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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | Individual #1's financial record stated that at the end of December 2019, she had $152.83 to her name in her spending account at the home. Her January 2020 starting balance in her spending account, stated she only had $128.41 in her home spending account. There is $24.42 unaccounted for and no explanation by way of financial log, resources or receipts, for where the missing money is. | (2) Disbursements made to or for the individual.
| Program Manager
What/How: Reviewed December and January Financials (Attachments #25-26) and determined that the error was not made by Eagle Valley. Note on the date of state survey (1/24/2020), only one page of Januarys financial records was located in the working logbook. The remainder of the documentation was filed in the home. Surveyor indicated a starting amount for January of $128.41. This was the starting balance for the page beginning on 1/20/2020. (Attachment #26, page 5). The actual starting balance for Jan 1, 2020 was $152.83 (Attachment #26, page 1). This is a difference of $24.42, which is accounted for via receipts of $30.00 (Attachment #26, page 8) for manicure less $5.58 of deposits documented (Attachment #26, page 1).
Plan to prevent future occurrences: This was not an error or violation due to adequate and accurate accounting of CLs finances. |
01/27/2020
| Implemented |
| 6400.80(b) | The deck immediately outside the back garage egress door, was covered in a sheet of ice, creating a hazardous condition outside of the egress door. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Program Specialist/Maintenance
What: Reviewed issue causing ice. Fixed issue causing ice.
When: 2/3/2020
How: PS observed that gutters were dripping above area that was icy due to a seam in the gutters. This was relayed to maintenance who was able to seal the seam to prevent any further dripping. Ice melt is kept at all homes to ensure staff are able to address any icy areas that they find to ensure safe and passable walkways. This area is not used as an entryway or exit from the home, as it is not a logical exit in the event of an emergency, nor is it a convenient entryway or exit to/from the home for daily use; therefore, it was overlooked when salting the morning of inspection. Maintenance completed repair of the gutter via a water-proof sealant on 2/3/2020, as this was the first warm enough day following inspection to utilize sealant. (See Attachment #31). |
02/03/2020
| Implemented |
| 6400.113(a) | Individual #2 had been residing with the agency, Eagle Valley Supportive Living, since 2015. Individual #1 recently moved into this specific residential home location on 6/9/19. Upon moving into the new residential location, there is no evidence that the individual received training in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place, and smoking safety procedures specific to this home upon admission to the specific home. He did not receive said training until 1/1/2020, outside the regulatory requirements. | 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. | Program Specialist reviewed policy related to Fire Safety Training and updated to include transfer to another home to clarify and direct to need for updated fire safety training upon move to a new home, even within the same Program. (See Attachment #32) |
03/20/2020
| Implemented |
| 6400.144 | REPEAT from 1/3/2019 annual inspection: The agency, Eagle Valley Supportive Living, is responsible to ensure 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 failed to provide health services to Individual #1 as evidenced by the following:
-Individual #1's physician ordered the agency to gather Individual #1's weight daily, starting 4/3/19. There were weekly occurrences where there individual was physical at her residential home location and the agency staff did not attempt to have the individual weigh herself and log the data. The agency recorded that the individual was on vacation for many days during the month and that's why the individual's weight could not be obtained. However, the individual's program specialist, Staff #1, confirmed during the inspection that the individual was home on most of the days where the individual's weight was not obtained or attempted to be obtained.
-Individual #1's podiatrist stated on 4/24/19 that the individual was to return in 2 months for continued treatment and monitoring. The individual's podiatrist also recorded his diagnoses of the 4/24/19 to include, "Onychomycosis, pain in limb, LE {lower extremity} edema, no open wound, nails debrided, diffuse itchy dry skin." Onychomycosis is a nail fungal infection that requires the constant monitoring of a podiatrist or physician. LE edema is a medical condition of swelling in the lower extremities that could cause additional pain and requires monitoring from a medical professional. At the time of the 1/22/2020 inspection, Individual #1 never returned to her podiatrist or any other medical professional to monitor and treat her symptoms described by her podiatrist on 4/24/19. There was a note in the individual's record that stated, a podiatrist came to Individual #1's residence to complete foot care however Individual #1's mother refused to have the individual seen by said doctor. Individual #1's mother is not a medical power of attorney nor her legal guardian and does not have the legal authority to refuse medical treatment to her daughter, Individual #1.
-On 5/2/19 Individual #1's physician signed and dated an appointment summary form that stated, "please address the following: multi-vitamin daily, otc {over the counter} pain management for menstrual cramps, headache, etc, and otc treatment for fever." According to the individual's May 2019 medication administration record (mar), Individual #1 did not start taking a multi-vitamin daily until 5/21/19 with no evidence in the delay.
-On 8/13/19 Individual #1's physician stated the individual was to return in 3 months. At the time of the 1/22/2020 inspection, there is no evidence that the individual returned to her physician. | 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.
| Program Specialist
What: Encouraged CL to attend Podiatry appointment (Attachment #29), updated weight checks
When: 1/30/2020
How: Reminded CL of her right to refuse any part of treatment at time of service. She opted to refuse nail trimming but did allow debridement of her nails (Attachment #29). She then participated in a pedicure later for Night to Shine per her preference. Additionally, her weight checks were reviewed and changed to weekly (See Attachment #7,9) and may be completed at any time of day (set for 8pm in March to allow any staff to obtain) to allow consistent monitoring of her weight while still providing ample opportunity to visit outside the facility if she desires. CL has an appointment scheduled for April 3, 2020 for her annual physical but in light of the COVID-19 Pandemic, this will likely be re-scheduled until such time that the benefit of being seen in her physicians office outweighs the current risk of contracting the virus
Plan to prevent future occurrence: Team meeting was held to ensure that CLs family is aware of the importance of ensuring that all paperwork is brought back to the home and that it is imperative that staff attend appointments with CL to ensure that all necessary paperwork is maintained, as some of the issues pertaining to this violation are related to missing documentation due to not receiving from family. (See Attachment #30). This indicates that CLs mother would like to be notified of all appointments, so that she can meet her. |
01/30/2020
| Implemented |
| 6400.151(c)(3) | Staff #2's 6/28/19 physical examination did not include a signed statement that the staff person is free of communicable diseases or specific precautions that should be taken to prevent the spread of diseases to individuals. | 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. | Human Resources Director, Program Manager, Program Specialist
What: Updated existing Policy
When: 3/20/2020
How: Reviewed current policy to determine how blanks were missed. Determined that there was no official review procedure that would provide a checks/balance system to ensure that forms are appropriately filled out by the physicians. Included a Form Review Procedure for the Staff Health and Individual Physical Exam policies. Additionally, reviewed form for Staff physicals and adjusted to ensure that Date of Exam is clearly documented to ensure that the exam was performed within the 1-year time frame. Included is the first Resident Physical form completed and reviewed per the updated policy (Attachment #15) and the policies updated in response (Attachments #16-18). In response to the COVID-19 pandemic, there were no recent staff physicals to review in conjunction with the new review policy.
Plan to prevent future occurrences: Policy was updated and PS and PM were educated in the double-review process of all physical forms being submitted for regulatory purposes. |
03/20/2020
| Implemented |
| 6400.151(c)(4) | Staff #2's 6/28/19 physical examination did not include information of medical problems which might interfere with the health of the individuals. Any section on the physical examination document pertaining to this requirement, was left blank. | The physical examination shall include: Information of medical problems which might interfere with the health of the individuals. | Human Resources Director, Program Manager, Program Specialist
What: Updated existing Policy
When: 3/20/2020
How: Reviewed current policy to determine how blanks were missed. Determined that there was no official review procedure that would provide a checks/balance system to ensure that forms are appropriately filled out by the physicians. Included a Form Review Procedure for the Staff Health and Individual Physical Exam policies. Additionally, reviewed form for Staff physicals and adjusted to ensure that Date of Exam is clearly documented to ensure that the exam was performed within the 1-year time frame. Included is the first Resident Physical form completed and reviewed per the updated policy (Attachment #15) and the policies updated in response (Attachments #16-18). In response to the COVID-19 pandemic, there were no recent staff physicals to review in conjunction with the new review policy.
Plan to prevent future occurrences: Policy was updated and PS and PM were educated in the double-review process of all physical forms being submitted for regulatory purposes. |
03/20/2020
| Implemented |
| 6400.181(e)(12) | Individual #1's 4/19/19 assessment did not include recommendations for services, training, and programing. This section was left blank and the required information could not be found throughout her entire assessment. Staff #1, the program specialist responsible for creatine the individual's assessments, confirmed on 1/23/2020 this required, regulatory information was not included in Individual #1's 4/19/19 assessment. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Program Specialist
What: Updated Annual Assessment to include Recommendation section as mandated.
When: February annual review date. Annual Assessment completed and submitted on 2/25/2020.
How: Program Specialist wrote updated Annual Assessment (Attachment #28) in conjunction with annual review date per ISP timeline.
Plan to prevent future occurrences: Program Specialist wrote the annual almost 45 days prior to due date. This is unusual practice and should not occur again. This was completed early in an attempt to keep the Annual Assessment in alignment with her usual ISP review date. In doing so, Program Specialist completed the assessment in a hurry and overlooked this one section. This should not again occur in the future. |
02/25/2020
| Implemented |
| 6400.46(b) | Staff #2 has been employed with the agency since 2016 and requires annual fire safety trainings covering content described in 6400.46(a). Staff #2 received fire safety training on 4/29/19 and there is no evidence of her receiving said training in 2018; which is outside the annual timeframe requirement. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Program Manager/Program Specialist
What: Reviewed annual training records. Staff person in question did complete her fire safety training in 2018 but did not attend the annual fire training session held by Swartz. She instead completed the OSHA workplace Fire Safety video and quiz. (Attachment #31). This was deemed unacceptable at licensing survey. The employee in question also completed her fire safety requirement in 2019 via the video and quiz. In response to this violation as well as the expectation in the 6100 regulations to ensure that fire safety training is performed by a fire safety expert,¿ Eagle Valley has re-structured the fire safety training.
How: Eagle Valley has designated 3 individuals to participate in a training webinar to become a certified fire safety expert. Program Manager for CHS has completed this training on 3/19/2020 (Still awaiting certificate to be issued). Additionally, she is creating a new fire training curriculum. (Attachment #23, #31). This will be administered to all new staff upon hire and each existing staff annually by one of our fire safety experts.
Plan to prevent future occurrence: It is expected that with restructuring the fire safety curriculum within the program, the issue of not having an adequate fire safety training process should no longer be an issue.
*Certificate will be forwarded upon receipt. Awaiting via email. |
03/19/2020
| Implemented |
| 6400.50(a) | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending was not kept, as required, for every training topic for some staff.
Staff #11's training record only included a training log, with a list of training topics he was trained on. The content discussed for each training listed was not kept for: annual mandatory in-service, human services training quiz 1-3, DHS competency test, osha, medication training, non-oral medication training. The training record did not include who the trainer was for any of the topics except the annual mandatory in-service training. Staff #11's training record also listed that he received 15 hours of medication training in one day, 12/1/19. According to program specialist, Staff #1, this didn't all occur on 12/1/19. His training record does not list out each date he received the training, the content, trainer, length of training etc. for each day. Staff #11's training record also listed that she received 17 hours of training on 12/1/19.
Staff #1 and #2's training record also doesn't include the trainer for their human services quiz 1-3 held within the training year. | 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. | Program Specialist/Program Manager
What: PS reviewed current system for keeping training records. Program Manager redesigned filing system for training records with input from PS following review
When: January/Feb, 2020
How: Upon close review of the training system in place, PS determined that training sheets were not kept for all training topics. PS consistently utilized the training sheets and documentation for training topics that she mandated, but PM did not consistently do the same. Her training records contained only content and were kept separate from PS training records. This led to a separation of training information that didnt effectively allow for retrieval when needed. Upon review, it was determined that all training materials were kept (photos of 2019 training binder Attachment #24). PS re-assigned filing and document maintenance of ALL training materials to be the PMs responsibility to prevent further inhibition of effective and adequate filing. Her new system employs the training sheet, with the attached content for each training topic to ensure effective retrieval of needed training records. (Binder for 2020, Attachment #24)
Plan to prevent future occurrences: By restructuring the responsibilities of the Program Manager, it is expected that without interference from the Program Specialist this should not occur in the future. PS shall oversee the documentation of training materials in conjunction with PM.
*System was corrected following inspection date and has been implemented retroactively for the duration of January through March (to date). |
01/31/2020
| Implemented |
| 6400.165(c) | Individual #1's medications must be administered as prescribed. She is prescribed Ashlyna, take 1 tablet by mouth once daily for period regulation. According to the individual's record, there were three, different medication administration records (mars; where staff record if the medication was administered the to the individual and by whom) for May 2019. Due to this, there were multiple staff initialing as administering Ashlyna to Individual #1 on 5/4/19, 5/5/19, and 5/6/19 on multiple mars, indicating that the medication dosage was doubled and tripled; not how the medication was prescribed. None of the individual's mars recorded an explanation for why there was three, separate mars or why multiple staff initialed as administering the individual's Ashlyna more than the prescribed dosage.
- Staff #4 signed two out of the three mars on 5/4/19 recording that the medication was administered at 8Am, twice, therefore double the prescribed dose.
- Staff #5 signed all three 5/5/19 mars for Individual #1, stating that she administered three doses of Ashlyna at 8AM; not the doctor's order.
- Staff #5 and #10 both signed two different 5/6/19 mars indicating both of the staff administered Ashlyna at 8AM to the individual; not the doctor's order.
Individual #1's April 2019 mar stated that Metformin 500mg was administered at 8AM on 4/3/19 and 4/4/19, 1000mg on 4/5/19 and 4/6/19, then 2000mg from 4/7/19-current, 1/22/2020. The agency provided a doctor's order stating, Metformin 1000mg tablet, take 1 tab by mouth 2 times a day with morning and evening meals was prescribed on 4/11/19. There is no evidence that Metformin was prescribed prior to 4/11/19 or an explanation for why Individual #1 was administered Metformin starting on 4/3/19. Per program specialist, Staff #1, on 1/22/2020, Individual #1's mother brought the Metformin to the residential home on 4/3/19 and agency staff administered the medication to Individual #1, without a doctor's order to do so.
Individual #1's Meformin 1000mg dose was not administered at 4PM on 4/12/19 and 10/7/19. There is no evidence why the medication was not administered. A medication error was never completed, referenced under 6400.167(b). | A prescription medication shall be administered as prescribed. | Program Manager/Program Specialist
What: PM Reviewed MARS weekly following inspection through the months of February and March, 2020 (Attachment #14) while Program Specialist worked with documentation system to get EMAR up and running for the facility. Slated to start on April 1, 2020.
When: Feb 1-Mar 31, 2020
How: Beginning Feb 1, 2020, Program Manager was tasked with Weekly MAR checks (Attachments #14) to oversee the MARs during transition from a paper MAR system to a digital EMAR system. This was decided based on the illegibility of MARs reviewed upon inspection and administration felt that EMAR would be a cleaner, more governable format for maintaining the MARs. Program Specialist formatted all medications in the current documentation system to be compatible with the EMAR program offered by the current documentation system. A pilot date was set for 2/27/2020, which allowed paper MARs to be maintained through the month of March while allowing Team Leaders, initially, to be inputting medication administration into EMAR using the EMAR system. After a 2-week trial period involving only Team Leaders, all remaining staff were instructed to utilize the EMAR system as well, while maintaining formal paper MARs. During the pilot period, a number of issues were noted, and Program Specialist worked with documentation system programmers to rectify issues and ensure that the EMAR system was going to be a satisfactory replacement for current paper MAR system. By March 20, 2020, it seemed that all issues with the programming related to EMAR had been resolved, which allowed all staff 11 more days in the pilot period before completing the full transition on April 1, 2020.
Plan to prevent future occurrences: Transitioning to EMAR will alleviate many of the issues with the current MAR system, specifically illegibility on the MAR, passing and documenting meds passed at time of admission, master log signatures with appropriate initials, recording date and time of all medications, and indicating dosage for medications that allow flexibility of dose dependent upon severity of symptoms. EMAR prints neatly and legibly, requires that medications are passed and confirmed within the time frame set by the provider (2 hour window per Medication administration course), maintains master signature log based on current staff list at the bottom of each MAR, records date and time of administration of meds in real time as meds are passed, and prompts for units for any medication with flexibility of administration such as novolog, decongestants and pain relievers. As administration can review all MARs at any time in real time, EMARs allow more managerial oversight, which will reduce or eliminate issues with the presentation of the MAR when completed. (Attachment 9,10) March 20, 2020 PS confirmed that EMAR was running smoothly. EMAR will officially replace paper MARS on April 1, 2020
Attachments: 7-10, 14, 20-22 |
03/20/2020
| Implemented |
| 6400.166(a)(7) | Staff #6 initialed on Individual #1's July 28, 2019 medication administration record (mar) that "ibuprofen 200mg 2 or 3 tablets by mouth for pain/fever every 4-6 hours as needed," was administered at 10AM. However, Staff #6 did not record the number of pills that she administered, thus not recording the dosage of medication she administered.
Staff #7 initialed the individual's mar stating she administered Ibuprofen to the individual on 6/30/19 but did not include the number of pills she administered. Staff #7 only recorded her initials and administration time of "7:15." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Program Manager/Program Specialist
What: PM Reviewed MARS weekly following inspection through the months of February and March, 2020 (Attachment #14) while Program Specialist worked with documentation system to get EMAR up and running for the facility. Slated to start on April 1, 2020.
When: Feb 1-Mar 31, 2020
How: Beginning Feb 1, 2020, Program Manager was tasked with Weekly MAR checks (Attachments #14) to oversee the MARs during transition from a paper MAR system to a digital EMAR system. This was decided based on the illegibility of MARs reviewed upon inspection and administration felt that EMAR would be a cleaner, more governable format for maintaining the MARs. Program Specialist formatted all medications in the current documentation system to be compatible with the EMAR program offered by the current documentation system. A pilot date was set for 2/27/2020, which allowed paper MARs to be maintained through the month of March while allowing Team Leaders, initially, to be inputting medication administration into EMAR using the EMAR system. After a 2-week trial period involving only Team Leaders, all remaining staff were instructed to utilize the EMAR system as well, while maintaining formal paper MARs. During the pilot period, a number of issues were noted, and Program Specialist worked with documentation system programmers to rectify issues and ensure that the EMAR system was going to be a satisfactory replacement for current paper MAR system. By March 20, 2020, it seemed that all issues with the programming related to EMAR had been resolved, which allowed all staff 11 more days in the pilot period before completing the full transition on April 1, 2020.
Plan to prevent future occurrences: Transitioning to EMAR will alleviate many of the issues with the current MAR system, specifically illegibility on the MAR, passing and documenting meds passed at time of admission, master log signatures with appropriate initials, recording date and time of all medications, and indicating dosage for medications that allow flexibility of dose dependent upon severity of symptoms. EMAR prints neatly and legibly, requires that medications are passed and confirmed within the time frame set by the provider (2 hour window per Medication administration course), maintains master signature log based on current staff list at the bottom of each MAR, records date and time of administration of meds in real time as meds are passed, and prompts for units for any medication with flexibility of administration such as novolog, decongestants and pain relievers. As administration can review all MARs at any time in real time, EMARs allow more managerial oversight, which will reduce or eliminate issues with the presentation of the MAR when completed. (Attachment 9,10) March 20, 2020 PS confirmed that EMAR was running smoothly. EMAR will officially replace paper MARS on April 1, 2020
Attachments: 7-10, 14, 20-22 |
03/20/2020
| Implemented |
| 6400.166(a)(12) | Individual #1's medication administration record (mar) shall include the date and time of administration for each medication administration. Individual #1's mars throughout the year have a few instances where the time of administration was not recorded for some medications. The following are examples of when the date and/or time was not recorded on the individual's mar:
-On one of Individual #1's May 2019 mars, Staff #4 initialed as administering Ashlyna to the individual on 5/4/19 and Staff #5 administered the same medication on 5/5/19. The time of administration was not recorded on the mar.
-Staff #7 initialed the individual's mar stating she administered Ibuprofen to the individual on 6/30/19 but did not include the time the medication was administered to Individual #1. Staff #7 only recorded her initials and administration time of "7:15", and did not include AM or PM. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | Program Manager/Program Specialist
What: PM Reviewed MARS weekly following inspection through the months of February and March, 2020 (Attachment #14) while Program Specialist worked with documentation system to get EMAR up and running for the facility. Slated to start on April 1, 2020.
When: Feb 1-Mar 31, 2020
How: Beginning Feb 1, 2020, Program Manager was tasked with Weekly MAR checks (Attachments #14) to oversee the MARs during transition from a paper MAR system to a digital EMAR system. This was decided based on the illegibility of MARs reviewed upon inspection and administration felt that EMAR would be a cleaner, more governable format for maintaining the MARs. Program Specialist formatted all medications in the current documentation system to be compatible with the EMAR program offered by the current documentation system. A pilot date was set for 2/27/2020, which allowed paper MARs to be maintained through the month of March while allowing Team Leaders, initially, to be inputting medication administration into EMAR using the EMAR system. After a 2-week trial period involving only Team Leaders, all remaining staff were instructed to utilize the EMAR system as well, while maintaining formal paper MARs. During the pilot period, a number of issues were noted, and Program Specialist worked with documentation system programmers to rectify issues and ensure that the EMAR system was going to be a satisfactory replacement for current paper MAR system. By March 20, 2020, it seemed that all issues with the programming related to EMAR had been resolved, which allowed all staff 11 more days in the pilot period before completing the full transition on April 1, 2020.
Plan to prevent future occurrences: Transitioning to EMAR will alleviate many of the issues with the current MAR system, specifically illegibility on the MAR, passing and documenting meds passed at time of admission, master log signatures with appropriate initials, recording date and time of all medications, and indicating dosage for medications that allow flexibility of dose dependent upon severity of symptoms. EMAR prints neatly and legibly, requires that medications are passed and confirmed within the time frame set by the provider (2 hour window per Medication administration course), maintains master signature log based on current staff list at the bottom of each MAR, records date and time of administration of meds in real time as meds are passed, and prompts for units for any medication with flexibility of administration such as novolog, decongestants and pain relievers. As administration can review all MARs at any time in real time, EMARs allow more managerial oversight, which will reduce or eliminate issues with the presentation of the MAR when completed. (Attachment 9,10) March 20, 2020 PS confirmed that EMAR was running smoothly. EMAR will officially replace paper MARS on April 1, 2020
Attachments: 7-10, 14, 20-22 |
03/20/2020
| Implemented |
| 6400.166(a)(13) | Individual #1's medication administration record (mar), or master staff identification list that can be kept by the agency to identify the staff administering medications, did not include the name and initials of the person administering the medication to the individual on a few occasions throughout the previous year. The following are examples of said scenario:
-Staff #3, administered Metformin 1000mg to Individual #1 at 4PM on 12/14/19 but did not record their initials or name.
-Unidentifiable letters were recorded on Individual #1's 11/20/19 for the administration of Metformin 1000mg to Individual #1 at 4PM. There is no evidence that the individual refused this medication. | 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. | Program Manager/Program Specialist
What: PM Reviewed MARS weekly following inspection through the months of February and March, 2020 (Attachment #14) while Program Specialist worked with documentation system to get EMAR up and running for the facility. Slated to start on April 1, 2020.
When: Feb 1-Mar 31, 2020
How: Beginning Feb 1, 2020, Program Manager was tasked with Weekly MAR checks (Attachments #14) to oversee the MARs during transition from a paper MAR system to a digital EMAR system. This was decided based on the illegibility of MARs reviewed upon inspection and administration felt that EMAR would be a cleaner, more governable format for maintaining the MARs. Program Specialist formatted all medications in the current documentation system to be compatible with the EMAR program offered by the current documentation system. A pilot date was set for 2/27/2020, which allowed paper MARs to be maintained through the month of March while allowing Team Leaders, initially, to be inputting medication administration into EMAR using the EMAR system. After a 2-week trial period involving only Team Leaders, all remaining staff were instructed to utilize the EMAR system as well, while maintaining formal paper MARs. During the pilot period, a number of issues were noted, and Program Specialist worked with documentation system programmers to rectify issues and ensure that the EMAR system was going to be a satisfactory replacement for current paper MAR system. By March 20, 2020, it seemed that all issues with the programming related to EMAR had been resolved, which allowed all staff 11 more days in the pilot period before completing the full transition on April 1, 2020.
Plan to prevent future occurrences: Transitioning to EMAR will alleviate many of the issues with the current MAR system, specifically illegibility on the MAR, passing and documenting meds passed at time of admission, master log signatures with appropriate initials, recording date and time of all medications, and indicating dosage for medications that allow flexibility of dose dependent upon severity of symptoms. EMAR prints neatly and legibly, requires that medications are passed and confirmed within the time frame set by the provider (2 hour window per Medication administration course), maintains master signature log based on current staff list at the bottom of each MAR, records date and time of administration of meds in real time as meds are passed, and prompts for units for any medication with flexibility of administration such as novolog, decongestants and pain relievers. As administration can review all MARs at any time in real time, EMARs allow more managerial oversight, which will reduce or eliminate issues with the presentation of the MAR when completed. (Attachment 9,10) March 20, 2020 PS confirmed that EMAR was running smoothly. EMAR will officially replace paper MARS on April 1, 2020
Attachments: 7-10, 14, 20-22 |
03/20/2020
| Implemented |
| 6400.166(b) | When medications are administered to Individual #1, all requirements described under 6400.166(a)(12) and (a)(13) must be recorded at the time of administration. If the individual is not administered medication, staff should not record their initials on the individual's medication administration record (mar). Staff #8 recorded on Individual #1's mar as administering all the individual's medications to her on 10/6/19. However, Individual #1 was out of program and this could not have occurred. The individual's mar stated that she was on vacation on 10/7/19. Per Staff #1, the individual was out of program on 10/6/19 and medications were not administered to her via agency staff. Individual #1 was in the agency's care on 10/7/19, however, staff initialed on the 10/6/19 mar for when they administered the individual's medications on the 7th. The correct date and time and name and initials of the person administering the medication must be accurate at the time of administration and it was not.
Staff #9 initialed on Individual #1's mar as administering Metformin at 4PM to the individual on 12/14/19 and 11/20/19. However, her signature was illegible and the mar did not include the initials of Staff #9 to identify the name of the person administering the medication. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Program Manager/Program Specialist
What: PM Reviewed MARS weekly following inspection through the months of February and March, 2020 (Attachment #14) while Program Specialist worked with documentation system to get EMAR up and running for the facility. Slated to start on April 1, 2020.
When: Feb 1-Mar 31, 2020
How: Beginning Feb 1, 2020, Program Manager was tasked with Weekly MAR checks (Attachments #14) to oversee the MARs during transition from a paper MAR system to a digital EMAR system. This was decided based on the illegibility of MARs reviewed upon inspection and administration felt that EMAR would be a cleaner, more governable format for maintaining the MARs. Program Specialist formatted all medications in the current documentation system to be compatible with the EMAR program offered by the current documentation system. A pilot date was set for 2/27/2020, which allowed paper MARs to be maintained through the month of March while allowing Team Leaders, initially, to be inputting medication administration into EMAR using the EMAR system. After a 2-week trial period involving only Team Leaders, all remaining staff were instructed to utilize the EMAR system as well, while maintaining formal paper MARs. During the pilot period, a number of issues were noted, and Program Specialist worked with documentation system programmers to rectify issues and ensure that the EMAR system was going to be a satisfactory replacement for current paper MAR system. By March 20, 2020, it seemed that all issues with the programming related to EMAR had been resolved, which allowed all staff 11 more days in the pilot period before completing the full transition on April 1, 2020.
Plan to prevent future occurrences: Transitioning to EMAR will alleviate many of the issues with the current MAR system, specifically illegibility on the MAR, passing and documenting meds passed at time of admission, master log signatures with appropriate initials, recording date and time of all medications, and indicating dosage for medications that allow flexibility of dose dependent upon severity of symptoms. EMAR prints neatly and legibly, requires that medications are passed and confirmed within the time frame set by the provider (2 hour window per Medication administration course), maintains master signature log based on current staff list at the bottom of each MAR, records date and time of administration of meds in real time as meds are passed, and prompts for units for any medication with flexibility of administration such as novolog, decongestants and pain relievers. As administration can review all MARs at any time in real time, EMARs allow more managerial oversight, which will reduce or eliminate issues with the presentation of the MAR when completed. (Attachment 9,10) March 20, 2020 PS confirmed that EMAR was running smoothly. EMAR will officially replace paper MARS on April 1, 2020
Attachments: 7-10, 14, 20-22 |
03/20/2020
| Implemented |
| 6400.167(b) | Individual #1's Meformin 1000mg dose was not administered at 4PM on 4/12/19 and 10/7/19. There is no evidence why the medication was not administered. Documentation of the medication errors, follow up action taken and the prescriber's response was never completed. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | Program Specialist
What: Reviewed dates suspected of medication errors due to blanks on MARs
When: Reviewed following inspection between 1/24/2020 and 1/29/2020
How: Medications are routinely and systematically monitored for accuracy of administration via single dose packs, prepared by the pharmacy. Medication errors are most often recognized in this manner (med not popped from appropriate date). All medication passes in question can be verified as being appropriately administered via recognizing the ¿dot¿ placed in each box (placed when medication is poured into the medication cup) as well as the confirmation of count of medications being appropriate, with the exception of 8pm medications on 1/19/2020. This was an error of omission and was recognized promptly at 7:30am on 1/20/2020 during routine daily review of MARs by the Team Leader at the home when blanks were noted in the MAR. Eagle Valley staff are trained to dot each med as they are popped into the cup. This had not been done on the evening of 1/19/2020 and no initials were present. This prompted an investigation of the medication packs by the Team Leader, who noted that all medications dated for 1/19/2020 had remained in the dose packs. Narcotic record was reviewed as well and indicated that narcotic medication for 8pm was also omitted. Immediately upon report to PS, administering staff from the previous evening was contacted and returned into work to review with PS and determined that she must have forgotton to pass meds, though she thought she had. Following confirmation of medication error of omission, and EIM report was filed (Incident #8645603). Appropriate follow-up was completed and Staff in question was pulled from medications, retrained and counseled until 4 observations deemed her to be in compliance with medication administration procedures. She was also instructed to set an alarm on her phone to ensure that she was reminded to administer medications at the appropriate time. Observations were completed on 2/7/2020.
Plan to prevent future occurrence: Eagle Valley is transitioning to an EMAR system to ensure more oversight by administration. Program Specialist has marshalled the transition for all staff and has communicated with Tabula (documentation system currently in place) to ensure a smooth transition. The additional layer of administrative oversight will allow closer review of MARs on a real-time basis which will enable recognition of blank MAR spaces in a more timely manner, therefore alleviating the likelihood of blanks being misinterpreted as Medication errors. As of March 20, 2020, EMAR system in place is effective. Paper MARS were maintained for the duration of the month of March and April 1 will be transition date for EMAR system to replace paper MAR system. (See attachments #11-13) |
03/20/2020
| Implemented |
| 6400.186 | Implementing Individual #1's plans as written is a responsibility of the agency, Eagle Valley Supportive Living, to ensure that the agency is providing the care required and decided upon by the individual's team members. Failing to do so, could jeopardize the individual's health and safety.
Individual #1's 4/19/19 assessment created by agency Staff #1 explains in detail the need for staff to assist her in checking the individual's skin integrity to prevent further harm. Her assessment states, "{Individual #1} is morbidly obese and as a result, may experience breakdown of the skin under her belly folds, breasts and or groin area. Staff must check these areas about weekly to ensure skin integrity is intact," "{Individual #1} is morbidly obese and therefore may require assistance in monitoring her skin for breakdown especially under her belly folds, breasts and in her groin area. Due to high threshold for pain, she may not recognize discomfort in these areas in a timely fashion to enable swift treatment of any excoriation she may be experiencing," "{Individual #1} historically has had lesions that have become infected due to her lack of pain sensation and awareness of the severity of the lesion," and "{Individual #1} does require staff supports related to showering via skin checks on a weekly basis to ensure skin remains intact." Per program specialist, Staff #1, on 1/23/2020, staff are only completing monthly skin checks, not weekly skin checks as the individual's plan describes.
Individual #1's Individual Plan contains a component referencing her Restrictive Procedure Plan (RPP) to be implemented by the agency. The individual's RPP approved by the Human Rights Committee (HRC; the required committee to approve restrictive plans) on 3/5/19 for implementation on 4/2/19 stated "staff are to complete safety checks each day. These safety checks include checking {Individual #1's} bedroom for stolen food and drinks and checking her backpack or other bags to be sure that she has not brought food or drinks into the home with her." There is no evidence that the safety checks described above, are completed daily.
Individual #1's Individual Plan also states that the individual has a behavior support protocol (different from her RPP) to be implemented by the agency. The behavior support protocol states "staff will complete safety checks each day. They include checking her bedroom for stolen food and drinks and checking her backpack or other bag to be sure that she has not brought food or drinks into the home with her. Addendum as of 11/6/19 safety checks will also include checking the pockets of {Individual #1's} clothing and outerwear. If i{Individual #1} is outside the home with staff or others, upon re-entering the home staff will begin the safety check immediately in the following steps" ask the individual to place her bags on the table to be checked, ask the individual to place her coat/outerwear on the table to be checked, ask the individual to empty her pants pockets (asking her to pull the pockets out of her pants is helpful in ensuring that all contents of her pockets have been emptied.) Staff will then check the individual's bag(s) and outerwear for wrappers, food, drinks, etc. If empty packaging or wrappers are found, staff will calculate the total calorie amount and record this information on her calorie log. Bedroom checks will occur one per day, even if the individual has agreed to have her pockets and bags checks." At the time of the 1/22/2020 inspection, there is no evidence that this is being done. Staff #1 confirmed that the above protocol is not being implemented as written. | The home shall implement the individual plan, including revisions. | Program Manager/Program Specialist
What: Update MAR to reflect safety checks (PRN and daily routine). Update Annual Assessment accordingly.
How: Program Manager updated documentation system to include Daily Room checks in the Treatment Administration Record and also included a PRN safety check to be documented upon return to facility at any time she is out of the building (See Attachments #7,9). Program Specialist had determined via skin check in June that as a result of clear skin checks for greater than 2 months and observation of adequate daily hygiene, could reduce to the company standard of monthly skin checks. This began on 7/1/19 and has continued monthly See Attachment # 27). Annual Assessment had not been updated to reflect the change. This error was corrected in Feb, 2020 with Annual update of Assessment (Attachment #28)
Plan to prevent future occurrences: Program Specialist will review the annual assessment in conjunction with each quarterly review to ensure that the Annual Assessment contains accurate information. This was an oversight by Program Specialist in the midst of 2 admissions in the span of 2 months. This will be more clearly managed in her calendar to ensure this does not occur in the future.
Attachments 7,9,27,28 |
02/25/2020
| Implemented |
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