| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(a) | Individual #1 is unable to manage any amount of funds and required total assistance from staff and a representative payee. The individual goes into the community with hired, direct support staff from another agency. On 7/19/23 the individual's written monthly financial record and receipts show a credit card was used three times to purchase $8.21 total, from three different locations. The records indicate the purchases were made when Individual #1 was in the community with their staff from another agency.
It's reported to the Department during the 7/27/23 inspection, the home used Individual #1's funds to reimburse the staff for using their card to purchase items when out in the community. The agency's, MaxCare HCBS LLC, financial and property record policy does not include how the home is to protect and adequately account for the individual's funds when a staff outside their agency is requesting to be reimbursed from Individual #1's account. The policy does not include how the agency is going to adequately account for individual's funds if the home provides cash to an outside agency's staff when working with the individual outside the home. | There shall be a written policy that establishes procedures for the protection and adequate accounting of individual funds and property and for counseling the individual concerning the use of funds and property. | The agency's financial policy has been updated to reflect the proper procedure to protect all individual funds (See Attachment 1). |
08/31/2023
| Implemented |
| 6400.22(d)(1) | Individual #1's record includes a handwritten receipt attached to the December 2022 "Participant Monthly Account" for "Coats (B)" and "Soda" for a total amount of "$4.60", however, this expense is not dated or addressed in the financial record. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | Program Specialist and Director have verified that the receipt was not to be part of the individual's records and as such it has been removed 8/7/2023. The individual's record indicates that all of their funds have been accounted for and nothing is missing. All staff members working in the program and other homes will be retrained on the need to ensure the accuracy and reporting of individuals funds, as well as the need to not comingle funds and receipts. |
08/31/2023
| Not Implemented |
| 6400.43(b)(1) | The home's financial policy for the protection of individual's funds states for all cash received in the home, the individual's cash on hand record must include: the date, the payer and descriptions, amount received, check number, balance after the addition, and the staff making the balance. Individual #1's representative payee provided monthly, cash spending to the individual's home cash account, per the home's report. The home only documents the date of the transaction, "deposit" as the description, the amount deposited, and the staff making the entry. The home does not record the payer or description of the deposit being cash. For example, written on the individual's monthly cash records was: "deposit 100.00" on 5/25/23, 3/25/23, and once in July 2023. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | The Cash on Hand form (See Attachment 2) has been updated to excel format and shared with the Program Specialist and Director. All residential habilitation staff will be retrained on the financial policy and process to document financial information on this report form by 8/31/23. |
08/31/2023
| Implemented |
| 6400.43(b)(4) | As referenced in Article X.1007 (OAPSA) of this report, the agency, MaxCare HCBS LLC, failed to meet compliance with § 6400.21(a) and (b). At the time of the 7/25/23 annual inspection, the agency did not request an application for a Pennsylvania criminal history record check for any of their employees or receive records from the employees of their residence over the previous 2 years to determine if an FBI criminal history record check is needed.
Staff person #4's date of hire is 11/21/22 and their 11/18/22 physical examination record did not record the results of their Tuberculin skin test by Mantoux method. The agency failed to obtain the results of the Tuberculin skin test upon staff's date of hire and did not request the results until 7/25/23. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Compliance with this chapter. | Pennsylvania State Police background checks were conducted for all current employees on 7/25/23 and results obtained by 7/27/23 (See Attachment 3). A New Hire Checklist has been updated and will be reviewed for completion before all staff members can attend orientation (See Attachment 4). The results were received from Concentra on 7/25/23 and indicated negative result was read on 11/21/22. Going forward, the New Hire Checklist will be used to ensure all records have been reviewed prior to orientation. |
08/31/2023
| Not Implemented |
| 6400.61(a) | During the 7/27/23 onsite fire drill, Individuals #1 and #2 required physical assistance to ambulate out the threshold of the home. The threshold dropped approximately 3-4 inches from the floor level. The individual's held onto staff and the door frame to steady themselves to evacuate safely. Individual #1 stood in the living room not responding to the alarm but laughing. It was unclear if they could hear the alarm or if they did not know how to respond to the alarm. Individuals #1 and #2 did not respond to an overnight fire drill held at their previous residence within the last 6 months.
The home is not equipped with bed shakers, strobe lights, and the individual's do not have personal body devices to use to alert them in the event of an emergency. | A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. | Individual #1 can hear the alarm however, due to cognitive decline, needs verbal prompts and directions to evacuate the home. Due to the physical limitations, they require physical assistance to transition out of the home. A weather and skid resistant transition ramp has been purchased for the site to aid in transitioning out of the home. Strobe lights have been purchased as of 8/7/23 to aid in visually recognizing when the fire alarm is sounding (See Attachment 5). The Director will follow up to ensure installation of the strobe lights. The agency is in the process of researching and acquiring bed shaker(s) to install to support individuals while sleeping to recognize the alarm. Contact has been made with Summit Fire & Security to discuss the appropriate system. The house has an awake overnight staff member who does regular checks throughout the night to ensure that the individuals are safe and will be able to guide them to evacuate safely in the event of a fire. |
08/31/2023
| Implemented |
| 6400.61(b) | According to Individual #1's current, 6/26/2023 individual support plan, onsite staff reports during the 7/25/23 inspection, and fire drill records the individual participated in since their date of admission, Individual #1 refuses to evacuate the home, requires verbal and physical assistance to evacuate the home, and neither individual responded to an overnight fire drill when held at their previous residence. The current home is not equipped with strobe lights or bed shakers to ensure the individuals are notified in the event of an emergency.
During the 7/27/23 onsite fire drill, Individuals #1 and #2 required physical assistance to ambulate out the threshold of the home. The threshold dropped approximately 3-4 inches from the floor level. The individual's held onto staff and the door frame to steady themselves to evacuate safely. Individual #1 stood in the living room not responding to the alarm but laughing. It was unclear if they could hear the alarm or if they did not know how to respond to the alarm. Walking about the home and outside the home, Individual #1 shuffled their feet slowly, inches themselves forward a few inches at a time. When the individual was close enough to a wall, surface, or another person present during the inspection, they reached out to hold onto the surface or person.
Individual #1's current, 6/26/2023 individual support plan states the individual has a history of falls. They fell and broke their right hip in the fall of 2020. They fell and broke their left hip on 3/13/21. They dislocated their left hip while healing from the fracture and fell down a flight of stairs on 4/30/22. They use handrails for support when on steps. Their legal guardian reports concerns for the individual's memory and hearing loss. Their memory is continuing to decline, and their legal guardian is concerned for signs of dementia. Their balance is unsteady. At the time of the 7/25/23 inspection the home had not reviewed the history of falls or ambulation concerns with the individual's physician(s). They have not had a fall assessment or fall risk assessment completed for the individual and did not have any adaptive equipment in the home to assist with the individual safely getting into and out of the bathtub/shower combination. The individual's plans state the home is going to work with the family to create a shower schedule or plan to assist with getting the individual to shower regularly. Currently, the individual's shower schedule is unknown, the home doesn't have a shower schedule or plan, and is not tracking the individual's shower habits. The home reports there was an attempt at using a shower chair, however it is unknown if this was the appropriate size or recommendation to use from the individual's physicians. The bathtub/shower combination was more than 12 inches to step over to shower.
The individual had difficulties stepping down out of the threshold of their home which was approximately 3-4 inches difference.
Individual #1's current medical records state they have vision difficulties, severe hearing loss, and has hearing aids. It is unknown where the individual's hearing aids are located, if they wear them, or if their ears are clean and free of cerumen impaction to use their hearing aids. | A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have adaptive equipment necessary for the individuals to move about and function at the home. | Individual #1 can hear the alarm as evidenced by the individual visually covering their ears when the alarm sounds. They are hard of hearing and have been prescribed hearing aids which they refuse to wear. Due to this and their cognitive decline, Individual #1 requires verbal prompts and directions to evacuate the home safely.
Due to their physical limitations, they require physical assistance to transition out of the home. A weather and skid resistant transition ramp has been ordered for the site to aid in transitioning out of the home (see attachment 6). Strobe lights have been ordered as of 8/7/23 to aid in visually recognizing when the fire alarm is sounding (See Attachment 5). The Director will follow up to ensure installation of these items by 8/15/23. The agency is in the process of researching and acquiring bed shaker(s) to install to support individuals while sleeping to recognize the alarm. Contact has been made with Summit Fire & Security to discuss the appropriate system. The house has an awake overnight staff member who does regular checks throughout the night to ensure that the individuals are safe and will be able to guide them to evacuate safely in the event of a fire.
Individual #1 was seen by their Primary Care Physician on 8/8/23 and concerns related to fall-risk and hearing difficulty were addressed. The PCP will be sending referral for the individual to be assessed by a physical therapist in relation to the fall risk.
Individual #1 was seen by ENT on 8/4/23 in which tubes were placed in their ears.
A HCQU request has been submitted as of 7/27/23 for possible assessment and training of staff members with respect as to how to best support this individual. |
08/31/2023
| Implemented |
| 6400.64(a) | The washcloth available to Individual #2 in their shower was a "white" washcloth. However, the entire cloth was covered in dark brown matter. It is unclear how long the soiled and stained washcloth has been used and the last time it was laundered.
Individual #2's toilet seat contained brown smears on the back of the toilet seat.
The floor in front of Individual #2's toilet had dried matter stuck to the floor that appeared to be dried urine. | Clean and sanitary conditions shall be maintained in the home. | The soiled washcloth was discarded on 7/27/23 and replaced with a clean one (See attachment 7). The toilet and floor were cleaned by the Residential Site Supervisor upon inspection on 7/27/23. |
08/31/2023
| Not Implemented |
| 6400.67(b) | The entire lint trap, approximately 4 inches by twelve inches, was covered with lint. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The lint was removed during the licensing inspection 7/27/23. |
08/31/2023
| Implemented |
| 6400.71 | The telephone number to the nearest hospital was not located on or near the telephone in the living room and staff office. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| Information has been affixed to all phones at each site location. |
08/31/2023
| Implemented |
| 6400.103 | At the time of the 7/25/23 inspection, the home did not have a written emergency evacuation procedure that included individual and staff responsibilities, means of transportation and an emergency shelter location for the home. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The Emergency Evacuation Procedures Plan has been updated as of 8/7/23 for each individual receiving residential services through MaxCare HCBS LLC (See Attachment 8). The Program Specialist will review the plans with the individuals and train all staff on the plans by 8/31/23. |
08/31/2023
| Not Implemented |
| 6400.104 | Individuals #1 and #2 moved into the home on 7/8/23. At the time of the 7/25/23 inspection, the home has not notified the local fire department of the individual's needs with evacuation or the location of their bedrooms. The home sent a letter to the local fire department on 6/12/23 notifying them that individuals will be moving into the home and when they do, the fire department will be sent information about their needs and location of their bedroom. The home did submit another letter on 7/7/23 stating the individual's moved into the home but only need verbal assistance and did not indicate the location of their bedrooms. During the 7/27/23 drill held at the home, both Individuals #1 and #2 required physical assistance to evacuation the home, and Individual #1 stood in the living room not responding to the alarm but laughing. It was unclear if they could hear the alarm or if they did not know how to respond to the alarm.
According to Individual #1's individual support plan, staff interviews onsite, and fire drill records from another agency (MaxCare HCBS LLC) home they previously resided in, Individual #1 refuses to evacuate the home, requires verbal and physical assistance, and neither individual responded to an overnight fire drill when held at their previous residence. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| The letter to the fire department has been updated to reflect the specific needs of each individual in order to safely evacuate the home. The floor plan that is attached to the notification indicates the exact bedroom location of each individual. Copies were mailed to the associated fire departments 8/7/23. |
08/31/2023
| Implemented |
| 6400.113(a) | Individuals #1 and #2 moved into the home on 7/8/23. At the time of the 7/25/23 inspection, they did not receive training on general fire safety, evacuation procedures, responsibilities during a fire, the designated meeting plan, and smoking safety procedures specific to the home. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | A Fire Safety Training was completed for Individuals #1 and #2 on 7/10/23 (See Attachment 8B). This was still late and as such, a New Admission Checklist has been created to ensure all required trainings are completed during admission, including the Fire Safety Training (See Attachment 8). The Residential Site Supervisor will be trained on the checklist as well as what is required to be completed prior to an individual moving into a home. |
08/31/2023
| Implemented |
| 6400.141(a) | Individual #1 moved into the home on 10/27/22. They did not receive a physical examination until 12/1/22. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | MaxCare HCBS LLC Annual Physical form has been updated to meet the regulatory requirements. All new admissions will be required to have this form completed prior to admission. The Director and/or Program Specialist will review to ensure compliance. If the information presented is not compliant, the Program Specialist will work with the individual's team to have the form corrected. Admission into the residential program will be postponed until the document is satisfactory. |
08/31/2023
| Implemented |
| 6400.141(c)(1) | Individual #1's 12/1/22 physical examination record did not document if the physician reviewed the individual's lifetime medical history. The physical examination record documented a lifetime medical history document was attached. However, it was not attached. The home did create a lifetime medical history document on 12/6/22, but there are no records if this was reviewed and approved by the individual's physician after creation. | The physical examination shall include: A review of previous medical history. | Individual #1 has an appointment with their primary care physician on 8/8/23 in which the Lifetime Medical History will be reviewed. |
08/31/2023
| Implemented |
| 6400.141(c)(11) | Individual #1's 12/1/22 physical examination record did not include health maintenance needs. This field is left blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | An appointment has been scheduled with Individual #1's primary care physician on 8/8/23 for the physician to provide recommendation on Health Maintenance Needs. Recommendations will be attached to Individual #1 annual physical and staff members will be trained accordingly. |
08/31/2023
| Not Implemented |
| 6400.141(c)(12) | Individual #1's 12/1/22 physical examination record did not include a review of their physical limitations. This field is left blank. | The physical examination shall include: Physical limitations of the individual. | An appointment has been scheduled with Individual #1's primary care physician for the physician to provide recommendation on their physical limitations. Recommendations will be attached to Individual #1 annual physical and staff members will be trained accordingly. |
08/31/2023
| Not Implemented |
| 6400.141(c)(14) | Individual #1's 12/1/22 physical examination record did not include a review of information pertinent to diagnosis in case of an emergency. A field to record pertinent information was not included on the examination record. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | An appointment has been scheduled with Individual #1's primary care physician on 8/8/23 for the physician to provide recommendation on supporting the individual in case of an emergency. Recommendations will be attached to Individual #1 annual physical and staff members will be trained accordingly. |
08/31/2023
| Not Implemented |
| 6400.141(c)(15) | Individual #1's 12/1/22 physical examination record did not include their dietary needs. A field to indicate this information was not included on the examination record. | The physical examination shall include:Special instructions for the individual's diet. | An appointment has been scheduled with Individual #1's primary care physician on 8/8/23 for the physician to provide recommendation on their dietary needs. Recommendations will be attached to Individual #1 annual physical and staff members will be trained accordingly. |
08/31/2023
| Implemented |
| 6400.143(a) | Individual #1 refused medications on a few occasions (for example: 11/3/22, 11/5/22, 11/7/22, 11/10/22, 11/30/22), refused a prostate exam on 12/1/22, refused an echocardiogram on 5/31/23, refused two EKG's, and the home does not have documentation of retraining in the need to complete the health services as ordered and prescribed, or a plan to continue to discuss the need to complete health services as ordered with the individual. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | A refusal plan form (See Attachment 9) has been developed and the Program Specialist is completing a plan for each type of event that has been refused. Staff members will be re-trained to complete the progress notes for the refusal plan by 8/31/23.
The nurse will follow up with the individual's prescriber to discuss the refusal of the medication and determine the best course of action. The nurse will document the conversation on a Telephone Conversation Record and review the information with all staff who administer medications at the site by 8/31/23. |
08/31/2023
| Implemented |
| 6400.144 | The home failed to provide the following health services to the individual as ordered:
On 12/9/22 Individual #1's dentist scheduled a follow up cleaning and examination to be completed on 6/13/23. At the time of the 7/25/23 inspection, the individual did not have a cleaning or examination by their dentist.
On 3/24/23 the individual's dentist recorded a note stating, "due to patients condition they are not able to open their mouth to examine." It was recommended the home take the individual to a dental office where the individual can be sedated. There are no records why the home attempted to have Individual #1 examined by a dentist on 3/24/23, why the individual was unable to open their mouth, or that the home has attempted to follow up with oral heath care as ordered for the individual.
The individual requires assistance to brush and floss their teeth 2-3 times daily. The home did not produce records that they are assisting the individual with brushing and flossing 2-3 times daily. During the 7/27/23 Individual #1's teeth and skin around the outside of their mouth, were covered in a brown, dried substance. It was unclear how long this was on their mouth or what the substance was.
On 2/9/23 Individual #1's podiatrist stated the individual was seen due to pain in left and right toes, and routine debriding. The individual was instructed to call the podiatrist office when their nails are painful, use topical moisturizers and creams to feet, use over the counter antifungal spray or powder to feet, and use rubbing alcohol to the interspaces daily. There are no records the home is completing the podiatrist's daily creams, moisturizers, antifungal spray, rubbing alcohol, or reporting and documenting when/if the individual is having pain in their feet.
The individual was scheduled to have a follow up podiatry appointment on 4/20/23. The individual wasn't seen for routine podiatric care until 5/19/23. There's no record why the appointment on 4/20/23 was missed, or if the appointment on 5/19/23 was the earliest appointment available if that's when it was rescheduled.
On 5/19/23 their podiatrist again stated the individual is to call the podiatrist office when their nails are painful, use topical moisturizers and creams to feet, use over the counter antifungal spray or powder to feet, and use rubbing alcohol to the interspaces daily. There are no records the home is completing the podiatrist's daily creams, moisturizers, antifungal spray, rubbing alcohol, or reporting and documenting when/if the individual is having pain in their feet.
On 11/16/22 the individual's physician ordered a DEXA scan and laboratory blood work: T4 Free and TSH to be completed by or around 1/26/23, and CMP and Vitamin D hydroxy panel by or around 1/27/23. Their record does not include the DEXA scan, or the results if a DEXA scan was completed. Their record documents they did not complete a CMP, Vitamin D25 hydroxy panel, T4, and TSH until 2/6/23.
On 12/27/22 Individual #1's primary care physician ordered Debrox ear drops, 5 drops twice daily for 7 days due to cerumen impaction and is to follow up with their ENT (Ear Nose Throat specialist). There are no records the home administered Debrox. There are no records that the home followed up with the individual's ENT until 2/15/23.
On 2/15/23 the ENT reported the individual's right ear still needs flushed. Staff documented a note on 2/15/23 stating, "{the individual} went to get ears flushed at the audiologist and to get new hearing aids. The physician explained that they are able to wear their hearing aids now." During the onsite Individual #1 did not have their hearing aids, was not wearing them, it's unknown if the individual was provided hearing aids after their 2/15/23 appointment, nor did staff know where the hearing aids were. It is unknown if the individual is wearing them or refusing to wear them.
On 3/3/23 the individual's ENT ordered Debrox drops due to cerumen impaction and is to return on 5/5/23. The individual did not return until 6/2/23 with no record why the appointment was late.
On 6/2/23 the ENT physician documented the individual had right impacted cerumen, bilateral cerumen, there was a decline in speech awareness, tube placement in OR was recommended, there is hearing loss, and the individual is to continue weekly debrox in both ears (5 drops each side) until the procedure. There are no records Debrox was administered as ordered or if the individual has a schedule tube placement appointment. The individual's June 2023 medication administration record (mar) did not record the same order as the physician's written order on 6/2/23. However, no administration of debrox was recorded on the mar. There are no records that the individual's legal guardians were contacted about the physician's recommendations to have a procedure completed in the operating room on Individual #1 and their wishes to proceed or not proceed.
On 3/6/23 the individual was seen by central pa surgery due to being referred for a posterior neck cyst. This record documents the individual needs to be scheduled to have the cyst excised. On 3/23/23 the surgery was not completed on this date due to the individual eating chocolate, per the agency nurse. This same note made by the agency nurse also documents, "appointment was cancelled due to the family declining to have surgery done on the individual." However, the home does not have the date this was made in the record, or written records from the legal guardians of what they were declining to have completed for Individual #1 and when they declined the procedure(s). The home also doesn't have documentation of how the individual was to prepare for surgery on 3/23/23 to ensure that they could have surgery on this day if they wanted it done. There isn't record that the legal guardians were contacted about their wishes for Individual #1's cyst removal surgery prior to the 3/23/23 date of when surgery was scheduled. It was also reported to the Department that the individual didn't eat chocolate on 3/23/23 but it's what their mouth looked like due to chewing their medications that morning.
The agency reports that the individual is being seen by a cardiologist. The individual's records do not record any records of the appointments, diagnosis, or orders from the cardiologist. There is a record on 5/31/23 that the individual refused treatment of an echocardiogram. There aren't records of completion of a refusal of treatment plan or retraining on the need to complete health services recommended for them. | 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.
| The agency has a nurse that is responsible to coordinate all health care services for all of the individuals supported. The CEO and the Director will meet with the agency nurse and the Program Specialist on 8/23/23 to train them on how to best coordinate and ensure that recommended services are provided to the individuals. The training will include the use of the newly subscribed EHR Therap to record and track appointment due dates as well as how to review appointment forms for recommended treatments after each appointment.
The Program Specialist will supervise the agency nurse to ensure that the services prescribed or planned for the individual are arranged, coordinated, and provided as prescribed. At least monthly, the Program Specialist and Director will review all appointments completed for each individual and ensure that no appointment was missed as well as each recommendation by the healthcare provider is duly provided.
With respect to appointments that were missed prior to the July 25, 2023, inspection,
-The Director is in the process of working with Individual #1's insurance to locate a dental provider that can perform the dental cleaning for the individual under sedation.
-The Program Specialist will update the dental plan for individuals to address the recommended care and assistance required for oral hygiene as indicated by the dentist by 8/31/23.
-Available documents indicate the guardians were contacted to provide consent to the procedure and provided consent for the procedure.
-The Program Specialist will utilize a Consent for Treatment form and discuss upcoming recommended procedures with the Legal Guardians to obtain consent or declination. The form will be maintained in the individuals' site file affixed to the corresponding medical appointment record.
-The agency has subscribed to Therap and staff are being trained on how to use it to complete tasks including documentation of care such as podiatric care. Once training is completed, Residential Site Supervisors and Program Specialist will review the home's daily documentation to ensure that all of the recommended care is being provided and documented accordingly. |
08/31/2023
| Not Implemented |
| 6400.145(3) | At the time of the 7/25/23 inspection, the home did not have a written emergency medical plan that included an emergency staffing plan. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | The Program Specialist has created an Emergency Medical Plan (Attachment 11) that includes the emergency staffing plan as of 8/8/2023. The Program Specialist is reviewing the record of all individuals supported by the agency to ensure that all have an Emergency Medical Plan. The Program Specialist will train all staff on the written plan by 8/31/2023. |
08/31/2023
| Implemented |
| 6400.151(a) | Staff person #2's date of hire is 10/24/22 and they did not receive a physical examination until 10/27/22. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The Director has reviewed all employee records, and all have a physical examination. The agency policy and ODP regulations regarding staff physical will be reviewed with all staff, Program Specialist and nurse by 8/31/23. |
08/31/2023
| Not Implemented |
| 6400.151(b) | Staff person #3's 8/18/22 physical examination record was not completed, signed, or dated by a licensed physician or another qualified medical professional. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | The agency has an Employee Physical form (Attachment 13) that has been developed and will be used for all initial and biannual physicals going forward. It is specified on the form who can complete the physical for the staff members, and the Director will work with Concentra (contracted vendor) to ensure that the regulatory requirements are being met. The Director has reviewed all employee records, and all have a physical examination. The agency policy and ODP regulations regarding staff physical will be reviewed with all staff, Program Specialist and nurse by 8/31/23. |
08/31/2023
| Implemented |
| 6400.151(c)(2) | Staff person #2's date of hire is 10/24/22 and they did not receive a Tuberculin skin test by Mantoux method with negative results until 10/31/22. Additionally, the record does not state the medical license qualifications of the person who read Staff person #2's Tuberculin skin test results on 10/31/22.
Staff person #3's Tuberculin skin test was read negative on 3/1/22. However, the record did not indicate the medical qualifications of the person who read the test. The Tuberculin skin test and the results were not included on their 8/18/22 physical examination record.
Staff person #5's Tuberculin skin test was read negative on 6/8/23, but an RT (radiology technician). There are no records that a registered nurse, licensed practical nurse, licensed physician, licensed physician's assistance or certified nurse practitioner reviewed the record and approved of the results. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The Director will contact the medical provider to ensure the documentation is accurate and results provided by the correctly certified personnel. The Director will indicate on the authorization form that a LPN, RN, Doctor, or PA-C must review the TB results. The agency policy and ODP regulations regarding staff physical will be reviewed with all staff, Program Specialist and nurse by 8/31/23. |
09/30/2023
| Not Implemented |
| 6400.151(c)(3) | Staff person #3's 8/18/22 physical examination record did not include if the physician reviewed if the staff had any communicable diseases and the precautions to take to prevent the spread, or if the staff was free of communicable diseases. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | The Director is going to ensure that new hires are using the agency staff physical examination form for all of their physical examinations (new hire and bi-annual). has been reviewing all physical screening forms that have been submitted and are returning incomplete forms for correction for them to be completed properly. The agency policy and ODP regulations regarding staff physical will be reviewed with all staff, Program Specialist and nurse by 8/31/23. |
08/31/2023
| Implemented |
| 6400.151(c)(4) | Staff person #3's 8/18/22 physical examination record did not include if the physician reviewed if the staff had any medical problems that would interfere with provisions of service being rendered to individuals. | The physical examination shall include: Information of medical problems which might interfere with the health of the individuals. | The Director has reviewed all employee records, and all have a physical examination. Moving forward, the Director will ensure that all physicals are completed on the Employee Physical Form (See Attachment 13). The agency policy and ODP regulations regarding staff physical will be reviewed with all staff, Program Specialist and nurse by 8/31/23. All new hires will be required to complete the physical examination prior to their scheduled orientation date. |
08/31/2023
| Implemented |
| 6400.171 | A circle, crustable, sandwich that was cut in half was uncovered on a used plate in the refrigerator. The sandwich was not protected from contamination or labeled with whom the sandwich belonged to.
Two halves of watermelon were stored in the refrigerator mostly covered with tin foil. However, some of the tin foil was curled up exposing the fruit flesh. | Food shall be protected from contamination while being stored, prepared, transported and served.
| The food items noted on the 7/27/23 inspection have been discarded. The Program Specialist and Residential Site Supervisor during their visit to the homes will ensure that food items are properly stored. The Director, Program Specialist,and agency nurse are developing a training that will be offered to all staff members and Residential Site Supervisors by 8/31/23 regarding the USDA guidelines for food safety. |
08/31/2023
| Implemented |
| 6400.181(d) | Individual #1's 12/12/22 assessment wasn't dated by the program specialist. The program specialist did sign the assessment. However, all dates of completion recorded on the assessment were typed onto the document. The document wasn't created using a secure system that time stamps the assessment when it is created and signed by the program specialist.
Individual #1's 12/12/22 assessment wasn't created by the program specialist. The document states the home supervisor (direct support staff without qualifications of a program specialist) created the assessment. The supervisor signed the document. The date they created the document was typed on the document. Again, the program used to create the document wasn't a secure system that electronically populated the date when it was created by the supervisor. | The program specialist shall sign and date the assessment. | The Residential Assessment Template has been updated as of 8/2/23 (See Attachment 14) and the Program Specialist is working to complete the updated assessments for all of the individuals supported by the agency by 8/31/23. |
08/31/2023
| Implemented |
| 6400.181(e)(4) | Individual #1's current, 12/12/22 assessment does not clarify their supervision needs. The assessment states they require an awake overnight staff and a sleep overnight staff. The home is not staffed at a ratio that would have two staff at night for the individual's needs, plus additional staff at night for their housemate's needs. The assessment states that at home Individual #1 may remain on the property alone with staff on the premises for 15 minutes. Then the assessment states the individual may be able to watch tv or in their room while staff do outdoor chores for 2 hours. This discrepancy is never rectified. | The assessment must include the following information: The individual's need for supervision.
| The Program Specialist has clarified the supervision needs for Individual #1 and emailed the Supports Coordinator to update the ISP (See Attachment 15).
The Program Specialist will retrain all staff on Individual #1's supervision care needs as well as update the Individual's assessment using the updated Residential Assessment Template by 8/31/2023. |
08/31/2023
| Implemented |
| 6400.181(e)(5) | Individual #1's current, 12/12/22 assessment states the individual can not recognize and distinguish their medication, doesn't know the prescribed amount of medication to take, doesn't know when to take their medication, cannot identify what could happen if too much or too little medication is taken, only requires gestural prompts to complete these medication administration tasks, can't identify purpose of medications, and they can safely and independently take over the counter medications. The last statement vastly contradicts the individual's purported abilities with medication administration. The home reports the individual requires total assistance with all medication management. | The assessment must include the following information: The individual's ability to self-administer medications. | The Program Specialist has emailed the Supports Coordinator with the updated information to update the Individual's ISP with respect to the Individual's awareness and competency with medication and medication administration (See Attachment 15). The staff will be trained on the updated information regarding the individual by 8/31/23. |
08/31/2023
| Not Implemented |
| 6400.181(e)(8) | Individual #1's current, 12/12/22 assessment states they independently respond to fire alarms and evacuate the home. However, the individual refused to evacuate their home multiple times during many fire drills over a 6-month time frame, required verbal assistance if they evacuate, and did not respond to the fire alarm on one occasion.
During the 7/27/23 onsite fire drill, Individuals #1 required physical assistance to ambulate out the threshold of the home. The threshold dropped approximately 3-4 inches from the floor level. The individual held onto staff and the door frame to steady themselves to evacuate safely. Before staff intervened to assist Individual #1 to the threshold of the home, Individual #1 stood in the living room not responding to the alarm but laughing. It was unclear if they could hear the alarm or if they did not know how to respond to the alarm. | The assessment must include the following information: The individual's ability to evacuate in the event of a fire. | Individual #1 was relocated to their new home from the previous residence due to concerns with their abilities to evacuate during fire drills.
Individual #1 can hear the alarm as evidenced by them visually covering their ears when the alarm sounds. They are hard of hearing and have been prescribed hearing aids which they refuse to wear. Due to this and their cognitive decline, Individual #1 requires verbal prompts and directions to evacuate the home safely.
Due to the physical limitations, they require physical assistance to transition out of the home. A weather and skid resistant transition ramp has been ordered for the site to aid in transitioning out of the home (see attachment 6). Strobe lights have been ordered as of 8/7/23 to aid in visually recognizing when the fire alarm is sounding (See Attachment 5). The Director will follow up to ensure installation of these items by 8/15/23. The agency is in the process of researching and acquiring bed shaker(s) to install to support individuals while sleeping to recognize the alarm. Contact has been made with Summit Fire & Security to discuss the appropriate system. The house has an awake overnight staff member who does regular checks throughout the night to ensure that the individuals are safe and will be able to guide them to evacuate safely in the event of a fire.
Individual #1 was seen by their Primary Care Physician on 8/8/23 and concerns related to fall-risk and hearing difficulty were addressed. The PCP will be sending referral for the individual to be assessed by a physical therapist in relation to the fall risk.
Individual #1 was seen by ENT on 8/4/23 in which tubes were placed in their ears.
A HCQU request has been submitted as of 7/27/23 for possible assessment and training of staff members with respect as to how to best support this individual.
Individual #1 Residential Assessment will be updated by the Program Specialist with any recommendations made. |
08/31/2023
| Implemented |
| 6400.181(e)(9) | Individual #1's medical records lists diagnosis of vitreous degeneration of right eye, retinal pigment epithelial mottling of macula, isotropic right eye, dry eye syndrome, presence of intraocular lens, presbyopia, atrial septal defect, bilateral impacted cerumen, cataracts bilateral, closed fracture of left olecranon process, closed fracture of left proximal humerus, down syndrome, eustachian tube dysfunction, gout, heart murmur, hyperlipidemia, hyperopia, hypothyroid, has a posterior neck cyst, anemia due to vitamin b12 deficiency, age-related osteoporosis with current pathological fracture with routine healing, hip dislocation, closed right hip fracture, closed left hip fracture, mood disorder, down syndrome, hypothyroidism, indigestion, insomnia, has severe vision and hearing loss, has ambulation difficulties, their legal guardians have reported their concerns for the individual's hearing and memory loss, has hearing aids, uses handrails on steps, has an unsteady gait, has fallen down a flight of stairs in the last year, and did not respond to a fire drill at their previous residence.
The individual's current, 12/12/22 assessment states the individual has no medical or functional limitations, is not visually or hearing impaired, does not use adaptive equipment, and is diagnosed with down syndrome, hypothyroidism, indigestion, insomnia, and postnasal drip. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | The Residential Assessment Template has been updated to include the following areas to be documented: the individual's disability, including functional and medical limitations. The Program Specialist will interview the agency nurse regarding the individual's diagnoses, current and recommended treatment plans when completing the updated Residential Assessment for each individual. The Program Specialist will complete the updated Residential Assessment by 8/31/23. |
08/31/2023
| Not Implemented |
| 6400.181(e)(10) | Individual #1's current, 12/12/22 assessment didn't include their lifetime medical history. | The assessment must include the following information: A lifetime medical history. | The lifetime medical history has been updated and submitted to the PCP for review on 8/8/23. The PCP's office has requested for staff to pick up the document during the week. A signed copy will be included with the Residential Assessment and sent to all support team members including family and the Supports Coordinator. The Program Specialist will review the records of each individual supported by the agency to ensure that the Lifetime Medical History is attached to the Residential Assessment by 8/31/23. |
08/31/2023
| Not Implemented |
| 6400.181(e)(13)(i) | Individual #1's current, 12/12/22 assessment doesn't include their current level of health needs. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| The Residential Assessment Template has been updated to include the following areas to be documented: the current level of health needs. The Program Specialist will complete an updated Residential Assessment for the individual by 8/31/23. The Program Specialist will interview the agency nurse regarding the individual's current level of health when completing the updated Residential Assessment for each individual. Information from HRST will also be used when completing the assessment. |
08/31/2023
| Implemented |
| 6400.181(e)(13)(iii) | Individual #1's current, 12/12/22 assessment is unclear of their current level abilities in residential living. The assessment states the individual independently and completely prepares breakfast, lunch and dinner. The assessment also states the individual needs verbal prompts to be able to prepare simple foods or simple meals. Both statements have a varied degree of assessment and support needed without explanation for which is accurate.
The assessment states the individual does not complete laundry care and that this section is not applicable for them. However, completing laundry is a part of living and the individual's abilities are not included on the assessment.
The assessment states the individual doesn't use a telephone, answer the telephone, dial a telephone, and that the use of a telephone is not applicable to the individual. However, the individual should always have access to telecommunication devices per their individual rights defined in 6400.32. The assessment does not include their skills level or assistance needed to complete telecommunications. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | The Program Specialist is in the process of updating the assessment using the updated Residential Assessment Template. This update will clarify the individual's abilities with respect to residential living by interviewing support staff members, agency nurse, and family. The updated assessment will be shared with the individual's ISP team members by 8/31/23. |
08/31/2023
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's current, 12/21/22 assessment doesn't identify their current level and abilities or needs in financial independence. The assessment states the individual doesn't take care of their own finances, that this is not applicable for them, but that they use a bank and maintain their own bank account with only gestural prompts needed. The individual has a representative payee handle the individual's bank account as the individual is unable to manage this. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| The Program Specialist is in the process of updating the assessment using the updated Residential Assessment Template. This update will clarify the individual's abilities with respect to financial management by interviewing support staff members, agency nurse, and family. The updated assessment will be shared with the individual's ISP team members by 8/31/23 for his ISP to be updated accordingly. The staff will be retrained on the new information by 8/31/23. |
08/31/2023
| Not Implemented |
| 6400.212(a) | Individual #1's record contained medication records and an individual support plan signature sheet for their housemate. | A separate record shall be kept for each individual.
| The agency has subscribed with Therap Services, an EHR system, and all staff will be trained on utilizing the documentation aspects and storage of the system. Using this system will minimize the error associated with paper documentation. In the meantime, Residential Site Supervisors, Program Specialist and agency nurse will be re-trained on accurate filing of documents to include where they are to be filed (site file, main book, program related documents, etc.) by 8/31/23. |
08/31/2023
| Implemented |
| 6400.214(b) | Individual #1's individual support plan (isp) in their record and available to staff at the home was last updated on 7/19/22. At the time of the 7/25/23 inspection, this plan is over a year old.
The individual's isp has been updated numerous times since then with the most recent on 6/26/23. Additionally, the individual moved to a new residence on 7/8/23 and information about their new living arrangement has not been updated in the individual's individual plan or assessment. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The agency has contracted with Therap Services which will be used to store individuals' ISP for easy access by staff. When an ISP is updated, the Program Specialist will download the updated ISP from HCSIS and upload into Therap. All staff members working with the individuals will receive an alert to review the updated ISP and complete the acknowledgement. The Director will ensure all staff members will be trained on Therap and how to access the ISP within the system by 9/30/23.
The updated ISPs were provided to the home and as well signatures sheets obtained to ensure accurate training of each plan. The Residential Site Supervisors will be retrained on the importance of training staff on this information maintain the information as well as the location of where the information is to be filed within the program. |
09/30/2023
| Not Implemented |
| 6400.216(a) | During the 7/27/23 onsite inspection, staff were not occupying or using any items in the staff office and Individuals #1 and #2 were home. The staff office contained all individuals' records, identifying information, and their medications. The staff office was unlocked during the inspection until the home was instructed to lock the office as nobody had been occupying or using items in the staff office. | An individual's records shall be kept locked when unattended.
| Staff member of concern has been retrained on the need to lock the office to prevent unauthorized access to individuals' confidential records as well as to prevent unsupervised access to medications on 7/27/23. During staff meeting, the Residential Site Supervisor will reiterate the requirement to lock the office so that all staff are aware and following the regulation. |
08/31/2023
| Implemented |
| 6400.32(v) | During the 7/25/23 annual inspection, Individual #1's records and plans do not document their, or their legal guardians', wishes if the individual wants a key, or locking mechanism suitable to their abilities, for their bedroom door and an entry door of their home. Additionally, the plans do not document if this practice would be unsafe and harmful to the individual if they were offered the locking mechanisms. | An individual's rights may only be modified in accordance with § 6400.185 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. | A Key Agreement form has been created (See Attachment 16). The Program Specialist will review this with each individual supported and their legal guardians to accurately document the individual's or legal guardian's preference. Each individual's assessment will be updated to include the preferences to obtain a key or locking mechanism and their ability to use it. This will be completed by 8/31/23. |
08/31/2023
| Implemented |
| 6400.34(a) | Individual #1's rights reviewed with them and one of their legal guardians upon admission did not include a review of their individual rights defined in Pa. Code 55 chapter 6400.31 and 6400.33. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | The Individual Rights and Civil Rights document has been updated to include 6400.31 and 6400.33 (See Attachment 17). The Program Specialist will review the updated rights documents for each individual supported and/or their guardians by 8/31/23. |
08/31/2023
| Not Implemented |
| 6400.44(b)(1) | Individual #1's 12/12/22 assessment wasn't created by the program specialist. The document states the home supervisor (direct support staff without qualifications of a program specialist) created the assessment. | The program specialist shall be responsible for the following: Coordinating the completion of assessments. | The Program Specialist has been retrained as of 8/4/23 and informed of their responsibility to complete all assessments. They are aware that Residential Site Supervisors may be interviewed to gather information for the completion of the assessment. The Program Specialist is working to complete updated assessments for all individuals supported by 8/31/23. |
08/31/2023
| Implemented |
| 6400.46(a) | Staff person #2's date of hire is 10/24/22 and purportedly started working with individual's on 11/9/22. Staff person #3's date of hire is 11/21/22 and purportedly started working with individuals on 11/22/22. Staff person #4's date of hire is 11/21/22 and started working with individuals on 11/26/22. Staff person #5's date of hire is 6/12/23 and purportedly started working with individuals on 7/3/23. At the time of the 7/25/23 inspection, Staff person #2-#5 did not receive training in general fire safety, evacuation procedures, responsibilities, meeting place, smoking safety, the use of fire extinguishers and smoke detectors and fire alarms, or notification to the local fire department. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | All Staff are trained on the areas of general fire safety and fire extinguisher use. All current staff will be trained on the fire safety policies, evacuation procedures, meeting places, smoking safety, the use of smoke detectors and fire alarms, and notification to the fire department by 8/11/2023. A New Hire and Orientation checklist has been developed to ensure that all staff members receive the fire safety training as part of their orientation. |
09/30/2023
| Implemented |
| 6400.50(a) | Staff person #2's content for their training titled "orientation" on 11/7/22 was not documented. The staff's record contained a training sign in sheet. The agency, MaxCare HCBS LLC, reported during the 7/25/23 inspection that the orientation training topics changed throughout the year. There are no records for the topics that Staff person #2 received training on for 11/7/22.
Staff persons #3 and 4's training sheet for "orientation" completed on 11/21/22 did not include the content of what was reviewed. Another training sign in sheet for orientation on this date did not include the length of the training provided to staff. The content of the orientation provided to each staff was unclear as the topics reviewed during orientation have changed throughout the year, per the agency. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | The Director provided the orientation power point containing the curriculum and training information during the licensing inspection 7/25-7/28/23. The Director reviewed the 6400 regulation and made note of all required orientation trainings. An orientation checklist has been created which will be used to ensure that new hires receive all the needed training. The Director and Program Specialist will review the records of all existing employees to ensure each of them have received the required trainings. The company will have a master folder containing the content of each in-house training provided. |
09/30/2023
| Implemented |
| 6400.51(b)(1) | Staff person #4's date of hire is 11/21/22 and first started working with individuals on 11/26/22. At the time of the 7/25/23 inspection, they did not receive training in person centered practices until 12/24/22 and didn't receive training in building relationships until 12/22/22. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The Director reviewed the 6400 regulation and made note of all required orientation trainings including person centered practices and building relationships. An orientation checklist has been created which will be used to ensure that new hires receive all the needed training. The Director and Program Specialist will review the records of all existing employees to ensure each of them have received the required trainings. The company will have a master folder containing the content of each in-house training provided. |
09/30/2023
| Implemented |
| 6400.51(b)(2) | Staff person #2's date of hire is 10/24/22 and started working with individuals on 11/9/22. Staff person #4's date of hire is 11/21/22 and started working with individuals on 11/26/22. At the time of the 7/25/23 inspection, they did not receive orientation training in, the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. § § 10225.101---10225.5102), the Child Protective Services Law (23 Pa.C.S. § § 6301---6386), the Adult Protective Services Act (35 P.S. § § 10210.101---10210.704) and applicable protective services regulations, until 12/21/22 and 12/23/22, respectively. | The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations. | The Director reviewed the 6400 regulation and made note of all required orientation trainings including the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. § § 10225.101---10225.5102), the Child Protective Services Law (23 Pa.C.S. § § 6301---6386), the Adult Protective Services Act (35 P.S. § § 10210.101---10210.704) and applicable protective services regulations. An orientation checklist has been created which will be used to ensure that new hires receive all the needed training. The Director and Program Specialist will review the records of all existing employees to ensure each of them have received the required trainings. The company will have a master folder containing the content of each in-house training provided. |
09/30/2023
| Implemented |
| 6400.51(b)(3) | Staff person #1's date of hire is 6/1/22. At the time of the 7/25/23 inspection, they did not receive orientation training in, individual rights.
Staff person #4's date of his is 11/21/22 and started working with individuals on 11/26/22. They did not receive training in the above topics until 12/23/22. | The orientation must encompass the following areas: Individual rights. | The Director reviewed the 6400 regulation and made note of all required orientation trainings including individual rights. An orientation checklist has been created which will be used to ensure that new hires receive all the needed training. The Director and Program Specialist will review the records of all existing employees to ensure each of them have received the required trainings. The company will have a master folder containing the content of each in-house training provided. |
09/30/2023
| Implemented |
| 6400.51(b)(4) | Staff person #4's date of his is 11/21/22 and started working with individuals on 11/26/22. At the time of the 7/25/23 inspection, they did not receive orientation training in, recognizing and reporting incidents until 12/23/22. | The orientation must encompass the following areas: recognizing and reporting incidents. | The Director reviewed the 6400 regulation and made note of all required orientation trainings including recognizing and reporting incidents. An orientation checklist has been created which will be used to ensure that new hires receive all the needed training. The Director and Program Specialist will review the records of all existing employees to ensure each of them have received the required trainings. The company will have a master folder containing the content of each in-house training provided. |
09/30/2023
| Implemented |
| 6400.51(b)(5) | Staff person #1's date of hire is 6/1/22. At the time of the 7/25/23 inspection, they did not receive orientation training in job-related knowledge and skills.
Staff person #2's date of hire is 10/24/22 and started working with individuals on 11/7/22. Staff person #3's date of hire is 11/21/22 and started working with individuals on 11/22/22. Staff person #4's date of hire is 11/21/22 and started working with individuals on 11/26/22. Staff person #5's date of hire is 6/12/23 and started working with individuals on 7/3/23. At the time of the inspection, there are no records that the staff received in-person training on individual's plans, protocols, and all other health and safety needs and services specific to the individual's they work with, prior to working with them. | The orientation must encompass the following areas: Job-related knowledge and skills. | The Director reviewed the 6400 regulation and made note of all required orientation trainings including job-related knowledge and skills. An orientation checklist has been created which will be used to ensure that new hires receive all the needed training. The Director and Program Specialist will review the records of all existing employees to ensure each of them have received the required trainings. The company will have a master folder containing the content of each in-house training provided. |
09/30/2023
| Not Implemented |
| 6400.52(b)(2) | Staff person #1's date of hire is 6/1/22. At the time of the 7/25/23 inspection, during their first year of employment with the agency, MaxCare HCBS LLC, they did not have any annual training hours. The agency produced records that Staff person #1 did not have any training until 6/26/23, more than a year after their date of hire. Training records of provider orientation they completed on 4/20/22, did not include documentation of the length of hours associated with the only course. | The following shall complete 12 hours of training each year: Dietary, housekeeping, maintenance and ancillary staff persons. This provision does not include a person who provides dietary, housekeeping, maintenance or ancillary services, if the person is employed or contracted by the building owner and the licensed facility does not own the building. | Staff #1 has completed the trainings effective 8/7/23. The agency has created an annual training plan to guide all staff members in the required trainings that are part of the annual training process (See Attachment 18). The agency has created a Training Credit Hour excel sheet that tracks the date, description, credit hours, and type of training (in-person, web-based) to maintain accurate tracking records. |
10/05/2023
| Implemented |
| 6400.52(c)(1) | Staff person #1's date of hire is 6/1/22. At the time of the 7/25/23 inspection, they did not receive annual training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships, during the agency's (MaxCare HCBS LLC) fiscal training year: 7/1/22-6/30/23. Staff person #1 received this training on 4/20/22, and has not received the training again within a year from when they first received the training. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | Staff #1 has completed the trainings effective 8/7/23 pertaining to the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. The agency has created an annual training plan to guide all staff members in the required trainings that are part of the annual training process (See Attachment 18). The agency has created a Training Credit Hour excel sheet that tracks the date, description, credit hours, and type of training (in-person, web-based) to maintain accurate tracking records. |
10/05/2023
| Implemented |
| 6400.52(c)(2) | Staff person #1's date of hire is 6/1/22. At the time of the 7/25/23 inspection, they did not receive annual training in, the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. § § 10225.101---10225.5102), the Child Protective Services Law (23 Pa.C.S. § § 6301---6386), the Adult Protective Services Act (35 P.S. § § 10210.101---10210.704) and applicable protective services regulations during the agency's (MaxCare HCBS LLC) fiscal training year from 7/1/22-6/30/23. Staff person #1 received this training on 4/20/22, and has not received the training again within a year from when they first received the training. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | Staff #1 has completed the trainings effective 8/7/23 pertaining to the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. § § 10225.101---10225.5102), the Child Protective Services Law (23 Pa.C.S. § § 6301---6386), the Adult Protective Services Act (35 P.S. § § 10210.101---10210.704) and applicable protective services. The agency has created an annual training plan to guide all staff members in the required trainings that are part of the annual training process (See Attachment 18). The agency has created a Training Credit Hour excel sheet that tracks the date, description, credit hours, and type of training (in-person, web-based) to maintain accurate tracking records. |
10/05/2023
| Implemented |
| 6400.52(c)(3) | Staff person #1's date of hire is 6/1/22. At the time of the 7/25/23 inspection, they did not receive annual training in individual rights during the agency's (MaxCare HCBS LLC) fiscal training year: 7/1/22-6/30/23. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Staff #1 has completed the trainings effective 8/7/23 pertaining to individual rights. The agency has created an annual training plan to guide all staff members in the required trainings that are part of the annual training process (See Attachment 18). The agency has created a Training Credit Hour excel sheet that tracks the date, description, credit hours, and type of training (in-person, web-based) to maintain accurate tracking records. |
10/05/2023
| Implemented |
| 6400.52(c)(4) | Staff person #1's date of hire is 6/1/22. At the time of the 7/25/23 inspection, they did not receive annual training in recognizing and reporting incidents during the agency's (MaxCare HCBS LLC) fiscal training year: 7/1/22-6/30/23. Staff person #1 received this training on 4/20/22, and has not received the training again within a year from when they first received the training. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | Staff #1 has completed the trainings effective 8/7/23 pertaining to recognizing and reporting incidents. The agency has created an annual training plan to guide all staff members in the required trainings that are part of the annual training process (See Attachment 18). The agency has created a Training Credit Hour excel sheet that tracks the date, description, credit hours, and type of training (in-person, web-based) to maintain accurate tracking records. |
10/05/2023
| Implemented |
| 6400.163(b) | Individual #1 is prescribed levothyroxine 88mg, I tablet per day to be administered in the morning. During the 7/27/23 onsite inspection, a 30-day supply pill packet of individually packaged levothyroxine pills was at the home for the individual. The pill packet had 19 pills popped out of their individual pockets and no longer in the pill packet, with most of the empty pockets having a written date and staff initials next to the empty pocket. The dates next to the empty pockets go in numerical order up to 7/27/23. However, the amount of empty pill pockets in the 30-day supply, would mean that the individual was already administered their medication to the morning of 7/28/23 which has not occurred. The home documents that the individual received one pill per day from 7/10-7/27, however there is an extra pill popped out and removed from the pill packet without an explanation of what happened to the extra pill removed from the original container. | A prescription medication may not be removed from its original labeled container in advance of the scheduled administration, except for the purpose of packaging the medication for the individual to take with the individual to a community activity for administration the same day the medication is removed from its original container. | It is unclear what happened to the 7/28/23 medication that was popped however, it is likely that the medication was popped when the individual went home during a home visit. The agency will be instituting a new practice whereby staff will "OP" on the blister pack to denote administration Out of Program. Also, a medication count sheet will be completed by staff and family during pick up and drop off of the individual to help track how many medications were taken off site and returned. The Program Specialist will ensure that all staff members are trained on this new practice by 8/31/23. |
08/31/2023
| Implemented |
| 6400.163(d) | During the 7/27/23 onsite inspection, staff were not occupying or using any items in the staff office, and Individuals #1 and #2 were home. The staff office contained all individuals' records, identifying information, and their medications. The staff office was unlocked during the inspection and the medication cabinet in the unlocked staff office, was also unlocked and all medications were accessible. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Staff member of concern has been retrained on the need to lock the office to prevent unauthorized access to individuals' confidential records as well as to prevent unsupervised access to medications on 7/27/23. During staff meeting, the Residential Site Supervisor will reiterate the requirement to lock the office so that all staff are aware and following the regulation. |
08/31/2023
| Implemented |
| 6400.165(b) | Individual #1's ear drops were dispensed from the pharmacy on 6/2/23 with the medication label documenting the home is to administer 5 drops in both ears once weekly. The June and July 2023 medication administration records (mars) stated, ear wax removal drops, instill 5 drops in both ears daily once a day for a week repeat one week prior to follow up appointment. The home did not initiate administration of ear drops once weekly until 7/13/23 nor did they update the mar until 7/13/23 to reflect the pharmacy issued medication label attached to the medication.
The medication label and the updated July 2023 mar do not match the ENT's written order for use of debrox on 6/2/23, which is: the individual is to continue weekly debrox in both ears (5 drops each side) until the procedure. | A prescription order shall be kept current. | The Program Specialist and Residential Site Supervisor have contacted the provider's office to confirm the exact order for the debrox/ear wax removal and are awaiting reply. The MAR will be updated accordingly based upon the information provided by the ENT office. The agency nurse, Program Specialist and all support staff will be retrained to ensure that all MAR, pharmacy labels and provider orders match by 8/31/23. |
08/31/2023
| Implemented |
| 6400.165(c) | On 12/1/22 Individual #1's physician ordered cetirizine 10mg tablet to be administered daily. The home didn't initiate administration of this medication until 12/7/22.
The home documented Individual #1 was not administered their melatonin or quetiapine at 8pm on 12/2/22 due to staff not showing up for shift.
On 12/27/22 Individual #1's primary care physician ordered Debrox ear drops, 5 drops twice daily for 7 days due to cerumen impaction and is to follow up with their ENT. There are no records the home administered Debrox.
On 6/2/23 the individual's physician documented the individual had right impacted cerumen, bilateral cerumen, there was a decline in speech awareness, tube placement in OR was recommended, there is hearing loss, and the individual is to continue weekly debrox in both ears (5 drops each side) until the procedure. There are no records debrox was administered until 7/13/23.
According to the individual's physician print out on 4/3/23, they are prescribed cholecalciferol 1000-unit (25mg) tablet, to administer 1000 units by mouth every morning. According to the individual's April, May, June, and July 2023 mars, the individual was administered vitamin d3 1000U, take 2 tablets by mouth once daily.
Individual #1's cetirizine 10mg tablet was not administered on 5/30/23 and 5/31/23.
Individual #1's ferrex capsule stated do not crush on the medication label and monthly mars. The home reports the individual chews all their medication tablets and capsules. There are no records from the prescribing physician that it is ok to crush or chew all their prescribed medications.
Individual #1's vitamin d3 and vitamin b-12 were not administered at 8am on 1/5/23. The individual's melatonin and quetiapine fumarate were not administered at 8pm on 1/14/23. The individual's mars were left blank.
Staff recorded a V on the individual's mars for 8am administrations of vitamin d3 and calcium carb on 11/20/22 and 11/27/22, but did not record an explanation what V referenced. There are no staff using the initial V to documentation medication administration.
Individual #1's mars have OP documented in multiple locations every month, from October 2022 to current, July 27, 2023. The name and initials of the staff person referenced with OP is not included on the mars. The mars don't explain what OP references. The following are examples of when OP was written on the individual's mars with no explanation of what occured: 8am and 9am medications on 3/5/23, 8am medications on 4/2/23, 6/4/23, 6/11/23, and 7/23/23, and 8pm medications on 6/3/23. | A prescription medication shall be administered as prescribed. | This violation contains errors relating to missed medication administration and medication instructions not corresponding to physician orders. To correct this error, The Program Specialist and agency nurse will obtain medication lists from each individuals' healthcare providers and confirm that all medications ordered are current. The agency nurse will update all med logs/EMAR to reflect accurate orders. The nurse will ensure any discrepancies are corrected by the pharmacy or prescriber.
-The agency currently has 2 certified medication trainers. All current DSPs have been trained and have satisfied the requirements for certification as of 8/4/23 to avoid medication error due to lack of trained staff.
-The "OP" signifies the individual was Out of Program and it was used when the individual goes home, and the medications were administered by family.
******-With regards to the individual chewing their medication, the Program Specialist and the agency nurse are following up with the PCP to ensure this is ok or not. |
09/30/2023
| Implemented |
| 6400.165(g) | According to Individual #1's medication administration records (mars), they are prescribed quetiapine fumarate for mood disorder. There are no records that this medication is reviewed with a licensed physician every 3 month to include the medication, dosage, reason for prescribing the medication and the need to continue the medication. | 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 is scheduled to see the prescriber on 8/25/23 for medication review. Staff will ensure that accurate forms are used to document the review. |
08/31/2023
| Not Implemented |
| 6400.166(a)(9) | Individual #1's ear drops were dispensed from the pharmacy on 6/2/23 with the medication label documenting the home is to administer 5 drops in both ears once weekly. The June and July 2023 medication administration records (mars) state, ear wax removal drops, instill 5 drops in both ears daily once a day for a week repeat one week prior to follow up appointment. The home did not initiate administration of ear drops once weekly until 7/13/23 nor did they update the mar until 7/13/23 to reflect the medication label on the medication at the home until 7/13/23. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | The MAR was updated late, and the individual has since had a procedure for which this medication was preparing them for. The Program Specialist is in contact with the individual's prescriber to obtain the current medication list to compare it to the medications at the house to ensure that the orders are being followed as prescribed. This will be done for each individual supported by the agency by 9/30/23. |
09/30/2023
| Implemented |
| 6400.166(a)(10) | Individual #1 was administered Robafen on 4/10/23. The time of administration was never recorded. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | Staff will be retrained on the administration and documentation of PRN and OTC medications by the agency med trainer by 8/31/2023. |
08/31/2023
| Implemented |
| 6400.166(a)(11) | Individual #1's October and November 2022 medication administration records (mars) do not include the reason for prescribing quetiapine fumarate and fluticasone spray.
The individual's March 2023 mar doesn't include the reason for prescribing ear wax removal drops.
Individual #1 had over the counter Imodium in their as needed medication container. This over the counter, as needed, medication wasn't listed on the individual's mars. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The Program Specialist and agency nurse are following up with the individuals' prescribers to obtain the reason/diagnosis for all medications and contact the pharmacy to ensure that the MARs are updated correctly by 8/31/2023. |
08/31/2023
| Implemented |
| 6400.166(a)(13) | According to Individual #1's medication administration records (mars), Staff person #7 administered medications to Individual #1 in April, May, and June, 2023. Staff person #7 did not include their signature, initials, or legible name on some of the individual's mars for those three months.
Staff's name, and occasionally their initials, recorded on Individual #1's mars from October 2022 to current, July 2023, are illegible on many months' documentation. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | A Central Medication Administrator List has been created and will be completed by all staff administering medications at a residential location each month. The form will be kept in a plastic sheet protector to maintain the integrity of the document. The agency is in the process of transferring to Therap EHR where signatures will be documented electronically to avoid the issue of illegibility. |
08/31/2023
| Implemented |
| 6400.167(b) | The mediation errors described in 6400.165(c) of this report weren't documented, follow up action wasn't taken, and the prescriber's response was not sought or documented. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | The Program Specialist is reviewing EIM records and entering all unreported medication error incidents accordingly. This is expected to be completed by 8/9/23. |
09/30/2023
| Implemented |
| 6400.167(c) | The medication errors described in 6400.165(c) of this report weren't reported to the Department as an incident as specified in § 6400.18(b). | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | The Program Specialist is reviewing EIM records and entering all unreported medication error incidents accordingly. This is expected to be completed by 8/9/23. |
09/30/2023
| Not Implemented |
| 6400.169(a) | Staff person #6 initialed as the medication administration trainer who completed components of Staff person #4's initial medication administration training documents. Staff person #6 documented that Staff person #4 passed the training, however, did not document the date Staff person #4 passed all requirements thus able to administer medications. Staff person #4 has been administering medications recently. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | The agency medication trainer has corrected the medication administration training documents to reflect the certification date for Staff #4. |
09/30/2023
| Implemented |
| 6400.181(b) | The agency, MaxCare HCBS LLC, recognized Individual #1's house placement when they were admitted to their agency was not meeting the individual's needs. The individual was unable to physically evacuate their home during fire drills, and having a decline in abilities and health needs, i.e. history of falls, and memory, vision, and hearing decline. A change in service location and needs was done on 7/8/23, when the agency moved Individual #1 to a new home.
At the time of the 7/25/23 inspection, Individual #1's 12/12/22 assessment was never updated even though the agency started noticing a decline in the individual's health, decline in their abilities, increase in needs, and required a different layout of their home to attempt to assist with successful evacuations during simulated monthly fire drills.
According to the individual's legal guardians, the physicians, and individual support plan, the individual is showing memory loss, has severe hearing loss in both ears, has vision loss, shown a decline in speech awareness, there is concern for signs of Dementia, balance is unsteady, and the cause for the unsteady gait is unknown. The individual's assessment was never updated to include the decline in abilities or the increased need for support in multiple areas. | If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have an assessment completed as required under this section. | The Program Specialist has been retrained on the need to update the assessment when there are changes in the individual's abilities and level of functioning. The Residential Assessment Template has been updated to include the assessment of the individual's functional skills entailing the current level of performance of each skill/activity, as well as whether they've made progress or regressed. The Program Specialist is in the process of completing the new assessment for the individual using the updated template and is expected to be done before or by 8/31/23. |
08/31/2023
| Implemented |
| 6400.181(f) | The program specialist did not send Individual #1's 12/12/22 assessment to any team member. | 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 is currently updating individual #1's assessment using the updated template to ensure that it captures all the regulatory requirements. Once completed, this assessment with be shared with the ISP team members for Individual #1 by 8/31/23. Documentation will be kept together with the assessment in the individual's record at the agency. |
08/31/2023
| Not Implemented |
| 6400.183(c) | A note from the individual's program specialist reports an annual individual support plan meeting was held on 12/19/22. The home does not have record of those in attendance for the individual's annual individual support plan meeting. | The list of persons who participated in the individual plan meeting shall be kept. | The Program Specialist has emailed the Supports Coordinator to obtain the ISP attendance sheet from the 12/19/22 meeting (Attachment 22) |
08/31/2023
| Implemented |
| 6400.186 | Individual #1's current, 6/26/23 individual support plan (isp) states the individual has difficulty accepting change and the team will remind the individual of change multiple times before it happens. Residential will start a sleep chart to keep track of the individual's sleep. Individual #1 requires assistance with dental hygiene. Staff will work with family to create a shower routine at home which will be more successful.
The home is not reminding the individual of changes or appointments coming up to prepare them for the change in their routine, is not tracking the individual's sleep or using a sleep chart, is not documenting if support if being provided to complete daily dental hygiene, does not have a shower chart, tracking, or shower routine, and is not implementing any communication skills refinement plans. | The home shall implement the individual plan, including revisions. | The agency has contracted with Therap Services and charts have been developed to track daily routines including showering, sleeping, dental hygiene, etc. The Program Specialist and Director will be training all staff members on how to use these charts for documentation by 8/31/23.
Individual #1's SEEN plan has been updated to reflect the need to discuss changes in advance and how to provide the supports. The staff will be trained on the updated SEEN plan by 8/31/23. |
08/31/2023
| Implemented |
| Article X.1007 | The agency, MaxCare HCBS LLC, 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 #2's date of hire is 10/24/22. Staff person #3's date of hire is 11/21/22. Staff person #4's date of hire is 11/21/22. Staff person #5's date of hire is 6/12/23. At the time of the 7/25/23 inspection, Staff persons #2-#5 have direct contact with individuals and the agency has not requested or completed a Pennsylvania criminal history background check for said staff.
Additionally, the agency does not have record from Staff person #2, #3, #4, or #5 reporting their residence over the previous two years. The agency did not request or complete a Federal Bureau of Investigation background check for Staff person #2 or #5. | 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. | The Director completed the Pennsylvania State Police background checks for all current employees on 7/25/23 and results obtained by 7/27/23 (See Attachment 3). A New Hire Checklist has been updated and will be reviewed for completion before all staff members can attend orientation (See Attachment 4). Going forward, the New Hire Checklist will be used to ensure all records have been reviewed prior to orientation. |
08/31/2023
| Not Implemented |