| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.71(a)(7) | At time of inspection on 3/26/24 the blood pressure for both Individual #1 and Individual #2 was being taken two times per day with results to be recorded on the agency "Vital Information Log." Both Individual #1 and Individual #2 had Vital Information Logs dated March 2024 with values entered from 3/1/24-3/26/24-AM.
The same Rite Aid /Omron RC212 blood pressure monitor was used for both Individuals. According to the Instruction Manual for the device a total of 30 readings could be held in the memory function of the device.
Given the 30-reading memory and both Individuals using the device, the numbers in the memory would span from 3/19/24-AM to 3/26/24-AM; a total of 15 readings per Individual.
A comparison of the documented readings and those in the memory of the machine reveled that the numbers documented on the Vital Information Logs for both Individual #1 and Individual #2 did not match with those in the memory of the device.
Of the 30 total numbers in the memory only three could be verified as consistent with the numbers recorded on the Vital Information Logs for the specified time period.
When the discrepancies were pointed out to Staff #1 on 3/26/24 they noted possible reasons for the discrepancies as Individual #2 sometimes moving around a lot and staff not getting an accurate reading. When the inconsistent entries were discussed with Staff #1 again on 4/4/24 they stated that the inconsistencies were likely due to changing the batteries of the device.
No further explanation for the discrepancies could be determined. | The Department may deny, refuse to renew or revoke a certificate of compliance for fraud or deceit in obtaining or attempting to obtain a certificate of compliance. | The agency filed an EIM based on the Licensing Representative findings. The EIM was filed for neglect as it was alleged that staff were not recording the actual readings from the BP recording device. Staff reported that they always measured the BP for both individuals and recorded what was on the device on the paper log. Please see the attached EIM for the full report and findings. The agency contacted the individual's Physician to clarify the need and frequency for BP monitorings. The agency retrained the staff at the home as to following the physicians orders for both individuals. Please see attached documents for each Individual as well as the training documents. |
04/18/2024
| Implemented |
| 20.71(a)(1) | Licensing representative (LR) spoke to Staff #1 on 4/4/24 at the provider office for the purpose of investigation and interview. At the conclusion of the interview Staff #1 was handed witness statement forms so that they may provide their written witness statement while LR interviewed two other staff members. At the conclusion of the day the witness statement was not received from Staff #1. An email request was then sent to Staff #1 on 4/12/24 for the document to be submitted. As of 5/1/24 Staff #1 failed to provide the written statement as requested on 4/4/24 and 4/12/24. | The Department may deny, refuse to renew or revoke a certificate of compliance for failure to comply with this chapter. | The Residential Director provided the Witness Statement to the Licensing Representative as requested although late in submitting. The Residential Director has received corrective employee action regarding failure to follow directives from agency COO. All communications from Licensing Representatives will be personally followed up by either the CEO or the COO with email submissions. |
06/07/2024
| Implemented |
| 6400.22(c) | According to the Individual Support Plan (ISP) for Individual #1 last updated on 3/28/24 Individual #1 is "nonverbal." Individual #1 is physically incapable of requesting the provider to purchase a meal on their behalf. Financial records for Individual #1 record that on 1/5/24, 1/11/24, 1/12/24, 1/15/24, 1/17/24, 1/18/24, 1/22/24, 1/23/24, 1/30/24, 1/31/24, 2/1/24, 2/5/24, 2/6/24, 2/7/24, 2/8/24, 2/9/24. 2/19/24, 2/23/24, 3/4/24 and 3/7/24 meals were purchased while Individual #1 was not being provided services by their residential provider. Attendance records for Individual #1 confirm that Community Participation and Supports (CPS) program services were being provided when the meals were purchased. Staff #1 noted that the meals were purchased for Individual #1 due to a meal not being prepared for them to take to their Community Participation and Supports (CPS) program. Staff #2 confirmed the purchasing of food and noted that residential staff would drop Individual #1 off at the CPS program then purchase a meal and bring it back for Individual #1's noon meal. Staff #3 was reported to have made many of the purchases and stated that the meals were purchased due to the overnight not ensuring that a meal was ready to take and that there was no time for them to complete the task. The purchase of the meals was not completed at the request of Individual #1 but rather for the convenience of the residential staff members. The funds for Individual #1 were not being used for their benefit. | Individual funds and property shall be used for the individual's benefit. | The individual's account was reimbursed for any instances that MW had a food purchase outside the home back to last year-2023 of concern out of an abundance of caution as the findings indicate that due to being non verbal there may be a question as to her actual desire for food purchases. The agency retrained the staff in the home as to Financial Room and Board requirements and the requirement to make an individual lunch to take to programs of any sort. Please see the attached documentation for the same. |
06/10/2024
| Implemented |
| 6400.68(a) | At the time of inspection there was no hot water in the only bathroom sink of the home. Upon report Staff #1 went into the bathroom and opened the valve under the sink that allows hot water to flow to the faucet. Once opened hot water was immediately available. There was no explanation for why the hot water had been shut off. | A home shall have hot and cold running water under pressure. | The water valve under the sink was turned on at time of inspection.
The staff in the home will monitor the bathroom sink for both hot and cold water being operative through out the shift. The individual SW has a history of turning of spigots valves under the sink along with other tampering behaviors. |
03/26/2024
| Implemented |
| 6400.144 | At time of inspection both Individual #1 and Individual #2 were documented as having their blood pressure checked two times daily. Documentation of this directive was requested for both Individual #1 and Individual #2 but could not be verified.
Individual #1 has a diagnosis of Paroxysmal Atrial Fibrillation and is prescribed Metoprolol. On 1/9/23 Individual #1 was recommended to "BP monitor 3x week, recommend 6 month follow-up, call office for elevated HR >120." At the time of inspection, the recommendation for monitoring the blood pressure of Individual #1 was not being followed. At time of inspection provider staff were taking Individual #1's blood pressure two times per day.
On 3/27/24 the residential provider requested documentation from the physician for Individual #2 and asked if there was a "script or protocol to keep track of [Individual #2] blood pressure. The physician responded by stating "Not to my knowledge." Provider staff had been taking Individual #2's blood pressure without an order in place for an undetermined length of time.
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. | 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 reached out to both individual's Physician with regard to need and frequency of BP measurings. The physician indicated that for MW three times per week was more than adequate, and for SW there was no need to take his BP from a medical care standpoint. The physician did state that there was no harm in measuring the BP two times per day. The agency has discontinued the practice of SW's BP measuring all together. The agency has retrained all staff in the home as to the new directives for BP measuring. |
04/18/2024
| Implemented |
| 6400.32(c) | Individual #1 was financially exploited by course of conduct, including misrepresentation or failure to obtain informed consent which results in monetary loss to the individual. According to the Individual Support Plan (ISP) for Individual #1 last updated on 3/28/24 Individual #1 is "nonverbal." Individual #1 is physically incapable of requesting the provider to purchase a meal on their behalf. Financial records for Individual #1 record that on 1/5/24, 1/11/24, 1/12/24, 1/15/24, 1/17/24, 1/18/24, 1/22/24, 1/23/24, 1/30/24, 1/31/24, 2/1/24, 2/5/24, 2/6/24, 2/7/24, 2/8/24, 2/9/24. 2/19/24, 2/23/24, 3/4/24 and 3/7/24 meals were purchased while Individual #1 was not being provided services by, or in the care of, their residential provider. As verified by time stamped receipts and Community Participation Supports (CPS) attendance records, meals were purchased by the residential provider to be taken to the CPS provider on the dates listed for Individual #1 to consume at their noon meal. Staff #1 confirmed that the meals were purchased due to a meal not being prepared and provided by the residential provider. Staff #1 and Staff #2 both reported that Individual #1 would be transported to the CPS program then staff would go purchase the meal then return to the CPS program and drop off the meal for Individual #1. Individual #1 was not present when the meals were purchased. Staff #3 was reported to have made many of the purchases and stated that the meals were purchased due to the overnight not ensuring that a meal was ready to take and that there was no time for them to complete the task. The meals purchased were for the convenience of the residential staff members and should have been supplied by the residential provider. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | The individual's account was reimbursed for any instances that MW had a food purchase outside the home back to last year-2023 of concern out of an abundance of caution as the findings indicate that due to being non verbal there may be a question as to her actual desire for food purchases. The agency retrained the staff in the home as to Financial Room and Board requirements and the requirement to make an individual lunch to take to programs of any sort. Please see the attached documentation for the same. |
06/10/2024
| Implemented |