| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency did not complete the self-assessment of the home with 3-6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| Self assessment will be completed immediately and in completion. |
| Implemented |
| 6400.21(a) | Staff #4 was hired on 7/11/22. Staff #4 did not have an application for a Pennsylvania criminal history record check submitted within 5 working days after the person's date of hire. The application for a Pennsylvania criminal history record check was not completed until 7/20/22. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| Staff has completed the background check. No staff is to officially start working with consumers until all requirements are meant including FBI check, Criminal history check and Child abuse clearance within 5 days of hire. |
11/30/2022
| Implemented |
| 6400.22(d)(1) | Individual #4 was placed in the home as respite care on 10/16/2022. Individual #4 arrived at the home with money that is maintained in the individual's medication administration record. There was $120 in the envelope. The home did not maintain an up-to-date financial record that included funds received by or deposited with the family or home. | 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. | On 10.31.22 Individuals $120 was given back to mother by staff. Staff also gave mother a written receipt verifying that no purchases made.
Staff had a discussion with the Director of Residential explaining how funds are to be maintained separately and tracked by each purchase in an up to date ledger or financial form. |
11/18/2022
| Not Implemented |
| 6400.43(b)(4) | The chief executive officer (CEO) is not ensuring the administration and general management of the home including compliance with this chapter. The CEO is not adequately overseeing the daily functioning of the homes and ensuring that all regulations are followed resulting in significant areas of noncompliance including subject areas: Self-Assessment of Homes, Incident Report and Investigation, Criminal History Record Check, Individual Funds and Property, Individual Rights, Chief Executive Officer, Staff Training, Training Records, Orientation, Annual Training, Poisons, Sanitation, Surfaces, Screens, Windows and Doors, First Aid Kit, Bathrooms, Fire Drills, Fire Safety Training for Individuals, Smoking Safety Procedures, Individual Physical Examination, Prescription Medications, Medication Record, medication Errors, Three Meals a Day, Quantity of Food/Groups, Assessment, Individual Plan Process/Content of the Individual Plan/Implementation of the Individual Plan, Staff Training Behavioral Support, Emergency Information, Individual Records, Respite Care. The CEO identified a previous Director who is no longer with the company and who was relieved of his duties in April 2022 as the person responsible for ensuring that Chapter 6400 regulations were followed and complied with and the failure of the former Director to oversee. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Compliance with this chapter. | The CEO has now gained additional knowledge and with the assistance of Director of Residential services will ensure the compliance of all required 6400 regulations. |
11/30/2022
| Not Implemented |
| 6400.62(a) | Individual #4's Individual Support Plan (ISP) noted that the individual is not poison safe. Dial Complete Antibacterial soap was located on the bathroom counter. The label of the Dial soap provided direction to "If swallowed get medical help or contact Poison Control Center right away." | Poisonous materials shall be kept locked or made inaccessible to individuals. | The dish soap is now removed from the home and replaced with a poison safe hand soap. |
11/30/2022
| Implemented |
| 6400.64(a) | The vent in the living/dining room area was covered in a significant amount of dust. Toothbrushes for Individual #2 and Individual # 4 were located on separate shelves in the mirrored medicine cabinet above the bathroom sink. Each toothbrush was laying on a shelf with the bristles uncovered and directly in contact with the shelves. The shelves had small areas covered with a dried white substance that appeared to be toothpaste, at the time of inspection the toothbrushes were in contact with the dried white substance. | Clean and sanitary conditions shall be maintained in the home. | Staff cleaned vents with broom and rag to remove the dust. Staff will be replacing the current toothbrushes and there will be caps to ensure safe hygienic practices. |
11/30/2022
| Implemented |
| 6400.72(b) | The screen on the sliding door leading to the balcony was broken. The screen was in the open position and off the track, not able to be closed when the sliding door is open. | Screens, windows and doors shall be in good repair. | Maintenace was contacted to fix the problem. Correspondence will be collected and followed up on to ensure screen is in proper repair. |
11/30/2022
| Implemented |
| 6400.77(b) | The first aid kit did not contain a thermometer. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | New first aid kits are in the home. New electronic thermometers are also in the home. |
11/30/2022
| Implemented |
| 6400.82(f) | The bathroom in the home did not contain individual clean paper or cloth towels at the time of inspection. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Hand towels will be purchased for the home as well as a paper towel holder with fresh paper towels. |
11/30/2022
| Implemented |
| 6400.112(c) | The fire drill record for a fire drill conducted on 4/29/22 did not include the amount of time it took for evacuation. The record indicated that it was an unsuccessful drill. There was not documentation of any problems encountered. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Fire drills will have forms filled out in there entirety reflecting correct times and if any problems were encountered. |
11/30/2022
| Implemented |
| 6400.113(a) | Individual #2 moved into the home on January 9, 2022. Individual #2 was not 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 until 1/11/22. Individual #4 moved into home on 10/16/22. Individual #4 was not 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. | 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. | Individuals face sheet and emergency plan were updated for individual #2. Individual and staff was instructed on individual's primary language or mode of communication, 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. |
11/30/2022
| Implemented |
| 6400.114(b) | Written smoking safety procedures are not being followed. Upon entry of the home on 10/18/22, inspectors were overwhelmed with the smell of cigarette smoke. When staff were questioned, they stated that the smoke was entering the home through a vent. During the initial inspection of the home on 10/13/22, the home did not have any odor of cigarette smoke. The odor dissipated slightly during the time that the inspectors were at the home. Upon examination of the deck of the home off of the kitchen, a water bottle that would be used for drinking water was located and was half full of cigarette butts. Supreme Nursing Care and Supported Living smoking policy states: "Supreme Nursing Care and Supported Living does not allow smoking anywhere in the homes we operate. Individuals and staff that smoke is permitted to smoke in predetermined areas on the property. Each designated area is specific to the home you work. It is your responsibility to know where that area is and utilize that area only. This includes any waiver supported person of Supreme Nursing Care and Supported living. The team should meet and discuss with the person where they are permitted to smoke. Supreme Nursing Care and Supported Living provides smoke receptacles for each Community Home location for the use of anyone who smokes. At no time is smoking permitted in an agency vehicle. Smoking not permitted while transporting individuals under Supreme Nursing Care and Supported Living. It is the smoker's responsibility to discard the cigarette appropriately in the receptacle to reduce any chance of fire or loss of property to themselves, the individuals in their care and Supreme Nursing Care and Supported Living, LLC. Safety and the Individual we support are our priority. If the receptacle is damaged or missing, please report this immediately to your supervisor." There was not a predetermined area on the property identified for staff or individuals to safely smoke and there was not an appropriate smoking receptacle located at the home. | Written smoking safety procedures shall be followed. | Smoking policy will be updated . Staff will be trained on smoking policy. Receptacles were purchased to discard of any cigarettes . |
11/30/2022
| Implemented |
| 6400.141(a) | Individual #2 did not have a physical examination within 12 months prior to placement. Individual #2 was placed in the home on 1/9/22. Individual #2 did not have a physical examination completed until 1/13/22. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individuals will ensure that a physical is completed immediately |
11/30/2022
| Implemented |
| 6400.141(c)(6) | Individual #2's physical examination completed on 1/13/22 did not include a Tuberculin skin testing by Mantoux method with negative result. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Individual will be scheduled to go in to get a TB test that will be documented correctly. |
11/30/2022
| Implemented |
| 6400.144 | 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. Psychological services are no being planned and provided for Individual #2. Individual #2's Individual Service Plan (ISP) indicates that the indicates that the individual has a behavior support plan. There is no information regarding the behavior support plan and the ISP states: "Individual #2 started with a behavioral specialist on 5/25/22, where Individual #2 had assessment done and would continue to follow up but do to short staffing, they haven't been able to start." There is no documentation that attempts have been made to engage services with the behavior specialist who completed the assessment in May 2022 or that another provider has been sought to provide psychological services to Individual #2 | 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.
| Director of residential services and CEO are working with staff to ensure appointments are up to date and Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are being provided as needed. As of 11.18.22 the individual has a SEEP Plan in lieu of a Behavior plan as behavior services were suspended. |
12/02/2022
| Implemented |
| 6400.172 | At least three meals a day are not available to the individual in the home. There was minimal food in the home. During the initial visit to the home on 10/13/22, Iindividual #2 was the only individual residing in the home. At that time, there was load of bread, half a bag of pretzels, 1 pack of cheese, a package of frozen hamburger, 2 waffles, 6 pancakes, ¼ bag of rice, 1 turkey sausage breakfast, 2 servings of pancakes, an egg patty breakfast meal, condiments, and chocolate milk. Individual #4 moved into the home on 10/16/2022. During a subsequent visit to the home on 10/18/22, the food available for Individual #2 included: 1 bag of pretzels, 1 bag of marshmallows, half a bag of Chex mix, 7 boxes od Kool aid drink pouches 1 box of yahoo chocolate milk, three half gallons of Twister juice, half a gallon of chocolate milk, a tub of Country Crock butter, 18 eggs, a Reese's Peanut Butter candy bar, a Kit Kat candy bar, a box of 8 popsicles and quart of chocolate ice-cream. During the visit on 10/18/22, the food available for Individual #4 included: 11 individual cups of applesauce, a container of hummus, a pack of whole wheat sandwich wraps, two half gallons of Almond Breeze milk, 2 cases of Bubbly sparkling water, 1 can of Campbells Italian Wedding Soup, a box of Sleepy time herbal tea bags, three bananas and a box of oatmeal with 5 packets. Individual #2 and Individual #4 do not have access to food consistent with three meals a day that are nutritionally balanced or food consistent with a meal. Staff indicated that Individual #2's father purchases the food for the home using the individual's food stamps and Individual #4 likes to eat from WaWa and a card for WaWa was provided by the family. | At least three meals a day shall be available to the individuals.
| The home now has its own debit card for food purchases. A grocery list and meal plan are also in development. |
11/30/2022
| Implemented |
| 6400.173 | The quantity of food served for each individual does not meet minimum daily requirements as recommended by the United States Department of Agriculture. There is not an sufficient amount of food available in the home to allow for the quantity of food served to the individual's in the home to receive the minimum daily requirements as recommended by the United States Department of Agriculture. | The quantity of food served for each individual shall meet minimum daily requirements as recommended by the United States Department of Agriculture, unless otherwise recommended in writing by a licensed physician.
| Groceries have been purchased to fit individuals needs and also remain in compliance. |
11/30/2022
| Implemented |
| 6400.174 | The home is not ensuring that at least one meal each day shall contain at least one item from the dairy, protein, fruits and vegetables and grain food groups, unless otherwise recommended in writing by a licensed physician for individuals. There is not adequate food available in the home to meet the requirements of meals containing daily, protein, fruits and vegetables, and grain food groups. | At least one meal each day shall contain at least one item from the dairy, protein, fruits and vegetables and grain food groups, unless otherwise recommended in writing by a licensed physician for individuals.
| Groceries have been purchased that include at least one item from the dairy, protein, fruits and vegetables and grain food groups, unless otherwise recommended in writing by a licensed physician for individuals. |
11/30/2022
| Implemented |
| 6400.181(a) | Individual #2 did not have an initial assessment completed within 1 year prior to or 60 calendar days after admission to the residential home. Individual #2 was admitted to the home on 1/9/22 and the individual's assessment was completed on 10/12/22. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Individual now has an assessment. |
11/30/2022
| Implemented |
| 6400.211(b)(1) | Individual #2's emergency information did not include the name, address, telephone number and relationship of a designated person to be contacted in case of emergency. | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
| Individuals face sheet and emergency plans were updated to reflect the name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. |
11/30/2022
| Implemented |
| 6400.211(b)(2) | Individual #2's emergency information did not include the name, address and telephone number of the individual's physician or source of health care. | Emergency information for each individual shall include the following: The name, address and telephone number of the individual's physician or source of health care. | Individual #2s face sheet and emergency plans were updated to reflect the name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. |
11/30/2022
| Implemented |
| 6400.211(b)(3) | Individual #2's emergency information did not include The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| Individuals face sheet and emergency plans were updated to reflect the name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. |
11/30/2022
| Implemented |
| 6400.211(b)(4) | Individual #2's emergency information did not include a copy of the individual's most recent annual physical examination. | Emergency information for each individual shall include the following: A copy of the individual's most recent annual physical examination.
| Individual will be scheduled for a physical to ensure compliance. |
11/30/2022
| Not Implemented |
| 6400.18(c) | The individual and persons designated by the individual were not notified within 24 hours of discovery of the medication errors including: medications, Divalproex SOD ER 250mg, take 1 tablet by mouth 3 times daily at 7a-3p-11p, Divalproex SOD ER 500mg tab, take 1 tablet by mouth 3 times daily at 7a-3p-11p and Clonidine HCL 0.2mg tablet, take 1 tablet by mouth 3 times daily at 7a-3p-11p being administered at the incorrect time of 11AM and not 11PM. | The individual and persons designated by the individual shall be notified within 24 hours of discovery of an incident relating to the individual. | All staff working in the home will have a medication training review that ensures they understand the basics of medication administration including the five rights by 12.2.22 by Director of residential services.
CEO and Director of residential worked with the pharmacy to get those times corrected between the dates of 10.27.22-11.4.22 |
12/02/2022
| Not Implemented |
| 6400.18(b)(2) | Medication errors were not reported through the Department's information management system or on a form specified by the Department with 72 hours of discovery by a staff person. Individual #2 is is prescribed Divalproex SOD ER 250mg tab, take 1 tablet by mouth 3 times daily at 7a-3p-11p, Divalproex SOD ER 500mg tab, take 1 tablet by mouth 3 times daily at 7a-3p-11p and Clonidine HCL 0.2mg tablet, take 1 tablet by mouth 3 times daily at 7a-3p-11p. The medications are not being administered at 11p as instructed. There is a handwritten 11AM next to the label on the 11PM blister pack doses for all three of the medications. CEO, indicated that the pharmacy made an error as no one takes medications at that time and the staff administer them at 11AM. There is no documentation of a physician's order changing the time of the administration of the three medications | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | The Director of Residential and CEO worked with the doctors and pharmacy who distribute medications for our individuals11.2722-11.4.22 to ensure these medications were up to date and reflected the same on the doctors orders and medications on hand. Staff was given a brief overview on the importance of adhering to medication practice guidelines. All staff will be given a medication administration overview by 12.2.22 to help refresh and enhance their skills. |
12/02/2022
| Not Implemented |
| 6400.32(c) | Individual #2 and Individual #4 are being financially exploited. Individual #2 receives food stamps in an unknown amount. Individual #2's parents maintain the individual's food stamp card in the parent's possession. Individual #2's parents will purchase food for the individual when the believe it is needed. Individual #2 has been placed in the home since 1/9/22 and the agency does not provide food for the individual as part of the individual's room and board as the individual receives food stamps. Individual #4 is being financially exploited. Individual #4 has resided in the home as a respite placement since 10/16/22, The home is not providing food for the individual. Individual #2 came to the home with limited food items including 11 I individual cups of applesauce, a container of hummus, a pack of whole wheat sandwich wraps, two half gallons of Almond Breeze milk, 2 cases of Bubbly sparkling water, 1 can of Campbells Italian Wedding Soup, a box of Sleepy time herbal tea bags, three bananas and a box of oatmeal with 5 packets. Individual #2 and Individual #4 do not have access to food consistent with meals that are nutritionally balanced or food consistent with a meal. Staff indicated that Individual #4 likes to eat food from WaWa and had a card to purchase food from WaWa if the individual desired something to eat. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | Room and board contracts will be updated as well as a team review of all individual funds reflecting appropriately that the individuals get what they need. |
11/30/2022
| Not Implemented |
| 6400.32(t) | Individual #2 and Individual #4 do not have access to food at any time. There was minimal food in the home. During the initial visit to the home on 10/13/22, individual #2 was the only individual residing in the home. At that time, there was load of bread, half a bag of pretzels, 1 pack of cheese, a package of frozen hamburger, 2 waffles, 6 pancakes, ¼ bag of rice, 1 turkey sausage breakfast, 2 servings of pancakes, an egg patty breakfast meal, condiments, and chocolate milk. Individual #4 moved into the home on 10/16/2022. During a subsequent visit to the home on 10/18/22, the food available for Individual #2 included: 1 bag of pretzels, 1 bag of marshmallows, half a bag of Chex mix, 7 boxes of Kool aid drink pouches, 1 box of yahoo chocolate milk, three half gallons of Twister juice, half a gallon of chocolate milk, a tub of Country Crock butter, 18 eggs, a Reese's Peanut Butter candy bar, a Kit Kat candy bar, a box of 8 popsicles and quart of chocolate ice-cream. During the visit on 10/18/22, the food available for Individual #4 included: 11 individual cups of applesauce, a container of hummus, a pack of whole wheat sandwich wraps, two half gallons of Almond Breeze milk, 2 cases of Bubbly sparkling water, 1 can of Campbells Italian Wedding Soup, a box of Sleepy time herbal tea bags, three bananas and a box of oatmeal with 5 packets. Individual #2 and Individual #4 do not have access to food consistent with meals that are nutritionally balanced or food consistent with a meal. | An individual has the right to access food at any time. | Groceries have been purchased. And individuals in the home have access to snacks and maintain at least three meals a day Team meetings are being scheduled to review individual funds and update Room and board contracts. |
11/30/2022
| Not Implemented |
| 6400.34(a) | Individual #2 was admitted to the home on 1/9/22 and Individual #4 was admitted to the home on 10/16/2022. The home did not inform and explain individual rights and the process to report a rights violation Individual #2 or Individual #4, and person designated by the individual, upon admission to the home. | 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. | Individuals have been informed of all rights and the process to report any violation, and who to report to. |
11/30/2022
| Not Implemented |
| 6400.46(a) | Staff #4 was hired on 7/11/22. Staff #4 did not receive training in General fire safety. | 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. | Staff is now Fire safety trainied. |
11/30/2022
| Not Implemented |
| 6400.46(b) | Staff #3 was hired on 2/12/2020. Is not trained annually by a fire safety expert fire safety. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Staff is now Fire safety trainied. |
11/30/2022
| Not Implemented |
| 6400.46(c) | Staff #4 was hired on 7/11/22. Staff #4 did not receive training in first aid techniques before working with individuals. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques. | Staff is scheduled for first aid training effective immediately. |
11/30/2022
| Not Implemented |
| 6400.51(b)(1) | Staff #4 was hired on 7/11/22. Staff #4 did not receive training in the application of Person-centered practices, community integration, individual choice and to develop and maintain relationships. | 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. | Staff is now trained on Person-centered practices, community integration, individual choice and to develop and maintain relationships. |
11/30/2022
| Not Implemented |
| 6400.51(b)(5) | Staff #4 was hired on 7/11/22. Staff #4 did not receive training in job related knowledge and skills specifically implementation of the individual service plan in if the staff works directly with an individual. | The orientation must encompass the following areas: Job-related knowledge and skills. | Staff is now trained job related knowledge and skills specifically implementation of the individual service plan in if the staff works directly with an individual. |
11/30/2022
| Not Implemented |
| 6400.52(c)(6) | Staff #3 did not receive annual training in the implementation of the individual plan if the person works directly with an individual. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Staff is now trained in the implementation of the individual plan. |
11/30/2022
| Not Implemented |
| 6400.165(c) | The home is not administering Individual #2's medications as prescribed. Individual #2 is prescribed Divalproex SOD ER 250mg tab, take 1 tablet by mouth 3 times daily at 7a-3p-11p, Divalproex SOD ER 500mg tab, take 1 tablet by mouth 3 times daily at 7a-3p-11p and Clonidine HCL 0.2mg tablet, take 1 tablet by mouth 3 times daily at 7a-3p-11p. The medications are not being administered at 11p as instructed. There is a handwritten 11AM next to the label on the 11PM blister pack doses for all three of the medications. Chief Executive Officer (CEO) indicated that the pharmacy made an error as no one takes medications at that time and the staff administer them at 11AM. There is no documentation of a physician's order changing the time of the administration of the three medications. | A prescription medication shall be administered as prescribed. | This error has been corrected and the updated documents and medications are in the home. |
11/30/2022
| Implemented |
| 6400.165(f) | Individual #2 is prescribed medications to treat symptoms of a diagnosed psychiatric illness, there is not a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | A Social Emotional support plan is currently being written for this individual that will address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. |
11/30/2022
| Implemented |
| 6400.165(g) | Individual #2 is prescribed to treat symptoms of a psychiatric illness. Individual #2 did not have a review of these medications by a licensed physician at least every 3 months. Individual #2 had review of these medications on 2/18/22, 4/14/22 and 9/22/22. The medication reviews that were completed did not include documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | 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 is being scheduled for a medication review effective immediately. |
11/30/2022
| Implemented |
| 6400.166(b) | Individual #2 is prescribed Acetaminophen 325mg, 2 tabs by mouth every 6 hours as needed for mild or moderate pain. This medication was administered to Individual #2 on 10/12/22 and 10/13/22 and was not documented on the Medication Administration Record. Missing information includes the Individual's name, the name of the prescriber, drug allergies, the name of medication, strength of medication, dosage form, dose of medication, route of medication, frequency of administration, administration times, diagnosis or purpose for the medication, including pro re nata, date and time of medication administration, name and initials of the person administering the medication, duration of treatment, if applicable, special instructions if applicable and side effects of the medication, if applicable.
Individual #4 is prescribed Aripiprazole 5mg, take one tablet by mouth every day, Vitamin D3 50mcg, take 1 tablet by mouth every day, Sertraline HCL 50mg tablet, take 1 tablet by mouth every day, Guanfacine HCL ER 2mg tablet, take 1 tablet by mouth every morning, Docusate Sodium 100mg soft gel, take 1 capsule by mouth twice a day. These medications are documented on Individual #4's Medication Administration Record (MAR), however the MAR does not include all of the required information. Missing information includes: This medication was not listed on Individual #3's medication administration record. These medications are not documented on the documented on the MAR. Missing information includes name of the prescriber, drug allergies, dose of medication, diagnosis or purpose for the medication, including pro re nata, special instructions if applicable and side effects of the medication, if applicable. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Between the dates of 10.27.22 and 11.4.22 CEO and Director of residential updated the MARs in the home to reflect the information in subsection Individual's name, the name of the prescriber, drug allergies, the name of medication, strength of medication, dosage form, dose of medication, route of medication, frequency of administration, administration times, diagnosis or purpose for the medication, including pro re nata, date and time of medication administration, name and initials of the person administering the medication, duration of treatment, if applicable, special instructions if applicable and side effects of the medication, if applicable are all present. Staff have also had a brief unofficial medication overview. An official refresher training will be done by 12.2.22 |
12/02/2022
| Implemented |
| 6400.167(a)(4) | The home is failing to administer medication at the prescribed time. Individual #2 is prescribed Divalproex SOD ER 250mg tab, take 1 tablet by mouth 3 times daily at 7a-3p-11p, Divalproex SOD ER 500mg tab, take 1 tablet by mouth 3 times daily at 7a-3p-11p and Clonidine HCL 0.2mg tablet, take 1 tablet by mouth 3 times daily at 7a-3p-11p. The medications are not being administered at 11p as instructed. There is a handwritten 11AM next to the label on the 11PM blister pack doses for all three of the medications. The Chief Executive Officer indicated that the pharmacy made an error as no one takes medications at that time and the staff administer them at 11AM. There is no order changing the time of the administration of the three medications. | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | Between the dates of 10.27.22 and 11.4.22 CEO and Director of residential updated the MARs and medications to reflect appropriate times. Staff have also had a brief unofficial medication overview. An official refresher training will be done by 12.2.22 |
12/02/2022
| Not Implemented |
| 6400.167(b) | Documentation of medication errors, follow-up action taken and the prescriber's response, is not kept in the individual's record. Individual #2 is prescribed Divalproex SOD ER 250mg tab, take 1 tablet by mouth 3 times daily at 7a-3p-11p, Divalproex SOD ER 500mg tab, take 1 tablet by mouth 3 times daily at 7a-3p-11p and Clonidine HCL 0.2mg tablet, take 1 tablet by mouth 3 times daily at 7a-3p-11p. The medications are not being administered at 11p as instructed. There is a handwritten 11AM next to the label on the 11PM blister pack doses for all three of the medications. The CEO indicated that the pharmacy made an error as no one takes medications at that time and the staff administer them at 11AM. There is no documentation of a physician's order changing the time of the administration of the three medications. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | Effective immediately (11.18.22) direct care staff, Director of Residential and CEO will ensure Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. |
11/18/2022
| Implemented |
| 6400.167(c) | Medication errors are not reported as an incident as specified in §6400.18(b) (relating to incident report and investigation). Individual #2 is prescribed Divalproex SOD ER 250mg tab, take 1 tablet by mouth 3 times daily at 7a-3p-11p, Divalproex SOD ER 500mg tab, take 1 tablet by mouth 3 times daily at 7a-3p-11p and Clonidine HCL 0.2mg tablet, take 1 tablet by mouth 3 times daily at 7a-3p-11p. The medications are not being administered at 11p as instructed. There is a handwritten 11AM next to the label on the 11PM blister pack doses for all three of the medications. Chief Executive Officer indicated that the pharmacy made an error as no one takes medications at that time and the staff administer them at 11AM. There is no documentation of a physician's order changing the time of the administration of the three medications. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | CEO and Director of residential worked with pharmacy, doctors and staff on updating medications and MARs to reflect appropriately the correct times.
Staff was given a brief overview. An official refresher training will be conducted by Director of Residential services by 12.2.22 |
12/02/2022
| Not Implemented |
| 6400.186 | The home is not implementing Individual #4's Individual Service Plan (ISP). Individual #4 was admitted to the home on 10/16/22. Individual #4's ISP indicates that the Individual is not safe with poisons and poisons need to be locked. Dial Complete Antibacterial soap was located on the bathroom counter. The label of the Dial soap provided direction to "If swallowed get medical help or contact Poison Control Center right away." | The home shall implement the individual plan, including revisions. | All poison items have been removed and replaced with options that are "poison safe". Any cleaning supplies are locked up. |
11/30/2022
| Implemented |
| 6400.196(a) | Individual #4 has a behavior support plan in place. Staff working in the home who implement and manage the behavior support component of an Individual #4'a plan are not trained in the use of the specific techniques or procedures that are used. | A staff person who implements or manages a behavior support component of an individual plan shall be trained in the use of the specific techniques or procedures that are used. | Staff were trained on the behavior supports required by individuals mother. Behavior specialist was not available in allotted time |
11/30/2022
| Implemented |
| 6400.213(1)(i) | Individual #2's individual record did not include the individual's height, weight, hair color, eye color, identifying marks, admission date, next if kin and a dated photograph. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | Individuals face sheet was updated to reflect the above mentioned items with a current photograph. |
11/30/2022
| Implemented |