| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1 is incontinent and relies solely on staff to complete all personal hygiene. Individual #1 is also in a wheelchair during awake hours due to their diagnosis of Cerebral Palsy. On 2/14/22, Individual #1 was taken to their PCP for multiple open bedsores. Per EIM #8979869, a certified investigation was completed, and staff witnesses indicate that they had been noticing redness on Individual #1's bottom since at least 2/11/22, however, no further action was taken to treat Individual #1's bottom until they had 3 open bedsores on 2/14/22. Individual #1's physician prescribed a cream to be applied for 2 weeks, which was administered as ordered. Per EIM #8979869 the preventative corrective action to this incident, staff member #27, the agency nurse, was to train staff on pressure injuries by 2/23/22. Additionally, "a health protocol will be developed to minimize the potential for [Individual #1] to develop pressure injuries. Staff will be required to reposition [Individual #1] when [they] are in their wheelchair every 2 hours. Repositioning of [Individual #1] will be documented." Staff person #13 was responsible for this corrective action, which was to be in place by 3/11/22. During this inspection completed on 9/9/22, PAI confirmed the preventative corrective actions described in EIM #8979869 were not implemented.
Per EIM # 9028045, on 5/16/22, staff person #28 sent an email to Individual #1's team reporting redness on Individual #1's bottom and reminding the team of repositioning needs and how to stop pressure ulcers. There was no further action taken until 5/20/22, when staff reported the start of a bedsore on Individual #1's bottom. During this inspection, PAI confirmed that Individual #1's PCP, or any other medical staff, were not contacted. The Certified Investigation completed for this incident, noted the following, "The photo taken on 5/20/22 of the pressure injury on [Individual #1]'s left butt cheek shows the sore is pink in color and the skin is peeling. The photo taken on 5/23/22 of the pressure injury on [Individual #1]'s left butt cheek shows the sore is a darker pink to slightly red color with some peeling skin. The sore appears to have some loss of skin with no bleeding or open wounds." Staff person # 13 provided a "repositioning protocol" for Individual #1 to the certified investigator which was confirmed to the department was put into place on 5/24/22. As of the 9/9/22 inspection, PAI confirmed that there are no documents verifying that staff have been trained on this protocol. There were repositioning tracking documents provided to the department during this inspection that began on 5/24/22, however, most dates and shifts are missing information, so it is unknown if the repositioning protocol is being followed accurately to prevent further pressure ulcer injuries.
Per EIM #9087876, on 9/6/22, staff person #29, a CPS staff member who works with Individual #1, noticed the start of a pressure injury on Individual #1's buttocks and emailed the agency nurse. The CPS supervisor then called the agency nurse on 9/7/22 to again report the injury. Individual #1's house staff was not notified of this injury until 9/7/22, and Individual #1 was not taken to their PCP to seek medical care until 9/8/22.
The failure to implement a repositioning protocol, train staff appropriately after the 2/14/22 incident, as well as the delay and/or lack of seeking medical care in all instances noted above put individual #1 at risk for harm and creates conditions conducive to neglect. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | An investigation was completed in regard to the incidents noted in this violation. The management team was retrained on 10-3-22 by Director of Residential Services that they are required to ensure the corrective actions identified by the administrative review team are implemented. The individual is being taken to their PCP on 10-3-22 for a referral for consistent wound care by a wound care specialist due to their present diagnosis and wheelchair requirements which make them susceptible to pressure injuries. This is being done in an attempt to mitigate potential pressure injuries. |
10/03/2022
| Implemented |
| 6400.112(a) | There were no fire drills held during the following months: January, February, March & April 2022. | An unannounced fire drill shall be held at least once a month. | The management team was retrained by Director of Residential Services on 9-27-22 in regard to unannounced fire drills being held at least once a month. A fire drill was completed for the home on 9-12-22. |
10/03/2022
| Implemented |
| 6400.112(e) | There was a sleep fire drill held 10/29/21 and not again until 5/23/22. | A fire drill shall be held during sleeping hours at least every 6 months. | The management team was retrained by Director of Residential Services on 9-27-22 in regard to fire drills being held during sleeping hours at least every 6 months. |
10/03/2022
| Implemented |
| 6400.141(c)(3) | (Repeated Violation -- 9/7/21) Individual #1's 7/25/22 annual physical examination does not have accurate or current information regarding Individual #1's TDAP vaccination. Their 7/16/21 physical indicates that this immunization was received on 4/30/19, however, their 7/25/22 annual physical states that this immunization has not been received since 5/29/09. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The physical was returned to the physician's office and they updated the form with the correct date for the TB test to state 7-25-22. The TDAP immunization was completed on 4-20-19. The current physical was taken to the PCP on 9-29-22 and the updated date was added to the current physical. |
10/03/2022
| Implemented |
| 6400.144 | (Repeated Violation -- 3/23/22 and 9/7/21) Individual #1 has a seizure protocol that was signed by their physician on 7/16/21 and 7/25/22 indicating that if Individual #1 has a seizure that lasts more than 5 minutes, 911 is to be called. If Individual #1 has more than 2 seizures in 24 hours, their PCP is to be contacted. This protocol does not describe the type of Individual #1's seizures, nor what staff are to do while the seizure is occurring. This information is also not in Individual #1's Individual Plan. Staff person #13 described Individual #1's seizures as staring spells in which the individual is unresponsive. There is no documentation that staff are trained to recognize when Individual #1 is having a seizure in order to determine if more medical attention is necessary.
According to Individual #1's 10/7/21 ISP, Individual #1 completes daily in home physical therapy with the assistance of staff. There is no tracking completed on the following dates, and it is not known if the physical therapy was refused, completed, or not attempted:
· All of October, November, and December 2021
· January 2022: 1, 2, 18
· February 2022: 1, 2, 4 through 20, 22, 25 through 28
· March 2022: 4, 5,6, 12 through 15, 19, 22, 26, 27, 29, 30
· April 2022: 5, 12, 15 through 18, 21, 26, 30
· May 2022: 3, 7, 10, 13, 17, 20 through 25, 30, 31
· June 2022: 5, 7, 11, 16 through 24, 26, 28
· July 2022: 2 through 10, 12, 14 through 17, 19 through 23, 26 through 28, 31
· August 2022: 2, 4, 7 through 13, 16 through 20, 23, 25, 26, 28 through 30
· September 2022: 1 through 6
Individual #1 has a bowel protocol approved by their doctor on 7/16/21 and 7/25/22 indicating that if Individual #1 does not have a bowel movement in 3 days, they are to receive a Bisocadyl Suppository at 7pm on the 3rd day. If there is still no bowel movement, the suppository can be repeated at 7pm on the 4th day. There was no tracking completed for the following dates, so it is unknown if Individual #1's bowel PRN protocol was being followed appropriately:
· All of October, November, and December 2021
· January 2022: 1, 2
· May 2022: 20, 21, 22, 23
· June 2022: 16, 17, 18, 19, 20, 21, 22, 23, 24
· July 2022: 3, 4, 5, 6, 8, 9
· August 2022: 8, 9, 10, 28, 29, 30
· September 2022: 3, 4, 5
On 10/4/21, Individual #1 had an eye doctor appointment with a 2-3 month recall. This appointment was scheduled for 12/15/21. Staff person #13 reported that Individual #1 was a no-show for this appointment. As of the 9/9/22 inspection, this appointment has not been rescheduled or completed.
On 10/6/21, Individual #1 had a podiatrist appointment with a follow up appointment at 12/8/21. As of the 9/9/22 inspection, there is no documentation provided that this appointment was completed or rescheduled as ordered.
On 10/21/21, staff person #30 noted on Individual #1's medical telephone log that a nurse called with a results of Individual #1's dilantin levels. Staff noted that the nurse's instructions were to "continue dose and recheck bloodwork in 3 weeks." This follow up blood work was never completed.
At the time of the 9/8/22 inspection, Individual #1's PRN medications, Onsendatron and Bisacodyl, were not available in the home. Verification was provided to licensing that this medication was requested to be refilled on the same date of inspection. | 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.
| An updated seizure protocol has been implemented on 9-29-22. A new physical therapy exercise checklist form has been created. A new paper Bowel Movement chart form has been created as the paper form will make it easier for staff to track the bowel movements. An appointment has been made with the optometrist for 10-19-22. The podiatrist appointment occurred on 9-26-22. Blood work for dilantin levels were completed on 6-20-22. All staff were retrained in this regulation on 9-22-22 by Staff #31. Ondansetron and Bisacodyl were re-ordered. |
10/03/2022
| Implemented |
| 6400.151(c)(2) | (Repeated Violation -- 9/7/21) Staff person #7 had their most recent tuberculin test read on 10/13/21, however, this test is not signed and dated that it was read by a medical professional allowed by regulation.
Staff person #3 had their most recent tuberculin test read on 5/11/22, however, this test is not signed and dated that it was read by a medical professional allowed by regulation. | 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. | An email has been sent to members of the HR team who review staff physicals, reminding them of which medical professionals may complete and certify staff physicals upon hire and for reexaminations. |
10/03/2022
| Implemented |
| 6400.212(b) | Individual #1's dosage of Dilantin was increased on their 10/2022 MAR by an unknown staff on an unknown date. The "one" in the dosage was crossed out and "two" written above it with no additional notes. | Entries in an individual's record shall be legible, dated and signed by the person making the entry.
| All staff were retrained in this regulation on 9-22-22 by Staff #13. |
10/03/2022
| Implemented |
| 6400.214(b) | (Repeated Violation -- 3/23/22) At the time of the 9/8/22 inspection, the most recent ISP available in the home for Individual #3 was dated 10/7/21. This Individual's ISP was most recently updated on 5/11/22. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The most recently updated ISP was placed in the record on 9-20-22. All management staff were retrained on this regulation by Director of Residential Services on 9-29-22. |
10/03/2022
| Implemented |
| 6400.217 | The release dated 4/5/21 that is on file with the provider agency is not complete. This documentation has Individual #1's stamp, but it does not indicate if the individual does or does not given permission for the various statements within the document. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Written consent was received by the individual on 9-22-22. All management staff were retrained in this regulation on 9-22-22. |
10/03/2022
| Implemented |
| 6400.18(a)(9) | Staff person #29 reported the start of a pressure injury to Individual #1's buttocks on 9/6/22 to the agency nurse. This injury was not reported through the department's incident management system until 9/12/22. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Injury requiring treatment beyond first aid.
| All staff in residential were retrained in this regulation by Director of Residential Services on 10-3-22. The incident was added to EIM and an investigation was initiated. |
10/03/2022
| Implemented |
| 6400.18(g) | Staff person #29 reported the start of a pressure injury to Individual #1's buttocks on 9/6/22 to the agency nurse. This injury was not reported through the department's incident management system until 9/12/22, and at that time a certified investigator was assigned. | The home shall initiate an investigation of an incident, alleged incident or suspected incident within 24 hours of discovery by a staff person. | All staff in residential were retrained in this regulation by Director of Residential Services on 10-3-22. The incident was added to EIM and an investigation was initiated. |
10/03/2022
| Implemented |
| 6400.46(d) | Staff person #8 was trained in CPR and First Aid on 10/18/19 and not again until 11/4/21. This staff person's 2019 certification was a 2-year certification. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | When the provider became aware that the employee was out of compliance, the employee was mandated to get recertified as soon as possible before working again in program. All management staff and HR staff were retrained in this regulation by Director of Residential Services on 10-3-22. |
10/03/2022
| Implemented |
| 6400.50(a) | (Repeated Violation -- 3/23/22) All staff working at Individual #1's home signed a training sheet indicating that they had read all Individual #1's plans and protocols, however, staff person #13 could not provide verification of the content of these trainings to show that staff have been trained on all Individual #1's protocols. These acknowledgement of responsibility documents also did not include the length of the training. | 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. | All staff were retrained by Director of Residential Services on 10-3-22. |
10/03/2022
| Implemented |
| 6400.51(a)(3) | Staff person #11's date of hire is 11/18/21 and first day working with individuals is 11/19/21. Staff person #11 did not complete their orientation trainings until they were past the 30 day timeframe. The trainings required in 6400.51b1 were not complete until 12/25/21. The trainings required in 6400.51b2 were not completed until 12/28/21. The trainings required in 6400.51b3 were not completed until 12/21/21. The trainings required in 6400.51b4 were not completed until 12/25/21. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Direct service workers, including full-time and part-time staff persons. | When the provider became aware that the employee lapsed in their orientation trainings, employee was mandated to complete all required orientation trainings immediately. All management and HR were retrained in this regulation by Director of Residential Services on 10-3-22. |
10/03/2022
| Implemented |
| 6400.52(a)(1) | Staff person #6 only completed 23.75 hours of annual training in training year July 1, 2021 through June 30, 2022.
Staff person #7 only completed 23.5 hours of annual training in training year July 1, 2021 through June 30, 2022.
Staff person #8 only completed 22.75 hours of annual training in training year July 1, 2021 through June 30, 2022. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | The 3 staff were retrained by the Training Lead on 9-29-22 in regards to regulation 6400.52(a)(1). |
10/03/2022
| Implemented |
| 6400.52(c)(6) | Individual #1 and Individual #2 both require the use of a hoyer lift for transfers. The following staff have worked with Individuals #1 & 2 since 1/1/22 and have not been trained in the use of a hoyer lift: Staff person #8, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, and #25.
Staff person #26 first worked in Individual #1's home on 6/25/22. There is no documentation that staff person #26 received training on Individual #1's plans and protocols before working in the home. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | All staff identified will receive hoyer lift training by Friday October 7th. Staff person 26 did sign the acknowledgement form on 6-25-22. |
10/03/2022
| Implemented |
| 6400.165(c) | (Repeated Violation -- 9/7/21) Individual #1 is to receive 1 capful of Polyethlene Glycol by mouth at 8am on Mondays, Wednesdays, and Fridays. Individual #1 was administered this medication on the following dates that were not Mondays, Wednesdays, or Fridays: 2/1/22, 3/29/22, 3/31/22, 4/5/22, 7/26/22, 7/28/22, 7/30/22, 7/31/22, 8/2/22.
Individual #1 has a bowel protocol that states that if Individual #1 does not have a bowel movement in 3 days, they are to receive a Bisacodyl Suppository at 7pm on the 3rd day. If there is still no bowel movement, the suppository can be repeated at 7pm on the 4th day. Individual #1 was administered Bisacodyl on 10/5/21 and 10/13/21, however, there is no tracking document provided to the department to verify that this PRN was administered per doctor's orders. Additionally, Individual #1 went 3 days without a bowel movement on the following dates and no PRN was administered:
· January 2022: 3, 4, 5
· February 2022: 18, 19, 20; 25, 26, 27
· March 2022: 29, 30, 31
· May 2022: 24, 25, 26 | A prescription medication shall be administered as prescribed. | An updated, paper document on the Bowel Movement chart has been created for the individual. All staff were retrained in this regulation by Director of Residential Services on 10-3-22. |
10/03/2022
| Implemented |
| 6400.165(e) | On 10/4/21, Individual #1's eye doctor ordered Refresh Relieva eye drops to be administered to Individual #1, 1 drop 3 times daily (8am, 12pm, 8pm) for 2 months. As of the 9/9/22 inspection, this medication is still being administered to Individual #1. There is no doctor's order provided increasing the duration of this treatment beyond 2 months.
On 9/30/21, staff person #19 noted that Individual #1's PCP office called and that their Dilantin dose was to increase to 2 100mg tablets daily. There are no doctor's written orders to change this prescription. At some point in 10/2022, staff member #30, who is not a medical professional, updated the dosage on Individual #1's Medication Administration Record. It is unclear if doctor's orders were received or when the change was made in Individual #1's Dilantin dosage.
Individual #1 has a PRN prescription for Tylenol that indicates that Individual #1 can take 2-325mg tablets every 6 hours as needed for pain/fever. Individual #1 was given Tylenol on 12/3/21 at 11:30am and again at 3pm for fever. The allotted timeframe was not followed in this administration.
On 1/6/22, Individual #1's pantoprazole was discontinued and Nexium was started. There are no doctor's orders documenting the discontinuance of this medication or ordering the start of a new medication. | Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. | All residential staff were retrained in this regulation by Director of Residential Services on 9-29-22. |
10/03/2022
| Implemented |
| 6400.165(g) | (Repeated Violation -- 3/23/22) Individual #1 had a psychiatric medication review on 10/6/21 and not again until 7/25/22. | 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. | All management staff were retrained in this regulation on 9-21-22. |
10/03/2022
| Implemented |
| 6400.166(a)(5) | (Repeated Violation -- 3/23/22) Individual #1 was administered Tylenol at 11:30am and 3pm on 12/3/21, however, this entry on the Medication Administration record did not include the strength of medication.
Individual #1 was administered Tylenol Cold & Flu on 3/24/22 and 3/25/22, however, this entry on the MAR did not include the strength of medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | All Management in Residential were re-trained by Director of Residential Services, on 9-19-22 explaining 6400 regulations regarding administering and documenting medications according to regulatory timeframes. All management in Residential were retrained in regards to ensuring the strength of the medication is listed. |
10/03/2022
| Implemented |
| 6400.166(a)(6) | (Repeated Violation -- 3/23/22) Individual #1 was administered Tylenol at 11:30am and 3pm on 12/3/21, however, this entry on the Medication Administration record did not include the dosage form.
Individual #1 was administered Tylenol Cold & Flu on 3/24/22 and 3/25/22, however, this entry on the MAR did not include the dosage form. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | All Management in Residential were re-trained by Director of Residential Services, on 9-19-22 explaining 6400 regulations regarding administering and documenting medications according to regulatory timeframes. All management in Residential were retrained in regards to ensuring the dosage of the medication is listed. |
10/03/2022
| Implemented |
| 6400.166(a)(11) | (Repeated Violation -- 3/23/22) Individual #1 was administered Tylenol at 11:30am and 3pm on 12/3/21, however, this entry on the Medication Administration record did not include the diagnosis or purpose of the medication. | 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. | All Management in Residential were re-trained by the Director of Residential Services, on 9-19-22 explaining 6400 regulations regarding administering and documenting medications according to regulatory timeframes. All management in Residential were retrained in regards to ensuring the diagnosis or purpose of the medication is listed. |
10/03/2022
| Implemented |
| 6400.167(a)(1) | Repeated Violation -- 9/7/21) Staff person #19 initialed that they administered Individual #1's 8pm dose of Dilantin on 12/9/21, however, this staff then wrote a note on the back of the MAR stating "I CZ did not mean to sign for the 8pm Dilantin" on 12/9/21. This medication appears to have not been administered at this time.
On 1/25/22 at 8am, Individual #1 did not receive their dose of Refresh Relieva eye drops.
On 2/28/22 at 8pm, Individual #1 did not receive their dose of Refresh Relieva eye drops.
On 3/30/22, a Wednesday, Individual #1 did not receive their 8am dose of Polyethlene Glycol.
On 4/29/22, a Friday, Individual #1 did not receive their 8am dose of Polyethlene Glycol.
On 8/1/22, Individual #1 did not receive their 12pm dose of Refresh Relieva eye drops. | Medication errors include the following: Failure to administer a medication. | All management staff were retrained in this regulation by Director of Residential Services on 10-3-22. |
10/03/2022
| Implemented |
| 6400.167(b) | There is no documentation provided verifying that the medication errors in 6400.167a1 were reported as medication errors to the department or to Individual #1's prescriber. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | All management staff were retrained on this regulation by Staff #13 on 9-21-22. All med errors were added on EIM. |
10/03/2022
| Implemented |
| 6400.169(a) | (Repeated Violation -- 3/23/22) Staff person #10 has not completed the required number of observations to be considered fully certified in Medication Administration. Staff person #10 completed their Medication Administration written test on 6/13/22 and their Medication Administration certification was signed as complete without a date. Staff person #10 had 1 observation completed on 6/13/22 and 2 observations completed on 8/14/22. Additionally, staff person #10's Initial Medication Administration packet does not include their written documentation test information. At this time, staff person #10 would need to complete 4 more observations by day 105 (9/26/22) after the written exam to be fully certified, as well as complete the required written documentation examination. | 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). | Staff #10 will complete the med training class over again on 10-10-22. |
10/03/2022
| Implemented |