appointments 16. Division vice president reminded all program specialists of their role in addressing any audit concerns 19. Program directors mandated training on Relias Learning named Abuse and Neglect of Individuals with IDD 6&18. Division abuse/neglect policy posted in homes 17. Program specialists and directors conducted random visits at the residences to ensure no incidents of neglect/abuse. To prevent future occurrences- Newly hired staff will complete the training within 30 days of hire date 27. Program directors conduct comprehensive training of each Program Specialist's & nurse's role/responsibility at the Program Chart Training, bi annually or more often as needed 10. Abuse and neglect, including supervision of individuals, is reviewed with all staff upon hire 7. Program Directors will ensure that all staff receive annual policy and procedure training 3. Client Abuse Policy 17 and Reportable Incident Policy 20 are provided and reviewed during this training. Weekly visits to all homes are rotated among the QA staff, Assist and Residential Directors 23. All supervisory visits ensure the appropriate supervision in the home & appropriate staff-consumer interactions. Routine site visits during the week by Program Supervisors to the homes, in addition to at least one late night visit per week to all sites24. IDD Compliance Officer completes random site checks throughout the quarter to ensure health and safety at all times 28 Program nurses will provide in service training for all staff on "The Fatal Four"; Seizures, Choking, Dehydration, and Constipation 26. New employees will be required to take Fatal Four training within 90 days from date of hire 27. Compliance of directive will be tracked by assistant CHS director. Compliance officer will complete random audits to ensure that any change related to individual's needs are reported to the supports coordinator and plan team members 22. Identified issues will be brought to the attention of program specialist or nurse Compliance Officer will ensure that identified issues are addressed as needed. Program directors, assistant CHS director, and QA staff complete full chart audits & note any areas of non-compliance Identified issues will be brought to the attention of the program specialist or nurse Managers will ensure identified issues are addressed as needed 22. To monitor compliance Weekly visits to all homes rotated among the QA staff, Assist and Residential Directors to ensure the appropriate supervision in the home & the appropriate staff-consumer interactions as well 23. IDD Compliance Officer completes random site checks to ensure health and safety at all times 28. Rotating supervisory weekend site visits and routine site visits during the week by Program Specialists including at least one late night visit per week to all sites 24. Staff receive ongoing training, in addition to mandated annual policy/procedure training, in required staffing ratio expectations, examples of what constitutes neglect, call out procedure/chain of command, and reporting requirements. Standard rotating cell phone among on call/after hour supervisors & all sites/staff are provided with updated on-call personnel contact information so that there is a consistent number and always someone available to staff 25. These systems will monitor that no individual is subject to abuse |
09/18/2018
| Not Implemented |
| 6400.16 | On April 9, 2018, Individual #1 experienced a choking episode while eating at the home. She was transported to Temple Memorial Hospital and subsequently admitted to the Intensive Care Unit and placed on a ventilator. She did not regain any neurologic functions. Life-sustaining treatment was discontinued at the request of her family. Individual #1 died on April 12, 2018.Intercommunity Action, though a combination of negligence and systematic failure to provide needed care to Individual #1, created conditions that directly contributed to Individual #1's death:· Individual #1 was given food that was not properly prepared to prevent choking. On April 9, 2018, Individual #1 was in the living area of the home while Staff Person #1 was preparing dinner in the kitchen area. Individual #1 began to disrobe and express a desire to take a shower. Staff Person #1 provided Individual #1 with French fries to "keep her occupied" while Staff Person #1 continued to prepare dinner in the kitchen area. Individual #1 continued to disrobe while eating the French fries. When Staff Person #1 turned to Individual #1 to verbally redirect her to stop disrobing, she saw Individual #1 choking. Individual #1 subsequently lost consciousness. A Modified Barium Swallow Study (an examination of a person's swallowing function conducted by a Speech-Language Pathologist) was completed for Individual #1 on February 15, 2018. The results, which were transmitted to Intercommunity Actions on February 21, 2018, concluded that Individual #1 should have a diet of mechanical soft solids. Potatoes prepared to meet mechanically-softened standards must be mashed, baked, boiled, or creamed. French fries do not meet mechanical soft standards.· Individual #1's eating protocols were not followed. The February 15, 2018 Barium Swallow Study also recommended that Individual #1 take sips of liquid in between bites of food and to eat slowly to prevent aspiration. Individual #1 was not provided with liquid along with the French fries or encouraged to eat slowly.· The staff person working in the home was never trained on Individual #1's eating protocols. Staff person #1 stated that she did not know that Individual #1 had eating protocols of any kind.· Intercommunity Action failed to recognize a prior choking event as a sentinel precursor to the event that lead to her death. On November 12, 2017, Individual #1 choked while eating a peanut butter and jelly sandwich. Staff dislodged the food and contacted 911. First responders determined that Individual #1's airway was clear and that hospitalization was not necessary. When reporting the incident to the Administrative Entity, Intercommunity Action listed the supports provided as "Informal Counseling" and "Natural Supports." The Administrative Entity notified Intercommunity Action that they "may wish to review [the event] with the Primary Care Physician on November 12, 2018. This recommendation led to a January 3, 2018 appointment with Individual #1's Primary Care Physician, who subsequently recommended an evaluation by a specialist, which in turn lead to the February 15, 2018 Barium Swallow Study. Absent direction from the Administrative Entity, no such study would have been conducted. Intercommunity Action failed to update Individual #1's care plans to reflect eating protocols following the Barium Swallow Study. Individual #1's most recent assessment was completed on August 22, 2017, and last updated on October 10, 2017. The "Dietary Constraints" section of the assessment reads "[Individual #1] is diagnosed with diabetes and should limit and watch her sweet intake. Per her PCP, [Individual #1] should follow a 1700 calorie diet with high fiber intake. No changes." Individual #1's most recent Individual Support Plan was completed on January 10, 2018. The "Meals/Eating" section of the plan reads that Individual #1 "does not require a special diet," and that she "can prepare simple meals such as a sandwich. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | Immediate action - A review of all resident records determined no other records out of compliance and needing correction Division vice president & program directors conducted an immediate retraining/review with Program Specialists and nurses regarding their role/responsibility which included staff training regulations updating records & recognizing and preventing abuse/neglect 8 & 9. Program directors ensured program specialists & nurses were retrained on flow of medical appointments 16. Division vice president reminded all program specialists of their role in addressing any audit concerns 19. Program directors mandated training on Relias Learning named Abuse and Neglect of Individuals with IDD 6&18. Division abuse/neglect policy posted in homes 17. Program specialists and directors conducted random visits at the residences to ensure no incidents of neglect/abuse. To prevent future occurrences- Newly hired staff will complete the training within 30 days of hire date 27. Program directors conduct comprehensive training of each Program Specialist's & nurse's role/responsibility at the Program Chart Training, bi annually or more often as needed 10. Abuse and neglect, including supervision of individuals, is reviewed with all staff upon hire 7. Program Directors will ensure that all staff receive annual policy and procedure training 3. Client Abuse Policy 17 and Reportable Incident Policy 20 are provided and reviewed during this training. Weekly visits to all homes are rotated among the QA staff, Assist and Residential Directors 23. All supervisory visits ensure the appropriate supervision in the home & appropriate staff-consumer interactions. Routine site visits during the week by Program Supervisors to the homes, in addition to at least one late night visit per week to all sites24. IDD Compliance Officer completes random site checks throughout the quarter to ensure health and safety at all times 28 Program nurses will provide in service training for all staff on "The Fatal Four"; Seizures, Choking, Dehydration, and Constipation 26. New employees will be required to take Fatal Four training within 90 days from date of hire 27. Compliance of directive will be tracked by assistant CHS director. Compliance officer will complete random audits to ensure that any change related to individual's needs are reported to the supports coordinator and plan team members 22. Identified issues will be brought to the attention of program specialist or nurse Compliance Officer will ensure that identified issues are addressed as needed. Program directors, assistant CHS director, and QA staff complete full chart audits & note any areas of non-compliance Identified issues will be brought to the attention of the program specialist or nurse Managers will ensure identified issues are addressed as needed 22. To monitor compliance Weekly visits to all homes rotated among the QA staff, Assist and Residential Directors to ensure the appropriate supervision in the home & the appropriate staff-consumer interactions as well 23. IDD Compliance Officer completes random site checks to ensure health and safety at all times 28. Rotating supervisory weekend site visits and routine site visits during the week by Program Specialists including at least one late night visit per week to all sites 24. Staff receive ongoing training, in addition to mandated annual policy/procedure training, in required staffing ratio expectations, examples of what constitutes neglect, call out procedure/chain of command, and reporting requirements. Standard rotating cell phone among on call/after hour supervisors & all sites/staff are provided with updated on-call personnel contact information so that there is a consistent number and always someone available to staff 25. These systems will monitor that no individual is subject to abuse |
09/18/2018
| Not Implemented |
| 6400.33(a) | Individual #1 was neglected as described in the violation of § 6400.16, above. | An individual may not be neglected, abused, mistreated or subjected to corporal punishment. | Immediate action- A review of all resident records determined that there were no other records out of compliance and needed to be corrected. Program directors mandated (#6) training on Relias Learning named Abuse and Neglect of Individuals with IDD (#18). Program nurses will provide in service training for all staff on "The Fatal Four"; Seizures, Choking, Dehydration, and Constipation, by Nov 1, 2018 (#26). Division abuse/neglect policy posted in homes (#17). Program specialists and directors conducted random visits at the residences to ensure no incidents of neglect/abuse. To prevent future occurrences ¿ Abuse and neglect, including supervision of individuals, is reviewed with all staff at orientation 7. Program Directors will ensure that all staff receive annual policy and procedure training 3. Client Abuse Policy 17 and Reportable Incident Policy (#20) are provided and reviewed during this training. Newly hired staff will complete the training within 30 days of hire (#27). Weekly visits to all homes are rotated among the Quality Assurance staff, Assistant and Residential Directors (#23). All supervisory visits ensure the appropriate supervision in the home and the appropriate staff-consumer interactions. Routine site visits during the week by Program Supervisors to the homes, in addition to at least one late night visit per week to all sites, occur 24. IDD Compliance Officer completes random site checks throughout the quarter to ensure health and safety at all times (#28) New employees will be required to take Fatal Four training within 90 days from date of hire 27. In order to monitor compliance - there are weekly visits to all homes rotated among the Quality Assurance staff, Assistant and Residential Directors to not only ensure the appropriate supervision in the home and the appropriate staff-consumer interaction as well (#23) IDD Compliance Officer completes random site checks throughout the quarter to ensure health and safety at all times 28. There continues to be a rotating supervisory weekend site visit schedule to ensure all sites are visited by a supervisor on the weekends. Routine site visits during the week by Program Supervisors to the homes, in addition to at least one late night visit per week to all sites, continue to occur (#24). All staff receive ongoing training, in addition to mandated annual policy/procedure training, in required staffing ratio expectations, examples of what constitutes neglect, call out procedure/chain of command, and reporting requirements. Cameras which were installed in some of the homes are also monitored periodically to ensure the safety and proper supervision for individuals. Standard rotating cell phone among on call/after hour supervisors and all sites/staff are provided with updated on-call personnel contact information so that there is a consistent number and always someone available to staff 24/7 25. These systems will monitor that no individual is neglected, abused, mistreated or subjected to corporal punishment. |
09/18/2018
| Not Implemented |
| 6400.44(b)(11) | Individual #1's change in eating needs was not reported to her supports coordinator. | The program specialist shall be responsible for the following: Reporting a change related to the individual's needs to the SC, as applicable, and plan team members. | Immediate action - Review of resident records determined that there were no other records out of compliance and needing correction. Program nurses developed information cheat sheets/resident profiles posted in homes reviewed and signed by staff 11. Immediate retraining/review with all Program Specialists & nurses regarding their role/responsibility, which included staff training regulations & updating records 8&9. This training will be completed upon date of hire of any new program specialists or nurses. Division vice president reminded all program specialists of their role in addressing any audit concerns 19. To prevent future occurrences - Nurse will immediately update the resident profile whenever there is a change 11. Program specialist will post updated profile at the site and inform all staff of the change. Program nurse will provide staff training, if needed, on the change, and document the training. Program specialist will inform supports coordinator of the change, so the ISP is updated. Program nurse will forward updated resident profile sheet to Assistant CHS director and quality assurance assistant so that they monitor that the protocol is followed. Compliance officer will conduct random chart audits to monitor that protocol is followed. Compliance officer will complete a random audit of individual's books to ensure that any change related to individual's needs are reported to the supports coordinator and plan team members 22. Any identified issues will be brought to the attention of the program specialist and nurse. Program directors, assistant CHS director, and quality assurance director complete full chart audits and note any areas of noncompliance. Any identified issues will be brought to the attention of the program specialist and nurse. Compliance Officer will ensure that audit issues are addressed as required and appropriate follow up will occur for noncompliance. Training of Program Specialists and nurses regarding their role/responsibility, including staff training regulations and updating records will be completed upon date of hire of any new program specialists or nurses 8. Program directors conduct more comprehensive training of each Program Specialist's and nurse's role/responsibility at the Program Chart Training 10. Program directors will conduct program chart training at least bi annually or more often as needed, to ensure staff's understanding. Individualized training is available if needed or requested 22.
To monitor compliance: Compliance officer will complete a random audit of individual's books to ensure that any change related to individual's needs are reported to the supports coordinator and plan team members 22. Any identified issues will be brought to the attention of the program specialist and nurse. Program directors, assistant CHS director, and quality assurance director complete full chart audits and note any areas of noncompliance. Any identified issues will be brought to the attention of the program specialist and nurse. Compliance Officer will ensure that audit issues are addressed as required and appropriate follow up will occur for noncompliance. Program directors will conduct program chart training at least bi annually or more often as needed, to ensure staff's understanding. Individualized training is available if needed or requested 10. |
09/18/2018
| Not Implemented |
| 6400.44(b)(18) | Staff Person #1 was not trained in Individual #1's eating protocols.
Staff Person #4 reported that she was never notified that Individual #1 was on a special diet, nor was she trained on any special dietary restrictions for Individual #1, despite the fact that she referenced (inaccurate) dietary needs in her February and March monthly reports (see § 6400.16 above). | The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. | Immediate action- A review of all resident records determined that there were no other records out of compliance and needed to be corrected. Program nurses developed information cheat sheets/resident profiles for every individual in every home which were placed in the homes and reviewed with staff who signed off on them 11. Immediate retraining/review with all Program Specialists and nurses regarding their role/responsibility, which included staff training regulations and updating records, including lifetime medical history and assessment, as well as supports coordinator made aware of the change 8 & 9. Program directors ensured that program specialists and nurses were retrained on the flow of medical appointments 16. Division vice president reminded all program specialists of their role in addressing any audit concerns 19. To prevent future occurrences - program nurse will immediately update the resident profile, whenever there is a change 11. Program specialist will post updated profile at the site and inform all staff of the change. Program nurse will provide staff training, if needed, on the change, and document the training. Program specialist will inform supports coordinator of the change, so the ISP is updated. Program nurse will forward updated resident profile sheet to Assistant CHS director and quality assurance assistant so that they monitor that the protocol is followed. Compliance officer will conduct random chart audits to monitor that protocol is followed. Compliance officer will complete a random audit of individual¿s books to ensure that any change related to individual's needs are reported to the supports coordinator and plan team members 22. Any identified issues will be brought to the attention of the program specialist and nurse. Program directors, assistant CHS director, and quality assurance director complete full chart audits and note any areas of noncompliance. Any identified issues will be brought to the attention of the program specialist and nurse 22. Compliance Officer will ensure that audit issues are addressed as required and appropriate follow up will occur for noncompliance. Training of Program Specialists and nurses regarding their role/responsibility, including staff training regulations and updating records will be completed upon date of hire of any new program specialists or nurses 8. Program directors conduct more comprehensive training of each Program Specialist's and nurse's role/responsibility at the Program Chart Training, at least bi annually or more often as needed, to ensure staff's understanding. Individualized training is available if needed or requested 10.
In order to monitor compliance - Weekly visits to all homes rotated among the Quality Assurance staff, Assistant and Residential Directors to not only ensure the appropriate supervision in the home and the appropriate staff-consumer interactions as well 23. IDD Compliance Officer completes random site checks throughout the quarter to ensure health and safety at all times 28. There continues to be a rotating supervisory weekend site visit schedule to ensure all sites are visited by a supervisor on the weekends. Routine site visits during the week by Program Supervisors to the homes, in addition to at least one late night visit per week to all sites, continue to occur 24. These systems are in place to monitor the health and safety needs of all individuals. Any issues will be immediately addressed and training will take place related to any health and safety needs. |
09/18/2018
| Accepted |
| 6400.45(e) | On April 9, 2018, Individual #1 was in the living area of the home while Staff Person #1 was preparing dinner in the kitchen area. Individual #1 began to disrobe and express a desire to take a shower. Staff Person #1 provided Individual #1 with French fries to "keep her occupied" while Staff Person #1 continued to prepare dinner in the kitchen area. Individual #1 continued to disrobe while eating the French fries. When Staff Person #1 turned to Individual #1 to verbally redirect her to stop disrobing, she saw Individual #1 choking. Individual #1 subsequently lost consciousness. Individual #1 required supervision and direction while eating to prevent choking. | An individual may not be left unsupervised solely for the convenience of the residential home or the direct service worker. | Immediate action - Review of all resident records determined no other records out of compliance and needing correction. Staff received a reminder memo that individuals must always be monitored when eating and food must never be used as a distraction 21. Program specialists and directors conducted random visits at residences around varied meal times to monitor that individuals are supervised when eating & food is not used as a distraction. Program Directors & program specialists ensured staff completed Relias Learning Trainings titled Choice Making for People with IDD 5 & 6. Routine site visits during the week by Program Supervisors to the homes, in addition to at least one late night visit per week to all sites 24.Weekly visits to all homes rotated among the QA staff, Assist and Residential Directors 23 Supervisory visits ensure the appropriate supervision in the home, the appropriate staff-consumer interaction, & the monitoring that no individual is left alone solely for the convenience of the residential home or direct service worker Supervisors model positive interactions with the DSP to demonstrate and role play how to engage individuals to ensure that no individual is left alone solely for the convenience of the residential home or direct service worker. By November 1, 2018, program nurses will provide in service training for all staff on "The Fatal Four"; Seizures, Choking, Dehydration, and Constipation. This training will include tools for staff to assure that they will not leave individuals unsupervised solely for the convenience of staff and tools on how to deal with situations that prevent them from doing other work to provide necessary supervision 26. To prevent future occurrences Program Directors will ensure that all staff receive annual policy and procedure training 3 where meaningful activities and community participation is reviewed as well as direct care staff's role in choices 4. New employees will complete Relias Learning g Trainings titled Choice Making for People with IDD within 30 days of hire 5. Compliance of training directive will be tracked by assistant CHS director. Routine site visits during the week by Program Supervisors to the homes, in addition to at least one late night visit per week to all sites 24. Weekly visits to all homes are rotated among the Quality Assurance staff, Assistant and Residential Directors 23. All supervisory visits ensure the appropriate supervision in the home, the appropriate staff-consumer interaction, and the monitoring that individuals are not left alone solely for the convenience of the residential program or direct service worker Program directors conduct more comprehensive training of each Program Specialist's and nurse's role/responsibility at Program Chart Training 10. New employees will be required to take Fatal Four training within 90 days from date of hire 27. To monitor compliance- Weekly visits to all homes rotated among the QA staff, Assist and Residential Directors to not only ensure the appropriate supervision in the home but the appropriate staff-consumer interaction as well 23. IDD Compliance Officer completes random site checks throughout the quarter to ensure health and safety at all times 28. There continues to be a rotating supervisory weekend site visit schedule to ensure all sites are visited by a supervisor on the weekends. Routine site visits during the week by Program Supervisors to the homes, in addition to at least one late night visit per week to all sites, occur 24. All staff receive ongoing training in addition to mandated annual policy/procedure training, in required staffing ratio expectations, examples of what constitutes neglect, call out procedure/chain of command, and reporting requirements Standard rotating cell phone among on call/after hour supervisors and all sites/staff are provided with updated on-call personnel contact information so that there is a consistent number and always someone available to staff 24/7 25. |
09/18/2018
| Not Implemented |
| 6400.144 | Intercommunity Action failed to provide dietary services to Individual #1.
On April 9, 2018, Individual #1 experienced a choking episode while eating French fries at the home. She was transported to Temple Memorial Hospital and subsequently admitted to the Intensive Care Unit and placed on a ventilator. She did not regain any neurologic functions. Life-sustaining treatment was discontinued at the request of her family. Individual #1 died on April 12, 2018.
A Modified Barium Swallow Study (an examination of a person's swallowing function conducted by a Speech-Language Pathologist) was completed for Individual #1 on February 15, 2018. The results, which were transmitted to Intercommunity Actions on February 21, 2018, concluded that Individual #1 should have a diet of mechanical soft solids, to take sips of liquid in between bites of food, and to eat slowly to prevent aspiration.
Potatoes prepared to meet mechanically-softened standards must be mashed, baked, boiled, or creamed. French fries do not meet mechanical soft standards.
Staff Person #1 provided Individual #1 with French fries to "keep her occupied" while Staff Person #1 continued to prepare dinner in the kitchen area. | 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.
| Immediate action Review of all resident records determined no other records out of compliance and needing correction. Program nurses developed information cheat sheets/resident profiles for every individual placed in the homes and reviewed and signed by staff 11. Immediate retraining/review with Program Specialists and nurses regarding their role/responsibility which included staff training regulations & updating records 8&9. Immediate retraining/review with program specialists & nurses on flow of medical appointments 16. Choking precaution and prevention fact sheet completed by nurse which includes foods that can be choking hazards posted at all sites 12. Medical tracking spreadsheet developed & updated with every appointment. Spreadsheet is sent out the first Friday of any month. If a scheduled appointment is missed an incident report is completed indicating the reason for missed appointment and the date of the rescheduled appointment. Appropriate disciplinary follow up occurs depending on the reason for missed appointment. Program directors mandated current staff to complete Relias Learning Training titled Safe Eating 13&14. Program specialists and directors ensured PA DHS Health Alert on Choking posted at every site 15. To prevent future occurrences -When there is a new diagnosis or change in diagnosis, program nurse will immediately update the resident profile, it will be posted at site and nurse will provide needed staff training, within 48 hours. Program specialist will ensure that new staff are trained on the profile prior to working with individuals. Program nurse will ensure that any follow ups related to a change will be arranged/provided for within the first two weeks after a change. Compliance officer completes a random audit of individual's books to ensure that resident profiles are accurate and needed training took place. Compliance office audits charts to assure that planned/prescribed services were arranged/provided as needed & that medical appointments took place as scheduled and Program directors, assist CHS director, and QA staff complete full chart audits and note any areas of noncompliance with assuring that planned/prescribed services were arranged/provided 22. Identified issues brought to the attention of the program specialist and nurse. Compliance Officer will ensure that audit issues are addressed as required. Newly hired staff complete the training entitled Safe Eating within 30 days of hire 14 &27. Program directors will conduct bi annual comprehensive training of each Program Specialist's and nurse's role/responsibility at Program Chart Training 10. Comprehensive chart training includes the responsibility to assure that planned/prescribed services are arranged& provided to ensure staff's understanding Individualized training is available if needed or requested. Program nurses will provide in service training for all staff on "The Fatal Four"; Seizures, Choking, Dehydration and Constipation, by November 1, 2018 26. If an appt is missed an incident report will be immediately written indicating the reason the appt is missed and the date of the rescheduled appt. To monitor compliance: Assist CHS director will track compliance of required trainings. Appropriate follow up will occur for noncompliance. Compliance officer will audit program and medical charts to monitor that all 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 22. Immediate follow up to occur for any areas of noncompliance. Medical tracking spreadsheet will be sent out the first Friday of each month, and areas of noncompliance will be addressed. Compliance officer will receive copies of all incident reports for missed appts and will track areas of noncompliance. |
09/18/2018
| Not Implemented |
| 6400.188(d) | Intercommunity Action failed to provide functionally appropriate services to Individual #1.
On April 9, 2018, Individual #1 experienced a choking episode while eating French fries at the home. She was transported to Temple Memorial Hospital and subsequently admitted to the Intensive Care Unit and placed on a ventilator. She did not regain any neurologic functions. Life-sustaining treatment was discontinued at the request of her family. Individual #1 died on April 12, 2018.
A Modified Barium Swallow Study (an examination of a person's swallowing function conducted by a Speech-Language Pathologist) was completed for Individual #1 on February 15, 2018. The results, which were transmitted to Intercommunity Actions on February 21, 2018, concluded that Individual #1 should have a diet of mechanical soft solids, to take sips of liquid in between bites of food, and to eat slowly to prevent aspiration.
Potatoes prepared to meet mechanically-softened standards must be mashed, baked, boiled, or creamed. French fries do not meet mechanical soft standards.
Staff Person #1 provided Individual #1 with French fries to "keep her occupied" while Staff Person #1 continued to prepare dinner in the kitchen area. | The residential home shall provide services that are age and functionally appropriate to the individual. | Immediate action Review of resident records determined no other records out of compliance and needing correction Program nurses developed information sheets/resident profiles placed in homes and reviewed and signed by staff 11. Immediate retraining/review with Program Specialists & nurses regarding their role/responsibility including staff training regulations updating records & review of ISP's &information sheets which detail age and functionally appropriate services 8 & 9. Immediate retraining with all program specialists & nurses on flow of medical appointments 16. Nurse developed choking precaution and prevention fact sheet which includes foods that can be choking hazards & posted at all sites 12. Staff received reminder memo individuals must always be monitored when eating & food must never be used as a distraction 21. Staff mandated to complete Relias Learning Training Choice Making for People with IDD which reviewed supporting & empowering individuals to make choices as well as providing strategies to staff to offer & support choices 5 & 6. Assist CHS director tracked compliance and appropriate follow up needed. Employees receive review of agency & residential division mission statement/Everyday Lives philosophy, normalization/community integration expectations & Individual Rights at orientation 1&2. To prevent future occurrences Compliance officer completes random chart audits for age & functionally appropriate services provided and bi annual chart audits completed by CHS co directors assist CHS director & QA Assistant 22. Identified issues brought to the attention of program specialist & nurse. Compliance Officer ensures audit issues addressed as required. Program Directors ensure staff receive annual policy & procedure training (3) where meaningful activities & community participation is reviewed as well as direct care staff's role in choices 4. Routine site visits by Program Specialists to the homes including at least one late night visit per week 24. Rotating weekly visits to all homes among the QA Assist, Assist & Res Directors to ensure the appropriate supervision in the home appropriate staff-consumer interaction & the monitoring that age and functionally appropriate services are provided 23. Supervisors model positive interactions with DSP to demonstrate age & functionally appropriate services. Program directors conduct comprehensive training of each Program Specialist's & nurse's role/responsibility at Program Chart Training at least bi annually or more often as needed to ensure staff's understanding Individualized training is available if needed or requested 10. Training with Program Specialists & nurses regarding their role/responsibility including staff training regulations updating records & review of ISP's & cheat sheets, which detail age and functionally appropriate services completed upon date of hire 8. Within 30 days of hire Choice Making for Individual's with IDD training 5&27. At orientation employees receive review of agency & residential division mission statement/Everyday Lives philosophy, normalization/community integration expectations & Individual Rights 1&2. To monitor compliance Weekly home visits rotated among QA staff, Assist & Res Directors to ensure appropriate supervision in home & appropriate staff-consumer interactions 23. IDD Compliance Officer completes random site checks to ensure health and safety at all times 28. Rotating supervisory weekend site visit schedule as well as routine visits by program specialists with at least one late night per week 24. Staff receive ongoing training in addition to mandated annual policy/procedure training. Rotating schedule for on call/after hour supervisors to provide a consistent number and always someone available to staff 25. These systems will monitor that the residential home provides services that are age and functionally appropriate. |
09/18/2018
| Not Implemented |
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