| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Kitchen cabinet under the sink had sticky residue which was able to be removed by wiping with wet paper towel during the walkthrough. The Kitchen trash can has sticky residue on the outside of the can which was able to be removed by wiping with a wet paper towel during the walkthrough on 10/07/20. | Clean and sanitary conditions shall be maintained in the home. | Critical Analysis of cause of violation:
The kitchen and bath areas of the home are particularly susceptible to surface residue. As evidenced by the ease with which the residue was removed during inspection, these surfaces are being cleaned however it is not being done with sufficient frequency to insure constant cleanliness. This may also be the result of increased use of the kitchen during the pandemic as people are spending more time at home and there are more meals being prepared.
Immediate Correction:
As noted within the citation, the cabinet was cleaned during the inspection.
Change in procedure:
Monthly job duties are assigned to all staff to include dusting, mopping, and cleaning oven. The duties assignments have been modified to increase the frequency of occurrence and expanded to include wiping down cabinets twice monthly, cleaning trash cans weekly, wall plates and surrounding wall surfaces twice monthly.
Specific steps to be taken:
Direct Support Staff are to complete each task as assigned on the Job Duty Assignment and initial the list once the job is completed. House Coordinators will review the list and the home each week to insure job assignments are being completed. Attachment B
The Executive Director will conduct random unannounced inspections of the home and provide written feedback to the House Coordinators and Direct Support Staff on the findings of the inspections.
In the event that deficiencies are found, the House Coordinator will conduct hands on training with the Direct Support Staff to insure that they have the proper skills and supplies to complete the assigned tasks. Any such training will be documented to include the specific task being trained and a signed acknowledgement will kept on file. In the event of further deficiencies being found, the responsible person will be subject to formal disciplinary actions intended to insure that the home consistently maintains a clean and healthy environment. |
10/27/2020
| Implemented |
| 6400.67(b) | Black residue (with a mold like appearance) was located along the bottom of the cinderblock wall next to the freezer. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Critical Analysis of cause of violation:
The cinderblock foundation of the home is below ground level. The home was built in 1958 and to our knowledge has not had any foundation work done since original construction. While there has not been any ground water penetration occurring during the 16 years that the agency has rented the building, the moisture found in this particular area is not inconsistent with that found in construction of this type and age.
Immediate correction:
The wall has been cleaned and treated with concrobium which destroys mold and mildew below the surface and provides a microbial surface shield to prevent future surface mildew. The surface was then dry locked to prevent future moisture penetration. Attachment C1 C2
Change in procedure:
Maintenance person has been instructed by the agency President to inspect all foundation walls for any visible evidence of water, moisture, mildew, mold or any another indication of any potential health threatening condition and/or structural compromise on a quarterly basis.
Specific steps to be taken:
The Maintenance person will submit a written report of findings for each home to the President. The report shall contain photographs of any affected areas as well as any lab analysis from independent sources as to the specific nature of any substance found, as appropriate.
In the event that the situation cannot be resolved through the application of topical treatments as described above, property owners will be notified and professional contractors specializing in remediation of moisture issues will be hired to correct the situation.
The Maintenance person shall complete a course of study in the detection and remediation of residential construction moisture issues within the next six months. In the absence of a formal course of study, the Maintenance person shall submit independent research documentation to the President within that same period of time. |
10/27/2020
| Implemented |
| 6400.71 | Phone in the kitchen has a sticker on the back of the phone with emergency numbers which have been rubbed off and is illegible. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| Critical Analysis of cause of violation.:
The emergency numbers posted by each telephone in the home have been attached to the handset of cordless telephones to insure that they are available regardless of the location of the telephone at any given time. Through the extended use of the telephone, the label used to contain these numbers is subjected to repeated rubbing as well as the normal oils of human skin, thereby over time resulting in the deterioration of the label and or ink on the label which eventually renders it illegible.
Immediate correction:
The sticker has been replaced. Attachment D
Change in procedure:
After applying the label containing the required emergency contact numbers, a clear transparent tape shall be applied on top of the label to provide protection from repeated exposure to use.
Specific Steps to be taken:
All cordless phones in the homes will continue to have the emergency numbers affixed to the handsets. All homes have been provided with replacement stickers to be used as needed to ensure legibility as well as a roll of transportation. House Supervisors shall inspect the phone list to insure legibility on a monthly basis. Documentation of the inspection will be maintained on the monthly job duty sheet.
House Supervisors will within seven days instruct staff as to the effect of excessive wear on the labels, the purpose of the clear coating tape and the importance of using 911 as the primary emergency number to be used in the event of an actual emergency. |
10/27/2020
| Implemented |
| 6400.77(b) | No tape was found in the first aid kit during the walkthrough on 10/07/20. | 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. | Critical Analysis of cause of violation.:
Many of the required contents of the First Aid kit are intended to be available for use and are by their nature consumable and/or disposable items. Once they are used, they must be replaced immediately to insure continual availability. The agency has been made aware that there is a requirement that there not be multiple first aid kits in the home in order to avoid potential confusion. There lacks a method for insuring that any required item in the First Aid Kit is immediately replenished once it has been consumed and/or disposed of.
Immediate Correction:
Tape in the first aid kit has been replenished. Attachment E1
Specific Steps to be taken:
A checklist of required contents of the first aid kit has been added to the monthly fire drill record listing all required contents of the first aid kit. Attachment E2
Each home will continue to maintain a separate storage container which includes replacement consumable/disposable items. In addition to the current requirement that Direct Support Staff immediately report any injury to the individuals, they will now be required to report any injury or condition requiring the use of any item in the First Aid Kit by anyone in the home including staff, visitors, etc. to the on call supervisor. After insuring the health and safety of everyone in the home, the on call supervisor will instruct the staff to immediately replace the consumed item as needed from the storage container of replacement items and report the use of the specific item to the Office Manager who will obtain and issue any items needed to replenish the replacement storage container.
The Executive Director shall provide instruction to all on call supervisors regarding the above referenced procedural change within seven days.
The House Supervisors shall instruct all Direct Support Staff in the modified reporting requirements outlined in the revised procedure prior to the end of the next scheduled work shift of the DSP. |
10/27/2020
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination dated 06/08/20 does not include Information pertinent to diagnosis and treatment in case of an emergency. The space lists the date of his most recent TB test. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Critical Analysis of cause of violation
Direct Support Staff have historically accompanied individuals to all medical appointments including annual physicals. A 4-page pre-populated comprehensive documentation form is sent with them to these appointments. This document was developed by Philadelphia Coordinated Health Care (PCHC) and is a part of their Health Information Software package. Information on these forms is updated and maintained by the Program Specialist and during the visit, the individual¿s physician is requested to fill in the requested information. These forms were developed by PCHC and each individual¿s baseline information including all updates from the prior year¿s medical activities is populated within the document. The Annual Physical Examination Form identifies the person and contains basic information such as name, address, date of birth, social security number and date of the exam. Further, these documents include sections on diagnosis/significant health conditions, current medications/pre-authorized over-the-counter medications, a lifetime medical history summary, immunizations, diagnostic tests, and a general physical examination checklist which contains a comment section where questions are a mix of multiple choice and lines that must be answered more fully.
During the visit, Direct Support Staff hand the documents off to physicians and/or other medical personnel in the office to complete. There are times when physicians are unable to review, complete questions on the forms, and sign each section prior to the completion of the visit. This trend has become more frequent as more physicians are working under tighter restrictive timelines to spend with patients during a visit. Often, completed forms are picked up from the office at a later date/time or, in some cases, are mailed back into the HAP, Inc. office.
In the instance of the citation for 6400.141 c (14), one of the lines on the 6/8/20 annual physical form Information pertinent to diagnosis and treatment in case of emergency¿ was not completed by the physician, and this was not noticed prior to the overall document being placed in the individuals record book.
There was also hand-written information within the Additional Comments section that recorded that a TB screen was completed in the office during the visit. This information was in a location on the paper near where the line in question was located. The HAP Registered Nurse read the skin test on 6/10 and recorded the results directly underneath the information regarding the TB screening.
Immediate correction:
The Annual Physical form cited was taken back to the primary physician¿s office by the Registered Nurse and a request was made for the line in question to be filled in by the physician. Information was written regarding blood pressure parameters (patient is diagnosed with hypertension in Axis 3) and an appropriate response to a life-threatening hyper/hypotensive episode (call 911 or physician) was outlined. This document is included in our attachments for review.Attachment F
Change in procedure:
While Direct Support Staff will still transport individuals to annual physical appointments, the Registered Nurse will also attend these annual visits to ensure that clear and concise direction is both given and received. It will also be the Registered Nurse¿s responsibility to review all medical documentation issued by physicians for completeness and accuracy.
Specific steps to be taken:
The current software being used for documentation in regard to health and medical information is being re-evaluated for potential transition to electronic health information in order to develop a more precise record-keeping and exchange of information between doctors and service providers.
Training will be provided within 7 days to house supervisors and support staff by Registered Nurse on reviewing medical documentation for accuracy before, during, and after medical appointments and implementation of physician¿s instructions therein.
Agency Procedure is being developed and distributed to all support staff re procedure for reporting medical visit results and documentation to Registered Nurse for review within 24 hours of all visits. A signed acknowledgement for this instruction will be maintained at the administrative office |
10/27/2020
| Implemented |
| 6400.145(3) | The emergency medical plan for Individual #1 does not include the plan for emergency staffing in case of a medical emergency. Instead, the plan directs staff to contact someone else for the plan. The document reads- "The emergency-staffing plan can be obtained by contacting the Program Director···or On-Call personnel···phone number". | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | Critical Analysis of cause of violation:
The plan indicates the action that is required for the Direct Support Staff to initiate the process for Emergency Staffing but does not include the steps that result from that initiation.
Immediate correction:
The written emergency medical plan has been expanded to include the steps to be taken by the on call personnel. Attachment G
Change in Procedure:
There is no change in the actual procedure for providing for Emergency Staffing.
Specific steps to be taken:
The Direct Support Staff are to contact the on call supervisor who will provide emergency backup coverage to the home either by arranging for off duty staff to come in or by providing the coverage themselves. The on call supervisor will then notify the agency Nurse of the specific nature of the emergency. |
10/27/2020
| Implemented |
| 6400.51(a)(1) | Staff #1 was hired on 03/30/20. Staff # 1 was not provided orientation contents as identified and required in Regulation 51b as of the date of the inspection October 06, 2020. | Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons. | Critical Analysis of cause of violation:
Staff#1 was hired as a licensed registered nurse in the midst of the COVID-19 pandemic. The agency had not employed a full time nurse in the past The primary focus of the orientation provided was specific to a comprehensive examination of all individuals medical histories and current medical conditions in order to identify people who would be considered as being at greater risk and to assist in the development of strategies and practices that were consistent with the evolving guidance being provided by the CDC, ODP, the medical community as well as government leaders. Given the circumstances, the prioritization of putting this additional service in place as quickly as possible took precedent over insuring that the orientation requirements of the regulations were met.
Immediate Correction:
Staff#1 has now completed all required training as identified in Regulation 51b. Attachment H
Specific Steps to be taken:
The President acknowledges the violation of the regulation and has instructed the Executive Director that all employees who will have interactions with the individuals and a presence in the homes must have completed all required orientation training prior to providing services regardless of the role of the employee or the circumstances surrounding the necessity for their immediate employment.
The Executive Director shall examine the orientation training records of all new hires prior to their beginning to work in the homes to insure compliance with the governing regulations.
All subsequent new hires have received all required orientation training per ODP regulations. |
10/27/2020
| Implemented |
| 6400.166(a)(2) | Individual # 1s Medication Administration Records for 2020 do not include the name of the prescribing Physician. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | Critical Analysis of cause of violation
Medical Administration Records (MAR) are developed and updated monthly by Program Specialist. Information on these forms is updated by the Program Specialist based on new orders, changes, or modifications by physicians during the previous month. At the end of the month, the new MAR for the upcoming month is printed in the office for distribution to individual residences. While an individuals medical records, which includes all signed orders, are kept at the residence, the MAR template was erroneously constructed without including the name of prescribing physician for each individual medication.
Immediate correction:
Updating of the Medication Administration Record has been completed to now include Prescribing Physician for each listed medication and treatment. Attachment I
Change in procedure:
A monthly review of all MAR will now be performed by company Nurse for accuracy and updates including prescribing physician. This has been completed for all November MARs
Specific steps to be taken:
An investigation by the Registered Nurse has been undertaken to match each prescribed medication to the correct prescriber in the Medication Administration Records for all individuals. This process involves reviewing current and past years medical records across multiple specialties (PCP, Psychiatrists, Neurologists, etc.), reviewing pharmacy orders which in some cases has highlighted differences between how information is written on our paperwork by a physician as a result of an office visit and how it is e-scribed and ultimately labeled on the bottle, tube, or package. Physician offices are also contacted for medication confirmation which at times highlights differences in physician office records and our historical records such as older or unintended continuation of older prescriptions. This should be completed for all 27 individuals receiving services.
The current software being used for MAR development and maintenance is currently being re-evaluated for potential transition to electronic medication records in order to develop a more precise record-keeping and exchange of information between doctors and HAP service providers. |
10/27/2020
| Implemented |