| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1 has a diagnosis of Mild IDD, Dementia, Depression, Mood Swings, and Urinary and Fecal Incontinence. Individual #1 is verbal and began residing at Apex Healthcare Services on 7/18/19. Individual #1's Individual Support Plan indicates that the individual is prone to Urinary Tract Infections (UTIs) due to their incontinence and the need to wear adult briefs. Individual #1 needs full assistance from staff in changing their briefs and cleaning themselves after using the restroom as well as full assistance to ensure cleanliness when Individual #1 is showering.
Symptoms of a UTI include pain in the flank, lower abdomen, pelvic area, or lower back, pressure in the lower part of the pelvis, urinary incontinence, frequent urination, urge incontinence, pain or burning when urinating, nausea, and mental changes or confusion. Urinary Tract Infections that go untreated can spread to the bladder, kidneys, and beyond. Sepsis can occur when left untreated. There are multiple ways to prevent Urinary Tract Infections, including drinking water regularly and practicing good genital and urinary hygiene. There are 16 staff who worked in Individual #1's home from 1/1/24 -- 4/30/24, and none of them have been trained in recognizing the potential symptoms of a UTI.
On 1/10/24, staff noted in daily logs that they believed Individual #1's UTI had returned, but no further action was taken. Individual #1 reported to staff on 1/22/24 that they experienced burning while urinating and burning on their bottom. Per daily logs, Desitin was applied, but no further action was taken. On 1/23/24, daily logs indicated that Individual #1 was up every hour overnight to use the restroom. On 1/26/24, Individual #1 again reported burning and itching in their genital area and staff noted that the individual used the restroom 9 times in 1 ½ hours and every 15 minutes thereafter. The only follow up action taken was that cream was applied to Individual #1's bottom. Individual #1 reported that their bottom was bothering them on 1/27/24, so cream was applied. No further action was taken until 1/29/24, when Individual #1 was taken to the doctor to receive care for a potential UTI. At this appointment, Individual #1 was to increase their fluids and was prescribed an antibiotic. If symptoms persisted, the doctor was to be called.
On 2/6/24, daily notes indicated that Individual #1 was up 10 times overnight to use the restroom. Individual #1 had an annual wellness visit with their PCP on 2/7/24, however, the concerns regarding potential UTIs were not discussed with the physician. There were a total of 13 more occasions between 2/8/24 and 4/30/24 where staff noted that Individual #1 used the bathroom frequently, had nausea, and even mentioned on 4/2/24 that they believed Individual #1 had a UTI, but there were no further medical follow ups conducted for Individual #1 until 5/3/24, when a UTI was suspected and Individual #1's increased history of potential UTIs and UTI symptoms was discussed with the doctor and a referral to Urology was made.
Individual #1 was diagnosed with dementia in December 2015. The individual's symptoms have been worsening and Individual #1 was approved for Supplemental Habilitation and 1:1 coverage from 8am to 9pm, 7 days a week on 5/8/23. This coverage continues. As described in 6400.186, there were 70 instances from 1/1/24 through 4/30/24 that this 1:1 coverage was not maintained. The times this coverage was not maintained ranged from 3 minutes to 2 hours and 51 minutes.
The failure to train staff in Individual #1's medical needs, the ongoing failure to seek medical care, and the failure to provide the supplemental supervision required due to Individual #1's worsening dementia creates conditions conducive to serious harm for Individual #1. | 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. | UTI's were added to the syllabus of "Diagnosis Training". Annual training was conducted from 6/10/24 and 6/18/24. All staff were trained in the symptoms and prevention of a UTI. All staff attended annual training. (Attachment # 2-15 ). Staff #2 & 9 are no longer employed by Apex. Diagnosis Training also includes the protocol training of what to do if symptoms are noticed - to communicate verbally and through writing. (Attachment # 16) All staff were also trained during Annual Training on Abuse and Neglect. (Attachment # 17-30)
Examples were given from this investigation in this training.
The following dates and Sup Hab shifts were reviewed to examine time discrepancies.
· 1/1/24 -- 12:20pm - 5:32pm - Individual #1 was at their sisters for the holiday. - 12:30-5:30
· 1/2/24 -- 3:07pm - 3:13pm; 8:00am -- 8:03am; Staff member # 6 was late; Late clock-in - Staff member #8
· 1/3/24 -- 8:00am - 8:15am - Staff member #8 was late.
· 1/4/24 -- 8:00am - 8:05am - Staff member # 8 was late. Staff member #1 stayed over their shift by 6 minutes to cover the time lapse, even though they are not Sup-Hab.
· 1/5/24 -- 8:00am - 8:10am - Staff member # 8 was late.
· 1/9/24 -- 8:00am - 8:05am #8 was late; 3:11pm -- 313pm - #6 was late.
· 1/10/24 -- 8:00am - 8:22am - #8 was late.
· 1/11/24 -- 8:00am - 8:06am - #8 was late.
· 1/13/24 -- 3:02pm -- 3:11pm - #6 and # 7 simply switched services. They both worked doubles. Coverage never stopped. #6 was simply late clocking out of regular service and into Sup Hab Service.
· 1/14/24 -- 8:00am -- 8:03am - Clock in issue for #7
· 1/16/24 -- 8:00am -- 8:05am - Late clock in for # 8.
· 1/17/24 -- 8:00am -- 8:05am - Late clock in for #8.
· 1/18/24 -- 8:00am -- 8:15am - Late clock in for # 8.
· 1/20/24 -- 3:08pm -- 3:12pm - #6 and # 7 simply switched services. They both worked doubles. Coverage never stopped. #6 was simply late clocking out of regular service and into Sup Hab Service
· 1/21/24 -- 8:00am -- 8:06am - # 7 was late.
· 1/22/24 -- 2:58pm -- 3:14pm - # 7 clocked out early and # 6 clocked in late.
· 1/24/24 -- 8:00am -- 8:18am- # 8 was late.
· 1/25/24 -- 8:00am -- 8:09am - #8 was late.
· 1/26/24 -- 8:00am -- 8:10am - # 8 was late.
· 1/28/24 -- 8:00am -- 8:04am - #7 clocked in late.
· 1/30/24 -- 8:00am -- 8:15am - #8 was late.
· 1/31/24 -- 3:06pm -- 3:11pm - #6 was late.
· 2/1/24 -- 8:00am -- 8:13am - # 8 was late.
· 2/4/24 -- 8:00am -- 8:04am - # 7 clocked in late.
· 2/6/24 -- 8:00am -- 8:13am - # 8 clocked in late.
· 2/7/24 -- 8:00am -- 8:11am - # 8 clocked in late.
· 2/8/24 -- 8:00am -- 8:26am - # 8 clocked in late.
· 2/9/24 -- 8:00am -- 8:21am - # 8 clocked in late.
· 2/12/24 -- 2:58pm -- 3:12pm - #7 worked a double, switching from a regular shift to the Sup Hab shift. There was no break in coverage, #7 was just late switching.
· 2/13/24 -- 8:00am -- 8:52am - # 8 clocked in late.
· 2/14/24 -- 8:00am -- 8:05am - # 8 clocked in late.; 12:25pm -- 3:04pm - Individual # 1 went to lunch with their sister.
· 2/15/24 -- 8:00am -- 8:08am - # 8 clocked in late. Overnight shift stayed till 8:03.
· 2/16/24 -- 8:00am -- 8:10am - # 8 clocked in late.
· 2/20/24 -- 8:00am -- 8:08am - # 8 clocked in late.
· 2/22/24 -- 8:00am -- 8:12am - # 8 clocked in late.
· 2/23/24 -- 8:00am -- 8:41am - # 8 clocked in late.
· 2/27/24 -- 8:00am -- 8:04am =# 8 clocked in late.
· 2/28/24 -- 8:00am -- 8:06am -# 8 switched from regular overnight shift straight into Sup Hab - there was no break in coverage, just late switching services; 3:07pm - 3:11pm - #7 clocked in late. Staff #4 stayed to cover the Sup Hab till 3:16. The service was not switched on the schedule.
· 2/29/24 -- 8:00am -- 8:20am - # 8 clocked in late.
· 3/1/24 -- 8:00am -- 8:26am - # 8 clocked in late.
· 3/5/24 -- 8:00am -- 8:16am - # 8 clocked in late.
· 3/6/24 -- 8:00am -- 8:11am - # 8 switched from regular overnight shift straight into Sup Hab - there was no break in coverage, just late switching services
· 3/7/24 -- 8:00am -- 9:20am - Supervisor covered this part of the shift but they clocked in under Admin Shift.
· 3/8/24 -- 8:00am -- 8:05am -# 8 clocked in late.
· 3/10/24 -- 8:00am -- 8:14am - #7 clocked in late.
· 3/12/24 -- 8:00am -- 8:14am - # 8 clocked in late.
· 3/14/24 -- 8:00am -- 8:08am - # 8 clocked in late.
· 3/15/24 -- 8:00am -- 8:14am - # 8 clocked in late.
· 3/19/24 -- 8:00am -- 8:13am - # 8 clocked in late.
· 3/20/24 -- 8:00am -- 8:05am - # 8 clocked in late.
· 3/21/24 -- 8:00am -- 8:19am - # 8 clocked in late.
· 3/26/24 -- 8:00am -- 8:13am - # 8 clocked in late.
· 3/29/24 -- 8:00am -- 8:07am - # 8 clocked in late.
· 4/2/24 -- 8:00am -- 8:11am - # 8 clocked in late.
· 4/4/24 -- 8:00am -- 8:08am - # 8 clocked in late.
· 4/9/24 -- 8:00am -- 8:20am - # 8 clocked in late.
· 4/10/24 -- 8:00am -- 8:05am - # 8 clocked in late.
· 4/12/24 -- 8:00am -- 8:10am - # 8 clocked in late.
· 4/14/24 -- 8:00am -- 8:13am - #7 clocked in late.
· 4/16/24 -- 8:00am -- 8:04am - # 8 clocked in late.
· 4/17/24 -- 8:00am -- 8:06am - # 8 clocked in late.
· 4/18/24 -- 8:00am -- 8:16am - # 8 clocked in late.
· 4/19/24 -- 8:00am -- 8:05am - # 8 clocked in late.
· 4/22/24 -- 5:13pm -- 5:55pm - #7 clocked in late.
· 4/25/24 -- 3:08pm -- 6:00pm - Individual #1's housemate went out with family. Staff # 13 who was on the regular shift stayed on for Sup Hab, but the schedule does not reflect this. Staff # 6 came on a 6:00 - Sup Hab for double coverage.
· 4/28/24 -- 8:00am -- 8:11am - Staff # 6 worked the regular overnight shift and went into the morning Sup Hab shift. No brake in coverage, just a late clock-in for the shift.
If a staff member who is working a regular shift and stays over to cover the Sup Hab, administration will amend the schedule to reflect the Sup Hab hours on their time.
After careful review there is one staff (# 8) who will receive disciplinary action for their tardiness to start shift.
In addition, by 7/31/24, a staff logbook will be placed in the home for times of arrival and departure of all staff. in the instance of a clock in issue or if a supervisor is covering for a late staff, the log in book will document staff arrival and departure.
All Countryside staff will be trained by 7/31/24 on the importance of remembering to clock in and out at the correct time and how it meets Individual #1's supervision needs. In addition, training on the different funding sources and how clock in (outs) affect the individual's care will be emphasized. Training confirmation will be sent upon completion.
All staff will be trained on this POC by 8/2/24. Training confirmation will be sent upon completion. |
06/18/2024
| Implemented |
| 6400.141(c)(4) | Individual #1 had an audiology consult for hearing aids on 3/14/22, with a follow up appointment to occur in July 2022. There is no documentation provided verifying that Individual #1 attended that follow up appointment or has had a hearing examination since 3/14/22. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual # 1 is scheduled for an Audiology appointment on 10/7/2024 @ 9:00 a.m. (attachment # 31)
Individual #1 had an audiology appointment on 10/9/2023. (attachment # 32)
Individual # 1 attended the follow up for their hearing aid fitting in July of 2022, however, the documentation is missing. At that appointment, Individual #1 received their hearing aids and registered them with a phone number in case they got lost. Individual # 1 lost their hearing aids three times. The first time they were replaced under insurance. The second time they were found with the registered phone number. The third time they were replaced at full price by Apex Healthcare Services, LLC.
Missing documentation means there is no proof of attendance at the appointment.
Audiology appointment on 3/14/22.
A new procedure will be put into place for the maintenance of documentation. Upon completion of an appointment, the staff accompanying the individual will drop the appointment summaries at the Community Home Office, immediately after the appointment. Mailboxes will be set up in a locked cabinet at the Community Home Office for each home and each individual so that documentation can be kept in an orderly manner
All Apex staff will be trained on this POC by 8/2/24. |
09/30/2024
| Not Implemented |
| 6400.141(c)(14) | Individual #1's 10/9/23 annual physical examination does not include 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. | There was a document titled Information Pertinent to Diagnosis and Treatment for Individual # 1, however it was not taken to the physical. (Attachment # 35). This document will be sent to Individual # 1's PCP, who performed the physical, by 7/31/24, for signature to be included with the Annual physical documentation.
All Apex staff will be trained on this POC by 8/2/24. |
09/30/2024
| Not Implemented |
| 6400.142(d) | Individual #1 had a dental examination on 9/19/23, however, the dentist was unable to examine and clean Individual #1's teeth. There is no record that Individual #1 has had a complete examination and cleaning since their 7/18/19 date of admission. | The dental examination shall include teeth cleaning or checking gums and dentures. | The Program Specialist has started filling out new patient forms for consultation for dental work under sedation. (Attachment # 36) All providers closer to Individual #1 were researched and options were exhausted. Special Smiles will take the insurance and perform all work needed under sedation.
Prior to the exam on 9/19/23 they were seen on:
1/5/23 - Periodontics Consult
9/6/22 - Annual
5/25/21, 4/12/21, 4/6/21, 3/30/21 - Partial dentures
12/15/20, 12/7/20 - Denture Consultations
10/28/20 - Special Smiles - Full mouth rehab under anesthesia
8/26/20 - Consult for dental procedure under anesthesia
(Attachment # 37 - #44)
House Supervisors, Lead DSPs, and the Program Specialists will be retrained on the importance of dental hygiene, a new dental goal for Individual # 1, and following through with recommendations made at an appointment by 7/14/24. Confirmation of the training will be sent upon completion.
All staff will be trained on this POC by 8/2/24.
All staff will be retrained on the importance of dental hygiene and following through with recommendations made at an appointment by 8/2/24. |
09/30/2024
| Implemented |
| 6400.142(e) | Individual #1 had a periodontics consultation on 1/5/23. During this consultation, the doctor recommended full mouth scaling to be completed by an oral surgeon and included an oral surgeon referral due to stage 4 periodontal disease. This follow up work has not been completed or scheduled.
At Individual #1's 9/19/23 dental examination, the dentist recommended sedation dentistry as an examination and cleaning could not be completed. This follow up work has not been completed or scheduled. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | The new Program Specialist has begun the initial paperwork for Special Smiles for dental work needed under sedation. (Attachment # 36) Research has been completed on oral surgeons and dentists who will complete the work under sedation and who will accept the individual's insurance. Special Smiles was located in Philadelphia, PA. |
09/30/2024
| Not Implemented |
| 6400.144 | Individual #1 had a SIS Assessment on 3/30/23 that indicated that Individual has exceptional medical needs that include physical therapy exercises. The individual needs to complete stand up/sit down exercises, moving their feet and legs, and wrist exercises. Individual #1 is to complete these exercises once per day. These exercises are not being completed with Individual #1.
Individual #1 has a bowel movement protocol in place due to chronic constipation. If Individual #1 goes 2 days without a bowel movement, 10 ounces of prune juice are to be given daily until a bowel movement occurs. If Individual #1 goes 3 days without a bowel movement, the program specialist and PCP are to be notified immediately for further instructions. Additionally, Individual #1 is to be encouraged to drink at least 64 ounces of water daily. There is no tracking in place to ensure that Individual #1 is drinking enough water, and there were multiple dates, listed below, that Individual #1 went 3 or more days with no tracked bowel movement and no follow up action was taken:
· January 29, 30, and 31, 2024
· February 26, 27, and 28, 2024
· March 9, 10, and 11, 2024
· March 19, 20, 21, and 22, 2024
· March 29, 30, and 31, 2024
· April 4, 5, and 6, 2024
On 1/14/24, Individual #1 was seen in the emergency room for a worsening cough. The discharge instructions indicated that if Individual #1's oxygen levels were below 92%, they were to return to the emergency room. There is no documentation verifying that Individual #1's oxygen levels were monitored after this visit.
On 2/7/24, Individual #1 was seen for their annual wellness visit. Follow up labs were ordered, but there is no documentation verifying these labs have been completed or scheduled.
Individual #1 has an unsteady gait and requires a walker to ambulate. The individual has had 2 falls since 1/1/24. Additionally, Individual #1's PCP confirmed that Individual #1 is a fall risk at their 2/7/24 annual wellness visit. The provider does not have a fall protocol in place for Individual #1. | 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.
| Individual # 1 is completing their PT exercises. At some point the service notes were revised, and the PT exercises were removed from the note. Staff were not trained how to assist with the exercises. Upon recognition of this deficit, staff were given the information needed to assist in the exercises at Annual Training (6/10-6/18) and Individual # 1 resumed their PT exercises daily. The service notes will be revised to include a check box of the PT exercise completion by 8/1/24. |
08/01/2024
| Not Implemented |
| 6400.181(e)(4) | Individual #1 has required 1:1 supplemental habilitation from 8am to 9pm daily due to their diagnosis of dementia. This supervision requirement is not included in Individual #1's 8/8/23 assessment. | The assessment must include the following information: The individual's need for supervision.
| The assessment for Individual's #1 will be revised to include need for supervision by 7/8/24. |
07/08/2024
| Implemented |
| 6400.181(e)(10) | There is not a lifetime medical history included with Individual #1's 8/8/23 assessment. | The assessment must include the following information: A lifetime medical history. | The lifetime medical history was added to Individual #1's assessment. |
07/30/2024
| Not Implemented |
| 6400.18(b)(2) | The medication errors described in 6400.167a1 are not reported in the department's incident management system. | 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. | Individual #1 began a 5 day, twice daily course of Cephalexin at 6pm on 1/1/24. This medication was only administered until 8am on 1/5/24. A full 5-day course would have to be taken until 8am on 1/6/24, meaning Individual #1 was not administered 2 doses of this medication. - A Medication Error was entered into the EIM system. - #9443805
Individual #1 was prescribed Oseltamivir Phosphate on 1/14/24 to begin 1/15/24 in the morning. A Medication Error was entered into the EIM system.
Individual #1 wasn't administered this medication for the first time until 1/15/24 at 8pm. Individual #1 also was not administered their 8pm dose of this same medication on 1/16/24. A Medication Error was entered into the EIM system.
Individual #1 was not administered their 8am dose of Propranolol on 3/27/24. A Medication Error was entered into the EIM system.
Individual #1 was not administered their 6pm dose of Ziprasidone on 4/1/24 and their 6pm dose of Metformin on 4/7/24. A Medication Error was entered into the EIM system.
All staff will be given 2 extra observed medication pours over the next 90 days to ensure they are using the 15 steps of Medication Administration Training. The documentation sheets will be sent upon completion.
All staff will be retrained by 7/31/24 on reporting medication errors immediately to their supervisor. MARs will be checked by the Lead DSP each day that they work. The House Supervisor will check the MARs at least 2x/wk and the Program Specialist will check the MARs 1x/wk for the next 90 days.
All staff will be retrained on reporting medication errors immediately to their supervisor. MARs will be checked by the Lead DSP each day that they work. The House Supervisor will check the MARs at least 2x/wk and the Program Specialist will check the MARs 1x/wk. |
07/03/2024
| Implemented |
| 6400.52(c)(6) | Individual #1 has an Individual Support Plan and bowel protocol in place. Individual #1 also has a diagnosis of dementia and requires daily physical therapy exercises. Staff require training on all these areas to work with Individual #1.
· Staff persons #11 and 13 are not trained in Individual #1's Individual Support Plan.
· Staff person #13 has not been trained in dementia.
· None of the 16 staff persons who have worked in Individual #1's home since 1/1/24 have been trained in Individual #1's bowel protocol or the individual's daily physical therapy exercises. | 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. | Staff #13 was trained on Individual #1's ISP and Health and Safety Plan on 2/20/24 in their Orientation Training (Attachment # 55) and again on 6/2/24 in Annual Training. (Attachment # 56) Staff #13 was trained on Dementia on 2/22/24 in their Orientation Training (Attachment # 57) and again on 6/12/24 in Annual Training.
Staff #11 was trained on Individual #1's ISP on 6/12/24 in Annual Training. (Attachment # 58) Staff # 11 was trained on the bowel protocol in Annual Training on 6/12/24. (Attachment # 59) They have not worked in the home since they did a shadow shift there on 3/2/24. They could not shadow in the home where they work because the individual was not yet admitted.
Staff were trained in Individual #1's bowel protocol and PT exercises in Annual Training. (6/10/24-6/18/24).
All staff will be trained on this POC by 8/2/24. Confirmation of the Training will be sent upon completion. |
08/16/2024
| Not Implemented |
| 6400.162(b)(2)(ii) | On 1/22/24, staff person #6 administered a topical medication to Individual #1. Staff person #6 is not trained to administer topical medications.
On 1/26/24 and 1/27/24, staff person #7 administered a topical medication to Individual #1. Staff person #7 is not trained to administer topical medications. | A prescription medication that is not self-administered shall be administered by one of the following: A person who has completed the medication administration course requirements as specified in § 6400.168 (relating to medication administration training) for the administration of the following: Topical medications. | The RN trained the Director of Community Homes, who is the Medication Administration trainer, on using Ear drops, Eye Drops, Topicals and Patches on 6/10/24. (Attachment #61) The Director of Community Homes/Medication Administration Trainer trained all staff who are Med Trained to use Ear Drops, Eye Drops, Topicals and Patches in Annual Trainings from 6/10/24-6/18/24. (Attachment # 62-76) |
08/16/2024
| Implemented |
| 6400.165(a) | On 1/22/24, 1/26/24, and 1/27/24, staff noted that Individual #1 reported burning and discomfort on their bottom and that "cream" and "Desitin" were administered. Individual #1 does not have a prescription from an authorized prescriber for this medication.
On 1/13/24, Individual #1 was taken to an Urgent Care due to a cough and chest congestion for the 2 weeks prior to the visit. The staff person accompanying the individual reported that Robitussin had been administered to Individual #1. Individual #1 does not have a prescription from an authorized prescriber for this medication. | A prescription medication shall be prescribed in writing by an authorized prescriber. | Individual #1's staff who are med trained will receive remediation training consisting of documentation practice and a review of what needs to be done when PRN or time limited medications are ordered by 7/31/24. In addition what documentation is needed for a PRN or time limited medication to be administered will be reviewed as well. A record of the training will be sent after completion.
The Program Specialist sent new PRN sheets to all individuals' PCPs for authorization. These will be sent upon receipt from the PCP.
Any PRN medications that are in addition to regular PCP's orders, or any time limited medications that will be added to the MAR will be done so under observation by the Medication Administration Trainer or the RN for the next 90 days. This compliance plan will be distributed to all staff by 7/14/24.
All staff will be trained on this POC by 8/2/24. |
09/30/2024
| Implemented |
| 6400.165(c) | Individual #1 was prescribed Ciprofloxacin on 1/29/24 to be administered twice daily for 3 days. This medication was administered twice daily on 1/30/24, 1/31/24, and 2/1/24, when it should have been discontinued after the evening dose. Individual #1 was administered a dose of the medication in the morning on 2/2/24. | A prescription medication shall be administered as prescribed. | Individual #1 was prescribed Ciprofloxacin on 1/29/24 to be administered twice daily for 3 days. This medication was administered twice daily on 1/30/24, 1/31/24, and 2/1/24, when it should have been discontinued after the evening dose. Individual #1 was administered a dose of the medication in the morning on 2/2/24. - A Medication error was entered in the EIM system. -
All staff will be given 2 extra observed medication pours over the next 90 days to ensure they are using the 15 steps of Medication Administration Training. The documentation sheets will be sent upon completion.
All Countryside staff will be retrained by 7/31/24 on reporting medication errors immediately to their supervisor. MARs will be checked by the Lead DSP each day that they work. The House Supervisor will check the MARs at least 2x/week and the Program Specialist will check the MARs 1x/week for the next 90 days.
All staff will be retrained on reporting medication errors to their supervisor by 8/2/24. |
08/16/2024
| Implemented |
| 6400.165(g) | Individual #1's 2/7/24 psychiatric medication review does not include the names of the medication and the necessary dosage. Additionally, there is no documentation verifying that Individual #1 had a psychiatric medication review before this date. Individual #1's date of admission was 7/18/19. | 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. | Individual #1's medications and diagnosis are on a separate sheet that did not get uploaded. The Psych Medication Check sheet will be printed back-to-back, so the medications/diagnoses are always attached to the form. Individual # 1 was seen on the following dates:9/3/19, 12/3/19, 3/5/20, 4/21/20, 7/23/20, 10/20/20, 1/6/21, 3/3/21, 6/2/21, 9/1/21, 10/7/21, 12/9/21, 2/17/22, 2/25/22, 2/28/22, 3/24/22, 6/9/22, 10/28/22(phone consult), 12/1/22, 1/19/23 and 1/20/23(e-message consult, 2/1/23, 2/16/23, 4/13/23, 5/2/23 (e-message consult), 5/11/23, 5/25/23, 5/30/23, 6/1/23, 6/6/23, 6/19/23, 7/18/23, 8/4/23 (e-message consult), 9/19/23 - (Psych Eval), 9/25/23, 12/19/23, 2/7/24, 5/14/24. The next Med check is scheduled for 7/31/24. (Attachment # 78- #116) |
06/28/2024
| Implemented |
| 6400.166(a)(1) | At Individual #1's 1/13/24 urgent care appointment, Tessalon and Albuterol were prescribed to Individual #1, but these PRN medications were not documented on the Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Individual's name. | Individual #1's staff who are med trained will receive remediation training consisting of documentation practice and a review of what needs to be done when PRN medications are ordered by 7/31/24. A record of the training will be sent after completion. |
09/30/2024
| Implemented |
| 6400.166(a)(2) | Individual #1's January 2024 Medication Administration Record did not include the prescriber's name for the following medications: Oseltamivir Phosphate, Fluconazole, and Ciprofloxacin. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | Individual #1's January 2024 Medication Administration Record was amended to include the prescriber's name for the following medications: Oseltamivir Phosphate, Fluconazole, and Ciprofloxacin. (Attach. #117) MARs for February, March, April, May and June were reviewed to ensure compliance with 166a2. |
07/31/2024
| Implemented |
| 6400.166(a)(10) | Individual #1's January 2024 Medication Administration Record did not include the administration time for Fluconazole. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | Individual #1's staff who are med trained will receive remediation training consisting of documentation practice to include all items to be included on the MAR whether typing it or writing it by 7/31/24. A record of the training will be sent after completion. |
07/31/2024
| Implemented |
| 6400.166(a)(11) | Individual #1's January 2024 Medication Administration Record did not include the diagnosis or purpose for the following medications: Oseltamivir Phosphate, Fluconazole, Ciprofloxacin, Doxycycline, and Amoxicillin. | 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. | Individual #1's MARs for February, March, April, May and June were reviewed to ensure compliance with 166a11.
The current practice of logging medications when they arrive from the pharmacy is to have the RN check them in and compare the MAR to the label. The Lead DSP's do a second check of the labels against the MAR when they enter the house. Both staff are to call immediately if there is a discrepancy. The RN and all Leads will be retrained on this practice that includes comparing the MAR to the label practice. by 7/31/24. Documentation of this remediation training will be sent upon completion. Individual #1's staff who are med trained will receive remediation training consisting of documentation practice to include all items to be included on the MAR whether typing it or writing it by 7/31/24. A record of the training will be sent after completion. |
09/30/2024
| Implemented |
| 6400.166(b) | On 1/22/24, 1/26/24, and 1/27/24, staff noted that Individual #1 reported burning and discomfort on their bottom and that "cream" and "Desitin" were administered. These administrations were not documented on the individual's Medication Administration Record.
On 1/13/24, Individual #1 was taken to an Urgent Care due to a cough and chest congestion for the 2 weeks prior to the visit. The staff person accompanying the individual reported that Robitussin had been administered to Individual #1. These administrations were not documented on the individual's Medication Administration Record.
Individual #1 went to the ER on 1/14/24 for a worsening cough, which was then diagnosed as influenza, and it was reported to the physician that Tessalon had been administered to the individual, however, these administrations are not included on the Medication Administration Record. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Individual #1's staff who are med trained will receive remediation training consisting of documentation practice and a review of what needs to be done when PRN or time limited medications are ordered by 7/31/24. In addition what documentation is needed for a PRN or time limited medication to be administered will be reviewed as well. A record of the training will be sent after completion.
The Program Specialist sent new PRN sheets to all individuals' PCPs for authorization. These will be sent upon receipt from the PCP. |
09/30/2024
| Implemented |
| 6400.167(a)(1) | Individual #1 began a 5 day, twice daily course of Cephalexin at 6pm on 1/1/24. This medication was only administered until 8am on 1/5/24. A full 5-day course would have to be taken until 8am on 1/6/24, meaning Individual #1 was not administered 2 doses of this medication.
Individual #1 was prescribed Oseltamivir Phosphate on 1/14/24 to begin 1/15/24 in the morning. Individual #1 wasn't administered this medication for the first time until 1/15/24 at 8pm. Individual #1 also was not administered their 8pm dose of this same medication on 1/16/24.
Individual #1 was not administered their 8am dose of Propranolol on 3/27/24.
Individual #1 was not administered their 6pm dose of Ziprasidone on 4/1/24 and their 6pm dose of Metformin on 4/7/24. | Medication errors include the following: Failure to administer a medication. | Individual #1 began a 5 day, twice daily course of Cephalexin at 6pm on 1/1/24. This medication was only administered until 8am on 1/5/24. A full 5-day course would have to be taken until 8am on 1/6/24, meaning Individual #1 was not administered 2 doses of this medication. - A Medication Error was entered into the EIM system.
Individual #1 was prescribed Oseltamivir Phosphate on 1/14/24 to begin 1/15/24 in the morning. A Medication Error was entered into the EIM system.
Individual #1 wasn't administered this medication for the first time until 1/15/24 at 8pm. Individual #1 also was not administered their 8pm dose of this same medication on 1/16/24. A Medication Error was entered into the EIM system.
Individual #1 was not administered their 8am dose of Propranolol on 3/27/24. A Medication Error was entered into the EIM system.
Individual #1 was not administered their 6pm dose of Ziprasidone on 4/1/24 and their 6pm dose of Metformin on 4/7/24. A Medication Error was entered into the EIM system.
All staff will be given 2 extra observed medication pours over the next 90 days to ensure they are using the 15 steps of Medication Administration Training. The documentation sheets will be sent upon completion.
All staff will be retrained by 7/31/24 on reporting medication errors immediately to their supervisor. MARs will be checked by the Lead DSP each day that they work. The House Supervisor will check the MARs at least 2x/week and the Program Specialist will check the MARs 1x/week for the next 90 days.
A new MAR tracking system for Lead DSP's, House Supervisors, and the Program Specialist will be put into place. (Attachment # 54) The Director of Community Homes will train the Lead DSP's, House Supervisors, and the PS on using the tracking system by 7/31/24. Results will be reported to the Medication Administration Trainer and the EIM Representatives immediately so the errors can be entered into EIM within 72 hours. |
09/30/2024
| Implemented |
| 6400.181(f) | Individual #1's 8/8/23 assessment was not sent to their team. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The Program Specialist (#1) will be retrained in the requirements for sending assessments to the team by 7/31/24. Confirmation of the retraining will be sent upon completion. |
09/30/2024
| Not Implemented |
| 6400.186 | Individual #1's Individual Support Plan indicates that the Individual is to receive checks every 2 hours while sleeping to ensure their safety. There is no tracking in place to ensure these checks are being completed.
Individual #1 receives 1:1 Supplemental Habilitation from 8am to 9pm daily due to their worsening dementia. There were many times from 1/1/24 through 4/30/24 that this 1:1 coverage was not maintained during these hours:
· 1/1/24 -- 12:20pm - 5:32pm
· 1/2/24 -- 3:07pm - 3:13pm; 8:00am -- 8:03am
· 1/3/24 -- 8:00am - 8:15am
· 1/4/24 -- 8:00am - 8:05am
· 1/5/24 -- 8:00am - 8:10am
· 1/9/24 -- 8:00am - 8:05am; 3:11pm -- 313pm
· 1/10/24 -- 8:00am - 8:22am
· 1/11/24 -- 8:00am - 8:06am
· 1/13/24 -- 3:02pm -- 3:11pm
· 1/14/24 -- 8:00am -- 8:03am
· 1/16/24 -- 8:00am -- 8:05am
· 1/17/24 -- 8:00am -- 8:05am
· 1/18/24 -- 8:00am -- 8:15am
· 1/20/24 -- 3:08pm -- 3:12pm
· 1/21/24 -- 8:00am -- 806am
· 1/22/24 -- 2:58pm -- 3:14pm
· 1/24/24 -- 8:00am -- 8:18am
· 1/25/24 -- 8:00am -- 8:09am
· 1/26/24 -- 8:00am -- 8:10am
· 1/28/24 -- 8:00am -- 8:04am
· 1/30/24 -- 8:00am -- 8:15am
· 1/31/24 -- 3:06pm -- 3:11pm
· 2/1/24 -- 8:00am -- 8:13am
· 2/4/24 -- 8:00am -- 8:04am
· 2/6/24 -- 8:00am -- 8:13am
· 2/7/24 -- 8:00am -- 8:11am
· 2/8/24 -- 8:00am -- 8:26am
· 2/9/24 -- 8:00am -- 8:21am
· 2/12/24 -- 2:58pm -- 3:12pm
· 2/13/24 -- 8:00am -- 8:52am
· 2/14/24 -- 8:00am -- 8:05am; 12:25pm -- 3:04pm
· 2/15/24 -- 8:00am -- 8:08am
· 2/16/24 -- 8:00am -- 8:10am
· 2/20/24 -- 8:00am -- 8:08am
· 2/22/24 -- 8:00am -- 8:12am
· 2/23/24 -- 8:00am -- 8:41am
· 2/27/24 -- 8:00am -- 8:04am
· 2/28/24 -- 8:00am -- 8:06am; 3:07pm -- 3:11pm
· 2/29/24 -- 8:00am -- 8:20am
· 3/1/24 -- 8:00am -- 8:26am
· 3/5/24 -- 8:00am -- 8:16am
· 3/6/24 -- 8:00am -- 8:11am
· 3/7/24 -- 8:00am -- 9:20am
· 3/8/24 -- 8:00am -- 8:05am
· 3/10/24 -- 8:00am -- 8:14am
· 3/12/24 -- 8:00am -- 8:14am
· 3/14/24 -- 8:00am -- 8:08am
· 3/15/24 -- 8:00am -- 8:14am
· 3/19/24 -- 8:00am -- 8:13am
· 3/20/24 -- 8:00am -- 8:05am
· 3/21/24 -- 8:00am -- 8:19am
· 3/26/24 -- 8:00am -- 8:13am
· 3/29/24 -- 8:00am -- 8:07am
· 4/2/24 -- 8:00am -- 8:11am
· 4/4/24 -- 8:00am -- 8:08am
· 4/9/24 -- 8:00am -- 8:20am
· 4/10/24 -- 8:00am -- 8:05am
· 4/12/24 -- 8:00am -- 8:10am
· 4/14/24 -- 8:00am -- 8:13am
· 4/16/24 -- 8:00am -- 8:04am
· 4/17/24 -- 8:00am -- 8:06am
· 4/18/24 -- 8:00am -- 8:16am
· 4/19/24 -- 8:00am -- 8:05am
· 4/22/24 -- 5:13pm -- 5:55pm
· 4/25/24 -- 3:08pm -- 6:00pm
· 4/28/24 -- 8:00am -- 8:11am | The home shall implement the individual plan, including revisions. | The Program Specialist developed an overnight tracker for Individual number 1. The tracker will be placed in the service note binder. Staff will be trained on the overnight tracker by 7/14/24. Confirmation of the training will be sent upon completion.
The following dates and shifts were reviewed to examine time discrepancies.
· 1/1/24 -- 12:20pm - 5:32pm - Individual #1 was at their sisters for the holiday. - 12:30-5:30
· 1/2/24 -- 3:07pm - 3:13pm; 8:00am -- 8:03am; Staff member # 6 was late; Late clock-in - Staff member #8
· 1/3/24 -- 8:00am - 8:15am - Staff member #8 was late.
· 1/4/24 -- 8:00am - 8:05am - Staff member # 8 was late. Staff member #1 stayed over their shift by 6 minutes to cover the time lapse, even though they are not Sup-Hab.
· 1/5/24 -- 8:00am - 8:10am - Staff member # 8 was late.
· 1/9/24 -- 8:00am - 8:05am #8 was late; 3:11pm -- 313pm - #6 was late.
· 1/10/24 -- 8:00am - 8:22am - #8 was late.
· 1/11/24 -- 8:00am - 8:06am - #8 was late.
· 1/13/24 -- 3:02pm -- 3:11pm - #6 and # 7 simply switched services. They both worked doubles. Coverage never stopped. #6 was simply late clocking out of regular service and into Sup Hab Service.
· 1/14/24 -- 8:00am -- 8:03am - Clock in issue for #7
· 1/16/24 -- 8:00am -- 8:05am - Late clock in for # 8.
· 1/17/24 -- 8:00am -- 8:05am - Late clock in for #8.
· 1/18/24 -- 8:00am -- 8:15am - Late clock in for # 8.
· 1/20/24 -- 3:08pm -- 3:12pm - #6 and # 7 simply switched services. They both worked doubles. Coverage never stopped. #6 was simply late clocking out of regular service and into Sup Hab Service
· 1/21/24 -- 8:00am -- 8:06am - # 7 was late.
· 1/22/24 -- 2:58pm -- 3:14pm - # 7 clocked out early and # 6 clocked in late.
· 1/24/24 -- 8:00am -- 8:18am- # 8 was late.
· 1/25/24 -- 8:00am -- 8:09am - #8 was late.
· 1/26/24 -- 8:00am -- 8:10am - # 8 was late.
· 1/28/24 -- 8:00am -- 8:04am - #7 clocked in late.
· 1/30/24 -- 8:00am -- 8:15am - #8 was late.
· 1/31/24 -- 3:06pm -- 3:11pm - #6 was late.
· 2/1/24 -- 8:00am -- 8:13am - # 8 was late.
· 2/4/24 -- 8:00am -- 8:04am - # 7 clocked in late.
· 2/6/24 -- 8:00am -- 8:13am - # 8 clocked in late.
· 2/7/24 -- 8:00am -- 8:11am - # 8 clocked in late.
· 2/8/24 -- 8:00am -- 8:26am - # 8 clocked in late.
· 2/9/24 -- 8:00am -- 8:21am - # 8 clocked in late.
· 2/12/24 -- 2:58pm -- 3:12pm - #7 worked a double, switching from a regular shift to the Sup Hab shift. There was no break in coverage, #7 was just late switching.
· 2/13/24 -- 8:00am -- 8:52am - # 8 clocked in late.
· 2/14/24 -- 8:00am -- 8:05am - # 8 clocked in late.; 12:25pm -- 3:04pm - Individual # 1 went to lunch with their sister.
· 2/15/24 -- 8:00am -- 8:08am - # 8 clocked in late. Overnight shift stayed till 8:03.
· 2/16/24 -- 8:00am -- 8:10am - # 8 clocked in late.
· 2/20/24 -- 8:00am -- 8:08am - # 8 clocked in late.
· 2/22/24 -- 8:00am -- 8:12am - # 8 clocked in late.
· 2/23/24 -- 8:00am -- 8:41am - # 8 clocked in late.
· 2/27/24 -- 8:00am -- 8:04am =# 8 clocked in late.
· 2/28/24 -- 8:00am -- 8:06am -# 8 switched from regular overnight shift straight into Sup Hab - there was no break in coverage, just late switching services; 3:07pm - 3:11pm - #7 clocked in late. Staff #4 stayed to cover the Sup Hab till 3:16. The service was not switched on the schedule.
· 2/29/24 -- 8:00am -- 8:20am - # 8 clocked in late.
· 3/1/24 -- 8:00am -- 8:26am - # 8 clocked in late.
· 3/5/24 -- 8:00am -- 8:16am - # 8 clocked in late.
· 3/6/24 -- 8:00am -- 8:11am - # 8 switched from regular overnight shift straight into Sup Hab - there was no break in coverage, just late switching services
· 3/7/24 -- 8:00am -- 9:20am - Supervisor covered this part of the shift but they clocked in under Admin Shift.
· 3/8/24 -- 8:00am -- 8:05am -# 8 clocked in late.
· 3/10/24 -- 8:00am -- 8:14am - #7 clocked in late.
· 3/12/24 -- 8:00am -- 8:14am - # 8 clocked in late.
· 3/14/24 -- 8:00am -- 8:08am - # 8 clocked in late.
· 3/15/24 -- 8:00am -- 8:14am - # 8 clocked in late.
· 3/19/24 -- 8:00am -- 8:13am - # 8 clocked in late.
· 3/20/24 -- 8:00am -- 8:05am - # 8 clocked in late.
· 3/21/24 -- 8:00am -- 8:19am - # 8 clocked in late.
· 3/26/24 -- 8:00am -- 8:13am - # 8 clocked in late.
· 3/29/24 -- 8:00am -- 8:07am - # 8 clocked in late.
· 4/2/24 -- 8:00am -- 8:11am - # 8 clocked in late.
· 4/4/24 -- 8:00am -- 8:08am - # 8 clocked in late.
· 4/9/24 -- 8:00am -- 8:20am - # 8 clocked in late.
· 4/10/24 -- 8:00am -- 8:05am - # 8 clocked in late.
· 4/12/24 -- 8:00am -- 8:10am - # 8 clocked in late.
· 4/14/24 -- 8:00am -- 8:13am - #7 clocked in late.
· 4/16/24 -- 8:00am -- 8:04am - # 8 clocked in late.
· 4/17/24 -- 8:00am -- 8:06am - # 8 clocked in late.
· 4/18/24 -- 8:00am -- 8:16am - # 8 clocked in late.
· 4/19/24 -- 8:00am -- 8:05am - # 8 clocked in late.
· 4/22/24 -- 5:13pm -- 5:55pm - #7 clocked in late.
· 4/25/24 -- 3:08pm -- 6:00pm - Individual #1's housemate went out with family. Staff # 13 who was on the regular shift stayed on for Sup Hab but the schedule does not reflect this. Staff # 6 came on a 6:00 - Sup Hab for double coverage.
· 4/28/24 -- 8:00am -- 8:11am - Staff # 6 worked the regular overnight shift and went into the morning Sup Hab shift. No break in coverage, just a late clock-in for the shift.
If a staff member who is working a regular shift and stays over to cover the Sup Hab, administration will amend the schedule to reflect the Sup Hab hours on their time.
After careful review there is one staff (# 8) who will receive disciplinary action for their tardiness to start shift.
All staff will be trained by 7/31/24 on the importance of remembering to clock in and out at the correct time. In addition, training on the different funding sources and how clock in (outs) affect the individual's care will be emphasized. Training confirmation will be sent upon completion.
All staff will be trained on this POC by 8/2/24. |
08/16/2024
| Implemented |
| Article X.1007 | Apex Healthcare Services is required to maintain criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff person #13 was hired on 2/20/24 and first worked with individuals on 3/7/24. A Pennsylvania State Police criminal history check was not initiated until 3/13/24. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | As soon as it was realized that Staff # 13 did not have a PA Criminal History check, it was completed. (Attachment # 51) The late Criminal check is noted on the Self Assessment dated 3/15/24. (Attachment # 52) |
06/28/2024
| Implemented |