|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.107 | During the inspection conducted 9/27/2023, at 11:38AM a portable space heater was on a file cabinet in the staff office. | Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms.
| At the time of the inspection, when discovered, the portable heater was removed from the site on 9/27/23. The Director of IDD removed it and then returned it to it's owner. The portable heater was similar looking to a fan. The inspector educated the Director of IDD that if it has coils inside it is a heating element. When the staff was located that brought the portable heater on- site she was very apologetic. She is a case manager within the Dept of aging and said that it wasn't plugged in however. She promised the Director of IDD Services that she will never bring the portable heater to our location again. This conversation of supervisory assistance/feedback took place on 9/27/23. Emmaus sent out to our entire agency, through a monthly publication that portable heaters are not allowed on any premise. |
10/20/2023
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(14) | The physical examination completed on 3/25/16 for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Emmaus has changed their Physician's Medical Form as of 09/27/2016 to include a line that states, "Please list Medical information pertinent to diagnosis and treatment in case of an emergency:" A line is also provided for comment by the Physician. This statement is on page 2 of 2 of the document. However, for the record, Emmaus feels that our form has been utilized since 2011 and previous BHSL Inspectors did not comment on this absence. The entire form encompasses medical information that is pertinent to diagnosis and treatement in case of an emergency. This new Physician's Medical Form will be utilized throughout the agency for all of our individuals under the 6400 Regulations. [Individual #1 (AS 11/1/16)] will take this new form with her to her Annual Physical exam in March of 2017. Individual #1 (AS 11/1/16)]'s Residential Advisor, Angie Monk, will ensure that the new updated Physician's Medical Form, revised 09/27/2016, will be used.[Individual #1's medical information was updated on 10/25/16 to included medical information pertinent to diagnosis and treatment in case of an emergency. Immediately and upon completion, the Director of IDD services shall review all individuals' physical examinations to ensure all required information is included and there are not areas of required information left blank. Designated staff persons shall immediately obtain missing information from the completing physician. Documentation of reviews shall be kept. (AS 11/1/16) |
09/27/2016
| Implemented |
| 6400.163(c) | Individual #1's two most recent reviews with documentation by a licensed physician were 2/9/16 and 6/3/16. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Individual #1 (AS 11/1/16)] had a previously scheduled Psychiatric Evaluation on 5/3/16, but missed it due to a family vacation. Residential Advisor, Angie Monk, asked that she be placed on a cancellation list. But, to no avail, the Merck Program was unable to reschedule Individual #1 (AS 11/1/16)] within the 90 day requirement. Deanna wasn't seen again until 6/3/16. At which time, Dr. Farr, Psychiatrist, signed off on a letter stating that Deanna's health was Not compromised due to missing the 5/3/16 Evaluation/appointment. However, to meet the 6400.163 Regulation, Emmaus devised a new form, on 10/5/16, by Kelly Stillwell, Director of I/DD Services, called Quarterly Physician's Medication Review- Psychotropic Medication. This form will be used as a Medication Review when necessary, if an Evaluation is missed beyond the 3 months (90 days), to be signed by a Licensed Physician. The entire Emmaus Community of Pittsburgh will utilize this new form as needed for quarterly Psychotropic Medication Reviews. |
10/05/2016
| Implemented |
|
|