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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.110(f) | Individual #1's individual support plan, last updated 8/15/2023, states the individual has hearing aids in both ears and at times he refuses to wear them. Individual #2's individual support plan, last updated 6/07/2023, states he is diagnosed with sensorial hearing loss in the left ear and acute hearing loss in the left ear and uses hearing aids. There was no documentation for Individual #1 and Individual #2 if smoke detectors should be equipped so they can be alerted in the event of a fire. During the inspection conducted 9/27/2023 there were two interconnected strobe lights in the home, one in the staff office and one in Individual #1's bedroom. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | 6400.110f- Strobe Lights for individual¿s that have hearing challenges/wear hearing aids or require hearing aids. The house had two strobe lights however the lights are not in view from all areas of the house, including the bathrooms, basement, the living room area and the individual #2's bedroom. The strobe lights should be present in bedrooms and all common areas, including; bathrooms, the basement, living areas, etc. On 9/29/23 the Director of IDD made a phone call and left a message with our Alarm systems, Guardian and Barrier. On 10/12/23 and email was sent out to our contact with Barrier Systems to make changes to the house, including adding more strobe lights to the common areas and/or bedroom(s). We have chosen to contract business with Barrier rather than Guardian. The Compliance officer will be responsible to ensure that the strobe lights are installed as desired by Emmaus Community to meet regulation 110f. The Director of IDD will ensure that each RA (Residential Advisor) according to the house, will be trained and/or a review of the new strobe lights location and bed shakers will take place once they¿re installed. The Fire Drill forms will be updated to include a check list that all strobe lights were in working order during monthly drills. The Residential Advisor, the Residential Program Manager and the Director of IDD Services will ensure that each home with strobe lights and bed shakers maintains that they are in working order monthly. The Facilities Manager will install a bed shaker to individual #1 as soon as possible. The bed shaker will also be added to the corresponding house fire drill form. Each DSP will be responsible for making sure the bed shaker is in working order during drills. The DSP will check off documentation on the form when the bed shaker is successfully engaged during drills. The Residential Advisor, the Residential Program Manager and the Director of IDD Services will ensure that each home with bed shakers maintains monthly documentation and that they are in working order. Going forward, each individual that requires strobe lights and bed shakers based upon their current ISP, upon admission Emmaus will install the requirements for 110f (strobe lights in all areas and bed shakers). Based upon the individual¿s¿ needs, if a person¿s ability declines in the area of hearing the alarm system, as soon as this is indicated via an audiologist or physician appointment or recommendation, an immediate plan will be incorporated to add strobe lights and a bed shaker as soon as possible. The person responsible for this addition will be the Residential Advisor to communicate this information, The Director of IDD Services to begin contacting the Alarm interconnected system carrier (most typically Barrier Services), the Compliance Officer for installation, along with the Facilities Manager. The Residential Advisor is responsible for ensuring all systems are in working order based upon monthly Fire Drill forms. |
10/20/2023
| Implemented |
| 6400.163(h) | During the inspection conducted 9/27/2023, Acetamin 500mg Tab "Take 1 tablet by mouth every 6 hours as needed", expired 8/09/2023, and was identified in Individual #1's medications. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Individual #1 came from another agency (PFQ) with his PRN medications on 7/10/23. Upon admission his medication that was close to expiring on 8/9/23, was identified. However, it remained in his medication container past the date of expiration. Although, he did not receive any tablets from the expired Acetamin the regulation 6400.163 (h) is being followed. While the inspectors were on-site the medication was destroyed appropriately on 9/27/23. A new PRN medication of Acetamin was replaced that is not expired. |
10/20/2023
| Implemented |
| 6400.166(a)(12) | Individual #1 is prescribed Quetiapine Tab 200mg "Take 1 tablet by mouth twice a day at 7am and 4pm for mood". Individual #1 is prescribed Bethanechol 25mg tablet "Take 1 tablet by mouth twice a day for bladder. Take medication on an empty stomach 1 hour before, or 2-3 hours after a meal, unless otherwise directed by your doctor." Individual #1's September 2023 medication administration record documents the medications administration time as 8:00AM, but the medications administration times should be 7:00AM. | 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. | Following the Inspection individual #1's MAR was changed from 8AM to 7 AM accurately, since the Bethanechol 25 mg should be 1 hour before, on an empty stomach. The MAR was changed as of 9/28/23 by the Healthcare and Quality Manager to accurate reflect regulation 6400.166(a)(12). |
10/20/2023
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.80(b) | The back porch of the home has numerous areas of peeling paint and evidence of rotting wood. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | What specific change will be made? All loose paint will be scrapped from the back porch and all rotten planks will be replaced ( note: the rotting wood is on the decorative face pieces and the end of the planks, thus not posing any danger to residetns or staff. Structurally the deck is very sound.) The deck will then be primed and re-painted. Who will make the change? Karen Jacobsen, Executive Director will coordinate the oversight of this project with the help of Jon Dunik, Emmaus Maintenance man. Volunteers will be used to scrape and prepare the surface for re-painting and will do the painting, after a contractor from Deckmasters replaces the rotten planks and facia (decorative wood pieces). When will the change occur? The scraping has already been completed by a volunteer group on 9/6/14. The planks will be replaced before 10/17/14 and the re-painting will occur on 10/18/14. What system has been implemented to make sure the violation does not happen again? Emmaus was aware that this project needed to be done. Volunteers from "Senior Connection" were scheduled for May 2014, but were unable to do so. In the future, if a project can not be completed internally by the maintenance man at Emmaus, nor by a volunteer group in a timely manner,the Emmaus Maintenance man will call an outside contractor and Emmaus will pay to have the job done in a timely manner. A monthly check list has been updated for the maintenance man to ensure that "yards, and outside of builings are well maintained and in good repair and free from unsafe conditions."
What training will be provided to staff? Emmaus Maintenance man, Jon Dunik, has resigned his job description and Emmaus policy 1001- Facilities Maintenance. All direct care staff and supervisors are tained on how to submit a maintenance request when facility repairs are needed. Maintenance request forms are available on the Emmaus website and copies are available in the office of each home. |
09/12/2014
| Implemented |
| 6400.213(9) | The most current ISP in the record of individual #1 was dated 7-1-13 to 6-30-14. | Each individual's record must include the following information: A copy of the current ISP. | What specific change will be made? All ISPs will be printed out and filed on July 1st of every fiscal year. Who will make the change? Kristy Buczynski, Residential Program Manager/ Program Specialist. When? This change has already been made for all Emmaus residents. All ISPs for the 2014-2015 fiscal year have been printed and filed accordingly.
What system has been implemented to make sure that the same violation does not happen again? This violation was not made intentionally. Emmaus has always printed out the most recent ISP after the annual meeting / revisions have been made, and staff reads and singns off on it. In 20 years of being licensed, Emmaus has never been cited on this regulation, nor were we ever informed that everyone must have the ISP cover page and service detail page printed on July 1st of every year in order for it to "count" as the "most recetn" ISP due to fiscal year dates and service detail rates updates. Emmaus will, from now on, print everyone's entire ISP every July 1st so that the fiscal year, all program content, and the service detail information is current as of each new fiscal year. What training will be provided to staff? The Program Specialists, Kelly Stillwell and Kristy Buczynski, will be responsible for making sure that all Residential Advisors (supervisors) know and follow this policy by writing a policy that staff will sign off on. To be completed by 10/31/2014. |
09/12/2014
| Implemented |
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